Endod Dent Traumatol 1994: 10: 105-108
Printed in Denmark . AU rights reserved
Coronal leakage as a cause of failure in root-
canal therapy: a review
Saunders WP, Saunders EM. Coronal leakage as a cause of
failure in root-canal therapy: a review. Endod Dent Traumatol
1994; 10: 105-108. © Munksgaard, 1994.
Abstract - This paper reviews the evidence that coronal leakage
of root canals may lead to failure of root-canal therapy. The
causes of coronal leakage and methods by which this leakage
may be prevented are described.
Root-canal treatment can be difficult and time con-
suming, especially in molars with multiple fine,
curved root canals. In order to provide an environ-
ment where healing can occur and be maintained,
it is important that sufficient care is taken, not only
during the cleaning, shaping and obturation of the
canal system, but also when restoring the crown.
Apical leakage as a cause of failure
Failure of root-canal treatment can be attributed to
a number of causes, but leakage through the root
filling itself is thought to be a major factor. Strind-
berg (1), in 1956, considered that the most common
cause of failure was leakage of tissue fluids apically
around inadequate root fillings. The University of
Washington School of Dentistry Study, undertaken
to evaluate treated endodontic cases and to deter-
mine their rate of success, was reported by Ingle (2)
in 1965. This study found that of 104 failed cases,
66 were associated with a poor apical seal. Other
studies (3, 4) have shown that prognosis for success-
ful root-canal therapy was poorer when there were
^'oids apically between the root filling and the wall
of the canal. But why should this result in failure?
^t seems very likely that necrotic debris and micro-
organisms cannot be completely eliminated from
Copyright © Munksgaard 1994
Endodontics &
Dental Traumatology
ISSN 0109-2502
Review article
W. p. Saunders\ E. M. Saunders^
^Department ot Adult Dental Care, Glasgow Dental
Hospital and School, ^Department of Conservative
Dentistry, Dundee Dental School, Scotland, UK
Key words: root canal treatment; failure; coronal
leakage.
W P Saunders, Department of Adult Dental
Care, Glasgow Dental Hospital and School,
378 Sauchiehall Street, Glasgow G2 3JZ,
Scotland.
Accepted October 13, 1993
the prepared root canal (5-7). If the canal space is
not sealed adequately then micro-organisms them-
selves, or their toxins, can cause inflammation in
the periapical tissues (8).
Importance of coronal leakage in failure of root canal
treatment
Obturated root canals may be recontaminated by
micro-organisms in a number of ways:
1) Delay in placing a coronal restoration following
root canal treatment. Although temporary re-
storative materials such as Cavit G and re-
inforced zinc oxide eugenol cements, such as
Kalzinol and IRM, have good sealing properties
they tend to dissolve slowly in the presence of
saliva, and the seal may break down. If a tem-
porary restoration is of inadequate thickness,
leakage will occur (9).
2) Fracture of the coronal restoration and/or tooth.
3) Preparation of post space for the provision of
a post-retained restoration when the remaining
apical section of the root filling is of inadequte
density and/or length.
The concept that one cause of failure of root-
canal treatment may be the result of coronal leakage
is not a new one. Marshall & Massler (10), in 1961,

Saunders & Saunders
were concerned about the role of the occlusal seal in
root-filled teeth. They wondered whether the overall
seal of the root canal was altered if the seal was
broken coronally. They also speculated on the prog-
nosis of root-canal treatment if the quality of obtu-
ration of the root canal was poor, but the coronal
seal was good. They indertook a leakage study using
a radioactive tracer and showed that coronal leak-
age occurred despite the presence of a coronal
dressing.
Allison et al. (11) in 1979 made brief reference
to the possibility that a poor coronal seal might
contribute to clinical failure.
In 1987 the importance of coronal leakage in the
prognosis of root-canal treatment was readdressed.
An in vitro leakage study (12) showed that after only
three days exposure to artificial saliva there was
extensive coronal leakage of a tracer dye through
apparently sound root fillings. They considered that
leakage of this nature should be taken into account
as a potential aetiological factor in failure of root-
canal treatment. Madison & Wilcox (13) confirmed
that exposure of root canals to the oral environment
allowed coronal leakage to take place, in some cases
along the whole length of the root canal.
