International Endodontic Journal {1996) 29,150-155
Time-course and risk analyses of the development and healing of
chronic apical periodontitis in man
D. 0RSTAVIK •
Department of Endodontics, School of Dentistry, University of North Carolina, Chapel Hill NC, USA
Summary
Roots with and without preoperative chronic apical
periodontitis were root canal treated and followed clini-
cally and radiographically yearly for up to 4 years. Of
732 roots treated, 599 (82%) were available for evalua-
tion at one or several recalls. Chronic apical periodon-
titis (CAP) was recorded with the periapical index
scoring system. CAP developed in 29 of 473 (6%) of
teeth without preoperative signs of disease, whereas 111
of 126 (88%) initially diseased roots showed signs of
healing. The rate of healing CAP and the rate of
emerging CAP were calculated, and analyses of event
occurrence each year of observation were performed.
Peak incidence of healing or emerging CAP was at
1 year in both instances. Risk assessments at 2, 3, and
4 years did not indicate an added risk of filled roots
developing CAP during this period. Complete healing of
preoperative CAP in some instances required 4 years for
completion, while signs of initiated, but incomplete,
healing were visible in at least 89% of all healing roots
after 1 year. Risk analyses may provide relevant in-
formation in addition to or in substitution for
success/failure analyses. , essential for adequate timing of postoperative controls of
Keywords: apical periodontitis, endodontics, prognosis,
risk analyses.
Introduction
Chronic apical periodontitis as diagnosed radiographi-
cally dominates the evaluation of endodontic success or
failure (Strindberg 1956, Kerekes & Tronstad 1979,
0rstavik et al 1987). Conversely, analyses of success
and failure following endodontic treatment have been a
Correspondence: Dr. Dag 0rstavik, NIOM, Scand. Inst. Dent. Mater.,
Postboks 70, Kirkeveien 71B, N-1344 Haslum, Norway.
150
main source of clinical information about periapical
disease. Despite numerous and extensive follow-up
studies, however, little is known, or has been system-
atized, regarding the kinetics of development and
healing of chronic apical periodontitis.
The use of the terms success and failure has a long
tradition in clinical dentistry. They convey a simple
rationale for further treatment decisions for both dentist
and patient. With the recognition of the dynamic nature
of diseases such as caries and marginal periodontitis, the
use of success or failure to characterize treatment has
largely disappeared in restorative dentistry and
periodontology. While the technical possibility of
completely eliminating infection from the root canal
might form a basis for retention of the success/failure
terminology in endodontics, the diagnosis of healing or
developing disease or its absence might provide a more
rational basis for treatment decisions in thisfieldas well.
Also pertinent to the needs of clinical decision-making
is knowledge of the time-course of apical periodontitis.
The time necessary for healing of a lesion to occur will
decide when more treatment may be indicated, and the
time needed for development of a diagnosable lesion is
endodontically treated teeth without preoperative,
apical periodontitis.
Apical periodontitis may occur in teeth irrespective of
whether they have been endodontically treated or not.
Thus, chronic apical periodontitis emerging in a root-
filled tooth some time after treatment may be viewed as
an event occurrence and analysed in relation to the
general risk of any given tooth developing the disease
during a certain period of time. Similarly, the occurrence
of healing of preoperative, apical periodontitis may also
be assessed in relation to the number of teeth actually 'at
risk' for the event to occur.
The present study was performed in order to assess, in
a prospective study, (a) when chronic apical perio-
©.1996 Blackwell Science Ltd

