Clinical Research
Accuracy of Orthopantomography for Apical
Periodontitis without Endodontic Treatment
Cosimo Nardi, MD,* Linda Calistri, MD,* Silvia Pradella, MD, PhD,* Isacco Desideri, MD,†
Chiara Lorini, PhD,‡ and Stefano Colagrande, MD*
Abstract
Introduction: This study aimed to evaluate the diag-
nostic accuracy of orthopantomography (OPT) for the
detection of clinically/surgically confirmed apical peri-
odontitis (AP) without endodontic treatment using
cone-beam computed tomographic (CBCT) imaging as
the reference standard. Methods: One hundred twenty
patients without endodontically treated AP (diseased
group) were detected via CBCT imaging using the periap-
ical index system. They were divided into groups of
10 each according to the size of the lesion (2–4.5 mm
and 4.6–7 mm) and the anatomic area (incisor, canine/
premolar, and molar) in both the upper and lower arches.
Another 120 patients with a healthy root and periapex
(healthy group) were selected. Each diseased and healthy
patient underwent OPT first and a CBCT scan within
40 days of the OPT. The periapical index system was
also used to assess AP by OPT. Sensitivity, specificity,
positive predictive value, negative predictive value, and
diagnostic accuracy for OPT images with respect to
CBCT imaging were analyzed. The k value was calculated
to assess both the interobserver reliability for OPT and
the agreement between OPT and CBCT imaging. Results:
OPT showed low sensitivity (34.2), negative predictive
value (59.3), and diagnostic accuracy (65.0) and high
specificity (95.8) and positive predictive value (89.1).
Interobserver reliability for OPT was substantial
(k = 0.71), and agreement between OPT and CBCT imag-
ing was fair (k = 0.30). The best and worst identified AP
were located in the lower molar area and the upper/lower
incisor area, respectively. Conclusions: OPT showed
high specificity and positive predictive value. However,
overall, it was not an accurate imaging technique for
the detection of untreated AP, especially in the incisor
area. (J Endod 2017;43:1640–1646)
Key Words
Apical periodontitis, cone-beam computed tomographic
imaging, diagnostic accuracy, orthopantomography,
panoramic radiography, periapical index
From the *Department of Experimental and Clinical Biomedical Sciences, Radiodiagnostic Unit n. 2 and †Department of Experimental and Clinical Biomedical Sci-
ences, Radiotherapy Unit, University of Florence–Azienda Ospedaliero-Universitaria Careggi; and ‡Department of Health Science, University of Florence, Florence, Italy.
Address requests for reprints to Dr Cosimo Nardi, Dipartimento di Scienze Biomediche Sperimentali e Cliniche, Radiodiagnostica 2, Universit
a di Firenze, AOU
Careggi, Largo Brambilla 3, Firenze 50134, Italy. E-mail address: cosimo.nardi@unifi.it
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.06.020
1640 Nardi et al.
A pical periodontitis (AP)
is a periapical bone
lesion arising from an end-
Significance
Apical periodontitis is a very common and often
asymptomatic clinical problem that has to be
odontic infection determined
treated, especially when anticancer therapy is
by microorganisms pene-
expected. Therefore, there should be a reliable
trating into the root canal
imaging technique available to detect apical
up to the apex (1). The
periodontitis. Can OPT fulfill this task?
defense mechanism in the
apical periodontium leads
to resorption of the apical bone, which appears as a radiolucency around the root on
radiographs (2, 3).
AP is often asymptomatic and generally recognized by incidental findings during
routine radiographic examinations using periapical radiography and orthopantomog-
raphy (OPT) (4). These techniques have significant limitations because of
2-dimensional imaging of 3-dimensional structures, anatomic noise, superimposition,
and geometric distortion effect (5–7). In addition, to be radiographically visible,
periapical radiolucency should reach nearly 30%–50% of the bone mineral loss
(8). For all these reasons, AP might be present even when it is not radiographically iden-
tified (9). This is especially the case if AP is confined within the cancellous bone, without
the involvement of the cortical bone (10–12).
Recently, cone-beam computed tomographic (CBCT) imaging has proven to
perform well for the volumetric study of bone structures (13), including the detection
of periapical bone lesions (14–16). Furthermore, CBCT imaging involves a low
radiation dose compared with multislice computed tomographic imaging (17), is
only moderately affected by metal artifacts (18), offers a high spatial resolution
(0.075–0.4 mm isotropic voxel) (19), and allows accurate 2-dimensional/3-
dimensional measurements without distortion and magnification (20–22).
Nevertheless, the routine use of CBCT imaging in endodontic practices is not justified
(23). This imaging technique must be performed only in patients with unclear or con-
tradictory clinical signs and symptoms using a small field of view (FOV) (24).
Biopsy represents the only way to get a histologic confirmation of AP, but it is an
invasive procedure and complications can occur. Therefore, definite indices based on
the radiologic features of the periapical bone lesions are generally used to detect and
classify AP in routine clinical practice (25–27).
Only 1 article compared the accuracy of OPT and CBCT imaging for the assessment
of AP (28) although it did not distinguish among lesions of different sizes. The aim of
this retrospective study was to evaluate the diagnostic accuracy of OPT in the detection of
clinically/surgically confirmed AP without endodontic treatment using CBCT imaging as
the reference standard.
JOE — Volume 43, Number 10, October 2017

