The Impact of Coronal Flaring Files on Pericervical Dentin Thickness in Mandibular Molars.

INTRODUCTION: This study aimed to assess the influence of different coronal flaring files on dentin removal in mandibular teeth using cone-beam computed tomographic (CBCT) images. METHODS: CBCT images of 48 mandibular molar teeth were acquired and randomly divided into 2 main groups, with each main group further divided into 3 subgroups. In the first main group, root canal preparation was performed using TruNatomy (Dentsply Sirona, Ballaigues, Switzerland), ProTaper Gold (Dentsply Sirona), and One Curve (Micro-Mega, Besancon, France) files without the use of coronal flaring files. In the second main group, root canal preparation was performed using the same files with the use of coronal flaring files. After the completion of root canal preparation, a second set of CBCT images was obtained. Subsequently, the dentin removal and remaining critical dentin were assessed by measuring at 4 distinct points below the furcation level. Data were compared between groups using the Mann-Whitney U and Kruskal-Wallis tests with alpha set at 5%. RESULTS: The ProTaper Gold files demonstrated higher dentin removal compared with the TruNatomy files. In the no-flaring groups, the One Curve files exhibited greater dentin removal than the TruNatomy files at specific levels. The use of coronal flaring files generally did not significantly impact dentin removal, except for certain cases in the TruNatomy and ProTaper Gold groups. CONCLUSIONS: The TruNatomy instrument group was more effective in preserving pericervical dentin compared with the other instrument groups. Coronal flaring files can be confidently used to preserve critical dentin during root canal treatment.

Pulp Regenerative Therapy Using Autologous Dental Pulp Stem Cells in a Mature Tooth with Apical Periodontitis: A Case Report.

The utility and feasibility of pulp regenerative therapy with autologous dental pulp stem cells (DPSCs) in mature teeth with irreversible pulpitis were clinically demonstrated. On the other hand, there is no evidence of the utility of DPSCs in mature teeth with apical periodontitis. The aim of this case report was to describe the potential utility of regenerative cell therapy in mature teeth with apical periodontitis. A 44-year-old man was referred for pulp regeneration due to a periapical lesion in his maxillary first premolar. Root canal disinfection was performed by irrigation and intracanal medication by nanobubbles with levofloxacin and amphotericin B in addition to conventional irrigation. Autologous DPSCs isolated from an extracted third molar were transplanted into the root canal after residual bacteria and fungi were below the detection level by polymerase chain reaction assay using universal genes to amplify specific regions within bacterial 16S ribosomal DNA and fungal ribosomal DNA (ITS1), respectively. There were no adverse events or systemic toxicity assessed for clinical evaluations during the 79-week-follow-up period and laboratory evaluations after 4 weeks. The affected tooth was responsive to the electric pulp test. Cone-beam computed tomographic imaging revealed a reduced lesion size, remission of the periapical tissue, and mineralized tissue formation in the apical part of the canal after 79 weeks. The signal intensity on magnetic resonance imaging of the regenerated tissue in the affected tooth was comparable to that of the normal pulp in the adjacent teeth after 24 weeks. This case report demonstrated the potential use of DPSCs for pulp regenerative therapy in mature teeth with apical periodontitis.

Endodontic management of type IIIb dens invaginatus in central incisor: A case report.

We described a type IIIb dens invaginatus, its root canal treatment, and results on 3- and 12-month visits. Despite its significant challenges, proper endodontic therapy in such cases can cause positive prognosis and successful outcome.

Non-surgical Removal of Dens Invaginatus in Maxillary Lateral Incisor Using CBCT: Two-year Follow-up Case Report.

A 14-year female presented with an atypical looking tooth #7 with a sinus tract on tooth #8. A gutta-percha point inserted into the sinus tract confirmed the affected tooth #7. A radiographic examination of tooth showed a lateral radiolucency with respect to tooth #7. Cone-beam computed tomographic imaging was done for the three-dimensional reconstruction analysis. Dens invaginatus (Oehler's type III) with pulp necrosis and chronic apical periodontitis was the definitive diagnosis. Use of the dental operating microscope and ultrasonics helped in the removal of the invaginated structure. At the two year follow-up, no clinical and radiographic evidence of infection was observed.

