REVIEW ARTICLE „ 139

Hany Mohamed Aly Ahmed

Elective root canal treatment: A review and clinical

update

Hany Mohamed
Aly Ahmed, BDS,
HDD(Endo)
Key words elective, intentional, prevalence, root canal treatment Department of Restorative
Dentistry, School of Dental
Sciences, Universiti Sains
Minimum intervention and retention of every part of the tooth structure is an imperative objective Malaysia, 16150, Kubang
in contemporary endodontic practice. Nevertheless, elective (intentional) root canal treatment (RCT) Kerian, Kelantan, Malaysia

of sound teeth with normal pulps may be necessary. This article aims to define the criteria for con- Correspondence to:
Dr Hany Mohamed Aly
sidering RCT as an elective treatment, to discuss the indications of this approach and the prevalence Ahmed
among different countries, and to outline special precautions that should be considered when com- Department of Restorative
Dentistry,
mencing elective RCT. In addition, other elective pulp treatment procedures are highlighted. School of Dental Sciences,
Universiti Sains Malaysia,
Kubang Kerian, 16150,
Kelantan, Malaysia
H/p: +60129857937
Email: hany_endodontist@
„ Introduction (b) discuss the indications of this treatment ap- hotmail.com
proach; (c) discuss the prevalence of RCT among
Complete debridement of the root canal system different countries; (d) outline special precautions
from inflamed or necrotic pulp tissues and microor- that should be considered when commencing elec-
ganisms is the main objective of conventional root tive RCT; and (e) highlight other elective pulp treat-
canal treatment (RCT)1. Apart from this universally ment procedures.
accepted indication, elective (intentional) RCT of
teeth with normal pulps may become necessary. In
1961, Bohannan and Abrams2 first described this „ Literature search methodology
treatment as a component of an interdisciplinary oral
rehabilitation of mal-aligned periodontally affected An electronic search was conducted in PubMed and
teeth with vital pulps, and summed up this procedure Google Scholar search engines until April 2013, to
by saying that “no tooth or part of a tooth should be identify the available publications written in the
regarded as sacred if the prognosis of the remaining English language using the following keywords:
dentition is improved by its sacrifice”. ‘elective’ OR ‘intentional’ AND ‘pulpectomy’ OR
Although some dental practitioners may be reluc- ‘endodontic therapy OR ‘endodontic treatment’
tant to practice elective RCT, the feeling of guilt as- OR ‘root canal therapy’ OR ‘root canal treatment’.
sociated with this procedure is no more justified than Cross citations of the selected articles have also been
a similar feeling related to the removal of enamel identified. After duplicate studies were deleted, an-
and dentine in crown preparation. Case selection other search was undertaken in endodontic text-
and decision making for elective RCT require criti- books to find more information about this treatment
cal appraisal and careful assessment. Therefore, the approach. Finally, the selected data were analysed
purpose of this review is to: (a) determine the criteria and discussed according to the current guidelines in
for considering a given RCT as an elective treatment; endodontic practice.

