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Endodontic Topics 2012, 26, 5775

All rights reserved

2013 John Wiley & Sons A/S

ENDODONTIC TOPICS
1601-1538

Cone beam computed tomography

and other imaging techniques
in the determination of
periapical healing
CHRISTINE I. PETERS & OVE A. PETERS
To be able to determine if endodontic treatment of apical pathosis is successful or not, healing of lesions is
followed up by radiographic imaging. This can be done by observing changes in apical radiolucencies. Recently,
cone beam computed tomography (CBCT) has been introduced as a method of gaining an unabridged view of
dental anatomy, thus eliminating some of the most prevalent problems, such as superimposition and distortion.
CBCT reduces false diagnosis and is rapidly replacing other radiographic techniques in diagnosis, quality control
of treatment methods and techniques, and outcome assessment. Healing assessment using conventional and newer
three-dimensional imaging includes, but is not limited to, periapical osseous lesions, conditions of the maxillary
sinus, status after endodontic surgery, hard tissue deposition in regeneration procedures, and horizontal root
fractures. Due to a low predictive value of two-dimensional periapical radiographs to distinguish between
periapical disease and health, future assessment of endodontic treatment efficacy may include 3D imaging from
small field-of-view CBCT units.
Received 29 September 2012; accepted 18 November 2012.

Introduction
Endodontic disease has been characterized by the
presence of periapical inflammation (1). The
occurrence of disease can remain unnoticed for
prolonged periods of time or a patient in pain may seek
dental care. Clinically, the existence of apical pathosis
may be detected by sensitivity to biting or percussion,
but asymptomatic apical periodontitis frequently does
not elicit such a response. Symptomatic apical
periodontitis is caused primarily by penetration and
colonization of root canal space by a wide-ranging
microbial flora (2). Continuous egress of proinflammatory microbial products from an endodontically infected tooth stimulates the host to develop

periapical inflammation and bone loss (3,4), frequently

as a chronic process with little or no symptoms (57).
To rule out problems with adjacent teeth or other
local factors as source of any symptoms, routine pulp
sensibility testing is typically executed. Unfortunately,
these clinical tests are not always accurate (8,9). A
significant weakness of most such tests is that they only
give an assessment of the neural reaction to thermal
stimuli and no information about the state of pulpal
vasculature and blood supply (10). Both false positive
and false negative results can occur. Thermal tests may
indicate or support suspected pulpal pathosis or apical
periodontitis but they are unreliable in the presence of
pulp canal obliteration (11) immature teeth (12),
trauma (13) and multirooted teeth (14). Unless there

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Peters & Peters

Table 1: Potential and actual areas for endodontic healing assessment with CBCT
Condition/procedure

Variable

Species

Reference

non-surgical endodontics

bone fill

human
dog

(92,93,141)
(98,138)

non-surgical endodontics

sinus membrane changes

human

(136,142)

surgical endodontics

bone fill

human

(45,91,143)

trauma

horizontal fracture healing?

human

(128,144)

direct pulp capping

hard tissue bridge?

human

Regenerative endodontics

root lengthening, root bulk increase

human

(140,145)

$ no published cases (Dr. Lars Bjrndal, personal communication)

is an obvious indication of an acute or chronic abscess,

such as localized swelling or a sinus tract, determination of the location and progression of an
apical periodontitis lesion is not feasible without
radiographic imaging.
A dental practitioner will then expose the affected
tooth or area site to one or more radiographs (11,15).
Radiography is an irreplaceable adjunct to clinical
examination and is often the only way to determine
the presence of disease, as periradicular inflammatory
or cystic lesions with bone resorption are mainly
detected by their radiological features. To diagnose
pathosis and to determine the extent and location of
dental infection, clinicians have used radiographic
images since the late nineteen hundreds (16).
Conventional intraoral periapical radiography
remains the standard for radiological diagnosis of
existence, persistence or healing of apical periodontitis.
Digital radiography has become widespread since the
1980s; it reduced patient dose and eliminated development time (17). Cone beam computed tomography
(CBCT) has been introduced in the 1990s and has
found a variety of indications in endodontics (18,19).
It has also been suggested to be superior in detecting
periapical bone loss in situations where no pathosis was
detected in periapical radiographs (20).
Non-surgical and surgical root canal treatment for
cases with periapical pathosis predictably results in a
high frequency of success, as determined by healing
of the osseous lesion (21). Diagnostic procedures
that show such healing are required for root canal
treatment outcome assessment. However, endodontic
healing may also be defined in a wider sense (see
Table 1) to include hard tissue deposition after vital
pulp therapy or pulp regeneration as well as root

58

fracture healing. The following text will explore the

ability and limitations of radiographic techniques
to detect presence and resolution of periapical
periodontitis, with a focus on cone beam computed
tomography (CBCT).

