Critically Review the Advantages and Disadvantages of Three Dimensional Imaging Systems and their Potential Future Role in Contemporary Endodontics

 

An academic article in partial fulfilment of an MSc in Endodontology in the Faculty of Health & Social Care at the University of Chester by Dr MJ Rowland-Warmann BSc BDS (Manc) MSc Aes.Med. (Lond) MJDF RCS (Eng)

 

 

 

Critically Review the Advantages and Disadvantages of Three Dimensional Imaging Systems and their Potential Future Role in Contemporary Endodontics

 

 

This is an academic article on endodontics. If you are a patient and have arrived here looking for treatment for a painful or hot tooth then follow the link to our main page on root canal treatment.  Alternatively if you are a dentist looking to make a referral for a CBCT scan then follow the link here for our dental referrals and CBCT scan page.

Easily the best dentist appointment I've had. I was recommended to go by a friend who couldn't have spoken more highly of them. The facilities are top notch, service friendly and comforting. The staff were great. The treatment was thorough, honest and well explained. First class (excuse the airline pun...you'll see why!)
Adam Samy
Adam Samy
19:10 01 Jun 17
I found Smileworks after looking online for the best specialist orthodontist, and after several visits now, I do believe that they live up to the hype! Every visit has been a pleasure, with the excellent reception always offering a warm and hearty welcome. Due to the severity of problems with my teeth, my treatment plan is extensive and means that despite being early days, I have met with and been treated by a range of the staff here; I can confirm that they're all fantastic and incredibly thorough - everything is explained in detail and nothing is ever rushed. I should also thank Paula (and her assistant whose name I've forgotten - sorry!) yesterday for cleaning the insides of my teeth so thoroughly when I don't even think it was necessarily part of the appointment (the appointment was for a filling). I look forward to continued excellent care from Smileworks and can't wait to get my braces on! Cheers guys!
Michael Kelly
Michael Kelly
08:04 14 Apr 17
Absolutely great find. Friendly staff and MJ who treated me was professional, reassuring and positively fantastic about what my needs were and what I was looking for. There was no pressure on anything and she spoke in depth about full details on every procedure without any rush in me in making an option. I will definitely be visiting again. Thank you once again!
Samina Mubarak
Samina Mubarak
20:02 06 May 17
Absolutely excellent service. All the staff are friendly and make sure all your treatment options are fully explained. Don't do anything unless your 100% sure of all that's available. Shiron made sure my treatment was the absolute best it could be.
Keith Chellew
Keith Chellew
18:41 24 May 17
I had dental work and a procedure on my top lip. I was really nervous on my first visit but the staff are truly lovely and put me at ease straight away. I loved the quirkiness of the waiting room- very different from any dentist/doctors waiting room I've been in. The treatment rooms are very clean, love the design and layout. I also loved the patients photo smiles on the wall!! straight away I relaxed and I could feel the friendliness of the staff. MJ really listened to my fears and listened to what I required, she understood completely my views and the treatment I received was given exactly as I requested!! They really want to help you and they're interested in what you have to say - they love their job!!! I've made a follow up visit and will continue to use them. I've also recommended Smileworks to my friends and will continue to do so.
Nicci Richards
Nicci Richards
20:11 26 Feb 17
I went to Smileworks to have the composite reconstructions on my two front teeth replaced as well as my teeth whitened. On my first appointment with M.J I was given detailed explanations of what these processes involved, which not only eased my apprehensions but stood out from all the previous dentists I had visited. The teeth whitening took approximately two weeks, after which I had the most amazing reconstruction done on my front teeth by Dr Billal Arshad, including a flawless colour match to my newly whitened teeth. The treatment I received was incredible and the end results speak for themselves, I have had numerous people within the fist week comment on how incredible my teeth look. To all the staff at Smileworks I say thank you so much, you have made me a very happy customer.
David Birtles
David Birtles
11:55 26 Jul 17
The staff at Smileworks are fantastic, very welcoming and accommodating. They are always happy to go the extra mile to help you. I had fast braces and 1ml lip filler, i absolutely love the result. Would 100% recommend to anyone looking to get braces or facial aesthetics, they really listen to what you want and combined with their professional knowledge you achieve the perfect result.
Kerry Browne
Kerry Browne
10:46 27 Jul 17
I received my Spmu eyeliner treatment today at Smileworks. I am completely over the moon with the results and would highly recommend the treatment. The clinic itself it just wonderful really clean, fresh and highly professional. My therapist was Hannah Taffe who was extremely knowledgeable, but also so warm and welcoming and put me completely at ease. The treatment was really relaxing and didn't hurt one bit. So very impressed and will certainly be back. Next time I will be booking in to see an orthodontist. Huge thanks to Hannah you really are just fabulous. Sarah Bell xx
SARAH BELL
SARAH BELL
18:10 05 Aug 17
Visited smileworks Saturday, place is amazing everyone was really welcoming and friendly. I was given all the answers to any questions i had before I even asked them!. Hannah was fantastic she gave me a full consultation. I am really happy with the outcome. I will be visiting smileworks in the future.
Laura Harte
Laura Harte
18:39 07 Aug 17
The most welcoming and friendly staff I have ever experienced anywhere, let alone a dentist. I felt in safe hands from the get-go and was so happy with the staff arranging appointments for me even outside of the practice. The creative and clever practice design (airplane) topped the fun experience off! Thanks MJ, Georgiana and Heloise.
Sean Donohue
Sean Donohue
22:03 03 Sep 17
Had my fast braces fitted at Smileworks at the beginning of the year and recently had my lips done, MJ and the team are Lovely! Always a Friendly and professional service! Perfect opening hours which work around my job. Highly recommend! 😀
Elle Benson
Elle Benson
13:25 05 Sep 17
I did went Saturday morning as an emergency customer. No previous contact with them in the past. I was extremely happy of what I found. The place itself & location is great. But even better the staff; They were very understanding and helpful. MJ who finally attend my case did work the extra mile (and extra time too :)) so later than 17:30 Sat. Quick/Nice/Effective & Reliable. So far the best dental clinic I have been. Definitively I will recommend & use them again.
FERNANDO
FERNANDO
13:30 03 Oct 17
After breaking a tooth whilst away in Liverpool, I googled local dentist and called the first number in the list. Smileworks offered me an A1 service and managed to temporary fix my tooth until I returned home allowing me to continue my few days away. Not only was the cost very reasonable for an emergency appointment their practice is the funkiest I’ve ever seen. The dental staff were all fantastic too, I couldn’t have asked for more. Just gutted that there isn’t a smileworks in Cambridgeshire!
Lee Clayton-Harvey
Lee Clayton-Harvey
16:21 24 Oct 17
If you're looking for the best place for your treatment, you've got to choose and visit smile works. They make you feel beautiful, their all friendly and talented personnel. Their welcoming smile alone will make you feel at ease that you're in the right place for your treatment. Their smile really works.
Tiana Bukolami
Tiana Bukolami
22:52 11 Nov 17
team I'd like to provide you with some feedback on my treatment to date: After 1:1 advice and guidance with the smile-works team, I recently attended for my first treatment (root canal). I was greated and treated professionally throughout, experienced no pain, and was informed and entertained by MJ, whom I found to be extremely reassuring, competent and also hilariously funny. Withought hesitation I can fully recommend this practice, and I am so excited about completing my planned course of treatment, which is bespoke and excellent value for money, just in time for Christmas ! Kindest regards Dave Sent from my i
