Endodontic procedures for retreatment of periapical lesions

Massimo Del Fabbro; Stefano Corbella; Patrick Sequeira‐Byron; Igor Tsesis; Eyal Rosen; Alessandra Lolato; Silvio Taschieri

doi:10.1002/14651858.CD005511.pub3

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Figure 1

Study flow diagram

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Figure 4

Forest plot of comparison: 1 Root‐end resection versus root canal retreatment, outcome: 1.1 Healing ‐ one year

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Figure 5

Forest plot of comparison: 6 Ultrasonic versus Bur, outcome: 6.1 Healing ‐ one year

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Analysis 1.1

Comparison 1 Root‐end resection versus root canal retreatment, Outcome 1 Healing ‐ 1 year.

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Analysis 1.2

Comparison 1 Root‐end resection versus root canal retreatment, Outcome 2 Healing ‐ 4 years.

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Analysis 1.3

Comparison 1 Root‐end resection versus root canal retreatment, Outcome 3 Healing ‐ 10 years.

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Analysis 1.4

Comparison 1 Root‐end resection versus root canal retreatment, Outcome 4 Participants reporting pain.

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Analysis 1.5

Comparison 1 Root‐end resection versus root canal retreatment, Outcome 5 Participants reporting swelling.

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Analysis 2.1

Comparison 2 CBCT versus periapical radiography, Outcome 1 Healing ‐ 1 year.

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Analysis 3.1

Comparison 3 Antibiotic prophylaxis versus placebo, Outcome 1 Occurrence of postoperative infection ‐ 4 weeks.

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Analysis 4.1

Comparison 4 Magnification devices, Outcome 1 Loupes versus endoscope ‐ healing at 1 year.

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Analysis 4.2

Comparison 4 Magnification devices, Outcome 2 Microscope versus endoscope ‐ healing at 2 years.

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Analysis 5.1

Comparison 5 Type of incision, Outcome 1 PBI versus complete mobilisation ‐ papilla height.

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Analysis 5.2

Comparison 5 Type of incision, Outcome 2 PBI versus complete mobilisation ‐ pain.

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Analysis 6.1

Comparison 6 Ultrasonic versus bur, Outcome 1 Healing ‐ 1 year.

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Analysis 7.1

Comparison 7 Root‐end filling material, Outcome 1 MTA versus IRM ‐ healing at 1 year.

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Analysis 7.2

Comparison 7 Root‐end filling material, Outcome 2 MTA versus IRM ‐ healing at 2 years.

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Analysis 7.3

Comparison 7 Root‐end filling material, Outcome 3 MTA versus IRM ‐ pain.

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Analysis 7.4

Comparison 7 Root‐end filling material, Outcome 4 SuperEBA versus MTA ‐ healing at 1 year.

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Analysis 7.5

Comparison 7 Root‐end filling material, Outcome 5 MTA versus gutta‐percha ‐ healing at 1 year.

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Analysis 7.6

Comparison 7 Root‐end filling material, Outcome 6 MTA versus gutta‐percha ‐ pain.

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Analysis 7.7

Comparison 7 Root‐end filling material, Outcome 7 Glass ionomer cement (GIC) vs amalgam ‐ healing at 1 year.

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Analysis 7.8

Comparison 7 Root‐end filling material, Outcome 8 Glass ionomer cement (GIC) vs amalgam ‐ healing at 5 years.

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Analysis 7.9

Comparison 7 Root‐end filling material, Outcome 9 IRM vs Gutta‐percha ‐ healing > 1 year.

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Analysis 7.10

Comparison 7 Root‐end filling material, Outcome 10 IRM vs SuperEBA ‐ healing > 1 year.

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Analysis 8.1

Comparison 8 Grafting versus no grafting, Outcome 1 Calcium sulphate (CaS) versus no grafting ‐ healing at 1 year.

