3A|
2C|
2B|
2A|
1B|
SUMMARY REVIEW/ENDODONTICS
1A|
CBCT is valuable for diagnosis of tooth fracture Abstracted from Long H, Zhou Y, Ye N, et al. Diagnostic accuracy of CBCT for tooth fractures: a meta-analysis. J Dent 2014; 42: 240–248. doi: 10.1016/j.jdent.2013.11.024. Epub 2013 Dec 7. PubMed PMID: 24321294. Address for correspondence: Wenli Lai, Department of Orthodontics, State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, No. 14, Section 3, Ren Min South Road, Chengdu 610041, China. E-mail: [email protected]
Question: Is cone-beam computed tomography (CBCT) effective for the diagnosis of tooth fractures?
Commentary The enigma of tooth fracture is a frequent concern in dental practice. There is little incidence and prevalence data. Diagnosis of tooth fracture is complex and imprecise. Symptoms may include pain to touch, pain with occlusion, pain with cold, and pain on
Data sources PubMed, Embase, Web of Science, ProQuest
release of pressure. A fracture on the coronal surface of a tooth
Dissertations & Theses, CNKI and SIGLE databases.
may continue subgingivally creating a narrow, deep periodontal
Study selection Two reviewers independently selected studies. Studies
pocket. Treatment of tooth fracture depends on the location and
examining the diagnostic accuracy of CBCT for tooth fractures in vivo
extent. A fracture across or within the crown of a tooth may be
were considered. Only studies with a minimum of ten participants
treated with a restoration.
using a reference test of surgical exploration or extractions to establish
A fracture that crosses the pulp will cause pulpal necrosis, sen-
the diagnosis of tooth fractures were included.
sitivity and pain. Extraction is the only treatment for a fracture
Data extraction and synthesis Data abstraction was carried out
that bisects a tooth. Traditional techniques for diagnosis of tooth
independently by two reviewers and study quality assessed using the
fracture include visual and tactile inspection, transillumination,
Quality Assessment of Studies of Diagnostic Accuracy-2 (QUADAS-2)
exploratory excavation, percussion test, periodontal probing, dye
tool. The main study outcomes were sensitivity, specificity, positive
test, bite test (with a wooden stick or a plastic tool), radiography
likelihood ratio (LR), negative LR and summary receiver operating
and microscopic detection.1 Two-dimensional radiography offers
characteristic (SROC).
low diagnostic reliability. Cone-Beam Computed Tomography
Results: Twelve studies were included in a meta-analysis. The pooled
(CBCT) offers promise as a diagnostic modality. However, few
sensitivity was 0.92 (95% CI=0.89–0.94) and pooled specificity 0.85
studies analyse the sensitivity and specificity of CBCT for diagno-
(95% CI=0.75–0.92). The pooled positive and negative likelihood
sis of tooth fracture.
ratios were 5.68 (95% CI=3.42–9.45) and 0.13 (95% CI=0.09–0.18)
This systematic review examines evidence to answer the ques-
respectively. The summary receiver operating characteristic was
tion; for patients with tooth fracture, does CBCT compared to
0.94 (95% CI=0.90–0.98). The pooled prevalence of tooth fractures
conventional radiography have higher diagnostic accuracy?
in patients with clinically suspected but periapical-radiography-
Additionally, how does this costly diagnostic technique fit into a
undetected tooth fractures was 91% (95% CI = 83%-97%). Positive
diagnostic pathway for tooth fracture? Included studies utilised
and negative predictive values were 0.98 and 0.43 (subgroup analysis:
surgical exploration or extraction as index tests. Authors searched
0.98 and 0.28 for endodontically treated teeth; 0.99 and 0.77 for non
six electronic databases including a database of gray literature.
endodontically treated teeth).
Inclusion criteria were studies that examined the diagnostic accu-
Conclusions We suggest that CBCT has a high diagnostic accuracy for
racy of CBCT for detecting tooth fractures in vivo, included at least
tooth fractures and could be used in clinical settings. We can be very
ten subjects and included clinical inspection and a surgical refer-
confident with positive test results but should be very cautious with
ence test. Two authors conducted the searches independently and
negative test results. For patients with negative results, close follow-ups
in duplicate. Authors solved disagreement by discussion or referral
are recommended. The diagnostic accuracy of CBCT is similar among
to a third author. This systematic review does not specify included
different types of tooth fractures, which should be interpreted with
study types by name. Searching reference lists may have revealed
caution due to unavailability of data for subgroup analysis on horizontal
more studies.
and oblique tooth fractures.
