CBCT Patterns of Bone Loss and Clinical Predictors for the Diagnosis of Cracked Teeth and Teeth with Vertical Root Fracture

The exploration of a compound cone-beam CT contrast agent for diagnosis of human extracted cracked tooth

Objectives

This study aims to investigate the use of sodium iodide (NaI), dimethyl sulfoxide (DMSO), ethyl alcohol, and ethyl acetate as cone-beam CT (CBCT) contrast agents for diagnosing cracked teeth. The optimal delay time for detecting the number of crack lines beyond the dentino-enamel junction (Nd), the number of cracks extending from the occlusal surface to the pulp cavity (Np), and the depth of the crack lines was explored.

Methods

14 human extracted cracked teeth were collected, 12 were used for enhanced scanning, and 2 were used for exploring the characteristic of crack lines. The teeth were scanned in 3 CBCT enhanced scanning (ES) modes: ES1 using meglumine diatrizoate (MD); ES2 using NaI and DMSO, ES3 using NaI, DMSO, ethyl alcohol and ethyl acetate. Three delay times (15mins, 30mins, and 60mins) were set for scanning. Nd, Np, and depth of crack lines were evaluated.

Results

There were totally 24 crack lines on 12 cracked teeth. Nd was 10 in ES1 at 60mins, 24 in ES2 at 60mins and 24 in ES3 at 15mins. Np was 1 in ES1 at 60mins, 10 in ES2 at 60mins and 21 in ES3 at 60mins, and there were significantly different among them (p < 0.01). The average depth presented on ES3 was significantly deeper than ES1 and ES2 (p < 0.01).

Conclusion

NaI, DMSO, ethyl alcohol and ethyl acetate show potential as contrast agents for enhanced CBCT scanning in diagnosis of cracked teeth and their depth in vivo. A delay time of 15 min is necessary to confirm the existence of crack lines, while a longer delay time is required to ascertain if these crack lines extend to the pulp cavity.

Managing Cracked Teeth with Root Extension: A Prospective Preliminary Study Using Biodentine™ Material

Purpose

The authors of this study proposed an innovative approach involving the use of Biodentine™ material as an intraorifice barrier in cracked teeth with root extension to promote internal crack sealing, preventing the possibility of microinfiltration and apical crack propagation.

Materials and Methods

The dental records of 11 patients with 12 posterior cracked teeth with root extension were included with a precise protocol performed by a senior endodontist. The treatment protocol included pulp diagnosis, crack identification using a dental operating microscope (DOM), endodontic treatment, placing a Biodentine™ as an intraorifice barrier, and immediate full-coverage restoration. The effectiveness of the treatment was assessed at two intervals, 6 months, and 1-3 years posttreatment, evaluating clinical, radiographic, and tomographic aspects. The treatment was deemed successful if there were no indications of radiolucency, sinus tracts, edema, or periodontal pockets associated with the crack line.

Results

The study observed remarkably positive outcomes during the follow-up period, which spanned from 1 to 3 years. All the cracked teeth (100%) remained asymptomatic, meaning they were free of pain or discomfort. Furthermore, these teeth were in occlusal function. Both radiographic and tomographic assessments revealed the absence of bone loss along the crack line. This outcome signifies that the treatment effectively prevented further deterioration of the surrounding bone.

Conclusions

Integrating advanced biomaterials and conservative restorative techniques has paved the way for innovative approaches in dental care. This protocol suggests a proactive step for managing cracked teeth with root extension. It addresses both biological aspects by sealing internal cracks and mechanical aspects by preventing crack progression, thereby improving these teeth' prognosis and long-term survival.

Prevalence of Vertical Root Fractures in a University Endodontics Program versus a Private Endodontics Office

Introduction

Vertical root fractures (VRFs) typically have a poor prognosis with an extraction or occasionally root amputation as the preferred treatment. VRFs have been considered an epidemic, motivating changes in the access openings, as well as in the preparation and disinfection protocols of endodontic treatment. Hence, we aimed to evaluate the prevalence of VRFs by tracking cases in both a University Endodontic Program (UEP) and a private endodontics practice (PP). We also evaluated changes in prevalence during COVID-19 along with the alterations in the frequency of cases diagnosed by clinical and radiographic signs which were later confirmed by direct visualization compared to those in which the suspicion was based on clinical and radiographic signs alone.

