Does a Combination of Two Radiographs Increase Accuracy in Detecting Acid-induced Periapical Lesions and Does It Approach the Accuracy of Cone-Beam Computed Tomography Scanning?

Evaluation of roots, root canal morphology, and bilateral symmetry of maxillary first molars in a Syrian subpopulation using cone beam computed tomography

OBJECTIVE

Successful endodontic treatments require a comprehensive knowledge of the root canal anatomy, so this study aimed to investigate the number of roots, configurations of root canals, and their bilateral symmetry of maxillary first molars in the Syrian subpopulation, and also the effect of gender on this symmetry.

MATERIALS AND METHODS

The study sample consisted of 250 cone beam computed tomography images (140 for females; and 110 for males), including 500 maxillary first molars. Images were investigated by two endodontists. Root number and canal configuration in each root were recorded, according to Vertucci classification, by studying the image at all levels (axial, coronal, sagittal, oplique, and three-dimensional) to assess the bilateral symmetry and its relation to gender. Statistical analysis was performed with SPSS and the χ2 test was used to compare the bilateral symmetry in males and females.

RESULT

The most common shape of the maxillary first molars was three roots (97.6%). All the roots are symmetrical by 100% in both genders. The root canal configuration was mainly Vertucci type I classification in the distobuccally (73.6%), and palatal root (98%). While the most common types in mesial root were type II (33.3%), this root showed all different types of Vertucci classifications except type VIII, and the proportion of symmetry was (37.2%) without significant difference between the gender (p = .441).

CONCLUSION

Most maxillary first molars in a Syrian population were three-rooted with four root canals (type II), the numbers of roots achieved perfect symmetry 100%, and higher than symmetry ratios in the number of canals and canals configurations (37.2%).

Comparative assessment of the efficacy of two-dimensional digital intraoral radiography to three-dimensional cone beam computed tomography in the diagnosis of periapical pathologies

Background:

Periapical intraoral radiographs are useful in assessing periapical pathologies; essential information often is not extracted owing to difficult interpretation and two-dimensional presentation of three-dimensional structures focusing on using cone beam CT (CBCT) and other advanced imaging modalities.

Aims:

The present study was conducted to comparatively assess the digital intraoral radiography to CBCT in the diagnosis of periapical pathologies.

Materials and Methods:

In 50 teeth, CBCT and digital imaging were compared in assessing periapical pathologies using CBCTPA and six-point scoring. The scores obtained were assessed and compared with statistical evaluation. The data were expressed in percentage and number and mean and standard deviation. The level of significance was kept at P < 0.05.

Results:

On comparing 3D CBCT and 2D digital imaging for assessing the study parameters, it was seen that resorption was seen in 33, 30, and 9 teeth, respectively, on 3, 2, and 1 rooted tooth on CBCT and 13, 16, and 7 teeth on digital radiography. The numbers of roots and root canals on CBCT were 45, 34, and 18 in 3, 2, and 1 rooted tooth and 50, 32, and 18 on digital imaging. Lesions were detected on CBCT in 16, 18, and 18 teeth on CBCT in 3, 2, and 1 rooted tooth, respectively, and in 14, 14, and 16 teeth on digital imaging. Comparing the five-point scale for lesions and CBPAI index for CBCT and digital imaging, the difference was statistically significant with P = 0.004 and <0.0001, respectively.

Conclusion:

The present study concludes that 3D CBCT is superior in accuracy to 2D imaging in diagnosing the periapical lesions, especially concerning multirooted teeth. Owing to its high radiation exposure and cost, 2D imaging can be incorporated in assessing periapical pathology for the single-rooted tooth.

[Imaginology in the diagnosis and planning of root duct systems: an updated review]

Root canal systems present a varied morphological conformation for each group of teeth. Several authors have described the anatomical conformation and its variants in different classifications, including the main, collateral, lateral, secondary, accessory, interduct, recurrent, apical delta and interradicular cavus canals. Currently, radiology still does not allow visualization of all these structures. However, proper use of imaging techniques together with the use of new 3D equipment for adjustments of acquisition parameters with adequate software and algorithms allows greater image precision, facilitating diagnosis and the planning of the most adequate approach for endodontic treatments. The objective of this article was to conduct a review of the literature to identify new concepts and useful imaging tools for better diagnoses.

