1093936

research-article2022
JDRXXX10.1177/00220345221093936Journal of Dental Research X(X)Root Canal Treatment Survival Analysis in National Dental PBRN Practices

Research Reports: Clinical

Journal of Dental Research
1­–7
Root Canal Treatment Survival Analysis © International Association for Dental
Research and American Association for Dental,

in National Dental PBRN Practices Oral, and Craniofacial Research 2022

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https://doi.org/10.1177/00220345221093936
DOI: 10.1177/00220345221093936
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T. Thyvalikakath1,2 , M. LaPradd3,4, Z. Siddiqui5,6, W.D. Duncan7,8,

G. Eckert4 , J.K. Medam6,9, D.B. Rindal10, M. Jurkovich10, G.H. Gilbert11,
and National Dental PBRN Collaborative Group12

Abstract
Few studies have examined the longevity of endodontically treated teeth in nonacademic clinical settings where most of the population
receives its care. This study aimed to quantify the longevity of teeth treated endodontically in general dentistry practices and test the
hypothesis that longevity significantly differed by the patient’s age, gender, dental insurance, geographic region, and placement of a
crown and/or other restoration soon after root canal treatment (RCT). This retrospective study used deidentified data of patients who
underwent RCT of permanent teeth through October 2015 in 99 general dentistry practices in the National Dental Practice-Based
Research Network (Network). The data set included 46,702 patients and 71,283 RCT permanent teeth. The Kaplan–Meier (product
limit) estimator was performed to estimate survival rate after the first RCT performed on a specific tooth. The Cox proportional
hazards model was done to account for patient- and tooth-specific covariates. The overall median survival time was 11.1 y; 26% of RCT
teeth survived beyond 20 y. Tooth type, presence of dental insurance any time during dental care, placement of crown and/or receiving a
filling soon after RCT, and Network region were significant predictors of survival time (P < 0.0001). Gender and age were not statistically
significant predictors in univariable analysis, but in multivariable analyses, gender was significant after accounting for other variables. This
study of Network practices geographically distributed across the United States observed shorter longevity of endodontically treated
permanent teeth than in previous community-based studies. Also, having a crown placed following an RCT was associated with 5.3 y
longer median survival time. Teeth that received a filling soon after the RCT before the crown was placed had a median survival time of
20.1 y compared to RCT teeth with only a crown (11.4 y), only a filling (11.2 y), or no filling and no crown (6.5 y).

Keywords: retrospective studies, big data, dental informatics, data science, electronic health records, electronic dental record

