Clinical Research
A New Periapical Index Based on Cone Beam
Computed Tomography
Carlos Estrela, DDS, MSc, PhD,* Mike Reis Bueno, DDS, MSc,†
Bruno Correa Azevedo, DDS, MSc,‡ José Ribamar Azevedo, DDS,§ and
Jesus Djalma Pécora, DDS, MSc, PhD!
Abstract
The purpose of this study was to evaluate a new
periapical index based on cone beam computed tomog-
raphy (CBCT) for identification of apical periodontitis
(AP). The periapical index proposed in this study (CBCT-
PAI) was developed on the basis of criteria established
from measurements corresponding to periapical radi-
olucency interpreted on CBCT scans. Radiolucent im-
ages suggestive of periapical lesions were measured by
using the working tools of Planimp software on CBCT
scans in 3 dimensions: buccopalatal, mesiodistal, and
diagonal. The CBCTPAI was determined by the largest
lesion extension. A 6-point (0 –5) scoring system was
used with 2 additional variables, expansion of cortical
bone and destruction of cortical bone. A total of 1014
images (periapical radiographs and CBCT scans) origi-
nally taken from 596 patients were evaluated by 3
observers by using the CBCTPAI criteria. AP was iden-
tified in 39.5% and 60.9% of cases by radiography and
CBCT, respectively (P ! .01). The CBCTPAI offers an
accurate diagnostic method for use with high-resolu-
tion images, which can reduce the incidence of false-
negative diagnosis, minimize observer interference, and
increase the reliability of epidemiologic studies, espe-
cially those referring to AP prevalence and severity.
(J Endod 2008;34:1325–1331)
Key Words
Apical periodontitis, cone beam computed tomography,
diagnostic imaging, endodontic diagnosis, radiography
From the *Federal University of Goiás, Goiânia, GO, Brazil;
†
University of Cuiabá, Cuiabá, MT, Brazil; ‡Department of
Dental Diagnostic Science, University of Texas, San Antonio,
Texas; §Dental and Radiological Institute of Brasília, Brasília,
DF, Brazil; and !University of São Paulo, Ribeirão Preto, SP,
Brazil.
Address requests for reprints to Prof Dr Carlos Estrela, Centro
de Ensino e Pesquisa Odontológica do Brazil (CEPOBRAS), Rua
C-245, Quadra 546, Lote 9, Jardim América, CEP: 74.290-200,
Goiânia, GO, Brazil. E-mail address: estrela3@terra.com.br.
0099-2399/$0 - see front matter
Copyright © 2008 American Association of Endodontists.
doi:10.1016/j.joen.2008.08.013
JOE — Volume 34, Number 11, November 2008
P eriapical radiography is an essential resource in endodontic diagnosis, because it
offers important evidence on the progression, regression, and persistence of apical
periodontitis (AP) (1, 2). It is known that periapical radiolucencies might not be visible
radiographically, although they exist clinically (3–5). Moreover, radiographs are 2-di-
mensional representations of 3-dimensional structures, and certain clinical and bio-
logic features might not be reflected in radiographic changes. Clinical and radiologic
criteria are frequently used to assess the status of endodontic treatment and its
correlation with AP (6 –14), but morphologic variations, surrounding bone den-
sity, x-ray angulations, and radiographic contrast can influence radiographic in-
terpretation (12, 13).
With the great technological advances of recent years, new imaging modalities
have been added to dental radiology as viable diagnostic tools, namely digital radiog-
raphy, densitometry methods, cone beam computed tomography (CBCT), magnetic
resonance imaging, ultrasound, nuclear techniques (13, 15–23), providing detailed
high-resolution images of oral structures and permitting early detection of bone lesions.
CBCT has been used for several clinical and investigational purposes in endodon-
tics (15, 16, 18 –20). According to a recent study (16), the specific endodontic appli-
cations of cone beam volumetric tomography (CBVT) are being identified as this tech-
nology becomes more prevalent, but its potential indications include diagnosis of
pathosis from endodontic and nonendodontic origins, assessment of root canal mor-
phology, evaluation of root and alveolar fractures, analysis of external and internal root
resorption and invasive cervical resorption, and presurgical planning in root-end sur-
geries. Scarfe et al. (21) have stated that important innovations of imaging systems
involve the change from analog to digital imaging and advances in imaging theory and
volume-acquisition data, allowing detailed 3-dimensional imaging. Investigations (22,
23) have demonstrated that a cyst could be distinguished from periapical granulomas
by CBCT because it shows a marked difference in density between the content of the cyst
cavity and granulomatous tissue, thus favoring a noninvasive diagnosis. At this point in
time, scientific consensus has been reached to the fact that AP is correctly detected by
histologic analysis (24).
Previous studies (1, 8, 10) have referred to the periapical index (PAI) as a scoring
system for radiographic assessment of AP. The PAI represents an ordinal scale of 5
scores ranging from no disease to severe periodontitis with exacerbating features and is
based on reference radiographs with confirmed histologic diagnosis originally pub-
lished by Brynolf (8). Ørstavik et al. (1) applied the PAI to both clinical trials and
epidemiologic surveys and might be transformed into success and failure criteria by
defining cutoff points on the scale for a dichotomous outcome assessment (13).
Given the limitations of conventional radiography for detection of AP and the
availability of new emerging 3-dimensional imaging modalities, the development of new
periapical indices seems to be a necessity. The purpose of this study was to evaluate a
new PAI based on CBCT for identification of AP.
Material and Methods
Cone Beam Computed Tomography Periapical Index
The Cone Beam Computed Tomography Periapical Index (CBCTPAI) proposed in
this study was developed on the basis of criteria established from measurements cor-
responding to periapical radiolucency interpreted on CBCT scans. The sizes of radiolu-
Computed Tomography Periapical Index 1325
Clinical Research

