Quality Resource Guide€¦ · root canal system, especially in anatomically complex or missed...

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Author AcknowledgementsRENATO M. SILVA, DDS MS PHDDepartment of Endodontics

ARIADNE M. LETRA, DDS MS PHDDepartment of Endodontics Department of Diagnostic and Biomedical Sciences

School of DentistryUniversity of Texas Health Science Center at Houston

Drs. Silva and Letra have no relevant relationships to disclose.

The following commentary highlights fundamental and commonly accepted practices on the subject matter. The information is intended as a general overview and is for educational purposes only. This information does not constitute legal advice, which can only be provided by an attorney.

© Metropolitan Life Insurance Company, New York, NY. All materials subject to this copyright may be photocopied for the noncommercial purpose of scientific or educational advancement.

Published December 2017. Expiration date: December 2020.

The content of this Guide is subject to change as new scientific information becomes available.

Educational ObjectivesFollowing this unit of instruction, the learner should be able to:

1. Appropriately assess a tooth that demonstrates signs and symptoms of endodontic treatment failure.

2. Discuss potential causes of an endodontic treatment failure with the patient.

3. Communicate the potential treatment options and relative prognosis of each to a patient having a tooth experiencing endodontic failure.

4. Work with the patient experiencing endodontic failure, and appropriate other clinicians, to facilitate the next stages of therapy or referral, and follow-up care.

IntroductionPreservation of a patient’s natural dentition remains an important aspect in securing his/her oral health. Conventional endodontic therapy has been shown to be a very predictable treatment modality (success approximately 90%) for infected pulpal tissue.1 However, endodontic therapy can occasionally fail.2 Signs and symptoms of endodontic treatment failure include radiographic apical/periapical radiolucency, swelling, sinus tract and pain. Treatment inadequacies are the major cause of endodontic failure.3-5

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Quality Resource Guide

Managing Endodontic Treatment Failures

Quality Resource Guide l Managing Endodontic Treatment Failures 1st Edition 2

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treated tooth that has clinical symptoms and/or persistent apical periodontitis will often respond to nonsurgical endodontic retreatment, apical surgery, or intentional replantation.6

Endodontic treatment failures typically demonstrate complexities (root morphology, tooth position, comorbidities) and should generally be treated by a general practice dentist with extensive experience in endodontic therapy, or referred to an endodontist, to assure optimal results from retreatment. This Quality Resource Guide (QRG) summarizes important aspects to help the general dentist to identify endodontic treatment failures, determine potential causes of the failure, and assist the patient to determine appropriate steps to address the failure. The QRG will also briefly review contemporary endodontic approaches that may be used in retreatment of endodontic failures, so the practitioner may better discuss those potential options with the patient and other clinicians who may become involved in therapy.

Diagnosis of an Endodontic Treatment FailureThe initial consultation with a patient demonstrating a history and symptoms consistent with a tooth experiencing endodontic failure should allow adequate time to listen to the patient’s chief complaint, and any additional information they may possess (length of time since the previous treatment, why the treatment was performed, any issues that occurred during therapy or during the post-operative period, and past, as well as

The most common treatment deficiencies leading to failure include:

• Inappropriate or inadequate debridement of microorganisms and their products from the root canal system, especially in anatomically complex or missed canals.

• Iatrogenic complications, such as root perforations, ledges, over or under extension of the root canal filling, and separated instruments.

• Inadequate fill and/or seal, resulting in coronal leakage and/or leakage around the canal filling material.

• Inability to adequately remove apical calculus or extraradicular biofilms.

• Failure to detect tooth fracture

Infrequently, endodontic treatment may appear to have followed the highest practice standards and yet may fail. Failure is most often attributed to a persistent or secondary intraradicular infection in these situations, although extraradicular infections cannot be discarded as a potential cause.3

An important step in evaluating a tooth with failed endodontic therapy is assessing why the previous endodontic treatment may have failed and determining what additional care is best suited for the patient. Treatment options to save natural teeth should generally be very carefully considered before recommending extraction of a tooth with failing endodontic therapy. An endodontically

current symptoms). Information obtained from the clinician providing initial therapy, as well as any other clinicians the patient has seen to address the present symptoms may add helpful details.