Detection of Simulated Periapical Lesion in Intraoral Digital Radiography with Different Brightness and Contrast

Objective:

To assess the detection of simulated periapical lesions in digital intraoral radiography with different levels of brightness and contrast combinations, and to investigate the observers’ preference of image quality for this diagnostic task.

Methods:

Digital radiographs were acquired prior to periapical lesion simulation and after each one of four defects enlargement. Original images were adjusted in 4 brightness and contrast combinations. Five observers evaluated the images according to the presence of periapical lesion on a 5-point scale. In a second moment, the observers ordinated the images subjectively, according to quality, from the best to the worst to detect the bone defect. The area under the receiver operating characteristic curve was calculated for the diagnostic values and compared by two-way ANOVA. The significance level was set at 5% (P<0.05).

Results:

No differences were found between the diagnostic values of the five combinations of brightness and contrast (P>0.05). The overall results showed low values of area under the Receiver Operating Characteristic (ROC) curve and sensitivity of the periapical radiography in the detection of periapical lesions of sizes from 1 to 3, which rose substantially in size 4. For image quality, combinations with the lowest brightness and highest contrast were preferred by the observers in 58% of the cases.

Conclusion:

Brightness and contrast adjustments do not influence the detection of simulated periapical lesions in digital intraoral radiography. Lower brightness and higher contrast images were preferred for this diagnostic task.

Accuracy of Periapical Radiography and CBCT in Endodontic Evaluation

Introduction

A radiological evaluation is essential in endodontics, for diagnostic purposes, planning and execution of the treatment, and evaluation of the success of therapy. The periapical radiography is nowadays the main radiographic investigations used but presents some limits as 3D anatomic alteration, geometric compression, and possible anatomical structures overlapping that can obscure the area of interest. CBCT (cone beam computed tomography) in endodontics allows a detailed assessment of the teeth and surrounding alveolar anatomy for endodontic diagnosis, treatment planning, and follow-up.

Objective

The purpose of this study was to evaluate the accuracy of CBCT in comparison with conventional intraoral radiographs used in endodontic procedures.

Materials and Methods

Statistical analysis was performed on 101 patients with previous endodontic treatments with the relative radiographic documentation (preoperative, postoperative, and follow-up intraoral X-ray) that had underwent at CBCT screening for surgical reasons. The CBCT scans were evaluated independently by two operators and compared with the corresponding periapical images.

Results

Our analysis shows that the two radiological investigations statistically agree in 100% of cases in the group of patients without any endodontic sign. In the group of patients with an endodontic pathology, detected with CBCT, endodontic under extended treatments (30.6%), MB2 canals in nontreated maxillary molars (20.7%), second canals in nontreated mandibular incisors (9%), root fractures (2.7%), and root resorption (2.7%) were not always visible in intraoral X-ray. Otherwise, positivity in the intraoral X-ray was always confirmed in CBCT. A radiolucent area was detected in CBCT exam in 46%, while the intraoral X-ray exam was positive only in 18%.

Conclusions

Our study shows that some important radiological signs acquired using CBCT are not always visible in periapical X-ray. Furthermore, CBCT is considered as a II level exam and could be used to solve diagnostic questions, essential to a proper management of the endodontic problems.

Reliability of cone beam computed tomography as a biopsy-independent tool in differential diagnosis of periapical cysts and granulomas: An In vivo Study

Background:

Differential diagnosis of periapical cysts and granulomas is required as their treatment modalities are different.

Aim:

The aim of this study was to evaluate the efficacy of cone beam computed tomography (CBCT) in the differential diagnosis of periapical cysts from granulomas.

Settings and Design:

A single-centered observational study was carried out in the Department of Conservative Dentistry and Endodontics, Dr. R. Ahmed Dental College and Hospital, using CBCT and dental operating microscope.

