Review Article

Artificial Intelligence in Endodontics: A Narrative Review

Parvathi Sudeep, Paras M. Gehlot, Brindha Murali, Annapoorna B. Mariswamy
Department of Conservative Dentistry and Endodontics, JSS Dental College and Hospital, JSS Academy of Higher Education and Research (JSSAHER), JSS Medical
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Institutions Campus, Mysuru, Karnataka, India

Abstract
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Aim: With the help of developments in artificial intelligence (AI), picture archiving systems, and computer-aided diagnostic systems,
dentists have been able to augment the quality of treatment and ensure a favorable outcome, by improving and facilitating the delivery
of appropriate dental care. There has been a breakthrough in designing the diagnosis, treatment plans, and predicting prognoses recently,
which has helped to explore newer options for better treatment. Materials and Methods: A literature search was conducted using
MeSH terms in a variety of databases, including PubMed, Cochrane, Scopus, and Web of Science, to gather information on “Artificial
intelligence (AI) in endodontics.” Unpublished data, literature written in other languages, and articles with only abstracts were discarded.
Forty-one relevant articles were included. Results: Since there were not many papers referring to AI in endodontics, papers published
relating to AI in dentistry were also referred. The search showed that the use of AI in dentistry, specifically in endodontics, has enormous
promise. Although useful, AI has its disadvantages as well as the need for long-term studies. Conclusion: AI, consisting of a sequence
of algorithms, work on a concept that mimics the human brain and thinking. AI in endodontics has been used widely in locating apical
foramina, identifying periapical pathologies, diagnosis of vertical root fractures, evaluating the outcome of regenerative procedures and
retreatments, and assessment of root morphologies and difficulties associated with canal preparations. Being a potential game changer
and beginning something called a “fourth industrial revolution,” AI has what it takes to revolutionize endodontics with time.

Keywords: Artificial Intelligence, Deep Learning, Endodontics, Machine Learning, Neural Networks
Received: 06-12-2022, Revised: 12-01-2023, Accepted: 13-01-2023, Published: 28-04-2023.

Introduction “Father of Artificial intelligence,” organized a conference

Digitalization in dentistry has increased remarkably over
the last two decades. In most developing countries, the
shortage of medical and dental professionals demands the
need for technology, especially artificial intelligence (AI)
software. This can reduce expenses, time, the need for human
knowledge, and the number of medical errors.[1] A model
designed to work almost identically to the human brain has
been an enigma for a lot of researchers and scientists over
the years. Their constant effort and hard work resulted in
the evolution of “Artificial Intelligence.”[2] The term AI,
explains how, through technology, a machine or software,
may replicate human intellect to do particular tasks.[3]
In 1955, John McCarthy coined a term which explained
the possibility of machines to carry out activities that
can be encompassed within “intelligent” tasks.[4] In
the year 1956, McCarthy, also widely recognized as the
in Dartmouth, which paved the way for the extensive
research on AI, from 1950s to 1970’s.[5]
AI can be described as “a field of science and engineering
concerned with the computational understanding of what
is commonly called intelligent behavior, and with the
creation of artefacts that exhibit such behavior.”[6]
Today, dentistry has abundant data which are acquired
from a patient at each step of the treatment process.
This poses a challenge for obtaining, examining, and
utilizing the knowledge gained. The vast amount of
Address for correspondence: Dr. Paras M. Gehlot,
Department of Conservative Dentistry and Endodontics, JSS Dental College
and Hospital, JSS Academy of Higher Education and Research (JSSAHER),
JSS Medical Institutions Campus, Sri Shivarathreeshwara Nagara, Mysuru
570015, Karnataka, India.
E-mail: dr.parasmullj@jssuni.edu.in

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DOI: How to cite this article: Sudeep P, Gehlot PM, Murali B, Mariswamy
10.4103/jioh.jioh_257_22 AB. Artificial intelligence in endodontics: A narrative review. J Int
Oral Health 2023;15:134-41.

