Comparative Evaluation of Cone-beam Computed Tomography versus Direct Surgical Measurements in the Diagnosis of Mandibular Molar Furcation Involvement

Emerging Applications of Digital Technologies for Periodontal Screening, Diagnosis and Prognosis in the Dental Setting

AIM

To comprehensively review digital technologies (including artificial intelligence, AI) for periodontal screening, diagnosis and prognosis in the dental setting, focusing on accuracy metrics.

MATERIALS AND METHODS

Two separate literature searches were conducted for periodontal screening and diagnosis (part I, scoping review) and prognosis (part II, systematic approach). PubMed, Scopus and Embase databases were searched.

RESULTS

In part I, 40 studies evaluated AI and advanced imaging on different substrata. The combination of AI with 2D radiographs was the most frequently investigated and demonstrated a high level of periodontitis detection and stage definition. In part II, eight studies, identified as having a high risk of bias, tested supervised machine learning models using 6-74 predictors. The models demonstrated variable predictive accuracy, often outperforming traditional risk assessment tools and classical statistical models in the few studies evaluating such comparisons.

CONCLUSIONS

AI and advanced imaging techniques are promising for periodontal screening, diagnosis and prognosis in the dental setting, although the evidence remains inconsistent and inconclusive. In addition, AI-driven analysis of 2D radiographs (for diagnosis and staging of periodontitis), neural networks and the aggregation of multiple algorithms (for predicting tooth-related outcomes) appear to be the most promising approaches entering clinical application.

Comparison of the Tomographic, Clinical Presurgical, and Intrasurgical Assessments of Furcation Involvement in the Lower Molars

This cross-sectional study compared cone-beam computed tomography (CBCT) measurements with clinical presurgical and intrasurgical measurements in the lower molars with furcation involvements (FIs). The sample consisted of 22 lower molars diagnosed with FI. The presurgical clinical examination included assessments of the probing depth, clinical attachment level, and horizontal bone loss (H-BL). Tomographic and intrasurgical measurements were taken to evaluate the vertical bone loss (V-BL), the distance of the cementoenamel junction to the base of the bone defect (CEJ-B), the horizontal bone loss (H-BL), root trunk length (RT), and furcation entrance width (FEW). Statistical analysis was performed, and values with p < 0.05 were considered statistically significant. The study of horizontal bone involvement showed a high level of agreement between presurgical, intrasurgical, and tomographic assessments. Strong correlations were found between intrasurgical and CBCT measurements for H-BL and furcation entrance width. Regarding the intrasurgical evaluation, class I FI was more prevalent, while class II FI was more frequently identified in CBCT evaluations. H-BL was significantly greater in class II FI compared to class I lesions. Moreover, the V-BL was greater in subclass B FI than in subclass A lesions. We found a strong correlation between horizontal furcation involvement measurements from CBCT and intrasurgical exams. CBCT was more accurate in assessing furcation morphology and vertical bone defects, making it a valuable complementary tool for decision-making in the surgical management of furcation involvements.

Accuracy of Ionizing-Radiation-Based and Non-Ionizing Imaging Assessments for the Diagnosis of Periodontitis: Systematic Review and Meta-Analysis

AIMS

To evaluate the diagnostic accuracy of periapical, bitewing or panoramic radiographs (standard 2D radiographs) in detecting and monitoring periodontitis (PICO 1) and to assess the clinical relevance of alternative and emerging diagnostic methods (e.g., cone-beam computed tomography [CBCT], magnetic resonance imaging [MRI], ultrasound imaging [USG]) compared to standard 2D radiographs or clinical/intra-surgical examination in the diagnosis and surveillance of the disease (PICO 2).

MATERIALS AND METHODS

A systematic literature search was conducted through MEDLINE EMBASE, Scopus and Cochrane Library. When feasible (n > 2 comparable studies), a meta-analysis of diagnostic accuracy was performed.

