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Original Article

Evaluation of Quality of Endodontic Re‑Treatment and Changes in

Periapical Status
Nausheen Aga1, Manoj Kumar Thakur2, Muhammad Atif Saleem Agwan3, Muna Eisa1, Amel Yousif Habshi1, Sarah Azeem4

1
Department of Endodontics, Background: The present study was conducted to assess quality of root

Abstract
University of Sharjah,
UAE, 2Department of
canal (RC) filling before and after RC re‑treatment. Materials and Methods: Two
Prosthodontics and Crown hundred and thirty‑eight radiographs of failed endodontic treatment were assessed.
and Bridge, Vananchal The periapical status of the endodontic treatment was evaluated with periapical
Dental College and Hospital index (PAI) scoring system. PAI <3 showed absence and PAI >3 showed presence
(VDCH), Garhwa, Jharkhand, of periapical lesion. Results: There was a statistically significant increase in
India, 3Department of scores 1 and 3 and decrease in scores 2, 4, 5, and 6 after treatment (P < 0.05).
Restorative Dentistry, College
of Dentistry in Alrass,
PAI score >3 was seen in 37% before which decreased to 16% after endodontic
Qassim University, KSA, retreatment. 34.6% obturation was homogenous and 65.4% was nonhomogenous
4
Huntly Dental Practice, before endodontic retreatment. After endodontic retreatment, 95.2% became
AB54 8DT, Aberdeenshire, homogenous and 4.8% nonhomogenous. The reason for endodontic failure was
Scotland, United Kingdom furcation in 2%, iatrogenic causes in 3%, loss of coronal seal in 16%, periapical
pathology in 25%, and inadequate root filling in 54%. Conclusion: There was
significant improvement and decrease in size of periapical lesions in re‑endodontic
Submitted: 08‑Dec‑2020 cases as compared to primary RC treated teeth.
Accepted: 09‑Dec‑2020
Published: 05-Jun-2021. Keywords: Apical periodontitis, re‑treatment, root canal therapy

Introduction Recently, newer radiographic diagnostic aid such as

A pical periodontitis (AP) may result from dental
caries, fracture tooth, traumatic occlusion, etc. The
main treatment for AP is root canal treatment (RCT).[1]
It is evident from numerous studies that the quality of
endodontic treatment performed in general practice
in less superior than those performed in specialized
dentistry.[2] Hence, the success rate of RCT is obviously
high. In spite of better treatment outcome, failure
rate cannot be completely avoided. The presence of
tenderness in RC treated tooth and radiological evidence
of periodontal ligament widening and loss of lamina
dura in indicative of failed RCT.[3]
There is a high prevalence of AP that ranged from
8%–72%. Numerous studies have done so far depicting
prevalence of AP using various intraoral radiographs
such as intraoral peri‑apical radiographs (IOPAR) and
panoramic radiographs. These radiographic aids helped
in assessing the periapical region as well as in detecting
quality of the RCT.[4,5]
cone‑beam computed tomography (CBCT) has emerged
with better image quality as compared to intraoral
radiographs such as IOPARs. AN accuracy of 0.54
with panoramic radiographs and 0.70 with peri‑apical
radiographs has been found. The only drawback of
CBCT is high radiation exposure as compared to single
intraoral peri‑apical radiograph.[6] The present study was
conducted to assess the quality of RC filling before and
after RC re‑treatment.
Materials and Methods
This retrospective study was initiated in the department
of endodontics which comprised of 238 radiographs
of failed endodontic treatment. Ethical committee of
the institute was approached for the approval and after
explaining the utility of the study approval was taken.
Address for correspondence: Dr. Nausheen Aga,
Department of Endodontics, University of Sharjah, Sharjah, UAE.
E‑mail: drnausheenaga@gmail.com

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How to cite this article: Aga N, Thakur MK, Saleem Agwan MA, Eisa M,
DOI: 10.4103/jpbs.JPBS_814_20 Habshi AY, Azeem S. Evaluation of quality of endodontic re-treatment
and changes in periapical status. J Pharm Bioall Sci 2021;13:S379-82.

