HEALING OF PERIAPICAL PERIODONTITIS – CONE BEAM COMPUTED TOMOGRAPHY VISUALIZATION – CASE REPORT
Paula Perleaa*, Coralia Cristina Nistorb
Department of Endodontology, Faculty of Dental Medicine, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
a MD, PhD, Specialist in endodontics, Senior Lecturer
b MD, Specialist in endodontics, Senior Lecturer
Senior Lecturer Paula Perlea, MD, PhD, 57 Levantica Str, District 3, RO-031402 Bucharest, Romania.
Tel: +40744 377 011, Fax: +40213468888, e-mail: firstname.lastname@example.org
Aim: The clinical case highlights the outcome of a large periapical periodontitis using radiograph compared with Cone Beam Computed Tomography (CBCT).
Summary: Periapical periodontitis is one of the most frequent reasons for endodontic treatments. The outcome of the endodontic procedures can be appreciated either by radiographs or Cone Beam Computed Tomography (CBCT). The periapical radiolucency can increase, decrease or resolve over a period of time. CBCT, compared with PA radiographs shows a higher accuracy in detecting the real extend of periapical lesions, facilitating the visualization of the outcome of the treatment.
Key learning points:
Even larger periapical periodontitis can be treated in a single visit.
No medication or surgical procedures are needed for a positive outcome of endodontic treatment of periapical lesions.
Radiographs are providing limited informations about the healing of periapical pathosis.
Radiographs are not detecting smaller periapical radiolucency.
CBCT shows more accurate detection of apical periodontitis.
Key words: periapical periodontitis, radiograph, CBCT, endodontics, outcome
The presence of bacteria in the root canal system and the marginal leakage of the tooth restoration with penetrating caries leads to persistent periapical periodontitis. Medication beyond the apex has no effect, because chronical lesions are considered sterile (1). Surgical elimination of the lesion might be an alternative. The first choice in periapical periodontitis should be the orthograde treatment. The purpose of this procedure is to eliminate the infected content of the endodontic system and to seal it with a proper root canal filling. Correct treatment leads to a reduction or complete healing of the periapical lesion. The outcome of an endodontic treatment can be visualize using PA radiographs or Cone Beam Computed Tomography (CBCT).
Our clinical case reveals the healing of periapical periodontitis after a single-visit treatment revealed on a CBCT compared with PA radiograph.
A 51 year old patient was referred to our endodontic department for endodontic treatment of tooth 47. The clinical examination revealed a large caries penetrating into the pulp chamber. The tooth was slightly positive to percussion and the vitally test showed negative response. No swelling or draining sinus could be detected. There was no periodontal probing more than 3 mm. The initial periapical radiograph showed a radiolucency due to infection noted around both mesial and distal roots of tooth 47 (Fig. 1). Rubber dam was placed and the alterate dentine was removed. The coronal walls were reconstructed using glass ionomer cement. The root canal treatment was performed in a single visit. Full working lengths were achieved for all three canals. After negociating the canals with manual instruments, ProTaper Universal rotary instruments (Dentsply, Maillefer, Switzerland) was used for shaping and cleaning. Preheated 5,25% NaoCl and 17% EDTA were used as irrigants. After drying the canal, the root canal filling was performed using warm vertical condensation of gutta-percha (Fig. 2). A post was inserted and the tooth was crowned.
The one year follow-up radiograph shows complete healing of the periapical lesion (Fig. 3). In comparison, on the CBCT, especially in the coronal plan, we can visualize a clear radiolucency, CBCTPAI 2 (Fig. 4).
CBCT is a great asset in daily endodontics, especially in the diagnosis of periapical endodontic pathosis and in the appreciation of the success or failure after endodontic treatment (progression of healing of the periapical periodontitis).
CBCT is a relatively new technology which should be introduced in daily dentistry. Dr Martin Level, member of The American Board of Endodontics was considering in 2010 that 42% of the patients had to be scanned (2). The radiological beam is cone shaped and needs one single rotation for aquiring the 3D images. The visualization is axial, transaxial, coronal and sagittal.
Conventional radiography is essential for an accurate endodontic diagnosis (3). However, the classical radiography is the two-dimensional expression (mesial-distal) of a three-dimensional reality, ignoring the vestibulo-lingual plane/direction (4). The obtained information is relative because of the incidence of the radiography.
Periapical pathosis cannot be correctly viewed on a retroalveolar, isometric and orthoradial radiograph, considering the overlapping of the anatomical structures, the anatomic noise and the geometric distortion. The conventional radiograph provides us with limited informations regarding the localization and the real extend of periapical, lateral or interradicular chronical periodontitis (5).
The CBCT can provide crucial informations even for the identification of small periapical lesions, which cannot be identified on periapical conventional radiograph. Friedman demonstrated that early endodontic treatment increases the succes rate of endodontic treatment, when periapical pathosis was detected on CBCT prior to conventional radiograph, which couldn’t reveal yet the radiolucency (6, 7) . Huumonen prooved the accuracy of CBCT in the diagnosis of chronical periapical periodontitis in case of patients with diffuse pain and inconclusive clinical tests when radiographs showed no pathological modifications (8).
Unlike the conventional X ray which gives a two dimensional view, the CT scanner can reveal all the three dimensions, providing accurate informations about the size of the radiolucency. A decrease in size of a periapical radiolucency, even if the lesion is not completely remineralized, is a sign of healing (9).
The sensitivity of periapical radiographs is lower compared with the CBCT (10, 11).
The radiographic outcome determined with PA radiographs could be untrue (12).
Just CBCT makes accurate diagnosis of periapical lesions possible.
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