Clinical Research
Levels of Evidence for the Outcome of Nonsurgical
Endodontic Treatment
Mahmoud Torabinejad, DMD, MSD, PhD,* Diana Kutsenko, DMD,††
Tanya K. Machnick, DDS, MS,‡‡ Amid Ismail, BDS, MPH, DPH,§§ and
Carl W. Newton, DDS, MSD¶¶
Abstract
The purpose of this systematic review was (a) to search
for clinical articles pertaining to success and failure of
nonsurgical root canal therapy, and (b) to assign levels
of evidence to these studies. Electronic and manual
searches were conducted to identify studies published
between January 1966 and September 2004 with in-
formation on the success and failure of nonsurgical root
canal therapy. Articles were reviewed and graded for
strength of level of evidence (LOE) from one (highest
level) to five (lowest level). This review resulted in the
identification of 306 clinical studies related to this topic
area. Six articles were randomized controlled trials
(RCTs, LOE 1). This search also identified 12 low-quality
RCTs (LOE 2), 14 cohort studies (LOE 2), five case-
control and eight cross sectional studies (LOE 3), four
low-quality cohort studies (LOE 4), and five low-quality
case-control studies (LOE 4). The majority (73) of the
often-quoted “success and failure” studies were case
series (LOE 4). The rest of the articles were descriptive
epidemiological studies (42), case reports (114), expert
opinions (18), literature reviews (4), and one meta-
analysis. Based on these findings, it appears that a few
high-level studies have been published in the past four
decades related to the success and failure of nonsur-
gical root canal therapy. The data generated by this
search can be used in future studies to specifically
answer questions and test hypotheses relevant to the
outcome of nonsurgical root canal treatment.
Key Words
Outcome, endodontics, clinical trials, systematic review
From the *Department of Endodontics of the School of
Dentistry, Loma Linda University, Loma Linda, California; ††Pri-
vate practice; ‡‡Private practice; §§Department of Cariology,
Restorative Sciences, and Endodontics at the School of Den-
tistry and Department Epidemiology, School of Public Health,
University of Michigan, Michigan; ¶¶Department of Endodon-
tics, Indiana University School of Dentistry, Indiana.
Address request for reprints to Dr. Mahmoud Torabinejad,
Professor and Director, Endodontic Residency Program Depart-
ment of Endodontics School of Dentistry Loma Linda University
Loma Linda, CA 92350. E-mail address: mtorabinejad@sd.llu.edu.
Copyright © 2005 by the American Association of
Endodontists
JOE — Volume 31, Number 9, September 2005
W hen the dental pulp undergoes pathologic changes because of trauma or the
progression of dental caries, bacteria and other irritants from the oral cavity
invade the root canal system. The major objectives of root canal therapy are removal of
pathologic pulp, cleaning, and shaping of the root canal system, disinfection of con-
taminated root canals, and obturation of the root canal system in three dimensions to
prevent reinfection. Adherence to these treatment objectives should result in maintain-
ing normal radiographic and clinical conditions in teeth without preoperative perira-
dicular lesions. Similar radiographic and clinical outcomes are expected in teeth with
preoperative periradicular lesions when the same principles are practiced during root
canal therapy.
When a clinician is involved in treatment planning with a patient, the following ques-
tions must be answered: What is the success rate of root canal therapy? What evidence is
available? How is it compared to alternative treatment modalities? And finally, can the out-
comes of root canal therapy be compared with that of alternative treatments?
If the decision must be made whether to save a natural tooth by performing root
canal therapy, a patient has the right to know the prognosis of the proposed treatments
to make an informed decision. The parties involved (patients, dentists, insurance com-
panies) have different perspectives and expectations regarding the outcome of root
canal treatment. Patients are usually content as long as their teeth are functionally and
esthetically pleasing, insurance companies may measure success by survival rate of
endodontically treated teeth, and endodontists are usually most concerned with the
absence of disease clinically and radiographically.
Clinical and radiographic examinations are the most common procedures that are
used to determine outcomes of root canal therapy. As far back as 1966, Bender and
co-workers (1) identified some of the factors that could affect the “success” of root
canal treatment. They noted that radiographic interpretation is often subject to personal
bias and that a change in angulations can often give a completely different appearance
to the lesion, making it appear either smaller or larger. They also discussed the fact that
clinical symptoms such as pain, swelling, and presence of a sinus tract can occur
without radiographic evidence of bone destruction. In addition, they indicated that not
all radiolucencies located in the periapical area are of pulpal origin, and that some of
these lesions are caused by systemic conditions.
