REVIEW ARTICLE

Amanda Pelegrin Candemil,

DDS, MSc, PhD,*†
Accuracy of Magnetic
Guilherme Nilson Alves dos
Santos, DDS, MSc,*
Resonance Imaging in Clinical
Matheus L. Oliveira, DDS, MSc,
PhD,‡ Filippo Gatti, DDS, MSc,
Endodontic Applications:
PhD,† Yara T. C. Silva-Sousa,
DDS, MSc, PhD,§ Alice C. Silva-
A Systematic Review
Sousa, DDS,*
Jardel Francisco Mazzi-Chaves,
DDS, MSc, PhD,* and
Manoel Damia ~o Sousa-Neto,
DDS, MSc, PhD*
ABSTRACT
SIGNIFICANCE
Introduction: The development of dedicated coils and new magnetic resonance imaging
MRI has high diagnostic value (MRI) sequences has led to an increase in image resolution and a reduction in artifacts.
in the evaluation of tooth and Consequently, numerous studies have demonstrated the utility of MRI as a nonionizing
root canal anatomy, pulp alternative to cone-beam computed tomographic imaging. The aim of this systematic review
vitality, and regeneration, as was to evaluate the accuracy of MRI in clinical applications in endodontics. Methods: A
well as in assessing the effect literature search was conducted using PubMed, Embase, Scopus, and Web of Science. The
of caries on dental pulp, inclusion criteria encompassed studies evaluating MRI applications in endodontics, covering
periapical lesions, and root tooth and root canal anatomy, root canal working length, pulp vitality and regeneration, the
cracks or fracture. The effect of caries on dental pulp, guided endodontics, periapical lesions, and root cracks/
accuracy of MRI is comparable fractures. The selected studies examined both ex vivo and in vivo human teeth using clinical
to or even higher than that of MRI units. Two researchers independently screened the studies, applied the eligibility criteria,
reference standards such as and assessed the potential risk of bias using the revised QUADAS-2 tool (Bristol Medical
CBCT imaging, micro-CT School, University of Bristol, UK). Results: A total of 18 studies were included in this
imaging, and histology. systematic review, demonstrating that the use of MRI has a high diagnostic value in
endodontics. In the evaluation of tooth and root canal anatomy, pulp vitality and regeneration,
the effect of caries on dental pulp, periapical lesions, and root cracks/fractures, MRI’s
accuracy is comparable to or even higher than reference standards such as cone-beam
computed tomographic imaging, micro–computed tomographic imaging, and histology.
Conclusions: MRI has high potential accuracy for diagnosing various clinical endodontic
From the *Department of Restorative tasks, except for root canal length, size of caries, and periapical lesion dimensions, which are
Dentistry, School of Dentistry of Ribeira~o
~o Paulo, Sa~o Paulo,
overestimated in MRI. (J Endod 2024;50:434–449.)
Preto, University of Sa
Brazil; †CentraleSup elec, Ecole Normale
Supe rieure Paris-Saclay, Centre national KEY WORDS
de la recherche scientifique, Laboratoire
de Me canique Paris-Saclay, Universite Dentistry; diagnosis; endodontics; magnetic resonance imaging
Paris-Saclay, Gif-sur-Yvette, France;
‡
Division of Oral Radiology, Department of
Oral Diagnosis, Piracicaba Dental School, During the pre-, intra-, and postoperative stages of endodontic treatment, professionals require imaging
University of Campinas, Piracicaba, Brazil; examinations as a complementary method to aid in diagnosis and treatment planning. Generally, the first-
and §School of Dentistry, University of choice examination is periapical radiography; however, because of its limitation regarding overlapping of
Ribeir~ao Preto, Ribeira~o Preto, Brazil
structures1,2, cone-beam computed tomographic (CBCT) imaging has been frequently indicated despite
Address requests for reprints to Dr its relatively higher radiation dose3,4.
Amanda Pelegrin Candemil, Department
The dose of ionizing radiation delivered to the patient should be considered when requesting an
of Restorative Dentistry, School of
Dentistry of Ribeir~
ao Preto, University of imaging examination, taking into account the purpose of the examination and the individual needs and
~o Paulo, Av do Cafe
Sa -Subsetor Oeste- physical aspects of the patient5. Accordingly, a higher frequency of CBCT indication reflects greater
~o Preto, Sa
11 (N-11), Ribeira ~o Paulo radiation exposure to the population, particularly in young and child populations, who are more sensitive
14040-904, Brazil. to the deleterious effects of X-rays6,7. Thus, the use of nonionizing imaging examinations, especially in
E-mail address: amandacandemil@usp.br
0099-2399/$ - see front matter
young patients and children, is fundamental.
Magnetic resonance imaging (MRI) is formed by the interaction between atomic nuclei, commonly
Copyright © 2024 American Association
of Endodontists.
those of hydrogen, and a powerful static magnetic field. The nuclei capture energy from an oscillating
https://doi.org/10.1016/ magnetic field at a specific resonant frequency. The use of spatially varying magnetic fields enables spatial
j.joen.2024.01.014 encoding of nuclei and the generation of cross-sectional images8. Although there is hydrogen in the water