Methods:

Forty-five lesions were analyzed using CBCT scans. One evaluator analyzed each CBCT scan for the presence of the following six characteristic radiological features: cyst like-location, shape, periphery, internal structure, effect on the surrounding structures, and cortical plate perforation. Another independent evaluator analyzed the CBCT scans. This process was repeated after 6 months, and inter- and intrarater reliability of CBCT diagnoses was evaluated. Periapical surgeries were performed and tissue samples were obtained for histopathological analysis. To evaluate the efficacy, CBCT diagnoses were compared with histopathological diagnoses, and six receiver operating characteristic (ROC) curve analyses were conducted.

Statistical Analysis Used:

ROC curve, Cronbach's alpha (α) test, and Cohen Kappa (κ) test were used for statistical analysis.

Results:

Both inter- and intrarater reliability were excellent (α = 0.94, κ = 0.75 and 0.77, respectively). ROC curve with regard to ≥4 positive findings revealed the highest area under curve (0.66).

Conclusion:

CBCT is moderately accurate in the differential diagnosis of periapical cysts and granulomas.

Diagnostic accuracy of periapical radiography and cone beam computed tomography in detecting apical periodontitis using histopathological findings as a reference standard

AIM

To compare the diagnostic accuracy of periapical radiography (PR) and cone beam computed tomography (CBCT) in detecting apical periodontitis (AP) using histopathological findings as a reference standard.

METHODOLOGY

Jaw sections containing 67 teeth (86 roots) were collected from unclaimed bodies due for cremation. Imaging was carried out to detect AP by digital PR with a central view (DP group), digital PR combining central with 10˚ mesially and distally angled (parallax) views (DPS group) and CBCT scans. All specimens underwent histopathological examination to confirm the diagnosis of AP. Sensitivity, specificity and predictive values of PR and CBCT were analysed using rater mean (n = 5). Receiver-operating characteristic (ROC) analysis was carried out.

RESULTS

Sensitivity was 0.27, 0.38 and 0.89 for DP, DPS and CBCT scans, respectively. CBCT had specificity and positive predictive value of 1.0 whilst DP and DPS had specificity and positive predictive value of 0.99. The negative predictive value was 0.39, 0.44 and 0.81 for DP, DPS and CBCT scans, respectively. Area under the curve (AUC) for the various imaging methods was 0.629 (DP), 0.688 (DPS), and 0.943 (CBCT).

CONCLUSIONS

All imaging techniques had similar specificity and positive predictive values. Additional parallax views increased the diagnostic accuracy of PR. CBCT had significantly higher diagnostic accuracy in detecting AP compared to PR, using human histopathological findings as a reference standard.

CBCT-based evaluation of integrity of cortical sinus close to periapical lesions

The purpose of the present study was to test the applicability of cone beam computed tomography (CBCT) to evaluate the integrity of the cortical sinus close to periapical lesions. Two observers analyzed samples of 64 alveoli of first molar roots in macerated swine maxillas prepared with perchloric acid to simulate periapical lesions. The specimens were evaluated using CBCT (55-mm high and 100-mm diameter cylinder at 0.2-mm voxel resolution) for the presence of oroantral communication (OAC) caused by the simulated lesions. Sensitivity, specificity, and accuracy were calculated. Fair values were obtained for accuracy (66%-78%) and good values for specificity (70%-98%), whereas the values for sensibility showed relevant variation (41%-78%). For this reason, the interobserver agreement score was weak. CBCT proved capable of evaluating the integrity of the cortical sinus (absence of oroantral communication) when it lies close to an apical periodontitis lesion. However, the low interobserver agreement reflects the difficulty in performing diagnoses when OAC is adjacent to a periapical lesion, using the acquisition protocol adopted in this research. This could be attributed to the high level of image noise.

