Clinical Research

Incidence and Size of Periapical Radiolucencies

Using Cone-beam Computed Tomography in
Teeth without Apparent Intraoral Radiographic
Lesions: A New Periapical Index with a Clinical
Recommendation
Mahmoud Torabinejad, DMD, MSD, PhD,* Dwight D. Rice, DDS,† Omar Maktabi, DDS, MSD,‡
Udochukwu Oyoyo, MPH,§ and Kenneth Abramovitch, DDS, MS†

Abstract
Introduction: The purpose of this study was to deter- Key Words
mine the incidence and size of periapical radiolucencies Apical periodontitis, cone-beam computed tomography, endodontics, periapical index,
using cone-beam computed tomographic (CBCT) imag- radiography
ing in teeth without apparent signs of intraoral radio-
graphic lesions. Methods: One hundred twenty roots
from 53 patients who had been determined to have
no signs of intraoral radiographic lesions were included
T he main objective of
root canal treatment
(RCT) is to provide long-
Significance
From this study, CBCT imaging detects more api-
in this study. Limited-volume CBCT scans were taken at cal radiolucencies than standard imaging.
term comfort, function,
0.125-mm3 voxel size. The widest area of apical radiolu- Because these findings may not be pathological,
and esthetics for patients
cency of each root canal–treated tooth was measured clinicians are cautioned against overtreatment.
with pulpal and periapical
and assigned a numeric score based on the CBCT- Long-term follow-up studies are needed to deter-
diseases. This is achieved
Endodontic Radiolucency Index (ERI). CBCT data were mine the proper course of actions for these
by complete cleaning,
evaluated by 2 radiologists with an interclass correlation findings.
shaping, and obturation
coefficient of 0.96. Results: The majority of of canals and the place-
roots (53.3%) had periodontal ligament widths ment of permanent restorations on the affected teeth (1–3). Because of the
#0.5 mm; 26.7% had radiolucency widths of complexity of root canal systems, inadequate chemomechanical instrumentation,
0.5 < x # 1 mm, 15.0% had radiolucency widths of insufficient obturation, and leakage of permanent restorations, the elimination of
1.0 < x # 1.5 mm, 0.8% had radiolucency widths bacteria from the root canal systems of affected teeth is not always possible (4, 5).
of 1.5 < x # 2.0 mm, 1.7% had radiolucency Consequently, not all root canal–treated teeth have 100% successful healing. The
widths of 2.0 < x # 2.5 mm, and 2.5% had radiolucency healing and regeneration of periradicular tissues may take months to years.
widths of >2.5 mm. Patient age, recall interval, tooth Recommended follow-up periods have ranged from 6 months to 27 years (6–10).
type, and arch type had no statistically significant effect The evaluation of endodontic outcomes is based primarily on the findings noted
on the ERI distribution. Conclusions: Twenty percent of from clinical and radiographic examinations. Another method for the evaluation of RCT
teeth with successful root canal treatment based on con- outcomes is to biopsy the periradicular tissues. Biopsies are already used for histologic
ventional periapical imaging had CBCT radiolucencies diagnosis when endodontic surgery is indicated. However, a biopsy is not routinely per-
measuring greater than 1 mm. Because these radiolu- formed to determine clinical outcomes of nonsurgical RCTs. Therefore, clinical and
cencies may not be pathological changes, clinicians radiographic examinations remain the contemporary methods used to determine
are cautioned against overtreatment of them before RCT outcomes.
determining the true nature of these findings. Clinical The presence of persistent signs or symptoms after routine RCT is usually an indi-
studies with long follow-up times are needed to deter- cation of negative outcomes. However, the mere absence of clinical symptoms does not
mine the proper course of actions for these cases. (J En- necessarily mean a positive outcome. Periapical pathosis may exist without significant
dod 2017;-:1–6) clinical symptoms either pre- or post-RCT (11). The absence or resolution of periapical
pathosis after nonsurgical RCT is usually a radiographic indication of a positive

