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00/0 JOURNALOF ENDODONTICS Copyright 1995 by The American Association of Endodontists

Printed in U.S.A. VOL. 21, NO. 7, JULY 1995

CLINICAL ARTICLES Evaluation of Success and Failure after Endodontic Therapy Using a Glass Ionomer Cement Sealer
Shimon Friedman, DMD, Claus L6st,, Malaekeh Zarrabian, DDS, and Martin Trope, DMD

The purpose of this multicenter, prospective clinical study was to assess the treatment results following endodontic therapy using a glass ionomer cement sealer (Ketac-Endo) and to relate the results to various clinical factors. A total of 486 teeth were treated by three operators, using the "standardized technique" for canal preparation and either single cone or laterally condensed gutta-percha, in one or multiple treatment sessions. Six to 18 months postoperatively, the treatment results were assessed clinically and radiographically, and related to preoperative, intraoperative, and postoperative factors using a X2 analysis with 5% level of significance. Of 378 followed-up teeth, there was a 78.3% success, 15.6% incomplete healing, and 6.1% failure. Statistically, differences in the results were related to the number of canals (p < 0.04), primary treatment and retreatment (p < 0.02), pulp vitality (p < 0.001), periapical lesion (p < 0.001), preoperative symptoms (p < 0.003), operative complications (p < 0.001), and absence of restoration (p < 0.03). It was concluded that these treatment results were compatible with those reported in previous studies, and supported the clinical use of Ketac-Endo as an acceptable endodontic sealer.

Recently, a glass ionomer cement endodontic sealer was introduced (Ketac-Endo, ESPE Gmbh, Seefeld, Germany) (3). It is biocompatible in bone (4), and exhibits modified working and setting times, no shrinkage upon setting, and superior adaptation to the canal walls and radiopacity as compared with Grossman's sealer (3). In addition, because of its dentinal bonding, KetacEndo--filled roots are more resistant to vertical fracture (5). Because of these favorable characteristics, only a single gutta-percha cone is advocated when using Ketac-Endo (3). If required, retreatment is possible with the use of solvent and ultrasonic instrumentation (6). The use of a single gutta-percha cone is also likely to prevent vertical root fractures, which may be associated with gutta-percha condensation techniques (7). The purpose of this multicenter, prospective clinical study was to assess the treatment results after endodontic therapy using Ketac-Endo sealer, and to relate the results to various preoperative, intraoperative, and postoperative clinical factors.

M A T E R I A L AND METHODS A total of 486 teeth in 401 patients were endodontically treated by three operators, in Tiibingen, Germany (C.L.), Philadelphia, PA (M.T.), and Jerusalem, Israel (S.F.). The study material included a variety of clinical conditions, excluding only teeth in which endodontic therapy was contraindicated (Figs. 1 to 4). For each tooth, the following preoperative information was recorded: demographic data, tooth location, number of root canals, previous endodontic treatment, clinical signs and symptoms, responses to percussion and vitality tests, and periapical status. Based on these findings, the preoperative condition was classified as one of the following: vital, nonvital, endodontically treated; with or without periapical lesion; and symptomatic or asymptomatic. All of the teeth were treated using a standardized protocol. Root canals were prepared with hand instruments and 0.5% sodium hypochlorite irrigation. Canals were enlarged according to the standardized technique (3, 8), to 1 mm short of the radiographic apex wherever possible and to a minimum size 35 at the working length. Therapy was completed in single or multiple treatment sessions. In the latter case, a mixture of calcium hydroxide powder and anesthetic solution was placed in the canals, with a Lentulo spiral between appointments. Ketac-Endo was used according to

Numerous studies, representing various endodontic techniques, report that the success rate of endodontic therapy ranges from 48 to 95% (Table 1). One of the prerequisites for successful endodontic therapy is the complete filling of the root canal system, which provides a biological environment for healing of the periradicular tissues (1). The endodontic filling mainly consists of gutta-percha, as the core filling material, and sealer, which is expected to seal the interface between the gutta-percha cones and canal walls. It appears that the choice of sealer may influence the treatment results of endodontic therapy (2).

