By Rebekah Lucier Pryles, DMD;    and Brooke Blicher, DMD

Vital Pulp Therapy in Mature Permanent Teeth: A Paradigm Shift. Image courtesy of destina/stock.adobe.com. 


The spectrum of procedures from pulp capping to pulpotomies, known as vital pulp therapy, has been a mainstay treatment modality to manage deep caries in the primary dentition and immature permanent dentition. In the latter, vital pulp therapy is employed to facilitate root development, otherwise known as apexogenesis. Traditional materials for vital pulp therapy included formocresol and calcium hydroxide. Although treatment with these materials was associated with reasonable success in these primary and immature permanent teeth, success was less predictable in mature permanent teeth.

This difference in prognosis stems from the anatomic differences in pulp tissue that occur secondary to root maturation. The robust vasculature and stem cell populations found in immature roots allow them to regenerate even under unfavorable conditions, whereas mature permanent teeth possess more limited mechanisms to survive pulpal irritants.

Mature permanent teeth with carious pulp exposures were given a diagnosis of “asymptomatic irreversible pulpitis” because that carious pulp exposure was thought to induce terminal pulpal inflammation.

 The historic treatment recommendation for teeth with asymptomatic irreversible pulpitis was nonsurgical root canal therapy, with its increased risk of complications including root fracture as well as increased restorative needs over the lifetime of the tooth.

The introduction of bioceramics, a class of calcium silicate-based materials with distinct biocompatibility advantages, has shifted this paradigm and calls into question the diagnosis of asymptomatic irreversible pulpitis. According to the new position statement from the American Association of Endodontists, vital pulp therapy with bioceramics now represents the treatment of choice for certain carious exposures in mature permanent teeth.

 Large-scale studies showcase the ability of bioceramics to repair carious exposures and reverse early-stage pulpal irritation for these teeth. Furthermore, success rates for vital pulp therapy with bioceramic materials are comparable to those for nonsurgical root canal therapy.

Preoperative images (A and B) depicting deep caries in tooth No. 2 without associated symptoms or clinical testing abnormalities allowed for conservative direct pulp capping to manage the carious exposure (C).

Bioceramic materials aren’t exclusive to vital pulp therapy. They are mainstay repair materials for root canal perforations and have been widely utilized as retrofilling materials during apical microsurgery. This is in large part due to their favorable interactions with cells from the periodontal ligament and alveolar bone, promoting bone regeneration in a way that other dental materials are incapable of doing.

 Further research on their interaction with pulp tissues has highlighted their unique potential in vital pulp therapy. Bioceramics are nonirritating to pulpal tissues and provide an excellent seal against microbial contaminants.

 Their placement adjacent to the pulp tissue promotes pulp survival. Their mechanism of action is similar to calcium hydroxide in contact with the pulp. They create a localized area of tissue necrosis, followed by calcific bridging. Their enhanced coronal seal is thought responsible for their markedly higher success rates as direct pulp-capping agents.

The improved outcomes in vital pulp therapy are attributable to bioceramics, although several other treatment-related factors have a demonstrable positive impact on outcomes.

 These include careful disinfection, minimization of additional pulpal irritation, and magnification. Careful disinfection includes the use of dental dam isolation, clean water supplies, and irrigation of the pulp exposure with sodium hypochlorite. Avoiding microbial contaminants is necessary because microbes are a known pulpal irritant. Clinicians must also be mindful of minimizing additional pulpal irritation, particularly by employing water coolant spray when removing caries adjacent to the pulp. High temperatures are known to produce pulpal necrosis. Lastly, magnification is known to enhance outcomes. Magnification, via the surgical operating microscope or loupes, is essential for accurate visualization of pulp tissues as well as complete caries excavation.

Deep caries associated with signs and symptoms of reversible pulpitis in tooth No. 29 (A) resulted in hyperemic pulp tissue extending throughout the pulp chamber, warranting bioceramic pulpotomy to achieve hemostasis (B).

The recommendation to treat mature permanent teeth with carious pulp exposures with vital pulp therapy techniques represents a paradigm shift in endodontics.

Careful diagnosis and case selection are foundational to the appropriate provision of vital pulp therapy. In mature permanent teeth with carious pulp exposures, the health of the pulp tissue must be ascertained prior to selecting vital pulp therapy as the treatment of choice. A confirmed response to pulp sensitivity testing must be obtained, and cold testing is considered the most reliable means of testing.

 Baseline testing of control teeth can indicate the reliability of testing in the individual patient. Although some patients may not experience a cold response, including older patients with dentinal tubules or pulp chambers that have undergone calcification, many individuals who warrant consideration for vital pulp therapy will have viable and robust pulps that will respond to this test under normal circumstances.

 That said, when in doubt, electric pulp testing can serve as a viable sensitivity test alternative. Patients should, however, be made aware of limitations in pulp sensitivity testing potentially creating false negatives.