ENDO (Lond Engl) 2014;8(2):139–144

140 „ Ahmed Elective root canal treatment
Table 1 American and European guidelines for endodontic treatment.
American guidelines for clinical endodontics
(Fifth edition)17
Indications for treatment –
Nonsurgical root canal treatment for permanent teeth is
indicated if any of the following clinical situations exists:
1. Symptomatic or asymptomatic irreversible pulpitis with
or without evidence of periapical disease.
2. Necrotic pulp with or without evidence of periradicular
disease.
3. Teeth with a pulp that would be compromised during
dental procedures, including but not limited to, caries
removal, over denture abutments, malposed teeth and
root resection.
4. Restorative reason when a placement of a core or
possibly a post is necessary for retention of a fixed
restoration.
5. Cracked or fractured teeth with pulp involvement (with
or without clinical symptoms) that can reasonably be
expected to maintain satisfactory periodontal health.
6. Teeth with thermal hypersensitivity that significantly
interferes with normal function, when alternative
methods have failed to reduce the sensitivity.
„ Definition
The literature shows that elective/intentional RCT,
whenever indicated, refers to RCT of either a normal
pulp3-9, a doubtful pulp prior to restorative proce-
dures10-12, calcified pulp canal (calcific metamor-
phosis)13,14 or an injured pulp following traumatic
dental injuries such as avulsion and some luxation
injuries15,16.
On the basis of this definition and the Ameri-
can and European guidelines for endodontic treat-
ment11,17 (Table 1), it seems that the criteria for
describing elective RCT are quite confusing and
rather subjective. The true distinctions between ‘a
doubtful/compromised pulp’ and other pulp inflam-
matory changes are not clear, though it can be in-
directly inferred from the literature that a doubtful/
compromised pulp refers to ‘a presumed impaired
health of the pulp that is not yet severed with irre-
versible inflammatory changes’. In addition, confu-
sion may arise from considering RCT scheduled for
mature teeth severed with avulsion as an elective
procedure, because avulsed teeth with complete
root formation are not likely to revascularise. RCT
is always recommended in such cases and it is not
considered as an elective procedure18,19.
ENDO (Lond Engl) 2014;8(2):139–144
European quality guidelines for endodontic treatment11
Root canal treatment may be carried out on all patients
where other dental procedures may be undertaken. Spe-
cific indications are:,
1. An irreversibly damaged or necrotic pulp with or
without clinical and/or radiological findings of apical
periodontitis.
2. Elective devitalisation, e.g. to provide post space,
prior to construction of an overdenture, doubtful pulp
health prior to restorative procedures, likelihood of
pulpal exposure when restoring a (misaligned) tooth
and prior to root resection or hemisection.
„ Indications
„ Restorative procedures
Elective RCT should be planned for teeth with pre-
sumed doubtful pulps scheduled for fixed prosthetic
procedures, as well as teeth that cannot be restored
without using the pulp chamber and root canals for
retention and support7,10-12,20 (Fig 1). The same pro-
cedure is also applicable to over-erupted and tilted
teeth that must be reduced drastically where the
pulp is certainly involved and where severely worn
dentition is observed7,11,21,22.
„ Over-denture construction
Over-dentures are commonly indicated in patients
>55 years23,24, and patients with congenital disease
such as hypohidrotic ectodermal dysplasia25. The
standard guidelines for endodontic procedures are
followed. The crown of the tooth should only be re-
moved after the completion of RCT to ensure proper
placement of the rubber dam assembly during the
entire treatment. Teeth scheduled for over-denture
are usually sound, and RCT should ONLY be defined
as elective if no signs and/or symptoms of irrevers-
ible pulp affection are found.

