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Table of Contents   
CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 1  |  Page : 99-101
Cone beam computed tomography: A tool for the diagnosis of confusing periapical lesions in conventional radiographs


Department of Stomatology, Bauru School of Dentistry, University of Sao Paulo, Bauru, Sao Paulo, Brazil

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Date of Submission23-Mar-2012
Date of Decision21-Jun-2012
Date of Acceptance09-Apr-2013
Date of Web Publication21-Apr-2014
 

   Abstract 

We report two cases in which cone beam computed tomography (CBCT) was essential for the establishment of the diagnosis of periapical lesions. CBCT allows a three-dimensional assessment of a specific region with no superimposition of structures. Therefore, its use is recommended when radiographic images are not sufficient for the diagnosis.

Keywords: Cone beam computed tomography, periapical lesion, periapical radiograph

How to cite this article:
Fernandes LR, Cardoso CL, Rubira-Bullen IF, Capelozza AA. Cone beam computed tomography: A tool for the diagnosis of confusing periapical lesions in conventional radiographs. Indian J Dent Res 2014;25:99-101

How to cite this URL:
Fernandes LR, Cardoso CL, Rubira-Bullen IF, Capelozza AA. Cone beam computed tomography: A tool for the diagnosis of confusing periapical lesions in conventional radiographs. Indian J Dent Res [serial online] 2014 [cited 2020 Nov 27];25:99-101. Available from: https://www.ijdr.in/text.asp?2014/25/1/99/131150
Dental radiographs are bidimensional projections of a tridimensional structure, and therefore, superimposition of anatomic landmarks can masquerade important findings. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Cone beam computed tomography (CBCT) is an advanced technology that allows the tridimensional assessment of the region of interest by means of reformations in sagittal, coronal, and axial views. [2],[3],[4] CBCT is an useful tool for the diagnosis of confusing lesions that cannot be properly assessed in dental radiographs. The aim of this article is to report two cases of persistent periapical lesions that presented confusing radiographic images as well as to discuss the benefits of CBCT images for the elucidation of both cases.


   Case Report Top


Case 1

A 31-year-old female was referred to our stomatology clinic complaining of "gingival lump." The symptomatic lesion had been observed 2 months before. Her dentist sent us a letter in which assessment and treatment of the region were required. The initial hypothesis suggested by her dentist was buccal exostosis. During clinical examination, we observed a symptomatic nodular lesion, firm to palpation and covered by normal mucosa, located in the buccal region of apex of right maxillary first premolar (tooth #5) [Figure 1]a. Two periapical radiographs were then performed with different horizontal angles of exposure. The related tooth was root-filled, but no significant change was clearly seen in the periapical region [Figure 1]b. Considering that more information was necessary for the diagnosis establishment, a CBCT scan was done on a Classic i-CAT unit (Imaging Sciences International, Hatfield, PA, USA) using 8 cm field of view (FOV) and 0.3 voxel size. During assessment of transversal views, hypodense images suggestive of periapical lesions and absence of endodontic filling material inside the root canal were observed [Figure 1c]. Cortical bone resorption was also observed [Figure 1]d and 1e]. The patient was then referred for endodontic retreatment of tooth #5.
Figure 1: (a) A symptomatic nodular lesion, fi rm to palpation and covered by normal mucosa, located in the buccal region of apex of right maxillary fi rst premolar (tooth #5). (b) Periapical radiograph of the affected tooth with confusing image of the periapical region. (c) CBCT transversal views in which the red arrow indicates the palatal periapical lesion and the white arrow indicates the buccal periapical lesion, with cortical bone resorption. The green arrow indicates absence of endodontic fi lling material. (d) CBCT axial reformation in which the resorption of cortical bone caused by the buccal lesion is observed, as well as in the illustrative three-dimensional reconstruction (e)

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Case 2

A 28-year-old male attended our stomatology clinic complaining of pain in the left side of his face. The patient did not present any temporomandibular joint disorder or othorrinolaryngologic and neurological disturbances. During clinical examination, no swelling was observed and the oral mucosa was normal. Then we performed panoramic and periapical radiographs of the left maxillary premolars and molars in order to detect any possible cause of the pain. His left maxillary first molar (tooth #14) was endodontically treated and presented a metallic crown [Figure 2]a. Considering that a possible radiolucent image related to tooth #14 was confusing in radiographs, we decided to do a CBCT scan on a Classic i-CAT unit (Imaging Sciences International, Hatfield, PA, USA) using 6 cm FOV and 0.3 voxel size. In CBCT images, it was possible to detect periapical lesion related to a mesiobuccal root canal with no root filling of the tooth #14 [Figure 2]b and c.
Figure 2: (a) Periapical radiograph of the left maxillary fi rst molar, which was endodontically treated and presented a metallic crown. (b) CBCT axial section in which the green arrow indicates the mesiobuccal root canal with no root fi lling of the tooth #14. (c) CBCT transversal views in which the white arrow indicates a large periapical hypodense image. The red arrow indicated a hypodense image inside maxillary sinus related to the affected tooth

