Association between dental anxiety and intraoperative pain during root canal treatment: a cross-sectional study.

AIM: To investigate whether dental anxiety influences the intraoperative pain felt by patients during root canal treatment. METHODOLOGY: In a cross-sectional design, 180 patients (90 men and 90 women) were included. Pre-operative anxiety levels were assessed using the short-form Dental Anxiety Inventory (S-DAI). Pain during root canal treatment was evaluated using a 10-cm visual analogue scale (VAS) that ranked the level of pain between 'Absence of pain' and 'Unbearable pain'. The minimal sample size was determined using the software of the National Center for Advancing Translational Sciences (NIH, UK). Multivariate logistic regression analysis was used to identify relationships between variables. RESULTS: Mean pain level during root canal treatment was 2.2 ± 2.1. The mean anxiety S-DAI score was 27.2 ± 12.5. Fifty percent of men had mild anxiety levels, while in 70% of women anxiety was moderate or high (P = 0.017). Anxiety correlated positively with intraoperative pain (R = 0.406). Multivariate logistic regression analysis revealed that anxiety was significantly associated with intraoperative pain felt by patients (OR = 4.0; 95% C.I. = 1.7-9.3; P = 0.001). CONCLUSIONS: Anxious patients were more than twice as likely to feel moderate or intense intraoperative pain during root canal treatment. To know the patient´s degree of anxiety could help the dentist to decide whether to use anxiolytic premedication and/or supplemental local anaesthesia to assure better control of pain during root canal treatment.

Cardiovascular diseases and apical periodontitis: association not always implies causality.

BACKGROUND: Several studies published in the last two decades have found an association between the prevalence of apical periodontitis (AP) or root canal treatment (RCT) and cardiovascular diseases (CVDs). However, the demonstration of association does not prove by itself the existence of a cause-effect relationship. Two diseases can appear as statistically related without any of them directly affecting the values of the other, resulting in a non-causal relationship. The aim of this narrative review is to summarize the current state of knowledge regarding the association between AP and CVDs, analysing it according to the Hill's causality criteria. MATERIALS AND METHODS: Epidemiological studies carried out on the association between CVDs and AP or RCT published in English until 8 December 2019 were identified. Forty-four articles were selected and its results were analysed. RESULTS: Numerous cross-sectional epidemiological studies have found significant relationship between CVDs and AP. The odds ratio values range 1.6 - 5.4. However, other studies have not found significant association. Respect to RCT, some studies found correlation, but others found no association or even found that RCT is a protective factor against CVDs. CONCLUSIONS: The results are inconsistent and a causal relationship between CVDS and endodontic disease cannot be stablished. The risk factors common to both diseases can act as confounding factors, biasing the results. To reach definitive conclusions about the type of association (causal or non-causal) between both diseases, longitudinal epidemiological studies must be carried out to establish the temporal relationship and the dose-response gradient.

Effectiveness and clinical implications of the use of topical antibiotics in regenerative endodontic procedures: a review.

Regenerative endodontic procedures (REPs) are biologically based procedures planned to replace damaged tissues, including dentinee and root structures, as well as cells of the pulp-dentine complex. Effective sterilization of the root canal is essential in REPs, and antibiotics have been widely used to disinfect root canals. The aim of this paper was to review the scientific literature on (i) Effectiveness of antibiotics used in REPs against bacteria implicated in endodontic disease; (ii) Scientific evidence supporting the use of topical antibiotics in REPs; (iii) Clinical implications of the use of antibiotics in REPs and the possible side effects; (iv) Effect of antibiotics on dental pulp stem cells; and (v) Ongoing research on the use of antibiotics in REPs. Antibiotics used in REPs are effective against bacteria implicated in endodontic infections. Triple antibiotic pastes with minocycline attain complete disinfection of immature teeth with necrotic pulps, without affecting SCAP. Experimental studies carried out in dogs support the use of antibiotics in REPs. Clinical studies report high success rates of RET using antibiotics as intracanal dressings. However, tooth discolouration is an important side effect of the use of TAP. An antibiotic paste containing only metronidazole and ciprofloxacin could be a good alternative to the use of TAP. The use of antibiotic-containing scaffolds or clindamycin-modified triple antibiotic (metronidazole, ciprofloxacin and clindamycin) polymer could be a biologically safe antimicrobial drug delivery system in REPs.