434 Candemil et al. JOE  Volume 50, Number 4, April 2024

and adipose tissue that make up bones,
morphologic studies with MRI are still
considered challenging. The mineralized
composition of bone causes the signal emitted
by it to quickly disappear, requiring specific
pulse sequences that are not always available
in devices used daily in diagnostic centers9.
Furthermore, although dental pulp produces a
hyperintense signal (bright) in MRI images,
enamel, dentin, and cementum reveal a
hypointense signal (black) because of their low
water concentration and very short relaxation
constants of the hydrogen atoms. Thus, these
structures can be indirectly depicted by
contrasting them with adjacent signal-emitting
structures9.
Recently, the development of dedicated
coils and new MRI sequence techniques has
led to an increase in image resolution and a
decrease in artifacts originating from
metals10,11. Thus, the scientific literature has
been showing different studies evaluating the
use of MRI in endodontics as a nonionizing
alternative to CBCT imaging or other imaging
modalities on diagnosis tasks such as tooth
and root canal anatomy, root canal working
length, pulp vitality and regeneration, dental
pulp and caries, guided endodontics,
periapical lesion, and root cracks or fractures.
However, there is still a need for further
elucidation regarding the applicability of MRI in
endodontics.
Considering the extensive use of X-ray
imaging in endodontics and the potential
biological harm by X-rays to patients,
nonionizing imaging examinations should be
preferred. However, with the increasing
adoption of MRI for different diagnostic tasks in
endodontics, it is essential for professionals to
understand when and how to recommend it as
well as to recognize its limitations and
advantages. Therefore, the aim of this
systematic review was to evaluate the
accuracy of MRI in clinical applications in
endodontics in comparison with other imaging
methods and/or clinical examination.
MATERIALS AND METHODS
Protocol and Study Design
This systematic review followed the Preferred
Reporting Items for Systematic Reviews and
Meta-Analysis12 checklist, and the protocol
was registered in the International Prospective
Register of Systematic Reviews (PROSPERO-
2022 CRD42022382668). Based on this
protocol, the review explored aspects related
to the application of clinical MRI in the field of
endodontics. The sample for this review
comprised all relevant in vivo and ex vivo
studies concerning the applicability of MRI in
endodontics, covering the period from 2004–
JOE  Volume 50, Number 4, April 2024
2023. To assess all applications of clinical MRI
in endodontics, a guiding question and an
eligibility strategy were used in the review
process. The guiding question of the study
was the following: Among ex vivo and in vivo
teeth, how does MRI compare with 2-
dimensional and 3-dimensional images (CBCT
and micro–computed tomographic [micro-CT]
imaging) and other images such as histology in
terms of applicability and diagnostic accuracy
in endodontics? The PICO (Patient,
Intervention, Comparison, and Outcome)
strategy was used to define the key elements
of the guiding question. The study population
(P) consisted of ex vivo and in vivo teeth
samples, the intervention (I) involved studies
using MRI in endodontics, and the comparison
(C) comprised studies that used 2-dimensional
and 3-dimensional image (CBCT and micro-
CT imaging) evaluation and histology. The
outcome (O) evaluated the applicability and
diagnostic accuracy in endodontics.
Literature Search Strategy
The search strategy, as described in Table 1,
included only studies indexed in the following
electronic databases: PubMed, Scopus,
Embase, and Web of Science. No search was
conducted in the gray literature. All included
studies were written in English. The search
was performed using terms from Medical
Subject Headings, Emtree (Embase), or Text
Word combined with the Boolean connectors
“OR” and “AND” to encompass the key
elements from the guiding question.
Study Selection and Screening
Process
Two researchers (A.P.C. and G.N.A.S.)
independently screened titles and abstracts of
the identified studies and selected those that
met the eligibility criteria described later.
Disagreements were resolved through
consensus. The full text of the selected studies
was then assessed to determine if they aligned
with the present guiding question. Both A.P.C.
and G.N.A.S. independently reviewed these
studies to decide which ones to include in this
systematic review, with any disagreements
resolved through consensus. Additionally, 1
examiner (A.C.S.S.) assessed the selected
studies to identify additional ones that could
address the guiding question. Language was
not a restriction. Microsoft Excel (Microsoft
Corporation, Redmond, WA) was used to
register the decisions.
Inclusion and Exclusion Criteria
The inclusion criteria encompassed all studies
evaluating MRI applications in endodontics.
The selected studies examined ex vivo and
Endodontic Applications of Magnetic Resonance Imaging
in vivo human teeth using clinical MRI units and
were indexed in the search.
The exclusion criteria covered studies
using animal studies, small sample sizes (,5
teeth), review studies, systematic reviews,
editorials, and book chapters. Studies
unavailable for full-text assessment were also
excluded.
Data Extraction
The data extraction considered general
information that identified the study (author
and year), study topic, MRI system, MRI unit,
MRI coil, MRI pulse sequence, MRI acquisition
parameters, presence of contrast, objective,
design, sample, and presence of control. The
summary of this extraction is presented in
Tables 1 and 2. The weighted kappa test was
used to measure intrareviewer agreements,
and the results were interpreted according to
Landis and Koch13 as follows: 0.00–0.20,
poor; 0.21–0.40, reasonable; 0.41–0.60,
moderate; 0.61–0.80, good; and 0.81–1.00,
excellent.
Risk of Bias Assessment
Two reviewers (A.P.C. and G.N.A.S.)
independently evaluated the potential risk of
bias using the revised QUADAS-230. In the
event of disagreements, a third reviewer was
consulted to reach a consensus. This
assessment tool comprises 4 key domains:
patient selection, index test, reference
standard, and flow and timing. Each item was
appraised by addressing specific guiding
questions, resulting in a classification of "low
risk of bias" (for negative responses), "high risk
of bias" (for positive responses), or "unclear"
(for missing information).
RESULTS
Selected Studies
A total of 5658 studies were preselected; 5611
were excluded because of duplication or a lack
of relevance to the study topic. The titles and
abstracts of the 47 remaining studies were
carefully reviewed, leading to the exclusion of
25 studies that used in vitro MRI units.
Additionally, 2 studies were excluded because
of the use of animal samples, and another 2
studies were excluded because of a low
sample number (,5 teeth). Therefore, a total of
18 studies were included in this systematic
review (Fig. 1). The level of agreement between
the reviewers was excellent (0.98).
The extracted data from the studies are
summarized based on the MRI acquisition
parameters and the studies’ characteristics in
accordance with 8 diagnosis tasks: tooth and
root canal anatomy (5%), root canal working
length (10%), pulp vitality (16%), pulp
435
TABLE 1 - Search Strategy According to the Database

PubMed: 517 studies found

(Tooth[MeSH Terms]) OR (Teeth[Title/Abstract])
((((((((((((((((((((((((((((((((((((((((Magnetic Resonance Imaging[MeSH Terms]) OR (Imaging, Magnetic Resonance[Title/Abstract])) OR (NMR Imaging[Title/
Abstract])) OR (Imaging, NMR[Title/Abstract])) OR (Zeugmatography[Title/Abstract])) OR (MR Tomography[Title/Abstract])) OR (NMR
Tomography[Title/Abstract])) OR (Tomography, NMR[Title/Abstract])) OR (Steady-State Free Precession MRI[Title/Abstract])) OR (Steady State
Free Precession MRI[Title/Abstract])) OR (Tomography, MR[Title/Abstract])) OR (Imaging, Chemical Shift[Title/Abstract])) OR (Chemical Shift
Imagings[Title/Abstract])) OR (Imagings, Chemical Shift[Title/Abstract])) OR (Shift Imaging, Chemical[Title/Abstract])) OR (Shift Imagings,
Chemical[Title/Abstract])) OR (Chemical Shift Imaging[Title/Abstract])) OR (Magnetic Resonance Image[Title/Abstract])) OR (Image, Magnetic
Resonance[Title/Abstract])) OR (Magnetic Resonance Images[Title/Abstract])) OR (Resonance Image, Magnetic[Title/Abstract])) OR
(Magnetization Transfer Contrast Imaging[Title/Abstract])) OR (MRI Scans[Title/Abstract])) OR (MRI Scan[Title/Abstract])) OR (Scan, MRI[Title/
Abstract])) OR (Scans, MRI[Title/Abstract])) OR (Tomography, Proton Spin[Title/Abstract])) OR (Proton Spin Tomography[Title/Abstract])) OR
(fMRI[Title/Abstract])) OR (MRI, Functional[Title/Abstract])) OR (Functional MRI[Title/Abstract])) OR (Functional MRIs[Title/Abstract])) OR (MRIs,
Functional[Title/Abstract])) OR (Functional Magnetic Resonance Imaging[Title/Abstract])) OR (Magnetic Resonance Imaging, Functional[Title/
Abstract])) OR (Spin Echo Imaging[Title/Abstract])) OR (Echo Imaging, Spin[Title/Abstract])) OR (Echo Imagings, Spin[Title/Abstract])) OR
(Imaging, Spin Echo[Title/Abstract])) OR (Imagings, Spin Echo[Title/Abstract])) OR (Spin Echo Imagings[Title/Abstract])
Scopus: 3.836 studies found
(TITLE-ABS-KEY (magnetic AND resonance AND imaging)) AND (TITLE-ABS-KEY (tooth))
Embase: 512 studies found
tooth:ti,ab,kw AND ’magnetic resonance imaging’:ti,ab,kw
Web of Science: 793 studies found
tooth (All Fields) AND magnetic resonance imaging (All Fields)