Imaging techniques to detect

periapical changes
An important question when deciding about success
or failure of an endodontically treated tooth with
apical periodontitis is: What is the best tool to evaluate
outcomes?
Factors cited to verify that treatment was successful
include functionality, with retention of the tooth in
the patients mouth, a symptom-free situation,
radiographic healing of the radiolucency and absence
of inflammation (2124). Methods to evaluate bone
healing include clinical examination, radiographic
images taken with intraoral and extraoral techniques,
radiographic
subtraction
techniques
(25,26),
ultrasound (27,28), MRI (29,30), tuned aperture
computed tomography (TACT) (31,32), computed
tomography (CT) (33,34) and CBCT (18,35).

Intraoral radiography
Worldwide, conventional periapical radiographs
continue to provide the primary means of pretreatment and follow-up evaluation of endodontic
therapy and are used in most retrospective assessments
(Fig. 1) (21). rstavik recalled patients with
preoperative periapical lesions to monitor healing.
After 4 years 75.4% of the lesions had healed and

Cone beam computed tomography and other imaging techniques in the determination of periapical healing

Fig. 1. Classical follow-up series with conventional periapical radiographs. Pre-operative and post-operative films of
the tooth apex are mounted for assessment. Note: The final six digits show date of exposure (e.g. 870626 = June 26,
1987). Reprinted with permission from rstavik & Pitt Ford, 2008 (139).

12.7% demonstrated signs of incomplete healing

(23). Molvens group (36,37) compared radiographic
diagnoses by comparing endodontic outcomes in two
series of intraoral radiographs that were exposed
1017 and again 2027 years after initial therapy.
Healing of lesions after more than 17 years was
observed in 6.4% of the roots that had radiolucencies
at the first follow-up appointment. This gives reason to
believe that outcome tracking may need to be
extended. On the other hand statistical analyses based
on periapical radiographs suggest that the vast majority
of lesions heal in a 4-year time frame (38).

Histological assessment of serial bone sections, with

the treated tooth embedded in alveolar bone are the
gold standard that allows a final decision about if
healing was successful. However, these studies are not
clinical and mostly limited to examination of teeth in
deceased patients. Green et al. (39) studied 29 cadaver
teeth and discovered that 26% of teeth that appeared
radiographically healthy showed histologic evidence
of slight to moderate inflammation. The authors
concluded that periapical lesions correlated with
inflammation, but the absence of a radiolucency did
not signify histologic health.

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Peters & Peters

Fig. 2. Assessment of maxillary right central and lateral incisors after root canal treatment. (A) Baseline image taken
immediately after root canal treatment. (B) Follow-up image taken 14 days after the baseline image. (C) Follow-up
image taken 98 days after the baseline image. (D) Follow-up image taken 552 days after the baseline image. (E)
Subtraction image (B minus A). (F) Subtraction image (C minus A). (G) Subtraction image (D minus A). (H) Six
regions of interest (ROIs) in the subtraction image G. Reprinted with permission from Yoshiokia et al., 2002 (42).

Subtraction radiography
Subtraction radiography is a technique to enhance
contrast and detection ability for subtle changes in
conventional radiographic films; the technique uses
standardized intraoral radiographs taken with film
holders that are individualized with impression
material. Using appropriate image editing software,
pre- and postoperative images can be subtracted,
eliminating all structures that are identical in the two
images. Digital subtraction radiography was more
sensitive to detect small changes in cortical and
cancellous bone in periapical lesions than conventional
radiography that used morphometric analysis with
outlining and area calculation (40). In addition, more
changes in bone were observed with healing evident
very early after treatment (41,42) (Fig. 2).

Extraoral radiography (panoramic)

Panoramic radiographs are good screening and
overview images for teeth, TMJ, sinuses, nasal cavity
and maxilla and mandible. However, this type of image

60

is not recommended to detect details in caries

diagnostics, periodontal bone assessment, apical
pathosis and as tool to follow up on healing of
radiolucencies. Molander (43) compared diagnostic
yields of panoramic and periapical radiographs. The
consensus reached between the two radiographic
techniques in periapical diagnosis was 55% for the
extraoral and 46% for the intraoral technique. The
conclusion of the authors was that there is not
sufficient radiographic agreement for panoramic
radiography to be used as a stand-alone tool to
diagnose periapical lesions, marginal bone loss or
caries and that additional, intra-oral radiographs are
required to assure comprehensive evaluation of both
periapical and periodontal status (43,44).

