Clinical Research

Prevalence of Apical Periodontitis in Root CanalTreated Teeth From an Urban French Population: Inuence of the Quality of Root Canal Fillings and Coronal Restorations
Paula B.L. Tavares, MSc,* Eric Bonte, DDS, Tchilalo Boukpessi, DDS, Jose F. Siqueira, Jr, PhD,* and Jean-Jacques Lasfargues, PhD
Abstract
This cross-sectional study determined the prevalence of apical periodontitis in 1035 root canaltreated teeth from adult French patients and investigated the inuence of the quality of canal llings and coronal restorations on the periradicular status. Periapical radiographs were used for analyses, and teeth were classied as healthy or diseased according to the periapical index scoring system. Overall, the prevalence of apical periodontitis in root canaltreated teeth was 33%. Only 19% of the teeth had endodontic treatments rated as adequate. The success rate (number of healthy teeth) for cases with adequate endodontic treatment was 91%, which was signicantly higher when compared with teeth with inadequate treatment (61%). Teeth with adequate restorations had signicantly decreased prevalence of apical periodontitis (29%) as compared with teeth with inadequate restorations (41%). The combination of adequate endodontic treatment and adequate restorations yielded the highest success rate (93.5%). The quality of the endodontic treatment was the most important factor for success, although the quality of the coronal restoration also inuenced the treatment outcome. (J Endod 2009;35:810813)

Key Words
Apical periodontitis, endodontic treatment, outcome assessment, periradicular pathology, root canal lling

he potential for an optimal outcome of endodontic treatment reaches up to 90% 95% of the cases when teeth are treated under controlled clinical conditions (13). However, cross-sectional studies have demonstrated that the reality for the overall population might be somewhat different, with only 35%60% of the root canal treated teeth exhibiting no disease (49). The great majority of these studies revealed a strong correlation between the quality of endodontic treatment and periradicular status (7, 10). These data have been suggested to reect the realistic outcome of endodontic treatment in the general population (11). In vitro studies have revealed that even with adequate root canal llings and regardless of the obturation technique or lling material, leakage of bacteria (from saliva or in pure cultures) and bacterial products occurs along the root canal lling, even after a short-term challenge (1219). Findings from a cross-sectional study of 1010 root canaltreated teeth suggested that the quality of the coronal restoration had a greater impact on the periradicular status than the quality of the endodontic treatment (20). Other studies (2123) also reported a correlation between the quality of the coronal restoration and the periradicular status of root canaltreated teeth, although not as pronounced as reported by Ray and Trope (20). Tronstad et al (10) found the quality of the coronal restoration only to be of signicant inuence on outcome when combined with adequate endodontic treatment. Siqueira et al (7) observed that the quality of the coronal restoration only was of signicance when associated with teeth with inadequate treatment. The latter 2 studies agreed in that the technical quality of the endodontic treatment had a greater impact on the outcome than the quality of coronal restorations. Moreover, Ricucci and Bergenholtz (24) reported that in cases with adequate endodontic treatment, exposure of root canal llings to the oral environment was not necessarily associated with post-treatment apical periodontitis. The purpose of the present cross-sectional study was to assess the prevalence of apical periodontitis in root canaltreated teeth from an urban adult French population and evaluate the inuence of the quality of root canal llings and coronal restorations on the periradicular status of these teeth.

From the *Department of Endodontics, Faculty of Dentistry, Estacio de Sa University, Rio de Janeiro, RJ, Brazil; and Department of Endodontics, Faculte de Chirurgie Dentaire, Universite Paris Descartes, et Service dOdontologie-Hopital Bretonneau, Paris, France. Address requests for reprints to Jose F. Siqueira Jr, DDS, MSc, PhD, Faculty of Dentistry, Estacio de Sa University, Rua Alfredo Baltazar da Silveira, 580/cobertura, Recreio, Rio de Janeiro, RJ, Brazil 22790-710. E-mail address: jf_siqueira@ yahoo.com. 0099-2399/$0 - see front matter Copyright 2009 American Association of Endodontists. doi:10.1016/j.joen.2009.03.048

