Background <p>Periodontitis is characterized by the inflammatory destruction of tooth-supporting alveolar bone. Dental magnetic resonance imaging (MRI) using dynamic contrast-enhanced perfusion can potentially detect vascular inflammatory responses. This study aims to assess the feasibility of perfusion dental MRI and characterize periodontal lesions with perfusion profiles.</p> Materials and methods <p>In this prospective study, 19 patients with severe periodontitis underwent pretreatment 3-T dental MRI with T2-weighted, high-resolution dynamic contrast-enhanced T1-weighted perfusion protocol, and contrast-enhanced T1-weighted fat-suppressed sequences as well as cone-beam computed tomography (CBCT). Periodontal bone lesions were segmented semiautomatically using a multistep threshold-based algorithm, guided by T1-weighted contrast enhancement, T2-weighted hyperintensity, as well as CBCT-based bone loss. Volumetric analyses and clinical data were compared with perfusion parameters.</p> Results <p>In all 95 assessed periodontal lesions, perfusion parameter elevations were significantly different when compared to normal distant bone (<i>p</i> &lt; 0.001 to 0.026). Moreover, structurally normal-appearing bone adjacent to T2-hyperintense/T1-contrast-enhancing signal alterations exhibited increased permeability (<i>p</i> = 0.036–006) but showed no significant change in blood flow (<i>p</i> = 0.270) compared to bone control areas. Lesions with bleeding showed higher vascular permeability and blood flow markers than lesions without bleeding (<i>p</i> = 0.004–0.006). Additionally, lesions with excessive edema and areas of bone loss exhibited significantly elevated permeability and blood flow parameters (<i>p</i> = 0.001–0.028).</p> Conclusion <p>Perfusion dental MRI for periodontal lesion assessment is feasible. Permeability/perfusion parameters elevations are related to clinical signs of inflammation and CBCT-based bone loss, with the potential for detecting early inflammatory responses.</p> Relevance statement <p>Perfusion dental MRI effectively characterizes periodontal disease by detecting inflammation-related vascular changes beyond structural imaging on CBCT and conventional MR, offering potential for improved diagnosis, monitoring, and treatment evaluation. Longitudinal studies are needed.</p> Key Points <p><UnorderedList Mark="Bullet"> <ItemContent> <p>Perfusion dental MRI detects increased blood flow and vascular permeability in periodontal lesions.</p> </ItemContent> <ItemContent> <p>Increased permeability in adjacent bone suggests early inflammatory changes before structural loss.</p> </ItemContent> <ItemContent> <p>Dental MRI perfusion metrics could aid early lesion detection and monitoring of periodontitis.</p> </ItemContent> </UnorderedList></p> Graphical Abstract <p></p>