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Original Article Histological evaluation of the root apices of

failed endodontic cases

Camilla Nicole Pecora, Jagan Kumar Baskaradoss1, Abdullah Al-Sharif2,

Mansour Al-Rejaie3, Hussein Mokhlis4, Khalid Al-Fouzan5, Gabriele E. Pecora
Private practice, Rome, Italy, 1Department of Dental Public Health, School of Dental Medicine, Case Western
Reserve University, Cleveland, Ohio 44106, USA, 2Consultant, Director of Endodontic Board, Riyadh Military
Armed Force Hospital, 3Consultant Endodontist, King Saud Bin Abdulaziz University for Health Sciences,
KAMC, National Guard Health Affairs, 4Consultant, Department of Endodontics, Prince Sultan Military Medical
City, Denal Clinics, 5Consultant and Head of Endodontics Division, College of Dentistry, King Saud Bin
Abdulaziz University for Health Sciences, KAMC, National Guard Health Affairs, Riyadh, Saudi Arabia

Key words:
Apical third, bacteria, debris, endodontic
failure, histology
Address for correspondence:
Dr.Khalid AlFouzan,
Consultant and Head Division,
Endodontics, College of Dentistry,
KSAUHS, King Abdulaziz Medical
City, P.O.Box22490,
Riyadh 11426, Saudi Arabia.
Email:fouzank@ngha.med.sa
ABSTRACT
Aim: The aim of this histological study was to evaluate the different causes
of the failures of the endodontic treatment. Materials and Methods: Adult
patients who were referred for endodontic surgery and for whom rootend
resection was considered suitable were invited to participate in this study.
The inclusion criteria were: (1) Patients aged between 18 and 65years;
(2) teeth with apical periodontitis that was diagnosed radiographically;
(3) the tooth could not be adequately and better managed by rootcanal
retreatment; and (4) the crown of the tooth was adequately restored. One
hundred root apices were surgically removed together with the periapical
pathological tissue from 92patients(56males and 36 women).Histological
sectioning was performed on calcified specimens that were embedded in
a suitable medium. Results: The causes of endodontic failure identified
through histological evaluation were as follows: Presence of bacterial
and debris into canals (51%), apex transposition and overfilling (3%),
presence of the isthmus(21%), bacterial colonization of root surface(2%),
untreated canals(11%), and filling material outside root canal(4%).
There was no significant difference between the distribution of teeth and
the causes of endodontic failures(P=0.32). Conclusions: The present
study demonstrated that the most common cause of endodontic failure
is the insufficient cleaning of the root canal system. It also explores the
effectiveness of histological evaluation of the root apex following rootend
resection in exploring the causes of endodontic failures.

INTRODUCTION hermetic apical seal. Of late, the focus has shifted

to encourage comprehensive threedimensional

H igh standard of care is required to minimize

the incidence of endodontic failures. [1,2]
In the past, the success of root canal therapy
filling of the whole root canal space after
thorough debridement.[3]

