Published reports of overlooked disease, missed/delayed diagnosis, and important findings that extend beyond the initial treatment area. Each entry identifies the examination, evidence, and reported outcome. Oral cancer cases may involve a clinical examination or biopsy; they do not all involve CBCT.
The interpretation of CBCT scans remains one of the most vexing problems for practitioners who take their own scans and is potentially among their greatest sources of liability. Truth is, dentists have two options: Interpret the images themselves or refer to a radiologist. Whoever reads the scan, however, is responsible for reading all of it, not just the anatomic region for which the scan was taken.
76 articles
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01Keating Jones Hughes; The Bulletin; Oregon Association of Defense Counsel
Legal case · Oral examination · Reported lawsuit and defense verdict
$27.9 million sought in Bend, Oregon tongue-cancer lawsuit
Bend teacher Christopher Shunk alleged that dental practices failed to investigate a worsening tongue sore before his cancer diagnosis. The reported November 2023 trial ended with a complete defense verdict, so the allegations should not be presented as established negligence.
Peter Tuenge and Trent Andreasen Obtain Defense Verdict in Dental Malpractice Lawsuit
Clinical examination / biopsy; no CBCT role established
Defense verdict on November 17, 2023; Deschutes County case 21CV49326.
The complaint describes allegations; the verdict is documented by defense counsel and a defense-association report.
02Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Missed or delayed · CBCT · Published case abstract
A spinal lesion was reported. The report was not fully read.
An implant-planning CBCT revealed a lesion in the second cervical vertebra of a 23-year-old patient. The treating provider did not fully read the radiology report. An inquiry from the radiologist brought the finding to the provider's attention, and the patient was notified. Further dental treatment was deferred pending a medical diagnosis.
Incidental radiolucent lesion in the cervical vertebrae
CBCT
The reported finding needed follow-up. The image had been interpreted. The abstract gives no final diagnosis, documented injury, or conclusion that the lesion was malignant.
03Imaging Science in Dentistry
Missed or delayed · Panoramic X-ray · Case report
Jaw cancer mistaken for a tooth infection
A man with jaw pain received an extraction and antibiotics for a presumed dental infection. His earlier panoramic image showed an ill-defined lesion and erosion of the mandibular border. About four months later, imaging showed destruction of the right mandibular ramus and an invasive mass. Biopsy confirmed primary intraosseous squamous cell carcinoma. The authors attribute the diagnostic delay to inadequate interpretation of the original radiograph.
Delayed diagnosis of a primary intraosseous squamous cell carcinoma: A case report
Panoramic X-ray
Aggressive bone changes. The initial image was interpreted as infection. Cancer was diagnosed after extensive local destruction. Subsequent treatment and survival were not reported.
04Journal of Taibah University Medical Sciences
Missed or delayed · Panoramic X-ray · Case report
Lymphoma overlooked across four dental clinics
A woman reported a month of visits to four dental clinics for facial swelling, with antibiotics and incision and drainage. The authors describe an earlier panoramic image that had not been carefully interpreted: bone destruction and a soft-tissue shadow without an associated decayed tooth or periodontal pocket. Fine-needle aspiration established non-Hodgkin lymphoma. Medical CT showed extensive facial disease involving the maxillary sinus and extending toward the orbit.
Delayed diagnosis in the maxillofacial region: Two case reports
Panoramic X-ray
Signs inconsistent with a routine infection. Lymphoma was diagnosed after repeated dental treatment. The article does not report the patient's later treatment or survival.
05Case Reports in Dentistry
Missed or delayed · CBCT · Peer-reviewed case report
A child's palatal tumor was missed clinically and found on CBCT
A 9-year-old girl had CBCT for orthodontic assessment. Palatal bone erosion prompted closer examination of a subtle swelling that the child, parents and initial clinical examination had not identified.
Incidental Cone Beam CT Finding of Juvenile Pleomorphic Adenoma
CBCT identified pressure erosion of the hard palate; biopsy established the salivary-gland diagnosis.
Pleomorphic adenoma was removed; no clinical recurrence was reported at 18 months.
The finding was a benign tumor, and the key CBCT clue was its effect on bone.
06American Journal of Case Reports
Missed or delayed · CBCT · Peer-reviewed case report
A presumed maxillary infection led to a multiple-myeloma diagnosis
A 65-year-old woman presented with maxillary expansion initially considered an infection. CBCT revealed widespread destructive bone lesions, prompting biopsy and hematology investigations that identified previously undiagnosed multiple myeloma.
Osteolytic Lesion of the Maxilla in an Undiagnosed Multiple Myeloma Patient Identified Incidentally by Cone Beam Computed Tomography
CBCT showed the bone lesions; pathology, laboratory testing and bone-marrow assessment confirmed myeloma.
The report describes chemotherapy, a period of remission and subsequent death.
The systemic diagnosis required multidisciplinary testing; CBCT alone did not establish myeloma.
07Journal of Endodontics
Missed or delayed · CBCT · Peer-reviewed case report
Lymphoma was treated first as periodontal and then endodontic disease
A 40-year-old woman's maxillary lesion was initially diagnosed and treated as periodontal disease and then endodontic disease. CBCT and three-dimensional analysis helped evaluate the lesion before surgical sampling established diffuse large B-cell lymphoma.
Non-Hodgkin Lymphoma Mimicking Endodontic Lesion: A Case Report with 3-dimensional Analysis, Segmentation, and Printing
CBCT characterized the lesion and supported three-dimensional planning; biopsy established the diagnosis.
Histopathologic and immunohistochemical examination identified lymphoma.
The accessible abstract does not establish a long-term survival outcome.
08International Journal of Clinical Pediatric Dentistry
Missed or delayed · CBCT · Peer-reviewed case report
A child's presumed facial cellulitis was Ewing sarcoma
A 12-year-old boy had rapidly progressing mandibular swelling initially considered facial cellulitis. Panoramic imaging and CBCT revealed destructive changes suggesting an aggressive bone tumor, leading to cancer-center referral and biopsy.
Ewing's Sarcoma of Mandible: A Case Report with Review of Literature
Panoramic radiography and CBCT exposed the bone lesion; MRI, staging tests and biopsy completed the workup.
