Endod Dent Traumatol 2000; 16: 218221 Printed in Denmark .

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Copyright C Munksgaard 2000

Endodontics & Dental Traumatology

ISSN 0109-2502

Inuence of coronal restorations on the periapical health of endodontically treated teeth

Tronstad L, Asbjrnsen K, Dving L, Pedersen I, Eriksen HM. Inuence of coronal restorations on the periapical health of endodontically treated teeth. Endod Dent Traumatol 2000; 16: 218221. C Munksgaard, 2000. Abstract The purpose of the study was to evaluate a possible relationship between the quality of the coronal restoration, the root canal obturation and the periapical status of endodontically treated teeth. Full mouth series of radiographs from randomly selected patient charts at the Dental Faculty, University of Oslo were examined. A total of 1001 endodontically treated teeth restored with a permanent restoration were evaluated independently by two examiners. According to a predetermined set of radiographic criteria, the technical quality of the root lling of each tooth was scored as either good (GE) or poor (PE), and the technical quality of the coronal restoration was scored as good (GR) or poor (PR). The root and the surrounding structures were then evaluated and according to the periradicular ndings, the treatment was categorized as success or failure. The success rate for all endodontically treated teeth was 67.4% (n1001). Teeth with root canal posts had a success rate of 70.7% (n527) and teeth without posts had a success rate of 63.6% (n472). The two groups with technically good endodontics had the highest success rates. In combination with technically good restorations the success rate was 81% (GEGR, 81%) and combined with technically poor restorations the success rate was 71% (GEPR, 71%). The two groups with technically poor endodontics combined with either good restorations or poor restorations had signicantly lower success rates (PEGR, 56% and PEPR, 57%). The technical quality of the endodontic treatment as judged radiographically was signicantly more important than the technical quality of the coronal restoration when the periapical status of endodontically treated teeth was evaluated.
L. Tronstad, K. Asbjrnsen, L. Dving, I. Pedersen, H. M. Eriksen
Department of Endodontics, Faculty of Dentistry, University of Oslo, Oslo, Norway

Key words: apical periodontitis; dental treatment; endodontic treatment; periapical repair Leif Tronstad, Department of Endodontics, Faculty of Dentistry, University of Oslo, P.O. Box 1109 Blindern, N-0317 Oslo, Norway Accepted March 4, 2000

It is generally accepted that the prognosis of endodontic treatment is positively correlated with the technical quality of the root lling (14). This appears logical in that the root lling is meant to establish a bacteria tight seal of the root canal so that oral bacteria cannot reach the periapical tissues and cause disease. The materials that are available for the purpose of sealing the root canal system are not without aws, and a number of studies using a variety of techniques have 218

suggested that even apparent adequate root llings may not be effective over time (59). Thus, in one in vitro study of coronal leakage of root lled teeth without coronal restorations, bacterial products were found at the apex of the teeth after 3 weeks (10). Undoubtedly a well-sealing coronal restoration is of importance to protect the root lling from the inuence of the oral environment. Ray & Trope (11) in a study from 1995 have attempted to determine the relative

Coronal restorations and periapical health

Table 1. Success of endodontic treatment in a cross sectional study of dental school patients, University of Oslo Success in percent 67.4% 71.0%* 64.0%*

n
Entire material Teeth with posts Teeth without posts 1001 528 473

Failure 326 154 172

Success 675 374 301

* The difference between the success rate of teeth with root canal posts and teeth without posts was not statistically signicant (P0.025).

importance of the root lling and the coronal restoration in establishing and maintaining periapical health in conjunction with endodontically treated teeth. Probably somewhat unexpected, in their material they found that the quality of the coronal restoration was signicantly more important for the long term success of endodontic treatment than the quality of the root lling itself (11). This study is important in that it directly involves clinical therapy. At least to some extent the results undermine the fundamental understanding in endodontics that it is the root lling that creates the bacteria tight seal and that the coronal restoration as much as possible protects the root lling and completes the restoration of the tooth to function (12). Thus, it was felt that this question is important enough that it should be looked at again. It was the purpose of this investigation to duplicate the work by Ray & Trope (11) as much as possible to again study the relationship between the quality of the coronal restoration, the root lling and periapical health of endodontically treated teeth.
Material and methods

