The Limitations of Periapical X-ray Assessment in Endodontic Diagnosis—A Systematic Review
Abstract
:1. Introduction
2. Materials and Methods
2.1. Inclusion Criteria
- Articles that are published in English or use English as a second language;
- Articles that use histopathology as a gold standard for periapical diagnosis;
- Articles that have used periapical X-ray as the main imaging technique or that include periapical X-ray as a comparative study to other imaging investigations;
- Articles that perform study on living organisms: human beings or animals;
- Articles that relate the histopathological diagnosis to the imaging investigation;
- Studies that approach distinctly the imaging assessment (if the assessment has been performed using various techniques—OPG, periapical, CBCT).
2.2. Exclusion Criteria
- Studies performed on human or animal cadavers (simulated tissue for X-ray exposure is not an accurate assessment);
- Studies that do not use histopathology as a gold standard in diagnosis;
- Book chapters, personal opinions, letters, narratives, commentaries and conference abstracts;
- Studies that could not be found published in English;
- Studies that use other imaging techniques to assess the periapical status (OPG/CBCT);
- Induced pathology was not accepted (intra-oral exposed pulp for a defined period of time).
2.3. Study Selection
2.4. Data Collection Process
3. Results
Reason for Exclusion | Article (Author and Year) |
---|---|
The study was performed on cadavers and/or used simulated tissue for X-ray exposure | (Trope et al., 1989) (Green et al., 1997) (Barthel, Zimmer and Trope, 2004) (Kanagasingam, Hussaini et al., 2017) (Leonardi Dutra et al., 2016) (Kanagasingam, Lim et al., 2017) (Holtzmann et al., 1998) [29,30,31,32,33,34,35] |
The study did not use histopathology as a gold standard method for diagnosis confirmation | (Estrela et al., 2008) (Tsai et al., 2012) (Low et al., 2008) (Halse, Molven and Fristad, 2002) (Lofthag-Hansen et al., 2007) (Tikku et al., 2010) [36,37,38,39,40,41] |
The study did not use periapical X-ray for imaging assessment or did not clearly mention the X-ray type included in the Materials and Methods section or elsewhere in the article text (OPG/CBCT) | (Lin, Louis M. et al., 1991) (Becconsall-Ryan, Tong and Love, 2010) (Carrillo, Celia et al., 2008) (Simon et al., 2006) (Cotti et al., 2003) (Natkin, Oswald and Carnes, 1984) (Rud, Andreasen, 1972) (Seltzer, S., Bender, Smith, Freedman and Nazimov, 1967a) (Seltzer, S., Bender, Smith, Freedman and Nazimov, 1967b) (Yanagisawa, 1980) (Akinyamoju, O Gbadebo and Adeyemi, 2014) (Penarrocha et al., 2011) (Schulz et al., 2009) (Carrillo, C. et al., 2008) (Block et al., 1976) (Baumann, Rossman, 1956) (Bhaskar, 1966) (Lalonde, 1970) (Kizil, Energin, 1990) (Linenberg, Waldron and DeLaune, 1964) (Alotaibi et al., 2020) [25,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61] |
The study induced the pathological status of the periapical tissue | (Tanomaru-Filho et al., 2009) (López et al., 2014) (Paula-Silva et al., 2009) [22,62,63] |
The study is a narrative review | (Hamood, 2001) (Lin, L. M., Huang and Rosenberg, 2007) [64,65] |
The study does not contain information that could be linked to the reviewed subject | (Spatafore et al., 1990) (Teixeira-Salum et al., 2010) (Seltzer, Samuel, 1999) (Gallego Romero et al., 2002) (Ricucci, D., Lin and Spangberg, 2009) (Laux et al., 2000) (Patel et al., 2009) [66,67,68,69,70,71,72] |
The study did not differentiate between OPG, CBCT or periapical X-ray when performing the imaging analysis and its correlation to the histological status | (Croitoru et al., 2016) (Syrjänen et al., 1982) [73,74] |
Study Selected for Review | Type of Study Perfomed | Sample Size | Details Abouth the PA X-ray Assessment | Details Abouth the Histological Assessment | Results |
---|---|---|---|---|---|
(O Gbadebo, Akinyamoju and Sulaiman, 2014) [26] | Retrospective study | 19 patients | Diagnosis verified by Endodontic Consultants | Results verified by Oral Pathologists | Quantitative measures and quantitative analysis |
(Kruse et al., 2017) [9] | Follow-up study | 19 patients/19 teeth | Imaging assessment was performed by three observers (two Endodontists, one Oral Radiologist), and when the result had three different versions, a single result was agreed by consesus | Samples were cut at 3–4 µm and analysed by one Oral Pathologist | Quantitative measures and quantitative analysis |
(Bornstein et al., 2015) [23] | Follow-up study | 62 patients/62 teeth | Imaging assessment was performed by four blinded observers (two Oral Surgeons and two Residents in Oral Surgery) | Two experienced investigators diagnosed the samples, and the disagreement was solved by debate and consensus | Quantitative measures and quantitative analysis |