Biopsy confirmed Ewing sarcoma; the child received specialist oncologic treatment.
CBCT suggested malignancy but could not distinguish Ewing sarcoma definitively from other aggressive lesions.
09Imaging Science in Dentistry
Missed or delayed · CBCT · Peer-reviewed two-case report
Limited dental scans did not show the key clues to sinus fungus balls
Two women seeking implant or tooth-pain care had sinus fungus balls. Panoramic films and limited-field CBCT did not adequately show the upper-sinus calcifications; subsequent paranasal sinus CT supplied the important diagnostic detail.
Characteristic features of fungus ball in the maxillary sinus and the location of intralesional calcifications on computed tomographic images: A report of 2 cases
Limited-field CBCT had incomplete sinus coverage; medical sinus CT revealed more characteristic findings.
The report documents additional imaging and diagnosis of sinus fungus balls.
This demonstrates a field-of-view limitation, not proof that larger scans should routinely be taken for every dental patient.
10BMJ Case Reports
Missed or delayed · CBCT · Peer-reviewed case report
A lesion treated as root caries was invasive cervical resorption
A cervical root lesion had initially been diagnosed and managed as caries. CBCT later identified invasive cervical resorption and mapped the defect for microsurgical retreatment.
Cone beam CT assisted re-treatment of class 3 invasive cervical resorption
CBCT clarified the type and extent of root destruction.
The lesion was surgically removed and restored; the authors report successful retreatment.
This is a dental hard-tissue diagnostic error rather than a missed systemic disease or cancer.
11Indian Journal of Otolaryngology and Head & Neck Surgery
Missed or delayed · CBCT · Published case report
A five-year-old's presumed dental abscess proved to be Ewing sarcoma
Facial swelling and fever were initially managed as a dental abscess. CBCT and MRI demonstrated an osteolytic tumor with bone erosion in the pterygopalatine region, and tissue assessment established Ewing sarcoma.
The Diagnosis and Management of a Ewing's Sarcoma of the Pterygopalatine fossa in a 5-year-old girl
CBCT; MRI; histology and immunohistochemistry
Further investigation replaced the abscess diagnosis with a malignant tumor diagnosis.
Published online in November 2024 and in the January 2025 issue. CBCT showed structural disease; definitive tumor identification required tissue evaluation.
12Journal of Prosthetic Dentistry
Missed or delayed · Oral examination · Published clinical case report
A denture sore that persisted for six months
A 65-year-old woman's ulcer persisted after new dentures were fitted and even after she stopped wearing them. Biopsy eventually identified invasive, poorly differentiated squamous cell carcinoma, about six months after her initial prosthodontic visit.
Oral squamous cell carcinoma misdiagnosed as a denture-related traumatic ulcer: A clinical report
Clinical examination / histopathology
Oral squamous cell carcinoma confirmed by biopsy.
Single case; does not show that dentures caused the cancer or that CBCT would have diagnosed it.
13Journal of Medical Case Reports
Missed or delayed · Dental imaging · Published three-patient case series
Three jaw complaints that proved to be oral cancer
Three patients referred with jaw pain, swelling, and other complaints had delayed diagnoses of oral squamous cell carcinoma. One had received mouthwash and antibiotics over six months before specialist evaluation; the series illustrates persistent symptoms requiring reassessment.
Three oral squamous cell carcinomas diagnosed and referred for oncologic care.
Small illustrative series; no CBCT detection benefit or general miss rate established.
14Annals of the Royal College of Surgeons of England
Missed or delayed · Dental imaging · Retrospective clinical case series
Twelve cancers diagnosed after initial dental treatment
This selected Melbourne series identified 12 patients who received dental treatment before cancer assessment. Extractions were common, the average interval to surgical assessment exceeded eight weeks, and all 12 had stage IV disease at diagnosis.
Delayed diagnosis of oral squamous cell carcinoma following dental treatment
Dental imaging / clinical assessment / biopsy
Extensive cancer treatment required in many of the selected patients.
Selected retrospective sample, not the cancer risk after extraction or proof that extraction caused progression.
15British Dental Journal
Missed or delayed · Panoramic X-ray · Retrospective cohort with illustrative case histories
Oral cancer mistaken for abscess, TMJ pain, or a nonhealing socket
Six clinical histories show how mouth cancer can be mistaken for dental infection, jaw-joint dysfunction, trauma, or delayed extraction healing. The authors identified referral delay or initial misdiagnosis in 35 of 246 patients reviewed by one multidisciplinary service.
Professional delays in referral of patients with mouth cancer: six case histories
Clinical assessment / panoramic radiography / medical imaging / biopsy
Variable advanced cancer presentations, including palliative care.
One service's retrospective cohort; does not establish a general dental diagnostic-error rate or CBCT screening benefit.
16British Dental Journal
Missed or delayed · Dental imaging · Published two-patient clinical report
Two oral lesions that failed to improve under dental care
Two patients underwent prolonged dental review before referral for oral squamous cell carcinoma. A persistent buccal lesion and rapidly progressing maxillary tooth mobility illustrate different warning patterns and different tumor behavior.
Both lesions diagnosed as cancer; the cases had contrasting clinical courses.
Does not show that all oral cancers progress at the same rate or that a particular scan could have prevented either outcome.
17International Endodontic Journal
Missed or delayed · Oral examination · Published case report
Nine months of dental treatment before lymphoma diagnosis
A 38-year-old woman with upper-jaw pain underwent extraction, root-canal treatment, and apical surgery. More extensive exploration finally identified non-Hodgkin lymphoma nine months after the initial presentation.
Non-Hodgkin lymphoma diagnosed after a prolonged dental-treatment pathway.
Abstract verified; no specific CBCT role established.
18Medicine
Missed or delayed · Medical imaging · Published clinical case report
Maxillary lymphoma initially treated as periodontal disease
A 67-year-old woman had persistent upper-jaw pain and swelling despite extractions and antibiotics. Contrast-enhanced CT demonstrated destructive maxillary disease, and biopsy with immunohistochemistry established diffuse large B-cell lymphoma.