Pulp sensitivity tests are used to establish the pulpal diagnosis.

 Teeth with a diagnosis of normal pulp, indicated by a normal response to cold, or those with a diagnosis of reversible pulpitis, a hypersensitive but not lingering response to cold, can in most cases be appropriately treated with vital pulp therapy. Teeth with a diagnosis of irreversible pulpitis, namely a hypersensitive and lingering response to cold, may also be treated by vital pulp therapy in certain circumstances. Data support the application of bioceramic-based vital pulp therapy ranging from direct pulp caps to pulpotomy, even in exposed pulps with evidence of pulpitis.

 These data have many discussing potential changes to the diagnostic terminology of asymptomatic irreversible pulpitis. Wolters et al proposed a new classification system dividing irreversible pulpitis into initial, mild, moderate, and severe iterations to better classify treatability using minimally invasive methodologies.

Most agree that teeth with evidence of progressive irreversible pulpitis, in which degeneration of the pulp is imminent, should be treated more aggressively given the high likelihood of microbial contaminants and progression to apical periodontitis. Therefore, spontaneous or unprovoked pain and percussion tenderness indicative of apical periodontitis are considered contraindications for vital pulp therapy and indications for pulpectomy instead.

 Teeth with a diagnosis of pulp necrosis are also not candidates for vital pulp therapy.

Although vital pulp therapy was planned for tooth No. 31 during the consultation visit—at which the patient had no symptoms or abnormalities on clinical testing (A) —discomfort and cold sensitivity on the day of treatment were consistent with hyperemic pulp tissue extending into the roots. The diagnosis of symptomatic irreversible pulpitis instead warranted nonsurgical root canal therapy to manage (B)

Treatment plans for vital pulp therapy fall on a spectrum, depending on the extent of inflammation visualized during care. Updated protocols for the use of bioceramics should still be applied to primary and immature permanent teeth. However, the novel applications discussed include certain mature permanent teeth with carious or traumatic exposures. Direct pulp capping with bioceramics should now be considered primary treatment for asymptomatic carious exposures, with few exceptions. Partial or full pulpotomies may be required when there is evidence of additional inflammation.

Ultimately, the choice to pursue vital pulp therapy versus nonsurgical endodontics involves a thoughtful and comprehensive approach to treatment planning. In many cases, the benefits of minimally invasive care offered by vital pulp therapy permit more conservative restorative care. This reduces risks of postoperative complications secondary to tooth structure removal, including fracture. More conservative restorative care also is associated with a reduced cost.

Pursuing vital pulp therapy does not obviate the future development in some patients of pulpal or periapical disease warranting endodontic interventions. In certain cases, this risk of future treatment needs may be intolerable, such as when major restorative procedures are indicated that could be compromised by a future endodontic access. For example, a tooth that is planned to serve as a fixed partial denture abutment, in which the inherent risk of future endodontic involvement is high and access through the occlusal surface risks the integrity of the new restoration, might be considered for nonsurgical root canal therapy over vital pulp therapy even in the absence of symptoms.

 Similarly, patients with certain medical comorbidities, such as patients with poorly controlled diabetes, may have a higher risk of progressive apical periodontitis and reduced success with treatment, so a thoughtful discussion may warrant more aggressive endodontic interventions in an earlier stage for the individual.

Comprehensive informed consent should precede the delivery of all dental care, including vital pulp therapy, and both verbal and written consent is advisable. Patients must be informed about the potential for treatment progression depending on clinical findings. This means that during treatment, patients should be aware that signs of pulpal inflammation may warrant progression from planned direct pulp capping to partial or full pulpotomy or even pulpectomy.

If pulp necrosis is indeed found upon caries excavation, the provider must have already obtained informed consent for pulpectomy. For example, although many teeth undergoing vital pulp therapy may be definitively restored using direct composites, indirect restorations involving full cuspal coverage are warranted when pulpal disease necessitates pulpectomy on a posterior tooth.

 Postoperatively, patients should understand that signs or symptoms of pulpal disease may progress and therefore may require greater levels of endodontic intervention. Follow-up and awareness of the potential downstream need for nonsurgical root canal therapy should be a part of the informed consent process.

Following consent, the patient should be comfortably anesthetized. Adequate anesthesia should be confirmed by a negative cold test on the tooth to be treated. Dental dam isolation must be applied, and clinicians must confirm the absence of saliva contamination or leakage.

 Although single tooth isolation is traditionally employed for endodontics, involvement of interproximal surfaces in many vital pulp therapy cases necessitates multiple tooth or quadrant isolation. Disinfection of the coronal surface can be considered to eliminate superficial contaminants prior to caries removal. This can be accomplished with sodium hypochlorite or hydrogen peroxide rinses.