Materials and Methods

The sample for this cross-sectional study consisted of 213 adult patients, 93 men and 120 women, seeking routine dental care at the Bretonneau Hospital, AP-HP, Paris, France. To be enrolled in the study, the patients chart had to contain a current fullmouth periapical radiographic series. All periapical digital radiographs were taken by a dental radiologist with image plate technology. The resolution of the image plate is up to 22 line pairs per millimeter. The plate was read through the Durr VistaScan Perio workstation (Durr Dental, Bietigheim-Bissingen, Germany). Images were analyzed by the software Durr DBSWIN 4 with no image enhancement. The radiographs of the rst 1035 root-lled teeth were read and evaluated on the computer screen (Samsung SyncMaster 19 940N, matrix of 1280 1024 pixels; Samsung, Seoul, Korea) at 6 magnication in a darkened room. The teeth were grouped according to the radiographic qualities of the root canal lling and the coronal restoration. The criteria used for evaluation were slightly modied from those described by Tronstad et al (10), as follows:

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Endodontic Treatment
(1) Adequate: All canals obturated. No voids present. Root canal llings end from 02 mm short of the radiographic apex. (2) Inadequate: Root canal llings end more than 2 mm short of the radiographic apex or grossly overlled. Root canal llings with voids, inadequate density, unlled canals, and/or poor condensation. the analysis with the criteria of Strindberg (1) were 681 (66%) healthy teeth and 354 (34%) diseased teeth. There was no statistically signicant difference when comparing the results provided by the 2 methods (P = .7). Because of the similarities observed for ndings from both criteria including all comparisons involving the quality of coronal restorations/endodontic treatment, only the data from the PAI score system are presented here to allow comparisons with most of the other similar studies in the literature. The overall success rate (healthy teeth) of root canaltreated teeth was about 67% (teeth scored as PAI 1 or 2) (Table 2). Nineteen percent (198/1035) of the teeth included in this study presented endodontic treatment rated as adequate. Of these, 78% (154) were scored as PAI 1 and 13% (26) as PAI 2. Of the 837 teeth (81%) rated as having inadequate endodontic treatment, 39% (327) were classied as PAI 1 and 22% (184) as PAI 2. Overall, the success rate (number of healthy teeth) for cases with adequate endodontic treatment was 91%, which was highly statistically signicant when compared with teeth with inadequate treatment (61%) (P < .001). Of the 668 teeth (64.5%) that were found to have adequate coronal restorations, 53% (353) were scored as PAI 1 and 18% (120) as PAI 2 (Table 3). Thus, the endodontic success rate in this group was 71%. The group with inadequate restorations consisted of 367 teeth (35.5%), of which 35% (128) of the teeth were PAI 1 and 24% (90) were PAI 2. The success rate in this group was 59%. Highly signicant difference was observed when comparing treatment outcome for teeth with adequate and inadequate restorations (P < .001). The success rate was 93.5% (143/153) for cases with both adequate endodontic treatment and adequate restorations (Table 4). Of these healthy teeth, 126 and 17 were scored as PAI 1 and PAI 2, respectively. No disease was observed in 82% (37/45) of the teeth with adequate treatment and inadequate restoration (Table 4). The difference between the 2 groups was statistically signicant, indicating that the outcome of adequately treated root canals was affected by the quality of the coronal restoration (P = .04). To evaluate which factor had the greater impact on outcome, combinations of extreme conditions of the 2 factors (adequate treatment and inadequate restoration and inadequate treatment and adequate coronal restoration) were compared. The former showed a signicantly better outcome (82% versus 64%, P = .02), indicating that the quality of treatment was the most inuencing factor on treatment outcome (Table 4). Statistical analysis revealed that the success rate of inadequate endodontic treatment was also signicantly affected by the quality of coronal restorations. Teeth with inadequate treatment and inadequate restoration yielded the lowest success rate of this study, ie, 56% (181/322). When compared with teeth with inadequate treatment and adequate restoration, the difference was statistically signicant (P = .03) (Table 4). When cases with adequate or inadequate coronal restorations were subdivided according to the quality of the endodontic treatment,
TABLE 2. Periradicular status of root canaltreated teeth as related to the quality of the endodontic treatment Adequate treatment (n = 198)
154 (78%) 26 (13%) 0 (0%) 11 (6%) 7 (3%)