Material and Methods
Patients
Between November 2011 and December 2016, we selected from
our CBCT database all patients with at least 1 not endodontically treated
radiolucent periapical bone lesion using the following key words: radio-
lucent periapical bone lesion, apical periodontitis, endodontically
Clinical Research
treated, root canal treatment, and size (Fig. 1). One hundred twenty pa-
tients (67 women and 53 men) 22–84 years old (mean age = 57 years)
were enrolled in the disease group. One AP lesion was selected for each
of them. The clinical queries for the CBCT examinations were implant
planning (76 patients), dental extractive planning (34 patients), and
focal bone lesions (10 patients). This study was approved by the
research ethics committee, and informed written consent was obtained

Records identified by CBCT database searching

247 patients with:

- at least one not endodontically treated radiolucent periapical bone lesion from 2 mm to 7 mm
- OPT carried out during the earlier 40 days

- 51 patients without an endodontic infection clinically confirmed

or a periapical infection surgically removed

196 patients with 272 clinically/surgically confirmed AP and assessed by two radiologists

- 13 AP with no agreement on PAI values between the

two radiologists

259 AP with concordant PAI values between the two radiologists

- 25 AP with PAI 2-3

234 AP with PAI 1 or PAI 4-5

51 incisors 72 canines/premolars 111 molars

16 upper arch, 2-4.5 mm 31 upper arch, 2-4.5 mm 49 upper arch, 2-4.5 mm

11 upper arch, 4.6-7 mm 13 upper arch, 4.6-7 mm 16 upper arch, 4.6-7 mm
14 lower arch, 2-4.5 mm 18 lower arch, 2-4.5 mm 33 lower arch, 2-4.5 mm
10 lower arch, 4.6-7 mm 10 lower arch, 4.6-7 mm 13 lower arch, 4.6-7 mm

Selection of AP:
- only one lesion per patient
- better visual assessment (i.e. high image quality without motion or metal artifacts)
- shorter period of time between CBCT and OPT

10 AP for each arch and size 10 AP for each arch and size 10 AP for each arch and size

120 AP enrolled by CBCT by two radiologists, subsequently assessed by OPT by others three radiologists

Figure 1. A flowchart of the selection criteria for enrolling patients and AP.

