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ConeCanal
Root Beam-Computed
Irrigants andTomography
Disinfectants
in Endodontics
adiographic imaging is essential in diagnosis, treatment planning and follow-up in endodontics. The interpretation of an
R image can be confounded by a number of factors including the regional anatomy as well as superimposition of both the
teeth and surrounding dentoalveolar structures. As a result of superimposition, periapical radiographs reveal only limited
aspects, a two-dimensional view, of the true three-dimensional anatomy.1,2 Additionally, there is often geometric distortion
of the anatomical structures being imaged with conventional radiographic methods.3 These problems can be overcome by
utilizing small- or limited-volume cone beam-computed tomography imaging techniques, which produce accurate 3-D im-
ages of the teeth and surrounding dentoalveolar structures.1,2,4
CBCT is accomplished by using a rotating gantry to which an x-ray source and detector are fixed. A divergent pyramidal-
or cone-shaped source of ionizing radiation is directed through the middle of the area of interest onto an area x-ray detector
on the opposite side of the patient. The x-ray source and detector rotate around a fixed fulcrum within the region of interest.
During the exposure sequence, hundreds of planar projection images are acquired of the field of view (FOV) in an arc of
at least 180°. In this single rotation, CBCT provides precise, essentially immediate and accurate 3-D radiographic images.
As CBCT exposure incorporates the entire FOV, only one rotational sequence of the gantry is necessary to acquire enough
data for image reconstruction. At the present time, CBCT is considered a complementary modality for specific applications
rather than a replacement for 2-D imaging modalities.4 The Food and Drug Administration approved the first CBCT unit
for dental use in the United States in March 2001. Since then, there have been several additional CBCT units approved by
the FDA. This newsletter discusses the features, benefits and risks of using CBCT in endodontics.
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ENDODONTICS: Colleagues for Excellence
parameters used (kVp, mAs); pulsed beam versus continuous beam; amount, type and shape of the beam filtration; the
number of basis images dependent partly on the use of 360° or lesser rotations; and limitations on the size of the FOV.
Factors such as beam quality and filtration are unique to a specific machine, while other factors, such as FOV, can some-
times be operator controlled. Typically, the smaller the FOV for a given system, the lower the radiation dose applied.7,8
Since the effective dose is computed from a weighted summation of doses to various organs, removing some organs
from the path of the x-ray beam can reduce the effective dose.
Table 1
ALARA Principle
ALARA is the acronym for As Low As Reasonably Achievable and is a fundamental principle for diagnostic radiology.
Dose minimization can be achieved by:
1. Following appropriate radiograph selection criteria after taking a history from the patient, then clinical evaluation
by an appropriate health care professional;
2. The use of properly trained and credentialed personnel to make radiographic exposures upon the prescription of
a licensed health care professional;
3. The use of optimal technique factors including beam projection geometry, beam energy, collimation and filtration;
and
4. Use of the fastest x-ray detector consistent with obtaining a radiographic image of adequate diagnostic quality.9
Clinicians should use CBCT only when the need for imaging cannot be answered adequately by lower dose conven-
tional dental radiography or alternate imaging modalities.
Accuracy of Reproduction: Computed tomography and CBCT images are composed of a huge volume of data consisting
of millions of 3-D voxels. CT voxels are anisotropic; the height of the voxel depends on the CT beam slice thickness,
which limits the accuracy of reconstructed images. With CBCT data, the voxels are isotropic, meaning they are equal in
length, height and depth, which allows for geometrically accurate measurements in any plane.10,11 The 3-D accuracy has
been confirmed in several studies.12,13
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ENDODONTICS: Colleagues for Excellence
Limitations of CBCT: A significant issue that can affect the image quality and diagnostic accuracy of
CBCT images is the scatter and beam hardening artifacts caused by high density adjacent structures,
such as enamel, and radiopaque materials such as metal posts, restorations and root filling materials
(Figure 1).14-16 Additional artifacts that may obscure radiographic findings are patient movement dur-
ing the scan and volume reconstruction.
