Treatment concepts for restoration of endodontically treated teeth: A nationwide survey of dentists in Germany

Michael Naumann, DMD,a Saskia Kiessling, DMD,b and Rainer Seemann, DMD, PhDc Charite, University Medical School, Campus Virchow, Berlin, Germany Statement of problem. Opinions concerning proper restoration of endodontically treated teeth (ETT)
vary. A variety of techniques and materials for post-and-core restorations are available. The rationale for post placement performed by German dentists was unknown. Purpose. The purpose of this study was to determine current opinions, applied techniques, and materials for the restoration of ETT in Germany. Material and methods. A nationwide questionnaire-based survey containing 18 multiple choice questions regarding treatment philosophies, favored post type, and materials for core foundations was mailed to 36,500 German general dentists. A total of 6029 questionnaires (16.5%) were returned. Data were evaluated in terms of the dentists occupational experience and the frequency of post placement. Descriptive statistics were used to analyze the data. Results. Irrespective of their occupational experience, 52% of the surveyed dentists consider post placement for almost every postendodontic restoration of ETT. The majority of dentists (54%) believe that a post reinforces ETT. Cast posts and cores are used by 55% of all dentists, whereas 34% use prefabricated posts exclusively. Screw posts are the most popular prefabricated post type (47%). Composite resin (51%) is preferred for core foundation, followed by glass ionomer cements (GICs) (26%). Amalgam is seldom used (0.5%). Posts are placed primarily with zinc phosphate cement (51%), followed by GIC (38%). Conclusion. The treatment philosophy of German dentists is not in complete agreement with recommendations found in the literature. The belief that a post would reinforce an ETT might explain the high frequency of post placements. Due to the partially inconsistent responses, it is difcult to derive a generalized treatment concept. (J Prosthet Dent 2006;96:332-8.)

CLINICAL IMPLICATIONS
A wide spectrum of techniques and materials are used by German dentists for postendodontic restoration of ETT. In contrast to the existing evidence, the use of endodontic posts for the purpose of reinforcing ETT is common.

he prognosis of endodontically treated teeth (ETT) is inuenced by a variety of different parameters such as the number of adjacent teeth,1,2 occlusal contacts,3 position of the tooth in the dental arch,4,5 apical status,6 collagen degradation,7 intermolecular crosslinking of the root dentin,8 amount of hard tissue loss,9-14 remaining dentin wall thickness,5,15-17 type of denitive restoration,2,4,18-20 presence of a minimum of 1.5- to 2.0-mm-high ferrule preparation,21 and type of post22 and core material used. Amalgam and composite resin materials were found to be superior to glass ionomer cements (GICs) for core foundations.12,23-27 It is generally accepted that

Assistant Professor, Department of Prosthodontics and Geriatric Dentistry. b Scientic Assistant, Department of Prosthodontics and Geriatric Dentistry. c Assistant Professor, Department of Operative and Preventive Dentistry.

the purpose of post placement is to retain a core foundation8,28 and not to reinforce an ETT.11,29-31 However, an increased load capability of restored ETT following adhesive post placement has been observed in vitro.17,32-37 Despite their disadvantages, screw-type cast posts and cores are widely used.38-45 A cast post and core and prefabricated posts with composite resin foundations were found to result in comparable loads-to-fracture,36 and similar short-term survival rates were found for teeth restored with either titanium or glass-ber-reinforced posts.46 Dentists are confronted with a continuously growing number of various materials for postendodontic restoration and with an increasing occurrence of ETT in need of treatment.47 However, the scientic literature provides numerous, primarily material-oriented, noncomparable and, thus, possibly confusing in vitro studies.48 There is a lack of well-designed randomized controlled clinical trials.49 Hence, it is not surprising that the manner in which postendodontic restorative care is
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performed does not fully reect recommendations from the literature,50 but is inuenced by geographic location, age, and speciality status.51 These ndings suggest that each dentist develops his/her own experiencebased treatment concept. Thus, surveys are important tools to assess and to understand treatment approaches in postendodontic restoration. Several surveys have been performed in various countries to elucidate which treatment concepts and materials for endodontic and postendodontic restoration are favored by dental practitioners.42-45,50-53 The present survey was conducted to assess the current use of different post and core techniques for the restoration of ETT by German dentists.