JOE — Volume 43, Number 10, October 2017 Orthopantomography for Apical Periodontitis 1641
Clinical Research
Figure 2. Cutout OPT that shows both a tooth without the crown and the
other structures within the range of 8 mm mesially and distally from the
root apex.
from all patients. Moreover, 120 patients with a healthy root and peri-
apex (ie, the control group [the healthy group without AP]) were
selected using CBCT imaging also. They had the same mean age/sex
and the same number/subdivision of the teeth as the diseased group.
Each of the 240 patients (120 diseased and 120 healthy) underwent
an OPT first and a CBCT scan within 40 days of the OPT.
Devices
OPT was performed via the Orthoceph OC200 D (Instrumentarium
Dental, Tuusula, Finland). It was a digital orthopantomograph with a
rotation time of 17.6 seconds, 66 kV, and 4.5–6.8 mA. CBCT imaging
was performed via the NewTom 5G (QR srl, Verona, Italy) equipped
with a pulsed pyramidal X-ray beam (360 rotation), a very small focal
spot (0.3 mm), and an amorphous silicon flat-panel detector
(20  25 cm). The protocols used for imaging were named
TABLE 1. True Positives, False Positives, True Negatives, and False Negatives for Orthopantomography (OPT) in Relation to Cone-beam Computed Tomographic
(CBCT) Imaging
Diseased (PAI 4–5), n (%)
OPT
Positive (PAI 2–3 + PAI 4–5) 41 (34.1)
Negative (PAI 1) 79 (65.9)
Total 120 (100)
PAI, periapical index.
1642 Nardi et al.
Hi-Res-Regular and Hi-Res-Enhanced by the producer, lasting 26 and
36 seconds and comprising 360 and 480 basis image frames, respec-
tively. Furthermore, they had a small FOV (6  6 cm or 8  8 cm),
110 kV, and 7.1–14.3 mA. All CBCT volumes were reconstructed
with a 0.15-mm isometric voxel size.
OPT and CBCT images were displayed on a 20-inch medical
monitor with a 3-megapixel Barco display (Barco, Kortrijk, Belgium)
and 2048  1536 resolution. The software programs originally sup-
plied with the systems were used for image evaluation.
Study Design and Assessment of AP
The 120 AP lesions were divided into 60 lesions of the upper arch
and 60 lesions of the lower arch. In each arch, 30 small lesions from
2.0–4.5 mm and 30 large lesions from 4.6–7.0 mm were selected.
These, in turn, were divided into 3 groups of 10 in the incisor,
canine/premolar, and molar areas, respectively. Finally, the lesions
affecting the cortical bone were distinguished from those affecting
only the cancellous bone. The 120 patients with AP had not received
any root canal therapy; the presence of periapical infection was
confirmed either clinically or surgically.
AP was assessed using the periapical index (PAI) system of
Ørstavik et al (25) applied to CBCT imaging (28). PAI is a 5-score scale
based on periapical radiographs of histologically confirmed AP: 1,
normal periapical structures; 2, small changes in bone structure; 3,
changes in bone structure with some mineral loss; 4, periodontitis
with a well-defined radiolucent area; and 5, severe periodontitis with
exacerbating features. In the current study, a PAI of 2 and 3 and a
PAI of 4 and 5 were grouped together. Therefore, our PAI system was
divided into 3 scores: PAI 1, PAI 2 to 3, and PAI 4 to 5.
In CBCT imaging, only PAI 1 and PAI 4 to 5, corresponding to the
healthy group and diseased group, respectively, were selected. PAI
scores of 2 to 3 were discarded to avoid unclear or poorly defined
changes in the bone structure. AP was measured using a standardized
and reproducible method (29). It was oriented 3-dimensionally to
make the intersection between the sagittal and coronal planes coincide
with the longitudinal axis of the interested tooth. The axial plane was
automatically oriented perpendicularly to the other 2 planes. The di-
mensions of the AP lesions were recorded, taking into account the
largest measurement observed in 1 of the 3 planes.
Once all the diseased and healthy teeth were chosen on CBCT
scans, the corresponding OPT images were electronically cut by means
of the software originally supplied with the systems in order to display
only the dental root (no crown should be shown) and surrounding tis-
sues up to 8 mm mesially and distally from the root apex (Fig. 2). This
was done to avoid the observers being influenced by an eventual crown
treatment/disease or the overall status of the patient’s mouth. All 240
roots cut out from OPT were evaluated using the PAI system divided
into 3 scores: PAI 1, PAI 2 to 3, and PAI 4 to 5. PAI 2 to 3 scores
were included into AP as well as PAI scores 4 to 5. No image was
CBCT imaging
Healthy (PAI 1), n (%) Total
5 (4.2) 46
115 (95.8) 194
120 (100) 240
JOE — Volume 43, Number 10, October 2017
 Clinical Research
TABLE 2. Sensitivity, Specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), Diagnostic Accuracy, and Kappa Value for Orthopantomography
in Relation to Cone-beam Computed Tomographic Imaging
Anatomic area/lesion size Sensitivity Specificity PPV NPV Accuracy Kappa
Both arches 34.2 95.8 89.1 59.3 65.0 0.300
Upper arch, incisive area 15.0 95.0 75.0 52.8 55.0 0.100
Upper arch, canine 35.0 100 100 60.0 67.5 0.350
premolar area
Upper arch, molar area 20.0 95.0 80.0 54.3 57.5 0.150
Lower arch, incisive area 15.0 85.0 50.0 50.0 50.0 0.000
Lower arch, canine- 60.0 100 100 71.0 80.0 0.600
premolar area
Lower arch, molar area 60.0 100 100 71.4 80.0 0.600
Small lesions (2–4.5 mm) 20.0 95.8 70.6 70.6 70.6 0.193
Large lesions (4.6–7 mm) 48.5 95.8 85.3 78.8 80.0 0.495
Apical periodontitis were divided by the anatomic area and the size of the lesions.