From the Departments of *Endodontics, †Radiology and Imaging Sciences, and §Dental Educational Services, School of Dentistry, Loma Linda University, Loma Linda,
California; ‡Private Practice in Endodontics, Coralville, Iowa.
Address requests for reprints to Dr Kenneth Abramovitch, Department of Radiology and Imaging Sciences, School of Dentistry, Loma Linda University, 11092 An-
derson Street, PH 4409, Loma Linda, CA 92350. E-mail address: [email protected]
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2017.11.015

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Clinical Research
treatment outcome. However, treated teeth without radiographic lesions TABLE 1. Distribution of the Teeth in This Study
may have clinical symptoms indicative of negative treatment outcomes.
Anterior Premolar Molar
Therefore, a combination of clinical and radiographic findings must be
used to assess RCT outcomes. Maxilla 6 14 15
Mandible 10 8 16
For decades, investigators have tried to establish definitive clinical
and radiographic signs of RCT outcomes. Strindberg (12) created a 3-
step scale based on a history of symptoms, clinical examination, and
radiographic signs. His criteria were extremely strict because even periapical radiolucencies with OneVolume Viewer software (Version
the appearance of a poorly defined lamina dura was considered ‘‘fail- 2.813.20.3946, J. Morita USA). Monitor contrast and brightness were
ure.’’ Ørstavik et al (13) suggested a periapical index (PAI) to deter- adjusted to the preferences of the examiners. A slice thickness of
mine RCT outcomes. This index is based on a 5-point ordinal scale 0.5 mm or less depending on the examiner’s discretion was used for
for a tooth or a root with ‘‘1’’ meaning no sign of periapical bone the multiplane views.
destruction, ‘‘2’’ probably no destruction, ‘‘3’’ uncertain, ‘‘4’’ probably In the multiplanar reconstructions, the long axes of the selected
periapical destruction, and ‘‘5’’ definite periapical bone destruction. teeth were parallel to the sagittal and coronal planes of imaging. Teeth
This study and others (14, 15) did not use quantifiable radiographic were evaluated in all planes until the widest area of radiolucency in the
descriptive terms for identifying periapical health or disease. periapical region adjacent to the apex was identified. The linear width of
Intraoral and panoramic radiographic assessment of periapical the widest radiolucent area perpendicular to the root surface was
tissues is 2-dimensional (ie, radiography) and has been the only imag- measured and assigned a numeric score according to the CBCT-
ing modality in endodontics for many years (16). Cone-beam computed Endodontic Radiolucency Index (ERI) ranking developed for this
tomographic (CBCT) imaging is a technology that provides multiplane purpose (Table 2).
and 3-dimensional reconstruction imaging of dental hard tissues. CBCT
imaging has been recommended for endodontic diagnostic and treat- Statistical Analysis
ment planning as well as assessing outcomes of RCT (16, 17). Using
Chi-square analysis and the Mann-Whitney U test were performed
this technology, several investigators have shown the presence of
to determine whether tooth type or arch type were significantly associ-
periapical radiolucencies in cases in which no radiographic pathosis
ated with the ERI distribution. Spearman rho was used to examine the
was detected with conventional intraoral radiographic techniques
relationship, if any, between the recall interval and the age of the patient
(18–24). A recent literature search in MEDLINE (National Center for