Caries should be excavated with a high-speed handpiece with sufficient water coolant spray to minimize overheating of the pulp, with direct effects to reduce caries vitality in the present and future.

 Although this is the standard set forth by Occupational Safety and Health Administration, it bears repeating that dental water lines must be free of bacteria because minimizing contamination is essential for vital pulp therapy. Even though protocols for indirect pulp capping sometimes advise leaving caries to avoid pulp exposure, the use of bioceramics warrants complete caries excavation to eliminate sources of microbial recontamination.

 Complete caries excavation should be confirmed visually with magnification, tactically by contact with sound, as well as with the use of caries detecting agents or laser fluorescence.

Caries removal in these cases will result in pulp exposure. Hemostasis of a vital, bleeding pulp may be achieved with the use of sodium hypochlorite as a rinsing agent or with pressure applied via a soaked cotton pellet.

 Sodium hypochlorite possesses superior efficacy and safety versus other hemostatic agents, including epinephrine or ferric sulfate.

 Clinicians should, however, be prepared for cases in which hemostasis is not immediately achievable.

 Continued bleeding indicates more extensive inflammation with an expected lower success of vital pulp therapy due to persistent postoperative inflammation. Furthermore, bleeding is associated with poorer sealing of the bioceramic materials, wherein microbial recontamination will impede healing. In these cases, additional pulp tissue should be removed with the high-speed handpiece under water coolant or a sterile spoon excavator.

 The partial or full pulpotomy should be completed up to the level so that hemostasis can be readily achieved. If hemostasis remains unachievable, pulpectomy should be initiated.

Once hemostasis is achieved, exposed pulp tissue should be dried and restored with a 1- to 2-mm thickness of bioceramic material. Several bioceramic options are available in the dental marketplace. It behooves any clinician to understand the benefits of each before choosing which to utilize. Early iterations of mineral trioxide aggregate (MTA) were associated with significant dental staining. Their use should therefore be limited, especially in esthetic zones in favor of nonstaining alternatives.

Additionally, many practitioners find MTA challenging to handle and prefer newer putty-based bioceramic materials. Of note, resin-containing calcium silicate materials should not be utilized for vital pulp therapy procedures given the cytotoxic effects of resin-based materials on the dental pulp.

 Bioceramics are more costly than prior materials used in vital pulp therapy. However, cost-effectiveness analysis finds that they, in fact, represent more economical options given their higher success and reduced lifetime need for retreatment.

Following placement of the bioceramic plug, the tooth may be immediately and definitively restored.

The advent of bioceramic materials has ushered in a paradigm shift in endodontics. Nonsurgical root canal therapy is no longer the standard recommendation for an asymptomatic or mildly symptomatic carious pulp exposure. Ultimately, clinicians should be prepared for the potential need for vital pulp therapy during any restorative procedure in which the possibility of pulp exposure exists. The pulp tissues of mature permanent teeth are exquisitely sensitive to pulpal irritants in the form of restorative materials, especially resin-based materials; thus, their use should be absolutely avoided when pulpal exposures occur. The routine use of dental dam isolation during restorative dentistry, especially when work approximates the pulp, and ready availability of simple materials including sodium hypochlorite and bioceramic cements can have a great impact on long-term pulpal health. 

Kundzini R, Stangvaltaite L, Eriksen HM, Kerosuo E. Capping carious exposures in adults: a randomized controlled trial investigating mineral trioxide aggregate versus calcium hydroxide. 

2017;50(10):924-932. doi:10.1111/iej.12719

Langeland K. Management of the inflamed pulp associated with deep carious lesion. 

 1981;7(4):169-181. doi:10.1016/S0099-2399(81)80231-2

Mjör IA. Pulp-dentin biology in restorative dentistry. part 7: the exposed pulp. 

Tronstad L, Mjör IA. Capping of the inflamed pulp. 

. 1972;34(3):477-485. doi:10.1016/0030-4220(72)90327-1

Kling M, Cvek M, Mejare I. Rate and predictability of pulp revascularization in therapeutically reimplanted permanent incisors. 

1986;2(3):83-89. doi:10.1111/j.1600-9657.1986.tb00132.x

Glossary of endodontic terms. American Association of Endodontists. May 7, 2020. Accessed August 3, 2022. https://www.aae.org/specialty/clinical-resources/glossary-endodontic-terms/

Awawdeh L, Hemaidat K, Al-Omari W. Higher maximal occlusal bite force in endodontically treated teeth versus vital contralateral counterparts. 

 2017;43(6):871-875. doi:10.1016/j.joen.2016.12.028

Caplan DJ, Cai J, Yin G, White BA. Root canal filled versus non-root canal filled teeth: a retrospective comparison of survival times. 

 2005;65(2):90-96. doi:10.1111/j.1752-7325.2005.tb02792.x

Fuss Z, Lustig J, Katz A, Tamse A. An evaluation of endodontically treated vertical root fractured teeth: impact of operative procedures. 

