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JOURNAL OF ENDODONTICS
Copyright 9 1983 by the American Association of Endodontists

Printed in U.S.A.
VOL. 9, NO. 5, MAY 1983

CLINICAL ARTICLES
Twenty Years of Endodontic Success and Failure
David B. Swartz, DDS, MS, A. E. Skidmore, AB, DDS, MS, and J. A. Griffin, Jr., BS, MS, DDS

Recall radiographs of 1,007 endodonUcally treated

teeth with 1,770 canals were evaluated for success
or failure. Results revealed that 8 9 . 6 6 % of 1,770
canals received a successful evaluation. Evaluation
of several variables suggests that a lower success
rate is associated with overfilled canals, canals with
preexisting rarefaction, and teeth not properly restored following completion of root canal therapy.
A significantly lower success rate was also found in
male patients and mandibular first molars in this
study. No significant difference in success rate was
found when evaluating age of the patient or type of
filling material.

persistent pain, but normal radiographical appearance, cannot be considered successful. However,
teeth which are functional and comfortable, even with
persistence of a slight rarefaction, are rarely candidates for extraction or endodontic surgery. A common-sense approach to evaluating endodontic success is needed to monitor future treatment techniques
to improve our already excellent results.
While success rates varying from 68 to 9 6 % have
been reported, a majority of the literature concurs that
a success rate of 85 to 90% is a reasonable goal
using good basic endodontic techniques. An extensive study by Seltzer et al. (2) reported 76% success
for teeth with preexisting rarefactions and 92% success when no rarefaction was originally present. Barbakow et al. (11 ) recently reported 87.4% success in
566 cases completed in a general dental practice.
The purpose of this study was to determine the
degree of success or failure of conventional root canal
therapy performed at West Virginia University School
of Dentistry from 1959 to 1979.

"The Washington Study" by Ingle (1) is the classic

study regarding success and failure of endodontic
therapy. Ingle reported 91.54% success after evaluating 1,229 cases completed during the mid-1950's.
Although 34.25% of these cases were treated surgically, no significant difference was found between
conventional and surgical treatment results. No significant difference in success rates was found when
comparing age or sex of the patient or types of teeth
being treated.
Numerous other studies have been published evaluating success and failure of endodontic therapy utilizing radiographical examination alone (2-4) or utilizing a combination of clinical and radiographical examinations (5-11). Bender and Seltzer (12) demonstrated that the size of a radiographical rarefaction
does not correlate with the actual amount of bone
destruction, thus decreasing the validity of evaluating
success solely on radiographical interpretation. A
study by Goldman and co-workers (13) further demonstrates the problem of accurately and consistently
determining endodontic success using radiographical
evidence alone. A combined clinical and radiographical approach offers a sensible and more reliable
method to evaluate endodontic success. Teeth with

MATERIALS AND METHODS

Patients receiving root canal therapy at West Virginia University School of Dentistry are recalled at
intervals of 6 months, 1 year, 2 years, 5 years, and
10 years for radiographical and clinical evaluation of
their endodontically treated teeth. Prior to exposure
of recall radiographs, patients are questioned to determine if the involved teeth are symptomatic. Recall
radiographs are placed in individual treatment packets, and the patient's response concerning any clinical
symptoms is recorded. Those recall records with a
minimum 1-year recall period were evaluated for success or failure of conventional root canal therapy
completed from 1959 to 1979. A minimum recall
period of 1 year was selected since 1-year recall films
are currently accepted by the American Board of
Endodontics for specialty board certification (14). A
total of 1,007 teeth with 1,770 canals were evaluated.
198

Endodontic Success and Failure

Vol. 9, No. 5, May 1983

In addition to evaluation of success or failure, the

following data were recorded for each tooth or canal:
1. Sex and age of patient at time of treatment
2. Tooth number
3. Number of canals treated
4. Presence or absence of a proper restoration at
time of recall
5. Type of filling material
6. Presence or absence of preexisting rarefaction
7. Apical termination of filling material
All 1,007 cases were completed in the Department
of Endodontics at West Virginia University School of
Dentistry using standardized techniques. With few
exceptions, the canals were filled 3 to 7 days after
obtaining a negative culture.
The criteria for success or failure as published by
Bender et al. (15) were selected as being most appropriate for current usage taking into consideration clinical symptoms rather than relying entirely on radiographical interpretation. Cases were considered to be
successful when the following criteria were met:
1. Absence of pain or swelling
2. Disappearance of any sinus tracts
3. No loss of function
4. Radiographical evidence of resolved or arrested
areas of rarefaction after a posttreatment interval of 1
year
The following criteria were used to determine failures:
1. Presence of pain, swelling, or sinus tracts
2. Loss of function
3. Rarefaction that increases in size or does not
decrease in size after obturation