Coronal Restoration
(1) Adequate: Any permanent restoration that appeared intact radiographically. (2) Inadequate: Any permanent restoration with detectable radiographic signs of overhangs, open margins or recurrent caries, or presence of temporary coronal restoration. Teeth with no coronal restorations, permanent or temporary, were also included in this group. Presence of posts was also recorded. The outcome of the endodontic treatment was radiographically evaluated on the basis of both the periapical index (PAI) score (25) and the criteria of Strindberg (1). By the rst approach, a healthy tooth corresponded to PAI 1 (normal periradicular structures) or PAI 2 (small changes in bone structure), whereas diseased teeth were scored as PAI 3 (changes in bone structure with some mineral loss), PAI 4 (periodontitis with well-dened radiolucent area), and PAI 5 (severe periodontitis with elements indicating expansion of the lesion) (22, 25, 26). The worst score of all canals was taken to represent the PAI score for multicanaled teeth. By the approach of Strindberg, healthy teeth exhibited no radiographically discernible periradicular changes except for widened periodontal ligament, whereas diseased teeth presented any discernible apical radiolucency (1, 27). Two observers were previously calibrated against a set of 100 reference teeth. Afterwards, they examined all the radiographs independently. Agreement was reached in 84%. A third observer, a highly experienced endodontist, was consulted about the few cases for which disagreement occurred. The data obtained were statistically analyzed by means of the c2 test with Yates correction or the Fisher exact test. Signicant level was set at 5% (P < .05).

Results
Of the 1035 root canaltreated teeth investigated in this study, 433 (41.8%) were from men and 602 (58.2%) from women. Mandibular molars were the most frequently treated teeth, followed by maxillary molars, maxillary premolars, and mandibular premolars (Table 1). Mandibular incisors were the teeth with the lowest frequency of endodontic treatment. On the basis of the PAI scoring system, 691 (67%) teeth were classied as healthy and 344 (33%) as diseased. Correspondent gures for
TABLE 1. Distribution of root canaltreated teeth according to the tooth group (n = 1035) Tooth
Central incisor Lateral incisor Canine Premolar Molar Total

Maxillary
78 (7.5%) 65 (6.3%) 68 (6.6%) 204 (19.7%) 206 (19.9%) 621 (60%)

Mandibular
18 (1.7%) 10 (1.0%) 20 (1.9%) 141 (13.6%) 225 (21.7%) 414 (40%)

PAI
1 2 3 4 5

Inadequate treatment (n= 837)

327 (39%) 184 (22%) 153 (18%) 114 (14%) 59 (7%)

Total (n = 1035)
481 (46%) 210 (20%) 153 (15%) 125 (12%) 66 (6%)

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TABLE 3. Periradicular status of root canaltreated teeth as related to the quality of the coronal restoration Adequate restoration (n = 668)
353 (53%) 120 (18%) 99 (15%) 66 (10%) 30 (4%)

PAI
1 2 3 4 5

Inadequate restoration (n = 367)

128 (35%) 90 (24%) 54 (15%) 59 (16%) 36 (10%)

Total (n = 1035)
481 (46%) 210 (20%) 153 (15%) 125 (12%) 66 (6%)

a signicantly better outcome was observed for cases with adequate treatment (P < .001 for comparisons involving both situations). In this study, 53% (550/1035) of the teeth were restored with a post. Of these, 376 (68%) were healthy. This was not signicantly different from teeth not restored with posts, 65% (315/485) of which were healthy (P = .27).

Discussion
Cross-sectional studies are observational in nature and provide a snapshot of a group of participants at one point in time. This type of study design has limitations because the data to be analyzed are restricted to available information and thereby are subject to biases of interpretation. For example, because no information was available about the time elapsed since endodontic treatment, the possibility exists that many lesions were reducing in size and might have been still healing. On the other hand, misinterpretations and misdiagnoses in crosssectional studies are known to be fairly equally distributed, so that the results still remain meaningful (28). It has also been assumed that cross-sectional studies are less prone to be biased by the opinion of the investigators when compared with longitudinal studies (29). The greatest advantage of cross-sectional studies is that a large number of cases can be gathered and data are generally easier to obtain. Large sample sizes have the potential to dilute interpretation biases. Another limitation of this and other studies with similar methodology is that radiographs are allegedly of incomplete diagnostic value. For instance, leaky occlusal margins and cracks in restorations might not be observed in radiographs. Likewise, apical peridontitis lesions limited to the cancellous bone might pass unnoticed in radiographic examination (30). Further studies with more sensitive techniques, such as cone beam computed tomography (31, 32), have the potential to minimize this limitation. In this study involving French patients, about one third of the root canaltreated teeth exhibited apical periodontitis lesions. This gure is within the range reported by several epidemiologic studies from different countries: Belarus (45%) (33), Belgium (40%) (8), Brazil (51%) (7), Canada (44% and 51%) (21), Denmark (52%) (22), Germany (61%) (5), Greece (60%) (34), Japan (40%) (35), Lithuania (39%) (23), Scotland (51%) (36), Spain (64.5%) (4), Turkey (40.5%) (37), and USA (39%) (20). High prevalence of apical periodontitis was mostly related to the also high prevalence of teeth with inad-

