Role of periodontal endoscopy in clinical decision-making for teeth with suspected vertical root fractures

Role of periodontal endoscopy in clinical decision-making for teeth with suspected vertical root fractures | 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 Role of periodontal endoscopy in clinical decision-making for teeth with suspected vertical root fractures Min Yang, Xuefei Sun, Gaofeng Fang, Yunpeng Xue, Qianqian Dong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6535793/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Dec, 2025 Read the published version in BMC Oral Health → Version 1 posted 18 You are reading this latest preprint version Abstract Background: This study aimed to evaluate the role of periodontal endoscopy in clinical decision-making for teeth with suspected vertical root fractures (SVRFs) and assessed its diagnostic accuracy for vertical root fractures (VRFs). Methods: A prospective cohort of 115 SVRFs meeting inclusion criteria was analyzed. Teeth were independently evaluated by two endodontists and categorized into three pre-endoscopic treatment groups: flap surgery (S group, n=56), endodontic treatment (R group, n=48), and extraction (E group, n=11). Periodontal endoscopic examination was performed for all subjects, and treatment plans were reassigned based on findings. Definitive VRF diagnosis was confirmed by intraoperative crack identification or clinical failure within a 1-year follow-up. Three cases were excluded due to loss to follow-up. Results: Periodontal endoscopy reduced unnecessary nonsurgical treatment by 39.58% (19/48) and surgical treatment by 64.28% (36/56), while improving diagnostic accuracy by 49.1%. The sensitivity of periodontal endoscopy for VRF detection was 88.1%. Conclusions: Periodontal endoscopy enhances clinical decision-making and significantly reduces unnecessary nonsurgical and surgical interventions in SVRFs. Vertical root fracture Periodontal endoscopy Diagnostic accuracy Minimally invasive dentistry Clinical decision-making Figures Figure 1 Figure 2 Figure 3 Background Vertical root fracture (VRF),defined as longitudinally oriented complete or incomplete fractures extending through the root structure at any level[ 1 ],presents significant diagnostic and therapeutic challenges in contemporary endodontics.Advanced VRFs usually present with significant fracture displacement and extensive alveolar bone resorption at the fracture interface, culminating in a poor prognosis. While early detection is paramount for tooth preservation[ 2 , 3 ]. Clinically, VRFs manifest as sinus tracts, recurrent occlusal pain, narrow and deep (> 6 mm) periodontal pockets, and other such atypical symptoms[ 4 – 9 ]. diagnosis remains complicated by the subtle and variable presentation of initial symptoms [ 10 ]. Periapical radiographs may show abnormal widening of the root canal[ 11 ], but the efficacy of X-rays for diagnosing VRFs is limited by the imaging angle and overlapping tissues[ 12 ]. Cone-beam computed tomography (CBCT) images may show alveolar bone resorption along hypodense fracture lines, seen as a “halo” or “J” translucency[ 5 , 6 ]. CBCT can diagnose VRF more accurately than X-rays[ 13 – 17 ], but CBCT still has its limitations. Smaller voxels and field-of-view sizes provide higher detection accuracy for VRF[ 18 ],In fact, for small VRFs, the accuracy of CBCT examination in vivo is only 29%[ 19 ]..Root canal filling materials or crown-square restorations can block projections and create artifacts in or blur out fracture lines[ 20 ]. Therefore, the diagnostic accuracy for teeth with no root canal treatment is 2.399 times higher than that for teeth with root canal treatment[ 21 ] . Clinically ,Suspected vertical root fractures(SVRFs) have overlapping clinical manifestations with VRFs, but no obvious cracks were observed on CBCT[ 22 ],include localized periodontal disease, combined periodontal-pulpal lesions, early VRFs, and transverse root fractures. The diagnosis of SVRFs is essential as failure to diagnose VRFs in SVRFs can lead to increased alveolar bone resorption, while overdiagnosis of non-VRF teeth can lead to unnecessary tooth extractions. When assessing SVRFs, diagnostic protocols mandate CBCT evaluation following clinical examination, with treatment decisions contingent upon radiographic findings and periodontal parameters[ 22 – 25 ]: definitive fracture visualization warrants extraction[ 26 ]; teeth with compromised periodontal support (probing depth ≥ 6 mm with mobility) are scheduled for extraction; those with adequate bone support and inadequate root canal treatment undergo RCT/Re-RCT and periodontal treatment; while teeth with persistent apical pathology despite adequate obturation are directed to surgical intervention. The gold standard for VRF is flap surgery[ 27 ], but is invasive[ 7 ].As a result, this study was working to find a non-invasive and easy way to check for VRF. A periodontal endoscope is an optical instrument composed of multiple parts, including a cold light source probe, fiber optic cables, image transmission systems, and screen display systems. By inserting the cold light source lens into the periodontal pocket, it allows for viewing magnified images of the root surface on a display to check for any obvious crack lines. The cold light source probe of the periodontal endoscope is designed to be compact, enabling examination of the root surface with minimal invasiveness. Zhang Peng et al[ 28 ]. used the periodontal endoscope to diagnose vertical root fractures, achieving a correct index of 83.7%, which is higher than the 53.1% accuracy rate of CBCT. This study investigates its clinical utility in therapeutic decision-making and diagnostic accuracy for SVRFs. Methods Study Design and Participants A prospective cohort of 196 consecutive patients presenting with suspected vertical root fractures (SVRFs) was screened between July 2022 and June 2023. The sample size was calculated using diagnostic test assumptions (α=0.05, β=0.20, expected sensitivity=85%) based on pilot data, requiring ≥100 evaluable cases. Inclusion criteria: 1) 18–70 years old. 2) ≥1 clinical symptom: recurrent gingival swelling, sinus tract, or occlusal pain. 3) Isolated periodontal pocket depth >6 mm (UNC-15 probe, Hu-Friedy). 4) Absence of definitive fracture lines on two-plane CBCT reconstructions (NewTom VGi, 90kV, 8.9mA). Exclusion criteria: 1) Systemic contraindications (HbA1c>7.5%, uncontrolled hypertension). 2) Generalized periodontitis (≥30% sites with CAL≥5mm). 3) Existing root fractures or iatrogenic cracks. 4) Pregnancy/lactation. Diagnostic Workflow 1. Initial Assessment: One endodontist and one radiologist jointly assessed whether the teeth met the inclusion and exclusion criteria; disagreement was resolved by consultation with a senior surgeon. Two endodontists evaluated the SVRFs and depending on the root canal filling status, restoration status, and periodontal status selected the most appropriate treatment plan and divided into three groups, considering flap surgery, root canal therapy/ root canal retreatment (RCT/Re-RCT), or extraction. (S, R, and E groups, respectively). 2. Periodontal Endoscopy Protocol: Periodontal endoscopy was carried out as follows. The periodontal pockets of SVRFs were infiltrated and anesthetized with 4% articaine with 1:100,000 epinephrine and then cleaned of tartar, plaque, and diseased bone. The root surface was stained with methylene blue and observed using the cold light source probe of a periodontal endoscope (P100, Bangwo, China). All endoscopic examinations were performed by a doctor who was able to skillfully operate the periodontal endoscope. 