Introduction
1
Dental Informatics, Department of Cariology, Operative Dentistry &
Root canal treatment (RCT) continues to be an important Dental Public Health, Indiana University School of Dentistry, Indianapolis,
treatment to maintain natural teeth affected by pulpal or peri- IN, USA
apical diseases. Conserving the natural dentition and sup- 2
Center for Biomedical Informatics, Regenstrief Institute, Inc.,
porting essential oral functions throughout old age is a major Indianapolis, IN, USA
3
goal of dental care with the increased life span of the popula- Current affiliation: Syneos Health, Morrisville, NC, USA
4
tion (Johnstone and Parashos 2015). Therefore, the need for Department of Biostatistics and Health Data Science, Indiana University
School of Medicine, Indianapolis, IN, USA
long-term studies of endodontically treated teeth is essential 5
Current affiliation: West Virginia University School of Pharmacy,
(Pirani et al. 2015; Prati et al. 2018), especially in common, Morgantown, WV, USA
nonacademic clinical settings where most of the population 6
Dental Informatics, Department of Cariology, Operative Dentistry &
receives its care. The establishment of practice-based Dental Public Health, Indiana University School of Dentistry, IUPUI,
research networks has enabled the study of treatment out- Indianapolis, IN, USA
7
comes by accessing practices’ electronic dental treatment Current affiliation: University of Florida College of Dentistry,
documentation. Gainesville, FL, USA
8
Affiliation during study: Biomedical Data Science and Shared Resource,
Existing studies reported high success rates of endodonti-
Roswell Park Cancer Center, Buffalo, NY, USA
cally treated teeth performed in academic and large health care 9
Current affiliation: ELLKAY, Elmwood Park, NJ, USA
settings and among insured populations (Ng et al. 2008; 10
HealthPartners Institute, Minneapolis, Bloomington, MN, USA
Paredes-Vieyra and Enriquez 2012; Jordal et al. 2014; 11
National Dental Practice-Based Research Network, Department of
Petersson et al. 2016; Chatzopoulos et al. 2018; Pirani et al. Clinical and Community Sciences, School of Dentistry, University of
2018). However, substantial variations exist in the definitions Alabama at Birmingham, Birmingham, AL, USA
12
University of Alabama at Birmingham, Birmingham, AL, USA
of treatment success in these studies. These definitions included
radiographic evidence of periapical tissue healing following A supplemental appendix to this article is available online.
treatment, reduction in the periapical radiolucency, and tooth
Corresponding Author:
survival (Pirani et al. 2015; Gomes et al. 2017; Chatzopoulos T. Thyvalikakath, Dental Informatics, Indiana University School of Dentistry,
et al. 2018). For example, the mean success rates ranged from IUPUI, 415 Lansing Street, OH144A, Indianapolis, IN 46202, USA.
31% to 96% (Ng et al. 2007) when RCT success was defined Email: tpt@iu.edu
2 Journal of Dental Research 00(0)
as the absence of apical periodontitis clinically and radiograph-
ically. The mean success rates were 60% to 100% when suc-
cess was based on defining success as a reduction in the
periapical lesion size (Ng et al. 2007).
With the emergence of the single-tooth implant restoration
as an alternative to RCT, tooth survival has become an impor-
tant outcome by which to compare RCT success to single-tooth
implant success (Chatzopoulos et al. 2018). Tooth survival is
especially salient as an outcome given that RCT teeth can be
lost for reasons other than just the RCT, such as caries, peri-
odontal disease, tooth fractures, and prosthodontic failures that
develop after RCT. Moreover, tooth survival rates can assist
clinicians with assessing tooth-specific prognosis, treatment
planning activities, and communicating these topics in lay lan-
guage with patients. A meta-analysis of 31 studies revealed the
pooled probability of tooth survival 8 to 10 y after RCT ranged
from 86% to 93% (Ng et al. 2010). Subsequently, large studies
using private or public claims data have reported 84% to 97%
survival after 3 to 8 y of follow-up (Salehrabi and Rotstein
2004; Fransson et al. 2016).
While claims data provide important insights (Salehrabi
and Rotstein 2004; Fransson et al. 2016), they have shortcom-
ings (Hyman 2015). A key limitation is that their analysis only
allows study of populations who have dental insurance. Other
drawbacks typically include absence of diagnosis and an
inability to evaluate the quality of the data due to limited infor-
mation reported in claims data (Hyman 2015; Kebke et al.
2021). Furthermore, most RCT outcome studies have been per-
formed in academic and specialty practice settings, which lim-
its their generalizability to community-based general dentistry
