Comparison of the efficacy of conventional radiography, digital

radiography, and ultrasound in diagnosing periapical lesions

Namita Raghav, MDS,a Sujatha S. Reddy, MDS,b A. G. Giridhar, MD,d
Srinivas Murthy, MDS,c Yashodha Devi B. K, MDS,b N. Santana, MDS,b N. Rakesh, MDS,b
and Atul Kaushik, MDS,b Mathura and Bangalore, India
K. D. DENTAL COLLEGE AND HOSPITAL, M. S. RAMAIAH DENTAL COLLEGE AND HOSPITAL,
AND M. S. RAMAIAH MEDICAL COLLEGE AND TEACHING HOSPITAL

Objectives. The aim of this study was to evaluate the efficacy of conventional radiography, digital radiography and
ultrasound imaging in diagnosing periapical lesions.
Study design. Twenty-one patients aged between 15 and 45 years with well defined periapical radiolucency
associated with anterior maxillary or mandibular teeth requiring endodontic surgery or extraction were selected and
consented to the study. Preoperative intraoral periapical radiographs and digital images using charge-coupled device
obtained by paralleling technique were assessed by 3 specialist observers who gave their diagnosis of the periapical
lesions. Then ultrasound examination was performed and the images were assessed for size, contents, and vascular
supply by 3 ultrasonographers. It was followed by curettage of periapical tissues to enable histopathologic
investigation, which is the gold standard in diagnosis. The data were statistically analyzed using SPSS, analysis of
variance, and ␬ statistics.
Results. The percentage accuracy of diagnosing periapical lesions using conventional radiography was 47.6%, digital
radiography 55.6%, and ultrasound 95.2%. Ultrasound had the highest sensitivity and specificity: 0.95 and 1.00,
respectively.
Conclusion. Conventional and digital radiography enable diagnosis of periapical diseases, but not their nature,
whereas ultrasound provides accurate information on the pathologic nature of the lesions, which is of importance in
predicting the treatment outcome. Therefore ultrasound can be used as an adjunct to conventional or digital
radiography in diagnosing periapical lesions. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:379-385)

Periapical lesions after pulpal pathology are usually
diagnosed and treated based on the radiologic findings.
The majority of periapical radiolucencies after dental
caries or trauma include periapical granuloma, periapi-
cal cyst, and periapical abscess.1,2 Conventional radi-
ography (CR) traditionally forms the backbone in the
diagnosis, treatment planning, and follow-up of periapical
lesions. In the past 2 decades, digital radiography (DR)
has gained popularity as an alternative to CR, because of
significant reduction in radiation exposure by ⬃50%-
80%,3 and because it allows image enhancement using
image processing software which includes brightness,
a
Department of Oral Medicine, Diagnosis and Radiology, K. D.
Dental College and Hospital.
b
Department of Oral Medicine, Diagnosis and Radiology, M. S.
Ramaiah Dental College and Hospital.
c CR and DR, in that it is not as expensive and haz-
Department of Conservative Dentistry, M. S. Ramaiah Dental Col-
lege and Hospital.
d
Department of Radiodiagnosis, M. S. Ramaiah Medical College and
Teaching Hospital.
Received for publication Nov 9, 2009; returned for revision Apr 23,
2010; accepted for publication Apr 24, 2010.
1079-2104/$ - see front matter
© 2010 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2010.04.039
contrast, sharpness, image orientation, and pseudocolor
alteration. However, recent studies have shown that direct
DR, even with image processing and enhancement, is no
better than CR in the diagnostic accuracy of periapical
lesions.4-6 To overcome these shortcomings, it is neces-
sary to evaluate new and more promising methods, such
as ultrasound (US), computerized tomographic (CT) scan,
digital radiometric analysis, and biochemical procedures
in the diagnosis of periapical lesions.
Ultrasound imaging is an easy and reproducible
technique that has the potential to supplement CR or
DR in the diagnosis of periapical lesions. Ultrasound
along with Color Doppler describes the content and
vascularization of the lesion, which forms an impor-
tant factor in diagnosing periapical lesions and in
differentiating periapical cyst from a granuloma.7-9
Therefore, US imaging can be used as an adjunct to
ardous regarding radiation exposure as CT scan.10-13
Correct diagnosis of periapical lesions aids in pre-
dicting the treatment outcome and helps in decreas-
ing the incidence of root canal treatment failures
associated with lack of proper diagnosis owing to the
limitations of routinely used CR or DR. Therefore,
the present study was undertaken to evaluate the