nicola jonnes
nicola jonnes
15:31 22 Nov 17
5 Star service and quality! Had my lips done for the first time and couldn't be more happy with them! MJ works wonders, would recommend 100% !!
davina Johnston
davina Johnston
14:10 25 Nov 17
Wow what an absolute amazing experience said no person ever going to the dentist. Well until now... Had severe pain due to a Wisdom tooth and couldn't sleep the night before and knew I had to finally face my fear and go to the dentist and get this sorted. Sat up all night due to lack of sleep watching and reading horror stories on having a Wisdom tooth removed and was dreading it more and more as time went on. Called Smileworks at 9am Saturday morning to get an emergency appointment and was given one within 3 hours. When i arrived I was greeted with cheer into what could only be described as the coolest dental reception area of all time. The receptionist (forget her name) automatically put my mind at ease. Normally my experience at dentists was sit and wait for an absolute age to be called. Not at Smileworks. MJ came into the reception area so cheery and got me and brought me to the room which was something out of a futuristic movie it was absolutely amazing. From start to finish MJ kept my mind at ease telling me every step of the way on what was happening and what the plan of action was. We even meditated over the removal of my wisdom tooth which really calmed me down. MJ was absolutely amazing in the removal and I had built up such a hype and horror pictures of what was going to happen. The exact opposite happened. This had made me build up my confidence in a dentist again and I would highly highly highly recommend Smileworks to anyone.
Kyle Boyd
Kyle Boyd
14:03 27 Nov 17
Me and my mum came here for the first time last year,and I can’t praise Mj and the staff anymore we felt so welcome and at ease straight away. My lips where and still are amazing and i get so many compliments! They literally do go “above and beyond” and totally make you feel “first class” x
Vicky Diamond
Vicky Diamond
20:49 28 Nov 17
I arrived at Smileworks just as they were closing early for the Christmas break. When I explained my situation (needed emergency treatment) & was going on holiday on Boxing Day MJ agreed to sort out my tooth. She was so friendly & I didn't feel like I was putting her out at all. One of the girls who had her coat on to go home even offered to stay to help. Within 20 minutes I was sorted out & could get on with my Christmas shopping!!! Thank you MJ & the nice dental nurse I now know I go away without having to worry about my tooth. 👍
Pauline McLoughlin
Pauline McLoughlin
02:06 24 Dec 17
Had my lip filler done here as well as a non-surgical nose job and couldn't be happier with the results. Such friendly staff who are all amazing at what they do and give me all the information I needed prior to my treatments. I wont be going anywhere else in Liverpool other than Smileworks!
Lauren Thompson
Lauren Thompson
13:05 26 Dec 17
I felt so welcome and comfortable here! I admire Dr MJ very much, because I did root treatment, which I thought was painful and complex. But it only took 1 hour and I did not feel a little pain. I trust them so much that I feel sleepy! And the reception girls are energetic and full of smiles. This is a wonderful place to make your smile beautiful and confident!
jiadi he
jiadi he
16:57 02 Jan 18
Smileworks are by far the best dentist I’ve been too!! So friendly and welcoming, the waiting area is fun, the receptionist are very helpful and informative, the dentists are highly skilled and make you feel comfortable and are very reassuring. I have had metal braces before when I was younger and feared getting them again but I am happy I went with Smileworks MJ and Bambi who have both been my dentist are fab as well as each assistant that supports them. I actually enjoy going each month and finding out what stage I am at and what’s to come next I never feel anxious. I’ve actually referred two people here, worth every penny 🙂
Emma Gillespie
Emma Gillespie
16:53 04 Jan 18
Reception staff welcoming and friendly. Decor is cool. Bambi and Eva so friendly patient and welcoming. Bambi explains the treatment plan and is patient. Got other few appointments to go. Would recommend. Thanks
Da Mc
Da Mc
19:03 10 Jan 18
I’ve been going to Smileworks for all my treatments since it first opened and I have not and will not go anywhere else. Everyone is always commenting on how good my lips look, my skin. My teeth are straight after only 3 months of a brace. Everyone there is so friendly and everything is explained throughly. The surgery is so clean and modern and MJ is the most qualified person out there for anything you need. I shall be continuing to go there for the rest of my time. Amazing. Love all the team at Smileworks 💕
Keeley Cawley
Keeley Cawley
00:32 17 Jan 18
I have visited MJ at Smileworks many times and I can not recommend the company any more ! All of the staff are so friendly and make you feel welcome as soon as you walk through the door. I always look forward to visiting Smileworks because the experience is always positive, the treatments provided are fantastic and I always leave feeling a million dollars.
Rebecca Zaidi
Rebecca Zaidi
20:11 16 Jan 18
First class customer service and care. The vibe of Smileworks is friendly yet ultimately professional. I have completed 3 sessions of PLEXR on my eyelids and the results are incredible! I will not hesitate to come back. Thank you Smileworks, you really have helped me to rebuild my confidence 😌
Sarah Parkinson
Sarah Parkinson
17:12 19 Jan 18
Called and obtained next day appointment. Clear instructions on how to find the surgery. Very thorough examination. X-rays and dental photos fully explained. Options for further treatment discussed. Follow up appointment arranged to check burn on my palate roof of which I was unaware and make sure nothing more serious. Dental hygiene scale and polish carried out and very pleased with outcome. Excellent service from Rebecca and Lucy. Recommended A+++++
Stephen Olive
Stephen Olive
18:39 23 Jan 18
A very welcoming, warm, friendly and professional atmosphere. I Felt very relaxed and at ease whilst I had my treatment which was a 1ml of lip filler. MJ was very informative and listened to what I wanted and personalised my treatment. I am super happy with the results and could not have asked for a better practitioner whilst receiving this procedure. Fantastic company and would highly recommend anyone to go here!
helen murray
helen murray
14:27 01 Feb 18
I've recommended Smileworks to a few people now, as I've had nothing but good experiences within the past 6 months. I decided to get my braces fitted here because I thought, with all the good reviews, I couldn't go wrong. I'm so glad I braved it because the results, only 5 months into the treatment, are amazing!!! MJ and Georgi are absolutely lovely. They're so friendly, and really just make you feel so comfortable there, which is a massive plus for nervous patients, as I was to begin with. The waiting area and reception is so fun. It makes a really nice change to what you usually see in a dentists waiting room. So, if you're thinking about going to Smileworks, do it! They're fantastic 😀
Sarah Hornby
Sarah Hornby
21:05 04 Feb 18
I needed an emergency appt & got one quickly. I needed a tooth extraction - I had an excellent (female) dentist who gave a really good local (enough & I could still feel my face!). The extraction was tough but I was well cared for. I've not had any problems at all since and I had it taken out 4 days ago. Thank you.
James Piper
James Piper
02:19 13 Feb 18
Great dentist, just had my brace removed and really happy with the results. All the staff are really friendly and welcoming. The late opening hours are a bonus too, so you have lots of flexibility when booking appointments. Would highly recommend.
Chris Brady
Chris Brady
14:11 17 Feb 18
I had the best first appointment. I had to change dentists because the last one was simply not fixing my issues. I was very hesitant to try a new dentist but I am glad I did. The staff are very polite and attentive. Dentist office itself is exceptionally clean. After my check up everything was explained well. Very good experience .
Shan Parke
Shan Parke
15:56 14 Mar 18
Smileworks is easily the most professional, friendliest practice I have ever been too. All the staff are so welcoming and I would never go to another practice for any of my treatments after being see here! Smileworks is the best!
