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Endod Dent Traumatol 1994: 10: 105-108 Printed in Denmark .

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Endodontics & Dental Traumatology

ISSN 0109-2502

Review article

Coronal leakage as a cause of failure in rootcanal therapy: a review

Saunders WP, Saunders EM. Coronal leakage as a cause of failure in root-canal therapy: a review. Endod Dent Traumatol 1994; 10: 105-108. Munksgaard, 1994. Abstract - This paper reviews the evidence that coronal leakage of root canals may lead to failure of root-canal therapy. The causes of coronal leakage and methods by which this leakage may be prevented are described. W. p. Saunders\ E. M. Saunders^
^Department ot Adult Dental Care, Glasgow Dental Hospital and School, ^Department of Conservative Dentistry, Dundee Dental School, Scotland, UK

Key words: root canal treatment; failure; coronal leakage. W P Saunders, Department of Adult Dental Care, Glasgow Dental Hospital and School, 378 Sauchiehall Street, Glasgow G2 3JZ, Scotland. Accepted October 13, 1993

Root-canal treatment can be difficult and time consuming, especially in molars with multiple fine, curved root canals. In order to provide an environment where healing can occur and be maintained, it is important that sufficient care is taken, not only during the cleaning, shaping and obturation of the canal system, but also when restoring the crown. Apical leakage as a cause of failure Failure of root-canal treatment can be attributed to a number of causes, but leakage through the root filling itself is thought to be a major factor. Strindberg (1), in 1956, considered that the most common cause of failure was leakage of tissue fluids apically around inadequate root fillings. The University of Washington School of Dentistry Study, undertaken to evaluate treated endodontic cases and to determine their rate of success, was reported by Ingle (2) in 1965. This study found that of 104 failed cases, 66 were associated with a poor apical seal. Other studies (3, 4) have shown that prognosis for successful root-canal therapy was poorer when there were ^'oids apically between the root filling and the wall of the canal. But why should this result in failure? ^t seems very likely that necrotic debris and microorganisms cannot be completely eliminated from

the prepared root canal (5-7). If the canal space is not sealed adequately then micro-organisms themselves, or their toxins, can cause inflammation in the periapical tissues (8). Importance of coronal leakage in failure of root canal treatment Obturated root canals may be recontaminated by micro-organisms in a number of ways: 1) Delay in placing a coronal restoration following root canal treatment. Although temporary restorative materials such as Cavit G and reinforced zinc oxide eugenol cements, such as Kalzinol and IRM, have good sealing properties they tend to dissolve slowly in the presence of saliva, and the seal may break down. If a temporary restoration is of inadequate thickness, leakage will occur (9). 2) Fracture of the coronal restoration and/or tooth. 3) Preparation of post space for the provision of a post-retained restoration when the remaining apical section of the root filling is of inadequte density and/or length. The concept that one cause of failure of rootcanal treatment may be the result of coronal leakage is not a new one. Marshall & Massler (10), in 1961,