379

380 Raghav et al.
efficacy of CR, DR, and US in differentiating peri-
apical cysts from granulomas.
MATERIALS AND METHODS
A total number of 21 patients aged 15-45 years with
periapical radiolucency in relation to anterior maxillary
or mandibular teeth were selected for the study. Ap-
proval from the Ethical Committee was obtained, and
informed consent was taken from each patient after
explaining the aim and methodology of the study.
A case sheet was formulated to record a detailed
patient history, and clinical examination included all of
the endodontic diagnostic procedures: CR examination,
DR examination, US examination, and histopathologic
examination. Three observers (2 oral radiologists and 1
endodontist) and 3 ultrasonographers were asked to
measure the periapical lesions and give their diagnosis
from the images obtained from the various diagnostic
techniques.
The inclusion criterion was a well defined periapical
radiolucency associated with maxillary and mandibular
anterior teeth as a sequel to dental caries or trauma
indicated for extraction or root canal treatment. The
lesions that did not appear radiographically to represent
periapical inflammatory disease, teeth with ill-defined
periapical radiolucency, endoperio lesion, periodontitis,
root canal–treated teeth, patients with systemic conditions
associated with bony pathology such as hyperparathyroid-
ism, Paget disease, fibrous dysplasia, multiple myeloma,
etc., and patients undergoing orthodontic treatment were
excluded. The patients were subjected to intraoral peria-
pical radiograph, then DR, followed by US imaging.
Conventional radiographic examination
A preoperative periapical radiograph was taken for
all of the patients by paralleling technique using a film
holder with beam-aiming device (XCP; Dentsply Rinn,
Elgin, IL, USA) and an Explor-X 70 dental x-ray unit
(Confident Dental Equipments, Milano, Italy; 70 kVp,
8 mA, 2 mm aluminium filtration, 60 mm beam diam-
eter), and Kodak E-speed (Eastman Kodak Co., New
York, NY, USA) film no. 2 (31 ⫻ 41 mm) was used.
The films were exposed at 0.3 seconds and 0.25 sec-
onds for maxillary and mandibular anterior views, re-
spectively.
The radiographs were processed manually in fresh
chemicals and allowed to air dry. The radiographs were
viewed and evaluated on a view box under normal
operating illumination. Three observers (1 endodontist
and 2 radiologists) were asked to make a detailed
description of the periapical lesions (size and borders)
and give their diagnosis based on the criteria suggested
by Wood and Goaz12: periapical granuloma as a well
circumscribed periapical radiolucency measuring ⬍1.6
OOOOE
September 2010
cm in diameter, periapical cyst as a well defined peri-
apical radiolucency with sclerotic border measuring
⬎1.6 cm in diameter, and periapical abscess as an
ill-defined periapical radiolucency with diffuse mar-
gins.
The dimensions of all of the lesions were measured
in superoinferior (SI) and mesiodistal (MD) directions
by using a divider and a ruler on a millimeter scale by
all 3 observers to minimize the interobserver error.
Digital radiographic examination
After CR examination, the patients were subjected to
DR examination by paralleling technique using Suni
Ray digital charge-coupled device (CCD) intraoral sen-
sor, size #2, 43 ⫻ 33 mm (Imaging Microsystems, San
Jose, CA) and Samtron 56 V monitor for image display
with a P4 computer using Suni Ray-X version a3 soft-
ware for image storage and manipulation. The sensors
were exposed at 0.04 seconds and 0.03 seconds for
maxillary and mandibular anterior views, respectively.
The 3 observers were asked to examine the digital
images and measure the SI and MD dimensions of the
periapical lesions using the digital ruler to minimize
interobserver bias. The observers were allowed to use
different image processing facilities provided by the soft-
ware of the system if required to enhance the image quality.
The radiographic diagnosis was based on the criteria sim-
ilar to that for CR.
Ultrasound examination
After radiographic examination, the tooth under in-
vestigation was subjected to US examination using the
diagnostic ultrasound machine Voluson 730 Pro Ma-
chine (GE Medical Systems) with color Doppler (CD),
incorporating a high-definition, multifrequency, 40 mm
linear footprint, ultrasonic probe (LA-39) operating at a
frequency of 8-11 MHz. The ultrasound probe was
covered with a layer of ultrasound gel (Ultragel; Medi-
con, India) and positioned outside the mouth against the
skin corresponding to the radicular area of tooth of
interest. Once the bony defect was identified, the probe
was moved slightly around the area, and its position
was changed several times to obtain an adequate num-
ber of transverse (axial plane) and longitudinal scans
(sagittal plane) to define the bony defect (Fig. 1).
The US images were obtained in all of the cases due
to thin anterior labial cortical bone and possible fenes-
tration as a result of periapical lesions, and the echo
characteristics (hypoechoic/anechoic) of the periapical
lesions were determined. All lesions were measured in
3 planes, i.e., anteroposterior (AP), SI, and MD, and
recorded. Color Doppler was applied to detect the
blood flow, and if it was observed, spectral tracings
were obtained.
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Volume 110, Number 3 Raghav et al. 381

