CBCT: A Game Changer for Root Canal Therapy

Welcome to The Dr. Phil Klein Dental Podcast. I'm Dr. Phil Klein. Today we'll be discussing how CBCT helps to accurately diagnose patients and expedite their healing journey, especially when standard dental x-rays and normal tests fall short. Our guest is Dr. Sonia Chopra. A diplomat of the American Board of Endodontics, she earned her DDS at the University of Maryland and completed two residencies in Brooklyn, New York, and Fort Lauderdale, Florida. She's also an accomplished author. Dr. Chopra, it's a pleasure to have you on Dental Talk. Thank you so much for having me here today, Phil. Yeah, it's really exciting to have an endodontist as someone I'm doing a podcast with because I'm a retired endodontist. I'm not retired, but I'm a retired endodontist. I'm definitely still working. So let me begin with this question. What kind of impact has CBCT had on your success rate of your endodontic therapy? Oh man, it's been such a game changer for me. It's one of those pieces of technology that you just don't know how you lived without it. Until you get moving and grooving with it. And it's one thing to have it and introduce it into your practice. And then there's one another thing to grow with it. You know, I've at first I was very hesitant to use it. I wasn't really sure how to build the value of comb beam into my practice. I think because I was not so certain that I knew what I was doing with it. But then once I started to. use it every day and seeing that, okay, I don't just need it for my retreatments or my surgeries. I'd need it for every case. And I, I made that transition, not right away, but like probably a few, maybe a year or two into using the cone beam because I really saw the added value of seeing what my tooth looked like on the inside before I got inside. Does that make sense? Yeah. I could imagine the advantage of seeing all of this stuff in a totally different realm of 3D. I mean, my whole practice was, you know, taking periapicals and holding them up and looking for the file in there and trying to figure out where I am. I mean, it's just a complete, we didn't even have the microscope when I retired. The microscope was just getting popular when I stopped practicing regularly, which was... in 1990. Well, some of the doctors had it, but I didn't have it in 1997. So how does CBCT technology serve as a kind of a crystal ball, so to speak, by allowing you to know what you'll encounter before you actually access the tooth? So again, like just to walk you through my journey, I initially did it to work on retreats because I wanted to see what was the primary etiology for that root canal failure. It's great to know what's the anatomy. Is there... an untreated canal that is creating this periapical lesion, or is it the tooth cracked? And so when you start to understand anatomy better by using your 3D, you can really be more certain and more predictable if your treatment is going to work or not. A typical infection will look like a J-shaped radiolucency on the radiograph, and it'll make you think, oh, that tooth is cracked. But then when you take the 3D and you see, oh, there's an MB2 that wasn't treated or a second distal canal that wasn't treated, and you see that same J-shaped radiolucency, then you can be more certain. that your treatment that you're going to provide for that patient is going to actually help them and they're not wasting their money and that tooth isn't going to get extracted down the road. So that was my main reason of wanting to use the cone beam. And that was the first way that I implemented it in my practice. And then I started to see that, okay, sometimes I would be in the tooth and I wouldn't see the MB2 myself. And I would stop what I was doing. I would put... hydroxide in the tooth, then take a mid-treatment comb beam to see, okay, did I miss anything here? And more often than not, I would see that I... Yeah, there was more anatomy to treat. So I was preventing a failure. So I can't live without this thing. And that's why I want to know, what does the anatomy look like beforehand? Can I keep my access conservative? Because now I understand that anatomy. I don't have to remove dentin if something isn't there, or I do have to remove dentin because it is there. I'm preventing my own failures in the future. And there's nothing worse than having your own root canal not work. No, for sure. got the cbct technology integrated into your practice your workflow the learning curve on how to how to use it how to get the staff to work with you all that stuff oh wow okay so i started my practice in 2008 and then in 2009 i went to a tdo meeting and that was when i was first introduced to combi and that's when it was either a choice of care stream or jamarita in the endodontic world and That's what I knew that I needed it for because my applications for comb beam were going to be endodontic in nature. I'm not placing implants. I'm not using it for airways. So I always tell people when you're in the market for a comb beam, really understand all the different applications that you're going to use it for. And I was lucky that my colleagues had kind of vetted the process for me. And it was either a CareStream or a Jaymerita. I actually initially started out with a CareStream and I bought that. I was first introduced in 2009, but I was a startup practice, so I couldn't really afford it. I implemented it in 2012, and I had that CareStream unit