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-
mine the incidence and size of periapical radiolucencies
using cone-beam computed tomographic (CBCT) imag-
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
in this study. Limited-volume CBCT scans were taken at
0.125-mm3 voxel size. The widest area of apical radiolu-
cency of each root canal–treated tooth was measured
and assigned a numeric score based on the CBCT-
Endodontic Radiolucency Index (ERI). CBCT data were
evaluated by 2 radiologists with an interclass correlation
coefficient of 0.96. Results: The majority of
roots (53.3%) had periodontal ligament widths
#0.5 mm; 26.7% had radiolucency widths of
0.5 < x # 1 mm, 15.0% had radiolucency widths of
1.0 < x # 1.5 mm, 0.8% had radiolucency widths
of 1.5 < x # 2.0 mm, 1.7% had radiolucency
widths of 2.0 < x # 2.5 mm, and 2.5% had radiolucency
widths of >2.5 mm. Patient age, recall interval, tooth
type, and arch type had no statistically significant effect
on the ERI distribution. Conclusions: Twenty percent of
teeth with successful root canal treatment based on con-
ventional periapical imaging had CBCT radiolucencies
measuring greater than 1 mm. Because these radiolu-
cencies may not be pathological changes, clinicians
are cautioned against overtreatment of them before
determining the true nature of these findings. Clinical
studies with long follow-up times are needed to deter-
mine the proper course of actions for these cases. (J En-
dod 2017;-:1–6)
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: kabramovitch@llu.edu
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2017.11.015
JOE — Volume -, Number -, - 2017
Key Words
Apical periodontitis, cone-beam computed tomography, endodontics, periapical index,
radiography
T he main objective of
root canal treatment
(RCT) is to provide long-
Significance
From this study, CBCT imaging detects more api-
cal radiolucencies than standard imaging.
term comfort, function,
Because these findings may not be pathological,
and esthetics for patients
clinicians are cautioned against overtreatment.
with pulpal and periapical
Long-term follow-up studies are needed to deter-
diseases. This is achieved
mine the proper course of actions for these
by complete cleaning,
findings.
shaping, and obturation
of canals and the place-
ment of permanent restorations on the affected teeth (1–3). Because of the
complexity of root canal systems, inadequate chemomechanical instrumentation,
insufficient obturation, and leakage of permanent restorations, the elimination of
bacteria from the root canal systems of affected teeth is not always possible (4, 5).
Consequently, not all root canal–treated teeth have 100% successful healing. The
healing and regeneration of periradicular tissues may take months to years.
Recommended follow-up periods have ranged from 6 months to 27 years (6–10).
The evaluation of endodontic outcomes is based primarily on the findings noted
from clinical and radiographic examinations. Another method for the evaluation of RCT
outcomes is to biopsy the periradicular tissues. Biopsies are already used for histologic
diagnosis when endodontic surgery is indicated. However, a biopsy is not routinely per-
formed to determine clinical outcomes of nonsurgical RCTs. Therefore, clinical and
radiographic examinations remain the contemporary methods used to determine
RCT outcomes.
The presence of persistent signs or symptoms after routine RCT is usually an indi-
cation of negative outcomes. However, the mere absence of clinical symptoms does not
necessarily mean a positive outcome. Periapical pathosis may exist without significant
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
Periapical Radiolucencies Using CBCT 1
Clinical Research
treatment outcome. However, treated teeth without radiographic lesions
may have clinical symptoms indicative of negative treatment outcomes.
Therefore, a combination of clinical and radiographic findings must be
used to assess RCT outcomes.
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
the appearance of a poorly defined lamina dura was considered ‘‘fail-
ure.’’ Ørstavik et al (13) suggested a periapical index (PAI) to deter-
mine RCT outcomes. This index is based on a 5-point ordinal scale
for a tooth or a root with ‘‘1’’ meaning no sign of periapical bone
destruction, ‘‘2’’ probably no destruction, ‘‘3’’ uncertain, ‘‘4’’ probably
periapical destruction, and ‘‘5’’ definite periapical bone destruction.
This study and others (14, 15) did not use quantifiable radiographic
descriptive terms for identifying periapical health or disease.