Vol. 21, No. 7, July 1995

Glass Ionomer Sealer in Endodontic Therapy TABLE 1. Studies in which treatment results of endodontic therapy were assessed
No. of Cases 775* 2019" 2921" 89 432 158 1886 800 4695 870 2459* 647* 660* 566 585 369 1007 1140 140 810" 64* 541 132 849* 1518 Follow-Up (yr) 0.5-10 4-5 0.5 2 1-5 1 0.5-2 1-5 1.5 0.5-7 2-7 3-5 2 ->1 1 1.5 1 1 2-5 1-4 2-12 10-17 0.5-2 8-10 5-13 Recall Rate (%) 76 44 Periapical Lesion (%) 36 19 40 68 23 65 60 27 12 46 77 84 66 37 58 40 81 56 67 73 50 85 46 54 37 76 38 66 34 42 34 ---5 -Some 100 -Retreatments (%) 38 34 Treatment Results (%) Success 83 82 84 86 90 87 90 70 93 88 53 91 48 87 95 89 88 91 85 95 89 80 84 91 84 Uncertain 3 6 --1 ----5 13 4 30 6 ----9 -------


Study Strindberg, 1956 Grahnen and Hansson, 1961 Seltzer et al., 1963 Zeldow and Ingle, 1963 Grossman et al., 1964 Storms, 1969 Harty et al., 1970 Heling and Tamshe, 1970 Selden, 1974 Adenubi and Rule, 1976 Jokinen et al., 1978 Kerekes and Tronstad, 1979 Bergenhoitz et al., 1979 Barbakow et al., 1980 Morse et al., 1983 Oliet, 1983 Swartz et al., 1983 Pekruhn, 1986 Bystr6m et al., 1987 Qrstavik et al., 1987 Akerblom and Hasselgren, 1988 Molven and Halse, 1988 Shah, 1988 Sj6gren et al., 1990 Smith et al., 1993

Failure 14 12 16 14 9 13 10 30 7 7 34 5 22 7 5 11 12 9 6 5 11 20 16 9 16

35 100 29 25 49 100 35 46

4 --43 31 --

* Roots, as opposed to teeth in other studies.

FIG 1. Radiographs demonstrating s u c c e s s following endodontic retreatment of both maxillary central incisors. (A) Preoperative view showing immature apices, overextended root canal fillings, and periapical lesions. (B) Root canal fillings with Ketac-Endo and single gutta-percha cones, after apexification with calcium hydroxide for 3 months and healing of lesions. (C) Six months postoperatively, the integrity of the periodontal ligament space is maintained periapically. Teeth are restored with temporary posts and crowns.

the manufacturer's directions. The capsule was activated and mixed in the Capmix vibrator (ESPE) for 10 sec. The sealer was then expressed either directly into the pulp chamber or onto a chilled glass slab, and placed in the canal with a Lentulo spiral. A

single standardized gutta-percha master cone, prefitted to the working length, was seated into the canal with a gentle pumping motion. In 320 teeth treated by two of the operators, no condensation was performed, and only in the canals designated for post-


Friedman el al.

Journal of EndodonUcs

sions; occurrence of procedural complications, such as perforation, breakage of files, and extrusion of sealer; density and length of the canal filling; and temporary restoration placed. Fillings extending to the radiographic apex or up to 2 mm shorter were recorded as "adequate," as opposed to "underextended" and "overextended" filling. Six to 18 months after treatment, the patients were recalled, and clinical and radiographic follow-up examinations were performed by the original operators. For teeth examined more than once, only the findings of the final examination were considered. The time elapsed since treatment, clinical signs and symptoms, and type of restoration were recorded as postoperative data. Then, the widest diameters of the periapical lesions in all preoperative and follow-up radiographs were measured by an independent examiner at random, blinded sequence. The lesion size was recorded as the following: smaller than 2 mm, 2 to 5 mm, 6 to 9 mm, and 10 mm or larger. All of the recorded information was coded and entered into a computerized database. The computer-derived treatment results were programmed as the following combinations of clinical and radiographic findings: (i) Success--absence of clinical signs, symptoms, or periapical radiolucency; slight tenderness to percussion was permitted (Fig. 1). (ii) Incomplete healing--absence of clinical signs and symptoms, including tenderness to percussion, and a decreased size of the periapical lesion (Fig. 2). (iii) Failure-presence of pain, swelling, or a sinus tract, regardless of the radiographic appearance, or decreased size of the periapical lesion and tenderness to percussion; or development of a periapical lesion or no change in size of the lesion (Fig. 3). Multirooted teeth were assessed according to the root that appeared the worst (Fig. 3). The relation of the treatment results to specific preoperative, intraoperative, and postoperative data was analyzed using )(2, with a 5% level of significance. Various combinations of data were analyzed to indicate the factors that were significantly identified with treatment success or failure.

