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A comparison of panoramic and intraoral radiographic surveys in evaluating a dental clinic population
comparison of panoramic and intraoral radiographic surveys in evaluating a dental clinic population A. H. Muhammed, B.D.S., MS.,” and L. R. Manson-Hing. Baghdad, Iraq, and Birmingham, Ala.
D.M.D., MS.,**
The effectiveness of radiographic surveys in detecting basic radiographic signs for the initial examination of patients in a specific dental clinic population was investigated. A sample of 300 patients showed that panoramic periapical and bitewing radiographs are all needed for a complete radiographic evaluation. Panoramic plus bitewings and periapical plus bitewings were the next most effective surveys with either survey being less effective than the other for some radiographic signs.
T he use of x-rays for diagnostic purposes has been well established since the discovery of the rays. Although warnings about radiation hazards and suggestions for radiation protection appear in the dental literature as early as 1914, the general awareness of the need for radiation hygiene is relatively recent. As a result of this awareness, steps have been taken to reduce the amount of radiation resulting from dental radiography. These measures include improved x-ray machines, the use of faster film and screens, and proper selection of radiographic technique. Patients in dental school clinics have been examined radiographically with panoramic, periapical, bitewing, or a combination of the three radiographic surveys.] Panoramic radiographs utilize intensifying screens and require less radiation but they have the disadvantage of having less definition and detail than conventional intraoral periapical and bitewing radiographs.2-4 Depending upon the information desired, one radiographic survey may be preferred or all methods may be employed. This study was designed to determine the method of radiographic examination most effective for the detection of interproximal caries and bone changes in the initial examination of patients in a dental school clinic patient population. *Department of Dental Radiology, School of Dentistry. **Department of Dental Radiology, School of Dentistry, University of Alabama.
MATERIALS
AND METHODS
A Panorex panoramic machine* was used in this study. The film used was 5 by 12 inch DuPont Cronex 2 DC. Kilovoltage peak was varied according to the size of the patient in order to maintain an average radiographic density. Intraoral radiographs were made with a General Electric 1000,t an S. S. White Flexomatic 90,* or a Ritter Explorer 90$ machine using 65 kVp and 10 mA with the exposure time varied to maintain average film density. The intraoral films were double-packet Kodak ultraspeed dental x-ray film. One film was placed in the patient’s chart and the duplicate used for this study. Patients were selected after they had been examined in the oral diagnosis clinic and complete-mouth radiographs had been prescribed. Edentulous patients and patients with facial swellings or a recent history of trauma were excluded from the study. Each patient was radiographed for a completemouth periapical intraoral survey, a set of intraoral bitewings, and one panoramic radiograph. Intraoral radiographic surveys were made by dental students or technicians in accordance with the present clinic policy. Panoramic radiographs were made by the investigators. Panoramic radiographs are normally *Pennwalt S. S. White, Philadelphia, Pa. 19102. Kieneral Electric Medical Systems Division, Milwaukee, 53201, $Ritter Company. Rochester, N. Y. 14603.
Wis.
Comparison of panoramic and intraoral
Fig. 1. The three radiographic surveys. Above, Periapical survey. Below, Panoramic survey.
made by technicians or the investigators in the clinic. Radiographic surveys are illustrated in Fig. 1. Films were processed in a standard, light-tight darkroom equipped with safelights using Morlite 2 and Wratten 6B filters. A Litton automatic processor was used to process all films. Three hundred patients in the school clinic population were examined. Two age groups were used to separate adult patients from patients with erupting teeth: 21 years of age or greater and 20 years of age or less. An attempt was made to obtain equal numbers for each group. Three sets of radiographs were prepared for study: a set of panoramic radiographs, a set of bitewings, and a set of intraoral periapical radiographs. Radiographic surveys in each set of radiographs were numbered and randomized for viewing.