Computed tomography (CT)

The usefulness of three-dimensional techniques for
the detection of periapical osseous lesions has been
described specifically when preparing for surgical endodontics (34). Indeed, well-documented limitations
of two-dimensional radiographic techniques such as

Cone beam computed tomography and other imaging techniques in the determination of periapical healing

Fig. 3. The use of computed tomography to track periapical healing after surgical endodontic treatment of tooth 39
(#19). (A) Periapical radiograph for initial diagnosis. (B) Sagittal slice showing the outline of the periapical lesion
(arrows). (C) Periapical radiograph: follow-up, 8 years after surgical treatment. (D) Sagittal slice showing bone repair
(arrows) between the mesial and distal roots of tooth 19. Modified with permission from Tanomaru-Filho et al., 2010
(45).

conventional periapical films make 3D assessment of

periapical lesions attractive (45) (Fig. 3).
Medical-grade CT units have been used in oral and
maxillofacial surgery since the 1970s, but there are
several disadvantages in comparison to CBCT that have
led to a rapid decline in use. Firstly a two-hundred fold
higher patient dose limits the use to select cases after a
risk-benefit calculation has been performed. The field
of view has become more suitable for the head and neck
region, but it is not possible to restrict it to small regions
such as quadrants of a patient. Metal and movement
artifacts can pose a considerable problem due to longer
scanning times (30).

Tuned aperture computed

tomography (TACT)
TACT represents yet another form of radiographic
imaging and is essentially a three-dimensional imageforming algorithm that can be used with any type of
digital imaging system (46). It produces 3D data from
several regular radiographs of a given area. Unlike other
3D images, the raw images used are not required to

have a rigid, identical orientation. TACT was able to

accurately detect osseous healing in surgical defects
(32).
Nair et al. used a common digital x-ray source that
they moved along a curved plane around the region of
interest where surgery had been performed. On this
plane, nine arbitrary projections were taken between 9
degrees and 20 degrees to either side of the central
projection axis (47). The gray level measurements
calculated from conventional radiographs, TACT slices
and iteratively restored TACT (with artifacts
subtracted) were correlated with histological analysis.
Iteratively restored TACT showed the best correlation
between radiographic findings and biopsy histology
(46). The diagnostic performance of TACT has been
described as comparable to CT (32).
A single digital radiograph exposes a patient to
approximately 15 mSv of radiation dose (4850).
TACT requires several radiographs to be exposed.
Taking into account that a small field-of-view CBCT
scans is roughly the size of a periapical film, with a
patient dosage of 1 to 3 conventional periapical
radiographs, TACT does not appear to be in
widespread use at this point.

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Peters & Peters

Fig. 4. Three-dimensional image of a radiolucent area (arrows in (A) before and (B) after treatment). Reprinted with
permission from Kaya et al., 2012 (99).

Cone beam computed tomography

(CBCT)
CBCT units were introduced for use in the maxillofacial region in the late 1990s by two groups
of researchers, an Italian group led by Mozzo (51)
and a Japanese group spearheaded by Arai (52). In
the past twelve years, the technique has rapidly
gained acceptance by specialties, in particular orthodontics, endodontology, implantology and oral and
maxillofacial surgery. Research and clinical applications
increased in the fields of restorative dentistry (53) and
periodontology (54). The dental community in general
in becoming more aware of the advantages that this
technique can offer to them and their patients, in
particular for diagnosis and treatment planning.
Position statements and guidelines about indications
for CBCT in dental diagnosis and treatment of surgical
and non-surgical cases have been issued jointly by the
American Association of Endodontists and American
Academy of Oral and Maxillofacial Radiography (55) as
well as other organizations (56,57).
While medical CT scans have been used for
improved surgical treatment planning in oral and
maxillofacial surgery since the 1970s (34,58,59),
CBCT scans afford a three-dimensional view of the
oral and maxillofacial region at increased resolution,
reduced radiation dose to the patient, shorter
scanning time and lower cost compared (50,60,61).
CBCT is not indicated as a routine technique
in detection of apical periodontitis. Current
recommendations stipulate that CBCT is to be used
for specific clinical indications only and as possibly an
adjunctive imaging technique (18). This includes

62

cases that exhibit pain and clinical signs of

inflammation but no periradicular correlate on
periapical radiographs (62). Only recently, CBCT has
been introduced as possible means for follow-up of
periapical healing (Fig. 4).

Problems in radiological diagnosis

of periradicular pathosis
Image quality
Ideally, follow-up digital dental radiographs are taken
with an individual x-ray holder to ensure that the
depicted area corresponds to the target region. Tube
voltage and current, exposure time, type of radiograph
and film size should be the same on recall images as on
the original that it is compared to. All radiographs
should be obtained by using the same digital imaging
system to ensure similar quality. In a study that investigated the implementation of quality assurance
requirements, conducted by Hellstern & Geibel, 8.5%
of the images were classified as distorted, i.e. elongated
or foreshortened (49).
In CT and CBCT images, dental fillings, root canal
fillings, posts and dental implants, often show dark
bands and cupping artifacts due to attenuation and
scattering of x-ray beams (63,64). These image faults
can considerably downgrade the diagnostic quality of a
scan, influence decision-making and reduce the
accuracy of CBCT-based treatment planning. Software
for artifact reduction can adapt to the atomic number
(Z) of implants and thus to the amount of backscatter
or attenuation. Projections through high-Z implants,

