Original Article
Assessment of the Impact of Quality of Canal Obturation, Coronal and Apical Seal on the Healing of CBCT-Diagnosed Periapical Lesions in Endodontically Treated Teeth in Sri Lanka
Authors: EMKS Ekanayake, MCN Fonseka, RMJ Jayasinghe, RD Jayasinghe
DOI: https://doi.org/10.37184/jlnh.2959-1805.2.20
Year: 2024
Volume: 2
Received: Apr 16, 2024
Revised: Jul 27, 2024
Accepted: Jul 30, 2024
Corresponding Auhtor: EMKS Ekanayake (d02970@pgim.cmb.ac.lk)
All articles are published under the Creative Commons Attribution License
Abstract
Background: Previous literature has investigated the association between the attribute of coronal
restoration and root canal obturation with the radiographic periapical status of endodontically treated teeth.
Objectives: This study intends to assess the status of periapical lesions/pathology and, the main
factors influencing the healing of periapical lesions of root canal-treated teeth clinically and radiographically
exploiting CBCT. The quality of coronal restoration, canal obturation, and apical seal were selected to be assessed,
as they have a greater impact on healing peri apical pathology.
Methods: This aretrospective study was conducted at the Department of Restorative Dentistry and the
Division of Oral Medicine and Radiology, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka. All the
patients who presented between January 2020 and January 2021, had root canal treatment done at least one year prior,
were referred for CBCT assessment for some other conditions, and fulfilled the inclusion criteria, were selected.
Root canal-treated teeth were recognized by radio-opaque filling material inside the canals in any anterior or
posterior teeth.
Results: A sum of 50 CBCT reports from 50 patients was encompassed in the dissertation. Median age
was 26 (±4) years, with 37.5% of reports belonging to males. Statistical analysis was performed utilizing
Statistical Package for Social Sciences (SPSS) version 20.0 software (IBM Corp). Out of fifty patients, 32 had been
found to have adequate clinical coronal seal while 31 have been found to have adequate radiographical coronal seal.
Further, 31 patients were found to have insufficient obturation and 28 were found to have adequate apical seal. A
significant association was observed between periapical healing and adequate coronal restoration in root-filled
teeth (p=0.048). However, the association between the healing of the periapical region, and adequate root canal
obturation (p=0.09) and adequate apical seal (p=0.777) were found to be non-significant.
Conclusion: The most influential factor for the healing of periapical lesions in endodontically
treated teeth appears to be adequate coronal
restoration, compared to root canal obturation and apical seal, in a cohort of patients in Sri Lanka.
Keywords: Prognosis, clinical outcomes, endodontics, root canal therapy, CBCT, periapical
lesion, teeth, Sri Lanka.
INTRODUCTION
Assessing the periapical status across various populations proves beneficial, aiding in the determination of
treatment requirements for each populace and assessing the impacts of different endodontic mediations on treatment
results [1]. In numerous countries, cross-sectional and epidemiological studies employing diverse approaches and
criteria, have documented the ubiquity of apical periodontitis (AP) [1, 2]. AP is the local inflammation of the
periapical region that originates from pulp inflammation which may happen with the progress of dental caries,
trauma, or as a result of operative dental procedures [3]. The primary reason for apical periodontitis is the
infected pulp, resulting from a kinetic interplay between microbial elements, and host defences at the boundary of
infected root pulp and periodontium.
This dynamic leads to local inflammation, hard tissue resorption, periapical tissue destruction, and the gradual
formation of various pathologies termed periapical lesions [4]. With proper endodontic treatment, healing of
periapical lesions progresses, distinguished by gradual decline and resolution of apical radio transparency in
following radiographs [5, 6].
Not all endodontically treated teeth may experience a reduction in apical radiolucency, as “endodontic
failure” may manifest through persistent or enlarging periapical lesions, clinical signs of apical
inflammation, and ongoing root resorption. Advanced complications, including endodontic failure, may arise
post-endodontic treatment due to pre-operative factors such as the size of periapical lesions, the presence of sinus
lesions, and perforations.