Patient Selection Criteria: CBCT must not be used routinely for endodontic diagnosis or for screening
purposes in the absence of clinical signs and symptoms. The patient’s history and clinical examina-
tion must justify the use of CBCT by demonstrating that the benefits to the patient outweigh the
potential risks.
Interpretation: Clinicians ordering a CBCT are responsible for interpreting the entire image volume
Fig.1. Axial CBCT image of
just as they are for any other radiographic image. Any radiograph may demonstrate findings that are teeth #3-6. Beam hardening
significant to the health of the patient. There is no informed consent process that allows the clinician artifacts (dark lines) can be
seen going mesiodistally
to interpret only a specific area of an image volume. Therefore, the clinician can be liable for a missed from the root filling materials
diagnosis, even if it is outside of his or her area of practice. Any questions by the practitioner regard- on teeth #4 and 5. These are
ing image data interpretation should promptly be referred to a specialist in oral and maxillofacial NOT root fractures.
radiology.17,18
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ENDODONTICS: Colleagues for Excellence
Detection of Apical Periodontitis: CBCT enables the detection of radiolucent findings before they are visualized on con-
ventional radiographs (Figures 2a and 2b). 19-24 Lesions in the cortical bone can only be detected radiographically when
there is perforation of the bone cortex, erosion from the inner
surface of the bone cortex, or extensive erosion or defects on the
outer surface. It is known that periapical lesions in cancellous
bone cannot be detected radiographically.25
CBCT, however, can reveal bone defects of the cancellous bone
and cortical bone separately. The prevalence of apical periodontitis
was found to be significantly higher when using CBCT, in com-
Fig. 2a. Periapical radiograph of parison with periapical radiographs.20 Moreover, the information
tooth #30.
obtained by CBCT evaluation of periapical repair following root
Fig. 2b. Sagital CBCT slice canal treatment was comparable to histological analysis, whereas
of tooth #30. Note extensive
periapical radiolucency.
conventional radiographs underestimated the size of the periapi-
cal lesion.24 One study showed that 34% of the radiolucencies
detected with CBCT were missed with periapical radiography in maxillary premolars and molars.22 It was concluded
that the detection of apical periodontitis was considerably higher with CBCT than with periapical radiography.20 Thus,
CBCT was found to be a more sensitive diagnostic method to identify apical periodontitis.
Presurgical Assessment: Three-dimensional imaging allows the anatomical relationship of the root apices to important
anatomical structures, such as the inferior dental canal, mental foramen and maxillary sinus, to be clearly identified in
any plane the clinician wishes to view.17,26-28 It was concluded that CBCT may play an important role in planning for
periapical microsurgery on the palatal roots of maxillary first molars.27 The distance between the cortical plate and the
palatal root apex could be measured, and the presence or absence of the maxillary sinus between the roots could be
assessed. By selecting relevant views and slices of data, the thickness of the cortical plate, the cancellous bone pattern,
fenestrations, as well as the inclination of the roots of teeth planned for surgery, can be accurately determined preop-
eratively.29 CBCT scans from 139 patients were analyzed to evaluate the proximity of the mandibular canal to the root
apices of 743 mandibular second premolar and first and second molar teeth.18 The results revealed that the CBCT scan
was an accurate, noninvasive method to evaluate the position of the mandibular canal. The variable position of this
structure between patients suggests the need for CBCT to determine the proximity of the nerve bundle before attempt-
ing invasive treatment in this area.
Assessment of Tooth Morphology and Complications: Root morphology and bony topography can be visualized in 3-D, as
can the number of root canals and whether they converge or diverge from each other. Unidentified and untreated root
canals may be identified using axial slices, which may not be readily identifiable with periapical radiographs.2,26 The ef-
ficacy of CBCT as a modality to accurately identify the presence of second mesiobuccal canals in maxillary first and
second molars has been evaluated.28 The CBCT images accurately identified the presence or absence of the MB2 canal
in 78.95% of samples. Statistical analysis showed that there was no significant difference in the ability of CBCT scan-
ning to detect the MB2 canal when compared with the gold standard of clinical sectioning. Additionally, CBCT images
have clearly demonstrated the presence of untreated or missed canals intraoperatively or in root-filled teeth, as well
as complications (i.e., perforations) (Figures 3-5). As such, it appears that the use of CBCT for nonsurgical as well as
surgical retreatment can be quite advantageous to the clinician.