Cone beam computed tomography and other imaging techniques in the determination of periapical healing
like gold, can lead to almost complete extinguishing of
x-ray caused gray values while projections through
low-Z implants, like titanium, are corrected for the
hardening of x-ray beams. An automatic regulation
method can replace these values by estimates based
on other projections or correct beam hardening
accordingly (63). Computer hardware modifications
with built-in copper pre-filtration were used to
suppress but not completely eliminate cupping
artifacts caused by beam hardening. Additional
corrections with a subtraction algorithm address
scatter contamination and eliminated cupping on
CBCT images (65).

Detection threshold for lesions

On the one hand, periapical radiographs are taken to
determine number and location of roots and root
canals but on the other hand to confirm absence or
presence of periradicular pathosis (66). In initial
stages, radiographic widening of the periodontal
ligament space indicates destruction of apical tissues by
an inflammatory process. This widening increases to a
typical radiolucency with or without clear borders that
progressively becomes more pathognomonic (67,68).

Superimposition
In studying the periapical region for visibility of
pathologic changes, a clinician has to extrapolate the
true diagnosis by ignoring so-called anatomical noise,
which refers to superimposition of overlapping
anatomy and by factoring in geometrical distortion
(19,30,69). CBCT scans allow a 3D rendering instead
of a 2D assessment as in dental radiographs. Because of
the ability to see details without overlapping anatomy,
detection of otherwise undetectable apical lesions is
possible (70).

Distortion
While distortion, elongation or foreshortening may
present a problem in any area of the dentition, the
maxillary molar area can be particularly challenging
because skewed images occur together with projection
of anatomy over the area of interest. Ideally, the film or
sensor is placed as parallel as possible to the tooth,
using a film or sensor holder with a biting surface. A
low palatal vault can require the film to be placed at an

angle to the long axis of the tooth. If the x-ray beam

is directed too much from an apical direction, this will
result in projection of the zygomatic bone and arch
onto the roots. At the same time, depending on the
chosen angle, this technique will produce a distorted
image of the roots (66). Divergent roots will present
different levels of elongation of foreshortening in
periapical radiography, while fused roots or roots that
lie close together may not be viewed separately in spite
of images taken from different horizontal angulations
(66).

Differential diagnosis of apical

periodontitis
To avoid unnecessary surgical treatments and in turn
avoid fruitless monitoring of true cysts for healing
that is unlikely to occur, non-invasive methods of
differentiating apical granulomas from cysts have been
investigated (71). That study compared CT scans with
histology in 8 cases with apical pathosis. The authors
were able to distinguish between a cyst and a periapical
granuloma in CT images due to a marked difference
in density between the content of the cyst cavity and
granulomatous tissue (71). Because cysts contain
fluid, debris and cholesterol, their corresponding
radiographic density will be lower than that of tissue in
inflammatory lesions.
Aggarwal et al. (72) evaluated 12 tissue samples of
periapical lesions histologically and compared the
cytological diagnosis with a preliminary diagnosis
based on CT values and ultrasound with color-power
Doppler flowmetry. The tentative diagnosis was
confirmed in all cases (72). In a similar study design,
Simon et al. used CBCT gray value measurements
for pre-surgical diagnoses and found that histopathology of tissue biopsies coincided in 13 out of
17 cases (73). In contrast, Rosenberg et al. found
that of 45 periapical samples, the accuracy of two
radiologists to render a correct periapical diagnosis
was low (74).

Evaluation of periapical status:

conventional radiography
Numerous studies using meticulous asepsis and up-todate root canal disinfection practices have shown that
if microbial contamination is removed to levels that are
undetectable by sampling, a high level of success for