Most previous nonsurgical root canal studies have used various criteria to deter-
mine “success;” therefore, the success rates from one study cannot be compared to
those of another study. Currently, the only way to evaluate the outcomes of different
techniques and materials is to approximate the findings of one study with another. For
example, it is possible to find some level of evidence to justify using various filling
techniques, but very little exists to conclusively prove one method is superior to others.
Recently, there has been a movement towards evidence-based dentistry to scien-
tifically evaluate the effectiveness of the treatments that are performed clinically. The
term “evidence based medicine” was coined at McMaster Medical School in Canada in
the 1980s to label this clinical learning strategy, which people at the school had been
developing for over a decade (2). The purpose of developing this approach was to allow
clinicians to use research findings as the basis for clinical decisions (3). Many clini-
cians continue to base their clinical decisions on increasingly outdated primary train-
ing, or the over-interpretation of experiences with individual patients (4).
Outcome of Nonsurgical Endodontic Treatment 637
Clinical Research
TABLE 1. The MeSH terms related to success and failure of nonsurgical root canal therapy used for MedlinePlus search
(Exp Endodontics/ or exp Dental Pulp Diseases/ or exp Periapical
Diseases/ or exp “Root Canal Filling Materials”/ or Dental Pulp Test/ or
Dental Pulp/ or Dental Pulp Cavity/) or (“root canal”.mp. or
apicectom:.mp. or apicoectom:.mp. or (dead adj3 (teeth or tooth)).mp. or
(dental adj3 pulp:).mp. or endodont:.mp. or endont:.mp. or endosonic.mp.
or ((lateral or vertical) adj condensation).mp. or ((non-vital or
nonvital) adj3 (teeth or tooth)).mp. or obtura.mp. or obturation.mp. or
obturate.mp. or (pulp adj3 (capping or therap: or extirpation:)).mp. or
(pulp adj (canal$1 or chamber$1)).mp. or pulpectomy.mp. or pulpotomy.mp.
or replantation.mp. or (“root” adj end adj5 fill:).mp. or ((silver or
gutta) adj3 (percha or balata).mp. or (silver adj (cone$1 or
point$1)).mp. or thermafil.mp. or trans-polyisoprene.mp. or
transpolyisoprene.mp. or ultrafil.mp.) or ((periradicular or radicular or
periapical or apical).mp. and (exp tooth/ or exp tooth components/)) or
(hemisection:.mp. not (spine or spinal).mp.)) and (Clinical Protocols/ or
exp Clinical trials/ or exp Patient Care Management/ or Patient Selection/
or Practice Guidelines/ or clinic:.mp. or (recall adj3 appointment$1).mp.
or ((patient or research) adj3 (recruitment or selection)).mp. or
(selection adj3 (criteria or treatment or subject$1)).mp. or (treatment
adj protocol$1).mp. or ra.fs. or radiograph:.mp. or ah.fs. or
histolog:.mp. or (nonsurg: or non-surg:).mp.) and (exp Disease
progression/ or exp Morbidity/ or exp Mortality/ or exp “Outcome
assessment (health care)”/ or exp Patient satisfaction/ or exp Prognosis/
or exp Survival analysis/ or exp Time factors/ or exp Treatment outcome/
Or co.fs. or course.mp. or (inception adj cohort$1).mp. or (natural adj
History).mp. or outcome$1.mp. or predict$.mp. or prognos$.mp. or
Surviv$3.mp. or fail$5.mp. or longevity.mp. or durability.mp. or
Succes:.mp. or exp Case-control studies/ or exp Cohort studies/ or exp
“Comparative study”/ or Retreatment/ or Recurrence/ or (retreat: or
Revis:).mp.)) not ((Dentition, Primary/ or Child, Preschool/ or Child/ or
(immatur: adj3 (teeth or tooth)).mp. or (open adj3 (apex or apices or
Apexes)).mp. or blunderbuss.mp.) not (Dentition, Mixed/ or Dentition,
Permanent/ or Adolescent/ or exp Adult/ or (mature adj3 (teeth or
Tooth)).mp. or (closed adj3 (apex or apices or apexes)).mp.))) not
(Animal/ not Human/)) limit 1 to english language

The concept of evidence-based healthcare has gained strength in
the last decade. All branches of healthcare now subscribe to the evi-
dence-based philosophy. However, evidence-based practice requires
the availability of primary research to answer the clinical questions that
practitioners face in their practices. Evidence-based dentistry (EBD) is
a new approach to oral healthcare that integrates the best clinical evi-
dence to support a practitioner’s clinical expertise for each patient’s
treatment needs and preferences.