Emily Jones
Emily Jones
22:31 08 Mar 18
I was initially nervous and apprehensive. I hadn't visited this practice before but I had done my homework and went here on recommendation. I booked with MJ and went to have some work done with my upper lip & facial aesthetics. She put me at ease completely and I was expecting pain. It was so easy, straightforward, and I will definitely go back. I was a little tender the day after, but there was no discomfort on the day of treatment and it was much easier than having a dental filling 🙂 My result has been fabulous and I am very happy and would certainly recommend.
Angela Jones
Angela Jones
18:32 27 Mar 18
Great customer service and care! Friendly staff you feel home each time. I had my treatment with Billy and Eva and I'm so happy about the result. Definitely recommended
Gabriele Ganga
Gabriele Ganga
00:17 29 Mar 18
First went for an emergency fix, then second time for root canal treatment and veneers, splendid results!! Recommended it to my friend and he got his emergency fix done and was happy with it. I would recommend this dentist to everyone! Thanks Smileworks! You made me more confident now 🙂
Miz A.
Miz A.
23:01 03 Apr 18
A superb experience! From the initial call to the reception team through to the treatment and after-care level of service, my expectations were exceeded in every aspect. This is a very smart, clean, modern and friendly dental clinic with customers at the heart of service. The team of professionals take time to understand the issue, explain possible causes, possible treatments and put you at your ease. This was a first-class experience and although I don't live near here, I am considering switching from my regular dentist to Smileworks Liverpool. Oh and for aviation geeks, the clinic has an airline theme which is refreshingly different to the traditional style of dental surgeries.
Richard Salkeld
Richard Salkeld
18:47 08 Apr 18
I chose Smileworks for my braces and could not be happier with my decision and have been recommending them ever since! There is always a friendly atmosphere at Smileworks and I’m always talked through what will be happening during my appointment. The late opening hours are perfect for fitting in around work and I have never had to wait longer than my given appointment time on every visit so far. In just 5 months Smileworks have managed to drastically straighten my teeth which I didn’t even think was possible after expecting a minimum of 1 year treatment!
Chelsea Borrow
Chelsea Borrow
21:35 19 Apr 18
Honestly the best customer service I have ever received. The receptionist is so friendly and helpful and the staff who looked at my teeth were very professional, always making sure that I was okay throughout. Nothing was too much trouble and they made sure that I left with full knowledge of what my teeth whitening procedure was going to be and answered all questions! Will definitely be recommending to friends and I cant wait to come back for my next appointment!
Sophie B
Sophie B
11:20 28 Apr 18
From my consultation to the end result I received the best customer service I have experienced. I was looked after by Paula and Emily who were both so welcoming, friendly and helpful and answered all of my questions. The consultation itself was so in depth and helpful and I learnt things that no other dentist had told me. I would recommend this place to anyone wanting dental treatment and I would definitely return.
Amy Robertshaw
Amy Robertshaw
14:23 29 Apr 18
Excellent treatment performed by professional dentists. I did NOT feel the dentist's hands when digging the tooth that caused a strong pain. I did NOT feel at all what happened:) smile and thanks a lot after 30 min of treatment. A narrative: The clinic gave me a fast track consultation as an emergency appointment when I call them in the early morning because of sudden and increasing pain over night after passing another clinic in a day before. Recent equipments of x-ray 4k that can take images of teeth and identity problems before handelling any treatment clearly after 5 min. The clinic is on high standards. It is highly appreciated and highly recommended. Thanks a lot.
Hany Ahmed
Hany Ahmed
02:13 31 May 18
The customer service at this dental practice is some of the best I have experienced in any organisation period. All staff are a credit to themselves and their employer. Friendly, bubbly, knowledgable and considerate. The treatment was top class, the facilities brilliant and the location very central and convenient. I don't often bother to leave reviews on Google, but I think it's worth the effort this time. Well done to all at Smileworks - outstanding.
Paul Gregory
Paul Gregory
21:16 13 Jun 18
Amazing customer care and advice and treatment for removal of a very painful wisdom tooth. NHS removal via my own dentist was going to be 6-8weeks waiting time. Smileworks were very understanding and arranged emergency appointment and then an extraction within a few days. There were no complications and the whole experience was first class. Everything was explained and there were excellent follow up calls to check I was Ok and no issues. So glad not to be taking anymore pain relief. Am considering switching my dentist!
Mike Whiting
Mike Whiting
14:44 27 Jun 18
I booked an appointment having not been to the dentist for a while through Kerry who was very helpful. My consultation was completed by Bambi and Ewa. My appointment was very thorough and I was extremely impressed with the level of service. I would definitely recommend smileworks to my friends and family. Thank you for looking after me!
Ste Glover
Ste Glover
18:54 27 Jun 18
Amazing! In order to get braces I have done a comprehensive research and booked initial appointments in several places in Liverpool. I have found out that in many of them I wouldn’t be treated by an orthodontist, but by a person who only has a certificate (and is lacking the knowledge and experience that an orthodontist has), and in some places there was a weird, cold, "we don't really care" attitude, plus I would only see a dental nurse. Smileworks keeps it's standards high, will always welcome you like an old friend, with smiles and care! Laurence, the orthodontist, very nice and very professional guy, investigated my case, went through a treatment plan with me, and I left happy, knowing I found my place and that I can trust them. My first appointment with Smileworks was 10 months ago, and since then I enjoy every visit, every conversation, every appt follow up, everything about this place! Great energy, great people and great results. It’s a no brainer, I can’t recommend it enough! Thank you for creating such an amazing experience for your customers!
Maja Socha
Maja Socha
11:13 03 Jul 18
Amazing place to make yourself more confident and happy about your smile. All team are really friendly and helpful. Dr. Laurence is fantastic made me feel so comfortable and relaxed, he is so knowledgeable and explains everything!
Roma Neverdauskaitė
Roma Neverdauskaitė
16:49 05 Jul 18
Amazing! In order to get braces I have done a comprehensive research and booked initial appointments in several places in Liverpool. I have found out that in many of them I wouldn’t be treated by an orthodontist, but by a person who only has a certificate (and is lacking the knowledge and experience that an orthodontist has), and in some places there was a weird, cold, "we don't really care" attitude, plus I would only see a dental nurse. Smileworks keeps it's standards high, will always welcome you like an old friend, with smiles and care! Laurence, the orthodontist, very nice and very professional guy, investigated my case, went through a treatment plan with me, and I left happy, knowing I found my place and that I can trust them. My first appointment with Smileworks was 10 months ago, and since then I enjoy every visit, every conversation, every appt follow up, everything about this place! Great energy, great people and great results. It’s a no brainer, I can’t recommend it enough! Thank you for creating such an amazing experience for your customers!
Maja Socha
Maja Socha
11:14 03 Jul 18
Paula & Emily treated me very thoroughly and did a very good job at putting me at ease. The practice is very clean and modern. Dr Lawrence has also been brilliant. I have absolutely nothing negative to say, so glad I found this practice!
Jennifer Josephine
Jennifer Josephine
17:54 25 Jul 18
