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Evaluation of detailed features of the supporting bone is an important step in diagnosis and treatment planning for teeth with clinical attachment loss. Fractal analysis can be used as a method for evaluating the complexity of trabecular bone structures. The aim of this study was to evaluate the trabecular bone changes in periapical radiographs of patients with different stages of periodontitis using fractal analysis.Methods   This comparative cross-sectional study was performed on patients with and without clinical attachment loss in mandibular first molars. Teeth with clinical attachment loss were divided into mild, moderate, and severe periodontitis groups. Digital periapical radiographs were obtained from the mandibular first molars using the same exposure parameters. DICOM file of the radiographs was exported to ImageJ software for fractal analysis. Three regions of interest (ROIs) were considered in each radiograph: two proximal ROIs mesial and distal to the mandibular first molar and one apical ROI. Fractal dimension (FD) values were calculated using the fractal box counting approach. Statistical analysis was performed using the chi-square test, Mann–Whitney test, intraclass correlation coefficient, and ANOVA ( α  = 0.05).Results   FD values were significantly different between moderate and severe periodontitis and healthy periodontal bone ( P  < 0.05), except for the distal ROI for moderate periodontitis cases ( P =0.280). However, FD values of the supporting bone in periodontally healthy teeth and teeth with mild periodontitis did not show a statistically significant difference ( P  > 0.05).Conclusion   Fractal analysis is a useful tool for evaluation of bone alterations in moderate and severe periodontitis, but was not able to detect the most initial radiographic bone signs of mild periodontitis.

Application of Fractal Analysis in Detecting Trabecular Bone Changes in Periapical Radiograph of Patients with Periodontitis