settings (Lee et al. 2012; Pirani et al. 2015; Chatzopoulos et al.
2018). Using electronic dental record (EDR) data gathered in
community dental practices offers an opportunity to improve
the generalizability of studies regarding the longevity of RCT
teeth (Gilbert et al. 2010; Bernstein et al. 2012).
The National Dental Practice-Based Network (Network)
offers a unique opportunity to use EDR data to obtain a national
scope of long-term treatment outcomes (Gilbert et al. 2013).
An assessment of the Network practices’ data (Thyvalikakath
et al. 2020) demonstrated their feasibility to study the longev-
ity of endodontically treated permanent teeth performed in
these settings. The objective of this study was to 1) quantify the
longevity of teeth treated endodontically in general dentistry
practices and 2) test the hypothesis that longevity significantly
differed by the patient’s age, gender, dental insurance status,
placement of crown and/or other restoration soon after RCT,
and geographic region. This study takes advantage of general
dental practice data from 2 different EDR systems (Dentrix and
EagleSoft), the procedures for which are described in detail in
a published article (Thyvalikakath et al. 2020).
Methods
We recruited 99 Network practices that consisted of small
group and solo general dentistry practices who had used
Dentrix (Henry Schein One) or EagleSoft (Patterson Dental)
for at least 5 y to maintain electronic clinical documentation of
at least existing conditions and treatment performed. In addi-
tion, these practices performed at least 1 RCT on a permanent
tooth in at least 50 patients, had follow-up data for at least 2 y,
and continued performing these procedures between January 1,
2000, and October 31, 2015. As described in a previous article
(Thyvalikakath et al. 2020), we received deidentified data of
patients who underwent RCT of permanent teeth through
October 2015 from these practices. This data set included
46,702 patients and 71,283 RCT permanent teeth, identified
using procedure codes (D3310, D3320, D3330). The data
required to perform survival analysis, such as the tooth type
and dates of treatment, were present for all patients.
Descriptive statistics were performed to report patient
demographics, number of patient records included from the 6
Network regions, and the number of RCT teeth by tooth type.
For 85% of the individuals who had at least some post-RCT
follow-up data, the Kaplan–Meier (product limit) estimator
was performed to estimate the survival rate after the first RCT
performed on a specific tooth. This method considered the
right-censored data, which occurred if the patient did not
receive a second RCT on the tooth. We also analyzed the data
set with Cox proportional hazards models that account for mul-
tiple explanatory covariates: age, gender, tooth type (anterior,
bicuspid, molar), presence of dental insurance, receipt of a
crown and/or other restoration on the RCT-treated tooth soon
after RCT, and Network region. No model selection was per-
formed; variables included in the model were patient and tooth
factors previously reported as possibly affecting RCT longev-
ity and readily available within the EDR. Some individuals had
more than 1 RCT performed on different teeth; to account for
this correlation within the same patient, we considered the
marginal Cox model for clustered data. The Tukey method was
used to adjust for multiple comparisons. The data allowed us to
account for a procedure on the same tooth, which might indi-
cate that the subsequent procedure was a failure. These failure
types included procedure codes (D3300s) for any endodontic
treatment (including retreatment) after the first RCT code, api-
coectomy (D3400s), root amputation (D3450), root extraction
(D7250), simple (D7100s) and surgical (D7200s) tooth extrac-
tion, fixed prosthodontic pontics (D6200), dental implant body
(D6010), and removable dentures that included the RCT tooth
(D5000). In addition, specific conditions listed following the
first RCT code—namely, missing tooth or crown, root tips, and
retained root tips—were included as failure types. The follow-
ing procedure codes that indicated restorations were included
as covariates: amalgam restorations (D2100), resin restorations
(D2300), inlays and onlays (D2500 and D2600), and core
buildup with pin retention and cast post and core and prefabri-
cated post in addition to crown (D2900). We analyzed the data
using the software SAS, version 9.4 (SAS Institute). The meth-
ods described are in compliance with the Strengthening the
Reporting of Observational Studies in Epidemiology (STROBE)
checklist for cohort studies.
Root Canal Treatment Survival Analysis in National Dental PBRN Practices 3

