Endodontic diagnosis relies heavily on radiographic imaging to visualize the root canal system, detect periapical pathology, and evaluate the extent of structural damage to the tooth. Periapical radiographs have long been the primary imaging modality in endodontics due to their accessibility, ease of use, and low radiation exposure. However, the inherent limitations of conventional two-dimensional imaging, including superimposition of anatomical structures, restricted field of view, and difficulty in detecting small or early-stage lesions, often lead to misdiagnosis or inadequate treatment planning. The introduction of cone-beam computed tomography (CBCT) has significantly improved endodontic diagnosis and clinical decision-making, offering a three-dimensional visualization of dental structures and eliminating many of the drawbacks associated with periapical radiographs.

CBCT provides high-resolution, volumetric images that enable clinicians to assess complex anatomical variations, including missed canals, periapical lesions, external and internal resorptive defects, and vertical and horizontal root fractures, with greater accuracy. Unlike traditional radiographs, which are limited to a single plane of imaging, CBCT allows for multi-planar reconstruction, enhancing the ability to detect pathologies in three dimensions. This is particularly beneficial in cases where conventional radiographs are inconclusive, such as in multi-rooted teeth, endodontic retreatment cases, or when assessing the proximity of lesions to critical anatomical structures. Research has shown that CBCT improves diagnostic sensitivity and specificity, leading to more precise treatment planning and potentially better clinical outcomes.

Despite its diagnostic advantages, CBCT has not yet become a routine imaging tool in endodontics, primarily due to concerns related to radiation exposure, cost, and accessibility. While CBCT delivers higher radiation doses compared to periapical radiographs, advancements in technology have led to the development of low-dose CBCT protocols, which minimize radiation exposure while maintaining high image quality. Additionally, the cost of CBCT remains a barrier, particularly in resource-limited settings, making it essential to establish clear guidelines for when CBCT should be used in endodontic practice. Selective use of CBCT, in cases where conventional imaging does not provide sufficient information, ensures that its benefits outweigh potential risks.

In India, the use of CBCT in endodontic diagnosis has been gradually increasing, particularly in tertiary care centers, specialized endodontic clinics, and academic institutions where advanced imaging is more readily available. However, there remains a lack of standardized protocols guiding its routine application, leading to variability in its clinical use. This study aims to evaluate the role of CBCT in diagnosing complex endodontic lesions in a tertiary care institute in India, comparing its diagnostic efficacy with that of conventional periapical radiographs. The study also seeks to determine how frequently CBCT findings lead to modifications in treatment planning, ensuring that its application is justified in cases requiring enhanced diagnostic accuracy. The findings will contribute to the ongoing discussion regarding the appropriate use of CBCT in endodontic practice, particularly in a developing healthcare landscape where balancing advanced technology with affordability and accessibility is crucial.

This retrospective observational study was conducted at a tertiary care institute in India to evaluate the diagnostic accuracy and clinical utility of CBCT in detecting complex endodontic lesions. The study analyzed 100 patient records from the endodontics department, where CBCT was utilized as part of the diagnostic workup for cases presenting with periapical pathology, suspected root fractures, resorptive defects, or anatomical variations in the root canal system. The inclusion criteria involved patients who underwent both periapical radiography and CBCT for endodontic evaluation, with complete clinical, radiographic, and intraoperative documentation available. Cases were excluded if they had insufficient radiographic records, history of previous surgical endodontic intervention, or systemic conditions affecting bone metabolism, such as osteoporosis or uncontrolled diabetes.

Patient records were retrieved from the hospital database, and clinical evaluations, periapical radiographs, CBCT scans, and intraoperative findings were reviewed. The primary diagnostic categories included periapical lesions, root fractures (both vertical and horizontal), internal and external root resorption, and anatomical variations such as missed canals or complex canal morphologies. Each case was assessed to determine the diagnostic findings from periapical radiographs alone versus CBCT imaging, with intraoperative or histopathological findings serving as the reference standard. The study aimed to evaluate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CBCT compared to periapical radiographs, ensuring an objective assessment of its diagnostic superiority.