      
134 134
© 2023 Journal of International Oral Health | Published by Wolters Kluwer - Medknow
 Sudeep, et al.: Artificial intelligence in endodontics

acquired knowledge can be deemed necessary to solve databases were utilized for identifying the articles with the
complex clinical problems. The evolution of AI will likely required information.
not replace dentists, but would be a perfect addition to
accentuate their expertise and support them. This can Materials and Methods
indeed help a dentist to adapt to a new level of accuracy
The databases of PubMed/Medline and other sources
in diagnosis and prediction of outcomes, thus, rendering
which related with AI in endodontics, were thoroughly
better patient experience and treatment success.[7]
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searched from August 2021 to September 2022. The

The lack of standardization of treatment protocols can also following MeSH and keywords were used in the search:
pose a problem when newer technologies are used. Hence, “Artificial intelligence, Deep learning, Endodontics,
the use of AI can also be beneficial in understanding and Machine learning, and Neural networks.”
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identifying conditions wherein the said technology can be

applied.
To understand how AI can be utilized, key aspects such
as machine learning (ML), neural networks (NN), and
genetic algorithms have to be acknowledged. Previous
studies on the use of AI in dentistry explains how AI
can be an advantage in the various aspects of patient
management and treatment strategies.
The purpose of this narrative review was to understand about
the application of AI in endodontics and the effects that any
future advancements in this area might have in this field of
dentistry. In light of the paucity of research in this area, the
review here is based on articles taken from internationally
published research literature and review articles, based on a
specific set of key words which emphasized on the published
information about AI, its various applications in the field of
Endodontics and regarding its limitations as well. Computer
Eligibility criteria
The PICOS principles were followed while choosing the
inclusion criterion. The articles searched and included
were the following:
- All English-language papers with full-text abstracts
- Articles discussing the relationship between AI and
applications in endodontics
- Articles published since the use of AI in dentistry
- Studies (in vitro and in vivo) that explored the use of AI
in endodontics
The exclusion criterion included case series/reports, articles
written in languages other than English, unpublished
data, and unrelated studies. Dual publications were also
turned down. Possible outcomes were presented once the
data were examined and compared with each particular
paper under debate. On the retrieved data, no statistical
analysis was performed [Figure 1].

Search strategy
N = 251

Articles from PubMed Articles from other sources

x = 79 (Scopus, Cochrane, Web of Science)
y = 172

After exclusion of Duplicates and Foreign languages

z = 62

Number of articles
excluded (21)

Reasons for exclusion

Full text articles included
1. Full text not available n = 41
(14)
Articles on AI in dentistry
2. Editorials (7)
n = 22

Articles on AI in endodontics
n = 19

Figure 1: PRISMA flowchart

      Journal of International Oral Health ¦ Volume 15 ¦ Issue 2 ¦ March-April 2023 135  

