Periodontology
THE ROLE OF CBCT IN THE EVALUATION OF PERIODONTAL
DISEASES
Alexandra FOCHI (DUMITRESCU)1, Danisia HABA2
1
PhD Student, Faculty of Dental Medicine, “Gr. T. Popa” University of Medicine and Pharmacy, Iasi, Romania
2
Department of Radiology and Medical Imagery, Faculty of Dental Medicine “Gr. T. Popa” University of Medicine and Pharmacy,
Iasi, Romania
Corresponding author: fo_ale@yahoo.com
Abstract
Scope: Diagnosis of periodontal disease is firstly based
on clinical signs and symptoms, however, when bone
destruction is involved, radiographic examination is the
most conclusive diagnosis method to be recommended.
Even if the 2D radiography is most frequently used for
such a diagnosis, CBCT (Cone Beam Computed Technology)
comes to complete, help and provide new data on
diagnosing periodontal lesions. The present study reviews
original articles and synthesis papers issued between 2004-
2014 in ScienceDirect, EBSCO, PubMed. Conclusions: In
periodontology, CBCT appears as superior to 2D
radiographies, being especially useful in the diagnosis of
branch craters, lesions, vestibular and oral bone
destructions, offering to the patient highly superior benefits
compared to the risks caused by exposure.
Keywords: CBCT, CBCT in periodontology, periodontal
disease
1. INTRODUCTION
Nowadays, the area of radiology and medical
imaging is constantly evolving, which has a high
impact on general practitioners and dentists, who
may thus evaluate the presence, absence and
progression of lesions, permitting to establish a
correct diagnosis and useful treatment, alongwith
other laboratory investigations [1]. The aim of this
article is to underline the role of CBCT, which
comes to complete, aid and provide new data in
diagnosing periodontal lesions.
Cone Beam Technology appeared for the first
time on the European market in 1996 by QR SRL
(NewTom 9000), and on the American one - in
2001. The original members of the research group
awarded a prize for the invention of CBCT, on
October 2003 [2]. In less than 5 years, 5 CBCT
systems approved by FDA appeared. The image
produced by CBCT, achieved at a relatively low
radiation dose, is not used only for diagnosis, but
International Journal of Medical Dentistry
also for helping specialists to reach a higher level
of performance. [3]
CBCT represented a huge improvement in
dental imaging. Introduction of Cone Beam
Computed Tomography (CBCT) in the
maxillofacial field has opened up new horizons in
the use of three-dimensional (3D) imaging as a
diagnosis and treatment tools in orthodontics,
periodontics, implantology, oral surgery and
otolaryngology and maxillofacial surgery [4-6].
CBCT is an imaging method applied in different
medical fields, recently introduced in dental
medicine, too. The device on whose basis the
image is provided by CBCT is an X-ray cone beam
and a detector (image intensifier) which needs a
single rotation around the patient to take hundreds
of pictures in the area of interest, which are then
reconstructed using an imaging software, for
obtaining a 3D virtual model of the patient. In
terms of irradiation doses, studies showed that
the irradiation dose for CBCT is much lower
compared to that of a conventional CT, but higher
compared to a panoramic radiography [7,8].
CBCT gives the possibility of choosing the field of
view, depending on the area of interest, therefore
the area exposed to radiation is a single one, the
others being safe; last, but not least, this function
is considered as very important for the patient,
due to its low radiation dose [7,6]. Usually, it
performs a 360-degree rotation around the patient,
but some devices implemented a 180-degree or a
slightly higher rotation arc, sufficient to reconstruct
the image, which results in a significant reduction
of the radiation quantity [6]. CBCT can give details
on the bone defects at lingual and vestibular level,
on fenestration, furcations, craters; also, bone
measurements may be performed with minimal
207
Alexandra FOCHI (DUMITRESCU), Danisia HABA

errors, providing a detailed morphological present synthesis - conducted in June 2015 -

description of the alveolar bone [9].
Generally, review articles identify the literature,
the case studies and models which support the
chosen theme; in our case, as the number of
studies dedicated to the role of CBCT in
periodontology is quite reduced, the review
intends to highlight the need of its use in this area,
as a diagnosis method superior to the other
techniques.
2. METHODS
DOCUMENTATION SOURCES
Few studies have been dedicated to the role
of CBCT in the field of periodontology. The
reviews the diagnostic applications of CBCT,
namely its utilization in detecting periodontal
problems. Twenty-one relevant studies issued
between 2004-2014 were identified and included.
The data bases used were: ScienceDirect, EBSCO,
PubMed. The search was carried out using the
key words: “CBCT in periodontology”,
“periodontal disease”, “CBCT”. The reference
lists of the identified studies and reviews were
also examined. Studies reporting the use of CBCT
in periodontology are also included. In the
evaluation of studies, the following problems
were addressed: the advantages and
disadvantages of CBCT, the instructions for the
use of CBCT and the role of CBCT in the
evaluation of periodontal diseases.