Figure 1. Clinical case of mandibular molar showing the axial (A), sagittal (B), and coronal (C) planes. The CBCTPAI was determined by the largest extension of the
lesion.

TABLE 1. Cone Beam Computed Tomography Periapical Index Scores cent images suggestive of periapical lesions were delimited and mea-
sured by using the working tools of Planimp software (CDT Computing,
Quantitative Bone Alterations in Mineral
Score Cuiabá, MT, Brazil) on CBCT scans in 3 dimensions: buccopalatal, me-
Structures
siodistal, and diagonal (Fig. 1). The CBCTPAI was determined by the
0 Intact periapical bone structures
1 Diameter of periapical radiolucency " 0.5–1 mm
2 Diameter of periapical radiolucency " 1–2 mm
3 Diameter of periapical radiolucency " 2–4 mm
4 Diameter of periapical radiolucency " 4–8 mm
5 Diameter of periapical radiolucency " 8 mm
Score (n) Expansion of periapical cortical bone
# E*
Score (n) Destruction of periapical cortical bone
# D*
*The variables E (expansion of cortical bone) and D (destruction of cortical bone) were added to each
score, if either of these conditions was detected in the CBCT analysis.

Figure 2. Schematic representation of molars CBCTPAI. Figure 3. Schematic representation of premolars CBCTPAI.

1326 Estrela et al. JOE — Volume 34, Number 11, November 2008
 Clinical Research
Imaging Methods and Evaluation
The periapical radiographs were taken with Max S-1 x-ray equip-
ment (J. Morita Mfg Corp, Kyoto, Japan) with 0.8 mm & 0.8 mm tube
focal spot and with Kodak Insight film-E (Eastman Kodak Co, Rochester,
NY) according to the parallel radiographic technique. All films were
processed in an automatic processor and developed by using standard-
ized methods. CBCT images were obtained with 3D Accuitomo XYZ Slice
View Tomograph (model MCT-1; J. Morita Mfg Corp) voxel size of
0.125 & 0.125 & 0.125 mm, 12 or 8 bits. Images were examined by
using specific software (3D Tomo X version 1.0.51) in a PC workstation
running under Microsoft Windows XP professional SP-1 (Microsoft
Corp, Redmond, WA).
Three calibrated blinded observers evaluated all digital images by
using the CBCTPAI criteria described in Table 1. The level of interob-
server agreement was assessed by kappa statistics in 10% of the sample
(25). Data were analyzed statistically by the !2 test to determine signif-
icant differences among the imaging methods for detection of AP. Sig-
nificance level was set at " % 1%.

Results
Table 2 shows the prevalence of AP identified by periapical radi-
ography and CBCT by using the CBCTPAI. AP was detected in 39.5% and
60.9% of cases by periapical radiography and CBCT, respectively (P !

Figure 4. Schematic representation of canines CBCTPAI.

largest extension of the lesion. A 6-point (0 –5) scoring system was

used. In addition, considering that CBCT provides 3-dimensional im-
ages, with depth being added as a new plane of analysis in relation to
2-dimensional radiography, 2 variables were included in the scoring
system as appropriate, expansion of cortical bone (E) and destruction
of cortical bone (D) (Table 1 and Figs. 2–7).