 Sudeep, et al.: Artificial intelligence in endodontics
Results
Study recognition and preference
The initial electronic and manual search yielded 251
results the PubMed, Scopus, Cochrane and Web of
Science databases (2021–2022). On initial screening and
application of inclusion criteria 62 articles were chosen
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based on name, abstract, and whole text. Finally, the
narrative reviews, comprehensive reviews, umbrella
reviews, and clinical trials that met the criteria were
chosen.
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Characteristics of included studies
Randomized controlled trials, in vitro and in vivo research,
and reviews were all included. Forty-one papers that
met the requirements for inclusion were included in our
review. Out of these, 22 papers covered AI in dentistry
and 19 papers examined the applications of AI in
endodontics.
Assessment and quality of proof in studies included
The literature that is currently available in the research
(reviews, in vitro, and in vivo) all agree about the beneficial
impact of application of AI in the various fields of
dentistry. On this topic though, there were no meta-
analyses and the number of clinical trials appears to be
negligible. Future clinical research is crucial to understand
how AI can be applied in every aspect of dentistry and
especially, endodontics. Almost all studies employ the
best practices, and all relevant findings are presented in a
consistent, verified, and reliable manner.
Figure 2: Artificial intelligence (AI) in dentistry
136 136  Journal of International Oral Health ¦ Volume 15 ¦ Issue 2 ¦ March-April 2023
Discussion
AI methodologies used in dentistry
The composition of the technology used in AI consists
of a neural network pattern almost identical to human
brains.[8] This neural design imitates human thinking,
and is composed of firmly interconnected neurons.
To solve specific problems, these work together as a
“data-processing system.”[9] There has been amazing
developments in the application of neural networks in
dentistry over the years.
Conventional computer programs such as “expert
systems” use complicated formulas and numerical models
to accomplish computing and achieve an array of plans
formulated on the given programming patterns. At
present, AI research has entered a distinct field of study
known as “machine learning (ML).”[10] There are other
key areas of research included in AI as well [Figure 2].
Machine learning
Machine learning is an AI subset, that uses algorithms
to anticipate outcomes based on a dataset.[3] These
algorithms are used to discover data’s inherent statistical
patterns and structures.[11] Machine learning aims to make
it easier for machines to learn from and solve issues from
large data sets without the need for human intervention.[3]
For training, ML makes use of computational tools and
data (experience). It does so to assess the data presented
as input and to process the knowledge gained from former
experiences. “Experience gathering” or “active learning”
is at the heart of machine learning. In practice, this
 Sudeep, et al.: Artificial intelligence in endodontics
means that computers learn from their incoming data and
improve their properties by learning from their mistakes,
all without the requirement for complex programming or
the building of a numerical model.[12]
In a neural network, the number of neurons, levels or eras;
membership function selections in fuzzy logic; the size
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of the population, selection methods, rate of mutations,
and crossovers in optimization techniques; and hybrid
techniques that use fuzzy logic or neural network or both
inevitably necessitate parametric tweaking related to the
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objective scheme.[13] Various ML models, such as the
“Genetic Algorithm (GA),” “Artificial Neural Network
(ANN),” and “Support Vector Machine (SVM),” may
“learn” and “be trained” from provided data to perform
a variety of tasks.[14]
Neural networks
A prominent sort of ML model is neural networks, which
are made up of a series of algorithms that calculate signals
using artificial neurons. Its goal is to develop neural
networks that mimic the human brain.[3]
Artificial neural networks are a collection of a configurable
number of “artificial neurons or nodes” that are connected
in a systematic layering structure that includes an input
sequence, one or maybe more hidden units, and an output
vector. With the exception of the input nodes, each
neuron receives numerous weighted inputs and produces
an output that is usually an arbitrary expression of the
inputs.[15] By altering these weights regularly, a neural
network “learns.”
Their capacity to apply what they’ve learned from previous
representative cases, analyze non-linear data, deal with
unspecific data, and generalize; allowing the model to
be exposed to new information, has made them a very
appealing investigative tool. They have been employed
in clinical diagnosis, radiology and histopathology
image processing, intensive care data interpretation, and
waveform analysis.[7]
“Convolutional neural networks (CNNs)” for image
classifications and “dilated convolutional neural networks
(DCNNs)” for sematic scene partitions are two types of