Dental students' knowledge regarding the indications for antibiotics in the management of endodontic infections.

AIM: To determine the knowledge of undergraduate Spanish dental students regarding the indications of systemic antibiotics in the management of endodontic infections. METHODOLOGY: The final year dental students from four Spanish dental schools were requested to answer a one-page questionnaire on the indications for systemic antibiotics in the treatment of endodontic infections. One hundred and seventy-five students were asked to participate in this research. Data were analysed using descriptive statistics and chi-square test. RESULTS: One hundred and four students (93.7%) completed satisfactorily the survey and were included in the study. The average duration of antibiotic therapy was 7.0 ± 2.0 days. All respondents chose amoxicillin as the first-choice antibiotic in patients with no medical allergies, alone (47%) or associated with clavulanic acid (53%). The first drug of choice for patients with an allergy to penicillin was clindamycin 300 mg (99%). For cases of irreversible pulpitis, up to 63% of students would prescribe antibiotics. For the scenario of a necrotic pulp, symptomatic apical periodontitis and no swelling, 44% would prescribe antibiotics. Almost 40% of students would prescribe antibiotics for necrotic pulps with asymptomatic apical periodontitis and a sinus tract. CONCLUSIONS: It is necessary for the Spanish schools of dentistry to improve students' knowledge about antibiotics and their indications in endodontics. Interactive education analysing real endodontic cases using problem-based learning would help students acquire better skills in prescribing antibiotics in pulp-periapical pathosis.

Slow drilling speeds for single-drill implant bed preparation. Experimental in vitro study.

AIMS: To evaluate the real-time bone temperature changes during the preparation of the implant bed with a single-drill protocol with different drill designs and different slow drilling speeds in artificial type IV bone. MATERIALS AND METHODS: For this experimental in vitro study, 600 implant bed preparations were performed in 10 bovine bone disks using three test slow drilling speeds (50/150/300 rpm) and a control drilling speed (1200 rpm). The temperature at crestal and apical areas and time variations produced during drilling with three different drill designs with similar diameter and length but different geometry were recorded with real-life thermographic analysis. Statistical analysis was performed by two-way analysis of variance. Multiple comparisons of temperatures and time with the different drill designs and speeds were performed with the Tukey's test. RESULTS: T Max values for the control drilling speed with all the drill designs (D1 + 1200; D2 + 1200; D3 + 1200) were higher compared to those for the controls for 11 ± 1.32 °C (p < 0.05). The comparison of T Max within the test groups showed that drilling at 50 rpm resulted in the lowest temperature increment (22.11 ± 0.8 °C) compared to the other slow drilling speeds of 150 (24.752 ± 1.1 °C) and 300 rpm (25.977 ± 1.2 °C) (p < 0.042). Temperature behavior at crestal and apical areas was similar being lower for slow drilling speeds compared to that for the control drilling speed. Slow drilling speeds required significantly more time to finish the preparation of the implant bed shown as follows: 50 rpm > 150 rpm > 300 rpm > control (p < 0.05). CONCLUSIONS: A single-drill protocol with slow drilling speeds (50, 150, and 300 rpm) without irrigation in type IV bone increases the temperature at the coronal and apical levels but is below the critical threshold of 47 °C. The drill design in single-drill protocols using slow speeds (50, 150, and 300 rpm) does not have an influence on the thermal variations. The time to accomplish the implant bed preparation with a single-drill protocol in type IV bone is influenced by the drilling speed and not by the drill design. As the speed decreases, then more time is required.

Survival rates and bone loss after immediate loading of implants in fresh extraction sockets (single gaps). A clinical prospective study with 4 year follow-up.

