Nonsurgical

Retreatment:
Clinical Decision
Making
Spring 2017

ENDODONTICS:
Colleagues for Excellence
Published for the dental professional community by the

www.aae.org/colleagues
 ENDODONTICS: Colleagues for Excellence

Millions of teeth with disease of the pulp and periradicular tissues are saved every year through endodontic treatment.
Despite the high clinical success rates of nonsurgical root canal treatment, there are times when an endodontically
treated tooth may exhibit post-treatment disease requiring further intervention.
Post-treatment endodontic disease has four possible etiologies: microorganisms that are retained or reintroduced into
the canal system, microorganisms that survive in the apical tissues outside the canal system, foreign body reactions in
the apical tissues, and the presence of true periapical cysts (1, 2). Treatment for intracanal microorganisms includes
both surgical and nonsurgical options, but the other three etiologies only can be treated surgically. Because it is often
difficult to determine the causes of post-treatment endodontic disease, a thoughtful, evidence-based approach to
treatment planning is necessary.

Impact of CBCT on Treatment Planning

Treatment planning for diseased teeth is complex. A thorough dental history, clinical testing and radiographic
examination are necessary to make an accurate diagnosis prior to initiating treatment. The recent introduction of
three-dimensional imaging has had a significant impact on endodontic treatment planning. Limited field of view (FOV)
cone beam computed tomography (CBCT) is the imaging modality of choice for teeth with post-treatment disease.
The Joint Position Statement of the American Association of Endodontists and the American Academy of Oral and
Maxillofacial Radiology (3) states that limited FOV CBCT should be the imaging modality of choice when evaluating
the nonhealing of previous endodontic treatment, as well as for nonsurgical retreatment to assess treatment
complications or deficiencies that may have occurred during the previous endodontic therapy. When compared to
other types of CBCT devices with larger FOVs, the smaller FOV generally provides higher resolution with less radiation
exposure. Limited FOV CBCT enables the clinician to consider selective root retreatment, addressing only the roots
with radiographic evidence of disease (4), because of its increased sensitivity in detecting roots with a periapical low
density area when compared to 2-D radiographs (5). Perhaps the most compelling evidence supporting the diagnostic
value of CBCT in endodontics came from three recent studies showing that when CBCT data was added to otherwise
complete diagnostic information, the subsequent treatment plan was changed in 35 to 62% of the cases (6-8).
Limited FOV CBCT is useful in identifying untreated canals and root perforations, assessing complex anatomy such
as fins or fused roots, evaluating instrumentation and obturation quality, and visualizing bone loss patterns that are
consistent with apical periodontitis, marginal periodontitis, furcation involvement, or root fractures (Figure 1) (9).
Many times, situations can be discovered that would preclude successful endodontic retreatment so that clinicians
and their patients can avoid the frustration of performing treatments that have a low chance of success (Figure 2).
After diagnosis, treatment options must be effectively communicated to the patient so that they can make an informed
decision with the clinician.

A B C

D E
Fig. 1. Premolar bridge abutment
with newly completed root canal
therapy (A). Five years later (B) the
tooth became symptomatic. CBCT
(C, D) shows loss of buccal bone
consistent with a vertical root
fracture, which was confirmed on
surgical exploration (E).

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 Nonsurgical Retreatment: Clinical Decision Making

A B C

D E

Fig. 2. This asymptomatic molar (A) had extensive bone loss revealed by the CBCT (B, C).
Despite the poor prognosis, the patient wanted nonsurgical root canal therapy to attempt to
save her tooth. After removing the root filling materials (D), a large vertical fracture (yellow
arrows) was found on the mesial wall of the access preparation extending down into the
mesio-buccal canal and contacting the mesio-palatal root pulpal anastomosis (red arrows).
The prognosis is unfavorable.