Primary diffuse large B-cell lymphoma in the maxilla: A case report
Contrast-enhanced medical CT / biopsy
Chemotherapy and radiotherapy; alive at two-year follow-up.
The reported scan was medical CT. The discussion mentions CBCT, but the case should not be labeled a CBCT discovery.
19Journal of Oral and Maxillofacial Pathology
Missed or delayed · Oral examination · Published clinical case report
Recurrent gum growth proved to be lymphoma
A woman's mandibular gum mass was initially excised and treated as a pyogenic granuloma. It recurred and enlarged; tissue testing identified localized non-Hodgkin lymphoma.
Complete treatment response and new bone formation reported.
Single clinical mimic; no CBCT involvement reported.
20Dental Update
Missed or delayed · Oral examination · Published clinical case report
Oral cancer initially diagnosed as pericoronitis
This report describes oral squamous cell carcinoma initially mistaken for inflammation around an erupting tooth. It examines delayed recognition and the need to reassess the clinical diagnosis when the course is unexpected.
Accessible abstract verified; detailed patient course and imaging not independently inspected.
21Columbia Dental Review
Missed or delayed · Oral examination · University clinical case report
Anterior gum cancer treated repeatedly as periodontal disease
An 87-year-old woman without tobacco or alcohol history had an anterior gingival lesion managed as periodontal disease. The report describes repeated dental visits and nearly six months before the correct cancer diagnosis.
Misdiagnosis of Gingival Squamous Cell Carcinoma Presenting as a Periodontal Lesion of the Anterior Palate
Clinical examination / tissue diagnosis
Gingival squamous cell carcinoma diagnosed.
No CBCT benefit established; absence of common risk factors did not exclude cancer in this patient.
22Journal of Orofacial Pain
Missed or delayed · Oral examination · Clinical case report with literature review
Nasopharyngeal cancer presenting like a jaw-joint disorder
A clinical case and eight previously published patients illustrate nasopharyngeal cancer presenting with symptoms resembling temporomandibular disorders. Ear symptoms, facial pain, and limited opening can complicate the initial dental assessment.
Nasopharyngeal Carcinoma Mimicking a Temporomandibular Disorder: A Case Report
Clinical differential diagnosis; CBCT role not established
Nasopharyngeal carcinoma identified in the reported diagnostic pathway.
One original case plus previously published cases; do not count the literature cases as new independent articles.
23BMC Oral Health
Missed or delayed · Panoramic X-ray · Published clinical case report
Persistent toothache led to a nasopharyngeal cancer diagnosis
A 40-year-old woman had persistent symptoms despite periodontal treatment, extraction, and root-canal therapy. Later visual and hearing symptoms prompted further investigation; MRI and biopsy identified stage IVA nasopharyngeal carcinoma after a six-month diagnostic delay.
Nasopharyngeal carcinoma masquerading as refractory odontogenic pain: a case report
Panoramic radiography followed by MRI / biopsy
Chemoradiotherapy; well at five-year follow-up with mild hearing impairment.
The authors also document genuine dental indications for treatment; the lesson is reassessing persistent symptoms, not assuming every intervention was unnecessary.
24Case Reports in Dentistry
Missed or delayed · Panoramic X-ray · Published case report
A presumed dental abscess was aggressive mandibular osteosarcoma
A 19-year-old woman received antibiotics for a presumed dental abscess before referral. Jaw radiographs showed extensive destruction, and biopsy identified osteosarcoma.
Osteosarcoma of the Mandible Masquerading as a Dental Abscess: Report of a Case
Panoramic and lateral-oblique radiographs; biopsy; subsequent medical CT
The authors report death from rapidly progressive local disease before planned surgery.
A single unusually aggressive case; the report does not establish that the initial diagnostic delay caused the death. This is not a CBCT case.
25F1000Research
Missed or delayed · Panoramic X-ray · Published case report
A teenager's dental abscess diagnosis concealed stage IV Burkitt lymphoma
A 15-year-old girl's painful maxillary swelling was treated as endodontic disease. CT and oral biopsy revealed Burkitt lymphoma despite an initially unremarkable panoramic radiograph.
Case Report: Sporadic Burkitt lymphoma misdiagnosed as dental abscess in a 15-year-old girl
Panoramic radiograph; medical CT; oral biopsy; PET/CT
Stage IV disease was treated with rituximab and chemotherapy; the report describes complete remission.
A clinical and biopsy diagnosis with medical imaging, not evidence that a negative dental radiograph excludes lymphoma.
26Journal of Oral and Maxillofacial Pathology
Missed or delayed · Panoramic X-ray · Published case report
A socket that would not heal led to a multiple myeloma diagnosis
A 40-year-old man had persistent swelling and an unhealed socket after extraction for presumed cellulitis. Panoramic and CT imaging showed destructive mandibular disease; biopsy and further investigation identified multiple myeloma.
Multiple myeloma presenting as an unhealed extraction socket: Report of a case with brief review of literature
Panoramic radiograph; three-dimensional medical CT; biopsy and systemic workup
The oral presentation prompted diagnosis of an underlying plasma-cell malignancy.
The article reports CT without identifying it as CBCT. Imaging alone did not establish the diagnosis.
27Journal of Oral and Maxillofacial Pathology
Missed or delayed · Panoramic X-ray · Published case report
Persistent chin numbness after extraction revealed breast cancer metastasis
A woman previously treated for breast cancer developed lower-lip and chin numbness that did not improve after a molar extraction. A mandibular radiolucency, biopsy and bone scan revealed metastatic breast carcinoma.
Numb chin syndrome associated with metastatic invasive ductal carcinoma of breast
Panoramic radiograph; biopsy; bone scan
The patient was referred for palliative hormonal treatment and chemotherapy.
The case concerns a patient with prior breast cancer; chin numbness has multiple possible causes. No CBCT role is reported.
28International Journal of Clinical and Experimental Pathology
Missed or delayed · Dental imaging · Published case report
Progressive 'periodontitis' and tooth loss masked Langerhans cell histiocytosis
A 32-year-old woman was initially diagnosed with aggressive periodontitis and underwent multiple extractions as destruction progressed. Broader investigation and a tibial bone biopsy eventually established Langerhans cell histiocytosis.