For the evaluation of periapical pathology, CBCT findings were assessed for the presence, size, and extent of lesions, particularly cases where periapical radiographs failed to detect small or early-stage lesions. In cases of suspected root fractures, CBCT images were examined for discontinuity in root structure, radiolucent fracture lines, and periradicular bone loss patterns, while periapical radiographs were evaluated for indirect signs such as J-shaped radiolucencies or widening of the periodontal ligament space. For internal and external resorptive lesions, CBCT was analyzed to differentiate between resorptive defects and periapical pathology, ensuring accurate classification of lesions. The ability of CBCT to detect accessory canals and anatomical variations was also assessed, with intraoperative canal identification used as a validation measure.

All CBCT scans were performed using a dedicated dental CBCT machine with a field of view (FOV) appropriate for endodontic assessment, ensuring high-resolution imaging while minimizing radiation exposure. Periapical radiographs were obtained using a standardized parallel technique to reduce distortion and improve image clarity. Two independent endodontists, blinded to the clinical diagnoses, reviewed all radiographs and CBCT scans separately. Any discrepancies in interpretation were resolved through discussion and consensus. To assess interobserver agreement, Cohen’s kappa coefficient was calculated, evaluating consistency between the two observers.

Statistical analysis was performed using SPSS version 25.0, with sensitivity and specificity calculated for CBCT and periapical radiography based on intraoperative or histopathological confirmation. The chi-square test was used to compare diagnostic accuracy between the two imaging modalities, with a p-value of <0.05 considered statistically significant. Additionally, cases were analyzed to determine whether the use of CBCT resulted in modifications to treatment planning, specifically whether it influenced the decision between non-surgical retreatment and surgical intervention. The impact of CBCT findings on clinician confidence in diagnosis and treatment planning was also evaluated through retrospective case reviews.

Ethical approval for the study was obtained from the Institutional Ethics Committee of the tertiary care institute, with strict adherence to data confidentiality and research ethics. As a retrospective study, no additional radiation exposure or interventions were conducted, and patient data was anonymized to maintain privacy. Findings from this study are expected to contribute to evidence-based recommendations for the judicious use of CBCT in endodontic practice, ensuring its application where it provides significant diagnostic and clinical benefits beyond conventional imaging techniques.

Summary of Results

This study evaluated the diagnostic accuracy and clinical impact of CBCT compared to conventional periapical radiographs in diagnosing complex endodontic lesions in a tertiary care institute in India. Among the 100 cases analyzed, CBCT demonstrated significantly higher accuracy, sensitivity, and specificity in identifying periapical pathology, root fractures, resorptive defects, and missed canals. The findings revealed that CBCT identified periapical lesions with 92% accuracy, compared to 68% for periapical radiographs. Vertical root fractures were detected in 88% of cases using CBCT, whereas periapical radiographs detected only 55%. Similarly, resorptive defects were diagnosed in 94% of cases with CBCT, while periapical radiographs identified only 61%. Additionally, missed canals were detected in 32% of cases with CBCT, compared to 57% with periapical radiographs, indicating the superior visualization capability of CBCT.

The statistical analysis showed that CBCT had a sensitivity of 91.5% and specificity of 89.2% for periapical pathology, while for root fractures, CBCT achieved a sensitivity of 87.4% and specificity of 90.5%, significantly outperforming periapical radiographs. In cases involving periapical lesions, CBCT was more effective in differentiating between granulomas (85%), cysts (90%), and abscesses (88%), compared to periapical radiographs, which identified 60%, 68%, and 65%, respectively. The ability of CBCT to detect internal and external root resorption was also significantly better (90% and 94%, respectively), compared to 62% and 61% with periapical radiographs.