on the ERI distribution. Examiner reliability was evaluated with the in-
Biotechnology Information PubMed) showed the absence of any
traclass correlation coefficient (ICC) statistic. All tests of hypotheses
study reporting on the incidence of periapical radiolucency using
were conducted with The Statistical Package for Social Science (SPSS
CBCT imaging on endodontically treated teeth that had no apparent
v 24; SPSS Inc, Chicago, IL), and P = .05 was set as a threshold for
lesions using conventional radiographic techniques. The purpose of
statistical significance.
this study was to determine the incidence and size of periapical
radiolucencies using CBCT imaging in teeth without apparent signs of
radiographic lesions using conventional radiographic techniques. Results
The examiners’ ICC for the measurements was 0.96. Table 3 shows
the frequency and percent distribution of the CBCT-ERI scores of the
Materials and Methods roots. A CBCT-ERI score of 1 was found in 64 roots (53.3%). Thirty-
This study was approved by both the Institutional Review Board two roots (26.7%) had a CBCT-ERI score of 2 (0.5 < x # 1 mm),
and the Radiation Safety Committee of Loma Linda University, Loma 15% had a CBCT-ERI score of 3 (1.0 < x # 1.5 mm), 0.8% had a
Linda, CA. Fifty-three patients, 18 years of age or older, with 1 or CBCT-ERI score of 4 (1.5 < x # 2.0 mm), 1.7% had a CBCT-ERI score
more endodontically treated teeth with recall times of 2 to 15 years of 5 (2.0 < x # 2.5 mm), and 2.5% had a CBCT-ERI score of 6
were included in the study. Patients who were either confirmed or (>2.5 mm) (Figure 1). Twenty percent of the roots had an ERI in which
thought to be pregnant were excluded. the periapical radiolucency measured greater than 1 mm.
The additional inclusion criteria were teeth with initial RCT or
nonsurgical retreatment, lack of mucoperiosteal swelling, no gingival
probing depths greater than 4 mm, no sinus tract stoma, less than class TABLE 2. Cone-beam Computed Tomographic–Endodontic Radiolucency
3 mobility, and no purulence and clinically asymptomatic teeth. Recall Index (ERI)
periapical radiographs were taken of all teeth. A PAI score (13) of 1 or 2
ERI score Description
was also used as part of the radiographic inclusion criterion. Exclusion
criteria were as follows: presence of pain, swelling, sinus tract stoma, 1 Widest dimension of PDL:
# 0.5 mm
advanced periodontal disease, class 3 mobility, and a PAI rating greater 2 Widest dimension of PDL:
than 2. 0.5 mm < x # 1.0 mm
Patients meeting these criteria then gave written informed consent 3 Widest dimension of PDL:
for a limited-volume, 40 mm  40 mm field of view, CBCT scan of the 1.0 mm < x # 1.5 mm
affected jaw area (Veraviewepocs 3de; J. Morita USA, Irvine, CA). The 4 Widest dimension of PDL:
1.5 mm < x # 2.0 mm
exposure parameters were 80 kV at 0.125 mm3 with either 5 mA for 5 Widest dimension of PDL:
anterior teeth or 7 mA for posterior teeth. This overall group of 53 pa- 2.0 mm < x # 2.5 mm
tients provided a sample size of 120 roots from 69 teeth. There were 35 6 Widest dimension of PDL:
maxillary roots and 34 mandibular roots. A summary of the distribution > 2.5 mm
of the teeth is presented in Table 1. Modeled from Estrela et al (24). This index has smaller PDL width measurement increments. The
Two calibrated radiologists (K.A. and D.D.R.) assessed the CBCT smaller increments are more applicable to classify periapical disease early in its progression and
volumetric data independently and blindly for the identification of to quantify the incremental changes of the healing process.