Treatment Planning Decisions

There are essentially four options for treatment of a tooth that has post-treatment disease: do nothing, extraction,
nonsurgical retreatment, and surgical treatment (10). Avoiding treatment may result in the progression of disease
and continued destruction of supporting tissues as well as possible acute exacerbation of systemic side effects such
as cellulitis and/or lymphadenopathy. In most cases, these options are unacceptable. Extraction and replacement is
a viable option, but replacements for missing teeth rarely are better than an otherwise restorable natural tooth (11),
and nonreplacement usually results in unfavorable alterations in the adjacent dentition and surrounding tissues
as well as possible diminution of masticatory function. The decision of whether to perform nonsurgical or surgical
retreatment to retain the tooth also is complex. The American Association of Endodontists has produced a very helpful
publication to help clinicians with these topics, Treatment Options for the Compromised Tooth: A Decision Guide, which
is available at www.aae.org/treatmentoptions.
For most cases, the clinician needs to decide if retention of the tooth is in the patient’s best interest. This decision is
based on the restorability of the tooth and its strategic position in the dentition, periodontal health, the health history,
motivation and desires of the patient, and the skill level and experience of the dentist.
Generally, the restorability of the tooth is determined by the amount of healthy and intact tooth structure that remains
after careful removal of old restorations and caries or resorption. Important treatment planning questions to ask when
determining restorability include:
• Does adequate tooth structure remain to allow production of a ferrule for the restorative preparation?
• Will the margins of the potential restoration invade the biologic width?
• Will the remaining tooth structure be strong enough to resist fracture when occlusally loaded?
• Are there any pre-existing tooth fractures or perforations of the root that may compromise the outcome?
• Will crown-lengthening surgery, if necessary (or even possible), expose a furcation or disturb the attachment height
of adjacent teeth?
• Is the tooth necessary to keep in order for the patient to masticate effectively and will its loss result in the need for
replacement?
• Does the site have adequate bone to retain a possible implant?
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 ENDODONTICS: Colleagues for Excellence

Patient factors also are critical in the decision to save or lose a tooth. Is the patient healthy enough to tolerate the
treatment options? For example, patients with a history of use of medications to treat osteoporosis and certain types
of cancer may be at risk for medication-related osteonecrosis of the jaws (MRONJ) and the risk varies depending on
the type of medication (12). In these patients, it is often advisable to avoid extraction surgery and retain the tooth with
nonsurgical retreatment. Does the patient smoke or have diabetes? These conditions may affect outcomes of both root
canal therapy and implant placement (13-17). Does the patient have the motivation and resources needed to retain
a tooth or to place and restore an implant? Does their dental history reveal a problem with maintaining whichever
treatment is selected? Can the patient tolerate the long appointment times needed to perform whichever treatment
is selected? The clinician must answer these questions to help the patient make the best treatment decision for their
particular situation.

Retreatment Procedures
The procedures for endodontic nonsurgical retreatment can be grouped into disassembly, repair of existing
perforations, access to missed anatomy, shaping and disinfection of the canal system, and obturation (10). While
cleaning, shaping, and disinfecting the root canal space in retreatment can be similar to initial root canal therapy,
location and treatment of missed anatomy, disassembly and perforation repair are procedures that are very complex
and require a specialized armamentarium and knowledge. The dental operating microscope allows the clinician to
visualize the contents of canals and endodontic access preparations better than loupes or the naked eye (18) and
supports delicate and important retreatment procedures that cannot be accomplished in any other way. Without
the dental operating microscope and 3-D imaging, retreatment at the highest level is very difficult and sometimes
impossible to achieve.
Intraoperative decision making generally is very complicated in nonsurgical retreatment, since what one will find
inside of a treated tooth may be difficult to discern from the diagnostic data. “Expect the unexpected” is the general
rule during retreatment, and the clinician must be prepared to adapt to each unique clinical situation.
An endodontically treated tooth often has a full coverage restoration. The clinician must decide whether to remove the
coronal restoration or attempt to retain it by preparing an access through it. Removing an intact restoration with the
aim of reusing it can be unpredictable. Most times removal of the restoration is only considered when it needs to be
replaced. The simplest approach is usually to prepare the access through the existing restoration, though this does risk
damage that may require refabrication (19). It is always prudent to forewarn the patient that retreatment may result
in the crown debonding or otherwise being damaged in a way that will require a new restoration.