Intraoral and panoramic radiographic assessment of periapical
tissues is 2-dimensional (ie, radiography) and has been the only imag-
ing modality in endodontics for many years (16). Cone-beam computed
tomographic (CBCT) imaging is a technology that provides multiplane
and 3-dimensional reconstruction imaging of dental hard tissues. CBCT
imaging has been recommended for endodontic diagnostic and treat-
ment planning as well as assessing outcomes of RCT (16, 17). Using
this technology, several investigators have shown the presence of
periapical radiolucencies in cases in which no radiographic pathosis
was detected with conventional intraoral radiographic techniques
(18–24). A recent literature search in MEDLINE (National Center for
Biotechnology Information PubMed) showed the absence of any
study reporting on the incidence of periapical radiolucency using
CBCT imaging on endodontically treated teeth that had no apparent
lesions using conventional radiographic techniques. The purpose of
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.
Materials and Methods
This study was approved by both the Institutional Review Board
and the Radiation Safety Committee of Loma Linda University, Loma
Linda, CA. Fifty-three patients, 18 years of age or older, with 1 or
more endodontically treated teeth with recall times of 2 to 15 years
were included in the study. Patients who were either confirmed or
thought to be pregnant were excluded.
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
3 mobility, and no purulence and clinically asymptomatic teeth. Recall
periapical radiographs were taken of all teeth. A PAI score (13) of 1 or 2
was also used as part of the radiographic inclusion criterion. Exclusion
criteria were as follows: presence of pain, swelling, sinus tract stoma,
advanced periodontal disease, class 3 mobility, and a PAI rating greater
than 2.
Patients meeting these criteria then gave written informed consent
for a limited-volume, 40 mm  40 mm field of view, CBCT scan of the
affected jaw area (Veraviewepocs 3de; J. Morita USA, Irvine, CA). The
exposure parameters were 80 kV at 0.125 mm3 with either 5 mA for
anterior teeth or 7 mA for posterior teeth. This overall group of 53 pa-
tients provided a sample size of 120 roots from 69 teeth. There were 35
maxillary roots and 34 mandibular roots. A summary of the distribution
of the teeth is presented in Table 1.
Two calibrated radiologists (K.A. and D.D.R.) assessed the CBCT
volumetric data independently and blindly for the identification of
2 Torabinejad et al.
TABLE 1. Distribution of the Teeth in This Study
Anterior Premolar Molar
Maxilla 6 14 15
Mandible 10 8 16
periapical radiolucencies with OneVolume Viewer software (Version
2.813.20.3946, J. Morita USA). Monitor contrast and brightness were
adjusted to the preferences of the examiners. A slice thickness of
0.5 mm or less depending on the examiner’s discretion was used for
the multiplane views.
In the multiplanar reconstructions, the long axes of the selected
teeth were parallel to the sagittal and coronal planes of imaging. Teeth
were evaluated in all planes until the widest area of radiolucency in the
periapical region adjacent to the apex was identified. The linear width of
the widest radiolucent area perpendicular to the root surface was
measured and assigned a numeric score according to the CBCT-
Endodontic Radiolucency Index (ERI) ranking developed for this
purpose (Table 2).
Statistical Analysis
Chi-square analysis and the Mann-Whitney U test were performed
to determine whether tooth type or arch type were significantly associ-
ated with the ERI distribution. Spearman rho was used to examine the
relationship, if any, between the recall interval and the age of the patient
on the ERI distribution. Examiner reliability was evaluated with the in-
traclass correlation coefficient (ICC) statistic. All tests of hypotheses
were conducted with The Statistical Package for Social Science (SPSS
v 24; SPSS Inc, Chicago, IL), and P = .05 was set as a threshold for
statistical significance.
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
roots. A CBCT-ERI score of 1 was found in 64 roots (53.3%). Thirty-
two roots (26.7%) had a CBCT-ERI score of 2 (0.5 < x # 1 mm),
15% had a CBCT-ERI score of 3 (1.0 < x # 1.5 mm), 0.8% had a
CBCT-ERI score of 4 (1.5 < x # 2.0 mm), 1.7% had a CBCT-ERI score
of 5 (2.0 < x # 2.5 mm), and 2.5% had a CBCT-ERI score of 6
(>2.5 mm) (Figure 1). Twenty percent of the roots had an ERI in which
the periapical radiolucency measured greater than 1 mm.
TABLE 2. Cone-beam Computed Tomographic–Endodontic Radiolucency
Index (ERI)
ERI score Description
1 Widest dimension of PDL:
# 0.5 mm
2 Widest dimension of PDL:
0.5 mm < x # 1.0 mm
3 Widest dimension of PDL:
1.0 mm < x # 1.5 mm
4 Widest dimension of PDL:
1.5 mm < x # 2.0 mm
5 Widest dimension of PDL:
2.0 mm < x # 2.5 mm
6 Widest dimension of PDL:
> 2.5 mm
Modeled from Estrela et al (24). This index has smaller PDL width measurement increments. The
smaller increments are more applicable to classify periapical disease early in its progression and
to quantify the incremental changes of the healing process.