regeneration (16%), dental pulp and caries
(10%), guided endodontics (10%), periapical
lesion (22%), and root cracks or fractures
(11%) in accordance with the study aims
(Tables 2 and 3).
MRI Acquisition Parameters
The selected studies used 12 different MRI
units (Magnetom Avanto [Siemens
Healthineers, Erlangen, Germany],
Magnetom Trio [Siemens Healthineers],
Siemens Skyra [Siemens Healthineers],
Siemens Sinfonie [Siemens Healthineers],
Magnetom Prisma [Siemens Healthineers],
Sonata Vision [Siemens Healthineers],
Achieva [Philips Healthcare, Best,
Netherlands], Achieva Gyroscan [Philips
Healthcare], TX Achieva [Philips Healthcare],
Signa HDxt [GE Medical System, Milwaukee,
WI], OxfordMagnet [Oxford Instruments,
Oxford, UK], and Magnex Scientific
[Magnex, Oxford, UK]) with 1.5, 3.0, and
4.0 Tesla systems and 15 coils (custom
intraoral, 50-mm diameter intraoral,
radiofrequency receiver, intraoral
radiofrequency transceiver, 8-inch diameter
temporomandibular joint surface, head and
neck [Achieva Gyroscan], 4-channel special
purpose, 4-channel multifunctional
radiofrequency [Noras MRI Products,
Ho€chberg, Germany], 12-channel head and
matrix neck [Siemens Healthcare GmbH,
Erlangen, Germany], 15-channel dental
surface [Mandibula, Noras MRI Products],
channel multipurpose [Variety, Noras MRI
Products], 16-element neurovascular
receive, 20-channel head and neck
[Siemens Healthcare GmbH], 32-channel
head, and 64-channel head) (Table 2).
Eighteen pulse sequences were used in
the studies, including turbo spin echo, multiple
slab acquisition with view angle tilting gradient
with sampling perfection with application-
optimized contrasts using different flip angle
evolution, fast field echo, volumetric
interpolated breath-hold examination, fast low
angle, constructive interference in steady state,
fat saturated, sampling perfection with
application-optimized contrasts using different
flip angle evolution, fat suppression with turbo
rapid acquisition with refocusing echoes,
cartesian turbo spin echo, fat suppression,
balanced steady, fast recovery fast spin echo,
fast spoiled gradient echo, spin echo,
multiband sweep imaging with Fourier
transformation, sweep imaging with Fourier
transformation, and gradient echo (Table 2).
The acquisition parameters used varied
across a wide range: field of view from 8–
220 mm2, matrix size from 64 ! 64–
328 ! 512 mm, voxel size from 0.02–
125 mm2, acquisition time from 2:19–
10:25 minutes, echo time from 1.5–
400 milliseconds, repetition time from 4–
4580 milliseconds, number of slices from 10–
80, averages between 1 and 2, echo train
length from 1–73, flip angle from 10 –90 ,
factor from 2–40, and bandwidth from 90–
501 Hz/pixel. In 9 studies in which contrast
was considered, 7 contrast agents were used.
These included 0.1 mmol/kg gadolinium-
diethylenetriamine pentaacetic acid, 0.1 mmol/
kg gadolinium, ultrasmall superparamagnetic
iron oxide, 1.5% solution of agar with 0.2%
Magnevist (Bayer Schering Pharma, Berlin,
Germany) enterally, 0.1 mmoL/kg gadoterate
meglumine, 469 mg/mL Magnevist, and
gadolinium. One study25 did not specify which
contrast agent was used (Table 2).
Study Characteristics
The publication years of the selected studies
ranged from 2004–2023, with study designs
distributed as 80% in vivo and 20% ex vivo. In
the in vivo studies, sample sizes ranged from
5–92 patients, evaluating 5–584 teeth. In the
ex vivo studies, sample sizes ranged from 58–
100 teeth. Further examining sample sizes in
relation to diagnostic tasks, studies on pulp
regeneration used the lowest (5–18 teeth),
whereas those on pulp vitality used the highest
(162–1685 teeth), both having a 100% in vivo
design. Among all of the studies, 61% included
a control examination, which could be
panoramic radiography (9%), CBCT imaging
(46%), digital periapical radiography (9%),
histology examination (18%), micro-CT
imaging (9%), or micro-CT and CBCT imaging
(9%) (Table 3).
Risk of Bias
Figure 2A and B displays the risk of bias of the
included studies. Overall, the methods used
were homogeneous and showed a low risk of
bias, except for 2 studies11,29 that exhibited a
high risk. The highest bias risk was associated
with domain 1, “patient selection.” In in vitro
studies, the issue of patient selection was a
concern in the bias analysis because random
patient selection is not advocated. However,
most studies answered yes to the second
question in domain 1, which is related to the