radiographic
surveys
109
complete mouth survey. Middle, Bitewing
Radiographs were viewed under standardized conditions using a uniformly illuminated viewbox masked to obtain an illuminated area the same size as the radiograph to be read. All light in the room was eliminated except the viewbox and a small lamp at a distance of six feet behind the observer. The dim light from the small lamp allowed vision of the numbers on the data sheet. Two dentists independently interpreted each radiographic survey. All radiographic surveys were randomized for each observer in different orders. Sample radiographs depicting typical pathologic conditions were shown to each observer prior to his reading the experimental radiographs. The experimental radiographs were examined for proximal caries, periapical changes, and periodontal bone changes, and other bone alterations, such as foreign
I IO
Muhammed and Manson-Hing Radiograph
Interpreter’s
Date ~
number
I. -- lnterproximal caries - Indicate location 2. -- Periapical Lesion - Shade in lesion.
3. -- Periodontal
Name
in pencil. ‘Z?t,
Bone
l9!!Eb
FURCATION INVOLVEMENT Shade in
HORIZONTAL BONE LOSS Draw level of crest
VERTICAL BONE LOSS Shade in
Avg. % Bone Loss -0
-25 -50 -75 -100 4. -- Other
Draw and locate
changes
on chart
or list if outside
of teeth
area
RECORD -l
Right
Average
32 131 Other
periodontal
bone
]30]29/261271261
changes,
structures
25 124123
2.
Form
used by
]22/21120119116]
Left
17
or lesions
Submandibular salivary gland Foreign body (nose orbit) MUCOUS retention phenomenon Calcified stylohyoid ligament Osteosclerosis Impacted teeth and unerupted
Fig.
loss 0, 25, 50, 75, 100%
defect in maxillary
antrum
Osteoma Ectopic calcification Lymph node calcification
Other: teeth
readers
bodies, root apices, cysts, etc. Data were collected on forms, a sample of which is shown in Fig. 2. The number of interproximal carious lesions in the anterior and posterior segments was totaled for each patient for each radiographic survey. The anterior segment consisted of incisor and cuspid teeth and included the distal surfaces of the cuspid teeth. The number of periapical lesions in the anterior and posterior segments was collated. The level of periodontal bone support was recorded, with the cementoenamel junction and the root apex serving as reference points. The average degree of bone resorption was graded as 0, 25, 50, or 100 percent. Other changes, structures, or lesions of diagnostic interest were recorded. The Student t test was used to test for statistically significant differences between the amount of evidence of pathologic changes observed in the three types of radiographic surveys. The level of significance was set at the 5 percent level for all tests of significance. In addition to comparing the evidence
to record radiographic observations of pathologic changes detected by each type of survey, data from periapical surveys and bitewing surveys were combined and compared with data from panoramic surveys. Also, data from periapical surveys were combined with data from bitewing surveys and compared with the combined data from panoramic surveys and bitewing surveys. RESULTS
There were 300 patients in the sample. The number of male and female patients with and without pathologic findings detected by radiographic survey was collated. No statistically significant differences were observed between surveys when the Student t test was applied. Data about interproximal caries detected by radiographic survey and location for the two observers are presented in Table I. Periapical radiolucencies detected by radiographic surveys and their locations as interpreted by two observers are shown in Table II. The number of patients with alveolar bone loss according to type of
Volume
Comparison of panoramic and intraoral
5-t
Number
radiographic
I. Mean number of interpoximal for two observers
carious lesions detected by radiographic
Table
III
survey and location
Observer No. I
Periapical Bitt-wing Panoramic Perinpical Panoramic
Observer No. 2
Anterior caries
Sumer I 2. 3. 4. 5.
surveys
I
2.69 0.00 1 .OO 2.69 I.01
plus bite-wing plus bite-wing
Posterior caries
k 3.39
0.70 1.25 0.44 1.38 1.32
f 2.09 k 3.39 + 2.08
Table II. Periapical radiolucencies detected by radiographic two observers
Survq,
I
k + -t k i-
:
Anterior caries
1.20 1.80 0.85 1.84 1.79
2.63 0.00 1.03 2.64 1.05
t
3.34
i i t
2.13 3.36 2.16
Posterior caries 0.79 I.22 0.57 1.39 1.32
2 + t i k
1.29 1.74 0.98 1.78 1.76
surveys and their location as interpreted by
Posterior
1
Anrerior
Ma’y
Po/l(rjr-1
Toral
Observer No. I I. 2. 3. 4. 5.