Role of multidisciplinary approach in a case of Langerhans cell histiocytosis with initial periodontal manifestations
Dental and skeletal radiographs; tibial biopsy; immunohistochemistry and molecular testing
The diagnosis changed management after years of progressive dental destruction.
The diagnostic biopsy came from the tibia; a mandibular specimen was inconclusive. The report also describes missed follow-up, so it does not attribute the entire delay to one clinician.
29Journal of Periodontal & Implant Science
Missed or delayed · Dental imaging · Published two-case report
Gum swelling and apparent periodontal abscesses were signs of acute leukemia
Two patients presented with pronounced gingival enlargement. In one, an initial diagnosis of severe periodontitis and abscesses preceded blood testing and bone-marrow assessment that revealed acute myelomonocytic leukemia.
Clinical examination; dental imaging; complete blood count and bone-marrow testing
Both patients received hematologic treatment; the article reports remission.
The decisive evidence was hematologic, not CBCT. Gingival enlargement is nonspecific and must be interpreted with the wider clinical picture.
30Journal of Oral and Maxillofacial Pathology
Missed or delayed · Oral examination · Published case report
Persistent gingivitis was the first sign of granulomatosis with polyangiitis
A teenager's painful, bleeding gums persisted after scaling and root planing. The characteristic gingival appearance, biopsy and antibody testing supported a diagnosis of granulomatosis with polyangiitis.
Strawberry gingivitis – First sign of Wegener's granulomatosis
Clinical examination; gingival biopsy; serology
The report describes rapid improvement with medical treatment and stability at three months.
Panoramic imaging showed no underlying bony abnormality. This is a clinical and pathology lesson, not a CBCT detection claim.
31Journal of Medical Case Reports
Missed or delayed · Medical imaging · Published case report
Jaw numbness and headaches attributed to arteritis were lymphoma
A 57-year-old man with headache, double vision and jaw sensory symptoms was treated for presumed biopsy-negative giant cell arteritis. Further imaging showed bilateral trigeminal-cave infiltration, and histology confirmed diffuse large B-cell lymphoma.
Diffuse large B cell lymphoma involving Meckel's cave masquerading as biopsy-negative giant cell arteritis: a case report
MRI; PET/CT; biopsy
The diagnosis was revised to lymphoma; the article illustrates radiographic response after chemotherapy.
This is medical MRI/PET evidence involving skull-base soft tissues, not a dental CBCT case.
32Frontiers in Pain Research
Missed or delayed · Medical imaging · Published case report
Persistent toothache resolved only after heart surgery
A 76-year-old woman's tooth and gingival pain persisted despite dental extractions and treatment for atypical odontalgia. Later cardiac investigation identified severe coronary stenoses and a ventricular thrombus.
Case Report: A case of toothache of cardiac origin with a long-term clinical course
Clinical assessment; cardiac imaging and coronary angiography
The report states that toothache and chest discomfort resolved after cardiac surgery.
This was ischemic heart disease with intermittent chest symptoms, not a tooth-only screening diagnosis. Dental CBCT does not evaluate coronary arteries.
33AHRQ PSNet WebM&M
Missed or delayed · Medical imaging · Patient-safety case and expert commentary
A suspicious lung nodule remained in an unread final CT report
An emergency CT excluded aortic dissection, but the final report also described a suspicious lung nodule. That finding was not acted on, and lung adenocarcinoma was diagnosed after worsening symptoms months later.
Medical chest CT; final-report review; subsequent chest radiograph
Delayed diagnosis of primary lung adenocarcinoma.
An educational case, not an adjudicated malpractice finding. The lesson is communication and follow-up of the complete report; this is not dental CBCT.
34AHRQ PSNet WebM&M
Missed or delayed · Medical imaging · Patient-safety case and expert commentary
A lung mass on a shoulder X-ray went without follow-up
A radiologist noted a chest density on a postoperative shoulder film and recommended further imaging. The recommendation was not followed until a primary-care clinician found it months later; the mass was lung adenocarcinoma.
The Consequences of Miscommunication Regarding a Possible Artifact
Shoulder radiograph with incidental chest finding; medical CT-guided biopsy
The reported mass grew from 3.5 cm to 7 cm before resection; stage IIB cancer was treated surgically and with chemotherapy.
An educational case with a specific missed follow-up recommendation, not evidence about cancer screening by dental CBCT.
35AHRQ PSNet WebM&M
Missed or delayed · Medical imaging · Patient-safety case and expert commentary
Reassuring imaging and a stalled referral delayed a breast cancer diagnosis
A palpable breast mass received a probably-benign imaging assessment. After the mass grew, confusion over biopsy scheduling added further delay before invasive cancer was diagnosed.
Cancer involving axillary nodes and the spine was identified seven months after the initial presentation.
The source explicitly states that whether earlier diagnosis would have changed the outcome is unknown. This is not a dental or CBCT case.
36AHRQ PSNet WebM&M
Missed or delayed · Clinical workup · Patient-safety case and expert commentary
Repeated treatment for anemia left colon cancer undiagnosed
An older man repeatedly received iron and blood transfusions while a previous negative colonoscopy continued to reassure his clinician. Colon cancer was eventually found when he developed bowel obstruction.
The case reports surgical treatment and subsequent remission.
A lesson about reassessing persistent abnormalities despite earlier negative testing; no dental CBCT role.
37AHRQ PSNet WebM&M
Missed or delayed · Medical imaging · Patient-safety case and expert commentary
Worsening back pain was eventually traced to metastatic lung cancer
A woman with a heavy smoking history had progressive back pain attributed to common musculoskeletal causes and later depression. Emergency imaging a year after her first evaluation revealed a lung lesion and destructive skeletal disease.
Lung cancer with widespread metastases was diagnosed; the case reports subsequent hospice care.
The article discusses clinical reassessment, pain-related stigma and diagnostic delay. It does not establish that one earlier test would certainly have prevented the outcome.
38AHRQ PSNet WebM&M
Missed or delayed · Medical imaging · Patient-safety case and expert commentary
A preliminary 'normal' MRI missed an infant's intracranial bleed
A lethargic infant was discharged after a preliminary MRI interpretation. The attending radiologist's final review identified a small subdural hemorrhage, prompting recall and a broader safety evaluation.