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Peters & Peters

resolution of apical periodontitis can be anticipated
(75,76). While detection of a radiolucency associated
with an endodontically treated tooth typically has a
high positive predictive value (67,77) absence of a
radiolucency does not guarantee apical health.
Negative predictive values, i.e. the ability to predict
that no radiographically visible lesion in fact means
absence of pathosis, ranged from 25% (78), 53% (67),
67% (68) to 74% (39). Radiographic healing
encompasses bony fill of the radiolucency or shrinking
of the visible area, a continuous periodontal ligament
and regular bone pattern.
Images should be taken with a bisecting-angle
technique, or, if measurements taken off images are to
be more accurate, with a paralleling technique. Two
intraoral periapical radiographs obtained with a
paralleling technique are recommended to evaluate
presence or absence of bone radiolucencies: one at a
right angle and one at a 10-degree horizontal angle
(79). Even though this alleviates some of the
limitations of conventional radiography, multi-rooted
teeth have roots that can curve in different planes
bucco-lingually, and no radiograph will be able to
show a paralleling or bisecting angle take of all roots at
the same time. In other words, severe distortion may
be present in one root, while another is depicted more
or less accurately. Considering these limitations,
reconstructing the original three dimensions in a
patients tooth from periapical radiographs is a
problematic task (80).
Bender & Seltzer found that even large lesions in
cancellous bone may remain undetected in periapical
imaging as long as the cortical bone plate stays intact
(81). More than thirty years later, Barbat & Messer
(82) compared conventional and digital images in
detecting increasingly larger artificial bone defects
around molar roots. For all image types, bone cavities
were readily detectable after taking away the lamina
dura only. Detection became easier with further bone
removal, in particular when the cortical plate became
eroded (82).
Time has been described as the fourth dimension
regarding healing (80). In order to visualize decreasing
gray-levels in apical periodontitis, images need to be
taken from the same perspective, using the same
exposure parameters to show similar density and
contrast. If this is not the case, summation of anatomy
to the buccal or lingual of the scrutinized lesion can
mimic healing and bone fill. The clinician will then

64

assume that radiolucency is changing to a healthy state,

when in reality there is no change or even increase of
the area. To show detectable differences in gray-level,
radiolucencies that are not entirely located at or near
the cortico-medullary junction or surrounded by thick
bone must change more in size than a lesion situated in
less dense or thin bone.

Surgical wound healing versus apical

periodontitis
In endodontic surgery, CT and CBCT scans have been
used for decades to assess optimal access through
bone, sinus extension between the roots, lesion sizes
and locations in reference to sensitive anatomical
structures such as the maxillary sinus or mandibular
canal and to optimize the choice of surgical
instruments (34,83). Surgical wound healing has a
faster time-course than healing of apical periodontitis
(84). Initial healing, followed by reoccurrence of an
apical radiolucency has been observed as a sequel after
incomplete disinfection or omitted retreatment before
surgery. Additional problems, such as cracks and root
fracture that may or may not have been caused by
surgical procedures involving ultrasonic root end
preparation have been described (85).

Assessment of failure
To reduce the rate of false-positive diagnoses,
evaluators have developed indices and definitions of
periapical disease (23,8688). Only cases with lesions
that can be identified accordingly were recorded.
However, the rate of false-positive diagnoses is
much less than false-negative diagnoses, up to 1240%
of lesions that are present are overlooked of periapical
radiography (66,79,8993). During follow-up, the
time during which lesions are expected to heal is up
to 4 years, after which the treatment is typically
considered to have failed if no signs of healing are
present (94).

Conclusions about radiographic diagnosis

of periapical status
Paredes-Vieyra et al. state that radiographic images
of periapical bone lesions range from impossible or
difficult to see to being easily seen (95). Clinically,

Cone beam computed tomography and other imaging techniques in the determination of periapical healing
this suggests that if no lesion is visible on a periapical
film, it often still is present in vivo (81,96). Research
has shown that CBCT is significantly better in terms of
sensitivity, positive or negative predictive values, and
diagnostic accuracy than digital or conventional
radiographs (61,89,91,9799).

Evaluation of periapical
status: CBCT
As stated before, apical periodontitis lesions can be
obscured by overlapping structures and they are often
wider bucco-lingually than they are mesio-distally.
Christiansen et al. measured periradicular lesions and
discovered that periapical bone defects calculated on
periapical radiographs were roughly 10% smaller than
on coronal sections of the radiolucency as view by
CBCT (91).
When comparing osseous changes, gray scale values
obtained from CBCT are correlated with microcomputed tomography measurements (100) and
histopathologic bone densities (101). Gray scale
Hounsfield units (HU) (102) were originally
conceived as metrical descriptors to associate CT gray
levels to tissue type and condition. For example, air is
assigned an HU value of -1000 and water one of zero,
while bone may range from 400 to 700 to 3000 HU.
An increase in HU parallels bone fill and can be used
to track osteoblastic response in healing using CT
(103). CBCT units are typically not calibrated to
conform to HU measurements because they provide
wider gray level ranges (14 bit and more); however
both pixel gray values as well as derived extrapolated
Hounsfield units (104,105) may be used to track
periapical healing (99).
CBCT volumetry with specific software has recently
been evaluated for the evaluation of osseous healing
using a tibia model. This method showed significantly
correlated results for non-invasive quantitative
monitoring of bone defect healing in comparison to
histological findings (106) shows promise for the
assessment of endodontic outcomes using CBCT in
the future.

