Guidelines on the timing and frequency of bitewing radiography: a systematic review.

Objectives To identify guidelines on when and how frequently bitewing radiographs should be used in dentistry for the diagnosis of caries, and to provide an objective appraisal of their quality.Data sources MEDLINE (OVID), US National Guideline Clearinghouse (www.guideline.gov) and the Royal College of Surgeons of England (https://www.rcseng.ac.uk/fds/publications-clinical-guidelines/clinical_guidelines) websites were searched using a variety of relevant search terms (2 August 2016).Data selection Publications were included if they made recommendations on the issue of when and how frequently radiographs should be used in any dentally-related specialty pertaining to the diagnosis of caries; and/or if they were aimed at the individual practitioner (any health professional working within dentistry) and/or patients.Data analysis Thirteen published guidelines were included and assessed using the AGREE II instrument.Conclusions There was a significant variation amongst the guidelines in the recommendations at what age radiography should be undertaken. There was also disagreement on the frequency of repeat radiographs and how this is influenced by the age of the patient and their caries risk.

A benchmark for comparison of dental radiography analysis algorithms.

Dental radiography plays an important role in clinical diagnosis, treatment and surgery. In recent years, efforts have been made on developing computerized dental X-ray image analysis systems for clinical usages. A novel framework for objective evaluation of automatic dental radiography analysis algorithms has been established under the auspices of the IEEE International Symposium on Biomedical Imaging 2015 Bitewing Radiography Caries Detection Challenge and Cephalometric X-ray Image Analysis Challenge. In this article, we present the datasets, methods and results of the challenge and lay down the principles for future uses of this benchmark. The main contributions of the challenge include the creation of the dental anatomy data repository of bitewing radiographs, the creation of the anatomical abnormality classification data repository of cephalometric radiographs, and the definition of objective quantitative evaluation for comparison and ranking of the algorithms. With this benchmark, seven automatic methods for analysing cephalometric X-ray image and two automatic methods for detecting bitewing radiography caries have been compared, and detailed quantitative evaluation results are presented in this paper. Based on the quantitative evaluation results, we believe automatic dental radiography analysis is still a challenging and unsolved problem. The datasets and the evaluation software will be made available to the research community, further encouraging future developments in this field. (http://www-o.ntust.edu.tw/~cweiwang/ISBI2015/).

The effect of anatomical noise on perception of low contrast in intra-oral radiographs: an in vitro study.

OBJECTIVES: Radiographic images suffer from varying amounts of noise. The most studied and discussed of these is random noise. However, recent research has shown that the projected anatomy contributes substantially to noise, especially when detecting low-contrast objects in the images. Our aim, therefore, was to evaluate the extent to which overprojected anatomical noise affects the detection of low-contrast objects in intra-oral images. METHODS: Our study used four common sensor models. With each sensor, we took four series of images, three series with and one series without an anatomical phantom present. In each series, we exposed a low-contrast phantom at 18 different exposure times using a standardized method. 4 observers evaluated all 288 images. RESULTS: The low-contrast characteristics differed substantially when imaging low contrast on a homogeneous background compared with imaging low contrast when an anatomical phantom was present. For three of the sensors, optimal exposure times for low-contrast imaging were found, while the fourth sensor displayed a completely different behaviour. CONCLUSIONS: Calibrating the low-contrast properties of an imaging system using low-contrast objects on a homogeneous background is not recommended. On an anatomical background, low-contrast properties are completely different, and these will mimic the clinical situation much more closely, directing the operator how to best use the system. There is a clear demand for further research on this subject.

Influence of professional experience on detection and treatment decision of occlusal caries lesions in primary teeth.

AIM: To evaluate the influence of examiner's clinical experience on detection and treatment decision of caries lesions in primary molars. DESIGN: Three experienced dentists (Group A) and three undergraduate students (Group B) used the International Caries Detection and Assessment System (ICDAS) criteria and bitewing radiographs (BW) to perform examinations twice in 77 primary molars that presented a sound or carious occlusal surface. For the treatment decision (TD), the examiners attributed scores, analyzing the teeth in conjunction with the radiographs. The presence and the depth of lesion were validated histologically, and reproducibility was evaluated. The sensitivity, specificity, accuracy, and area under the ROC curve values were calculated for ICDAS and BW. The associations between ICDAS, BW, and TD were analyzed by means of contingency tables. RESULTS: Interexaminer agreement for ICDAS, BW, and TD were excellent for Group B and moderate for Group A. The two groups presented similar and satisfactory performance for caries lesion detection using ICDAS and BW. In the treatment decision, Group A was shown to have a less invasive approach than Group B. CONCLUSION: The examiner's experience was not determinant for the clinical and radiographic detection of occlusal lesions in primary teeth but influenced the treatment decision of initial lesions.