 2001;27(1):46-48. doi:10.1097/00004770-200101000-00017

Clinical guidelines position statements. American Association of Endodontists. March 14, 2022. Accessed August 3, 2022. https://www.aae.org/specialty/clinical-resources/guidelines-position-statements/

Bjørndal L, Simon S, Tomson PL, Duncan HF. Management of deep caries and the exposed pulp. 

 2019;52(7):949-973. doi:10.1111/iej.13128

Li Z, Cao L, Fan M, Xu Q. Direct pulp capping with calcium hydroxide or mineral trioxide aggregate: a meta-analysis. 

 2015;41(9):1412-1417. doi:10.1016/j.joen.2015.04.012

Asgary S, Eghbal MJ. Treatment outcomes of pulpotomy in permanent molars with irreversible pulpitis using biomaterials: a multi-center randomized controlled trial. 

2013;71(1):130-136. doi:10.3109/00016357.2011.654251

Asgary S, Eghbal MJ, Bagheban AA. Long-term outcomes of pulpotomy in permanent teeth with irreversible pulpitis: a multi-center randomized controlled trial. 

Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review--part II: leakage and biocompatibility investigations. 

2010;36(2):190-202. doi:10.1016/j.joen.2009.09.010

Hilton TJ. Keys to clinical success with pulp capping: a review of the literature. 

Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review--part I: chemical, physical, and antibacterial properties. 

 2010;36(1):16-27.doi:10.1016/j.joen.2009.09.006

Mainkar A, Kim SG. Diagnostic accuracy of 5 dental pulp tests: a systematic review and meta-analysis. 

. 2018;44(5):694-702. doi:10.1016/j.joen.2018.01.021

Ketterl W. Age-induced changes in the teeth and their attachment apparatus. 

Wolters WJ, Duncan HF, Tomson PL, et al. Minimally invasive endodontics: a new diagnostic system for assessing pulpitis and subsequent treatment needs. 

 2017;50(9):825-829. doi:10.1111/iej.12793

Hargreaves KM, Berman LH, Rotstein I, Cohen S. 

Cheung GS, Lai SC, Ng RP. Fate of vital pulps beneath a metal-ceramic crown or a bridge retainer. 

2005;38(8):521-530.doi:10.1111/j.1365-2591.2005.00982.x

Aminoshariae A, Kulild JC, Mickel A, Fouad AF. Association between systemic diseases and endodontic outcome: a systematic review. 

. 2017;43(4):514-519. doi:10.1016/j.joen.2016.11.008

Marotta PS, Fontes TV, Armada L, Lima KC, Rôças IN, Siqueira JF Jr. Type 2 diabetes mellitus and the prevalence of apical periodontitis and endodontic treatment in an adult Brazilian population. 

2012;38(3):297-300. doi:10.1016/j.joen.2011.11.001

Sorensen JA, Martinoff JT. Intracoronal reinforcement and coronal coverage: a study of endodontically treated teeth. 

 1984;51(6):780-784. doi:10.1016/0022-3913(84)90376-7

Suksaphar W, Banomyong D, Jirathanyanatt T, Ngoenwiwatkul Y. Survival rates from fracture of endodontically treated premolars restored with full-coverage crowns or direct resin composite restorations: a retrospective study. 

 2018;44(2):233-238. doi:10.1016/j.joen.2017.09.013

Beatty H, Svec T. Quantifying coronal tooth discoloration caused by Biodentine and EndoSequence root repair material. 

 2015;41(12):2036-2039. doi:10.1016/j.joen.2015.08.032

Vallés M, Roig M, Duran-Sindreu F, Martínez S, Mercadé M. Color stability of teeth restored with Biodentine: a 6-month in vitro study. 

. 2015;41(7):1157-1160. doi:10.1016/j.joen.2015.03.014

Schwendicke F, Brouwer F, Stolpe M. Calcium hydroxide versus mineral trioxide aggregate for direct pulp capping: a cost-effectiveness analysis. 

 2015;41(12):1969-1974. doi:10.1016/j.joen.2015.08.019

Articles

It’s important to understand this treatment modality and its challenges. 

Vital Pulp Therapy  in Mature Permanent Teeth: A Paradigm Shift

This article focuses on outcomes as a means to aid practitioners in treatment planning for endodontics procedures; specifically, the ways in which clinical prognostic factors can affect outcomes for our “big 3”—nonsurgical root canal therapy, nonsurgical retreatment, and apical microsurgery endodontic procedures.

An understanding of outcomes is fundamental to diagnosis and treatment planning in endodontics. Although some patients are often initially concerned about whether proposed treatment options are going to hurt, many are far more focused on the predictability and reliability of endodontic treatment. Treating clinicians must not only evaluate risk based on clinical and radiographic findings but also communicate both the risks and benefits of all treatment options as part of informed consent. Much of the conversation about risk centers around outcomes data and the factors that affect those outcomes.