ANN that have recently gained popularity.[16] The two
primary types of CNNs used for volumetric prediction
in particular are “Tiramisu” and DCNNs. “U-net” and
other Tiramisu-based models are particularly good at
estimating dosage ratios that are spatially compatible with
anatomy, such as the prostate dose volume. DCNNs also
utilize the complexities that bypass information during
the encoding process to help broaden their perspectives
and visual field.
DCNNs are likely to become more common in the
prediction of the amount of exposure for head and neck
intensity modulated radiation therapy as they can help
      Journal of International Oral Health ¦ Volume 15 ¦ Issue 2 ¦ March-April 2023
estimate the dose that is mobile with respect to anatomy,
such as in patients with head and neck cancer.[17]
Deep learning
Deep learning is a part of ML that process information
using a deep neural network with multiple computational
layers. To enhance feature identification, deep learning is
utilized to develop a computational model that detects
patterns automatically.[18] They employ simple features
such as line, edge, and texture to study complex systems,
pathologies, or entire organs.[19,20] The difference between
deep learning and NNs is similar to that between feed
forward NNs and feed backward NNs. Deep learning has
a more complicated technique of connecting layers, as
well as a higher number of neurons than other networks
to demonstrate sophisticated programs, more processing
capacity to train, and a preprogrammed character
recognition feature.[21]
Clinical decision support systems (CDSS)
“Any computer system that aids healthcare providers
in making clinical choices by handling clinical data or
medical knowledge” is referred to as a CDSS.[22] The
inference engine (IE), knowledge base (KB), explanation
module, and working memory are the four essential
components of most CDSS.[16] Any such system’s primary
component is the IE, which stores information about the
patient and draws conclusions about specific illnesses
from it. The knowledge used by IE is represented by the
knowledge base and tools that have been built to aid in
the accumulation and elaboration of this knowledge.
The working memory is the database where the acquired
data are saved or may take the shape of a signal. The
final component, the explanation module, is in charge of
justifying the IE’s conclusions when applying the KB’s
information to patient data and records in the working
memory.[23]
Fuzzy logic
The branch of logic known as fuzzy logic recognizes and
proves that everything is a matter of degree.[16] It offers
quite useful explanation for a hazy problem. Fuzzy logic
is a very simple ML technique that is also flexible to use.
The following are the four major components of the fuzzy
logic system:
(i) “Rule Basse,” (ii) “Fuzzification,” (iii) “Inference
Engine,” and (iv) “Defuzzification.”[2]
Fuzzy logic aims to emulate human reasoning abilities
when dealing with unclear issues.
Evolutionary computation
Evolutionary computation is a disputed dynamic
programming strategy for general-purpose problems based
on the generally accepted “neo-Darwinian” perspective,
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 Sudeep, et al.: Artificial intelligence in endodontics
which incorporates basic Darwinian evolutionary theory,
Weismann’s selectionism, and Mendel’s genetics. The
genetic algorithm is the most extensively used evolutionary
algorithm.[24] It uses various methods including mutation,
inheritance, selection, and crossover to find a better remedy.
The key advantage of genetic algorithms over traditional
methods is that they are based on conflict resolutions rather
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than numerical correlations, as used by traditional methods.
It is simple to use despite being a powerful upgrading
device, because it is based on normal standards.[2]
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Hybrid intelligent systems
Each AI technique has its own set of advantages and
disadvantages. Combining systems enable common sense
to be accommodated, knowledge to be extracted from
original assets, “human-like” cognitive mechanisms to
be used, ambiguity and inaccuracy to be dealt with,
and learning to keep up with the rapidly evolving and
unfamiliar environment. Developing fuzzy systems
for ANNs and vice versa, and Genetic Algorithms for
autonomously instructing and designing NNA structures
are just a few of the hybrid systems accessible.[7]
Endodontics and applications of AI [Figure 3]
Identification and diagnosis
AI has been used to detect and diagnose a wide range
of physiological and pathological abnormalities in the
teeth.[25] AI has also been shown in studies to be an effective
tool for understanding and spotting anomalies, as well as
for formulating the required treatment strategies.
Figure 3: Artificial intelligence models in endodontics
138 138  Journal of International Oral Health ¦ Volume 15 ¦ Issue 2 ¦ March-April 2023
Periapical pathologies
Radiographically, periapical pathosis can be detected
as periapical radiolucencies. On periapical radiographs,
panoramic radiographs, and cone-beam computed
tomography scans (CBCT), apical periodontitis is
frequently discovered as an unintentional finding. CBCT