Radiology Missed an Intracranial Bleed in a Lethargic Infant.
Ultrafast brain MRI; final specialist review; skeletal survey
The child returned for inpatient evaluation, and additional healing rib fractures were identified.
An educational case showing the importance of final interpretation and recall systems; no CBCT role.
39AHRQ PSNet WebM&M
Missed or delayed · Medical imaging · Patient-safety case and expert commentary
Repeated collapsed lungs preceded recognition of a rare cystic lung disease
A young woman had recurrent pneumothoraces, while CT findings were initially explained as blebs or mild emphysema. A subsequent specialist review recognized the pattern of lymphangioleiomyomatosis.
Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax
Medical chest CT; specialist review; biopsy
The case reports targeted treatment and no further pneumothorax recurrence at follow-up.
This is a medical chest-imaging case about recognizing the cause of recurrent disease; dental CBCT cannot assess the lungs.
40AHRQ PSNet WebM&M
Missed or delayed · Medical imaging · Patient-safety case and expert commentary
An unexplained pleural effusion preceded a missed pneumonia diagnosis
A febrile patient with chest pain and pleural effusion was discharged after CT excluded pulmonary embolism and showed no infiltrate. He returned three days later with worsening symptoms and pneumonia with parapneumonic effusion.
Chest radiograph; medical CT angiography; thoracentesis
He improved with antibiotics and inpatient care.
The case emphasizes that imaging is a snapshot and unresolved abnormalities need follow-up. It is not evidence that pneumonia was visible on the initial scan.
41Imaging Science in Dentistry
Incidental detection · CBCT · Case report
An implant scan reveals kidney-cancer spread in the sinus
A CBCT obtained for dental implant planning revealed an invasive mass in the sphenoid sinus of a 66-year-old woman previously treated for kidney cancer. She had no related symptoms. Further imaging and biopsy confirmed metastatic renal cell cancer. This report describes successful incidental detection and medical referral; it does not document an earlier missed diagnosis.
Incidental finding of metastatic malignancy involving the sphenoid sinus on a cone-beam computed tomographic scan: A case report
CBCT
Metastatic disease beyond the implant site. Medical evaluation confirmed the diagnosis. Subsequent cancer treatment and survival were not reported.
42Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics
Incidental detection · Panoramic X-ray · Case report
A dental X-ray prompts discovery of severe carotid narrowing
A panoramic dental image showed neck calcifications in an asymptomatic 75-year-old man. Follow-up ultrasound and angiography established severe right internal carotid artery narrowing, leading to vascular surgery. He was well at 12 months. The dental image prompted medical evaluation; calcification alone did not establish the diagnosis or degree of stenosis.
Carotid calcifications on panoramic radiography identify an asymptomatic male patient at risk for stroke: A case report
Panoramic X-ray
A reason for vascular assessment. Angiography confirmed 95% or greater narrowing. This historical case reports treatment and follow-up; it does not prove that a stroke was prevented.
A sinus CBCT revealed a giant internal carotid aneurysm
A 64-year-old woman underwent CBCT to investigate a radiopaque finding in her left maxillary sinus. The scan also revealed a giant internal carotid artery aneurysm in the right middle cranial fossa, leading to specialist management.
Unveiling incidental findings: A clinical review of a giant aneurysm detected by CBCT imaging
Dental CBCT detected the unexpected abnormality; vascular evaluation guided treatment.
The authors report successful endovascular treatment.
A single incidental case does not establish dental CBCT as an aneurysm screening test.
44Journal of the American Dental Association
Incidental detection · CBCT · Peer-reviewed case report
A salivary-gland scan uncovered an aggressive jaw tumor
A 45-year-old man was referred for CBCT sialography because of dry mouth. Review of the full scan found a mandibular lesion with cortical destruction and root resorption outside the salivary-gland focus.
Two dental patients had unexpected skull-base abnormalities on CBCT: a clival lesion in an orthodontic patient and an enlarged sella in an implant patient. MRI helped distinguish the possible diagnoses.
Incidental findings of skull-base abnormalities in cone-beam computed tomography scans with consultation by maxillofacial radiologists
CBCT raised the findings; MRI characterized them.
MRI favored a notochordal remnant in one patient and a partially empty sella without a pituitary mass in the other.
The clival diagnosis remained an imaging impression requiring follow-up; neither case proves cancer detection.
46Imaging Science in Dentistry
Incidental detection · CBCT · Peer-reviewed case report
An orthodontic CBCT found an unexpected lesion at the skull base
A 27-year-old man undergoing assessment for facial asymmetry had an incidental osteolytic clival lesion. The finding prompted neuroradiology consultation and MRI, although its precise nature remained unresolved.
Clival lesion incidentally discovered on cone-beam computed tomography: A case report and review of the literature
CBCT detected the osseous abnormality; MRI assessed its contents and surrounding tissues.
Further investigation was undertaken, but the patient was lost to follow-up.
No final diagnosis was established; this must not be presented as a confirmed skull-base tumor or cancer.
47Journal of the Belgian Society of Radiology
Pathology report · CBCT · Peer-reviewed case report
Atypical molar pain led to detection of high-grade lymphoma
A 47-year-old man was referred for atypical endodontic pain involving the upper molars. CBCT showed a poorly defined destructive area involving the posterior maxilla and sinus floor; a bone biopsy identified diffuse large B-cell lymphoma.
When Maxillofacial CBCT Permits Fortuitously to Diagnose Primary Non-Hodgkin’s Lymphoma: A Case Report
CBCT demonstrated aggressive bone destruction; histology established the lymphoma diagnosis.
The hematology team prescribed chemotherapy, including additional methotrexate.
This symptomatic case illustrates an abnormal imaging pattern, not a population screening benefit.
48BMC Oral Health
Pathology report · CBCT · Peer-reviewed case report
Poorly healing extraction sites were part of Langerhans cell histiocytosis
A 46-year-old man had multiple tooth extractions with delayed or incomplete healing and destructive lesions involving the jaws and skull base. CBCT clarified severe jawbone loss during a multidisciplinary investigation that ultimately diagnosed Langerhans cell histiocytosis.
