Title

Cone-Beam Computed Tomography vs. PA’s at Detecting Small Periapical Lesions

Clinical Question

In patients with acute pulpitis or acute periapical periodontitis is CBCT better at detecting small periapical lesions than traditional periapical radiography.

Clinical Bottom Line

CBCT imaging of teeth with small endodontic problems, like acute pulpitis or periapical periodontitis, is more accurate at diagnosing small periapical lesions than traditional periapical radiographs.

Best Evidence

PubMed ID	Author / Year	Patient Group	Study type (level of evidence)
22703662	Tsai/2012	6 dry mandibles with fabricated PA lesions of increasing sizes	In-vitro Study
Key results	Six half mandible block sections were used and only non-restored and disease free teeth were used in this study. The 2 CBCT devices had higher specificities (.892 and .862) than PA radiography (.754) at being able to identify the lesions. For CBCT images the AUCs were higher for all simulated lesions sizes than traditional PA radiography, with statistically significant differences (95% CI).
19298574	Patel/2009	10 dry mandibles with fabricated PA lesions	In-vitro study
Key results	Regarding the ability of the examiner to correctly identify lesions the overall sensitivity was .248 for intraoral radiography and 1.0 for CBCT, while both techniques had specificities of 1.0. The ROC analysis for intraoral radiography showed a lower Az value (.766) for radiography than CBCT (1.0) in detecting smaller PA lesions (P=.028).

Evidence Search

cone-beam computed tomography, periapical lesions

Comments on
The Evidence

In Tsai, teeth were carefully extracted and simulated lesions were placed at the base of the socket, ranging from 0.5mm to 1.8mm. The teeth were replanted and then imaged using 2 CBCT devices and 1 intraoral radiograph. The machines used were the Kodak 9000 3D, and the Veraviewpocs 3De (Morita). 5 examiners interpreted the images in a randomized order. PA radiography demonstrates poor diagnostic accuracy for even the largest simulated lesions. In Patel, 10 first molars on dry mandibles were atraumatically extracted and a small 2mm lesion was created at the base of the socket. The teeth were imaged, and the process was repeated after enlarging the lesion to 4mm. Six examiners assessed the images in a randomized order for periapical lesions.

Applicability

Studies have shown that by the time an endodontically related periapical lesion is visible on a periapical radiograph, its prognosis for a good outcome is drastically reduced. Although the results from these studies show CBCT’s validity and reliability in detecting small lesions better than PA radiographs, its use as a diagnostic tool still needs further investigation. A CBCT has significant more cost and is exposing the patient to more radiation than a traditional PA radiograph. In addition, most general dentistry and endodontic offices most likely do not own CBCT machines, so access to this technology could present a challenge to the clinician. Ultimately, when a patient comes in with acute pulpitis, they are expecting some sort of treatment to provide pain relief and the even though CBCT can provide a much more diagnostic image, the clinician must be prudent in which imaging modality he/she chooses to use.

Specialty

(Oral Medicine/Pathology/Radiology) (Endodontics) (General Dentistry)

Keywords

Cone-beam computed tomography, endodontics, periapical lesions

ID#

2319

Date of submission

08/09/2012

E-mail

steffy@uthscsa.edu

Author

Douglas Steffy

Co-author(s)

Co-author(s) e-mail

Faculty mentor

S. Thomas Deahl, II, DMD, PhD

Faculty mentor e-mail

deahl@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?)

by Douglas Steffy (San Antonio, TX) on 09/17/2012
The biologic basis for this treatment modality is early detection is infections at the periapex before they become visible with conventional radiography. Infection of the pulp tissue by oral microorganisms as a result of caries leads to chronic inflammation of the bone tissue of dental support, developing a pathologic process known as chronic apical periodontitis. Referencing the text book, “Principles and Practice of Endodontics,” it is known that once a periapical radiolucency is visible on a periodical x-ray, its prognosis is greatly reduced. Cone beam computed tomography images can detect widening of the periodontal ligament and bony changes at the periapex much earlier thus increasing the chances for a successful root canal treatment therapy.

Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs)

None available