IP Indian Journal of Conservative and Endodontics 2024;9(3):121–128

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IP Indian Journal of Conservative and Endodontics

Journal homepage: https://www.ijce.in/

Review Article
Success and failure of non-surgical endodontic treatment –A literature review

Shouvik Ganguly 1 *, Vaishali Waghmare 1, Sumanthini M.V 1, Anuradha Patil 1,

Aditya Shinde 1 , Jimish Shah 1
1 Dept. of Conservative Dentistry and Endodontics, MGM Dental College and Hospital, Navi Mumbai, Maharastra, India

ARTICLE INFO ABSTRACT

Article history: The aim of endodontic treatment is to prevent and treat apical periodontitis. To determine the outcome of
Received 09-06-2024 endodontic treatment, clinical and radiographic evaluations need to be done at the follow up appointments.
Accepted 13-08-2024 After complete assessment, the result of endodontic treatment can be categorized as successful or failed
Available online 05-09-2024 based on clinical and radiographic features. It can also be classified as healed, healing or diseased depending
on the periapical status of the treated tooth. This review article includes both these criteria. It explains
the clinical and radiographic features and their role in differentiating successful and failed cases. It also
Keywords: emphasizes on the importance of patient related factors, iatrogenic errors and post treatment factors like
Infection control
coronal seal that can directly influence the outcome of endodontic treatment.
Apical periodontitis
Endodontic treatment This is an Open Access (OA) journal, and articles are distributed under the terms of the Creative Commons
Root canal obturation Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon
Treatment outcome the work non-commercially, as long as appropriate credit is given and the new creations are licensed under
the identical terms.
For reprints contact: [email protected]

1. Introduction endodontic treatment. The endodontic treatment process

does not come to an end when the root canal system is
The goal of root canal therapy is to completely remove sealed. However, in order to track any changes, routine
any diseased pulp tissue from the root canal system by follow-ups must be done to evaluate the long term outcome.
debridement and chemical cleaning. This allows the root Nonetheless, being meticulous in the treatment phase may
canal space to be shaped and made ready for the obturation pay off in the long term for both the patient and the dentist.
of the canal with an inert material, thereby eliminating or
significantly reducing the risk of reinfection. Endodontic
1.1. Depending on Clinical, Radiographic and
treatment is predictable, with documented success rates
ranging up to 98%, if proper protocol is followed. 1 The Histologic features
4 to 6 year outcome of initial endodontic treatment was 1.1.1. Criteria for successful endodontic treatment
assessed for phase III of the Toronto Study. 2 Outcomes outcome
were examined as healed or diseased. The overall healed
1.1.1.1. Clinical features.
rate was 85%, but the authors noted that 95% of the teeth
While the lack of discomfort or any other symptoms does
were asymptomatic and fully functional. They also noted
not prove the healthy status, the existence of symptoms
that if slight tenderness to percussion were eliminated from
does indicate that pathology is present. There is some
the criteria, then 99% of the teeth would be functional. 2
association between the periapical disease and the existence
The research hasn’t, however, come to a precise agreement
of symptoms. 3
on standard definition of what constitutes "success" in
* Corresponding author. 1. No tenderness to percussion or palpation
E-mail address: [email protected] (S. Ganguly). 2. Normal tooth mobility

