A in vitro study comparing Digital Periapical Radiography and Cone Beam Computed Tomography for detecting root resorption in primary molars: a pediatric dentistry perspective

A in vitro study comparing Digital Periapical Radiography and Cone Beam Computed Tomography for detecting root resorption in primary molars: a pediatric dentistry perspective | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A in vitro study comparing Digital Periapical Radiography and Cone Beam Computed Tomography for detecting root resorption in primary molars: a pediatric dentistry perspective Juliana Nicolau Seára, Maria Eduarda Paz Dotto, Leticia Ruhland Corrêa, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4045333/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives The aim of this study was compare the accuracy of digital periapical radiography (DPR) and cone beam computed tomography (CBCT) in detecting root resorption in primary molars. Materials and Methods The sample was composed of 43 upper and lower primary molars, with and without root resorption. The teeth were placed in a dry human skull to obtain images using both digital radiography and tomography. A calibrated examiner interpreted the radiographic images initially and examined the tomographic images after seven days to identify the presence of root resorption. The examiner repeated the procedure two weeks after the initial assessment. The intra-examiner agreement was estimated using the Kappa test. A Kappa value of 0.84 was obtained for the radiographic and tomographic assessments. Results A statistically significant difference was found between CBCT and DPR in relation to the distal root of lower teeth (p = 0.03) and the palatal root of upper teeth (p = 0.05). The sensibility and specificity values for CBCT were 73.8% and 70.5%, respectively, and for DPR were 52.1% and 65.5%. Conclusion This study showed that CBCT radiographic technique demonstrated higher accuracy, sensitivity and specificity compared to DPR for detecting root resorption in primary molars. Clinical Relevance: The CBCT radiographic technique has shown superior accuracy, sensitivity, and specificity when compared to DPR in detecting root resorption in primary molars, highlighting it the potential of CBCT as a more dependable diagnostic tool for identifying such pathologies emphasizing its clinical significance in pediatric dentistry. Dental Radiography Cone-Beam Computed Tomography Root Resorption Primary Tooth Figures Figure 1 Figure 2 Figure 3 Introduction Primary teeth naturally undergo physiological root resorption during the normal exfoliation. However, when a pathological process with pulpal involvement occurs, roots may be prematurely reabsorbed [ 1 , 2 ]. The resorption can begin in the apical third of the roots or in any part of the root, being able to make a communication between the root canal and other surface of the tooth [ 3 ]. These resorptions are usually difficult to detect and visualize [ 4 , 5 ]. This can lead to incorrect diagnoses and consequently, may compromise the provision of appropriate treatment, particularly during endodontic treatment of primary teeth [ 4 ]. There is a report that lesions less than 0.3mm in depth and 0.6mm in diameter are not detected by conventional periapical radiography [ 6 ]. The lack of precision in visualization of the root resorption site when the root is perforated (the root canal communicates with the periodontium) may lead to overinstrumentation or extravasation of irrigants solutions and obturator material to the periradicular tissue, which can damage the germs of permanent teeth [ 7 , 8 ]. Resorption diagnosis is currently performed by conventional periapical radiography (CPR) or by digital periapical radiography (DPR) [ 8 ]. The radiographic method only produces two-dimensional images. A three-dimensional structure is projected onto two planes, which causes distortion and overlapping of the structures [ 7 ]. This is unacceptable as in many clinical situations, injuries, resorptions and anatomic structures can be masked, thereby leading to an incorrect assessment. In an attempt to improve diagnostic methods, cone beam computed tomography (CBCT) was introduced to odontology at the end of the 1990’s [ 7 , 9 ]. This method provides multiplanar three-dimensional images, which facilitate the visualization of structures with a complete absence of overlapping images [ 10 ]. CBCT is increasingly used in all branches of dentistry, including pediatric applications [ 11 ]. In existing literature, certain studies exclusively compare these two techniques in permanent teeth [ 2 , 5 , 10 , 12 – 22 ], with no research conducted on the detection of root resorption in deciduous teeth. Therefore, the aim of the present study was to compare two methods of diagnostic imaging, DPR and CBCT, in terms of detecting root resorption in primary molars. Materials and Methods Following prior approval from the Human Research Ethics Committee (No. 2003), for this in vitro experiment, a total of 43 primary human molars were selected, of which 13 were upper and 30 were lower. Thirty-four molars exhibited perforating root resorption in different locations (apical, middle and cervical) and nine were free of resorption. The inclusion criteria specified that the molars had to exhibit at least one of the roots with two thirds remaining. A dry human adolescent skull was used to obtain images. This skull included the maxilla and mandible, anterior primary teeth (canine to canine) with the alveoli