# Pseudo-color enhancement of CBCT images as a diagnostic tool for radicular cysts and periapical granulomas: A clinical feasibility study

## TL;DR

This study shows that pseudo-color enhancement of cone-beam CT images can help distinguish between radicular cysts and periapical granulomas in a non-invasive and cost-effective way.

## Contribution

The paper introduces pseudo-color enhancement as a novel, non-invasive method for differentiating radicular cysts and granulomas using open-access CBCT software.

## Key findings

- Pseudo-color enhancement showed high intra- and inter-examiner reliability (0.965 and 0.930, respectively).
- A statistically significant difference (p = 0.002) was found between cysts and granulomas using the scoring system.
- All cystic lesions were categorized as score 2, while 29 out of 49 granulomas were score 1.

## Abstract

The aim of this work was to present a novel, non-invasive, and cost-effective technique to effectively distinguish between radicular cysts and periapical granulomas. This approach involves the application of pseudo-color enhancement to cone-beam CT imaging data, which has the potential to provide clinicians with valuable preliminary diagnostic information prior to more invasive investigative procedures.

The study involved a total of 57 cases, including both radicular cysts and periapical granulomas, with cone-beam CT scans obtained for each case. The DICOM data were imported into an open-access software (R2Gate), and a pseudo-color enhancement tool was then applied to visualize the color distribution patterns within each case. A scoring system was subsequently developed based on the observed color distribution characteristics. Two blind investigators independently assessed and classified each case according to their diagnostic findings. The statistical analysis involved the use of the independent t-test to compare the two groups with normal distributions, and the categorical data were represented as numbers and percentages. The significance level for the statistical findings was set at 5%.

The reliability of the intra-examiner reliability was evaluated and showed high agreement (0.965). With regard to the inter-examiner reliability, it revealed high agreement (0.930). A statistically significant difference (p = 0.002) was revealed between the two groups (cysts and granulomas) according to the scoring system. The results showed that all cystic lesions were categorized in score 2 while 29 of cases diagnosed granulomas histopathologically (out of 49) followed score 1.

Within the settings of this study, it was possible to distinguish between radicular cysts and periapical granulomas with the pseudo-color enhancement of cone-beam CT images.

To date, no studies have evaluated the validity of using pseudo-color enhancement, available in open-access cone-beam CT software, for differentiating between radicular cysts and periapical granulomas. This novel technique holds promise as a non-invasive and affordable approach to distinguish these two common periapical lesions.

The online version contains supplementary material available at 10.1007/s00784-025-06425-y.