A standardized novel method to measure radiographic root changes after endodontic therapy in immature teeth.

INTRODUCTION: Outcome studies of endodontic treatment of necrotic immature permanent teeth rely on radiographic measures as surrogates of whether the treatment achieved regeneration/revascularization/revitalization. An increase in radiographic root length and/or width is thought to result in a better long-term prognosis for the tooth. In this study, a method to measure radiographic outcomes of endodontic therapies on immature teeth was developed and validated. METHODS: A standardized protocol was developed for measuring the entire area of the root of immature teeth. The radiographic root area (RRA) measurement accounts for the entire surface area of the root as observed on a periapical radiograph. Reviewers were given instructions on how to measure RRA, and they completed measurements on a set of standardized radiographs. RESULTS: The intraclass correlation between the 4 reviewers was 0.9945, suggesting a high concordance among reviewers. There was no effect of the reviewer on the measured RRA values. High concordance was also observed when 1 rater repeated the measurements, with an intraclass correlation value of 0.9995. There was no significant difference in RRA values measured at the 2 sessions by the same rater. Furthermore, significant differences in RRA were detectable between clinical cases that showed obvious continued root development and cases that did not demonstrate discernible root development. CONCLUSIONS: These results suggest that RRA is a valid measure to assess radiographic outcomes in endodontically treated immature teeth, and RRA should be useful in future clinical studies of regenerative endodontic outcomes.

Optimising radiographic bitewing examination to adult and juvenile patients through the use of anthropomorphic phantoms.

Four anthropomorphic phantoms (an adult male, an adult female, a 10-y-old child and a 5-y-old child) were exposed to bitewing radiographs at film and digital settings using both rectangular and round collimation. Optically stimulated dosemeters were used. For children, average organ doses were <40 µGy and the organs with the highest doses were the salivary glands, parotid, oral mucosa, skin and extrathoracic airway. For adults, average organ doses were <200 µGy. Highest adult doses were to the salivary glands, oral mucosa and skin. Effective doses ranged from 1.5 to 1.8 µSv for children and from 2.6 to 3.6 µSv for adults when optimised technique factors were employed, including digital receptors, rectangular collimation, size-appropriate exposure times and proper clinical judgment. Optimised doses were a fraction of the natural daily background exposure. Therefore, predictions of hypothetical cancer incidence or detriment in patient populations exposed to such low doses are highly speculative and should be discouraged.

Can audit improve patient care and treatment outcomes in endodontics?

Clinical audit is part of the NHS clinical governance framework for dentistry and is recommended as a quality improvement process for patient care, yet there is very mixed evidence supporting audit's ability to produce change in practice. Findings show evidence of changes following audit which improved patient care and practice efficiency. However, there is a general lack of dissemination of audit results, little useful feedback provided to participants, limited use of formal re-auditing of a particular topic and little reported on whether audit improves outcomes for patients. As part of its clinical governance responsibility, the Community Dental Service (CDS) is committed to ensuring that its clinical audit is robust, strategic and measures patient outcomes in its evaluation. The aim of this paper is to present a complete endodontic audit cycle; its recommendations and effects on the process and on outcomes of clinical patient endodontic care; and to evaluate if audit was a useful tool in this case.

Adherence to NICE guidelines on recall intervals and the FGDP(UK) Selection Criteria for Dental Radiography.

