Causes of root canal treatment failure. – Reasons why completed endodontic therapy may prove to be unsuccessful. –

Why has your tooth’s root canal treatment failed?

This page explains issues that are frequently identified as being the causative factor(s) in the failure of a tooth’s endodontic therapy.

• Some of these are diagnostic and procedural issues/errors that might have been handled more successfully.
• Other issues involve factors related to characteristics of the tooth, its root canal system or condition at the time of its treatment that made your case more of a challenge or less predictable.

Why cases fail.

Unsuccessful cases generally involve a situation where there is some type of deficiency associated with one (or both) of these fundamental goals of endodontic therapy:

• The cleaning aspect of the tooth’s procedure The steps. has been incomplete or ineffectual. With the irritants that remain inside the tooth causing the case’s failure.
• The seal created for the tooth (either during its root canal procedure The process. or by its final restoration placed afterward What kind is needed?) has not been successful in keeping contaminants from seeping into, or out of, the tooth.

  The seal might have been deficient initially, or was initially intact and has since deteriorated.

It may be that procedural shortcomings or complications have prevented the completion of the tooth’s work according to the standards needed. Or issues associated with the tooth’s preoperative condition may have created obstacles that prevented the tooth’s successful treatment.

What can be done for failed cases?

With each reason for endodontic failure, we also explain how the tooth’s situation might be remedied. Generally, there are only two options, extraction or case retreatment (conventional or surgical). This page explains in greater detail what those options may entail: What’s the fix for failed root canal treatment? Possible options.

Examples of specific reasons why root canal treatment may fail.

• Overlooked/Missed root canals.
• Unfilled accessory or lateral canals.
• Cracked teeth/roots.
• Unfilled/Ineffectually filled root canal system.
• Overextension of filling materials (overfill).
• Inadequate coronal seal.
• Clinician procedural errors.
• Preoperative pathology.
• Lack of clinician expertise.
• Compromised tooth condition.

Reasons why root canal treatment fails.

1) Missed canals.

Different types of teeth (molars, premolars, canines, incisors) characteristically have differing numbers of roots and root canals. What’s normal? | Variations. But unfortunately for the treating dentist, there are no hard rules about the configuration that actually exists.

• Specific roots of some types of teeth are well know for having, or frequently having, multiple canal configurations, and because of this should always be suspected of having more than one.
• Even beyond what might generally be expected, it’s always possible, no matter how rare, that the anatomy of a tooth’s root canal system is simply atypical.

The back root (root “a”) of a lower molar may have one or two canals.

If it has two but both aren’t found, its root canal treatment will fail.

A dentist’s due diligence.

• At a minimum, looking for possible variations takes additional time. Although, this should just be a minor consideration for the dentist.
• Worse, searching a tooth exhaustively can involve trimming away aspects of its interior that can result in structural weakening. Of course, this is especially disappointing when no additional canals are discovered.

For these reasons, it’s easy enough to understand why a dentist might not be astoundingly inquisitive if the configuration they have already discovered lies within the parameters of what can be considered normal for the tooth involved.

The underlying problem.

The crux of this issue is simply that any untreated (overlooked, undiscovered) canals, no matter how minute in size, will remain a locus of persistent infection.

And as such, that leaves the expectation that they will lead to the failure of the tooth’s root canal treatment.

An endodontist using a surgical microscope.

Incidence rates.

• A study by Iqbal determined that missed canals are a major cause of root canal failure (around 18% of failed cases), and most commonly associated with treatment provided by general dentists as opposed to specialists.

  (It’s common for an endodontist to use a surgical microscope as a visual aid in their search for additional canals. Also, a specialist is more likely to be familiar with what variations might exist, and more likely to be able to adequately treat very tiny canals. See discussion and link below.)

• A study by Hoen evaluated 337 failed root canal cases and determined that overlooked canals played a role in 42% of them.

▲ Section references – Iqbal, Hoen

What’s the solution for failed cases involving missed canals?

Once the untreated canal(s) has been identified, conventional retreatment of the case The process. is frequently successful.

2) Unfilled accessory and lateral canals.

The anatomy of the root canals inside a tooth can display variations.

Variant root canal anatomies.

• An accessory canal is any branch of one of a root’s main canals that leads off to its own exit point on the root’s surface.

  Somewhat arbitrarily, accessory canals are typically defined as canal branching found in the apical end (tip portion) of a tooth’s root (last 1/3 of the root or so).

• A lateral canal is also technically an accessory canal. But, and again arbitrarily, usually defined as branching that occurs in the upper 2/3rds of a tooth’s root.

  As a point of difference, lateral canals often run horizontally from the central canal directly to the root’s side. In comparison, accessory canals might be considered to have a more split-off/branched configuration (see animation).

The underlying problem.

With both of the above variations, it’s common that the division of the canal isn’t identified (they typically aren’t observed on x-rays). And even when detected, it may be difficult, or even impossible, for the dentist to adequately treat (clean, shape, fill) the branch.