Proper diagnostic procedures, including clinical and radiographic examinations (Table 1) must be carried out. Ideally, conventional periapical radiographs should be taken from different angulations and, in some cases additional images obtained from cone beam computed tomography (CBCT) may be of assistance (Case 1).

The clinician should consider these aspects following obtainment of clinical and radiological data:

• Positive palpation and percussion are generally indicators of apical periodontitis or inflammation of the periodontium.

• Occlusal evaluation and adjustment, if necessary, should be completed to eliminate occlusal stresses as a potential factor for symptoms.

• The presence of a positive response to thermal and electric pulp tests in a tooth having previous endodontic treatment may be an indication of missed or untreated canals.

• Sinus tract/parulis must be traced with a gutta-percha cone to localize the source of infection.

• A tooth with a deep periodontal pocket in a localized region may indicate root fracture.

• Periodontal attachment loss and tooth restorability should be carefully evaluated when considering endodontic retreatment, apical surgery or intentional replantation.

• Coronal microleakage through inadequate or fractured coronal restorations, as well dental caries, are common causes of treatment failure.

• Apical radiolucency alone is not an indication for endodontic retreatment.

• Additional signs and symptoms, as well as information provided by the patient and treating dentists, must be carefully considered before considering retreatment procedures.

Table 1 - Diagnostic Assessment

Clinical Examination Procedures

PalpationPercussionThermal TestsElectric Pulp TestPeriodontal ProbingTooth Mobility TestingTransillumination and StainingAssess Signs of Inflammation, Redness, Swelling, Fistula/Parulis

Radiographic Evaluation Questions

Dental caries?

Calcification(s)?

Radiolucencies or Radiopacities?

Root Resorption?

Root Perforation(s) and/or Fracture(s)?

Quality of Root Canal Filling or Altered Canal Anatomy?

Intracanal Post(s)?

Previous Apical Surgery?


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Case 1

Case #1 The Importance of a Correct Diagnosis. (A) The patient had previous endodontic treatment on tooth #18 due to a large apical radiolucency observed on a periapical radiograph that persisted post-therapy; (B,C) Cone-beam computed tomography showed the entire extension of the lesion and provided more details on a “C-shaped” root canal anatomy; (D) A sinus tract was observed in the buccal mucosa and an inserted gutta-percha cone pointed to the apical region of tooth #18; (E,F) Nonsurgical endodontic retreatment was performed on #18 and apical healing was observed after 12-months.

TREATMENT MODALITIES TO MANAGE ENDODONTIC TREATMENT FAILURESNonsurgical Endodontic RetreatmentWhen possible, endodontic retreatment should be carefully considered as the treatment choice for a tooth with endodontic failure.7 Endodontic retreatment involves removal of root canal filling materials (and posts, if present), followed by cleaning, reshaping, and obturation of the root canal system.6 The goal of endodontic retreatment is to

regain canal patency, provide maximum reduction of microorganisms via cleaning and shaping, and create a hermetic seal with biocompatible obturation materials and endodontic sealers.8 The challenges associated with endodontic retreatment include removal of the previous obturation material, correcting any procedural errors generated during the initial treatment, locating missed canals, and eliminating potential treatment-resistant bacteria.9

According to a recent meta-analyses, the pooled weighted success rate for nonsurgical retreatment is approximately 78% (range 62-90%).9-11

Retreatment success rates may be due to improved instrument properties and advanced technologies introduced since the time of initial therapy, allowing enhanced disinfection and obturation of the root canal system. An operating microscope has been shown to be an important asset for the clinician


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Table 2 - Ultrasonic Tips And Techniques Suggested For Post Removalproviding endodontic retreatment. Magnification and illumination improves the ability to locate canal orifices and/or untreated canals, remove core material and intracanal posts, and also detect separated instruments and pulp chamber perforations. A recent study reported that mesial buccal roots of maxillary first molars are three times more likely to present with a periapical radiolucency at the time of retreatment if the initial endodontic treatment was performed without the use of a microscope.12