equate endodontic treatment, which is in agreement with virtually all of the previous studies from different geographic locations. Specically, our ndings are in consonance with the study of Boucher et al (38) in a French subpopulation, which also observed a low frequency of endodontic treatment of good quality (21%). Our ndings demonstrated that teeth with inadequate root canal llings, irrespective of the quality of the coronal restoration, have a signicantly higher prevalence of apical peridontitis than adequately treated canals. The quality of the endodontic treatment seemed to exert a greater impact on the outcome than the quality of the coronal restoration. This can be visualized when one looks at the combinations of factors leading to the highest prevalence of healthy teeth (Table 4). Moreover, teeth with adequate root canal llings and inadequate coronal restorations (worst condition for adequately treated teeth) showed a success rate signicantly higher than teeth with inadequate root canal llings and adequate coronal restorations (best condition for inadequately treated teeth). This shows that the quality of the endodontic treatment is the most important determinant of the status of the periradicular tissues. In cases of inadequate root canal treatment, there is a higher probability for persistence or emergence of intraradicular infection, which is the primary cause of post-treatment disease (39). Data from cross-sectional studies have been widely used to evaluate the inuence of the quality of coronal restoration on the treatment outcome, and conicting results have been reported. Although Ray and Trope (20) suggested that the quality of the restoration had a greater impact on periradicular health than the quality of the root canal lling, other studies (7, 10) suggested that a correlation might exist between the quality of the restoration and periradicular health, but the quality of the restoration was signicantly of minor importance than the quality of the root canal lling. Other studies (22, 23) suggested that periradicular health of root-lled teeth depends equally on the quality of the root canal lling and the coronal restoration. The results of the present study revealed that although the greatest factor inuencing treatment outcome was the quality of the root canal treatment, higher rates of healthy teeth were observed for cases with adequate coronal restorations when the quality of the endodontic treatment was not included as a variable. In other words, higher success rates for teeth with adequate or inadequate endodontic treatment were always observed in teeth with adequate coronal restorations. In addition, when data from endodontic treatment were pooled regardless of the quality, teeth with good coronal restorations had a signicantly lower prevalence of apical periodontitis than teeth with poor restorations. Thus, this study demonstrates that the coronal restoration also inuences the treatment outcome, possibly by preventing reinfection of the root canal. About one half of the teeth examined in this study were restored with a post. Whereas some studies have reported an increased prevalence of apical periodontitis for teeth restored with posts (38, 40), several other studies found no difference (3, 4143). Our present ndings are in agreement with the latter because the presence or absence of posts per se was not associated with the outcome of the treatment. Our ndings and those from other studies emphasize that a worldwide improvement in the quality of root canal treatment in general dental

TABLE 4. Periradicular status of root canaltreated teeth as related to quality of the coronal restoration combined with quality of the endodontic treatment determined by the length and homogeneity of the root canal lling (n = 1035) Endodontic treatment
Adequate Adequate Inadequate Inadequate

Coronal restoration
Adequate Inadequate Adequate Inadequate

PAI 1
126/153 (82%) 28/45 (62%) 227/515 (44%) 100/322 (31%)

PAI 2
17/153 (11%) 9/45 (20%) 103/515 (20%) 81/322 (25%)

PAI 3
0/153 (0%) 0/45 (0%) 99/515 (19%) 54/322 (17%)

PAI 4
8/153 (5%) 3/45 (7%) 58/515 (11%) 56/322 (17%)

PAI 5
2/153 (1%) 5/45 (12%) 28/515 (5%) 31/322 (10%)

Healthy (PAI 1 & 2)

143/153 (93.5%) 37/45 (82%) 330/515 (64%) 181/322 (56%)

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practice is required to promote periradicular health (12). Although some divergence can be found as to the impact of the quality of coronal restorations and endodontic llings, the overall perception is that the highest success rate is invariably observed when both follow acceptable quality standards. This is supported by the present ndings and emphasizes the concept that restoring or maintaining the health of the periradicular tissues is dependent on approaching the tooth as a continuum.
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