produces high-resolution three-dimensional (3D) images
that are free of the deformation and superimposition
of bone and dental structures that might occur with
traditional radiography.[26] A dentist knows that it is always
crucial to have a dependable instrument that can assist
in making informed selections and treatment planning.
A study looked at how an AI-based CNN model may
be used to detect periapical lesions on radiographs, and
found that the model performed well, with high sensibility
and intermediate precision. For dentists, this approach
could be very useful in identifying and detecting periapical
lesions.[27]
Another model’s accuracy in recognizing periapical
diseases on CBCT images was astounding, with a 92.8%
accuracy rate.[28] An AI-based model was utilized in another
investigation to detect the existence of a periapical lesion.
There were unexpected findings, with a mean accuracy of
roughly 77.2%, and the authors stated that the reference
method was better than this approach, but that the results
may be improved in future work utilizing optimization
techniques.[29]
Setzer et al.[30] concluded that a DL algorithm trained in a
constrained CBCT setting produced high lesion detection
accuracy. Enhanced versions of AI may improve overall
voxel-matching accuracy, thus, revealing an accuracy of
93% for this study.
Endres et al.[31] found that the rate of detection of
periapical radiolucencies by 24 oral and maxillofacial
surgeons was similar to using a DL algorithm model. The
experiments revealed that adopting AI systems can lessen
the differences between examiners and bias.
Poswar et al.[32] analyzed the variations in gene expression
between a periapical cyst and a periapical granuloma
using a “multilayer perceptron neural network” for gene
categorization. The research had its own set of constraints.
Zheng et al.[33] compared a morphologically restricted
Dense U-Net with known clinical image analysis
approaches in terms of lesion diagnosis efficiency and dice
coefficient indices of a multilabel segmentation. Despite
the small size of the sample, the researchers found that the
novel deep learning strategy increased CBCT segmentation
and the precision of pathological identification.
Root fractures
“Vertical root fractures (VRFs)” are a very uncommon
occurrence in endodontically treated teeth. VRFs
are found in 3.7%–30.8% of teeth that have received
 Sudeep, et al.: Artificial intelligence in endodontics
endodontic therapy, according to studies.[34] Determining
VRFs on radiographs is difficult and may necessitate the
use of more advanced technology.
Johari et al.[35] performed research on the creation of an
AI-based model utilizing a PNN framework for detecting
VRFs on both intact and endodontically treated teeth using
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periapical radiographs and CBCT images. In comparison
to periapical radiographs, the model demonstrated to be
quite effective in diagnosing VRFs on CBCT images, with
an accuracy of 96.6%.
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CNNs, according to Fukuda et al.,[36] could be a viable
approach for detecting and measuring VRFs on
panoramic radiographs. In a study by Kositbowornchai
et al.,[37] who employed a probabilistic neural network
design to determine if a tooth root was sound or had a
vertical root fracture, the accuracy was 95.7%.
Root canal and root morphology
For a successful non-surgical root canal therapy, dentists
must first understand and identify root canal anatomy
and root morphologies. AI can assist in recognizing any
morphological irregularities as well as identifying errors
in locating new canals.
On panoramic radiographs, Hiraiwa et al.[38] investigated
the diagnostic efficacy of a DL system for categorization of
the root morphology of mandibular first molars. On CBCT
images, distal roots were investigated for the occurrence of
a single or additional root. For determining whether distal
roots were solitary or had supplementary roots, the DL
system exhibited a diagnostic reliability of 86.9%.
Lahoud et al. used the CNN technique to automate
3-dimensional tooth segmentation. In a rapid, efficient,
and reliable clinical benchmark, the authors analyzed 433
CBCT radiographic segmentations of teeth and found
that AI performed as well as a human operator but at a
considerably quicker pace.[39,40]
Working length determinations
The selection of the correct working length (WL) is
critical to ensuring successful root canal treatment
outcomes. Instrumentation beyond the apical foramen,
flare-ups, periapical foreign body reactions, and poor
microbiological control are all common consequences
of inadequate WL determination.[41] Finding the apical
foramen and estimating the WL can be done in a variety
of ways, including radiography, digital tactile sense, and
patient’s responses to a file or paper point.[42] The use
of digital technology has demonstrated both benefits in
terms of finding the apical foramen and drawbacks in
terms of mistakes. As a result, investigations on the use of
ANN to estimate the correct WL of teeth have been done.
In a human cadaver model, Saghiri et al.[41] used an
artificial neural network (ANN) method to determine
      Journal of International Oral Health ¦ Volume 15 ¦ Issue 2 ¦ March-April 2023