https://doi.org/10.18231/j.ijce.2024.027
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3. No evidence of subjective discomfort 1.2. Depending on healing, healed and disease status
4. The teeth exhibit normal form, function and aesthetics
The treatment results may be influenced by a number of
5. No sign of infection or swelling
pre-operative, intra-operative and post-operative conditions;
6. No sinus tract or integrated periodontal disease
teeth with minor lesions and overly short or overextended
7. Minimal to no scarring or discoloration.
root canal fillings may have better results as compared to
teeth with extensive lesions.
1.1.1.2. Radiographic features. The labels "healed," "healing," and "disease," as opposed
To assess success or failure, the radiographs taken at to relying on interpretations of "success" and "failure,"
different times should be comparable. accurately characterize the actual observation, as follows:
Radiographic standards for success of endodontic
treatment 3 1. Healed: Complete clinical and radiographic normalcy,
which means that there are no signs, symptoms or
1. Normal or slightly widened periodontal ligament residual radiolucency. 6
space 2. Healing in progress: Reduction in radiolucency size
2. Reduction of any preoperative radiolucency, if present. and return to clinical normality following a follow-up
3. No evidence of resorption. of less than four years. 7
4. Normal lamina dura. 3. Diseased: New, increasing, unchanged, or diminished
5. A three dimensional obturation of canal space that is radiolucency after observation longer than 4 years,
dense. irrespective of clinical presentation; symptoms present
regardless of radiographic appearance. 8
1.1.1.3. Histologic features.
The severity of periradicular inflammation is related to 1.3. Factors affecting outcome of endodontic therapy
presence of bacteria in the root canal. Even though root
canal treatment failures have been attributed to positive 1.3.1. Patient factors
preobturation cultures, a correlation between positive 1.3.1.1. Systemic health of patient.
preobturation cultures and bacteriologic status in the canal 1. Genetic factors and the patient’s systemic health
could not be established from surgical histopathologic status have a significant influence on the biological
specimens4 . However, it is not possible to demonstrate such mechanisms involved in tissue regeneration. 9
a link between histologic examination and pain in live 2. After root canal treatment the repair of periapical
patients. According to article published in 1991 by Lin LM, tissues can be affected or interfered with by gene
histologic features of a successful endodontic treatment are polymorphism and systemic factors such as nutrition,
as follows 4 stress, hormones, vitamin intake, hydration state and
systemic diseases like diabetes, cardiovascular disease,
1. No inflammation osteoporosis, smokers’ habits and others, etc. 10
2. Regeneration of periodontal ligament fibers 3. Periapical wound healing may be inhibited or delayed
3. The presence of bone mending by some systemic disorders due to their alteration of
4. Cementum repair bone turnover and fibroblast function. Other systemic
5. Lack of resorption diseases may change the microvasculature, which
6. Area repair that had previously undergone resorption would limit the periapical tissues’ access to nutrients
and oxygen. 11
1.1.2. Criteria for failure of endodontic treatment 4. Consequently, these systemic conditions can reduce
According to article published by Ashley M in 2001, the success rate of root canal treatment and lead to
failure is characterized by the return of clinical symptoms incomplete wound healing for example granulomatous
combined with periapical radiolucency. 5 Following are tissue formation in the periapical region. 12
some of the reasons for failure of endodontic treatment 5. This is not just a possibility; the results of other
articles have mentioned lower success rate of root canal
1. Inadequate filling of the canal treatment, with higher percentage of post-operative
2. Overextensions of root filling materials radiolucent periapical lesions and higher proportion of
3. Improper coronal seal no retained root filled teeth, in patients with systemic
4. Untreated canals both major and accessory diseases. 13
5. Iatrogenic procedural errors such as poor access cavity
1.3.1.2. Oral care by patient.
design
6. Complications of instrumentation such as ledges, 1. The patient should be motivated to follow all the post-
perforations, or separated instruments. operative instructions as guided by the endodontist.

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2. The patient should take enough care to maintain the like removing fractured posts and instruments, as well
coronal restoration and come for follow up evaluation. as repairing perforations. 19
3. Patient should maintain oral hygiene for periodontal 5. Overall, the integration of magnification into
maintenance. endodontic practice represents a significant stride
toward enhancing diagnostic accuracy and treatment
1.3.2. Treatment factors efficacy.
1.3.2.1. Effect of operator skill and knowledge.
1.3.2.4. Effect of access cavity design.
1. Clinicians must to be up to date on the expected course
of endodontic treatment as well as its prognosis. 1. Access cavity preparation is defined as creating an
2. Highly educated or trained clinicians exhibit result unobstructed opening to reach canal orifices and the
rates commensurate with their level of training and apical foramen.
experience such as general dentistry practitioners, 2. Even though there are numerous studies evaluating
postgraduate students, undergraduate students, and advantages and disadvantages of ultraconservative
specialists. access cavity designs, whether they compromise root
3. The overall understanding of the biological problem, canal system preparation, debridement and obturation,
in particular the motivation and integrity, with which in the meantime conventional access cavities are useful
the procedure is carried out, the refined and insightful for facilitating endodontic therapy in a predictable
technical execution, but also the impact of the manner without compromising periapical healing or
overall understanding of the biological problem on survival rates. 21
the intraoperative decision making of the operators is 3. However, outcome of endodontic therapy gets affected
difficult to measure. 14 if procedural errors happen while access opening.
4. Regardless of the criteria, the data showed that 4. Some of these procedural errors are
treatment provided by postgraduate students and (a) Incomplete removal of caries
professionals had the greatest weighted pooled i. In cases where a clinician is preoccupied
estimate of success. 15 with locating canal orifices, they may neglect
to fully excavate the caries. Especially
1.3.2.2. Effect of rubber dam isolation. common in maxillary molars, where the
1. An observational study on endodontic retreatment canal orifices are situated in the mesial
discovered a considerably higher periapical healing portion so the clinician neglects to remove
rate when rubber dam was utilized, compared with the distal portion of the caries.
cotton roll isolation. 16 ii. Incomplete removal of caries leads to
2. Retreatment when performed with aseptic tooth secondary caries, which ultimately weakens
isolation yields better results possibly, because using the tooth and increasing its susceptibility
a rubber dam allows for more efficient irrigation of the to fracture or in some cases this leads to
root canal. 17 periapical infection even after completion of
3. A different study found that, in endodontically treated root canal treatment.
cases, the occurrence of periapical lesion formation iii. Removal of old restorations is also important
was much lower under rubber dams. 18 as there can be secondary caries beneath the
restoration.
1.3.2.3. Effect of use of magnification and illumination. (b) Missed canals
1. In endodontic practice, advancements in technology i. Inability to carefully examine the
have revolutionized the way clinicians perceive and preoperative radiograph and incomplete
treat root canal complexities. 19 deroofing are the main causes of missed
2. The introduction of microscopes, offering canals.
magnification ranging from 3x to 30x, coupled ii. Clear periapical radiographs both before and
with superior illumination, has notably improved both after root canal contouring and cleaning.
surgical and conventional endodontic procedures. 20 Examine radiographs with a magnifying
3. Magnification plays a crucial role in traditional root glass.
canal procedures, aiding in various tasks such as iii. Several radiographs taken at different
crafting and refining the access cavity, accurately angles can assist the endodontist in
shaping the root canal, and ensuring thorough filling tracking additional canals and the tooth’s
of the canal system in three dimensions. architecture.
4. Additionally, it facilitates detecting root canal orifices, iv. Any missed canals must be found using
pinpointing missed canals, and addressing challenges magnification, microexcavation techniques,

