Endodontic Radiology PDF

Endodontic Radiology Dr. Asgeir Sigurdsson Chairman of the Quartararo Department of Endodontics NYU College of Dentistry New York [email protected] Radiographs Needed During Endodontic Therapy 1. Pre-op radiograph (for multi-rooted teeth two angulations are recommended) 2. Working length radiograph...

Endodontic Radiology Dr. Asgeir Sigurdsson Chairman of the Quartararo Department of Endodontics NYU College of Dentistry New York [email protected] Radiographs Needed During Endodontic Therapy 1. Pre-op radiograph (for multi-rooted teeth two angulations are recommended) 2. Working length radiograph 3. Cone fit radiograph 4. Final radiograph, after access has been (temp)restored and rubber dam/clamp removed. Radiographs Needed During Endodontic Therapy 1. Pre-op Radiograph: - Recent or a new radiograph taken with paralleling technique like XCP. New radiograph NEEDS to be taken if any treatment (including emergency tx.) has been done on the tooth by another Dr. Need to expose the total lesion – multiple radiographs needed if a large lesion. For multi-rooted teeth two different horizontal angulations indicated. Radiographs Radiographic Techniques Radiographic Film Holders: - Provide reproducible diagnostic radiographs. – 90 degree angle ensures minimal distortion. – Easy to use for non-experienced personnel. – Relatively inexpensive. Radiographic Interpretation ü Are the films of sufficient diagnostic quality? ü Is the lamina dura intact? ü Is the bony architecture intact or is there evidence of demineralization? ü Is the root canal system within normal limits or is there resorption, calcification or complex anatomy? ü What anatomic landmarks could be expected in this area? Radiographs Needed During Endodontic Therapy 2. Working Length Radiograph (WL): After completion of the access and location of all canals. – Size #15 file minimum, files in ALL canals. – In bicuspids and molars two radiographs with different angulation may be needed. – Radiographs Needed During Endodontic Therapy The distance from distal PDL to the file is longer than the comparable space on the mesial! The Apical Foramen Cementum Dentin Mesial view of an anterior tooth "Natural" constriction in the apical area 0.25 to 0.5 from the radiographic apex The Apical Foramen Cementum 0.5 to 1 mm Dentin Mesial view of an anterior tooth Standard radiographic view Diagnosis of Instrument Length Aim: As close to minor foramen as possible. Create shelf in apical dentin. Diagnosis of Instrument Length Working length ~1mm from radiographic apex Diagnosis of Instrument Length Success Rate of Root Canal Therapy Based on the Location of the Gutta Percha Success % 100 % Vital Teeth 80 % 60 % Non- Vital Teeth 40 % 20 % 0 0.6 0.7 0.8 0.9 +1.0 Distance from apex +1.1 Radiographic Determination Radiographs Needed During Endodontic Therapy 3. Cone Fit Radiograph: After selecting and fitting master cone, prior to placing sealer. In bicuspids and molars two radiographs with different angulations may be needed. Radiographs Needed During Endodontic Therapy 4. Final Radiograph: After completion of the fill, AND after temporization of the access, AND removal of the rubber-dam and clamp. – In bicuspids and molars two radiographs with different angulations may be needed – With good and reproducible angulation – RETREATMENT Helpful Hints Radiographs can and should be used in aid of finding canals. When there is a canal suspected but not located after deep access preparation a new radiograph should be taken with an instrument in the access for orientation. Radiographs Common Mistakes: 1. 2. 3. 4. 5. Too small files placed in the canals. You do not use assisting devices for proper angulation. The x-ray machine is incorrectly set. The film/sensor is incorrectly placed. (The radiograph is incorrectly filed and/or not dated.) Use and Abuse of Radiographs in Endodontics Remember the ALARA principles: Every effort should be made to reduce the effective radiation dose to the patient “as low as reasonably achievable”. AAE and AAOMR Joint Position Statement Use and Abuse of Cone Beam Computed Tomography (CBCT) in Endodontics Advocate appropriate radiation dosing during CBCT to the benefit of both patients and dentists, and supports moving from the concept of: “as low as reasonably achievable” (ALARA) to “as low as diagnostically acceptable” (ALADA). (Jaju PP and Jaju SP 2015) Use and Abuse of Cone Beam Computed Tomography (CBCT) in Endodontics Recommendation 1: Intraoral radiographs should be considered the imaging modality of choice in the evaluation of the endodontic patient. Recommendation 2: Limited FOV CBCT should be considered the imaging modality of choice for diagnosis in patients who present with contradictory or nonspecific clinical signs and symptoms associated with untreated or previously endodontically treated teeth. AAE and AAOMR Joint Position Statement Use and Abuse of Cone Beam Computed Tomography (CBCT) in Endodontics Recommendation 3: Limited FOV CBCT should be considered the imaging modality of choice for initial treatment of teeth with the potential for extra canals and suspected complex morphology, such as mandibular anterior teeth, and maxillary and mandibular premolars and molars, and dental anomalies. AAE and AAOMR Joint Position Statement Mandibular First Premolars ≈ 18% of all first premolars were diagnosed with Tome´s root trait (ASU=3-5): (Gu Y et al. 2013) Use and Abuse of Cone Beam Computed Tomography (CBCT) in Endodontics “Intraoral radiographs should be considered the imaging modality of choice for immediate postoperative imaging.” AAE and AAOMR Joint Position Statement Use and Abuse of Cone Beam Computed Tomography (CBCT) in Endodontics “Limited FOV CBCT should be considered the imaging modality of choice for diagnosis and management of limited dento-alveolar trauma, root fractures, luxation, and/or displacement of teeth and localized alveolar fractures, in the absence of other maxillofacial or soft tissue injury that may require other advanced imaging modalities” HOWEVER if you have you do not have a CBCT machine in your office DO conventional radiographs as to not delay treatment! AAE and AAOMR Joint Position Statement Crown-Root fractures (From Dr. Andreasen 1979) Diagnosis of Dental Trauma Why not CBCT for every case? A CBCT investigation of dental trauma seems to be best evaluation! However: The highest incidence rate of dental trauma is between the age of 8 to 14 years old. (Andreasen & Ravn 1972) Research evidence concerning CBCT indications in children remains limited. (Oenning A. et al. 2018) Care should be taken not to use this 3D image modality lightly, knowing that the effective dose of a CBCT is around 20–400 fold that of an intraoral radiograph. (Pauwels R. et al. 2012) Diagnosis of Dental Trauma Why not CBCT for every case? A Review of Doses for Dental Imaging in 2010–2020 Development of a Web Dose Calculator CBCT imaging: The child phantoms received about 29% more effective dose than the adult phantoms received. The effective dose of a large field of view (FOV) (>150 cm2) was about 1.6 times greater than that of a small FOV (<50 cm2). The maximum CBCT effective dose with a small FOV for children, 245.2 μSv, about 8% of the effective dose that a person receives on average every year from natural radiation, 3110 μSv. (Lee H and Badal A, 2021) Diagnosis of Dental Trauma Why not CBCT for every case? A CBCT investigation of dental trauma is probably best evaluation! However: - access to the machine has to be immediate, not refer to another practice. - ALARA principle (As Low As Reasonable Achievable) for radiation, remember even LFV covers large portion of the head of young individuals. - Most radiologist do not recommend using CBCT for follow-ups.