Post Removal Before Nonsurgical Endodontic RetreatmentThe presence of an intra-canal post presents an important consideration when planning endodontic nonsurgical retreatment. Post length and diameter, post type, cement used for post cementation, accessibility, width of the remaining root canal walls, and clinical skill can impact therapy outcome.13

Longer and wider posts are generally more difficult to remove, and increase the risk of root fracture during removal. When safe removal of the post is questionable or unpredictable, apical surgery or intentional replantation should be considered.

Different techniques and devices for post removal have been described in the literature (special burs, traction devices, pneumatic extractors and hemostatic forceps). However, these techniques are aggressive and increase the risk of perforations, root fractures and potential loss of the tooth. Conservative techniques using various ultrasonic devices and tips (Table 2), with the use of an operating microscope, appear to be the most prudent approach for post removal.

Filling Material Removal During Nonsurgical Endodontic RetreatmentThe need to remove filling materials from the root canal system is one of the major differences between primary endodontic therapy and retreatment. Removal of the obturating materials from the root canal system should not result in changes in canal morphology.14 Root-filling materials can be removed with stainless steel hand instruments or mechanized nickel-titanium

(NiTi) instruments, with or without heat, solvents, and/or ultrasonic instruments. Common obturating materials typically found during retreatment procedures are gutta-percha, plastic and metal gutta-percha carriers, and silver points. Different types of pastes and hard-setting cements largely used in the past [resorcinol-formaldehyde resin (Russian Red) and Sargenti paste] are also commonly found, particularly in root canals completed in some non-U.S. countries.

Removal of Gutta-PerchaGutta-percha is the most commonly used material for obturation of root canal systems. Considerations governing the retreatment of gutta-percha obturated canals include the quality of the condensation, the length of the obturation and the shape of the root canal system.15 When gutta-percha is poorly condensed, the best removal technique involves engaging the gutta-percha cones on the flutes of a hand file (Hedströen instruments are particularly


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effective).14,15 Hedströem files can be passively rotated clockwise into the gutta-percha mass, which is then removed upon withdrawal of the instrument from the canal.16 Gutta-percha cones can also be bypassed with small instruments, creating space for the use of Hedströen files to retrieve the cones.

When dealing with well-condensed gutta-percha, the coronal portion of the obturation mass should be removed with ultrasonic tips, rotary instruments, Gates Glidden burs, or heated pluggers. The initial space created by these instruments will facilitate the insertion of additional instruments for the removal of gutta-percha from the middle and apical thirds of the canal. The space created also serves as a reservoir for solvents that can improve access for further instrumentation.14 Solvents such as chloroform, xylol and halothane are important adjuvants to gutta-percha removal from smaller and more curved canals. Chloroform rapidly softens the gutta-percha and, when used in combination with hand instruments, allows removal of gutta-percha in a crown-down manner. Although the use of mechanized instrumentation is considered faster than manual removal of filling material, the use of a solvent does not speed up this procedure.17

Despite advances in instrument metallurgy, design and kinematics, as well as endodontic retreatment techniques, current research shows that, regardless of the instrument and/or technique used, obturation materials are unable to be completely removed from the root canal walls.17 Thus, several supplementary techniques have been proposed to enhance the removal of remaining root filling material during endodontic nonsurgical retreatment, including the use of lasers, specialized files and sonic/ultrasonic tips.17 Ultrasonic tips can be used in a passive irrigation mode with a non-cutting tip at low power, reaching approximately 2mm from the working length. Four cycles of 15 seconds each alternating NaOCl and EDTA rinses are generally recommended. The practitioner can also touch the canal walls with ultrasonic tips specially designed for retreatment, using lower power settings in a final attempt to remove any remaining material from the root canal walls.

