Finding vertical root fractures in endodontically treated teeth with CBCT
An endodontically treated tooth with a vertical root fracture (VRF) has a poor prognosis. Because there are no reliable methods for treatment, it is usually extracted.
A longitudinally-oriented fracture plane confined to the root, a VRF can only be seen if the primary imaging beam is within 4 degrees of the fracture plane. Superimposition of surrounding anatomic structures further impedes VRF visualization, which means detection occurs on periapical radiographs in only about one-third of cases.
To avoid unnecessary extraction of an otherwise treatable tooth, making a reliable diagnosis of VRF is the rationale behind using high-resolution cone-beam computed tomography (CBCT) imaging to detect VRF. However, the presence of imaging artifacts that may obscure the fracture plane calls into question the ability of CBCT to detect VRFs, scientists at the University of Toronto reported. Investigating CBCT’s diagnostic ability to detect VFRs in endodontically treated teeth, they searched the literature for studies published through August 2015 regarding patients with at least one endodontically treated permanent tooth suspected of having VRF on the basis of clinical signs and symptoms. They published their findings in the February 2016 issue of Journal of Endodontics.
Of 2,360 records initially identified, scientists analyzed four studies that met the inclusion criteria for this systematic review. Because of the small number of studies and marked clinical heterogeneity among them, the team opted not to perform a meta-analysis.
Results demonstrated a significant imprecision in the reported ranges of diagnostic ability owing to limited sample sizes, great variability in how studies were conducted, different CBCT models and imaging parameters, different types of reference testing and different populations under study. Examples included the subjective nature of radiologic interpretation and multiple sources of bias.
Definitive conclusions about diagnostic ability couldn’t be drawn, scientists said about the research. Instead, they asserted that the most clinically relevant question, “How accurate is CBCT in detecting VRFs in endodontically treated teeth?” remained unanswered. The findings were in agreement with two recent systematic reviews highlighted in discussion.
Scientists noted that CBCT is increasingly used in the clinical practice of dentistry, particularly within the specialty of endodontics, for the diagnosis of pathosis and preoperative assessment. “Because of the increased uptake of CBCT, the possibility of indiscriminant prescription and unjustified reliance on a test of unclear diagnostic ability is concerning,” they said. “To maximize the chances of detecting a VRF by using CBCT, the clinician’s best tools still consist of what is done before the CBCT (i.e. a thorough clinical examination and recognizing the signs and symptoms that are suggestive of a VRF).”
Among conclusions, they advised, “Until more evidence is presented to suggest that CBCT is both diagnostically accurate and efficacious, the prudent clinician should carefully consider its potential risks and harms before its prescription.”
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Consulting Editor: Dr. Susan Wood
Diplomate, American Board of Endodontics
MTA and pulpotomy in permanent teeth with caries
Calcium hydroxide (CH) had long been the chosen material for vital pulp therapy (VPT), showing favorable outcomes particularly in young teeth. However, its physical limitations, such as dissolution in tissue fluids, degradation on tooth flexure and the poor quality of the proximal hard-tissue barriers, are drawbacks documented in the literature.
Researchers publishing in the January 30 online edition of International Endodontic Journal noted that mineral trioxide aggregate (MTA) is the most commonly used material in VPT. They pointed out evidence showing MTA’s excellent marginal adaptation and ability to induce cell proliferation and the formation of a high-quality hard-tissue barrier.
Considering the evidence — including a lack of studies examining direct pulp capping and partial pulpotomy in symptomatic permanent teeth, a preponderance of studies that have used CH as the capping material, and a recent randomized clinical trial reporting a success rate of 78 percent for complete pulpotomy using a calcium-enriched mixture cement in mature molars, suggesting irreversible pulpitis over a five-year follow-up — they conducted a study. Their aim was to assess the outcome of complete pulpotomy in mature teeth with carious exposures demonstrating variable pulpal conditions using MTA over a three-year period.
To evaluate, scientists conducted clinical and radiographic evaluations of 52 permanent molars with fully developed roots and vital pulps in 43 patients aged 11 to 51 years. Scientists evaluated the teeth at three months, six months, one year and three years postoperatively.
Results showed the incidence of unfavorable outcomes to be low and the survival rate high. Overall survival rate at three years was 92.7 percent.
Authors say this was the first study to their knowledge to investigate the outcome of complete pulpotomy in cariously exposed mature permanent teeth with inflamed symptomatic pulps using MTA with a reasonable sample size and high recall rate.
Two primary conclusions drawn were:
- Over a three-year follow-up, MTA full pulpotomy was highly successful both clinically and radiographically in symptomatic permanent teeth with carious exposures.
- Teeth with signs and symptoms clinically suggestive of irreversible pulpitis may still have the potential to heal following full pulpotomy as it is likely that the radicular pulp is at worse reversibly inflamed. Longer-term observation may confirm the future benefits of this treatment option.
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Role of CBCT in diagnosing vertical root fracture
The unreliability of conventional radiographs in the detection of a vertical root fracture (VRF) creates challenging circumstances for the clinician. In fact, without a definitive diagnosis, invasive surgery or extraction may be performed unnecessarily.
Conventional radiographs can be insufficient for detection because the 2-dimensional aspect can obscure the root fracture, particularly when the orientation of the x-ray beam is not parallel to the fracture plane. Geometric distortion of the anatomic structures may also occur, resulting in a missed fracture.