436 Candemil et al. JOE  Volume 50, Number 4, April 2024

TABLE 2 - Magnetic Resonance Imaging Acquisition Parameters

System
Study Study topic (Tesla) Unit Coil Pulse sequence Acquisition parameters Contrast
Tymofiyeva Tooth and root canal 1.5 Magnetom 4-channel multifunctional 3D turbo spin echo FOV of 100 ! 60 ! 50 mm, matrix *
et al9 anatomy Avanto radiofrequency (Noras of 128 ! 76 ! 44 mm, voxel
MRI Products) size of 0.8 ! 0.8 ! 1 mm, echo
time of 100 ms and repetition
time of 1000 ms, turbo factor of
17
Zidan et al14 Root canal working 3.0 Magnetom 15-channel dental surface 3D MSVAT-SPACE FOV of 168 ! 131, matrix of *
length Trio coil (Mandibula) 384 ! 300 mm, voxel size of
0.44 mm3, acquisition time of
7:45 min, echo time of 6.4 ms,
repetition time of 1170 ms, and
80 slices
Zidan et al15 3.0 Magnetom 15-channel dental surface 3D MSVAT-SPACE FOV of 168 ! 131 mm, matrix of Noncontrast
Trio (Mandibula) 384 ! 300 mm, voxel size of
0.44 mm3, acquisition time of
7:45 min, echo time of 6.4 ms,
repetition time of 1170 ms, and
80 slices
Kress et al16 Pulp vitality 1.5 Siemens 8-inch diameter 1. T2 weighted 1. T2w: FOV of 230 mm3, 3. Gadolinium-
Sinfonie temporomandibular turbo spin matrix of 328 ! 512 mm, DTPA
joint surface 0.1 mmol/kg
echo (axial) acquisition time of
2. T1 weighted 3:46 min, echo time of
fast field echo 100 ms, repetition time of
(sagittal) 4523 ms, and slice
3. T1 weighted thickness of 3 mm
contrast 2. T1w: FOV of 270 mm3,
enhanced with matrix of 328 ! 512 mm,
fast field echo acquisition time 3.50 min,
(sagittal) echo time of 6.1 ms,
repetition time of 15 ms,
slice thickness of 1.5 mm,
and fat suppression with
proset water select
3. T1wgd: FOV of 270 mm3,
matrix of 328 ! 512 mm,
acquisition time 3:50 min,
echo time of 6.1,
repetition time of 15 ms,
slice thickness of 1.5 mm,
and fat suppression with
proset water select
Kress et al17 * * * 1. T2 weighted 1. T2w: FOV of 230, matrix 3. Gadolinium-
with turbo spin of 328 ! 512 mm, DTPA
0.1 mmol/kg
echo (axial) acquisition time of
2. T1 weighted 3:46 min, echo time of
with fast field 100 ms, repetition time of
echo (sagittal) 4523 ms, and slice
3. T1 weighted thickness of 3 mm
with contrast 2. T1w: FOV of 270, matrix
enhanced with of 328 ! 512 mm,
fast field echo acquisition time 3.50 min,
(sagittal) echo time of 6.1 ms,
repetition time of 15 ms,
slice thickness of 1.5 mm,
and fat suppression with
proset water select
3. T1wgd: FOV of 270,
matrix of 328 ! 512 mm,
acquisition time 3:50 min,
echo time of 6.1,
repetition time of 15 ms,
slice thickness of 1.5 mm,
and fat suppression with
proset water select
3.0

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TABLE 2 - Continued

System
Study Study topic (Tesla) Unit Coil Pulse sequence Acquisition parameters Contrast
Juerchott Magnetom 16-channel multipurpose 2 Gadolinium
1. T1 weighted 1. T1w: FOV of 140 mm ,
et al18 Trio coil (Variety) turbo spin matrix of 256 ! 256 mm, 0.1 mmol/
kg
echo voxel size of
2. T1 weighted 0.55 ! 0.55 ! 1.5 mm,
VIBE acquisition time of 6 min,
echo time of 15 ms,
repetition time of 779 ms,
2 averages, 3 echo train
length, 40 slices, and
bandwidth of 501 Hz/
pixel
2. T1w: FOV of 180 mm2,
matrix of 192 mm2, voxel
size of 0.9 mm3,
acquisition time of
5:46 min, echo time of
2.46 ms, repetition time of
4.47 ms, 1 average, 1
echo train length, flip
angle of 15 , and
bandwidth of 501 Hz/
pixel
Assaf et al19 Pulp regeneration 3.0 Siemens 20-channel head and 1. T1 weighted FOV of 180 ! 180 ! 96 mm, Noncontrast
Skyra neck (Siemens Medical (FLASH) matrix of 256 ! 256 ! 120 mm
Solutions, Erlangen, and voxel size of
Germany)
2. Fat saturated 0.7 ! 0.7 ! 0.8 mm
T1 weighted 1. T1w: acquisition time of 4:14 min,
(CISS); echo time of 3.26 ms, repetition
3. Fat saturated time of 21 ms, flip angle of 35 ,
T2 weighted bandwidth of 500 Hz/pixel
2. fsT1w: acquisition time of
4. CISS (turbo
5:18 min and repetition time of
spin echo with 34 ms
SPACE) 3. fsT2w: acquisition time of
5:14 min, echo time of 113 ms,
repetition time of 2000 ms, echo
train length of 72, echo distance
of 4.35 ms, and bandwidth of
575 Hz/pixel
4. CISS: acquisition time of
3:43 min, echo time of 3.43 ms,
repetition time of 6.85 ms, flip
angle of 49 , and bandwidth of
300 Hz/pixel
El-Kateb 3.0 Achieva Head and neck (Achieva 1. T2 weighted 1. T2 axial: voxel size of *
et al20 Gyroscan Gyroscan) turbo spin 1.3 ! 31.3 mm, echo
echo(axial) time of 100 ms, repetition
2. T2 weighted time of 54.5 ms, flip angle
3D of 90 , and 3-mm slice
thickness
2. T2 3D: voxel size of
1.3 ! 31.3 mm,
acquisition time of
3.50 min, echo time of
160 ms, repetition time of
1500 ms, 2.5-mm slice
thickness, and turbo
factor of 40
Nakashima 1.5 (Philips * Fat suppression T2- FOV of 220 ! 316 mm, matrix of *
et al21 Electronics weighted with 128 mm2, voxel size of
Japan, Turbo RARE T2 0.02 mm2, echo time 70–80 ms,
Tokyo, (axial) repetition time of 2500 ms, 4
Japan) average, slice thickness of 3 mm,
10–20 slices FA90, number of
excitations 3
Dental pulp and caries 1.5 Radiofrequency receiver

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438 Candemil et al. JOE  Volume 50, Number 4, April 2024

TABLE 2 - Continued

System
Study Study topic (Tesla) Unit Coil Pulse sequence Acquisition parameters Contrast
Tymofiyeva Magnetom 3D Cartesian Turbo FOV of 60 ! 30 ! 17 mm, voxel 1.5% solution
et al22 Avanto spin echo size of 0.3 ! 0.3 ! 0.4 mm, of agar with
time of acquisition of 8 min, echo 0.2%
time of 400 ms, repetition time of Magnevist
12 ms, and turbo factor of 5 enterally
Cankar 3.0 TX Achieva 32-channel head 1. T2-weighted 1. T1-weighted: FOV of *
et al23 turbo spin 140 mm2, matrix of
echo (axial) 156 ! 124 mm,
2. T1-weighted acquisition time of
fat 3.25 min, voxel size of
suppressed 0.9 ! 1.12 ! 2 mm,
proton density echo time of 400 ms,
(coronal and repetition time of 100 ms,
sagittal) single echo, thickness of
2 mm, 5 slices, and
bandwidth of 253 Hz/
pixel
2. T2 weighted: FOV of
160 mm2, matrix
380 ! 311 mm,
acquisition time of
10:24 min, voxel size
0.42 ! 0.51 ! 2.5 mm,
echo time of 15, 30, 45,
60, 75, 90 ms, repetition
time of 2000 ms, single
slice, slice thickness of
2.5 mm, and bandwidth
of 290 Hz/pixel
Leontiev Guided endodontics 3.0 Magnetom 64-channel head Balanced steady- Matrix of 384 ! 384 ! 120 mm, *
et al24 Prisma state free voxel size of
precession 0.4 ! 0.4 ! 0.8 mm, echo time
of 4.45 ms, repetition time
8.89 ms, acquisition time of
2:19 min, factor of 2, slice
oversampling of 20%, flip angle
of 40 , and bandwidth of
213 Hz/pixel
Geibel et al25 Periapical lesion 3.0 Achieva 16-channel neurovascular T1- (T1w) and T2- Acquisition time of 9:06 min (T1w) Used, however,
receive weighted (T2w) and 5:43 min (T2w) not specified
contrast
Lizio et al26 1.5 Signa HDxt Head-neck coil 1. T1-weighted 1. T1-weighted: matrix, Gadolinium-
fast spin echo 320 ! 224 mm, echo DTPA