Oral manifestation of Langerhans cell histiocytosis: a case report
CBCT mapped jaw destruction alongside PET/CT and MRI; a second biopsy established the diagnosis.
Chemotherapy produced clinical healing and imaging improvement; the report describes good condition at two years.
This was a complex systemic workup, not an incidental diagnosis made by CBCT alone.
49Oral Radiology
Pathology report · CBCT · Peer-reviewed case report
Six months of delayed care allowed extensive jaw destruction in a toddler
A toddler with facial swelling and abnormal jaw lesions had planned biopsy and treatment delayed during the COVID-19 outbreak. Serial CBCT examinations documented substantial progression over six months before tissue testing confirmed Langerhans cell histiocytosis.
Progressive destruction of jaws caused by the delayed treatment of Langerhans cell histiocytosis in a 2-year-old boy: A case report
Serial CBCT documented the change in bone destruction; biopsy and immunohistochemistry confirmed LCH.
The report describes improvement after 27 weeks of systemic treatment.
The documented delay was associated with pandemic disruption; it should not be described as proven clinician negligence.
50BMC Oral Health
Pathology report · CBCT · Peer-reviewed case report and literature review
Facial pain and numb maxillary teeth accompanied a rare sinus cancer
A 39-year-old woman presented with persistent facial pain and numbness around the upper anterior teeth. CBCT and spiral CT demonstrated a large destructive mass involving the maxillary sinus and nasal cavity.
Primary maxillary sinus carcinosarcoma with multidisciplinary management: a case report with 4 years follow-up and literature review
CBCT and medical CT showed the mass and bone destruction; the surgical specimen established carcinosarcoma.
Maxillectomy, chemotherapy and radiotherapy were followed by 39 months without evidence of disease in the reported follow-up.
This was evaluation of a symptomatic lesion, not a documented missed or incidental CBCT finding.
51Case Reports in Dentistry
Pathology report · CBCT · Peer-reviewed case report
A palatal salivary-gland cancer caused extensive bone destruction
A patient presenting with a maxillary soft-tissue growth had extensive destructive changes on CBCT, including involvement of the maxilla and sinus walls. The imaging raised concern for malignancy; tissue examination identified polymorphous adenocarcinoma.
Polymorphous Adenocarcinoma: A Rare Case Report with Unique Radiographic Appearance on CBCT
CBCT characterized bone involvement; histopathology identified the salivary-gland cancer.
The report describes maxillectomy and histopathologic diagnosis.
The role demonstrated is assessment of bone invasion, not reliable screening of soft-tissue salivary tumors.
52Imaging Science in Dentistry
Pathology report · CBCT · Peer-reviewed two-case report and literature review
Two dental patients had fungal disease in the maxillary sinus
Two middle-aged women were evaluated for maxillary sinus aspergilloma associated with dental treatment. The cases show how an abnormal sinus opacity can represent fungal disease and why imaging findings need clinical and histopathologic correlation.
The paper reports the patients' diagnostic and surgical management.
Similarity to other sinus disease can complicate diagnosis; CBCT appearance alone is not organism confirmation.
53Journal of the Korean Association of Oral and Maxillofacial Surgeons
Pathology report · CBCT · Peer-reviewed case report
A sinus finding on preoperative CBCT proved to be a fungal ball
An asymptomatic 37-year-old woman's preoperative CBCT showed changes resembling chronic sinusitis. During facial contouring surgery, a fungal ball was found in the maxillary sinus and removed; histology supported non-invasive aspergillosis.
Incidental discovery of a fungal ball during esthetic malar reduction surgery: a case report
CBCT showed mucosal thickening but did not specifically identify the fungal ball; surgery and histology clarified the finding.
The report describes postoperative recovery without recurrent sinus symptoms.
This is a case of nonspecific imaging and operative discovery, not a fungal diagnosis made by CBCT alone.
54Journal of International Society of Preventive & Community Dentistry
Pathology report · CBCT · Peer-reviewed case report
Rapid upper-jaw swelling revealed osteosarcoma
A 20-year-old man presented with rapidly growing painful swelling in the posterior maxilla. CBCT showed an aggressive lesion with a radiating bone pattern and extension through the maxillary sinus region; incisional biopsy confirmed osteosarcoma.
CBCT demonstrated destructive and bone-forming features; biopsy established osteosarcoma.
The report describes resection and reconstruction with a one-year disease-free follow-up.
This was assessment of an obvious symptomatic swelling, not an incidental or proven previously missed finding.
55Journal of Medical Case Reports
Pathology report · CBCT · Peer-reviewed case report
Jaw pain years after breast cancer proved to be mandibular metastasis
A 45-year-old woman developed jaw pain and swelling six years after treatment for breast cancer. CBCT formed part of the investigation of a destructive mandibular lesion; tissue testing established metastatic invasive ductal carcinoma.
Mandibular metastasis of invasive ductal carcinoma of the breast: a case report
CBCT characterized the jaw lesion; histology and immunohistochemistry confirmed its breast origin.
The authors report aggressive mandibular disease with a pathological fracture.
Her prior cancer history was central to the workup; the case is not evidence that CBCT independently identifies a distant primary cancer.
56Journal of Dentistry (Shiraz)
Pathology report · CBCT · Peer-reviewed case report
CBCT clarified a maxillary lesion that plain films could not fully define
A 28-year-old man had an anterior maxillary lesion with calcifications. Conventional radiographs showed the lesion but not its full extent or relationship to surrounding structures; CBCT improved characterization before removal and tissue diagnosis.
Cone Beam Computed Tomography Findings in Calcifying Cystic Odontogenic Tumor Associated with Odontome: A Case Report
CBCT defined extent and internal structure beyond the information available on plain radiographs.
Surgical removal and histology identified the lesion described by the authors as a calcifying cystic odontogenic tumor.
The article uses the diagnostic terminology of its publication period; it is not a malignant tumor case.
57Cureus
Pathology report · CBCT · Peer-reviewed case report
A destructive jaw lesion reflected an endocrine disorder
A 23-year-old woman with known parathyroid adenoma was referred for mandibular swelling. CBCT showed an expansile lesion with cortical destruction, interpreted alongside biochemical and tissue findings as a brown tumor associated with hyperparathyroidism.
