Evaluat ion of t echnical qualit y and periapical
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Bilge Gülsüm NUR1, Evren OK2, Mustafa ALTUNSOY12VPDQ6DPL$ö/$5&,3, Mehmet ÇOLAK4, Enes GÜNGÖR4
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4- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Dicle University, Diyarbakir, Turkey.
Corresponding address:%LOJH*OVP1XU'HSDUWPHQWRI3HDGLDWULF'HQWLVWU\)DFXOW\RI'HQWLVWU\ùLID8QLYHUVLW\ø]PLU7XUNH\3KRQH
3434445/1725 - 0505 4421826 - Fax: +90 232 3435656 - e-mail: dtbilgenur@hotmail.com
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ABSTRACT
http://dx.doi.org/10.1590/1678-775720140110
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EMHFWLYH7KLVVWXG\DLPHGWRDVVHVVWKHTXDOLW\RIURRW¿OOLQJVFRURQDOUHVWRUDWLRQV FRPSOLFDWLRQV RI DOO URRW¿OOHG WHHWK DQG WKHLU DVVRFLDWLRQ ZLWK DSLFDO SHULRGRQWLWLV( AP) det ect ed by cone- beam com put ed t om ography ( CBCT) im ages from an adult Turkish subpopulat ion. Mat erial and Met hods: The sam ple for t his st udy consist ed of 242 pat ient s ( aging from 15 t o 72 years) wit h 522 endodont ically t reat ed t eet h t hat were assessed for
WHFKQLFDOTXDOLW\RIWKHURRWFDQDO¿OOLQJDQGSHULDSLFDOVWDWXVRIWKHWHHWK$GGLWLRQDOO\WKH DSLFDOVWDWXVRIHDFKURRW¿OOHGWRRWKZDVDVVHVVHGDFFRUGLQJWRWKHJHQGHUGHQWDODUFK WRRWKW\SHDQGDJHFODVVL¿FDWLRQXQGHWHFWHGFDQDOVLQVWUXPHQWIUDFWXUHURRWIUDFWXUH
apical resorption, apical lesion, furcation lesion and type and quality of the coronal structure. St at ist ical analysis was perform ed using percent ages and chi- square t est . Result s: The success rat e of t he root canal t reat m ent was of 54.4% . The success rat es of adequat e
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periodont it is was found in 228 ( 45.6% ) t eet h t reat ed for root canals. Higher prevalence of AP was found in pat ient s aging from 20 t o 29 years [ 64 ( 27% ) t eet h] and in ant erior ( canines and incisors) t eet h [ 97 ( 41% ) t eet h] . Conclusions: The t echnical qualit y of root
FDQDO¿OOLQJSHUIRUPHGE\GHQWDOSUDFWLWLRQHUVLQD7XUNLVKVXESRSXODWLRQZDVFRQVLVWHQW
wit h a high prevalence of AP. The probable reasons for t his failure are m ult ifact orial, and t here m ay be a need for im proved undergraduat e educat ion and post graduat e courses t o im prove t he clinical skills of dent al pract it ioners in endodont ics.
Keyw ords: Cone- beam com put ed t om ography. Root canal. Apical periodont it is.
I N TRODUCTI ON
7KHTXDOLW\RIURRWFDQDO¿OOLQJVLVDVVRFLDWHGZLWK the adequate treatm ent of roots, which depends on t heir lengt h in relat ion t o t he apex, hom ogeneity and quality and type of coronal restorations23,29. The successful int erpret at ion of endodont ic problem s was associat ed wit h diagnost ic im aging t echniques t hat provide inform at ion about t he t eet h and t heir surrounding anat om y.
N u m e r o u s st u d i e s h a v e u se d p e r i a p i ca l radiographs t o assess t he anat om ic st ruct ure of t eet h and t o analyze t he num ber and locat ion of root canals23,29. However, periapical radiographs provide t wo- dim ensional im ages, t herefore, t hey
cannot provide adequat e inform at ion about t he r oot canal configurat ion. Recent ly, cone- beam com put ed t om ography ( CBCT) is being widely used in dent al pract ice and research. CBCT have been used t o provide great er det ails about t he root canal anatom y and their surrounding structures com pared t o radiographic im ages19.
by general dent al pract it ioners show m uch lower success rat es4,23,27,30. One of t he m ost im port ant r easons for such poor qualit y t r eat m ent is an increase in t he prevalence of apical periodont it is ( AP) .