BACKGROUND: The aim of this prospective study was to report the outcome of treatment with implants inserted after tooth extraction and immediately loaded. MATERIAL AND METHODS: Fifty-six patients with single tooth loss were treated with 116 IPX Galimplant® implants with internal connections and a sandblasted, acid-etched surface. All implants were placed after tooth extraction using a flapless approach without bone regeneration, and they were then immediately loaded with cemented acrylic prostheses. After a period of three months, definitive cemented ceramic prostheses were placed. Patients were examined throughout a total of 4 years of follow-up. Marginal bone loss and survival rates were evaluated using digital periapical radiographs, taking into account clinical variables such as age, gender, smoking, history of periodontitis, etiology of extraction, placement site, diameter, and implant length. The Mann-Whitney U and Kruskal-Wallis non-parametric tests were used to compare differences between subgroups created based on the different clinical variables identified. RESULTS: Clinical results indicate an implant survival and success rate of 97.4%. Three implants were lost. Of the 116 immediate acrylic single crowns initially placed, 113 were replaced with definitive ceramic crowns after 3 months. A total of 77.8% of implants were inserted in the maxilla, while 22.2% were inserted in the mandible. No further complications were reported after the follow-up period (4 years). The mean marginal bone loss was 0.67 mm ± 0.40 mm. No differences were found among the subgroups of study patients. CONCLUSIONS: This study indicates that dental implants that are inserted after tooth extraction and immediately loaded may constitute a successful and predictable alternative implant treatment.

Buccal bone dimensions and aesthetic outcome at maxillary incisors replaced by conventional dental implants. A case series with a 5-year follow-up.

In the aesthetic field, successful replacement of a tooth with a dental implant requires blend and harmony within the existing dentition. The influence of the dimension of buccal bone at implant sites on aesthetic outcomes and the relation between buccal bone horizontal and vertical dimensions are unclear. The aim of the present study is to investigate the correlation between buccal bone thickness, buccal bone level and aesthetic outcome in conventionally placed implants ­ placed five or more years previously ­ supporting single maxillary incisors. Eight subjects with 8 implants and with periapical and parallel profile X-rays were clinically examined to assess the "Pink Aesthetic Score" (PES). Buccal bone level and thickness, together with the interproximal bone level, were measured. Implant survival was 100%. The mean time of implants function was 89.3 months (standard deviation 43, range 61-145). The mean PES value was 9.4. The mean interproximal bone level was located 1.3 mm apically to the implant abutment junction, while the corresponding buccal value was 1.6 mm. Buccal bone was mostly absent at the implant abutment junction; 2 and 4 mm apically respect to the junction the thickness was on average 0.44 and 0.89 mm, respectively. The dimension of buccal bone level was correlated to the buccal bone thickness at 2mm-level, to the interproximal bone level and to the soft tissue contour score. Conventional implant placement in pristine bone might lead to satisfactory long-term aesthetic results. The level of the facial mucosa and appearance of the alveolar process might emerge as critical aspects.

A novel CAD/CAM-based surgical template for mandibular osteoplasty and guided implant insertion.

Bone shaping is often a necessary procedure prior to implant insertion in mandibular full-arch rehabilitations. Adopting guided surgery procedures is necessary to use two distinct templates: one for bone shaping, a second for guided implant insertion. The present report describes the case of a 60-year-old patient requiring a full-arch, immediately loaded implant-supported mandibular rehabilitation. A CAD/CAM-bone supported surgical template for osteoplasty was used to develop a template for guided implant during an all-on-six immediate-loaded computer-aided implant surgery. The report describes the feasibility, accuracy and usefulness of this double, CAD/CAM developed, surgical template.

Diabetes mellitus, periapical inflammation and endodontic treatment outcome.

The possible connection between chronic oral inflammatory processes, such as apical periodontitis and periodontal disease (PD), and systemic health is one of the most interesting aspects faced by the medical and dental scientific community. Chronic apical periodontitis shares important characteristics with PD: 1) both are chronic infections of the oral cavity, 2) the Gram-negative anaerobic microbiota found in both diseases is comparable, and 3) in both infectious processes increased local levels of inflammatory mediators may have an impact on systemic levels. One of the systemic disorders linked to PD is diabetes mellitus (DM); is therefore plausible to assume that chronic apical periodontitis and endodontic treatment are also associated with DM. The status of knowledge regarding the relationship between DM and endodontics is reviewed. Upon review, we conclude that there are data in the literature that associate DM with a higher prevalence of periapical lesions, greater size of the osteolityc lesions, greater likelihood of asymptomatic infections and worse prognosis for root filled teeth. The results of some studies suggest that periapical disease may contribute to diabetic metabolic dyscontrol.

Study of external root resorption during orthodontic treatment in root filled teeth compared with their contralateral teeth with vital pulps.