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Analysis 8.2

Comparison 8 Grafting versus no grafting, Outcome 2 GTR with bovine bone vs no grafting ‐ healing at 1 year ‐ TB.

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Analysis 8.3

Comparison 8 Grafting versus no grafting, Outcome 3 PRGF versus no grafting ‐ pain (VAS).

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Analysis 9.1

Comparison 9 Low energy level laser therapy (LLLT) versus placebo versus control, Outcome 1 Maximum pain (VRS).

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Summary of findings for the main comparison. Root‐end resection versus root canal retreatment

Root‐end resection versus root canal retreatment
Patient or population: people requiring retreatment of periapical lesions Setting: university clinics Intervention: root‐end resection (with root‐end filling) Comparison: root canal retreatment
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with root canal retreatment	Risk with root‐end resection and filling
Healing ‐ 1 year	726 per 1000	835 per 1000 (704 to 980)	RR 1.15 (0.97 to 1.35)	126 (2 RCTs)	⊕⊝⊝⊝ very low^a,b,c	RR after 4 years was 1.03 (0.89 to 1.20) (1 study, 82 participants) RR after 10 years was 1.11 (0.88 to 1.41) (1 study, 95 participants)
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Not assessed
Prevalence of pain ‐ 1 day	279 out of 1000	932 out of 1000 (572 to 1515)	RR 3.34 (2.05 to 5.43)	87 (1 study)	⊕⊕⊝⊝ low^d	Number of participants reporting pain each day in the first postoperative week was significantly higher in the surgical group than in the non‐surgical group.
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aQuality of evidence was downgraded owing to heterogeneity (inconsistency). ^bQuality of evidence was downgraded owing to imprecision (CI includes RR of 1.0). ^cQuality of evidence was downgraded because both studies had high risk of bias. ^dQuality of evidence was downgraded because it was based on a single small study at high risk of bias.

Summary of findings for the main comparison. Root‐end resection versus root canal retreatment

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Summary of findings 2. Cone beam computed tomography (CBCT) versus periapical radiography

CBCT versus periapical radiography
Patient or population: people requiring retreatment of periapical lesions Setting: university Interventions: CBCT vs periapical radiography
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with periapical radiography	Risk with CBCT
Healing ‐ 1 year	737 per 1000	752 per 1000 (516 to 1000)	RR 1.02 (0.70 to 1.47)	39 (1 RCT)	⊕⊝⊝⊝ very low^a
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Not assessed
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
^aQuality of evidence was downgraded because it was derived from a single study at high risk of bias with imprecise results.

Summary of findings 2. Cone beam computed tomography (CBCT) versus periapical radiography

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Summary of findings 3. Preoperative antibiotic prophylaxis versus placebo

Preoperative antibiotic prophylaxis versus placebo
Patient or population: people requiring retreatment of periapical lesions Setting: university Interventions: preoperative antibiotic prophylaxis vs placebo
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with placebo	Risk with antibiotic prophylaxis
Healing ‐ 1 year	Not assessed
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Not assessed
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	32 per 1000	16 per 1000 (3 to 85)	RR 0.49 (0.09 to 2.64)	250 (1 RCT)	⊕⊝⊝⊝ very low^a
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
^aQuality of evidence was downgraded because it was derived from a single study at unclear risk of bias with very imprecise results.

Summary of findings 3. Preoperative antibiotic prophylaxis versus placebo

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Summary of findings 4. Magnification devices

Different types of magnification devices
Patient or population: people requiring retreatment of periapical lesions Setting: university Interventions: magnification devices
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with loupes or microscope	Risk with endoscope
Loupes vs endoscope ‐ healing at 1 year	906 per 1000	952 per 1000 (834 to 1000)	RR 1.05 (0.92 to 1.20)	62 (71 teeth) (1 RCT)	⊕⊕⊝⊝ low^a
Microscope vs endoscope ‐ healing at 2 years	902 per 1000	911 per 1000 (803 to 1000)	RR 1.01 (0.89 to 1.15)	70 (100 teeth) (1 RCT)	⊕⊕⊝⊝ low^a
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Not assessed
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aQuality of evidence was downgraded because it was derived from a single study at high risk of bias.