Table 1.  Demographics of Patients Who Received a Root Canal Table 2.  Number of Root Canal Treated Permanent Teeth in the
Treatment (RCT) of Permanent Teeth in the 99 Network Practices 99 General Dental Network Practices, by Tooth Type and Location
through October 2015, by Age Group and Gender. (Maxillary and Mandibular Arches).

Age Group, y Female, n (%) Male, n (%) Total, N (%) Tooth Type Maxillary, n (%) Mandibular, n (%) Total, N (%)

Less than 18 1,360 (52) 1,280 (48) 2,640 (6) Anterior 10,721 (76) 3,419 (24) 14,140 (20)
18–44 11,989 (58) 8,729 (42) 20,718 (44) Premolar 14,077 (59) 9,630 (41) 23,707 (33)
45–64 9,834 (54) 8,267 (46) 18,101 (39) Molar 14,318 (43) 19,093 (57) 33,411 (47)
65 or older 2,636 (50) 2,605 (50) 5,241 (11) Total 39,116 (55) 32,142 (45) 71,258 (100)
Total 25,819 (55) 20,881 (45) 46,700 (100)

Results
Tables 1 to 3 display the numbers of patients, tooth types, and
follow-up periods included in the analyses. Appendix Table 1
displays the number of Network practices and number of teeth
with the RCT procedure across the 6 regions.
The overall median survival time was 11.1 y (10.7–11.5),
with 26.1% of root canals estimated to survive beyond 20 y
(Table 4 and Appendix Fig. 1a–h). Tooth type, presence of den-
tal insurance, placement of crown after the RCT, having a fill-
ing soon after the RCT but prior to a crown, and Network
region were all found to be significant predictors of survival
time (P < 0.0001). Gender and age were not statistically sig-
nificant predictors in the univariable analysis.
More specifically, RCT premolars were found to have a
median survival time of 10.3 y while anterior teeth had a
median time of 12.4 y. Patients having dental insurance at
some time during a patient’s EDR treatment history showed
median survival times of RCTs of almost 2 y longer than those
with no history of dental insurance. Having a crown placed
after an RCT was associated with a 5.3-y longer median sur-
vival time, and having a filling placed after the RCT but before
the crown showed a median survival time of 20.1 y compared
to 11.4 y when only a crown was placed, 11.2 y when only a
filling was placed, and 6.5 y when neither a filling nor crown
was placed after the RCT. The Northeast region of the United
States had a significantly longer median survival time (20.5 y)
compared to the Midwest (11.2 y), Southwest (11.2 y), South
Atlantic (9.1 y), South Central (9.0 y), and West (8.7 y) regions
(Table 4 and Appendix Fig. 1a–h).
Multivariable analyses showed similar results (Table 5);
however, gender was found to be significant when accounting
for the other variables. Having RCT on an anterior tooth versus
a premolar tooth or an anterior versus a molar showed similar
hazard ratios. This indicates that a premolar or molar RCT is
1.64 (1.0 ÷ 0.61) times more likely to fail at any given time
when compared with an anterior RCT. No difference was
found between premolar and molar teeth (P = 0.9831). RCTs in
male patients were found to be 1.1 times more likely to fail
than female patients at any given time point (P = 0.006). Not
having dental insurance indicates that a patient’s RCT is 1.2
(1.0 ÷ 0.83) times more likely to fail than those with dental
insurance (P < 0.0001). No significant differences were found
between the following regions by comparison: West versus
Midwest (P = 0.9995), West versus Southwest (P = 0.9989),
Midwest versus Southwest (P = 0.9475), and South Central
Table 3.  Electronic Dental Record Data Duration between First Root
Canal Treatment and Last Visit and the Number of Patient Records and
Teeth Present during Each Time Duration.
Number (%) of Patients Number (%) of Teeth
Time, y (n = 46,700) (n = 71,258)
0 y (1 visit) 3,627 (7.8) 4,348 (6.1)
Up to 5 y 2,858 (61.2) 40,694 (57.11)
>5 and ≤10 y 8,893 (19.0) 15,211 (21.4)
>10 and ≤15 y 4,319 (9.3) 8,242 (11.6)
>15 and ≤20 y 1,134 (2.4) 2,446 (3.4)
>20 y 142 (0.3) 317 (0.4)
While 15% of the patients did not report any follow-up after their first
visit, 35% had an observation time up to 5 y, 40% from 6 to 15 y, and
11% more than 15 y.
versus South Atlantic (P = 0.9915). The largest difference was
found between South Atlantic versus Northeast; a patient’s
RCT in the South Atlantic region was 2.0 times more likely to
fail than in the Northeast (P < 0.0001). Finally, an RCT with no
final restoration versus 1 with a filling placed and later a crown
was found to be 2.94 (1.0 ÷ 0.34) times more likely to fail at
any given time point (P < 0.0001). Harrell’s concordance sta-
tistic estimate is 0.71.
Discussion
This study observed substantial tooth-specific longevity fol-
lowing RCT from general dentistry practices. It also demon-
strated a strong association between this longevity and
restoration of the tooth following RCT, as well as a gradient in
longevity based on whether the tooth received a filling plus
crown, a crown only, a filling only, or no restoration. The high-
est longevity was observed among RCT teeth that had a filling
placed after the RCT but before a subsequent prosthetic crown
was placed on the tooth.
These results suggest a lower survival time (median time of
11.1 y) of RCT teeth than previously reported in most studies.
There are several reasons that might account for lower survival
times observed in this study. These could include 1) larger het-
erogeneity of the participating practices and patient population
in this study that had a national scope; 2) greater diversity due
to its inclusion of both dentally insured and uninsured patient
populations; 3) its inclusion of more dental codes than other
studies that identify that the tooth was removed (fixed prosth-
odontic pontic, removable partial denture, implant body, tooth
hemisection); 4) fewer crown placements among the patients
4 Journal of Dental Research 00(0)

Table 4.  Kaplan–Meier Statistics Estimating the Survival Time of 71,258 Root Canal Treated Permanent Teeth in 46,700 Patients from 99 General
Dentistry Network Practices.