AIM: To determine whether root filled teeth and those with vital pulps exhibit a similar degree of external root resorption (ERR) as a consequence of orthodontic treatment. METHODOLOGY: The study sample consisted of 77 patients, with a mean age of 32.7 +/- 10.7 years, who had one root filled tooth before completion of multiband/bracket orthodontic therapy for at least 1 year. For each patient, digital panoramic radiographs taken before and after orthodontic treatment were used to determine the proportion of external root resorption (PRR), defined as the ratio between the root resorption in the root filled tooth and that in its contralateral tooth with a vital pulp. The student's t-test, anova and logistic regression analysis were used to determine statistical significance. RESULTS: The mean PRR was 1.00 +/- 0.13, indicating that, in the total sample, there were no significant differences in root resorption in the root filled teeth and their contralateral teeth with vital pulps. Multivariate logistic regression analysis suggested that PRR was significantly greater in incisors (P = 0.0014; odds ratio = 6.2885, C.I. 95% = 2.0-19.4), compared to other teeth, and in women (P = 0.0255; odds ratio = 4.2, C.I. 95% = 1.2-14.6), compared to men. CONCLUSIONS: There was no significant difference in the amount or severity of external root resorption during orthodontic movement between root filled teeth and their contralateral teeth with vital pulps.

Pattern of antibiotic prescription in the management of endodontic infections amongst Spanish oral surgeons.

AIM: To identify antibiotic prescription practices in the treatment of endodontic infections amongst Spanish oral surgeons. METHODOLOGY: Members of the Spanish Oral Surgery Society (SECIB) were surveyed on antibiotic prescription on six different pulpal and periapical diagnoses. A total of 200 questionnaires were delivered with 127 returned (64%). RESULTS: The average duration of antibiotic therapy was 7.0 +/- 1.0 days. Ninety five percent of respondents selected amoxicillin as the first choice antibiotic in patients with no medical allergies, alone (34%) or associated to clavulanate (61%). The first drug of choice for patients with an allergy to penicillins was clindamycin 300 mg (65%), followed by azithromycin (15%) and metronidazole-spiramycin (13%). For cases of irreversible pulpitis, 86% of respondents prescribed antibiotics. For the scenario of a necrotic pulp, acute apical periodontitis and no swelling, 71% prescribed antibiotics. Almost 60% of respondents prescribed antibiotics for necrotic pulps with chronic apical periodontitis and a sinus tract; in this clinical situation, odontologists prescribed more frequently antibiotics compared to stomatologists (P = 0.0080; odds ratio = 8.0; C. I. 95% = 1.7-37.1). CONCLUSIONS: The majority of the members of the SECIB were selecting the appropriate antibiotic for use in endodontic infections, but there are still many who are prescribing antibiotics inappropriately. The use of antibiotics for minor infections, or in some cases in patients without infections, could be a major contributor to the world problem of antimicrobial resistance.

Horizontal augmentation of the maxillary alveolar ridge to change the prosthetic profile: Clinical and radiological results of a retrospective study.

BACKGROUND: In this retrospective study, we aimed to analyze the clinical and radiological results of compensating the long-term deficiencies in hard and soft tissues of edentulous patients by placing dental implants and performing a horizontal ridge augmentation. MATERIAL AND METHODS: We treated patients with edentulous maxillaries (Cawood-Howell type III or IV) by combining 4 implants, or 6 implants, or using zygomatic and conventional anterior implants as appropriate. Simultaneously, horizontal ridge augmentation was performed by combining autologous bone with Bio-Oss and membranes. RESULTS: A total of 14 zygomatic and 80 standard implants were used for the rehabilitations in 16 edentulous patients. The success rates were 93.75% and 85.71% for the standard and zygomatic implants, respectively. Also, respective gains of 5.79mm and 3.25mm were obtained at the levels of the midsagittal line and canines, with respective resorption rates of 10% and 8.6% after 20months. CONCLUSION: The millimeters gained by performing a horizontal augmentation optimizes the relation between the implant position and the prosthetic profile. This allows the different prostheses to be selected and for rehabilitation to be optimized. In this way, mucosal coverage can be avoided and fixed prosthetic design can be enhanced.

Pain associated with root canal treatment.