They could also result from intraoperative challenges like
*Corresponding author: EMKS Ekanayake, Department of Restorative Dentistry, University of Peradeniya, Peradeniya,
Sri Lanka and Post Graduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka, Email: 
href="mailto:d02970@pgim.cmb.ac.lk">d02970@pgim.cmb.ac.lk
Received: April 16, 2024; Revised: July 27, 2024; Accepted: July 30, 2024 DOI:
https://doi.org/10.37184/jlnh.2959-1805.2.20
difficulty in achieving canal patency and instrumentation up to the apical extent, overextension of filling
materials, insufficient aseptic management, and post-operative elements like scarce of tight coronal seals [7].
The efficacy of root canal treatment (RCT) hinges on the careful selection of clinical protocol. This selection
relies on several factors, including the canal disinfection process (comprising instruments implementation, irrigant
solution, irrigating technique, and canal dressing), determination of the apical restrict for canal preparation,
obturation, and the characteristics of the sealer used [8].
Some cross-sectional studies have implied, that the success rate of RCT is greatly influenced by the attribute of
coronal restoration. In contrast, other investigations have emphasized a positive relation between the success ratio
of RCTs and the technical standards of root obturation, with the attribute of coronal restoration playing a lesser
role in endodontic treatment outcomes [9-12]. Yet another study has concluded that both factors wield a comparable
influence on the accomplishment of RCT [13].
Both clinical and radiological assessments can aid in diagnosing periapical periodontitis. Clinical findings such as
tenderness to percussion (TTP), swelling, apical abscess, discharging sinus, mobility of tooth, and, deep pockets,
are indicative of periapical periodontitis. On the other hand, radiological findings including broadening of the
periodontal ligament space, loss of lamina dura, presence of periapical radiolucent areas, and lasting root
resorption are diagnostic of periapical periodontitis [14]. Endodontic successes are typically evaluated through a
comprehensive clinical examination, complemented by plain film radiographs. These assessments aim to identify the
absence or reduction of the factors above indicative of successful treatment [15].
Several studies have detailed the use of conventional periapical radiographs, along with evaluations of the standard
of canal obturation and, coronal restoration, as methods for assessing thrive in endodontics [10, 16].
The primary drawback of periapical radiographs in periapical assessment lies in the superimposition of dental
structures across many planes. This can impede their interpretation and potentially lead to false-negative results
[17, 18].
Moreover, the deficiency in resolution and the incapacity to evaluate conditions three-dimensionally can additionally
hinder proper assessment. In response to these limitations, the employment of cone beam computed tomography (CBCT)
technology has been advocated to conquer the constraints of two-dimensional periapical radiographic images and to
enhance the precision of detecting periapical lesions compared to other dental radiographic methods [19].
Therefore, CBCT has been considered a leading tactful diagnostic way to recognize PA [20]. Nevertheless, it is not
accepted for regular endodontic diagnostic motives due to its comparative inaccessibility and the high dose of
radiation exposure associated with CBCT.
In identifying the clinical significance, the results of this research could elucidate the factors contributing to
the healing of periapical lesions in root canal-treated teeth. The study findings will also underscore the
importance of coronal seals [21].
Therefore, this investigation aims to appraise the status of periapical lesions/pathology and the strands influencing
the healing of periapical lesions in CBCT-diagnosed endodontically treated teeth within a Sri Lankan setting.