Estimated Survival Percentage

Variable Level Median (95% CI), y P Value 5 y 10 y 20 y

Overall 11.1 (10.7–11.5) 75.4 (74.5–76.3) 53.7 (52.2–55.2) 26.1 (22.6–29.6)

Age, y 18–44 10.5 (9.5–11.2) 72.7 (70.7–74.7) 52.1 (48.3–55.8) NA
45–64 10.8 (10.4–11.6) 75.6 (74.3–76.9) 53.1 (51.0–55.2) 23.3 (18.6–28.0)
65 or Older 10.7 (10.0–11.8) 74.8 (73.1–76.4) 52.4 (49.8–55.0) 30.2 (25.1–35.2)
Less than 18a 10.8 (NA) 0.0621 63.6 (54.3–72.8) 60.0 (49.0–71.1) NA
Gender Male 10.6 (9.9–11.2) 74.4 (73.1–75.7) 52.0 (49.8–54.1) 21.9 (16.4–27.4)
Female 11.6 (11.0–12.1) 0.059 76.2 (75.1–77.4) 55.1 (53.2–57.1) 29.7 (25.2–34.2)
RCT tooth type Anterior 12.4 (11.5–13.3) 79.4 (77.7–81.1) 57.7 (54.7–60.6) 27.5 (20.4–34.6)
Premolar 10.3 (9.7–11.0) 73.6 (71.9–75.2) 51.0 (48.4–53.7) 27.7 (22.4–32.9)
Molar 11.0 (10.5–11.7) <0.0001 74.6 (73.3–75.0) 53.4 (51.3–55.6) 24.4 (18.8–29.9)
Dental insurance Yes 10.6 (9.9–11.1) 74.6 (73.1–75.9) 51.8 (49.4–54.2) 15.4 (8.8–22.0)
No 8.7 (8.0–9.1) <0.0001 67.9 (65.9–70.0) 42.9 (40.0–45.9) NA
Crown placed Yes 13.7 (13.0–14.5) 85.7 (84.7–86.7) 65.4 (63.3–67.5) 35.0 (29.1–40.9)
  following RCT No 8.4 (8.0–8.8) <0.0001 65.6 (64.3–66.9) 43.9 (41.2–45.0) 18.5 (14.6–22.4)
Filling before crown Yes 20.1 (15.5–24.7) 92.3 (90.3–94.3) 77.0 (72.2–81.7) 51.0 (36.3–65.8)
Crown only 11.4 (10.9–12.0) 77.2 (76.2–78.3) 55.5 (53.7–57.3) 26.8 (22.5–31.2)
Filling only 11.2 (9.2–13.5) 75.1 (73.5–78.7) 52.6 (48.5–56.8) 27.3 (17.4–37.2)
No filling and no crown 6.5 (5.8–7.1) <0.0001 55.9 (53.3–58.6) 33.8 (30.3–37.4) 8.3 (1.7–14.9)
Network region West 8.7 (7.7–9.9) 70.9 (67.9–73.9) 43.0 (37.7–48.4) NA
Midwest 11.2 (10.2–12.0) 76.8 (74.8–78.9) 54.1 (50.5–57.8) 18.1 (8.9–27.3)
Southwest 11.2 (10.1–12.4) 75.9 (73.8–77.9) 54.1 (50.6–57.5) NA
South Central 9.0 (8.3–9.7) 69.7 (67.7–71.8) 45.5 (42.2–48.8) NA
South Atlantic 9.1 (8.7–9.9) 70.1 (67.9–72.3) 45.8 (42.3–49.3) 19.2 (13.0–25.4)
Northeast 20.5 (18.6–22.4) <0.0001 89.8 (88.3–91.3) 76.1 (73.2–79.0) 55.4 (48.4–62.4)