Th e ch r on ic in flam m at ion of t h e per iapical st r u ct u r e u su ally d ev elop s it self w it h ou t t h e pat ient experiencing sym pt om s, t hus, radiological exam inat ion is st ill fundam ent al for it s det ect ion. AP is generally underest im at ed and som et im es not detectable in panoram ic and periapical radiographic im ages, because of the superposition of anatom ical landm arks6. The m ain advant age of a 3D view of m axillofacial st ruct ures is t hat t hey have no superim posit ions wit h anat om ical landm arks15.
Previous st udies assessed t he qualit y of root can al fillin gs by r adiogr aphy2 3 , 2 9. How ev er, n o st udies have yet assessed t he qualit y of root canal ¿OOLQJVXVLQJ&%&7LQD7XUNLVKVXESRSXODWLRQ7KLV study was aim ed to assess the quality and periapical VWDWXV RI URRW FDQDO ¿OOLQJV E\ &%&7 LQ D 7XUNLVK subpopulat ion.
M ATERI AL AN D M ETH ODS
&%&7LPDJHVRIURRWFDQDO¿OOLQJVZHUHREWDLQHG fr om pat ien t s w h o fir st v isit ed t h e Facu lt y of Dent ist ry of Dicle Universit y, Diyarbakir, Turkey, bet ween 2009 and 2011. We assessed a dat abase of 522 CBCT scans of endodont ically t reat ed t eet h obt ained from 276 pat ient s according t o sex and age (15-72 years), and records of third m olars were excluded. This st udy was based on a ret rospect ive assessm ent of CBCT im ages and appr oved by t he Medical Et hics Com m it t ee of ùifa Universit y ( Prot ocol # 33- 2013) .
The select ion crit eria included t he following:
1. Pat ient s over 14 years old;
3DWLHQWVYLVLWLQJWKHFOLQLFIRUWKH¿UVWWLPH 3. CBCT im ages of good quality;
4. Previous root canal t reat m ent perform ed by general pract it ioners.
Exclusion crit eria included t he following: 1. CBCT im ages present ing deform at ions; 2. Unsat isfact ory coronal rest orat ion; 3. Recent ly t raum at ized and t reat ed t eet h; 4. Ort hodont ic pat ient s.
Th e CBCT i m ag es w er e o b t ai n ed u si n g a CBCT scanner ( I - CAT Vision TM I m aging Science ,QWHUQDWLRQDO+DW¿HOG86$DWN9S m A, with an exposure tim e of 8-9 s. The voxel size of the im ages was 0.3 m m . The acquisition process was perform ed by an experienced radiologist according t o t he recom m endat ions of t he m anufact urer, wit h t he m inim um exposure necessary for adequat e im age qualit y. I nt raexam iner calibrat ion of t he CBCT im ages w as fir st per for m ed t o evaluat e t he reliabilit y of t he assessm ent . All im ages were assessed separat ely t wo t im es by t wo exam iners ( an endodont ist and a m axillofacial radiologist ) wit h a 2-week int erval bet ween t he assessm ent s. I n t he case of disagreem ent s bet ween t he pair, t hese w er e discussed w it h anot her radiologist unt il a consensus w as r eached. The follow ing fact ors were assessed in all im ages: sex, dent al DUFKWRRWKW\SHDQGDJHFODVVL¿FDWLRQXQGHWHFWHG canals, inst rum ent fract ure, root fract ure, apical r esor pt ion, apical lesion, fur cat ion lesion, t ype DQGTXDOLW\RIWKHFRURQDOVWUXFWXUHDQGVXI¿FLHQW RYHU¿OOHGDQGLQVXI¿FLHQWXQGHU¿OOHGURRWFDQDO ¿OOLQJ 5) )LJXUH 7KH FULWHULD XVHG IRU WKH H[DPLQDWLRQ ZHUH VOLJKWO\ PRGL¿HG IURP WKRVH described by De Moor, et al.4 VXI¿FLHQW 5) ZDV GH¿QHG DV D URRW FDQDO VSDFH WKDW ZDV
FRPSOHWHO\¿OOHGHQGLQJ±PPIURPWKHDSH[ DQGZLWKQRYRLGVLQVXI¿FLHQW5)ZDVGH¿QHGDVD root canal space that was poorly condensed, ending m ore t han 2 m m from t he apex, and wit h voids. Addit ionally, t he qualit y of coronal rest orat ion was assessed according t o any perm anent rest orat ion, radiographic signs of recurrent caries, open m argins or presence of t em porary coronal rest orat ions or no rest orat ion ( Figure 2) .
