BACKGROUND The purpose of this systematic review was to compare and quantify endodontic outcome using cone-beam computed tomographic (CBCT) imaging with intraoral periapical radiography. METHODS Two reviewers independently conducted a comprehensive literature search. The MEDLINE, Embase, Cochrane, and PubMed databases were searched. Additionally, bibliographies, gray literature of all relevant articles, and textbooks were manually searched. There was no disagreement between the 2 reviewers. RESULTS Six articles met the inclusion criteria with low to moderate risk of bias (good/fair quality). The certainty of evidence was moderate, indicating that the authors are moderately confident that the true effect lies close to that of the estimate of the effect as determined by Grading of Recommendations Assessment Development and Evaluation criteria. The odds ratio of CBCT imaging versus traditional imaging to detect a periapical lesion was 2.04 (95% confidence interval, 1.52-2.73). CONCLUSIONS Although intraoral radiographs are the imaging modality of choice, when 2-dimensional intraoral radiography is inconclusive, CBCT imaging was reported in this investigation to have twice the odds of detecting a periapical lesion than traditional periapical radiography in endodontic outcome studies.