The American Dental Association has outlined four steps for evi-
dence-based dental practice (5). The first step defines a clinically rel-
evant and focused question in the interest of finding the best available
evidence to promote the oral health of patients. The second step focuses
on systematically conducting searches for all studies to determine the
gaps in the knowledge related to a specific question. The third step of the
EBD process is to translate the findings from systematic reviews for use
by practitioners. The final step of the EBD process assesses the health-
care outcomes following the findings of the previously outlined steps.
A review of current literature shows absence of comprehensive
information regarding the design and quality of studies related to the
outcome of nonsurgical root canal therapy.
The purpose of this systematic review was (1) to search for clinical
articles pertaining to success and failure of nonsurgical endodontics,
and (2) to assign levels of evidence to these studies.
Methods
MEDLINE, a search tool of the National Library of Medicine served
as our primary computerized database. A search strategy was developed
to identify articles in MEDLINE dealing with success and failure of non-
surgical root canal therapy from January 1966 through September
2004. Additionally, “text words” describing different endodontic treat-
ments and phrases related to the success and failure of nonsurgical root
canal therapy were used to allow for a broader capture of literature. The
detailed search strategy is shown in Table 1. An endodontist and an
information expert selected search concepts and terms jointly. Before
the search was performed, the endodontist identified 13 core articles
that should be retrieved by the final search. The presences of these core
articles in the search results were used as a criterion to validate the
accuracy of the final MEDLINE search strategy.
In addition to MEDLINE, EMBASE, and the Cochrane Library were
also searched, with the MEDLINE search strategy modified substantially
to suit the unique structures and content of these different databases.
The EMBASE database does not include many of the MeSH headings
used in the MEDLINE search, and they are structured differently, making
it necessary to substantially enrich the free text terms used in the search.
The Cochrane database is smaller in size and more focused in scope,
making it unnecessary to include the breadth of free text terms or
methodology descriptors. The searches included human studies and
reviews in the English language, which contained clinical, radiographic,
histological, or microbiologic information on the outcome of nonsur-
gical root canal therapy.
Initially, the titles of all articles were printed and screened. Based
on our inclusion criteria, a group of articles was selected for closer
examination. The abstracts of these articles were then reviewed for
inclusion based on the following criteria:
1. Success and failure, such as periapical healing or persistence of
a lesion;
2. The success rate of endodontics in a specified population (epi-
demiological study);
3. The success rate of a unique case followed over time;
4. Clinical success as described by “an expert.”

638 Torabinejad et al. JOE — Volume 31, Number 9, September 2005


Articles that simply described a clinical technique or studies that did not
have a follow-up of 1-yr after initial treatment were excluded from the
search body. Articles that addressed a short-term success and failure,
such as presence or absence of pain, were reviewed but not included in
the final results.
In addition to the electronic searches, we included the chapters
regarding success and failure in Endodontics (6), Essential Endod-
ontology (7), Pathways of the Pulp (8), and Principles and Practice
of Endodontics (9). These chapters were reviewed and the articles that
matched the search criteria were pulled and cross-referenced as de-
scribed above. In addition to the literature in these textbooks, literature
binders used by Graduate Endodontics at Loma Linda University were
also included and subjected to the same review process as the other
databases that were searched.
For each reference that appeared to match the search criteria, the
article was photocopied and reviewed by a team of five reviewers (four
students and an endodontist). The reference section of each article was
then studied to determine if any of the references cited in the article
matched our search criteria. Each time a reference section was re-
viewed, the references were checked against a master list of articles
already located using the search of the electronic databases. If an article
did not appear on the master list, it was then pulled, reviewed and
cross-referenced. This cross-referencing process (locating articles and
studying the reference section) was continued until there were no
longer any new articles located in either the electronic databases or
through manual cross-referencing.