of the molar separated in order that the sample elements were positioned one by one to obtain images. The crown of the premolar was positioned intraosseous between the roots of the primary molar, corresponding to the permanent germ spaces. The bone labial and lingual surfaces of the maxilla and mandible were covered with baseplate wax pink 5Lb (BesQual, Florida, USA) to mimic soft tissue, thereby avoiding sudden differences of density, air and tooth which are undesirable in image forming [ 3 , 8 ]. Each tooth was submitted to a visual examination, digital radiography and a tomographic examination. The gold standard was a direct visualization of the presence or absence of root resorption. A calibrated examiner used a magnifying glass under natural light to assess the localization of root resorption and investigate if the resorption were perforating or not. The coronary chamber was opened using a spherical carbide drill FG 2 (Azdent®, FG2, Zhengzhou, China) and an Endo-Z drill (Dentsply Maillefer, Ballaigues, Switzerland), both at high rotation (Kavo®, Biberach, German) and under refrigeration. In order to confirm the presence of perforating resorption, an endodontic file (Flexofile #15, 21 mm, Dentsply Maillefer, Ballaigues, Switzerland) was introduced in the canal up to the point of apex or resorption (Fig. 1 ). DPR was conducted using a 3 x 4 cm phosphor plate (Digora Optime system - Soredex, Tuusula, Finland). The radiographic apparatus used was the Gendex 765 DC (Gendex Dental Systems, Milan, Italy), which operated with 65 kV and 7 mA. The radiographs were obtained using parallelism, with a Rinn XCP (Dentsply Maillefer, Ballaigues, Switzerland) radiographic film positioner (Fig. 2 a). The exposition time was 0.25 s and the focal distance was 30 cm. The images were visualized on a 24-inch computer monitor (Samsung T24A550 LED, Seoul, South Korea) using Digora software (Fig. 2 b). Tomographic images were obtained using the i-CAT New Generation (Imaging Sciences International, Hatfield, EUA) apparatus, operating at 120 kTP and 3–8 mA. The base images (axial) were obtained with voxel 0.2 mm (6 cm FOV and 26 s acquisition time) (Fig. 3 a). The images were processed, reconstructed and analyzed using Xoran software (Xoran Technologies, Ann Arbor, USA) (Fig. 3 b). The images were interpreted by an examiner who was a specialist in dental radiology. The DPR and CBCT images were analyzed randomly and at weekly intervals. With the CBCT images, the examiner could align the three planes (axial, sagittal and coronal) at any point, by clicking on the area of interest. It was permissible to adjust the brightness and contrast of images in both interpretations, and there was no time limit for the assessments. The examiner performed interpretations at two different times with both DPR and CBCT images, repeating the procedure in the same conditions and environment after a two week interval. At the end of each interval, the examiner recorded the presence or absence of root resorption and its location for each tooth. The data were submitted to the Cohen's Kappa intra, and the minimum value obtained 0.846, it was considered excellent [ 23 ]. The agreement test was carried out to assess the examiner in terms of methods, radiographic and tomographic images and the gold standard. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and accuracy of the methods were investigated. Results Table 1 displays the true positive (TP), true negative (TN), false positive (FP) and false negative values (FN) for the detection of resorption. Table 2 displays that CBCT obtained greater sensitivity, specificity and accuracy. Table 1 TP, TN, FP, FN values for the detection of root resorption. TP FP TN FN DPR 4 5 30 4 CBCT 7 2 30 4 Note. – TP = true positive, FP = false positive, TN = true negative, FN = false negative. Table 2 Calculation of sensitivity, specificity, PPV, NPV and the accuracy of DPR and CBCT (%). Sensitivity Specificity PPV NPV Accuracy DPR 52.1 65.5 57 61 79.07 CBCT 73.8 70.5 63 80 86.05 Note. – PPV = positive predictive values, NPV = negative predictive values The examiners assessment was compared with the gold standard for each root in isolation. Table 3 displays the number of correct and incorrect examiner diagnoses in relation to the different roots (mesial, distal and palatal). It is notable that the examiner obtained the same number of correct and incorrect diagnoses with both methods for the mesial root of both upper and lower teeth. A greater number of correct diagnoses were obtained with CBCT in relation to the distal and palatal root. A statistically significant difference was found between CBCT and DPR in relation to the distal root of lower teeth (p = 0.03) and the palatal root of upper teeth (p = 0.05). Table 3 Number of correct and incorrect diagnosis of the examiner for the different roots (mesial, distal and palatal) and the p-value. Digital Radiography Computerized Tomography Correct Diagnosis Incorrect Diagnosis Correct Diagnosis Incorrect Diagnosis p-value Lower teeth Mesial 21 9 21 9 1.00 Distal 15 15 23 7 0.03 Upper teeth Mesial 10 3 10 3 1.00 Distal 11 2 9 4 0.65 Palatal 4 9 9 4 0.05 Discussion Root resorption represents a complex three-dimensional process requiring precise measurement [ 7 ]. Despite its considerable limitations, DPR has traditionally served as the primary method for detecting root resorption [ 5 ]. Accurate identification of pathological root resorption is crucial for treatment planning [ 4 , 19 ]. Depending on