Patients
One thousand fourteen images (periapical radiographs and CBCT
scans) originally taken from 596 patients (241 men and 355 women;
mean age, 54 $ 17 years) between May 2004 and August 2006 were
selected from the Dental and Radiological Institute of Brasília (IORB,
Brasília, DF, Brazil) database. All patients had 1 or more teeth with
history of endodontic treatment. Some of the teeth in question radio-
graphically displayed an AP. The involved teeth were mandibular molars
(n % 126), maxillary molars (n % 203), mandibular premolars (n %
183), maxillary premolars (n % 226), mandibular canines (n % 11),
maxillary canines (n % 99), mandibular incisors (n % 13), and max-
illary incisors (n % 153).
The study design was independently reviewed and approved by the
Institutional Ethics in Research Committee. Figure 5. Schematic representation of incisors CBCTPAI.

JOE — Volume 34, Number 11, November 2008 Computed Tomography Periapical Index 1327
Clinical Research
Figure 6. Clinical cases of maxillary incisors CBCTPAI showing all scores used and 2 additional variables (expansion of cortical bone and destruction of cortical
bone).
.01). Table 3 presents the results of the diagnostic imaging tests by using
CBCTPAI kappa values for interobserver agreement, considering the
CBCTPAI scores ranged from 0.86 – 0.96 for periapical radiographs
and CBCT scans. Figs. 2–7 show the schematic representation and clin-
ical cases of groups of mandibular and maxillary teeth corresponding to
CBCTPAI.
Discussion
CBCT was more accurate than periapical radiography for AP
diagnosis. AP was identified in nearly 40% of the cases by using
periapical radiographs and in almost 61% of the cases by using
CBCT scans (Table 2).
The accuracy of CBCT scans compared with periapical radio-
graphic images is in accordance with the findings of previous studies (5,
16, 18, 19, 21–23, 26). Lofthag-Hansen et al. (26) compared intraoral
periapical radiography and a 3-dimensional imaging system (3D Accui-
tomo) for the diagnosis of apical pathology in 36 patients (46 teeth).
1328 Estrela et al.
When both diagnostic methods were analyzed by all observers, they
agreed that the CBCT images provided clinically relevant additional in-
formation not found in the periapical films. The capacity of computed
tomography to evaluate a region of interest in 3 dimensions might ben-
efit both novice and experienced clinicians alike. The advantages in-
clude increased accuracy, higher resolution, scan-time reduction, and
lower radiation dose (16).
The use of conventional radiography for detection of AP should be
done with care because of the great possibility of false-negative diagno-
sis. The benefits of using CBCT in endodontics refer to its high accuracy
in detecting periapical lesions even in its earliest stages and aiding in
differential diagnosis as a noninvasive technique (5).
Simon et al. (23) compared the differential diagnosis of large
periapical lesions (granuloma versus cyst) with traditional biopsy by
using CBCT. Seventeen large periapical radiolucencies (equal to or
greater than 1 & 1 cm) were scanned to determine densities, and a
preoperative CBCT diagnosis was made. The lesions were then removed
JOE — Volume 34, Number 11, November 2008
 Clinical Research

Figure 7. Clinical cases of maxillary molars CBCTPAI showing all scores used and 2 additional variables (expansion of cortical bone and destruction of cortical
bone).

surgically and sent for histopathologic examination. In 13 of 17 cases, The CBCTPAI proposed hereby has some advantages for clinical
the biopsy report and CBCT diagnosis coincided. In 4 of 17 cases, the applications. CBCTPAI scores are calculated by analysis of the lesion in
CBCT read cyst, whereas the oral pathologist’s diagnosis was chronic 3 dimensions, with CT slices being obtained in mesiodistal, buccopala-
AP. These results suggest that CBCT might provide a faster method to tal, and diagonal directions. The measurement of lesion depth contrib-
differentially diagnose a solid from a fluid-filled lesion or cavity, without utes significantly to the diagnosis and consequently to improve case
invasive surgery and/or waiting a long time to see whether nonsurgical prognosis. The addition of the variables expansion of cortical bone and
therapy is effective. destruction of cortical bone to CBCTPAI scoring system permits the analysis
of 2 possible sequels to AP that might be missed by periapical radiography.
Detection of these conditions will alter the diagnostic hypothesis and the
TABLE 2. AP Prevalence in Endodontically Treated Teeth as Determined by
Periapical Radiography and CBCT, by Using CBCTPAI (n % 1014)
treatment plan. The goal of this new index is therefore to offer a method
based on the interpretation of high-resolution images that can provide a
Periapical P more precise measurement of AP extension, minimizing observer interfer-
CBCT
Radiography Value* ence and increasing the reliability of research results.
Presence of AP 401 (39.5%) 618 (60.9%) !.001 The PAI as indicated by Ørstavik et al. (1) ranges from health to
Absence of AP 613 (60.5%) 396 (39.1%) severe periodontitis on the basis of the interpretation of 2-dimensional
AP, apical periodontitis; CBCT, cone beam computed tomography. radiographic images, whereas CBCTPAI scores have been established
*!2 test. according to the interpretation of 3-dimensional CBCT scans. These 2 peri-