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and most importantly, the knowledge of root 2. Smith and colleagues discovered that a "flared"
canal anatomy preparation had notably greater chance of success
v. To find the orifices, use size 06/08/10 ISO K- than a "conical" preparation, based on a loose set
file instruments or the DG16 explorer. The of criteria for success determination. The precise
C+ and Profinder files are the two files that degree of taper was not disclosed, and the effects
function well in these circumstances. of additional treatment and non-treatment parameters
(c) Iatrogenic cervical perforation were not controlled. 26
i. A perforation is a communication that arises 3. By using precise criteria, Hoskinson and associates 27
between the periodontium and the root canal and Ng and colleagues 28 did not find any difference in
space. Iatrogenic cervical perforation can the treatment outcome between narrow (0.05) and wide
occur as a result of incorrect bur orientation (0.10) canal tapers.
or pulp chamber calcification. 22 4. Ng and associates also examined the effects of these
ii. Misidentifying canals and removing too preparation tapers (0.05 and 0.10) with tapers (0.02,
much coronal dentine can easily lead to 0.04, 0.06, and 0.08), which are typically obtained
perforation in the coronal or furcation by employing larger taper nickel-titanium instruments.
regions. 22 They discovered no discernible differences in the
iii. The main strategy for management of course of therapy. 28
cervical perforations consists of using 1.3.2.7. Effect of root canal irrigation.
1:50,000 epinephrine to stop bleeding
followed by tricalcium silicate cements 1. Adding more particular irrigants had a major impact
or mineral trioxide aggregate (MTA) for on success rates, even though a higher concentration
perforation healing. of sodium hypochlorite had no effect on treatment
outcome.
1.3.2.5. Calcified canals. 2. Surprisingly, nevertheless, the treatment’s
1. The normal aging process causes the root canal system effectiveness was greatly decreased by the extra
to become more calcified, which may result in more irrigation of 0.2% chlorhexidine solution. 28
untreated canals that could become havens for bacteria 3. It is believed that the interaction product of
as a response to this aging process, pulp chambers in sodium hypochlorite and chlorhexidine is an insoluble
the tooth’s crown shrink in size and form more quickly precipitate that contains the cytotoxic and carcinogenic
on the roof and floor of posterior teeth. 23 compound parachloroaniline. 29
2. The calcification of root canals usually starts at the 4. The precipitate may induce long-term periapical tissue
coronal aspect and decreases as the canal moves irritation and obstruct dentinal tubules and accessory
apically. architecture in addition to mutually depleting the active
3. CBCT can help with the perioperative therapy of moiety in the two solutions for bacterial inactivation.
calcified canals, but magnification and illumination are This could also account for the observed reduced
necessary tools for their detection and management. 24 success rate in such situations. 30
4. Using software-based measurement tools,
1.3.2.8. Deviation from normal canal anatomy.
preoperative evaluation of calcified teeth using
CBCT can provide the optimal strategy for detecting 1. Root canal system is always multiplanar curved and
calcified canals in the chamber floor and roots. not as simple as is visualized in a two dimensional
5. The increased sensitivity and specificity provided by radiograph.
CBCT can also help in the determination of the PA 2. The most frequent operator error during shaping of
status of calcified root canals that may not require root canals is causing deviation of the canal from the
measures that can lead to procedural errors, such as off- natural anatomy.
course access, instrument fracture, or root perforation. 3. These deviations can lead to formation of ledge,
transportation, zipping, elbow or strip perforation.
1.3.2.6. Effect of negotiating & canal enlargement till the 4. All of these deviations can easily be prevented by
terminus of the canal. taking preoperative radiograph to assess and anticipate
1. As it was linked to the removal of "infected material the unusual root canal curvature.
and dentine," mechanical canal preparation was given 5. During biomechanical preparation, the canal’s patency
priority over other debridement techniques in the first needs to be preserved and precurving of files should be
conceptualization of root canal therapy. According to done.
Grossman, the canal endpoint diameter ought to be 6. Preparing of the canal should be done by sequential
increased by at least three file sizes. 25 use of files and timely recapitulation.