The articles on the master list were then divided among five re-
viewers. All articles were read thoroughly, and a one-page abstraction
sheet was written for each article that included the purpose, methods,
results, and discussion. Once the abstracts were completed, the five
evaluators stratified them jointly based on the levels of evidence (LOE).
Two additional experienced faculty members in evidence-based den-
tistry confirmed these ratings later. This process confirmed the initial
results and helped to ensure proper classification of the articles.
The LOE from one to five was determined (Table 2). Level one
included Randomized controlled trials (RCTs) and systematic reviews
of randomized control trials, level two included low-level RCTs, Cohort
studies and systematic review of cohort studies, level three included
Case control and systematic reviews of case control studies, level four
included low-level Cohort studies and Case series (noncomparative),
and level five included Case reports, Expert opinion, and literature
reviews. For each study that qualified as an RCT or a cohort study, a
further series of questions (Tables 3 and 4) were answered to deter-
mine if the study was a high- or low-quality RCT or Cohort study. If most
of the assessment criteria were not met for a study, it was lowered by one
evidence level. In addition to the quality evaluation conducted using the
criteria described in Table 3 for randomized controlled trials, an as-
TABLE 2. Evidence level stratification of relevant study designs
1 Randomized control trials (RCT)
Systematic reviews of randomized control trials
2 Low-quality randomized control trials
Cohort studies
Systematic review of cohort studies
3 Case control studies
Systematic reviews of case control studies
4 Poor-quality cohort and case control studies
Case series
5 Case reports
Expert opinion without explicit critical appraisal
Literature reviews
Adapted from Center for Evidence-based Medicine at Oxford.
JOE — Volume 31, Number 9, September 2005
Clinical Research
TABLE 3. Validity assessment questions for clinical control trials (RCTs; LOE
1, or LOE 2)
1. Did the trial address a clearly focused issue?
2. Is a trial (RCT) an appropriate method to answer this issue?
3. How were patients assigned to treatment groups?
4. Were staff and study personnel “blind” to treatment?
5. Were all the participants who entered the trial properly
accounted for at its conclusion?
6. Aside from experimental intervention, were the groups
treated in the same way?
7. Did the study have enough participants to minimize the
play of chance?
Adapted from Center for Evidence-based Medicine at Oxford.
TABLE 4. Validity assessment questions for cohort studies (LOE 2 or LOE 4)
1. Did the trial address a clearly focused issue?
2. Did the authors use an appropriate method to answer this
issue?
3. Was the cohort recruited in an acceptable way?
4. Was the exposure accurately measured to minimized bias?
5. Was the outcome accurately measured to minimized bias?
6a. Have the authors identified all the important
confounding factors?
6b. Have they taken account of the confounding factors in
the design and/or analysis?
7a. Was the follow up of subjects complete enough?
7b. Was the follow up of subjects long enough?
Adapted from Center for Evidence-based Medicine at Oxford.
sessment using some of the CONSORT guidelines (10, 11) was also used
for these studies.
Results
The MEDLINE search produced 3,211 articles; the EMBASE search
resulted in 1,677 articles, and the Cochrane Library provided 673 arti-
cles. The manual searches resulted in identification of 463 articles. The
articles dealing with outcomes of nonsurgical endodontic treatment
were selected based on their titles and abstracts. A total of 306 articles
were finally classified as relevant to the question of the review. The
criteria for success varied from study to study, and no attempt was made
to standardize the definition of “success.”
Of the 306 clinical “success and failure” studies, there were six
RCTs that is level of evidence 1 (12–17). Our search identified 12 low
quality RCTs (18 –29), 14 cohort studies (30 – 43), corresponding to
level of evidence 2, and five case-control studies (45– 48) and eight
cross sectional studies with the levels of evidence 3 (49 –56). Level of
evidence 4 includes four low quality cohort studies (57– 60), five low
quality case-control studies (61– 65), 73 case series (66 –138), and 42
descriptive epidemiological studies (139 –180). Level of evidence 5
includes 114 case reports (181–294), 18 expert opinion articles (1,
295–311), four literature reviews (312–315), and one meta-analysis
(316). Table 5 shows levels of evidence, classification of various studies
and the number of studies in each category.