forever, and then I recently renovated my practice, and I had an option to change, and I went and did a course and figured out that Jay Morita was really what I thought I needed in my practice in that time. So I've been using that since about 2020, so about two years now, Jay Morita. It has blown my mind. Granted, I'm sure CareStream has come up with another version, a more upgraded model, but this Jaymerita one that I have is what I love. What were some of the things going through your mind when you made that decision to purchase a Jaymerita? What were some of the considerations that were important to you when it comes to a cone beam machine? So for me, as an endodontist, I wanted something that will have the smallest field of view because that is going to contribute to some of my resolution. And I want to make sure that I have that resolution that can see inside the canal. I want to know, is there an MB1, an MB2? Is there a middle mesial? And when I compared images, that's what it showed me. And so I can... I love it when I can see anatomy. And then I love it even more when I've replicated that anatomy when I take my final obturation radiograph. So now that you rely on 3D technology using cone beam, it sounds like you'd be hard pressed to do a root canal using the legacy 2D digital radiography. I can't. I'm spoiled. I really consider the cone beam as cheating. There's just so many layers of benefits. again, that preoperative comb beam, which some people think it's overkill, but sometimes you have that case. Like I was doing a number two and I was able to diagnose that number two was the problem. The tooth was clearly necrotic. At first she was having referred pain, but I was able to pick up that the nerve had died. So my traditional diagnostic tests worked great. And to make the diagnosis, but then I took the cone beam and I saw that, oh, there was a wisdom tooth here before. And that wisdom tooth had drastically resorbed the distal buccal root of that maxillary molar to the point where there's really no more root. And that significantly decreased the prognosis for this patient. So it allows me to create this transparency that also allows my patient to comprehend it because they can see it. And then they can. make a better decision whether or not they want to accept treatment or not. Yeah. When I was practicing dentistry, we couldn't definitively say that there's a vertical root fracture in a tooth with the x-ray technology that we had at that time. With CBCT, how is that different? And how does it help us differentiate between the periodontal ligament space where GPs would refer to me and said, I think this tooth is fractured and it turned out to be the PDL space of the palatal root of number two or whatever. So what have you found using cbct when it comes to vertical root fractures well if there is a weakness to the technology it's still this it's still not a great resource to make a diagnosis on a vertical root fracture instead you're going to be looking for patterns of bone loss that could be suggestive of that fracture i don't know if i would create a definitive diagnosis from it, but it could be in my differential, which doesn't really take you away from the same differential that you had in the 2D diagnosis, but you do get more clarity. And again, it does help you in the conversation that you have with your patient because most of the time when there's a big fracture in the tooth that shows up on the cone beam, you could probably see it in the PA as well. So there's, it's very, maybe like... to 5% of the time, do I actually see the outright fracture on the comb beam? Instead, I'm interpreting the data in the bone as opposed to in the tooth because so much of that beam hardening and that reconstruction artifact that creates that scatter and all that stuff, you can misinterpret something that looks like a crack that has nothing to do with a crack because it's just the way the imaging was prepared. So I would say that it's still a weakness. There are, you know, certain... that are coming out on the market that kind of help reduce that questionability by, you know, making the imaging a little bit more sharper. But again, I think that this is still the one downside to our specialty. Yeah, we used to walk that perioprobe around the sulcus and perioprobe would drop down and say, okay. that's a good indication that there's a vertical root fracture. But of course, that attachment apparatus had to deteriorate by the time they got to our office for us to detect that. The problem is with that is that a draining sinus tract can drain through the sulcus because that was the body's pathway of least resistance. So it could still just be a necrotic pulp that's draining that mimics the look of a vertical root fracture. So again, by putting... the pieces together from your clinical diagnosis to just looking at the patient as a whole. Do they have bruxism? Is there any fracture of porcelain on that crown that's covering this tooth? Or maybe you see that spider web of cracks. We're kind of taking a holistic approach between the 2D imaging, the 3D imaging, the clinical signs and symptoms, and then the patient as a whole, just kind of zooming out and looking at them before we're making that. vertical root fracture diagnosis. So I feel like the cone beam is an aid, but it's not the 100% solution. As one endodontist to another in this discussion on this podcast, I have to ask you this. In your experience, what is the