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   Discussion Top


In both cases, the diagnosis of periapical pathology was difficult to establish. In the first case, buccal exostosis was the initial hypothesis considering clinical aspects of the lesion. However, most part of buccal exostosis is asymptomatic when covered by normal mucosa. CBCT was fundamental for the periapical lesion visualization, which was not clearly seen in periapical radiographs. The compromise of cortical bone was evident [Figure 1]d and e, even though Bender [1] stated that a periapical lesion, which affects cortical bone, can be usually seen in conventional radiographs. Also, CBCT images allowed a critical evaluation of the related endodontically treated tooth condition. It was possible to relate the incomplete root canal filling with the failure of the endodontic treatment and consequent persistent periapical lesion. [11]

In the second case, the diagnosis establishment was also challenging. The patient had facial pain and medical doctors had not detected its cause. CBCT images allowed the mesiobuccal root canal to be properly assessed, especially in axial view. The absence of root canal filling material allows the maintenance of microorganisms inside root canal systems, which can lead to persistent periapical lesion. [11] Since this lesion did not compromise cortical bone, its visualization was confusing in periapical radiographs. [1] Also we could identify a hypodense image inside maxillary sinus related to the affected tooth, which can indicate an inflammatory reaction of the sinusal membrane due to the persistent dental infection.

Although periapical lesion is a common finding in odontology, its detection can become challenging for the clinician, especially in root-filled teeth. [6] Clinical presentation or image appearance alone is not sufficient for the diagnosis of the radiolucent lesions. [12] It is important to combine both diagnosis resources in an effective way. A study showed that CBCT allowed 38% more periapical lesions to be detected than with conventional radiographs. [2] Tsai et al., [5] observed that periapical radiograph demonstrated poor diagnostic accuracy for small simulated lesions, whereas CBCT demonstrated good accuracy when simulated lesions diameter was more than 0.8 mm. CBCT accuracy is also superior when compared with the combination of two radiographic exposures for the detection of simulated lesions. [8] Therefore, the literature confirms that CBCT is an effective tool for the diagnosis of periapical lesions.

It is important to mention that CBCT generates a higher radiation dose for the patient in comparison to periapical radiographs. [10] Therefore, the ALARA (As Low As Reasonably Achievable) principle must be considered. CBCT is recommended when more information is required for the establishment of the diagnosis and treatment plan, especially for persistent periapical lesion that requires a complex endodontic approach. Also, CBCT allows the professional to differentiate periapical pathology from other conditions.

 
   References Top

1.Bender IB. Factors influencing the radiographic appearance of bony lesions. J Endod 1997;23:5-14.  Back to cited text no. 1
[PUBMED]    
2.Lofthag-Hansen S, Huumonen S, Grondahl K, Grondahl HG. Limited cone-beam CT and intraoral radiography for the diagnosis of periapical pathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:114-9.  Back to cited text no. 2
    
3.Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. J Endod 2008;34:273-9.  Back to cited text no. 3
    
4.Ordinola-Zapata R, Bramante CM, Duarte MH, Ramos Fernandes LM, Camargo EJ, de Moraes IG, et al. The influence of cone-beam computed tomography and periapical radiographic evaluation on the assessment of periapical bone destruction in dog's teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:272-9.  Back to cited text no. 4
    
5.Tsai P, Torabinejad M, Rice D, Azevedo B. Accuracy of cone-beam computed tomography and periapical radiography in detecting small periapical lesions. J Endod 2012;38:965-70.  Back to cited text no. 5
    
6.Tyndall DA, Kohltfarber H. Application of cone beam volumetric tomography in endodontics. Aust Dent J 2012;57 Suppl 1:72-81.  Back to cited text no. 6
    
7.Petersson A, Axelsson S, Davidson T, Frisk F, Hakeberg M, Kvist T, et al. Radiological diagnosis of periapical bone tissue lesions in endodontics: A systematic review. Int Endod J 2012;45:783-801.  Back to cited text no. 7
    
8.Sogur E, Grondahl HG, Baksi BG, Mert A. Does a combination of two radiographs increase accuracy in detecting acid-induced periapical lesions and does it approach the accuracy of cone-beam computed tomography scanning? J Endod 2012;38:131-6.  Back to cited text no. 8
    
9.Patel S, Wilson R, Dawood A, Mannocci F. The detection of periapical pathosis using periapical radiography and cone beam computed tomography-part 1: pre-operative status. Int Endod J 2012;45:702-10.  Back to cited text no. 9
    
10.Lennon S, Patel S, Foschi F, Wilson R, Davies J, Mannocci F. Diagnostic accuracy of limited-volume cone-beam computed tomography in the detection of periapical bone loss: 360 o scans versus 180 o scans. Int Endod J 2011;44:1118-27.  Back to cited text no. 10
    
11.Nair PN. On the causes of persistent apical periodontitis: A review. Int Endod J 2006;39:249-81.  Back to cited text no. 11
[PUBMED]    
12.Becconsall-Ryan K, Tong D, Love RM. Radiolucent inflammatory jaw lesions: A twenty-year analysis. Int Endod J 2010;43:859-65.  Back to cited text no. 12
    

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Correspondence Address:
Luciana Maria Paes da Silva Ramos Fernandes
Department of Stomatology, Bauru School of Dentistry, University of Sao Paulo, Bauru, Sao Paulo
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.131150

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