Though extraction, informed refusal, and vital pulp therapy may be alternative options, treatment plans for endodontic pathology frequently include the “big 3” procedures within the specialty’s scope: nonsurgical root canal therapy, nonsurgical retreatment, and apical microsurgery.

Outcomes studies may report success or survival. Survival is the broader representation and refers to the absolute presence or absence of the tooth in the mouth, whether or not there are signs or symptoms of disease. In the prognosis literature, survival is synonymous with “clinically functional.” Success takes that cohort of survived teeth and excludes any with symptoms or radiographic pathology.

 Failure in both includes teeth that have undergone extraction following endodontic treatment.

As far as the numbers are concerned, endodontic procedures are immensely predictable. For nonsurgical root canal therapy, success rates approach 90%; for retreatment, 82%; and for apical microsurgery, 90%.

 That said, these reported success rates do not represent absolute numbers. Clinicians should recognize that certain preoperative and treatment-related factors can significantly influence success in endodontics, both positively and negatively.

They must consider these factors, and discuss them with patients, to ensure thoroughness in informed consent. In this article, we focus on outcomes as a means to aid practitioners in treatment planning for endodontics procedures, specifically on how clinical prognostic factors can affect outcomes for the big 3 endodontic procedures. Applying these principles will allow for discussions on expected success and survival tailored to the individual patient.


Patients may present with certain preoperative factors that can directly affect outcomes. Though outside of clinician control, these factors must be considered with respect to treatment planning. The 3 associated with outcome alterations include apical periodontitis, periodontal status, and treatment history. Treatment-related factors go beyond the delivery of competent care. Successful nonsurgical treatment requires the locating, cleaning, shaping, and obturation of the root canal space, whereas surgical treatment requires the resection of the root apex, retropreparation into the root canal space, and adequate restoration of the apex. The treatment-related factors we discuss here represent those items within clinician control beyond the delivery of adequate care and include restorative care and the utilization of modern technologies. The factors are listed in

 Several factors can impact the prognosis following endodontic treatment, including preoperative factors and treatment-related factors. Preoperative factors represent those factors completely outside clinician control, whereas treatment-related factors go beyond the delivery of adequate care.


A comprehensive endodontic assessment requires a clinical and radiographic examination to formulate both a pulpal and periapical diagnosis. Apical periodontitis, particularly asymptomatic apical periodontitis, represents one of the many periapical diagnoses, and results from the egress of bacteria from a necrotic pulp or previously treated root canal space into the apical periodontium, leading to bony destruction.

 Essentially, the interplay between bacteria and host immune responses causes bony destruction. The bacterial component can present a significant treatment challenge.

The presence of apical periodontitis, and its relative size, are associated with a reduction in success rates following both nonsurgical root canal therapy and nonsurgical retreatment.

 This does not mean that patients with a diagnosis of apical periodontitis should be excluded from endodontic treatment. Rather, they should be informed of the factors beyond clinician control that may negatively influence treatment outcomes. The presence of apical periodontitis warrants mention so that patients can understand its interplay with respect to outcomes, particularly if other comorbidities exist. Larger apical radiolucencies are associated with a greater bioburden and more robust immune response, and consequently more effort is needed on the part of the immune system in order to heal. For this reason, patients should be encouraged to pursue endodontic care when lesions are small, rather than delaying until they enlarge. 

 depicts a case where apical periodontitis was successfully treated.

 Though cases presenting with preoperative apical periodontitis may have a reduced prognosis, complete apical healing is possible following endodontics. This patient presented with preoperative asymptomatic apical periodontitis on tooth #30 (A). Endodontic treatment was completed on the tooth (B), and at a 5-year follow-up (C) complete lesion healing was noted.


As part of the comprehensive endodontic assessment, a periodontal exam should be performed on endodontic patients, specifically measuring for probing depths and mobility. Marginal periodontitis, like its apical cousin, represents a bony response to bacterial challenges.

 For all the big 3 endodontic procedures, comorbid periodontal disease has the potential to negatively affect treatment outcomes.

 The presence of preoperative periodontal disease increases the odds of tooth loss following nonsurgical root canal therapy more than 5-fold.

 Periodontally involved teeth are similarly lost at higher rates following apical surgery.

 As with apical periodontitis, the presence of periodontal disease does not preclude endodontic therapy as a treatment option for patients; rather, patients must be informed of its potential negative impact on expected outcomes. More severe periodontal disease is associated with a greater likelihood of tooth loss.

 This represents a rationale for early treatment of periodontal disease to prevent progression.


