In a practice specializing in endodontics, CBCT has become indispensable, says Dr. Jörg Schröder. The endodontologist has been working with a CBCT in his specialist practice in Berlin since 2011. In an interview with Quintessence News, he explains how the field of application of these devices has changed, what advantages three-dimensional imaging offers and what aspects should be considered before purchasing a CBCT.

Dr. Schröder, how long have you been using CBCT in practice?

Dr. Jörg Schröder: Since 1 March 2011, we have been able to perform our radiological diagnostics in 3D.

How did you experience the development of this technology for use in dentistry?

Schröder: When we decided in September 2010 to use a CBCT in our practice, the reactions of colleagues ranged from regrettable head shaking to open hostility. Very few have seen the diagnostic possibilities that this technology offers the user. Particularly in the field of endodontics, the additional information gained by high-resolution 3-D diagnostics was viewed rather sceptically.

This has changed significantly in recent years. Our treatments have become considerably more predictable with the inclusion of three-dimensional X-ray diagnostics. In addition, we were able to push back the limits of what is technically possible and thus preserve teeth that would have been removed without comment just a few years ago. I would even like to go so far as to say that CBCT has become indispensable in a practice limited to endodontics.

Dr. Jörg Schröder, Berlin (Foto: Jet-photo, Berlin)

Dr. Jörg Schröder studied dentistry at the FU Berlin (Germany) from 1982 to 1988. Already in 2000 he began to intensively continue his education in endodontics and specialized in this field in 2005. Since then he has also been active as a lecturer at home and abroad.
Since 2003 he has had his own practice in Berlin, which he has been running as a private endodontic practice since 2013. The proven expert is a member of national and international professional associations, including the European Society of Endodontology, the German Society of Endodontology and Dental Traumatology, and the International College of Dentists (ICD, Fellow and Vice-Regent). In 2013, he was awarded the Peter Guldener Practitioner Prize of the journal “Endodontie”.
Dr. Schröder is also the author of the 2016 video “Ergonomics at the Dental Microscope” (Quintessenz, Berlin).

Often only the CBCT brings clarity

For which indications do you use CBCT today?

Schröder: We act according to the recommendations of the s2k guideline of the DGZMK for dental volume tomography. This includes, for example, apical pathologies with clinical symptoms if these cannot be detected or correlated spatially on two-dimensional images.

In order to be able to assess the technical feasibility and prognosis of an upcoming endodontic treatment, we perform preoperative 3-D diagnostics in the following cases, among others: internal and external resorption, retreatment after apicectomy, trauma with suspected alveolar bone fracture, trauma with suspected horizontal fracture, dental anomalies (e.g. dens invagintaus, gemination), instrument fragments located in the lower third of the root that cannot be clinically visualized.

Sometimes the high-resolution small-volume CBCT is also the only way to reliably exclude the necessity of endodontic treatment and thus save the patient from an inappropriate therapy. An example: A female patient, 40 y. old, was referred to us with the request to assess teeth 43 and 42 with regard to the necessity of endodontic treatment. The 2-D image clearly showed a widening of the periodontal ligament space, which suggests that the pulp is likely to be necrotic. The large filling in tooth 43 matched this. At 42 it became more difficult. No restoration, no anamnestic trauma to be determined and still a periapical translucency. And both teeth reacted positively to electric sensitivity testing. What to do?

The CBCT – taken in outstanding precision with the Veraview X800 – brought it to light. It was very likely stage 3 of a periapical cementoosseous dysplasia. This is a very rare disease, which can be often found in women about 40 years of age. As there is no relation to the root canal system, no therapy is indicated. We will just monitor the case.

Without the reliable imaging of the continuous periodontal ligament space in the area of the apical foramina, five or six innocent anterior teeth would most likely have been treated endodontically. If you want to know more about this rare disease and about possible differential diagnoses, I recommend the article published in the peer-reviewed Quintessenz Journal “Endodontie” 1/2010 (Schmied et al. Die periapikale zemento-ossäre Dysplasie, Endodontie 2010;19(1):37-41)

Which areas of application or indications and improvements would you like to see in practice?

Schröder: As we have a Veraview X800 M in our practice for a year now, we have all possible volumes to choose from with regard to the possible areas of application: From 4×4 centimeters for the quadrant or anterior region up to 10×8 centimeters large volume, which can image all tooth bearing parts of the upper and lower jaw.

For a more optimal referral communication and to simplify the reporting, I would like to see a reporting module implemented in the iDixel software.

You have opted for a Morita device. Why? What advantages does it offer you compared to other providers of DVT devices?

The Veraview X800 is a 2D/3D combination device of the latest generation. (Photo: Morita)

Schröder: When we made our purchase decision, our first priority was the image quality to be achieved in daily practice. This was already significantly better with our first CBCT, a VeraviewEpocs 3De, than with devices from other suppliers. The X800 M we use today sets even higher standards in this respect. In addition, the viewer software can also be operated intuitively by less experienced users. Since our CBCT room has certain spatial limitations, compact external dimensions were also important for us.

Checking real images from reference practices

In your experience, what should your colleagues look out for when they consider buying a CBCT or a 2-D/3-D combination device?

Schröder: The key question is: For which part of dentistry should the device be used? The required volumes can be derived from the answer. What imaging accuracy is required? This is influenced not only by the minimum possible resolution, but also by factors such as circulation time, possibilities of patient positioning and fixation and artifact suppression. Can the recording also be performed on a seated patient? In our experience, this significantly minimizes movement artifacts.

And before I decide on a device, I recommend that you view real images from reference practices and check whether the viewing software belonging to the device meets your own requirements in terms of operability.