Ex Vivo Detection of Apical Delta in Premolars: A Comparative Study Using Periapical Radiography, Cone-beam Computed Tomography, and Micro-computed Tomography.

INTRODUCTION: Imaging methods are essential for the correct identification of root canal anatomy, which is a key factor for successful endodontic therapy. This study aimed to evaluate the performance of periapical radiography (PR) and cone-beam computed tomographic (CBCT) imaging in identifying the apical delta (AD) using micro-computed tomographic imaging as the gold standard. METHODS: PR and CBCT images of 110 human premolars (120 root canals) were obtained using the VistaScan digital intraoral system (Durr Dental, Beitigheim-Bissinger, Germany) and the 3D Accuitomo CBCT unit (J Morita, Kyoto, Japan), respectively. Two oral radiologists assessed the PR and CBCT images for the presence of ADs using a 5-point scale. Additionally, in the CBCT images, the number of apical foramina was also evaluated. The gold standard was established by means of micro-computed tomographic imaging. The diagnostic values related to PR and CBCT imaging were compared using the McNemar test. The detection of the number of foramina was compared using the paired t test (α ≤ 0.05). RESULTS: ADs were present in 40 root canals (33.3%). Both PR and CBCT images differed significantly from the gold standard (P < .05) in the detection of ADs. CBCT imaging showed higher values than PR for all diagnostic tests (P < .05). Despite the moderate accuracy of PR (0.62) and CBCT imaging (0.73), these methods presented very low sensitivity values (0.07 and 0.35 for PR and CBCT, respectively). CBCT imaging had a tendency of underestimating the number of foramina (P < .05). CONCLUSIONS: CBCT imaging showed better performance than PR in the detection of ADs; both imaging modalities underestimate its presence when compared with the gold standard. In general, the number of apical foramina cannot be reliably assessed using CBCT imaging.

The Impact of Different Diagnostic Imaging Modalities on the Evaluation of Root Canal Anatomy and Endodontic Residents' Stress Levels: A Clinical Study.

INTRODUCTION: The purpose of this study was firstly to compare the impact of radiographs, cone-beam computed tomographic (CBCT) imaging, and 3D Endo software (Dentsply Sirona, Ballaigues, Switzerland) on the assessment of root canal anatomy and radiographic quality of endodontic treatment and secondly to assess stress levels in the same cohort of residents performing endodontic treatment. METHODS: Sixty patients requiring primary molar endodontic treatment were allocated randomly into 3 groups: group 1 (n = 20), conventional radiographs (periapical radiography [PR]) only; group 2 (n = 20), PR and CBCT imaging; and group 3 (n = 20), PR, CBCT imaging, and 3D Endo software. All treatment was performed using a standardized protocol. Residents completed a questionnaire to assess their stress levels and usefulness of the imaging modality used. The radiographic quality of completed cases was assessed by 2 experienced endodontists who were not involved in the supervision of the cases being assessed. RESULTS: Groups 2 (CBCT imaging) and 3 (PR, CBCT imaging, and 3D Endo) proved significantly better than group 1 (PR) (P < .001) for assessing the number of root canals and anatomy and estimating the working lengths. Group 3 provided a significantly more accurate determination of the working level (P = .002). There were significantly more cases with obturation short of the apex (<2 mm) and voids in group 1 compared with group 3 (P < .05) and a significantly higher number of cases with voids in group 1 compared with group 3 (P < .01). Clinicians found treatment to be moderately or very stressful in 75%, 5%, and 0% in groups 1, 2, and 3, respectively. CONCLUSIONS: 3D Endo software followed by CBCT imaging were found to be more desirable for the evaluation of root canal anatomy and working lengths and reducing the residents' stress levels.

Influence of Tube Current Settings on Diagnostic Detection of Root Fractures Using Cone-beam Computed Tomography: An In Vitro Study.