Teeth with a history of endodontic care warrant careful radiographic examination when clinicians are considering nonsurgical and surgical endodontic retreatment. Clinicians must take into account the impact the quality of prior treatment may have on outcomes. Outcomes are more predictable for teeth in which the quality of the initial treatment was poor.

 Poor quality may refer to untreated anatomy, ledged canals, and short fills, among other deficiencies. Clinicians should inform patients that when defined problems are found that can be fixed, outcomes are significantly improved. Quality should also include an assessment of complications from the prior procedure. Outcomes are less predictable for teeth with preexisting complications, including perforations, as seen in 

 Teeth with preexisting perforations have a poor expected prognosis for nonsurgical or surgical retreatment. This patient presented with severe palpation tenderness and an associated 7-mm periodontal probing depth on the facial aspect of tooth #8. Although the periapical radiograph (A) appeared largely normal, the sagittal view on cone beam computed tomography (CBCT; B) revealed restorative material extruded through a perforation. Extraction was recommended.

Treatment history becomes particularly important with respect to surgical care. When performing surgery on previously endodontically treated teeth, clinicians can expect the outcomes to be far more predictable when the initial treatment quality was poor, particularly with respect to the length of the initial endodontic fill.

 Another historic factor of importance is the technology associated with prior apical surgery. Historically, resurgery involving older surgical techniques using bur retropreparations and amalgam, intermediate restorative material (IRM), or SuperEBA (ethoxy benzoic acid) retrofills was associated with a poor prognosis.

 With more modern surgical techniques, a surgical history may be less relevant in terms of prognosis. Now resurgery is as predictable as initial treatment.


The clinician will assess the restorative history and existing coronal structure of any tooth being considered for endodontic treatment. Endodontic care does not exist in a vacuum. Outcomes are intimately tied to restorative care, and consideration with respect to restorability should be given both pre- and postoperatively. Restorability—namely the presence of adequate coronal structure—is perhaps the greatest preoperative consideration in deciding to pursue root canal therapy. Other factors excluded, the ability to maintain a ferrule and cavity wall length has a direct impact on outcomes.

 The same is true for nonsurgical retreatment. Teeth retaining less than 30% of their initial coronal structural volume have a higher proportion of unfavorable outcomes.

Before delivering endodontic care, clinicians should make patients aware of the importance of definitive restorative care. Teeth that are not definitively restored following endodontic treatment are more than 5 times likelier to undergo extraction.

 The type, quality, and timing of restoration selected all matter with respect to the prognosis for endodontically treated teeth. Outcomes in the posterior dentition are more predictable, with indirect restorations providing cuspal coverage as opposed to direct composites or amalgams, whereas anterior teeth may be successful when restored directly.

The goals of any coronal restoration, direct or indirect, are to maintain functionality of the tooth, protect the remaining tooth structure, and seal against coronal leakage. Therefore marginal integrity is paramount to positive outcomes following treatment.

Ideally, definitive restorative treatment should be completed immediately following root canal therapy due to the risks of coronal leakage with temporary restorations and fracture prior to cuspal coverage in the posterior dentition. In one study, patients who delayed definitive restorative care more than 4 months following endodontic treatment experienced a 3-fold higher risk of extraction than those with teeth restored in a timelier manner.

 Ultimately, timely delivery of restorative care can prevent premature loss of endodontically treated teeth.

The PreXion3D Explorer PRO CBCT Scanner is designed to combine precise 3D imaging, large image detail, diagnostics, and digital planning.


Although many of the preoperative factors we have previously discussed are largely outside clinician control, treatment-related factors, particularly the application of modern dental technologies, give clinicians a direct opportunity to improve patient outcomes. One of the simplest technologies available to practitioners is the dental dam. The bacterial origins of apical periodontitis are directly inhibited by dental dam isolation, which serves to minimize contamination of the root canal system by indigenous oral bacteria. As a result, dental dam isolation is directly associated with improved survival in both initial root canal therapy and nonsurgical retreatment.

 The dental dam offers other benefits, such as aiding in visualization by providing a clean operating field and preventing the ingestion or aspiration of dental materials, irrigant solutions, and instruments; thus, its use is considered the standard of care in nonsurgical endodontics.

Surgical microscopes like the PromiseVision 3D from Seiler Instruments provide unprecedented depth of field and field of view.

Magnification—specifically the use of a surgical operating microscope with the added benefit of illumination—represents another means to improve outcomes in both nonsurgical and surgical endodontics. In a retrospective, case-control study, outcomes in teeth treated without magnification were poorer than in those treated with magnification, as apical periodontitis was found more frequently in the former group.

 Stated differently, teeth treated without the use of microscopes developed recurrent pathology (ie, failed) more frequently than teeth treated using high-power magnification and illumination. Intuitively, this makes sense. Successful endodontic therapy is predicated upon finding, cleaning, and filling the entirety of the root canal space. Magnification enhances our ability to find anatomy and therefore our ability to clean it completely. The use of this technology is also associated with improved outcomes for retreatment and surgical endodontics.