„ Management of discoloured teeth
induced by:
a) Tetracycline staining
The psychological needs of every individual patient
are among the main factors to consider in select-
ing the most appropriate treatment. Abou-Rass3
first introduced intentional RCT followed by internal
bleaching as an alternative treatment for uni- and
multi-hued tetracycline discoloured teeth having
perfectly normal pulps. Following the recommended
guidelines will ensure favourable short and long term
prognosis of this treatment option4,5,26.
b) Calcific metamorphosis
Calcific metamorphosis is a sequelae of dental
trauma, and is characterised by the deposition of
hard tissue within the root canal space and a yellow
discolouration of the clinical crown13,14. If the patient
has aesthetic concerns, external bleaching should be
considered first. However, an elective RCT followed
by internal bleaching is considered a viable alternative
if the tooth is unresponsive to vital bleaching13,14.
„ Management of invasive cervical
resorption
Invasive cervical resorption differs from tradition-
ally known inflammatory external root resorption.
The pulp survives until late in the resorptive pro-
cess, walled off by the protective layer of predentine
and dentine barrier separating the inflammation-free
pulp from the resorptive defect15,27. Despite this,
elective RCT may be indicated when a high risk of
pulp exposure is expected (such as Class III inva-
sive cervical resorption). This elective procedure may
also allow better access to the deep infiltrating tissue
encircling the root canal15.
„ Root amputation to gain periodontal
healing
Root amputation may be a viable treatment for a
severe periodontal defect that affects one root of
a multi-rooted tooth8,9. In several cases, the pulp
may appear to be normal but elective RCT is war-
Ahmed Elective root canal treatment „ 141
Fig 1 This figure
shows a badly decayed
mandibular molar. Three
surfaces (the occlusal,
mesial and buccal walls)
were missing. Elective
RCT of the presumed
doubtful pulp followed
by post, core and crown
were planned, although
the pulp was not
exposed after complete
caries excavation.
ranted to prevent affecting the pulp after resecting
the root8,9, especially that the long-term prognosis
of vital root amputation via conventional proce-
dures (resecting one root of a given molar and re-
storing the exposed site via calcium hydroxide and
amalgam without performing RCT to other root/s)
is poor28.
Root amputation is also indicated in a multi-rooted
tooth that has an extensive external root resorption
affecting a single root. Root amputation is a tech-
nique-sensitive approach that requires a meticulous
diagnostic procedure to select potential candidates.
„ Surgical removal of some odontogenic
and non-odontogenic bone lesions
approximating the root apex
The management of odontogenic and non-odon-
togenic bone lesions may show considerable varia-
tions. Elective RCT of teeth with normal pulps prior
to surgical interference of some bone lesions, e.g. a
central giant cell lesion29, may be indicated because
of the high possibility of apical injury and compro-
mising the vascular supply of the related vital teeth
during curettage of the lesion30,31 (Fig 2). The same
principle can also be applied to teeth scheduled for
extensive periodontal surgery where the root apex is
certainly involved. Recent diagnostic modalities such
as cone beam computed tomography (CBCT) can
provide three dimensional, high resolution images
of bone lesions and their relation to root apices32.
ENDO (Lond Engl) 2014;8(2):139–144
142 „ Ahmed Elective root canal treatment
a b
d e
„ Others
Elective RCT has also been reported as an adjunct
component in the management of juvenile peri-
odontitis33, prior to tooth hemisection11, and for
traumatised vital teeth with discolouration resistant
to external bleaching15.
„ Prevalence
The literature indicates that the prevalence of
elective RCT ranges from 3.36 to 9%. Lal et al34
reported that 9% of endodontic procedures were
performed intentionally for restorative procedures
at Fatima Jinnah Dental College School in Kara-
chi, Pakistan. Khattak et al35 observed that only
3.36% of all cases were scheduled for elective RCT
at Islamic International Dental Hospital in Islama-
bad, Pakistan.
Givol et al36 conducted a survey of dental mal-
practice complaints reported to the Medical Con-
sultants International Company in Israel. The results
of the survey showed that 193 cases out of 661
(29.2%) were reported for elective RCT. Interest-
ingly, a similar distribution of operator errors and
ENDO (Lond Engl) 2014;8(2):139–144
c
Fig 2 Careful assessment is essential prior to surgical
removal of bone lesions. (a) A panoramic radiographic view
shows a large periapical radiolucency around the root apices
of mandibular anterior teeth (white arrows). The anterior
teeth were planned for elective RCT. During pulp extirpation,
all teeth showed reduced vascularity. During surgery and as a
result of the non-capsulated nature of the lesion, the curet-
tage approximated the root apex of the left first mandibu-
lar premolar. After histological examination, the lesion was
diagnosed as a central giant cell lesion. (b) After 12 months,
a favourable healing was initially observed. (c and d) After
18 months, the root canal treated teeth showed favourable
healing; however, (e) the patient complained of pain on
percussion on the sound mandibular left first premolar, which
showed periapical radiolucency (white arrow).
negative outcomes for teeth with elective RCT and
teeth with RCT caused by a pathologic process was
observed36.
In a recent survey at Ras Al Khaimah College of
Dental Sciences Hospital in the United Arab Emir-
ates, Khattak et al23 reported that the percentage
of intentional RCT was 4.7%. Among age groups,
intentional RCT from 18 years to 35 years, 35 years
to 55 years, and over 55 years accounted for 2%,
6.3%, and 19%, respectively, of the total. Among
people older than 55, intentional RCT was most
commonly performed because of the prosthetic rea-
son of using the remaining teeth as abutments for
over-dentures.
„ Clinical considerations
Elective RCT follows the universal guidelines and
bears the same risks as non-elective RCT. Similar oper-
ator errors of both elective and non-elective RCT have
been reported, and this raises the need to consider all
possible negative outcomes even during elective RCT.
Patients should be informed of the risks of elective
RCT and should be given information on alternative
treatments, their risks, and prognosis36.