AIM: The study investigated adherence of GDPs to National Institute for Health and Clinical Excellence (NICE) guidelines on recall intervals and the FGDP (UK)'s Selection Criteria for Dental Radiography. It also explored any factors that might influence GDPs' compliance with the guidelines. METHOD: A previously piloted questionnaire was circulated to all GDPs within the district of the Cardiff and Vale University Health Board (UHB). The questionnaire sought demographic data as well as answers to questions relating to compliance with guidelines. RESULTS: Of 215 questionnaires, 133 (61.9%) were returned. One hundred a nd thirty (97.7%) respondents were familiar with NICE recall guidelines and 112 (84.2%) were familiar with the FGDP(UK) publication Selection Criteria for Dental Radiography. Thirty six (27.7%) 'always' followed the NICE recall guidelines and, overall, 108 (81.8%) 'always or mostly' followed the guidance. Fifty one (38.6%) respondents 'always' carried out a caries risk assessment for adult patients and 57 (43.5%) 'always' carried out a caries risk assessment for child patients. Seventy nine (59.8%) reported that they 'always or mostly' recorded the patient's disease risk category in the notes. Fifty two (39.7%) respondents 'always' took bitewing radiographs that corresponded to disease risk. Overall, however, 119 GDPs (90.8%) 'always or mostly' took bitewing radiographs at appropriate intervals according to disease risk. Bitewing radiographs for new adult patients were prescribed more often for new child patients. The dentist's length of experience, NHS commitment, country of graduation, access to digital radiography or panoramic machines, receipt of any postgraduate qualifications or involvement in dental foundation training were proven not to have any statistically significant association with adherence to NICE or FGDP(UK) guidelines. CONCLUSIONS: Most dentists are familiar with NICE guidelines on recall intervals and the FGDP(UK)'s Selection Criteria for Dental Radiography. The number of dentists who always comply with these sets of guidance is low. None of the variables investigated were shown to have any statistically significant association with adherence to these guidelines.

Comparison of technique errors of intraoral radiographs taken on film v photostimulable phosphor (PSP) plates.

OBJECTIVE: The objective of this study was to compare the technical errors of intraoral radiographs exposed on film v photostimulable phosphor (PSP) plates. METHODS: The intraoral radiographic images exposed on phantoms from preclinical practical exams of dental and dental hygiene students were used. Each exam consisted of 10 designated periapical and bitewing views. A total of 107 film sets and 122 PSP sets were evaluated for technique errors, including placement, elongation, foreshortening, overlapping, cone cut, receptor bending, density, mounting, dot in apical area, and others. Some errors were further subcategorized as minor, major, or remake depending on the severity. The percentages of radiographs with various errors were compared between film and PSP by the Fisher's Exact Test. RESULTS: Compared with film, there was significantly less PSP foreshortening, elongation, and bending errors, but significantly more placement and overlapping errors. Using a wrong sized receptor due to the similarity of the color of the package sleeves is a unique PSP error. CONCLUSIONS: Optimum image quality is attainable with PSP plates as well as film. When switching from film to a PSP digital environment, more emphasis is necessary for placing the PSP plates, especially those with excessive packet edge, and then correcting the corresponding angulation for the beam alignment. Better design for improving intraoral visibility and easy identification of different sized PSP will improve the clinician's technical performance with this receptor.

The influence of malocclusion on the diagnostic value of the orthopantomogram in the maxillary labial segment.

OBJECTIVE: To investigate the effect of malocclusion and incisor inclination on the diagnostic value of the orthopantomogram in the maxillary labial segment. SETTING: The Department of Orthodontics at The Royal London Hospital. MATERIAL AND METHOD: A literature review identified seven key features of an ideal radiograph of the upper labial segment. This provided the 'Gold Standard'. Four previously extracted maxillary incisors were set-up with a complementary acrylic dentition in a dry human skull. The maxillary base was modified to facilitate the movement of the upper jaw to simulate a total of nine malocclusions, based on skeletal I, II with III patterns with varying upper incisor inclination. A lateral cephalogram was taken to quantify the upper incisor inclination. An orthopantomogram (OPG), upper standard occlusal (USO) and four long-cone periapical radiographs (PA) were also taken. Each radiograph was scored against the Gold Standard. In addition, a clinical audit involving 100 new orthodontic patients was carried out to determine whether in vivo findings mirrored the in vitro results. RESULTS: The orthopantomogram provides low levels of diagnostic value in the maxillary incisor region. The diagnostic value for the skeletal I skull set-up ranged from 57 per cent for the OPG, 71 per cent for the USO and 86 per cent for the PA view. CONCLUSION: The orthopantomogram showed poor diagnostic value in relation to the upper incisor teeth. Long-cone periapicals are recommended as the supplementary view of choice in the maxillary incisor region.

Detection of crestal radiolucencies around dental implants: an in vitro experimental study.