This systematic review included 12 validity studies. Each study included ten to 135 teeth. Reviewers evaluated each study according to Quality Assessment of Studies of Diagnostic Accuracy – 2 (QUADAS-2) http://www.bris.ac.uk/quadas/quadas-2/. Two authors evaluated studies independently and in duplicate. Authors found that all studies but one had a high or medium level of bias. High bias means that the studies are less likely to reflect the correct result. Patient selection bias was high for every study except for two rated 23
www.nature.com/ebd © 2015 Macmillan Publishers Limited. All rights reserved
ENDODONTICS ‘unclear’. The only demographic information reviewers analysed
David M Leader
was the age of subjects. QUADAS-2 rating of applicability was low
Department of Diagnosis and Health Promotion, Tufts University
or medium for all of the studies. Researchers chose patients who pre-
School of Dental Medicine, Boston, MA, USA
sented with symptoms of tooth fracture. There is no comment on studies should assure calibration of examiners. Case-control stud-
1. Mathew S, Thangavel B, Mathew CA, Kailasam S, Kumaravadivel K, Das A. Diagnosis of cracked tooth syndrome. J Pharm Bioallied Sci 2012; 4: S242–S244. doi: 10.4103/0975-7406.100219 (http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3467890/#__ffn_sectitle)
ies are useful to confirm reliability of tests and examiners. More
Evidence-Based Dentistry (2015) 16, 23-24. doi:10.1038/sj.ebd.6401082
calibration or randomisation of examiners in the studies. Individual
demographic data, practice types, and locations would inform
Practice point
generalisability. The authors of this structured review add to the available evidence for diagnosis of tooth fracture. They offer a place for CBCT in a diagnostic pathway for root fracture. After using traditional techniques and conventional radiography to diagnose a tooth fracture, CBCT is
• Use CBCT for teeth with suspected fracture after a negative periapical radiograph • A negative CBCT of an endodontically treated tooth with positive signs or symptoms does not rule out a fracture.
a useful next step.
24
© EBD 2015:16.1 © 2015 Macmillan Publishers Limited. All rights reserved
2C|
2B|
2A|
1B|
SUMMARY REVIEW/ENDODONTICS
1A|
CBCT is valuable for diagnosis of tooth fracture Abstracted from Long H, Zhou Y, Ye N, et al. Diagnostic accuracy of CBCT for tooth fractures: a meta-analysis. J Dent 2014; 42: 240–248. doi: 10.1016/j.jdent.2013.11.024. Epub 2013 Dec 7. PubMed PMID: 24321294. Address for correspondence: Wenli Lai, Department of Orthodontics, State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, No. 14, Section 3, Ren Min South Road, Chengdu 610041, China. E-mail: [email protected]
Question: Is cone-beam computed tomography (CBCT) effective for the diagnosis of tooth fractures?
Commentary The enigma of tooth fracture is a frequent concern in dental practice. There is little incidence and prevalence data. Diagnosis of tooth fracture is complex and imprecise. Symptoms may include pain to touch, pain with occlusion, pain with cold, and pain on
Data sources PubMed, Embase, Web of Science, ProQuest
release of pressure. A fracture on the coronal surface of a tooth
Dissertations & Theses, CNKI and SIGLE databases.
may continue subgingivally creating a narrow, deep periodontal
Study selection Two reviewers independently selected studies. Studies
pocket. Treatment of tooth fracture depends on the location and
examining the diagnostic accuracy of CBCT for tooth fractures in vivo
extent. A fracture across or within the crown of a tooth may be
were considered. Only studies with a minimum of ten participants
treated with a restoration.
using a reference test of surgical exploration or extractions to establish
A fracture that crosses the pulp will cause pulpal necrosis, sen-
the diagnosis of tooth fractures were included.
sitivity and pain. Extraction is the only treatment for a fracture
Data extraction and synthesis Data abstraction was carried out
that bisects a tooth. Traditional techniques for diagnosis of tooth
independently by two reviewers and study quality assessed using the
fracture include visual and tactile inspection, transillumination,
Quality Assessment of Studies of Diagnostic Accuracy-2 (QUADAS-2)
exploratory excavation, percussion test, periodontal probing, dye
tool. The main study outcomes were sensitivity, specificity, positive
test, bite test (with a wooden stick or a plastic tool), radiography
likelihood ratio (LR), negative LR and summary receiver operating
and microscopic detection.1 Two-dimensional radiography offers
characteristic (SROC).
