Clinical Research
Comparison of Classic Endodontic Techniques versus
Contemporary Techniques on Endodontic Treatment Success
Chris H. Fleming, DMD,* Mark S. Litaker, PhD,† Larry W. Alley, DMD,*
and Paul D. Eleazer, DDS, MS*
Abstract
Introduction: Many recent technological advance-
ments have been made in the field of endodontics;
however, comparatively few studies have evaluated
their impact on tooth survival. This study compared
the survival rates of endodontic treatment performed
by using classic techniques (eg, instrumentation with
stainless steel hand files, alternating 5.25% NaOCl
and 3% H2O2 irrigation, mostly multiple treatment visits,
and so on) versus those performed using more contem-
porary techniques (eg, instrumentation with hand and
rotary nickel-titanium files, frequent single-visit treat-
ment, NaOCl, EDTA, chlorhexidine, H2O2 irrigation,
warm vertical or lateral condensation obturation, use
of surgical microscopes, electronic apex locators, and
so on). Methods: Using a retrospective chart review,
clinical data were obtained for 984 endodontically
treated teeth in 857 patients. Survival was defined as
radiographic evidence of the treated tooth being present
in the oral cavity 12 months or more after initial treat-
ment. A mixed-model Poisson regression analysis was
used to compare failure rates. Results: Of the 459 teeth
in the classic group, there was an overall survival rate of
98% with an average follow-up time of 75.7 months. Of
525 teeth in the contemporary group, there was an over-
all survival rate of 96%, with an average follow-up time
of 34 months. Considerably more treatments in the
classic group were completed in multiple appointments
(91%) than in the contemporary group (39%). More
teeth in the classic group underwent posttreatment
interventions (6.7% vs 0.9%, respectively). Conclu-
sions: No statistically significant difference was noted
between the two technique groups or between single
or multiple visits in terms of survival. (J Endod
2010;36:414–418)
Key Words
Endodontics outcomes, multiple-visit endodontics,
temporary restorations
From the Departments of *Endodontics and †Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL.
Address requests for reprints to Dr Paul Eleazer, University of Alabama at Birmingham Department of Endodontics, 1530 3rd Avenue South, SDB 406, Birmingham, AL
35294. E-mail address: eleazer@uab.edu.
0099-2399/$0 - see front matter
Copyright ª 2010 American Association of Endodontists.
doi:10.1016/j.joen.2009.11.013
414 Fleming et al.
T he goal of endodontic treatment is to eliminate diseased pulpal tissue and to create
an environment that will allow for healing of periapical tissues and prevent the devel-
opment of apical periodontitis. Through the removal of diseased tissue, sealing of the
canal system, and subsequent restoration of the coronal tooth structure, affected teeth
are retained. This maintenance of arch integrity, esthetics, and function is what most
patients ultimately desire. Yet, there are other treatment options available for pulpally
and or periapically diseased teeth in addition to endodontic treatment. Extraction fol-
lowed by implant or removable/fixed partial denture placement are treatment options
that the dentist and patient may consider. Extensive literature has been published on the
success of endodontic treatment, but great variability exists between study protocols as
well as data obtained. Differences include the length of recall, radiographic interpreta-
tion, experience of practitioners, and methods of assessment of treatment outcomes.
Thus, treatment outcomes and success rates differ greatly. Some studies define success
based on strict radiographic healing, whereas others consider an endodontically
treated tooth a success if it remains present and functioning in the oral cavity (1–5).
Inconsistency in the definition of endodontic treatment ‘‘success’’ is confusing to
patients and practitioners and can cause injudicious treatment decisions. This concept
has become increasingly problematic in the debate between endodontic treatment and
implant-supported single-tooth replacement. In order to more effectively compare
treatment outcomes between endodontically treated teeth and implants, several recent
studies have evaluated endodontic success in terms of tooth survival rather than strict
radiographic and histologic criteria for healing (6–11).
Over the past few decades, huge technological advancements have been made in
the field of endodontics. Microscopes, rotary nickel-titanium files, ultrasonic instru-
mentation, electronic apex locators, digital radiography, new irrigation solutions,
and innovative obturation techniques have revolutionized the way in which endodontic
procedures are performed. Despite such advancements, the question exists as to
whether these technologies have improved the outcome of endodontic treatment and
increased the likelihood of tooth survival. The purpose of this retrospective study
was to evaluate and compare survival rates of endodontic treatment performed by an
experienced endodontist performing classic treatment techniques versus a group per-
forming more contemporary techniques.