Assessment of failure
On cone beam CT data, streaking and beam
hardening artifacts from metallic structures, and radioopaque root fillings, can make diagnosis of lesions

and root fractures difficult and can lead to

misinterpretation of remaining dentin thickness
(80,107). Beam hardening is a frequently found
artifact in dental CT scanning due to the increased
occurrence of metal objects, such as fillings, implants,
and stents with metal components or surgical materials, e.g. plates, screws or wires. Beam hardening
causes margins of objects to fade into streaks or
cupping. The dark lines streaking from posts or
radiopaque root canal sealers can mimic radiolucent
lines associated with root fracture. Potentially, this may
lead to overtreatment due to misinterpretation of dark
areas as fractures or osseous lesions related to pulp
necrosis.
Radiolucent zones next to a post caused by beam
hardening can erroneously suggest root perforation.
To circumvent misdiagnosis, Bueno et al. (108)
recommended a map reading strategy for CBCT
image data, which focuses on axial slices of a volume.
This study used images with a resolution of 200
micron and navigated in a coronal to apical direction
near the post tip. Looking at each slice allowed
visualization and localization of root perforations
associated with lateral radiolucencies (108). In
conclusion, the success rate determined by CBCT
appears to be 1040% lower than that diagnosed by
evaluation of periapical radiographs (66,79,89,91,92).

Healing of apical lesions

Kirkevang et al. (109) followed up patients between
1997 and 2008 and looked at teeth with apical
periodontitis on full-mouth radiographic surveys.
They noticed that although techniques and treatment
quality may have improved, the number of patient that
had teeth with apical pathosis enlarged with age, and
that effect remained unaltered by the time period the
treatment was completed in. In that respect, PaulaSilva et al. (78,98) state that periapical radiography
had a negative predictive value of 0.25 (0.46 for
CBCT), this indicates a low ability to detect absence of
periapical periodontitis. Ricucci and colleagues (110)
investigated root canal treated teeth with no signs of
inflammation on digitized conventional radiographs.
The investigators resected root ends and compared the
histological status of the teeth to the radiographic
diagnosis. In cases where they found no widening of
the periodontal ligament, interruption of the lamina
dura, or apical radiolucencies, it was rare to find

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significantly inflamed tissue during histology.
However, moderate inflammation in the apical area
was displayed as normal on conventional periapical
radiographs (110). It is important to distinguish
lesions after root canal treatment in order to be able to
both treat and monitor improvement of such defects.
Bornstein investigated root-filled molars and
discovered 25.9% more periapical lesions on CBCT
images than on radiographs (111). The discrepancy
was due to the fact that preoperative bone destruction
caused by apical granulomas and bone regeneration
after treatment can be monitored in 2D by periapical
radiographs and in three planes by CBCT.
Yoshioka and colleagues, using two different types of
small-FOV CBCT units, examined 532 teeth with
periapical lesions in 427 patients. CBCT accurately
identified the type of bone defect for persistent
periradicular lesions, as opposed to conventional
periapical radiographs. In addition, axial and coronal
images were able to determine the type of cortical
bone plate defect created by the lesion (112).

To standardize healing outcomes after endodontic

treatment, Estrela et al. used a modified periapical
index on CBCT scans. The group scored
radiolucencies on a 6-point (05) scale with 2
additional variables, expansion of cortical bone and
destruction of cortical bone (89) (Fig. 5).
In follow-up of apical lesions before and after endodontic treatment, Kaya et al. measured bone density
by recording Hounsfield units in periapical radiolucent
areas. The value assessed in the bucco-palatal direction
was compared to the value measured after 2 years and
an increase in density equivalent to healing of the
lesion was noted (99).

Healing of surgical bone defects

In cases with refractory periradicular lesions after endodontic treatment, apical microsurgery is performed
to remove the root tip, prepare a root end cavity and
seal the root canal from a retrograde aspect to allow
healing. While this treatment shows a high success

Fig. 5. Schematic representation of apical lesions of maxillary incisors, assessed with the cone beam CT based
periapical index (CBCTPAI). Modified with permission from Estrela et al., 2008 (134).

66

Cone beam computed tomography and other imaging techniques in the determination of periapical healing
rate, follow-up is important to ensure successful
resolution and bone regeneration. On average,
radiolucencies measured from periapical radiographs
are at least 10% smaller than seen in CBCT
(70,89,91). Using CBCT, a higher number of cases
still had remaining lesions 1 year after endodontic
surgery compared the conditions apparent in
periapical radiographs (91). On the other hand, it has
been argued, based on conventional periapical
radiographs, that the vast majority of cases that
ultimately will heal will show signs of healing after 6
months to 1 year. Moreover, using CBCT has the
potential to move the window of predictability to even
earlier time points (91,99) (Fig. 5).
This line of reasoning is based on the assumption
that all post-endodontic radiolucencies signify persistent pathosis or inflammation (67) that could pose a
cardiovascular risk factor. Hence, to remove the risk,
all lesions of endodontic origin would require
treatment (113). Other authors could not confirm this
association (114) and explained such results by a high
age of the participants (115).
Occasionally, healing may result in fibrous scar
tissue, which is radiographically indistinguishable from
an apical granuloma. The tissue removed by endodontic surgery may thus be a healed periapical scar (116).
More clinical studies are needed to support or negate
if persistent apical periodontitis can predispose or lead
to coronal heart disease or other detrimental health
effects.