MATERIAL AND METHODS

Surveys were mailed anonymously to 36,500 out of a total of 55,000 registered dentists throughout Germany as part of a periodical information mailing from the local dental organizations of each governmental district. The remaining 18,500 dentists could not be surveyed because the local dental organizations of 6 districts refused to send out the questionnaire. Dentists were asked to return the completed surveys by mail or fax. Nonresponders were not reminded due to the anonymous character of this survey. A slightly modied version of the questionnaire by Morgano et al51 was used. A cover letter stated the instructions, rationale, and purpose of this survey. The questionnaire contained 18 multiple-choice questions. The rst section collected general data about the responders, the second section concerned the treatment concept for ETT, and the third section contained questions related to the materials and methods used for the treatment. To ensure that a repeated treatment routine was reported, only questionnaires from dentists who reported restoring more than 30 ETT annually were included in the analysis. Dentists were divided into groups according to their clinical practice experience: less than 5 years in practice, 6 to 10 years, 11 to 20 years, 21 to 30 years, and more than 30 years. Regarding the frequency of post placement, seldom was dened as an assumed need for post placement in up to 30%, frequently, between 30 and 70%, and usually, in more than 70% of all ETT for which a cast restoration was planned. Data were analyzed with descriptive statistics using a software package (SPSS 11.0; SPSS Inc, Chicago, Ill).

RESULTS
A total of 6029 questionnaires were completed, representing a return rate of 16.5%. Five thousand eight hundred thirty-two (96.7%) dentists reported restoring more than 30 ETT annually. Four thousand two hundred forty-two (72.7%) of the responders were men, 1562 (26.8%) were women. Twenty-eight (0.5%)
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did not provide gender information. Table I shows the distribution of the responders clinical experience or professional experience. The majority of the questionnaires were returned by dentists with more than 30 years of professional experience (35%, n=2042). Three-hundred sixty dentists (6.2%) had up to 5 years of professional experience. The data focusing on treatment concept are presented in Tables I and II. According to these data, 52% of all dentists usually place a post when a cast restoration is planned for the tooth, 24% do this frequently, and 24% do not place a post (Fig. 1). Similar proportions were found when the professional experience groups were considered separately. The frequency of post placement differed signicantly between the groups depending on professional experience. Twenty-four percent believe that not every ETT requires a post. Of these, 41% (n=1889) reported that they usually place a post.Thirty percent (n=1354) do so frequently and 29% (n=1316) usually do not place a post. Ninety-three percent of dentists who believe that every ETT needs an endodontic post usually place one. A large percentage (41%) of those who are not of this opinion nonetheless place posts, whereas a smaller proportion (29%, n=1316) usually do not place endodontic posts. More than half of all respondents (54%, n=3162) expect reinforcement of the ETT and a decrease of fracture probability when posts are used. Sixty-ve percent (n=2070) of those who believe an ETT is reinforced by post placement do not believe that every ETT requires a post. However, 34% (n=1060) believe that a post is always indicated. One percent (n=32) did not provide this information. Clinicians with less than 5 years of experience believe in the reinforcement effect of a post to a slightly lesser extent than dentists with more experience. The results differ signicantly between the groups, depending on clinical experience. The supposition of a reinforcement effect causes 52% of dentists to place endodontic posts frequently, whereas 24% of the dentists usually do not place an endodontic post despite their belief in a reinforcement effect. Regardless of professional experience and frequency of post placement, approximately three fourths of the respondents believe that lowering the nish line, thus using a ferrule effect, increases the fracture resistance of the tooth. The data on the materials used are shown in Tables III and IV. More than half the respondents (55%, n=3189) use prefabricated posts as well as cast posts and cores in daily practice. Thirty-four percent (n=2003) use prefabricated posts exclusively, and 19% (n=1083) use only cast post and core. A small percentage (0.4%) of dentists place no posts, whereas 0.1% choose a composite resin core foundation without post placement. The prefabricated endodontic post is used signicantly more frequently for all types of teeth,
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Table I. Number of responses (percent) regarding treatment concept of reconstruction of ETT based on professional experience of respondents (n=5832)
Professional experience (y) ,5 6-10 11-20 21-30 [30