Summary
Conventional intraoral radiography provides clinicians with cost-effective, high-resolu-
tion imaging that continues to be the front-line method for dental imaging. However, it
is clear that there are many specific situations where the 3-D images produced by CBCT
facilitates diagnosis and influences treatment. The usefulness of the CBCT cannot be Fig. 7. Sagital CBCT slice of tooth #18
disputed. It is a valuable task-specific imaging modality, producing minimal radiation revealing an isolated osseous radiolucent
exposure to the patient and providing maximal information to the clinician. defect along the mid-distal aspect suggestive
of a root fracture.
References
1. Patel S, Dawood A, Pitt Ford T, Whaites E. The potential applications of cone beam computed tomography in the management of endodontic problems. Int
Endod J 2007;40:818-30.
2. Cotton TP, Geisler TM, Holden DT, Schwartz SA, Schindler WG. Endodontic applications of cone beam volumetric tomography. J Endod 2007;33:1121-32.
3. Grondahl HG, Huumonen S. Radiographic manifestations of periapical inflammatory lesions. Endod Topics 2004;8:55-67.
4. Scarfe WC, Levin MD, Gane D, Farman AG. Use of cone beam computed tomography in endodontics. Int J Dent 2009:1-20.
5. Valentin J. The 2007 recommendations of the International Commission on Radiological Protection. Publication 103, Annals of the ICRP 2009;37.
6. Ludlow JB, Davies-Ludlow LE, Brooks SL. Dosimetry of two extraoral direct digital imaging devices: NewTom cone beam CT and Orthophos Plus DS
panoramic unit. Dentomaxillofac Rad 2003;32:229-34.
7. Roberts JA, Drage NA, Davies J, Thomas DW. Effective dose from cone beam CT examinations in dentistry. Brit J Radiol 2009;82:35-40.
8. Ludlow JB, Davies-Ludlow LE, Brooks SL, Howeron WR. Dosimetry of 3 CBCT devices for oral and maxillofacial radiology: CB Mercuray, NewTom, 3G and
i-CAT. Dentomaxillofac Rad 2006;35:219-26.
9. Farman AG. ALARA still applies. Oral Surg Oral Med Oral Path Oral Radiol Endod 2005;100:395-7.
10. Scarfe WC, Farman AG, Sukovic P. Clinical applications of cone beam computed tomography in dental practice. J Canadian Dent Assoc 2006;72:75-80.
11. Scarfe WC, Farman AG. What is cone beam CT and how does it work? Dent Clin N Amer 2008;52:707-30.
12. Ludlow JB, Lester WS, See M, Bailey LJ, Hershey HG. Accuracy of measurements of mandibular anatomy in cone beam computed tomography images.
Oral Surg Oral Med Oral Path Oral Radiol Endod 2007;103:534-42.
13. Strateman SA, Huang JC, Maki K, Miller AJ, Hatcher DC. Comparison of cone beam computed tomography imaging with physical measures.
Dentomaxillofac Rad 2008;37:80-93.
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ENDODONTICS: Colleagues for Excellence
14. Mora MA, Mol A, Tyndall DA, Rivera E. In vitro assessment of local tomography for the detection of longitudinal tooth fractures. Oral Surg Oral Med Oral
Path Oral Radiol Endod 2007;103:825-9.
15. Katsumata A, Hirukawa A, Noujeim M, Okumura S, Naitoh M, Fujishita M, Ariji E, Langlais RP. Image artifact in dental cone beam CT. Oral Surg Oral Med
Oral Path Oral Radiol Endod 2006;101:652-7.