Fig. 1. Ultrasound scans in anterior maxillary region.

The US images were assessed by 3 ultrasonographers Table I. Summary of the measurements (mm) made
for the size and content (fluids, solid, or combination of by conventional radiography, digital radiography,
both), and diagnosis was based on the following crite- and ultrasound
ria: cystic lesion: hypoechoic well contoured cavity Dimension Technique Mean SD
surrounded by reinforced bony walls filled with fluid Superoinferior Conventional 9.89 2.59
and with no evidence of internal vascularization; gran- Digital 10.45 2.57
uloma: poorly defined hypoechoic area showing rich Ultrasound 5.85 2.59
vascular supply; and mixed lesion: predominantly a Mesiodistal Conventional 9.34 2.19
Digital 10.13 2.17
hypoechoic area with focal anechoic area showing rich Ultrasound 5.82 2.93
vascularity in some areas on CD examination. Anteroposterior Ultrasound 5.08 1.87

Surgical endodontics/extraction and

histopathologic examination
After extraction or root canal treatment, periapical
surgery was performed and tissue obtained from the
periapical area for histopathologic analysis. After fixa-
tion in 10% buffered formalin, the surgical specimens
were processed for routine histopathologic examination
and a diagnosis of the periapical lesions was given. All
of the 21 patients healed uneventfully and reported
being symptom free.
Data analysis was carried out using the SPSS, V. 11
software package (SPSS, Chicago, IL, USA). The in-
terobserver reliability for measuring the dimensions of
periapical lesions was analyzed by using analysis of
variance (ANOVA) for CR and DR, and a P value
of ⬍.05 was accepted as statistically significant. The
interobserver agreement for diagnosing the nature of
periapical lesions was analyzed using the ␬ statistics for
CR and DR. Percentage accuracy, sensitivity, and spec-
ificity of the diagnostic techniques were measured.
Digital radiographic examination
The diagnosis of periapical lesions by 3 observers
using DR showed that there was an agreement in 16 out
of 21 cases (76.2%). The mean SI measurement was
10.45 mm (SD ⫾2.6) and mean MD measurement was
10.13 mm (SD ⫾2.2; Table I).
Statistical comparison of conventional and digital
radiography
Using ␬ statistics showed that ␬ was 0.658 for CR
and 0.708 for DR, suggesting a good agreement
between the 3 observers regarding the diagnosis.
Using ANOVA, there was no statistically significant
difference between the 3 observers regarding the SI
and MD measurements, with P values of .901 and
.987, respectively; the P values were .987 for CR and
.987 for DR.

RESULTS Ultrasound examination

Conventional radiographic examination
The diagnosis of periapical lesions by 3 observers
using CR showed that there was an agreement in 15 out
of 21 cases (71.4%). The mean SI measurement was
9.89 mm (SD ⫾2.6) and mean MD measurement was
9.34 mm (SD ⫾2.2; Table I).
Of the 21 patients, 12 cases showed frankly anechoic
areas with well defined smooth contours with no evi-
dence of internal vascularization on CD and were di-
agnosed as periapical cyst (Fig. 2). One case displayed
echogenic content, rich vascular supply, and transonic
area of a mixed cystic and a granulomatous lesion.
 OOOOE
382 Raghav et al. September 2010

Fig. 2. A case of periapical cyst. a, Conventional radiograph, and b, digital image, showing well defined periapical radiolucency
with sclerotic borders in relation to right maxillary central and lateral incisors and superoinferior and mesiodistal measurement
of lesion. c, Ultrasound image shown on monitor in split-screen mode shows surface of thinned buccal cortical plate of bone (P),
the deep surface (S) of the periapical lesion, and the anechoic area in between P and S due to fluid contents. d, No evidence of
vascularization in the wall on color Doppler examination. e, Ultrasound image showing superoinferior, mesiodistal, and
anteroposterior measurement of the lesion. f, Diagrammatic equivalent of c and d. e, Histopathologic picture, showing cystic
epithelium of 6-8 cell layers thick, proliferating into the stroma in arcading pattern, underlying connective tissue with loosely
arranged collagen fibers and mild to moderate inflammatory cell infiltration and numerous endothelial-lined blood vessels and
extravasated red blood cells.

