Those of you who have been reading my blog know that I am a HUGE lover of endo technology. I simply can’t get enough of it because I know how powerful it is. And yet, I also want to be 100% transparent with you. So today, I’m sharing an honest CBCT review, offering some thoughts on electric pulp testing, and discussing how they stack up against each other.
Before I get into the specifics of my review, though, I want to mention that I have been using new endo tech like an operating microscope, a CBCT, and a Gentlewave for years now. Plus, I’m about to get a new laser!
I can say that, every year, I learn a little bit more about these tools, their ins and outs, and their impact on my patients’ outcomes.
I feel that a big part of why I was put on this earth is to bring awareness to endo tech, to fiddle with them for you, and share my very best tips and tricks to help my community of empowered dentists save teeth.
This blog post has been written to you with love, and in the name of that mission.
Is Electric Pulp Testing Just as Good as CBCT?
Let’s start with a little anecdote.
I was recently speaking at an event on endo technology and I got a question about electric pulp testing. The person asking the question seemed a bit frustrated that I was advocating a $100,000 CBCT machine, while he felt like the EPT, which is more like $100, served him just fine in all his years of practice. That’s valid, but let me share my thoughts and reasoning.
While the EPT was useful for me in the past (especially when a cold test wasn’t my friend), I don’t find myself using it much these days.
I am not saying that it doesn’t have its place in my practice, but I have found that my cone beam has soooo many applications built in that it makes the EPT almost obsolete. I honestly can’t remember the last time I pulled my EPT out.
The universe works in funny ways, because the very next day that I was at my practice, I saw two patients whose cases exemplified exactly what I was talking about. They both clearly illustrated how the value of my cone beam surpassed that of my EPT with respect to diagnosis.
I KNEW I had to share both tooth stories with you. Check out these two cases and let me know your thoughts to see if you think the cone beam was helpful in these situations.
You Know I Have a Tooth Story for You ….
I want to start with the referral slip in this situation.
As you know, I believe that everything starts with a good diagnosis. If your diagnosis is off, the rest of your treatment will be off.
I could tell right off the bat that this referring dentist was confused. I’m not mocking anyone here! There is SOOOO much to learn in dentistry, and I have the utmost respect for general dentists, and how much they have to keep in their heads. Y’all amaze me, truly.
I’m simply offering this example as an opportunity to keep an open mind, learn together, and keep reaching higher and higher.
The referral slip said that tooth #4 was thought to be the culprit tooth, but the tooth was vital and had a draining sinus tract for about 3 months. The sinus tract was traced and it went to tooth #4.
I did my own tracing and found the same thing…
My diagnostic tests were as follows:
Probings: WNL in the entire quadrant
Percussion: WNL on all teeth in quadrant
Bite: WNL on all teeth in quadrant
Cold: #2: WNL; #3: No Response; #4: WNL and #5: WNL
The only finding was the buccal sinus tract.
Clearly, the diagnosis was confusing for the referring dentist. Even though I could see that the endo on #3 looked a bit suspicious, I always like to be 100% sure and not leave anything to guesswork.
Let’s Take a Closer Look …
This I know—a sinus tract will probably trace to a radiolucency in the bone, so I wanted to see the area in 3D so that I can discover where this RL area might be and there is nothing better than my CBCT in this situation! I’ll get to my CBCT review proper, but for now, let’s say it was a lifesaver in this situation.
An electric pulp test is not going to help me in this situation. We already know that #4 is vital, and there is no reason to test with an EPT. Plus, #3 had a previous root canal, so the EPT is not going to add any value for this tooth either.
Here are my CBCT images…
You can clearly see the periapical radiolucency on the MB root.
And in the axial view, you can see the etiology of root canal failure is an untreated MB2.
I always love looking at my MB root in the coronal view, because it illustrates so well just how much space there is remaining in the root housing that MB2. Can you appreciate how offset the MB canal is to the buccal?
Using my CBCT, I can now appreciate that there is an untreated MB2, and I also know exactly where it sits in that canal.
We all know it’s never in the same place, right? I was able to locate it conservatively, and preserve dentin because I can be super selective in where I trough to find the canal.
Woohoo! CBCT saves the day!