3. Therapeutic Decision Tree: Teeth with endoscopically observed cracks( Fig1.b ) and those in the E group were extracted or underwent root amputation when the periodontal condition of the roots of the maxillary molars was still favorable[29]. In the surgical group, teeth in which no cracks were observed endoscopically were explored via flap surgery. Their root surfaces were stained with methylene blue and observed under a microscope (OMS2380, Zumax, China). If cracks were observed, the tooth was considered to have a verified VRF, thus requiring extraction or root amputation. Teeth without cracks( Fig1.a ) were considered to be verified as lacking VRFs and surgery was performed. For teeth in the R group, the filling material in the root canal was removed and methylene blue was used to stain the pulp chamber[22]; the upper one-third of the root canal or a root canal sizer was used for detection. If cracks were observed or the sizer suggested an abnormality, the tooth was scheduled for extraction or root amputation. Teeth with cracks detected during root amputation were considered to have a verified VRF; those with no obvious abnormality were considered to be verified as lacking VRFs and a root canal was performed; all such teeth were followed up for 1 year. If the symptoms did not resolve during that time and a root fracture was detected at a later date, the teeth were considered to have verified VRFs[27]. For extracted teeth, the extractions were performed by an experienced senior practitioner to minimize the possibility of intraoperative root fracture and avoid excessive rotational forces. All isolated teeth were examined microscopically for the presence or absence of cracks. Statistical analysis The efficacy of periodontal endoscopy for VRFs was assessed with respect to the reduction in the rate of root canal therapy (endoscopically determined VRFs in nonsurgical group/total nonsurgical group), the reduction in the rate of surgical treatment (endoscopically determined VRFs in surgical group/total surgical group), and in terms of sensitivity ([# patients with endoscopically determined VRFs/total # patients with VRFs] × 100%) and specificity ([# patients endoscopically determined to lack VRFs/total # patients without VRFs] × 100%). Inter- and intra-examiner agreement was assessed using a kappa analysis, and the relationship between multiple factors and VRFs using logistic regression. Statistical analysis was performed using SPSS 22.0 software. CASE 1: A 64-year-old male presented with a 1-year history of persistent occlusal pain in the left mandibular posterior region. The patient reported root canal treatment (RCT) performed on tooth #19 four years prior, with no history of dental trauma or parafunctional habits. Medical history was noncontributory, with no systemic contraindications to dental procedures. Fillings and overhangs were seen on the distal and middle adjacent surfaces of tooth #19, together with percussion and gingival redness and swelling. The proximal buccal periodontal pockets were probed to a depth of 16 mm. No sinus tracts were seen in the buccal alveolar mucosa, and the tooth was no mobility. In CBCT, No continuous hypodense line across root structure but endoscopy showed obvious fissure lines on the proximal buccal root surface. After extraction of tooth #19, proximal buccal root cracks were visible via microscopy ( Fig2 ) . Results The study population consisted of 112 patients (45 males and 67 females; mean age 44.6 ± 13.4 years) with 115 SVRFs; however, three SVRFs were excluded from the statistical analysis because the patients did not complete the 1-year follow-up. Of the 112 included SVRFs( Table 1 ) , molars (n = 86, 76.8%), premolars (n = 25, 22.3%), and anterior teeth (n = 1, 0.9%). Prior root canal treatment had been performed on 101 teeth (90.2%). Table 1 Prevalence of VRFs and 95% CI by independent factors Variables n/N(%) P value Age 0.362 ≤ 30 22/112(19.6) 31 ~ 40 22/112(19.6) 41 ~ 50 20/112(17.9) 51 ~ 60 20/112(17.9) ≥ 61 28/112(25.0) Sex 0.367 Female 67/112(59.8) Male 45/112(40.2) Tooth type 0.168 anterior teeth 1/112(0.9) Maxillary premolar 15/112(13.4) Maxillary molar 15/112(13.4) Mandibular premolar 10/112(8.9) Mandibular molar 71/112(63.4) ETT 0.07 ETT* 101/112(90.2) NETT* 11/112(9.8) Restoration 0.18 Unrestored 15/112 (13.4) Resin 23/112(20.5) Crown 74/112(66.1) PD(depth) - < 8mm 0/112(0.0) ≥ 8mm 112/112(100) Mobility 0.99 Normal 79/112(70.5) Ⅰ 23/112(20.5) Ⅱ 8/112(7.2) Ⅲ 2/112(1.8) sinus tracts 0.47 0 28/112(25.0) 1 78/112(69.6] 2 6/112(5.4) Root canal filling 0.077 Emptiness 11/112(9.8) Incomplete 36/112(32.2) Complete 65/112(58.0) * ETT, endodontically treated teeth.NETT: non-endodontic treatment. Examination of the 112 SVRFs revealed 70 cases (62.5%, 70/112)that had VRFs(Fig. 3 ). VRFs were identified through the following modalities: periodontal endoscopy (n = 59, 84.3%), surgical flap reflection (n = 3, 4.3%), crown removal (n = 3, 4.3%), and during root canal therapy (n = 3, 4.3%). Two additional VRFs (n = 2, 2.9%) in the extraction group (E group) were diagnosed post-extraction.Overall, identification of SVRFs via periodontal endoscopy reduced the need for surgical treatment by 64.3% (36/56) and for RCT/Re-RCT by 42.2% (19/45). The clinical diagnostic accuracy for VRFs was improved by 49.1% (55/112)( Table 2 ) . In the group S(n = 56), during endoscopic examination, one maxillary first molar tooth underwent root resection due to a discovered root fracture in the buccal root, while the alveolar bone around the other roots was still intact. In the group S-1 (n = 20), 14 teeth showed no cracks and underwent apicoectomy. One tooth was extracted due to extensive alveolar bone defect, one underwent repair for a perforation, three were extracted due to cracks discovered during surgery, and one was extracted due to a crack discovered during the one-year postoperative observation period. The group R-1 (n = 29) underwent endodontic treatment. Among them, 20 teeth showed no root cracks and had a good prognosis. Three teeth were extracted due to buccolingual cracks in the pulp chamber floor, one was extracted due to a crack in the mesiolingual canal, one was extracted due to an abnormal apex locator reading, one developed a root fracture four months after treatment, and three were lost to follow-up. In the group E (n = 11), no cracks were observed on the surface of five teeth, one had root surface defect, and cracks were observed on the root surface of five teeth. In both the group EX-1 and group EX-2, cracks were observed on the root surface after extraction. Table 2 Therapy plans before and after periodontal endoscopy examination for the SVRFs Therapy plan after periodontal endoscopy examination (n t ) Therapy plan before periodontal endoscopy examination (n t ) S ET EX Total S 20 0 36 56 ET 0 26 19 45 EX 0 0 11 11 Total 20 26 66 112 *S: flap surgery; ET: Endodontic treatment; EX: extraction; n t , number of teeth. Grey boxes represent no changes. The number of patients who had a therapy change after periodontal endoscopy examination are represented in white background. Interobserver agreement:the CBCT alone was moderate interobserver agreement (Cohen’s κ = 0.444), CBCT combined with periodontal endoscopy was interobserver agreement significantly improved to a high level (Cohen’s κ = 0.842). The sensitivity of periodontal endoscopy for identifying VRFs was 76.0% (19/25) for teeth in the group ET, 92.5% (37/40) in the group S, and 84.3% (59/70) in the periodontal endoscopy group. The specificity was 100% in all three groups. Discussion The present findings demonstrate that preoperative periodontal endoscopic evaluation of suspected vertical root fractures (SVRFs) significantly reduced unnecessary flap surgeries by 64.28% and endodontic retreatments by 42.22%, while improving diagnostic accuracy by 49.1% compared to conventional diagnostic methods. This noninvasive approach aligns with contemporary minimally invasive dentistry paradigms by enabling direct visualization of root surfaces through periodontal pockets,, eliminating the need to remove restorations or extract materials from the root canal for staining, or perform flap surgery to directly observe the root surface. When fractures were confirmed endoscopically, strategic extraction preserved alveolar