If that’s the case, and just like with missed canals discussed above, the result will be one where some of the tooth’s root canal system is left ineffectually treated. As a result, the deficient portion can provide a location where infection can persist and therefore act as a continued irritant to the tissues that surround the tooth’s root, ultimately leading to case failure.

Incidence.

The root canal systems of any and all teeth have the potential to include accessory canals in their configuration. (They form when tissues that play a role in root formation become entrapped during the calcification process.) And their existence is quite commonplace.

An evaluation of 493 extracted teeth by Ricucci determined that 75% of them had accessory/lateral canals.

The question then arises, if they are so common, and they are difficult to clean and fill, why aren’t they a dominant factor in root canal failure.

▲ Section references – Ricucci

What’s the solution for failed cases involving untreated lateral or accessory canals?

Once the untreated canal(s) has been identified, it may be possible to successfully retreat the case conventionally. In some cases, surgical retreatment Explained. (a process where the problematic portion of the root is trimmed off) may be needed.

Some cracked teeth may not be treatable.

3) Cracked roots.

As such, the tooth’s outlook is one of case failure. Short of amputating the affected root (if this option exists at all), case retreatment/further treatment is generally not possible.

Difficulties.

There are several issues that can make dealing with cracks especially difficult:

• When performing a tooth’s endodontic therapy, a dentist may be unaware that a crack exists (they can be very difficult to identify), or underestimate the extent of the ones they see. Either way, the tooth’s problems won’t be resolved by its treatment.
• It may be that the crack that has caused the tooth’s failure formed after it received its endodontic treatment.

  This might be because an inadequate “final” restoration was chosen for the tooth (such as one that didn’t provide a strengthening effect), or its permanent restoration was not placed soon enough (the damage occurred while the tooth’s provisional restoration was still in place).

• It’s also possible for what seemed to be a minor, manageable crack at the time of the tooth’s treatment to progress.

  Beyond cases like those just mentioned, this scenario is even possible with seemingly appropriately restored teeth (e.g. crown placement), if the chewing or clenching forces they’re subjected to are intense enough.

▲ Section references – Torabinejad

What’s the solution for failed cases involving cracked roots?

Tooth extraction is often the only option. With multi-rooted teeth, it may be possible to salvage the tooth by cutting off the problematic root (root amputation).

4) Inadequate root canal seal.

The integrity of the seal created inside a tooth during its root canal procedure is an important factor in treatment success.

• It serves as a barrier to the seepage of bacteria and other contaminants into or out of the tooth.

  (This is important in preventing recolonization of the tooth’s root canal system by microorganisms. Also, any leakage from the tooth would serve as a source of constant irritation to the tissues that surround its root.)

• The filling materials physically occupy the space of the root canal system. (When the full extent of a root canal is not filled in and sealed, tooth space remains that can harbor bacteria.)

It may be that the tooth’s intact seal has deteriorated over time. Or that the placement of its filling materials resulted in shortcomings initially (due to underfilling, the presence of voids, etc…). And while there can be technical reasons why underfilling a canal has occurred, deficient fills can generally be expected to correlate with the level of clinician expertise.

▲ Section references – Iqbal

What’s the solution for cases that have failed because they have lost their endodontic seal?

Conventional retreatment is often successful with these types of cases.

5) Overextension of the tooth’s filling material.

Studies have shown that in cases where the materials used to fill in and seal a tooth’s root canal system extend out beyond its root’s tip (overfilling, overextension), the likelihood of endodontic failure is increased. (Tabassum)

• In an evaluation of 337 failed root canal cases, Hoen determined that overfills played a role in 3% of them.
• Iqbal’s evaluation of 90 failures found that overfilled canals played a role in 10% of cases.

The cause.

The basic problem involved with this issue is one of bioincompatibility. Due to the presence of the materials, a foreign body/inflammation response may be triggered in the tissues surrounding the root’s tip.

This response doesn’t occur in all cases. And in fact, it’s possible for normal and complete postoperative healing to occur in the presence of an overfill.

▲ Section references – Tabassum, Iqbal, Hoen

What’s the solution for cases that have failed related to the overextension of root canal filling materials?

Successful conventional retreatment of the case may be possible. In situations where the gross overextension of materials can’t be retrieved, surgical retreatment may be necessary.

6) Inadequate coronal seal.

A defective or inadequate final restoration (the “permanent” one placed after the completion of a tooth’s endodontic treatment) can allow bacteria and other contaminants to reenter the inside of the tooth. (The x-ray graphic above shows an example of this situation.)

This phenomenon is referred to as “coronal leakage” and it is a major cause of root canal failure. For more information, use this link: What is Coronal Leakage? Causes. | Prevention.

Even the highest quality root canal work can’t survive (resist reinfection of the root canal space) if its tooth’s permanent restoration doesn’t provide an adequate seal. The study by Hoen cited above reported that 13% of failed cases involved complications with coronal leakage.

What’s the solution for cases that have failed because they have lost their coronal seal?

Since the tooth’s root canal system is now recontaminated, case retreatment (usually conventional) is needed.