Periapical Bitewing Panoramic Periapical Panoramic
plus bitweing plus bitewing
21 0 I7 21 17
14 0 21 I4 21
I3 0 8 I3 8
IO 0 8 IO 8
54 58 54
II 0 9 II 9
I2 0 IO I2 IO
57 0 54 57 55
5x 0
Observer No. 2 I. 2. 3. 4. 5.
Periapical Bitewing Panoramic Periapical Panoramic
plus bitewing plus bitewing
21 0 15 21 I5
13 0 20 I3 21
Ill. Number of patients with alveolar bone loss according to type of bone loss and the types of radiographic surveys
Table
Survey
Horizontal
Verlical
Furcation
1
Toral
Observer No. 1 I. 2. 3. 4. 5.
Periapical Bitewing Panoramic Pcriapical Panoramic
I. 2. 3. 4. 5.
Periapical Bitewing Panoramic Periapical Panoramic
plus bitewing plus bitewing
206 247 222 259 265
plus bitewing plus bitewing
213 250 221 264 266
I8 21 IO 27 31
7 3 2 8 4
231 271 234 294 300
I4 21 II 26 32
6 3 3 7 5
733 274 235 298 303
Observer No. 2
bone loss and the types of radiographic surveys is shown in Table III. The number and sex of patients with alveolar bone loss and the degree of alveolar bone loss detected by radiographic surveys as interpreted by two observers are shown in Table IV. Data concerning impacted and unerupted teeth detected by radiographic surveys and their locations as interpreted by two observers are shown in Table V.
The number of teeth with periodontal membrane changes as detected by radiographic surveys and their locations as interpreted by two observers are shown in Table VI. The bitewing survey does not properly depict periodontal membrane change; therefore periapical plus bitewing and panoramic plus bitewing surveys detect the same periodontal membrane changes as periapical and panoramic
I 12 Muhammed
and Munson-Hing
Oral Surg. .lUlj. 19x2
Table IV. Number and sex of patients with alveolar bone loss and the average degree of bone loss detected by radiographic surveys
I ~~
;~------
Survq
~
PUilC!Z/.\
MU/?.\
F~rwlr.\
Prrcmr of pcrtirnts
Avrriqe dqrer Oh.srrver
I. 2. 3. 4.
Periapical Bitcwing Pnnorllmic Pcriapical plus bitewing 5. Panoramic plus bitewing
Periapical Bitewing Panoramic Periapical plus bitewing 5. Panoramic plus bitewing
(I/
purrcnrs
/
.-iwrugr
’
ilC,lp~
7x 95 XY 99
12.22 87.96 X2.41 91 .hl
No. I 19.44 24.3 I 22.45 25.46
IO3
95.37
26.62
79 9X xx IO1
73. IS 90.74 x I .4x 93.52
No. 2 19.68 25.00 22.22 25.93
I34 IS7 133 163
69.79 79.17 69.21 84.90
IX.XX 70.83 I X.62 22.92
IO4
96.30
26.85
162
84.38
22.53
Obsrrvvr I. 7. 3. 4.