Participants treating more than 30 ETT per year Frequency of post placement 360 (6%) Seldom 86 (24%) Frequently 89 (25%) Usually 185 (51%)

1249 271 325 653

(21%) (22%) (26%) (52%)

1210 277 286 647 667 175 61 293 24

(21%) (22%) (24%) (54%) (55%) (15%) (5%) (24%) (1%)

971 202 232 537 544 132 57 220 25

(17%) (21%) (24%) (55%) (56%) (14%) (6%) (22%) (2%)

2042 538 462 1042 1096 237 184 507 57

(35%) (26%) (23%) (51%) (53%) (12%) (8%) (25%) (2%)

Do you believe that a post reinforces an ETT and reduces the fracture probability? Yes, denitely 172 (48%) 683 (55%) Yes, with adhesive luting 56 (16%) 169 (14%) Yes, with conventional luting 16 (4%) 56 (4%) No 109 (30%) 321 (26%) Not specied 8 (2%) 27 (1%)

Do you believe that reducing the level of the nishing line below the core foundation following post cementation increases the fracture resistance? Yes 271 (75%) 920 (74%) 878 (73%) 712 (74%) 1443 (71%) No 70 (20%) 273 (21%) 290 (23%) 230 (23%) 535 (25%) Not specied 19 (5%) 56 (5%) 42 (4%) 29 (3%) 210 (4%) Which post type do you use most frequently? Prefabricated Cast post Other 116 (32%) 62 (17%) 182 (51%) 392 (31%) 200 (16%) 657 (53%) (23%) (27%) (6%) (50%) (6%) (37%) (40%) (15%) (18%) (8%) (11%) (1%) 406 (34%) 220 (18%) 584 (48%) 307 348 65 559 78 506 453 181 307 63 137 11 (25%) (29%) (5%) (46%) (6%) (42%) (37%) (15%) (25%) (5%) (11%) (1%) 352 (36%) 178 (18%) 441 (46%) 260 263 69 448 64 466 299 165 295 53 107 12 (27%) (27%) (7%) (46%) (6%) (48%) (31%) (17%) (30%) (6%) (11%) (1%) 737 (36%) 423 (21%) 882 (43%) 473 663 113 947 162 964 663 327 668 122 200 22 (24%) (33%) (6%) (46%) (8%) (47%) (33%) (16%) (33%) (6%) (10%) (1%)

When you use a prefabricated metal post, which type do you prefer? * Parallel-sided 94 (26%) 291 Tapered 108 (30%) 337 Combined parallel-sided/tapered 21 (6%) 76 Screw type 188 (52%) 625 Split exible post 17 (5%) 77 Most frequent failures* Loss of retention Endodontic failure Crown fracture Root fracture No failures Other Not specied
*Multiple answers possible.

102 170 43 40 41 40 4

(28%) (47%) (12%) (11%) (11%) (11%) (1%)

462 501 183 229 102 135 18

with the exception of single-rooted abutment teeth for telescopic crowns as part of a combined xed-removable partial denture. In particular, in the planning for xed dental prostheses on multi-rooted teeth, the prefabricated post is preferred in two thirds of all treatments (Table III). Screw-post designs are used more frequently than any other prefabricated post system (47%, n=2767), irrespective of the frequency of post placement. The results differ signicantly depending on the years of experience. Tapered and parallel-sided posts are each used in approximately one fourth of all clinical situations. Half of the dentists cement endodontic posts with zinc phosphate cement (51%, n=2956), followed
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by GIC (38%, n=2199), and composite resin luting materials (15%, n=872). Reported reasons for unsuccessful post placements are loss of retention (43%), endodontic problems (36%), and root fractures (26%). The results differ signicantly between the groups depending on the years of experience. Crown fractures (15%) were reported to be seen comparatively seldom, irrespective of the professional experience.

