Cone Beam Computed Tomography in Periodontics: A Critical Narrative Review of Diagnostic Accuracy, Clinical Utility and the Persistent Gap Between Image Quality and Patient Benefit

Abstract

Cone beam computed tomography has become widely available in periodontal practice, yet its role remains contested. Two-dimensional radiography systematically misrepresents the three-dimensional architecture of periodontal osseous destruction, and volumetric imaging offers an obvious conceptual remedy. Whether that anatomical gain translates into better decisions, better treatment or better outcomes for patients is a separate question that the field has answered far less convincingly. This critical narrative review examines the evidence on cone beam computed tomography in the diagnosis, treatment planning and outcome assessment of periodontitis and peri-implant disease. Literature was identified through searches of PubMed/MEDLINE, Crossref Metadata Search and the Directory of Open Access Journals, supplemented by general web searching, related-record retrieval and examination of reference lists in recent reviews, with a final search date of 9 June 2026. Sources were appraised for design appropriateness, reference-standard quality, spectrum representativeness, observer procedures and external validity, and were synthesised thematically around the hierarchical model of diagnostic efficacy. The evidence is strong and internally consistent at the level of technical and diagnostic accuracy, particularly for furcation involvement, buccal and lingual defects and cortical plate integrity, where planar imaging fails outright. Evidence weakens sharply at the levels of diagnostic thinking and therapeutic efficacy, and is close to absent at the level of patient outcome. Peri-implant imaging is dominated by beam-hardening and streak artefacts, and accuracy estimates in that domain diverge more widely than in dentate applications. Acquisition parameters, defect morphology, cortical thickness and observer experience act as effect modifiers that are inconsistently reported and rarely analysed. The dominant methodological weaknesses are reliance on ex vivo models, small and highly selected samples, absence of blinded prospective designs and near-total neglect of patient-reported and health-economic endpoints. Priority should shift from further accuracy studies towards prospective trials in which imaging strategy is the randomised exposure and tooth or implant survival, defect resolution and radiation burden are the measured outcomes. Automated segmentation may make volumetric periodontal assessment routine, which increases rather than reduces the need for evidence of clinical benefit.