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1.3.2.9. Effect of number of treatment visits and intra 9. The definitive management includes: drainage through
appointment medicaments. coronal access opening, incision and drainage, proper
instrumentation, trephination, intracanal medicaments,
1. Studies indicate that the success rates of single- analgesics and antibiotics, when indicated.
visit and multiple-visit endodontic therapy are
comparable. 31 1.3.2.11. Impact of quality control on root canal
2. A study recorded 89% of healed outcome following disinfection and persistent bacteria.
single-visit endodontic therapy. Soltanoff studied one
hundred thirty five single visit cases and 195 multiple 1. The use of inter-appointment, antibacterial intra-canal
visit cases selected at random .They reported incidence dressings, increased the frequency of negative cultures
of pain with single visit endodontic treatment to be at the subsequent visit to an average of 71% of cases. 26
56%, whereas in multiple visit cases it was only 2. The technique of utilizing an interappointment culture
38%. Irrespective of different pain levels, it was seen test to verify the quality of bacterial disinfection
that both techniques provided success rates exceeding before root-filling was developed earlier. Only in the
85%. 31 event that a negative culture test result was obtained,
3. In 81% of the cases treated in a single visit and 71% "confirming" the absence of bacteria in the root canal
of the cases treated in two visits, Peters and Wesselink system, would obturation be initiated. 34
report that full radiographic healing was observed. 32 3. As time went on, the perceived predictability and
4. Comparable percentage of radiographic healing was favourable prognosis of root canal therapy without
seen in both the treatment protocols, but the calcium microbiological sampling became apparent, and this
hydroxide multiple-visit group showed fewer failed quality control method lost clinical favour due to
and more improved cases. perceived flaws like time-consuming, difficult to
perform, sometimes inaccurate and requiring a wealth
1.3.2.10. Effect of acute exacerbation during treatment. of laboratory resources, as well as uncertainties about
cost-effectiveness and business imperatives. 35
1. A flare-up is described as "an acute exacerbation of
periradicular pathosis after initiation or in continuation 1.3.2.12. Effect of iatrogenic errors.
of root canal treatment". 33
2. Endodontic flare-ups can significantly impact the 1. Perforation
outcome of endodontic treatment, as highlighted in (a) Endodontic failure is frequently caused by
recent research. These flare-ups, characterized by mechanical perforation.
post-operative pain, swelling, or discomfort, can (b) Perforation usually happens when the dentist is
compromise the success of root canal therapy. 29 confused about the bur’s direction and how it
3. A study conducted by Smith et al. emphasized relates to the pulp chamber or root’s structure.
that patients experiencing flare-ups were more likely (c) The molar and two-rooted maxillary premolars
to exhibit increased treatment failure rates and with thin roots mesiodistally and broad bucco-
decreased healing compared to those without such lingually with curved canals have the most
complications. 26 potential for furcation perforation.
4. Mechanical injuries from overinstrumentation, (d) Due to periodontal communication, furcation
insufficient debridement, or insufficient removal of perforation repair is unpredictable and happens
pulp tissue are among the factors that cause flare-ups. more frequently in high-stress scenarios.
5. Debris extrusion from the periapical region, chemical (e) The outcome of endodontic treatment is
damage to the periapical tissues from irrigants, favourable if the perforation is Apical or
intracanal medications, overextended root filling, or supracrestal, Small in size and immediate repair
microbiological injury are the most important factors has been done.
in the etiology of flare-ups. (f) In cases where the perforation is Equi-crestal,
6. It is also possible for iatrogenic and microbiological Large in size and repair has been delayed, the
factors to interact resulting in inter-appointment pain. outcome is unfavourable.
7. Management of flare-ups can be categorized as
2. Instrument Separation
preventive and definitive.
8. Preventative management includes: proper diagnosis, (a) Whether a clinician employs hand-operated or
long acting local anesthesia, determination of proper engine-driven instruments, or instruments made
working length, complete debridement, occlusal of stainless steel or nickel-titanium, there is
reduction, placement of intracanal medicament in case always a chance of separation. 36
of multi-visit root canal treatment, medications, closed (b) Inefficient use, physical property restrictions,
dressing, behavioural management. insufficient access, root canal anatomy, and