bone integrity for future prosthetic rehabilitation. Conversely, the absence of detectable cracks allowed for tooth preservation through targeted endodontic or periodontal interventions, consistent with current biological-oriented treatment philosophies[ 30 ]. In this experiment, vertical root fractures were more common in women, consistent with Pan Xiao's research findings[ 31 ]. This may be due to differences between men and women in food preferences, bite frequency and the presence of para-functional habits[ 32 ]. Notably, periodontal endoscopy exhibited superior diagnostic performance to cone-beam computed tomography (CBCT) in detecting treatable VRFs, particularly those amenable to endodontic management (51.3% accuracy differential). The observed sensitivity of 84.28% corresponds with recent advancements in intraoral imaging technologies. The elevated VRF prevalence (62.5%) in our cohort compared to general population estimates likely reflects stringent inclusion criteria focusing on high-risk indicators, including existing crown restorations (82.4%) and previous RCT (89.2%) - both well-documented predisposing factors for root fracture . In this study, three VRFs were detected during flap surgery that were not identified via periodontal endoscopy. There are several reasons for this. The cracks started at the root apex and were short while the length of the probe used in this study was 8 mm, which made it impossible to detect the apical third of the root. Also, the cracks were located on the proximal and distal mesial surfaces, and the neighboring teeth prevented placement of the endoscope into the proximal and distal periodontal pockets. Finally, the cracks may have extended across multiple root surfaces and/or corresponded to the periodontal pocket, complicating accurate endoscopic observation. The clinical gold standard for the detection of VRFs is observation of the root surface after flap surgery or extraction, but staining of the pulpal cavity and root canals during the root canal procedure has also been advocated. In our patients, microscopic observation of the apical half of the root canal for obvious cracks during retreatment of the affected teeth was difficult, while cracks located on the proximal and distal mesial sides might have been missed during flap surgery. For these reasons, we included postoperative observation of all SVRFs for 1 year; if there was no symptomatic relief or cracks were found, it was assumed that the patient had a small, not easily detectable longitudinal root fracture already at the time of the first preoperative checkup. The mean age of our patients with VRFs who had undergone RCT and experienced VRFs was 46.5 years while that of patients without RCT was 48.56 years, which suggests that RCT accelerates the occurrence of VRFs, in agreement with Pan et al[ 31 ]. It is possible that the cutting of the root canal wall during RCT, the pressure during filling, and the swelling properties of the filling material act together to promote root fracture[33, 34]. The rate of non-endodontic treatment(NETT) of VRFs in the present study was 9.8%, much lower than the 40% reported in other studies[ 33 ], probably because of the high detection rate of CBCT for VRFs in non-endodontically treated teeth with root fissures. In addition, longitudinal fissures of the roots that can be observed via CBCT fell under the exclusion criteria of our study. The vast majority of the SVRFs in this study had crown restorations, which would seem to suggest that they increase the risk of VRFs; however, the small sample size hindered confirmation of this hypothesis. Conclusion When used as an adjunct tool for clinical decision-making in patients with SVRFs, periodontal endoscopy can help avoid unnecessary nonsurgical and surgical treatments. Abbreviations VRF vertical root fractures SVRF suspected vertical root fractures Declarations Ethical approval This study was approved by the Institutional Review Board of Xi'an Jiaotong University Stomatological Hospital ( No. KY-QX-20240004 ). Written informed consent was obtained from all participants. Informed consent For this type of study, formal consent is required. Competing interests The authors declare that they have no competing interests Source of funding or financial interest None. Consent to Participate declaration Not applicable. Consent to Publish declaration Not applicable. Authors ’ contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by M Yang, YP Xue . The first draft of the manuscript was written by M Yang .QQ Dong supervised the project.All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgments Competing interests The authors declare no competing interests. The experimental procedures were performed at the Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, Clinical Research Center of Shaanxi Province for Dental and Maxillofacial Diseases,and Department of Cariology & Endodontics, College of Stomatology, Xi’an Jiaotong University, Xi'an Jiaotong University, Xi'an, China. References American Association of Endodontists. Apexification. In: Glossary of endodontic terms. 10th ed. Chicago: American Association of Endodontists; 2020. https://www.aae.org. 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Cite Share Download PDF Status: Published Journal Publication published 19 Dec, 2025 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 29 May, 2025 Reviews received at journal 29 May, 2025 Reviews received at journal 21 May, 2025 Reviews received at journal 15 May, 2025 Reviewers agreed at journal 13 May, 2025 Reviewers agreed at journal 13 May, 2025 Reviewers agreed at journal 12 May, 2025 Reviewers agreed at journal 10 May, 2025 Reviewers agreed at journal 10 May, 2025 Reviewers agreed at journal 09 May, 2025 Reviewers agreed at journal 08 May, 2025 Reviewers agreed at journal 08 May, 2025 Reviewers agreed at journal 07 May, 2025 Reviewers invited by journal 07 May, 2025 Editor invited by journal 07 May, 2025 Editor assigned by journal 06 May, 2025 Submission checks completed at journal 06 May, 2025 First submitted to journal 26 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6535793","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":454747211,"identity":"cf20155b-23eb-4434-a2ff-ebf198105d18","order_by":0,"name":"Min Yang","email":"","orcid":"","institution":"Xi’an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Yang","suffix":""},{"id":454747212,"identity":"b3dbc26d-7d09-49c2-86c8-e7610216869c","order_by":1,"name":"Xuefei Sun","email":"","orcid":"","institution":"Xi’an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Xuefei","middleName":"","lastName":"Sun","suffix":""},{"id":454747213,"identity":"34d9d914-5c0e-4087-9017-0b7a94c5d1af","order_by":2,"name":"Gaofeng Fang","email":"","orcid":"","institution":"Xi’an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Gaofeng","middleName":"","lastName":"Fang","suffix":""},{"id":454747214,"identity":"2f4f0056-f2b3-4729-a348-b476e3a94ef8","order_by":3,"name":"Yunpeng Xue","email":"","orcid":"","institution":"Xi’an Jiaotong University","correspondingAuthor":false,"prefix":"","firstName":"Yunpeng","middleName":"","lastName":"Xue","suffix":""},{"id":454747215,"identity":"a11a5918-652d-4497-9d57-3f15402f1f89","order_by":4,"name":"Qianqian Dong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAu0lEQVRIiWNgGAWjYDACZhBhwMDAz8x8+AFpWiTb2dIMSLPN4DyPggRRKvmOMz/d8KbALs/4MA/QshqbaIJaJA+zmd2cY5BcbHaY98ADhmNpuQ0E3XOYwew2jwFz4rbDfAkGjA2HidHC/g2opT5xczOPgQSRWnhAthxO3MBMrBbJwzxlQL8cT5xxGBjICcT4he/88W033vypTuzvP3z4wYcaG8JaGA4AMQ+Mk0BQOYaWUTAKRsEoGAXYAABfVT+C41dNlAAAAABJRU5ErkJggg==","orcid":"","institution":"Xi’an Jiaotong University","correspondingAuthor":true,"prefix":"","firstName":"Qianqian","middleName":"","lastName":"Dong","suffix":""}],"badges":[],"createdAt":"2025-04-26 15:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6535793/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6535793/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-025-07182-w","type":"published","date":"2025-12-19T15:57:48+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82620899,"identity":"fe9584ae-c347-4e4b-8139-3c5d7507d27e","added_by":"auto","created_at":"2025-05-13 12:17:50","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34761,"visible":true,"origin":"","legend":"\u003cp\u003ea) No cracks observed via endoscopy; b) a crack observed via endoscopy\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6535793/v1/e52f744147cf3fb32f3e8bcb.jpg"},{"id":82620902,"identity":"85059158-76c6-4774-9742-78751d6c1436","added_by":"auto","created_at":"2025-05-13 12:17:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":124638,"visible":true,"origin":"","legend":"\u003cp\u003ea) Sinus tract visible on the buccal side of tooth #19; b) proximal buccal exploration of a 16 mm periodontal pocket; c–f) “J” type alveolar bone resorption in the proximal buccal root; g) endoscopic examination of the proximal buccal root revealed a crack; h) the crack on the proximal buccal root.