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This in vivo study assessed whether there was a difference between periapical radiographs (PRs) and cone-beam computed tomographic (CBCT) imaging in the detection, assessment, and management of external cervical resorption (ECR). The secondary aim was to determine if parallax radiographs were of any further benefit compared with a single PR.PR and CBCT data were gathered for 115 teeth (98 patients) consecutively diagnosed with ECR. The diagnosis and treatment plan of each tooth were determined with PRs and CBCT imaging. Sensitivity, specificity, positive predictive values, negative predictive values, and receiver operator characteristic values were determined.The overall sensitivity (0.86) and specificity (0.89) of PRs was significantly lower than CBCT imaging (P < .001). PRs had a limited ability to accurately detect the size (0.75), circumferential spread (0.60), and location of ECR compared with CBCT imaging (P < .001). PRs also underestimated the size of the ECR lesion. Significant differences (P < .001) were apparent in the treatment plans formed when PRs were assessed versus CBCT imaging. Parallax radiographs were shown to be of no additional benefit compared with a single radiograph.PRs have significant limitations in the detection, assessment, and treatment planning of ECR when compared with CBCT imaging. A CBCT scan should be considered before the management of a potentially restorable ECR lesion.