ORIGINAL ARTICLE

Fariborz Moazami1, Safoora Sahebi1, Fereshte Sobhnamayan1*, Abbas Alipour1

Success Rate of Nonsurgical Endodontic Treatment of

Nonvital Teeth with Variable Periradicular Lesions
1- Department of Endodontics, Dental school, Shiraz University of Medical Sciences, Shiraz, Iran.

INTRODUCTION: Bacterial infection of tooth pulp can progress into periapical diseases. Root
canal treatment has been established as the best treatment. In cases of failure, nonsurgical
retreatment of teeth is preferred to surgical procedure and extraction.
MATERIALS & METHODS: In this historical cohort study, 104 permanent teeth with apical
lesion were treated during 2002-2008. All teeth showed radiographic evidence of periapical lesion
varying in size from 1 to >10mm. A total of 55 teeth were treated with initial root canal treatment
and 49 teeth required retreatment. Patients were recalled up to ≈7 years. All radiographs were
taken by RSV MAC digital imaging set and long cone technique. The presence/absence of signs
and symptoms and periapical index scores (PAI) were used for measuring outcome. Teeth were
classified as healed (clinical/radiographic absence of signs and symptoms) or diseased
(clinical/radiographic presence of signs and symptoms). The data were statistically analyzed using
student t-test and Pearson chi-square or fisher’s exact test.
RESULTS: The rate of complete healing for teeth with initial treatment was 89.7%, and for
retreatment group was 85.7%; there was no significant difference. Size of lesions did not
significantly affect the treatment outcomes. Success of tooth treatment did not reveal significant
correlation with gender and number of roots.
CONCLUSION: Orthograde endodontic treatment/retreatment demonstrates favorable outcomes.
Thus, nonsurgical endodontic treatment/retreatment should be considered as the first choice in
teeth with large periapical lesion.
KEYWORDS: Endodontics, Periapical Disease, Retreatment, Root Canal Therapy, Treatment Outcome

Received 27 February 2011; Revised 09 May 2011; Accepted 25 May 2011

*corresponding author at: Fereshte Sobhnamayan, Department of Endodontics, Dental school, Shiraz
University of Medical Sciences, Shiraz, Iran. Tel: +98-9173060679. E-mail: f-sobh-namayan @yahoo.com

INTRODUCTION 256 periapical lesions histologically and found

that 35% were abscesses, 50% were
Infection of root canal system occurs granulomas, while only 15% were cysts; 52%
subsequent to tooth caries, surgical treatments, of lesions had an epithelial compartment within
and trauma. The microbial flora is commonly their structures (5-7). The incidence of
mixed, predominantly gram-negative, periapical cysts has been reported to be 15-
anaerobic bacterium (1). The close relation 42%. Radiographs cannot distinct periapical
between tooth pulp and periapical region radiolucencies as a cyst or granuloma. The two
allows passage of bacteria, fungi, and cell types of periapical cysts are true and pocket
components with a path for initiating cysts. True cyst has lumen with intact epithelial
inflammatory processes in periapical regions lining which is separate from the root apex;
and activating resorption in the tissues. These whereas, pocket cyst shows the lumen which is
immunopathological mechanisms lead to open to the root canal of the infected tooth.
formation of abscess, granuloma, and periapical True cysts do not probably heal after non-
cyst (2-4). Ramachandran Nair et al. analyzed surgical endodontic therapy and usually require

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 Moazami et al.021

surgical procedures (8). Some clinical studies digital imaging long cone technique. All teeth
have shown healing of large periapical lesions were treated by one endodontist in one session.
following simple endodontic treatments (9,10). Access cavity was performed and teeth were
Previously, large periapical lesions were isolated with rubber dam. Working lengths
generally managed by surgical excision of cysts were determined using appropriate K-files
after root canal treatment of infected teeth (11); (Mani, Tochigi-ken, Japan). In teeth with
during recent years, increased knowledge of the previous endodontic treatment, gutta-percha
morphology and complexity of root canal and sealer were removed by hand and rotary
system has led to development of newer instrumentation including Gates-Glidden drills
technique, instrument and materials which (Mani, Tochigi, Japan), heated plugger, K and
consequently result in improved endodontic H files and also ProTaper rotary system
treatment and healing of cyst and a reduced need (Dentsply, Maillefer, Ballaigues, Switzerland).
for periapical surgery (12,13). Success rate of If needed chloroform was used as solvent.
about 90% is reported for endodontic treatments. Working lengths were determined radio-
Although several studies still believe that graphically. Subsequently, root canals were
treatment for teeth with periapical lesions has instrumented with rotary files. Irrigation was
lower success rate (20% decrease) (14-16). performed frequently with 2.5% sodium
hypochlorite (NaOCl). After drying with sterile
As there are no studies looking at the healing of paper points, canals were obturated with gutta-
endodontic lesions in Iran, the aim of this study percha (Ariadent Co., Tehran, Iran) and
was to evaluate the success rate of nonsurgical Tubliseal (Sybron Endo, CA, USA) using cold
endodontic treatment/retreatment of teeth with lateral condensation method. After root canal
various periapical lesions sizes. filling, teeth were restored permanently.
Patients were recalled every 4 m for up to 1 yr,
MATERIALS & METHODS and then every 12 m for about 6 yrs.