Let’s Look at a Second Case to Review CBCT Technology
Let’s take a look at another case, shall we?
An FMX capture was taken at the patient’s general dentist’s office, and they saw a periapical radiolucency at the apex of #9. The patient was asymptomatic and had no pain to percussion and no swelling.
This was just an incidental finding on the FMX…
And here is their preoperative radiograph blown up bigger, so you can get a close look…
And the referral slip…
Now, my PA shows the tooth story a bit differently. I don’t see a PARL on my image. This is another reason why, in endo, we must always take multiple angled radiographs. There will always be times where things are superimposed over your roots, so this extra imaging can go a long way.
Here is another angle…
But, since this patient was referred to me, I wanted to be 100% certain that I wasn’t missing anything. My CBCT gives me that extra layer of confidence and predictability! That’s such a crucial advantage to have.
So, here are my images from the CBCT…
From these images, I can be 100% certain that the alveolar bone immediately adjacent to the root is pristine. That PDL and lamina dura are stellar, and there is no sign of endodontic pathology around the root.
My impression of this case is most likely correct. The image that the referring dentist had taken was at an angle in which the nostril was superimposed over the root of the tooth and it looked like a periapical radiolucency.
Now, do you need a CBCT to tell you this? Probably not. But you also can’t use an electric pulp test in this situation, either.
However, as the specialist who has now acquired this case, I have to be sure I’m not missing any disease in the area.
And here’s the most crucial piece of my endorsement and review of CBCT tech: It gives me confidence. I can now diagnose this tooth with confidence as Previously Treated and Normal Apical Periodontium #9. I can also determine that no endodontic therapy is necessary at this time.
The EPT is an all or nothing indicator, it doesn’t have anywhere near the range of diagnostability as the CBCT. Either the tooth is vital or not. EPT tells me nothing else. Yet I often need more information than that in order to triage my patients.
My cold test, on the other hand (when it works, because we all know sometimes it doesn’t… but that doesn’t mean you should skip it!), gives me a gauge in how vital a tooth is and what the urgency of care needs to be with respect to my patient’s symptoms. The EPT just tells me if it is vital or not, so it really can’t offer me much information—especially if a tooth already has a root canal.
Sometimes electric pulp test machinery also just straight up isn’t my friend and does not work… which makes it pretty unreliable. Sometimes it reads out at around 60 or 65 because it is picking up some sensation from the PDL, and it will make me believe that my tooth is vital when it is actually necrotic! Not good.
Now, I may still use my EPT in calcified teeth or in trauma, but again, as I get more and more experience with my CBCT, I see myself drifting away from this piece of technology.
Some Closing Thoughts on Endo Tech…
In my practice, I use J Morita, and I. Love. It. So do the two other doctors in my practice.
I can’t even tell you the number of times it has been the make-or-break factor in a case. I honestly don’t know how I practiced before I had it.
I will admit that it’s not a cheap investment. And then, it can have a high learning curve. So you really do need to make sure you set aside the money and time to make the most of this invaluable piece of technology.
At the end of the day, I stand behind my CBCT review and general assessment of this technology. It has been a game-changer for me and how I practice, and I know that this added investment has brought so much value to my patients.
It may cost my patients an extra $200 to take a 3D image, but they are getting a bigger return on their investment.
With my CBCT, I not only get the correct diagnosis, I also understand the internal anatomy of the tooth that I am working on and don’t miss canals. I conserve more tooth structure in the process, and therefore prevent retreatment while decreasing the chance for a root fracture for that patient in the future. I can also see any special anatomical structures, or other pathology in their mouth and catch things early. I can prevent patients from having unnecessary treatment or help them get the right treatment. And I can help educate my patients with the advanced imaging and manage their expectations and fears a bit better too!
That’s huge, y’all!
I am so grateful that I am able to keep up with technology in endodontics, and I know my patients appreciate this, too.
I love sharing what I know about endo, and technology is an area I feel super passionate about. Discovering blind spots is an important element of your continuing education—whether they have to do with technology or other endo skills. Why not test your knowledge right now with my Endo Know-How Quiz?
And let me know in the comments… is a CBCT on your practice’s wish list?