Materials and Methods
This study was approved by the University of Alabama at Birmingham Institutional
Review Board. Two study groups were selected for analysis: the classic group and the
contemporary group. Patient records from four different treatment locations were iden-
tified, and data were collected by chart review. The classic group consisted of patient
records obtained from the practice of one endodontist who had been trained in the early
1970s. The ‘‘classic techniques’’ performed by this endodontist included
JOE — Volume 36, Number 3, March 2010

TABLE 1. Comparison of Treatment Techniques
Classic Group Contemporary Group
Hand SS files Hand/Rotary SS and NiTi files
Mostly two or more visits Predominately one visit
NaOCl and H2O2 NaOCl, CHX, ETDA, H2O2
Lateral condensation Warm vertical, lateral
obturation condensation obturation
No overfills More frequent obturation
flush or overfilled
Definitive restoration of Mostly temporary restorations
access in most patients
Surgical microscopes
Ultrasonic instrumentation
Electronic apex locators
Digital radiography
SS, stainless steel.
instrumentation with stainless steel hand files, alternating 5.25% NaOCl
and 3% H2O2 irrigation, mostly multiple treatment visits, placement of
calcium hydroxide and form cresol intracanal medicaments, strict
adherence to confining instrumentation and obturation short of the
radiographic apex, lateral condensation obturation, and frequent place-
ment of definitive restorations at the completion of the procedure. The
contemporary group consisted of patient records obtained from three
different endodontic practices in which where the practitioners were
trained within the past 15 years. The ‘‘contemporary techniques’’
used in this group included instrumentation with hand and rotary
nickel-titanium files, frequent single-visit treatment, NaOCl, EDTA, chlo-
rhexidine, H2O2 irrigation, warm vertical or lateral condensation obtu-
ration, use of surgical microscopes, electronic apex locators, digital
radiography, ultrasonic instrumentation, and placement of temporary
restorations. The treatment techniques for both groups are summarized
in Table 1. Patient records from the selected practices were reviewed in
alphabetical order. If an endodontic procedure was completed on
a patient, the record was further evaluated to determine if a clinical
or radiographic follow-up for that tooth was available. The only criteria
required for inclusion in the study was that a clinical or radiographic
follow-up of 12 or more months after endodontic treatment was avail-
able. Endodontically treated teeth without a clinical or radiographic
follow-up of at least 12 months were excluded from the study. Many
times follow-up radiographs were obtained at specific recall appoint-
ments. Other follow-up radiographs were obtained during the course
of treatment of the adjacent teeth. Only radiographs that displayed the
entire tooth including the periapex were used for evaluation. When
available, treatment data obtained for the endodontically treated tooth
included the following: tooth number, patient age at treatment, sex,
ethnicity, smoking habits, presence/absence of diabetes, length of
time to most recent recall, tooth restored and functioning in occlusion,
tooth presence in the mouth, number of treatment appointments, length
of obturation relative to the radiographic apex, presence of a post, pres-
ence of a preoperative periapical radiolucency, and posttreatment inter-
ventions. A modified periapical index scoring system was created by the
authors to evaluate pre-op radiographs for the presence of periapical
lesions. This system was similar to that used by Hannahan et al (11).
The parameters for the scoring system are shown in Table 2. Radio-
graphs were examined by a single evaluator and no calibration was
undertaken. The periodontal ligament surrounding the treated tooth
was evaluated for breaks in continuity and/or widening. The
surrounding alveolar bone was evaluated for radiolucencies. No data
were collected on the number of roots affected, size of the lesion, or
whether the lesion was well defined or diffuse. Teeth were classified
as having a pre-op lesion if there was breakdown or widening in the
PDL or radiolucency in the bone. This corresponded to a modified
JOE — Volume 36, Number 3, March 2010 Classic Endodontic Techniques versus Contemporary Techniques on Treatment Success
Clinical Research
TABLE 2. Summary of Modified Periapical Index Scoring System
PAI 1 Intact PDL
PAI 2 Possible broken or widened PDL
PAI 3 Broken or widened PDL
PAI 4 Break in PDL with possible radiolucency
PAI 5 Broken PDL with definite radiolucency
PDL, periodontal ligament. PAI scores $3 indicate periapical lesion.