Prrwtlt PuliPnt,\
surveys alone. The analysis was done for the total number of teeth with periodontal changes. There were 50 to 147 teeth with evidence of endodontic treatment detected by radiographic surveys. Since anterior bitewings were not utilized, comparisons between bitewings and other surveys were not made for anterior teeth. There were no statistically significant differences between any surveys for anterior or posterior teeth for this radiographic sign. There were ten to twenty-two teeth with hypercementosis as detected by radiographic surveys. The bitewing survey was not included in the analysis. There were no statistically significant differences between the other radiographic surveys and between observers. Analysis of eleven to twenty-one root tips detected by radiographic surveys showed no statistically significant differences between surveys for the total number of root tips detected. Analysis of two to four observations of foreign bodies, zero to four observations of mucous retention phenomena in the maxillary sinus, zero to three observations of cystlike lesions, three to five observations of odontomas, zero to seventeen observations of mandibular tori, zero to two observations of supernumerary teeth, zero to four observations of teeth with follicular enlargements, and one to three observations of fourth molars among the surveys showed no statistically significant differences between surveys. The data for zero to twenty-two observations of osteosclerosis, zero to thirty-nine observations of ectopic calcifications, and zero to twelve observations of calcified stylohyoid ligaments among the surveys
showed some statistically significant differences between surveys. The ranking of surveys according to the greatest number of radiographic signs detected and the surveys with statistically significant differences are shown for each radiographic sign in Table VII. DISCUSSION
In this study, only the detection of interproximal carious lesions was considered. Identification of the radiographic survey that shows the greatest number of interproximal carious lesions is desirable, since radiographs have been shown to be the most effective method of detecting these lesions and the radiographic surveys use different amounts of radiation. The periapical plus bitewing survey detected the most lesions and the panoramic survey used alone was the least effective in the detection of anterior and posterior interproximal lesions. For anterior caries, periapical radiographs depicted greater numbers of carious lesions than panoramic surveys. Since the bitewing survey did not evaluate carious lesions in anterior teeth, the periapical plus bitewing survey was similarly more effective than the panoramic plus bitewing surveys. The analysis of posterior caries showed that the periapical plus bitewing, panoramic plus bitewing, and bitewing surveys were the most effective in detecting these lesions, and there were no statistically significant differences among or between them. When used with posterior bitewings, the panoramic survey detected less total caries than the periapical
Comparison of panoramic and intraoral Table
V.
radiogruphic
surveys
113
impacted and unerupted teeth detected by radiographic surveys and their locations
I- _ Snrw,’
Third molar
Ma-\-i/la
Mandible Premolar
Cuspid
Fourth molar
Third molur
I
-r---IF=’ Prrnrolar
C‘uxpid
molar
Tofal
Observer No. I I. 2. 3. 4.
Periapical Bitewing Panoramic Pcriapical plub bitcwing 5. Panor;imic pluh bitcwing
109 104 I I2 119
2 2 3 2
2 2 3 2
0 0 0 0
112 81 115 134
0 0 0 0
7 I 7 7
4 0 5 4
136 190 245 178
I32
3
3
0
136
0
7
5
2X6
I, 2. 3. 4.
109 9x I IO II6
2 2 3 2
2 2 3 2
0 0 0 0
113 61 II2 121
0 0 0 0
7 I 7 7
4 0 5 4
231 I64 240 252
II7
3
3
0
122
0
7
5
7.57
Observer No. 2 Periupical Bitcwing Panoramic Periapical plus bitcwing 5. Panoramic plus bitewing
Table VI. Number of teeth depicting periodontal membrane changes as detected by radiographic surveys and their locations Mandible Premolar
Incisor Observer No. I
I. 2. 3. 4.
Pertapical Bitcwing Panoramic Periapical plus bitewing 5. Panoramic plus bitewing
29 0 21 29
I 0 3 2
6 0 I 6
II 0 I II
8 0 I 8
12 0 4 I2
67 0 31 68
21
3
2
I
I
4
32
I. 2. 3. 4.
29 0 21 29
I 0 3 I
6 0 I 6
I2 0 I I2
8 0 I 8
I2 0 4 I?
6X 0 31 68
21
3
I
I
I
4
31
Observer No. 2 Periapical Bitcwing Panoramic Periapical plus bitewing S. Panoramic plus bitewing -__--
plus bitewing survey. The difference was not totally due to the much greater effectivenessof the periapical radiographs in detecting anterior caries, since the data show that the periapicals and panoramic radiographs when used with bitewings detect more posterior lesions than the bitewing radiographs alone. The increased caries detection by combination surveys over bitewings indicates that the panoramic and periapical radiographs assist the diagnostician in observing some caries not seen clearly in bitewings. Less sharpness of the radiographic image is a basic reason why carious lesions are more difficult to detect on panoramic surveys. Image overlap of the
shadows of interproximal tooth surfaces is another factor that reduces the panoramic survey readability, since the panoramic x-ray beam direction is fixed while the intraoral radiograph can be made with operator-selected x-ray beam directions. Other studies which have compared panoramic and intraoral radiographs for the detection of interproximal caries include those of Stewart and Bieser,5 Ohba and Katayama,h and Stephens and associates.7 The present study agrees with these investigators in showing that the panoramic radiograph alone is not as effective as other surveys in detecting interproxima1lesions, that the panoramic plus bitewing survey
Oral Surg.