was ascribed to the ability of the operator to Numerous factors including the presence of
effectively sterilize the root canal and achieve a extraradicular and intraradicular microbes,
contributes toward endodontic failures. [4,5]
Access this article online Persistence of microbes in the apical portion of
Quick Response Code: the root canal system has been reported to be
Website:
one of the most common causes for endodontic
www.saudiendodj.com
failures.[6] Studies have demonstrated that bacteria
DOI:
located near isthmuses, ramifications, deltas,
10.4103/1658-5984.155450
irregularities and dentinal tubules may sometimes
be unaffected by endodontic disinfection
120 Saudi Endodontic Journal May-Aug 2015 Vol 5 Issue 2
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Pecora, etal.: Histological evaluation of endodontic failure
procedures.[6,7] This may allow the microorganisms to
survive and, depending on several factors, induce failure.
It has also been suggested that certain intrinsic or
extrinsic nonmicrobial factors may also contribute
toward endodontic failures. Foreign body reaction in the
periradicular tissues to cholesterol crystals precipitated
from disintegrating host cells can be an etiological
factor in nonresolving chronic inflammation.[8] Certain
rootfilling materials like talccontaminated guttapercha
cones, can initiate a foreign body reaction if they are
displaced into the periradicular tissues.[9] The cellulose
component of paper points and cotton wool may
contribute to failure of root canal treatment if they
come in contact with the periradicular tissues.[10]
Diagnosis of endodontic failures is usually made based
on the clinical presentation and radiologic evaluation.
Most of the endodontic failures are located near the
apical third, and it may not be possible to clearly define
the lesion based on radiographs alone.[11,12] Histological
evaluation after surgical apex resection would be able
to provide a more accurate diagnosis of the status of
the root apex.[13] The present study was designed to
histologically determine the causes of endodontic failure
from the apices of rootend resected teeth.
MATERIALS AND METHODS
This crosssectional study was performed in the
endodontic clinics at the College of Dentistry,
King Saud Bin Abdulaziz University for Health
Sciences (KSAUHS), Riyadh, Saudi Arabia. Adult
patients who were referred for endodontic surgery and
for whom rootend resection was considered suitable
were invited to participate in this study. Approval for
the study was obtained from the Institutional Ethics
Committee. The inclusion criteria included (1) patients
aged between 18 and65years; (2) teeth with apical
periodontitisthat wasdiagnosed radiographically; (3) the
tooth could not be adequately and better managed by
rootcanal retreatment; and (4) the crown of the tooth
was adequately restored[Figure1]. Preoperatively, there
was an assessment of the patients medical condition,
the general oral condition, percussion sensitivity and
mobility of the affected tooth, the presence of pain,
dental caries and restoration in the tooth, functioning
of the tooth and the endodontic status. Exclusion
criteria included (1) patients who were medically unfit
for the study; (2) presence of metallic restorations; and
(3) presence of root resorption or fractures.
Saudi Endodontic Journal May-Aug 2015 Vol 5 Issue 2
a b
Figure1: Periapical radiographs of failed endodontic treatment in
the right mandibular first molar showing periapicalradiolucency (a).
A 6-month post-operative radiograph showing failed endodontic
retreatment of the right mandibular first molar (b)
A convenient sample of 100 root apices that were
surgically removed together with the periapical
pathological tissue from 92patients were histologically
analysed. The surgical procedure was performed
under local anesthesia and preoperatively the patient
rinsed his/her mouth with an antiseptic mouthwash
(chlorhexidinegluconate 0.2%). Abuccalmucoperiosteal
tissue flap was raised and sufficient bone was removed
with a bur to expose the apex. The teeth were resected
apically 3mm from the root apex at a 90oangle to the
long axis of the root using a surgical microscope(Global,
St.Louis, MO, USA) at 8X magnification. The root
resection was made with a tungsten carbide straight
fissure bur mounted on contraangle, highspeed
handpiece(KavoDentale, Biberach, Germany) and with
constant water irrigation to avoid overheating. Ultrasonic
diamond tip (Spartan, Fenton, MO, USA) was used
to prepare 3mm retrograde cavities, which were filled
with mineral trioxide aggregate(MTA) carried with the
MAP system. Root ends were wrapped with wet gauze
to facilitate MTA setting. The wound was closed and
postoperative radiograph was taken to ensure adequate
technical quality of the procedure. The patient was asked
to take analgesics postoperatively and to use an antiseptic
mouthwash twice a day for 1week. After a week the
sutures were removed.
All the surgical procedures were performed by a
single calibrated endodontist. Apilot study, involving
a similar surgical procedure was performed on five
randomly selected teeth by the same endodontist. The
surgical technique was evaluated for consistency by
two experienced endodontists on the postoperative
radiograph. The intraexaminer reliability was found to
be good, with a kappa() value of 0.76.
The root apices were stored in 10% formalin and
histologically evaluated. Histological sectioning were
perfor med on calcified specimens embedded in
methylmethacrylate(MMA) and on demineralized
specimens embedded in LR White(Fluka, Buchs,
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Pecora, etal.: Histological evaluation of endodontic failure
Switzerland).Criteria of evaluation for failure were
adopted from Rud etal. [14] All the patients were
followedup for a minimum of 12months during
which, all the teeth remained asymptomatic and showed
radiographic evidence of healing[Figure2].
Statistical analysis
All statistical analyses were carried out using SPSS
17.0(Statistical Package for the Social Sciences for
Windows; SPSS Inc., Chicago, IL, USA). Frequency
distribution for all the categorical variables were
obtained. 2 test of significance was performed to
Figure2: A 12-month post-operative radiograph of the right
mandibular second premolar and first molar showing radiographic
evidence of healing
a b
Figure4: Photomicrograph of the debris outside the root canal at low
power magnification (a) and at high power magnification (b)
Figure6: Photomicrograph of untreated and missed canal
122
determine the relationship between causes of failures
and distribution of teeth.
RESULTS
The study population consisted of 56males(60.9%)
and 36females(39.1%), with a mean age of
49.2years(SD10.3). Of the apices of the teeth
included in the study, 30 were from anteriors,
26 from premolars and 44 from molars. The causes of
endodontic failures are shown in Table1. The results
indicated that the presence of bacteria[Figure3] and
debris[Figure4] in the root canal were the most
common causes for endodontic failures(51%). In
addition, the presence of isthmus[Figure5], untreated
Figure3: Photomicrograph of the bacterial colonization in the root canal
a b
Figure5: Cross-sectional photomicrographof the debris in the isthmus
of root canalat low power magnification (a) and at high power
magnification (b)
Figure7: Photomicrograph of micro-fracture
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Pecora, etal.: Histological evaluation of endodontic failure

canals[Figure6] and microfractures[Figure7] also reported to be successful in reducing the bacterial

contributes toward endodontic failures. There was
no significant difference(P=0.32) between the
distribution of teeth and the causes of endodontic
failures[Table2].
DISCUSSION
counts in the root canal space.[21,22] In the present study,
the number of surviving bacteria was observed to be
higher than those reported in other studies.[23] However,
it must be mentioned here, that the histological findings
from samples obtained during apical surgery may differ
from findings obtained by teeth extractions.[24]