(Berar et al., 2016) [75] | Case study | 60 patients/60 teeth | PA X-rays were assessed by two observers | Perfomed using a Leica DM750 Microscope | Quantitative measures and quantitative analysis |
(Rózyło-Kalinowska, 2007) [24] | Retrospective study | 221 digital X-rays | Digora ver. 2.0 (Soredex—Orion Company, Finland), Dimaxis ver. 2.4.4 (Planmeca, Finland) and Emago ver. 3.42 (Oral Diagnostic Systems, ACTA, Holland) were the software used for density measurements | Not mentioned | Quantitative measures and quantitative analysis |
(Shrout, Hall and Hildebolt, 1993) [76] | Case study | 10 biopsies of periapical lesions | Regions of interest were digitaly drawn on each X-ray for histogram analysis and cumulative percent histogram calculation | Samples were assessed by two board-certified Oral Pathologists | Quantitative measures and quantitative analysis |
(White et al., 1994) [77] | Case study | 55 periapical lesions were histologicaly examined | NIH Image was used for X-ray measurements | Histology was assessed by one to three board-certified Oral Pathologist(s) | Quantitative measures and quantitative analysis |
(Correa et al., 2017) [78] | Descriptive study | 14 samples of apical lesions | VixWin Platinum (version 3.3, Gendex INC, USA) was used for the imaging measurements | Not mentioned | Quantitative measures and quantitative analysis |
(Çalışkan et al., 2016) [28] | Retrospective study | 93 teeth | Two blinded, trained observers investigated the X-rays in special conditions | Serial sectioning was performed in 4 µm thickness and examined by 1 Oral Pathologist | Quantitative measures and quantitative analysis |
(Ricucci, Mannocci and Pitt Ford, 2006) [15] | Case study | 57 teeth | Two blinded, trained observers investigated the X-rays in special conditions | Serial sectioning was performed (150–600) in 4–5 µm thickness | Quantitative measures and quantitative analysis |
(Ricucci, Siqueira, 2010) [79] | Retrospective study | 71 samples | Lesions were divided into 2: ≤5 mm and >5 mm, and no other information was available | Serial sectioning was performed in 4–5 µm thickness, and the assessment was separately performed by two evaluators | Quantitative measures and quantitative analysis |
(Priebe, Lazansky and Wuehrmann, 1954) [80] | Prospective study | 101 patients | The ø of the apical rarefaction was ≲1 cm, and the imaging assessment was performed independently by four observers (two Oral Surgery Teachers and two Dental Roentgenology Teachers) | Microscopic serial sectioning was performed obtaining > 16,000 sections assessed by a Pathologist | Quantitative measures and quantitative analysis |
(Gundappa, Ng and Whaites, 2006) [81] | Comparative in vivo pilot study | 15 patients | Three observers (two expert dental Radiologists and one Endodontist) examined the images on day 1, day 7 and day 14 to minimise errors | The biopsies were processed for routine histopathological assessment | Quantitative measures and quantitative analysis |
(Mortensen, Winther and Birn, 1970) [82] | Research article | 396 periapical lesions were histologically examined | All X-rays were reassessed by one of the authors to minimise subjectivity | The specimens were processed for routine histologic assessment | Quantitative measures and quantitative analysis |
(Zain, Roswati and Ismail, 1989a) [83] | Retrospective study | 69 cases | The measurements of the radiolucency were performed by operators respecting a defined criteria and a standard protocol | The lesions were reassessed respecting the general criteria | Quantitative measures and quantitative analysis |
(Cunningham, Penick, 1968) [84] | Cross-sectional study | 41 lesions | The roentgenograms were assessed by two investigators after the injection of the contrast agent | The specimens were examined by an Oral Pathologist | Qualtitative measures and qualtitative analysis |
STUDIES | (Kruse et al., 2017) [9] | (Ricucci, Mannocci & Pitt Ford, 2006) [15] | (Bornstein et al., 2015) [23] | (Rózyło-Kalinowska, 2007) [24] | (O Gbadebo, Akinyamoju & Sulaiman, 2014) [26] | (Çalışkan et al., 2016) [28] | (Berar et al., 2016) [75] | (Shrout, Hall & Hildebolt, 1993) [76] | (White et al., 1994) [77] | (Correa et al., 2017) [78] | (Ricucci, Siqueira, 2010) [79] | (Priebe, Lazansky & Wuehrmann, 1954) [80] | (Gundappa, Ng & Whaites, 2006) [81] | (Mortensen, Winther & Birn, 1970) [82] | (Zain, Roswati & Ismail, 1989) [83] | (Cunningham, Penick, 1968) [84] |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Quality measures | ||||||||||||||||