(axial) time of 9–12 ms,

2. T2-weighted repetition time of 400–
fast recovery 580 ms, echo train length
fast spin echo of 3, slice thickness of
(axial or 3 mm, interslice gap of
sagittal) 0.3 mm, and number of
3. T1-weighted excitations of 3
fast spoiled 2. T2-weighted: matrix of
gradient echo 320 ! 224 mm, echo
(axial or time of 120 ms, repetition
sagittal) time of 3440–3680 ms,
echo train length of 17,
slice thickness of 3 mm,
interslice gap of 0.3 mm,
and number of excitations
of 6
3. T1 weighted: matrix of
256 ! 192 mm, echo
time of 1.5–5 ms,
repetition time of 6–
10 ms, flip angle of 10–
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JOE  Volume 50, Number 4, April 2024 Endodontic Applications of Magnetic Resonance Imaging 439
TABLE 2 - Continued

System
Study Study topic (Tesla) Unit Coil Pulse sequence Acquisition parameters Contrast

15 , echo train length of
1, slice thickness of
2 mm, interslice gap of
0 mm, and number of
excitations of 2
Juerchott 3 Magnetom 12-channel head coil and 1. T2 weighted 1. T2wfs: FOV of 150 mm2, 0.1 mmoL/kg
et al27 Trio matrix neck coil with fat matrix of 240 ! 320 mm, gadoterate
(Siemens Healthcare) meglumine
suppression acquisition time of
(T2wfs turbo 4:26 min, echo time of
spin echo) 87 ms, repetition time of
2. T1 weighted 4580 ms, 2 averages
(T1w spin number, echo train length
echo) of 9, flip angle of 150 ,
3. T1 weighted slice thickness of 2 mm,
with fat 40 slices, and bandwidth
suppression of 90 Hz/pixel
(T1wfs spin 2. T1w: FOV of
echo) 168 ! 210 mm, matrix of
192 ! 320 mm,
acquisition time of
4:20 min, echo time of
6.4 ms, repetition time of
680 ms, 1 average
number, 1 echo train
length, flip angle: 90 ,
slice thickness of 2 mm,
40 slices, and bandwidth
of 248 Hz/pixel
3. T1wfd: FOV of
168 ! 210 mm, matrix of
218 ! 320 mm,
acquisition time of
3:18 min, echo time of
8.1 ms, repetition time of
700 ms, 2 average
number, 1 echo train
length, excitation flip
angle of 58 , slice
thickness of 1.8 mm, 19
slices, and bandwidth of
159 Hz/pixel
Pigg et al28 1.5 Sonata Vision S/I 1. Axial T1  T1, T2 SIR, T1 gd and T1 Magnevist
weighted fs gd (1, 2, 4, 5) with voxel (469 mg/mL,
Schering
2. Axial T2 SIR size of 0.9 ! Nordiska)
3. Axial 3D CISS 0.8 ! 3.0 mm and
4. Axial T1  3D CISS (3) with voxel size gadolinium
weighted with of 0.6 mm3 contrast
gadolinium
contrast (T1
gd)
5. Axial T1
weighted with
fat
suppression
and
gadolinium
contrast
administration
(T1 fs gd)
Groenke Root cracks or 4.0 OxfordMagnet Custom intraoral (Agilent MB-SWIFT FOV of 120 mm3, acquisition time of *
et al11 fractures DirectDrive console, 5:39 min, voxel size of
Palo Alto, CA) 0.25 mm3, repetition time of

(continued on next page )

440 Candemil et al. JOE  Volume 50, Number 4, April 2024

TABLE 2 - Continued
System
Study Study topic (Tesla)
Schuurmans 4.0
et al29
*Not informed.
3D, 3-dimensional; CISS, constructive interference in steady state; FLASH, fast low angle; FOV, field of view; gd, gadolinium; GRE, gradient echo; MB, multiband; MSVAT, multiple slab
acquisition with view angle tilting gradient; RARE, rapid acquisition with refocusing echoes; SIR, short tau inversion recovery; SPACE, sampling perfection with application optimized
contrasts using different flip angle evolution; SWIFT, sweep imaging with Fourier transformation; VIBE, volumetric interpolated breath-hold examination.
control group (Was a case-control design
avoided?). Regarding domain 2 (index test),
which is related to the blinding of the examiner
during sample analysis, 7
studies11,16,17,19,25,29,31 did not comply with or
specify the criteria. In domain 3, which pertains
to the reference standard, conduct, and
interpretation of results to reduce bias risk, 4
studies11,19,25,29 did not report or specify this
domain. In domain 4, which is related to
sample standardization, only 1 study29 did not
report or specify this domain.
Application in Endodontics
Tooth and Root Canal Anatomy
Tymofiyeya et al9 compared the diagnostic
accuracy of 1.5 Tesla MRI images and
panoramic images in pediatric patients. The
results showed that MRI is well suited for
evaluating the anatomy of teeth, dental pulp,
mandibular canal, and cortical bone.
Root Canal Working Length
Recent studies evaluated the applicability of
3 Tesla MRI in determining the working length
of premolars and molars14 as well as incisors
and canines15. Although the measurement
reliability was excellent, MRI had a tendency to
underestimate the working length in 67.6%–
95.5% of the measurements compared with
CBCT imaging, restricting its clinical
application. The authors believe that the lower
accuracy of MRI may be attributed to its lower
spatial resolution compared with CBCT
imaging, primarily associated with voxel size
and acquisition time.
Pulp Vitality
According to Kress et al16, it is possible to
produce 1.5 Tesla MRI images that show the
perfusion of dental pulp when a contrast agent
is present. However, when comparing images
before and after contrast agent administration,
significant differences in signal intensities were
JOE  Volume 50, Number 4, April 2024
Unit Coil Pulse sequence
Magnex Intraoral radiofrequency SWIFT
transceiver
observed between vital and nonvital teeth.
Conversely, Kress et al17 measured age-
related changes in pulp cavity signal intensity
with MRI and revealed that older teeth
exhibited a lower signal intensity difference
between the non–contrast- and contrast-
enhanced images due to dental pulp volume
decreasing with age as a result of additional
dentin deposition. More recently, Juerchott
et al18 assessed pulpal contrast enhancement
using 3 Tesla MRI by measuring post- and
precontrast pulp signal intensity. They found
no effects of age, sex, or jaw type. Although
there were minor differences observed among
tooth types, statistical significance was
reached. According to the authors, blood
intensity can influence the increase in T1 values
on postcontrast images and/or the circulation
of the contrast agent in the extravascular area.
Because dental pulp does not have a tight
blood-tissue barrier, the lack of contrast
enhancement may be considered as an
absence of pulp vascular supply.
Pulp Regeneration
Assaf et al19 evaluated revascularization of
teeth after traumatic dental injuries in children
and adolescents. Using 3 Tesla MRI, they
demonstrated a feasible means of visualizing
changes in in vivo dental pulp to assess tooth
vitality without the need for a contrast agent.
The authors believe that 3 Tesla MRI can be
indicated for children to prevent unnecessary
root canal fillings in affected teeth because the
pulp signal alterations of the affected tooth
compared with a vital one can be explained by
early degeneration of the tissue. Similarly, but
without the use of contrast, El-Kateb et al20
evaluated tissue regeneration after a
regenerative endodontic procedure using
3 Tesla MRI. The signal intensity in treated
teeth was higher after 3 months of
regeneration, decreased significantly during
follow-up, and became equivalent to that of
normal contralateral teeth after 12 months.
Endodontic Applications of Magnetic Resonance Imaging
Acquisition parameters Contrast