I 14 Muhammed and Manson-Hing
July. 1982 VII. Surveys in order of greatest amount of radiographic signs detectable for each sign (surveys with statistically significant differences are underlined)
Table
PA + BW
PA
I’X + BW
PX
P/\ t BW
PX t BW
is-<
PA
+++++ PA PA+BW PX t BW PA + BW _..__.._.__.._.._.._..~..~..~....~.. +++++ ++ PX + BN PA + BW
++ PX RU
Px+Bw PX
PA
HU
PA
PX
PA + BW PX + BW
P.A P.A t BW
I’X + BW BW’
BW PX
PX PA
PA+BW
PA
PX t BU r,x
PX
BW
pi-+
H-i.
PXtBW PA t BW PA PX PX t BW
I’X
i,i- 1 -ii,-
is not much less effective than the periapical plus bitewing survey, and that the advantage of the periapical survey in detecting lesions is mainly in the anterior region. Hurlbert and Wuehrmann4 studied a group of patients similar to the patients used in this study and found that the difference between the panoramic plus bitewing and the periapical plus bitewing surveys was mainly due to the ability of the intraoral radiographs to detect small carious lesions. Thus, if the diagnostic objective is to detect carious lesions the panoramic plus bitewing will probably be as effective as other surveys. If small lesions must be identified, then additional types of examination will be needed in the anterior region. In the present investigation there were no data permitting the identification of false positive and false negative responses. However, Horton and associates8 found that there were no significant differences in false negative or false positive responses in interpreting caries in radiographs. The incidence of periapical radiolucencies in this study was 14.3 percent, and this is in general
__
PA+BW
PA t BW PA PA + BW PX+BW PX
PX
_
PA PX PX t BW P4 + BW P:4 i,i,. ~. ii--------
PX __
_. _.
PA
BW
PX PX+BW PX PA PA t BW _. _. P,I t B%
BU BW BW BW
PA t BW
BW
Bb
agreement with other studies.9-‘J Periapical radiolucencies were seen more frequently in mandibular teeth than in maxillary teeth and more frequently in the anterior than in the posterior region. These findings support the results of Alattar and associates,‘* Lilly and colleagues,14 and Johnson.‘s The greater frequency of periapical radiolucencies in the anterior area has been attributed by some authors to the fact that this segment of both the maxilla and the mandible is more prone to trauma. The comparison between radiographic surveys revealed that the periapical survey showed more periapical radiolucencies than the panoramic survey. However, there was no significant difference between these surveys. The bitewing survey does not depict the apices of teeth; thus there is no increase in periapical radiolucency detection when the bitewing is combined with other radiographs. Changes in the periodontal tissues were measured for different radiographic signs. The incidence of horizontal bone loss seen in patients in this study was 79.9 percent. Other studies have shown incidences of 64.0 percentI and 68.77 percent.16 The panoramic
Vulume
54
Comparison of panoramic and intraoral
plus bitewing survey identified the greatest number of patients with horizontal bone loss. The periapical plus bitewing survey showed a slightly smaller number, but there was no statistically significant difference between the surveys. The bitewing survey was more efficient in identifying patients with horizontal bone loss than the panoramic or periapical surveys, and there was some indication that the combination of surveys was more efficient than bitewings alone. The incidence of vertical bone loss among patients in this study was 7.13 percent. Marshall-Day and Shourie’” reported an incidence of 3 1.07 percent. The panoramic plus bitewing survey showed the greatest number of cases with vertical bone loss. The periapical plus bitewing survey showed a slightly smaller number of cases with vertical bone loss, but there was no statistically significant difference between the surveys. All other surveys showed a smaller number of cases with vertical bone loss and were significantly different from the combination-type surveys. The incidence of furcation changes in patients in this study was 1.7 percent. Marshall-Day and Shourie16 found no such changes in their study of 177 patients. The periapical plus bitewing survey showed the most furcation changes; however, the number found was small and there were no significant differences between surveys for this radiographic sign. The degree of alveolar bone loss for the entire dentition was estimated as an average percentage loss. The data revealed that the panoramic plus bitewing survey showed the greatest amount of alveolar bone loss and the periapical survey the least amount. There was no significant difference between the combined surveys and the bitewing survey, but the analysis shows that these three surveys depicted more bone loss than the panoramic or periapical survey alone. Other studies have compared panoramic and periapical radiographic surveys for the detection of bone 10ss.“.‘~ The present study agrees with these investigations in showing that the panoramic survey produces a higher bone loss score than the periapical survey; however, in another studyI orthopantomographs and periapical surveys were found to be equally effective in estimating bone loss. The present study also shows that a combination of bitewings with panoramic or periapical radiographs is significantly better than either of the surveys alone in evaluating the average degree of bone loss. There were more periodontal membrane changes found in the mandible than in the maxilla. This may be due, to some extent, to the superimposition of the xygomatic arch on maxillary molar areas. The periapical survey detected the most membrane changes.