DISCUSSION
This nationwide German survey found that a majority of dentists believe in the reinforcement effect of an endodontic post. Hence, posts are placed frequently,
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Table II. Responses regarding treatment concept for ETT based on frequency of post placement by respondents
Frequency of post placement - n (%) Seldom Frequently Usually

Do you believe that every ETT must receive a post? Yes 51 (4%) 37 (3%) 1138 (93%) No 1316 (29%) 1354 (30%) 1889 (41%) Not specied 7 (15%) 3 (6%) 37 (79%) Total 1226 (21%) 4559 (78%) 47 (1%) Do you believe that a post reinforces an ETT and reduces the fracture probability? Yes, denitely 427 (23%) 550 (24%) 2185 (53%) No 640 (44%) 470 (32%) 340 (24%) Do you believe that reducing the level of the nishing line below the core foundation following post cementation increases the fracture resistance? Yes 956 (70%) 1033 (74%) 2235 (73%) No 369 (27%) 316 (23%) 713 (23%) Not specied 49 (3%) 45 (3%) 116 (4%) Total 1374 (100%) 1394 (100%) 3064 (100%)

Fig. 1. Frequency of post placement as function of number of responding dentists in percent: Seldom, up to 30% of ETT were treated with posts (n=1374, 24%); frequently, between 30% to 70% of ETT were treated with posts (n=1394, 24%); usually, when more than 70% of ETT were treated with posts, when cast restoration was planned (n=3064, 52%).

even when they are not specically needed to support a core. The return rate of the questionnaire was only 16.5%. This is low compared with return rates from other published studies ranging from 25.1% to 70%.42,43,52 Unfortunately, the anonymous nature of the survey did not allow for a reminder. Furthermore, there is no established postgraduate education and licensing for prosthodontists or endodontists in Germany. Therefore, it was not possible to survey a sample of dentists with specialty status such as prosthodontists. Another shortcoming of the questionnaire is that it did not distinguish between the restoration of anterior and posterior teeth. It was apparent that half of the respondents usually place (in more than 70% of all treatments) an endodontic post, and a fourth of them do so frequently (in 30% to 70% of all treatments). The majority (78%) of responders were not of the opinion that every ETT must be treated with a post. This result is similar to a Swedish survey.45 In comparable studies among general practitioners in Sweden, the United Kingdom, and the United States, 29%, 25%, and 59% (nonfaculty members), respectively, were of the opinion that a post reinforces an ETT.44,45,51 In Germany, half of the dentists surveyed, regardless of experience, are convinced of this for all treatments, and a smaller percentage assumes a reinforcing effect when post placement is performed either adhesively or conventionally. However, while almost 90% of those who believe that a post is always necessary usually place one, only 30% of those who believe that it is unnecessary actually refrain from placing a post. Therefore, it may be concluded that dentists are aware that a post is not needed for every ETT, although they
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assume a reinforcing effect. This is contrary to the current state of evidence-based knowledge, which maintains that a post does not result in reinforcement of the root or tooth.11,31 The number of those who perceived a reinforcement effect by using the ferrule effect averaged 72%, which is in agreement with the scientic literature, where the ferrule effect is suggested as a key element for avoiding clinical failures.21,54-59 Dentists who frequently or usually use posts were most aware of this effect. The preference for prefabricated post systems in general differed clearly from data gathered from Swedish and British dentists,44,45 for whom cast post and core was the treatment of choice. In Germany, independent of the type of intended treatment and the tooth to be restored, prefabricated posts were favored. Only for single-rooted teeth, for which a telescopic crown is planned as part of a combined xed-removable partial denture, is the cast post and core used with the same frequency as the prefabricated post. In contrast to this, in the United Kingdom prefabricated posts were considered predominately for the restoration of posterior, multi-rooted teeth.42 The question remains as to which decision criteria led to the preferred use of each selected post system. In the scientic literature, no clear evidence-based recommendations exist. The comparatively high retention of a screw design post, even with a low placement depth, may be a decisive factor for its favored position among prefabricated post types.22 However, screw design posts are generally known to introduce high stress levels within the root, resulting in root fractures. Therefore, it may not be surprising that root fractures have been observed as the
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Table III. Type of post used in restoration of endodontically treated single- and multi-rooted teeth*
Cast post and core Tooth type Denitive restoration n % Prefabricated post n % n Not specied %