INTRODUCTION: This study assessed the influence of tube current settings (milliamperes [mA]) on the diagnostic detection of root fractures (RFs) using cone-beam computed tomographic (CBCT) imaging. METHOD: Sixty-eight human anterior and posterior teeth were submitted to root canal preparation, and 34 root canals were filled. The teeth were divided into 2 groups: the control group and the fractured group. RFs were induced using a universal mechanical testing machine; afterward, the teeth were placed in a phantom. Images were acquired using a Scanora 3DX unit (Soredex, Tuusula, Finland) with 5 different mA settings: 4.0, 5.0, 6.3, 8.0, and 10.0. Two examiners (E1 and E2) classified the images according to a 5-point confidence scale. Intra- and interexaminer reproducibility was assessed using the kappa statistic; diagnostic performance was assessed using the area under the receiver operating characteristic curve (AUROC). RESULTS: Intra- and interexaminer reproducibility showed substantial (κE1 = 0.791 and κE2 = 0.695) and moderate (κE1 × E2 = 0.545) agreement, respectively. AUROC was significantly higher (P ≤ .0389) at 8.0 and 10.0 mA and showed no statistical difference between the 2 tube current settings. CONCLUSIONS: Tube current has a significant influence on the diagnostic detection of RFs in CBCT images. Despite the acceptable diagnosis of RFs using 4.0 and 5.0 mA, those settings had lower discrimination abilities when compared with settings of 8.0 and 10.0 mA.

Accuracy of Orthopantomography for Apical Periodontitis without Endodontic Treatment.

INTRODUCTION: This study aimed to evaluate the diagnostic accuracy of orthopantomography (OPT) for the detection of clinically/surgically confirmed apical periodontitis (AP) without endodontic treatment using cone-beam computed tomographic (CBCT) imaging as the reference standard. METHODS: One hundred twenty patients without endodontically treated AP (diseased group) were detected via CBCT imaging using the periapical index system. They were divided into groups of 10 each according to the size of the lesion (2-4.5 mm and 4.6-7 mm) and the anatomic area (incisor, canine/premolar, and molar) in both the upper and lower arches. Another 120 patients with a healthy root and periapex (healthy group) were selected. Each diseased and healthy patient underwent OPT first and a CBCT scan within 40 days of the OPT. The periapical index system was also used to assess AP by OPT. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy for OPT images with respect to CBCT imaging were analyzed. The k value was calculated to assess both the interobserver reliability for OPT and the agreement between OPT and CBCT imaging. RESULTS: OPT showed low sensitivity (34.2), negative predictive value (59.3), and diagnostic accuracy (65.0) and high specificity (95.8) and positive predictive value (89.1). Interobserver reliability for OPT was substantial (k = 0.71), and agreement between OPT and CBCT imaging was fair (k = 0.30). The best and worst identified AP were located in the lower molar area and the upper/lower incisor area, respectively. CONCLUSIONS: OPT showed high specificity and positive predictive value. However, overall, it was not an accurate imaging technique for the detection of untreated AP, especially in the incisor area.

Influence of Cone-beam Computed Tomography on Endodontic Retreatment Strategies among General Dental Practitioners and Endodontists.

INTRODUCTION: Treatment options for endodontic failure include nonsurgical or surgical endodontic retreatment, intentional replantation, and extraction with or without replacement of the tooth. The aim of the present study was to determine the impact of cone-beam computed tomographic (CBCT) imaging on clinical decision making among general dental practitioners and endodontists after failed root canal treatment. A second objective was to assess the self-reported level of difficulty in making a treatment choice before and after viewing a preoperative CBCT scan. METHODS: Eight patients with endodontically treated teeth diagnosed as symptomatic apical periodontitis, acute apical abscess, or chronic apical abscess were selected. In the first session, the examiners were given the details of each case, including any relevant radiographs, and were asked to choose 1 of the proposed treatment alternatives and assess the difficulty of making a decision. One month later, the examiners reviewed randomly the same 8 cases with the additional information from the CBCT data. RESULTS: The examiners altered their treatment plan after viewing the CBCT scan in 49.8% of the cases. A significant difference in the treatment plan between the 2 imaging modalities was recorded for endodontists and general practitioners (P < .05). After CBCT evaluation, neither group altered their self-reported level of difficulty when choosing a treatment plan (P = .0524). The extraction option rose significantly to 20% after viewing the CBCT scan (P < .05). CONCLUSIONS: CBCT imaging directly influences endodontic retreatment strategies among general dental practitioners and endodontists.