Saunders & Saunders were concerned about the role of the occlusal seal in root-filled teeth. They wondered whether the overall seal of the root canal was altered if the seal was broken coronally. They also speculated on the prognosis of root-canal treatment if the quality of obturation of the root canal was poor, but the coronal seal was good. They indertook a leakage study using a radioactive tracer and showed that coronal leakage occurred despite the presence of a coronal dressing. Allison et al. (11) in 1979 made brief reference to the possibility that a poor coronal seal might contribute to clinical failure. In 1987 the importance of coronal leakage in the prognosis of root-canal treatment was readdressed. An in vitro leakage study (12) showed that after only three days exposure to artificial saliva there was extensive coronal leakage of a tracer dye through apparently sound root fillings. They considered that leakage of this nature should be taken into account as a potential aetiological factor in failure of rootcanal treatment. Madison & Wilcox (13) confirmed that exposure of root canals to the oral environment allowed coronal leakage to take place, in some cases along the whole length of the root canal. Further studies have confirmed the importance of coronal leakage as a possible cause of failure of root-canal treatment. Torabinejad et al. (14) found that 50% of single-rooted teeth, root filled using lateral condensation of guttapercha and a sealer cement, were contaminated with bacteria along the whole length of the root after 19 days or 42 days, depending on the contaminating organism. Another study (15) assessed salivary penetration through obturated root canals. The results led to a recommendation that root fillings which had been contaminated coronally for at least three months, should be re-done prior to placement of the definitive restoration. More recently, Khayat et al. (16) have shown that root canals obturated with gutta-percha and Roth's sealer, using either lateral condensation or vertical condensation were contaminated apically with bacteria from saliva exposed to the coronal part of the root canal only. All canals were contaminated within 30 days of exposure. Post space preparation and coronal leakage Restoration of a root-filled tooth sometimes requires the use of an intra-canal post. During mechanical preparation of the post space it is possible that the root filling may be twisted or vibrated, with disruption of the seal (17). To avoid this problem there was a vogue for placing sectional silver or guttapercha cones in the apical portion of the root canal. It now seems that the advantages of leaving the apical portion of the root filling undisturbed is 106 outweighed by the fact that much of the. canal system is vulnerable to contamination from an inadequate seal coronally. Three-dimensional obturation of the whole canal with gutta-percha will coat the wall of the root canal with sealer and may allow the filling of lateral root canals. Provided a minimum of 5 mm of sound apical root filling is left in situ (18, 19), studies have shown that removal of laterally condensed gutta-percha does not affect the apical seal. This is the case irrespective of whether the post space is prepared immediately after obturation or is delayed (18, 20, 21). Coronal leakage associated with molar teeth Most studies of coronal leakage have involved the use of single-rooted teeth. It is probably more important, however, to seal the coronal part of the root canal system in molars because accessory canals may be present in the floor of the pulp chamber (22). Gontamination through these canals may be responsible for inflammatory changes taking place in the periodontal tissues of the furcation due to direct spread of micro-organisms and their toxins from the pulp chamber (23, 24). Saunders & Saunders (25) showed that coronal leakage was a significant problem in root-filled molars. They demonstrated in a laboratory-based experiment, that the common practice of packing excess gutta-percha and root canal sealer over the floor of the pulp chamber after completion of lateral condensation, did not provide an adequate coronal seal of the root canals. It was recommended that excess guttapercha should by removed level with the openings of the root canals and the floor of the pulp chamber sealed with a restorative material such as amalgam or glass polyalkenoate. Other factors influencing coronal ieakage When the root canal walls are instrumented a tenacious layer of debris is formed which is known as the smear layer (5). This layer cannot be removed with canal irrigation techniques using sodium hypochlorite in a hand-held syringe. Therefore, the smear layer is present in most root-filled teeth. The effect that the smear layer may have on the prognosis of root-canal therapy is unknown (26), but conceivably it might be broken down by bacterial toxins (27). This would provide a path through which leakage could take place. Hovland & Dumsha (28) showed that most leakage occurs between the root-canal sealer and the wall of the root canalIt is important, therefore, that this route for contamination is restricted as much as possible. If the smear layer were to be removed then this

Coronal leakage & root canal therapy would expose patent dentinal tubules into which a sealer may flow, thereby decreasing the possibility of leakage taking place. The smear layer can be removed with acids, such as citric acid, and chelating agents such as EDTA (ethylenediaminetetra acetic acid). Cameron (29) showed that sodium hypochlorite, used with an ultrasonically powered endodontic file, could also remove the smear layer. Smear-layer removal tends to be easier in the coronal than in the apical part of the canal (30). Another way in which contamination could be restricted is by using a root-canal sealer that bonds ehemically to the wall of the root canal. None of the more commonly used root-canal sealers adhere chemically to tooth structure. A recent study used a glass ionomer lining material, Vitrebond, as a root-canal sealer (31). In order to prolong the set, the cement was allowed to cure chemically. When the smear layer was removed, the sealer flowed into the dentinal tubules and coronal leakage was reduced compared with Tubliseal, a commonly used zinc-oxide eugenol-based, root-canal sealer. Glass ionomer bonds to the inorganic part of dentine and the use of such a material may have a place in endodontics. A proprietary glass ionomer root canal sealer, Ketac Endo, has recently become available and early research reports are, on the whole, favourable (32, 33). Prevention of coronai leakage It is essential, following root-canal treatment, that the canal system is protected from subsequent leakage as much as possible. In the case of molars the floor of the pulp chamber should be covered with a lining of glass ionomer after removing excess guttapercha and sealer. The crown of the tooth should be restored expeditiously in such a way as to reduce leakage to a minimum. Coronal access cavities of teeth that cannot be restored immediately should be dressed with a proprietary temporary filling material, ensuring that it is at least 3.5 mm thick to reduce leakage (9). If simple repair of an access cavity jeopardises the coronal seal of an existing restoration, then the complete restoration should be replaced. Of course rootfilled teeth have no pulpal sensory innervation and, therefore, leaking coronal restorations may go unnoticed by patients for many months. It is important, therefore, that regular reviews are made of root-filled teeth, not only to monitor the periradicular status, but to ensure that coronal leakage is not taking place. Conclusions

be paid to the prevention of such leakage, both during and after root-canal therapy, by paying careful attention to the coronal restoration to the tooth. The use of chemically active, adhesive, root-canal sealers may, in future, play an important role in minimising coronal microleakage. References

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