Photon-counting detector vs. cone-beam CT in endodontics: a study of simulated endodontic conditions, treatments, and associated complications.

Objective To assess the diagnostic performance of photon-counting detector computed tomography (PCD-CT) and cone-beam computed tomography (CBCT) at dose-matched radiation levels (high, standard, and low) for detecting and evaluating simulated endodontic conditions, treatments, and associated complications.Methods Sixteen extracted third molars with eight endodontic tasks were imaged using PCD-CT and CBCT. Qualitative (image quality, artifact susceptibility, diagnostic interpretability) and quantitative (endodontic working length) parameters were assessed by two observers using a five-point Likert scale. Descriptive statistics and weighted kappa (κ) were used for data analysis.Results High- and standard-dose PCD-CT demonstrated superior image quality and anatomical visualization compared to CBCT (median 5, IQR 5-5; κ = 1.0; all p < 0.001). Low-dose PCD-CT remained diagnostically robust, outperforming CBCT, except in root canal visualization, where both performed similarly. Diagnostic accuracy of pathologies and complications was slightly higher with PCD-CT (80-88%) than with CBCT (75-88%). Endodontic working length measurements were consistently accurate across all protocols, with near-perfect inter-observer agreement (κ = 0.84-0.86, all p < 0.001).Conclusions PCD-CT demonstrated superior diagnostic performance over CBCT across multiple endodontic tasks, particularly at high and standard doses. Even at low doses, PCD-CT maintained robust accuracy and image quality, outperforming dose-matched CBCT in most parameters. Endodontic working length assessment was equally reliable across both modalities. Overall, PCD-CT offers diagnostic advantages over CBCT, particularly in challenging cases involving complex anatomy or high-density materials. Its effective performance at lower radiation levels emphasizes its clinical potential and supports broader implementation in dentomaxillofacial diagnostics.