AIM: To determine the pain experienced by patients during root canal treatment and to correlate with age and gender, pulpal diagnosis, previous periapical status, dental characteristics and length of treatment. METHODOLOGY: One hundred and seventy-six patients (68 men and 108 women), with ages ranged from 6 to 83 years, were randomly recruited. Patients completed a 10-cm visual analogue scale (VAS) that ranked the level of pain experienced during root canal treatment. RESULTS: The mean pain level during root canal treatment was 1.2 +/- 0.8 in a VAS between 0 and 10. Fifty-four per cent of patients did not experience pain. There were no significant differences in relation to gender or age groups. Mandibular teeth had a significantly (P < 0.05) higher percentage incidence of pain in comparison with maxillary teeth. Pain was absent in 63% of anterior teeth compared with 44% in posterior ones (P < 0.01). Interventions shorter than 45 min resulted in a significantly higher percentage of pain absence (P < 0.05). Root canal treatment was significantly (P < 0.05) more painful in teeth with irreversible pulpitis and acute apical periodontitis compared to the group with necrotic pulps and chronic apical periodontitis (P = 0.049). CONCLUSIONS: Root canal treatment in teeth with irreversible pulpitis and acute apical periodontitis was more painful. Age, tooth type and length of the treatment were factors associated with increased risk for pain experienced during the procedure. Knowledge of pain levels endured by patients will allow dentists to decide when to use supplemental local anaesthesia.

High prevalence of apical periodontitis amongst smokers in a sample of Spanish adults.

AIM: To study the prevalence of apical periodontitis in smoker and nonsmoker patients. METHODOLOGY: In a cross-sectional study, the records of 180 subjects, 109 smokers and 71 nonsmokers, were examined. All participants underwent a full-mouth radiographic survey incorporating 14 periapical radiographs. The periapical region of all teeth, excluding third molars, was examined. Periapical status was assessed using the Periapical Index score. Statistical analyses were conducted using the Cohen's Kappa test, analysis of variance and logistic regression. RESULTS: Apical periodontitis in at least one tooth was found in 74% of smokers and in 41% of nonsmokers (P < 0.01; odds ratio = 4.2; 95% C. I. = 2.2-7.9). Amongst smoker patients 5% of the teeth had apical periodontitis, whereas in nonsmoker subjects 3% of teeth were affected (P = 0.008; odds ratio = 1.5; 95% C. I. = 1.1-2.1). The percentage of root filled teeth in smoker and nonsmoker patients was 2.5% and 1.5%, respectively (P < 0.05; odds ratio = 1.7; C. I. 95% = 1.0-2.6). CONCLUSIONS: In this study population, smoking was significantly associated with a greater frequency of root canal treatment and with an increased prevalence of apical periodontitis.

Relevant aspects in the surface properties in titanium dental implants for the cellular viability.

Roughness and topographical features are the most relevant of the surface properties for a dental implant for its osseointegration. For that reason, we studied the four surfaces more used in titanium dental implants: machined, sandblasted, acid etching and sandblasted plus acid etching. The roughness and wettability (contact angle and surface free energy) was studied by means 3D-interferometric microscope and sessile drop method. Normal human gingival fibroblasts (HGF) were obtained from small oral mucosa biopsies and were used for cell cultures. To analyze cell integrity, we first quantified the total amount of DNA and LDH released from dead cells to the culture medium. Then, LIVE/DEAD assay was used as a combined method assessing cell integrity and metabolism. All experiments were carried out on each cell type cultured on each Ti material for 24h, 48h and 72h. To evaluate the in vivo cell adhesion capability of each Ti surface, the four types of discs were grafted subcutaneously in 5 Wistar rats. Sandblasted surfaces were significantly rougher than acid etching and machined. Wettability and surface free energy decrease when the roughness increases in sand blasted samples. This fact favors the protein adsorption. The DNA released by cells cultured on the four Ti surfaces did not differ from that of positive control cells (p>0.05). The number of cells per area was significantly lower (p<0.05) in the sand-blasted surface than in the machined and surface for both cell types (7±2 cells for HGF and 10±5 cells for SAOS-2). The surface of the machined-type discs grafted in vivo had a very small area occupied by cells and/or connective tissue (3.5%), whereas 36.6% of the sandblasted plus acid etching surface, 75.9% of sandblasted discs and 59.6% of acid etching discs was covered with cells and connective tissue. Cells cultured on rougher surfaces tended to exhibit attributes of more differentiated osteoblasts than cells cultured on smoother surfaces. These surface properties justify that the sandblasted implants is able to significantly increase bone contact and bone growth with very good osseointegration results in vivo.

High prevalence of apical periodontitis amongst type 2 diabetic patients.