dontitis becomes radiographically detectable in teeth
without lesions preoperatively, and (b) when a normal
apical periodontium may be diagnosed after treatment of
teeth with preoperative, chronic apical periodontitis.
Moreover, 'at risk'-probabilities were computed for
comparison with data from epidemiological studies.
Materials and methods
Eight hundred and ten roots in 571 teeth, treated by
undergraduate students at the University of Oslo in the
early 198O's (0rstavik et al. 1987, Erilcsen et al. 1988b)
formed the basis of the study. Of these, 78 roots with
uncertain periapical diagnosis at the start of treatment
(PAI score = 3, see method below) were excluded,
leaving 732 roots for analysis. Clinical and radiographic
variables were registered before and during treatment
and after 1,2,3 and 4 years postoperatively.
The endodontic procedures followed a strict aseptic
regimen. After access preparation, a rubber dam was
placed and the field disinfected with 1% benzalkonium
chloride. Instrumentation was with reamers and
Hedstrom files in the presence of 1% sodium hypochlo-
rite. Canals were prepared with a standardized method
to a median reamer size of ISO 60, with 90% of roots
instrumented from sizes 45 to 90. Roots with chronic
apical periodontitis were always treated in two or
several appointments with a dressing of calcium
hydroxide in sterile water applied with a lentulo spiral
and sealed with zinc oxide-eugenol cement. If roots with
vital pulps and no apical periodontitis were treated in
more than one appointment, calcium hydroxide was
used as an inter-appointment dressing. Root filling was
with gutta-percha and sealer (ZnO-rosin-chloroform-,
epoxy resin-, or ZnO-eugenol-based) using lateral con-
densation (0rstavik et al. 1987).
Apical periodontal status was recorded with the PAI
scoring system (Orstavik et al. 1986), which grades
chronic apical periodontitis (CAP) on a scale from 1 to 5
(Table 1). The scoring system is based on the histo-
logic/radiographic studies by Brynolf (1967), and is
performed by comparing the roots under study with a set
of reference radiographs corresponding to the steps on
the scale. The scoring is done observer-blind and with
recorded measures of reproducibility (0rstavik et al.
1986, 0rstavik 1988). ;'- I
Each root in the study was characterized hy its PAI
scores at times 0,1,2,3 and 4 years after treatment.
Five hundred and seventy-seven roots had a preopera-
tive PAI score of 1 or 2 and were considered to be
without CAP at the time of treatment. Twenty-nine
© 1996 Blackwell Science Ltd, Intenmtional Etidodontic Journal 29, 150-155
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Prognosis and risk analyses 151
Table 1 The periapical index (PAI) scoring system
PAI score Verbal descriptors
1 Nortnal apical periodontium
2 Bone structural changes indicating, but not j% •'
pathognomonic for, apical periodontitis
3 Bone structural changes with some mineral loss
-• ,• characteristic of apical periodontitis
4 Well defined radiolucency -. - • :
5 Radiolucency with radiating expansions of bone
structural changes
roots (out of 473 presenting for recall) which showed
signs of developing CAP after treatment were analysed
in greater detail. For each root, the year of recall which
showed a PAI score of 3 or higher, establishing a
diagnosis of CAP, was recorded. Also recorded was
whether the root had been available for diagnosis the
year previous to the year when CAP was diagnosed.
New cases of CAP were calculated as a percentage of
the total number of new cases over the 4-year period
and of the actual number of cases at risk presenting at
recall. ; =
One hundred andfifty-fiveroots had a preoperative
PAI score of 4 or 5 and were considered as having
definite CAP at the start of treatment. Ninety-five (out of
126 appearing for recall) which were later found to give
a PAI score of 1 or 2, indicating that complete or near-
complete healing had taken place, were analysed in
greater detail. For each of these roots, the first year of
recall which showed a PAI score of 1 or 2 was recorded,
as was whether or not the tooth had been available for
recall the year before that. For each year, healed roots
were calculated as a percentage of the total numher of
healed roots over the 4-year period and of the number of
cases which actually were available at the time of recall.
As the occurrence of healing is desirable, it was referred
to as an 'at-hope' rather than an 'at-risk' event.
A score of 3 (or lower) was at some time assigned to
111 of the 126 initially diseased roots. These were
considered to he definitively healing, but not completely
healed cases. Calculations were made expressing these
roots as a percentage of the total number of healing
roots over the 4-year period and of the number of cases
which actually were available, 'at-hope', at the time df
recall. . , , ; ;•
For roots with no data the year prior to a diagnosis of
healing (or developing) CAP, a definite year of event of
occurrence was not available. Half of these roots were
considered to have healed (or become diseased) the year
before and half at the year of detection.
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152 D.Orstavik

Results cases were diagnosed after 1 year, and 7 and 5% after 2

and 3 years, respectively (Table 4).
When CAP (PAI score 3 or higher) developed in
The incidences of CAP developing (or healing) in
roots with no preoperative lesion, 76% were detectable
relation to the number of cases presenting at recall
after 1 year, with 14, 7 and 3% of cases diagnosed after
actually at-risk (or 'at-hope') are listed at the bottom of
2, 3 and 4 years, respectively (Table 2). The 22 roots
Tables 2 - 4 . The risk of CAP occurring had a peak at
which showed CAP after 1 year were available for
1 year which was significantly greater than the risk at
recall at 2, 3 or 4 years. The CAP persisted in all of these
years 2, 3 and 4. Conversely, the incidence of complete
teeth.
healing, though similarly levelling out, remained at 25%
When complete healing of CAP (initial PAI score of 4
or higher throughout the 4-year period. The diagnosis of
or 5) occurred, it was diagnosed after 1 year in 51% of
definite, but incomplete, healing, however, occurred at a
the cases, with 35,12 and 3% diagnosed after 2, 3 and 4
peak incidence at 1 year (Tables 2-4). None of the cases
years respectively (Table 3).
with a first diagnosis of PAI score 3 after more than
When healing of initially diseased roots was unequiv- 1 year had been available for any other recall since the
ocal but incomplete (PAI score 3 on follow-up), 88% of time of root filUng. . ?• :- - -/.. ?