Primary Hyperparathyroidism-Induced Brown Tumor of the Mandible: A Diagnostic Dilemma
CBCT characterized the jaw lesion; endocrine tests, clinical history and pathology supplied the cause.
Parathyroid surgery and jaw-lesion curettage were followed by biochemical and clinical improvement.
The endocrine disorder was known before dental referral; this is not a case of CBCT discovering previously unsuspected hyperparathyroidism.
58Imaging Science in Dentistry
Pathology report · CBCT · Peer-reviewed case report
An orthodontic evaluation identified a mastoid bone tumor
A 48-year-old woman seeking orthodontic treatment had a longstanding hard swelling behind the ear. CBCT was used to assess the mass and its attachment to the temporal bone, supporting the diagnosis of mastoid osteoma.
Mastoid osteoma: A rare incidental finding in an orthodontic patient
Clinical examination identified the swelling; CBCT characterized the bony mass.
The report documents imaging assessment and diagnosis of mastoid osteoma.
The mass was clinically visible and benign; it should not be described as a hidden cancer found solely on a scan.
59Oral and Maxillofacial Surgery Cases
Pathology report · CBCT · Published two-case report
Severe dental-looking disease concealed invasive fungal infection
Two patients developed marked tooth mobility and destructive maxillary disease after COVID-19 hospitalization and corticosteroid treatment. CBCT in one case showed extensive bone destruction; tissue examination identified mucormycosis.
CBCT in the first case; panoramic imaging; biopsy and fungal assessment
Both patients improved following specialist management and surgical debridement, with antifungal treatment used in the second case.
The report describes a particular clinical setting and does not quantify risk after COVID-19. CBCT depicted damage; microscopy established the fungal diagnosis.
60Cureus
Pathology report · Medical imaging · Published five-patient case series
Five late oral-cancer presentations with clinical and CT findings
Five patients from rural Tamil Nadu presented with varied forms of oral squamous cell carcinoma. Clinical photographs, contrast-enhanced CT, and biopsy illustrate the spectrum of late presentation, including a lateral-tongue lesion.
Dentist’s Delay or Dexterity to Diagnose the Deadly: A Clinico-radiological Series of Oral Malignancies Exhibiting Varied Presentations in the Tamil Nadu Rural Belt
Clinical examination / contrast-enhanced medical CT / biopsy
Five biopsy-confirmed oral squamous cell carcinomas.
Late presentation is not synonymous with a proven professional miss; these were medical CT examinations.
61Journal of the Irish Dental Association
Pathology report · Dental imaging · Published case report
One month of jaw pain was the first presentation of multiple myeloma
A 69-year-old woman presented to an oral surgery clinic with unilateral jaw pain and swelling. A 2 cm lytic mandibular lesion led to tissue sampling and systemic testing that confirmed multiple myeloma.
Plain radiographs; aspiration and biopsy; skeletal survey and laboratory testing
Dental assessment initiated the diagnosis of systemic malignancy.
This is a detection case, not a documented negligent miss; no CBCT role is reported in the abstract.
62Latest appellate order
Legal case · Oral examination · Court record
$11.46 million judgment after a persistent tongue lesion went uninvestigated
A Pennsylvania patient repeatedly sought care for a worsening tongue lesion. The appellate record describes more than six visits without cancer screening, biopsy, specialist referral, or scheduled follow-up. An oral surgeon later recognized the lesion as potentially malignant; biopsy confirmed squamous cell carcinoma. Heffelfinger v. Shen concerns the response to a visible oral lesion, not a missed finding on CBCT.
Heffelfinger v. Shen: Superior Court opinion and Supreme Court appeal order
Oral examination
Judgment upheld. The Superior Court affirmed $11,459,513.69 in July 2025. The Pennsylvania Supreme Court denied permission to appeal in February 2026.
63Dental Protection
Legal case · CBCT · Anonymized dentolegal case account
Tongue tumor overlooked during CBCT reporting
A dentolegal account describes a patient investigated with CBCT for jaw-joint symptoms whose tongue tumor was later considered inoperable. Dental Protection reports that the developing lesion had been missed on the first scan; the regulator dismissed the complaint against the referring oral surgeon.
The source calls the lesion a cancerous neuroma but supplies no histology or images; it does not establish CBCT as a general tongue-cancer screening test.
64Undated reportKassel McVey
Legal case · Oral examination · Plaintiff counsel's verdict report
$2 million verdict after tongue cancer was attributed to tooth trauma
The patient's lawyers report that an oral surgeon attributed a tongue lesion to tooth trauma. A biopsy seven months later identified stage III squamous cell carcinoma. The jury awarded $2 million, reduced to $1.2 million because of comparative fault.
Reported $2 million verdict; $1.2 million recovery after 40% comparative fault.
Undated account from the patient's law firm; not independently retrieved court findings or evidence of CBCT detectability.
65MLMIC
Legal case · Medical imaging · Insurer case study and settlement account
$1.75 million settlement after delayed tongue-cancer diagnosis and missing photographs
A 36-year-old patient was asked to return in six months after a tongue lesion was photographed. The later biopsy showed stage II squamous cell carcinoma, and the original photographs could not be recovered. The insurer reports a $1.75 million settlement.
Clinical photography / biopsy; subsequent medical CT
$1.75 million settlement; remission reported after treatment.
Settlement is not a trial finding; the article concerns clinical follow-up and records, not CBCT cancer detection.
66Virginia Dental Association
Legal case · Medical imaging · Professional association's dentolegal case review
Presumed lichen planus followed by stage IV tongue cancer
A case review describes a 46-year-old woman whose tongue sore was initially considered lichen planus. Subsequent encounters did not resolve the concern, and medical CT later showed a mass with nodal involvement. The reported lawsuit ended in a defense verdict.
Dentist Misjudges Patient’s Tongue Lesion, Resulting in Missed Oral Cancer Diagnosis
Clinical examination / medical CT
Stage IV tongue squamous cell carcinoma; defense verdict.
The author's risk-management criticism is distinct from the jury's finding; no CBCT role reported.