JOE — Volume 34, Number 11, November 2008 Computed Tomography Periapical Index 1329
Clinical Research
TABLE 3. Results of Imaging Diagnostic Tests with CBCTPAI, on the Basis of Criteria Established from Measurements Corresponding to Periapical Radiolucency
("0.5–1 mm to "8 mm), with 2 Additional Variables, Expansion of Cortical Bone (E) and Destruction of Cortical Bone (D) (n % 1014)
CBCT
n 0 1 2 E D 3 E D 4 E D 5 E D Total
Periapical radiography 0 386 53 83 16 1 42 21 3 45 25 4 4 3 1 613
1 10 26 44 6 — 10 3 — 4 1 2 1 — — 95
2 — 3 51 14 1 58 33 5 44 22 8 4 2 1 160
E — — — — — — — — — — — — — — —
D — — — — — — — — — — — — — — —
3 — — — — — 22 14 2 48 32 7 17 8 7 87
E — — — — — — — — — — — — — — —
D — — — — — — — — — — — — — — —
4 — — 1 — — — — — 33 17 8 13 6 6 47
E — — — — — — — — — — — — — — —
D — — — — — — — — — — — — — — —
5 — — — — — — — — — — — 12 6 5 12
E — — — — — — — — — — — — — — —
D — — — — — — — — — — — — — — —
Total 1014
CBCTPAI, Cone Beam Computed Tomography Periapical Index.

