CBCT to Evaluate Apical Lesions

We have been discussing the use of CBCT in the practice of endodontics. There have been questions about whether CBCT is really necessary, or just another cool image. That particular question was one of the biggest we had in our decision to move to CBCT. We also ask that question to ourselves when we recommend a CBCT scan to our patients. However, much like a microscope, until you look through the scope, you often don't know what you are missing. I have found that quite regularly, I will find things that I could not have seen otherwise and it has changed the treatment that I have recommended.

Here's an example of a routine CBCT scan that I did prior to endodontic surgery. This scan gave me added information, that then changed the treatment plan and give us better prognosis.

This patient presented for evaluation. The teeth are asymptomatic, but a lesion seen by his general dentist. The lesion is obviously on the MB root of #3, with ledged MB canal. The crown margins looked good and since the MB canal is ledged, we were planning to treat this tooth with an apicoectomy. I recommended a routine, pre-surgical CBCT to evaluate the root anatomy, sinus proximity and buccal bone contours.


This slice through the MB root shows that there is a missed MB#2 canal.

A slice through the palatal root shows a periapical lesion on the palate not visible in the original, pre-op radiograph. This now changes our treatment recommendation. An apicoectomy will resolve the MB issues, but fail to resolve the palatal lesion. This could cause continued problems and lead to the assumption of a failed endodontic surgery, when the palatal root could be the problem.

An additional slice through the palatal roots shows that #2 also has a significant periapical lesion requiring treatment.

A sagittal view of #2 again shows the extent of the lesion.

While the lesion on the palate of #2 is visible in the original radiograph, there is no doubt about it's presence with the sagittal view above.

In this case the additional information about the palatal lesion on #3 changed the treatment recommendation and will thereby improve the prognosis. Lack of CBCT scan in this case would have led to wrong treatment recommendation.

That being said, I know there are those who will say..."alway retreat first" and you don't need a CBCT scan to make that decision.

CBCT provides improved imaging of the the teeth and periapex. I welcome the added information into the diagnostic and treatment part of my practice. For more information about the application of CBCT into endodontics, the upcoming Inner Space Seminar is right around the corner.

Implant Training by Mentorship!!!!????

I think we all agree that continuing education is one of the foundations of every profession.

It guarantees that practitioners remain up to date and abreast of new techniques, materials and research studies that are continuously changing and improving.
With that in mind, I have noticed a trend in the past two years that in my opinion is alarming, if not outright dangerous for the dental profession.

Recently many, for profit, seminar groups, institutes and other continuing education providers are marketing so called “Implant Mentorship courses”. Most of these courses are 2-4 days. Most faculties are general dentists and they claim they provide training for implant placement and restoration in that time period, through “mentoring”.
As an educator and a practitioner; I believe these kinds of so called “training”, will only give a false sense of knowledge and competence to people attending them.
The advances in implant dentistry have been wonderful for patients who are missing one or more teeth. In my opinion, any general dentist, who is interested in implant dentistry, should seriously think about attending these courses.

The best continuing education training programs in implant dentistry are offered by dental schools through out the United States. These programs are spread over a few months (usually about 300 CE hours or more) and all aspects of implant dentistry from A – Z are covered.
Faculties are periodontists, oral surgeons, prosthodontists and general dentists. And, they will tell you at the end of these programs, that you should not take on certain implant cases due to level of difficulty or possibility of complication. Keep in mind that a poorly done endodontic case, can easily be corrected by retreatment or apical micro-surgery. A poorly done implant case, is very very difficult and sometimes impossible to correct.

From a legal point of view,when a general dentist begins to perform procedures that are primarily performed by specialists, the law holds them to the standard of care, expected of specialists providing similar procedures on a regular basis.
Before you sign up for one of these implant training or mentorship courses, stop and think. Would you have an implant done on yourself or a loved one by a dentist that had training for 2-3 days?

I welcome your comments.

Robert Salehrabi, DDS

Did you know that 70% of Americans are afraid of root canals?

Root canal treatment allows patients to save their natural teeth. The endodontists at Superstition Springs Endodontics are partners with general dentists in helping to save natural teeth. Modern, microscopic endodontic treatment can be a relaxing and pain-free experience.

In a recent AAE survey, 76 percent of participants said they would prefer a root canal to tooth extraction.

Nearly a third would not sell a healthy front tooth for any amount of money.

Most people are not aware that root canal treatment is a viable alternative to tooth extraction

Despite great progress in modern endodontic therapy, there are still misunderstandings about root canal treatment.

Myth #1: Root canal treatment is painful.
Myth #2: Root canal treatment causes illness. (focal infection theory still persists today!)
Myth #3: A good alternative to root canal treatment is extraction.