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TABLE 3. Cone-beam Computed Tomographic–Endodontic Radiolucency One must determine at what point widened PDL findings in
Index (ERI) Distribution endodontically treated teeth change the diagnosis of health to a diag-
ERI score Frequency Percent nosis of pathosis. The latter diagnosis could lead to further treatments
such as nonsurgical retreatment, surgical retreatment, or extraction. In
1 64 53.3 a previous study, the diagnosis for 22 of 53 teeth (41%) changed after
2 32 26.7
3 18 15.0 evaluation with CBCT imaging compared with the initial evaluation with
4 1 0.8 conventional radiography (27). The diagnosis of a healthy pulp
5 2 1.7 changed in 5 of 27 healthy teeth after CBCT examination to one in which
6 3 2.5 disease was recognized (ie, necrotic pulp, apical periodontitis, external
Total 120 100.0
resorption, root fracture, and so on) (27).
This table lists the frequency counts of root apices in each of the ERI categories. The percent of the According to Recommendation 5 of the Joint Position Statement of
total 120 apices is listed in the third column. the American Association of Endodontists and the American Academy of
Oral and Maxillofacial Radiology, intraoral radiographs should be
considered the imaging modality of choice for immediate postoperative
Statistical analyses of the results show that ERI levels are not asso- imaging (17). Unfortunately, there is no recommendation regarding
ciated with tooth type (Pearson chi-square, P > .05) or arch type incidental findings from postoperative images using CBCT imaging on
(Mann-Whitney U test, P > .05). Although a longer recall interval ap- endodontically treated teeth that are asymptomatic and have no
pears to be present for ERI 3 compared with ERI 1, 2, and 5, lesion apparent lesions using conventional radiographic techniques. To treat
size is not correlated with the recall interval (Spearman the cases in this study with radiolucent measurements greater than
rho = 0.024, P > .05). Lesion size was also not correlated with patient 0.5 mm is probably an overtreatment because these teeth were clinically
age (Spearman rho = 0.073, P > .05). asymptomatic and radiographically sound based on the standard peri-
apical radiographic images taken as part of their follow-up examination.
Discussion Because currently there are no scientific data regarding the true nature
With CBCT imaging, physiologic periodontal ligament (PDL) of these incidental findings from CBCT imaging, we recommend intrao-
spaces in successful endodontically treated teeth were found in only ral radiographs as the imaging modality of choice for postoperative eval-
53.3% of the roots in this study. Conversely, a total of 46.7% of cases uation of endodontically treated teeth in conjunction with the clinical
had periapical radiolucencies with widened PDL spaces larger than findings. We currently do not advocate CBCT imaging as part of an
0.5 mm. This alteration of the periapical attachment area was noted RCT status postoperative follow-up evaluation. Our data show that
in the teeth selected for the study that met the strict clinical and conven- widened apical PDLs may be increasingly noted as incidental findings
tional radiographic inclusion and exclusion criteria to be considered on CBCT examinations taken to evaluate symptomatic conditions of
successfully treated. Patient age, recall interval, tooth type, and arch other teeth. The detection of a CBCT-ERI of 2 to 6 may represent a tooth
type had no statistical effect on the ERI distribution. that is in the process of healing (6–10).
Previous studies have shown that CBCT imaging is more sensitive A higher success rate of 83% was noted at the 4- to 6-year follow-
than conventional radiographic imaging at identifying apical periodon- up nonsurgical retreatment examinations when compared with the
titis (18–24). The information from these studies and our CBCT data 70.9% noted at the 2- to 4-year follow-up examinations (28). Another
show that not all of these radiolucencies are indicative of the study of nonsurgical retreated teeth showed nonphysiologic PDL width
presence of periapical disease. Hence, in the absence of clinical after 10 to 17 years but not at the 27-year mark (10). In the recall
disease, CBCT findings can include a broader range of periapical period for our study, which ranged from 2 to 15 years, the recall period
radiolucencies. did not statistically influence the ERI distribution.
To determine the size of lesions in this study, we chose to modify The periapical radiolucency of an asymptomatic endodontically
the already existing CBCT-PAI as developed by Estrela et al (24). This treated tooth may also require no treatment because it represents
was done because the measurements in their study were defined as scar tissue rather than periapical pathosis (29–32). In these cases,
the ‘‘largest extension of the lesion.’’ However, when making a linear further treatment is again not warranted.
measurement with CBCT software, it is not clear whether the largest The determination of the presence of periapical radiolucencies is
measurement is from the root surface or whether it is the widest or very subjective when using the PAI (13). The specific categories in the
longest linear dimension extension of a radiolucency’s rhomboidal PAI lack a detailed description. In the first category, 1 is ‘‘healthy’’ and 5
shape, ovoid length, or circular diameter. This lack of clarity in Estrela is ‘‘severe periodontitis with exacerbating features.’’ On the contrary,
et al’s (24) definition makes it difficult to have comparable reproduc- there are no worded descriptions of categories 2 to 4. The greatest
ible measurements for either longitudinal or cross-sectional studies of aids for the interpretation of the different categories are drawings
periapical radiolucent disease. Furthermore, their CBCT-PAI uses larger and corresponding radiographs. This lack of specific objective radio-
measurement intervals that limit the ability to document the detail of graphic criteria may lead to a wide range of interpretation and various
small dimensional changes afforded by CBCT imaging. The use of this treatments. In a classic study (33), 6 examiners agreed on the presence
larger measurement scale further limits one to categorize early disease of rarefaction in only 42.1% of cases. The subjectivity of radiographic
or healing at the root apex. The revised CBCT-PAI (25) defined in more interpretation is further evidenced by the fact that these examiners
detail how to position the tooth in 3 fixed and reproducible dimensions agreed with their own diagnoses in only 72%–88% of cases 6 to
but otherwise still offered the same measurement scale. Tsai et al (26) 8 months later (34).
showed that small-volume high-resolution CBCT scans could distin- Because one cannot determine the histologic diagnosis of radiolu-
guish periapical radiolucencies less than 0.5 mm. Our CBCT-ERI pre- cency around the apex of an endodontically treated tooth observed on
sents an objective, quantitative, and reproducible CBCT index with CBCT imaging, practitioners should not necessarily initiate further treat-
higher sensitivity to document subtle radiographic findings. Because ment procedures. The nature of these radiolucencies can be only deter-
the ICC for the measurements between the 2 radiologists was 0.96, mined by histologic examination, which was not included and performed
this supports the CBCT-ERI as a reproducible measurement variable. in this study. The outcomes of treatment of the teeth in this study were

