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Title Improved Sensitivity of Cone-Beam Computed Tomography for Periapical Lesion Detection Compared with Periapical Radiography
Clinical Question In adult patients with posterior teeth symptomatic of pulpal necrosis, is CBCT more accurate than conventional PA radiography in detecting apical lesions?
Clinical Bottom Line In posterior permanent teeth, it was noted that CBCT was significantly more sensitive in detecting periapical lesions and other anatomic structures compared to conventional PA radiography. However, due to the high cost and limited availability of CT in general dental practices, CT should be considered as an adjunct to conventional radiography in cases where pathology is not detectable by conventional radiography even though clinical tests and patient symptoms indicate so, when other anatomic structures are in close proximity to the roots, or when endodontic surgery is planned. (See Comments on the CAT below)
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 18436034Low/200874 teeth yielding 156 roots from 45 adult patients (mean age 51 yrs) referred for possible periapical surgery with clinical signs or symptoms and/or radiographic apical periodontitis, previous endo treatment, and involved teeth examined with periapical radiography and cone beam tomography (CBT)Clinical trial
Key resultsPeriapical radiographs were concurrently analyzed by an endodontist & an oral radiologist, with CBCT images analyzed at least 2 weeks later. 47 roots had no discernable lesions with PA and CBT. 72 roots had lesions detected by both modalities, and 37 roots had lesions discernable only by CBT and missed by PA radiography. Overall results showed 34% of lesions were missed by PA radiography compared to CBT (p<0.001). The detection of lesions with roots in close proximity to the maxillary sinus was significantly worse for PA radiography alone, and second molars proved most difficult for lesion detection by PA radiography alone. Lesions classified by PA radiography as being in contact with or overlapping the maxillary sinus floor were found to still have interposing bone by CBT. PA radiography was significantly worse at detecting lesions that expanded into the maxillary sinus than CBT. CBT identified more teeth with sinus membrane thickening, apico marginal communication, and missed canals than PA radiography.
#2) 11740486Velvart/200150 patients (mean 50 - 11 yrs) referred for surgical tx of a persistent apical periodontitis in 80 roots of previously treated mandibular premolars & molars. Each patient was examined clinically & radiographically with periapical (PA) radiography and high resolution computed tomography (CT) for each tooth. All involved teeth had the planned periapical surgery within 2-3 weeks from the radiographic exposure.Clinical Trial
Key resultsA single examiner analyzed all radiographic & CT images separately to detect and localize periapical lesions in relation to the mandibular canal. All 78 lesions diagnosed during surgery were identified by CT, compared to only 61 detected by conventional radiographs (Chi Square, P<0.0001). The mandibular canal was detected in only 31 cases by PA radiography compared to all cases by CT (P<0.0001).
Evidence Search PubMed: (Periapical Periodontitis;[Mesh] OR &;Periapical Abscess&;[Mesh]) And ;Tomography, X-Ray Computed&;[Mesh] ...view in PubMed
Comments on
The Evidence
The evidence seems to show that Computed Tomography is a more sensitive method for identifying, characterizing and localizing periapical abscesses in adult posterior teeth in addition to surrounding anatomic structures than conventional Periapical Radiography. Though the results were statistically significant for certain comparisons, others did not show any statistical significance. Further testing, using controls and randomization, would further validate the evidence as presented.
Applicability Computed Tomography, that is utilized in other areas of medicine due to its sensitivity and ability to characterize objects of interest, is more costly than conventional radiography and is less available. It should be considered as an adjunct to conventional radiographic diagnosis of periapical lesions, but should be reserved for cases that have not responded to previous conventional therapy, when the roots of adult posterior teeth are in close proximity to anatomic structures such as the mandibular canal or maxillary sinus, or surgery is being considered.
Specialty/Discipline (Oral Medicine/Pathology/Radiology) (Endodontics) (General Dentistry) (Oral Surgery) (Periodontics)
Keywords Computed Tomography, Apical Periodontitis, Posterior Maxillary Teeth, Apical Lesion, Cone Beam Computed Tomography
ID# 287
Date of submission: 11/11/2009spacer Revised: 10/12/2011
E-mail miklos@livemail.uthscsa.edu
Author Patrick Miklos, DDS
Co-author(s) e-mail
Faculty mentor/Co-author Stephen Matteson, DDS
Faculty mentor/Co-author e-mail matteson@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
post a rationale
None available
Comments and Evidence-Based Updates on the CAT
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by Stacey Carawan (San Antonio, TX) on 04/12/2012
I searched PubMed on this topic in April 2012. The articles listed in the CAT and in the previous comments are of the highest level and most recent evidence on this topic. The previously mentioned publications are also the most applicable to the clinical question as stated in the CAT.
by Tom Cockerell, D.D.S. (Fort Worth, Texas) on 09/02/2011
I have had a CBCT for a little over two years in my office. I began to find incidental findings of periapial lesions. The improved diagnostic sensitivity for lesions on aymptomatic teeth is accompanied with an unexpected requirement to inform the patient and recommend treatment. One has to think through the implications of apical lesions.
by Terry Glenn (San Antonio, TX) on 07/13/2011
A study published in the J Endod by Estrela in 2008 (PMID: 18291274 also supports the increased accuracy of CBCT for detection of apical periodontitis (AP). In this study 888 imaging exams of patients with endodontic infection were selected and analysis was performed to assess the diagnostic accuracy of the panoramic and periapical images compared to CBCT. Prevalence of AP was significantly higher with CBCT.
by Matthew Dietrich (Helotes, TX) on 07/12/2011
Recent studies, although with similar or lower levels of evidence than the Low article, support the findings of that CBCT has a higher sensitivity than traditional periapical radiographs for detecting apical periodontitis.
by Stephen R. Matteson (San Antonio, TX) on 09/20/2010
An article published by de Paula-Silva in 2009 provides additional support to the concept reported in the CAT. (PMID 19567324). Histological verification of the presence of periapical periodontitis was used as the gold standard to verify the accuracy of CBCT to detect this condition. Diagnostic accuracy of periapical radiography and CBCT was reported as 0.78 and 0.92 respectively.

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