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6535793/v1/f38bb4a09ae1e40a2a8e4011.jpg"},{"id":82620901,"identity":"3f3f2f8c-b0b4-44ad-8ad2-88992915e716","added_by":"auto","created_at":"2025-05-13 12:17:50","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":87828,"visible":true,"origin":"","legend":"\u003cp\u003eEnrollment, and Follow-up\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6535793/v1/5cfda3891359c3cbcef014b7.jpg"},{"id":98814074,"identity":"6d63cbdc-9d27-4d25-b331-1d3df7d048fb","added_by":"auto","created_at":"2025-12-22 16:10:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":915349,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6535793/v1/6961345a-f4df-4959-8739-b637f3f01d94.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Role of periodontal endoscopy in clinical decision-making for teeth with suspected vertical root fractures","fulltext":[{"header":"Background","content":"\u003cp\u003eVertical root fracture (VRF),defined as longitudinally oriented complete or incomplete fractures extending through the root structure at any level[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e],presents significant diagnostic and therapeutic challenges in contemporary endodontics.Advanced VRFs usually present with significant fracture displacement and extensive alveolar bone resorption at the fracture interface, culminating in a poor prognosis. While early detection is paramount for tooth preservation[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Clinically, VRFs manifest as sinus tracts, recurrent occlusal pain, narrow and deep (\u0026gt;\u0026thinsp;6 mm) periodontal pockets, and other such atypical symptoms[\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. diagnosis remains complicated by the subtle and variable presentation of initial symptoms [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePeriapical radiographs may show abnormal widening of the root canal[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], but the efficacy of X-rays for diagnosing VRFs is limited by the imaging angle and overlapping tissues[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Cone-beam computed tomography (CBCT) images may show alveolar bone resorption along hypodense fracture lines, seen as a \u0026ldquo;halo\u0026rdquo; or \u0026ldquo;J\u0026rdquo; translucency[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. CBCT can diagnose VRF more accurately than X-rays[\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], but CBCT still has its limitations. Smaller voxels and field-of-view sizes provide higher detection accuracy for VRF[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e],In fact, for small VRFs, the accuracy of CBCT examination \u003cem\u003ein vivo\u003c/em\u003e is only 29%[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]..Root canal filling materials or crown-square restorations can block projections and create artifacts in or blur out fracture lines[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore, the diagnostic accuracy for teeth with no root canal treatment is 2.399 times higher than that for teeth with root canal treatment[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] .\u003c/p\u003e \u003cp\u003eClinically ,Suspected vertical root fractures(SVRFs) have overlapping clinical manifestations with VRFs, but no obvious cracks were observed on CBCT[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e],include localized periodontal disease, combined periodontal-pulpal lesions, early VRFs, and transverse root fractures. The diagnosis of SVRFs is essential as failure to diagnose VRFs in SVRFs can lead to increased alveolar bone resorption, while overdiagnosis of non-VRF teeth can lead to unnecessary tooth extractions.\u003c/p\u003e \u003cp\u003eWhen assessing SVRFs, diagnostic protocols mandate CBCT evaluation following clinical examination, with treatment decisions contingent upon radiographic findings and periodontal parameters[\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]: definitive fracture visualization warrants extraction[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]; teeth with compromised periodontal support (probing depth\u0026thinsp;\u0026ge;\u0026thinsp;6 mm with mobility) are scheduled for extraction; those with adequate bone support and inadequate root canal treatment undergo RCT/Re-RCT and periodontal treatment; while teeth with persistent apical pathology despite adequate obturation are directed to surgical intervention. The gold standard for VRF is flap surgery[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], but is invasive[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].As a result, this study was working to find a non-invasive and easy way to check for VRF.\u003c/p\u003e \u003cp\u003eA periodontal endoscope is an optical instrument composed of multiple parts, including a cold light source probe, fiber optic cables, image transmission systems, and screen display systems. By inserting the cold light source lens into the periodontal pocket, it allows for viewing magnified images of the root surface on a display to check for any obvious crack lines. The cold light source probe of the periodontal endoscope is designed to be compact, enabling examination of the root surface with minimal invasiveness. Zhang Peng et al[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. used the periodontal endoscope to diagnose vertical root fractures, achieving a correct index of 83.7%, which is higher than the 53.1% accuracy rate of CBCT. This study investigates its clinical utility in therapeutic decision-making and diagnostic accuracy for SVRFs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA prospective cohort of 196 consecutive patients presenting with suspected vertical root fractures (SVRFs) was screened between July 2022 and June 2023. The sample size was calculated using diagnostic test assumptions (α=0.05, β=0.20, expected sensitivity=85%) based on pilot data, requiring ≥100 evaluable cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp; \u0026nbsp;18–70 years old.\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp; \u0026nbsp;≥1 clinical symptom: recurrent gingival swelling, sinus tract, or occlusal pain.\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp;\u0026nbsp;Isolated periodontal pocket depth \u0026gt;6 mm (UNC-15 probe, Hu-Friedy).\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp; \u0026nbsp;Absence of definitive fracture lines on two-plane CBCT reconstructions (NewTom VGi, 90kV, 8.9mA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1)\u0026nbsp; \u0026nbsp;Systemic contraindications (HbA1c\u0026gt;7.5%, uncontrolled hypertension).\u003c/p\u003e\n\u003cp\u003e2)\u0026nbsp; \u0026nbsp;Generalized periodontitis (≥30% sites with CAL≥5mm).\u003c/p\u003e\n\u003cp\u003e3)\u0026nbsp; \u0026nbsp;Existing root fractures or iatrogenic cracks.