Indications for endodontic surgery in private practice and temporal trends before and after adoption of laser-activated irrigation: a retrospective practice-based study

Abstract

OBJECTIVES: To characterize indications for endodontic microsurgery (EMS) and compare the relative proportion of these indications across two calendar periods before and after the practice's adoption of laser-activated irrigation (LAI). MATERIALS AND METHODS: A retrospective time-period comparison of consecutive EMS cases (n = 1,672) treated by six endodontists (April 2019-August 2025) was analyzed. Two periods were prespecified based exclusively on the date of surgery: Before-Laser Treatment (BLT) and After-Laser Treatment (ALT) following implementation of an Er, Cr: YSGG intracanal LAI protocol (August 2022). Each surgical tooth was assigned one or two predefined reasons. Proportions were compared between periods using Generalized Estimating Equations (GEE) adjusting for patient clustering, demographics, tooth class, and provider. RESULTS: The most frequent indications overall were large post (22.2%), uncleaned accessory canal (21.8%), and excessive calcification (14.4%). In adjusted models, the proportion of EMS cases attributed to uncleaned accessory canals decreased from 26.6% (204/767) in BLT to 17.7% (160/905) in ALT (adjusted OR = 0.49; 95% CI 0.37 to 0.65; P < .001). Conversely, the proportion of EMS cases attributed to excessive calcification increased from 10.8% (83/767) to 17.3% (157/905) (adjusted OR = 1.65; 95% CI 1.21 to 2.25; P = .002). CONCLUSIONS: In this practice-based case series, the ALT period was associated with a lower proportion of EMS cases performed for uncleaned accessory canals. By contrast, the proportion of EMS cases attributed to excessive calcification was higher in the ALT period. Causal inference regarding LAI effectiveness is limited by the time-period design and the lack of non-surgical denominator. CLINICAL RELEVANCE: Following the adoption of laser-activated irrigation (LAI) in non-surgical endodontics, uncleaned accessory anatomy constituted a smaller relative share of subsequent microsurgical cases. Conversely, clinicians should anticipate a continued substantial burden of calcification- and post-related surgical challenges.

The authors' abstract, as published at the source. Clinical Oral Investigations, 2026 · DOI ↗