RESULTS

For PICO 1, 26 studies met the inclusion criteria. Pooled-data analysis from three studies showed a sensitivity of 0.77 (95% confidence interval, CI: 0.66-0.85), specificity of 0.76 (95% CI: 0.64-0.84) and accuracy of 0.82, with a diagnostic odds ratio (DOR) of 137.99 (95% CI: 6.99-368.90). For PICO 2, 51 articles were included dealing with different techniques. The meta-analysis for CBCT (three studies) showed a pooled sensitivity and specificity of 0.98 (95% CI: 0.96-1.00) and 0.98 (95% CI: 0.95-1.00), respectively, and a diagnostic accuracy of 0.99 in the detection of furcation involvement compared to intra-surgical measurements.

CONCLUSIONS

Standard 2D radiographs appear to have adequate diagnostic accuracy for periodontitis, while CBCT is highly sensitive and specific to detect and classify furcation involvement. The role of non-ionizing techniques (MRI and USG) in diagnosing periodontitis remains under investigation.

Correlation between the Middle Mesial Canal and Furcation Radiolucency in Mandibular Molars

Introduction

The middle mesial canal (MMC) of mandibular molars is of particular interest in endodontics due to its complexity. This study investigated the association between MMC presence in first and second mandibular molars and the radiolucency in the furcation area using cone-beam computed tomography (CBCT) scans.

Materials and Methods

CBCT scans of 400 patients referred to the largest radiology center in Kerman City from January 1, 2022, to January 1, 2023, were examined. All CBCT scans were assessed for radiolucency in the furcation area and the presence of MMC. Variables, including age, gender, tooth number, and MMC presence were recorded. Chi-squared tests and logistic regression analyses were employed to compare MMC frequency and its impact on furcation radiolucency.

Results

Of 201 examined teeth, 37 (18.4%) had MMC, and 23 (11.4%) exhibited furcation radiolucency. However, teeth with a mesial canal showed a higher prevalence of furcation lesions compared to those without (38% vs. 5.2%) (P<0.001). A significant association was observed between a mesial canal and furcation radiolucency, with odds of furcation radiolucency at 12.7 after controlling for age and gender (P<0.001).

Conclusion

A strong association exists between MMC presence in first and second mandibular molars and furcation radiolucency, unaffected by age and gender.

Application of artificial intelligence-based detection of furcation involvement in mandibular first molar using cone beam tomography images- a preliminary study

BACKGROUND

Radiographs play a key role in diagnosis of periodontal diseases. Deep learning models have been explored for image analysis in periodontal diseases. However, there is lacuna of research in the deep learning model-based detection of furcation involvements [FI]. The objective of this study was to determine the accuracy of deep learning model in the detection of FI in axial CBCT images.

METHODOLOGY

We obtained initial dataset 285 axial CBCT images among which 143 were normal (without FI) and 142 were abnormal (with FI). Data augmentation technique was used to create 600(300 normal and 300 abnormal) images by using 200 images from the training dataset. Remaining 85(43 normal and 42 abnormal) images were kept for testing of model. ResNet101V2 with transfer learning was used employed for the analysis of images.

RESULTS

Training accuracy of model is 98%, valid accuracy is 97% and test accuracy is 91%. The precision and F1 score were 0.98 and 0.98 respectively. The Area under curve (AUC) was reported at 0.98. The test loss was reported at 0.2170.

CONCLUSION

The deep learning model (ResNet101V2) can accurately detect the FI in axial CBCT images. However, since our study was preliminary in nature and carried out with relatively smaller dataset, a study with larger dataset will further confirm the accuracy of deep learning models.