If a clinician chooses to use multiple appointment treatment is used, intracanal medication such as calcium hydroxide [Ca(OH)2] paste can be used between appointments. Ca(OH)2 inhibits microbial growth and dissolves necrotic tissue remnants inside the root canal system.18

Removal Of Carrier-Based Obturation SystemsCarrier-based obturation systems consist of a coating of gutta-percha surrounding another type of material (plastic, metal or a core of cross-linked gutta-percha), which serves as a carrier. Although developed in an effort to simplify obturation procedures, carrier-based obturations may result in a more time-consuming and/or more difficult retreatment procedure.19 The gutta-percha around the carrier can be penetrated with hand or rotary files to create space for an instrument or ultrasonic tips to remove the carrier. Chloroform solvent can also be used to facilitate instrument penetration into the gutta-percha mass. The instrument should be used to penetrate into the carrier and pull it out. This usually requires multiple attempts as the instrument may have to reach far down alongside the carrier to engage it.

The use of heated pluggers touching the core and allowing it to cool for approximately 10 seconds and then removing it together with the plastic carrier from canal space has been proposed as a technique, however it is only efficient with plastic carriers. One must also consider the possibility of periodontal ligament damage that may occur due to excessive heat.

Removal of Bioceramic SealersBioceramic sealers have been introduced in endodontics on the premise of providing an obturation method that can be successfully and predictably performed by a majority of practitioners.20 These bioceramic sealers are produced with nanosphere particles that allow the material to react with the moisture present in the dentinal tubules creating a mechanical bond on setting. The technology eliminates the potential for shrinkage, rendering a material with exceptional dimensional stability. Obturation consists of a single gutta-percha cone that is coated with bioceramic material, in conjunction with a bioceramic sealer.21

The use of bioceramic sealers has increased considerably, bringing additional concerns for nonsurgical retreatment procedures.22 Usual retreatment techniques have proven unable to fully remove the bioceramic sealers from the root canal system. Furthermore, regaining working length and establishing patency has been reported as challenging with the persistence of sealer within the root canals. In these cases, a recommended approach is to combine the use of ultrasonic tips and rotary or reciprocating instruments for gutta-percha removal, with constant irrigation in an attempt to ‘break’ the sealer for easier removal from the root canal walls.22 If the presence of bioceramic sealer persists in the apical area or blocking the canals, apical surgery or intentional replantation should be considered.

Removal of Silver Points Although the possibility of corrosion of silver points must be considered, corrosion is not a sole attributable factor in endodontic failures.23 The possibility of corrosion is generally related to the quality of the endodontic filling technique. Signs of corrosion are more visible in the apical third of the silver point, where there is generally an insufficient amount of sealer.23 A poorly adapted or loosely cemented silver point showing its handle in the chamber usually poses no problem for removal. In contrast, removing a tightly fitted, well-cemented silver cone that is flush with the canal orifice, is often a challenging task.24 The use of ultrasonic tips, alone or in combination with additional silver point retrieval devices, offers the following advantages: (a) conservation of remaining tooth structure; (b) avoidance of surgical treatment; and (c) saves time during the retreatment appointment.24

Removal of Separated InstrumentsA separated instrument left inside the canal may lead to endodontic treatment failure if it obstructs the passage of additional instruments to complete cleaning and shaping procedures. Three important aspects should be taken into consideration when retreating a tooth showing a separated instrument: diameter; length; and position of the instrument inside the root canal system. The clinician should attempt to remove the separated instrument if it is


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due to anatomic limitations. When properly performed, intentional replantation can provide good long-term results for teeth that otherwise would be regarded as hopeless.31 A relatively fast and simple procedure, it typically results in minimal postoperative discomfort,32 reduced procedure time, and presents fewer complications and decreased cost in comparison to non-surgical endodontic retreatment or dental implants.33 The use of intentional replantation can also be an alternative when a perforation defect is too large to be repaired surgically or when the perforation is inaccessible without excessive bone removal.31 Teeth with divergent, long and/or curved roots are not suitable for intentional replantation because of the risk of fracture during extraction.34 Inflammatory root resorption and ankylosis due to trauma to the periodontal ligament are complications that may occur after intentional replantation.35 For better outcomes, the procedure should be carried out within 15 minutes of tooth extraction.32,35

Intentional replantation is not a frequently used treatment technique because of the wide variance in reported success rates and the absence of an established protocol.