discarded by OPT; no measurement of the size of the lesions was
performed by OPT.
In summary, 2 dental radiologists enrolled the 240 teeth/patients
using CBCT imaging (120 diseased and 120 healthy) so that the
diseased group had 10 AP lesions for each of the 3 anatomic areas
(incisor, canine/premolar, and molar) in both the upper and lower
arches and for each of the 2 sizes of lesions (2–4.5 mm and
4.6–7 mm). This was achieved in order to have unambiguous subdivi-
sions of the lesions for each area and size.
Observers and Statistical Analysis
All CBCT and OPT examinations were performed by the same tech-
nical staff with 10 years of experience in dental imaging to achieve stan-
dardization of the execution method. For both the diseased and healthy
groups, each root of the selected tooth was assessed by OPT indepen-
dently by 3 radiologists skilled in dental maxillofacial imaging (31, 18,
and 12 years of experience, respectively). They were appointed over
and above the 2 radiologists assigned to the selection of AP and were
blinded to any information about both the patient and the PAI value
of the CBCT examinations. The largest (ie, the most represented)
OPT PAI value was taken when the opinion was not unanimous. An
assessment in consensus was made if the 3 opinions differed from
each other.
Sensitivity, specificity, positive predictive value, negative predictive
value, and diagnostic accuracy for OPT images with respect to the CBCT
reference standard images were calculated. Moreover, the Cohen kappa
value was calculated to assess the agreement between OPT and CBCT
imaging. These analyses were fulfilled in the total sample and stratified
for both the size and area of the lesions.
In the whole sample, interobserver reliability for the OPT PAI sys-
tem–categoric variable defined by the 3-score scale (PAI 1, PAI 2–3,
and PAI 4–5) was also calculated using the Cohen kappa. Kappa values
of 0.01–0.20, 0.21–0.40, 0.41–0.60, 0.61–0.80, 0.81–0.99, and 1
represented slight, fair, moderate, substantial, almost perfect, and
perfect agreement, respectively. A P value #.05 was considered to be
statistically significant.
Results
Observer/Device Agreement
The Cohen kappa values showed a substantial agreement between
the 3 observers (observer 1 vs observer 2: k = 0.63; observer 1 vs
observer 3: k = 0.77; and observer 2 vs observer 3: k = 0.74). True
positives, false positives, true negatives, false negatives, sensitivity, spec-
ificity, positive predictive value, negative predictive value, diagnostic ac-
curacy, and kappa values for OPT images with respect to CBCT images
are provided in Tables 1 and 2. Only specificity and positive predictive
value had high values (95.8 and 89.1, respectively).
Assessment of AP
True positives (Table 3) were about one third of the cases
(34.2%), of which slightly more than half were underestimated as
PAI 2 to 3 (Fig. 3A–C). In the upper arch (Table 4), the true positives
were 15.0%, 35.0%, and 20.0% in the incisor, canine/premolar, and
molar area, respectively, and 0% (0/20) and 23.1% (3/13) for the
small and large lesions affecting just the cancellous bone, respectively.
In the lower arch (Table 5), the true positives were 15.0%, 60.0%, and
60.0% in the incisor, canine/premolar, and molar area, respectively,
and 23.1% (6/26) and 61.2% (11/18) for small and large lesions
affecting just the cancellous bone, respectively.
Analysis of the Errors
OPT generated 5 false positives, 4 of which were judged as PAI 2 to
3 and only 1 as PAI 4 to 5. Three of these false lesions were identified in
the lower incisor area (Fig. 4). False negatives comprised about two
thirds of the cases. Most of the AP lesions (43.0%, 34/79) were not
recognized in the upper and lower incisor areas.