Accuracy of Cone-beam Computed Tomography in Measuring Dentin Thickness and Its Potential of Predicting the Remaining Dentin Thickness after Removing Fractured Instruments.

INTRODUCTION: The purpose of this study was to evaluate the accuracy of cone-beam computed tomographic (CBCT) to measure dentin thickness and its potential of predicting the remaining dentin thickness after the removal of fractured instrument fragments. METHODS: Twenty-three human mandibular molars were selected, and 4-mm portions of #25/.06 taper K3 files (SybronEndo, Orange, CA) were fractured in mesial canals. The teeth were then scanned using a micro-computed tomographic (micro-CT) system and a CBCT unit. Dentin thickness was measured and compared between both micro-CT and CBCT images to study the accuracy of CBCT readings. Then, the process of removing the fragments was simulated in CBCT images using the MeVisLab package (MeVis Research, Bremen, Germany); the predicted minimal remaining dentin thickness after removal was measured in different layers using VGStudio MAX software (Volume Graphics, Heidelberg, Germany). Data were compared with the actual minimal remaining dentin thickness acquired from micro-CT images, which were scanned after removing fractured instruments using the microtrepan technique. The results were analyzed statistically using intraclass correlation coefficients (ICCs) and a forecasting regression model analysis. RESULTS: The ICC for the dentin thickness was 0.988. The forecasting regression model of CBCT imaging estimating dentin thickness was micro-CT imaging = 15.835 + 1.080*CBCT, R2 = 0.963. The ICC for the remaining dentin thickness was 0.975 (P < .001). The forecasting regression model of CBCT imaging forecasting remaining dentin thickness was micro-CT imaging = 147.999 + 0.879*adjusted CBCT, R2 = 0.906. CONCLUSIONS: The study showed that CBCT imaging could measure dentin thickness accurately. Furthermore, using CBCT images, it is reliable and feasible to forecast the remaining dentin thickness after simulated instrument removal.

Rare Root Canal Configuration of Mandibular Second Premolar Using Cone-beam Computed Tomographic Scanning.

The aim of this case report was to demonstrate how the use of cone-beam computed tomographic (CBCT) imagery is beneficial when treating a tooth with an unusual anatomic variation. A 43-year-old female patient presented to our private practice after a referral from her general dentist. Endodontic therapy was previously initiated and unable to be completed because of suspicious anatomic anatomy. CBCT imagery confirmed the presence of a C-shaped root configuration and 3 canals within the tooth. Root canal treatment was completed successfully without complications. The use of CBCT imaging was valuable in determining the root morphology and rare canal anatomy to enhance treatment and success.

Prevalence of Middle Mesial Canals and Isthmi in the Mesial Root of Mandibular Molars: An In Vivo Cone-beam Computed Tomographic Study.

INTRODUCTION: Many studies have investigated the morphology of the mandibular molar, but the prevalence of the middle mesial (MM) canal in the mesial root of the mandibular molar is still the subject of controversy. In addition, in previous literature, a true MM canal has not been clearly distinguished from an isthmus between the mesiobuccal and mesiolingual canals. Therefore, the objectives of this study were 2-fold: METHODS: Ninety limited field of view cone-beam computed tomographic scans were observed. One hundred twenty-two mature mandibular first and second molars with no previous root canal treatment, no root resorption, and intact crowns were retrospectively evaluated. Data regarding the sex, age, presence of MM canals, and number of root canals in the mesial root were recorded. RESULT: Of the 122 teeth, 20 (16.4%) had true MM canals. The prevalence of MM canals was 26% in first molars and 8% in second molars (P < .05). The frequency of isthmi in the mesial roots was 64.7%. The frequency of isthmi was higher in second molars, but the difference was not statistically significant (P > .05). CONCLUSIONS: This study showed a high prevalence of mandibular molars with MM canals or isthmi. The detection and biomechanical cleaning of these areas during nonsurgical or surgical root canal treatment are critical.