67Illinois Appellate Court
Legal case · Oral examination · Official appellate court order
Tongue lesion, cheek biopsy, and a new trial on appeal
Georgie Anne Geyer alleged delayed diagnosis after a persistent tongue lesion and a biopsy taken from her cheek. The appellate court set aside the defense result and ordered a new trial because prejudicial evidence denied a fair trial.
2015 remand for a new trial after the initial defense verdict.
The appellate ruling addressed trial fairness, not a final determination of malpractice; subsequent disposition not established here.
68MLMIC · The Scope
Legal case · Oral examination · Insurer claim report
$1.15 million settlement after delayed referral of changing oral lesions
MLMIC describes a patient with longstanding lichen planus whose changing lesions and delayed specialist referral preceded an oral squamous-cell carcinoma diagnosis. Surgery removed five teeth.
An Analysis of Misdiagnosis in Dental Claims Involving Oral Cancer — Case 1
Clinical examination and biopsy; no CBCT reported.
Settled before trial.
Anonymous case; distinct from the lichen-planus defense-verdict article.
69MLMIC · The Scope
Legal case · Oral examination · Insurer claim report
$275,000 settlement after delayed diagnosis of cancer near an extraction site
A 53-year-old woman with prior Hodgkin lymphoma developed stage III oral cancer near tooth #19. MLMIC identifies gaps in screening documentation and investigation of the lesion.
An Analysis of Misdiagnosis in Dental Claims Involving Oral Cancer — Case 2
Clinical examination and biopsy; no CBCT reported.
The patient later died from an unrelated cardiac event.
Anonymous case.
70Undated insurer reportEastern Dentists Insurance Company
Legal case · Oral examination · Insurer claim report
$300,000 settlement after a presumed canker sore proved to be tongue cancer
EDIC describes a tongue sore assessed as a canker sore, with instructions to return if it persisted. The patient did not return for reassessment, was later diagnosed with tongue cancer, and died. His estate alleged delayed diagnosis and wrongful death.
More than $200,000 in defense costs for an alleged missed jaw lesion
A patient alleged that a dentist missed a jaw lesion on earlier radiographs. Later bone destruction prompted referral, CBCT, biopsy, and partial jaw removal. CNA reports a defense win after experts supported the referral timing and disputed whether the lesion was malignant.
CNA Dental Professional Liability 2016 Claim Report — Successful Defense of a Dentist
Periapical radiographs followed by CBCT and biopsy. The alleged miss concerned earlier radiographs, not a proven CBCT interpretation error.
The court ruled for the dentist. The claimant sought an unspecified amount in the mid-six figures.
The initial pathology was consistent with fibrosarcoma, but defense specialists disputed malignancy. The article does not establish confirmed cancer or a plaintiff award.
72Robins Kaplan
Legal case · Oral examination / biopsy · Plaintiff-counsel account
$1.7 million settlement after repeated tongue-lesion referrals and delayed biopsy
The patient’s law firm describes repeated referrals for a tongue lesion over nearly four years before a biopsy identified squamous-cell carcinoma. Advanced disease required extensive head-and-neck surgery, radiation, and chemotherapy. The firm reports a mediated settlement from all defendants.
$1.48 million verdict before fault reduction in delayed tongue-cancer case
In Jager v. Flynn, the patient’s estate alleged that an oral surgeon failed to biopsy a persistent tongue lesion or ensure that it resolved. An Ingham County, Michigan jury returned a $1,476,031 verdict and assigned 40% fault to the patient.
Jager v. Flynn — Estate: Cancerous lesion not timely diagnosed
Clinical lesion assessment and biopsy; no CBCT is described.
The jury assigned 60% fault to the defendant. Counsel told the publication that a pretrial agreement setting minimum and maximum payments resolved the case.
Ingham County Circuit Court, 14-577-NH. The agreement’s limits and final payment are not disclosed; the gross verdict is not a confirmed recovery.
74RWK Goodman · Dental Negligence Team
Legal case · Dental X-ray / biopsy · Claimant-solicitor account
£142,674.20 settlement after delayed investigation of jaw cancer
The patient’s solicitors describe persistent jaw pain after an extraction, followed months later by an X-ray showing a suspicious mandibular lesion and an unhealed socket. Biopsies confirmed cancer. The patient died in 2018; her estate’s claim settled in January 2023.
Delayed dental radiography and subsequent biopsy; the source does not identify CBCT.
The solicitors report a £142,674.20 settlement after proceedings were issued.
The combined claim also concerned restorative treatment and periodontal disease. No cancer-only allocation is given. The currency is British pounds.
75MLMIC
Legal case · Mammography · Insurer claim report
$1.85 million settlement after an abnormal mammogram went without follow-up
A mammogram identified a developing nodule and recommended additional imaging. MLMIC describes failures to notify the patient, communicate with her physicians, and follow up on the report. The 53-year-old patient was subsequently diagnosed with stage IV breast cancer.
$675,000 settlement after a possible lung mass was not communicated
An emergency physician treated a 58-year-old woman for pneumonia. A radiologist later identified a chest-X-ray density that could represent a tumor but did not alert the patient or emergency department. Subsequent investigation found lung cancer, with additional follow-up delays before treatment.
Lack of Communication Between Treating Physicians is a Serious Detriment to Patient Care — Case 2
Chest radiography, later CT and PET; no dental CBCT.
The insurer reports settlement of the delayed-diagnosis lawsuit.
This anonymous insurer case is separate from the AHRQ lung-imaging cases elsewhere in the library.
Selected cases do not measure disease frequency or establish a reason to scan every patient. Dates refer to publications or the cited legal event; later developments may exist. Research updated October 21, 2026.
Clinical case reports, patient-safety analyses, court records, and firsthand claim accounts provide different kinds of evidence. Allegations, settlements, plaintiff judgments, and defense verdicts are labeled in their entries. A settlement is not a finding of negligence. A published clinical report does not establish legal liability.
The CBCT filter includes reports in which CBCT contributed to the assessment; it does not mean CBCT established the final diagnosis or that every case was an incidental discovery. Tissue diagnosis and medical imaging are identified where relevant. Source titles and direct links are available beside every summary.