PAI score of 3 or greater. A modified PAI score of 3 or greater was
used to identify the presence of a periapical lesion. Postoperative radio-
graphs were only evaluated for the presence or absence of the treated
tooth. Evaluation of periapical pathosis using the modified periapical
index was not completed for postoperative recall radiographs. Survival
of endodontic treatment was defined as radiographic evidence of the
treated tooth still present in the mouth 12 months or more after the
initial treatment. A tooth was classified as a failure if extracted at any
time after treatment. Failure rates were compared between the two
groups using a mixed-model Poisson regression analysis. A term repre-
senting the individual patients was included as a random effect in the
model in order to account for correlation caused by the occurrence
of multiple treatments for some patients. The analysis was implemented
using SAS statistical software (Release 9.2; SAS Institute, Inc, Cary NC).
Results
Of the nearly 8,000 charts reviewed, 984 endodontically treated
teeth in 857 patients met the inclusion criteria. A summary of findings
is presented in Table 3. The classic group included 459 treated teeth in
414 patients; the contemporary group consisted of 525 contemporarily
treated teeth in 443 patients. In the classic group, nine teeth were ex-
tracted, resulting in an overall survival rate of 98.0%. Twenty-one fail-
ures were noted in the contemporary group data with an overall survival
rate of 96.0%. Molars were the most frequently treated group of teeth in
both groups followed by premolars and anteriors. The patient popula-
tion averaged 48.9 years of age in the classic group (standard deviation
= 14.1 years) and 53.9 years in the contemporary group (standard
deviation = 15.2 years, p < 0.0001). Women were treated more
frequently in both groups; 98.6% of patients treated in the classic group
were white and 1.4% black. Eighty-six percent of patients treated by the
endodontists in the contemporary group were white and 12.2% black
with few Asians and Hispanics represented. The ethnic distributions
of the two groups were significantly different (p < 0.0001). Ethnicity
data were unavailable for 108 patients. Nearly 10% of the population
in the contemporary group reported a history of diabetes, whereas
only four patients in the entire population of the classic group reported
a history of diabetes. The average time to recall in the classic group was
75.7 months, ranging from 12 to 301 months, which was over double
that of the contemporary group (34.0 months, ranging from 12-219
months). In the classic group, the average number of treatment
appointments was 2.2. Most of the classic group root canal treatments
were completed in two visits (71.9%); an additional 19.6% were treated
in three or more visits. Only 8.5% of the treatments were performed in
a single visit. Root canal treatments in the contemporary group required
an average number of 1.41 appointments. The majority of cases in the
contemporary group were completed in a single visit (60.2%). Fewer
treatments required more than one visit (39.8%). Of the teeth treated
in more than one session in the contemporary group, only 0.95% neces-
sitated three or more visits. The number of treatments performed in
a single visit was significantly different between the classic group and
contemporary group (p < 0.0001). Calcium hydroxide was the most
frequently placed intracanal medicament. In the classic group, form
415
Clinical Research
TABLE 3. Summary of Data
Classic Group (%) Contemporary Group (%)
Treated teeth 459 525
Anteriors 88 (19.2) 106 (20.2)
Premolars 149 (32.5) 129 (24.6)
Molars 222 (48.4) 290 (55.2)
Avg treatment age* 48.9 (SD = 14.1) 53.9 (SD = 15.2) p < 0.0001
Females 267 (58.2) 299 (56.9)
Males 192 (41.8) 226 (43.1)
Ethnicity* White: 98.6% White: 86% p < 0.0001
Black: 1.4% Black: 12.2%
Smoker NA N: 340 of 401 (84.8)
Y: 61 of 401 (15.2)
Diabetes N: 455 (99.1) N: 361 of 401 (90.0)
Y: 4 (0.9) Y: 40 of 401 (10.0)
Avg recall time 75.73 months 34.07 months
Avg number visits 2.2 1.41
1 visit* 39 (8.5) 316 (60.2) p < 0.0001
2 visits 330 (71.9) 204 (38.9)
3+ visits 90 (19.6) 5 (0.95)
Overfills 0 21
Post present N: 402 (87.6) N: 445 (84.8)
Y: 57 (12.4) Y: 80 (15.2)
Preoperative lesion N: 317 (69.1) N: 378 (72.0)
Y: 142 (30.9) Y: 147 (28.0)
Post Tx interventions* 31 (6.7) 5 (0.9) p = 0.0141
Apico: 10 Apico: 3
Retreat- 20 Retreat: 2
Hemisection: 1 NA
Failures (extractions) 9 21
Success 98.03% 96.00
Y, yes; N, no; NA, not applicable; SD, standard deviation.
*Indicates statistical significance.