4 ms, flip angle of 12.0 , pulse
length of 4 ms, delay after pulse
of 3.7 ms, and bandwidth of
128 kHz
FOV of 120 mm3, acquisition time of *
3.5 min, voxel size of 0.27mm3,
and excitation bandwidth of
100 kHz
Dental Pulp and Caries
Tymofiyeya et al22 assessed carious lesions
and their proximity to the dental pulp using
1.5 Tesla MRI. Although the evaluations were
feasible, the images showed an overestimation
of the cavity size compared with digital
periapical radiography. The authors of the
aforementioned study hypothesized that the
MRI signal was obtained from the porous,
demineralized tooth substance or from an
occult carious lesion. The results obtained
demonstrated that the potential of MRI for
caries diagnosis extends beyond open cavities
and includes measuring the minimum distance
to the dental pulp. Conversely, Cankar et al23
examined the dental pulp’s response to caries
progression using 3 Tesla MRI. The results
showed differences in signal intensity T2
between intact and affected dental pulp
regions, with these values showing a strong
correlation with the severity of caries according
to the International Caries Detection and
Assessment System (ICDAS) score.
Regardless of dental pulp depth or tooth type,
intact teeth (ICDAS 0) exhibited approximately
40-millisecond higher signal intensity T2 values
than severely caries-affected teeth (ICDAS
4–6).
Although the influence of carious lesions
on dental pulp is well-documented in the
scientific literature, the present systematic
review focused solely on studies using clinical
MRI units. Excluded studies used a
microscopic MRI unit with Tesla values
exceeding 4 and longer exposure times, which
are not used in routine clinical patient care.
Guided Endodontics
Recently, Leontiev et al24 evaluated the
accuracy of 3 Tesla MRI for detecting root
canals during guided endodontics. The mean
accuracy in the buccolingual and mesiodistal
dimensions, as well as angle deviation,
generally exhibited similarities to the results of
Zehnder et al32, who considered only CBCT
441
FIGURE 1 – A Flow diagram of the study selection following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement.
images. However, there was a notable
difference in the overall success rate, with MRI
achieving 91% accuracy compared with a
100% rate in the CBCT study. The authors of
this study believe that this discrepancy may be
attributed to lower precise planning or
accurate access cavity preparation because
teeth are solid structures, and direct imaging is
challenging with MRI33. To ensure adequate
alignment between MRI and stereolithography
data, an indirect visualization of the tooth
crown was performed. Unlike CBCT planning
software, which can overlay Digital Imaging
and Communications in Medicine and
stereolithography data automatically, manual
positioning was necessary for MRI scans.
According to the authors of the mentioned
study, manual positioning may have
introduced errors that can account for the
observed variation, outliers, and angle
deviation between the models. Furthermore,
442 Candemil et al.
because the resolution of measurements was
lower in MRI compared with CBCT imaging,
the MRI-based method exhibited lower overall
accuracy.
Periapical Lesion
Geibel et al25 evaluated the applicability of
3 Tesla MRI for evaluating apical periodontitis
in direct comparison with CBCT imaging. In all
of the patients analyzed, MRI showed similar
sensitivity in diagnosing periapical lesions
compared with CBCT imaging. However,
significant differences were observed in lesion
dimensions between the 2 imaging modalities.
This difference may be attributed to the lower
spatial resolution of MRI compared with CBCT
imaging or the distinct physical principles
underlying these 2 imaging modalities.
Lizio et al26 investigated the diagnostic
reliability and accuracy of 1.5 Tesla MRI in
distinguishing periapical lesions of endodontic
origin and compared the results with
histopathological information. The observers
exhibited the highest consistency when
identifying characteristics such as pattern
(homogeneous in granulomas and
nonhomogenous in cysts), the presence of a
low-intensity outline (fibrous capsule), and the
contrast-enhanced distribution pattern on T1-
weighted images (epithelial wall). Interrater
agreement between radiologists and
pathologists was excellent. However, the
authors of this study believe that making a
specific diagnosis based solely on MRI can be
challenging, especially when distinguishing
between cysts and granulomas, which may
pose difficulties for less experienced
radiologists. Similarly, Juerchott et al27
evaluated the differentiation of periapical
granulomas from periapical cysts using 3 Tesla
MRI. The results showed 6 lesion
characteristics that could clearly distinguish
JOE  Volume 50, Number 4, April 2024
 TABLE 3 - Data Extraction from the Included Studies
JOE  Volume 50, Number 4, April 2024
Study Study topic Objective
9
Tymofiyeva et al Tooth and root canal Assess the feasibility of MRI of
anatomy dental abnormalities in
children
Zidan et al14 Root canal working Assess the reliability and
length accuracy of high-resolution
MRI for endodontic working
length measurements
Zidan et al15 Evaluate whether high-
resolution, non–contrast-
enhanced MRI can reliably
and accurately measure the
canal length
Kress et al16 Pulp vitality Assess whether it is possible to
measure tooth vitality using
MRI
Endodontic Applications of Magnetic Resonance Imaging
Kress et al17 Determine if it is possible to
measure age-related pulp
cavity signal intensity changes
by using MRI
Juerchott et al18 Optimize the assessment of
pulpal contrast enhancement
on MRI and investigate
physiological pulpal contrast
enhancement patterns
Assaf et al19 Pulp regeneration Evaluate whether root canal
treatment is necessary and
whether revitalization of
affected teeth is possible and
measurable
El-Kateb et al20 Quantify assessed tissue
regeneration after
regenerative endodontic
443
Design Sample
In vivo 16 patients (3 with
mesiodens, 9 with
supernumerary teeth
other than a mesiodens, 1
with gemination, 1 with
dilaceration, 1 with
transmigration, and 1 with
transposition)
In vivo 9 patients (34 root canals
from 12 molars [4/8,
upper/lower jaw], 22 root
canals and 11 premolars
[2/9 upper/lower jaw], 12
root canals)
In vivo 31 patients (67 teeth [25
central incisors, 22 lateral
incisors, and 20 canines],
28 from the upper jaw and
39 from the lower jaw)
In vivo 35 patients (clinical vitality
evaluated on 162 teeth)
In vivo 92 patients born between
1930 and after 1980 (302
inferior premolars and 282
inferior molars)
In vivo 70 patients (1585 teeth–33
females, 37 males; 50
patients, 348 incisors, 189
canines, 351 premolars
and 396 molars; 638
superior 646 inferior)
In vivo 7 patients (13 upper anterior
teeth)
In vivo 18 necrotic mature maxillary
anterior teeth (17 maxillary
Control Conclusion
Panoramic MRI is a safe, well-tolerated
radiography imaging method that can be
used for the diagnosis of dental
abnormalities in children.
CBCT imaging MRI root canal lengths were
systematically underestimated
compared to CBCT.
CBCT imaging MRI measurements were
underestimated compared with
CBCT imaging.
None Non-contrast sequences cannot
provide sufficient information
about pulpal perfusion.
However, a comparison of
sequences before and after
contrast injection shows a
significant difference between
vital and avital teeth.
None MRI can be used to determine pulp
cavity signal intensity changes
with age.
None Pulpal contrast enhancement in
dental MRI was a stable
intraindividual marker with only
minor differences between
different tooth types.
None MRI could demonstrate that root
canal treatment is not necessary
in every case.
None Vital pulplike tissue could be
successfully regenerated in
mature teeth using regenerative
(continued on next page )
 TABLE 3 - Continued
444
Candemil et al.
Study Study topic Objective
procedures with 2 different
apical preparation sizes in
mature teeth
Nakashima et al21 Assess the safety, potential
efficacy, and feasibility of
autologous transplantation of
mobilized dental pulp stem
cells in pulpectomized teeth
Tymofiyeva et al22 Dental pulp and Assess the feasibility of MRI of 3-
caries dimensional visualization and
quantification of carious
lesions, as well as
measurement of the distance
between the lesion and dental
pulp in vivo
Cankar et al23 Quantify dental pulp response to
caries progression using the
T2 mapping method
Leontiev et al24 Guided endodontics Demonstrate that MRI is
sufficiently accurate for the
detection of root canals using
guided endodontics
