From: Terry Pannkuk
To: ROOTS
Sent: Thursday, November 26, 2009 3:58 AM
Subject: [roots] CBCT scan on "routine" lesion

How about this one? The tooth clearly tested positive to cold thermal stimulation.
Moderate percussion sensitivity, no mobility, and normal perio findings.  I suggested a
CBCT to see 3-D spatial symmetry and association with the periapex.   It looked
garden-variety  at least scanned and with conventional radiography.  Routine endo? Zebra?

I thought the odd presentation of cold sensitivity warranted a scan.  It seems extremely rare
that a tooth with a chronic lesion of this size would still have surviving n fibers in the pulp
transmitting normal cold sensitivity.  I presented the algorithm to the patient this way:

CBCT scan:
  if asymmetric lesion buccal or lingual to the root apices, then refer to oral surgeon for
  second opinion, biopsy, dx.

  if symmetric lesion centered around root apices, then proceed with endo, which we plan on
  doing now that we know.

I'm interested in how the pulp will look upon access.  The patient was told the CBCT likely wasn't
going to change the plan (it only would have had the lesion been asymmetrically located behind or
in front of the roots).  He was willing to pay the CBCT scan fee to rule out the unlikely possible
chance that the lesion was not associated with the root apices. If he hadn't been willing to pay
to rule this out I would have simply accessed the tooth anyway like I am.  If I find a vital pulp
we are still going to be concerned about a "zebra" and he may still end up going to the
oral surgeon for a biopsy to rule out entities like an OKC, etc.

Utilization of CBCT is complex and involves complicated communication and considerations.
If I was a wealthy philanthropist I could simply give these services away for free, not charge any
patients extra for them and it wouldn't be so complicated.  Because the machine was expensive
required financing increasing my overhead I have to figure out how to pass this on fairly and
appropriately to patients.

It's tough not being a pimp. :):):) - Terry

P.S. These types of discussions are what got me kicked off of TDOChat.. not the accepted Kool-Aid:)



Terry what technique do you suggest to perform cold test with full crown restauration?
single isolation and a bath with cold water? - Javier Pascual

Ice pencil,  he felt it very clearly and it wasn't a gingival response. I repeated it 3 x's and
tried to trick him.  Water can leak to an adjacent tooth.  I'm more likely to get false negative
responses than false positives the way I do it. I start by placing the ice pencil on the gingiva
explaining that is the "gum tissue" and not the feeling we are looking for. I then pick a
contrlateral tooth to test finding one that will give clear sharp pulp response, demonstrating
the difference before I start testing teeth in question - Terry