TABLE 3. Synopsis of the True Positives (Apical Periodontitis Judged as Periapical Index 4–5 and Periapical Index 2–3) by Orthopantomography according to the
Anatomic Area, Size, and Bone Involvement of the Lesion
Anatomical area Lesion size Bone resorption type
Dental arch Incisor Canine/premolar Molar Small (2.0–4.5 mm) Large (4.6–7.0 mm) Cortical Cancellous
Upper arch 15.0 35.0 20.0 10.0 36.7 39.2 7.5
Lower arch 15.0 60.0 60.0 30.0 60.0 56.7 33.3
Both arches 15.0 47.5 40.0 20.0 48.3 47.9 20.4
Total 34.2 34.2 34.2
Cone-beam computed tomographic imaging was used as the reference standard. Data are reported as percentage values.

JOE — Volume 43, Number 10, October 2017 Orthopantomography for Apical Periodontitis 1643
Clinical Research

Figure 3. True positive. (A and B) Upper jaw CBCT imaging. AP of the size of 6.6 mm affecting the cortical bone (arrow) at the distobuccal root of the first molar.
(C) In OPT, the distobuccal root of the first molar was superimposed on the mesiobuccal root of the second molar; despite the large size of the lesion and the
involvement of the cortical bone, the AP appeared to be a small change in the bone structure with some mineral loss. Thus, it was underestimated as PAI 2 to 3.

Discussion
OPT showed low sensitivity (34.2), negative predictive value
(59.3), and diagnostic accuracy (65.0) and high specificity (95.8)
and positive predictive value (89.1) in the detection of AP. Furthermore,
the agreement between OPT and CBCT imaging was fair (k value = 0.30).
The best identified AP lesions were the large lesions located in the lower
canine/premolar and molar areas, whereas the upper and lower incisor
areas were the most difficult to assess. Our results proved that the recog-
nition of AP depended on both the anatomic area/size of the lesion and
the involvement of the cortical bone.
In the upper molar area, the air within the maxillary sinus, the
presence of numerous roots not orthogonal to the X-ray beam, and
the undulating morphology of the maxillary sinus floor in close connec-
tion with the root apex made it difficult to identify AP. These reasons
were only partly applicable to the premolar teeth and not applicable
to the canine teeth, which explains the better diagnostic accuracy of
AP in the upper canine/premolar area compared with the upper molar
area.
The AP lesions in the canine/premolar and molar areas were more
identifiable in the lower arch compared with the upper arch because the
roots in the lower arch were more orthogonal to the X-ray beam, there
was no nasal/sinusal air, and there was a lower superimposition of the
extraoral anatomic structures although the projection of the nerve fora-
men and canals can correspond to the periapical area.
In the incisor area, the superimposition of the cervical spine and
the skull base impaired the identification of the periapical area. The
other structures that undermined the identification of AP were the nasal
bone/cartilage/air and hard palate in the upper arch and, especially, the

TABLE 4. Assessment of the Upper Arch of the 60 Diseased Patients by Orthopantomography

Upper arch
Incisors Canines/Premolars Molars
2.0–4.5 mm 4.6–7.0 mm 2.0–4.5 mm 4.6–7.0 mm 2.0–4.5 mm 4.6–7.0 mm
OPT PAI Cor Can Cor Can Cor Can Cor Can Cor Can Cor Can Total
1 2/2 8/8 2/4 5/6 1/3 7/7 1/4 4/6 4/5 5/5 6/9 1/1 46/60
2–3 0/2 0/8 1/4 1/6 1/3 0/7 2/4 1/6 1/5 0/5 2/9 0/1 9/60
4–5 0/2 0/8 1/4 0/6 1/3 0/7 1/4 1/6 0/5 0/5 1/9 0/1 5/60
Can, cancellous bone; Cor, cortical bone; PAI, periapical index.
Cone-beam computed tomographic imaging was used as the reference standard. Apical periodontitis (AP) lesions were divided according to 3 anatomic areas (incisor, canine/premolar, and molar). Ten AP
lesions with a size of 2.0–4.5 mm and 10 AP lesions with a size of 4.6–7.0 mm were evaluated for each anatomic area. AP lesions were additionally subdivided between those affecting exclusively the cancellous
bone and those also involving the cortical bone.

