The Limitations of Periapical X-ray Assessment in Endodontic Diagnosis-A Systematic Review

Abstract

Diagnosis is a key aspect in endodontic treatment, in a decade where invasive interventions are misapprehended as social tendency instead of medical necessity. All diagnostic facets should be considered before intending the operative phase. Intraoral endodontic radiology-based diagnosis has been shown to be limited. Periapical X-ray is the most used endodontic imaging, yet it does not provide high accuracy. Traditionally, dentists have been trained to diagnose a cyst by certain aspects (size, shape and appearance); hence, an assumption that teeth are affected by "periapical cyst" were subjected to unnecessary extraction or apicoectomy. The aim of this systematic review is to critically appraise the publications that relate the histological diagnosis of a periapical lesion (considered the gold standard) to intraoral X-ray investigation. Ovid Medline, PubMed, ScienceDirect, Mendeley and Scopus were searched for English-language studies comparing periapical diagnosis obtained by using two techniques (histopathology and X-ray). Sixteen articles were included for the final analysis (qualitative and quantitative evaluation) out of which only two supported the statement that periapical diagnosis can be coherently assessed through periapical imaging. Although there is not enough evidence to deliver a definitive conclusion, there are many publications that refute the diagnosis of a cyst via periapical X-ray.

Keywords: apical periodontitis; cyst; endodontic diagnosis; granuloma; histology periapical radiology.

Figure 1

Flowchart of the search strategy indicating the number of articles and source.

Figure 2

Schematic of histological features of a periapical pocket and true cyst [92]. Lin et al. deduced that the reason for cysts causing failure in endodontics is not yet established. In their study, 9 out of 29 teeth with endodontic treatment and histological diagnosis of periapical cyst did not show periapical imaging changes at the time the conventional RCT was performed [42]. The study does not mention whether there was a coherent protocol carried out by trained specialists, and since the absence of periapical radiolucencies does not certify the absence of a periapical pathology [93,94], their conclusions may be spurious. On the other hand, the presence of periapical radiolucencies neither certifies an existing disease, but according to other studies, these imaging findings can also mark the presence of a scar tissue that does not require further treatment [95,96].