3. RESULTS AND DISCUSSION

Table 1. Indications, Advantages and Disadvantages of CBCT [8,10]

INDICATIONS OF DISADVANTAGES OF
ADVANTAGES OF CBCT
CBCT CBCT
1. 3D view of teeth 1. Most of CBCTs offer fields of view of differ- 1. The high cost compared
position and struc- ent sizes (small, medium and large). The smaller to that of standard 2D radi-
ture the field of view, the lower is the effective radi- ographies.
2. Determination of ation dose. 2. It cannot offer a resolu-
anatomic bone sizes 2. Compared to CT, the time of exposure to tion with increased con-
3. Study of the air radiations is more reduced. trast and also it is not
ways 3. Its cone beam allows the limitation of radia- indicated in the explora-
4. Positioning of tions in the interested area. tion of soft tissues, but only
temporary anchor- 4. The accuracy of the image is given by a reso- in the exploration of bone
ing devices lution ranging between 0.4 mm to 0.076 mm. tissue in the maxilla-facial
5. Cephalometric 5. The effective dose of radiations on a patient sphere.
analyses in the case of CBCT is between 29 and 477 3. A significant disadvan-
6. ATM evaluation microSv while, in the case of CT, it is of about tage of CBCT is represented
7. Evaluation before 2000 microSv. by the artefacts that may be
the implant 6. CBCT succeeds in reconstructing the 3D present on the image - not
8. Endodontic eval- image of the patient in three planes (sagittal, due to the scan, but to the
uation coronal and axial). presence of implants, resto-
9. Periodontal eval- 7. Panoramic and multi-plane images may be rations from the amalgam,
uation obtained by increasing the number of voxels, metallic prosthetic restora-
10. Evaluation of on also permitting the use of the 3D volume tions or endodontic treat-
bone resorption mode, reaching the desired image through cor- ments. These artefacts are
11. 3D reconstruc- responding settings. characterized by hyper-
tions 8. Rendering of the 3D volume is possible dense lines and dark
through direct and indirect techniques. images, which affect the
9. The presence of artifacts on the images given quality of the desired
by CBCT is much reduced. image.

208 volume 19 • issue 3 July / September 2015 • pp. 207-211

 THE ROLE OF CBCT IN THE EVALUATION OF PERIODONTAL DISEASES

Table 2. Aspects on the role of CBCT in periodontology, described in literature [1,4,8,9,17,19]

[4] The image provided by CBCT is qualitatively superior. Defects of bones, craters and furcation
areas are much better described on CBCT than on intraoral radiography, even if they do not offer
significant advantages at bone level.
[8] Currently, CBCT is used for multiple diagnosis and treatment plans, but, up to now, its use in
periodontology was not very well-reviewed and documented. 2D radiographs have been used
until the occurrence of CBCT, but, in the case of craters, lamina dura and periodontal bones, the
images are limited by the geometry of projection and overlapping of the other anatomical elements.
These shortcomings of 2D imaging are eliminated by CBCT, which evidences distinct benefits in
periodontics; however, its utilization and indications should be strictly followed, if considering
the potential hazards of examination.
[9] CBCT is very important in periodontal therapy, because it can analyze the depth, weight and
morphology of the bone.
[17] The results of this study indicate that the 3D imaging method, CBCT, is more accurate than
the periapical films used in the diagnosis of interradicular periodontal lesions.
[19] CBCT is superior to intraoral digital radiography, reproducing superior images in the case of
craters and furcation.
[1] CBCT may be useful in cases of infra-bone defects and furcation lesions, where clinical and
conventional radiographic examinations do not provide the information needed for their mana-
gement.