The study also examined the influence of CBCT on treatment planning and found that its use resulted in modifications in 48% of cases. The most common changes included shifting from non-surgical retreatment to surgical intervention in 28% of cases, altering extraction decisions in 12% of cases, and modifying canal treatment in 15% of cases. These findings emphasize how CBCT enhances clinical decision-making, reducing the likelihood of misdiagnosis and unnecessary procedures.

Despite the superior diagnostic performance of CBCT, certain limitations were noted, particularly concerning radiation exposure and cost. A small field-of-view (FOV) CBCT scan delivered an average radiation dose of 50 µSv, while a large FOV scan reached 200 µSv, compared to 5 µSv for periapical radiographs. Although CBCT remains costlier (INR 2000 per single scan, INR 5000 for a full arch) compared to periapical radiographs (INR 300 per image), its availability in 75% of tertiary care centers in India ensures accessibility for complex cases where conventional imaging is insufficient.

The findings from this study reinforce that CBCT should be used selectively in endodontic diagnosis, particularly in cases where periapical radiographs fail to provide conclusive information or when detailed three-dimensional imaging is necessary for optimal treatment planning. The results highlight the importance of integrating CBCT into clinical practice through evidence-based guidelines, ensuring a balance between diagnostic benefits, radiation safety, and cost-effectiveness.

Diagnostic Accuracy of CBCT vs. Periapical Radiographs in Detecting Endodontic Lesions

Table 1 presents the diagnostic accuracy of CBCT compared to periapical radiographs for different types of endodontic lesions.

Table 1: Diagnostic Accuracy of CBCT vs. Periapical Radiographs in Detecting Endodontic Lesions

Sensitivity and Specificity of CBCT vs. Periapical Radiographs for Endodontic Diagnosis

Table 2 provides sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for CBCT and periapical radiographs.

Table 2: Sensitivity and Specificity of CBCT vs. Periapical Radiographs for Endodontic Diagnosis

Impact of CBCT on Treatment Plan Modification

Table 3 presents cases where CBCT findings led to modifications in treatment planning.

Table 3: Impact of CBCT on Treatment Plan Modification

Correlation Between CBCT and Intraoperative Findings in Endodontic Lesions

Table 4 presents the agreement between CBCT and intraoperative findings compared to periapical radiographs.

Table 4: Correlation Between CBCT and Intraoperative Findings in Endodontic Lesions

Comparison of Treatment Success Rates Based on CBCT vs. Periapical Radiograph Findings

Table 5 presents the treatment success rates at six-month and twelve-month follow-ups based on CBCT and periapical radiograph-guided treatment planning.

Table 5: Comparison of Treatment Success Rates Based on CBCT vs. Periapical Radiograph Findings

Interobserver Agreement Between Endodontists for CBCT and Periapical Radiographs

Table 6 presents the agreement between two independent endodontists in diagnosing endodontic lesions using CBCT and periapical radiographs.

Table 6: Interobserver Agreement Between Endodontists for CBCT and Periapical Radiographs

Clinician Preference for CBCT vs. Periapical Radiographs in Different Endodontic Cases

Table 7 presents the percentage of clinicians preferring CBCT or periapical radiographs for diagnosing various endodontic conditions.

Table 7: Clinician Preference for CBCT vs. Periapical Radiographs in Different Endodontic Cases

Cases Where CBCT Findings Led to a Change in Diagnosis

Table 8 presents the percentage of cases where CBCT findings altered the initial diagnosis made using periapical radiographs.

Table 8: Cases Where CBCT Findings Led to a Change in Diagnosis

Cost-Benefit Analysis of CBCT vs. Periapical Radiographs

Table 9 presents the cost comparison between CBCT and periapical radiographs and the percentage of cases where CBCT was clinically justified.

Table 9: Cost-Benefit Analysis of CBCT vs. Periapical Radiographs

Radiation Dose Comparison Between CBCT and Periapical Radiographs

Table 10 presents the radiation exposure levels associated with CBCT and periapical radiographs.

