Prevalence of Hypercementosis in Radiographic Studies: A Systematic Review and Meta-Analysis With Clinical...

Hypercementosis is a non-neoplastic condition characterized by excessive cementum deposition along the root surface, resulting in altered apical morphology. Although often asymptomatic and detected incidentally on radiographs, changes in apical contour may influence anatomical complexity in endodontic treatment.

To estimate the pooled prevalence of hypercementosis based on radiographic observational studies and to explore variability according to imaging modality and study characteristics while contextualizing potential implications for endodontic case complexity assessment. Furthermore, this study proposes a standardized framework for radiographic diagnosis to mitigate current methodological heterogeneity and enhance the clinical assessment of anatomical complexity in endodontic practice.

A systematic review and meta-analysis were conducted following PRISMA 2020 guidelines and were registered in PROSPERO (CRD420251270539). PubMed/MEDLINE, Scopus, Web of Science and Embase were searched up to November 2025 without year restrictions; studies in any language were eligible, provided that an English abstract was available for screening. Cross-sectional radiographic studies reporting the prevalence of hypercementosis in humans using periapical radiographs, panoramic radiographs or cone-beam computed tomography (CBCT) were included. Pooled prevalence estimates were calculated at the patient and tooth levels using a DerSimonian-Laird random-effects model with logit transformation. Risk of bias was assessed using an adapted Newcastle-Ottawa Scale, and the certainty of evidence was appraised using the GRADE approach.

Ten observational studies (14 881 participants) were included. At the patient level, the pooled prevalence of hypercementosis was 3.9% (95% CI: 2.0%-7.3%), with very high heterogeneity (I² = 98%). Tooth-level meta-analysis, based on three studies evaluating 52 666 teeth, showed a pooled prevalence of 0.25% (95% CI: 0.06%-1%), also with substantial heterogeneity (I² = 98%). Variability across studies was influenced by imaging modality, sampling strategies and diagnostic thresholds.

Hypercementosis is uncommon at the tooth level but present in a clinically relevant proportion of patients. However, extreme heterogeneity and very low certainty of evidence limit the precision of prevalence estimates. Standardized diagnostic criteria and harmonized imaging protocols are needed to improve reproducibility. Within contemporary CBCT-based prognostic frameworks, hypercementosis may be considered a potential modifier of anatomical complexity, warranting further outcome-oriented investigation.