For this historical cohort study, 104 permanent All radiographs were taken by RSV imaging set
teeth of 81 patients were analyzed. All teeth and long cone technique with standardized
had been endodontically treated during 2002- exposure time and no need for processing. The
2008. Patients with endodontic-periodontal largest diameter of the lesions was measured
lesions, contributory systemic disease, with RSV imaging software. The presence or
obturation techniques other than lateral absence of signs and symptoms and also PAI
condensation, inter-appointment dressings >1 scores were used for measuring the outcome.
session, and follow-ups <6 months were
excluded from this study. An informative form Teeth were classified as healed when there was
including individual, medical and dental clinical absence of signs and symptoms and
information in addition to detailed records of radiographic PAI score ≤2. Teeth were termed
previous root canal treatments was performed diseased in cases with clinical presence of signs
for each patient. Among the included teeth, 41 and symptoms or when PAI≥3. Multi-rooted
were single rooted, 7 were double rooted, and teeth were assigned the highest PAI scores of
the remaining 56 were multiple rooted. their roots. Teeth with the absence of any sign
Radiographically, all teeth showed periapical or symptoms regardless of PAI score were
lesion with the size between 1mm to >10mm. considered functional. Three trained observers
According to patient records 41 teeth had (two endodontist and one radiologist) analyzed
different sign and symptoms of acute apical radiographs. PAI were assigned to each
periodontitis e.g. pain, tenderness to radiograph. If there was any controversy
percussion, localize or diffused swelling and between observers the two that were similar
also mobility. The remaining 66 teeth were were chosen.
symptom-free. A total of 55 teeth were root
canal treated for the first time and 49 teeth were The data were statistically analyzed using
retreated (failed treatments). Radiographic student t-test and Pearson chi-square or fisher’s
examination was performed using RSV MAC exact test, where applicable (with a preset

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Nonsurgical endodontic treatment/020

Table 1. Association between outcomes of treatment with independent variables

Outcome of treatment [N (%)]
Independent variable P-value
Healed (n=91) Diseased (n=13)
Female 65 (86.7) 10 (13.3) a
Gender 0.482
Male 26 (89.7) 3 (10.3)
Initial treatment 49 (89.8) 42 (85.7) b
Treatment 0.602
Retreatment 6 (10.9) 7 (14.3)
Single-rooted 38 (92.7) 3 (7.3) b
Root 0.162
Multi-rooted 3 (84.1) 10 (15.9)
≤5mm 60 (89.6) 7 (10.4) a
Lesion size 0.289
>5mm 31 (83.8) 6 (16.2)
a. Fisher exact test, b. chi-square test

probability of P<0.05 and considering of greater than persistent group patients

variance equality with Leven test). Experi- (32.96±22.11 mon vs. 28.62±20.14 mon), this
mental results are presented as arithmetic Mean difference was not statistically significant
±SD. Normality of parameters’ distribution was (P=0.562). Other associations between
evaluated with one sample Kolmogorov- outcomes of treatment with independent
smirnov test. For the evaluation of non linear variables are shown in Table 1. There were no
association between frequencies of persistent remarkable correlation between outcome of
disease state with prognostic factors treatment with gender and previous treatment
(independent variables that P-value of status of patients, number of roots and also
association of those with disease status in lesion size.
Univariate analysis was less than 0.2) binary
logistic regression was performed. Multilevel analysis for evaluation of
association between outcome of treatment with
RESULTS prognostic variable (root number and age) was
evaluated. There were no association between
Eighty one patient, with 104 teeth (72.1% of age of patients (OR=1.033; P=0.169) and
teeth were in female patients and 72.1% in number of roots (OR=2.092; P=0.293) with
males) were evaluated in this historical cohort treatment outcome.
study with the age ranging from 8-82 years
(mean=38.36, SD=13.49). Follow-up time DISCUSSION
ranged between 4 to 81 month (mean=31.92,
SD=21.82). A total of 55 (52.9%) teeth Unlike other studies that evaluated the success
underwent initial treatment and 49 (47.1%) rate in all treated teeth, regardless of periapical
teeth were retreated. Also, 41 teeth (39.4%) lesions, this study focused on the success rate
were single-rooted and 63 (60.6%) teeth were of teeth with periapical lesions. This may
multi-rooted. Total of 67 (64.4%) teeth had explain the difference between the various
lesion ≤5mm and in the remaining 37 (35.6%) outcomes.
teeth the lesions were ≥5mm. Ninety one teeth
(87.5%) were “healed” and the other 13 Several factors may influence endodontic
(12.5%) teeth had persistent disease at the treatment outcome, which are called outcome
follow-up. Cumulative incidence of healing predictors. Radiographic outcomes have been
was 0.875 (95% CI: 0.811, 0.939). used to indicate "success" and "failure" of
endodontically treated teeth and have been
Association between outcome of treatment with compared with clinical evaluations. Since
demographic and other independent variables Goldman et al. demonstrated poor inter- and
were evaluated. Age of patients in healed and intra-observer reliability in interpretation of
diseased groups were 37.57±12.88 and periapical radiographs, and in order to make
43.85±16.71 years respectively; which was not more reliable criterion PAI was used to
statistically significant (P=0.117). Although describe the status of periapical tissues
follow-up time in healed group patients was (17,18).