Improvement in the techniques, as well as the
introduction of new instruments, have positively raised
the quality of endodontic treatment.[15] Instrumentations
of the pulp chamber may leave debris in the root
canal.[16,17] This debris increases the risk of bacterial
contamination which may lead to the failure of
endodontic treatment. [5] Debris may be compacted
along the entire length of the canal surface and results
in reduced adaptation of sealer and guttapercha.
The high percentage of bacteria and the debris in
the root canal shows that electronic apex locators
and nickel titanium rotary instruments, together with
vertical condensation of guttapercha with cement,
may not always be effective in the apical third of the
root. Previous studies have shown that the number
of bacterial cells persisting after instrumentation and
irrigation with sodium hypochlorite is usually low in
teeth with chronic periapical access.[18] Also, the use
of bacteriostatic and bactericidal liquids,[19,20] have been
Table1: Causes of endodontic failures
Cause for endodontic failure Percentage
Presence of bacteria and debris in the canals
Apex transposition and overfilling
Presence of the isthmus
Bacterial colonization of root surface
Untreated canals
Filling material outside of the root apex
Microfractures
The high number of untreated canals provides evidence
that despite the accuracy and the experience of the
operators, it is difficult to detect calcified canals. It
has been reported that the vertical condensation may
induce microfractures in the apical dentin.[25] This can
be an important reason for surgical failure especially
if they go undetected. Also, the bacterial colonization
of microfractures is difficult to detect with clinical and
radiographical exploration alone. This finding reinforces
the fact that clinicians have to be extremely careful
while selecting the size of their spreaders and also the
amount of pressure applied during the procedure.
Mandibular molars in our study constituted
approximately onethird of the failures overall and 70%
of the endodontic failures. This is similar to the study
by Swartz etal.[26] which described significantly lower
success rate while treating mandibular molars.
Another important finding of this study was the
detection of untreated isthmus, present in 21% of the
teeth. The isthmus is a narrow connection between two
root canals and it usually contains pulp tissues.[27] This
anatomic formation is a part of the root canal system
51
3
and not a separate entity. Although the new endodontic
21 techniques and instruments have improved the cleaning
2 and the shaping capability, treating the isthmus with
11 a nonsurgical approach may still be challenging.
4 Untreated isthmus was found in18 apices of the molars,
8
two apices of the lower central incisors and one in a

Table2: Teeth distribution vs. causes of endodontic failures

Tooth Failures
Bacteria Apex Isthmus Bacterial Untreated Filling material Microfractures Total
and debris transposition colonization of canals outside of the
in canal and overfilling root surface root apex
Maxillary anteriors 12 0 3 1 0 0 0 16
Maxillary premolars 7 0 5 0 0 0 2 14
Maxillary molars 11 1 5 0 2 2 3 24
Mandibular anteriors 6 1 3 0 2 2 0 14
Mandibular premolars 8 0 2 0 1 0 1 12
Mandibular molars 7 1 3 1 6 0 2 20
Total 51 3 21 2 11 4 8 100
P=0.32

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Pecora, etal.: Histological evaluation of endodontic failure
premolar. The complicated anatomy of the tooth and
clinical error on the part of the treating dentist could
explain the mismanagement of the isthmus.[27,28]
Within the limitation of this study, it would be possible
to recommend dentists to undergo adequate training
prior to attempting endodontic procedures. But, good
clinical skill alone may not be sufficient to ensure a
successful outcome. The importance of correct case
selection and a clear understanding of the biological
basis of treatment must also be appreciated.
CONCLUSIONS
The present study demonstrated that the most
common cause of endodontic failure is the insufficient
cleaning of the root canal system. It also explores the
effectiveness of histological evaluation of the root apex
following rootend resection in exploring the causes of
endodontic failures.
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How to cite this article: Pecora CN, Baskaradoss JK, Al-Sharif A,
Al-Rejaie M, Mokhlis H, Al-Fouzan K, et al. Histological evaluation of the
root apices of failed endodontic cases. Saudi Endod J 2015;5:120-4.
Source of Support: Nil. Conflict of Interest: None declared.
Saudi Endodontic Journal May-Aug 2015 Vol 5 Issue 2