radiographic
surveys
I I5
The survey was more than twice as efficient as the panoramic survey and was of significant statistical difference. The bitewings did not show any membrane changes, and thus the combination types of survey were not different from the periapical and panoramic surveys alone. The differences between surveys disagrees with Horton and colleagues8 study that compared a periapical plus bitewing survey with a panoramic survey of 100 patients and found no significant differences between the surveys. There were ninety-eight patients with impacted or unerupted teeth in this study, resulting in an incidence of 32.7 percent. Other studies have reported 25.2, 45, and 22.3 percent.‘~“~‘~ Most of the impacted or unerupted teeth were in the third molar region, but a number were also located in the premolar or cuspid regions. The panoramic plus bitewing survey identified the most impacted or unerupted teeth with the periapical plus bitewing showing a few less cases. The bitewing survey revealed a considerably smaller number of these teeth and was the only survey statistically significantly different from the other surveys. Three other entities showed differences among surveys. These were twenty-two cases of osteosclerosis, twelve calcified stylohyoid ligaments, and thirtyeight ectopic calcifications. For all of these conditions, the panoramic survey was significantly better than the periapical and bitewing surveys. There were many more teeth with root canal fillings in the maxilla than in the mandible, and this agrees with the findings of other investigators.‘3,‘4 Hypercementosis was found only in posterior teeth. There were more premolar teeth with hypercementosis than molar teeth. The data support the findings of Christen and associates9 and Gardner and Goldstein.2o The bitewing survey detected no teeth with hypercementosis. The periapical survey discovered more teeth with hypercementosis than the panoramic survey, but the difference was not statistically significant. All retained root tips were located in the molar region, which supports the results of others.‘3~2’~2’ Most investigators attribute this root tip distribution to the greater difficulty in extracting posterior teeth. The periapical survey discovered more root tips than the panoramic survey, and the panoramic more than the bitewing survey; however, there were no significant differences between radiographic surveys in the detection of root tips. The results of this study show that the best surveys for over-all evaluation are the panoramic plus bitewing and periapical plus bitewing surveys. When bitewings are not used, the effectiveness of either the
I 16
Muhammed and Manson-Hing
panoramic or periapical survey is significantly reduced for many radiographic signs. The periapical plus bitewing and panoramic plus bitewing surveys are statistically significantly different for anterior caries (the former being more effective), for periodontal membrane changes (the former being more effective), for osteosclerosis (the latter being more effective), for calcified stylohyoid ligaments (the latter being more effective), and for ectopic calcifications (the later being more effective). For a complete radiographic evaluation, a survey must include periapical, panoramic, and bitewing radiographs. Other studie@*.” which have also indicated this finding suggest that the inclusion of the panoramic radiograph is due to the radiograph examining a larger area of the patient’s mandible and maxilla. In these studies, 46 additional findings in 140 patients, 160 additional findings in 3,059 patients, and 23 additional findings in 100 patients were discovered on panoramic radiographs. CONCLUSIONS