cresol was placed in many vital cases. Obturation in the classic group
was confined within the tooth in all cases, with lengths ranging from
0 to 5 mm inside the radiographic apex. Most of the obturation lengths
were confined within 2 mm from the radiographic apex. No gross over-
fills were noted. The contemporary group had more overfills (3.8%);
however, most of the fills were less than 2 mm short of the radiographic
apex. A larger percentage of teeth with pretreatment lesions (PAI score
of $3) (31.2%) occurred in the classic group versus the contemporary
group (28.0%) although the difference was not statistically significant
(p = 0.3796). Although no specific data were recorded, most of the
access preparations in the classic group were restored by the endodon-
tist with a definitive restoration. All teeth that did not require multisur-
face buildups were restored with amalgam or composite at the
completion of endodontic treatment. When temporary restorations
were placed, cotton pellets were seldomly used. Almost all teeth in
the contemporary group were restored with a temporary restoration.
Cotton pellets were more frequently placed.
A significantly greater number of teeth underwent posttreatment
interventions in the classic group (6.7%) than in the contemporary
group (0.9%, p = 0.0141). Only one of the teeth that received posttreat-
ment intervention was subsequently extracted. A summary of data on
posttreatment interventions is presented in Table 4. Most of the post-
treatment interventions in both groups were performed on molars
and on teeth with pretreatment periapical radiolucencies. The most
frequent posttreatment intervention performed in the classic group
was retreatment, whereas apicoectomy was marginally more frequent
in the contemporary group. Most of the interventions in the classic
group were performed on teeth originally treated in multiple visits.
The average obturation lengths of intervention teeth were similar to
those of the nonintervention teeth in both groups.

TABLE 5. Characteristics of Failures

TABLE 4. Characteristics of Post Treatment Interventions
Contemporary
Contemporary Classic Group (%) Group (%)
Classic Group (%) Group (%) Failures 9/459 21/525
Interventions 31/459 5/525 Percentage 1.96% 4.00%
Percentage 6.70% 0.90% Anteriors 1 (11.1) 0 (0.0)
Anteriors 7 (22.6) 1 (20.0) Premolars 1 (11.1) 13 (61.9)
Premolars 6 (19.4) 1 (20.0) Molars 7 (77.8) 8 (38.1)
Molars 18 (58.1) 3 (60.0) Diabetes 1 (11.1) 1 (0.05)
Diabetes 1 (3.2) 1 (20.0) 1 visit 0 (0.0) 12 (57.1)
1 visit 1 (3.2) 2 (40.0) 2 visit 3 (33.3) 7 (33.3)
2 visit 20 (64.5) 3 (60.0) 3+ visits 6 (66.7) 2 (9.5)
3+ visits 10 (32.3) 0 (0.0) Overfills/flush fills 0 (0.0) 9 (42.9)
Overfills/flush fills 0 (0.0) 3 (60.0) Post present 0 (0.0) 8 (38.1)
Post present 3 (9.7) 2 (40.0) Preoperative area 4 (44.4) 10 (47.6)
Preoperative area 19 (61.3) 3 (60.0) Post Tx intervention 1 (11.1) 0 (0.0)

416 Fleming et al. JOE — Volume 36, Number 3, March 2010


Of the nine failures in the classic group, the majority (77.8%) were
molars. No failures were noted on teeth with single-visit treatments. No
overfills or flush fills were present. Four of the nine extracted teeth had
pretreatment periapical radiolucencies. In the contemporary group, 21
failures were noted. Premolars accounted for 61.9% of the failures in
the contemporary group. Most of the extracted teeth had single-visit
initial treatment. Nine overfills or flush fills were noted. Ten of the 21
failures had pretreatment lesions. A summary of failure for both groups
is presented in Table 5. After statistical analysis, no significant difference
in failure rates was noted between the two technique groups.
Discussion
The overall survival rate of root canal–treated teeth in the classic
group and the contemporary Group was very high (98% and 96%,
respectively). No statistically significant difference was noted between
the two groups. These rates were consistent with other studies that
used tooth survival as a criterion for success (6-11). This study reiter-
ates the fact that root canal treatment is a very successful and reliable
treatment. A recent meta-analysis review by Iqbal and Kim (12) found
success rates ranging from 81.2% to 100% in studies that used survival
as the criterion for success.