Further studies have confirmed the importance
of coronal leakage as a possible cause of failure of
root-canal treatment. Torabinejad et al. (14) found
that 50% of single-rooted teeth, root filled using
lateral condensation of guttapercha and a sealer
cement, were contaminated with bacteria along the
whole length of the root after 19 days or 42 days,
depending on the contaminating organism. Another
study (15) assessed salivary penetration through ob-
turated root canals. The results led to a recommen-
dation that root fillings which had been contami-
nated coronally for at least three months, should be
re-done prior to placement of the definitive restora-
tion. More recently, Khayat et al. (16) have shown
that root canals obturated with gutta-percha and
Roth's sealer, using either lateral condensation or
vertical condensation were contaminated apically
with bacteria from saliva exposed to the coronal
part of the root canal only. All canals were contami-
nated within 30 days of exposure.
Post space preparation and coronal leakage
Restoration of a root-filled tooth sometimes requires
the use of an intra-canal post. During mechanical
preparation of the post space it is possible that the
root filling may be twisted or vibrated, with disrup-
tion of the seal (17). To avoid this problem there
was a vogue for placing sectional silver or gutta-
percha cones in the apical portion of the root canal.
It now seems that the advantages of leaving the
apical portion of the root filling undisturbed is
106
16009657, 1994, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.1994.tb00533.x by Health Research Board, Wiley Online Library on [23/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
outweighed by the fact that much of the. canal sys-
tem is vulnerable to contamination from an inad-
equate seal coronally. Three-dimensional obturation
of the whole canal with gutta-percha will coat the
wall of the root canal with sealer and may allow
the filling of lateral root canals.
Provided a minimum of 5 mm of sound apical
root filling is left in situ (18, 19), studies have shown
that removal of laterally condensed gutta-percha
does not affect the apical seal. This is the case ir-
respective of whether the post space is prepared
immediately after obturation or is delayed (18, 20,
21).
Coronal leakage associated with molar teeth
Most studies of coronal leakage have involved the
use of single-rooted teeth. It is probably more im-
portant, however, to seal the coronal part of the
root canal system in molars because accessory canals
may be present in the floor of the pulp chamber
(22). Gontamination through these canals may be
responsible for inflammatory changes taking place
in the periodontal tissues of the furcation due to
direct spread of micro-organisms and their toxins
from the pulp chamber (23, 24). Saunders & Saund-
ers (25) showed that coronal leakage was a signifi-
cant problem in root-filled molars. They demon-
strated in a laboratory-based experiment, that the
common practice of packing excess gutta-percha
and root canal sealer over the floor of the pulp
chamber after completion of lateral condensation,
did not provide an adequate coronal seal of the
root canals. It was recommended that excess gutta-
percha should by removed level with the openings
of the root canals and the floor of the pulp chamber
sealed with a restorative material such as amalgam
or glass polyalkenoate.
Other factors influencing coronal ieakage
When the root canal walls are instrumented a ten-
acious layer of debris is formed which is known as
the smear layer (5). This layer cannot be removed
with canal irrigation techniques using sodium hypo-
chlorite in a hand-held syringe. Therefore, the
smear layer is present in most root-filled teeth. The
effect that the smear layer may have on the prog-
nosis of root-canal therapy is unknown (26), but
conceivably it might be broken down by bacterial
toxins (27). This would provide a path through
which leakage could take place. Hovland & Dum-
sha (28) showed that most leakage occurs between
the root-canal sealer and the wall of the root canal-
It is important, therefore, that this route for con-
tamination is restricted as much as possible.
If the smear layer were to be removed then this

would expose patent dentinal tubules into which a
sealer may flow, thereby decreasing the possibility
of leakage taking place. The smear layer can be
removed with acids, such as citric acid, and chel-
ating agents such as EDTA (ethylenediaminetetra
acetic acid). Cameron (29) showed that sodium
hypochlorite, used with an ultrasonically powered
endodontic file, could also remove the smear layer.