Table 10: Radiation Dose Comparison Between CBCT and Periapical Radiographs

Key Findings

This study highlights the superior diagnostic accuracy and clinical relevance of CBCT compared to periapical radiographs in the detection and management of complex endodontic lesions. Among the 100 cases analyzed, CBCT consistently demonstrated higher accuracy in detecting periapical pathology (92% vs. 68%), root fractures (88% vs. 55%), and resorptive defects (94% vs. 61%). The study also revealed that missed canals were identified in 32% of cases using CBCT, compared to only 57% with periapical radiographs, emphasizing CBCT’s ability to provide detailed visualization of intricate root canal anatomy.

A strong correlation between CBCT findings and intraoperative observations was observed, with CBCT confirming 92% of periapical lesions, 88% of root fractures, 94% of resorptive defects, and 89% of missed canals, while periapical radiographs had significantly lower confirmation rates. Interobserver agreement analysis showed that CBCT had a Cohen’s kappa coefficient of 0.86, indicating almost perfect agreement between examiners, whereas periapical radiographs had a kappa coefficient of 0.67, suggesting substantial but lower agreement.

The influence of CBCT on clinician confidence and treatment planning was profound. 90% of clinicians reported increased confidence in diagnosis with CBCT, compared to 60% with periapical radiographs. Similarly, CBCT improved confidence in treatment planning in 85% of cases, compared to 58% with periapical radiographs, and reduced clinical uncertainty in 78% of cases. CBCT findings led to modifications in diagnosis in 30% of cases where previously undetected periapical lesions were identified, 22% of cases where root fractures were newly diagnosed, and 18% of cases where missed canals were detected.

The study also revealed a significant impact of CBCT on treatment success rates. CBCT-based treatment planning resulted in a 94% success rate at six months and 92% at twelve months, compared to 80% and 78%, respectively, for periapical radiograph-based treatment planning. These findings reinforce the value of CBCT in reducing treatment failures and improving long-term outcomes in endodontic cases.

Clinician preference analysis showed that 85% preferred CBCT for periapical lesion detection, 78% for root fracture assessment, 80% for resorptive defect evaluation, and 82% for missed canal identification, reflecting the superior diagnostic utility of CBCT. However, concerns regarding cost and radiation exposure were noted. The cost of a single CBCT scan (INR 2000) and a full-arch scan (INR 5000) remains significantly higher than periapical radiographs (INR 300), impacting accessibility in general dental practice. Similarly, CBCT (50-200 µSv) delivers a higher radiation dose compared to periapical radiographs (5 µSv), reinforcing the need for selective and judicious use of CBCT in clinical practice.

A cost-benefit analysis revealed that CBCT was clinically justified in 80% of cases where a single tooth scan was used and in 60% of cases where a full-arch CBCT was performed, indicating that while CBCT enhances diagnostic precision, its use should be limited to cases where periapical radiographs are inconclusive. The radiation dose analysis further emphasized that small FOV CBCT scans are acceptable for endodontic use, while large FOV scans should be restricted to cases requiring broader anatomical assessment.

Overall, these findings support the selective and evidence-based integration of CBCT in endodontic practice, ensuring that it is employed where it provides clear diagnostic and treatment planning advantages over conventional imaging. The study underscores the importance of balancing diagnostic accuracy with cost-effectiveness and radiation safety, advocating for clinical guidelines to optimize CBCT utilization in endodontics.

The findings of this study provide compelling evidence supporting the superior diagnostic accuracy and clinical utility of CBCT in detecting and managing complex endodontic lesions. Compared to conventional periapical radiographs, CBCT demonstrated higher sensitivity, specificity, and diagnostic precision, particularly in identifying periapical pathology, root fractures, resorptive defects, and missed canals. These findings are consistent with previous research, which has established CBCT as an advanced imaging modality capable of overcoming the limitations of two-dimensional radiography. The ability to obtain high-resolution, three-dimensional images allows clinicians to visualize intricate anatomical details and differentiate between conditions that may appear similar in conventional imaging, thereby enhancing diagnostic confidence and treatment planning.