Periapical and endodontic status scale based on periapical bone lesions and endodontic treatment quality evaluation using cone-beam computed tomography

INTRODUCTION

The purpose of this study was to present a new periapical and endodontic status scale (PESS) that is based on the complex periapical index (COPI), which was designed for the identification and classification of periapical bone lesions in cases of apical periodontitis, and the endodontically treated tooth index, which was designed for endodontic treatment quality evaluation by means of cone-beam computed tomographic (CBCT) analysis.

METHODS

Periapical and endodontic status parameters were selected from the already known indexes and scientific literature for radiologic evaluation. Radiographic images (CBCT imaging, digital orthopantomography [DOR], and digital periapical radiography) from 55 patients were analyzed. All parameters were evaluated on CBCT, DOR, and digital periapical radiographic images by 2 external observers. The statistical analysis was performed with software SPSS version 19.0 (SPSS Inc, Chicago, IL). Chi-square tests were used to compare frequencies of qualitative variables. The level of significance was set at P ≤ .05.

RESULTS

Overall intraobserver and interobserver agreements were very good and good, respectively. CBCT analysis found more lesions and lesions of bigger dimension (P < .001). CBCT imaging was also superior in locating lesions in the apical part on the side compared with DOR and in the diagnosis of cortical bone destruction compared with both methods (P < .001). Through CBCT analysis, more root canals and more canals associated with lesions were found. The most informative and reproducible periapical and endodontic status parameters were selected, and a new PESS was proposed.

CONCLUSIONS

The classification proposed in the present study seems to be reproducible and objective and adds helpful information with respect to the existing indexes. Future studies need to be conducted to validate PESS.

The importance of cone-beam computed tomography in the management of endodontic problems: a review of the literature

INTRODUCTION

To obtain essential information in clinical endodontics, cone-beam computed tomographic (CBCT) imaging can be used in all phases of treatment including diagnosis, treatment planning, during the treatment phase, and through post-treatment assessment and follow-up. The purpose of this article was to review the use of CBCT imaging in the diagnosis, treatment planning, and assessing the outcome of endodontic complications.

METHODS

Literature was selected through a search of PubMed electronic databases for the following keywords: tooth root injuries, tooth root radiography, tooth root perforation, tomography, cone-beam computed tomography, endodontic complications, tooth root internal/external resorption, root fractures, and broken instruments. The research was restricted to articles published in English. One hundred twelve articles met the inclusion criteria and were included in this review.

RESULTS

Currently, intraoral radiography is the imaging technique of choice for the management of endodontic disease, but CBCT imaging appears to have a superior validity and reliability in the management of endodontic diagnosis and complications.

CONCLUSIONS

Endodontic cases should be judged individually, and CBCT imaging should be considered in situations in which information from conventional imaging systems may not yield an adequate amount of information to allow the appropriate management of endodontic problems. CBCT imaging has the potential to become the first choice for endodontic treatment planning and outcome assessment, especially when new scanners with lower radiation doses will be available.

The detection of periapical pathoses in root filled teeth using single and parallax periapical radiographs versus cone beam computed tomography - a clinical study

AIM

To clinically assess the diagnostic yield from single parallel periapical, two parallax radiographs and cone beam computed tomography (CBCT) by comparing the prevalence of periapical lesions associated with individual roots, and the total number of root canals in root-treated teeth in patients referred for root canal retreatment.

METHODOLOGY

Single and parallax periapical radiographs, and CBCT scans, were taken of 100 teeth in 78 patients who had been referred for root canal retreatment. The presence of a periapical lesion associated with each specific root and the number of identifiable root canals were assessed using each imaging modality by a consensus panel of two examiners. The number of root canals was confirmed using the dental-operating microscope during treatment. In addition, the panel was asked to decide whether they felt they had adequate information to manage each case.

RESULTS

A total of 209 paired roots were assessed for periapical lesions. Lesions were identified in 41%, 38% and 68% of paired roots when using single radiographs, two parallax radiographs and CBCT respectively. The number of root canals identified were 186, 218, 242 and 239 when using parallel, parallax, CBCT and the dental-operating microscope, respectively.

