Dissertation: Narrative Literature Review on CBCT in Endodontics

This dissertation presents a narrative literature review investigating the efficacy of cone beam computed tomography (CBCT) in clinical decision-making within the field of endodontics. The research employed PubMed, Google Scholar, and Open Grey databases, initially yielding 571 articles. After rigorous screening and application of inclusion/exclusion criteria, 12 articles were selected for review based on the Fryback and Thornbury hierarchical model of efficacy. The studies were critically appraised using the CASP checklist. The review examines the impact of CBCT on diagnostic thinking, therapeutic efficacy, and patient outcomes. The findings indicate that CBCT significantly influences treatment planning, particularly in retreatment strategies, offering more detailed information compared to traditional imaging modalities. The study includes a summary of the findings of the studies, critical appraisal of the included articles and a summary of the search strategy.

Running head: DISSERTATION
Narrative literature review
Name of the Student
Name of the University
Author Note

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Results
5.1 Outcomes of the literature search
With the aim of extracting articles that would address the research question, “What is
the efficacy of cone beam CT in clinical decision making in endodontics?” three search
engines and electronic databases namely, PubMed, Google Scholar and Open Grey were
used. The initial search of the databases yielded 571 published scholarly literature. From the
preliminary hits that were obtained from the databases, 459 scientific articles were excluded,
following conduction of an extensive screening such as, duplicate articles present in all the
search engines, or those that were not relevant to the research question. Through examination
of the remaining 112 articles further lowered their number to 30.
This exclusion was primarily conducted after reviewing the abstracts presented by the
authors. The primary reason for elimination of those can be accredited to the fact that the
abstracts did not contain any relevant information on the effects of cone beam CT for
endodontics related clinical decision making. The 30 articles were then analysed for their
adherence to the inclusion criteria, following which only 12 were found most suitable for the
narrative review. These 12 articles were selected based on the Fryback and Thornbury
hierarchical model of efficacy (Fryback and Thornbury 1991). The studies were analysed on
the basis of levels 3, 4, 5, and 6 of the models.
Hierarchical level Studies identified
Level 3: Diagnostic Thinking efficacy
 Does the medical test help clinicians
come to a diagnosis?
 Does the test change clinician's
pretest estimate of the probability of
11

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a specific disease?
Level 4: Therapeutic Efficacy
 Does the medical test aid in planning
treatment?
 Does the medical test change or
cancel planned treatments?
8
Level 5. Patient Outcome Efficacy
 Do patients benefit from the use of
the test?
 Do patients who undergo this
medical test fare better than similar
patients who are not tested?
3
Level 6. Societal Efficacy
 Cost–benefit and cost-effectiveness
0
Table 1- Summary of the articles included on the basis of F&T hierarchy levels
The review question was then formalised as a statement of my intention of the
structured critical review. This was developed from what was found through the available
evidence to what I further planned to find out. A theoretical approach, exploring factors that
lead to a process, was to be taken. The retrieved studies were then critically examined with
the use of the CASP checklist (Munnet al. 2014). A summary of the search strategy is given
below:

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Figure 1- Search strategy for inclusion of articles in the review

Running head: DISSERTATION
Summary of findings of the studies
Author/Year Aim Study type Control group Results Implications
Rodríguez et
al. 2017
Determine the effect of
CBCT on clinical
decision making amid
endodontist and dental
general practitioners
Longitudinal
study
PA radiographs and CBCT
images were performed in
two separate sessions. For
each case the examiners were
asked to select one of the
recommended treatments and
assess the decision making
difficulty. A month later,
they randomly reviewed the
cases.
Treatment plan was modified
after observing CBCT scans
in 49.8% cases. Endodontist
recorded noteworthy
difference in 2 imaging
modalities. No group changed
self-reported level of trouble.
Prominent increase was
observed in extraction option
(p<0.05)
CBCT plays an important
role onendodontic
retreatment strategies
Rodríguez et
al. 2017
Assess the impact of
CBCT on clinical
decision making amid
specialists
CPR (Clinical
Prediction
Rule)
30 endodontic cases with
variable degrees of intricacy
were selected. In the
preliminary evaluation,
examiners were provided
with detailed information on
CBCT created an impact on
treatment plan for high
difficulty endodontic cases
(p<0.05). Difficulty level was
more after observing
CBCT imaging has a
considerable influence on
endodontic decision
making