PURPOSE: The aim of this study was to compare the diagnostic potentials and practical advantages of different imaging modalities in detecting bone defects around dental implants. MATERIALS AND METHODS: Crestal bone defects with sequentially larger diameters were randomly prepared around 100 implants that were inserted in bovine bone blocks. Conventional periapical radiography (PR), direct digital radiography (DDR), panoramic radiography (PANO), cone-beam computed tomography (CBCT), and multislice computed tomography (MSCT) were performed for all specimens. The diagnostic accuracies of the devices, confidence of the answers, subjective image quality, defect visibility in planar orientations, and duration of diagnosis were analyzed based on the interpretations of 7 calibrated observers. RESULTS: The agreement levels of intra- and interobserver scores were rated good. PR, DDR, and CBCT were mostly more accurate than PANO and MSCT (P < .05). Confidence levels were positively correlated with the defect size (ρ = 0.20, P < .01), and that of DDR was the highest (P < .05). The subjective image quality of PR and DDR was higher than that of CBCT, PANO, and MSCT (P < .05 for all comparisons). Axial-coronal-sagittal visibilities of the defects were higher for CBCT compared with MSCT (P < .05). The diagnostic time was shorter for DDR (P < .05) and longer for the tomographic systems (P < .05) than for the other devices. CONCLUSIONS: DDR may provide a faster and more confident diagnostic option that is as accurate as PR in detecting peri-implant radiolucencies. CBCT has a comparable potential to these intraoral systems but with slower decision making and lower image quality, whereas PANO and MSCT become more reliable when bone defects have a diameter that is at least 1.5 mm larger than that of the implant.

Does a combination of two radiographs increase accuracy in detecting acid-induced periapical lesions and does it approach the accuracy of cone-beam computed tomography scanning?

INTRODUCTION: The purpose of this study was to determine whether the use of a combination of 2 images (storage phosphor plates [SPPs] and F-speed films [Eastman Kodak, Rochester, NY]) with a 10° difference in horizontal beam angulation resulted in better detectability of chemically created periapical defects than when only 1 image was used and whether a detectability as good as that achieved by limited cone-beam computed tomography (LCBCT) scanning could be achieved. METHODS: Lesions were created by 1, 1.5, and 2 hours of acid application apical to extracted teeth in jaw specimens. After repositioning, teeth were radiographed with Accu-I-Tomo LCBCT, Digora Optime SPP system, and F-speed films. The SPPs and films were exposed at 0° and 10° horizontal angulations. The diagnostic accuracy (Az) was compared using 2-way analysis of variance; pair-wise comparisons were performed using the post hoc t test. Kappa was used to measure interobserver agreement. RESULTS: A combination of 2 exposures with a 10° difference in horizontal angulation caused an increase, although not statistically significant, in the accuracy of both films and SPPs for all acid durations (P > .05) compared with when only 1 exposure was used. The accuracy did not approach that of LCBCT. CONCLUSIONS: Using a combination of 2 exposures instead of 1 did not significantly increase the accuracy in detecting acid-induced lesions at the apices of single-rooted premolars. The accuracy of LCBCT was superior.

Value of cone beam CT in detection of dental root fractures.

OBJECTIVE: The primary objective of this investigation was to evaluate the detection of root fracture using cone beam CT (CBCT) images and compare these findings with real samples of extracted teeth. A second aim was to determine the importance of reconstructed images in the diagnosis of root fracture. METHODS: Conventional periapical radiographs and CBCT images of 10 cases, each with a suspected diagnosis of root fracture, were evaluated in accordance with a pre-established scoring system by a maxillofacial radiologist who was unaware of the clinical symptoms of the patients. Then, the radiologist and an endodontist, aware of patient symptomatology, performed a second evaluation by cross-comparison of these images with clinical findings. Final patient results were based on direct visualization of each extracted tooth and its colourization. RESULTS: CBCT shows good potential for use in the detection of root fracture as it ensures a high level of diagnostic score accuracy. Reconstructed axial views were more effective in confirming specific diagnoses than other reconstructed views. Combining the clinical and radiographic findings further improved the results. CONCLUSIONS: CBCT can be an ideal alternative in the diagnosis of root fracture in the field of endodontics. This option may also increase assurance of dentists and oral surgeons obtaining an accurate diagnosis of their patients' problems and help decrease the potential failure of treatment and/or the prescription of unwarranted dental procedures.

Pre-operative diagnostic radiograph interpretation by general dental practitioners for root canal treatment.