What is the most clinically relevant

method of imaging to determine
periapical healing?
Risks and benefits
CBCT units offer a wide range of exposure parameters
such as tube current, exposure time, size of the
scanned area and the degree of rotation of the gantry
around a patients head (83). Task-dependent
individualizing of these parameters can help avoid
unnecessary exposure to radiation dose (117).
Recently, a change from a 360 to a 180 rotation of
the gantry has been proposed to halve radiation for
patients. The image resolution remains unchanged,
however, a 180 rotation reduces the number of beam
projections, which in turn reduces radiation exposure.

The downside of this approach is that this results in a

lower resolution images because less raw data slices
are included in image. An exchange of image quality
versus imaging dose can be achieved in order to
establish optimal low-dose CBCT scan protocols that
maximize dose reduction while minimizing image
quality loss (118).
Durack et al. compared the ability of periapical
radiographs, 180 rotation CBCT scans or 360
rotation CBCT scans to allow detection of artificial
external inflammatory root resorption lesions (119).
The ability of small volume CBCT to identify
simulated external root resorption was not influenced
by rotations of 180 or 360 in CBCT scans. CBCT,
had higher negative predictive values and higher
positive predictive values than periapical radiography,
no matter what degree of rotation was preset.
Dawood et al. (83) tested the image quality of a
lower-dose 180 protocol versus 360 rotation when
measuring bone width and anatomic structures in
future implant sites. This task requires less sharp
images than certain endodontic diagnoses, for example
the intricacies of root canal anatomy are more difficult
to assess with reduced image resolution. The
reconstructed image at 180only marginally affected
the reviewer preference of the resulting images but
patient dose was significantly less (83).
It appears that variable amount of radiation a patient
is exposed to is correlated to the quality of the image
obtained, however image quality has little degradation
over a large range of dose variation (118). Effective
patient dose is directly proportional to the size of the
field of view (FOV) or scanned area. The effective dose
for different scanned sections of a patients cranium
with CBCT devices can show a 20-fold range (117). A
cost-benefit calculation should be carried out in
deciding if a small-, medium- or large-field CBCT is
obligatory for a specific diagnostic task.

CBCT: availability in clinical practice

Because of the expected increase in use of CBCT in
dentistry, the U.S. Food and Drug Administration
(FDA) has developed a web site in August 2012 that
serves to give patients and healthcare providers the
up-to-date information about use and safety of dental
CBCT. Market reports divide practitioners into two
groups, CBCT non-users (resistors, undecided,
potential users) and CBCT users (low potential for

67

Peters & Peters

purchase, recent purchase, potential upgrade purchase
and repeat purchase) (120).
The dental equipment market includes dental units,
instruments and chair-side equipment, CAD/CAM
systems, small device units, dental lasers, intra-oral
and extra-oral radiology units, and CBCT scanners.
Worldwide diagnostic imaging market growth is
calculated to increase from $20.7 billion in 2010 to
$26.6 billion by 2016, at a Compound Annual
Growth Rate of 4.2% from 2011 to 2016. An
increasingly aged population and expanded applications of diagnostic imaging as well as constantly new
developments are cited as main drivers for adoption of
CBCT (121).

Consequences for treatment

decision-making
In view of the high rate of undetectable lesions on
other images, CBCT yields a greater number of
incidental findings. Such findings are discovered as
chance observations on the scanned field of view.
Nevertheless, unexpected diagnoses cannot be ignored
and must be included into a treatment plan or referred
to a specialist (122). This leads this review back lead to
the question of what is success or failure. Should all
lesions detected outside the region of interest lead to
treatment? Or will treating all asymptomatic lesions
lead to overtreatment? There is a possibility that the
presence of periapical radiolucencies do not represent
inflammation but healing by scar tissue (116,123). In
100 cases with histological evaluation of periapical
lesions, Love & Firth found only two periapical scars,
one after apicoectomy with an amalgam root-end
filling and the other case surrounding extruded root
filling material (124). Eighty percent of the other
periapical lesions were periapical granulomas and 18%