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each case, excluding CBCT
scan. They had to choose
from the proposed treatment
options and assess decision-
making difficulty levels. A
month later they randomly
assessed the cases with extra
CBCT information.
preoperative CBCT scan
Ee, Fayad and
Johnson 2014
Associate the
comparative worth of
CBVT scanning and
pre-operative peri-apical
radiographs in
endodontic decision-
making process
Observational
study
Random selection of 30
endodontic cases, having
CBCT scan and pre-
operative digital periapical
radiograph, followed by their
review. CBCT volumes were
reviewed after 2 weeks, after
which evaluators selected
treatment plan and diagnosis
based on personal
2 imaging modality in 63.3%,
56.6%, and 66.7% cases for
examiners 1, 2, and 3
Pre-operative CBVT
imaging delivers extra
information

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interpretation
Davies et al.
2015
Determine diagnostic
yield from 2 parallax,
single parallel peri-
apical and CBCT, by
comparing per-apical
lesion prevalence
Longitudinal
study
100 teeth in 78 patients were
subjected to the techniques,
followed by assessment of
peri-apical lesion and root
canals that were identifiable
Lesions were found in 41%,
68%, and 38% of 209 paired
roots suing single radiograph,
CBCT, and 2 parallax with
186, 242, and 218 root canals.
CBCT demonstrated more
efficacy in detection of
peri-apical lesions and
root canals, when
compared to the other two
techniques.
Lo Giudice et
al. 2018
Explore evaluate
accurateness of CBCT,
compared to orthodox
intraoral radiographs for
endodontic procedures.
Observational
study
101 patients having
endodontic treatments were
subjected to statistical
analysis with radiograph
documentation that was
subjected to CBCT screening
100% agreements were found
in the two investigations.
CBCT always confirmed
intraoral X-ray positivity and
also helped in detecting
radiolucent areas (46%).
Certain radiological
indications are not visible
in peri-apical X-
rays.CBCT is measuredto
be II level exam.
Long et al.
2014
To assess diagnostic
accurateness of CBCT
for in-vivo tooth
fractures
Meta-analysis Electronic databases such as,
Embase, PubMed, ProQuest
Dissertations & Theses, Web
of Science, SIGLE, and
CNKI were searched for
Of the 12 studies included,
pooled sensitivity, summary
receiver operating
characteristic, positive
likelihood ratio, specificity,
CBCT demonstrated
increased diagnostic
precision for tooth
fractures and can be
implemented across

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literature from 1990-2013.
QUADAS-2 helped in
assessing the research quality
of the extracted studies
negative likelihood ratio were
0.92 (95% CI = 0.89–0.94),
0.94 (95% CI = 0.90–0.98),
5.68 (95% CI = 3.42–9.45),
0.85 (95% CI = 0.75–0.92),
and 0.13 (95% CI = 0.09–
0.18) respectively.
clinical settings.
Kruse et al.
2018
To explore how
supplementary
information from CBCT
affects treatment
planning and peri-apical
assessment, on the basis
of peri-apical
radiographs (PR) and
clinical examination
Observational
study
74 SER receiving patients
participated and their PR was
assessed based on two
different scales. This was
followed by making
treatment plans namely,
further observation, no
treatment, extraction or SER
reoperation
CBCT brought about a change
in the radiographic
assessments in 51.4% cases,
where 47.3% had a greater
Rud&Molven score
(p<0.001). 24.3% had a
changed treatment plan.
18.9% teeth showed a change
from no treatment/further
observation to intensive
CBCT use after SER
increases cases diagnosed
with recurrent or persistent
apical periodontitis