CBCT imaging represents a significant development in dental radiography. In 2 dimensions, structural overlap can significantly impede clinicians’ ability to discern the presence, and sometimes absence, of pathology. CBCT imaging facilitates the appreciation of the entirety of the root structure, supporting periodontium, and pulp anatomy, which can aid in the diagnosis of endodontic pathologies, even in the earliest stages.

 This patient presented for an evaluation of tooth #4, and the periapical radiograph (A) revealed a resorptive defect on the tooth. Further examination with CBCT noted the palatal resorptive defect on the axial (B) and sagittal (C) sections, as well as additional resorptive defects on tooth #3 that would have gone undetected without 3D imaging.

 This patient presented with biting pain associated with a previously treated tooth #14. The periapical radiograph (A) revealed thin root fillings in the tooth as well as the presence of posts. The axial (B) and coronal (C) CBCT sections revealed evidence of untreated anatomy within the mesiobuccal root of the tooth. Based on an understanding of prognostic factors, retreatment was recommended to address the untreated canal.

CBCT technology is particularly useful in identifying factors that complicate a simple endodontic diagnosis, including resorptive dental defects (

 With proper diagnosis, resorptive dental diseases can be predictably managed; however, their misdiagnosis can easily lead to failure of endodontic treatment.

 Though CBCT images do not often elicit fracture lines themselves, they can detect very localized areas of bone loss pathognomonic to this pathology. In particular, CBCT images are adept at detecting the narrow, angular bony defects adjacent to fractures, midroot lateral radiolucencies, and bony defects found on the buccal or lingual surfaces that are not visualizable on traditional 2-dimensional radiography.

 As the extension of fractures onto root structure is associated with a less predictable prognosis for treatment, early detection of these defects can facilitate more thoughtful treatment planning.

CBCT imaging additionally is critical in the assessment of teeth with a history of endodontic treatment. This imaging modality can inform clinicians of the presence of untreated anatomy, procedural errors, fractures, and other findings that can affect future treatment and the resultant prognosis, as previously discussed. With the aid of CBCT imaging, clinicians can develop thoughtful and informed treatment plans that take into consideration the 3-dimensional radiographic realities. 

 illustrates the use of CBCT in assessing a previously treated tooth.

Ultrasonics represent a significant addition to the endodontic armamentarium. Not only does this technology facilitate more conservative endodontic treatment, its use is associated with significantly improved outcomes. The use of ultrasonics, among other armamentaria, during nonsurgical root canal retreatments notably improves outcomes.

 Its utilization is similarly associated with improved outcomes in surgery. These instruments facilitate more conservative osteotomies and create retropreparations that are deep, parallel, and follow the existing anatomy.

 Taken together, these factors result in more conservative and efficacious treatment that in turn results in improved patient outcomes.

Apical microsurgery, using modern technologies including magnification, ultrasonic root preparation, and bioceramic-based root filling materials, has an excellent prognosis. This patient presented with a large lesion associated with tooth #9 on sagittal CBCT section (A), and both nonsurgical and surgical treatment were recommended and completed (B). At 1-year follow-up, complete reformation of the periodontal ligament was noted on sagittal CBCT section (C).

Bioceramic materials represent the final technological advancement associated with improvements in prognosis. These represent a significant development in endodontics, especially when applied to apical microsurgery (

). Their use as restorative materials in the resected and retroprepared root tip offers a dramatic improvement over previously standard materials, including amalgam, SuperEBA, and IRM, and represents the material of choice for modern surgical endodontics. Bioceramic materials seal exceptionally well, even in the presence of moisture, including blood, and are bioactive. They facilitate the deposition of bone and cementum over the apical seal, both of which facilitate better healing.

These materials have significantly improved outcomes in apical microsurgery compared with older materials.


Outcomes matter to clinicians but even more so to patients. Prognostic data are fundamental to case selection and can help both clinicians and patients make educated choices regarding the optimal strategies for individualized care. By treatment planning with the end in mind, clinicians can fully appreciate the variables that may impact outcomes and more appropriately care for their patients. Clinicians must recognize that some prognosis-related factors represent insurmountable hurdles, whereas others are entirely within clinician control. Thoughtful consideration of all these factors will facilitate the delivery of predictable endodontic care, allowing clinicians to maintain their patients’ teeth and their confidence.

1. de Chevigny C, Dao TT, Basrani BR, et al. Treatment outcome in endodontics: the Toronto study––phase 4: initial treatment. 

. 2008;34(3):258-263. doi:10.1016/j.joen.2007.10.01

2. de Chevigny C, Dao TT, Basrani BR, et al. Treatment outcome in endodontics: the Toronto study––phases 3 and 4: orthograde retreatment. 