Single-root

Multi-root

Crown Fixed prosthesis Telescopic F-RPD Crown Fixed prosthesis Telescopic F-RPD

2293 2445 2778 1557 1788 2071

39 42 48 27 31 36

3404 3216 2812 4059 3788 3449

58 55 48 70 65 59

135 171 242 216 256 312

2 3 4 4 4 5

F-RPD, Combined xed-removable partial denture. *Multiple answers possible.

Table IV. Post design and material used for prefabricated and cast post-and-core restoration*
Post/core material Post shape n %

Prefabricated post Metal Screw type Tapered Parallel-sided Combined parallel-sided/tapered Threaded Nonmetal Tapered Parallel-sided Combined parallel-sided/tapered Other No answer Core Composite resin Glass ionomer cement Modied glass ionomer cement Amalgam Other No answer Cast post and core Post/core Gold cast Nonprecious alloy Titanium All ceramic Dont know
*Multiple answers possible.

2767 1719 1425 344 398 889 237 298 202 552 3000 1505 967 27 624 691 4287 727 330 153 30

47.4 29.5 24.4 5.9 6.8 15.2 4.1 5.1 3.5 9.5 51.4 25.8 16.6 0.5 10.7 11.8 73.5 12.5 5.7 2.6 0.5

United States.51 While composite resin and amalgam are recommended as core materials, GIC was found to be unsuitable, especially for large defects without hard tissue support.23,24,27 The relatively frequent use of GIC and RMGIC in Germany (about 40%) may cause an increased risk of failure of the postendodontic restoration. In view of the partially contradictory data, dentists seem to have difculty in developing a consistent treatment concept from the great range of various materials, procedures, and supporting evidence available. One possible explanation for these inconsistencies is that the majority of current treatment recommendations are primarily based on in vitro studies, and unequivocal evidence from long-term clinical studies on the success rates of different restorative techniques is scarce. It is expected that once a certain treatment concept is supported by data from clinical studies, including randomized controlled trials and large observational studies, a more homogeneous evidence-based dental practice will emerge.

CONCLUSIONS
Within the limitations of this study, the following conclusions were drawn: 1. Both cast posts and cores are used by the majority of German dentists (55%), whereas one third (34%) use prefabricated posts exclusively. Screw designs are the post of choice used by half of the surveyed dentists (47%). 2. Composite resin cores (51%) are preferred by more than half of the dentists, followed by GIC (26%) and RMGIC (17%). Amalgam is rarely used. 3. Adhesive post placement plays a small role (15%); conventional post placement with zinc phosphate cement is popular (51%), followed by the use of GIC (38%). 4. The majority of dentists (55%) indicate that a post reinforces an ETT, and yet a majority of those (65%) believe that not every ETT must receive a post. However, one third of the dentists in Germany will place a post in every ETT.
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third most common cause for failure (26%) in the present survey. Interestingly, screw design posts are not used frequently (approximately 10%) in the United States.51 Combined, parallel-sided and tapered post designs, as recommended by other authors,30 are accepted by only a minority in this study. Although results found in 2 regions of the United Kingdom42,44 and the United States51 indicate amalgam is popular, it is rarely used for core foundation procedures in Germany (0.5%). This may be due to the fact that within the German population amalgam is still considered to cause health threats, such as mercury intoxication. The majority of German dentists use composite resin, followed by GIC and resin-modied GIC (RMGIC). With the exception of GIC, these results are in agreement with observations made in the
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5. Due to the partially contradictory responses, it is difcult to derive a generalizeable, clear, and structured treatment concept.
The authors thank the local German Association of Dentists for the gratuitous distribution of questionnaires, and the participating dentists for their interest and cooperation.

