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To be able to determine if endodontic treatment of apical pathosis is successful or not, healing of lesions is followed up by radiographic imaging. This can be done by observing changes in apical radiolucencies. Recently, cone beam computed tomography (CBCT) has been introduced as a method of gaining an unabridged view of dental anatomy, thus eliminating some of the most prevalent problems, such as superimposition and distortion. CBCT reduces false diagnosis and is rapidly replacing other radiographic techniques in diagnosis, quality control of treatment methods and techniques, and outcome assessment. Healing assessment using conventional and newer three-dimensional imaging includes, but is not limited to, periapical osseous lesions, conditions of the maxillary sinus, status after endodontic surgery, hard tissue deposition in regeneration procedures, and horizontal root fractures. Due to a low predictive value of two-dimensional periapical radiographs to distinguish between periapical disease and health, future assessment of endodontic treatment efficacy may include 3D imaging from small field-of-view CBCT units.

The quality and technical standard of Australian endodontic treatment is generally unknown. Two hundred and forty-three patients from a metropolitan dental hospital were radiographically assessed for quality of root canal therapy. Total teeth examined were 5647 with 499 teeth (8.84%) being root-filled. Teeth were scored using Ørstavik's Periapical Index. Periapical Index scores indicating a healthy periapical state were found in 392 root-filled teeth (78.56%) and those indicative of periapical disease in 107 root-filled teeth (21.43%). Of the 499 root-filled teeth, 149 (29.9%) were adequate in terms of length, with 120 teeth (80.5%) of these healthy. Three hundred and fifteen teeth (63.1%) were filled short with 271 (86.0%) classified as healthy. Thirty-five teeth (7.0%) were filled long with only one tooth (2.9%) in this category deemed healthy. Four hundred and fifty-nine teeth (92.0%) were adequate in density, with 365 teeth (79.5%) being healthy. Forty teeth (8.0%) showed inadequate density with 27 (67.5%) being healthy. One hundred and forty-five teeth (29.1%) were adequate in length and density with 117 teeth (80.7%) deemed healthy. A significant statistical correlation between root filling quality and periapical status was not found. Factors, such as the coronal restoration quality, should be further investigated.

Cone beam computed tomography (CBCT) has been specifically designed to produce undistorted three-dimensional information of the maxillofacial skeleton, including the teeth and their surrounding tissues with a significantly lower effective radiation dose compared with conventional computed tomography (CT). Periapical disease may be detected sooner using CBCT compared with periapical views and the true size, extent, nature and position of periapical and resorptive lesions can be assessed. Root fractures, root canal anatomy and the nature of the alveolar bone topography around teeth may be assessed. The aim of this paper is to review current literature on the applications and limitations of CBCT in the management of endodontic problems.

Patel S, Dawood A, Pitt Ford T, Whaites E. The potential applications of cone beam computed tomography in the management of endodontic problems. International Endodontic Journal, 40, 818– 830, 2007. Aim To provide core information on cone beam computed tomography (CBCT) technology and its potential applications in endodontic practice. Summary CBCT has been specifically designed to produce undistorted three-dimensional information of the maxillofacial skeleton as well as three-dimensional images of the teeth and their surrounding tissues. This is usually achieved with a substantially lower effective dose compared with conventional medical computed tomography (CT). Periapical disease may be detected sooner using CBCT compared with periapical views, and the true size, extent, nature and position of periapical and resorptive lesions can be assessed. Root fractures, root canal anatomy and the true nature of the alveolar bone topography around teeth may be assessed. CBCT scans are desirable to assess posterior teeth prior to periapical surgery, as the thickness of the cortical and cancellous bone can be accurately determined as can the inclination of roots in relation to the surrounding jaw. The relationship of anatomical structures such as the maxillary sinus and inferior dental nerve to the root apices may also be clearly visualized. Key learning points • CBCT has a low effective dose in the same order of magnitude as conventional dental

