Diagnostic yield of conventional radiographic and cone-beam computed tomographic images in patients with atypical odontalgia

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/).

Persistent pain after successful endodontic treatment in a patient with Wegener’s granulomatosis: a case report

Wegener’s granulomatosis (WG) is a condition with immune-mediated pathogenesis that can present oral manifestations. This report describes the case of a patient diagnosed with WG 14 years previously, who was affected by persistent pain of non-odontogenic origin after successful endodontic treatment. A 39-year-old woman with WG was diagnosed with pulp necrosis and apical periodontitis of teeth #31, #32, and #41, after evaluation through a clinical examination and cone-beam computed tomography (CBCT). At the first appointment, these teeth were subjected to conventional endodontic treatment. At 6- and 12-month follow-up visits, the patient complained of persistent pain associated with the endodontically treated teeth (mainly in tooth #31), despite complete remission of the periapical lesions shown by radiographic and CBCT exams proving the effectiveness of the endodontic treatments, thus indicating a probable diagnostic of persistent pain of non-odontogenic nature. After the surgical procedure was performed to curette the lesion and section 3 mm of the apical third of tooth #31, the histopathological analysis suggested that the painful condition was likely associated with the patient's systemic condition. Based on clinical, radiographic, and histopathological findings, this unusual case report suggests that WG may be related to non-odontogenic persistent pain after successful endodontic treatments.

The effect of botulinum toxin A on patients with persistent idiopathic dentoalveolar pain-A systematic review

BACKGROUND

It has been suggested that botulinum toxin A (BONT-A) is a safe and effective treatment in relieving pain in patients with persistent idiopathic dentoalveolar pain (PIDP).

OBJECTIVES

This study aimed to systematically evaluate all the available studies investigating the pain-relieving effects of BONT-A in patients with PIDP.

METHODS

A systematic search with specific search terms was made in PubMed, Web of Science and Scopus. Two authors screened titles and abstracts and selected eligible studies for inclusion in the systematic review. The quality of the studies was evaluated by the 12 items Quality Assessment Tool for Observational studies (Pre-Post) Studies with No Control Group, and the level of evidence was assessed according to GRADE.

RESULTS

Three observational studies of 3695 identified were included (445 overlapping studies; 3247 excluded studies). All studies were uncontrolled observational studies investigating the pain-relieving effect of BONT-A in patients with PIDP. The included studies had a fair quality (moderate risk of bias) and insufficient level of evidence. The pain reducing effect by BONT-A injections was in average 50% or more in two studies, in one study 3 out of 4 patients became almost pain free.

CONCLUSIONS

This systematic review shows that presently the level of scientific evidence is insufficient to evaluate the pain-relieving effect of BONT-A injections in patients with PIDP. There are indications that BONT-A injections could be a possible management option for patients with PIDP that seems to be safe and with few adverse events. There is a need for well-designed placebo-controlled, double-blind RCTs.

Persistent dentoalveolar pain disorder: A putative intraoral chronic overlapping pain condition

Chronic overlapping pain conditions (COPCs) are conditions that share several clinical characteristics and symptomatology, are usually considered idiopathic in nature, and are frequently comorbid. Currently, there are no established inclusion criteria to determine which conditions should be included under this umbrella term despite different systems proposed. Persistent dentoalveolar pain disorder (PDAP), also referred to as atypical odontalgia and thought to be a component of persistent idiopathic facial pain, is a chronic pain condition that manifests as a persistent tooth pain or pain over a dentoalveolar site formerly occupied by a tooth in the absence of detectable pathology during clinical or radiological examination. PDAP is considered idiopathic in nature, and its pathophysiological mechanisms are not fully understood. Our objective was to investigate whether PDAP fits the conceptual paradigm of COPC given its characteristics and commonalities with other COPC, based on published literature identified through a scoping review. We found that PDAP fits 16 out of 18 common characteristics among COPCs, and based on this finding, we discuss the implications of PDAP being considered a COPC.

Comparison of diagnostic accuracy between periapical and panoramic radiographs and cone beam computed tomography in measuring the periapical area of teeth scheduled for periapical surgery. A cross-sectional study

Background

The aim of the study was compare the sensitivity and measurements obtained from teeth with apical lesions scheduled for periapical surgery using three different diagnostic methods: periapical radiography (Gendex Expert DC), panoramic radiography (Planmeca® Promax 3D Classic) and cone beam computed tomography (CBCT) (Planmeca® Promax 3D Classic).