Discussion
This paper presents a systematic review of the design and quality of
studies that are published to answer the following clinical question:
What are the designs, and what is the quality of success and failure
studies of nonsurgical endodontic therapy? This question does not fol-
low the standard PICO format (population, intervention, comparison,
and outcomes) because this project, while it followed a systematic ap-
proach for searching for studies, is not a systematic review of a clinical
question or an intervention. Rather, this study should be viewed as a
Outcome of Nonsurgical Endodontic Treatment 639
Clinical Research
TABLE 5. LOE, Classification of various studies and the number of studies in each category
LOE Classification of Various Types of Studies
1 Randomized control trials (RCT)
Systematic reviews of randomized control trials
2 Low-quality randomized control trials
Cohort studies
Systematic review of cohort studies
3 Case control studies
Systematic reviews of case control studies
4 Poor-quality cohort and case control studies
Case series
5 Case reports
Expert opinion without explicit critical appraisal
Literature reviews
Total
survey of clinical evidence and development of a database to be used by
residents, teachers and researchers. The data created by this search can
be used in future studies to specifically answer clinically relevant ques-
tions and test hypotheses (i.e. in patients with endodontically treated
teeth, does the quality of the coronal restoration result in a better out-
come? Does single- or multiple-appointment treatment result in a better
outcome? Does the use of systemic antibiotics before, during or after
treatment result in a better outcome?).
The three search engines used in this study were the MEDLINE,
EMBASE, and Cochrane Library. The utilization of these search engines
should have allowed for the broadest capture of the literature related to
success and failure of nonsurgical root canal therapy. The MEDLINE is
a search strategy for the National Library of Medicine computerized
bibliographic database. The EMBASE database is the European equiva-
lent of MEDLINE, and is primarily surgical and pharmaceutical in scope.
Because of the relative poverty of endodontic terms in EMBASE, the
search strategy was revised to emphasize text word searching rather
than structured-vocabulary searching.
The Cochrane Library is a highly selective database of expert-se-
lected articles, primarily high-quality clinical studies. While the data-
base itself in Cochrane is much smaller than either MEDLINE or EM-
BASE, the content is of superior quality overall. This search strategy was
simpler since the database content was already focused on clinical
research concepts. Despite extensive searching, some articles may still
have been missed during the electronic or manual search of published
studies. The rating of levels of evidence was initially performed as a
group to avoid the bias of single reviewer and to promote discussion
about the rating process itself. Participation of two experienced faculty
members in evidence-based dentistry later helped to ensure proper
classification of the articles. A large proportion of articles located in our
initial search were on pain. Ninety-nine of these studies were identified;
these articles were eliminated from our review, because they only take
into account the short-term success of treatment, and not the long-term
success rate. Pain articles may dominate the field because of the interest
of clinicians, patients and pharmaceutical companies in this subject. In
addition, pain studies are usually of short duration and are easier to
conduct compared to those requiring long-term follow-ups.
Examination of the data from our search shows variability in ma-
terial composition, treatment procedures and evaluation criteria. We
found six studies with the highest level of evidence (LOE 1). Begg and
co-workers developed the Consolidated Standards for Reporting of Tri-
als (CONSORT) statement to help improve the quality of reports of RCTs
in medicine (10). Moher and co-workers compared reports prepared
pre-CONSORT with reports prepared post-CONSORT and found that the
use of the CONSORT statement was associated with improved quality of
640 Torabinejad et al.
Number of
Studies
6
26
13
124
137
306
reports of RCTs (11). The quality characteristics of randomized con-
trolled trials included in this assessment are: description of inclusion/
exclusion criteria; definition of outcomes; sample size; randomization
protocol; concealment of allocation; masking of evaluators; and fol-
low-up rates of participants. Application of CONSORT guidelines to the
six studies with the highest level of evidence (LOE 1) reveals some
deficiencies in these articles (12–17). The CONSORT guidelines should
be used for the future RCTs in endodontics.
Predictors of success and failure can be divided into preoperative,
intraoperative and postoperative factors. The preoperative factors include
age, gender, tooth location, presence or absence of lesions, lesion size, pulp
status, symptoms, and periodontal condition. The intraoperative factors in-
clude quality of cleaning, shaping, and obturation, size of apical enlarge-
ment, culturing, number of appointments, materials and techniques used
during root canal therapy, accidental procedures and flare-ups. The major
postoperative factor that can affect the outcome of root canal treatment is
restoration of endodontically treated teeth. Except for very few predictive
factors, presence or absence of a lesion (29, 38, 92, 99), or placement of a
final restoration following root canal therapy (50, 51, 53, 170, 177), the
present data shows absence of consistent relationship between most of these
factors and outcomes of root canal therapy. The lack of relationship be-
tween these factors and outcomes of root canal therapy could be a real
phenomenon, or it could be a result of the designs of currently available data
and the absence of randomized clinical trials related to this subject. The
randomization process usually results in equal distribution of contributing
factors and prevents experimental biases.