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17. Use of Cone Beam-Computed Tomography in Endodontics. Joint Position Statement of the American Association of Endodontists and the American
Academy of Oral and Maxillofacial Radiology 2010.
18. Kovisto T, Ahmad M, Bowles W. Proximity of the mandibular canal to the tooth apex. J Endod 2011;37:311–5.
19. Lofthag-Hansen S, Huumonen S, Grondahl K, Grondahl HG. Limited cone beam CT and intraoral radiography for the diagnosis of periapical pathology. Oral
Surg Oral Med Oral Path Oral Radiol Endod 2007;103:114-9.
20. Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic radiography for the detection of
apical periodontitis. J Endod 2008;34:273-9.
21. Patel S, Mannocci F, Wilson R, Dawood A, Pitt Ford T. Detection of periapical defects in human jaws using cone beam computed tomography and intraoral
radiography. Int Endod J 2009;42:507-15.
22. Low K, Dula K, Burgin W, von Arx T. Comparison of periapical radiography and limited cone beam computed tomography in posterior maxillary teeth
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23. Yoshioka T, Kikuchi I, Adorno CG, Suda H. Periapical bone defects of root filled teeth with persistent lesions evaluated by cone beam computed
tomography. Int Endod J 2011;44:245-52.
24. Paula-Silva FG, Wu MK, Leonardo MR, da Silva LA, Wesselink PR. Accuracy of periapical radiography and cone beam computed tomography scan in
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25. Bender IB, Seltzer S. Roentgenographic and direct observation of experimental lesions in bone: I. J Endod 2003;29:702-6.
26. Patel S. New dimensions in endodontic imaging: Part 2. Cone beam computed tomography. Int Endod J 2009;42:463-75.
27. Rigolone M, Pasqualkini D, Bianchi L, Berutti E, Bianchi SD. Vestibular surgical access to the palatine root of the superior first molar: low-dose cone beam
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28. Blattner TC, George N, Lee CC, Kumar V, Yelton CD. Efficacy of cone beam computed tomography as a modality to accurately identify the presence of
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29. Nakata K, Naitoh M, Izumi M, Inamoto K, Ariji E, Nakamura H. Effectiveness of dental computed tomography in diagnostic imaging of periradicular lesion
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30. Cohenca N, Simon JH, Roges R, Morag Y, Malfaz JM. Clinical indications for digital imaging in dento-alveolar trauma. Part 1: traumatic injuries. Dent
Traumatol 2007;23:95-104.
31. Bhuva B, Barnes JJ, Patel S. The use of limited cone beam computed tomography in the diagnosis and management of a case of perforating internal root
resorption. Int Endod J 2011; in press.
32. Bernardes RA, de Moraes IG, Húngaro Duarte MA, Azevedo BC, de Azevedo JR, Bramante CM. Use of cone beam volumetric tomography in the diagnosis
of root fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108;270-7.
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7
Saving the Natural Tooth
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The AAE’s Treatment Options for the Compromised Tooth
Guide helps you evaluate a variety of conditions using:
Also available—Treatment
▪ case examples with radiographs and clinical photographs;
Options for the Diseased
▪ clinical considerations; and
Tooth patient brochure!
▪ guidance for successful outcomes based on prognosis.
▪ Describes endodontic
treatment options in easy-to-understand
Download your free copies today at language
▪ Explains the benefits of implants when a
www.aae.org/treatmentoptions tooth must be extracted
The AAE wishes to thank Dr. Frederic Barnett for authoring this issue of the newsletter, as well as the following article
reviewers: Drs. James A. Abbott, Gary R. Hartwell, William T. Johnson and James F. Wolcott.
The information in this newsletter is designed to aid dentists. Practitioners must use their best professional judgment, taking into
account the needs of each individual patient when making diagnosis/treatment plans. The AAE neither expressly nor implicitly
warrants against any negative results associated with the application of this information. If you would like more information,
consult your endodontic colleague or contact the AAE.