Cases Requiring Retreatment Due to Missed Canal - A Retrospective Analysis
B. Vivek Babu1, Dr. Sowmya. K2*, Dr. SS Raj3
1 Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai, Tamil Nadu, India.
2 Senior Lecturer, Department of Conservative Dentistry and Endodontics, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai, Tamil Nadu, India.
3 Associate Professor, Department of Public Health Dentistry, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai, Tamil Nadu, India.
*Corresponding Author
Dr. Sowmya. K,
Senior Lecturer, Department of Conservative Dentistry and Endodontics, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha
University, Chennai, Tamil Nadu, India.
E-mail: sowmyak.sdc@saveetha.com
Received: July 30, 2021; Accepted: August 10, 2021; Published: August 17, 2021
Citation:B. Vivek Babu, Dr. Sowmya. K, Dr. SS Raj. Cases Requiring Retreatment Due to Missed Canal - A Retrospective Analysis. Int J Dentistry Oral Sci. 2021;8(8):3877-3881. doi: dx.doi.org/10.19070/2377-8075-21000793
Copyright: Dr. Sowmya. K©2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
The success of endodontic therapy requires thorough knowledge of root anatomy and its variations. A good debridement and cleaning of the root canal system of any infected pulp tissue and filling of the root canal space with an inert material prevents or minimises any chance of reinfection. This cannot be achieved when the clinicians fail to locate one or more canals. Hence this retrospective study was undertaken to analyse the teeth requiring re root canal treatment due to missed canals. Data of patients undergoing retreatment in Saveetha dental college was collected and reviewed to identify cases with missed canals. The data was tabulated and Chi square analysis done using IBM SPSS software version 20. Of all the cases analysed, 6.5% cases underwent retreatment due to missed canals (P value- 0.003 < 0.05; Chi square test). Within the limitations of this study, failure to locate and properly debride the canals is still one of the reasons for failure of root canal treatment, even with the advancements in diagnosis and magnification currently available.
2.Introduction
3.Conclusion
4.References
Keywords
Diagnostic Aids; Missed Canal; Re-Infection; Retreatment; Root Canal Anatomy.
Introduction
The prognosis of Endodontic treatment is fairly predictable with
a reported success rate of 86.95% [41, 38]. Endodontic failure is
characterized by a recurrence of clinical symptoms alongside the
presence of periapical radiolucency [15]. Several factors including
persistent bacteria, improper root canal filling or coronal seal and
iatrogenic errors contribute to this failure [52, 40].
The main aim of endodontic treatment is thorough debridement
of the infected tissue and cleaning of the root canal space to be
filled with an inert material. The root canal system is complex
and hence the variations in the root canal morphology should
be considered a rule rather than an exception [62, 49]. New root
canal configurations are studied and reported by several authors
in different populations [56, 17, 63]. Inadequate knowledge of
the complexities of the root canal system hinders proper debridement
and can result in reinfection and recurrence of symptoms
leading to the failure of root canal treatment [50, 21].
Proper understanding and diagnosis is critical for achieving successful
treatment outcomes. Conventional and angulated radiographs
can provide a valuable insight into the number of canals
present and their morphology [6, 27, 41]. A more sophisticated
diagnostic aid like cone beam computed tomography (CBCT) has
an advantage over conventional radiography as it allows clinician
to have a three dimensional and multi slice view of the root canal
system [33, 32]. The use of ultrasonic devices, trans illumination
and endodontic microscopes are also an important adjunct in locating
and managing the root canals and has made endodontic
treatment more predictable [1, 35, 11].
A root canal retreatment becomes necessary when a previously
root canal treated tooth fails to heal or if a recurrent infection is
evident or the symptoms recurs [22]. It is not uncommon to miss
a canal while carrying out endodontic therapy especially in multi
rooted teeth where the number of canals often outnumbers the
number of roots [13]. The inability to locate and treat all the canals
is one of the causes for endodontic failure [36, 45]. Improper
diagnosis and inadequate access opening makes it difficult to locate all the canals [16]. Bacteria residing in these missed canals
causes persistent infection and symptoms [45, 16].