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Aga, et al.: Endodontic re‑treatment

Radiographs which were of poor quality, nondiagnostic,
and with radiographic errors were not considered to be
involved in the study. Digital IOPARs were taken with
Schick sensor using Gnatus intraoral radiographic unit
operating at 72 kVp, 8mA tube current and exposure
time ranged from 0.30–0.50 sec. Rinn X tension C-one
P-arallelying (XCP) holder was used for holding sensor.
The periapical status of the endodontic treatment was
evaluated with periapical index (PAI) scoring system.
Scoring ranged from 1 to 5 was opted. The PAI sores
were based on absence and presence of periapical lesion
where score 0 was indicative of absence of pathology
and 1 suggested presence of pathology. PAI <3 showed
absence and PAI >3 showed presence of periapical lesion.
Baseline and follow‑up radiographs at 6 months were
compared. Density of the filling and the distance
between the end of the filling and the radiographic apex
indicated the quality of RC filling that scored from
1 to 6 based on scoring suggested in study by Unal
et al.[6] The absence of voids and the condensation of
the filling material in the RC indicated of homogenous
RC filling. A RCT with an acceptable filling length
and a homogenous root filling was defined as being an
adequate RCT. The results were clubbed together and
were compared statistically using the Mann–Whitney
U‑test where P < 0.05 was mentioned as significant.
Graph 3 shows that reason for endodontic failure
was furcation in 2%, iatrogenic causes in 3%, loss of
coronal seal in 16%, periapical pathology in 25%, and
inadequate root filling in 54%.
Discussion
It is evident in few studies that a short homogenous RC
filling result in highest success rate of 90%–94%. It is
also observed and suggested in literature that RC filling
must terminate at 0.5 to 1 mm short of radiographic
apex. It is further ascertained that over instrumentation
and overfilling results in extrusion of micro‑organisms
into periapical area and hence must be prevented.[7] As
suggested by Abbot,[8] the presence of symptomatic
teeth, evidence of periapical radiolucency and increase
in size radiographically is suggestive of failed RCT and
no signs and symptoms of pain and reduction in size
of periapical lesion is indicative of successful RCT.
Inadequate aseptic control, poor access cavity design,
Table 1: Distribution of patients
Gender Male Female
n 128 110
Mean age (years) 41.2 40.5
AP (%) 57.4 48.6
AP: Apical periodontitis

Results
Table 2: Comparison of quality of obturation before and
Table 1 shows that out of 238 patients, males were 128
after endodontic retreatment
and females were 110. The mean age of males was
Scoring Before (%) After (%) P
41.2 years and females were 40.5 years. AP was seen in 1 14.1 72.2 0.01
57.4% males and 48.6% females. 2 25.4 6.2 0.02
Table 2 and Graph 1 shows that score 1 was seen I in 3 2 10.7 0.05
14.1% before and 72.2% after endodontic retreatment, 4 17.1 2.4 0.04
5 40.2 8.5 0.01
score 2 was 25.4% before and 6.2% after, score 3
6 1.2 0 0.17
was 2% before and 10.7% after, score 4 was seen in
17.1% before and 2.4% after, score 5 was seen
in 40.2% before and 8.5% after and score 6 was seen Table 3: Comparison of periapical index before and after
in 1.2% before and 0% after endodontic retreatment. endodontic retreatment
There was a statistically significant increase in scores PAI PAI before (%) PAI after (%) P
1 and 3 and decrease in scores 2, 4, 5, and 6 after 1 43 70 0.01
treatment (P < 0.05). 2 20 14 0.05
3 19 12 0.12
Table 3 and Graph 2 shows that PAI score >3 was 4 14 3 0.03
seen in 37% before which decreased to 16% after 5 4 1 0.05
endodontic retreatment. The difference was statistically PAI: Periapical index
significant (P < 0.05).
Table 4 shows that 34.6% obturation was homogenous Table 4: Homogeneity of obturation before and after
and 65.4% was nonhomogenous before endodontic endodontic retreatment
retreatment. After endodontic retreatment, 95.2% became Duration Homogenous Nonhomogenous P
homogenous and 4.8% nonhomogenous. The difference Before 34.6 65.4 0.001
was statistically significant (P < 0.05) After 95.2 4.8 0.001