OMG! If you're looking for an outstanding consultation or just wanna make yourself prettier, then Smileworks is THE place! Excellent clinicians, very talented, and performing only at the highest possible standard! Love it 😍
Georgiana Taulea
Georgiana Taulea
21:39 04 Aug 18
Found Smileworks online Friday night when my veneer came off and was seen and sorted by lunchtime Saturday! Amazing customer service, so helpful! If you need a new dentist that opens weekends or in need of emergency treatment don’t hesitate to contact Smileworks! My husband thinks my veneer looks better now than it did originally! Thanks again to the Smileworks team!
Tara Byrne
Tara Byrne
19:17 11 Aug 18
Absolutely lovely people that work there, great service and make you feel at home. As for the quality of braces, it's well worth it! I've had mine in only for 4 months and they look amazing! The difference already is unbelievable. Thank you so much smileworks!
Anto70411
Anto70411
10:58 23 Aug 18
The best money well spent, my appointment was with Zoe. I felt welcomed, I was thoroughly advised on my options and what to expect. Very honest about the pros and cons regarding the treatment. I had one tooth pulled out and I felt nothing bearing in mind that this "thing" was "rotten" but "clinging for dear life", yet I felt nothing. Zoe made me roar with laughter with the conversations she was having with me and her colleague, whilst playing "tug of war" with the tooth. Errors made by my previous dentist Zoe corrected and I am well pleased. Very sterile, good looking business. Thankyou
Robertha Jones
Robertha Jones
12:13 27 Aug 18
Absolutely enjoyable team from nurses to doctors. No waiting, instant meetings and rapid assistance with perfect service. I highly recommend to everyone who needs professional help.
Jiri Vyborny
Jiri Vyborny
17:57 25 Aug 18
One of the best dental practice I have ever seen. Thank you all for your helping me during my emergency visit. للأخوة العرب المقيمين أو الزائرين إلى ليفربول، هذه العيادة من أفضل عيادات الأسنان التي رأيتها في حياتي بدء من الاستقبال وحتى الطبيب المعالج. اذا احتجت الى زيارة طبيب الاسنان اجعل هذي العيادة خيارك الأول!
Ali Alsolme
Ali Alsolme
14:19 01 Sep 18
I unfortunately lost a tooth a few years ago due to a nasty abscess that too many root canal treatments could not cure. I decided at the beginning of the year that it was time to fix my smile and went for a consultation for a dental implant. I visited a couple of dental practices and decided on smileworks due to the friendliness of staff and their ability to answer all of my questions and put my mind at ease. Plus an added benefit was that they offered credit to help finance the treatment. I could not be more happy with my decision and my results. I have a perfect smile once more and dealing with the team was an absolute pleasure! I cannot recommend their services highly enough.
Grainne Mulholland
Grainne Mulholland
12:34 05 Sep 18
Very pleased with the dermal fillers administered by MJ and the semi permanent makeup from Hannah. Both took the time and effort to ensure I received the best options for treatment. In addition, the reception staff were very polite and welcoming which added to my positive experience. Would definitely recommend.
Rose
Rose
21:59 10 Sep 18
I couldn’t recommend Smileworks more! All staff are so friendly and make you feel welcome. Hannah is absolutely amazing! An absolute perfectionist in semi-permanent makeup. Anyone who is considering having eyebrows/eyeliner/lips done should 100% have Hannah do them, you won’t regret it!
Abby Cowdell
Abby Cowdell
16:26 17 Sep 18
Went to smileworks to have my eyebrows done by Hannah! From the moment you walk in everyone is super friendly and Hannah greets you like an old friend! This was my second visit as it was a top up! My eyebrows are really not easy as they pretty much non existent and what was there was super wonky! Hannah was amazing! She was so patient and spent a ridiculously long time making sure I went home happy! Would 100% recommend to everyone!! X
Bethany Sheldon
Bethany Sheldon
16:31 06 Oct 18
I went to smileworks last week for a new retainer. The service I received was great, from meeting the receptionists to when I was receiving treatment from Paula and the dental nurse. Everyone was very smiley, friendly and helpful. Paula especially took the time to explain whitening treatments to me (as I mentioned I would like whiter teeth on my patient details form) and also explained treatments such as composite bonding which could help me achieve the perfect smile I was looking for. The dental nurse helping was also very calming and patient. I would definitely recommend to others and would really like to compliment their great customer service. Thanks smileworks and all their lovely staff.
Victoria Thomas-Hui
Victoria Thomas-Hui
20:33 10 Oct 18
Had bad experiences with other dentists. Went to smileworks. I could not have been treated better. The staff are amazing and my dentist Susan is fantastic. She put me completely at ease. I've never said this before but I now enjoy going to see her and get work done on my teeth. Would highly recommend smileworks
Karen Wells
Karen Wells
04:22 11 Oct 18
Had my first appointment today with Paula and Jess. It was very nice, friendly and professional! I was talked through a plan for future treatments that I wanted and given a price estimate, so helpful! Appointment was also 2 days after I phoned them, so seen very quickly!
Laura Johnston
Laura Johnston
14:22 19 Oct 18
I feel 5 star is not enough and those guys deserve an infinite number of stars and a unicorn on top of that! I have a severe phobia if it comes to my teeth, I'm a survivor of Polish public dentist care and let me tell you that's something straight from nightmares and torture chambers. As a results my teeth are not in a great way (those that did survive), to add to the "fun" I also have major orthodontic issues. I knew I needed help and it took me about a year and a half (this is not an exaggeration) to make my way to Smileworks. In the meantime I tried two other 5-star rated places and I wasn't convinced enough to stick around. The second I called Smileworks I had a warm fuzzy feeling in my belly that this place is the right place finally, It took a few months and multiple appointment before the right treatment plan could be created, since my case is complicated to say the least. I feel that there was a LOT of thoughts put into finding a solution, which made me feel at ease and gain enough trust to go ahead with the treatment. Every time I come to visit everyone is just brilliant. All the ladies and gents are nice and bubbly, which definitely helps to relax. Their approach is very gentle, a lot of attention is given to the patients and you just get the feeling that this guys really know what they do. I feel spoiled and I stopped fearing every dentist visit as I used to in the past. I know it sounds odd, but if anyone is able to make dentist appointments as pleasurable as possible, that's the people at Smileworks! As to address the money, things like that cost a lot, that's the unfortunate reality and there's no way to avoid that. For what I've been offered i think that's worth every penny. If it comes to the plane theme, I think it's amazing and I absolutely love it, especially because of all the little details. Finally a place with a sense of humor! I get how people scared of dentist AND flying can find it disturbing, but I think that's just an edge case. I will preach the genius of this place forever and share it with anyone who is eager to listen (or is not eager to listen at all but just haven't ran fast enough from me).
Joanna Skorupa
Joanna Skorupa
10:24 26 Oct 18
Can't recommend smileworks enough amazing service! Really helpful over the phone and booking my first visit was so easy. Laurence and Georgie were so friendly and discussed the different options and treatment plan in detail. Nothing was too much trouble 🙂 Thanks guys!
Sam Abbott
Sam Abbott
16:06 07 Nov 18
Great experience. Very happy with my new smile. All the staff are faultless and so welcoming!!
Jessica Hudson
Jessica Hudson
16:13 14 Nov 18
First time for lip fillers, so obviously a little nervous on the outcome but I am over the moon. A natural yet full look could not recommend smileworks anymore. MJ is unreal at what she does and puts you at ease within a few seconds of the consultation whilst also giving all the right info and questions. Excited for another ml already!
Rosa Horsley
Rosa Horsley
12:13 26 Nov 18
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Introduction