Methods and Materials

This retrospective study looked at the prevalence of VRF in patient records at UEP and a PP. Data for the pre-COVID-19 and COVID-19 time periods were extracted from patient records and referral letters then compared. Data for suspected and confirmed prevalence were compared.

Results

The UEP group included 21,156 patients while the PP group comprised 7,209 patients. The prevalence of VRFs in the former cohort was 1.80%, while 2.62% of the latter cohort exhibited VRFs with a combined total of 2.01%. The combined total prevalence of VRFs pre-COVID-19 was 1.72%, increasing from 2.1% to 3.82% during COVID-19 (p < 0.0001). The same applied to suspected cases for both clinical settings. The increase in confirmed cases between the two periods was statistically significant for the UEP group (p=0.0202) but it was insignificant for the PP group (p=0.0721).

Conclusion

The combined prevalence for VRFs was 2.01% for all years denying the claim that VRF is a pandemic phenomenon. COVID-19 period saw almost a double increase in the prevalence of VRF compared to pre-COVID-19 era. This was consequently associated with a significant increase in the number of suspected VRF cases.

A Survey on Cone-beam Computed Tomography Usage Among Endodontists in the United States

INTRODUCTION

The aim of the study was to investigate the accessibility and frequency of cone-beam computed tomography (CBCT) usage and to assess the economic and logistical factors involved with its usage among active American Association of Endodontists (AAE) members, utilizing a web-based survey.

METHODS

A survey of 19 questions was sent to 3,071 AAE members addressing participant access to, along with financial and logistical aspects of CBCT imaging. Descriptive analysis was performed and Fisher exact test utilized to test associations between groups (P < .05).

RESULTS

The overall response rate was 14.7% (n = 544). Ninety-five percent of respondents (n = 486) had an in-office CBCT unit, with those graduating after the year 2000 statistically more likely to have one (P < .05). Utilization of CBCT imaging for every case was reported by 40% of providers. Eighty-nine percent reported taking the scan at the consultation visit and 20% included this charge with the consultation fee. For those who charged for the scan separately, 85% charged more than $100. Providers who paid off their unit did so within 1-2 years (41%), 3-4 years (36%), 4-5 years (12%), and 5+ years (11%). Limited field of view was utilized by 95% of respondents. Fifty-eight percent reported interpreting the scans themselves, 38% send only if pathology is expected, and 3% always send their scans to a radiologist.

CONCLUSIONS

In conclusion, accessibility and utilization of CBCT imaging among United States endodontists has increased and acquisition of this equipment has not made a long lasting financial burden on providers.

Risk factors for and clinical presentations indicative of vertical root fracture in endodontically treated teeth - a systematic review and meta-analysis

INTRODUCTION

The aim of this study was to identify specific clinical signs or symptoms and potential risk factors which are most likely associated with the presence of a vertical root fracture (VRF) in endodontically treated teeth (ETT).

METHODS

Electronic databases (MEDLINE via PubMed, EMBASE via Ovid, Scopus, and Web of Science) were searched by two reviewers in October 2022 for clinical studies, in which at least either the clinical presentation or potential risk factors associated with a VRF were assessed. Risk of bias was assessed using the Newcastle-Ottawa scale. Meta-analyses of odds ratios (ORs) were performed separately for several signs or symptoms and risk factors.

RESULTS

Fourteen sources reporting on 2,875 teeth (489 with VRF and 2,388 without VRF) were included in the meta-analyses. Regarding the clinical presentation, the presence of sinus tracts (OR=4.87; 95%-CI: 1.58-15.0), increased periodontal probing depths (OR=13.24; 95%-CI: 5.44-32.22), swelling/abscess (OR=2.86; 95%-CI: 1.74-4.70), and tenderness to percussion (OR=1.74; 95% CI: 1.18-2.61) were significantly associated with the presence of a VRF (P_adj. value<.05). None of the assessed risk factors (sex, type of teeth, tooth location, posts, indirect restoration, apical extension of the root canal filling), were found to be significantly associated with the presence of a VRF (P_adj. value>.05).

