Clinical Research

The Dynamics of Periapical Lesions in Endodontically

Treated Teeth That Are Left without Intervention:
A Longitudinal Study
Igor Tsesis, DMD,* Tomer Goldberger, DMD,* Silvio Taschieri, MD, DDS, Mottie Seifan, DMD,
Aviad Tamse, DMD,* and Eyal Rosen, DMD*
Abstract
Introduction: The long-term dynamics of periapical
lesions in endodontically treated teeth is not fully elucidated, thus presenting a clinical dilemma regarding the
need for an intervention. The aim of the study was to retrospectively evaluate the long-term dynamics of periapical
lesions that were left without intervention in endodontically treated teeth. Methods: Periapical status surveys
of patients treated in a public dental clinic were retrospectively evaluated for the presence of periapical lesions in
endodontically treated coronally restored teeth. The
dynamics of the included periapical lesions was evaluated
based on the periapical index (PAI) score changes between
2 consecutive periapical surveys of at least a 4-year interval.
The influence of various factors on lesion dynamics was
statistically evaluated. Results: The study cohort consisted
of 74 patients with a total of 200 endodontically treated
teeth having periapical lesions that fulfilled the inclusion
criteria. Fifty-seven (28.5%) lesions remained unchanged,
103 (51.5%) lesions worsened (PAI score increased), and
40 (20%) lesions improved (PAI score decreased). Poor
root canal filling and poor restoration were found to
adversely affect the long-term dynamics of the periapical
lesions (P < .05). Age, sex, and the presence of a post
had no statistically significant influence on lesion dynamics
(P > .05). Conclusions: Poor root canal filling and poor
restoration may adversely affect the long-term dynamics
of periapical lesions that are left without intervention in
endodontically treated teeth. Therefore, in cases of poor
root canal filling or poor restoration, further intervention
may be indicated. (J Endod 2013;39:15101515)

Key Words
Endodontically treated teeth, periapical lesion, persistent apical periodontits

From the *Department of Endodontology, Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel; Center for Research in Oral Health,
Department of Biomedical, Surgical, and Dental Sciences, Universita degli Studi di Milano, IRCCS Istituto, Ortopedico Galeazzi, Milan, Italy; and MaccabiDent, Tel Aviv, Israel.
Address requests for reprints to Dr Igor Tsesis, Department
of Endodontology, Tel Aviv University Dental School, Ramat
Gan, Israel. E-mail address: dr.tsesis@gmail.com
0099-2399/$ - see front matter
Copyright 2013 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2013.09.010

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he main goal of endodontic treatment is either to prevent or to treat periapical pathology (1). However, a relatively high prevalence of persistent apical periodontitis
(AP) in endodontically treated teeth, ranging from 40%61%, has been identified in
cross-sectional studies (24). The main reason for the persistence of AP after
endodontic treatment is bacteria remaining in the root canal system or penetrating
the root canal system as a result of coronal leakage (510). Additional possible
etiologies include the presence of true cysts, extraradicular infection, or foreign
body reactions (1114).
The treatment alternatives for persistent AP include nonsurgical endodontic retreatment, surgical endodontic treatment, or tooth extraction (15, 16). Another
alternative for certain cases is to leave the tooth without intervention and adopt a
long-term follow-up protocol (17). What may be the consequences of treating or not
treating an existing pathology is a crucial question, which constitutes the core of the
clinical decision-making process (18). However, the long-term dynamics of periapical
lesions in endodontically treated teeth and possible influencing factors are not fully
elucidated, thus presenting a real clinical dilemma regarding the need for an intervention. The aim of this study was to retrospectively evaluate the long-term dynamics of
periapical lesions that were left without intervention in endodontically treated coronally
restored teeth and the effects of possible influencing factors.