Smear-layer removal tends to be easier in the cor-
onal than in the apical part of the canal (30). An-
other way in which contamination could be re-
stricted is by using a root-canal sealer that bonds
ehemically to the wall of the root canal. None of
the more commonly used root-canal sealers adhere
chemically to tooth structure. A recent study used
a glass ionomer lining material, Vitrebond, as a
root-canal sealer (31). In order to prolong the set,
the cement was allowed to cure chemically. When
the smear layer was removed, the sealer flowed into
the dentinal tubules and coronal leakage was re-
duced compared with Tubliseal, a commonly used
zinc-oxide eugenol-based, root-canal sealer. Glass
ionomer bonds to the inorganic part of dentine and
the use of such a material may have a place in
endodontics. A proprietary glass ionomer root canal
sealer, Ketac Endo, has recently become available
and early research reports are, on the whole, favour-
able (32, 33).
Prevention of coronai leakage
It is essential, following root-canal treatment, that
the canal system is protected from subsequent leak-
age as much as possible. In the case of molars the
floor of the pulp chamber should be covered with a
lining of glass ionomer after removing excess gutta-
percha and sealer.
The crown of the tooth should be restored ex-
peditiously in such a way as to reduce leakage to a
minimum. Coronal access cavities of teeth that can-
not be restored immediately should be dressed with
a proprietary temporary filling material, ensuring
that it is at least 3.5 mm thick to reduce leakage (9).
If simple repair of an access cavity jeopardises the
coronal seal of an existing restoration, then the com-
plete restoration should be replaced. Of course root-
filled teeth have no pulpal sensory innervation and,
therefore, leaking coronal restorations may go un-
noticed by patients for many months. It is important,
therefore, that regular reviews are made of root-filled
teeth, not only to monitor the periradicular status,
but to ensure that coronal leakage is not taking place.
Conclusions
Coronal leakage is an important cause of failure of
treatment. It is essential that due regard
16009657, 1994, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.1994.tb00533.x by Health Research Board, Wiley Online Library on [23/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Coronal leakage & root canal therapy
be paid to the prevention of such leakage, both
during and after root-canal therapy, by paying care-
ful attention to the coronal restoration to the tooth.
The use of chemically active, adhesive, root-canal
sealers may, in future, play an important role in
minimising coronal microleakage.
References
1. STRINDBERG L Z .The dependence of the results of pulp ther-
apy on certain factors. Acta Odontol Scand 1956; 14: (suppl
21): 1-175.
2. INGLE J I , BEVERIDGE E E , CLICK D H , WEICHMAN J A , ABOU-
RASS M . Modern endodontic therapy. The Washington
Study. In.Endodontics, Philadelphia; EEA & FEBIGER, 1985;
27-49.
3. HARTY F J , PARKIXS BJ, WENGRAF AM. Success rate in root
canal therapy: a retrospective study of conventional cases.
Br Dent J 1970; 128: 65-70.
4. ADENUBI JO, RULE DC. Success rate for root fillings in young
patients fa retrospective analysis of treated cases;. Br Dent J
1976; Ml: 237-241.
5. McCoMB D, SMITH DC. A preliminary scanning electron
microscopic study of root canals after endodontic procedures.
J Endodon 1975; /.• 238-242.
6. McCoMB D, SMITH DC, BEAGRIE C S . The results of in vivo
endodontic chemomechanical instrumentation: a .scanning
electron microscopic study. J Br Endod Soc 1976; 9.- 11-18.
7. BYSTROM A . ScNDqviST C. Bacteriologic evaluation of the
efficacy of mechanical root canal instrumentation in endo-
dontic therapy. Scand J Dent Res 1981: 8: 321-328.
8. SAFAVI K F . NICHOLS F C . Fffect of calcium hydroxide on
bacterial lipopolysaccharide. J Endodon 1993; 1: 76-78.
9. WEBBER R T , DEL RIO C E . BRADY J M , SEGALL R O . Sealing
quality of a temporary filling material. Oral Surg Oral Med
Oral Pathol 1978: 46: 123-130.
10. MARSHALL FJ, MASSLER M . The sealing of pulpless teeth
e\aluated with radioisotopes. J Dent Med 1961; 16: 1 72-184.
11. ALLLSOX D. WEBER C. WALTON R . The influence of the
method of canal preparation on the quality of apical and
coronal obturation. J Endod 1979; 5: 28-304.