RESULTS A total of 378 teeth (78%) presented for follow-up examination. The majority of the missing patients (83 teeth) could not be located to be recalled, and the remaining patients did not respond to the recall. Overall, 296 teeth (78.3%) were classified as a treatment success, 59 teeth (15.6%) as incomplete healing, and 23 teeth (6.1%) as a failure. Distribution of the followed-up teeth by age, sex, and location is presented in Tables 2 and 3, respectively. Distribution by significant preoperative factors and the related treatment results are presented in Table 4. Statistically significant differences in treatment results were found between teeth with single and multiple canals (p < 0.04), primary treatment and retreatment (p < 0.02), vital and nonvital teeth (p < 0.001), teeth with and without periapical lesion (p < 0.001), and teeth with and without symptoms (p < 0.003). Differences related to age (dr = 12, p > 0.6), sex (dr = 2, p > 0.1), tooth location (dr = 10, p > 0.4), and size of the periapical lesion divided into four categories (dr = 6, p > 0.2) were not statistically significant. However, combining lesion sizes to smaller or larger than 2 mm yielded statistically significant differences (p < 0.04). Distribution of the teeth by significant intraoperative factors and the related treatment results are presented in Table 5. Statistically

FIG 2. Radiographs demonstrating incompletehealing following endodontic therapy of mandibular lateral incisor. (,4) Root canal filling with Ketac-Endo and a single gutta-percha cone. There is an extensive periradicular lesion. (B) Eight months postoperatively, the size of the lesion is considerably decreased. The access cavity is still temporarily filled with Intermediate Restorative Material.

placement accessory gutta-percha cones were passively inserted. In the remaining 58 teeth, treated by the third operator, the guttapercha was laterally condensed in all canals using D-11-T spreaders, without additionally coating the accessory cones with sealer. Upon completion of obturation, the access cavity was sealed with either Cavit (ESPE), IRM (L. D. Caulk Co., Milford, DE), or glass ionomer cement (Ketac-Fill, ESPE). In several cases, a crown was removed to facilitate retreatment, then temporarily recemented on top of the temporary filling. For each tooth, the following intraoperative information was recorded: the number of treatment ses-

Vol. 21, No. 7, July 1995

Glass Ionomer Sealer in Endodontic Therapy


FIG 3. Radiographs demonstrating failure following endodontic therapy of first mandibular molar. (A) Preoperative view showing a periapical lesion and external root resorption associated with the distal root. (B) Root canal filling with Ketac-Endo and single gutta-percha cones after intracanal dressing with calcium hydroxide for I month. (C) Eight months postoperatively, there is complete periapical healing of the distal root, but a new lesion developed associated with the mesial root. The tooth is restored with a composite resin inlay.