AIM: To study the prevalence of AP in patients with and without type 2 diabetes mellitus. METHODOLOGY: In a retrospective cohort study, the records of 38 subjects with diabetes and 32 control subjects were examined. All participants underwent a full-mouth radiographic survey incorporating 14 periapical radiographs. The periapical region of all teeth, excluding third molars, was examined. Periapical status was assessed using the periapical index score. Statistical analyses were conducted using the Cohen's kappa test, analysis of variance and logistic regression. RESULTS: Apical periodontitis in at least one tooth was found in 81.3% of diabetic patients and in 58% of control subjects (P = 0.040; OR = 3.2; 95% CI = 1.1-9.4). Amongst diabetic patients 7% of the teeth had AP, whereas in the control subjects 4% of teeth were affected (P = 0.007; OR = 1.8; 95% CI = 1.2-2.8). CONCLUSIONS: Type 2 diabetes mellitus is significantly associated with an increased prevalence of AP.

Prevalence of apical periodontitis and frequency of root-filled teeth in an adult Spanish population.

AIM: To estimate the prevalence of teeth with apical periodontitis (AP) and root-filled teeth in an adult Spanish population. METHODOLOGY: A total of 180 subjects, aged 37.1 +/- 15.7 years, presenting as new patients to the Faculty of Dentistry, Seville, Spain, were examined. All participants underwent a full-mouth radiographic survey (14 periapical radiographs). The frequency of root canal treatment and the periapical status of all teeth, using the periapical index (PAI) score, were assessed. An intraobserver agreement test on PAI scores produced a Cohen's kappa of 0.77 (substantial agreement). Results were analysed statistically using the Chi-square test. RESULTS: Apical periodontitis in one or several teeth was found in 110 subjects (61.1% prevalence), and 73 (40.6% prevalence) had at least one root-filled tooth. Among subjects with root-filled teeth, 48 (65.8%) had AP affecting at least one root-filled tooth. A total of 4453 teeth were examined, of these 186 (4.2%) had AP. The total number of root-filled teeth was 93 (2.1%), of which 60 (64.5%) had AP. Among non-root filled teeth, only 2.9% had AP. The prevalence of AP in connection with molar teeth was higher (5.5%) than for premolar (4.5%) and anterior teeth (3.2%; P < 0.01). More premolar and molar teeth were root-filled (2.8 and 2.7%, respectively) than anterior teeth (1.3%; P < 0.01). The prevalence of AP increased with age. CONCLUSIONS: The prevalence of AP in root-filled and untreated teeth, and the frequency of root-filled teeth were comparable to those reported in previous similar studies carried out in European countries. The prevalence of root-filled teeth with AP was found to be higher compared to that demonstrated in other epidemiological studies.

Periapical status and quality of root fillings and coronal restorations in an adult Spanish population.

AIM: To investigate the quality of root fillings and coronal restorations and their association with periapical status in an adult Spanish population. METHODOLOGY: A total of 180 subjects, aged 37.1 +/- 15.7 years, who presented as new patients at the Faculty of Dentistry, Seville, Spain, were examined. All participants underwent a full-mouth radiographic survey incorporating 14 periapical radiographs. The periapical region of all root filled teeth, excluding third molars, were examined. The technical quality of root fillings was evaluated in terms of length in relation to the root apex and lateral adaptation to the canal wall. Radiographic signs of overhang or open margins associated with coronal restorations were also evaluated. Periapical status was assessed using the Periapical Index score. Statistical analyses were conducted using the Cohen's kappa test and logistic regression. RESULTS: The total number of root filled teeth was 93, and 60 (64.5%) had apical periodontitis (AP). Presence of AP in root filled teeth was associated with inadequate adaptation of the filling (OR = 2.29; P = 0.06), inadequate length of the root filling (OR = 2.44; P = 0.048), and with poor radiographic quality of the coronal restoration (OR = 2.38; P = 0.054). Only 34.4% of the root fillings were adequate from a technical perspective. When both root fillings and coronal restorations were adequate the incidence of AP decreased to 31.3% (OR = 5.50; P < 0.01). CONCLUSIONS: The incidence of AP in root filled teeth was high. Many root fillings were technically unsatisfactory. Adequate root fillings and coronal restorations were associated with a lower incidence of AP; an adequate root filling had a more substantial impact on the outcome of treatment than the quality of the coronal restoration.