St at ist ical analysis
The CBCT im ages used t o assess t he t echnical TXDOLW\ RI URRW FDQDO ¿OOLQJV ZHUH DQDO\]HG XVLQJ t he chi- square t est ( p< 0.05) .
RESULTS
I n t his st udy, a t ot al of 522 t eet h obt ained from 276 pat ient s ( 134 fem ales and 142 m ales) , aging from 15 to 72 years, were assessed. Of these teeth, 265 ( 50.8% ) were from fem ales, and 257 ( 49.2% ) were from m ales; t he difference bet ween genders ZDVVWDWLVWLFDOO\VLJQL¿FDQWS:LWKUHJDUGWR age, patients under 20 and over 60 years presented lower prevalence of endodontic treatm ent (Table 2).
Table 1 list s t he t ypes and prevalence of root-¿OOHG WHHWK 7KHUH ZHUH PD[LOODU\
t eet h and 152 ( 29.1% ) m andibular t eet h. I ncisors and canines (݊= 232) were treated m ost frequently, followed by prem olars (݊= 166) and m olars (݊= 124). The periapical st at us of all root- t reat ed t eet h is present ed in Table 1. Of all t he endodont ically t reat ed t eet h, 54.3% showed a healt hy periapical st ruct ure, whereas 45.7% showed t he presence of AP lesions in dent al arches, and t he difference w as not st at ist ically significant ( p> 0. 05) . The dist r ibu t ion f r equ en cy of t h e AP af f ect ed t h e m axillae [ 168 t eet h ( 45.4% ) ] and m andible [ 70 t eet h ( 4 6 % ) ] in t h e den t al ar ch w as sim ilar. There were found 238 ( 45% ) AP lesions. The AP lesions were locat ed m ost frequent ly in m axillary incisors and canines [ 80 ( 15.3% ) t eet h] , followed by m axillar y pr em olar s [ 50 ( 9.6% ) t eet h] and m axillary m olars [ 38 ( 7.3% ) t eet h] . The AP lesions were locat ed less frequent ly in m andibular incisors and canines [ 17 ( 3.3% ) teeth] . I n addition, without consider ing t he t echnical qualit y of r oot canal t reat m ent s, t he prevalence of apical healt h and coronal structure of the teeth showed no statistically VLJQL¿FDQW GLIIHUHQFH S! $Q DVVHVVPHQW of t he coronal st ruct ure of t he t eet h w it h root FDQDO ¿OOLQJV UHYHDOHG WKDW KDG FRURQDO rest orat ions, whereas 38.1% had been crowned. The r elat ionship bet w een t he per iapical st at us
Parameters Criteria Characterization
Quality of root canal treatments
'HQVLW\RIURRWFDQDO¿OOLQJ Adequate 1RJDSVSUHVHQWLQWKHURRW¿OOLQJRUEHWZHHQURRW¿OOLQJDQGURRW
canal walls.
Poor *DSVSUHVHQWLQWKHURRW¿OOLQJRUEHWZHHQURRW¿OOLQJDQGURRWFDQDO
walls.
/HQJWKRIURRWFDQDO¿OOLQJ Adequate 5RRW¿OOLQJHQGLQJPPIURPWKHUDGLRJUDSKLFDSH[
Poor 5RRW¿OOLQJRYHUWKHUDGLRJUDSKLFDSH[RUURRW¿OOLQJ!PPIURP
the radiographic apex.
Quality of coronal restoration Adequate Any permanent restoration that appeared intact radiographically. Poor Any permanent restoration with detectable radiographic signs of
recurrent caries or open margins or presence of temporary coronal restorations.
Missing No permanent or temporary coronal restoration.
Periapical status Healthy periodontal
ligament
The periodontal ligament was intact with no signs of periapical pathosis.
Apical periodontitis
The periapical radiolucency in connection with the apical part of the tooth exceeding at least two times the width of the lateral part of the
periodontal ligament.
and t ype and qualit y of coronal st ruct ure was not VWDWLVWLFDOO\VLJQL¿FDQWS!WKHGLVWULEXWLRQLV present ed in Table 1.