A recent systematic review and meta-analysis revealed a weighted mean survival of 88% for intentional replanted teeth.33 Although the mean survival of

located in the coronal or middle third of the canal. To facilitate removal, the practitioner should use the dental operating microscope and appropriate ultrasonic tips (Figure 1) to create a straight line access to the separated instrument and vibrate the separated instrument until it moves, alternating with/without irrigation.

If the instrument is located in the apical third and/or in curved segments of the root canal, removal is often more complicated, and an attempt to bypass the instrument and continue with instrumentation and obturation is generally the best option. If the separated instrument can be bypassed with small hand instruments (0.6, 0.8 and 0.10 mm), the clinician is generally able to continue with root canal cleaning and shaping and obturation. The prognosis of endodontic treatment when a fractured instrument fragment is left within a root canal is not significantly reduced if it can be bypassed and the root canal adequately completed.25,26

A systematic review showed that nonsurgical retreatment offers a favorable long-term outcome (4-6 years) with a success rate of 83.0%.10

Apical surgery or intentional replantation should be considered in cases where the separated instrument cannot be retrieved or bypassed or when nonsurgical retreatment is considered impractical.

Apical SurgeryIf nonsurgical endodontic retreatment is not a viable option for retreatment of failed endodontic therapy, apical surgery should be considered. The main objective of surgical endodontic treatment is to provide a clinical environment favoring healing and repair of the periradicular tissues. Apical surgery aims to prevent bacterial leakage from the root-canal system into the periradicular tissues by placing a tight root-end filling following root-end resection and proper sealing of all apical portals of exit.27 By using state-of-the-art equipment, instruments and materials that match biological concepts with clinical practice, microsurgical approaches produce predictable outcomes in the healing of lesions of endodontic origin.28

The ideal characteristics of a root-end filling placed during apical surgery includes the ability to adhere to dentin, maintain a sufficient seal, be insoluble

in tissue fluids, maintain dimensional stability, be nonresorbable over time, appear radiopaque, be easily manipulated, have adequate compressibility, allow appropriate working time, and be biocompatible with human tissues.29 Mineral trioxide aggregate (MTA) (a tri-silicate cement composed of Portland cement, calcium, silicon, aluminum, and bismuth oxide) and bioceramic materials (composed of calcium silicates, zirconium oxide, tantalum pentoxide, calcium phosphate monobasic and filler agents) have proven successful as retrofilling materials.29

A meta-analysis showed that contemporary root-end surgery techniques with microinstruments but only loupes or no visualization aids had a 88% positive outcome while endodontic microsurgery using the same instruments and materials but with high-power magnification as provided by the surgical operating microscope or the endoscope showed 94% positive outcome.

Intentional ReplantationIntentional replantation involves extracting a tooth and reinserting it into its socket after endodontic manipulation.30 It is considered a reliable and predictable treatment for cases in which conventional endodontic retreatment failed or is impractical, and endodontic surgery is hampered

(A,B) Reduce the dentin wall around the separated file with diamond ultrasonic tips, gates-glidden or mechanized instruments in order to create a straight line access to the separated instrument. (B) Vibrate the separated file until it moves. (C) Repeat step 2 until the separated file is removed with irrigation.

Figure 1


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implant-supported single crowns was higher than intentionally replanted teeth, these authors concluded that intentional replantation may have a role when an implant-supported single crown is not practicable. 33

When properly performed, intentional replantation can provide good long-term results for teeth that otherwise would be regarded as hopeless. The patient’s desire to keep the natural teeth and proper case selection play a crucial role in the prognosis and clinical outcomes associated with the procedure.