CONCLUSIONS

CBCT detected significantly more periapical lesions and root canals than both single and parallax periapical radiographs. There was no significant difference between CBCT and the clinical microscope in the identification of root canals. Whilst two parallax radiographs detect significantly more root canals than a single radiograph, they did not increase detection of periapical lesions when compared to a single periapical radiograph.

Accuracy of digital radiography and cone beam computed tomography on periapical radiolucency detection in endodontically treated teeth

Objectives

The aim of the present study was to compare the accuracy of intraoral digital periapical radiography and cone beam computed tomography in the detection of periapical radiolucencies in endodontically treated teeth.

Material and Methods

Radiographic images (cone beam computed tomography [CBCT] scans and digital periapical radiography [PR] images) from 60 patients, achieved from September 2008 to July 2013, were retrieved from databases of the Department of Oral Diseases, Lithuanian University of Health Sciences. Twenty patients met inclusion criteria and were selected for further evaluation.

Results

In 20 patients (42.4 [SD 12.1] years, 65% men and 35% women) a total of 35 endodontically treated teeth (1.75 [SD 0.91]; 27 in maxilla and 8 in mandible) were evaluated. Overall, it was observed a statistical significant difference between the number of periapical lesions observed in the CBCT (n = 42) and radiographic (n = 24) examinations (P < 0.05). In molar teeth, CBCT identify a significantly higher amount of periapical lesions than with the radiographic method (P < 0.05). There were significant differences between CBCT and PR in the mean number of lesions identified per tooth (1.2 vs 0.66, P = 0.03), number of teeth with lesions (0.71 vs 0.46, P = 0.03) and number of lesions identified per canal (0.57 vs 0.33, P = 0.005). Considering CBCT as “gold standard” in lesion detection with the sensitivity, specificity and accuracy considering as score 1, then the same parameters of PR were 0.57, 1 and 0.76 respectively.

Conclusions

Within the limitations of the present study, it can be concluded that cone beam computed tomography scans were more accurate compared to digital periapical radiographs for detecting periapical radiolucencies in endodontically treated teeth. The difference was more pronounced in molar teeth.

A comparative investigation of cone-beam computed tomography and periapical radiography in the diagnosis of a healthy periapex

INTRODUCTION

This research aimed to compare the appearance of healthy periapical tissues on cone-beam computed tomography (CBCT) with periapical radiography and to measure the periodontal ligament (PDL) space on CBCT for teeth with healthy and necrotic pulps.

METHODS

Patient records from specialist endodontic practices were examined for teeth that had a high-resolution (0.08-mm voxel) and small field-of-view CBCT scan, a periapical radiograph, and clinical pulp tests (CO2 and electric pulp testing). The periapical regions of the CBCT scans and radiographs were scored individually by 2 calibrated, blinded examiners by using a modified CBCT-periapical index (CBCT-PAI) for both and represented as CBCT-PAI and PAI, respectively. The Fisher exact and χ(2) statistics tested the relationships between CBCT-PAI, PAI, and pulp status.

RESULTS

Of 200 teeth included in the study, 166 showed clinical signs of pulpal health, and the CBCT-PAI score was greater than the PAI in 72% (119 of 166), with a vital pulp likely to have a radiographic PDL space widening of 0-1 mm (P < .001). Although 2 healthy teeth showed radiolucencies 2-4 mm on CBCT scan when the periapical radiograph showed none, a PDL space of greater than 1-2 mm was indicative of a necrotic pulp (P < .001).

CONCLUSIONS

Teeth with necrotic pulps were more likely to have PDL widening, but the PDL space of a healthy tooth demonstrated significant variation when examined by CBCT. The radiographic interpretation of health and disease on CBCT must be further investigated before usage in outcome or epidemiologic investigations. This research questions the traditional radiographic interpretation of the PDL space.