A B C

Fig. 3. The top of a threaded post

D E embedded in core material is shown
in the access preparation (A). After
careful removal of the core material with
ultrasonics and machining the post head
with a trephine bur (B), a tap wrench is
screwed down onto the post (C). Turning
the tap wrench retrieves the post (D). In this
case, an untreated MB2 canal was found
with the dental operating microscope (E).

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 Nonsurgical Retreatment: Clinical Decision Making

Generally, if a post and core is present, there is a high likelihood that the coronal restoration will be lost. Endodontists
currently use very conservative access preparations to preserve as much tooth structure as possible, but a pre-existing
access in a tooth initially treated years ago will usually be larger. In addition, access enlargement often is necessary
to excavate around and remove posts in the canals to be retreated. Post removal requires careful use of ultrasonic
instruments to remove surrounding core material and disrupt the intracanal cement seal around the post (20). Great
care must be taken to avoid overheating the post since heat transmitted to the ligament during post removal may
cause large areas of bone destruction and tooth loss (21-23). Intermittent application of the ultrasonic tip with a
copious air/water coolant spray is necessary. There are many other types of instruments and techniques that can aid
in the removal of a post and the clinician should have training for and access to a wide selection of them to be able to
remove posts in all situations (Figure 3).
Following post retrieval, removal of the pre-existing root filling materials is necessary. The techniques used vary
depending on the materials that are found in the canals (10). Removal of gutta-percha and solid-core obturators
(with plastic or cross-linked gutta-percha carriers) usually is performed with some combination of heat, solvents, and
endodontic files and reamers (both manual and engine-driven). Metal solid-core carriers usually require a different
procedure since use of engine-driven instruments is contraindicated due to the risk of instrument breakage. Soft paste
root fillings require a crown-down technique to minimize extrusion of the potentially toxic paste components into
the periradicular tissues, and hard pastes generally are removed with ultrasonics and other solvents. Silver points are
removed with endodontic files, forceps, special elevators, or a tube system.
Occasionally, a separated instrument is found in the canal space. The presence of the separated instrument is not
a direct cause of post-treatment disease; rather it is necrotic pulp tissue or bacteria in the canal that cannot be
removed because the separated instrument prevents disinfection (24). If there is a separated file in the canal, and it is
positioned coronal to the canal curvature, many times it can be removed successfully, but this requires very specialized
techniques and armamentarium including the dental operating microscope (25). Frequently, removal of tooth
structure deep in the canal is required to access and remove the separated instrument. This can result in perforation
of the root or weakening of the tooth structure increasing chances of fracture in the future (Figure 4).

A B

C D

Fig. 4. Removal of a separated instrument from a lower molar (A). The separated
instrument is seen in the canal (B) but the enlargement needed to remove it has
weakened the root (C). Despite the good healing evident on the two-year re-
evaluation (D), the longer-term prognosis is questionable.

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 ENDODONTICS: Colleagues for Excellence

A B

Fig. 5. There is a ledge in the mesial canal of this lower molar (A, arrow). Using pre-bent files, much patience, and time,
the ledge was bypassed and the apical canal was three-dimensionally obturated (B).