The removal of carious lesions per se can guide
the dental operator in locating the pulp chamber
and canals, which is not the case in elective RCT of
sound teeth. Access cavity preparation of a sound
tooth requires careful attention. The direction of the
bur should always be at the long access of the tooth
to ensure appropriate location of the pulp chamber.
In anterior teeth that have calcific metamorphosis,
the drop off sensation of entering the pulp space
does not occur. Preparing the access cavity close
to or through the incisal edge may provide a more
predictable approach14. Several types of magnifica-
tion can enhance visibility and aid in distinguishing
colour differences between the deposited dentine
in the pulp chamber and that of the normal sur-
rounding dentine. Long-neck burs, ultrasonic tips,
dyes, and high concentrations of sodium hypochlo-
rite may also be helpful. In extremely deep access
preparations, taking radiographic images at multiple
angles to maintain alignment and direction is use-
ful. Once the canal is captured, utilisation of small
files and path finding instruments will facilitate the
instrumentation procedure14.
Elective RCT is usually performed in a single ap-
pointment if the pulp is not infected and no in-
tracanal medicament is needed37; however, RCT
of a tooth having calcific metamorphosis is some-
times challenging, and may require more than one
appointment. In case of class III invasive cervical
resorption, some authors have claimed that the
treatment is best performed as a single-visit pro-
cedure during surgery so that a permanent restor-
ation can engage the resorption cavity and the root
canal for sufficient retention38. However, with such
a treatment procedure, proper isolation cannot be
achieved and there is high possibility for contamina-
tion. To prevent blockage of the exposed canal dur-
ing surgical management of the resorptive defect,
an access cavity is prepared followed by insertion
of a conical piece of plastic tube in the canal orifice.
After restoring the resorptive defect and temporisa-
tion of the access cavity, a second appointment is
scheduled in which the rubber dam is placed and
RCT is continued. Care should be taken to avoid an
accidental displacement of the cervical restoration
during the mechanical instrumentation and obtura-
tion of the root canal.
Ahmed Elective root canal treatment „ 143
„ Other elective pulp treatment
procedures
Vital pulp therapy via pulpotomy is the partial or com-
plete amputation of the irreversibly inflamed coronal
pulp tissue, and capping the remaining pulp tissue
with a suitable material39. Despite its usual indication
for treating primary teeth, recently, studies have dem-
onstrated successful clinical applications in permanent
teeth with immature and mature root apex using bio-
compatible capping materials39-42. As a result of these
favourable clinical outcomes, the application of vital
pulp therapy via elective pulpotomy (where the pulp
tissue is not irreversibly inflamed but indicated for
elective intervention) may provide a reasonable and
predictable treatment approach especially in instances
of calcific metamorphosis where elective RCT can be
rather challenging, and when the pulp canal space is
not scheduled for post placement. The application of
such biocompatible materials, such as mineral triox-
ide aggregate (MTA), may also re-introduce vital root
amputation as a more conservative elective procedure
than an elective RCT that follows amputation. Clinical
investigations are warranted to validate these alterna-
tive treatment approaches as elective procedures.
To provide a more conservative treatment, Liva-
ditis6 reported the treatment of a severely inclined
maxillary central incisor through intentional pulp ex-
posure rather than RCT, followed by bipolar electro-
coagulation of the exposed pulp to provide durable
haemostasis. Subsequently, the tooth was restored
and a prosthetic crown was constructed. Although the
prognosis was favourable for over 2 years, this treat-
ment cannot be accepted universally unless a clinical
investigation is formulated with a suitable sample size
and long-term follow up.
„ Concluding remarks
• Elective RCT is a valid treatment approach and
its prevalence may reach up to 9%; however,
a universal guideline is warranted to precisely
define the criteria for considering a given RCT as
an elective procedure.
• Elective RCT bears the same risks as non-elective
RCT. Dental practitioners should be aware of pro-
cedural errors and subsequent negative outcomes.
ENDO (Lond Engl) 2014;8(2):139–144
144 „ Ahmed Elective root canal treatment
• Future studies are warranted to validate the ap-
plication of elective vital pulp exposure/pulpot-
omy procedures as viable alternatives.
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