CI, confidence interval; NA, not available for this subgroup; RCT, root canal treatment.

who received RCT, owing to its inclusion of dentally uninsured
patients; 5) differences in dental insurance coverage and proce-
dures covered across the 6 network regions; 6) RCTs were
done by general dentists rather than endodontic specialists in
this study; and 7) regional differences in patients’ health liter-
acy, follow-up care, and preventive behaviors.
Previous studies conducted in academic or specialist pri-
vate practice settings and using dental insurance claims data
reported higher survival rates. For example, large dental insur-
ance claims data studies of RCT have reported 98% tooth sur-
vival at 1 y, 92% at 5 y, and 86% at 10 y (Burry et al. 2016);
97% tooth survival after 8 y (Salehrabi and Rotstein 2004);
94% after a mean follow-up time of 3.5 y (Lazarski et al.
2001); 84% at 3 y (Raedel et al. 2015); and 93% after 5 y
(Chen et al. 2007). Studies conducted in community practice
settings with incomplete dental insurance coverage have
largely reported lower survival times than their counterparts
(Tilashalski et al. 2004; Gilbert et al. 2010; Ng et al. 2010;
Bernstein et al. 2012; Kebke et al. 2021), which is confirmed
in this larger national study of RCT performed in community
practices.
The current study was limited to general dentistry practices.
Some previous studies observed longer survival times when
RCT was done by endodontic specialists rather than general
dentists (Alley et al. 2004; Burry et al. 2016), although others
have not while acknowledging a more complex case mix for
endodontists (Lazarski et al. 2001). A retrospective study from
1 general dentistry practice in Germany observed that 6% of
795 RCT teeth were extracted during a mean observation
period of 4.5 y, although an eligibility criterion was that all
teeth received a restoration within 6 months of the RCT
(Skupien et al. 2013). Given that general dentists tend to refer
teeth for which they anticipate more challenging treatment,
survival times may be expected to be longer on average for
RCT teeth treated by general dentists as compared to endodon-
tists. Nevertheless, survival times are also dependent on mul-
tiple factors as described above.
It is also noteworthy that this study demonstrated that
meaningful insights can be gained through the analysis of
existing dental practice data from routine electronic dental
records. Our use of dental practice data differs from other den-
tal outcome studies in at least 2 important ways. First, because
participating practices were geographically distributed across
the United States, we were able to study a larger, more diverse
set of patients. To the best of our knowledge, this study is the
first to determine the survival rates of endodontically treated
teeth with a large patient cohort of US community-based prac-
tices not limited to patients with dental insurance.
Our use of practice data gave us the means to compare out-
comes between insured and noninsured patients. Anecdotal
reports indicate significant geographic differences in dental
insurance coverage. For instance, Medicaid in Indiana does not
Root Canal Treatment Survival Analysis in National Dental PBRN Practices 5

Table 5.  Multivariable Cox Model for Root Canal Treated Teeth by Crown, Dental Insurance, Tooth Type, Gender, Filling before Crown, and
Network Region.