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 Moazami et al.022

Unfortunately, methodological problems com- (≤5mm) compared to those with larger

plicate the comparison of different studies (19). periradicular lesions after either initial treat-
Several studies have compared the success rate ments (10,23-25,35) or retreatments (4). In some
of teeth with and without apical periodontitis studies, comparable outcomes have been
(lesions with different size). Most quoted reported for both small and large lesions after
≈15%-20% lower success rate for teeth with initial treatment (23-25,35) and retreatment (36).
apical periodontitis (20-23). This is inconsistent Soares et al. showed the complete resolution of
with our study. Peters et al. had a success rate large periapical lesion after 2-year follow-up (2);
of about 75% in 115 teeth with periapical Caroline et al. also showed complete healing of
lesion; 20% lower than the cases without large lesions (10×15mm) after 2yrs (28). Saatchi
lesions (20). A further study found a similar demonstrated the 12-month periapical healing of
pattern with 74% success rates for teeth with large lesion after using calcium hydroxide as an
apical periodontitis (72 teeth) which was 15% intracanal dressing (11). These case reports
lower than teeth with healthy periapical confirm the high probability of healing of large
condition (22). Farzaneh et al. also showed the periapical lesions without periapical surgery,
success rate of teeth with periapical lesion was similar to our study. However, Hoskinson et al.
79% in 70 cases which is 14% lower than cases suggested that there was nearly an 18%
without periapical lesion (21). The current decrease in the probability of success rate with
study shows a success rate of about 87%. Our every 1mm increase in the lesion size. He also
study may be more reliable than other studies described the periapical lesion as the most
as the experimental procedures were performed significant factor affecting outcome of
by one operator who was a specialist; also treatment which is not in agreement with this
factors not assessed in the regression analysis study (34). The better outcome in teeth with
could thus be better controlled (relative to each smaller lesions that is suggested in this study
other) than in retrospective studies with data (though statistically insignificant) is probably
pooled from a clinic. However, a greater due to the greater time required for a large
number of teeth were included in this survey, lesion to heal, and the probability of repairing
except one other study which may result in scar tissue in large lesions (10).
better reliability in the treatment outcome.
Whether RCT was performed as initial treatment
In the present study, all teeth were treated in or as retreatment did not significantly influence
one session. Some studies believe that there is the outcome in this study. This finding is
no significant difference between one-visit and consistent with that of Marending et al. (37) and
two-visit endodontic treatments (10,19,23). contrary to other studies like Peters et al., and
Others advocate that using intracanal medica- some other investigators (20,24,38-40). There
ment such as calcium hydroxide between was an insignificant lower success rate for
sessions especially in very large periapical retreatments, which may be due to treatment
lesions is beneficial, as shown in several case complications. Some studies believe in
reports and studies (23-29). Generally, there is impairment of healing by complications
a great tendency among practitioners to use including perforation of the pulp chamber or
calcium hydroxide in canals specifically in root, broken instruments that prevent adequate
those with periapical lesions. In this study we cleaning, and massive extrusion of filling
showed high success rate (84%) in cases with materials (24,35). Otherwise, the etiology of
large peri-apical lesion without using calcium failure in well-obturated teeth may be more
hydroxide as it is thought that this medicament likely related to extraradicular infection, cystic
is not always effective and its action is lesions, foreign body reaction, and undiagnosed
unreliable (30-34). infractions as the conditions that might not
respond to retreatment favorably (41).
The outcome of treatments in this study did not
show any correlation with size of lesion. This study showed different, but insignificant,
Although there is some evidence to indicate outcomes for single-rooted and multi-rooted
better outcomes for cases with small lesions teeth agreeing with several other studies

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Nonsurgical endodontic treatment/021

(14,22,42-44); contrary to study carried out in 6. Soares JA, Queiroz CES. Periapical
Toronto phase II and IV (21,45). pathogenesis-Clinical and radiographic aspects, and
treatment for the bone and root resorption of
The lower outcomes in multi-rooted teeth can endodontic origin. Jornal Brasileiro de Endo/Perio
be due to the challenge of eliminating root 2001;21:124-35.
7. Ramachandran Nair PN, Pajarola G, Schroeder
canal infections. However, the difference could
HE. Types and incidence of human periapical
be attributed to the use of the tooth as a unit, lesions obtained with extracted teeth. Oral Surg
reflecting the double or triple probability of Oral Med Oral Pathol Oral Radiol Endod
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G, Frostell G. correlation of positive cultures with
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