Good restoration: Any permanent restoration that appeared intact radiographically. Poor restoration: Any permanent restoration with radiographic signs of overhangs, recurrent decay or open margins. The radiographic appearance of the root and surrounding structures was then evaluated and categorized as follows: Success: Normal width of periodontal ligament space. Normal appearance of surrounding bone. Failure: Periradicular radiolucency. Three observers (KA, LD, IP) were calibrated according to the system of Halse & Molven (13). The evaluation criteria were discussed before initiation of the study. Forty-seven roots were used for calibration in order to establish a uniform understanding and application of the criteria. One observer selected the roots and 2 observers examined the radiographs independently. Agreement was reached in 61,7%. Disagreement was dealt with by joint discussion. If consensus was not reached, the third observer made the nal decision. After the study, 44 of the rst roots that were examined were re-examined. Agreement was reached in 79,5%. After joint discussion there was 100% agreement.
Statistical analysis

Differences between the groups were examined statistically using the chi-square test. A P-value 0.01 was considered to indicate statistically signicant differences.
Results

A cross-sectional study was performed by examining full mouth radiographs from randomly selected patient charts at the Faculty of Dentistry, University of Oslo. The radiographs of the rst 1001 endodontically treated teeth with a permanent restoration were evaluated. Two independent observers examined the radiographs using a X-ray viewer with 2 magnication. Teeth with and without posts were examined. Multirooted teeth were categorized by the root with the most incomplete rootlling. The teeth were grouped according to the radiographic qualities of the root lling and the coronal restoration as follows: Good endodontics: All canals obturated. No voids present. Root lling ending between 2 mm short of and 1 mm beyond radiographic apex. Poor endodontics: Root lling ending more than 2 mm from radiographic apex. Root lling with voids or canals not lled. Root lling poorly dimensioned or poorly condensed.

The success rate for all endodontically treated teeth (n1001) was 67.4%. Teeth with root canal posts (n 528) had a success rate of 71% and teeth without posts (n473) had a success rate of 64%. The difference between the groups with and without posts was not statistically signicant (Table 1).
Table 2. Periradicular status of groups of teeth with good endodontic treatment, poor endodontic treatment, good coronal restorations and poor coronal restorations Endodontic treatment GE PE Any Any Coronal restoration Any Any GR PR Success in percent 78%* 56%* 70%** 63%**

n
506 495 663 338

Failure 111 216 201 126

Success 395 279 462 212

GEGood Endodontics; PEPoor Endodontics; GRGood Restoration; PR Poor Restoration; AnyAny Quality. * The difference between the success rate of teeth with Good and Poor Endodontics was statistically signicant (P0.0001). ** The difference between the success rate of teeth with Good and Poor Restoration was stastistically signicant (P0.0001).

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Tronstad et al.
Table 3. Success rate of endodontic treatment of good or poor quality in teeth with good or poor coronal restorations Endodontic treatment GE GE PE PE Coronal restoration GR PR GR PR Success in percent 81%* 71%* 56%* 57%*

n
364 142 299 196

Failure 70 41 131 85

Success 294 101 168 111

GEGood Endodontics; PEPoor Endodontics; GRGood Restoration; PR Poor Restoration. * The difference between the success rate with Good Endodontics and Poor Endodontics was statistically signicant (P0.0001) regardless of the quality of the coronal restoration (GR or PR).

Table 4. Periradicular status of the various groups of teeth with root canal posts Endodontic treatment GE GE PE PE Coronal restoration GR PR GR PR Success in percent 84%* 70%* 56%* 66%*

n
205 70 154 98

Failure 33 21 67 33

Success 172 49 87 65

Good Restorations (GEGR, n364) were combined, the success rate was 81%. When the groups Good Endodontics and Poor Restorations (GEPR, n142) were combined, the success rate was 71%. The difference between the 2 groups was statistically signicant (Table 3). The teeth with Poor Endodontics combined with the teeth with Good Restorations (PEGR, n299) gave a success rate of 56% whereas the combination of Poor Endodontics and Poor Restorations (PEPR, n196) resulted in a success rate of 57%. The difference between the success rate with Good Endodontics and Poor Endodontics was statistically signicant regardless of the quality of the coronal restoration. The results of the combined groups in teeth with posts and without posts are shown in Tables 4 and 5. The presence of a post did not affect the endodontic success rate negatively in any of the combinations. The lowest success rate (48%) was found in the combination Poor Endodontics and Poor Restorations (PEPR) in teeth without posts (Table 5).
Discussion