4. Development of a rarefaction where no rarefaction was originally present

Recall radiographs were examined by the primary
investigator using a viewbox and magnifying glass,
and the data were recorded for 1,007 teeth with 1,770
canals. Chi-square analysis was used to determine if
any variable significantly affected the success rate for
these cases.

RESULTS
A successful evaluation was recorded for 89.66%
of the 1,770 canals treated. Since failure of one canal
of a multicanal tooth resulted in case failure, the
success rate of the 1,007 cases was slightly lower at
87.79% success.
Chi-square analysis was performed comparing success of each tooth type with success of the remaining
teeth. Mandibular first molars had a significantly lower
success rate than the remaining teeth. A chi-square
value of 5.78 was calculated for the mandibular first
molars, and this value exceeds the value of 3.84
required to rule out chance at the 5% significance
level with 1 df. The analysis according to tooth type is
summarized in Table 1.
Analysis of success and failure according to age of
the patient at time of treatment revealed no significant
difference among the various age groups as summarized in Table 2.
Males were found to have a significantly lower success rate than females in this study. The success rate
for males was 84.70% compared with 90.29% for
females (X2 -- 7.25). Table 3 summarizes the analysis
of success and failure according to sex.

TABLE 1. Analysis of success and failure by individual tooth

Tooth
Maxillary
Central incisors
Lateral incisors
Canines
I st premolars
2nd premolars
I st molars
2nd molars
Total
Mandibular
Central incisors
Lateral incisors
Canines
I st premolars
2nd premolars
I st molars
2nd molars
Total
Total no. of treated
cases

199

No. of Cases

No. of Successes

% Successes

No. of Failures

% Failures

Frequency of
Treatment

X2

153
158
39
75
79
1 O0
34

140
143
34
69
65
88
31

91. 50
90.51
87. 18
92. 00
82.28
88.00
91.16

13
15
5
6
14
12
3

8.50
9_49
1 2.82
8_00
1 7.72
1 2.00
8_82

15.19
15.69
3.87
7.45
7.85
9.93
3.38

2.33
1.29
0.01
1.34
2.43
0.01
0.38

638

570

89.34

68

10.66

63.36

56
21
13
47
52
1 35
45

48
18
12
41
48
110
37

85.71
85.71
92.31
87.23
92.31
81. 48
82.22

8
3
1
6
4
25
8

14.29
14.29
7.69
12_77
7_69
18.52
1 7.76

5.56
2.09
1.29
4.67
5.16
13.40
4.47

369

314

85. 09

55

14.91

36.64

1,007

884

87. 79

123

1 2.21

100%

0.24
0.09
0.25
0.01
1.05
5.78
1.36

200

Journal of Endodontics

Swartz et al.

Although

the

success

s l i g h t l y l o w e r at 8 8 . 4 4 %

rate

of

silver points

as compared

r a t e of 8 2 . 9 1 %

was

compared

with 9 4 . 2 2 %

s u c c e s s in

c a s e s w i t h o u t p r e e x i s t i n g r a r e f a c t i o n . S i n c e t h e X2

with 9 1 . 2 3 %

for g u t t a - p e r c h a , a X2 value of 3 . 6 4 w a s b e l o w the

v a l u e of 5 8 . 7 8 e x c e e d s t h e c r i t i c a l v a l u e of 3 . 8 4 , it

c r i t i c a l v a l u e o f 3 . 8 4 , so no s i g n i f i c a n t d i f f e r e n c e in

c a n b e c o n c l u d e d t h a t p r e s e n c e o f p r e e x i s t i n g rare-

s u c c e s s r a t e w a s f o u n d b e t w e e n t h e s e filling m a t e -

faction was a s s o c i a t e d with a significantly lower suc-

rials. T a b l e 4 d e m o n s t r a t e s t h i s c o m p a r i s o n of f i l l i n g

cess rate than c a s e s with no rarefaction. A s u m m a r y

materials.