Root Perforations Leading to Endodontic FailureRoot or furcation perforations are iatrogenic or pathologic communications between the root canal space and the periradicular tissues. They often result from procedural errors during endodontic treatment (during access preparation, searching for canal orifices, negotiating curved or calcified canals, preparing post space). Perforations are generally associated with dramatically compromised endodontic treatment

outcomes. They can quickly produce a pathway of communication with the gingival sulcus. Injury to the periodontium results in the development of inflammation, destruction of periodontal fibers, bone resorption, formation of granulomatous tissue, proliferation of epithelium, and ultimately in the development of a periodontal pocket.36,37

Successful treatment of a root perforation depends on the timely diagnosis and sealing of the perforation to eliminate the risk of continuing infection. Recent developments in the techniques

Case 2

Case #2: Intentional Replantation. (A) The tooth upon extraction - touching the roots and periodontial ligament should be avoided; (B) Apicoectomy; (C, D) Retropreparation with ultrasonic tips; (E, F) retrofilling with a biocompatible material; (G) Radiographic images illustrating multiple sinus tracts traced with gutta-percha points; (H,I) After tooth extraction and replantation and after 15-months showing evidence of apical healing.


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SummaryEndodontic treatment failure, while uncommon, provides challenges for the general dentist. Patients facing the situation typically have many questions regarding the reasons for failure, and are often skeptical regarding additional therapy. While the complexity of a failed endodontic case most often requires the technical skills of a clinician with considerable clinical experience or an endodontist for successful retreatment, the general dentist plays a critical role in the process.

Their ability to identify an endodontic treatment failure, determine the potential causes of the failure and assist the patient to determine appropriate steps to address the failure are vital steps in increasing the chances for a successful retreatment outcome. Considering all factors, retention of the patient’s natural tooth utilizing endodontic retreatment should be carefully considered. However, the patient’s needs and expectations should always be respected when discussing therapy options. If endodontic retreatment is chosen, follow up visits following therapy should be carefully planned, coordinated between all clinicians involved and presented to the patient as an integral part of total care.

and materials (including clinical microscopes, CBCTs and new sealing materials) utilized in root perforation repair have dramatically enhanced the prognosis of both surgical and nonsurgical repair procedures. Prognosis of a repaired perforated tooth depends on the: location of the perforation; length of time that the perforation has been open to contamination; size of the perforation; accessibility to the main canal and perforation site and; ability to seal the perforation.37,38

• Time: immediate closure carries the best prognosis. This is not usually possible in previous endodontically treated teeth.

• Size: large perforations are associated with decreased prognosis.

• Location: perforations located in the apical or middle third of the root are more easily accessed and are associated with better prognosis. Furcation perforations typically have much poorer prognoses.

The decision to treat a perforation is also dependent on the periodontal condition of the region. The presence of periodontal involvement frequently requires additional procedures for management and lowers the prognosis for successful repair. Complete healing is a long process and may require >4 years to occur.39

References1. Salehrabi R, Rotstein I. Endodontic treatment

outcomes in a large patient population on the USA: an epidemiological study. J Endod 2004; 12: 846-850.

2. Nair PNR. Pathogenesis of apical periodontitis and the causes of endodontic failures. Critical Reviews in Oral Biology & Medicine 2004; 15:348-381.

3. Siqueira Jr JF. Aetiology of root canal treatment failure: why well-treated teeth can fail. Int Endod J 2001; 34:1-10.

4. Song M, Kim HC, Lee W, Kim E. Analysis of the cause of failure in nonsurgical endodontic treatment by microscopic inspection during endodontic microsurgery. J Endod 2011; 37:1516-1519.

5. Tabassum S, Khan FR. Failure of endodontic treatment: The usual suspects. Eur J Dent 2016; 10:144-147.

6. Del Fabbro M, Corbella S, Sequeira-Byron P, Tsesis I, Rosen E, Lolato A, Taschieri S. Endodontic procedures for retreatment of periapical lesions. Cochrane Database Syst Rev. 2016 Oct 19;10: CD005511.