Table 2 Apical periodontitis developing in filled roots with initially

healthy periapices. Absolute figures and at-risk calculations. Diseased Discussion
cases adjusted for the number of roots not examined the year before
detection Chronic apical periodontitis is a sequel to bacterial infec-
Parameter Data at treatment and recalls Code^
tion of the dental pulp space (Sundqvist 1976). The
formation of granulation tissue and bone structural
Year 0 1 2 3 4 1-4 A
changes develop slowly. The extent of the lesion is partly
Total 577 577 577 577 577 577 B
Absentees 0 192 211 237 356 104 C dependent on the amount of bacteria in the canal
Carry-overs''1 0 0 22 12 5 0 D (Sundqvist 1976). i :r,\ o , t i r • - • ! ' • ' ''-..' .:
Carry-overs 2 0 0 0 2 1 0 E There are few reports in the literature on the time-
Carry-overs 3 0 0 0 0 1 0 F
course of development of chronic apical periodontitis in
At-risk 577 385 344 326 214 473 G
New cases'^ 0 22 4 2 1 29 H man. Traumatized front teeth have been followed with
% of total 0 76 14 7 3 100 I some estimations of time of event occurrence (Jacobsen
% of at-risk 0 5.7 1.2 0.6 0.5 6.1 J & Kerekes 1977, Andreasen 1986, 1989); however,
a G = B - C - D - E - F ; I=H/sum(Hl to H4)*100; J=H/G*100. these studies are mainly focused on the diagnosis of pulp
"Carry-overs are diseased cases which presented for examination also necrosis rather than apical periodontitis, making direct
on the subsequent follow-up(s). comparisons difficult. Moreover, trauma is an initiating
•^The year when a PAI score of 3 or higher was assigned.

Table 3 Apical periodontitis healed in filled roots with initially Table 4 Apical periodontitis healing in filled roots with initially
diseased periapices. Absolute figures and 'at-hope' calculations. Healed diseased periapices. Absolute figures and 'at-hope' calculations.
cases adjusted for the number of roots not examined the year before Healing cases adjusted for the number of roots not examined the year
detection before detection

Parameter Data at treatment and recalls Codea Parameter Data at treatment and recalls 1Code«

Year 0 1 2 3 4 1234 A Year 0 1 2 3 4 1234 A

Total 155 155 155 155 155 155 B Total 155 155 155 155 155 155 B
Absentees 0 45 62 69 104 29 C Absentees 0 45 62 69 104 29 C
Carry-overs'" 1 0 0 34 28 15 0 D Carry-overs''1 0 0 74 64 35 0 D
Carry-overs 2 0 0 0 29 15 0 E Carry-overs 2 0 0 0 7 5 0 E
Carry-overs 3 0 0 0 0 9 0 F Carry-overs 3 0 0 0 0 3 0 F
At-hope 155 110 59 29 12 126 G At-hope 155 110 19 15 8 126 G
New heats'^ 0 48 33 11 3 95 H New heats'^ 0 98 8 5 0 111 H
% of total 0 51 35 12 3 100 I % of total 0 88 7 5 0 100 I
% of at-hope 0 43.6 55.9 37.9 25.0 75.4 J % of at-hope 0 89.1 42.1 33.3 0.0 88.1 I
aG=B-C-D-E-F;I=H/sum(HltoH4ri00;J=H/G*100. ='G=B-C-D-E-F; I=H/sum(Hl to H4)*100; J=H/G*100.
''Carry-overs are healed cases which presented for examination also on ''Carry-overs are healing cases which presented for examination also
the subsequent follow-up(s). on the subsequent follow-up(s).
'^Healing registered at the year when a PAI score of 1 or 2 was '^Healing registered at the year when a PAI score of 3 or lower was
assigned. ' ,:,..;,,.•; •» . : .,• : ^Ura, 'HHr .181.: r . assigned. i!r:'';i;i''r>T •!.,•'-:?"u • • ( • 'jf:- •-.i,-s ^ u h ; , . : ; ! - ; , ;

