Fractal Analysis and Artificial Intelligence for Radiographic Detection of Periodontal Bone Loss: A Systematic Review

<b>Background/Objectives</b>: Accurate diagnosis and staging of periodontitis rely on clinical measurements and radiographic assessment of alveolar bone loss. <b>Methods</b>: Studies published between 1 January 2020 and 31 October 2025 were searched in the Web of Science and PubMed databases in accordance with the PRISMA guidelines. Original research articles that evaluated periodontal pathology on radiographic images using fractal analysis and/or artificial intelligence approaches, with clearly defined methodologies, were included. Due to methodological heterogeneity, a quantitative meta-analysis was not performed, and the findings were summarized using a narrative synthesis approach. <b>Results</b>: Of 346 records, 80 studies (9 fractal, 71 AI) met the inclusion criteria. Fractal analysis studies predominantly calculated the fractal dimension on panoramic or periapical radiographs using the box-counting method. In artificial intelligence studies, the task types mainly comprised classification, segmentation, detection, and hybrid approaches (multi-stage models or models combining multiple tasks). Panoramic and intraoral radiographs were the predominant imaging modalities. Performance metrics were reported across wide ranges (sensitivity 0.23-1.00; accuracy 0.506-1.00; specificity 0.41-0.99; F1 score 0.15-0.99; AUC 0.75-0.99), and in some studies, these metrics were only partially reported. <b>Conclusions</b>: Fractal analysis and artificial intelligence approaches offer objective and reproducible assessment of periodontal bone loss; however, methodological and reporting heterogeneity limit comparability and generalizability. Standardization of ROI definitions, datasets, study designs, and performance reporting is needed to improve clinical applicability. Future research should also explore hybrid models that combine the quantitative microstructural insights of fractal analysis with the automated detection capabilities of artificial intelligence to enhance diagnostic precision.