MATERIALS AND METHODS
Between 2020 and 2021, a retrospective cross-sectional study was conducted. It utilized 50 CBCT images from patients
aged 16 to 50. The sample size was the total number of patients who presented to the Department of Oral Medicine and
Radiology Department for a CBCT for any other purpose and who fulfilled the study criteria. The sample was collected
by filtering the total 250 CBCT taken in that year. These images, sourced from the annals in the Division of Oral
Medicine and Radiology at the Faculty of Dental Sciences, University of Peradeniya, Sri Lanka, were originally
referred for various assessments, including impacted teeth, dento-alveolar pathology, implant site evaluation, and
other pathological conditions. The inclusion criteria encompassed patients aged 16 to 50 years with teeth exhibiting
closed apices and having undergone endodontic treatment at least 3 months prior (as evidenced by radio-opaque
material within the root canals). Additionally, these teeth were required to have remained untreated until the CBCT
appointment. Patients meeting any of the following criteria were excluded from the study: those who had undergone
retreatment of root canal treatment (RCT) or subsequent modification of coronal restorations, individuals with teeth
exhibiting open apices or poorly developed roots, patients with severe periodontitis, resulting in bone loss around
the evaluated teeth, individuals with prior-endo lesions, specific systemic conditions, or undergoing certain drug
therapies such as diabetes mellitus, bisphosphonate therapy, or treatment for multiple myeloma. Additionally, teeth
with a history of trauma post-RCT, avulsed or severely intruded teeth, those subjected to any surgical procedures
related to the tooth, or those treated with Mineral Trioxide Aggregate (MTA) were also excluded. Further, any tooth
with breakage of instruments inside the root canals, perforations, or any error in preparation or obturation of the
root canal was denied. The research
protocol received approval from the Ethics Review Committee of the Faculty of Dental Sciences, University of
Peradeniya. The CBCT scans were conducted utilizing a CBCT scanner (Vatech Corporation, South Korea) using a range
of 18-200Usv, 60 to 90 kbp, and 2-15 Ma allowing any adjustment within each FOV and voxel size under standard
settings. The resulting images were stored and transformed into a DICOM file format using the acquisition software
integrated into the above CBCT machine. Quantifications were acquired utilizing EzDent software with a precision of
0.1 mm. Two calibrated observers interpreted all selected CBCT scans in the axial, coronal, sagittal, and
trans-axial planes using the least possible persisting slice thickness. Firstly, all 5o scans were analyzed by the
junior expertise with 10 years of clinical experience and finally, the results were confirmed by the most senior
expertise with 15 years’ experience. Consensus was reached in cases of interpretation disagreement. All
measurements were taken at the occlusal plane level, yielding the following results.
Following the acquisition of written informed consent, all patients underwent a comprehensive session comprising
history taking, clinical examination, and radiological assessment. The history encompassed the chief complaint, past
medical and surgical history, current drug regimen, and detailed dental history, counting specifics of root canal
treatment such as timing, number of visits until completion, timing and material used for coronal restorations,
instances of dislodgement, timing thereof, and whether rubber dam isolation was utilized. The details of root canal
treatment were collected from the patient’s folder.
Clinical and radiographic assessments were carried out according to the clinical and radiographic status of coronal
restoration, the radiographic status of the canal obturation, the radiographic status of the three- dimensional
apical seal at the apical cross sections, and the radiographic periapical status of the teeth. The observers were
two experienced specialized experts in the field of Restorative Dentistry at the Faculty of Dental Sciences.
The patients and the CBCT images were assessed and categorized as follows:
The clinical condition of coronal restorations on root canal-treated teeth was evaluated and scored based on the
modified Ryge’s criteria [22], which included:
Fine restoration edges
Traping of the probe
Aperture restricted to the enamel
Aperture involving the dentine
Fractured restoration
Disengaged restoration
Strayed restoration
Values of 1 and 2 were deemed indicative of adequate coronal restoration, while scores of 3 to 7 were classified as
inadequate coronal restoration.
Additionally, root canal-treated teeth were radiographically evaluated utilizing available CBCT images, categorized
as follows:
Unblemished restoration devoid of marginal leakage
Restoration with unbolted margin
Restoration with secondary decay
A score of 1 was regarded as indicative of adequate restoration, while scores of 2 and 3 were classified as
inadequate restorations according to the modified Ryge’s criteria [22].
The radiographic status of canal obturation was also evaluated based on:
Root obturation confining 0-2mm from the apex of the radiograph, displaying homogenous root filling, perfect
condensation, and no visible vacuity.
Root obturation confining >2mm from the apex of the radiograph or reaching over it, showing nonhomogeneous
root filling, inadequate condensation, and visible vacuity.
A score of 1 was deemed indicative of adequate root filling, while a score of 2 was considered inadequate according
to the modified Ryge’s criteria [22].
The Radiographic condition of the three-dimensional seal at the apex was assessed as follows:
The entire seal of the apex
insufficient seal extending less than 50% of the apex
insufficient seal extending greater than 50% of the apex (1 was considered as adequate apical seals 2,3 were
considered as inadequate) according to the modified Ryge’s criteria [22].