\u003c/p\u003e\n\u003cp\u003e4)\u0026nbsp; \u0026nbsp;Pregnancy/lactation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic Workflow\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. \u003cstrong\u003eInitial Assessment:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;One endodontist and one radiologist jointly assessed whether the teeth met the inclusion and exclusion criteria; disagreement was resolved by consultation with a senior surgeon. Two endodontists evaluated the SVRFs and depending on the root canal filling status, restoration status, and periodontal status selected the most appropriate treatment plan and divided into three groups, considering flap surgery, root canal therapy/ root canal retreatment (RCT/Re-RCT), or extraction. (S, R, and E groups, respectively).\u003c/p\u003e\n\u003cp\u003e2. \u003cstrong\u003ePeriodontal Endoscopy Protocol:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePeriodontal endoscopy was carried out as follows. The periodontal pockets of SVRFs were infiltrated and anesthetized with 4% articaine with 1:100,000 epinephrine and then cleaned of tartar, plaque, and diseased bone. The root surface was stained with methylene blue and observed using the cold light source probe of a periodontal endoscope (P100, Bangwo, China). All endoscopic examinations were performed by a doctor who was able to skillfully operate the periodontal endoscope.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.\u0026nbsp; \u0026nbsp;Therapeutic Decision Tree:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTeeth with endoscopically observed cracks(\u003cstrong\u003eFig1.b\u003c/strong\u003e) and those in the E group were extracted or underwent root amputation when the periodontal condition of the roots of the maxillary molars was still favorable[29]. In the surgical group, teeth in which no cracks were observed endoscopically were explored via flap surgery. Their root surfaces were stained with methylene blue and observed under a microscope (OMS2380, Zumax, China). If cracks were observed, the tooth was considered to have a verified VRF, thus requiring extraction or root amputation. Teeth without cracks(\u003cstrong\u003eFig1.a\u003c/strong\u003e) were considered to be verified as lacking VRFs and surgery was performed. For teeth in the R group, the filling material in the root canal was removed and methylene blue was used to stain the pulp chamber[22]; the upper one-third of the root canal or a root canal sizer was used for detection. If cracks were observed or the sizer suggested an abnormality, the tooth was scheduled for extraction or root amputation. Teeth with cracks detected during root amputation were considered to have a verified VRF; those with no obvious abnormality were considered to be verified as lacking VRFs and a root canal was performed; all such teeth were followed up for 1 year. If the symptoms did not resolve during that time and a root fracture was detected at a later date, the teeth were considered to have verified VRFs[27].\u003c/p\u003e\n\u003cp\u003eFor extracted teeth, the extractions were performed by an experienced senior practitioner to minimize the possibility of intraoperative root fracture and avoid excessive rotational forces. All isolated teeth were examined microscopically for the presence or absence of cracks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe efficacy of periodontal endoscopy for VRFs was assessed with respect to the reduction in the rate of root canal therapy (endoscopically determined VRFs in nonsurgical group/total nonsurgical group), the reduction in the rate of surgical treatment (endoscopically determined VRFs in surgical group/total surgical group), and in terms of sensitivity ([# patients with endoscopically determined VRFs/total # patients with VRFs] × 100%) and specificity ([# patients endoscopically determined to lack VRFs/total # patients without VRFs] × 100%). Inter- and intra-examiner agreement was assessed using a kappa analysis, and the relationship between multiple factors and VRFs using logistic regression. Statistical analysis was performed using SPSS 22.0 software.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCASE 1:\u0026nbsp;\u003c/strong\u003eA 64-year-old male presented with a 1-year history of persistent occlusal pain in the left mandibular posterior region. The patient reported root canal treatment (RCT) performed on tooth #19 four years prior, with no history of dental trauma or parafunctional habits. Medical history was noncontributory, with no systemic contraindications to dental procedures. Fillings and overhangs were seen on the distal and middle adjacent surfaces of tooth #19, together with percussion and gingival redness and swelling. The proximal buccal periodontal pockets were probed to a depth of 16 mm. No sinus tracts were seen in the buccal alveolar mucosa, and the tooth was no mobility. In CBCT, No continuous hypodense line across root structure but endoscopy showed obvious fissure lines on the proximal buccal root surface. After extraction of tooth #19, proximal buccal root cracks were visible via microscopy (\u003cstrong\u003eFig2\u003c/strong\u003e) .\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study population consisted of 112 patients (45 males and 67 females; mean age 44.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4 years) with 115 SVRFs; however, three SVRFs were excluded from the statistical analysis because the patients did not complete the 1-year follow-up. Of the 112 included SVRFs( Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e, molars (n\u0026thinsp;=\u0026thinsp;86, 76.8%), premolars (n\u0026thinsp;=\u0026thinsp;25, 22.3%), and anterior teeth (n\u0026thinsp;=\u0026thinsp;1, 0.9%). Prior root canal treatment had been performed on 101 teeth (90.2%).\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\u003ePrevalence of VRFs and 95% CI by independent factors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en/N(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.362\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22/112(19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"4\" rowspan=\"5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026thinsp;~\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22/112(19.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u0026thinsp;~\u0026thinsp;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20/112(17.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51\u0026thinsp;~\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20/112(17.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28/112(25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.367\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67/112(59.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45/112(40.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTooth type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eanterior teeth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/112(0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"4\" rowspan=\"5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaxillary premolar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15/112(13.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaxillary molar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15/112(13.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandibular premolar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/112(8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandibular molar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71/112(63.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eETT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eETT*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101/112(90.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNETT*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/112(9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRestoration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnrestored\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15/112 (13.