FiG 4. Radiographs demonstrating incomplete healing following endodontic retreatment of a mandibular first molar. (A) Preoperative view showing poorly filled canals and a second, untreated distal root, a perforation into the furcation and an extensive periradicular lesion. (B) Root canal fillings with Ketac-Endo and single gutta-percha cones. There is extensive extrusion of sealer; the largest observed in all treated teeth. (C) Six months postoperatively, the lesion has decreased in size with evidence of new bone trabeculation in the interradicular area. There is no evidence of resorption of the extruded sealer. The tooth is restored with an amalgam filling.

significant differences were found between teeth in which operative complications occurred, particularly periapical extrusion of the sealer, and teeth without complications (p < 0.001 and p < 0.003, respectively). Differences between teeth treated in one and multiple sessions were statistically borderline (p = 0.052). Differences related to laterally condensed and single-cone gutta-percha (df =

2, p > 0.4), the operator (df = 4, p > 0.2), the temporary filling material (dr = 6, p > 0.7), the filling density (dr = 2, p > 0.07), or the apical extension of the canal filling (df = 4, p > 0.1), were not statistically significant. Combining overextended and underextended fillings as "inadequate" yielded statistically significant differences from the "adequate" fillings (p < 0.05). A general


Friedman et al. TABLE 2. Distribution of the study material by patient age and sex Sex Female Male Total No. of teeth 217 (57%) 161 (43%) 378 100 % Age <19 10 11 21 5.6% 20-29 36 22 58 15.3% 30-39 63 38 101 26.7% 40-49 64 35 99 26.2% 50-59 27 29 56 14.8%

Journal of Endodontics

60-69 7 15 22 5.8%

>70 10 11 21 5.6%

TABLE 3. Distribution of the study material by tooth location Arch Maxilla Mandible Total No. of Teeth 212(56%) 166(44%) 378(100%) Location in Arch Anteriors 64(16.9%) 18(4.8%) 82(21.7%) Premolars 59(15.6%) 48(12.7%) 107(28.3%) Molars 89(23.5%) 100(26.5%) 189(50%)

TABLE 5. Relation of intraoperative factors to treatment results following endodontic therapy using Ketac-Endo sealer No. of Teeth Treatment Results (%) Success Incomplete Failure Healing 85.8 75.4 8.5 18.4 5.7 6.2

Examined Factor Treatment Sessions One Two or more p = 0.052 Working length Adequate Inadequate p < 0.05 Complications Absent Present p < 0.001 Extruded sealer Absent Present p < 0.003

106(28%) 272(72%)

TABLE 4. Relation of preoperative factors to treatment results following endodontic therapy using Ketac-Endo sealer No. of Teeth Treatment Results (%) Success Incomplete Failure Healing 85.4 73.9 10.4 18.8 4.2 7.3

306(81%) 72(19%)

79.4 73.6

16.0 13.9

4.6 12.5

Examined Factor No. of canals One Two or more p < 0.04 Nature of Treatment Primary Retreatment p < 0.02 Vitality Vital Nonvital p < 0.001 Periapical lesion Absent Present p < 0.001 In nonvital teeth Absent Present p < 0.001 In retreated teeth Absent Present p < 0.001 Lesion size -<2 mm >2 mm p < 0.04 Symptoms Absent Present p < 0.003

315(83%) 63(17%)

81.9 60.3

13.7 25.4

4.4 14.3

144(38%) 234(62%)

315(91%) 30(9%)

81.9 56.7

13.7 26.7

4.4 16.6

250(66%) 128(34%)

82.4 70.3

12.0 22.7

5.6 7.0

108(43%) 142(57%)

93.5 73.9

1.9 19.7

4.6 6.3

TABLE 6. Relation of postoperative factors to treatment results following endodontic therapy using Ketac-Endo sealer No. of Teeth Treatment Results (%) Success Incomplete Failure Healing 66.0 81.6 95.7 22.0 14.5 0 12.0 3.9 4.3

Examined Factor 169(45 %) 209(55%) 97.0 63.2 0 28.2 3.0 8.6 Follow-up (months) 6 7-12 >12 p < 0.003 Final restoration None Temporary filling Definitive filling Post present Crown alone p < 0.03

29(20%) 113(80%)

93.1 69.0

0 24.8

6.9 6.2

100(26%) 255(68%) 23(6%)

42(20%) 86(67%)

100.0 55.8

0 33.7

0 10.5

4(1%) 78(21%) 90(24%) 142(37%) 64(17%)