 

In order to diagnose and effectively treat an endodontic problem, imaging is essential.  Various techniques have been found to be effective, and developments in imaging have facilitated all stages of endodontic treatment from diagnosis to completion and healing, in addition to identifying pathoses of odontogenic and nonodontogenic origin and preventing complications (Durack & Patel, 2012; Mota de Almeida, Knutsson, & Flygare, 2014).  Nevertheless, imaging in endodontics is only an adjunct, however useful, and not a replacement for sound clinical decision making based on pathological signs and symptoms (Estrela, Bueno, Leles, Azevedo, & Azevedo, 2008)

 

 

The first “radiogram” in root canal treatment was produced in 1899 and since, intraoral radiographs, whether analogue or in recent years digital, have become the mainstay of image-based diagnosis in endodontics (Scarfe, Levin, Gane, & Farman, 2009).  In recent years, investigations have been made to assess the feasibility of digital subtraction radiology (DSR), ultrasound (US), Magnetic resonance imaging (MRI) and computed tomography (CT); due to its simplicity and ease of use conventional radiography systems have prevailed (Durack & Patel, 2012).

 

 

High quality three-dimensional imaging systems such as cone beam computed tomography (CBCT) enable visualisation of the maxillo-facial area with a lower patient dose than conventional CT (Durack & Patel, 2012; Scarfe et al., 2009).  However, as with any exposure, the possible benefits to the patient must outweigh the risks. 

 

 

Conventional imaging techniques

 

Due to its simple technique, low sensitivity but high specificity, periapical radiography is the imaging method of choice for endodontic practice (Mota de Almeida et al., 2014).

 

The interpretation of conventional radiographs is limited by the compression of three-dimensional structures into two-dimensional images, lacking appreciation of the spatial relationship of anatomical structures and being clouded by superimposition of structures, so-called “anatomic noise”.  It is complicated by morphological variation, differences in bone density, the angulation of the tube (and difficulty standardising this relative to the subject position) and misrepresentation of the size of any lesion on conventional radiography (Estrela et al., 2008).

 

Furthermore, due to the separation between object and receptor, a minimum of 5% magnification is to be expected.  In an attempt to improve spatial perception in conventional radiography, parallax technique can be employed by shifting the tube horizontally by 10-15 degrees; however, this is rarely achieved perfectly due to positioning errors, which are often further exacerbated by bending films for ease of access (Durack & Patel, 2012; Patel, Dawood, Whaites, & Pitt Ford, 2009; Scarfe et al., 2009).

 

 

Imaging techniques considered for Endodontic use

 

Tuned aperture computed tomography (TACT) relies on 8-10 images exposed at different geometries to reconstruct a 3D image.  Advantages of less anatomic noise, dosages as low as two periapical films and absence of scatter from metal restorations with resolution of 2D radiographs are cited.  Studies by Nance et al 2000 showed 36% detection of MB2 versus no detected lesions in periapical films (Nance, Tyndall, Levin, & Trope, 2000).  However, the true rate of MB2 canals is around 85%, which implies that the detection rate of TACT may leave a little to be desired.  TACT was mentioned as a novel diagnostic tool in 2009 with exciting applications for the future; however, this has not yet materialised some decade later, so a rapid increase in its use in the short term may not be forthcoming.

 

Magnetic resonance imaging does not use xrays to generate the image, but instead relies on changing the alignment of hydrogen atoms and using radio signals to detect their movements.  MRI is not distorted by metallic objects within the mouth.  However, the technology for MRI is complex, large and costly, restricting its use for the dental setting.  As teeth and bone do not emit signals to be detected, they appear dark on MRI scans.  Whilst MRI has been used for salivary gland imaging and is very useful for soft tissues, its use for dental hard tissues is limited.

 

Ultrasound, like MRI, does not use ionising radiation to generate an image.  Instead, it relies on varying acoustic properties of tissues to generate a reading.  Tissues with greater density will create a greater reflection and be visible as an outline. Whilst useful in the detection of cysts, ultrasound does not effectively pass through bone and as such is often of little use for periapical diagnosis unless the lesion is large and advanced through the cortical plate.

 

Computed Tomography involves taking a series of 2D images and reconstructing them to a 3D representation.  The patient is usually supine and passes through the ‘donut’ which contains the radiation source and the sensor.  Conventional CT is able to eliminate anatomical noise and has been found to be more effective in the detection of periapical pathology than conventional radiography, at 78% versus 39%.  However, resolution depends on the slice interval, and an increase in resolution with a decrease in slice interval will significantly increase the radiation dose to the patient.  In any case, the effective dose of conventional CT is often several hundred times that of a periapical radiograph (Patel et al., 2009).

 

 

CBCT

 

The most exciting and, for the endodontic practice realistic in terms of use and accessibility, imaging method of the current age is CBCT.  Different to conventional spiral CT in that it offers views specific to the maxillo-facial area, CBCT allows three-dimensional appreciation of anatomy and pathology relevant to dentistry (Durack & Patel, 2012; Scarfe et al., 2009).

 

With over 40 different models providing varying diagnostic yields available on the market, the basic principles of CBCT are the same (Endodontology et al., 2014).  A cone-shaped x-ray beam is emitted and directed from a source that rotates about the patient situated in the centre, with the detector positioned on the opposite side to the beam at all times and rotating correspondingly, as seen in Figure 1 (Durack & Patel, 2012; Scarfe et al., 2009).

 

 

 

CBCT scanning equipment rotates around the subject
Figure 1: CBCT scanning equipment rotates around the subject, from (Dawood, Patel, & Brown, 2009)

 

 

A scan takes approximately 10-40 seconds, in which time hundreds of images are acquired to reconstruct a cylindrical volume, the individual units of which are known as voxels (3D pixels) (Durack & Patel, 2012).  The resultant volume allows appreciation in axial, sagittal and coronal views as a reconstructed image (Durack & Patel, 2012).

 

 

Since its inception for dental practice use in 2001, access to CBCT is increasing.  A recent study by Rosen et al found that 34.2% of respondents had access to CBCT in USA (Rosen, Taschieri, Del Fabbro, Beitlitum, & Tsesis, 2015).  Whilst this gadgetry has surely poses improved visibility of structures within the dentist’s treatment field, it is important to consider whether the use of CBCT would significantly change the treatment plan or aid the diagnosis in any event; the long term health risks, especially the potential for malignancy and the risks to children, are unknown (Rosen et al., 2015).

 

 

Classification of CBCT

 

CBCT is classified according to patient position, functionality or scan volume.  Patients may be positioned standing, sitting or supine, the former two being most widely found in dental practices due to their smaller footprint (Scarfe et al., 2009).  CBCT machines may be limited to 3D imaging or multimodal, encompassing panoramic and cephalometric radiography in addition to CBCT, such as the Planmeca ProMax series.  Scan volume can be divided as follows with corresponding volume sizes which are cylindrical;

 

 

  • Small volume or small field: less than 5cm height
  • Single arch: 5-7cm height
  • Interarch or dual arch: 7-10cm height
  • Maxillofacial: 10-15cm height
  • Craniofacial: over 15cm height (Durack & Patel, 2012; Scarfe et al., 2009)

 

 

A smaller field of view (FOV) is preferred by dental practitioners, as reporting on the images will fall within their competency.  For clinicians regularly assessing the temporomandibular joint or performing maxillofacial surgery, larger volumes are required (Scarfe et al., 2009).  Smaller volumes benefit from better resolution.  As the FOV increases, as does the radiation dose to the patient, so it is important that the FOV is only slightly larger than the area of interest (Endodontics, 2015; Holroyd & Gulson, 2009).  An example of classifications according to scan volume has been employed by Planmeca, as seen in Figure 2.