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23/112(20.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCrown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74/112(66.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePD(depth)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;8mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0/112(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;8mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112/112(100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79/112(70.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅠ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23/112(20.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅡ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/112(7.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eⅢ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/112(1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esinus tracts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28/112(25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78/112(69.6]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/112(5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoot canal filling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmptiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/112(9.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncomplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36/112(32.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65/112(58.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e*\u003c/b\u003eETT, endodontically treated teeth.NETT: non-endodontic treatment.\u003c/p\u003e \u003cp\u003eExamination of the 112 SVRFs revealed 70 cases (62.5%, 70/112)that had VRFs(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). VRFs were identified through the following modalities: periodontal endoscopy (n\u0026thinsp;=\u0026thinsp;59, 84.3%), surgical flap reflection (n\u0026thinsp;=\u0026thinsp;3, 4.3%), crown removal (n\u0026thinsp;=\u0026thinsp;3, 4.3%), and during root canal therapy (n\u0026thinsp;=\u0026thinsp;3, 4.3%). Two additional VRFs (n\u0026thinsp;=\u0026thinsp;2, 2.9%) in the extraction group (E group) were diagnosed post-extraction.Overall, identification of SVRFs via periodontal endoscopy reduced the need for surgical treatment by 64.3% (36/56) and for RCT/Re-RCT by 42.2% (19/45). The clinical diagnostic accuracy for VRFs was improved by 49.1% (55/112)( Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the group S(n\u0026thinsp;=\u0026thinsp;56), during endoscopic examination, one maxillary first molar tooth underwent root resection due to a discovered root fracture in the buccal root, while the alveolar bone around the other roots was still intact. In the group S-1 (n\u0026thinsp;=\u0026thinsp;20), 14 teeth showed no cracks and underwent apicoectomy. One tooth was extracted due to extensive alveolar bone defect, one underwent repair for a perforation, three were extracted due to cracks discovered during surgery, and one was extracted due to a crack discovered during the one-year postoperative observation period.\u003c/p\u003e \u003cp\u003eThe group R-1 (n\u0026thinsp;=\u0026thinsp;29) underwent endodontic treatment. Among them, 20 teeth showed no root cracks and had a good prognosis. Three teeth were extracted due to buccolingual cracks in the pulp chamber floor, one was extracted due to a crack in the mesiolingual canal, one was extracted due to an abnormal apex locator reading, one developed a root fracture four months after treatment, and three were lost to follow-up.\u003c/p\u003e \u003cp\u003eIn the group E (n\u0026thinsp;=\u0026thinsp;11), no cracks were observed on the surface of five teeth, one had root surface defect, and cracks were observed on the root surface of five teeth. In both the group EX-1 and group EX-2, cracks were observed on the root surface after extraction.\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\u003eTherapy plans before and after periodontal endoscopy examination for the SVRFs\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=\"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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eTherapy plan after periodontal endoscopy examination (n\u003csup\u003et\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTherapy plan before periodontal endoscopy examination (n\u003csup\u003et\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eET\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eET\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*S: flap surgery; ET: Endodontic treatment; EX: extraction; n\u003csup\u003et\u003c/sup\u003e, number of teeth. Grey boxes represent no changes. The number of patients who had a therapy change after periodontal endoscopy examination are represented in white background.\u003c/p\u003e \u003cp\u003eInterobserver agreement:the CBCT alone was moderate interobserver agreement (Cohen\u0026rsquo;s κ\u0026thinsp;=\u0026thinsp;0.444), CBCT combined with periodontal endoscopy was interobserver agreement significantly improved to a high level (Cohen\u0026rsquo;s κ\u0026thinsp;=\u0026thinsp;0.842). The sensitivity of periodontal endoscopy for identifying VRFs was 76.0% (19/25) for teeth in the group ET, 92.5% (37/40) in the group S, and 84.3% (59/70) in the periodontal endoscopy group. The specificity was 100% in all three groups.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present findings demonstrate that preoperative periodontal endoscopic evaluation of suspected vertical root fractures (SVRFs) significantly reduced unnecessary flap surgeries by 64.28% and endodontic retreatments by 42.22%, while improving diagnostic accuracy by 49.1% compared to conventional diagnostic methods. This noninvasive approach aligns with contemporary minimally invasive dentistry paradigms by enabling direct visualization of root surfaces through periodontal pockets,, eliminating the need to remove restorations or extract materials from the root canal for staining, or perform flap surgery to directly observe the root surface. When fractures were confirmed endoscopically, strategic extraction preserved alveolar bone integrity for future prosthetic rehabilitation. Conversely, the absence of detectable cracks allowed for tooth preservation through targeted endodontic or periodontal interventions, consistent with current biological-oriented treatment philosophies[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this experiment, vertical root fractures were more common in women, consistent with Pan Xiao's research findings[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This may be due to differences between men and women in food preferences, bite frequency and the presence of para-functional habits[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNotably, periodontal endoscopy exhibited superior diagnostic performance to cone-beam computed tomography (CBCT) in detecting treatable VRFs, particularly those amenable to endodontic management (51.3% accuracy differential). The observed sensitivity of 84.28% corresponds with recent advancements in intraoral imaging technologies. The elevated VRF prevalence (62.5%) in our cohort compared to general population estimates likely reflects stringent inclusion criteria focusing on high-risk indicators, including existing crown restorations (82.4%) and previous RCT (89.2%) - both well-documented predisposing factors for root fracture .\u003c/p\u003e \u003cp\u003eIn this study, three VRFs were detected during flap surgery that were not identified via periodontal endoscopy. There are several reasons for this. The cracks started at the root apex and were short while the length of the probe used in this study was 8 mm, which made it impossible to detect the apical third of the root. Also, the cracks were located on the proximal and distal mesial surfaces, and the neighboring teeth prevented placement of the endoscope into the proximal and distal periodontal pockets. Finally, the cracks may have extended across multiple root surfaces and/or corresponded to the periodontal pocket, complicating accurate endoscopic observation.