50.0 80.8 80.0 75.4 81.3

0 14.1 14.4 19.7 10.9

50.0 5.1 5.6 4.9 7.8

92(44%) 117(56%)

72.8 55.6

20.7 34.1

6.5 10.3

126(33%) 252(67%)

87.3 73.8

11.9 17.5

0.8 8.7

restoration, having either no filling or still the temporary filling (Fig. 2). Statistically significant differences were found between various observation periods (p < 0.003), and between teeth with and without a restoration (p < 0.03). Differenees related to the type of restoration were not statistically significant (df = 6, p > 0.7). DISCUSSION The present study was prospective, in an attempt to standardize treatment protocols and maximize the recall rate. The recall rate of

observation was that periapically extruded Ketac-Endo was not absorbed by the tissues during the observation period (Fig. 4). Distribution of the teeth by significant postoperative factors and the related treatment results are presented in Table 6. Eighty-two of the teeth presented for follow-up examination without a final

Vol. 21, No. 7, July 1995

Glass Ionomer Sealer in Endodontic Therapy


78% compared well with previous studies (Table 1). When patients do not respond to recall, there is always the possibility that the missing teeth represent failures of treatment; therefore, the teeth that are followed-up may not truly represent the study population (9). However, missing teeth from patients who cannot be recalled are not considered as representing a particular treatment result category (9). In this study, 83 of the missing teeth (77%) were from patients who could not be recalled, suggesting that the teeth that were followed-up truly represented the entire study population. The composition of the material included in this study represented the routine treatments performed by the three operators, and in all probability, the treatments performed in any endodontic specialty practice. When comparing the treatment results observed in this study with those of previous studies, in which other techniques and sealers were used, differences in assessment criteria and composition of the material must be considered (2) (Table 1). As in other studies (8-13), success excluded any evidence of periapical lesion. Tenderness to percussion was permitted, however, considering that it may be frequently associated with conditions unrelated to periapical healing, such as traumatic occlusion, food impaction, or periodontal disease. In a few studies, success included cases in which the periapical lesion decreased (14, 15) or remained the same (16). In this study, these findings were considered incomplete healing and failure, respectively. In addition, the presence of signs and symptoms overruled the radiographic appearance, whereas in several studies only a radiographic evaluation was performed (2, 8, 14, 15). The present study material included 209 teeth (55%) with periapical lesion and 128 (34%) retreatments, both of which are frequently associated with failure of endodontic therapy (8-11, 14-16). In contrast, other studies included <40% teeth with periapical lesions (2, 8-14, 16), and <5% retreatments (8, 10, 14, 15). Finally, the rate of incomplete healing, resulting from the relatively short observation period in the present study, reduced the success rate as compared with studies based on longer observation periods (2, 8, 9, 11-13, 17). Therefore, considering the assessment criteria and composition of the material in this study, the success rate was expected to be lower than in previous studies. Nevertheless, the general distribution of the treatment results was within the range reported in the prognostic studies on endodontic treatment and retreatment. These results supported the clinical application of Ketac-Endo as an acceptable root canal sealer in endodontic therapy. Regarding demographic and preoperative factors, the insignificance of age, sex, and tooth location in this study was in agreement with most previous studies (8-10, 12-15). Teeth with single canals, however, showed a higher success rate than teeth with multiple canals, reflecting the increased probability of failure in muttirooted teeth, which were assessed according to the worst root (9). In several studies, roots, rather than teeth, were observed individually (8-14, 17), a factor that could have contributed to a higher success rate reported in those studies (Table 1). As previously demonstrated (10, 15), the success rate was lower following retreatment than initial treatment. In an extensive study on retreatment, complete healing was observed in 48% of the retreated roots, incomplete healing in 30%, and failure in 22% (17). Those results are considerably poorer than the ones observed in the present study. The failure rate in teeth with infected canals and resulting periapical lesions was almost three times higher than in teeth without lesions. This difference was accentuated by the retreatment cases, with 10% failure in the former group, as opposed to 100%

