Imaging Recommendations for Endodontics

For initial assessment and tooth evaluation, 2D imaging is the primary modality of choice.^52,102,103

CBCT may be indicated after initial clinical evaluation and 2D imaging assessment with consideration given to:

• Contradictory or non-specific signs and symptoms

• Unusual root or apical anatomy

• Suspected or unclear apical pathosis

• Large radiolucency involving multiple teeth or involving one or both cortical plates

• Calcified canals

• Root resorption

• External cervical resorption

• Previous endodontic treatment

• Persistent pain

• Suspected perforation or separated instrument

• Suspected maxillary sinusitis of endodontic origin

When CBCT is indicated, the smallest field of view (FOV) should be used to record the needed information using voxel sizes ≤0.1mm to provides improved diagnostic accuracy.¹

For diagnosis and treatment planning of dentoalveolar trauma, CBCT is the modality of choice in patients with confirmed or suspected dentoalveolar trauma not adequately assessed with 2D imaging.^52,102,103

• MRI, ultrasonography, sialography, or other advanced imaging may be indicated for salivary or other soft tissue injuries in the absence of other maxillofacial or soft tissue injury.¹

For the management of endodontically treated teeth with secondary, persistent, or recurrent disease, CBCT is indicated to assess the causes of new, persistent, or recurrent apical periodontitis and to determine the indications and strategies for surgical or nonsurgical retreatment like lesion size, cortical involvement, surgical planning, and grafting need.^{2,52,99,101,102-110}

• CBCT may be helpful in the discussion of endodontic and non-endodontic options for general dentists who often perform the initial screening and discuss further treatment options with the patient and consultation with an endodontist.¹

For intentional reimplantation and autotransplantation, CBCT is indicted for confirmation of root anatomy compatibility with atraumatic extraction, and fabrication of a 3D tooth replica of the donor tooth.

CBCT imaging may be helpful in difficult treatment.^52,102

• Intra-operative imaging is indicated for the identification and localization of calcified canals, canal branching, canal obstruction, and perforation.

• CBCT aids in identification of the spatial relationship of obliterated canals and assists in guided endodontics.

For post-treatment evaluation, periapical imaging is indicated unless there is evidence of persistent disease (Figure 12). A small FOV CBCT should be considered to identify the etiology and treatment planning options for persistent disease.^52,102,111

• For the diagnosis of vertical root and crown-to-root fractures, periapical imaging or CBCT may be indicated. CBCT is the modality of choice when the clinical examination and intraoral imaging are inconclusive.^52,102,111

• Periapical imaging is better in endodontically treated teeth but CBCT imaging in non-endodontically treated teeth is useful to detect patterns of peri-radicular bony changes indicative of root fractures or when the clinical examination and 2D imaging are inconclusive.^102,111

• To evaluate endodontic treatment complications, CBCT is indicated for assessment of perforations,^52,102 root resorption that may be amenable to surgical or nonsurgical retreatment, or other complications.^52,102

• For nonsurgical retreatment, CBCT is indicated to localize root apexes and locate adjacent structures, canal obstruction, thickness of remaining dentin, major voids, or irregularities in obturation.^52,102

• For surgical retreatment, CBCT was found to have higher accuracy than 2D imaging for definitive assessment of surgical endodontic treatment outcomes.¹¹²