Materials and Methods

All records of patients treated in a public dental clinic between 2007 and 2009
were retrospectively collected. Approval for the project was obtained from the institutional review board. Only records with 2 consecutive full periapical status surveys with
an interval of at least 4 years were further evaluated. The teeth included in the study were
teeth with root canal treatment (RCT) and coronal restoration that had been completed
at least 1 year before the first survey and with a periapical lesion present at the first
survey. Only teeth that were presented in the periapical status surveys in at least 2 periapical x-rays with different angulations were included.
Teeth excluded from the study were teeth that were extracted, endodontically
retreated, or with coronal restoration replaced before the second survey. Teeth with
a radiographic lesion not located in the periapical area and/or with a discernible
root perforation (19) or a vertical root fracture (20) were also excluded.
All relevant radiographs were digitized into JPEG format using Nikon CoolPics 950
digital camera (Nikon, Tokyo, Japan) at a resolution of 1600  1200 pixels; brightness
and contrast were automatically adjusted for all images using Adobe Photoshop 7.0 software (Adobe, San Jose, CA), and the images were then evaluated in a dark room using a
15-inch computer screen and a 1280  800 pixel resolution. Images of the initial periapical status surveys were evaluated for relevancy based on the inclusion and exclusion
criteria separately by 2 observers (T.G. and I.T.). Later, only for the included cases, the
consecutive periapical status surveys were evaluated separately by the 2 observers (T.G.
and I.T.). In cases of disagreement, the images were evaluated jointly by the observers
until an agreement was achieved.
The periapical status of the involved teeth was evaluated during the inclusion
process and at each time point using the periapical index (PAI) score (21). A set of

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*Adequate coronal restoration = a permanent restoration appeared radiographically intact; inadequate coronal restoration = the permanent restoration had detectable radiographic signs of overhangs or open margins or cases of recurrent caries; adequate root canal filling = all canals
appeared radiographically obturated, no voids were present, and the root canal filling ended between 0 and 2 mm short of the radiographic apex. Root fillings that did not fulfill these criteria were defined as inadequate.

10 (53)
23 (70)
19 (47)
2 (67)
14 (67)
35 (42)
103
9 (47)
10 (30)
22 (53)
1 (33)
7 (33)
48 (58)
97
11 (58)
12 (37)
19 (47)
1 (37)
10 (48)
26 (32)
79
8 (42)
21 (63)
22 (53)
2 (66)
11 (52)
57 (68)
121
19
33
41
3
21
83
200

Results
A total of 720 periapical status surveys were initially identified; 74
that had a consecutive periapical status survey were further analyzed. In
these periapical status surveys, 398 teeth had been endodontically
treated; 200 of these teeth with periapical lesions present at the first survey fulfilled the inclusion criteria.
Thus, the final study cohort consisted of 74 patients (38 [51.45%]
women and 36 [48.6%] men) with 200 evaluated teeth (Table 1).

TABLE 2. Distribution of Root Canal Treatment Quality, Coronal Restoration Quality, and Post Presence for Each Tooth Location

100 radiographs numbered consecutively were used for calibration by

the observers. A scoring sheet was used with a corresponding radiograph.
Only cases with a PAI score $2 determined based on the initial
periapical status survey were included. In multirooted teeth, the PAI
score was determined based on the root with the worst score. For cases
in doubt, a higher score was assigned. The dynamics in the periapical
status between the 2 consecutive status surveys was defined as
improved when the PAI score decreased, unchanged when the
PAI score remained unchanged, or worse when the PAI score
increased. For cases that presented with a PAI score of 5 both at the
initial and the consecutive status surveys, the dynamics in the periapical
status between the 2 consecutive status surveys was defined as following:
improved when the size of the periapical lesion decreased, unchanged when the size of the periapical lesion was unchanged, or
worse when the size of the periapical lesion increased.
Data for the following variables of interest were collected from the
patients medical records: age, sex, follow-up period, presence of a
post, and tooth location. The quality of the root canal filling was radiographically evaluated and was defined as adequate in case all canals
were obturated, no voids were present, and the root canal filling ended
between 0 and 2 mm short of the radiographic apex. Root fillings that
did not fulfill these criteria were defined as inadequate (22).
The quality of the coronal restoration (23, 24) was
radiographically evaluated and was defined as adequate when a
permanent restoration appeared intact radiographically. The coronal
restoration was defined as inadequate in cases in which the
permanent restoration had detectable signs of overhangs or open
margins and in cases of recurrent caries.
The influence of the variables of interest on the difference in the
periapical status between the 2 consecutive status surveys was statistically evaluated using logistic regression. To estimate the effect of
possible variables of interest on periapical change, a multiple linear
regression model was constructed with combination of the generalized
estimation equation method. This technique allowed us to take into accounts the clustering effect of several teeth within the same patient. Classification of lesions to worsening of lesion (yes/no) had been
performed. Logistic regression with the generalized estimation equation
method was used in order to model this binary variable. Statistical significance was set to P < .05.