\u003c/p\u003e \u003cp\u003eThe clinical gold standard for the detection of VRFs is observation of the root surface after flap surgery or extraction, but staining of the pulpal cavity and root canals during the root canal procedure has also been advocated. In our patients, microscopic observation of the apical half of the root canal for obvious cracks during retreatment of the affected teeth was difficult, while cracks located on the proximal and distal mesial sides might have been missed during flap surgery. For these reasons, we included postoperative observation of all SVRFs for 1 year; if there was no symptomatic relief or cracks were found, it was assumed that the patient had a small, not easily detectable longitudinal root fracture already at the time of the first preoperative checkup.\u003c/p\u003e \u003cp\u003eThe mean age of our patients with VRFs who had undergone RCT and experienced VRFs was 46.5 years while that of patients without RCT was 48.56 years, which suggests that RCT accelerates the occurrence of VRFs, in agreement with Pan et al[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. It is possible that the cutting of the root canal wall during RCT, the pressure during filling, and the swelling properties of the filling material act together to promote root fracture[33, 34].\u003c/p\u003e \u003cp\u003eThe rate of non-endodontic treatment(NETT) of VRFs in the present study was 9.8%, much lower than the 40% reported in other studies[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], probably because of the high detection rate of CBCT for VRFs in non-endodontically treated teeth with root fissures. In addition, longitudinal fissures of the roots that can be observed via CBCT fell under the exclusion criteria of our study. The vast majority of the SVRFs in this study had crown restorations, which would seem to suggest that they increase the risk of VRFs; however, the small sample size hindered confirmation of this hypothesis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhen used as an adjunct tool for clinical decision-making in patients with SVRFs, periodontal endoscopy can help avoid unnecessary nonsurgical and surgical treatments.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVRF \u0026nbsp;vertical root fractures\u003c/p\u003e\n\u003cp\u003eSVRF \u0026nbsp;suspected vertical root fractures\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Xi'an Jiaotong University Stomatological Hospital (\u003cstrong\u003eNo. KY-QX-20240004\u003c/strong\u003e). Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor this type of study, formal consent is required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of funding or financial interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e’\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by M Yang, YP Xue . The first draft of the manuscript was written by M Yang .QQ Dong supervised the project.All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eThe experimental procedures were performed at the Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, Clinical Research Center of Shaanxi Province for Dental and Maxillofacial Diseases,and \u0026nbsp;Department of Cariology \u0026amp; Endodontics, College of Stomatology, Xi’an Jiaotong University, Xi'an Jiaotong University, Xi'an, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmerican Association of Endodontists. Apexification. In: Glossary of endodontic terms. 10th ed. Chicago: American Association of Endodontists; 2020. https://www.aae.org. Accessed 15 Jan 2020.\u003c/li\u003e\n\u003cli\u003eHuang CC, Chang YC, Chuang MC, et al. Analysis of the width of vertical root fracture in endodontically treated teeth by 2 micro\u0026ndash;computed tomography systems. J Endod. 2014;40(6):698\u0026ndash;702. doi:10.1016/j.joen.2013.12.015.\u003c/li\u003e\n\u003cli\u003eRiyahi A. Findings, identification and etiology of vertical root fractures. Egypt Dent J. 2023;69(4):3321\u0026ndash;6. doi:10.21608/edj.2023.228392.2681.\u003c/li\u003e\n\u003cli\u003eAmerican Association of Endodontists. Cracked tooth studies guidelines. 2016. https://www.aae.org. Accessed 15 Jan 2016.\u003c/li\u003e\n\u003cli\u003eAlaugaily I, Azim AA. CBCT patterns of bone loss and clinical predictors for the diagnosis of cracked teeth and teeth with vertical root fracture. J Endod. 2022;48(9):1100\u0026ndash;6. doi:10.1016/j.joen.2022.06.004.\u003c/li\u003e\n\u003cli\u003ePradeepKumar AR, Shemesh H, Jothilatha S, et al. Diagnosis of vertical root fractures in restored endodontically treated teeth: a time-dependent retrospective cohort study. J Endod. 2016;42(8):1175\u0026ndash;80. doi:10.1016/j.joen.2016.04.012.\u003c/li\u003e\n\u003cli\u003eWalton RE. Vertical root fracture. J Am Dent Assoc. 2017;148(2):100\u0026ndash;5. doi:10.1016/j.adaj.2016.11.014.\u003c/li\u003e\n\u003cli\u003eVon Arx T, Bosshardt D. Vertical root fractures of endodontically treated posterior teeth: a histologic analysis with clinical and radiographic correlates. Swiss Dent J SSO. 2017;127(1):14\u0026ndash;23. doi:10.61872/sdj-2017-01-233.\u003c/li\u003e\n\u003cli\u003eHaupt F, Wiegand A, Kanzow P. Risk factors for and clinical presentations indicative of vertical root fracture in endodontically treated teeth: a systematic review and meta-analysis. J Endod. 2023;49(8):940\u0026ndash;52. doi:10.1016/j.joen.2023.06.004.\u003c/li\u003e\n\u003cli\u003eLiao WC, Chen CH, Pan YH, et al. Vertical root fracture in non-endodontically and endodontically treated teeth: current understanding and future challenge. J Pers Med. 2021;11(12):1375. doi:10.3390/jpm11121375.\u003c/li\u003e\n\u003cli\u003ede Lima KL. Influence of intracanal materials in vertical root fracture pathway detection with cone-beam computed tomography. J Endod. 2017;43(7):1170\u0026ndash;5. doi:10.1016/j.joen.2017.02.006.\u003c/li\u003e\n\u003cli\u003eLeite de Lima K, Silva LR, Andrade Mota Neto M, et al. Impact of fracture line width on radiographic diagnosis of vertical root fractures: analysis of the generalised estimating equation model. Chin J Dent Res. 2022;25(3):197\u0026ndash;204. doi:10.3290/j.cjdr.b3317977.\u003c/li\u003e\n\u003cli\u003eEe J, Fayad MI, Johnson BR. Comparison of endodontic diagnosis and treatment planning decisions using cone-beam volumetric tomography versus periapical radiography. J Endod. 2014;40(7):910\u0026ndash;6. doi:10.1016/j.joen.2014.03.002.\u003c/li\u003e\n\u003cli\u003eWang P, Yan X, Lui D, et al. Detection of dental root fractures by using cone-beam computed tomography. Dentomaxillofac Radiol. 2011;40(5):290\u0026ndash;8. doi:10.1259/dmfr/84907460.\u003c/li\u003e\n\u003cli\u003eEdlund M, Nair MK, Nair UP. Detection of vertical root fractures by using cone-beam computed tomography: a clinical study. J Endod. 2011;37(6):768\u0026ndash;72. doi:10.1016/j.joen.2011.02.034.\u003c/li\u003e\n\u003cli\u003eByakova SF, Novozhilova NE, Makeeva IM, et al. The accuracy of CBCT for the detection and diagnosis of vertical root fractures in vivo. Int Endod J. 2019;52(8):1255\u0026ndash;63. doi:10.1111/iej.13114.\u003c/li\u003e\n\u003cli\u003eBernardes RA, de Moraes IG, H\u0026uacute;ngaro Duarte MA, et al. Use of cone-beam volumetric tomography in the diagnosis of root fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108(2):270\u0026ndash;7. doi:10.1016/j.tripleo.2009.01.017.\u003c/li\u003e\n\u003cli\u003ede Lima KL, Silva LR, de Paiva Prado TB, et al. Influence of the technical parameters of CBCT image acquisition on vertical root fracture diagnosis: a systematic review and meta-analysis. Clin Oral Investig. 2023;27(2):433\u0026ndash;74. doi:10.1007/s00784-022-04797-z.\u003c/li\u003e\n\u003cli\u003eMakeeva IM, Byakova SF, Novozhilova NE, et al. Detection of artificially induced vertical root fractures of different widths by cone beam computed tomography in vitro and in vivo. Int Endod J. 2016;49(10):980\u0026ndash;9. doi:10.1111/iej.12549.