Success & failure in Endodontics

Success: Is the absence of any peri-radicular tissue changes.

Failure: Is the persistence or development of periapical pathosis.
Criteria of successful endodontics:
1. Absence of pain
2. Absence of sinus tract
3. Absence of periapical lesion
4. Absence of swelling
5. No loss of function
6. No mobility

Factors affecting success or failure of endodontic therapy in

every case:
1. Diagnosis and the treatment planning.
2. Radiographic interpretation.
3. Anatomy of the tooth and root canal system.
4. Debridement of the root canal space.
5. Asepsis of treatment regimen.
6. Quality and extent of apical seal.
7. Quality of post endodontic restoration.
8. Systemic health of the patient.
9. Skill of the operator.

Methods of evaluation:
1. Clinical examination:
Signs and/or symptoms, if marked and persistent, are probably indications
of disease and of failure. Importantly, absence of pain or other symptoms does
not confirm success. This is because periradicular pathosis without significant
symptoms is usually present in teeth before as well as after root canal
treatment.

There is little correlation between the presence of pathosis and

corresponding symptoms; yet when signs and/or symptoms are evident there
is a strong likelihood that there is a pathosis. Persistence of adverse significant
signs (e.g., swelling or sinus tract) or symptoms (e.g., spontaneous pain, dull
persistent ache, or mastication sensitivity) indicates failure.

2. Radiographic examination:

Success is the absence of an apical radiolucent lesion. This means that a

resorptive lesion present at the time of treatment has resolved or if there was
no lesion present at the time of treatment, none has developed. Thus, success
is evident by the elimination or nondevelopment of an area of rarefaction for a
minimum of 1 year after treatment.

Failure is the persistence or development of radiographically evident

pathosis. Specifically, this is a radiolucent lesion that has remained the same,
has enlarged, or has developed since treatment.

Causes of Endodontic Failures

1. PREOPERATIVE CAUSES

Failure of root canal treatment is often traced to misdiagnosis, errors in

treatment planning, poor case selection (dentists attempting treatment beyond
their skill levels), or treatment of a tooth with a poor prognosis.

before any invasive dental procedure, including root canal treatment, the
dentist should make a "tentative" pulpal and periradicular diagnosis. That
diagnosis is based on all available information: history of signs and symptoms,
current signs and symptoms, radiographic evaluation, and vitality tests.
Without evaluating all these factors and forming a diagnosis, there is a risk of
inappropriate treatment and/or the wrong tooth being treated. Obviously, the
problem would not be resolved.

2. OPERATIVE CAUSES

For predictable success, several steps need to be followed. These include

chemomechanical cleaning and shaping of the canal space followed by a dense
obturation that is confined to the root canal system and then by a quality
coronal restoration.
Mechanical Objectives
An overlooked but important part of successful root canal treatment is
a straight-line access preparation that will facilitate debridement and
obturation. The access is even more important, with the use of rotary nickel-
titanium file systems.

If the access is underextended, several mishaps may occur that ultimately

will lead to failure.

A canal may be missed; the treatment is likely to fail although the located
canals were appropriately treated.

If the pulp horns are not opened in anterior teeth, debris and sealer may
remain in the coronal pulp space. Such remnants often result in discoloration
and therefore treatment failure.

Overextended access cavities, prepared at the expense of dentin, are also

a problem. Excessive loss of dentin weakens the tooth, possibly allowing
fractures, and increases the risk of perforation.

A common error of instrumentation is failure to maintain canal curvature

because files cut to the outside of the curve ("transportation" of the canal
and/or apex). This alters canal morphology and leaves potentially infected
debris in the canal system.

Marked deviation or overzealous flaring or overpreparation in the

"danger" zone or in the apical '/3 may result in perforation (strip perforation).

Confining operative procedures and materials to the canal space

enhances repair."' Overinstrumentation causes some tissue damage,
periradicular hemorrhage, and transitory inflammation. Continuous
overinstrumentation provokes a persistent inflammatory response capable of
resorbing dental and osseous tissues." Overinstrumentation may also transfer
microorganisms from the canal into the periapex, possibly compromising the
outcome.

Likewise, overextended obturation may lead to treatment failure. In many

cases it is probably not the material that causes the periradicular lesion; gutta-
percha is relatively inert. Rather, the combination of an inadequate seal
probably preceded by overinstrumentation causes the failure. The gutta-percha
cone slips through the apex because there was inadequate taper or shelf,
resulting in inadequate matrix to confine and condense and seal with the gutta-
percha.

In addition, sealers are irritating or toxic to the periradicular tissue.Errors

in obturation result from poor canal shaping or selecting an inappropriate
obturating technique. A poorly condensed obturation (either underfilled or
containing voids) is related to apical and/or coronal percolation. Either
underobturation or overfilling is likely to result in failure, particularly in the
presence of pulp necrosis and an apical lesion.

Biologic Objectives
Ideally, after preparation the root canal would be free of bacteria. With
a vital pulp this means prevention of contamination and with a necrotic pulp,
to achieve disinfection. However, as shown experimentally, complete
debridement of the canal is virtually impossible. Therefore, bacterial counts are
minimized by opious NaOCI irrigation.

The intracanal medicament, calcium hydroxide, will reduce the number of

bacteria, enhance the speed of healing, and reduce inflammation."" However,
there is uncertainty whether use of this medicament ultimately results in a
better prognosis.

POSTOPERATIVE FACTORS
Lack of a coronal seal is probably the most common, but best controllable,
problem. Coronal restoration protects and seals the tooth, preventing diffusion
of saliva and bacteria apically, which results in failed treatment.

There is a definite correlation between poorly restored crowns of

endodontically treated teeth and leakage of dye or bacteria or endotoxin
through the canals and a poorer prognosis. Restoration should occur soon after
obturation, using the same disinfection barriers as those used during the root
canal treatment, i.e., rubber dam isolation in a saliva-free environment.
 There should be no space between the coronal filling and the obturation
in the cervical area; there is a risk for bacterial contamination through exposed
cervical root dentin. Restorative errors also may compromise success. For
example, excessive dentin removal for posts weakens the root and increases
susceptibility to fracture.