The periapical status of endodontically treated teeth was evaluated utilizing CBCT and the Periapical Index [23],
which included the following classifications:
Ordinary periapical tissues
Broadening of periodontal space
Minor change in apical bone
Alter in bone with a few mineral losses
Periodontitis with sharply defined radiolucent area
Severe periodontitis associated with aggravating characteristics
Scores ranging from 1 to 2 were interpreted as indicative of good periapical health, while scores exceeding 3 were
considered indicative of periapical pathosis.
According to the above values, six variables were set as:
Adequate and inadequate coronal restoration,
Adequate and inadequate root canal
Adequate and inadequate apical seal (Different
scenarios are displayed in Figs. (1-7)).
All particulars were recorded in Excel (Microsoft) spreadsheets. Statistical analysis was performed utilizing
Statistical Package for Social Sciences (SPSS) version 20.0 software (IBM Corp), and the level of significance was
set at p=0.05. Associations between all six variables (adequate coronal restoration, inadequate coronal
restoration, adequate root canal obturation, inadequate root canal obturation, adequate apical seal, and inadequate
apical seal) were assessed using the Chi- Square test.
RESULTS
A sum of 50 CBCT reports owned to 50 patients were enrolled in the experimentation. The mean age was 26 (±4)
years. Thirty-seven to five percent of the reports belonged to males. All teeth in a patient that were root- filled
were considered as the sample. The majority of the patients (81.2%) presented with more than one canal in the tooth
that was treated. The average number of teeth
per individual investigated was 1. The detailed results of the 6 variables are attached in Appendix 1
and their summary is as follows, (Tables 1 and 2).
Table 1: Clinical and radiographic status of coronal restoration in
root-filled teeth.
Factor | Adequate | Inadequate |
Clinical coronal restoration | 32 teeth | 18 teeth |
Radiographically, coronal restoration | 31 teeth | 19 teeth |
Radiographically canal obturation | 31 teeth | 19 teeth |
Radiographically apical seal | 28 teeth | 22 teeth |
Table 2: Radiographic status of apical seal among the patients.
Peri apical status | Number of teeth |
Healthy peri apical tissues | 26 |
Peri apical pathology | 24 |
Association Between Variables
Overall results reveal that most of the patients had an adequate response in periapical healing after the root canal
treatment. A significant association was observed between periapical healing and adequate coronal restoration in
root-filled teeth (p=0.048). However, the association between the healing of the periapical region and adequate root
canal obturation (p=0.09) and adequate apical seal (p=0.777) was found to be non-significant.
Further, the clinical status of coronal restoration significantly positively corresponded with a radiographic status
of coronal restoration (r=0.958, p<0.001) (Fig. 8) and the clinical status of coronal
restoration was significantly positively related to radiographic periapical status (r=0.614, p<0.001)
(Fig. 9). Further, positive correlations were observed in the radiographic status of coronal
restoration with the radiographic periapical status of the root-filled tooth (r=0.650, p<0.001) (Fig.
10).
There was a weak positive correlation between the radiographic status of the apical seal and the radiographic status
of periapical status (r=0.35, p>0.05) Apart from that, the radiographic status of canal obturation did not
significantly correspond with the periapical status (r = -0.010, p>0.946).
DISCUSSION
In the present study, just below half of the patients presented with inadequate peri-apical healing or having
peri-apical radiolucency following root canal treatment which confirms the reported percentage of prevalence of
peri-apical radiolucency (32.2%-67%) in the literature [17]. Two third of the studies in the literature have shown
the most affecting factor for the healing of peri apical lesions as the coronal restoration. Our study of the Sri
Lankan population was also tallied with literature. However, some studies still proved that the quality of canal
obturation was having a huge impact on this.
In a cross-sectional study, three out of the four factors exerting influence on the outcome of RCT can be evaluated.
These factors include the attribute of the coronal restoration, the solidity of the obturation, and its apical
extent. The only factor not assessed here is the preoperative apical status. Due to the lack of information
regarding the pathological history and systemic diseases of the patients, it is challenging to ascertain, whether
the apical lesion is healing or progressing [7]. However, in this study, only patients who had completed root canal
treatment one year prior and had not undergone any dental treatment thereafter for the specific tooth were included.
This timeframe appeared sufficient to determine apical alterations following endodontic treatment [23].