Covariate Omnibus P Value Level Hazard Ratio (95% CI) Adjusted P Value

Tooth type <0.0001 Anterior vs. premolar 0.61 (0.54–0.69) <0.0001

Anterior vs. molar 0.61 (0.55–0.69) <0.0001
Premolar vs. molar 1.01 (0.92–1.10) 0.9831
Gender 0.0066 Female vs. male 0.90 (0.83–0.97) 0.0066
Dental insurance <0.0001 Yes vs. no 0.83 (0.77–0.90) <0.0001
Network region <0.0001 West vs. Midwest 0.98 (0.83–1.14) 0.9995
West vs. Southwest 1.03 (0.89–1.19) 0.9989
West vs. South Central 0.79 (0.68–0.91) 0.0190
West vs. South Atlantic 0.76 (0.64–0.90) 0.0140
West vs. Northeast 1.52 (1.23–1.89) 0.0016
Midwest vs. Southwest 1.06 (0.94–1.19) 0.9475
Midwest vs. South Central 0.81 (0.72–0.91) 0.0049
Midwest vs. South Atlantic 0.78 (0.68–0.90) 0.0076
Midwest vs. Northeast 1.56 (1.29–1.90) <0.0001
Southwest vs. South Central 0.77 (0.69–0.54) <0.0001
Southwest vs. South Atlantic 0.74 (0.65–0.84) <0.0001
Southwest vs. Northeast 1.48 (1.23–1.79) 0.0006
South Central vs. South Atlantic 0.96 (0.84–1.10) 0.9915
South Central vs. Northeast 1.93 (1.60–2.32) <0.0001
South Atlantic vs. Northeast 2.00 (1.64–2.46) <0.0001
Crown <0.0001 Yes vs. no 0.45 (0.41–0.50) <0.0001
Filling <0.0001 Filling before crown vs. crown only 0.67 (0.54–0.85) 0.0039
Filling before crown vs. filling only 0.92 (0.70–1.20) 0.9171
Filling before crown vs. no final restoration 0.34 (0.29–0.48) <0.0001
Crown only vs. filling only 1.36 (1.19–1.56) <0.0001