apical indices thus have different scoring systems as a result of the charac-
teristics of each target image (conventional periapical radiograph or CBCT
scan). The scope of the present study is to evaluate a new PAI that is based
on an imaging modality that allows detection of lesions that are not visible
radiographically. Considering the clinical history, the relation between
health and disease in CBCTPAI can be begun by stage 1, without detection of
cortical bone expansion or destruction of the cortical bone.
The limitations of periapical radiography to identify AP support the
need to review the epidemiologic studies conducted in different popu-
lations worldwide. A considerable discrepancy among the imaging
methods used to diagnose AP, especially with a new baseline value,
certainly might reduce the influence of radiographic interpretation and
the possibility of false-negative diagnosis.
In the present study, the kappa values for CBCTPAI scores ranged
from 0.86 – 0.96 for periapical radiographs and CBCT scans, which
indicate that a very good interobserver agreement was reached. High
kappa values (0.80 – 0.95 range) have also been observed in previous
studies that examined periapical radiographs (27, 28).
In spite of the dental imaging technique, care should be taken to
avoid misinterpretation. The presence of intracanal metallic posts, for
example, might lead to equivocated interpretations as a result of artifact
formation in CBCT images. Metallic objects can be present in either the
tooth of interest or an adjacent one and hinder the analysis of CBCT
images (26), although in current days the influence of this artifact has
been reduced. This artifact has been found to be closely related to the
type of tissue or object (ie, computed tomography value) and the x-ray
energy applied (29).
Under the tested conditions and within the limitations of this study,
it might be concluded that AP detection was considerably higher with
CBCT than with periapical radiography. The PAI proposed in this study
(CBCTPAI) offers an accurate diagnostic method for use with high-
resolution images, which can reduce the incidence of false-negative
diagnosis, minimize observer interference, and increase the reliability
of epidemiologic studies, especially those referring to AP prevalence
and severity.
References
1. Ørstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for
radiographic assessment of apical periodontitis. Endod Dent Traumatol 1986;2:
20 – 4.
2. Nair PNR, Sjögren U, Figdor D, Sundqvist G. Persistent periapical radiolucencies of
root-filled human teeth, failed endodontic treatments, and periapical scars. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:617–27.
3. Bender IB, Seltzer S. Roentgenographic and direct observation of experimental le-
sions in bone I. J Am Dent Assoc 1961;62:152– 60.
4. Bender IB, Seltzer S. Roentgenographic and direct observation of experimental le-
sions in bone II. J Am Dent Assoc 1961;62:708 –16.
5. Estrela C, Bueno MR, Leles CR, Azevedo BC, Azevedo JR. Accuracy of cone beam
computed tomography, panoramic and periapical radiographic for the detection of
apical periodontitis. J Endod 2008;34:273–9.
6. Strindberg LZ. The dependence of the results of pulp therapy on certain factors: an
analytical study based on radiographic and clinical follow-up examinations. Acta
Odontol Scand 1956;14:1–175.
7. Grossman LI, Sheprd LI, Pearson LA. Roentgenologic and clinical evaluation of end-
odontically treated teeth. Oral Surg Oral Med Oral Pathol 1964;17:368 –74.
8. Brynolf I. A histologic and roentgenologic study of the periapical region of human
upper incisors. Odontol Revy 1967;18:1–176.
9. Goldman M, Pearson AH, Darzenta N. Reliability of radiographic interpretations. Oral
Surg Oral Med Oral Pathol 1974;38:287–93.
10. Reit C, Grøndahl HG. Application of statistical decision theory to radiographic diag-
nosis of endodontically treated teeth. Scand J Dent Res 1983;9:213– 8.
11. Halse A, Molven O. A strategy for the diagnosis of periapical pathosis. J Endod
1986;12:534 – 8.
12. Molven O, Halse A, Fristad I. Long-term reliability and observer comparisons in the
radiographic diagnosis of periapical disease. Int Endod J 2002;35:142–7.
13. Huumonen S, Ørstavik D. Radiological aspects of apical periodontitis. Endod Topics
2002;1:3–25.
14. Estrela C, Leles CR, Hollanda ACB, Moura MS, Pécora JD. Prevalence and risk factors
of apical periodontitis in endodontically treated teeth in a selected population of
Brazilian adults. Braz Dent J 2008;19:34 –9.
15. Arai Y, Tammisalo E, Iwai K, Hashimoto K, Shinoda K. Development of a compact
computed tomographic apparatus for dental use. Dent Maxillofac Radiol 1999;28:
245– 8.
16. Cotton TP, Geisler TM, Holden DT, Schwartz SA, Schindler WG. Endodontic applica-
tions of cone beam volumetric tomography. J Endod 2007;33:1121–32.
17. Nair MK, Nair UP. Digital and advanced imaging in endodontics: a review. J Endod
2007;33:1– 6.
18. Nielsen RB, Alyassin AM, Peters DD, Carnes DL, Lancaster J. Microcomputed tomography:
an advanced system for detailed endodontic research. J Endod 1995;21:561–8.
19. Patel S, Dawood A, Pitt Ford T, Whaites E. The potential applications of cone beam
computed tomography in the management of endodontic problems. Int Endod J
2007;40:818 – 823.
20. Yajima A, Otonari-Yamamoto M, Sano T, et al. Cone beam CT (CB Throne) applied to
dentomaxillofacial region. Bull Tokyo Dent Coll 2006;47:133– 41.
21. Scarfe WC, Farman AG, Sukovic P. Clinical applications of cone-beam computed
tomograghy in dental practice. J Can Dent Assoc 2007;72:75– 80.
22. Trope M, Pettigrew J, Petras J, Barnett F, Tronstad L. Differentiation of radicular
cyst and granulomas using computerized tomography. Endod Dent Traumatol
1989;5:69 –72.
23. Simon JHS, Enciso R, Malfaz JM, Rogers R, Bailey-Perry M, Patel A. Differential
diagnosis of large periapical lesions using cone-beam computed tomography mea-
surements and biopsy. J Endod 2006;32:833–7.

1330 Estrela et al. JOE — Volume 34, Number 11, November 2008

24. Laux M, Abbott PV, Pajarola G, Nair PNR. Apical inflammatory root resorption: a
correlative radiographic and histological assessment. Int Endod J 2000;33:
483–93.
25. Landis JR, Koch GG. The measurement of observer agreement for categorical data.
Biometrics 1977;33:159 –74.
26. Lofthag-Hansen S, Hummonen S, Gröndahl K, Gröndahl H-G. Limited cone-beam CT
and intraoral radiography for the diagnosis of periapical pathology. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2007;103:114 –9.
JOE — Volume 34, Number 11, November 2008
Clinical Research
27. Nicopoulou-Karayianni K, Bragger U, Patrikiou A, Stassinakis A, Lang NP. Image
processing for enhanced observer agreement in the evaluation of periapical bone
changes. Int Endod J 2002;35:615–22.
28. Weiger R, Hitzler S, Hermle G, Löst C. Periapical status, quality of root canal fillings
and estimated endodontic treatment needs in an urban German population. Endod
Dent Traumatol 1997;13:69 –74.
29. Katsumata A, Hirukawa A, Noujeim M, et al. Image artifact in dental cone-beam CT.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:652–7.
Computed Tomography Periapical Index 1331