Use of Cone Beam Computed Tomography in Endodontics
Figure 6
A female patient presented with a twenty-year history of mostly continuous, unilateral, poorly localized severe aching of the maxillary left quadrant. The pain was not associated with sensory loss or other physical signs and pulp tests, and conventional imaging studies were within normal limits. Clinically there was no cessation of pain after administration of local anesthetic. This neuropathic pain syndrome, initially termed atypical facial pain, is more recently known as persistent idiopathic facial pain (PIFP). PIFP refers to pain along the territory of the trigeminal nerve that does not fit the classic presentation of other cranial neuralgias. Diagnostically challenging, PIFP is frequently misdiagnosed and is often attributed by patients to dental procedures, facial trauma, and rarely, by some clinicians, as Neuralgia-Inducing Cavitational Osteonecrosis (NICO). Dynamic visualization of sequential curved planar parasagittal CBCT-reformatted images at 0.076 mm thickness (a) confirmed the absence of obvious pathosis of odontogenic origin as diagnosed from the original intraoral periapical of the region (b). Note the radiolucent area within the coronal portion of the first molar under the radiopaque disto-occlusal restorative material; this represents a streak artifact due to “photostarvation” in the horizontal plane due to the attenuation of adjacent amalgam and radiopaque material and subsequent reduction in available data for image reconstruction. A negative CBCT imaging finding is often very reassuring for these unfortunate patients who often question a nonodontogenic diagnosis. Psychiatric symptoms of depression and anxiety are prevalent in this population and compound the diagnostic conundrum.