A Survey of Cone-beam Computed Tomographic Use among Endodontic Practitioners in the United States.

INTRODUCTION: Cone-beam computed tomographic (CBCT) imaging is an emerging technology for clinical endodontic practice. The aim of this study was to investigate the acceptance, accessibility, and usage of CBCT imaging among American Association of Endodontists members in the United States by means of an online survey. METHODS: An invitation to participate in a web-based survey was sent to 3076 members of the American Association of Endodontists. The survey consisted of 8 questions on demographics, access to CBCT machines, field of view (FOV), frequency of use for particular applications, and reasons in case CBCT was not used. RESULTS: A total of 1083 participants completed the survey, giving an overall completed response rate of 35.2%; 80.30% of the participants had access to a CBCT scan, of which 50.69% (n = 443) were on-site and 49.31% (n = 431) were off-site, and 19.30% of all respondents denied having access to CBCT imaging. Limited FOV was used by 55.26% participants, 22.37% used larger FOV formats, and the remaining 22.37% were not sure about the format. There was a significantly greater usage of CBCT technology in residency programs (n = 78/84 [92.86%]) compared with practitioners who had finished an endodontic specialty program (n = 796/999 [79.68%]) (χ2 = 10.30, P = .02). Practitioners used CBCT imaging "frequent" or "always" for internal or external resorptions (47.28%), preoperatively for surgical retreatment or intentional replantation (45.34%), missing canals (25.39%), preoperatively for nonsurgical retreatments (24.91%), differential diagnosis (21.16%), identifying periradicular lesions (18.26%), calcified cases (13.54%), immature teeth (4.71%), and to assess healing (3.87%). There was a significant difference in on-site and off-site CBCT imaging use for any of these applications (P < .001). Prevalent reasons for not using CBCT technology were cost (53.79%) and lack of installation space (8.29%). General concerns were expressed about resolution limitations, radiation exposure, and cost to the patient. CONCLUSIONS: There is a widespread application of CBCT technology in endodontic practice; however, results from the survey also confirmed that the benefit versus risk ratio should always be in favor of the patient if CBCT scans are taken.

Influence of Cone-beam Computed Tomography in Clinical Decision Making among Specialists.

INTRODUCTION: Clinical information and diagnostic imaging are essential components of preoperative diagnosis. The aim of this study was to determine the influence of cone-beam computed tomographic (CBCT) imaging on clinical decision-making choices among different specialists (prosthodontists, endodontists, oral surgeons, and periodontists) in endodontic treatment planning. A secondary objective was to assess the self-reported level of difficulty in making a treatment choice before and after viewing a preoperative CBCT scan. METHODS: In accordance with the endodontic case difficulty guidelines of the American Association of Endodontists, 30 endodontic cases with varying degrees of complexity were selected. Each case included clinical photographs, digital periapical radiographs, and a small-volume CBCT scan. In the first evaluation, examiners were given all the information of each case, except the CBCT scan. Examiners were asked to select one of the proposed treatment alternatives and assess the difficulty of making a decision. One month later, the examiners reviewed randomly the same 30 cases with the additional information from the CBCT data. RESULTS: The CBCT scans only had a significant influence on the treatment plan when the endodontic case was classified as high difficulty (P < .05). The level of difficulty in choosing a treatment choice was significantly more difficult after viewing a preoperative CBCT scan (P < .05), with the exception of the endodontists (P = .033). After viewing the CBCT scan, the extraction option increased significantly (P < .05). CONCLUSIONS: CBCT imaging has a substantial impact on endodontic decision making among specialists, particularly in high difficulty cases.

As Low Dose as Sufficient Quality: Optimization of Cone-beam Computed Tomographic Scanning Protocol for Tooth Autotransplantation Planning and Follow-up in Children.