12. SwANsox K, MADISON S. An evaluation of coronal micro-
leakage in endodontically treated teeth. Part 1. Time
periods. J Endod 1987: /J.- 56-59.
13. MADISON S, \VILCOX ER. An evaluation of coronal micro-
leakage in endodontically treated teeth. Part 3. In vivo study.
J Endod 1988: 14: 455-458.
14. TORABINEJAD M , UXG B, KETTERIXG J D . In vitro bacterial
penetration of coronally unsealed endodontically treated
teeth. J Endod 1990; /^.- 566-569.
15. KHAYAT A, EEE S-J, TORABINEJAD M . Human saliva pene-
tration of coronally unsealed obturated root canals. J Endod
1993: 19: 458-461.
16. MAGURA M E . KAFRAVVY AH, BROWN CE, NEWTON C W .
Human saliva coronal microleakage in obturated root ca-
nals: an in vitro study. J Endod 1991: 17: 324-331.
17. JEFFREY I W M , SAUXDERS AVP. An investigation into the
bond strength between a root canal sealer and root-filling
points. Int"EndodJ 1987; 20: 217-222.
18. ZMENER O . Effect of dowel preparation on the apical seal of
endodontically treated teeth. J Endod 1980; 6: 687-690.
19. NEAGLEY R E . The effect of dowel preparation on the apical
seal of endodontically treated teeth. Oral Surg Oral Med Oral
Pathol 1969; 25.- 739-745.
20. BOURGEOIS R S , EEMON R R . Dowel space preparation and
apical leakage. J Eridod 1981; 7: 66-69.
21. PoRTELL FR, BERNIER WE, EoRTON E, PETERS D D . The
107

Saunders & Saunders
effect of immediate versus delayed dowel space preparation
on the integrity of the apical seal. J Endod 1982; 8: 154-160.
22. VERTUCCI FJ, ANTHONY RE. A scanning electron micro-
scopic investigation of accessory foramina in the furcation
and pulp chamber of molar teeth. Oral Surg Oral Med Oral
Pathol 1986; 62: 319-326.
23. SINAI I H , SOLTANOFF W. The transmission of pathologic
changes between the pulp and the periodontal structures.
Oral Surg Oral Med Oral Pathol 1973; 36: 558-568.
24. GuTMANN JE. Prevalence, location and patency of accessory
canals in the furcation region of permanent molars. J Peridon-
tol 1978; 49: 21-26.
25. SAUNDERS W P , SAUNDERS EM. Assessment of leakage in the
restored pulp chamber of endodontically treated multirooted
teeth. Int Endodon J 1990; 23: 28-33.
26. MERYON S D , JAKEMAN K J , BROWNE R M . Penetration in vitro
of human and ferret dentine by three bacterial species in
relation to their potential role in pulpal inflammation. Int
Endod J 1986; 19: 213-220.
108
16009657, 1994, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.1994.tb00533.x by Health Research Board, Wiley Online Library on [23/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
27. CzoNSTKOwsKY M, WiLSON E C , HoLSTEiN FA. The smear
layer in endodontics. Dent Clin .K America 1990; 34: 3-25.
28. HOVLAND E J , DUMSHA T C . Eeakage evaluation in vitro of the
root canal sealer cement Sealapex. Int Endod J 1985; 18:
179-182.
29. CAMERON JA. The use of ultrasonics in the removal of the
smear layer: a scanning electron microscope study. J Endod
1983; 9: 289-292.
30. SAUNDERS WP, SAUNDERS EM, HERD D, STEPHENS E. The
use of glass ionomer as a root canal sealer - a pilot study.
Int Indod J 1992; 25: 238-244.
31. SAUNDERS WP, SAUNDERS EM. The effect of smear layer
upon the coronal leakage of gutta-percha root fillings and a
glass ionomer sealer. Int Endod J 1992; 25: 245-249.
32. RAY HE, SELTZER S. A new glass ionomer root canal sealer.
J Endodon 1991: //.• 598-603^
33. TROPE M , RAY HE. Resistance to fracture of endodontically
treated roots. Oral Surg Oral Med Oral Pathol 1992; 73:
99-102.
16009657, 1994, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1600-9657.1994.tb00533.x by Health Research Board, Wiley Online Library on [23/09/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License