Our retrospective format allowed for the evaluation of a large
number of endodontically treated teeth. Yet, this format has several short-
comings. The data obtained were limited to what was available from clin-
ical notes and radiographs. No standardization of diagnosis or treatment
protocols was possible because of major or minor treatment protocols by
practitioners included in this study. As noted by Iqbal and Kim (12),
a retrospective case study only provides a ‘‘fair’’ assessment of data
quality. Data for this study were limited to treated teeth with a minimum
12-month recall time in patients who opted to return to the provider of
the original treatment. A study by Orstavik (13) showed that the majority
of posttreatment periapical lesions occurred within the first year; there-
fore, a 1-year recall is a good predictor of success. In the current study,
no attempt was made to determine why the tooth was extracted. Many
factors may influence this treatment decision including periodontal
disease status, development of fractures, lack of an adequate coronal
restoration, excessive caries involvement, or patient financial limitations.
Although both treatment groups showed high rates of survival,
several differences were interesting to note. One of the main differences
in philosophy between the two groups was the treatment of cases in one
or multiple visits. The doctor whose patients comprised the classic group
treated the vast majority of cases in two or more visits, whereas the contem-
porary group had a large percentage of single-visit treatments. There has
been a recent movement toward single-visit endodontics. A recent review
by the Cochrane Group showed that no difference existed in the effective-
ness of root canal treatment in terms of radiographic success between
single and multiple visits (14). Several other studies have supported this
claim (15–17). The traditional view that was held by the practitioner in
the classic group was that complete disinfection of the canals could best
be achieved by multiple visits with the use of intracanal medicaments as
proposed by Bystrom et al (18) and Sjogren et al (19).
Another interesting difference between groups was the larger
percentage of posttreatment interventions performed in the classic
group. Because only one of these teeth was subsequently extracted,
one must wonder if some of the teeth extracted in the contemporary
group could have been further treated with apical surgery or retreatment.
The classic group and the contemporary group also differed in the length
of obturation. Of all the endodontic treatment performed in the classic
group, no gross overfills occurred, whereas 21 obturations in the
contemporary group were beyond the radiographic apex. Extensive
histologic research has shown that obturation materials present in the
JOE — Volume 36, Number 3, March 2010 Classic Endodontic Techniques versus Contemporary Techniques on Treatment Success
Clinical Research
periapical tissue result in persistent chronic inflammation and a greater
incidence of epithelial proliferation and cyst formation (20, 21).
A final difference of note between the two groups was the place-
ment of definitive restorations after root canal treatment. Several studies
have shown the importance of an adequate coronal seal and the suscep-
tibility of temporary restorations to leakage over time (22–26).
This study compared the survival rates of endodontic treatment
performed by a practitioner using classic techniques versus three using
more contemporary techniques. There was no statistically significant
difference in the success rate for the ‘‘classic techniques’’ group versus
contemporary counterparts; the primary clinically significant difference
was the equivalence of one-visit and two-visit techniques. Although no
significant difference in treatment outcome was found between the
two study groups, one must consider the limitations of the study. The
first limitation involves the individual variation in abilities between the
practitioners. The classic group consisted of treatments rendered by
only one endodontist, whereas the contemporary group consisted of
treatments by multiple endodontists. Therefore, because of the small
number of practitioners, we were unable to determine if the differences
in success were caused by differences in treatment techniques or in clin-
ical abilities. Another possible reason for skewed data is that the typical
office routine was to ask patients to return for a 6-month follow-up eval-
uation. Many of the patients who qualified for this study presented for an
endodontic procedure on another tooth and were likely satisfied with
a successful outcome of the prior treatment.
A further limitation of the study is the large difference in the
average time to recall. The classic group had a much longer average
time to recall than group 2. This may have been caused in part by the
fact that the endodontist in the classic group practiced for over 30 years
in the same area and had a large number of repeat patients on which
recall radiographs could be taken. The longer time to recall as seen
in the classic group would allow for a longer time for the treated tooth
to fail. Therefore, the failure rate of the contemporary group might have
been higher if the time to recall was as long. Despite these limitations,
this study confirmed the findings of many previous studies that endon-
dontic treatment can result in very high rates of tooth survival.
Acknowledgment
Data in this study are part of a larger study supported by
a grant from the American Association of Endodontists Research
Foundation
References
1. Friedman S. Prognosis of initial endodontic therapy. Endod Topics 2002;2:
59–88.
2. Friedman S. Treatment outcome and prognosis of endodontic therapy. In:
Orstavik D, Pitt Ford TR, eds. Essential Endodontology. Oxford: Blackwell Science;
1998:367–401.