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treatment (p=0.005)
Song et al.
2017
Assess the variation in
CBCT and peri-apical
radiography in vivo
performance
physiognomies for
assessment of RCO
Experimental
study
The peri-apical radiographs,
photomicrograph and CBCT
images for 323 tooth roots
were individually assessed,
followed by evaluation of the
performance characteristics..
1.0
intraobserver/interobserver
agreement as attained with
photomicrography. 2 OR
agreements were greater than
CBCT, under circumstances
that detected void (p<0.05).
CBCT sensitivity was greater
than PR for detection of
overextension. Poor
sensitivity (0.24, 95% CI
0.19–0.30) and specificity
(0.67, 95% CI 0.54–0.78) was
demonstrated by CBCT,
during void detection.
CBCT proved better than
PR for evaluation of RCO
apical extension, however,
failed to assess the RCO
quality.
Matsuda et al.
2015
To assess the different
radiographic prognostic
Experimental 143 patients were made to
undergo CBCT assessment
15 cases demonstrated peri-
apical hypercementois and 51
CBCT is an useful
technique for the

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signs that create an
influence on root canal
treatment outcomes
study that comprised of 276 roots
containing peri-apical
radiographs. This was
followed by independent
CBCT re-interpretation for
peri-apical hypercementosis
and resorption.
manifested peri-apical root
resorption. Significant
variation was observed in
prognosis by hypercementosis
and other groups.
evaluation of endodontic
treatment prognosis
Parker et al.
2017
The aim of the study
was to determine effect
of experience level on
the process of detection
of the peri-apical lesions
in CBCT volumes
Experimental
study
CBCT volumes of 22
maxillary molars were
interpreted by three
edodontic professional, 3
endodontic students and 3
endodontic residents. The
results of these 3 groups are
compared with opinion of
two experienced
maxillofacial and oral
In comparison to radiologists,
the average kappa value for
the endodontic faculty is 0.49,
for endodontic resident is 0.35
and for dental student is 0.32
Experience of the
clinicians co-related with
their ability to correctly
diagnose the peri-apical
disease with the help of
CBCT volume

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radiologist
Table 2- Summary table of the collected evidences

Running head: DISSERTATION
5.2. Critical appraisal of the included articles
Rodríguez et al.(2017a) focused their study on determining the impacts of CBCT on
clinical decision making among dental practitioners, following unsuccessful root canal
treatments. They also aimed to explore self-reported trouble in making treatment choices,
prior to and after inspecting pre-operative CBCT scan. Authors selected eight patients who
have been treated endodontically and are diagnosed as symptomatic apical preodontitis, acute
apcal abscess and chronic apical abscess. During the first instances, the examiners were
provided with the details of each of the cases along with relevant radiographs. They were
then asked to select one of the proposed treatment alternatives and then assess the level of the
difficulty in the decision making process. After one month, the same set of examiners
randomly reviewed the same 8 samples along with additional information extracted from the
CBCT data. The analysis of the data highlighted that the treatment plan is altered by the
examiners upon viewing the CBCT scan among 49.8% of cases. Potential difference was
highlighted in the treatment plan between the two different imaging modalities among the
endodontists and the general practitioners. After the CBCT evaluation, none of the group
altered their self-reported difficulty level while selecting the treatment plan. The extraction
option increased to 20% after reviewing the CBCT scan. At the end, the authors concluded
that CBCT imaging directly influences endodontic retreatment strategies among the general
group of dental practitioners and endodontists practitioners.
Influence of Cone-beam Computed Tomography on Endodontic Retreatment Strategies
among General Dental Practitioners and Endodontists.
1. Addressed a clearly
focused issue?
Yes- showed adherence to the PICO framework
Population- Dental practitioners and endodontists
Intervention- CBCT
Comparison- (None)