were cysts. In 125 samples, Schulz et al. found 70%

granulomas, 23% cysts and 5% abscesses, 1% scar
tissues, and 1% keratocysts (125). It therefore appears
to be reasonable to assume that, in most cases,
periapical lesions are true pathosis and not scars.
In an editorial for the International Endodontic
Journal entitled Radiographs and CBCTtime for a
reassessment, the authors recommend the use of
CBCT imaging to verify presence or absence of apical
periodontitis, especially in light of its diagnostic value
and the limited radiation exposure (126).
From recent literature that compares imaging
techniques to measure outcome of endodontic
treatment, it may be concluded that in some instances
up to half of all cases that are diagnosed as healthy
based on periapical radiographs display radiolucencies
in CBCT scans after endodontic treatment (66,91).
Therefore, it would only be logical to assume that the
assessment of success of endodontic treatment derived
from PA radiographs may be insufficient. Similarly, the
differentiation of best clinical techniques based on
periapical radiographs might not be feasible.
An example for a treatment dilemma that requires
better resolution imaging is fracture diagnosisearly
identification of a vertical root fracture is crucial to
avoid unwarranted extractions or widespread bone loss
along the affected root (127) and healing of fractures
(128). Edlund et al. diagnosed vertical root fractures
on CBCT scans, verified the diagnosis during apical
surgery and found that CBCT was better qualified to
accurately diagnose vertically fractured roots (129).
However, microscopic cracks that are below the
resolution of a CBCT scan will continue to stay
undetectable, but a larger number of cases will be
assessed than with periapical imaging alone (130).
Patient dose and costs have continuously decreased
since the introduction of CBCT to the dental market;

Fig. 6. CBCT follow-up of a revascularization case over a 21-month period. (A, B) The view at presentation. (C) At
4 months, there was a slight indication that the walls on the upper right central incisor (URI) were thickening.
(D) The upper left central incisor (ULI) walls showed no indication of thickening, but there was a dramatic decrease
in the size of the apical radiolucency. (E) At the 11-month follow-up, revitalization of the root canal if the URI was
obvious with a distinct thickening of the dentinal walls and closure of the apex of the root. For the ULI, no evidence
of revitalization could be seen. (F) At this point, the apical radiolucency had resolved completely, and a distinct
radiopaque barrier was seen at the apical opening, suggesting the formation of a hard-tissue barrier similar to that seen
after a successful apexification procedure. (G) At 21 months, successful revitalization of the URI was obvious as was
the fact that the ULI had not revitalized. (H) The radiopaque hard-tissue barrier at the apex of the ULI was even more
distinct. Reprinted with permission from Lenzi & Trope, 2012 (140).

68

Cone beam computed tomography and other imaging techniques in the determination of periapical healing

69

Peters & Peters

at the same time resolution and availability have
improved. If this trend continues, then CBCT units
will be readily available in private practice. At this point
in time, there is no existing optimal dose guide for
CBCT. Reasons include the complicated x-ray beam
geometry of CBCT and the reality of quality control
measurements for CBCT units (131). Clinical research
is required to justify possible dose directories and to
determine how these recommendations translation to
patient dose.
The guidelines for the use of CBCT are clear at this
point: only with a specific indication should such a
scan be prescribed. However, the list of these specific
indications may be expanded to include diagnosis and
follow-up for cases with horizontal root fracture or
regenerative procedures in the future (see Table 1 and
Fig. 6).

Concluding remarks
CBCT will undoubtedly affect the expected standards
of care, and this has implications for increased
practitioner responsibility both in the performance,
optimal visualization and interpretation of volumetric
datasets. (132). Once the root canal system has
become infected to an extent that apical periodontitis
becomes visible on PA radiographs, chances for
successful endodontic treatment decrease (133).
If earlier diagnosis prompts treatment at a smaller
stage of the radiolucency, healing after endodontic
treatment might be faster or more complete (50).
Estrela et al. measured increasing sizes of
radiolucencies with a modified periapical index.
The smallest lesions were 0.51.0 mm in diameter
(134). Treating such initial stages of pathosis as
opposed to larger, established lesions may influence
outcomes (70).
Other, future and current situations where a
successful outcome could be measured with 3D
imaging in endodontics include healing after apical
surgery (45) healing after trauma with alveolar
fractures or luxation injuries (50), stabilization of
resorptive defects (135), healing of inflammation and
membrane thickening in paranasal sinuses (136) and
healing of furcal or lateral defects after perforation
repair (137).
Liang identified two outcome predictors for
periapical healing from CBCT data, which were
density of the root filling and a leakage-free coronal

70

restoration (92). A second, follow-up CBCT scan may

be needed to reliably confirm or negate healing of
preexisting lesions (138).
CBCT imaging offers a new direction to minimize
false diagnoses and is rapidly replacing other
radiographic techniques in the fields of diagnosis,
quality assessment of treatment modalities and
techniques as well as outcome assessment. Tracking of
healing with both conventional methods and newer
3D imaging can include apical radiolucencies,
maxillary sinus membrane thickening, hard tissue
regeneration, root fractures and regenerative
treatment of immature necrotic teeth.
Because of the low predictive value of twodimensional periapical radiographs to detect periapical
disease or confirm periapical health, future assessment
of endodontic treatment efficacy may include small
field-of-view CBCT scans.

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