success in the latter group. In addition, the treatment results were significantly poorer in symptomatic teeth than in asymptomatic teeth, in contrast to previous reports (10, 13). Some of the symptomatic teeth probably had limited pulpat infection, whereas the others had fully established infection with periapical extension. The finding of poorer treatment results in the infected teeth is in agreement with most studies (8-17). Regarding intraoperative factors, treatment in a single session resulted in a 10% higher success rate than multiple session treatment, supporting previous evidence that single session endodontic therapy is highly successful (10). In teeth with infected canals, however, intracanal dressing with calcium hydroxide between appointments is believed to control the intracanal infection (18). Therefore, for these teeth, multiple session treatment, including intracanal calcium hydroxide dressing, was expected to be more successful than single session treatment. Indeed, the infected teeth treated in multiple sessions, in contrast to the overall trend, showed a 9% higher success rate and almost half the failure rate shown by infected teeth treated in a single session, but the differences were not statistically significant. The prognosis of endodontic therapy is poorer when the root canal fillings are overextended (9, 12-14, 16) or underextended (13). In this study, the treatment results did not differ significantly for underextended, adequate, or overextended fillings. However, the greatest overextension was only 0.5 mm, and underextension occurred mostly in calcified canals, a condition shown to have an endodontic success rate of 89% (11). Nevertheless, the importance of the apical extension of root canal fillings was confirmed by the lower failure rate of adequate fillings as compared with "inadequate" fillings (8). Voids in the root canal fillings were observed in 4% of the teeth, which indicated that the technique used when filling the canals with Ketac-Endo was consistent. Avoiding voids in the sealer is very important when obturation relies on the sealer rather than gutta-percha, as in the case of the single cone technique. In this study, however, voids were not associated with an increased failure rate, possibly because the voids were isolated rather than continuous, and bordered by areas in which the sealer may have entirely filled the lumen of the canal. In such situations, there may not be communication between the voids and the apex, and propagation of bacteria to the apical area may be prevented. Teeth filled with a single cone or laterally condensed gutta-percha demonstrated comparable treatment results. This finding was expected in view of the superior adaptation of Ketac-Endo to the canal walls (3), and it supported the recommended application technique (3, 6). Avoiding condensation of gutta-percha should save time and effort, and vertical root fractures associated with condensation (7) may be prevented. Complications in therapy decreased the success rate in this study. The most frequent "complication" was extrusion of sealer through the apical foramen, which occurred in 9% of the teeth. Unlike other sealers (19), the extruded Ketac-Endo was not absorbed during the follow-up period. When Ketac-Endo is implanted in bone, it does not stimulate an osteoclastic response; this allows bone to grow in its immediate proximity without a fibrous tissue interface (4). Therefore, when Ketac-Endo is extruded through the apical foramen, it becomes an "implant" in the periapical tissues, not an irritant. The increased failure rate associated with extruded sealer may, therefore, have been related to other factors such as preoperative periapical lesions. These results do suggest, however, that extrusion of Ketac-Endo should be avoided