the location (cervical, middle, or apical) of resorption in primary teeth, treatment may involve extraction or a more conservative endodontic approach [ 4 , 24 ]. The results of the present study demonstrate that the interpretation of the radiographic image should be performed with care. CBCT was more sensitive and correctly identified both positive (TP) and negative cases (TN). The high sensitivity observed with CBCT underscores its ability to accurately detect root resorption, crucial for appropriate treatment selection. In contrast, DPR exhibited lower sensitivity, elevating the risk of FN. Such inaccuracies could result in incorrect treatment decisions, potentially leading to unnecessary radical interventions or inadequate conservative approaches. The results of the present study are similar to those of previous studies [ 2 , 5 , 12 – 14 , 16 ] that also reported CBCT as more sensitive than a conventional periapical radiograph in the visualization of simulated root resorptions in permanent teeth. In a systematic review, with 15 included studies, the authors suggest that CBCT could be reliable to detect the presence of root resorption in clinical practice and has a higher diagnostic efficacy than periapical radiographs [ 22 ]. Some authors it has been noted that the exceptional accuracy of CBCT in diagnosing resorption stems from its three-dimensional assessment capability [ 25 , 26 ]. In contrast, conventional or digital periapical radiographs only offer two-dimensional images of a three-dimensional structure [ 14 ]. Taravati et al . 2022 and Dudic et al. 2009 demonstrated that CBCT was more successful than DPR at detecting root resorption based on the fact that resorptions are a three-dimensional phenomenon, the full extent of which can be precisely visualized using CBCT [ 4 , 27 ]. Until now, radiographic methods, despite their significant limitations, have been the only techniques used to assess root resorption [ 4 ]. However, these results must be interpreted with caution and attention has been demonstrated in the present study. Studies have reported that the size of the resorption also influences the diagnosis of images. Goldberg et al. 1998 and Durack et al. 2011 stated that CPR was inadequate to detect resorption in the initial stages [ 6 , 14 ]. In the study conducted by Goldberg et al. 1998 examiners were not able to diagnose small resorptions using CPR [ 6 ]. A similar scenario may have occurred in the current study. Two studies have previously compared CPR and RPD, both concluding that the techniques offer satisfactory diagnostic capabilities for detecting resorption [ 28 , 29 ]. However, these authors did not conduct a direct comparison between the two radiographic techniques and CBCT. When roots were analyzed separately in the present study, the examiner obtained a greater number of correct diagnoses (distal and palatal root) using CBCT. This can be explained by the fact that when using DPR, the three planes are projected in a two-dimensional image, resulting in the germ of the permanent successor and other roots overlapping the distal and palatal [ 14 , 27 ]. The present study was conducted using ex vivo primary molars, providing a highly reliable gold standard. Patient-based studies, such as that conducted by Patel et al. 2009, do not eliminate the possibility of FN results since visual examination of the root surface is not feasible, making it impossible to rule out the presence of resorption [ 19 ]. Additional ex vivo studies are recommended for more accurate measurements and to compare the sensitivity of imaging modalities in detecting root resorption. In addition to utilizing ex vivo primary molars, this study aimed to depict the most realistic scenario by employing a dry human skull covered with wax to simulate soft tissue presence. Alveoli were filled with primary teeth, and the germ of the permanent tooth was positioned between the roots of the primary molar. In addition, the teeth exhibited natural root resorption rather than simulated resorption. In studies involving permanent teeth, root resorption is typically simulated using drills. While CBCT offers highly detailed three-dimensional imaging on any plane, this method exposes the patient to a higher dose of radiation [ 19 ]. A study demonstrated that CBCT is appropriateness and has a important role in pediatric dentistry, highlighting that its use must be justified based on the patient's case, ensuring that the benefits outweigh the risks of exposure [ 30 ]. Moreover, the cost-benefit ratio is supported by the substantial diagnostic information produced by CBCT. While the radiation exposure to patients in both DPR and CBCT is low [ 31 ], the decision to use CBCT radiographic technique should be based on diagnostic criteria specific to pediatric patients, elective, short-term treatments, without the need for additional CBCT scans [ 32 ]. The authors confirm that, for now, CBCT cannot replace DPR, although in certain cases where the outcome directly impacts treatment, the 3D images provided by CBCT may be more appropriate than those from periapical radiography [ 27 , 32 ]. Some studies suggest a significant reduction in CBCT radiation doses to optimize imaging conditions and minimize irradiation, but further research is needed to identify the ideal approach [ 33 ]. However, accurate identification of root resorption can result in more precise treatment, enhancing the prognosis of the affected tooth. Conclusion The CBCT radiographic technique demonstrated