4. DISCUSSION traced through clinical or radiological

Periodontal diseases represent a group of
affections encountered at the level of the oral cavity,
nowadays present among children, teenagers and
adults. “The term “periodontal disease” includes
any inherited or acquired disorder of the tissue
supporting the tooth (gum, cement, periodontal
ligament, alveolar bone)” [11].
The periodontal disease is characterized by
destruction of the periodontal tissue and of the
alveolar bone following a secondary inflammatory
response of an infection produced by periodontal
bacteria [11]. In the oral cavity there are about
700 species of bacteria, of which 400 are
encountered in the subgingival bacterial plaque,
considered as the main etiological factor
producing the periodontal disease. In the
subgingival bacterial plaque from the deep
periodontal pockets, anaerobic gram-negative
bacteria and spirochetes - in particular
Porphyromonas gingivalis, Agregatibacter
actinomicetemcomitans, Bacteroides forsithus,
Prevottela intermedia and Fusobacterium nucleatum
- are usually present. In the beginning, the
periodontal disease may be asymptomatic, being
examination [12].
Radiological examination has an important
role in diagnosing the periodontal disease.
Different types of radiographies may be used in
this respect, among which: bitewing, periapical,
panoramic and CBCT radiographies. The
radiological examination used in the evaluation
of the periodontal disease provides information
related to the level and manner of bone destruction,
which may be measured from the small-cement
junction to the alveolar ridge. Furthermore, this
examination also provides information related to
lamina dura, the periodontal ligament, the junction
level, impacted teeth, calculi, incorrectly adapted
obturations and root shape [13].
The panoramic radiography is used to evaluate
the periodontal disease, as it offers information
related both to the alveolar bone and teeth and
to the neighbouring structures, even if, due to
the geometric projection used for their
achievement, artefacts and different elements
may appear superposed. Periapical radiography
is most often used for the evaluation of the
periodontal disease, but it can also present
certain shortcomings, which prevent reaching of

International Journal of Medical Dentistry 209

Alexandra FOCHI (DUMITRESCU), Danisia HABA
a precise diagnosis [13,8]. To overcome the
difficulties created by the intraoral radiography,
CBCT has been introduced and used at large
scale in the maxillofacial sphere [14].
Nowadays, the use of CBCT in periodontology
is quite limited, about 3% of the published articles
mentioning it, as well as its use in the OMF
sphere [13,15]. A precise evaluation of the bone
level and of the present changes induced by the
manifestation of the periodontal disease usually
requires a 3D radiological investigation or a
combination between the radiological image
given by standard 2D and 3D radiographies [16].
Different scientists, [17-19] who conducted
studies on skull and hemimandible, concluded
that CBCT is more accurate than conventional
radiography in detecting bone defects, that it
provides increased precision in the case of bone
defects in the oro-vestibular orientation, that it
shows an improved sensitivity compared to
intraoral radiography, and that it is superior in
evaluating craters and furcations, compared to
the conventional techniques [4,17,18]. The first
signs encountered in the periodontal disease
may be related to the interruption of lamina dura
continuity on the mesial and distal face of a tooth,
signs which cannot be assessed on 2D conventional
radiographs (which also show some significant
drawbacks, among which the overlap of some
anatomical elements, caused by positioning of
the radiation tube), because they require a special
fineness, achieved only by CBCT [4,20]. However,
it is interesting that another scientist [21] found
out no significant differences in bone
measurements made on conventional radiographs
and CBCT, even if measurements on the facial
and lingual face could not be made on 2D
radiographs [21]. A great scientist [19] conducted
a laboratory study, on also emphasizing that the
differences between 2D radiographs and CBCT
are not significant, however, later in 2008, a more
extended in vivo study, also conducted by him,
revealed the accuracy of measurements obtained
with CBCT, compared to those of intraoral
radiographs. The same study revealed the
superiority of CBCT to intraoral radiographs in
assessing craters and furcation injuries. Alveolar
bone defects are also well-revealed by CBCT,
which was proved in a study using intraoral,
panoramic, CT and CBCT.
210
5. CONCLUSIONS
To sum up, CBCT represents a new step in the
evolution of dental imaging. Even if, currently,
the studies devoted to the use of CBCT in
periodontology are quite few, the already existing
ones have demonstrated its usefulness and
advantages compared to other imaging
investigation techniques. CBCT remains useful
in particular situations of advanced periodontitis,
becoming mandatory in patients who require
implantar rehabilitation.
Acknowledgements
This paper received financial support by the
project “Programme of excellence in doctoral
and postdoctoral multidisciplinary research in
chronic diseases”, Grant No.
POSDRU/159/1.5/S/133377, project co-financed
by the Sectorial Operational Programme of
Human Resources Development, financed from
the European Social Fund.
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