History of Endodontics aae/abe



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CBCT


-Coneshaped beam captures variable size cylindrical/spherical volume data (FOV)

-Isotropic cubic Voxels (3-D pixels) comprise the image

-3 Orthogonal planes: Axial, Coronal, and Sagittal; Multiplanar reconstruction

-Spatial Resolution is less (2 line pairs/mm) than digital PA (7-25 line pairs/mm)



Diagnosis: Hassan – Axial view best for VRF detection

  1. Patel 2007 – Applications for CBCT & Endo:

  • Detection of PA changes & Diagnosis (PRE-OP)

  • Anatomical anomalies (i.e.: Dens), Resorptive lesions

  • Treatment complications – Perforations, VRFs, sep instruments

  • Pre-surgical planning

  • Healing/Treatment Outcomes (POST-OP)

  1. Simon 2006 – Large PARL, Granuloma vs. Cyst; CBCT (grey scale) >Biopsy

  2. Bernardes/Azevedo 2009; Ozer 2010 – VRF detection: CBCT > Digital PA

  3. Ozuk 2011 – Accumoto 93% accuracy VRF (confirmed via Sx/RETX)

  4. Ee/Johnson 2014 – CBCT>Digital PA Diagnosis: VRFs, Resorption, Perforations, PARLs- 83% vs 36%. CBCT changed recomm. tx 60% of time

  5. Blattner 2010 – MB2 detection: CBCT = Sectioning (gold standard)

CBCT

Radiation:

  1. Ludlow 2006/AAE 2011 – Kodak: Effective dose (Sv): Max Ant: 4.7, Max Post: 9.8, Mand Post: 38.3; 1 dig. PA: 6, FMX: 171, Background (day): 7-8

CBCT vs. PA Radiograph (PARL detection):


  1. Velvart 2001 – Mand. Molars, CBCT 100%, E speed PA 78%

  2. Lofthag-Hansen 2007 – CBCT 100%, F speed PA 62%

  3. Bornstein/Von Arx 2011 – Mand. Molars, CBCT 100%, F speed PA 75%

  4. Tsai/Torabinejad 2012 – Simulated lesions (0-1.4 mm), CBCT > Digital PA


CBCT vs. PA Radiograph (Mandibular canal detection):

  1. Velvart 2001 – Mand. Molars, CBCT 100%, E Speed PA 61%

  2. Bornstein/Von Arx 2011 – Mand. Molars, CBCT 100%, F speed PA 35.3%


Working length:

  1. Jeger/Bornstein 2012 – NSD using CBCT and Digital PAs for FWL

Subjective & Objective Examination

  1. Reeves/Stanley – Irrev. pulpitis - caries w/in 0.5mm of pulp or reparative dentin

  2. Tronstad – direct pulp cap is only 50% successful (= Irrev. Pulpitis)

  3. Barthel – direct pulp cap (CaOH2) – 5 yrs: 40% fail, 10 yrs: 80% fail

  4. Cvek – Cvek (partial) pulpotomy (trauma/2 mm/7 days) = 96% success

  5. Kretzschmar – referred pain may come from Max. sinus (Rhinosinusitis)

  6. Cold test

    1. Rickoff/Trowbridge – no pulp injury Cold CO2 5 min, Heat 10s

    2. Miller – RS(TFE) > CO2 Pulp temp red; PFM/All Ceram/Gold Crns

    3. Jones/Rivera/Walton – RS Faster response than CO2 snow

    4. Petersson – Overall accuracy: Cold 86%, EPT 81%, Heat 71%

      1. Sensitivity (test identifies disease): 83%, 71%, 86%

      2. Specificity (test identifies healthy): 93%, 93%, 41%

      3. Pos. Predictive Value (given test states diseased, probability subject is diseased): 89%, 88%, 48%

      4. Neg. Predictive Value (given test states healthy, probability subject is healthy): 90%, 84%, 83%

    5. Villa-Chavez 2013 – Cold>Heat>EPT – Accuracy, Reproducibility

    6. Trowbridge – mode of action Cold test – hydrodynamic theory

  7. Cold + EPT

    1. Peters/Baumgartner - Cold neg + EPT neg = True Necrotic

    2. Weisleder/Trope - RS + CO2 + EPT: All 3 tests positive (NPP): 97% vital, All 3 tests negative (PPP): 90% necrotic; Cold + EPT  accuracy

  8. Barodontalgia –pain caused by change in pressure (flying/diving)

    1. Senia/Cunninghaminflammed vital pulp tissue

    2. Fenjensick – 86% faulty restorations

  9. Histopathologic correlation with testing & clinical symptoms

    1. Seltzer/Bender; Dummer – no correlation btw diagnostic tests (except PN) & histo pulp status and clinical signs/symptoms & histo pulp status

  10. Localization of Pain:

    1. Friend/Glenwright –37% patients could localize symptoms to offending tooth, to 3 teeth 80% (EPT stimulation – Vital teeth)

    2. McCarthy/McClannahan –73% patients could localize symptoms to the offending tooth (Irreversible Pulpitis); 90% Perc + patients, 30% Perc - patients; 100% No midline cross; pain (VAS) =  localization

  11. Mechanical Allodynia (percussion sensitivity):

    1. Khan/Hargreaves – 67% Irrev. Pulpitis, 57% Pulp Necrosis

    2. Owatz/Hargreaves – 57% Irreversible Pulpitis

Vitality testing = Sensibility testing = pulpal nerve status only

*** Does not evaluate blood/vascular supply***


Reliability:

  1. Fulling/Andreasen; Fuss/Trowbridge – immature developing teeth, unreliable response to EPT, use CO2 snow/RS (Higher EPT thresholds/late innervation of plexus of rashkow)

  2. Bhaskar trauma cases - EPT, cold and heat tests – unreliable (due to nerve damage w/out altering blood supply)

  3. Fuss/Trowbridge –EPT unreliable w/ large restoration

EPT:

  1. Narhi- Mode of action – low threshold Aδ fibers (prepain sensation) – ionic fluid shift

  2. Abdel Wahab- Technique - slowly increased current- more accurate

  3. Mumford – No relationship between EPT value and pulp histopathology

  4. Bender – test Incisal Edge in Anterior teeth

  5. Jacobson – test Middle 1/3rd F -Incisors, Occlusal 1/3rd B -Premolars

Heat test:

  1. Schindler – used on refractory (persistent AP) cases to identify missed canals or late stage of irreversible pulpitis

Laser Doppler

LDF = Use of infared beam of light – scatters by Doppler principle when interacting with moving RBCs – photodetector reads this Doppler shifted backscattered light = Index of pulpal blood flow




  1. Yanpiset/Trope 2001 – dog study, avulsion/reimplantation - detect return of pulpal blood flow by 4 wks




  1. Gazelius 1988 – case report, Lateral luxation 4 lower incisors – detected blood flow 6 wks (partially), 9 mos (complete)




  1. Chandler/Sundquist 1999 – case report: LDF – Dx: Periapical COD




  1. Mesaros/Trope 1997 – case report: 8 yr old, luxation #8,9 – LDF- vital



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