Finding inconclusive evidence about the superiority of cone-beam computed tomography (CBCT) over periapical radiographs (PRs) for the detection of VRFs, scientists in India conducted their own study. They sought to provide evidence about the accuracy of CBCT imaging in diagnosing VRFs in teeth, both with and without endodontic treatment, compared with conventional or digital radiography. They also sought to establish optimal imaging parameters for using CBCT to detect VRFs. Their objective was to add information clinicians can use for the actual utility of CBCT in VRF diagnosis.
Eleven studies met the study’s criteria for systematic review, and four were considered in the meta-analysis from all ex vivo and in vivo studies in the PubMed, Embase and Cochrane Central Register of Controlled Trials databases from January 1990 to November 2013.
Key aspects of using different CBCT systems to detect VRFs were evaluated, including voxel size, field of view and other exposure parameters. Scientists also compared the accuracy of these methods with intraoral PRs and the heterogeneity among studies.
Among results, scientists found that in vitro studies showed CBCT imaging has a significantly higher sensitivity than PRs in the detection of VRFs in unfilled teeth, particularly when a voxel size of 0.2 millimeters was used. CBCT showed lower specificity in the presence of high-density materials, such as root canal filling or a metal post, which create artifacts that may resemble fracture lines. These inherent problems of beam-hardening artifact formation are likely responsible for low pooled sensitivity and specificity of CBCT imaging in detecting VRFs in endodontically treated teeth, researchers said.
The study showed a better performance trend in CBCT imaging compared with PRs for unfilled teeth. However, the presence of filling material in the canals significantly reduced the specificity of CBCT imaging with streaking artifacts. With PRs, the overall sensitivity was reduced in filled teeth because of lesser visibility of fractures on radiographs. However, the overall diagnostic ability for PRs was marginally better than CBCT imaging in filled teeth. The diagnostic ability of CBCT imaging in cases of filled teeth may not be reliable.
Authors deduced that the chief reason for choosing CBCT imaging for certain cases may be the 3-dimensional image reconstruction of the area of interest, which may enable direct visualization of the fracture line. It may also overcome problems of magnification, distortion and anatomic superimposition of structures, they said.
The report was published in the January 2016 issue of Journal of Endodontics.
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Materials for direct pulp capping evaluated
Various materials have been used as pulp-capping agents, including bonding substances, cements, resins and calcium hydroxide (CH). It’s well recognized that the most promising materials are CH and mineral trioxide aggregate (MTA), since both materials have the capacity to induce bridging of the pulp surface with reparative dentin.
Finding conflicting results in the body of literature when CH was compared with MTA for direct pulp capping, scientists in China conducted a study to help clinicians make a choice between the two materials. They published their findings in the October 2015 issue of International Journal of Clinical and Experimental Medicine.
To investigate, they conducted an electronic search of PubMed, Springer Link, Scopus and Cochrane Databases and ultimately identified four studies comparing the two materials on a total of 501 teeth. Two studies were conducted in the United States, one in France and one in Turkey. In each of the studies, an experimental group received direct pulp capping with MTA and a control group received CH. Each of the four studies selected was a randomized controlled trial.
Results demonstrated a statistically significant difference in dentin bridge formation success rates between the two regimens, with MTA showing a higher clinical success rate. Scientists asserted that MTA might be a suitable replacement for CH.
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It’s the 10th anniversary of Root Canal Awareness Week
Join the American Association of Endodontists in celebrating the 10th anniversary of Root Canal Awareness Week, March 27-April 2 and assure your patients that root canals aren’t what they used to be.
Root Canal Awareness Week is a national effort to raise awareness of endodontists, so that patients and general dentists know to contact a specialist when root canal treatment is needed. It is an excellent time to explain the important role endodontists play in dental health, to emphasize the importance of saving the natural dentition and to teach the public that root canals should not be feared. Visit the AAE website to download a Root Canal Awareness Week poster to display in your practice.
Save the date: AAE16 convenes April 6-9 in San Francisco
There’s still time to register for the American Association of Endodontists’ annual meeting, April 6-9 in San Francisco. The world’s largest endodontics education, exhibit and networking event, AAE16 features a broad range of speakers and great variety in program formats. In addition to traditional lectures, other educational sessions will feature point/counterpoint debates, talk show-style interviews, panel discussions and shorter, more focused programs called “CE Express.” New educational tracks at AAE16 this year include Interdisciplinary Care and Derailment. In addition, AAE16 hosts more than 100 vendors offering the latest in endodontic equipment, materials and supplies. For more information and to register, visit the AAE website.
Clearly explain root canal with ADA video
Educating patients about endodontic treatment is easier with visuals. The ADA video “Root Canal” helps patients understand the causes of injured pulp, consequences of a missing tooth and steps of root canal treatment.
The video is available on the Toothflix 2.0 Dental Procedures DVD. To order, call 1-800-947-4746 or go to adacatalog.org. Readers who use the code 16405E before March 31 can save 15 percent on all ADA Catalog products.
Watch the short endodontic video to see just how easy and effective a 2-step instrumentation system can be.
Click here to view.
What is Specialty Scan?
This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on endodontics, the first in the series on this topic for 2016. Other specialty scan issues are devoted to oral pathology, oral and maxillofacial radiology, orthodontics, periodontics and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. We welcome your feedback on this and all specialty scan issues.
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