7. Bergenholtz G, Lekholm U, Milthon R, et al. Retreatment of endodontic fillings. Scand J Dent Res 1979:87:217-224.

8. Machtou P, Reit C. Non-surgical retreatment. In: Bergenholtz G, Hørsted-Bindslev, Reit C editor(s). Textbook of Endodontology. Second Edition. Chichester, West Sussex, UK: John Wiley & Sons, Wiley-Blackwell, 2010:335-47.

9. He J, White RK, White CA, Schweitzer JL, Woodmansey KF. Clinical and Patient-Centered Outcomes of Nonsurgical Root Canal Retreatment in First Molars Using Contemporary Techniques. J Endod 2017; 43:231-237.

10. Torabinejad, M., Corr, R., Handysides, R., and Shabahang, S. Outcomes of nonsurgical retreatment and endodontic surgery: a systematic review. J Endod. 2009; 35: 930–937.

11. Ng, YL, Mann, V., and Gulabivala, K. A prospective study of the factors affecting outcomes of nonsurgical root canal treatment: part 1: periapical health. Int Endod J. 2011; 44: 583–609.

12. Khalighinejad N, Aminoshariae A, Kulild JC, Williams KA, Wang J, Mickel A. The effect of the dental microscope on the outcome of nonsurgical root canal treatment: a retrospective case-control study. J Endod 2017, 43:728-732.

13. Plotino G, Grande NM, Bedini R, Pameijer CH, Somma F. Flexural properties of endodontic posts and human root dentin. Dent Mater 2007; 23:1129-1135.

AcknowledgmentsThe authors would like to thank:

Leticia Chaves de Souza, DDS MS PhD Bruno Crozeta, DDS MS

for their contributions and review of this manuscript.


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14. Friedman S, Stabholz A, Tamse A. Endodontic retreatment – case selection and technique. Part 3. Retreatment techniques. J Endod 1990; 16:543-549.

15. Stabholz A, Friedman S. Endodontic retreatment – case selection and technique. Part 2: treatment planning for retreatment. J Endod 1988; 14:607-614.

16. Ruddle CJ. Nonsurgical retreatment. J Endod 2004; 30: 827-845.

17. Kfir A, Tsesis I, Yakirevich E, Matalon S, Abramovitz I. The efficacy of five techniques for removing root-filling material: microscopic versus radiographic evaluation. Int Endod J 2012; 45:35-41.

18. Law A, Messer H. An evidence-based analysis of the antibacterial effectiveness of intracanal medicaments. J Endod 2004; 30:689-694.

19. Wilcox LR, Juhlin JJ. Endodontic retreatment of thermafill versus laterally condensed gutta-percha. J Endod 1994; 20:115-117.

20. Koch K, Brave D. Bioceramic technology—the game changer in endodontics. Endod Pract 2009; 2:13–17.

21. Silva Almeida LH, Moraes RR, Morgental RD, Pappen FG. Are premixed calcium silicate-based endodontic sealers comparable to conventional materials? A systematic review of in vitro studies. J Endod 2017, 43:527-535.

22. Hess D, Solomon E, Spears R, He J. Retreatability of a Bioceramic Root Canal Sealing Material. J Endod 2011; 37:1547-1549.

23. Goldberg F. Relation between corroded silver points and endodontic failures. J Endod 1981; 7: 224–227.

24. Krell KV, Fuller MW, Scott GL. The conservative retrieval of silver cones in difficult cases. J Endod 1984; 10: 269-273.

25. Spili P, Parashos P, Messer HH. The impact of instrument fracture on outcome of endodontic treatment. J Endod 2005; 31: 845−850.

26. Panitvisai P, Parunnit P, Sathorn C, Messer HH. Impact of a retained instrument on treatment outcome: a systematic review and meta-analysis. J Endod 2010; 36:775-780.

27. von Arx T. Apical surgery: A review of current techniques and outcome. Saudi Dent J 2011; 23: 9-15.