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Aga, et al.: Endodontic re‑treatment

assessed endodontic retreatment outcomes based on

quality of obturation and healing in 199 radiographs
of patients who had received endodontic retreatment.
The results showed that 78.9% of the endodontic
re‑treatments were both homogeneity and length
acceptable. Homogeneity and length unacceptable before
endodontic retreatment was 47.2% reduced to 2.5% after
retreatment.
We found that there was significant increase in scores
1 and 3 and decrease in scores 2, 4, 5, and 6 after
treatment. Score 1 was seen I in 14.1% before and
Graph 1: Comparison of quality of obturation before and after endodontic 72.2% after endodontic retreatment, score 2 was 25.4%
retreatment
before and 6.2% after, score 3 was 2% before and
10.7% after, score 4 was seen in 17.1% before and
2.4% after, score 5 was seen in 40.2% before and 8.5%
after and score 6 was seen in 1.2% before and 0% after
endodontic retreatment. It is found that micro‑organisms
found in endodontic re‑treatment are more resistant
to antiseptics as compared to those found in primary
RCT.[11]
In the present study, 34.6% obturation was homogenous
and 65.4% was nonhomogenous before endodontic
retreatment. After endodontic retreatment, 95.2%
became homogenous and 4.8% nonhomogenous. The
reason for endodontic failure was furcation in 2%,
Graph 2: Comparison of periapical index before and after endodontic iatrogenic causes in 3%, loss of coronal seal in 16%,
retreatment
periapical pathology in 25% and inadequate root filling
in 54%. It is known that the main cause for failure of
RCT is insufficient disinfection and the inability to
prevent recolonization of residual microorganisms.
Nonsurgical retreatment is often considered the
treatment of choice if a previously treated tooth has
persistent AP. The presence and size of the apical
lesion, the root end filling material, type and quality
of the coronal restoration, the status of previous RCT
etc., helps in deciding whether surgical or nonsurgical
treatment is to be planned.[12]
The shortcoming of the present study is small sample
size and short follow‑up. Postoperative IOPARs were
considered rather than advanced radiographic method
Graph 3: Reasons of endodontic failure such as CBCT images.

missed or accessory canals, inadequate instrumentation, Conclusion

leaking temporary or permanent fillings, and procedural The authors found that there was significant
errors are among few causes of endodontic failures.[9] improvement and decrease in size of periapical lesions
The present study was conducted to assess quality of RC in re‑endodontic cases as compared to primary RC
filling before and after RC re‑treatment. treated teeth.
Financial support and sponsorship
In the present study, out of 238 patients, males were 128
and females were 110. AP was seen in 57.4% males and Nil.
48.6% females. Mean age of males was 41.2 years and Conflicts of interest
females were 40.5 years. Alharmoodi and Al‑Salehi[10] There are no conflicts of interest.

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Aga, et al.: Endodontic re‑treatment

References fillings performed by undergraduate dental students. Eur J Dent

1. Barrieshi‑Nusair KM, Al‑Omari MA, Al‑Hiyasat AS.
Radiographic technical quality of root canal treatment performed
by dental students at the Dental Teaching Center in Jordan.
J Dent 2004;32:301‑7.
2. Fezai H, Al‑Salehi S. The relationship between endodontic
case complexity and treatment outcomes. J Dent
2019;85:88‑92.
3. Bierenkrant DE, Parashos P, Messer HH. The technical quality of
nonsurgical root canal treatment performed by a selected cohort
of Australian endodontists. Int Endod J 2008;41:561‑70.
4. Siqueira JF Jr. Aetiology of root canal treatment failure: Why
well‑treated teeth can fail. Int Endod J 2001;34:1‑10.
5. Covello F, Franco V, Schiavetti R, Clementini M, Mannocci A,
Ottria L, et al. Prevalence of apical periodontitis and quality
of endodontic treatment in an Italian adult population. Oral
Implantol 2010;3:9‑14.
6. Unal GC, Kececi AD, Kaya BU, Tac AG. Quality of root canal
2011;5:324‑30.
7. Chala S, Abouqal R, Abdallaoui F. Prevalence of apical
periodontitis and factors associated with the periradicular status.
Acta Odontol Scand 2011;69:355‑9.
8. Abbott PV. Recognition and prevention of failures in clinical dentistry.
Endodontics. Ann R Australas Coll Dent Surg 1991;11:150‑66.
9. Hession RW. Long‑term evaluation of endodontic treatment:
Anatomy, instrumentation, obturation – The endodontic practice
triad. Int Endod J 1981;14:179‑84.
10. Alharmoodi R, Al‑Salehi S. Assessment of the quality of
endodontic re‑treatment and changes in periapical status on a
postgraduate endodontic clinic. J Dent 2019;92:103261.
11. Ng YL, Gulabivala K. Outcome of non‑surgical re‑treatment.
Endod Top 2008;18:3-30.
12. Lambrianidis T, Tosounidou E, Tzoanopoulou M. The effect
of maintaining apical patency on periapical extrusion. J Endod
2001;27:696‑8.

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