Previously our team has a rich experience in working on various
research projects across multiple disciplines. (Jain, 2017 [14]),
(Varghese, Ramesh and Veeraiyan, 2019 [54]), (Ashok and Ganapathy,
2019 [3]), (Padavala and Sukumaran, 2018 [28]), (Ke et al.,
2019 [18]), (Ezhilarasan, 2018 [7]), (Krishnan et al., 2018 [20]),
(Ezhilarasan, Sokal and Najimi, 2018 [9]), (Pandian, Krishnan and
Kumar, 2018 [30]), (Ramamurthy and Mg, 2018 [39]), (Gupta,
Ariga and Deogade, 2018 [10]), (Vikram et al., 2017 [60]), (Paramasivam,
Vijayashree Priyadharsini and Raghunandhakumar,
2020 [31]), (Palati et al., 2020 [29]), (Samuel, Acharya and Rao,
2020 [47]) Now the growing trend in this area motivated us to
pursue this project.
In spite of all the advancements, the location of all the canals has
still been challenging. Hence the aim of this study was to evaluate
the cases requiring re root canal treatment due to missed canals
[53].
Materials And Methods
This was a retrospective study done in a university setting. An
institutional committee approval was obtained to access the personal
data of the patients. The data of patients requiring re root
canal treatment from the period of June 2019 to April 2020 was
collected and analysed. The teeth requiring retreatment were examined
clinically and radiographically. Cross verification was done
by two reviewers to minimise bias. The type of teeth requiring
retreatment and the reason for retreatment was noted. Any reason
for retreatment other than the presence of missed canals (iatrogenic
errors, over obscuration, under obscuration, persistent lesion)
was put together as other reasons. The data was tabulated
and analysed using IBM SPSS software version 20. Descriptive
statistics was done to determine the frequency percentage and Chi
square test was done to find the association between the teeth
requiring retreatment and the reason for retreatment. The level of
significance was set at 0.05.
Results & Discussion
A total of 307 retreatment cases were analysed. The frequency
of retreatment performed was highest for the anteriors (45.6%)
followed by molars (35.5%) and anteriors (18.9%) [Figure 1]. The
frequency of teeth requiring retreatment was higher in the mandibular
arch (62.9) than the maxillary arch (37.1%) [Figure 2]. Of
all the cases evaluated, only 6.5% of cases required retreatment
due to missed canals [Figure 3].
The number of teeth requiring retreatment due to missed canals
was significantly lower compared to other reasons for retreatment
(Chi square: p value-0.003) [Figure 4]. On analysing the tooth type
and arch in teeth requiring retreatment due to missed canals, no
significant association was found (Chi square: p value- 0.871) [Figure
5]. This could be attributed to the less number of cases that
required retreatment due to missed canals.
In our study, out of all the cases analysed, only 6.5% required
retreatment due to a missed canal. Previous studies have reported
varying percentages of missed canals in teeth requiring retreatment.
A study evaluating the most common possible causes of
failure of endodontically treated teeth found the most common
reason to be leakage around the canal filling material (30.4%), followed
by a missed canal (19.7%), underfilling (14.2%), anatomical
complexity (8.7%), overfilling (3.0%), iatrogenic problems (2.8%), apical calculus (1.8%), and cracks (1.2%) [19]. According to another
study, the evidence of missed canals was reported to be
42% of all 1100 endodontically failing teeth [12]. In a study conducted
by David E Witherspoon et al., missed canals were identified
in 64 of the 133 previously root canal treated teeth (48%)
[61, 23].
With the recent developments in diagnostic imaging, the understanding
of root canal anatomy has drastically improved. The incidence
of two canals at the tooth's apex is reported to be 1%
to 43% [55, 26]. Failure to locate all the canals present has been
recognised as a reason for failure in different teeth. The most
supreme reason for endodontic failure of mandibular central incisors
was found to be the presence of an undetected lingual canal
or an untreated isthmus [55, 48]. The prevalence of two canals
in mandibular incisors has been reported to be from 11.5% to
44.1% although many merge into one canal in the apical 1–3 mm
of the root [56, 48].