7) Other types of technical shortcomings with the tooth’s procedure.

Beyond the clinician-associated issues mentioned above, other technical/procedural errors and complications can arise and have a detrimental effect on the treatment outcome of a tooth. This might include:

• Failure to treat the entire length of the tooth’s canals. – An important aspect of the root canal process is establishing the length of each of a tooth’s individual root canals How this is done., and then treating this entire distance.

  Falling short can result in leaving debris and contaminates behind that can be a constant source of irritation to the tissues that surround the tooth’s root, thus resulting in treatment failure.

• Problems caused when shaping the canals – A dentist’s use of root canal files may inadvertently create an internal configuration that deviates from normal canal anatomy. (Applicable terms include: canal ledging, apical transportation or zipping.)

  This kind of alteration can make the process of cleaning and/or sealing the affected canal(s) difficult or impossible.

• Perforations – When using drills or files, a dentist may inadvertently create a hole Perforation. that penetrates the side of the tooth’s root.

  Depending on the size and location of the perforation, some can be repaired successfully. However, in some instances the presence of the opening may make it difficult or impossible for the dentist to slide their tools and sealing materials beyond that point, thus inhibiting complete (proper) canal cleaning and sealing.

• Broken instruments – The files Details. | Pictures. that a dentist uses to clean a tooth’s root canal system sometimes break. It’s generally attributed to manufacturing defects, fatigue from usage, or with rotary instruments, creating a situation that places too much torque on the file.

  As a worst-case scenario, the broken piece may be lodged inside the tooth and cannot be retrieved. If so, while leaving the fragment inside the tooth is never the dentist’s first choice, the point during the treatment process when the incident occurred may be a mitigating factor.

  If the file separation has occurred after the canal’s cleaning process has already been completed, then possibly the canal can still be adequately sealed even with the fragment present. If the incident occurred during the cleaning process and inhibits its completion, the prognosis for the tooth’s treatment is much less favorable.

Statistics.

The study of 90 endodontic failures by Iqbal cited above determined that about 6% of the cases could be attributed to problems associated with perforations, and 7% broken instruments.

What’s the solution for these types of failed cases?

If the dentist thinks that they can overcome or correct the previous difficulty, then endodontic retreatment is indicated. If not, the tooth will need to be extracted. Why?

8) Lack of clinician expertise.

Research suggests that treatment performed by endodontists (root canal specialists) tends to have a higher success rate Study findings. than that provided by general dentists.

For example, the study by Iqbal cited above that evaluated failed cases determined that roughly 80% of them had been attempted by general dentists. (See additional statistics below.)

Why referral to a specialist may make sense.

Any dentist can tell you, providing endodontic therapy for some teeth will prove to be amazingly straightforward, and then for others surprisingly involved. Unfortunately, a tooth’s level of difficulty can’t always be predicted.

For this reason, some dentists may feel they can boost their patient’s chances of success by referring suspect cases on to an endodontist before complications arise. Per the data found on our failed root canal page Statistics., this might be an especially prudent choice for certain types of teeth (like molars).

Additionally, our page “Endodontist vs. General Dentists- Which makes the best choice, and when?” How to choose. discusses this issue in detail.

A periapical radiolucent lesion.

Teeth having pre-op radiolucencies may be more likely to fail.

9) Preoperative tooth pathology.

The Iqbal study cited above suggests that the success rate of teeth having this initial condition (vs. those that don’t) may be lower, on the order of 20%.

What’s the solution for these types of failed cases?

In cases where the dentist’s evaluation of the quality of the tooth’s previously performed root canal treatment seems acceptable, the solution for this situation may be a minor surgical procedure referred to as an “apicoectomy with retrograde filling.”

During this procedure, the tip of the tooth’s root is trimmed away (an apicoectomy is performed). The exposed root canal opening on this trimmed surface is then sealed by placing a filling (a “retrograde” filling).

10) Contributing / Complicating factors.

It’s possible that your tooth’s root canal treatment has been successful but the tooth itself has problems due to other factors.

a) The tooth has broken or fractured.

Teeth that have undergone root canal treatment are typically considered less structurally sound than they were originally, possibly substantially so. And for this reason, they often require the placement of a dental crown for strengthening and protection. How it does that.

If an endodontically treated tooth does break, it’s not always a big problem.

• Assuming that the damage is confined to just the crown portion of the tooth (not its root), it’s quite likely that the tooth can be rebuilt. (In some instances, the repair may require the placement of a dental post and core. When is this needed?)
• If the crack extends into the tooth’s root, an evaluation will need to be made to determine if the likelihood of making a successful repair seems possible (see above).

b) The tooth has extensive decay or gum disease.

Just like any other tooth, teeth that have had root canal treatment are at risk for the formation of tooth decay and gum disease. And if allowed to advance, either of these conditions can ultimately lead to the tooth’s loss.

What’s the solution for these types of failed cases?

If the tooth’s condition can be corrected or overcome, then endodontic retreatment is indicated. If not, then the tooth will need to be extracted.