Cone-Beam Computed Tomography (CBCT)-Based Diagnosis of Dental Bone Defects

Cone Beam Computed Tomography (CBCT) has completely changed the way that bone disorders are diagnosed and treated, especially in the dental and maxillofacial domains. This article examines the diverse applications of computed tomography (CBCT) in the diagnosis and treatment of facial trauma, including mandibular, dentoalveolar, and other facial fractures, as well as bone abnormalities like dislocations and fractures. CBCT is useful for a wide range of dental conditions and greatly improves diagnostic accuracy in periodontics, orthodontics, endodontics, and dental implantology. Additionally, a comparison between CBCT and conventional imaging methods was conducted, emphasizing the latter's inferior 3D imaging capabilities, allowing for more precise treatment planning and better patient outcomes with CBCT. Although CBCT has many benefits, it also has some drawbacks, such as requiring specific training for accurate interpretation, cost considerations, and a higher radiation exposure than with traditional dental X-rays. In order to optimize benefits and reduce risks, the conclusion highlights CBCT's revolutionary influence on clinical practice while arguing for its prudent and responsible application.

Assessing the Accuracy and Reliability of Cone-Beam Computed Tomography (CBCT) in Diagnosing Grade II and III Furcation Involvement Compared to Traditional Clinical Examination Methods

Introduction Chronic periodontal diseases can lead to bone defects and tooth loss, making accurate diagnosis essential for treatment. Various methods are used for diagnosing furcation involvement, with clinical examination and cone-beam computed tomography (CBCT) being the most effective. CBCT produces reliable images with submillimeter resolution, revealing marginal bone contours and furcation defects. Limited studies show that CBCT is more precise than clinical detection for diagnosing furcation involvement. Therefore, CBCT technology can be considered as an adjunct method for furcation involvement detection. This study tests the accuracy and efficiency of CBCT and clinical examination in detecting furcation involvement. Material and methods The study included 25 patients (68 molars) with generalized periodontitis of stage II to IV, Grade B and C. Inclusion criteria required at least two intrabony defects with probing depth > 6mm in both jaws and criteria of periodontitis in at least 30% of the teeth present. Results The study compared clinical examination and CBCT readings for measuring maxillary and mandibular teeth furcation involvement. The results show significant differences between clinical and CBCT measurements of maxillary teeth furcation involvement, particularly in specific areas and types of furcation involvement. In contrast, there were significant differences between clinical and CBCT readings for only a few measurements of mandibular teeth furcation involvement. Therefore, the study suggests that CBCT imaging may be beneficial for accurate diagnosis and treatment planning in cases of furcation involvement in maxillary teeth. Conclusion CBCT imaging is a reliable adjunct method for detecting furcation involvement in maxillary teeth, while clinical examination alone may not be sufficient. Therefore, the use of CBCT technology should be considered in cases where accurate detection of furcation involvement is necessary for successful treatment outcomes. However, further studies with larger sample sizes are needed to confirm these findings.

Is cone-beam computed tomography (CBCT) an alternative to plain radiography in assessments of dental disease? A study of method agreement in a medically compromised patient population

OBJECTIVES

Poor oral health and dental infections can jeopardize medical treatment and be life-threatening. Due to this, patients with head and neck malignancies, generalized tumor spread, organ transplant, or severe infection are referred for a clinical oral and radiographic examination. The aim of this study was to compare the diagnostic agreement of three radiographic modalities: intraoral radiographs (IO), panoramic radiographs (PX), and cone beam computed tomography (CBCT) for diagnosis of dental diseases.

MATERIALS AND METHODS

Three hundred patients were examined with IO, PX, and CBCT. Periapical lesions, marginal bone level, and caries lesions were diagnosed separately by four oral radiologists. All observers also assessed six teeth in 30 randomly selected patients at two different occasions. Kappa values and percent agreement were calculated.

RESULTS

The highest Kappa value and percent agreement were for diagnosing periapical lesions (0.76, 97.7%), and for the assessment of marginal bone level, it varied between 0.58 and 0.60 (87.8-89.3%). In CBCT, only 44.4% of all teeth were assessable for caries (Kappa 0.68, 93.4%). The intra-observer agreement, for all modalities and diagnoses, showed Kappa values between 0.5 and 0.93 and inter-observer agreement varied from 0.51 to 0.87.