Geibel et al25 Periapical lesion Evaluate the applicability of MRI
for the assessment of apical
periodontitis in direct
comparison with CBCT
imaging
Lizio et al26 Investigate the diagnostic
reliability and accuracy of MRI
to differentiate periapical
lesions of endodontic origin
Juerchott et al27 Evaluate whether periapical
granulomas can be
differentiated from periapical
JOE  Volume 50, Number 4, April 2024
cysts
Pigg et al28 Examine the occurrence of MRI
signal changes in the painful
regions of patients with
atypical odontalgia
Groenke et al11 Root cracks or Describe the narrowest VRF
fractures detectable using micro-CT
imaging as reference
Design Sample
central incisors and 1
lateral incisor)
In vivo 5 patients (5 teeth [1 upper
premolar, 2 upper
incisors, and 2 lower
premolars])
In vivo 5 patients (7 teeth with
carious lesions – 1 upper
incisor, 1 upper premolar,
4 upper molars and 1
lower premolar)
In vivo 12 patients (74 teeth, 34
single rooted and 40
multirooted)
Ex vivo One hundred extracted teeth
(anterior and premolar)
In vivo 19 patients (34 teeth with
periapical lesions
[3 molars, 14 premolars,
and 7 front teeth])
In vivo 34 patients (34 teeth with
periapical lesion)
In vivo 11 patients (11 teeth with
periapical lesion)
In vivo 20 patients (30 teeth, 1-3 per
patient)
Ex vivo 62 teeth
Control Conclusion
endodontic procedures, which
was not significantly affected by
the size of the apical diameter.
CBCT imaging The signal intensity of MRI of the
regenerated tissue in the root
canal after 24 weeks was similar
to the normal dental pulp in the
untreated teeth.
Digital periapical MRI demonstrated high feasibility
radiography to 3-dimensionally visualize and
quantify carious lesions,
including approximal lesions and
occult dentin lesions, and
measure the minimum distance
to the dental pulp in vivo.
None T2 mapping of dental pulp can be
used to reliably quantify its
response to caries progression.
None MRI is suitable for guided
endodontic access cavity
preparation.
CBCT imaging No difference on lesion visibility
was observed.
Histopathological The reliability and accuracy of MRI
analysis were high and comparable to
histopathological reliability.
Histopathological MRI enables a reliable
analysis differentiation between
periapical cysts and
granulomas.
CBCT imaging MRI examination revealed no
changes in the painful region in a
majority of patients with atypical
odontalgia, suggesting that
inflammation was not present.
Micro-CT MRI showed the ability to detect
VRFs with median widths of
45 mm with an interquartile range
of 26–64 mm.
(continued on next page )
 between the 2 lesion types in line with
histopathological findings. The study
cracks/fractures., in relation to
specificity for the detection of
MRI demonstrated comparable
measures of sensitivity and
underscores the limited diagnostic value of
Conclusion non–contrast-enhanced T1-weighted images
because lesion margins may not be distinctly
delineated in many cases.
CBCT imaging.
Pigg et al28 evaluated the occurrence of
1.5 Tesla MRI signal changes in painful regions
of patients with atypical odontalgia, correlating
them with periapical bone defects detected on
radiographic examinations. The main finding
indicated that radiographic and MRI evaluation
had a similarity of 75% of patients with atypical
Micro-CT and CBCT
odontalgia. The authors of the aforementioned
study hypothesized that the results may be
Control
attributed to the MRI signal alterations when a
imaging
defect in periapical bone was detected, and
probably inflammatory changes were present.
On the contrary, in case of the absence of
signal alteration, despite the presence of a
periapical bone defect, bone healing may be in
progress. However, because this study did not
consider a reference standard image, the true
CBCT, cone-beam computed tomographic; MRI, magnetic resonance imaging; SWIFT, sweep imaging with Fourier transformation; VRF, vertical root fracture.
significance of these results remains uncertain.
Sample
Furthermore, 70% of the painful area had a
history of endodontic treatment, rendering
tooth vitality evaluation impossible and
58 teeth
compromising the identification of periapical
bone defect.
Root Cracks or Fractures
Schuurmans et al29 evaluated the diagnostic
Design
accuracy of 4 Tesla MRI for identifying root
Ex vivo
cracks and fractures. When comparing
diagnoses between MRI and CBCT imaging,
both modalities exhibited high specificity (0.83
and to establish reliability and
and 0.90, respectively) and poor sensitivity
crack/fracture identification
accuracy in their detection
(0.59 and 0.59, respectively). Similarly,
Develop MRI criteria for root
Groenke et al11 detected 55% of the vertical
root fracture in root canal–treated teeth, with
Objective
the smallest observed width falling within the
calculated theoretical limit of detection for MRI,
ranging from 10–20 mm, demonstrating the
capability of 4 Tesla MRI for this diagnosis.
DISCUSSION
The present systematic review showed that
Study topic
the use of MRI has a high diagnostic value in
endodontics in most of the tasks discussed
earlier, including the evaluation of tooth and
root canal anatomy, pulp vitality and
regeneration, the effect of caries on dental
pulp, periapical lesions, and root cracks or
fractures. MRI’s accuracy is similar to or even
29
TABLE 3 - Continued
Schuurmans et al
higher than imaging references such as CBCT
imaging, micro-CT imaging, and histology.
Furthermore, MRI offers significant advantages
because of its high soft tissue contrast and the
Study
ability to vary the contrast by altering the
sequence design27.
JOE  Volume 50, Number 4, April 2024 Endodontic Applications of Magnetic Resonance Imaging
Although MRI shows high accuracy in
different diagnostic tasks, this imaging
modality is not reliable in measuring root canal
length14,15, cavity sizes of caries22, and
periapical lesion dimensions25. It also
demonstrated less accurate planning and
cavity preparation for guided endodontics with
a 91% success rate24. The studies indicate
that the results of these objective evaluations
have a consensus of overestimation compared
with measurements performed using ionizing
imaging modalities14,15,22,25. Conversely,
regarding the evaluation of root cracks or
fractures, although the results show similar
diagnostic accuracy between MRI and CBCT
images, the sensitivity of both images is
poor11,29. Overall, the reliability of CBCT
diagnosis of root cracks and fractures is
questionable, mainly because of artifacts
arising from high-density materials in the tooth
of interest, such as filling material34,35. MRI
may be an alternative diagnostic imaging
method because of the absence of ionizing
radiation, better contrast (depending on the
unit and acquisition parameters), and inclusion
of useful information about soft tissues8.
Because MRI has a high ability to
characterize soft tissues, such as in the
differentiation of chronic and acute lesions and
the detection of early inflammation, pulp
vitality, pulp regeneration, and periapical
lesions have shown to be well evaluated19,36. It
enables precise differentiation between blood-
filled structures within dental pulp and
neighboring tooth components19,37, while also
aiding in the detection of soft tissue anomalies
resulting from inflammation because of water
increase38,39. MRI can reveal tooth vitality by
the increase of signal intensity within the pulpal
cavity after the administration of contrast,
facilitating the distinction between vital and
nonvital teeth16-18,21.
The outcome of conservative pulp-
saving treatment is significantly influenced by
the extent of dental pulp inflammation and the
remaining dentin thickness treatment40,41.
Consequently, an early and precise evaluation
of dental pulp tissue response to caries
progression is of paramount importance
before making treatment decisions42. The MRI
signal intensity in carious lesions increases due
to an increase in relaxation time caused by the
increase of liquid within the dentin tubules,
stemming from the porous structure of the
affected dentin43. Conversely, Weglarz et al44
explained this signal enhancement as a
consequence of contrast medium penetration
into the porous demineralized tooth
substance, resulting in an elevated proton
density.
Compared with CBCT imaging, MRI has
the advantages of the absence of harmful
445
FIGURE 2 – Risk of bias charts results, encompassing the assessment of 4 key domains, as well as the overall classification of the sample review (n 5 20). (A ) The traffic plot
illustrates the classification of each domain, and (B ) the summary plot shows the distribution of classifications across these domains.