INTRODUCTION: Tooth autotransplantation (TAT) offers a viable biological approach to tooth replacement in children. To enhance the outcome predictability of the TAT procedure, a cone-beam computed tomographic (CBCT)-based surgical planning and transfer technique has been developed. The aim of this study was to optimize the CBCT scanning protocol to achieve a dose as low as possible and to maintain sufficient image quality. METHODS: A sectional head phantom (SK150; The Phantom Laboratory, Salem, NY) was scanned using 18 exposure protocols in 3 different CBCT machines: 3D Accuitomo 170 (Morita, Kyoto, Japan), ProMax 3D MAX (Planmeca, Helsinki, Finland), and NewTom VGI EVO (QR Verona, Verona, Italy). The effective dose (ED) was calculated using Monte Carlo simulation and pediatric voxel phantoms (5- and 8-year-old males and a 12-year-old female). Image quality was assessed by comparing segmented teeth volumes, evaluation of the visibility of the lamina dura, and morphologic surface analysis of 3-dimensional models. A general linear mixed model was fit to combine image quality parameters and radiation effective dose for each protocol in order to rank and compare the protocols examined in the study. RESULTS: The ED for the preoperative scan can be reduced to the range of 74.6-157.9 µSv, with ProMax with ultra-low-dose high-definition reconstruction (Planmeca) 100 × 90 scoring the highest. The ED for the postoperative scan can be reduced to the range of 24.2-41.5 µSv with ProMax with ultra-low-dose normal-dose reconstruction 50 × 55 and NewTom 50 × 50 with the standard mode scoring the highest. CONCLUSIONS: A considerable reduction in the pediatric ED can be achieved while maintaining sufficient image quality for tooth autotransplantation planning and follow-up using the dose optimization protocols.

Cone-beam Computed Tomography Uses in Clinical Endodontics: Observer Variability in Detecting Periapical Lesions.

INTRODUCTION: The accurate interpretation of a cone-beam computed tomographic (CBCT) volume is critical in identifying the presence of disease correctly and consistently. The aim of this clinical study was to determine the effect of experience level on the detection of periapical lesions in CBCT volumes. METHODS: CBCT volumes of 22 maxillary molars were interpreted by 3 endodontic faculty, 3 endodontic residents, and 3 dental students. These groups were compared with the consensus opinion of 2 experienced oral and maxillofacial radiologists. The observers determined the presence or absence of apical radiolucencies for each root using a 5-point Likert scale. RESULTS: Compared with the radiologists, the average weighted kappa value for endodontic faculty was 0.49, for endodontic residents it was 0.35 and for dental students it was 0.32. Intrarater reliability for each group showed endodontic faculty having the highest average weighted kappa value of 0.68 followed by endodontic residents (0.48) and dental students (0.28). CONCLUSIONS: Clinicians' experience level appears to be correlated with their ability to correctly diagnose periapical disease in CBCT volumes. In addition, experience leads to better inter-rater reliability. In neither of these 2 categories was agreement found to be excellent, suggesting that more can be done to improve the CBCT interpretation skills of clinicians at various levels of experience.

The Assessment and Management of External Cervical Resorption with Periapical Radiographs and Cone-beam Computed Tomography: A Clinical Study.

INTRODUCTION: This in vivo study assessed whether there was a difference between periapical radiographs (PRs) and cone-beam computed tomographic (CBCT) imaging in the detection, assessment, and management of external cervical resorption (ECR). The secondary aim was to determine if parallax radiographs were of any further benefit compared with a single PR. METHODS: PR and CBCT data were gathered for 115 teeth (98 patients) consecutively diagnosed with ECR. The diagnosis and treatment plan of each tooth were determined with PRs and CBCT imaging. Sensitivity, specificity, positive predictive values, negative predictive values, and receiver operator characteristic values were determined. RESULTS: The overall sensitivity (0.86) and specificity (0.89) of PRs was significantly lower than CBCT imaging (P < .001). PRs had a limited ability to accurately detect the size (0.75), circumferential spread (0.60), and location of ECR compared with CBCT imaging (P < .001). PRs also underestimated the size of the ECR lesion. Significant differences (P < .001) were apparent in the treatment plans formed when PRs were assessed versus CBCT imaging. Parallax radiographs were shown to be of no additional benefit compared with a single radiograph. CONCLUSIONS: PRs have significant limitations in the detection, assessment, and treatment planning of ECR when compared with CBCT imaging. A CBCT scan should be considered before the management of a potentially restorable ECR lesion.