CONCLUSIONS

CBCT was an alternative to IO in diagnosing periapical lesions. Both modalities found the same healthy teeth in 93.8%. All modalities were performed equally regarding marginal bone level. In caries diagnosis, artifacts were the major cause of fallout for CBCT.

CLINICAL RELEVANCE

Intraoral radiography is the first-hand choice for diagnosing dental disease. For some rare cases where intraoral imaging is not possible, a dedicated panoramic image and/or CBCT examination is an alternative.

The effect of different spatial resolutions and enhancement filters on radiographic detection of simulated furcation defects with intraoral digital radiography

OBJECTIVE

The objective of this study was to evaluate the effects of spatial resolution and the application of enhancement filters in the diagnosis of simulated furcation defects and image quality with intraoral radiographs.

STUDY DESIGN

Periapical images were acquired with photostimulable phosphor plates of molars in dry skulls (n = 8) and mandibles (n = 10) with 4 stages of furcation defect simulation. The plates were scanned in fast scan and high resolution modes to produce different spatial resolutions. Four image filters were applied. Six observers scored the detection of furcation defects. Mean values of area under the curve in receiver operating characteristic evaluation, accuracy, sensitivity, and specificity were calculated. Mean gray value (brightness), noise, and contrast-to-noise ratio (CNR) were calculated for enamel, dentin, and alveolar bone to evaluate image quality. Analysis of variance compared the values between the different spatial resolutions and filters. The significance of difference was established at P < .05.

RESULTS

There were no significant differences in overall diagnostic values comparing image spatial resolutions and filters. Diagnostic outcomes were significantly better for the largest defects than the smallest lesions but were generally poor in detecting lesions. All structures showed greater brightness in high resolution. . Noise was greater in all structures with all enhancement filters except inversion. Dentin and alveolar bone exhibited more noise and lower CNR in high resolution.

CONCLUSIONS

Varying spatial resolution and applying enhancement filters did not significantly affect the diagnosis of furcation defects.

Diagnostic application of intraoral ultrasonography to assess furcation involvement in mandibular first molars

OBJECTIVES

The objectives were to clarify if intraoral ultrasonography (USG) is: (1) more accurate than conventional periodontal examinations in detection of furcation involvement, and (2) comparable to conventional periodontal examinations in accurate horizontal classification of furcation involvement in comparison to cone beam computed tomography (CBCT).

METHODS

The buccal furcation in 61 lower first molars were evaluated with conventional periodontal examinations, intraoral USG and CBCT. The presence and classification of the horizontal depth of furcation involvement were defined clinically by assessment with a Nabers periodontal probe and a periapical radiograph with reference to the bone loss under the fornix. The horizontal depth of furcation involvement was measured in intraoral USG and CBCT images. Based on the measurements, presence diagnosis and horizontal classification were performed. Results from conventional periodontal examinationsand intraoral USG were compared with those from CBCT.

RESULTS

κ value (κ) for agreement of presence diagnosis of furcation involvement between intraoral USG and CBCT was 0.792, while agreement with conventional periodontal examinations was 0.225. Diagnostic accuracy of intraoral USG exhibited higher values (sensitivity: 98.3%, accuracy: 98.4 %) than conventional periodontal examinations (81.4% and 81.9 %). Weighted κ statistics showed substantial agreement in the classification between intraoral USG and CBCT (κ = 0.674). High agreement (ICC: 0.914) for the measurement of horizontal depth of furcation involvement was found between intraoral USG and CBCT.

CONCLUSIONS

Intraoral USG may be a reliable diagnostic tool for assessment of furcation involvement of mandibular molars with a similar performance to CBCT, but without ionizing radiation.

Bone replacement grafts with guided tissue regeneration in treatment of grade II furcation defects: a systematic review and meta-analysis

AIM

The present systematic review appended with meta-analysis aimed to evaluate the efficacy of bone replacement graft (BRG) with guided tissue regeneration (GTR) over BRG or open flap debridement (OFD) alone in the treatment of grade II furcation defects.