Was the research objective clear? | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
Was the methodology described in detail? | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | Y | N | N | Y |
Was the histology assessment protocol described? | Y | Y | Y | N | N | Y | Y | Y | N | N | Y | Y | Y | Y | Y | N |
Was the imaging assessment protocol described? | Y | Y | Y | Y | N | Y | Y | Y | Y | Y | N | N | Y | Y | Y | Y |
Was it stated how subjects were attained? | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y |
Were the subjects clearly defined? | Y | Y | Y | N | Y | Y | Y | N | Y | Y | Y | Y | Y | Y | Y | Y |
Was the method of allocation, or similarity between groups described? | N/A | Y | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | Y | N/A | N/A | N/A | N/A | N/A |
Were diagnostic tools compared on any variables? | Y | Y | Y | N | Y | Y | Y | Y | N | Y | Y | Y | Y | Y | Y | N |
Were the outcome measures clearly defined? | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | N |
Were the outcome measures objective? | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | N/A |
Were the outcome assessors blinded? | Y | N | Y | N | N | N/A | N/A | N | N | N | N | N | N | N | N | Y |
Were the participants blinded? | N/A | N | N/A | N/A | N/A | N/A | N/A | N/A | N | N | N | N/A | N/A | N | N/A | N |
Was the statistical analysis appropriate? | Y | Y | Y | Y | Y | Y | Y | N/A | Y | Y | Y | Y | Y | Y | Y | N/A |
Was the sample size for each group given? | Y | Y | Y | Y | Y | Y | Y | N | Y | Y | Y | Y | Y | Y | Y | N/A |
Was there a sample size justification? | N/A | N | N/A | N | N | N/A | N/A | N/A | N | N | N | N | N | Y | Y | N/A |
Was the statistical significance defined? | Y | Y | Y | Y | Y | Y | Y | N | N | Y | Y | N | Y | Y | N | N/A |
Was drop-out rate given? | Y | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N | N/A | N | N/A | Y | N/A | N/A |
Was drop-out rate <10%? | Y | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N | N/A | N/A |
Were drop-outs accounted for? | Y | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A | Y | N/A | N/A |
Quality score | 17 | 14.5 | 15 | 11.5 | 12.5 | 20.5 | 13.5 | 11.5 | 11 | 12.5 | 13.5 | 11 | 15.5 | 14.5 | 13.5 | 10.5 |
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Normal Apical Tissues | Teeth with Normal Periradicular Tissues That Are Not Sensitive to Percussion or Palpation Testing. The Lamina Dura Surrounding the Root Is Intact, and the Periodontal Ligament Space Is Uniform. |
---|---|
Symptomatic apical periodontitis | Inflammation, usually of the apical periodontium, producing clinical symptoms including a painful response to biting and/or percussion or palpation. It might or might not be associated with an apical radiolucent area. |
Asymptomatic apical periodontitis | Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area, and does not produce clinical symptoms. |
Acute apical abscess | An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation and swelling of associated tissues. |
Chronic apical abscess | An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort, and the intermittent discharge of pus through an associated sinus tract. |
Condensing osteitis | Diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus, usually seen at apex of tooth. |
Periapical Abscess | Periapical Granuloma | Periapical Cyst |
---|---|---|
Epithelialized abscess | Epithelialized granuloma | Apical true cyst |
Non-epithelialized abscess | Non-epithelialized granuloma | Apical pocket cyst |
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Gliga, A.; Imre, M.; Grandini, S.; Marruganti, C.; Gaeta, C.; Bodnar, D.; Dimitriu, B.A.; Foschi, F. The Limitations of Periapical X-ray Assessment in Endodontic Diagnosis—A Systematic Review. J. Clin. Med. 2023, 12, 4647. https://doi.org/10.3390/jcm12144647
Gliga A, Imre M, Grandini S, Marruganti C, Gaeta C, Bodnar D, Dimitriu BA, Foschi F. The Limitations of Periapical X-ray Assessment in Endodontic Diagnosis—A Systematic Review. Journal of Clinical Medicine. 2023; 12(14):4647. https://doi.org/10.3390/jcm12144647
Chicago/Turabian StyleGliga, Alexandru, Marina Imre, Simone Grandini, Crystal Marruganti, Carlo Gaeta, Dana Bodnar, Bogdan Alexandru Dimitriu, and Federico Foschi. 2023. "The Limitations of Periapical X-ray Assessment in Endodontic Diagnosis—A Systematic Review" Journal of Clinical Medicine 12, no. 14: 4647. https://doi.org/10.3390/jcm12144647
APA StyleGliga, A., Imre, M., Grandini, S., Marruganti, C., Gaeta, C., Bodnar, D., Dimitriu, B. A., & Foschi, F. (2023). The Limitations of Periapical X-ray Assessment in Endodontic Diagnosis—A Systematic Review. Journal of Clinical Medicine, 12(14), 4647. https://doi.org/10.3390/jcm12144647