CONCLUSIONS

Four clinical presentations were identified to be the most significant signs or symptoms for a VRF in ETT: presence of sinus tracts, increased probing depths, swelling/abscess, tenderness to percussion. None of the assessed risk factors pointed out to be significantly associated with a VRF.

REGISTRATION

CRD42022354108 (PROSPERO).

Sensitivity and Specificity of MRI versus CBCT to Detect Vertical Root Fractures Using MicroCT as a Reference Standard

INTRODUCTION

Vertical root fracture (VRF) in root-canal-treated teeth frequently results in tooth loss, partly because VRFs are difficult to diagnose and when detected the fracture is often beyond the point of preservation with surgical intervention. Nonionizing magnetic resonance imaging (MRI) has demonstrated the ability to detect small VRFs, but it is unknown how its diagnostic capabilities compare with the current imaging standard for VRF detection, cone-beam computed tomography (CBCT). This investigation aimed to compare the sensitivity and specificity between MRI and CBCT for detecting VRF, using micro-computed tomography (microCT) as a reference.

METHODS

A total of 120 extracted human tooth roots were root canal treated using common techniques, and VRFs were mechanically induced in a proportion. Samples were imaged using MRI, CBCT, and microCT. Axial MRI and CBCT images were examined by 3 board-certified endodontists, who evaluated VRF status (yes/no) and gave a confidence assessment for that decision, from which a receiver operating characteristic curve was generated. Intra- and inter-rater reliability were calculated, sensitivity and specificity, and area under the curve.

RESULTS

Intra-rater reliability was 0.29-0.48 for MRI and 0.30-0.44 for CBCT. Inter-rater reliability for MRI was 0.37 and for CBCT 0.49. Sensitivity was 0.66 (95% confidence interval [CI], 0.53-0.78) and 0.58 (95% CI, 0.45-0.70), and specificity 0.72 (95% CI, 0.58-0.83) and 0.87 (95% CI, 0.75-0.95) for MRI and CBCT, respectively. Area under the curve was 0.74 (95% CI, 0.65-0.83) for MRI and 0.75 (95% CI, 0.66-0.84) for CBCT.

CONCLUSIONS

There was no significant difference in sensitivity or specificity between MRI and CBCT in detecting VRF, despite the early-stage development of MRI.

CBCT in contemporary endodontics

Cone-beam computed tomography (CBCT) is a three-dimensional imaging modality which can aid endodontic diagnosis and treatment planning. While there are guidelines available describing the indications, there are divergent philosophies on when this technology should be applied in clinical practice. This paper reviews the applications of CBCT including the clinical relevance of parameters which can be assessed, highlights the limitations of this technology, and provides guidance on how to maximise its clinical utility.

PROBE 2023 guidelines for reporting observational studies in endodontics: Explanation and elaboration

Observational studies play a critical role in evaluating the prevalence and incidence of conditions or diseases in populations as well as in defining the benefits and potential hazards of health-related interventions. There are currently no reporting guidelines for observational studies in the field of Endodontics. The Preferred Reporting Items for study Designs in Endodontology (PRIDE) team has developed and published new reporting guidelines for observational-based studies called the 'Preferred Reporting items for OBservational studies in Endodontics (PROBE) 2023' guidelines. The PROBE 2023 guidelines were developed exclusively for the speciality of Endodontics by integrating and adapting the 'STrengthening the Reporting of OBservational studies in Epidemiology (STROBE)' checklist and the 'Clinical and Laboratory Images in Publications (CLIP)' principles. The recommendations of the Guidance for Developers of Health Research Reporting Guidelines were adhered to throughout the process of developing the guidelines. The purpose of this document is to serve as a guide for authors by providing an explanation for each of the items in the PROBE 2023 checklist along with relevant examples from the literature. The document also offers advice to authors on how they can address each item in their manuscript before submission to a journal. The PROBE 2023 checklist is freely accessible and downloadable from the PRIDE website (http://pride-endodonticguidelines.org/probe/).