Of 522 t eet h, 199 ( 38.1% ) had inadequat e OHQJWKRI¿OOLQJEHLQJVKRUWRIWKHUDGLRJUDSKLFDSH[ RURYHU¿OOHGZKHUHDVRQO\KDGLGHDO ¿OOLQJOHQJWK7KHSUHYDOHQFHRI$3ZDV LQXQGHU¿OOHGWHHWKDQGWHHWKKDGEHHQ RYHU¿OOHG ZLWK JXWWDSHUFKD RU VHDOHU PDWHULDO 2YHUDOODURRWFDQDO¿OOLQJZDVFRQVLGHUHGDVDQ DGHTXDWH¿OOLQJOHQJWKZLWKSHULDSLFDOKHDOLQJLQRQO\ RIDOOLGHDO¿OOLQJOHQJWKZKHUHDV$3 was recorded in 80 t eet h ( 24.8% ) . I n t he present
VWXG\WKHFRPSOLFDWLRQVRIDOOURRW¿OOHGWHHWKZHUH assessed. One ( 0.02% ) had broken inst rum ent s inside t he canals, 44 ( 8.4% ) had undet ect ed root canals, 2 ( 0.4% ) had root fract ures, 77 ( 14.8% ) showed apical resorpt ion, 76 ( 14.6% ) had apical lesions, and 1 ( 0.2% ) had furcat ion lesions.
DI SCUSSI ON
7KLVVWXG\LVWKH¿UVWWRDVVHVVWKHSHULDSLFDO VWDWXVRIURRW¿OOHGWHHWKXVLQJ&%&7LPDJHVRID Turkish subpopulat ion. The negat ive fact or of t his st udy is t hat t he dat a analyzed are rest rict ed t o Total Apical periodontitis Periapical status
Healthy
Chi-square P values n % n % n %
Sex
Female (n:134) 265 50.8% 103 38.9% 162 61.1%
0.01 Male (n:142) 257 49.2% 135 52.5% 122 47.5%
Dental arch
Maxilla 370 70.9% 168 45.4% 202 54.6%
0.484 Mandible 152 29.1% 70 46% 82 54%
Tooth type
Incisors+Canines 232 44.5% 97 40.5% 135 47.5% Maxilla:0.04 Premolars 166 32% 71 30% 95 33.5% Mandible:0.29
Molars 124 23.5% 70 29.5% 54 19%
$JHFODVVL¿FDWLRQ
14-20 44 8.4% 12 27.3% 32 72.7%
0.016 20-30 119 22.8% 64 53.8% 55 46.2%
30-40 107 20.5% 52 48.6% 55 51.4% 40-50 117 22.4% 47 40.2% 70 59.8% 50-60 109 20.9% 47 43.1% 62 56.9%
DQGĹ 26 5% 16 61.5% 10 38.5%
Undetected canals 44 8.4% 30 68.2% 14 31.8% 0.002 Filling length
8QGHU¿OOHG 152 29.1% 113 74.3% 39 25.7%
0.000 Adequate 323 61.9% 80 24.8% 243 75.2%
2YHU¿OOHG 47 9% 45 95.7% 2 4.3%
Instrument fracture 1 0.2% 1 100% - 0.456 Root fracture 2 0.4% 1 50% 1 50% 0.704 Apical resorption 77 14.8% 69 89.6% 8 10.4% 0.000 Apical lesion 76 14.6% 74 97.4% 2 2.6 % 0.000 Furcation lesion 1 0.2% 1 100% - 0.456 Type and quality of
coronal structure
Restoration 323 61.9% 156 65.5 % 167 58.8%
0.06 Crowned 199 38.1% 82 34.5% 117 41.2%
available inform at ion and t hus m ay suffer from pr econcept ion24. How ev er, t he m ost im por t ant advant age of t his m et hod is t he com prehensive sam ple size8. Pr ev iou s st u dies t y pically u sed convent ional panoram ic17 or full- m out h periapical r ad i o g r ap h s8 , 2 3 , 2 9. Th e m ai n d i sad v an t ag e o f convent ional radiographs is t hat t hey only provide static inform ation about a dynam ic process and it is im possible t o est im at e whet her a periapical lesion is increasing or decreasing in size23. Recent ly, CBCT has been widely used in endodont ic t herapy5. The m ost im port ant advant age of CBCT in endodont ics is t hat it allows a bet t er visualizat ion of t he det ails of the root canal anatom y than radiographic im ages and provides a 3D view for diagnosing and m anaging endodont ic com plicat ions5,19, t herefore, we used CBCT im ages in this study. I n our study, endodontic t reat m ent was m ore prevalent in pat ient s aging bet ween 20 and 30 ( 22.8% ) and bet ween 40 and 50 ( 22.4% ) years, and t hese result s lead t o t oot h loss wit h advancing age. Furt herm ore, pat ient s aging over 60 years present ed lower prevalence of endodont ic t reat m ent t han t hose under 60 years in t his st udy, because t his populat ion probably have ext ract ed t eet h - especially m olar t eet h.
