Diagnostic accuracy of cone-beam computed tomography in detecting root perforations: a systematic review and meta analysis

Background and Rationale Endodontic root perforations represent a severe iatrogenic or pathological complication characterized by an unnatural communication between the aseptic root canal system and the highly vascularized periodontal apparatus. If not immediately diagnosed and repaired, these defects rapidly precipitate microbial colonization, localized inflammatory responses, and crestal bone loss, ultimately jeopardizing the survival of the tooth. While conventional two-dimensional (2D) periapical radiography is the standard frontline diagnostic tool, it is intrinsically constrained by anatomical superimposition, often rendering perforations on the buccal or lingual root surfaces imperceptible. Although Cone-Beam Computed Tomography (CBCT) has revolutionized three-dimensional maxillofacial imaging, its specific diagnostic test accuracy (DTA) for detecting root perforations remains inconsistently reported in the literature, particularly regarding the profound confounding variables of spatial resolution and beam-hardening artifacts caused by intracanal radiopacities. Purpose and Objectives The primary objective of this systematic review is to comprehensively aggregate, synthesize, and critically evaluate the diagnostic test accuracy (Sensitivity and Specificity) of CBCT specifically for the detection of endodontic root perforations. The secondary objectives are to determine how diagnostic accuracy is modulated by specific technical and clinical parameters, namely: The obturation status of the root canal system (evaluating the detrimental impact of photon starvation and beam-hardening artifacts caused by gutta-percha, heavy-metal sealers, and metallic posts). The spatial resolution of the CBCT scan (comparing high-resolution versus low-resolution voxel sizes). The anatomical localization of the defect (e.g., furcal, lateral, strip, or apical perforations). The comparative accuracy of CBCT against alternative diagnostic modalities, specifically Electronic Apex Locators (EALs) and digital periapical radiography. Methodological Scope To ensure strict statistical homogeneity, this review utilizes a specialized PIRD (Population, Index test, Reference standard, Diagnosis of interest) framework. The analysis will be strictly limited to primary diagnostic accuracy studies utilizing extracted permanent human teeth (in vitro and ex vivo laboratory models) validated by an absolute, independent physical reference standard (e.g., digital calipers or stereomicroscopy). Continuous linear measurement studies and animal models are explicitly excluded. The methodological quality and external applicability of the included literature will be independently appraised utilizing the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) framework. Expected Outcomes and Clinical Significance The anticipated outcome of this systematic review is the establishment of the first definitive, evidence-based clinical imaging guidelines for the detection of root perforations. This project is expected to demonstrate that while CBCT significantly outperforms 2D radiography in anatomical "blind spots," its application must be highly strategic. We anticipate the data will formulate the following clinical directives: For non-obturated teeth: Low-resolution CBCT is highly efficacious and should be utilized to strictly adhere to the ALARA (As Low As Reasonably Achievable) radiation dosimetry principle. For obturated teeth: The expected data will likely prove that CBCT accuracy is severely compromised by artifact scatter, necessitating either high-resolution scanning protocols to mitigate partial volume averaging, or a multimodal diagnostic approach prioritizing radiation-free Electronic Apex Locators (EALs) and eccentric multi-angle periapical radiography during active retreatment procedures.