GEGood Endodontics; PEPoor Endodontics; GRGood Restoration; PR Poor Restoration. * The difference between the success rate with Good Endodontics and Poor Endodontics was statistically signicant (P0.0001) regardless of the quality of the coronal restoration (GR or PR).

Table 5. Periradicular status of the various groups of teeth without root canal posts Endodontic treatment GE GE PE PE Coronal restoration GR PR GR PR Success in percent 76%* 71%* 57%* 48%*

n
157 72 145 98

Failure 37 21 63 51

Success 120 51 82 47

GEGood Endodontics; PEPoor Endodontics; GRGood Restoration; PR Poor Restoration. * The difference between the success rate with Good Endodontics and Poor Endodontics was statistically signicant (P0.0001) regardless of the quality of the coronal restoration (GR or PR).

The treatment was rated as Good Endodontics (GE) in 506 teeth. In this group the success rate was 78%. The group with Poor Endodontics (PE) had a success rate of 56%. The difference between the 2 groups was statistically signicant (Table 2). 663 teeth were found to have Good Restorations (GR). The endodontic success rate in this group was 70%. The group with Poor Restorations (PR) consisted of 338 teeth and the endodontic success rate in this group was 63%. The difference between the 2 groups was statistically signicant (Table 2). When the groups with Good Endodontics and 220

The present study is a cross-sectional study based on evaluation of radiographs. Such a study has certain limitations (1316), but misinterpretations and misdiagnoses are known to be fairly equally distributed so that the results will be meaningful (17). Also, the reliability of the present results was strengthened by the fact that a large material was studied. The overall endodontic success rate was 67.4%. This was in good agreement with the results of other studies of this nature (11, 16, 18, 19). Of considerable clinical interest was the fact that the presence of root canal posts did not negatively affect the outcome of the endodontic treatment (20). Because of this, the groups of teeth with posts and without posts were grouped together in the study of the relationship between the quality of the coronal restoration and the root lling and periapical health. Not unexpectedly the highest success rate (81%) was found in the teeth diagnosed with Good Endodontics and Good Restorations (GEGR). In the teeth diagnosed with Good Endodontics and Poor Restorations (GEPR) the success rate dropped 10% to 71%. This difference was statistically signicant. Thus, the importance of a well sealing coronal restoration for lasting success of endodontic treatment that was stressed by the ndings of Ray & Trope (11) was evident in this study as well. In the literature there is a consistant association between periapical radiolucency and root canal llings of poor quality (for review, see 21). This was conrmed by the present results. In the teeth diagnosed with Poor Endodontics the success rate dropped and was the same regardless of the quality of the coronal

Coronal restorations and periapical health

restoration (PEGR, 56% and PEPR, 57%). Thus, if the root canal was not properly obturated, the quality of the coronal restoration had no bearing on the outcome of the endodontic treatment. This nding was in agreement with a recent study from Lithuania (22). However, it was in clear contrast to the ndings of Ray & Trope (11) who conclude that the quality of the coronal restoration is signicantly more important than the quality of the root lling in securing periapical health. The reasons for the discrepancies in the results of the two studies are not immediately clear. We tried to select a material as similar to the American material as we could (dental school patients, University of Oslo versus dental school patients, Temple University). Certain differences in clinical technique migth exist, but since the evaluation criteria were very simple (Good Endodontics v. Poor Endodontics and Good Restoration v. Poor Restoration) it is unclear whether this would have any bearing on the outcome of the studies. In any case, the ndings of this study were clear. The quality of the root lling was the most important factor for the outcome of endodontic treatment. If the quality of the root lling was good, a good restoration improved on the endodontic success rate. However, if the quality of the root lling was poor, the quality of the coronal restoration was of no importance for the outcome of the endodontic treatment.
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