Summary of findings 4. Magnification devices

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Summary of findings 5. Papilla base incision (PBI) incision versus complete mobilisation

Papilla base incision (PBI) versus complete mobilisation
Patient or population: people requiring retreatment of periapical lesions Setting: university Intervention: PBI vs complete mobilisation
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with complete mobilisation	Risk with PBI
Healing ‐ 1 year	Not assessed
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Mean pain was 90 mm	Mean pain in the intervention group was 2.25 lower (7.17 lower to 2.67 higher).	‐	38 (1 RCT)	⊕⊝⊝⊝ very low^a
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla ‐ 1 year	Mean height loss of interdental papilla was 0.98 mm.	Mean height loss of interdental papilla in the intervention group was 1.04 mm lower (1.48 lower to 0.60 lower).	‐	12 (1 RCT)	⊕⊝⊝⊝ very low^b
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
^aQuality of evidence was downgraded because it was derived from a single small study at unclear risk of bias with very imprecise results. ^bQuality of evidence was downgraded because it was derived from one small split‐mouth study at high risk of bias.

Summary of findings 5. Papilla base incision (PBI) incision versus complete mobilisation

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Summary of findings 6. Ultrasonic instruments versus bur

Ultrasonic instruments versus bur
Patient or population: people requiring retreatment of periapical lesions Setting: university Intervention: ultrasonic instruments vs bur
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with bur	Risk with ultrasonic
Healing ‐ 1 year	709 per 1000	809 per 1000 (709 to 922)	RR 1.14 (1.00 to 1.30)	290 (1 RCT)	⊕⊕⊝⊝ low^a	There was inconclusive evidence that use of ultrasonic devices could produce a better success rate after 1‐year follow‐up.
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Not assessed
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
^aQuality of evidence downgraded because it was derived from one study at high risk of bias (attrition bias).

Summary of findings 6. Ultrasonic instruments versus bur

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Summary of findings 7. Root end fillings