1. To identify useful radiographic signs in the initial evaluation of a dental clinic patient, a complete radiographic survey, made with present-day clinical conditions, must include periapical, panoramic, and bitewing radiographs. 2. The panoramic plus bitewing survey is deficient in identifying small anterior caries and small periodontal membrane changes. 3. The periapical plus bitewing survey is deficient in identifying osteosclerosis, calcified stylohyoid ligaments, and ectopic calcifications. 4. Either the panoramic, the periapical, or the bitewing survey, used alone, is deficient for the evaluation of many radiographic signs. 5. The panoramic plus bitewing survey is the most effective survey for identifying patients with alveolar bone loss changes as well as impacted or unerupted teeth. 6. The periapical plus bitewing survey is the most effective survey for identifying interproximal caries and periodontal membrane changes. REFERENCES I. Henry, J. L., and Gracia. D. A.: Use of Radiographic ProJectrons in Dental Schools in the United States and Canada, J. Am. Dent. Assoc. 97: 947-948, 1978. 7. Van Aken. J., and Van der Linden, L. W.: The Integral Absorbed Dose in Conventional and Panoramic Complete Mouth Examinations, ORAL SURG. 22: 603-616. 1966. 3. Manson-Hing, L. R., and Greer, D. F.: Radiation Exposure and Distribution Measurements for Three Panoramic X-Ray Machines. ORAL SLIKG. 44: 3 13-321, 1977. 4. Hurlburt. C. E., and Wuehrmann, A. H.: Comparison 01 Interproximal Carious Lesion Detection in Panoramic and
Or‘il Surg. JUI!. 1982
5.
6.
7.
8. 9.
IO.
I I.
12.
13.
14.
15. 16.
17.
18.
19.
20. 21.
22.
23.
24.
25.
26.
27.
2X. 29.
Standard Intraoral Radiography, J. Am. Dent. Assoc. 93: 1154-l 158, 1976. Stewart, J. L., and Bieser. L. F.: Panoramic Roentgenograms Compared With Conventional Intraoral Roentgenograms, ORAL SURC. 26: 39-42, 1968. Ohba, T., and Katayama, H.: Comparison of Orthopanotomography With Conventional Periapical Dental Radiography. ORAL SURC. 34: 524-530, 1972. Stephens. R. G.. et al.: A Comparison of Panorex and Intraoral Surveys for Routine Dental Radiography, J. Can. Dent. Assoc. 43: 281-286, 1977. Horton P. S.. et al.: Analysis of Interpretations of Full Mouth and Panoramic Surveys. ORAL &KG. 44: 468-475, 1977. Christen. A. G., et al.: Oral Health of Dentists: Analysis of Panoramic Radiographic Survey. J. Am. Dent. Assoc. 75: 1167-l 168, 1967. Meister. F:.. et al.: Oral Health of Airmen: Analysts of Panoramic Radiographic and Polaroid Photographic Survey, J. Am. Dent. Assoc. 94: 335-339, 1977. Cuttino, C. L., et al.: Panoramic Radiographic Survey of Dentists, Interpretation of Findings, J. Am. Dent. Assoc. 79: 1179-l 182, 1969. Alattar, M. M.. et al.: A Survey of Panoramic Radiographs for Evaluation of Normal and Pathologic Findings, ORAL SURG. 50: 472-478, 1980. Hansen, B. F., and Johansen, J. R.: Oral Rocntgenologic Findings in a Norwegian Urban Population, ORAL SURG. 41: 261-266, 1976. Lilly, G. E., et al.: Oral Health Evaluation: Analysis of Radiographic Findings, J. Am. Dent. Assoc. 