Material and Methods

This cross-sectional study involved 35 patients (45 teeth) scheduled for periapical surgery in which periapical radiographs, panoramic radiographs and CBCT scans had been obtained. The images were used to analyze the maximum vertical and horizontal dimension and the resulting areas of the periapical lesions based on the three diagnostic methods.

Results

The two-dimensional techniques (periapical radiography and panoramic radiography) yielded a sensitivity of 82% versus 100% in the case of CBCT. The mean vertical dimension of the apical areas was 5.48 mm with periapical radiography and 5.04 mm with panoramic radiography - the difference with respect to CBCT being statistically significant (6.36 mm for the coronal sections). There were no significant differences among the three techniques in terms of horizontal dimension (p>0.05) or lesion area.

Conclusions

The sensitivity of periapical radiolucencies detected using CBCT was significantly greater than with the two-dimensional imaging techniques. Significant differences between the latter and CBCT were only observed in the case of the vertical measurements. Key words:Periapical lesion, apicoectomy, CBCT, periapical radiography, panoramic radiography.

Cone beam computed tomography in Endodontics - a review of the literature

The use of cone beam computed tomography (CBCT) in the diagnosis and/or management of endodontic problems is increasing and is reflected in the exponential rise in publications on this topic in the last two decades. The aim of this paper is to: (i) Review current literature on the endodontic applications of CBCT; (ii) Based on current evidence make recommendations for the use of CBCT in Endodontics; (iii) Highlight the areas in which more research is required.

Prevalence, predictive factors and clinical course of persistent pain associated with teeth displaying periapical healing following nonsurgical root canal treatment: a prospective study

AIMS

To investigate the prevalence, pain catastrophizing and other predictive factors and clinical course of persistent pain/discomfort associated with teeth displaying periapical healing following nonsurgical root canal treatment (NSRCT).

METHODOLOGY

One hundred and ninety-eight patients (264 teeth) who had NSRCT were reviewed at 5-14 months, postoperatively. Teeth with persistent post-treatment pain or discomfort, plus evidence of periapical healing were further monitored 0.5, 4 and 10 years later. Pain Catastrophizing Scale (PCS) and Short Form of the McGill Pain Questionnaire (SF-MPQ) were completed. Predictive factors were investigated using logistic regression models.

RESULTS

Twenty-four per cent (60/249) of teeth displaying periapical healing at first review were associated with persistent pain or discomfort. Fifty-five teeth monitored 6-7 months later were associated with reduction in pain (17/30) or discomfort (7/25). Cone beam computed tomography (CBCT) of eight teeth with persistent symptoms and complete periapical healing (by conventional radiographs) revealed distinct, small apical radiolucencies (n = 3) or root apex fenestration through the buccal plate (n = 2). History of chronic pain (headache, temporo-mandibular joint, masticatory muscle, neck, shoulder or back pain; P = 0.005), preoperative pain (P = 0.04), responsive pulp (P = 0.009), tooth crack (P = 0.05) and small periapical radiolucency (P = 0.005) were significant predictive factors. The PCS revealed 16 patients (22 teeth) were catastrophizers (PCS ≥ 30), but this had no influence on post-treatment symptoms (P = 0.5).

CONCLUSIONS

Persistent pain or discomfort associated with teeth showing periapical healing at the first review after NSRCT, decreased in intensity in most cases over the following 6 months. Longer-term follow-up revealed spontaneous improvement or symptom resolution in the majority of those with confirmed radiographic the absence of periapical disease. Five predictive factors (history of chronic pain, teeth with responsive pulps, association with pain, diagnosis of tooth crack before treatment and diameter of preoperative radiolucency) were identified.

AAE and AAOMR Joint Position Statement: Use of Cone Beam Computed Tomography in Endodontics 2015 Update

The following statement was prepared by the Special Committee to Revise the Joint American Association of Endodontists/American Academy of Oral and Maxillofacial Radiology Position on Cone Beam Computed Tomography, and approved by the AAE Board of Directors and AAOMR Executive Council in May 2015. AAE members may reprint this position statement for distribution to patients or referring dentists.

Differential diagnoses for persistent pain after root canal treatment: a study in the National Dental Practice-based Research Network

INTRODUCTION

Pain present 6 months after root canal treatment (RCT) may be of odontogenic or nonodontogenic origin. This is important because treatments and prognoses are different; therefore, the aim of this study was to provide specific diagnoses of patients reporting pain 6 months after receiving initial orthograde RCT.