 2008;34(2):131-137. doi:10.1016/j.joen.2007.11.00

3. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: a meta-analysis of the literature––part 1: comparison of traditional root-end surgery and endodontic microsurgery. 

4. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats.

. 1965;20:340-349. doi:10.1016/j.joen.2010.08.007

5. Ng YL, Mann V, Gulabivala K. Outcome of secondary root canal treatment: a systematic review of the literature. 

. 2008;41(12):1026-1046. doi:10.1111/j.1365-2591.2008.01484.x

6. Page RC, Schroeder HE. Pathogenesis of inflammatory periodontal disease. summary of current work. Lab Invest. 1976;34(3):235-249.

7. Setzer F, Boyer K, Jeppson J, et al. Long-term prognosis of endodontically treated teeth: a retrospective analysis of preoperative factors in molars. 

. 2011;37(1):21-25. doi:10.1016/j.joen.2010.10.005

8. Chércoles-Ruiz A, Sánchez-Torres A, Gay-Escoda C. Endodontics, endodontic retreatment, and apical surgery versus tooth extraction and implant placement: a systematic review. 

. 2017;43(5):679-686. doi:10.1016/j.joen.2017.01.004

9. Barone C, Dao TT, Basrani BR, Wang N, Friedman S. Treatment outcome in endodontics: the Toronto study ––phases 3, 4, and 5: apical surgery. 

. 2010;36(1):28-35. doi:10.1016/j.joen.2009.09.001

10. Khalighinejad N, Aminoshhariae A, Kulild JC, Wang J, Mickel A. The influence of periodontal status on endodontically treated teeth: 9-year survival analysis. 

. 2017;43(11):1781-1785. doi:10.1016/j.joen.2017.06.022

11. Song M, Shin SJ, Kim E. Outcomes of endodontic micro-resurgery: a prospective clinical study. 

12. Naumann M, Schmitter M, Frankenberger R, Krastl G. “Ferrule comes first. Post is second!” Fake news and alternative facts? a systematic review. 

. 2018;44(2):212-219. doi:10.1016/j.joen.2017.09.020

13. Al-Nuaimi N, Patel S, Austin RS, Mannocci F. A prospective study assessing the effect of coronal tooth structure loss on the outcome of root canal retreatment. 

. 2017;50(12):1143-1157. doi: 10.1111/iej.12760

14. Lazarski MP, Walker 3rd WA, Flores CM, Schindler WG, Hargreaves KM. Epidemiological evaluation of the outcomes of nonsurgical root canal treatment in a large cohort of insured dental patients. 

. 2001;27(12):791-796.doi: 10.1097/00004770-200112000-00021

15. Suksaphar W, Banomyong D, Jirathanyanatt T, Ngoenwiwatkul Y. Survival rates from fracture of endodontically treated premolars restored with full-coverage crowns or direct resin composite restorations: a retrospective study. 

. 2018;44(2):233-238. doi: 10.1016/j.joen.2017.09.013.

16. Ray HA, Trope M. Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. 

. 1995;28(1):12-18. doi: 10.1111/j.1365-2591.1995.tb00150.x.

17. Pratt I, Aminoshariae A, Montagnese TA, Williams KA, Khalighinejad N, Mickel A. Eight-year retrospective study of the critical time lapse between root canal completion and crown placement: its influence on the survival of endodontically treated teeth. 

. 2016;42(11):1598-1603. doi: 10.1016/j.joen.2016.08.006

18. Lin PY, Huang SH, Chang HJ, et al. The effect of rubber dam usage on the survival rate of teeth receiving initial root canal treatment: a nationwide population-based study. 

. 2014;40(11):1733-1737. doi: 10.1016/j.joen.2014.07.007

19. Van Nieuwenhuysen JP, Aouar M, D’Hoore W. Retreatment or radiographic monitoring in endodontics. 

. 1994;27(2):75-81. doi: 10.1111/j.1365-2591.1994.tb00234.x.

20. Khalighinejad N, Aminoshariae A, Kulild JC, Williams KA, Wang J, Mickel A. The effect of the dental operating microscope on the outcome of nonsurgical root canal treatment: a retrospective case-control study. 

. 2017;43(5):728-732. doi: 10.1016/j.joen.2017.01.015

21. 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. 

. 2017;43(2):231-237. doi: 10.1016/j.joen.2016.10.029

22. Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T. Detection of periapical bone defects in human jaws using cone beam computed tomography and intraoral radiography. 

. 2009;42(6):507-515. doi: 10.1111/j.1365-2591.2008.01538.x

23. AAE and AAOMR joint position statement: Use of Cone Beam Computed Tomography In Endodontics 2015 Update.

Prognostic data are fundamental to case selection and can help both clinicians and patients make educated choices regarding the optimal strategies for individualized endodontic care.