1644 Nardi et al. JOE — Volume 43, Number 10, October 2017

TABLE 5. Assessment of the Lower Arch of the 60 Diseased Patients by Orthopantomography
Incisors
2.0–4.5 mm 4.6–7.0 mm
OPT PAI Cor Can Cor Can
1 1/2 8/8 4/6 4/4
2–3 1/2 0/8 1/6 0/4
4–5 0/2 0/8 1/6 0/4
Can, cancellous bone; Cor, cortical bone.
Cone-beam computed tomographic imaging was used as the reference standard. Apical periodontitis (AP) were divided according to 3 anatomic areas (incisor, canine/premolar, and molar). Ten AP lesions with
a size of 2.0–4.5 mm and 10 AP lesions with a size of 4.6–7.0 mm were evaluated for each anatomic area. AP lesions were additionally subdivided between those affecting exclusively the cancellous bone and
those also involving the cortical bone.
morphologic diversities of the mental fossa, simulating false lacuna
bone images in the lower arch (Fig. 4). In fact, in the current study,
the false positives amounted to 4.2%, 80% of which were located in
the incisor area. This disagreed with Estrela et al’s study (28). They
observed false positives in only 0.06% of the cases.
OPT showed lower sensitivity in the detection of small lesions
(2.0–4.5 mm) compared with large lesions (4.6–7.0 mm) because the
smaller lesions were recognized less frequently than the larger ones, as
already observed for periapical X-rays (30, 31). This indicated that the
size of the periapical radiolucency was a key point in the detection of
AP by OPT because small lesions were unlikely to amount to 30%–50%
of bone mineral loss, which represents the required threshold for the
radiographic identification of AP. Therefore, small lesions were not
generally detected and could be mistaken for physiological lacunae of
the cancellous bone, also taking into account the fact that the teeth in
our study were not endodontically treated.
The lower canine/premolar area for the small lesions and the
lower molar area for the large lesions were the areas in which the AP
Figure 4. False positive. At the level of the periapex of the lower incisor, in the
OPT the mental fossa simulated a radiolucent periapical bone lesion charac-
terized by changes in bone structure with mineral loss.
JOE — Volume 43, Number 10, October 2017
Clinical Research
Lower arch
Canines/Premolars Molars
2.0–4.5 mm 4.6–7.0 mm 2.0–4.5 mm 4.6–7.0 mm
Cor Can Cor Can Cor Can Cor Can Total
0/1 5/9 1/4 2/6 0/1 7/9 0/2 1/8 33/60
1/1 2/9 1/4 2/6 0/1 2/9 1/2 2/8 13/60
0/1 2/9 2/4 2/6 1/1 0/9 1/2 5/8 14/60
lesions were easier to identify. In the canine/premolar area, the limited
buccolingual bone thickness facilitated the recognition of the small le-
sions because bone demineralization of 30%–50% was more frequently
reached. On the contrary, bone mineral loss usually exceeded this
threshold value in large lesions. Thus, the latter were easier to identify
in the molar area than the canine/premolar area because of the lack of
anatomic structures (mental fossa, canal, and foramen) that can be
superimposed on the root apex. The root apex was placed more or
less close to the cortical bone, and the different buccolingual bone
thickness for the incisor, canine/premolar, and molar areas in the up-
per and lower jaws deeply influenced the percentage of bone deminer-
alization, which is a prerequisite for AP detection. The cortical bone had
a higher bone mineral content than the cancellous bone. Therefore,
cortical bone involvement, for the same anatomic area and size of the
lesion, resulted in easier detection of AP by OPT, as previously stated
for periapical X-rays (10–12).
The normal proximity of the root apex to the cortical bone in the
upper arch caused a higher involvement of the upper cortical bone than
the lower one. In contrast, the teeth of the lower arch had a smaller
number of roots, which were usually mesiodistally oriented and located
inside the cancellous bone, with no contact with the cortical bone.
Our results proved that digital OPT was an imaging technique with
a higher risk of underdiagnosis; 53.6% of true positives (only 34.2% in
aggregate) were underestimated as PAI 2 to 3. The present study was
compared with the only article that studied OPT and CBCT imaging
for the assessment of AP. Estrela et al (28) used a conventional (ie,
not digital) orthopantomograph and observed 45% of true positives,