of t h i s a n a l y s i s is p r e s e n t e d in T a b l e 5.
W h e n t h e s u c c e s s r a t e w a s a n a l y z e d a c c o r d i n g to

C a s e s with preexisting rarefaction had a s u c c e s s

TABLE 2. Analysis of success and failure by age

Age
Under 10
10-19
20-29
30-39
40-49
50-59
60-69
70-79
Total

No. of Cases

No. of Successes

8
316
297
143
139
65
31
8

7
280
263
119
124
56
27
8

1007

884

% Successes

No. of Failures

% Failures

X2

87.50
86.61
88.55
83.22
89.21
86.15
87.10
100.00

1
36
34
24
15
9
4
O

12.50
11.39
11.45
16.78
10.79
13.85
12.90
0.00

0.001
0.29
0.23
3.24
0.31
0.17
0.01
1.12

87.79

1 23

12.21

TABLE 3. Analysis of success and failure by sex

Sex

No. of Cases

No. of Successes

% Successes

Male
Female

451
556

382
502

84.70
90.29

69
54

15.30
9.71

~007

884

87.79

~23

~2.21

Totat

No, of Failures

% Failures

X 2 = 7.25

TABLE 4. Analysis of success and failure by filling material

Filling Material

No. of Canals

No. of Successes

% Successes

No. of Failures

% Failures

Gutta-Percha
Silver

775
995

707
880

91.23
88.44

68
115

8.77
11.56

1770

1587

89.66

183

10.34

Total

X2 = 3.64

TABLE 5. Analysis of success and failure~presence or absence of preexisting rarefaction

No. of Canals

No. of Successes

% Successes

No. of Failures

% Failures

Preexisting rarefaction
No rarefaction

714
1056

592
995

82.91
94.22

122
61

17.09
5.78

Total

1770

1587

89.66

183

10.34

X2 = 58.78

TABLE 6. Analysis of success and failure--apical termination of filling material

Apical Termination

No. of Canals

No. of Successes

% Successes

No. of Failures

% Failures

Over
Under
Flush

123
1432
215

78
1316
193

63.41
91.90
89.77

45
116
22

36.59
8.10
10.23

Total

1770

1587

89.66

183

10.34

Comparison of overfill versus undeHill:

X2 =

99.02

Comparison of oveHill versus flush fill:

X2 =

34.19

Comparison of flush fill versus underfill:

X2 =

1.11

Endodontic Success and Failure

Vol. 9, No. 5, May 1983

201

TABLE 7. Analysis of success and failure--posttreatment restoration

proper restoration
Not properly restored
Total

No. of Cases

No. of Successes

% Successes

No. of Failures

% Failures

451
556

415
469

92.02
84.35

36
87

7.98
15.65

1007

884

87.79

123

12.21

x 2 = 13.65

apical termination of the filling material, two significant

differences were found. Overfills had a significantly
lower success rate than underfills (X2 = 99.02), and
overfills had a significantly lower success rate than
flush fills (X2 -- 34.19). The critical value was 3.84,
and this analysis is summarized in Table 6.
Analysis of success and failure considering presence of a proper restoration revealed a significantly
lower success rate when no proper restoration was
present at time of recall (X2 -- 1 3.65, critical value -3.84). Table 7 summarizes the analysis comparing
presence or absence of a proper posttreatment restoration.
DISCUSSION

A success rate of 89.66% of the 1,770 canals

treated compares favorably with other published studies which have reported success rates varying from
68 to 96% (6-11 ). Success was achieved in 81.48%
of 135 mandibular first molars included in this study.
The most common cause of endodontic failure is
apical percolation, which can be caused by incomplete obturation or failure to detect and treat all canals
in a tooth (1). Since four canals were treated in more
than 25% of the 135 mandibular first molars, it appears unlikely that the higher failure rate of mandibular
first molars was due to failure to treat a canal. The
25% with four canals closely approximates the value
of 28.9% published by Skidmore and Bjorndal (1 6) in
1971. Many of the mandibular first molar failures may
be related to use of silver points in young patients
when apical root formation may have been incomplete,
thus resulting in incomplete obturation. Many cases
of failure in mandibular first molars may also be explained by lack of a proper restoration resulting in
silver points being exposed to oral fluids. Placement
of a proper restoration to seal the access opening and
use of Frank's apexification technique prior to filling
immature roots may increase our success rate. Barbakow et al. (11) also reported a 65% success rate
for mandibular molars, which was significantly lower
than their overall success rate of 87.4%.
No significant differences in success rates were
found when comparing ages of the patients, and this
agrees with studies of Strindberg (5) and Ingle (1).
Results of this study did indicate a significantly lower
success rate in males than females. No other studies