Root perforations (iatrogenic or resorptive) can cause periradicular periodontitis in root-treated teeth and an
assessment of whether the defect can be repaired is part of the treatment planning process. Ideally, the perforation
should be repaired as soon as possible (26), and repair of perforations below the periodontal attachment must be
done using bioceramic materials to enhance complete healing (27).
After disassembly procedures are completed, the canals should be cleaned thoroughly and made into an ideal
shape for reception of new filling materials. This is frequently a complicated process in teeth with post-treatment
disease due to iatrogenic canal irregularities (blockages, ledges, zips, and canal transportation) from the previous
treatment (28). Bypassing blockages and ledges and thoroughly cleaning and disinfecting zipped or transported apical
preparations is very difficult and time consuming (Figure 5) (10). Untreated canal ramifications (such as missed
canals and lateral canals) are another challenge that needs to be addressed in retreatment but all of these factors must
be managed to create a predictable outcome (29).
The final step in retreatment is to thoroughly disinfect and then three-dimensionally obturate the canal space. When
these teeth are handled properly, the complete healing rates for nonsurgical retreatment are high, ranging from 74% -
98% (30) while quality of life and normal mastication is rapidly restored (Figure 6) (31).

A B C

Fig. 6. Previous root canal therapy (A) with symptomatic apical periodontitis due to a missed distal canal and short fills of
the mesial canals. Successful nonsurgical retreatment (B) results in complete healing and an asymptomatic patient at the
19-month re-evaluation (C).

For most clinicians, referral to an endodontist will be made if retention of the tooth is the selected treatment choice,
since they are the clinicians who are best equipped to make these planning decisions and perform the highly
specialized procedures needed to retain the tooth. What may not be so obvious is that the endodontist is also the
specialist who can be most helpful in deciding whether the tooth is restorable. Their specialized training in full
time post-graduate residency includes not only evidence-based treatment procedures, but also effective diagnosis
and treatment planning for teeth with post-treatment disease. Coupled with great experience in “what works,” the
endodontist will be the dentist’s most valuable partner in patient care when these hard decisions need to be made.

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 Nonsurgical Retreatment: Clinical Decision Making