84.9% of which were underestimated as PAI 2 or PAI 3. Nevertheless,
94.5% of the teeth investigated by Estrela et al were treated endodonti-
cally, whereas no root canal filling was enrolled in the current study.
The agreement between the observers was substantial. We hypoth-
esized that the lack of a higher grade of agreement could be caused by
the assessment being performed by using electronically cut OPT small
images. However, in our opinion, the visualization of the crowns in un-
treated roots, and especially the overview of the entire mouth, can influ-
ence the radiologic diagnosis of a healthy/diseased periapex.
In addition, OPT is recognized as being a technique with poor repro-
ducibility because of the difficulty in the patient’s positioning, morphologic
variations of the periapical area, bone mineralization, X-ray angulations,
and radiographic contrast, which influence OPT analysis (32, 33).
In the current study, 2 different CBCT image acquisition modes
(Hi-Res-Regular and Hi-Res-Enhanced) were used. We believe that this
choice did not affect the result of the study because both modes provided
high-resolution images at the highest mA values, and the voxel size used for
all of the reconstructions was always the same and as small as possible.
Our study was affected by several limitations. These were represented
by the recruitment of periapical bone lesions only between 2 and 7 mm,
Orthopantomography for Apical Periodontitis 1645
Clinical Research
discarding PAI 2 and PAI 3 in CBCT images, and examining just 3 anatomic
areas (incisor, canine/premolar, and molar) for each arch. The enroll-
ment of lesions smaller than 2 mm or larger than 7 mm should increase
the false negatives and the true positives, respectively. OPT assessment of AP
with CBCT PAI values of 2 or 3 should significantly increase the false
negatives too because we considered that the majority of AP cases would
be underestimated as PAI 1 (ie, the absence of a lesion).
We hope that further works will analyze AP for each individually
studied tooth, distinguishing completely radiolucent lesions from periap-
ical radiolucencies surrounded by sclerotic tissue. Gathering a large
number of untreated AP cases represents a real research challenge. At
present, only 2 articles (34, 35) have focused merely on teeth without
root canal treatments by comparing periapical X-rays and CBCT imaging.
Another weakness was represented by the clinical/surgical diag-
nosis of the lesions and, therefore, the choice of CBCT imaging as a refer-
ence examination. However, histologic analysis of AP is very difficult to
implement in clinical practice, and high-resolution CBCT imaging is
currently considered the most accurate examination for the assessment
of AP (25–27). Although in the present study OPT showed low sensitivity,
negative predictive value, and diagnostic accuracy in the detection of AP,
it cannot be replaced by CBCT imaging for any suspected periapical bone
lesion for radioprotection reasons.
An additional weakness was that we assessed OPT images in the
most difficult conditions (ie, being unable to visualize the whole
mouth). The scrap of OPT did not represent clinical reality. However,
this was our choice. We did not want to be influenced by any dental
treatment. In contrast, we wanted all the teeth investigated (ie, teeth
with and without AP) to appear radiologically healthy. Two comparative
studies are ongoing between untreated and treated AP and between the
evaluation of the root only and complete OPT.
In the follow-up of undetected AP by OPT before endodontic
treatment, a topic of discussion for future research is which imaging
technique is more appropriate among OPT, periapical X-ray, and
high-resolution CBCT imaging with a small FOV.
Conclusions
In our series, OPT showed high specificity and positive predictive
value, mainly for AP greater than 4.5 mm located in the lower canine/
premolar and lower molar areas. However, OPT was not generally an
accurate imaging technique for the detection of untreated AP because
of low sensitivity and negative predictive value, especially for AP lesions
smaller than 4.5 mm located in the upper and lower incisor areas.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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JOE — Volume 43, Number 10, October 2017