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NAUMANN, KIESSLING, AND SEEMANN

51. Morgano SM, Hashem AF, Fotoohi K, Rose L. A nationwide survey of contemporary philosophies and techniques of restoring endodontically treated teeth. J Prosthet Dent 1994;72:259-67. 52. Slaus G, Bottenberg P. A survey of endodontic practice amongst Flemish dentists. Int Endod J 2002;35:759-67. 53. Trautmann G, Gutmann JL, Nunn ME, Witherspoon DE, Shulman JD. Restoring teeth that are endodontically treated through existing crowns. Part II: survey of restorative materials commonly used. Quintessence Int 2000;31:719-28. 54. Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of endodontically treated teeth. J Prosthet Dent 1990;63:529-36. 55. Isidor F, Brondum K, Ravnholt G. The inuence of post length and crown ferrule length on the resistance to cyclic loading of bovine teeth with prefabricated titanium posts. Int J Prosthodont 1999;12:78-82. 56. Zhi-Yue L, Yu-Xing Z. Effects of post-core design and ferrule on fracture resistance of endodontically treated maxillary central incisors. J Prosthet Dent 2003;89:368-73. 57. Pierrisnard L, Bohin F, Renault P, Barquins M. Corono-radicular reconstruction of pulpless teeth: a mechanical study using nite element analysis. J Prosthet Dent 2002;88:442-8. 58. Sorensen JA, Martinoff JT. Intracoronal reinforcement and coronal coverage: a study of endodontically treated teeth. J Prosthet Dent 1984;51: 780-4.

59. Guzy GE, Nicholls JI. In vitro comparison of intact endodontically treated teeth with and without endo-post reinforcement. J Prosthet Dent 1979;42: 39-44. Reprint requests to: DR MICHAEL NAUMANN DEPARTMENT OF PROSTHODONTICS AND GERIATRIC DENTISTRY CHARITE, UNIVERSITY MEDICAL SCHOOL, CAMPUS VIRCHOW FOHRERSTR. 15 D-13353 BERLIN, GERMANY FAX: 49-0-30-450-562900 E-MAIL: michael.naumann@charite.de 0022-3913/$32.00 Copyright 2006 by The Editorial Council of The Journal of Prosthetic Dentistry.

doi:10.1016/j.prosdent.2006.08.028

Noteworthy Abstracts of the Current Literature

Evaluation of stress induced in peri-implant bone tissue by mist in multi-implant prosthesis Natali AN, Pavan PG, Ruggero AL. Dent Mater 2006;22:388-95.

Objectives: The objective of the present work was to use numerical analysis to evaluate the relevance of stress states induced in peri-implant bone tissue by a mist in a dental xed prosthesis. Mists in both mesial-distal and lingual-labial directions were considered to investigate a realistic conguration of the problem. Materials and methods: A nite element model of a portion of a mandible with two implants connected by a gold alloy bar was dened on the basis of the morphometric data of a partial edentulous patient. A specic procedure was developed to represent the bar-implant coupling in the case of a misalignment between the implant and central axes of the anchoring site to the bar. Loading conditions related to occlusal forces were also considered. Results: The numerical analysis of the implant-bridge mist showed signicant stress effects on the periimplant bone tissue. For the specic prosthetic conguration considered, the maximum compressive stress was in the range of 40-60 MPa, depending on the mist considered. The stress level was largely affected by the axial and bending stiffness characteristics of bar-implant compound. Signicance: Stress analysis using numerical methods made it possible to estimate stress states with high accuracy in terms of intensity and location. For the case considered, stress induced by mist was comparable with that related to occlusal forces. Therefore, a possible bar-implant mist should be carefully considered to ensure the reliability of the prosthetic system.Reprinted with permission of The Academy of Dental Materials.

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