3. Friedman S, Abitol S, Lawrence H. Treatment outcome in endodontics: The Toronto
Study-Phase I: initial treatment. J Endod 2003;29:787–93.
4. Ingle JI, Beveridge EE, Glick DH, et al. Modern endodontic therapy. In: Ingle JI, ed.
Endodontics (ed 3). Philadelphia, PA: Lea and Febiger; 1985:26–50.
5. Strindberg LZ. The dependence of the results of pulp therapy on certain factors. An
analytic study based on radiographic and clinical follow-up examinations. Acta
Odontol Scand 1956;14:1–175.
6. Alley BS, Kitchens GG, Alley LW, et al. A comparison of survival of teeth following
endodontic treatment performed by general dentists or by specialists. Oral Surg
Oral Med Oral Path Oral Radiol Endod 2004;98:115–8.
7. Alley BS, Buchanan TH, Eleazer PD. Comparison of the success of root canal
therapy in HIV/AIDS patients and non-infected controls. Gen Dent 2008;56:
155–7.
8. Doyle SL, Hodges JS, Pesun IJ, et al. Factors affecting outcomes for single-tooth
implants and endodontic restorations. J Endod 2007;33:399–402.
417
Clinical Research
9. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population
in the USA: an epidemiological study. J Endod 2004;30:846–50.
10. Lazarski MP, Walker WA, Flores CM, et al. Epidemiological evaluation of the
outcomes of nonsurgical root canal treatment in a large cohort of insured dental
patients. J Endod 2001;27:791–6.
11. Hannahan JP, Eleazer PD. Comparison of success of implants versus endodontically
treated teeth. J Endod 2008;34:1302–5.
12. Iqbal MK, Kim S. Single tooth implant versus root canal treatment and restoration for
compromised teeth: a meta-analysis. Int J Oral Maxillofac Implants 2007;22(Suppl):
96–116.
13. Orstavik D. Time-course and risk analyses of the development and healing of
chronic apical periodontitis in man. Int Endod J 1996;29:150–5.
14. Figini L, Lodi G, Gorni F, Gagliani M. Single versus multiple visits for endodontic
treatment of permanent teeth. Cochrane Database Syst Rev 2007;17:4.
15. Molander A, Warfvinge J, Reit C, et al. Clinical and radiographic evaluation of one-
and two-visit endodontic treatment of asymptomatic necrotic teeth with apical perio-
dontitis: a randomized clinical trial. J Endod 2007;33:1145–8.
16. Peters LB, Wesselink PR. Periapical healing of endodontically treated teeth in one
and two visits obturated in the presence or absence of detectable microorganisms.
Int Endod J 2002;35:660–7.
17. Lin LM, Lin J, Rosenberg P. One-appointment therapy: biological considerations.
J Amer Dent Assoc 2007;138:1456–62.
418 Fleming et al.
18. Bystrom A, Happonen RP, Sjogren U, et al. Healing of periapical lesions of pulpless
teeth after endodontic treatment with controlled asepsis. Endod Dent Traumatol
1987;3:58–63.
19. Sjogren U, Figdor D, Persson S, et al. Influence of infection at the time of root canal
filling on the outcome of endodontic treatment of teeth with apical periodontitis. Int
Endod J 1997;30:297–306.
20. Seltzer S, Soltanoff W, Smith J. Biological aspects of endodontics. V. Periapical tissue
reactions to root canal instrumentation beyond the apex and root canal fillings short
of and beyond the apex. Oral Surg 23;36:725–737.
21. Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation,
part 2. A histological study. Int Endod J 1998;31:394–409.
22. Ray HA, Trope M. Periapical status of enodontically treated teeth in relation to the tech-
nical quality of the root filling and the coronal restoration. Int Endod J 1995;28:112–8.
23. Saunders WP, Saunders EM. Coronal microleakage as a cause of failure in root-
canal therapy: a review. Endod Dent Traumatol 1994;10:105–8.
24. Torabinejad M, Ung B, Kettering JD. In vitro bacterial penetration of coronally un-
sealed endodontically treated teeth. J Endod 1990;16:566–9.
25. Safavi KE, Dowen WE, Langeland K. Influence of delayed coronal permanent resto-
ration on endodontic prognosis. Endod Dent Traumatol 1987;3:187–91.
26. Iqbal MK, Johansson AA, Akeel RF, et al. A retrospective analysis of factors associ-
ated with the periapical status of restored, endodontically treated teeth. Int J Pros-
thodont 2003;16:31–8.
JOE — Volume 36, Number 3, March 2010