Mandibular premolars are known to be the most difficult teeth
to treat and are found to have the highest rate of non-surgical
endodontic treatment failure (11.45%). This is attributed to the
high variations in the root canal morphology and the difficulty in
accessing the second canal [57]. One study found a prevalence of
two canals to be 27.8% and 8.9% in first and second mandibular
premolars respectively, and when this is not identified, it will affect
the outcome [62, 43].
Among the different teeth, molars had the highest number that
required retreatment due to missed canals in this study. In multirooted
molar teeth, of the total missed canals, 44% involved
maxillary first molar and 11% involved a maxillary second molar.
One previous study has shown that for the maxillary first molars,
93% of all missed canals were identified in the mesiobuccal root
whereas in the mandibular second molars, 29% of missed canals
were identified in the distal and 71% in the mesial root. In the
mandibular first molars, 86% of the missed canals were identified
in the distal and 14% were identified in the mesial root [61].
Most problems that occur during endodontic treatment are due
to inadequate knowledge about the tooth morphology and root
canal system (Al-Qudah and Awawdeh, 2006). Hence it is imperative
to assess the morphology of the root canals and their numerous
variations before initiating root canal treatment to ensure long
term prognosis [56, 2, 4].
The small sample size was the major limitation of the study.
Evaluation of a greater number of samples can provide better
understanding on the distribution and impact of missed canals
on primary root canal treatment. Future studies can be combined
with CBCT evaluation of teeth to corroborate the clinical and
radiographic findings.
Our institution is passionate about high quality evidence based
research and has excelled in various fields ( (Pc, Marimuthu and
Devadoss, 2018 [34]; Ramesh et al., 2018 [41]; Vijayashree Priyadharsini,
Smiline Girija and Paramasivam, 2018 [59]; Ezhilarasan,
Apoorva and Ashok Vardhan, 2019 [8]; Ramadurai et al., 2019
[37]; Sridharan et al., 2019 [[51]]; Vijayashree Priyadharsini, 2019
[58]; Chandrasekar et al., 2020 [5]; Mathew et al., 2020 [24]; R et
al., 2020 [44]; Samuel, 2021 [46]). We hope this study adds to this
rich legacy.
Figure 1 - Bar graph represents the association between gender and type of TMD. X-axis represents the gender and Y-axis represents the percentage of patients with TMD. Chi-square test was done.(Pearson Chi-square P value:0.950(>0.05), hence not statistically significant). There is no statistically significant association between gender and type of TMD.
Figure 2 - Bar graph represents the association between age and type of TMD(. X-axis represents the age and Y-axis represents the percentage of patients with TMD. Chi-square test was done. (Pearson Chi-square P value: 0.342(>0.05), hence not statistically significant). There is no significant association between age and type of TMD.
Figure 3 - Bar graph represents the association between dental status and type of TMD. X-axis represents the dental status and Y-axis represents the percentage of patients with TMD. Chi-square test was done and association was not found to be statistically significant. (Pearson Chi-square P value:0.404(>0.05), hence not statistically significant). There is no significant association between dental status and type of TMD.
Figure 4 - Bar graph represents the association between dental status and type of TMD. X-axis represents the dental status and Y-axis represents the percentage of patients with TMD. Chi-square test was done and association was not found to be statistically significant. (Pearson Chi-square P value:0.404(>0.05), hence not statistically significant). There is no significant association between dental status and type of TMD.
Figure 5 - Bar graph represents the association between dental status and type of TMD. X-axis represents the dental status and Y-axis represents the percentage of patients with TMD. Chi-square test was done and association was not found to be statistically significant. (Pearson Chi-square P value:0.404(>0.05), hence not statistically significant). There is no significant association between dental status and type of TMD.
Conclusion
Within the limitations of this retrospective study, we conclude
that the number of teeth requiring retreatment due to missed canals
was significantly lower compared to other reasons for retreatment.
Proper knowledge and understanding the complexities of
the root canal system along with the use of advanced diagnostic
aids and magnification can help in identification and adequate disinfection
of root canals, ensuring long term success of the endodontically
treated teeth.
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