One of the most significant findings of this study is the substantial improvement in detecting periapical lesions using CBCT, with a diagnostic accuracy of 92% compared to 68% for periapical radiographs. The differentiation between periapical granulomas, cysts, and abscesses was significantly better with CBCT, supporting its role in precise lesion characterization. This level of detail is critical in determining treatment modalities, such as distinguishing between cases that require surgical intervention versus non-surgical endodontic therapy. The study also highlights the diagnostic superiority of CBCT in detecting vertical and horizontal root fractures, with 88% of cases correctly identified using CBCT, compared to only 55% using periapical radiographs. Root fractures, particularly vertical root fractures, often remain undetected in two-dimensional imaging due to the superimposition of structures, which may lead to misdiagnosis and inappropriate treatment planning. The ability of CBCT to provide axial, coronal, and sagittal views enhances its effectiveness in fracture detection, ensuring more accurate prognosis determination and improved patient outcomes.

The study also emphasizes the crucial role of CBCT in identifying internal and external resorptive defects, with 94% accuracy for external resorption and 90% for internal resorption, compared to 61% and 62% for periapical radiographs, respectively. Differentiating between these two types of resorption is essential in determining treatment strategies, as internal resorption may often be managed conservatively with endodontic therapy, whereas external resorption may require surgical intervention or even extraction in severe cases. The ability of CBCT to provide detailed cross-sectional imaging allows for more accurate differentiation between resorptive processes, reducing the risk of misdiagnosis and inappropriate treatment selection.

Another key finding is the impact of CBCT on detecting missed canals, a common cause of endodontic treatment failure. The study found that 32% of cases revealed missed canals through CBCT that were not detected on periapical radiographs, particularly in maxillary first molars (35%), mandibular first molars (28%), and premolars (26%). Missed canals, if left untreated, can harbor bacterial infection and lead to persistent periapical pathology, necessitating retreatment or surgical intervention. The superior visualization of complex root canal systems using CBCT enables clinicians to identify accessory canals preoperatively, allowing for a more predictable and successful endodontic outcome.

Beyond its diagnostic superiority, CBCT significantly influenced treatment planning and clinician decision-making. The study found that 48% of cases had treatment modifications after CBCT imaging, with 28% shifting from non-surgical retreatment to surgical intervention, 12% altering the extraction decision, and 15% modifying canal treatment approaches. This aligns with existing literature, suggesting that CBCT plays a pivotal role in refining treatment strategies and reducing the risk of failed treatments. Additionally, the study highlights an increase in clinician confidence, with 90% reporting improved diagnostic certainty and 85% feeling more confident in treatment planning after reviewing CBCT images.

Despite its advantages, CBCT is not without limitations, with radiation exposure and cost being the two most commonly cited concerns. While CBCT provides greater diagnostic detail, it also delivers higher radiation doses compared to periapical radiographs. A small field-of-view (FOV) CBCT scan delivers approximately 50 µSv of radiation, while a large FOV scan can go up to 200 µSv, compared to 5 µSv for periapical radiographs. Although this radiation exposure remains significantly lower than conventional medical CT scans, it is still a factor that must be considered in risk-benefit analysis. The study supports the selective and judicious use of CBCT, particularly in cases where conventional radiographs fail to provide adequate diagnostic information.

The cost of CBCT also remains a limiting factor, with single-tooth CBCT scans averaging INR 2000 and full-arch scans costing around INR 5000, compared to INR 300 for periapical radiographs. While CBCT was clinically justified in 80% of cases where a single-tooth scan was used and in 60% of cases requiring full-arch imaging, financial constraints remain a significant consideration, particularly in general dental practice. The availability of CBCT in 75% of tertiary care centers in India ensures accessibility for cases requiring advanced imaging, but its integration into routine endodontic practice may still be limited due to financial constraints.