 

 

 

 

CBCT classification according to scan volume
Figure 2: CBCT classification according to scan volume; this allows lower patient exposure, from (Planmeca, 2018)

 

 

CBCT dosages

 

Radiation load to the patient is presented in effective dose, measured in micro Sieverts (mSv) (Scarfe et al., 2009).  Conventional CT dosages can be as high as 500-1000mSV (Blattner, George, Lee, Kumar, & Yelton, 2010), whereas the doses from modern CBCT units can be as low as panoramic radiographs, at around 13-44mSv.  Comparatively, a small intraoral radiograph carries a dose of 1-5mSv (Durack & Patel, 2012; Venskutonis, Plotino, Juodzbalys, & Mickeviciene, 2014).  Representative values are shown in Figure 3.

 

 

When prescribing a CBCT for use in endodontics, or for any purpose, the dosage must follow the ALARA “as low as reasonably achievable”-rule.  Imaging parameters such as kV and mA, beam filtration, beam type (pulsed versus continuous) and the shape of the beam contribute to the dose to the subject (Scarfe et al., 2009).  Reduction of mA and exposure time reduces dose to the patient (Endodontology et al., 2014), with a smaller FOV for optimal resolution of the endodontic lesion further reducing risk (Endodontics, 2015).  However, in an attempt to reduce the dose, noise can reduce resolution, which for endodontic problems so small in nature they are missed on periapical films would defeat the object of taking a CBCT in the first place (Dawood et al., 2009).  Conversely, selecting unnecessarily high resolution may not necessarily improve diagnostic outcome (Hassan, Payam, Juyanda, van der Stelt, & Wesselink, 2012).

 

 

Resolution in CBCT also depends on the voxel size, with smaller voxel size allowing better resolution, but in turn producing a higher dose of radiation to the patient (Endodontics, 2015; Vizzotto et al., 2013).  Protocols therefore need to be optimised in order to find the right balance between resolution and dose.

 

 

Figure 3: effective dose ranges of dental imaging techniques, from (SEDENTEXCT, 2011)
Figure 3: effective dose ranges of dental imaging techniques, from (SEDENTEXCT, 2011)

 

 

Advantages of CBCT in Endodontics

 

CBCT allows appreciation of endodontic disease without any superimposition or anatomic noise often associated with conventional radiography with excellent visualisation of the sometimes complex interplay between tissues and pathology.  Due to the isotropic nature of voxels, measurements are geometrically accurate (Durack & Patel, 2012; Mota de Almeida et al., 2014; Scarfe et al., 2009).  Advances in equipment mean that whilst still a significant investment, CBCT machines are now attainable by dental practices, with the ease of use of manipulating software certainly playing a part in the rise in popularity (Durack & Patel, 2012).

 

 

In a study by Mota et al, just 4% of cases referred to endodontic clinics in their study were assessed using CBCT technology.  It was found that when used in accordance with the European Commission guidelines, there was a significant impact on therapeutic decision efficacy in the cases selected for imaging, allowing distinction between pathology and normal anatomy.  However, It was noted that in order to be entirely of benefit, the proposed diagnostic method of CBCT must have the ability to change the treatment decision and subsequent outcome (Mota de Almeida et al., 2014).

 

 

Limitations of CBCT in endodontics

 

Metal restorations in the patient’s mouth can cause issues in the diagnostic acceptability of a CBCT scan output; this causes beam hardening, the result of which is a distorted image with distortion of metal structures or streaks between dense objects (Durack & Patel, 2012; Scarfe et al., 2009; Venskutonis et al., 2014).  Artefacts can also be introduced by gutta percha, and also from the scanning equipment (Scarfe et al., 2009; Vizzotto et al., 2013).  Patients with advancing age usually have more restorations, but also are more likely to require endodontic treatment.  Not only do the restorations play a part in the diagnostic yield of the resultant CBCT image, but advancing age also affects diagnostic value negatively as cortical thinning causes reduced image quality (Ritter et al., 2009).

 

 

Whilst CBCT allows appreciation of the area of interest in three dimensions, the dose to the patient is significantly higher than conventional radiography and as yet the resolution of CBCT is inferior to intraoral radiographs (Durack & Patel, 2012; Endodontics, 2015).  Most practices do not have access to CBCT as for many the cost of the machinery is prohibitively expensive compared to periapical radiography (Mota de Almeida et al., 2014).  Furthermore, adequate training is required in order to report on the entire volume rather than simply the area of interest which can pose difficulties for general practitioners wishing to prescribe CBCT (Endodontology et al., 2014; Estrela et al., 2008).

 

 

 

Applications in endodontic practice

 

In order to critically appraise the advantages and limitations of CBCT in endodontic practice, specific applications must be assessed; endodontics is a field with a vast array of requirements for imaging.

 

 

In order to achieve a resolution that makes it possible to appreciate the complex clinical situation for which the CBCT has been ordered, such as investigation into the periodontal ligament space with an average dimension of just 0.2mm, voxel size needs to be less than 0.3mm (Scarfe et al., 2009), some even advocating 0.08-0.125mm for fine resolution (Dawood et al., 2009).

 

 

The justification of the exposure must be weighed up against the possible diagnostic benefit, however many feel that currently the selection criteria for the use of CBCT in endodontic practice is not transparent enough (Rosen et al., 2015).

 

 

The following recommendations for the use of CBCT in endodontics have been established, which draw on the information supplied by the European Commission and the joint position statement of the American Academy of Endodontists and the American Academy of Oral and Maxillofacial Radiology; the intent is for these guidelines to be used in conjunction with clinical decision making in order to arrive at a sound diagnosis.

 

 

The recommendations in the joint position statement issued by the American Academy of Endodontists and the American Academy of Oral and Maxillofacial Radiology were that CBCT should only be used in the treatment of complex endodontic cases, and periapical radiography was to remain the first choice for diagnostic and postoperative imaging.  Emphasis was placed on the need for a comprehensive examination prior to any CBCT prescription (Endodontics, 2015; Endodontology et al., 2014; Mota de Almeida et al., 2014).

 

Inclusion criteria

  1. Endodontic disease to be ruled out
    1. Vital teeth which are symptomatic or display contradictory signs but otherwise healthy
    2. Root filled teeth which are symptomatic but otherwise healthy, such as those where the patient reports persistent pain
    3. The absence of pathology on intraoral radiography with the presence of symptoms
  2. To confirm endodontic disease in a symptomatic tooth
    1. Fractures or trauma that cannot be identified on periapical radiography
    2. Resorptive lesions – internal or external and the definitive diagnosis thereof
  3. As an adjunct to treatment
    1. To assist in the management of internal or external resorptive lesions
    2. Prior to endodontic surgery if there is close proximity to significant anatomic structures
    3. Diagnosis and management of endodontic complications such as ledges, overextension and perforations, and foreign bodies such as broken files
    4. Assessment of unusual tooth anatomy and assist in planning endodontic intervention in complex root morphologies
    5. Diagnosis of previously uninstrumented canals after intial failed treatment

 

Exclusion criteria

  1. A previous CBCT has been taken
  2. Conventional radiography has allowed a definitive diagnosis and treatment plan to be established
  3. A different specialised imaging method is required (Endodontics, 2015; Endodontology et al., 2014; Mota de Almeida et al., 2014)

 

A larger field of view obtained by a CBCT may be justified if the endodontic lesion or pathology extends beyond the parameters of what can be viewed on a conventional radiograph (Endodontics, 2015).