,Q SUHYLRXV VWXGLHV RI URRW¿OOHG WHHWK LQ D 7XUNLVK VXESRSXODWLRQ RI URRW ¿OOLQJV were report ed t o be inadequat e; m any of t hese were undert aken in general pract ice or hospit al set t ings7,8,10,22,23. Kayahan, et al.10 ( 2008) assessed 1 2 6 8 t eet h f r om 2 8 0 p an or am ic r ad iog r ap h s and found apical lesions in 40.5% ( 514) of t he t eet h. Sunay, et al.22 ( 2007) assessed panoram ic radiographs of 375 pat ient s and found pat hological ¿QGLQJVLQRIWKHWHHWK,QWKLVVWXG\ ( 45.6% ) t eet h showed periapical lesions, and t he ot her 284 ( 54.4% ) showed a healt hy periapical st ruct ure.
The present st udy t arget s a populat ion from a r ural ar ea and parallel r esult s r egar ding t he pr ev alen ce of per iapical lesion s pr esen t ed in ot her st udies of a Turkish subpopulat ion7,10,22,29. The relat ion bet ween t his st udy and t hese result s lies in t he fact t hat t he incom e and t reat m ent opport unit ies for pat ient s, part icularly t hose living in t he rural areas of Turkey, are lim it ed. Finally, t he ext ract ion of t eet h due t o low socioeconom ic st at us leads t o a lim it ed epidem iological increase in t he QXPEHURIURRW¿OOHGWHHWK
However, Fernandes, et al.15 ( 2013) evaluat ed a t ot al of 5585 t eet h of 300 Brazilian pat ient s assessed by CBCT im ages and found periapical lesions in only 192 t eet h ( 3.4% ) . Peak, et al.16 ( 2001) evaluat ed t he t r eat m ent out com e of a WRWDORIWHHWKZLWKURRWFDQDO¿OOLQJVGRQHE\ m ilit ary general dent ist s in t he Royal Brit ish Arm y and found periapical lesions in 62 ( 15% ) t eet h. On t he ot her hand, in a Taiwanese populat ion, Chueh,
et al.2 ( 2003) assessed a t ot al of 1085 t eet h and found t hat t he rat e of root canals wit h adequat e ¿OOLQJV ZHUH :KLOH XQDFFHSWDEOH ¿OOLQJV GXHWRLQDGHTXDWHURRW¿OOLQJVZHUHRIDQG RYHU¿OOLQJ ZHUH RI KDG QR ¿OOLQJV in t heir root canals. Sim ilarly, in a Senegalese VXESRSXODWLRQRQO\RIWKHURRW¿OOLQJVZHUH technically acceptable27. I n the Kosovan population, Kam ber i, et al.9 ( 2 0 1 1 ) f ou n d t h at , f ollow in g endodont ic procedures by general dent ist s, 30.5% RIWKHURRW¿OOHGWHHWKZHUHWHFKQLFDOO\DFFHSWDEOH
Unlike t he r esult s of t he st udies m ent ioned above, Tarim , et al.23 ( 2013) assessed 1448 root s of 831 t eet h obt ained from 484 pat ient s. They found that 73.4% of these showed periapical lesions and t he ot her 26.6% showed a healt hy periapical st r u ct u r e. I n an ot h er st u d y7, t h e p an or am ic and periapical radiographs of 400 pat ient s were invest igat ed and t he r oot canal t r eat m ent was applied to 890 teeth, and the presence of periapical lesions could be found in 658 ( 73.9% ) t eet h.
I n our st udy, we found t hat 45.5% ( 238) of t he t eet h showed periapical lesions. This can be explained by t he fact t hat t he survey populat ion d i d n ot r ep r esen t t h e en t i r e cou n t r y ; t h er e w er e d if f er en ces in h ealt h car e ser v ices an d socioeconom ic factors; and the age of the assessed pat ient s, sam ple of pat ient s, and assessm ent m et hods differed from each ot her.