Most of the studies were carried out using plane radiographs together with clinical evaluation. Only a few recent
studies were carried out using more detailed cone beam computed tomography [10, 17]. The main drawback of plane
radiographs is the superimposition of structures in multiple planes which leads to false negative results and voids
in obturation are underestimated. Therefore, to avoid the problem, CBCT imaging mode with clinical evaluation of
certain possible factors were together considered for this study. However, CBCT also has some disadvantages, such as
overestimation of voids, complications due to scattered X-ray artefacts, high cost, and unavailability in every
centre. Further, radiation exposure is higher which is about four to five times greater compared to a more localized
two-dimensional plane radiograph for a simple routine diagnosis purpose [24]. It has an almost double capacity for
diagnosis of peri-apical lesions after endodontic treatments and the ability of early detection compared to
two-dimensional radiographs [25, 26]. Occasionally, healing may occur with fibrous tissues which is inappreciable in
an apical granuloma in radiographic images. The estimation error is unavoidable in these types of studies [10].
Therefore, the ideal mode of detection is histopathological imaging which is no longer practical in our context.
The result would help the clinicians in Sri Lanka to pay more attention to proper coronal restoration without leakage
to be placed following RCT to minimize possible failures.
LIMITATION OF THE STUDY
The study was carried out in a sample presented to the Faculty of Dental Sciences, University of Peradeniya, and
would not represent the whole population in the country. Further, the period between root filling and the CBCT scan
was not measured in the sample. Other influencing factors for the success of RCT such as pre- operative factors,
patient’s systemic conditions, oral
hygiene practices, diet habits, and technical variations were not assessed. Also, a large sample would be preferred
during an extended time frame.
CONCLUSION
Based on the findings of the present study, it appears that adequate coronal restoration, root canal obturation, and
apical seal contribute to favorable outcomes of RCT in a cohort of patients at our center in Sri Lanka.
Traditionally, the combination of high-quality endodontic obturation and coronal restoration has been associated
with successful outcomes in endodontically treated teeth. This study with a limited sample, in Sri Lanka, suggests
that the attribute of coronal restoration has an enormous influence on the healing of periapical pathosis. However,
some studies support this finding, others argue that the quality of canal obturation is more crucial.
Furthermore, the study indicates that there is a positive correlation between clinical and radiological assessments
of the status of coronal restoration, suggesting consistency between these two evaluation methods. However,
it’s important to note that the cross-sectional study design may have constraints, as it supplies information
about a population at a single point in time and lacks details on how the RCT was performed.
To enhance our understanding of RCT outcomes in Sri Lanka, future studies with wide-reaching sample sizes, more
precise information on the duration following RCT, and consideration of other influencing factors such as patient
factors, systemic factors, oral hygiene practices, and RCT techniques, are recommended. This would help to broaden
our knowledge of the factors impacting RCT outcomes and inform clinical practices in the region.
ETHICAL APPROVAL
An ethical clearance certificate was obtained from the Ethical Review Committee of the University of Peradeniya, Sri
Lanka (REF letter No. ERC/FDS/ UOP/E/2019/24). All procedures performed in studies involving human participants were
following the ethical standards of the institutional and/ or national research committee and the Helsinki
Declaration.
CONSENT FOR PUBLICATION
I am hereby giving consent for the publication of the manuscript detailed above, including any accompanying images
and data contained within the manuscript.
AVAILABILITY OF DATA
All data are available with the corresponding author and can be accessed on request.
FUNDING
Declared none.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ACKNOWLEDGEMENTS
Declared none.
AUTHORS’ CONTRIBUTION
EMKS Ekanayake; Conceptualization, Methodology, data
collection and analysis, Writing - original draft, Writing - review & editing.
MCN Fonseka: Methodology, Investigation, Writing
- review & editing, Data curation
RMJ Jayasinghe; Conceptualization, Methodology, Investigation, Data curation, Writing - original draft, Writing -
review & editing, Project administration.
RD Jayasinghe: Conceptualization, Methodology, Investigation, Resources, Writing - review & editing,
Supervision, Project administration.
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APPENDIX 1
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Number of clinical and radiographic observations in patients.
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PMID: 24789284
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