low diagnostic reliability. Cone-Beam Computed Tomography
Results: Twelve studies were included in a meta-analysis. The pooled
(CBCT) offers promise as a diagnostic modality. However, few
sensitivity was 0.92 (95% CI=0.89–0.94) and pooled specificity 0.85
studies analyse the sensitivity and specificity of CBCT for diagno-
(95% CI=0.75–0.92). The pooled positive and negative likelihood
sis of tooth fracture.
ratios were 5.68 (95% CI=3.42–9.45) and 0.13 (95% CI=0.09–0.18)
This systematic review examines evidence to answer the ques-
respectively. The summary receiver operating characteristic was
tion; for patients with tooth fracture, does CBCT compared to
0.94 (95% CI=0.90–0.98). The pooled prevalence of tooth fractures
conventional radiography have higher diagnostic accuracy?
in patients with clinically suspected but periapical-radiography-
Additionally, how does this costly diagnostic technique fit into a
undetected tooth fractures was 91% (95% CI = 83%-97%). Positive
diagnostic pathway for tooth fracture? Included studies utilised
and negative predictive values were 0.98 and 0.43 (subgroup analysis:
surgical exploration or extraction as index tests. Authors searched
0.98 and 0.28 for endodontically treated teeth; 0.99 and 0.77 for non
six electronic databases including a database of gray literature.
endodontically treated teeth).
Inclusion criteria were studies that examined the diagnostic accu-
Conclusions We suggest that CBCT has a high diagnostic accuracy for
racy of CBCT for detecting tooth fractures in vivo, included at least
tooth fractures and could be used in clinical settings. We can be very
ten subjects and included clinical inspection and a surgical refer-
confident with positive test results but should be very cautious with
ence test. Two authors conducted the searches independently and
negative test results. For patients with negative results, close follow-ups
in duplicate. Authors solved disagreement by discussion or referral
are recommended. The diagnostic accuracy of CBCT is similar among
to a third author. This systematic review does not specify included
different types of tooth fractures, which should be interpreted with
study types by name. Searching reference lists may have revealed
caution due to unavailability of data for subgroup analysis on horizontal
more studies.
and oblique tooth fractures.
This systematic review included 12 validity studies. Each study included ten to 135 teeth. Reviewers evaluated each study according to Quality Assessment of Studies of Diagnostic Accuracy – 2 (QUADAS-2) http://www.bris.ac.uk/quadas/quadas-2/. Two authors evaluated studies independently and in duplicate. Authors found that all studies but one had a high or medium level of bias. High bias means that the studies are less likely to reflect the correct result. Patient selection bias was high for every study except for two rated 23
www.nature.com/ebd © 2015 Macmillan Publishers Limited. All rights reserved
ENDODONTICS ‘unclear’. The only demographic information reviewers analysed
David M Leader
was the age of subjects. QUADAS-2 rating of applicability was low
Department of Diagnosis and Health Promotion, Tufts University
or medium for all of the studies. Researchers chose patients who pre-
School of Dental Medicine, Boston, MA, USA
sented with symptoms of tooth fracture. There is no comment on studies should assure calibration of examiners. Case-control stud-
1. Mathew S, Thangavel B, Mathew CA, Kailasam S, Kumaravadivel K, Das A. Diagnosis of cracked tooth syndrome. J Pharm Bioallied Sci 2012; 4: S242–S244. doi: 10.4103/0975-7406.100219 (http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3467890/#__ffn_sectitle)
ies are useful to confirm reliability of tests and examiners. More
Evidence-Based Dentistry (2015) 16, 23-24. doi:10.1038/sj.ebd.6401082
calibration or randomisation of examiners in the studies. Individual
demographic data, practice types, and locations would inform
Practice point
generalisability. The authors of this structured review add to the available evidence for diagnosis of tooth fracture. They offer a place for CBCT in a diagnostic pathway for root fracture. After using traditional techniques and conventional radiography to diagnose a tooth fracture, CBCT is
• Use CBCT for teeth with suspected fracture after a negative periapical radiograph • A negative CBCT of an endodontically treated tooth with positive signs or symptoms does not rule out a fracture.
a useful next step.
24
© EBD 2015:16.1 © 2015 Macmillan Publishers Limited. All rights reserved