OBJECTIVES: The aim of this study was to evaluate which radicular radiographic features general dentists want to interpret, determine which of the radicular radiographic features general dentists interpret and which ones they miss in a diagnostic radiograph and correlate how accurately general dentists are able to interpret radiographic features. METHODS: 20 general dental practitioners were selected and given 2 sets of questionnaires. The first set asked them to fill out the findings they would elucidate in a diagnostic radiograph while the second set consisted of 30 randomly selected intraoral radiographs to interpret. RESULTS: In the first set of questionnaires, more than 50% of dentists said they would interpret periapical changes, calcification, root curvature and the number of root canals. Less than 50% said they would interpret canal morphology, open apex, resorption, fracture, number of roots and lamina dura. In the second set of questionnaires, more than 90% missed grade 1 or 2 periapical changes (according to periapical index scoring), resorption and canal calcification. More than 80% of dentists missed extra roots and root curvature buccally while no dentists were able to interpret the periodontal ligament width changes, lamina dura and canal variation (C-shape). Using a paired t-test, there was significant variation in answers between the first set and second set of questionnaires. CONCLUSION: It is concluded from this study that general dental practitioners are able to detect radiographic changes when they are extensive but they miss periodontal ligament width and lamina dura changes.

Reproducibility of adjunct techniques for diagnosis of dental caries in an epidemiological situation.

PURPOSE: To evaluate the reproducibility of visual exams under natural light (VE1), visual exams under artificial light (VE2), radiographic bitewing exams (BW), fibre optic transillumination exams (FOTI) and DIAGNOdent exams (DD) in epidemiological settings. MATERIALS AND METHODS: Three examiners and one benchmark examiner examined thirteen 12-year-old schoolchildren under epidemiological conditions for the D3 (carious lesions in dentin) and D1+D3 (carious lesions in enamel or dentin) diagnostic criteria. RESULTS: The reproducibility (intra/interexaminer agreement) under both diagnostic criteria was 'almost perfect' for the exams VE1 (D3: κintra = 0.91/κinter = 0.85; D1+D3: κintra = 0.89/κinter = 0.84), VE2 (D3: κintra = 0.91/κinter = 0.85; D1+D3: κintra = 0.88/κinter = 0.83), BW (D3: κintra = 0.95/κinter = 0.92; D1+D3: κintra = 0.99/κinter = 0.90) and FOTI (D3: κintra = 0.97/κinter = 0.93; D1+D3: κintra = 0.87/κinter = 0.83) exams and 'fair' for the DD exam (D3: κintra = 0.36/κinter = 0.35; D1+D3: κintra = 0.30/κinter = 0.32). CONCLUSION: It was concluded that the VE1, VE2, BW, and FOTI exams presented good reproducibility under epidemiological conditions, and can be used accurately in epidemiological surveys.

Accuracy of linear measurements before and after digitizing periapical and panoramic radiography images.

The aim of this study was to evaluate the accuracy of linear measurements made on conventional and digitized periapical and panoramic radiographic images of dry human hemi-mandibles. Images from the posterior region of 22 dry human hemi-mandibles were obtained by conventional panoramic and periapical radiography technique. Using a digital caliper, 3 vertical measurements were marked directly on the dry hemi-mandibles (reference measurements) as well as on the tracing from the conventional radiographic images of the specimens made onto acetate paper sheet: Distance 1: between the upper limit of the alveolar ridge and the lower limit at the mandible base; Distance 2: between the upper limit of the alveolar ridge and the upper limit of the mandibular canal; Distance 3: between the lower limit of the mandibular canal and the lower limit of the mandible base. Next, the radiographs were digitized and the three measurements were made on the digital images using UTHSCSA Image Tool software. Data were analyzed statistically by one-way ANOVA (α=0.05). There was no statistically significant differences (p>0.05) between periapical and panoramic radiographs or between the measurements recorded using the digital caliper and UTHSCSA software compared with dry mandible specimens for Distances 1 (p=0.783), 2 (p=0.986) and 3 (p=0.129). In conclusion, the radiographic techniques evaluated in this study are reliable for vertical bone measurements on selected areas and the UTHSCA Image Tool software is an appropriate measurement method.

In vitro evaluation of ICDAS and radiographic examination of occlusal surfaces and their association with treatment decisions.