A novel method to estimate the volume of bone defects using cone-beam computed tomography: an in vitro study

INTRODUCTION

The routine use of high-resolution images derived from 3-dimensional cone-beam computed tomography (CBCT) datasets enables the linear measurement of lesions in the maxillary and mandibular bones on 3 planes of space. Measurements on different planes would make it possible to obtain real volumetric assessments. In this study, we tested, in vitro, the accuracy and reliability of new dedicated software developed for volumetric lesion assessment in clinical endodontics.

METHODS

Twenty-seven bone defects were created around the apices of 8 teeth in 1 young bovine mandible to simulate periapical lesions of different sizes and shapes. The volume of each defect was determined by taking an impression of the defect using a silicone material. The samples were scanned using an Accuitomo 170 CBCT (J. Morita Mfg Co, Kyoto, Japan), and the data were uploaded into a newly developed dedicated software tool. Two endodontists acted as independent and calibrated observers. They analyzed each bone defect for volume. The difference between the direct volumetric measurements and the measurements obtained with the CBCT images was statistically assessed using a lack-of-fit test. A correlation study was undertaken using the Pearson product-moment correlation coefficient. Intra- and interobserver agreement was also evaluated.

RESULTS

The results showed a good fit and strong correlation between both volume measurements (ρ > 0.9) with excellent inter- and intraobserver agreement.

CONCLUSIONS

Using this software, CBCT proved to be a reliable method in vitro for the estimation of endodontic lesion volumes in bovine jaws. Therefore, it may constitute a new, validated technique for the accurate evaluation and follow-up of apical periodontitis.

Pixel intensity and fractal dimension of periapical lesions visually indiscernible in radiographs

INTRODUCTION

The purpose of the study was to analyze pixel intensity (PI) and fractal dimension (FD) values in radiographs of chemically created but visually undetectable periapical lesions.

METHODS

Artificial lesions were created by applying 70% perchloric acid to the sockets of left and right first premolars in 12 cadaver mandibles. For preparation of relatively small lesions, the acid was applied for 30 and 60 minutes. Before and after each acid application, radiographs were taken (60 kVp, 7 mA, and 1.5 mm Al equivalent filtration for 0.12 second) with storage phosphor plates. An optical bench was used to standardize projection geometry. Image plates were scanned immediately after exposure, and the acquired images were saved uncompressed in TIF format. Six observers evaluated the images by using a 5-grade scale, and the images scored as "definitely absent" by all observers were used for the calculations of PI and FD. Box-counting FDs and differences in mean PI were computed for regions of interest at the apical areas of each premolar. Repeated-measures analysis of variance, Tukey test, and Pearson correlation coefficient test were used for statistical analysis.

RESULTS

A significant difference was found in FD values after both acid application periods (P < .05), whereas a difference in PI was detected only in images obtained after 60-minute acid application (P < .05). There was a negative correlation between FD and PI values (-0.754, P < .05).

CONCLUSIONS

Calculation of FD can be a tool for the early detection of periapical lesions given the presence of baseline radiographs.

Comparison of cone-beam computed tomography and periapical radiography in predicting treatment decision for periapical lesions: a clinical study

Objectives. To compare the ability of endodontists to determine the size of apical pathological lesions and select the most appropriate choice of treatment based on lesions' projected image characteristics using 2 D and 3 D images. Study Design. Twenty-four subjects were selected. Radiographic examination of symptomatic study teeth with an intraoral periapical radiograph revealed periapical lesions equal to or greater than 3 mm in the greatest diameter. Cone-beam Computed tomography (CBCT) images were made of the involved teeth after the intraoral periapical radiograph confirmed the size of lesion to be equal to greater than 3 mm. Six observers (endodontists) viewed both the periapical and CBCT images. Upon viewing each of the images from the two imaging modalities, observers (1) measured lesion size and (2) made decisions on treatment based on each radiograph. Chi-square test was used to look for differences in the choice of treatment among observers. Results. No significant difference was noted in the treatment plan selected by observers using the two modalities (χ²(3) = .036, P > 0.05). Conclusion. Lesion size and choice of treatment of periapical lesions based on CBCT radiographs do not change significantly from those made on the basis of 2 D radiographs.