CBCT scan on routine lesion - Courtesy ROOTS
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From: Terry Pannkuk
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
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