JOE — Volume -, Number -, - 2017

TABLE 3. Cone-beam Computed Tomographic–Endodontic Radiolucency
Index (ERI) Distribution
ERI score Frequency
1 64
2 32
3 18
4 1
5 2
6 3
Total 120
This table lists the frequency counts of root apices in each of the ERI categories. The percent of the
total 120 apices is listed in the third column.
Statistical analyses of the results show that ERI levels are not asso-
ciated with tooth type (Pearson chi-square, P > .05) or arch type
(Mann-Whitney U test, P > .05). Although a longer recall interval ap-
pears to be present for ERI 3 compared with ERI 1, 2, and 5, lesion
size is not correlated with the recall interval (Spearman
rho = 0.024, P > .05). Lesion size was also not correlated with patient
age (Spearman rho = 0.073, P > .05).
Discussion
With CBCT imaging, physiologic periodontal ligament (PDL)
spaces in successful endodontically treated teeth were found in only
53.3% of the roots in this study. Conversely, a total of 46.7% of cases
had periapical radiolucencies with widened PDL spaces larger than
0.5 mm. This alteration of the periapical attachment area was noted
in the teeth selected for the study that met the strict clinical and conven-
tional radiographic inclusion and exclusion criteria to be considered
successfully treated. Patient age, recall interval, tooth type, and arch
type had no statistical effect on the ERI distribution.
Previous studies have shown that CBCT imaging is more sensitive
than conventional radiographic imaging at identifying apical periodon-
titis (18–24). The information from these studies and our CBCT data
show that not all of these radiolucencies are indicative of the
presence of periapical disease. Hence, in the absence of clinical
disease, CBCT findings can include a broader range of periapical
radiolucencies.
To determine the size of lesions in this study, we chose to modify
the already existing CBCT-PAI as developed by Estrela et al (24). This
was done because the measurements in their study were defined as
the ‘‘largest extension of the lesion.’’ However, when making a linear
measurement with CBCT software, it is not clear whether the largest
measurement is from the root surface or whether it is the widest or
longest linear dimension extension of a radiolucency’s rhomboidal
shape, ovoid length, or circular diameter. This lack of clarity in Estrela
et al’s (24) definition makes it difficult to have comparable reproduc-
ible measurements for either longitudinal or cross-sectional studies of
periapical radiolucent disease. Furthermore, their CBCT-PAI uses larger
measurement intervals that limit the ability to document the detail of
small dimensional changes afforded by CBCT imaging. The use of this
larger measurement scale further limits one to categorize early disease
or healing at the root apex. The revised CBCT-PAI (25) defined in more
detail how to position the tooth in 3 fixed and reproducible dimensions
but otherwise still offered the same measurement scale. Tsai et al (26)
showed that small-volume high-resolution CBCT scans could distin-
guish periapical radiolucencies less than 0.5 mm. Our CBCT-ERI pre-
sents an objective, quantitative, and reproducible CBCT index with
higher sensitivity to document subtle radiographic findings. Because
the ICC for the measurements between the 2 radiologists was 0.96,
this supports the CBCT-ERI as a reproducible measurement variable.
JOE — Volume -, Number -, - 2017
Clinical Research
One must determine at what point widened PDL findings in
endodontically treated teeth change the diagnosis of health to a diag-
Percent nosis of pathosis. The latter diagnosis could lead to further treatments
such as nonsurgical retreatment, surgical retreatment, or extraction. In
53.3 a previous study, the diagnosis for 22 of 53 teeth (41%) changed after
26.7
15.0 evaluation with CBCT imaging compared with the initial evaluation with
0.8 conventional radiography (27). The diagnosis of a healthy pulp
1.7 changed in 5 of 27 healthy teeth after CBCT examination to one in which
2.5 disease was recognized (ie, necrotic pulp, apical periodontitis, external
100.0
resorption, root fracture, and so on) (27).