have found a sex difference in success rates of endodontic therapy, and no explanation of this finding is
offered.
Silver points were used in over 56% of the 1,770
canals, and no significant difference in success was
found in comparison to canals obturated with guttapercha. When properly used, silver points have a very
good success rate. Use of silver points in canals with
immature apices frequently leads to failure, since
these canals cannot be adequately sealed with a
single rigid cone. Proper restorations must also be
placed to avoid dislodgment of silver points or occlusal
leakage. Although step-back techniques have eliminated the frequent need to use silver points, it is
comforting to know that properly used silver points
offer a high degree of success.
This study confirms the results of numerous other
studies (2, 5, 8, 9) showing the endodontically treated
teeth with preexisting rarefaction have a significantly
lower success rate than when no preexisting rarefaction was present. No surgical cases were included in
this study, yet nearly 83% success was obtained in
cases with preexisting rarefaction. If Bhaskar (17) and
Lalonde and Luebke (18) are correct in their distribution of radicular cysts, then the results demonstrate
that conventional root canal therapy can lead to resolution of periapical cysts.
Results of this study indicated that overfilled canals
were four times more likely to fail than canals filled
short of the radiographical apex. A 36.59% failure
rate for overfilled canals clearly demonstrates the
need to maintain instruments and filling materials
within the confines of the root. Other studies also
revealed a poorer prognosis with overfilled canals (2,
3, 5).
Presence of a proper restoration is necessary to
restore masticatory efficiency, prevent fracture, and
seal the pulp chamber. The failure rate was almost
twice as high in cases without an adequate restoration
compared with cases properly restored. Weine (19)
has indicated that improper restoration leads to loss
of more endodontically treated teeth than actual failure of endodontic therapy. Many failures in this study
were due to improper restoration; dowel perforations,
nonrestorable crowns, and silver points exposed to
oral fluids were noted in many cases. It must be
emphasized to the patient that a proper restoration is
a necessary part of the successful treatment regimen.

202

Swartz et al.

SUMMARY AND C O N C L U S I O N S
The data supported the following conclusions regarding success of endodontic therapy completed at
West Virginia University School of Dentistry from 1959
to 1979:
1. Success was achieved in 8 9 . 6 6 % of 1,770 canals and in 8 7 . 7 9 % of 1,007 teeth (all canals successful in a multicanal tooth).
2. Mandibular first molars had a significantly lower
success rate than the other teeth.
3. Age of the patient at time of treatment had no
significant effect on success or failure.
4. Success was achieved in a significantly higher
percentage of females than males.
5. Type of filling material (gutta-percha or silver)
had no significant effect on success or failure.
6. Presence of preexisting rarefaction was associated with a significantly lower success rate than when
no rarefaction was present.
7. Overfilled canals had a failure rate nearly four
times higher than canals filled short of the radiographical apex.
8. Lack of a proper restoration was associated with
a significantly lower success rate than when a proper
restoration was placed.
9. The success rate achieved at West Virginia University is excellent and compares favorably with success rates in other major studies.
This work was completed as partial fulfillment for the Master of Science
Degree in Endodontics. The opinions are those of the authors and are not to
be construed as reflecting the views of the United States Air Force.
Dr. Swartz is an endodontist and Captain in the United States Air Force,

Journal of EndodonUcs
McGuire AFB, New Jersey. Dr. Skidmore is professor and chairman of
endodontics, and Dr. Griffin is professor of endodontics at West Virginia
University School of Dentistry. Requests for reprints should be directed to
Dr. A. E. Skidmore, Department of Endodontics, West Virginia University
School of Dentistry, Morgantown, WV 26506.

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