© 1996 Blackwell Science Ud. IntmmtionalEndodonlic joumal, 2 9 . 150-155


event wiiich does not in itself cause chronic apical
periodontitis; the subsequent events of pulp infection
and necrosis may take place at variable time intervals if
at all, confounding the relationship in time between
trauma and chronic apical periodontitis.
The present study was prospective in design and
included all cases assigned to dental students in the time
period covered. However, there was a reduction in the
number of roots at the recall appointments. Some 68,
63, 58, and 37% of the roots were available for evalua-
tion after 1,2,3, and 4 years. Extensive procedures were
employed to attract patients for recall appointments,
including at least two attempts by letter and two by
telephone. The reasons for patients not appearing for
recalls were not tabulated, but the two main reasons
seemed to be that they either could not be reached or
that they did not care to spend the time. Of the patients
that could be reached but did not care to come, few had
any comments about periapical disease or complaints
about the treatment. There was thus no indication that
the absentees represented a particular section of the
study material in regard to healing or development of
apical periodontitis.
Some 76% of chronic apical periodontitis cases devel-
oping after root filling were detectable at 1 year. In
absolute numbers, only seven cases of CAP were
detected at the 2- to 4-year recall appointments, and
none of these roots had been available at 1 year. This
may have some bearing on the time indicated for follow-
up examination of root-filled teeth without preoperative,
chronic apical periodontitis. It has been argued that
follow-up periods of 2, 4 or more years may be necessary
for assessment of the treatment result in individual teeth
or groups of teeth (Strindberg 1956, Kerekes & Tronstad
1979). From the present findings, it is clear that so-
called 'late failures' are infrequent and only marginally
affect overall evaluations of the periapical health in a
group of teeth: the 'failure rate' at one year was 5.7
(22/385) and overall 6.1 (29/473) % (Table 2).
For roots with no preoperative, chronic apical
periodontitis, the rationale for doing recalls many years
after treatment therefore seems questionable. Com-
parison with epidemiological studies may support this
assumption. Data presented by Eriksen et al (1988a)
and Eriksen & Bjertness (1991) on 35- and 50-year-old
patients may be read to indicate a risk of any given tooth
developing chronic apical periodontitis at some 0.2%
annually over a 15-year period. Similarly, the data
provided by Petersson etal. [1991) may be used to calcu-
late an annual risk (for mandibular premolars and
molars) of developing chronic apical periodontitis at
© 1996 Blackwell Science Ltd, International Endodontic journal 2 9 . 1 5 0 - 1 5 5
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Prognosis and risk analyses 153
0
Time (years)
Fig. 1. The risk (solid squares) with standard deviation for an initially
healthy root of presenting with apical periodontitis at each yearly
recall. Estimates of the risk for teeth in general (solid diamonds) and for
root filled (solid stars) or unfilled teeth (open squares) based on
computations from Petersson et al.'s (1991) data are shown for
comparison
0.13 (excluding root filled teeth) to 0.22 (all teeth) to
1.3% (root filled teeth only) over an 11-year period.
Fig. 1 shows the annual risk assessed at the 1, 2, 3- and
4-year recall in the present study in comparison with
calculated risk assessments from Petersson et al.'s
(1991) data. After 2, 3 and 4 years, the risk of a given
root in the present study developing CAP is down to 1.2,
0.6, and 0.5%, respectix'ely. Although apparently higher
than the general risk, the very low number of cases
actually detected (four, two, and one) precluded statis-
tical differentiation from it; 95 % confidence intervals of
the percentages included the values obtained by
Petersson et d. (1991). The emergence of chronic apical
periodontitis in filled roots after 2 years or more may,
therefore, not be directly related to particulars of the
endodontic treatment rendered. Although the root
filling is the prohable portal of entry for the infection, the
infiuence of other factors, such as delayed or insuiHcient
coronal restoration, may cause canal infection at a time
later than the endodontic procedures themselves. It is
questionable whether these cases can be classified as
'failures' of the endodontic treatment.
On the other hand, there was a small but statistically
significant, added risk of chronic apical periodontitis
developing within the first year after treatment, and it
seems reasonahle to assume that this risk is associated
with infection of the root canal system during the treat-
ment procedures. The assessment of risk of disease devel-
opment within 1 year may be appropriate for group
comparisons as well as for individual case prognostica-
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154 D. Orstavik