28. Kim S., Kratchman S. Modern endodontic surgery concepts and practice: a review. J. Endod 2006; 32: 601–623.

37. Velvart P, Peters CI. Soft Tissue Management in Endodontic Surgery. J Endod 2005; 31:4-16.

29. Torabinejad M, McDonald NJ. Endodontic surgery. in: M. Torabinejad, R.E. Walton (Eds.) Endodontics: principles and practice. 4th ed. Mosby, St Louis; 2009: 357–375.

30. Grossman LI. Intentional replantation of teeth. J Am Dent Assoc 1966; 72:1111-1118.

31. Kratchman S. Intentional replantation. Dent Clin North Am 1997: 41: 603–617.

32. Kingsbury BC Jr, Wiesenbaugh JM Jr. Intentional replantation of mandibular premolars and molars. J Am Dent Assoc 1971; 83:1053–1057.

33. Torabinejad M, Dinsbach N,Turman M, et al. Survival of intentionally replanted teeth and implant-supported single crowns: a systematic review. J Endod 2015; 41:992-998.

34. Tsesis I, Fuss Z. Diagnosis and treatment of accidental root perforations. Endodontics Topics 2006, 13: 95-107.

35. Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth. Oral Surg Oral Med Oral Pathol 1993: 76: 623–630.

36. Seltzer S, Sinai I, August D. Periodontal effects of root perforations before and during endodontic procedures. J Dent Res 1970: 49: 332–339.

37. Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Dental Traumatology 1996; 12: 255-264.

38. Sinai IH. Endodontic perforations: their prognosis and treatment. J Am Dent Assoc 1977, 95; 90- 95.

39. Orstavik D. Time-course and risk analysis of the development and healing of chronic apical periodontitis in man. Int Endod J 1996; 29:150-155.

References (continued)


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POST-TESTInternet Users: This page is intended to assist you in fast and accurate testing when completing the “Online Exam.” We suggest reviewing the questions and then circling your answers on this page prior to completing the online exam. (1.0 CE Credit Contact Hour) Please circle the correct answer. 70% equals passing grade.

1. What is a good indicator of symptomatic apical periodontitis?a. Positive response to cold testb. Deep periodontal pocketsc. Pain to percussion and palpationd. Positive response to electric pulp test

2. A positive response to thermal and electric pulp tests in an endodontically-treated teeth may indicate:a. root perforation.b. missed or untreated canals.c. internal root resorption.d. root fracture.

3. A deep periodontal pocket in a localized region of a tooth may indicate the presence of root fracture.a. Trued. False

4. The most common treatment deficiencies leading to endodontic failure include:a. inappropriate mechanical and/or chemical debridement, especially in

anatomically complex or missed canals.b. inadequate fill and/or seal, resulting in coronal leakage and/or

leakage around the canal filling material.c. iatrogenic complications, such as root perforations, ledges, over or

under extension of the root canal filling, and separated instruments.d. All of the above

5. Periodontal probing, tooth mobility test, transillumination, and staining are clinical examination procedures that may help with the diagnosis of:a. root fracture.b. internal root resorption.c. untreated canal.d. ledges.

6. The challenges associated with nonsurgical endodontic retreatment include:a. regaining canal patency.b. providing maximum reduction of microorganisms via cleaning and

shaping.c. locating missed canals.d. All of the above

7. Which irrigant solution is helpful in removing gutta-percha during nonsurgical endodontic retreatment?a. Ethylenediamine tetra-acetic acidb. Sodium hypochloritec. Chloroformd. Chlorhexidine

8. Radiographic evaluation may help in the identification of all the following factors, EXCEPT:a. Root resorptionb. Dental cariesc. Quality of root canal fillingd. Pulpal status

9. Which item is NOT a useful aid for carrier removal during endodontic retreatment?a. Rotary filesb. Ultrasonic tipsc. Endodontic explorersd. Chloroform

10. What are considered important factors for successful treatment of a root perforation?a. Time since perforation occurredb. Size of the perforationc. Location of the perforationd. All of the above

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