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Clinical Research

Figure 1. Examples of CBCT-ERI scores on the left with the corresponding apical enlargement area on the right. The periapical image is also included to show the
low PAI score. (A) CBCT-ERI score of 1. The apical PDL of tooth #12 measures <0.5 mm. (B) CBCT-ERI score of 2. The #30 distal apical PDL measures 0.5 mm < x
< 1.0 mm. (C) CBCT-ERI score of 3. The #4 apical PDL measures 1.0 mm < x < 1.5 mm. (D) CBCT-ERI score of 4. The #3 MB apical PDL measures 1.5 mm
< x < 2.0 mm. (E) CBCT-ERI score of 5. The #4 apical PDL measures 2.0 mm < x < 2.5 mm. (F) CBCT-ERI score of 6. The #2 mesiobuccal apical PDL measures
>2.5 mm.

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Figure 1. (continued)

deemed successful as defined by our inclusion criteria. The lack of clin- lucency measuring greater than 1 mm. Currently, there is no informa-
ical symptoms, despite the presence of radiolucencies using CBCT imag- tion to determine whether these radiolucencies represent incomplete
ing, does not support initiating further treatment. Nonsurgical healing, persistent disease, or fibrous scar tissue. Because these radio-
retreatment, surgical retreatment, or extraction do not appear to be lucencies may not be pathological changes, clinicians are cautioned
necessary because nearly 50% of successful endodontically treated teeth against overtreatment of them before determining the true nature of
have CBCT-ERI scores in which the PDL width is greater than 0.5 mm. these findings. Clinical studies with long follow-up times are needed
Thus, despite the increased sensitivity of CBCT imaging to identify changes to determine the cofactors that differentiate these findings from the
in the periapical tissues, clinical signs and symptoms and conventional disease entities for the proper course of actions for these cases.
radiography currently remain as major criteria to determine diagnosis
and treatment planning. Conversely, CBCT imaging may show CBCT-
ERI scores of 1 or 2 with demonstrable clinical symptoms as in the early Acknowledgments
stages of development of symptomatic apical periodontitis where the clin- The authors deny any conflicts of interest related to this study.
ical signs precede CBCT detectable bone changes.
Although further histologic studies would be helpful to determine
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