Aim To examine cases showing increased width of the periodontal space (IW) at a long-term follow-up examination and to determine whether this finding could be explained by endodontic or nonendodontic factors. Methodology A series of intraoral radiographs was obtained from 131 patients 20–27 years after root canal treatment. The same individuals had been examined 10 years earlier, and radiographs taken immediately after treatment were also available. Fourteen roots (5.6%) demonstrated increased width of the apical periodontal space at the end of the study period. These were subjected to further analysis in an attempt to disclose possible explanatory factors. Results Two of the 14 cases had reduced marginal bone levels interpreted as the origin of the IW. In three cases, overextended root filling material present 10 years earlier had disappeared and the persistent IW was interpreted as representing a remodelling process. In six cases the findings were explained as being caused by physical and anatomical factors that represented healing without complete re-formation of the apical periodontal structures, or both. Three cases were judged as unfavourable, on the basis of lacking progress in healing, unsatisfactory obturation of the apical portion of the root canal or dentine resorption close to the apical end of the root filling. Conclusion Most of the 14 IW cases examined after 20–27 years could be explained by reduced marginal bone support, or by physical and anatomical factors or they might represent incomplete reformation of the typical apical morphology and were thereby recorded as favourable outcomes.

A number of factors are involved in the development of pulp and periapical disease in primary and permanent teeth, with dental caries being the main factor. Although these factors are similar, the clinical management of a primary or permanent tooth with pulp or periapical disease may be quite different. This is based mainly on the differences between the two types of teeth, with primary tooth longevity, coronal structural integrity, root canal morphology, and root anatomy being important features to be taken into account when treatment planning. This paper reviews some aspects of primary teeth and the various treatment options for the management of pulp and periapical disease.

‘Apical periodontitis’ is a general term used to describe the periapical inflammatory process that occurs in response to the presence of micro-organisms and other irritants within the root canal system of a tooth. Although many patients will develop apical periodontitis without having symptoms for a long period of time, it is very likely that there will be an acute exacerbation at some stage and then various signs and/or symptoms will become obvious. However, there are other conditions that can mimic apical periodontitis – such as an ‘extension’ of pulpitis, periodontal disease, occlusal trauma, an accident that has damaged the periodontal ligament, and various tumors or cysts. Hence, it is essential that dental practitioners understand the progressive nature of the periapical disease process as well as how and why the various stages occur so they can be diagnosed and managed appropriately. The diagnosis will usually be based on the clinical and radiographic manifestations and the results of the various tests that can be performed as part of a routine dental examination.

Aim The aim of this study was to assess the radiographic features and factors affecting the long-term results of root canal treatment in the Lodź region of Poland. Methodology Three hundred and fifty-five periapical radiographs of previously endodontically treated teeth (282 root-filled teeth and 73 teeth with pulpotomy) from 236 patients were evaluated in the study. The patients were aged from 15 to 76 years and randomly selected amongst subjects referred to the Institute of Dentistry. Medical University of Lodź and two private dental practices. The radiographs were examined by the authors according to criteria proposed by De Cleen et al. (1993) using an illuminated viewbox in a dark room. The Fisher's exact test was used to compare the frequencies in teeth groups. Results Amongst root-filled teeth, 49% were adequately filled within 0-2 mm of the radiographic apex. Periapical radiolucencies were observed in 25% of root-filled teeth. Teeth without periapical pathosis were more often filled within 0-2 mm of the apex (59%) than teeth with pathosis (17%). Teeth were most often adequately filled (64%) in patients attending the Institute of Dentistry. In patients attending the dental outpatients' departments, 71% of teeth were inadequately filled. Amongst the teeth treated with pulpotomy, 67% had a periapical radiolucency. Conclusion The radiographic technical quality of the root canal treatment was associated with the outcome that root fillings of adequate standard were associated with health more often than inadequate root fillings. Pulpotomy was associated with periapical disease in the majority of cases.