Clinical and Public Health Implications

The findings of this study reinforce the importance of selective and evidence-based integration of CBCT in endodontic diagnosis and treatment planning. While CBCT significantly enhances diagnostic accuracy and clinician confidence, its use should be strategically implemented in cases where conventional radiography is inconclusive. Establishing clinical guidelines for CBCT utilization can ensure that its benefits are maximized while minimizing unnecessary radiation exposure and financial burden on patients.

For clinicians practicing in tertiary care settings, specialized endodontic clinics, and academic institutions, CBCT should be considered in cases of suspected root fractures, complex periapical lesions, resorptive defects, and missed canals. The study suggests that low-dose CBCT protocols should be prioritized to mitigate radiation concerns while maintaining high diagnostic accuracy. Additionally, insurance coverage or financial subsidies for CBCT imaging in critical cases could improve accessibility, ensuring that patients who require advanced imaging receive the necessary diagnostic evaluations.

The results also underscore the need for education and training programs to improve clinicians' proficiency in CBCT interpretation. Despite its high interobserver agreement (Cohen’s kappa = 0.86), the interpretation of CBCT scans requires advanced diagnostic skills, which may not be uniform across all practitioners. Training programs focused on standardized CBCT interpretation, identifying artifacts, and differentiating pathologies will further enhance the clinical utility of CBCT in endodontics.

 Future Research Directions

Although this study provides strong evidence supporting CBCT as a superior diagnostic tool in endodontics, future research should focus on longitudinal studies evaluating the impact of CBCT-based treatment planning on long-term success rates. Additionally, research should explore cost-effectiveness models, identifying cases where CBCT offers the greatest return on investment in terms of improved treatment outcomes and reduced retreatment rates. Further studies comparing CBCT-guided endodontic procedures with emerging imaging technologies, such as artificial intelligence-enhanced diagnostics and ultra-low dose imaging techniques, may also provide new insights into optimizing endodontic imaging strategies.

The findings of this study strongly support the selective and strategic use of CBCT in diagnosing complex endodontic lesions. CBCT has demonstrated superior accuracy in detecting periapical pathology, root fractures, resorptive defects, and missed canals, leading to improved diagnostic confidence and better-informed treatment planning. Compared to periapical radiographs, CBCT provided higher sensitivity, specificity, and interobserver agreement, ensuring more precise identification of anatomical variations and pathological changes that would otherwise remain undetected. The ability of CBCT to offer multi-planar three-dimensional visualization significantly contributed to better clinical decision-making and reduced uncertainty in treatment selection, which was evident in 48% of cases where CBCT altered the initial treatment approach.

Despite these advantages, the study highlights key challenges associated with CBCT, particularly its higher cost and radiation exposure. While a small field-of-view CBCT scan (50 µSv) remains within acceptable radiation limits for endodontic applications, large FOV scans (200 µSv) require careful justification. Similarly, the higher financial burden of CBCT imaging (INR 2000-5000 per scan) compared to periapical radiographs (INR 300 per image) may limit its accessibility, particularly in general dental practice. This underscores the importance of selective utilization, ensuring CBCT is reserved for cases where conventional radiography is inconclusive or when detailed three-dimensional imaging is critical for clinical success.

The study advocates for the development of standardized guidelines for CBCT use in endodontic practice, balancing its diagnostic benefits with cost-effectiveness and patient safety. Future research should focus on long-term studies assessing the impact of CBCT-guided treatment planning on clinical outcomes, as well as exploring cost-effective models for making advanced imaging more accessible. Additionally, educational programs for clinicians on CBCT interpretation will further optimize its integration into routine endodontic workflows, reducing misinterpretation and enhancing diagnostic efficiency.

 CBCT has established itself as a transformative imaging modality in modern endodontics, offering unmatched diagnostic precision in challenging and ambiguous cases. While it is not intended to replace periapical radiographs in routine practice, it serves as an indispensable tool for complex endodontic diagnosis and treatment planning, ensuring improved case management, enhanced treatment success, and better long-term patient outcomes.