The majority of well-known “success and failure” studies are ac-
tually nonrandomized and not controlled case series, which are as-
signed as evidence, level four. We found similar results when searches
were conducted to determine the levels of evidence for articles related
to surgical endodontics or re-treatment of “failed” nonsurgical root
canal therapy (317, 318). These findings do not mean that the current
modalities of endodontics are not successful or have no evidence to
support them. This has occurred as a result of the nature of root canal
treatment and lack of comparative treatment modalities similar to it.
Based on available studies that offer the best evidence, it appears 92 to
98% of teeth without periapical lesions remain free of disease after root
canal therapy (315). These studies also show 74 to 86% of teeth with
apical lesions completely heal after initial treatment or retreatment. In
addition, similar data shows that 91 to 97% of teeth that have had root
canal treatment remain functional over time (315).
There are fundamental differences in: indications and contraindi-
cations, procedures and techniques involved, factors affecting success
and failure, criteria used to determine success and failure of root canal
therapy, and treatment options following unsuccessful root canal treat-
JOE — Volume 31, Number 9, September 2005

ment compared to those for alternative treatments such as implants. The
indication for an alternative treatment such as an implant is usually
when a tooth cannot be saved and treated with root canal therapy. In
other words, a contraindication of root canal therapy is an indication for
placement of an implant. The procedures involved in the two treatment
modalities are also different. Initial root canal treatment does not in-
volve surgical procedures, and teeth can be restored immediately fol-
lowing the treatment. Implant dentistry involves surgical procedures,
and final restorations cannot be placed in most cases immediately fol-
lowing the placement of implants.
Furthermore, the criteria that have been used for success and
failure studies in root canal therapy have been more stringent than those
applied for the outcomes of implants. When survival rate (functional
teeth with or without radiographic lesions) for endodontically treated
teeth is used instead of the traditional criteria, the success rate of end-
odontically treated teeth by endodontists is equal or better than the long
term outcome of implants (60). Treatment options following unsuc-
cessful root canal therapy are retreatment and/or endodontic surgery.
In contrast, the treatment option for a failed implant is its removal and
the possible placement of another implant. Because of these differences
and ethical issues, it is very difficult to design clinical studies that would,
in a randomized fashion, examine the success rate of root canal therapy
compared to alternative treatment modalities such as implants.
Evidence-based dentistry, as defined by the American Dental As-
sociation (5), is “. . . an approach to oral health care that requires the
judicious integration of systematic assessments of clinically relevant
scientific evidence, relating to the patient’s oral and medical condition
and history, with the dentist’s clinical expertise and the patient’s treat-
ment needs and preferences.”
This definition implies that there are two important components in
an evidence-based practice. The first is the systematic assessment of
scientific evidence, and the second is use of the findings from systematic
reviews to form clinical decisions that take into account the dentist’s
clinical skills and the preferences of patients. “Scientific evidence” by
no means refers only to randomized controlled trials, but rather to the
goal of systematic reviews, which is to find the best evidence. Endodon-
tists provide a highly valuable healthcare service to patients suffering
from pulpal and periradicular diseases. Despite the absence of evidence
at the highest levels, the long-term healing of periradicular pathosis and
the preservation of millions of teeth every year underscore the success
of the current modalities of root canal therapy. Conducting research
projects at the highest levels of evidence (when possible) will strengthen
current data.
Based on the results of this systematic review, it appears that a few
high-level studies have been published in the past four decades related
to the success and failure of nonsurgical root canal therapy. The data
created by this review can be used for future studies to specifically
answer questions and test hypotheses relevant to the outcome of non-
surgical root canal treatment.
Acknowledgments
We would like to thank Drs. S. Garber and L. Stromberg, former
residents in the Department of Endodontics, School of Dentistry,
Loma Linda University, who assisted us with the initiation of this
project. In addition, we would like to thank Patricia Anderson for
conducting literature searches, and Dr. Khaled Bahjri for his assis-
tance with the evaluation of the levels of evidence regarding this
project.
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