Halse A, Molven O, Fristad I.Diagnosing periapical lesions ^ disagreement and borderline cases. International Endodontic Journal, 35, 703^709, 2002. Aim The aim of this paper is to present a selection of disagreement and borderline cases from a methodological study on the radiographic diagnosis of periapical disease. Methodology Thirty-two roots, 12% of the material in an earlier study, were subjected to joint discussion because of diagnostic problems. The aim was consensus. Six cases representing diierent teeth/roots illustrating typical problems are presented. Results The varying morphology of apical areas and varying density of surrounding bone present a number of challenges. Even so, the joint discussion resulted in an agreement for all the cases. Twenty-¢ve diagnoses were established and seven cases were not diagnosed owing to substandard radiographs. Conclusion A detailed analysis of the periodontal ligament space, the lamina dura, trabecular pattern and bone marrow spaces is mandatory for the radiographic diagnosis of periapical disease.

Molven O, Halse A, Fristad I. Long-term reliability and observer comparisons in the radiographic diagnosis of periapical disease. International Endodontic Journal , 35 , 142‐147, 2002. Aim The aim of this study was to evaluate and compare the long-term diagnostic consistency of two examiners, an endodontist and a radiologist, and to make comparisons with findings recorded by an observer with more recent scientific and clinical experience in endodontics. Methodology Three groups, each consisting of 20 full mouth series of intraoral radiographs, with 79, 93 and 85 endodontically-treated roots, respectively, were successively evaluated for periapical disease. Evaluations were at first performed separately by the three observers. Disagreement and difficult, borderline cases were subjected to joint evaluation. Intra- and interexaminer comparisons were made. For two of the observers the observations were compared with findings recorded several years before for the same cases in the same radiographs. Results The intra- and interobserver long-term reliability of the two original examiners resulted in 83% overall agreement, the kappa values were 0.54, 0.57 and 0.53. Comparisons between all three observers disclosed 82%, 85% and 86% agreement and kappa values 0.55, 0.58 and 0.60. The joint evaluations and decisions did not indicate a dominating influence from any of the observers. Conclusions The long-term reliability of the two original observers was judged as being satisfactory. All three observers judged the overall disease status of the material in the same way. The joint discussions of selected cases might reduce observer variation to an acceptable level, avoid a number of false recordings and increase the reliability and validity of the findings.

Bacteria play a major role in pulpal and periapical disease. They are capable of surviving in dentinal tubules and other canal ramifications that are inaccessible to mechanical instrumentation and irrigation. In order to predictably achieve bacteria-free root canal systems, especially in pulpless teeth, it is necessary to use intra-canal medicaments. These medicaments must be capable of destroying bacteria, reducing inflammation and stimulating hard tissue formation whilst not being toxic to the host tissues. Consideration of a material's therapeutic action must be made when selecting a medicament for any pathological condition. Many of the commercial preparations do not satisfy the requirements for the ideal root canal medicament.

To examine the prevalence and technical quality of root fillings and the periapical status of root-filled teeth in a subpopulation of Dakar, Senegal.Full-mouth periapical radiographs were obtained from 208 consecutive adults presenting as new patients to the Dental Service of the University. The occurrence and technical quality of root fillings were assessed for each root according to the apical extent of the root fillings and its density. The periapical status was evaluated using the Periapical Index Scoring System with a PAI2 indicating periapical disease. The presence of coronal restorations and posts was also noted. Statistical analysis was performed with the chi-square test with a significance level set at P0.05%.Of the 6234 teeth examined, 2.6% were root filled. A PAI2 was associated with 56.1% of the filled roots. Only 17.7% of the root fillings were technically acceptable and 26.2% of these were associated with a PAI2. In roots with unacceptable root fillings, 62.5% had a PAI2. Unacceptable root fillings were associated with a higher prevalence of periapical disease (P0.001). A post was seen in 18.9% of the filled roots with 66.2% associated with a PAI2. A permanent coronal restoration was present in 78.5% of the filled roots, of which 50.7% had a PAI2 vs 75.7% for no permanent restoration. At least one periapical lesion was seen in 59.6% of the subjects.The results indicate a low prevalence of teeth with radiographic periapical disease, a low prevalence of root-filled teeth and a high prevalence of unacceptable root fillings.