References 17. Chen H, Liu N, Xu X, Qu X, Lu E. Smoking, radiotherapy,

diabetes and osteoporosis as risk factors for dental implant
1. Sundqvist G, Figdor D. Endodontic treatment of apical failure: a meta-analysis. PloS one 2013;8:e71955.
periodontitis. In: Orstavik D, Pitt-Ford T, editors. Essential
Endodontology. Prevention and Treatment of Apical Periodontitis. 18. Perrin P, Neuhaus KW, Lussi A. The impact of loupes and
London: Blackwell Science Ltd; 1998;242. microscopes on vision in endodontics. int Endod J 2014;47:425-9.
2. Nair PN. On the causes of persistent apical periodontitis: a 19. Mulvay PG, Abbott PV. The effect of endodontic access cavity
review. Int Endod J 2006;39:249-81. preparation and subsequent restorative procedures on molar
crown retention. Aust Dent J 1996;41:134-9.
3. AAE and AAOMR Joint Position Statement: Use of Cone Beam
Computed Tomography in Endodontics 2015 Update. Oral Surg, 20. Buoncristiani J, Seto BG, Caputo AA. Evaluation of ultrasonic
Oral Med, Oral Pathol Oral Radiol 2015;120:508-12. and sonic instruments for intraradicular post removal. J Endod
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4. Nudera WJ. Selective Root Retreatment: A Novel Approach. J
Endod 2015;41:1382-88. 21. Schwartz RS, Robbins JW. Post placement and restoration
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5. Uraba S, Ebihara A, Komatsu K, Ohbayashi N, Okiji T. Ability 2004;30:289-301.
of Cone-beam Computed Tomography to Detect Periapical
Lesions That Were Not Detected by Periapical Radiography: A 22. Budd JC, Gekelman D, White JM. Temperature rise of the post
Retrospective Assessment According to Tooth Group. J Endod and on the root surface during ultrasonic post removal. Int Endod
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volumetric tomography versus periapical radiography. J Endod 2005;31:301-3.
2014;40:910-16. 24. Spili P, Parashos P, Messer HH. The impact of instrument
7. Mota de Almeida FJ, Knutsson K, Flygare L. The effect of cone fracture on outcome of endodontic treatment. J Endod
beam CT (CBCT) on therapeutic decision making in endodontics. 2005;31:845-50.
Dentomaxillofac Radiol 2014;43:20130137. 25. Gencoglu N, Helvacioglu D. Comparison of the different
8. Mota de Almeida FJ, Knutsson K, Flygare L. The impact of techniques to remove fractured endodontic instruments from
cone beam computed tomography on the choice of endodontic root canal systems. Eur J Dent 2009;3:90-5.
diagnosis. IntEndod J 2015;48:564-72. 26. Sinai IH. Endodontic perforations: their prognosis and
9. Cotton TP, Geisler TM, Holden DT, Schwartz SA, Schindler WG. treatment. J Am Dent Assoc 1977;95:90-5.
Endodontic applications of cone-beam volumetric tomography. J 27. Main C, Mirzayan N, Shabahang S, Torabinejad M. Repair of
Endod2007;33:1121-32. root perforations using mineral trioxide aggregate: a long-term
10. Roda R, Gettleman B. Non-surgical Retreatment. In: study. J Endod 2004;30:80-3.
Hargreaves K, Berman L, eds. Cohen’s Pathways of the Pulp. 11th 28. Jafarzadeh H, Abbott PV. Ledge formation: review of a great
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11. Iqbal MK, Kim S. For teeth requiring endodontic treatment, 29. Farzaneh M, Abitbol S, Friedman S. Treatment Outcome in
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Oral Maxillofac Implants 2007;22 Suppl:96-116.
30. Friedman S, Mor C. The success of endodontic therapy--
12. Ruggiero SL, Dodson TB, Fantasia J, Goodday R, Aghaloo T, healing and functionality. J Calif Dent Assoc 2004;32:493-503.
Mehrotra B, et al. American Association of Oral and Maxillofacial
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the jaw--2014 update. J Oral Maxillofac Surg 2014;72:1938-56. Clinical and Patient-centered Outcomes of Nonsurgical Root Canal
Retreatment in First Molars Using Contemporary Techniques. J
13. Duncan HF, Pitt Ford TR. The potential association between Endod 2017;43:231-7.
smoking and endodontic disease. Int Endod J 2006;39:843-54.
14. Lopez-Lopez J, Jane-Salas E, Martin-Gonzalez J, Castellanos-
Cosano L, Llamas-Carreras JM, Velasco-Ortega E, et al. Tobacco
smoking and radiographic periapical status: a retrospective case-
control study. J Endod 2012;38:584-8.
15. Fouad AF, Burleson J. The effect of diabetes mellitus on
endodontic treatment outcome: data from an electronic patient
record. J Am Dent Assoc 2003;134:43-51; quiz 117-8.
16. Segura-Egea JJ, Martin-Gonzalez J, Cabanillas-Balsera D, Fouad
AF, Velasco-Ortega E, Lopez-Lopez J. Association between diabetes
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2016;20:1133-41.

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 The AAE wishes to thank Dr. Robert S. Roda for authoring this issue of the newsletter, as well the following article reviewers:
Drs. Scott L. Doyle, Steven J. Katz, Linda G. Levin, Avina K. Paranjpe and Patrick E. Taylor.

Online Bonus Materials: Nonsurgical Retreatment

This issue of the Colleagues newsletter is available online at www.aae.org/colleagues with the following bonus materials:
• Full-Text Article: He J, White RK, White CA, Schweitzer JL, Woodmansey KF. Clinical and Patient-centered Outcomes of
Nonsurgical Root Canal Retreatment in First Molars Using Contemporary Techniques. J Endod 2017;43:231-7.
• Treatment Options for the Compromised Tooth: A Decision Guide
• AAE/AAOMR Revised Joint Position Statement on Cone Beam Computed Tomography in Endodontics
• Contemporary Endodontic Technology: Cone Beam Imaging in Treatment Planning

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