According to Recommendation 5 of the Joint Position Statement of
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
imaging (17). Unfortunately, there is no recommendation regarding
incidental findings from postoperative images using CBCT imaging on
endodontically treated teeth that are asymptomatic and have no
apparent lesions using conventional radiographic techniques. To treat
the cases in this study with radiolucent measurements greater than
0.5 mm is probably an overtreatment because these teeth were clinically
asymptomatic and radiographically sound based on the standard peri-
apical radiographic images taken as part of their follow-up examination.
Because currently there are no scientific data regarding the true nature
of these incidental findings from CBCT imaging, we recommend intrao-
ral radiographs as the imaging modality of choice for postoperative eval-
uation of endodontically treated teeth in conjunction with the clinical
findings. We currently do not advocate CBCT imaging as part of an
RCT status postoperative follow-up evaluation. Our data show that
widened apical PDLs may be increasingly noted as incidental findings
on CBCT examinations taken to evaluate symptomatic conditions of
other teeth. The detection of a CBCT-ERI of 2 to 6 may represent a tooth
that is in the process of healing (6–10).
A higher success rate of 83% was noted at the 4- to 6-year follow-
up nonsurgical retreatment examinations when compared with the
70.9% noted at the 2- to 4-year follow-up examinations (28). Another
study of nonsurgical retreated teeth showed nonphysiologic PDL width
after 10 to 17 years but not at the 27-year mark (10). In the recall
period for our study, which ranged from 2 to 15 years, the recall period
did not statistically influence the ERI distribution.
The periapical radiolucency of an asymptomatic endodontically
treated tooth may also require no treatment because it represents
scar tissue rather than periapical pathosis (29–32). In these cases,
further treatment is again not warranted.
The determination of the presence of periapical radiolucencies is
very subjective when using the PAI (13). The specific categories in the
PAI lack a detailed description. In the first category, 1 is ‘‘healthy’’ and 5
is ‘‘severe periodontitis with exacerbating features.’’ On the contrary,
there are no worded descriptions of categories 2 to 4. The greatest
aids for the interpretation of the different categories are drawings
and corresponding radiographs. This lack of specific objective radio-
graphic criteria may lead to a wide range of interpretation and various
treatments. In a classic study (33), 6 examiners agreed on the presence
of rarefaction in only 42.1% of cases. The subjectivity of radiographic
interpretation is further evidenced by the fact that these examiners
agreed with their own diagnoses in only 72%–88% of cases 6 to
8 months later (34).
Because one cannot determine the histologic diagnosis of radiolu-
cency around the apex of an endodontically treated tooth observed on
CBCT imaging, practitioners should not necessarily initiate further treat-
ment procedures. The nature of these radiolucencies can be only deter-
mined by histologic examination, which was not included and performed
in this study. The outcomes of treatment of the teeth in this study were
Periapical Radiolucencies Using CBCT 3
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.

4 Torabinejad et al. JOE — Volume -, Number -, - 2017


Figure 1. (continued)
deemed successful as defined by our inclusion criteria. The lack of clin-
ical symptoms, despite the presence of radiolucencies using CBCT imag-
ing, does not support initiating further treatment. Nonsurgical
retreatment, surgical retreatment, or extraction do not appear to be
necessary because nearly 50% of successful endodontically treated teeth
have CBCT-ERI scores in which the PDL width is greater than 0.5 mm.
Thus, despite the increased sensitivity of CBCT imaging to identify changes
in the periapical tissues, clinical signs and symptoms and conventional
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
stages of development of symptomatic apical periodontitis where the clin-
ical signs precede CBCT detectable bone changes.
Although further histologic studies would be helpful to determine
the nature of these incidental radiolucencies observed with CBCT imag-
ing and not seen using conventional radiographic techniques, such
invasive procedures are unlikely to be approved by most human
research committees now. There are no ethical indications to biopsy
these asymptomatic radiolucencies when diseases of greater morbidity
are not suspected in the differential diagnosis. Clinical studies with long
follow-up times are needed to determine the proper course of actions
for these cases.
Conclusion
Based on our data, it appears that 1 out of 5 teeth with successful
RCT based on conventional periapical imaging will have a CBCT radio-
JOE — Volume -, Number -, - 2017
Clinical Research
lucency measuring greater than 1 mm. Currently, there is no informa-
tion to determine whether these radiolucencies represent incomplete
healing, persistent disease, or fibrous scar tissue. Because these radio-
lucencies may not be pathological changes, clinicians are cautioned
against overtreatment of them before determining the true nature of
these findings. Clinical studies with long follow-up times are needed
to determine the cofactors that differentiate these findings from the
disease entities for the proper course of actions for these cases.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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