METHODS

We enrolled patients from the Midwest region of an existing prospective observational study of pain after RCT. Pain at 6 months was defined as ≥1 day of pain and average pain intensity of at least 1 of 10 over the preceding month. An endodontist and an orofacial pain practitioner independently performed clinical evaluations, which included periapical and cone-beam computed tomographic radiographs, to determine diagnoses.

RESULTS

Thirty-eight of the 354 eligible patients in the geographic area (11%) met the pain criteria, with 19 (50%) consenting to be clinically evaluated. As the sole reason for pain, 7 patients (37%) were given odontogenic diagnoses (4 involving the RCT tooth and 3 involving an adjacent tooth). Eight patients (42%) were given nonodontogenic pain diagnoses (7 from referred temporomandibular disorder pain and 1 from persistent dentoalveolar pain disorder). Two patients (11%) had both odontogenic and nonodontogenic diagnoses, whereas 2 (11%) no longer fit the pain criteria at the time of the clinical evaluation.

CONCLUSIONS

Patients reporting "tooth" pain 6 months after RCT had a nonodontogenic pain diagnosis accounting for some of this pain, with temporomandibular disorder being the most frequent nonodontogenic diagnosis. Dentists should have the necessary knowledge to differentiate between these diagnoses to adequately manage their patients.

Systematic review and recommendations for nonodontogenic toothache

Nonodontogenic toothache is a painful condition that occurs in the absence of a clinically evident cause in the teeth or periodontal tissues. The purpose of this review is to improve the accuracy of diagnosis and the quality of dental treatment regarding nonodontogenic toothache. Electronic databases were searched to gather scientific evidence regarding related primary disorders and the management of nonodontogenic toothache. We evaluated the level of available evidence in scientific literature. There are a number of possible causes of nonodontogenic toothache and they should be treated. Nonodontogenic toothache can be categorised into eight groups according to primary disorders as follows: 1) myofascial pain referred to tooth/teeth, 2) neuropathic toothache, 3) idiopathic toothache, 4) neurovascular toothache, 5) sinus pain referred to tooth/teeth, 6) cardiac pain referred to tooth/teeth, 7) psychogenic toothache or toothache of psychosocial origin and 8) toothache caused by various other disorders. We concluded that unnecessary dental treatment should be avoided.

The effect of cone beam CT (CBCT) on therapeutic decision-making in endodontics

OBJECTIVES

The aim was to assess to what extent cone beam CT (CBCT) used in accordance with current European Commission guidelines in a normal clinical setting has an impact on therapeutic decisions in a population referred for endodontic problems.

METHODS

The study includes data of consecutively examined patients collected from October 2011 to December 2012. From 2 different endodontic specialist clinics, 57 patients were referred for a CBCT examination using criteria in accordance with current European guidelines. The CBCT examinations were performed using similar equipment and standardized among clinics. After a thorough clinical examination, but before CBCT, the examiner made a preliminary therapy plan which was recorded. After the CBCT examination, the same examiner made a new therapy plan. Therapy plans both before and after the CBCT examination were plotted for 53 patients and 81 teeth. As four patients had incomplete protocols, they were not included in the final analysis.

RESULTS

4% of the patients referred to endodontic clinics during the study period were examined with CBCT. The most frequent reason for referral to CBCT examination was to differentiate pathology from normal anatomy, this was the case in 24 patients (45% of the cases). The primary outcome was therapy plan changes that could be attributed to CBCT examination. There were changes in 28 patients (53%).

CONCLUSIONS

CBCT has a significant impact on therapeutic decision efficacy in endodontics when used in concordance with the current European Commission guidelines.

Persistent dento-alveolar pain disorder (PDAP): Working towards a better understanding

• New terminology, persistent dento-alveolar pain disorder (PDAP), and diagnostic criteria have been put forward to address the shortcomings of existing nomenclature, which are associated with unclear criteria. • Arriving at an accurate diagnosis of PDAP is based on excluding other possible aetiologies, and may involve different care providers. • Synthesis of published data suggests that PDAP has a frequency of occurrence following root canal therapy of around 1.6%. • The putative risk factors involved in PDAP are largely unknown, but seem to be similar to those being identified with other post-surgical chronic pain disorders. • The underlying mechanisms involved in the development of and/or perpetuating PDAP are unknown and the approach to treatment remains empiric in nature.