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potentially manufacturing flaws are the most 2. Irrespective of the periapical condition, the apical
frequent reasons for file separation. extent of root filling had a substantial impact on
(c) Nevertheless, a number of issues could arise treatment success rates.
throughout the procedure and have an impact on 3. The best success rates were linked to flush root fillings,
the tooth’s prognosis. while the lowest success rates were linked to apically
(d) Surgery or tooth loss is not always required in extruded root fillings.
cases where an instrument separates.
(e) The prognosis depends on the existence of any 1.3.2.15. Effect of root-filling quality.
necrotic, diseased pulp tissue that is present
1. In Toronto study done by Mahsa Farzaneh in 2004,
within canal.
it was discovered that compact root fillings gave more
(f) When the separation happens, the results are better
successful result than inadequate root fillings. 40
if the canal was cleaned up to a later level of
2. The goal of completely obturating the root canal
preparation.
system is to stop newly invasive bacteria or residual
(g) The prognosis shouldn’t be influenced by the
infection from colonizing and recontaminating the
separated instrument if the preoperative pulp
area.
was healthy, noninfected and free of apical
3. According to study done by Hoskinson et al in 2002,
periodontitis. 37
theoretically both are avoided by a "tight" seal with the
3. Incomplete debridement of canal and over canal wall and the absence of cavities in the material’s
instrumentation body. 41
4. Because excellent obturation depends on correctly
(a) The primary irritant to the periapical tissues is the carried out initial steps in canal preparation, the quality
presence of necrotic and diseased pulp tissue in of root filling can therefore be viewed as a proxy for
the root canal. either inadequate root filling technique or the quality
(b) Complete root canal system debridement of the complete root canal treatment.
is necessary for the removal of these irritants.
(c) Inadequate debridement can result in the 1.3.3. Post root canal treatment factors
recolonization of leftover microorganisms, their 1. Effect of coronal seal
metabolites, and tissue debris, all of which can
worsen endodontic failure. (a) As shown in in vitro study done by Trope et
(d) Often clinicians tend to do overinstrumentation al.in 1993 the endotoxin can predictably move
during endodontic therapy. through an obturated root canal, thus with a
(e) However, over-instrumentation damages the leaking or absent restoration, it is conceivable
periodontal ligament and alveolar bone, which that the appropriate bacteria would only have
lowers the success rate. to populate the coronal aspect of the tooth and
the smaller endotoxin particles, or other bacterial
1.3.2.13. Effect of root filling material and technique. products, could move to the apex stimulating the
inflammatory response. 42
1. Teeth obturated using the lateral condensation (b) So after the initial chemo-mechanical phase of
technique evenly fills the apical and midroot spaces root canal treatment, the quality of the work of
creating compact obturation. 38 the restorative dentist appears most important for
2. There is no proof that the type of root filling material periapical health of the tooth. 43
or the method of placement has a major impact on the (c) Many studies done on endodontic failures
course of treatment. consider coronal leakage to be as a potential
3. Outcome of endodontic treatment depends on apical factor resulting in endodontic failure. 44
extent of the root filling and three dimensional (d) For an endodontically treated tooth to have a
obturation quality more than depending on root filling good prognosis the coronal area must have an
material or technique impermeable seal.
(e) Teeth with satisfactory restorations have a greater
1.3.2.14. Effect of apical extent of root filling. pooled success rate than teeth with subpar
restorations.
1. The effect of the apical extension of root fillings can
be grouped as three groups for statistical analyses:
2. Conclusion
extended beyond the radiographic apex (long), 0 to 2
mm within the radiographic apex (flush), and greater The success or failure of endodontic treatment can be
than 2 mm short of the radiographic apex (short). 39 evaluated based on clinical and radiographic features as

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Author biography

Shouvik Ganguly, Lecturer https://orcid.org/0000-0002-5638-0458

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