Eight cases showed uniformly hypoechoic areas with
thick mildly irregular walls and rich internal vascularity
on CD and were diagnosed as periapical granulomas (Fig. 3).
The US measurements were made in planes similar to CR
and DR, with the mean SI measurement at 5.85 mm
(SD ⫾2.6), mean MD measurement at 5.82 mm (SD ⫾2.9),
and mean AP measurement at 5.08 mm (SD ⫾1.9; Table I).
Histopathologic report
There was good agreement between the US diagnosis
regarding the nature of underlying lesions and his-
topathologic diagnosis. Twelve periapical lesions were
diagnosed by US as cystic; in each case, histopathology
revealed the presence of a cavity lined with stratified
squamous epithelium with underlying connective tissue
showing loosely arranged collagen fibers with mild to
moderate inflammatory cell infiltrate suggestive of
“periapical cyst” (Fig. 2). One case was diagnosed by
the US examination as a mixed lesion, and histopathol-
ogy revealed extensive granulomatous tissue contain-
ing a cystic cavity lined by stratified squamous epithe-
lium and intense pooling of chronic inflammatory cells,
suggestive of “infected periapical cyst.”
Eight cases were diagnosed by US as granulomas,
out of which 7 histopathologically showed connective
tissue with widespread areas of polymorphonuclear cells,
lymphocytes, monocytes, and newly formed blood vessels
suggestive of “periapical granulomas” (Fig. 3), and 1 case
diagnosed as periapical granuloma by US proved to be
periapical cyst on histopathologic examination.
The percentage accuracy, sensitivity, and specificity for
diagnosing periapical lesions using CR were 47.6%, 0.71,
and 0.50 using DR were 55.6%, 0.86, and 0.57, and using
US were 95.2%, 0.95, and 1.00 respectively (Table II).
DISCUSSION
Conventional radiography is undoubtedly the most
commonly used imaging modality to evaluate periapi-
cal lesions, because it is easy, economical, and acces-
sible. DR has gained popularity as an alternative to CR,
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Volume 110, Number 3 Raghav et al. 383

Fig. 3. A case of periapical granuloma. a, Conventional radiograph, and b, digital image showing well circumscribed periapical
radiolucency in relation to right maxillary central and lateral incisors and superoinferior and mesiodistal measurement of lesion.
c, Ultrasound image shown on monitor in split-screen mode shows surface of thinned buccal cortical plate of bone (P), the deep
surface (S) of the periapical lesion, and the hypoechoic area in between P and S. d, Spectral Doppler T trace showing blood flow.
e, Ultrasound image showing superoinferior, mesiodistal, and anteroposterior measurement of the lesion. f, Diagrammatic equivalent of
c and d. e, Histopathologic picture, showing connective tissue with immature to mature collagen fibers arranged in bundles and diffuse
mild to moderate chronic inflammatory cell infilteration seen with hemorrhagic areas; no lining epithelium was evident.

Table II. Accuracy, sensitivity, and specificity recorded clusively shown that no relation existed between the
in the 3 methods compared with histopathologic results presence of radiopaque border and the histopathologic
Method Accuracy Sensitivity Specificity diagnosis of the cysts.2,12
Conventional 47.61% 0.714 0.500 The various causes resulting in the failure of root
Digital 55.56% 0.857 0.567 canal therapy include operator errors and diagnostic
Ultrasound 95.24% 0.952 1.000 errors. It is important to differentiate between periapi-
cal granuloma and cyst, because that helps not only in
treatment planning and but also in predicting the treat-
ment outcome. The conventional root canal therapy is
because it has given the dentist the ability to perform the main treatment modality for periapical granuloma
radiographic examination with reduced radiation expo- but has no benefit for periapical cysts, because true
sure and allows enhancement of the image quality.4,5 cysts are less likely to be resolved by conventional root
Several radiographic features, such as the size and canal therapy and require surgical intervention. Peria-
shape of the lesion and the presence of sclerotic border pical pocket cysts, particularly smaller ones, heal com-
demarcating the lesion, support the diagnosis of peria- pletely after root canal therapy, whereas true cysts,
pical lesions. Although the statistical probability of cyst particularly large ones, are less likely to resolve by
occurrence may be higher among larger lesions, a con- nonsurgical endodontics and therefore may affect the
clusive relationship between the size of the lesion and treatment outcome. Similarly, periapical surgery per-
cystic nature has not yet been substantiated. Periapical formed based on the radiographic diagnosis of cysts
lesions can not be differentiated into cystic and non- might have resolved by root canal therapy alone. There-
cystic based on radiographic features alone. In a recent fore, to prevent the disproportionate application of peri-
histopathologic study of periapical lesions, it was con- apical surgery based on unfounded radiographic diag-