most common cause of root canal failure? Probably the untreated canal. And that's untreated from a GP or either another specialist or a GP? I think anyone can miss something. Even I can miss something. I'm not that good. I mean, I'm good, but like, yeah, I'm human, right? And we can all miss things. I mean, remember I got my cone beam in 2012. I still had four years of treating teeth before that. And so now in 2022, it's interesting. I see sometimes I'll get a failure from pre-2012 when I didn't have the comb beam. And now I know why, because I missed something. And now I don't miss that. because I'm taking that preoperative comb beam. And so your initial question on what has it done to my success rates, it's definitely improved my success rates because I can see way more before I even start. So the number one benefit to you endodontically is that canal that you may have missed, that extra canal. Yeah, but also it allows me to make sure that that treatment should hit my chair. Like if I see that resorption of the distal buccal root, I'm not finding out after the fact because my obturation spilled out of the canals because there was a huge void in the root. I can actually tell the patient, hey, do you want to invest your time, money, and energy into this tooth knowing that this is the clinical situation? Or do you want to go for the extraction now? I can prevent my patients from... undergoing anesthesia and another appointment and saving them time and money. So the benefit's not just for me, it's for the patient too, right? I can prevent them from having an unnecessary dental appointment and letting them reallocate those funds towards something that's going to give them something long-term because I have this technology. Yeah. So in addition to endodontics, can you give us another clinical indication that you have found CBCT to be useful? Oh my gosh, trauma, right? Just knowing if there's a root fracture, an alveolar fracture, is that fracture horizontal? Is it through and through? Same thing with resorption. Is the resorption buckle? Is it lingual? How extensive is it? Is it internal? Is it external? I don't have to do the slob rule anymore. I don't have to take three x-rays just to get the one thing and still be confused in the end. It gives me exact dimensions, exact locations, and pretty much gives me the exact prognosis. So in closing, Dr. Chopra, what recommendations would you give to our listeners if they're considering buying a CBCT machine and utilizing it for their endodontics? I will have to say the Jamerita is my favorite. It has been so easy to use and just very easy to read. And again, the images that I share are so clear that my patients can even... understand what I'm talking about. And also it's so easy to get caught up on the cost of something when you think that you can't pay it off. But there's so many hidden ROIs in dental technology across the board that you may not realize. in the beginning you may just be thinking oh i have to charge this for every scan in order to pay for that there's more than that it again it prevents treatments that are not productive in your workload to hit your chair and you get that added benefit of being able to be almost psychic before you waste time on it i just think that there's so many more benefits that are a little bit hidden that people kind of don't realize and maybe get caught up on too much on cost this is a game changer it will actually make you feel more confident your case is more predictable and just give you an ease when you're practicing and i think that's the beautiful part about it Yeah, great insight, great information. And I think every listener who's doing endodontics in their practice, maybe even a GP. Really helpful for the GP. I teach general dentists how to do better endo. And one of the things that I... think is so powerful for them. And again, it's a huge benefit to their patients too, is that the cone beam is really great for risk assessment. If you know that those premolars have an anatomy that starts separate, join, and then separate again, maybe that's an anatomy that you don't want to deal with and you think your patient is best treated by the endodontist. So you're not wasting your time. You don't start a treatment and then have to refer it midway because, you know, you got stuck in the middle and then the patient doesn't get upset. You don't lose the patient. It's just a win-win for everyone. I think the way GPs should use it for endo if they're not. already doing their endo themselves, really utilize it for risk assessment, both for your business practice, but also for your patient and really doing what's best for your patient. Yeah, that is an excellent point. Excellent point. There's nothing more, I wouldn't say embarrassing, but there's nothing more of a downer than having to tell the patient after starting a root canal. that I can't do this. I basically can't do this. I need to send it out to a specialist. No GP wants to do that. And it certainly doesn't build confidence in the patient for that doctor. So that is a very interesting approach to GPs using CBCT. And of course, they can use it for the same reasons that you use it endodontically, if they're fairly proficient in their technical skills. Dr. Chopra, it's been a fantastic podcast. Thank you so much for the insight. We look forward to having you on more of these in the future. Thank you so much. I would love that. Thank you so much. It's been a pleasure.