Different types of root end fillings
Patient or population: people requiring retreatment of periapical lesions Settings: university hospital
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of Participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Assumed risk	Corresponding risk	Relative effect (95% CI)	Number of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Intermediate restorative material (IRM)	Mineral trioxide aggregate (MTA)
Healing ‐ 1 year	806 per 1000	878 per 1000 (781 to 975)	RR 1.09 (0.97 to 1.21)	222 (2 RCTs)	⊕⊕⊝⊝ low^a,b	RR after 2 years as computed on 108 participants (1 study) was 1.05 (95% CI 0.92 to 1.20).
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Not assessed
Prevalence of pain ‐ 1 day	815 per 1000	823 per 1000 (684 to 994)	RR 1.01 (0.84 to 1.22)	100 (1 RCT)	⊕⊕⊝⊝ low^a,b	RR after 2 days as computed on 100 participants (1 study) was 0.94 (95% CI 0.73 to 1.20).
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
	MTA	SuperEBA
Healing ‐ 1 year	956 per 1000	927 per 1000 (870 to 994)	RR 0.97 (0.91 to 1.04)	192 (1 RCT)	⊕⊕⊝⊝ low^c	There was no evidence of a difference in success rate after 1‐year follow‐up when MTA or SuperEBA was used as root‐end filler.
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Not assessed
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
	Gutta‐percha	MTA
Healing ‐ 1 year	619 per 1000	990 per 1000 (706 to 1000)	RR 1.60 (1.14 to 2.24)	46 (1 RCT)	⊕⊕⊝⊝ low^c	There was evidence of better healing rate after 1‐year follow‐up when MTA as compared with gutta‐percha was used.
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Mean pain in the control group was 21.	Mean pain in the intervention groups was 4 units lower (‐16.69 to 8.69).		42 (1 RCT)	⊕⊕⊝⊝ low^c	After 2 days, mean difference in pain was 2.00 (‐6.22 to 10.22); after 3 days, mean difference in pain was 5.00 (‐4.37 to 14.37).
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
	Amalgam	Glass ionomer cement
Healing ‐ 1 year	904 per 1000	886 per 1000 (777 to 1000)	RR 0.98 (0.86 to 1.12)	105 (1 RCT)	⊕⊝⊝⊝ very low^a,d	RR after 5 years as computed on 82 participants (1 study) was 1.00 (95% CI 0.84 to 1.20).
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Not assessed
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
	Gutta‐percha	IRM
Healing ‐ 1 year (or longer)	885 per 1000	814 per 1000 (708 to 929)	RR 0.92 (0.80 to 1.05)	147 (1 RCT)	⊕⊝⊝⊝ very low^a,d	There is no evidence of a difference in success rate after 1‐year follow‐up when gutta‐percha or IRM was used as root‐end filler.
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Not assessed
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
	IRM	SuperEBA
Healing ‐ 1 year (or longer)	816 per 1000	906 per 1000 (808 per 1000)	RR 1.11 (0.99 to 1.24)	194 (1 RCT)	⊕⊝⊝⊝ very low^a,d	There was no evidence of a difference in success rate after 1‐year follow‐up when SuperEBA or IRM was used as root‐end filler.
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Not assessed
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
The basis for the assumed risk* (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
^aQuality of evidence was downgraded owing to imprecision (CI includes RR of 1.0). ^bQuality of evidence was downgraded because one study had high risk of bias (attrition bias). ^cQuality of evidence was downgraded because it was based on a single study and because of imprecision. ^dQuality of evidence was downgraded because it was based on a single study that had high risk of bias.

Summary of findings 7. Root end fillings

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Summary of findings 8. Grafting versus no grafting

Grafting versus no grafting
Patient or population: people requiring retreatment of periapical lesions Settings: university Intervention: grafting Control: no grafting
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	No grafting	Grafting
Healing ‐ 1 year		Calcium sulphate
	889 per 1000	996 per 1000 (738 per 1000)	RR 1.12 (0.83 to 1.50)	18 (1 RCT)	⊕⊕⊝⊝ low^a	There was no evidence that grafting the periapical lesion with calcium sulphate may improve healing of the lesion after 1‐year follow‐up.
		GTR + Bovine bone
	743 per 1000	832 per 1000 (639 per 1000)	RR 1.12 (0.86 to 1.46)	59 (1 RCT)	⊕⊕⊝⊝ low^a	There was no evidence that guided tissue regeneration improves healing of the lesion after 1‐year follow‐up.
		PRGF gel
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Mean pain was 73.3.	Mean pain in the intervention group was 51.6 lower (63.43 lower to 39.77 lower).	‐	36 (1 RCT)	⊕⊕⊝⊝ low^a	There was evidence that using plasma rich in growth factors may decrease postoperative pain in the early days after surgery. After 2 days, mean pain in the intervention group was 41.7 lower than in the control group (‐52.09 to ‐31.31); after 3 days, mean pain in the intervention group was 45 lower than in the control group (‐59.71 to ‐30.29).
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla	Not assessed
Maximum pain assessed with verbal rating scale (VRS)	Not assessed
The basis for the assumed risk* (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
^aQuality of evidence was downgraded two levels because it was based on a single study and because of imprecision.