Inadequate coronal
restoration* (%)

PAI, periapical index.

Maxillary incisor
Maxillary premolar
Maxillary molar
Mandibular incisor
Mandibular premolar
Mandibular molar
Total

17 (8.5)
37 (18.5)
69 (34.5)
63 (31.5)
14 (7)
200 (100)

Adequate coronal
restoration* (%)

0
88 (44)
88 (44)
22 (11)
2 (1)
200 (100)

Adequate root canal

treatment* (%)

1
2
3
4
5
Total

Inadequate root canal

treatment* (%)

No. of teeth on
final observation (%)

Total number of teeth

No. of teeth on
initial observation (%)

Tooth location

PAI
score

Post (%)

TABLE 1. Distribution of the Initial and Final Periapical Index (PAI) Scores
(median = 6-year interval)

16 (84)
30 (90)
9 (21)
2 (66)
18 (85)
38 (45)
113

Clinical Research

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Figure 1. Periapical status unchanged in a left maxillary premolar: (A) initial periapical status survey and (B) at the 5-year follow-up.

Patients age ranged between 27 and 70 years (median = 48 years). The

time interval between the 2 surveys ranged between 4 and 8 years (median = 6 years). The distribution of post presence, RCT quality, and coronal restoration quality for each tooth location is shown in Table 2.
From a total of 200 evaluated teeth, the dynamics of the periapical
status between the 2 consecutive status surveys was observed as unchanged in 57 (28.5%) teeth (Fig. 1A and B), worse in 103
(51.5%) teeth (Fig. 2A and B), and improved in 40 (20%) teeth
(Fig. 3A and B). The PAI change between the 2 consecutive status surveys is shown in Figure 4 (P > .05).
Poor root canal filling (n = 123, 61%), or poor restoration
(n = 97, 48%) adversely affected the dynamics of the periapical status
(P < .05) (Fig. 5). Age, sex, tooth location, and post presence had no
statistically significant influence on the dynamics of the periapical
status (P > .05).

Discussion
The relationship between AP and bacterial infections in the root
canal system is well established (2527), and it is generally accepted
that AP usually does not heal without intervention (1, 28, 29). After
endodontic treatments, a clinical and radiographic follow-up is indi-

cated to determine the treatment outcome (17). In case of persistent

AP after endodontic treatment, additional endodontic treatment or tooth
extraction are usually the treatments of choice (16). In certain cases,
especially in asymptomatic teeth, when the clinical and radiographic
history of the tooth is unknown, a long-term follow-up protocol may
be considered. However, because the long-term prognosis of teeth
with persistent AP that are left without intervention is not fully elucidated, rational clinical decision making is difficult. Fristad et al (30) reported that some teeth deemed to be failures based on radiographic
evaluation 1017 years after treatment were judged as healed after
an additional 10-year follow-up. Thus, they showed the potential for
late healing of failed endodontic treatments left without intervention
in an extended follow-up period. The present study was aimed to retrospectively evaluate the long-term dynamics of periapical lesions in
endodontically treated teeth left without intervention based on full
radiographic status surveys.
A full mouth series of periapical radiographs and not panoramic
radiographs were chosen for evaluation because the latter are considered less sensitive than periapical radiographs in detecting periapical
osteolytic lesions, especially in the anterior region (31). Eckerbom
and Magnusson (32) showed that the reliability of only 1 orthoradial
intraoral radiograph was poor when evaluating the lateral seal of an

Figure 2. Periapical status worsened in a left maxillary molar: (A) initial periapical status survey and (B) at the 4-year follow-up.

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Figure 3. Periapical status improved in a right mandibular molar: (A) initial periapical status survey and (B) at the 7-year follow-up.

endodontic treatment. The absolute diagnostic value of a single periapical view of a root-filled tooth was proven to be limited (33). Thus, in the
present study, the use of full periapical status surveys enabled diagnoses
based on at least 2 periapical x-rays with different angulations.
An assessment of the long-term outcome of endodontic treatments
based on a radiographic evaluation at a single time point after the treatment is limited because it provides only a static image on the course of a
dynamic process. However, in the current study, the data were collected
at 2 different time points, thus enabling the evaluation of the dynamics of
the periapical status. In the present study, the time periods between the
2 PA surveys ranged from 48 years. Orstavik (17) found that in some
cases, healing of AP after RCT required 4 years for completion. Strindberg (1) showed that the healing process of teeth with AP undergoing
RCT stabilized at 4 years after the RCT.
In the present study, not only the presence but also the degree of
apical periodontitis was assessed. The PAI score was used for quantifying the periapical status of the included teeth. The PAI system is an
example of a set of criteria that fulfills the requirements for use in epidemiologic research (measurable, mutually exclusive, meaningful related
to the condition under investigation, reproducible, and communicable)
(34). The PAI score is based on the study of Brynolf (35) that compared
histological and radiographic appearances of periapical changes in human autopsy materials in order to disclose to what extent histological