 

 

 

Apical Periodontitis detection

 

The periapical status of a tooth is important in arriving at a diagnosis and formulating a treatment plan (Kruse, Spin-Neto, Wenzel, & Kirkevang, 2015).  This uses clinical information alongside radiographs, the advantage of which is the visualisation of the apical lesion in a non-invasive, accurate manner (Abella et al., 2012).

 

 

With conventional radiography, assessment of apical pathology can be difficult due to anatomic noise, often resulting in the size of the lesion being underestimated (Cheung, Wei, & McGrath, 2013).  Lesions confined to cancellous bone are often missed on periapical radiographs due to the masking of the lesion by the overlying cortical plate.  Only when the lesion has expanded to erode the cortical plates are they likely to be readily visible on a radiograph, after resulting in 30-50% bone mineral loss.  Those very close to the sinus floor may be missed altogether (Estrela et al., 2008; Kruse et al., 2015; Patel et al., 2009; Venskutonis et al., 2014).

 

 

The absence of radiographic change therefore does not directly imply an absence of periapical inflammation (Cheung et al., 2013).  It is also thought that performing endodontic treatment prior to visible changes on the radiograph improves outcome scores (Durack & Patel, 2012).  This is where CBCT could be an exciting addition to the endodontist’s armamentarium.

 

 

Multiple studies have found CBCT to be a diagnostic tool with high sensitivity for the detection of periapical pathology, far outweighing the diagnostic accuracy of radiographs (Durack & Patel, 2012).  A study by Lofthag-Hansen et al showed that more periapical lesions were identified using CBCT than conventional radiography (Lofthag-Hansen, Huumonen, Grondahl, & Grondahl, 2007), which was confirmed by Estrela et al in their research on scoring periapical lesions and diagnostic efficacy of CBCT, showing that apical periodontitis is often present but undetected on conventional radiographs which were then scanned with CBCT suggesting high false negatives in 2D imaging (Estrela et al., 2008).

 

 

Scarfe et al compared various imaging methods to find that the diagnostic accuracy of CBCT is 61%, versus 39% for digital and 44% for conventional radiography in the detection of apical periodontitis (Scarfe et al., 2009).  Patel et al found that apical periodontitis was detected in 24.8% of cases with intraoral radiographs versus 100% of cases with CBCT (Patel et al., 2009); the same author followed up with further research some three years later and found that CBCT identified twice as many periapical lesions than CBCT in one research study (Patel, Wilson, Dawood, Foschi, & Mannocci, 2012) and a 62% more lesions in another (Durack & Patel, 2012).  Figure 4 shows a comparison between a periapical radiograph and a CBCT for the same tooth, and the difference in diagnosis possible with each, further highlighting the issues surrounding anatomic noise in 2D imaging and the efficacy of CBCT.

 

 

Radiograph of an upper incisor
Figure 4 a) and b): Radiograph of an upper incisor showing a possible but small increase in periodontal ligament space versus CBCT sagittal view showing a large, 3-4mm lesion associated with the apex of the same tooth. Anatomic noise has shrouded the lesion on the conventional radiograph. From (Estrela et al., 2008)

 

 

The size of the lesion is relevant for diagnosis.  Tsai et al found that in lesions smaller than 0.8mm, CBCT demonstrated poor accuracy, in those larger than 0.8mm the diagnostic accuracy was good, and above 1.4mm the diagnostic accuracy became excellent (Tsai, Torabinejad, Rice, & Azevedo, 2012).  Put into perspective, even at 1.0mm where conventional radiography may struggle to identify the lesion unless perforation of the cortical plate has occurred, CBCT could be a useful tool in identification of early apical periodontitis, especially in a tooth where the symptoms are vague (Patel et al., 2015).

 

 

A question that has been posed many times is whether the use of CBCT in the detection of apical periodontitis is likely to result in a change to the treatment plan.  Abella et al suggested that strategy, the type of irrigant used and case management may be influenced by access to CBCT (Abella et al., 2012).  Whilst undoubtedly the diagnosis can be facilitated by its use, Balasundaram et al came to the conclusion that it it is unlikely to significantly modify the treatment plan (Balasundaram et al., 2012).  Whilst guidelines have been suggested, there is no definitive protocol for CBCT in the use of periapical diagnosis and it is unknown whether the outcome for the tooth will change significantly with the use of CBCT (Kruse et al., 2015).

 

 

Assessment of surgical sites

 

As the distance between the inferior dental nerve and the lower molars can be accurately measured on only approximately half of all periapical radiographs, planning surgical endodontics with the use of CBCT, especially when adjacent to anatomical sites such as sinuses or nerves, can reduce morbidity significantly (Durack & Patel, 2012; Venskutonis et al., 2014).  It has been suggested that in around 70% of scanned cases, a CBCT showed clinically relevant information that had been missed on periapical radiographs (Venskutonis et al., 2014).

 

 

Dental trauma assessment and management

 

CBCT may assist in identification of horizontal root fractures which are difficult to diagnose on conventional radiography – unless the xray beam passes exactly through the fracture line, thus making it visible.  Accurate diagnosis improves outcomes as it affects treatment decisions (Durack & Patel, 2012).

 

 

Although CBCT would accurately illustrate the degree of displacement and likely allow fuller assessment in all spatial planes, current recommendation is that periapical radiographs are to be routinely taken at multiple angles for assessment of initial trauma and progression, and CBCT is suggested only if the results of these are inconclusive (Patel et al., 2015)

 

 

The peak incidence of traumatic dental injuries is between three and nine years, where extraoral imaging may be preferred to intrusive intraoral methods, especially if the child is distressed (Durack & Patel, 2012).  However, the risk posed by radiation versus the benefit of the information available with the use if CBCT must be carefully weighed up.

 

 

Vertical root fractures

 

Vertical root fractures (VRF) are often difficult to diagnose until they have been established for some time (Durack & Patel, 2012).  Hassan et al showed that CBCT has increased sensitivity in the detection of vertical root fractures over periapical radiographs (Hassan et al., 2012), and even that a low resolution CBCT has increased accuracy in diagnosis (Venskutonis et al., 2014).

 

 

Patel et al, in 2015, recommended that CBCT should not be relied upon for the diagnosis of VRF due to the likelihood of minor subject movement affecting scan quality.  It is however, probable that periradicular changes as a result of VRF will be visible on CBCT images prior to them being perceived on intraoral radiographs (Patel et al., 2015).

 

 

Root canal anatomy and morphology

 

It is known that accurately assessing canal number and morphology can help avoid repeat or surgical intervention (Durack & Patel, 2012).  CBCT assessment can be useful at the assessment stage to gauge canal number, the presence of dilacerated roots or aberrant morphology such as dens in dente in order to reduce the risk of perforation, transportation or ledges and avoid exploratory procedures (Durack & Patel, 2012; Todd, 2014; Venskutonis et al., 2014).