higher accuracy, sensitivity and specificity compared to DPR for detecting root resorption in primary molars. This finding underscores the potential of CBCT as a more reliable diagnostic tool for detecting such pathologies, thus emphasizing its clinical use in pediatric dentistry. Declarations Authors Contributions J.N.S writing, visualization, methodology and investigation. M.E.P.D visualization, prepared figures and writing. L.R.C conceptualization, reviewing and editing. M.C reviewing and editing. S.F.T.F conceptualization, reviewing and editing. M.C conceptualization, writing, reviewing and editing. M.B review, editing, supervision, project administration, methodology and conceptualization. Funding No funding was obtained for this study. Ethics approval The study protocol was approved by the local Ethics Committee (No. 2003). Conflict of Interests The authors deny any conflicts of interest related to this study. References Caleya AM, Gallardo NE, Feijoo G, Mourelle-Martinez MR, Martin-Vacas A, Maroto M (2022) Relationship between Physiological Resorption of Primary Molars with Its Permanent Successors, Dental Age and Chronological Age. 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Torres","lastName":"de Freitas","suffix":""},{"id":279409884,"identity":"b065a4b9-cc06-4bb7-a725-6a06dc7dd4c6","order_by":5,"name":"Mariane Cardoso","email":"","orcid":"","institution":"Universidade Federal de Santa Catarina","correspondingAuthor":false,"prefix":"","firstName":"Mariane","middleName":"","lastName":"Cardoso","suffix":""},{"id":279409886,"identity":"963a5775-0c04-4efe-8b4f-e33b12188224","order_by":6,"name":"Michele Bolan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYDACZgY2BoYChgQGdiDnYwNIiLHxAGEtBkAtzEC1MxsYJIBUA34tDEhamHnBWhgY8GrRbWd+9uCDgU0ePzPzs8e2O2zqdNsPA22psYnGpcXsMJu54QyDtGLJZjZz49wzaRJmZxKBWo6l5Tbg1MLDJs1jcDhxw2EGM+nctsMSZgeAWhgbDuPX8sfgP1AL+zdpS5CW8w+J0MJgcACohcdMmhGk5QZBW9jMJHsMkoF+4SmT7G1Lk9x2A2hLAj6/nD/8TOJHhV0eP3v7NomfbTb8ZufTHz74UGODUwsOkECa8lEwCkbBKBgFaAAAmwRbakDw+3YAAAAASUVORK5CYII=","orcid":"","institution":"Universidade Federal de Santa Catarina","correspondingAuthor":true,"prefix":"","firstName":"Michele","middleName":"","lastName":"Bolan","suffix":""}],"badges":[],"createdAt":"2024-03-08 14:17:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4045333/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4045333/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52923991,"identity":"d6985ac4-fa71-4a38-b464-bfe33e8f2024","added_by":"auto","created_at":"2024-03-18 17:48:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":657297,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of the protocol for obtaining final DPR and CBCT images. \u003cstrong\u003ea \u003c/strong\u003eDetection of resorption using an endodontic file. \u003cstrong\u003eb \u003c/strong\u003eSection at the crown-root junction (permanent tooth) to be accommodated in the bone socket to simulate spaces intended for permanent germs. \u003cstrong\u003ec \u003c/strong\u003eAlveolar bone removal, preparation of the cavity for the insertion of the permanent tooth germ. \u003cstrong\u003ed\u003c/strong\u003e Accommodation of the lower tooth crown in the mandibular alveolar bone. \u003cstrong\u003ee \u003c/strong\u003eExecution of radiographic and tomographic imaging.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4045333/v1/202491011e1f652c26b74125.png"},{"id":52923993,"identity":"0096270d-6e83-4f07-8646-5b61d665694f","added_by":"auto","created_at":"2024-03-18 17:48:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":865094,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative image depicting the process of digital periapical radiographic (DPR) capture. \u003cstrong\u003ea\u003c/strong\u003e DPR method. \u003cstrong\u003eb\u003c/strong\u003e DPR image.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4045333/v1/db1ef85ea496f8866bb9017a.png"},{"id":52923992,"identity":"182b5a79-3568-4b64-a0a5-c79b77c44aa5","added_by":"auto","created_at":"2024-03-18 17:48:53","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":790377,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative image depicting the process of cone beam computed tomography method. \u003cstrong\u003ea\u003c/strong\u003e CBCT image. \u003cstrong\u003eb\u003c/strong\u003e CBCT image.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4045333/v1/f0f5983c885a9acadfa19917.png"},{"id":53963078,"identity":"508d5653-fcee-4099-8698-d700c1d4d64d","added_by":"auto","created_at":"2024-04-02 18:38:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1912288,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4045333/v1/0f84144d-49e3-4370-abab-f106634dc4ef.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A in vitro study comparing Digital Periapical Radiography and Cone Beam Computed Tomography for detecting root resorption in primary molars: a pediatric dentistry perspective","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary teeth naturally undergo physiological root resorption during the normal exfoliation. However, when a pathological process with pulpal involvement occurs, roots may be prematurely reabsorbed [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The resorption can begin in the apical third of the roots or in any part of the root, being able to make a communication between the root canal and other surface of the tooth [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These resorptions are usually difficult to detect and visualize [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This can lead to incorrect diagnoses and consequently, may compromise the provision of appropriate treatment, particularly during endodontic treatment of primary teeth [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is a report that lesions less than 0.3mm in depth and 0.6mm in diameter are not detected by conventional periapical radiography [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The lack of precision in visualization of the root resorption site when the root is perforated (the root canal communicates with the periodontium) may lead to overinstrumentation or extravasation of irrigants solutions and obturator material to the periradicular tissue, which can damage the germs of permanent teeth [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResorption diagnosis is currently performed by conventional periapical radiography (CPR) or by digital periapical radiography (DPR) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The radiographic method only produces two-dimensional images. A three-dimensional structure is projected onto two planes, which causes distortion and overlapping of the structures [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This is unacceptable as in many clinical situations, injuries, resorptions and anatomic structures can be masked, thereby leading to an incorrect assessment.\u003c/p\u003e \u003cp\u003eIn an attempt to improve diagnostic methods, cone beam computed tomography (CBCT) was introduced to odontology at the end of the 1990\u0026rsquo;s [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This method provides multiplanar three-dimensional images, which facilitate the visualization of structures with a complete absence of overlapping images [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. CBCT is increasingly used in all branches of dentistry, including pediatric applications [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In existing literature, certain studies exclusively compare these two techniques in permanent teeth [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], with no research conducted on the detection of root resorption in deciduous teeth. Therefore, the aim of the present study was to compare two methods of diagnostic imaging, DPR and CBCT, in terms of detecting root resorption in primary molars.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eFollowing prior approval from the Human Research Ethics Committee (No. 2003), for this \u003cem\u003ein vitro\u003c/em\u003e experiment, a total of 43 primary human molars were selected, of which 13 were upper and 30 were lower. Thirty-four molars exhibited perforating root resorption in different locations (apical, middle and cervical) and nine were free of resorption. The inclusion criteria specified that the molars had to exhibit at least one of the roots with two thirds remaining.\u003c/p\u003e \u003cp\u003eA dry human adolescent skull was used to obtain images. This skull included the maxilla and mandible, anterior primary teeth (canine to canine) with the alveoli of the molar separated in order that the sample elements were positioned one by one to obtain images. The crown of the premolar was positioned intraosseous between the roots of the primary molar, corresponding to the permanent germ spaces. The bone labial and lingual surfaces of the maxilla and mandible were covered with baseplate wax pink 5Lb (BesQual, Florida, USA) to mimic soft tissue, thereby avoiding sudden differences of density, air and tooth which are undesirable in image forming [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Each tooth was submitted to a visual examination, digital radiography and a tomographic examination.\u003c/p\u003e \u003cp\u003eThe gold standard was a direct visualization of the presence or absence of root resorption. A calibrated examiner used a magnifying glass under natural light to assess the localization of root resorption and investigate if the resorption were perforating or not. The coronary chamber was opened using a spherical carbide drill FG 2 (Azdent\u0026reg;, FG2, Zhengzhou, China) and an Endo-Z drill (Dentsply Maillefer, Ballaigues, Switzerland), both at high rotation (Kavo\u0026reg;, Biberach, German) and under refrigeration. In order to confirm the presence of perforating resorption, an endodontic file (Flexofile #15, 21 mm, Dentsply Maillefer, Ballaigues, Switzerland) was introduced in the canal up to the point of apex or resorption (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDPR was conducted using a 3 x 4 cm phosphor plate (Digora Optime system - Soredex, Tuusula, Finland). The radiographic apparatus used was the Gendex 765 DC (Gendex Dental Systems, Milan, Italy), which operated with 65 kV and 7 mA. The radiographs were obtained using parallelism, with a Rinn XCP (Dentsply Maillefer, Ballaigues, Switzerland) radiographic film positioner (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). The exposition time was 0.25 s and the focal distance was 30 cm. The images were visualized on a 24-inch computer monitor (Samsung T24A550 LED, Seoul, South Korea) using Digora software (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTomographic images were obtained using the i-CAT New Generation (Imaging Sciences International, Hatfield, EUA) apparatus, operating at 120 kTP and 3\u0026ndash;8 mA. The base images (axial) were obtained with voxel 0.2 mm (6 cm FOV and 26 s acquisition time) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). The