Figure 4. Periapical index (PAI) change between the 2 consecutive status

surveys.

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changes are reflected radiographically. The PAI score consists of 5 categories, each representing a step on an ordinal scale ranging from
normal periapical bone to severe AP. Radiographs from Brynolfs original material represented each of the 5 groups and were used as visual
references in the development of the PAI score (21). The cases included
in the current study were assigned to PAI score categories using the visual references for the 5 categories within the PAI scale. If there was any
doubt about the appropriate score to assign to a tooth, the higher score
was chosen. This rule was based on the finding that histological examination usually reveals a more advanced lesion than the radiographic
examination (35).
In the present study, about one half of the RCT teeth exhibited AP.
This finding is consistent with several epidemiologic studies from

Figure 5. Periapical index (PAI) change in relation to root canal filling quality and coronal restoration quality. Adequate coronal restoration = a permanent restoration appeared radiographically intact. Inadequate coronal
restoration = the permanent restoration had detectable radiographic signs
of overhangs, open margins, or in case of recurrent caries. Adequate root canal filling = all canals appeared radiographically obturated, no voids were present, and the root canal filling ended between 0 and 2 mm short of the
radiographic apex. Root fillings that did not fulfill these criteria were defined
as inadequate.

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various countries in Europe, America, and Asia that found AP in 39%
64.5% of RCT teeth (24, 3647).
In the current study, age, sex, and tooth location had no influence
on the dynamics of the PAI score between the periapical status surveys.
This observation is consistent with previous reports that found that the
previously mentioned factors had no effect on treatment outcomes (13,
48, 49).
In this study, there was no correlation between the presence of a
post and the periapical status. Although some studies reported an
increased prevalence of AP in teeth restored with posts (36, 42),
several other studies found no effect of post presence on the
periapical status of endodontically treated teeth (13, 50, 51).
In the present study, worsening of the periapical status was mostly
related to inadequate endodontic treatment. This is consistent with
several other studies (23, 24). Bergstrom et al (52) reported that homogenic root filling had a more significant effect on lower AP frequency
than the length of obturation. Petersson et al (41) found that incompletely obturated root-filled teeth developed AP significantly more often
than completely obturated root canals. Ray and Trope (23) and Tronstad et al (24) stressed the importance of root canal filling and coronal
restoration quality in connection with AP.
Another important factor in the development of AP in root canal
treated teeth is coronal leakage (8, 23, 53). Although some studies
showed that well-prepared and filled root canals can resist bacterial
penetration even without intact coronal restoration (54), other studies
stressed the importance of adequate coronal restoration for periapical
healing (23, 24). Future large-scale studies are necessary to elucidate
the effect of other potentially influencing factors, such as the combination of poor restoration and good root canal filling.
The primary goal of endodontic treatments is the retention of teeth
by the prevention or treatment of periapical pathology (1, 22). A
decision of intervention for an endodontically treated tooth with
periapical radiolucency should be based on the technical feasibility
of the treatment, systemic factors, and patient values and preferences
(16, 28, 34, 55, 56). The results of the current study indicate that a
clinical decision regarding the treatment of asymptomatic teeth with
periapical radiolucency should be based on the evaluation of the
restoration and root canal filling quality. In this study, it was shown
that teeth with unsatisfactory root canal fillings and/or restorations
have a high potential for continuous deterioration of their periapical
condition. However, for functioning teeth with good root canal filling
and restoration, when an endodontic treatment is not feasible, the
option of continuing follow-up may be considered.

Conclusion
Poor root canal filling and poor restoration adversely affect the
long-term dynamics of periapical lesions left without intervention in
endodontically treated teeth. In such cases, there may be a stronger
argument in favor of an intervention.

Acknowledgments
The authors deny any conflicts of interest related to this study.

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