Objective: approximately 6.3% of adult teeth have apical periodontitis; the commonest kinds of periapical lesions are cyst and abscess (55-6%) and granuloma (46-84%). This systematic review and meta-analysis evaluated the accuracy of the diagnostic test of ultrasound imaging for endodontic. Methods: Using the electronic databases, we searched Cochrane Library, PubMed, and Embase for performing a systematic review of literature during the last decade from February 2011 to May 2021. Then, we employed the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool to assess the quality of the obtained investigations included in the present meta-analysis. In order to extract the required data, two reviewers blindly and individually dealt with the data extraction from the respective abstracts and full-texts of investigations. Diagnostic odds ratio, positive and negative likelihood ratio with a confidence interval (CI) of 95%, random-effects model, and REML method have been computed. Moreover, we assessed Meta-analysis using a statistical software called Stata/MP 16, the fastest version of Stata. Results: Totally, 94 topics and abstracts with potential relevance have been obtained in the electronic searches and eight studies required for this systematic review. Specificity and Sensitivity of ultrasonography for diagnosing the periapical granulomas equaled 92% (ES,0.92 95% CI 0.77,1.07) and 89% (ES,0.89 95% CI 0.74,1.04) and specificity and Sensitivity of ultrasonography for diagnosing periapical cyst equaled 92% (ES,0.92 95% CI 0.77,1.07) and 98% (ES,0.92 95% CI 0.83,1.13). Conclusion: Ultrasonography can be one of the alternative tools for differential diagnosis of periapical lesions (cysts and granulomas) with an endodontic origin.