images were processed, reconstructed and analyzed using Xoran software (Xoran Technologies, Ann Arbor, USA) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe images were interpreted by an examiner who was a specialist in dental radiology. The DPR and CBCT images were analyzed randomly and at weekly intervals. With the CBCT images, the examiner could align the three planes (axial, sagittal and coronal) at any point, by clicking on the area of interest. It was permissible to adjust the brightness and contrast of images in both interpretations, and there was no time limit for the assessments. The examiner performed interpretations at two different times with both DPR and CBCT images, repeating the procedure in the same conditions and environment after a two week interval. At the end of each interval, the examiner recorded the presence or absence of root resorption and its location for each tooth.\u003c/p\u003e \u003cp\u003eThe data were submitted to the Cohen's Kappa intra, and the minimum value obtained 0.846, it was considered excellent [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The agreement test was carried out to assess the examiner in terms of methods, radiographic and tomographic images and the gold standard. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and accuracy of the methods were investigated.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays the true positive (TP), true negative (TN), false positive (FP) and false negative values (FN) for the detection of resorption. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e displays that CBCT obtained greater sensitivity, specificity and accuracy.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTP, TN, FP, FN values for the detection of root resorption.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFN\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDPR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCBCT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote. \u0026ndash; TP\u0026thinsp;=\u0026thinsp;true positive, FP\u0026thinsp;=\u0026thinsp;false positive, TN\u0026thinsp;=\u0026thinsp;true negative, FN\u0026thinsp;=\u0026thinsp;false negative.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCalculation of sensitivity, specificity, PPV, NPV and the accuracy of DPR and CBCT (%).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePPV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNPV\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAccuracy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDPR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e79.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCBCT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e86.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote. \u0026ndash; PPV\u0026thinsp;=\u0026thinsp;positive predictive values, NPV\u0026thinsp;=\u0026thinsp;negative predictive values\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe examiners assessment was compared with the gold standard for each root in isolation. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e displays the number of correct and incorrect examiner diagnoses in relation to the different roots (mesial, distal and palatal). It is notable that the examiner obtained the same number of correct and incorrect diagnoses with both methods for the mesial root of both upper and lower teeth. A greater number of correct diagnoses were obtained with CBCT in relation to the distal and palatal root. A statistically significant difference was found between CBCT and DPR in relation to the distal root of lower teeth (p\u0026thinsp;=\u0026thinsp;0.03) and the palatal root of upper teeth (p\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNumber of correct and incorrect diagnosis of the examiner for the different roots (mesial, distal and palatal) and the p-value.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eDigital Radiography\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eComputerized Tomography\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorrect Diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncorrect Diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCorrect Diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIncorrect Diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003ep-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLower teeth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMesial\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDistal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eUpper teeth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMesial\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDistal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePalatal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eRoot resorption represents a complex three-dimensional process requiring precise measurement [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Despite its considerable limitations, DPR has traditionally served as the primary method for detecting root resorption [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Accurate identification of pathological root resorption is crucial for treatment planning [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Depending on the location (cervical, middle, or apical) of resorption in primary teeth, treatment may involve extraction or a more conservative endodontic approach [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The results of the present study demonstrate that the interpretation of the radiographic image should be performed with care. CBCT was more sensitive and correctly identified both positive (TP) and negative cases (TN). The high sensitivity observed with CBCT underscores its ability to accurately detect root resorption, crucial for appropriate treatment selection. In contrast, DPR exhibited lower sensitivity, elevating the risk of FN. Such inaccuracies could result in incorrect treatment decisions, potentially leading to unnecessary radical interventions or inadequate conservative approaches.