Summary of findings 8. Grafting versus no grafting

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Summary of findings 9. Low energy level laser therapy versus placebo versus control

Low energy level laser therapy compared with placebo for surgical retreatment of periapical lesions
Patient or population: people requiring retreatment of periapical lesions Setting: university Intervention: low energy level laser therapy (LLLT) Control: placebo
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Placebo	LLLT
Healing ‐ 1 year	Not assessed
Pain assessed with visual analogue scale (VAS) from 0 to 100 ‐ 1 day	Not assessed
Prevalence of pain ‐ 1 day	Not assessed
Occurrence of postoperative infection ‐ 4 weeks	Not assessed
Height loss of interdental papilla ‐ 1 year	Not assessed
	Placebo	LLLT
Maximum pain assessed with verbal rating scale (VRS)	0 per 1000	0 per 1000	Not estimable	52 (1) RCT	⊕⊝⊝⊝ very low^a
	Control	LLLT
Maximum pain assessed with verbal rating scale (VRS)	300 per 1000	0 per 1000	Not estimable	44 (1) RCT	⊕⊝⊝⊝ very low^a
The basis for the assumed risk* (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect
^aQuality of evidence was downgraded three levels because it is based on a single study at high risk of bias.

Summary of findings 9. Low energy level laser therapy versus placebo versus control

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Comparison 1. Root‐end resection versus root canal retreatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Healing ‐ 1 year Show forest plot	2	126	Risk Ratio (M‐H, Fixed, 95% CI)	1.15 [0.97, 1.35]

2 Healing ‐ 4 years Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3 Healing ‐ 10 years Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4 Participants reporting pain Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4.1 day 1	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 day 2	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.3 day 3	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.4 day 4	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.5 day 5	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.6 day 6	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.7 day 7	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Participants reporting swelling Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5.1 day 1	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 day 2	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.3 day 3	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.4 day 4	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.5 day 5	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.6 day 6	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.7 day 7	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Root‐end resection versus root canal retreatment

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Comparison 2. CBCT versus periapical radiography

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Healing ‐ 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 2. CBCT versus periapical radiography

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Comparison 3. Antibiotic prophylaxis versus placebo

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Occurrence of postoperative infection ‐ 4 weeks Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 3. Antibiotic prophylaxis versus placebo

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Comparison 4. Magnification devices

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Loupes versus endoscope ‐ healing at 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2 Microscope versus endoscope ‐ healing at 2 years Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 4. Magnification devices

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Comparison 5. Type of incision

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 PBI versus complete mobilisation ‐ papilla height Show forest plot	1		Mean Difference (Fixed, 95% CI)	Totals not selected

2 PBI versus complete mobilisation ‐ pain Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1 1 day	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 2 days	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 3 days	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 5. Type of incision

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Comparison 6. Ultrasonic versus bur

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Healing ‐ 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 6. Ultrasonic versus bur

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Comparison 7. Root‐end filling material

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 MTA versus IRM ‐ healing at 1 year Show forest plot	2	222	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.97, 1.22]

2 MTA versus IRM ‐ healing at 2 years Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3 MTA versus IRM ‐ pain Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.1 1 day	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 2 days	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 SuperEBA versus MTA ‐ healing at 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5 MTA versus gutta‐percha ‐ healing at 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6 MTA versus gutta‐percha ‐ pain Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.1 1 day	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 2 days	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 3 days	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Glass ionomer cement (GIC) vs amalgam ‐ healing at 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8 Glass ionomer cement (GIC) vs amalgam ‐ healing at 5 years Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9 IRM vs Gutta‐percha ‐ healing > 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

10 IRM vs SuperEBA ‐ healing > 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 7. Root‐end filling material

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Comparison 8. Grafting versus no grafting

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Calcium sulphate (CaS) versus no grafting ‐ healing at 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2 GTR with bovine bone vs no grafting ‐ healing at 1 year ‐ TB Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3 PRGF versus no grafting ‐ pain (VAS) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1 1 day	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 2 days	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.3 3 days	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 8. Grafting versus no grafting

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Comparison 9. Low energy level laser therapy (LLLT) versus placebo versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maximum pain (VRS) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 LLLT vs control	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 LLLT vs placebo	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 placebo vs control	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 9. Low energy level laser therapy (LLLT) versus placebo versus control

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