牙髓专科医师应用锥形束CT的现况调查

doi:10.19723/j.issn.1671-167X.2023.01.017

摘要/Abstract

摘要：

目的: 调查锥形束CT(cone-beam computed tomography, CBCT)在牙髓专科医师的临床使用情况, 分析CBCT在牙髓根尖周病诊治中作用, 为CBCT的合理应用提供参考。方法: 收集2021年1至12月北京大学口腔医院牙体牙髓科就诊并拍摄CBCT的患者临床资料, 纳入患者临床资料完整, 包括临床病历、放射申请单/报告及二维和三维影像学资料, 除外因正畸或修复等原因而拍摄者。分析临床资料, 调查应用CBCT的牙髓医师经验及培训背景、全年接诊患者数量, 同时检索CBCT检查目的和兴趣区、CBCT拍摄的技术参数(如机型和视野)、拍摄后的报告, 评估对诊断的影响。应用Wilcoxon和Mann-Whitney检验比较CBCT兴趣区的分布, 应用卡方检验及两两比较分析不同临床经验的牙髓专科医师(高、中、低年资)应用CBCT的情况。结果: 共61名临床医师全年接诊34 952人, 申请CBCT扫描共3 308份, 其中受检者3 218例(男∶女约为1 ∶2), 年龄中位数35岁(28, 49), 占全年接诊患者数量10%;其中98%的CBCT检查在拍摄二维根尖片后, 96%的CBCT扫描投照视野小于10 cm×10 cm。3 308份CBCT中83%的扫描兴趣区为上下颌后牙区, 拍摄数高于前牙17%(Z=-2.278, P < 0.05), 受检最多的上下颌第一磨牙占受检患牙的35%。统计CBCT扫描目的主要包括三方面: 明确临床诊断、指导手术和非手术牙髓治疗(包括牙髓治疗并发症处理)及疗效评估, 分别为1 111份(34%)、1 745份(54%)、311份(10%), 其他占2%。CBCT用于明确临床诊断, 主要应用于慢性根尖周炎、牙根折裂、牙根吸收和牙外伤, 其中353份CBCT检查用于牙根折裂的诊断和鉴别诊断, 阳性诊断率为35%(125/353)。为揭示根管系统解剖而拍摄的846份CBCT中, 297份为治疗失败后明确是否有遗漏根管, 其中58%(171/297)病例确认存在遗漏根管。在治疗并发症的处理中, CBCT主要用于辅助侧穿的诊断和分离器械的定位。311份CBCT检查应用于疗效评价, 包括根管治疗后240份和根尖手术后71份, 拍摄原因为复查或治疗后有临床症状、二维根尖片显示持续存在病损。使用CBCT的61名医师包括高年资医师23名, 占开具CBCT检查总数的45%, 中、低年资医师分别为15、23名, 开具CBCT检查占比分别为30%和25%。高年资与低年资医师申请CBCT检查各占接诊患者的10%, 高于中年资医师的8%(χ₁²=39.4, χ₂²=29.1, P < 0.001)。主任医师申请比例为18%, 高于副主任医师的9%(χ₁²=139.4, P < 0.001)。CBCT拍摄后医师改变诊断或调整计划者约31% (1 009/3 308)。结论: 牙髓专科医师应用CBCT获得更加丰富的临床信息, 有助于诊断和精准治疗及预后判断。

关键词: 锥形束CT, 牙体牙髓病, 牙髓专科医师

Abstract:

Objective: To investigate the clinical application of cone-beam computed tomography (CBCT) among endodontic practitioners, and to analyze the indications and reasonability of CBCT in the diagnosis and treatment of pulpal and periapical diseases. Methods: The clinical data were collected from patients who visited the Department of Cariology and Endodontology, Peking University School and Hospital of Stomatology and underwent CBCT examination from January to December, 2021. The data with their complete clinical information (including clinical records, radiology request forms/reports, two-dimensional and three-dimensional imaging data) were included. Those who underwent CBCT examination for orthodontic or prosthodontics were excluded. The experience and training background of the endodontic specialists, the number of patients treated in the whole year, the objective and region of interest (ROI) of CBCT examination, technical parameters, such as machine type, field of view (FoV) and radiographic reports were collected and analyzed to evaluate the impact on diagnosis. Wilcoxon and Mann-Whitney tests were used to compare the distribution of CBCT ROI. Chi-squared test and pairwise comparison were used to compare the application of CBCT by endodontic specialists with different clinical experience (senior, middle and junior). Results: In 2021, a total of 3 308 CBCT scans were prescribed by 61 endodontic specialists who treated 34 952 patients throughout the year. 3 218 patients (male ∶female about 1 ∶2) amounting for 10% of the patients treated in the whole year who received CBCT scans with an median age of 35 years (28, 49). Around 98% CBCT examinations were performed after clinical examination and two-dimensional periapical radiographs were taken. The FoV of CBCT scanning less than 10 cm×10 cm accounted for 96% of the total number of the images. Among the 3 308 CBCT scans, 83% of the ROI were in posterior teeth, with a higher number of anterior teeth (Z=-2.278, P < 0.05). Maxillary and mandibular first molars accounted for 35% of the examined teeth. The objectives of CBCT scanning included three aspects: clarifying clinical diagnosis, guiding surgical and non-surgical endodontic treatment (including management of endodontic complications), and outcome assessment, accounting for 1 111 (34%), 1 745 (54%), 311 (10%), respectively. and the others 2%. In the diagnosis process, CBCT was mainly used for the diagnosis of chronic periapical periodontitis, root fracture, root resorption and dental trauma. In the study, 353 CBCT were used in the diagnosis of root fracture, with a positive diagnosis rate of 35% (125/353). 846 CBCT used to reveal the anatomy of the root canal system, of which 297 cases were used to find missed/extra canals after treatment failure, and 58% (171/297) were used to confirm the missed/extra canals. In the management of complications or errors, CBCT was mainly used to assist the diagnosis of perforation and to locate the separated instruments. In the study, 311 CBCT scans were used for outcome assessment, including 240 cases related to non-surgical treatment and 71 cases related to surgical endodontic treatment for follow-up or presence of clinical symptoms, and persistent lesions on 2D films. Among the 61 endodontic specialists who used CBCT, 23 (45%) were with senior experience, 15 (30%) with middle experience, and 23 (25%) with junior experience. The proportion of senior or junior experience prescribing CBCT examination was 10%, higher than that of middle experience (8%, χ₁²=39.4, χ₂²=29.1, P < 0.001). The application rate of chief endodontists was 18%, which was higher than that of associate chief endodontists (9%, χ₁²=139.4, P < 0.001). 31% (1 109/3 308) cases of diagnosis or treatment plans were changed after CBCT was taken. Conclusion: Use of CBCT in endodontic practice could provide more clinical information, which is helpful for diagnosis, accurate treatment and prognosis evaluation.

Key words: Cone-beam computed tomography, Endodontics, Endodontic practitioners

中图分类号:

R781.3

叶佳学,梁宇红. 牙髓专科医师应用锥形束CT的现况调查[J]. 北京大学学报（医学版）, 2023, 55(1): 114-119.

Jia-xue YE,Yu-hong LIANG. A prevalence survey of cone-beam computed tomography use among endodontic practitioners[J]. Journal of Peking University (Health Sciences), 2023, 55(1): 114-119.

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参考文献 27

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Items	Examination content
Diagnosis and differential diagnosis
Periapical lesions	Determine the presence, scope and destruction of periapical lesions and alveolar bone
Abnormal development	Dens invaginatus, taurodontism, etc
Root fracture	Except or diagnose (vertical) root fracture
Root resorption	Except or diagnose root (internal or external) resorption
Traumatic injuries of the tooth	A clear history of trauma in the medical history and the target tooth was scanned
Guiding surgical and non-surgical endodontic treatment
Retreatment decisions(prognosis)	Guiding clinical treatment decisions (surgical/non-surgical/extraction)
Anatomy of root canal	Including retreatment, obstructed root canal, calcified canals, missed canal, C-shaped canal and other complex root canal system
Preoperative evaluation of surgery	Routine examination before surgery
Management of complications	Perforation, instrument separation, etc
Outcome evaluation
Post-root canal treatment	Follow-up after root canal treatment
ost-endodontic surgery	Follow-up after endodontic surgery
Others	Examination of hyperdontia, tumour, temporal-mandibular joints, extent of caries lesions, root development, maxillary sinus, etc

Treatments	Amount, n	Follow-up time/months	Absence	Reduction
Non-surgical	240	9.8(2-36)	54%	92%
Surgical	71	15.5(1-46)	44%	94%

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