MATERIALS AND METHODS

An electronic literature search of PubMed, Cochrane Library and Google Scholar databases accompanied with manual searching was done. Randomized controlled trials (RCTs) up to October 2019, comparing BRG+GTR with BRG or OFD in grade II furcation defects, were identified. Clinical attachment level (CAL) gain, changes in gingival marginal level (GML), vertical defect fill (VDF), horizontal defect fill (HDF) and reduction in defect volume were the outcome parameters.

RESULTS

Of a total of 12, 9 studies compared BRG+GTR vs BRG while 3 compared BRG+GTR vs OFD. Meta-analysis was carried out for CAL gain, VDF, HDF and GML changes. In the BRG+GTR vs BRG comparison group, out of 9 studies, 6 RCTs showed standardized mean difference (SMD) of 0.513 for VDF, 9 RCTs showed SMD of 0.83 for HDF and 2 RCTs showed SMD of 0.651 for CAL gain, whereas only 2 studies in the same group reported reduction in defect volume. Three studies of the BRG+GTR vs OFD group exhibited significant VDF and CAL gain with SMD of 2.002 and 1.161 respectively. However, no significant change was recorded for GML in both groups.

CONCLUSION

The present systematic review indicates supplemental benefits of combination therapy of BRG+GTR over monotherapy in resolving grade II furcation defects.

CLINICAL RELEVANCE

In our quest to achieve maximum regeneration in grade II furcation defects, combination therapies such as BRG+GTR have been accepted as treatment choices over other modalities. Clinical situations warranting near-complete regeneration of the tissues in such defects are better suited for combination therapies.

Reliability Assessment of the Clinical and Radiographic Diagnosis of Furcation Involvement

Aim:

The aim of the present study was to compare and assess the relationship and agreement between the clinical and radiographic detection of Furcation Involvement (FI) in the mandibular molars of patients with periodontitis.

Materials and Methods:

The sample size included 360 molars from 283 participants with a total of 180 molars involved with furcation clinically and 180 without. The inclusion criteria involved records of patients in the age range 35-76 years, diagnosed with generalized periodontitis, Stage II to IV, Grade B and C, and existing periapical radiographs/dental panoramic radiographs. The periodontal charts (Hamp’s classification) and radiographs were used to evaluate furcation on the buccal and lingual sites of first and second mandibular molars.

Results:

Of the 360 molars, half of the molars (50%, n=180) had clinical FI. Of the clinical FI group, the majority (73%, n=131) demonstrated FI in the radiological assessment with the periapical radiographs. In the not-clinically detected FI group, just less than half (49%, n=89) demonstrated FI in the radiological assessment. The sensitivity of the radiographic detection of FI as a diagnostic marker was 50.6%, and the specificity was 72.8%. Of the 180 sites analyzed with FI clinically, a slight agreement was found between the clinical assessment and radiographic findings using the kappa analysis (k=0.18). The first mandibular molars showed a fair agreement (k= 0.21) compared to the second mandibular molars (k=0.15). In terms of the individual sites, the lingual sites (k=0.24) had a fair agreement compared to the buccal sites with a slight agreement. The Spearman Correlation analysis for the first mandibular molar showed a moderate positive correlation (r=0.4, p<0.001) compared to the second mandibular molar with no or negligible relationship (r=0.19, p<0.001). Comparatively, the DPT radiograph showed a weak correlation and poor agreement.

Conclusion:

Both diagnostic tools, intraoral radiography and clinical assessment should be used for diagnosing FI in mandibular molars.

Cone beam computed tomography (CBCT) in periodontal diseases: a Systematic review based on the efficacy model

BACKGROUND

Periodontal diseases are prevalent among adult populations. Its diagnosis depends mainly on clinical findings supported by radiographic examinations. In previous decades, cone beam computed tomography has been introduced to the dental field. The aim of this study was to address the diagnostic efficacy of cone-beam computed tomographic (CBCT) imaging in periodontics based on a systematic search and analysis of the literature using the hierarchical efficacy model.