\u003c/p\u003e \u003cp\u003eThe results of the present study are similar to those of previous studies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] that also reported CBCT as more sensitive than a conventional periapical radiograph in the visualization of simulated root resorptions in permanent teeth. In a systematic review, with 15 included studies, the authors suggest that CBCT could be reliable to detect the presence of root resorption in clinical practice and has a higher diagnostic efficacy than periapical radiographs [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome authors it has been noted that the exceptional accuracy of CBCT in diagnosing resorption stems from its three-dimensional assessment capability [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In contrast, conventional or digital periapical radiographs only offer two-dimensional images of a three-dimensional structure [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Taravati \u003cem\u003eet al\u003c/em\u003e. 2022 and Dudic \u003cem\u003eet al.\u003c/em\u003e 2009 demonstrated that CBCT was more successful than DPR at detecting root resorption based on the fact that resorptions are a three-dimensional phenomenon, the full extent of which can be precisely visualized using CBCT [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Until now, radiographic methods, despite their significant limitations, have been the only techniques used to assess root resorption [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, these results must be interpreted with caution and attention has been demonstrated in the present study.\u003c/p\u003e \u003cp\u003eStudies have reported that the size of the resorption also influences the diagnosis of images. Goldberg \u003cem\u003eet al.\u003c/em\u003e 1998 and Durack \u003cem\u003eet al.\u003c/em\u003e 2011 stated that CPR was inadequate to detect resorption in the initial stages [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In the study conducted by Goldberg \u003cem\u003eet al.\u003c/em\u003e 1998 examiners were not able to diagnose small resorptions using CPR [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A similar scenario may have occurred in the current study.\u003c/p\u003e \u003cp\u003eTwo studies have previously compared CPR and RPD, both concluding that the techniques offer satisfactory diagnostic capabilities for detecting resorption [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, these authors did not conduct a direct comparison between the two radiographic techniques and CBCT. When roots were analyzed separately in the present study, the examiner obtained a greater number of correct diagnoses (distal and palatal root) using CBCT. This can be explained by the fact that when using DPR, the three planes are projected in a two-dimensional image, resulting in the germ of the permanent successor and other roots overlapping the distal and palatal [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study was conducted using \u003cem\u003eex vivo\u003c/em\u003e primary molars, providing a highly reliable gold standard. Patient-based studies, such as that conducted by Patel \u003cem\u003eet al.\u003c/em\u003e 2009, do not eliminate the possibility of FN results since visual examination of the root surface is not feasible, making it impossible to rule out the presence of resorption [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Additional \u003cem\u003eex vivo\u003c/em\u003e studies are recommended for more accurate measurements and to compare the sensitivity of imaging modalities in detecting root resorption.\u003c/p\u003e \u003cp\u003eIn addition to utilizing \u003cem\u003eex vivo\u003c/em\u003e primary molars, this study aimed to depict the most realistic scenario by employing a dry human skull covered with wax to simulate soft tissue presence. Alveoli were filled with primary teeth, and the germ of the permanent tooth was positioned between the roots of the primary molar. In addition, the teeth exhibited natural root resorption rather than simulated resorption. In studies involving permanent teeth, root resorption is typically simulated using drills.\u003c/p\u003e \u003cp\u003eWhile CBCT offers highly detailed three-dimensional imaging on any plane, this method exposes the patient to a higher dose of radiation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A study demonstrated that CBCT is appropriateness and has a important role in pediatric dentistry, highlighting that its use must be justified based on the patient's case, ensuring that the benefits outweigh the risks of exposure [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Moreover, the cost-benefit ratio is supported by the substantial diagnostic information produced by CBCT.