This in vitro study evaluated the performance of visual (International Caries Detection and Assessment System [ICDAS]) and radiographic (bitewing [BW]) examinations for occlusal caries detection and their associations with treatment decision (TD). Permanent teeth (n=104) with occlusal surfaces varying from sound to cavitated were selected. Sites were identified from 10× occlusal surface photographs. Standardized bitewing (BW) radiographs were taken. Four dentists with at least five years of experience scored all teeth twice (one-week interval) for ICDAS (0­6), BW (0=sound, 1=caries restricted to enamel, 2=caries in outer third dentin, 3=caries in inner third dentin), and TD (0=no treatment, 1=sealant, 2=microabrasion and sealant, 3=round bur sealant, 4a=resin, 4b=amalgam). Histological validation was performed by observation under a light microscope, with lesions classified on a five-point scale. Intraexaminer and interexaminer repeatability were assessed using two-way tables and intraclass correlation coefficients (ICCs). Comparisons between percentage correct, specificity, sensitivity, and area under the receiver-operating characteristic (ROC) curve were performed using bootstrap analyses. ICCs for intraexaminer and interexaminer repeatability indicated good repeatability for each examiner, ranging from 0.78 to 0.88, and among examiners, ranging from 0.74 to 0.81. Correlation between ICDAS and TD was 0.85 and between BW and TD was 0.78. Correlation between the methods and histological scores was moderate (0.63 for ICDAS and 0.61 for BW). The area under the ROC curve was significantly greater for ICDAS than for BW (p<0.0001). ICDAS had significantly lower specificity than BW did (p=0.0269, 79% vs 94%); however, sensitivity was much higher for ICDAS than for BW (p<0.0001, 83% vs 44%). Data from this investigation suggested that the visual examination (ICDAS) showed better performance than radiographic examination for occlusal caries detection. The ICDAS was strongly associated with TD. Although the correlation between the ICDAS and BW was lower, it is still valuable in the clinical decision-making process.

Clinical performance of two fluorescence-based methods in detecting occlusal caries lesions in primary teeth.

This in vivo study aimed to evaluate the performance of 2 fluorescence-based methods in detecting occlusal caries lesions in primary teeth, compared with the performance of visual inspection and radiographic methods, and to propose a mathematic correction of the diagnostic parameters due to the imperfect reference standard method used in the study. Two examiners assessed the occlusal surfaces of 407 primary teeth (62 children) using visual inspection (ICDAS), radiographic, DIAGNOdent pen (pen type laser fluorescence; LFpen), and fluorescence camera (FC) methods. At the noncavitated threshold (NC) the reference standard method was the results of ICDAS, and at the dentine caries threshold (D3) teeth diagnosed with dentine caries by ICDAS or radiographic methods were subjected to operative treatment to confirm the presence of lesion. Reproducibility, sensitivity, specificity, accuracy, and the area under the ROC curve were calculated for the methods at both thresholds. At the NC threshold, LFpen had a slightly better performance compared to the FC and radiographic methods. However, at the D3 threshold, both fluorescence-based methods performed similarly. Visual inspection and radiographic methods presented higher specificities but lower sensitivities than fluorescence methods. After corrections, there was a significant decrease in some parameters. In conclusion, both fluorescence-based methods presented similar performance in detecting occlusal dentine caries lesions in primary teeth, but they usually gave more false-positive results than did the visual and radiographic methods. The correction proposed shows that the performance of the methods can be overestimated, and the correction should be validated and considered in further studies that use an imprecise reference standard method.

Comparison between cone-beam computed tomography and intraoral digital radiography for assessment of tooth root lesions.

INTRODUCTION: Cone-beam computed tomography (CBCT) might be more accurate in identifying radicular surface lesions compared with digital periapical radiography. In this study, we compared these techniques in detecting simulated root resorption lesions. METHODS: A porcine mandible was used to support 10 human maxillary central incisors. CBCT and digital periapical radiographic images were generated before and after the introduction of standardized and sequentially larger root defects on either the mesial or the lingual root surfaces. The images were randomly labeled and evaluated by 3 examiners. Each image was classified according to defect size (0, none; 1, mild; 2, moderate; 3, severe). RESULTS: Interrater reliability was acceptable (0.856 ≤ P ≤ 0.981). The location of the root defect (mesial vs lingual) had no significant effect on the evaluation of defect size. Both periapical radiographs and CBCT were slightly better at detecting lingual defects than mesial defects (75% vs 65% and 65% vs 60%, respectively), but these effects were not statistically significant (P = 0.49 and P = 0.74, respectively). The mean percentages of correctly diagnosed defect sizes were 65% for CBCT and 75% for periapical radiographs. Examiners using CBCT images tended to overestimate defect sizes (κ = 0.481) and correctly categorized teeth with no, mild-moderate, and severe defects 80%, 45%, and 90% of the time, respectively. Examiners using periapical radiographs tended to underestimate defect sizes (κ = 0.636) and categorized teeth with no, mild-moderate, and severe defects 100%, 50%, and 100% of the time, respectively. CONCLUSIONS: There was no difference in accuracy of identifying defects between periapical radiographs and CBCT images.