reimburse for crown placement, and although small companies
may provide dental insurance to their employees in the
Northeast United States, dental insurance may not be available
for employees working in small companies in other Network
regions, such as the South Atlantic, South Central, and Midwest
regions. Thus, to improve health outcomes for all patients, it
may be important to include both insured and noninsured
patients. It is also possible that there are regional differences in
case selection, such as the clinician’s decision to proceed with
RCT on teeth that may be technically difficult or involved peri-
odontally. A key finding from this study is the gradient in lon-
gevity based on whether the tooth received a filling plus crown,
a crown only, a filling only, or no restoration. Comparable
findings have been observed in insured populations (Chen
et al. 2007) and a dental school clinic (Pratt et al. 2016).
Our study found longer survival times for RCTs performed
on anterior teeth as compared to both premolars and molars
(Table 5) but no significant difference between molars and pre-
molars. Similar results have been observed in other studies in
the literature (Lazarski et al. 2001), although 1 study observed
higher longevity in multirooted teeth (Raedel et al. 2015), a
systematic review reported mixed results (Ng et al. 2010), and
a large study from Taiwan observed higher survival rates in
anterior and premolar teeth as compared to molars (Chen et al.
2007).
The results also characterized differences in the survival
time by age, gender, tooth type, placement of a crown follow-
ing RCT, the patient’s dental insurance status, and Network
region. All differences except by age were statistically signifi-
cant. In the sections below, we highlight the clinical signifi-
cance of these results, study strengths, limitations, and future
work.
Females had significantly longer survival times for their
RCTs, once other covariates had been considered. An insur-
ance claims study observed no difference by gender (Lazarski
et al. 2001), as did a study of dental school patients (Chatzopoulos
et al. 2018) and a systematic review (Ng et al. 2010). The cur-
rent study considered receipt of restorative care and dental
insurance in the multivariable model, so we speculate that the
gender difference could be due to higher adherence to treat-
ment recommendations (e.g., follow-up care or dental hygiene)
than males (Manteuffel et al. 2014; Siddiqui et al. 2021), but
these data could not address this issue.
This study did have significant limitations. For example, we
could not evaluate the association between longevity and cer-
tain practice and practitioner characteristics. Nor were prac-
tices calibrated or standardized in providing RCT or diagnostic
methods used. Therefore, the possibility of unmeasured con-
founding variables exists. In addition, a substantial number of
patients (27%) were missing insurance status (Thyvalikakath
et al. 2020), and there was no information on patients’ race and
ethnicity. We also could not include ratings about the quality of
RCT such as obturation, root fill, placement of cast or prefab-
ricated post, and radiologic evidence of periapical tissue heal-
ing. Nor did we have information on periodontal and periapical
status at the time of RCT and whether the RCT teeth were
6 Journal of Dental Research 00(0)
taken out of occlusion as a sign of failed/failing RCT. We also
could not obtain the reason(s) for the RCT, such as diagnosis,
which is usually written in the clinical notes and not available
as structured data. Last, although we determined the dental
insurance status for a significant number of patients, we could
not specifically determine the insurance reimbursement for
RCT procedures or subsequent restorative procedures done on
the RCT tooth.
Despite these limitations, our study provides a sound basis
for conducting further investigations. Importantly, more
research is needed regarding the factors that improve the prog-
nosis following RCT. Such research studies should enable den-
tal practitioners and patients to make better-informed decisions
among dental treatment options, such as having a crown placed
on the endodontically treated tooth versus only having a filling.
We were also intrigued by the higher survival rates in the
Northeast region compared to the other Network regions. We
hypothesize that this is due to better dental insurance coverage
and health literacy in the Northeast, but more investigation is
needed. Future work should also include studying the practice-
level variations in the survival analysis and studying the role of
chronic medical conditions such as diabetes on the RCT sur-
vival time.
In addition to answering salient clinical questions, this
study demonstrated that new clinical information already cap-
tured during the routine care process can be used to answer
practical clinical questions to improve the quality of care. In
the business arena, information that can be used to improve
operations is highly valued and used whenever possible. The
dental profession can operate in a similar manner, using the
information to incorporate research and continuous quality
improvement as essential components of everyday clinical
practice (Gilbert et al. 2021).
Author Contributions
T. Thyvalikakath, contributed to conception, design, data acquisi-
tion, drafted and critically revised the manuscript; M. LaPradd,
W.D. Duncan, contributed to design, data acquisition, analysis,
and interpretation, drafted and critically revised the manuscript; Z.
Siddiqui, contributed to design, data acquisition, analysis, and
interpretation, drafted the manuscript; G. Eckert, contributed to
conception, design, data acquisition, analysis, and interpretation,
critically revised the manuscript; J.K. Medam, contributed to
acquisition and data analysis, critically revised the manuscript;
D.B. Rindal, contributed to conception, design, data acquisition
and interpretation, critically revised the manuscript; M. Jurkovich,
contributed to design, data analysis and interpretation, critically
revised the manuscript; G.H. Gilbert, contributed to conception,
design, data acquisition, analysis, and interpretation, drafted and
critically revised the manuscript; National Dental PBRN
Collaborative group, contributed to design, data acquisition, criti-
cally revised the manuscript. All authors gave final approval and
agree to be accountable for all aspects of the work.
Acknowledgments
We gratefully acknowledge the practitioner participants who
shared their data to conduct this study, without which this study
would not have been possible. We also gratefully acknowledge the
assistance of Neil Butler and Chris Wadsworth from Henry Schein
and Ted Fruchtl and Jessica Knaus from Patterson Dental with
extracting data from the network practices and the support of these
2 companies’ leadership for the study. We thank Dr. Anushri
Rajapuri Singh for formatting the manuscript, and the Regenstrief
Institute’s staff for their assistance with the project.
We are grateful to the network’s regional node coordinators,
who function as the “face” of the network in recruiting, training,
and interacting with the network’s practitioners (Midwest region:
Tracy Shea, RDH, BSDH; West region: Stephanie Hodge, MA;
Northeast region: Christine O’Brien, RDH; South Atlantic region:
Hanna Knopf, BA, and Deborah McEdward, RDH, BS, CCRP;
South Central region: Shermetria Massengale, MPH, CHES, and
Ellen Sowell, BA; Southwest region: Stephanie Reyes, BA,
Meredith Buchberg, MPH, and Colleen Dolan, MPH), as well as
the network’s program manager (Andrea Mathews, BS, RDH) and
program coordinator (Terri Jones).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
work was supported by National Institutes of Health grants
U19-DE-28717 and U19-DE-22516. Opinions and assertions con-
tained herein are those of the authors and are not to be construed
as necessarily representing the views of the respective organiza-
tions or the National Institutes of Health. This study was deter-
mined not to be human subjects research by the Indiana University
Institutional Review Board (IRB). Approvals or exemptions were
also obtained separately from the 6 network regions’ IRBs. The
manuscript coauthors reported having no conflicts of interest. An
Internet site devoted to details about the nation’s network is
located at http://NationalDentalPBRN.org.
ORCID iDs
T. Thyvalikakath https://orcid.org/0000-0002-7294-2318
G. Eckert https://orcid.org/0000-0001-7798-7155
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