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CBCT scan on routine lesion - Courtesy ROOTS

The opinions and photographs within this web page are not ours. Authors have been
credited for the individual posts where they are - www.rxroots.com
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
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