446 Candemil et al. JOE  Volume 50, Number 4, April 2024

radiation and artifact from filling materials
(endodontic sealer and gutta-percha) and
increased contrast25,29,45. However, it is
important to highlight that the presence of
metallic materials, patient movement during
the examination or even irregular illumination,
reading errors and cross talk with adjacent
slices, eddy currents, and B0 inhomogeneities
can reduce the image quality19,39. On the other
hand, specific optimized sequences with
reduced acquisition time have been shown to
minimize the risk of motion and metal
artifacts10,27,29.
Despite MRI not being a new modality
on the market, its application in endodontics is
relatively recent, and limited information is
available in the literature. Thus, there is no
consensus or guideline regarding its
indications or even the type of acquisition
protocol. Many factors can influence MRI
image quality such as Tesla strength,
channels, coil design, sequence, field of view,
imaging/reconstruction matrix, and voxel size.
Among the selected studies, there was
significant variability in terms of device
characteristics, coil types, and acquisition
parameters used. The measurement values
may be affected by the specific MRI
techniques, including hardware and software
features, as well as the type of contrast agent.
Therefore, different studies are often not
directly comparable18. MRI resolution is
directly associated with sensitivity and
acquisition time. Given the need to limit
acquisition time for clinical use (typically
10 minutes per acquisition), increasing
resolution requires higher magnetic field
strengths and the use of dedicated intraoral/
dental coils22,23,46. For instance, using a
3 Tesla magnet increases the signal-to-noise
ratio by 70% compared with a 1.5 Tesla
system47, and this increase may be even
greater with higher magnetic field strengths
(greater than 4 Tesla). However, such high-
field systems are not suitable for human in vivo
imaging. Additionally, dedicated coils can
reduce the field of view, acquisition time, and
generate thinner slices compared with
standard head coils, achieving a resolution of
up to 300 mm23,25. These coils have been
successfully used in combination with different
acquisition sequences, including turbo spin
echo22 and sweep imaging with Fourier
transformation11,29.
The limitations of the present
systematic review include the high
methodological heterogeneity of the selected
studies with different study topics, objectives,
designs, sample types and sizes, control
images, MRI units, and acquisition
parameters. It should be borne in mind that
the sample factor was responsible for the item
with the highest risk of bias, which was
analyzed based on prior testing, presentation,
intended use of the index test, and setting of
patient selection. Furthermore, it is important
to highlight the limitations of the studies, such
as low sample size (,15 teeth)9,19,21,27 and
the absence of a gold standard for the
diagnosis16-20,23,24, which may indicate poor
scientific evidence. Therefore, further studies
with a lower risk of bias in the patient selection
and a higher sample size are highly
encouraged.
Although MRI can be considered an
important alternative diagnostic tool in
endodontics, further developments are
needed to enhance image acquisition speed
and resolution, reduce cost, and improve
accessibility14. In addition, there is a great
need for further research on this topic to
provide professionals with the confidence to
recommend MRI in view of the great benefit for
patients.
CONCLUSION
Based on the studies published in the literature
regarding the use of MRI in endodontics, the
present systematic review can conclude that
MRI holds high accuracy potential for
diagnostic application in evaluating various
clinical endodontic tasks, with the exception of
root canal length, cavity size of caries, and
periapical lesion dimension measurements,
which tend to be overestimated in MRI. It is of
high importance that further studies and MRI
development be performed to provide more
information to the scientific community.
ACKNOWLEDGMENTS
Supported by Sa ~o Paulo Research Foundation
(grant nos. 2018/14450-1, 2021/01623-8,
and 2022/07081-5).
The authors deny any conflicts of
interest related to this study.

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