\u003c/li\u003e\n\u003cli\u003eDutra KL, Pach\u0026ecirc;co-Pereira C, Bortoluzzi EA, et al. Influence of intracanal materials in vertical root fracture pathway detection with cone-beam computed tomography. J Endod. 2017;43(7):1170\u0026ndash;5. doi:10.1016/j.joen.2017.02.006.\u003c/li\u003e\n\u003cli\u003eKapralos V, Koutroulis A, Irinakis E, et al. Digital subtraction radiography in detection of vertical root fractures: accuracy evaluation for root canal filling, fracture orientation and width variables. An ex-vivo study. Clin Oral Investig. 2020;24(10):3671\u0026ndash;81. doi:10.1007/s00784-020-03245-0.\u003c/li\u003e\n\u003cli\u003eLee K, Ahlowalia M, Alfayate RP, et al. Prevalence of and factors associated with vertical root fracture in a Japanese population: an observational study on teeth with isolated periodontal probing depth. J Endod. 2023;49(12):1617\u0026ndash;24. doi:10.1016/j.joen.2023.08.018.\u003c/li\u003e\n\u003cli\u003ePatel S, Brown J, Pimentel T, et al. Cone beam computed tomography in endodontics \u0026ndash; a review of the literature. Int Endod J. 2019;52(8):1138\u0026ndash;52. doi:10.1111/iej.13115.\u003c/li\u003e\n\u003cli\u003eAmerican Association of Endodontists. Nonsurgical retreatment: clinical decision making. 2017. https://www.aae.org. Accessed 15 Jan 2017.\u003c/li\u003e\n\u003cli\u003eAbbott P. Assessing restored teeth with pulp and periapical diseases for the presence of cracks, caries and marginal breakdown. Aust Dent J. 2004;49(1):33\u0026ndash;9. doi:10.1111/j.1834-7819.2004.tb00047.x.\u003c/li\u003e\n\u003cli\u003eGa\u0026ecirc;ta-Araujo H, Nascimento EHL, Oliveira-Santos N, et al. Effect of digital enhancement on the radiographic assessment of vertical root fractures in the presence of different intracanal materials: an in vitro study. Clin Oral Investig. 2021;25(1):195\u0026ndash;202. doi:10.1007/s00784-020-03353-x.\u003c/li\u003e\n\u003cli\u003eMetska ME, Aartman IHA, Wesselink PR, \u0026Ouml;zok AR. Detection of vertical root fractures in vivo in endodontically treated teeth by cone-beam computed tomography scans. J Endod. 2012;38(10):1344\u0026ndash;7. doi:10.1016/j.joen.2012.05.003.\u003c/li\u003e\n\u003cli\u003eZhang P, Yuan ZY, Cui D, et al. Comparative study of periodontal endoscopy and CBCT in the diagnosis of root vertical fractures with deep periodontal pockets. J Oral Med. 2021;11(6):988\u0026ndash;91. doi:10.13591/j.cnki.kqyx.2021.11.006.\u003c/li\u003e\n\u003cli\u003eBasten CH, Ammons WF Jr, Persson R. Long-term evaluation of root-resected molars: a retrospective study. Int J Periodontics Restorative Dent. 1996;16(3):206\u0026ndash;19.\u003c/li\u003e\n\u003cli\u003eCohen S, Blanco L, Berman L. Vertical root fractures: clinical and radiographic diagnosis. J Am Dent Assoc. 2003;134(4):434\u0026ndash;41. doi:10.14219/jada.archive.2003.0192.\u003c/li\u003e\n\u003cli\u003ePan X, Tang R, Gao A, et al. Cross-sectional study of posterior tooth root fractures in 2015 and 2019 in a Chinese population. Clin Oral Investig. 2022;26(12):6151\u0026ndash;7. doi:10.1007/s00784-022-04564-0.\u003c/li\u003e\n\u003cli\u003eYiğit \u0026Ouml;zer S, \u0026Uuml;nl\u0026uuml; G, Değer Y. Diagnosis and treatment of endodontically treated teeth with vertical root fracture: three case reports with two-year follow-up. J Endod. 2011;37(1):97\u0026ndash;102. doi:10.1016/j.joen.2010.09.002.\u003c/li\u003e\n\u003cli\u003eChan CP, Lin CP, Tseng SC, Jeng JH. Vertical root fracture in endodontically versus nonendodontically treated teeth: a survey of 315 cases in Chinese patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;87(4):504\u0026ndash;7. doi:10.1016/s1079-2104(99)70252-0.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Vertical root fracture, Periodontal endoscopy, Diagnostic accuracy, Minimally invasive dentistry, Clinical decision-making","lastPublishedDoi":"10.21203/rs.3.rs-6535793/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6535793/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eThis study aimed to evaluate the role of periodontal endoscopy in clinical decision-making for teeth with suspected vertical root fractures (SVRFs) and assessed its diagnostic accuracy for vertical root fractures (VRFs).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A prospective cohort of 115 SVRFs meeting inclusion criteria was analyzed. Teeth were independently evaluated by two endodontists and categorized into three pre-endoscopic treatment groups: flap surgery (S group, n=56), endodontic treatment (R group, n=48), and extraction (E group, n=11). Periodontal endoscopic examination was performed for all subjects, and treatment plans were reassigned based on findings. Definitive VRF diagnosis was confirmed by intraoperative crack identification or clinical failure within a 1-year follow-up. Three cases were excluded due to loss to follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Periodontal endoscopy reduced unnecessary nonsurgical treatment by 39.58% (19/48) and surgical treatment by 64.28% (36/56), while improving diagnostic accuracy by 49.1%. The sensitivity of periodontal endoscopy for VRF detection was 88.1%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Periodontal endoscopy enhances clinical decision-making and significantly reduces unnecessary nonsurgical and surgical interventions in SVRFs.\u003c/p\u003e","manuscriptTitle":"Role of periodontal endoscopy in clinical decision-making for teeth with suspected vertical root fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 12:17:45","doi":"10.21203/rs.3.rs-6535793/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-29T10:14:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-29T08:40:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-21T07:10:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-15T20:14:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99775651001040089125653915813096554537","date":"2025-05-13T20:34:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4795454418047541303743452125999294170","date":"2025-05-13T06:01:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83550089490337481081538863669978144717","date":"2025-05-13T02:51:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96006742599562776390459065123487383630","date":"2025-05-10T12:21:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223413747215961772476614785208525374647","date":"2025-05-10T04:48:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191094898794716312027062781840170622245","date":"2025-05-10T02:18:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315028460350400223734114922505844667702","date":"2025-05-08T16:11:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"71173699834503182370598721835151710592","date":"2025-05-08T04:11:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294015512105666136377168260585407167977","date":"2025-05-08T02:13:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-07T21:09:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-07T15:46:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-06T07:59:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-06T07:49:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-04-26T14:57:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a883a82b-cf73-4984-9fd9-767c129daa5f","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T16:04:59+00:00","versionOfRecord":{"articleIdentity":"rs-6535793","link":"https://doi.org/10.1186/s12903-025-07182-w","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2025-12-19 15:57:48","publishedOnDateReadable":"December 19th, 2025"},"versionCreatedAt":"2025-05-13 12:17:45","video":"","vorDoi":"10.1186/s12903-025-07182-w","vorDoiUrl":"https://doi.org/10.1186/s12903-025-07182-w","workflowStages":[]},"version":"v1","identity":"rs-6535793","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6535793","identity":"rs-6535793","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}