I n addition, a com m on problem in endodontics is t he lim it at ion of convent ional radiographic im ages, where t he anat om ical st ruct ures m ay be confused wit h periapical pat hosis, and t he num ber of canals in root canal t reat m ent m ight oft en be unclear19. Furt herm ore, int ernal, ext ernal, buccal or lingual OHVLRQV FRXOG QRW EH LGHQWL¿HG E\ FRQYHQWLRQDO radiography when com pared wit h CBCT13.
The correct diagnosis of com plicat ions such as perforat ions, resorpt ions, undet ect ed canals and root fract ure can be challenging and m ay result in an u n su it able t r eat m en t7 , 1 9. Th er ef or e, t h e assessm ent of such com plicat ions is part icularly im port ant in endodont ics. These problem s m ay be overcom e using t he CBCT t echnique t hat provides a 3D view for diagnosing and m anaging endodont ic com plicat ions3.
t issues w er e significant ly higher in t eet h w it h RSWLPDOURRWFDQDO¿OOLQJVLQDQ\W\SHRIUHVWRUDWLRQ Furtherm ore, Tronstad, et al.28 (2000) dem onstrated t hat t he qualit y of a well- sealed coronal rest orat ion LQÀXHQFHGWKHRXWFRPHVLJQL¿FDQWO\SRVLWLYHO\ZKHQ com bined wit h opt im al root canal t reat m ent . I n WKHSUHVHQWVWXG\URRW¿OOHGWHHWKUHVWRUHGZLWKRU ZLWKRXWFURZQVVKRZHGQRVWDWLVWLFDOO\VLJQL¿FDQW differences in the occurrence of periapical pathology ( p> 0.05) , but t eet h wit hout crowns showed m ore AP t han crowned t eet h.
I n t he lit erat ure, m any epidem iological st udies have shown t hat t here is a high prevalence of SHULDSLFDOGLVHDVHLQWKHURRW¿OOHGWHHWKZLWKSRRU t echnical qualit y1,22,23. I t is because bact eria can UHPDLQZLWKLQWKHURRWFDQDOV\VWHPLQ¿OOHGWHHWK and t heir product s m ay cause reinfect ion of t he root canal syst em in a relat ively short t im e25,26. The UHVXOWVIURPWKHSUHVHQWVWXG\FRQ¿UPWKH¿QGLQJV of ot her st udies t hat afir m ed t hat inadequat e URRW ¿OOLQJ WHHWK SUHVHQW KLJKHU $3 SUHYDOHQFH XQGHU¿OOHGDQGRYHU¿OOHGS $GHTXDWH URRW FDQDO ¿OOLQJV ZHUH IRXQG LQ ( 61.9% ) of all exam ined sam ples, 24.8% of t hese t eet h were recorded wit h presence of AP.
Finally, it is clear t hat t he qualit y of t he root FDQDO¿OOLQJVLVDVVRFLDWHGZLWKKLJKHUSURIHVVLRQDO st andards and a bet t er t echnique, undergraduat e and post graduat e t raining and bet t er equipm ent . Furt herm ore, we believe t hat an adequat e coronal restoration and root canal treatm ent were im portant t o t he overall success of t he root canal t reat m ent .
CON CLUSI ON
Th e t ech n ical q u alit y of r oot can al f illin g per for m ed by dent al pract it ioner s in a Tur k ish subpopulation was consistent with a high prevalence of AP. The present st udy, despit e it s lim it at ions, FRQ¿UPHGWKH¿QGLQJVRIRWKHUVWXGLHV7KHSUREDEOH reasons for t reat m ent failure are m ult ifact orial and m ay indicat e t he need for im proved undergraduat e education and postgraduate courses to im prove the clinical skills of dent al pract it ioners in endodont ics. There is a need t o st andardize t he assessm ent of WKHTXDOLW\RIURRWFDQDO¿OOLQJVWKHUHIRUHWKLVVWXG\ provides useful inform at ion about general dent al condit ions in a Turkish subpopulat ion, which can help in describing new st rat egies for t he t reat m ent and protection of periradicular tissues. Additionally, t his st udy cont ribut es t oward fut ure applicat ions of CBCT im ages in cross- sect ional st udies.
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