Large Reactional Osteogenesis in Maxillary Sinus Associated with Secondary Root Canal Infection Detected Using Cone-beam Computed Tomography.

Inflammatory injuries in the maxillary sinus may originate from root canal infections and lead to bone resorption or regeneration. This report describes the radiographic findings of 4 asymptomatic clinical cases of large reactional osteogenesis in the maxillary sinus (MS) associated with secondary root canal infection detected using cone-beam computed tomographic (CBCT) imaging. Apical periodontitis, a consequence of root canal infection, may lead to a periosteal reaction in the MS and osteogenesis seen as a radiopaque structure on imaging scans. The use of a map-reading strategy for the longitudinal and sequential slices of CBCT images may contribute to the definition of diagnoses and treatment plans. Root canal infections may lead to reactional osteogenesis in the MS. High-resolution CBCT images may reveal changes that go unnoticed when using conventional imaging. Findings may help define initial diagnoses and therapeutic plans, but only histopathology provides a definitive diagnosis. Surgical enucleation of the periapical lesion is recommended if nonsurgical root canal treatment fails to control apical periodontitis.

Association between the Presence of Apical Periodontitis and Clinical Symptoms in Endodontic Patients Using Cone-beam Computed Tomography and Periapical Radiographs.

INTRODUCTION: Cone-beam computed tomographic (CBCT) imaging is a valuable adjunct to endodontic practice. Among the endodontic applications of CBCT imaging, it aids in the diagnosis of apical periodontitis, often in cases in which there is no evidence of pathosis identified by conventional imaging. The purpose of this study was to correlate the presence of apical periodontitis of teeth evaluated with 2-dimensional periapical (PA) radiographs and 3-dimensional CBCT volumes with clinical signs and symptoms. METHODS: Clinical records were reviewed from patients examined at the graduate endodontics clinic. The examination included clinical examination, sensibility tests, PA radiographs, and limited field-of-view CBCT scans. Of 498 cases, 67 fulfilled the inclusion criteria and were evaluated for apical periodontitis and symptomology. CBCT slices and PA radiographs were evaluated by 2 board-certified endodontists and a board-certified oral and maxillofacial radiologist for the presence of apical periodontitis. RESULTS: Thirty eight of 67 teeth showed the presence of apical radiolucencies on PA radiographs and on CBCT imaging, whereas 14 teeth had no evidence of apical radiolucencies on either imaging modality. Fifteen cases showed the presence of apical radiolucencies visible on CBCT imaging that were not visible on PA radiographic images. The presence of apical radiolucencies on CBCT slices and PA radiographic images was correlated with clinical signs and symptoms, including the chief complaint. CONCLUSIONS: This research has important implications to prevent overexposure to radiation and to provide treatment for those patients with persistent symptoms lacking proper diagnosis based on conventional (2D) radiographs.

Endodontic management of a maxillary first molar with three roots and seven root canals with the aid of cone-beam computed tomography.

Variation in root canal morphology, especially in maxillary first molar presents a constant challenge for a clinician in their detection and management. This case report describes the successful root canal treatment of a three rooted right maxillary first molar presenting with three canals each in the mesiobuccal and distobuccal roots and one canal in the palatal root. The clinical detection of this morphologic aberration was made using a dental operating microscope, and the canal configuration was established after correlating and computing the clinical, radiographic and cone-beam computed tomography (CBCT) scan findings. CBCT images confirmed the configuration of the canals in the mesiobuccal and distobuccal roots to be Al-Qudah and Awawdeh type (3-2) and type (3-2-1), respectively, whereas the palatal root had a Vertucci type I canal pattern. This report reaffirms the importance of careful examination of the floor of the pulp chamber with a dental operating microscope and the use of multiangled preoperative radiographs along with advanced diagnostic aids such as CBCT in identification and successful management of aberrant canal morphologies.