 

 

Conventional radiography often overlooks supplemental canals and their omission in treatment can lead to endodontic failure (Blattner et al., 2010; Durack & Patel, 2012).  It is accepted that maxillary first molars have an incidence of 69-93% second mesio-buccal (MB2) canals and that their successful treatment is important to the outcome of root canal treatment (Blattner et al., 2010; Vizzotto et al., 2013).  Studies have shown that there is a reduced detection of MB2 canals when using intraoral radiography compared with CBCT, and that conventional periapicals fail to detect the MB2 in up to 40% of maxillary first molars (Vizzotto et al., 2013).  Compared with CBCT, which had detection of 3.58 canals on average in an upper first permanent molar, the detection rate with periapical radiography was just 3.1 canals (Scarfe et al., 2009).  Diagnosing MB2 canals using CBCT shows no difference in identification between 0.2mm and 0.3mm voxel size, suggesting that a dose-reducing protocol with a larger 0.3mm voxel size is sufficient (Vizzotto et al., 2013).

 

 

An interesting observation is, however, that there is only a single study comparing the effectiveness of identification of the MB2 canal between CBCT and microscopy, which would pose zero radiation dose and thus risk to the patient.  CBCT is not indicated as a standard method to demonstrate root canal anatomy over microscopy, which results often in adequate vision of canals with no radiation dose (Abuabara, Baratto-Filho, Anguigar Anele, Leonardi, & Sousa-Neto, 2013; SEDENTEXCT, 2011).

 

 

Root resorption

 

Resorptive lesions can be classified as inflammatory (internal or external), non-inflammatory, cervical or replacement, with complex aetiologies that are dependent on the source of the stimulus and the location (Bernardes et al., 2012)

 

 

The prognosis of a tooth with a resorptive defect is improved if detected early, and treatment efficacy relies on correct diagnosis (Bernardes et al., 2012; Todd, 2014).

 

 

Resorptive defects on the buccal or lingual surfaces are difficult to see with intraoral radiography and will often be missed on conventional radiographs (Bernardes et al., 2012).  However, comparative studies on the use of conventional imaging versus CBCT on resorptive lesions are limited (Durack & Patel, 2012).  It is accepted that assessment with CBCT in three dimensions is more effective than 2D radiography (Scarfe et al., 2009), and has been shown to have statistically higher detection rates (Bernardes et al., 2012).

 

 

The difference between internal and external resorption is often difficult to visualise on periapical radiographs  (D’Addazio et al., 2011).  External inflammatory root resorption (EIRR) after trauma is common, at 5-18%, and as high as 30% after avulsion, and is responsive to root treatment.  The outcome for EIRR can be improved by early diagnosis with CBCT; however, currently this is often prescribed when evidence of resorption has been established with conventional radiographs, which is rarely early stage (Durack & Patel, 2012).  With the current guidelines, the timing of when a CBCT should be undertaken is unclear; repeated exposures are difficult to justify (SEDENTEXCT, 2011).

 

 

Endodontic complications

 

Endodontic complications and failure can be difficult to discern on conventional radiographs.  CBCT can assist in planning a remedy and estimating the prognosis (Todd, 2014; Venskutonis et al., 2014) and results in the identification of a significantly higher number of endodontic mishaps than periapical radiography (D’Addazio et al., 2011).

 

 

Perforations can result in inappropriate treatment.  In over 80% of cases, perforations are missed on conventional radiographs.  In a comparative study by D’Addazio, perforations were recognised in all cases evaluated with CBCT.  Post deviations were identified in 60% of cases with CBCT, versus 40% in the non-CBCT group (D’Addazio et al., 2011).

 

 

CBCT is less useful in the detection of separated files than periapical radiography.  In the same study by D’Addazio, CBCT did not visualise 60% of files but identified 40% accurately, whereas radiographs did not see 40% of files but identified 60% accurately – this is possibly due to reduced resolution on CBCT as compared with radiographs (D’Addazio et al., 2011).

 

 

Endodontic complications therefore have mixed benefit from diagnosis with CBCT and the selection should be on a case by case basis.

 

 

Outcome of RCT

 

The success of root canal treatment is measured by the trifecta of lack of periapical pathology, adequate horizontal and vertical obturation and the absence of symptoms (Wesselink, 1994).

 

 

With CBCT, voids and shortcomings in the root filling can be visualised (Decurcio et al., 2010), and when using this in posttreatment evaluation, lower healing rates have been reported and root fillings considered sub-optimal (Durack & Patel, 2012; Patel et al., 2012; Venskutonis et al., 2014).  The healing rate one year postoperatively, comparing periapical radiography with CBCT, is 87% versus 62.6% (Patel et al., 2012).  This begs the question as to whether current quoted success rates are exaggerated by the use of periapical radiographs, whether these lesions are merely taking longer to resolve under the scrutiny of CBCT technology, or whether the endodontic procedure has in fact failed.

 

 

Some have advocated the use of CBCT as a pre- and post-operative measure (Durack & Patel, 2012), although due to radiation dose and complexity of a CBCT examination it is more useful and should be regarded as a diagnostic rather than intraoperative or postoperative evaluation tool (Venskutonis et al., 2014)

 

 

Conclusions

 

The usefulness of CBCT is undisputed in all dental disciplines including endodontics (Patel & Horner, 2009), especially with the introduction of machines capable of low dose and small FOV (Vizzotto et al., 2013).

 

The effective dose of CBCT is significantly higher than intraoral radiography, and if respecting the ALARA principle, the dose must reap significant benefits considering the increased risk to the patient.  CBCT should therefore not be used routinely, but is justified on a case-specific, individual basis when the information cannot be gleaned from lower dose diagnostic tests (Durack & Patel, 2012; Endodontics, 2015; Rosen et al., 2015).  Used correctly and reserved for complex endodontic problems, it can have significant impact on therapeutic decision making when used in accordance with the European Commission guidelines (Balasundaram et al., 2012; Mota de Almeida et al., 2014).

 

 

Even though the radiation dose to the patient is higher, the imaging method more technique sensitive and the equipment costlier than conventional radiography, CBCT has become popular in general and specialist practices alike.  Whilst advances in imaging are no doubt on the horizon, X-ray imaging including the use of CBCT is likely to be difficult to unseat from mainstay use.

 

 

CBCT is undoubtedly valuable for diagnosis of pathology.  It is sometimes difficult as clinicians to justify a CBCT scan when there is an absence of pathology on periapical radiographs.  Whilst there are guidelines on the use of CBCT in endodontics, they can be made to be universally applicable.

 

 

There is a need for further studies considering the impact of the use of CBCT on the management of endodontic disease, and whether there should be a follow up assessment given the variance in periapical versus CBCT images and the difference in outcome measure.  Currently, treatment strategies seem to change only in the presence of resorptive lesions.  Any imaging is only a snapshot in time, and as such critical evaluation of the need, and the timing of any radiographic examination must be carefully appraised.

 

 

The introduction of CBCT to the endodontic practice is exciting and has scope; however, it is not a panacea and its usage should be limited to justifiable applications.

 

 

 

References

 

Abella, F., Patel, S., Duran-Sindreu, F., Mercade, M., Bueno, R., & Roig, M. (2012). Evaluating the periapical status of teeth with irreversible pulpitis by using cone-beam computed tomography scanning and periapical radiographs. J Endod, 38(12), 1588-1591. doi:10.1016/j.joen.2012.09.003

Abuabara, A., Baratto-Filho, F., Anguigar Anele, J., Leonardi, D., & Sousa-Neto, M. (2013). Efficacy of clinical and radiological methods to identify second mesiobuccal canals in maxillary first molars. Acta Odontol Scand, 71(1), 205-209.

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