METHODS

A systematic search of electronic databases such as PubMed, Scopus, Web of Science, and Cochrane was conducted in February 2019 to identify studies addressing the efficacy of CBCT imaging in Periodontics. The identified studies were subjected to pre-identified inclusion criteria followed by an analysis using a hierarchical model of efficacy (model) designed for an appraisal of the literature on diagnostic imaging modality. Four examiners performed the eligibility and quality assessment of relevant studies and consensus was reached in cases where disagreement occurred.

RESULTS

The search resulted in 64 studies. Of these, 34 publications were allocated to the relevant level of efficacy and quality assessments wherever applicable. The overall diagnostic accuracy of the included studies showed a low or moderate risk of bias and applicability concerns in the use of CBCT. In addition, CBCT is accurate in identifying periodontal defects when compared to other modalities. The studies on the level of patient outcomes agreed that CBCT is a reliable tool for the assessment of outcomes after the treatment of periodontal defects.

CONCLUSION

CBCT was found to be beneficial and accurate in cases of infra-bony defects and furcation involvements.

Diagnostic accuracy of periapical radiograph, cone beam computed tomography, and intrasurgical linear measurement techniques for assessing furcation defects: a longitudinal randomised controlled trial

OBJECTIVES

The aim of this study was to evaluate the accuracy of cone beam computed tomography (CBCT), periapical radiograph, and intrasurgical linear measurements in the assessment of molars with furcation defects.

MATERIALS AND METHODS

This parallel, single-blinded, randomised controlled trial (RCT) consisted of 22 periodontitis patients who had molar with advanced furcation involvement (FI). All patients followed the same inclusion criteria and were treated following the same protocol, except for radiographic evaluation (CBCT vs. periapical). This study proposed and evaluated five parameters that represent the extent and severity of furcation defects in molars teeth, including CEJ-BD (clinical attachment loss), BL-H (depth), BL-V (height), RT (root trunk), and FW (width).

RESULTS

There were no statistically significant differences between CBCT and intrasurgical linear measurements for any clinical parameter (p > 0.05). However, there were statistically significant differences in BL-V measurements (p < 0.05) between periapical and intrasurgical measurements in maxillary molars. Meanwhile, the sensitivity were 62.8% and 56.9% for CBCT and periapical, respectively.

CONCLUSIONS

Overall, when compared to the intrasurgical measurements, CBCT provided better diagnostic, sensitivity, and quantitative information on CAL, height, depth, and width of the furcation defects than periapical radiograph.

CLINICAL RELEVANCE

An accurate presurgical furcation diagnostic can guide the clinicians from the stage of diagnosis to definitive management so that unnecessary periodontal surgical interventions can be prevented.

Role of Cone-Beam Computed Tomography in the Management of Periodontal Disease

The goal of this paper was to review the current literature surrounding the use of cone beam computed tomography (CBCT) related to the diagnosis, prognostic determination, and treatment of periodontal diseases. A literature review was completed to identify peer-reviewed articles related to CBCT and periodontics. The results were filtered to pool only articles specific to CBCT and periodontal diagnosis, prognosis, and treatment/outcomes. The articles were reviewed and findings summarized. Author’s commentary on technological advances and additional potential uses of CBCT in the field of periodontics were included. There is evidence to suggest that CBCT imaging can be more accurate in diagnosing specific periodontal defects (intrabony and furcation defects), and therefore be helpful in the prognostic determination and treatment planning. However, at this time, CBCT cannot be recommended as the standard of care. It is up to the individual clinician to use one’s own judgment as to when the additional information provided by CBCT may be beneficial, while applying the As Low As Reasonably Achievable (ALARA) principle. With continued technological advances in CBCT imaging (higher resolution, reduced imaging artifacts, lower exposure, etc.) the author’s believe that CBCT usage will become more prominent in diagnosis and treatment of periodontal diseases.