the working length and demonstrated an outstanding
accuracy of 96%, which is higher than the accuracy of
expert endodontists (76%). These findings matched those
of another study by the same author and his associates,
who used feature extraction processes from radiographs
before processing the data with an ANN. The study found
that finding the minor apical foramen was 93% accurate.[43]
Re-treatment predictions
CBS stands for “case-based reasoning,” which defines
the practice of coming up with solutions to queries
and doubts based on previous encounters with similar
challenges.[40] Campo et al.[44] used CBS to predict the
results of nonsurgical root canal retreatment, as well as the
associated risks and benefits. The system gave the data on
whether or not retreatment should be conducted, and also
provided the statistics on the efficiency of the procedure
done earlier, the risks involved, and the recall periods. The
system’s merit is that it may be able to properly forecast the
retreatment outcome. But the technique had a drawback
of relying too much on the data’s information, and not
analyzing possibilities from every perspective.
Regenerative endodontic procedures
Using the neuro-fuzzy inference technique, Bindal et al.
examined dental pulp stem cells in multiple rejuvenation
treatment modalities. This approach predicted the result
of a simulated clinical scenario by assessing the stem
cell vitality after bacterial lipopolysaccharide treatment.
Throughout several regenerative regimens, the neuro-
fuzzy interpretation method was employed to predict cell
viability, following microbial infection. The researchers
used neuro-fuzzy inferencing, which could be adjustable,
to test the outcome’s accuracy in forecasting stem cell
survival after pathogenic invasion.[40,45]
Shortcomings and gaps in AI and endodontics
Though AI has been found to be beneficial in a lot of
aspects, there have been downfalls associated with it, due to
which it has not been widely implemented in endodontics.
Some of the shortcomings and disadvantages associated
include the following:[40,46]
i. The health care system requires a standard
programming technology for organizing appointments,
managing patients and for periodic recall. This system
also has to be updated regularly to keep up to the
changes occurring in the healthcare sector.
ii. The cost of setting up an AI based system in
independent clinics would not be feasible.
iii. The availability of patient data using the individual
health records can prove to be useful in informing
the dentists about adverse reactions in respect to the
use of certain drugs and/or the adjustments required
in the treatment protocol. But this can also be a
139  
 Sudeep, et al.: Artificial intelligence in endodontics
disadvantage, as misuse of information can also occur
through the AI channels.
iv. There is no protocol that has been devised yet to
provide a precise diagnosis, that would affect the
prediction of outcomes or determination of the
prognosis. The clarity of this diagnosis would be
based on the clinical findings.
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v. Dynamic navigations in endodontic surgery can be
improved with the help of AI. Very minimal number
of studies look into these techniques and it is highly
recommended that further studies be done to check and
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assess robotically guided placement in endodontics.
vi. The complexity of the applications can be
misinterpreted by individuals and dentists who have
not been trained in AI.
vii. Data in endodontics can be often used for both
education and evaluation, leading to “data snooping
bias.”
viii. The results of AI in endodontics are not readily
significant as AI can give a single outcome as an
answer, where multiple outcomes could be present.
The limitation of this review is the constrained search
period (August 2021 to September 2022). Also, papers
with abstracts only and published in foreign languages
were not included. It is interesting to note that, a few more
articles related to AI in endodontics have been added to
the literature lately.
Conclusion
With inter-disciplinary dentistry becoming more popular
in the coming decades, it is indeed important to assess the
worth of AI and its applications in endodontics. The fate of
Endodontics, which is a highly researched subject, can be
changed by the incorporation of modified bioengineering
components like AI. The impact of AI in integrating the
various areas of knowledge can prove to be beneficial in
upgrading patient care. The combination of conventional
methodologies with AI technology can help in minimizing
the potential errors in interpretation and can indefinitely,
be adopted into routine clinical practice with ease.
Acknowledgement
Nil.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Authors contributions
PS and PG conceived the idea and study design. PS
performed the literature search and the extraction of
data. PS drafted the article. PG, BM and AM reviewed
the article.
140 140  Journal of International Oral Health ¦ Volume 15 ¦ Issue 2 ¦ March-April 2023
Ethical policy and Institutional Review board statement
Not applicable.
Patient declaration of consent
Not applicable.
Data availability statement
Not applicable.
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