Friedman et ah

Journal of Endodontics 2. Qrstavik D, Kerekes K, Eriksen HM. Clinical performance of three endodontic sealers. Endod Dent Traumatol 1987;3:178-66. 3. Ray HL, Seltzer S. A new glass ionomer root canal sealer. J Endodon 1991 ;17:598-603. 4. Jonck LM, Grobbelaar CJ, Strating H. Biological evaluation of glassionomer cement (Ketac-O) as an interface material in total joint replacement. A screening test. Clin Mater 1989;4:201-24. 5. Trope M, Ray HL. Resistance to fracture of endodontically treated roots. Oral Surg 1992;73:99-102. 6. Friedman S, Moshonov J, Trope M. Efficacy of removing glass inomer cement, zinc oxide eugenol and epoxy resin sealers from retreated root canals. Oral Surg 1992;73:609-12. 7. Dang DA, Walton RE. Vertical root fracture and root distortion: effect of spreader design. J Endodon 1989;15:294-301. 8. Kerekes K, Tronstad L. Long-term results of endodontic treatment performed with a standardized technique. J Endodon 1979;5:83-90. 9. Strindberg LZ. The dependence of the results of pulp therapy on certain factors. An analytic study based on radiographic and clinical follow-up examinations. Acta Odontol Scand 1956;14(suppl 21):1-175. 10. Pekruhn R. The incidence of failure following single-visit endodontic therapy. J Endodon 1986;2:68-72. 11. Akerblom A, Hasselgren G. The prognosis for endodontic treatment of obliterated root canals. J Endodon 1988;14:565-7. 12. Grahnen H, Hansson L. The prognosis of pulp and root canal therapy. A clinical and radiographic follow-up examination. Odontol Revy 1961;12: 146-65. 13. Sjogren U, H~gglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endodon 1990;16:498-504. 14. SeltzerS, BenderlB, TurkenkopfS. Factors affecting successful repair after root canal therapy. J Am Dent Assoc 1963;67:651-62. 15. Selden HS. Pulpoperiapical disease: diagnosis and healing. Oral Surg 1974;37:271-82. 16. Swartz D, Skidmore AE, Griffin JA. Twenty years of endodontic success and failure. J Endodon 1983;9:198-202. 17. Bergenholtz G, Lekholm U, Milthon R, Heden G, Odesjo B, Engstrom B. Retreatment of endodontic fillings. Scand J Dent Res 1979;87:217-24. 18. BystrSm A, Happonen R-P, SjSgren U, Sundqvist G. Healing of periapical lesions of pulpless teeth after endodontic treatment with controlled asepsis. Endod Dent Traumatol 1987;3:58-63. 19. Augsburger RA, Peters DD. Radiographic evaluation of extruded obturation materials. J Endodon 1990;16:492-7. 20. Eckerbom M, Magnusson T, Martinsson T. Prevalence of apical periodontitis, crowned teeth and teeth with posts in a Swedish population. Endod Dent Traumatol 1991;7:214-20.

by forming a firm apical stop with minimal apical patency during preparation of the root canal. In previous studies, the failure rate in teeth with intraradicular posts was either similar (13) or higher (20) than in teeth without posts. The placement of posts may result in failure by decreasing the seal of the remaining canal filling or vertically fracturing the root. In this study, the type of restoration and the presence or absence of a post did not significantly affect the success rate. Ketac-Endo may have sufficiently sealed the canal even after post placement and reinforced the roots against fracture, as observed in vitro (5). A surprising finding was that, several months after endodontic treatment, teeth remaining restored with temporary fillings performed as well as teeth with permanent restorations. Only the four teeth that presented without any restoration demonstrated significantly poorer results. This finding suggested that Ketac-Endo, like other sealers, does not prevent failure of endodontic therapy when coronally the pulp chamber and canals are not sealed.
The authors thank ESPE GmbH for supplying Ketac-Endo and the necessary armamentadum for its app)ication; Professor Adele Csima, University of Toronto, for assistance in designing the database; and Jennifer Payne, MSc, University of Toronto, for processing the statistical analysis. Dr. Friedman is associate professor and head, Department of Endodontics, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada. Dr. L6st is professor and chairman, Department of Conservative Dentistry,School of Dentistry, TLibingen University, T(Jbingen, Germany. Dr. Zarrabian is currently practicing in Toronto, Ontario, Canada. Dr. Trope is professor and chair, Department of Endodontics, Faculty of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC. Address requests for reprints to Dr. Shimon Friedman, Department of Endodontics, Faculty of Dentistry, 124 Edward Street, Toronto, Ontario M5G 1G6, Canada.

References 1. Nguyen TN. Obturation of the root canal system. In: Cohen S, Burns RC, eds. Pathways of the pulp. St. Louis: Mosby Year Book, 1991:193-5.

A Word to the Wise

Self-styled ethicists are prone to rabbit on about disobedience to lesser physical laws. Which sounds when walking gravity. on icy pavement, like a lot of gibberish. to moral law inevitably leading to subjugation It is m o r e i l l u m i n a t i n g t o s i m p l y o b s e r v e t h a t if, we risk becoming subject to the laws of

we disobey the laws of prudence,

William Cornelius