384 Raghav et al.
nosis of periapical lesions as cysts, and to improve the
treatment outcome, it is necessary to evaluate using
new and promising diagnostic methods such as US, CT
scan, DR analysis, and biochemical procedures in the
diagnosis of periapical lesions.2
Ultrasound real-time imaging is more convenient
than other imaging modalities, entails fewer biologic
adverse effects, and is economical. Ultrasound with
color power Doppler can supplement CR or DR in
diagnosing periapical lesions in case of doubt and can
provide accurate diagnosis, thus helping in treatment
planning and follow-up of periapical lesions.2,13,14
According to the studies by Yokota et al.4 and Tirell
et al.,15 DR outperforms CR in the diagnosis of initial
periapical lesions. In the present study, the percentage
accuracy was 55.6% for DR compared with 47.6% for
CR, and the image enhancement did not improve the
observer performance, which was similar to the find-
ings made by Barbat et al.,16 Bart et al.,17 and Sullivan
et al.5 Various studies have shown that ⬃66%-70.2% of
radiographic diagnosis is in correspondence with the
histopathological diagnosis of periapical lesions,18,19
whereas in the present study, it was much lower,
⬃47.6%, which could be due to the smaller sample size
and interobserver variation. In the present study, the
level of agreement on radiographic diagnosis among
the observers was good, in contrast to the study by
Paurazas et al.20 where it was poor.
In the present study, the percentage accuracy of US
in diagnosing periapical lesions was 95.2%; the US
diagnosis agreed with the histopathologic diagnosis in
every case except 1. The results showed that there was
a definite correlation between the echostructure of the
lesions and the histopathologic features. These findings
were consistent with the studies of Cotti et al.13,14 and
Gundappa et al.7 The sizes of periapical lesions were
smaller on the US compared with CR and DR, which
may be because the bony edges of the lesions cast an
acoustic shadow on the lateral walls, making it difficult
to place the electronic callipers for exact measure-
ment.7 However, the relative unimportance of lesion
size was confirmed by our study.
Ultrasound imaging is easy, reproducible, economi-
cal, and convenient to use compared with other ad-
vanced imaging modalities, such as CT scan. A work-
ing diagnosis can be made using US, which can also
provide dimensional measurements and location of
endodontic instruments. The real-time images obtained
are easy to read once the observer is trained, and they
are simple to store and retrieve. During treatment, CR
or DR can be used.
But the limitations of US imaging are operator de-
pendency, difficulty in attributing the lesions to a spe-
cific area of bone because the dental landmarks (i.e.,
OOOOE
September 2010
roots) were not specifically visualized, and that thin-
ning or discontinuity in the labial or buccal cortical
plate is required for US waves to penetrate and diag-
nose periapical lesions.13,21 Further research in the mul-
tiple differential diagnosis of bone lesions of the jaws is
suggested.
CONCLUSION
Ultrasound as a diagnostic tool has been widely used
in many medical fields, and its applications in dentistry
have not been sufficiently explored. The present study
confirmed that US imaging provides sufficient informa-
tion regarding the nature of the periapical lesions, un-
like CR and DR, and is a reliable diagnostic technique
for differentiating periapical lesions, i.e., periapical
cysts and granulomas, based on the echotexture of their
contents and the presence of vascularity using color
power Doppler. US imaging can be used as an adjunct
to routine use of CR and DR in the diagnosis of
periapical lesions and would be an important contribu-
tion to the trend toward radiation-free oral diagnostics.
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19. Bohay RN. The sensitivity, specificity, and reliability of ra- Senior Lecturer
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Comparison of diagnostic accuracy of digital imaging by India
using CCD and CMOS-APS sensors with E-speed film in the raghavnamita@gmail.com