\u003c/p\u003e \u003cp\u003eWhile the radiation exposure to patients in both DPR and CBCT is low [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], the decision to use CBCT radiographic technique should be based on diagnostic criteria specific to pediatric patients, elective, short-term treatments, without the need for additional CBCT scans [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The authors confirm that, for now, CBCT cannot replace DPR, although in certain cases where the outcome directly impacts treatment, the 3D images provided by CBCT may be more appropriate than those from periapical radiography [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Some studies suggest a significant reduction in CBCT radiation doses to optimize imaging conditions and minimize irradiation, but further research is needed to identify the ideal approach [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, accurate identification of root resorption can result in more precise treatment, enhancing the prognosis of the affected tooth.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe CBCT radiographic technique demonstrated higher accuracy, sensitivity and specificity compared to DPR for detecting root resorption in primary molars. This finding underscores the potential of CBCT as a more reliable diagnostic tool for detecting such pathologies, thus emphasizing its clinical use in pediatric dentistry.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJ.N.S writing, visualization, methodology and investigation. M.E.P.D visualization, prepared figures and writing. L.R.C conceptualization, reviewing and editing. M.C reviewing and editing. S.F.T.F conceptualization, reviewing and editing. M.C conceptualization, writing, reviewing and editing. M.B review, editing, supervision, project administration, methodology and conceptualization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was obtained for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the local Ethics Committee (No. 2003).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors deny any conflicts of interest related to this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCaleya AM, Gallardo NE, Feijoo G, Mourelle-Martinez MR, Martin-Vacas A, Maroto M (2022) Relationship between Physiological Resorption of Primary Molars with Its Permanent Successors, Dental Age and Chronological Age. 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J Radiol Prot 43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1088/1361-6498/acf868\u003c/span\u003e\u003cspan address=\"10.1088/1361-6498/acf868\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dental Radiography, Cone-Beam Computed Tomography, Root Resorption, Primary Tooth","lastPublishedDoi":"10.21203/rs.3.rs-4045333/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4045333/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjectives\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe aim of this study was compare the accuracy of digital periapical radiography (DPR) and cone beam computed tomography (CBCT) in detecting root resorption in primary molars.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMaterials and Methods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe sample was composed of 43 upper and lower primary molars, with and without root resorption. The teeth were placed in a dry human skull to obtain images using both digital radiography and tomography. A calibrated examiner interpreted the radiographic images initially and examined the tomographic images after seven days to identify the presence of root resorption. The examiner repeated the procedure two weeks after the initial assessment. The intra-examiner agreement was estimated using the Kappa test. A Kappa value of 0.84 was obtained for the radiographic and tomographic assessments.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA statistically significant difference was found between CBCT and DPR in relation to the distal root of lower teeth (p\u0026thinsp;=\u0026thinsp;0.03) and the palatal root of upper teeth (p\u0026thinsp;=\u0026thinsp;0.05). The sensibility and specificity values for CBCT were 73.8% and 70.5%, respectively, and for DPR were 52.1% and 65.5%.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study showed that CBCT radiographic technique demonstrated higher accuracy, sensitivity and specificity compared to DPR for detecting root resorption in primary molars.\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical Relevance:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe CBCT radiographic technique has shown superior accuracy, sensitivity, and specificity when compared to DPR in detecting root resorption in primary molars, highlighting it the potential of CBCT as a more dependable diagnostic tool for identifying such pathologies emphasizing its clinical significance in pediatric dentistry.\u003c/p\u003e","manuscriptTitle":"A in vitro study comparing Digital Periapical Radiography and Cone Beam Computed Tomography for detecting root resorption in primary molars: a pediatric dentistry perspective","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-18 17:48:47","doi":"10.21203/rs.3.rs-4045333/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0aeb2df8-639d-4b1d-b0f6-1fdf435795b9","owner":[],"postedDate":"March 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-02T18:30:51+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-18 17:48:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4045333","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4045333","identity":"rs-4045333","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}