tion. 'At risk of infection and inflammation' may also be 100

preferable to the unnecessary value-laden terms
'success' and 'failure' of treatment. Using a different
approach with emphasis on diagnostic reliability and on
cost-effectiveness of a recall programme in endodontics,
Reit (1987) also concluded that a 1-year initial recall
was advantageous. ' . .
Healing of chronic apical periodontitis follows effec-
tive disinfection of the root canal system (Bystrom et al.
1987), or a reduction of the bacterial load to a level
manageable by host tissue reactions. Apart from the
transient apical breakdown reported in luxated teeth
(Andreasen 1986) and regression of incipient or
sclerosing apical periodontitis in teeth with chronic
T;me (years)
pulpitis treated conservatively, there are very few case
histories of spontaneously regressing, chronic apical Fig. 2. Cumulated curves for completely healed roots which initially
periodontitis (Petersson et al. 1991); thus, the occur- were diagnosed with chronic apical periodontitis (soiid squares).
Analogous data from Cvek (1972, solid diamonds) and Cvek et al.
rence of healing following treatment is attributable to (1976, solid stars) are included for comparison
the endodontic procedures. The occurrence of healing,
particularly when assessed in relation to roots 'at-hope', to reflect the speed with which teeth treated with
was notable throughout the entire 4-year period. calcium hydroxide dressing and gutta-percha root filling
Although the absolute numbers were low and the demonstrate complete healing. As this method of
overall prognosis assessment hardly affected, healing in treating infected pulp canals is a current standard of
individual cases was observed as late as 4 years after reference (Cvek 1972, Bystrom et al. 1987, Sjogren et al.
treatment. 1991), this curve of cvtmulated healing cases may also
Whilst complete healing could take up to 4 years, the serve as a reference for comparison when other treat-
process of healing could be diagnosed earlier, as would ment methods are evaluated. When the present data for
be expected. With 88% of the roots which ever obtained detection of initiated, but not completed, healing were
a PAI score of 3 or lower doing so already at the 1-year compared with Cvek's data (Cvek 1972, Cvek et al.
recall, the prognosis of the roots treated for chronic 1976), healing was detected at a slightly slower rate in
apical periodontitis was well established at this time. the present study (Fig. 3). This may be explained by the
Moreover, none of the roots assigned a PAI score of 3
later than year 1 had been available for any other recall
100
since the time of rootfilling.It is possible, therefore, that
any tooth eventually healing will already have shown
radiographic signs of the process after 1 year. 80-
Reversal of the healing process was observed in only •f ; -
one case in the present study. Given the sizeable number 60-
of teeth studied, it would appear that secondary infection
of successfully treated, chronic apical periodontitis is not
40-
likely to confound assessment of treatment outcome,
certainly not on a group basis and unlikely also in
individual clinical eases. ;; • 20-
Cumulated curves for healed and healing cases were
constructed and compared with results from other
studies in which time of initiated and complete healing
were registered (Cvek 1972, Cvek et al. 1976). It was Time (years)
interesting to note that with near-identical treatment
Fig. 3. Cumulated curves for incompletely, but definitively healing
method, the half-year-results of Cvek (1972) coincided roots which initially were diagnosed with chronic apical periodontitis
exactly with the interpolated curve from the present (solid squares). Analogous data from Cvek (1972, solid diamonds) and
study (Fig. 2). The slope of this curve thus would appear Cvek el al.(1976, solid stars) are included for comparison

© 1996 Blackweii Science Ltd. Intemationai EmMontic joumal 2 9 . 1 5 0 - 1 5 5


unbiased nature of the PAI scoring system, which does
not permit assumptions of healing based on direct
comparison of radiographs in a series. The conventional
comparison of the preoperative with follow-up radio-
graphs may be more sensitive as indicated in Fig. 3, but
the inherent bias and the questionable reproducibility of
this type of evaluation (Reit & Hollender 1983) represent
a significant drawback in comparative studies. Improved
methods for quantitative analyses of radiographs are
needed for better discrimination of healing chronic
apical periodontitis.
Conclusions i ,
Roots without preoperative CAP showed development of
the disease in some 6% of cases. Most cases (76%) were
detectable at 1 year, and the risk of disease development
at 2 years or later was not greater than the general risk
based on epidemiological studies. Roots with preopera-
tive CAP showed healing in 88% of cases. Most cases
(88%) were detectable at 1 year. The rates of developing
or healing CAP were the same at 1 year as the accumu-
lated rates. At-risk analyses of initially healthy roots
indicated no added risk of these roots developing CAP
after the first year following treatment. Factors other
than the root canal treatment itself may contribute to
CAP developing later than 1 year after treatment.
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