71: 635-639, 1965. Johnson, C. C.: Analysis of Panoramic Survey, J. Am. Dent. Assoc. 81: 151-154, 1970. Marshall-Day, C. D., and Shouric, K. L.: A Roentgenographic Survey of Periodontal Disease in India. J. Am. Dent. Assoc. 39: 572-588. 1949. Cirondahl. H. G.. et al.: Diagnosis of Margrnal Bone Destruction With Orthopantomography and Intraoral Full Mouth radiography. Sven. Tandlak. Tidskr. 64: 439-446, I97 I. Ainamo, J.. and Tammisalo, E. H.: Comparison of Radiographic and Clinical Signs of Early Periodontal Disease, Stand. J. Dent. Res. 81: 548-552, 1973. Bjorn, H., and Holmberg, K.: Radiographic Determination Periodontal Bone Destruction in Epidemiological Research, Odont. Rev. 17: 232-250, 1966. Gardner. B. S.. and Goldstein, H.: The Signiticance of Hypercementosis, Dental Cosmos 73: IO65- 1069, I93 I. Klafstad, J.: Epidemiologiske Aspektcr pa Enkelte Tann-og Kjevesykdommcr I et Oralkirurgisk Pasientmateriale, Nor. Tannlaegeforen. Tid. 83: 172-l 79, 1973. Lehtinen, R., and Aitisalo, K.: Prevalence of Intra-osseous Retained Roots in a Selected Finnish Material, Suom. Hammaslaak. Toim. 70: 25-27, 1974. White, S. C.. and Weissman, D. 0.: Relative Discernment of Lesions by Intraoral and Panoramic Radiography. J. Am. Dent. Assoc. 95: I 117-l 121. 1977. Ainamo, J.. and Tammisalo. E. H.: The Orthopantomogram in Quantitative Assessment of Marginal Bone loss. Suom. Hammaslaak. Toim. 63: 132-l 38. 1967. Akiyoshi, M., and Mori, K.: Marginal Periodontitis: A Histological Study of the Incipient Stage. J. Periodont. Res. 38: 45-52. 1967. Barr, H. J.: The Diagnostic Value of Radiographic Examination for Proximal Caries in Deciduous Posterior Teeth, N.Z. J. Dent. 41: X9-102, 1945. Barr, J. ti.. and Gresham, A. If.: The Detection of Carious Lesions on the Proximal Surfaces of Teeth, J. Am. Dent. Assoc. 41: 198-204. 1950. Bhaskar, S. N: Pcriapical Lesions--Types. Incidence, and Clinical Features. ORAI. SLKG. 21: 657-67 I, 1966. Bhaskar. S. N.: Roentgenographic Interpretation for the
Volume 54 Number I
30.
31. 32. 33. 34. 35. 36. 37. 38. 39. 40
41 42 43 44 45
46.
47. 48. 49.
Comparison of panoramic and intraoral
Dentist. Radiolucent Lesions of the Jaws, 1970, The C. V. Mosby Company, pp. 70-73. Blayney, J. R.. and Greco, J. F.: The Value of Roentgenological vs. Clinical Procedures for the Recognition of Early Carious Lesions on Proximal Surfaces of Teeth, J. Dent. Res. 31: 341-345, 1952. Brueggemann, I. A.: Evaluation of the Panorex Unit, ORAL SURC. 24: 348-358, 1967. Burket. L. W.: The Accuracy of Clinical and Roentgenologic Diagnosis of Dental Caries and Determined by Microscopic Studies. J. Dent. Res. 20: 71-76. 1941. Chilton. N. W., and Greenwald, L. E.: The Role of Roentgenograms in Public Health. J. Dent. Res. 26: 129-140, 1947. Davies, E. E.. et al.: Panoramic Versus Periapical Surveys. A Comparison of Findings on Freshman Dental Students, Dent. Radiogr. Photogr. SO: 41-47, 1977. Delabarre, F. A.: Preschool Age Dentistry, J. Am. Dent. Assoc. 20: 124-128, 1933. Dunning, J. M.. and Leach, L. B.: Gingival-Bone Count: A Method for Epidemiological Study of Periodontal Disease, J. Dent. Res. 39: 506-1513, 1960. Fixott. H. C.: Use of Roentgen Rays in the Practice of Children’s Dentistry, J. Am. Dent. Assoc. 24: 91-97, 1937. Forsberg, A.. and Hagglund, G.: Differential Diagnosis of Radicular Cyst and Granuloma. Use of X-Ray Contrast Medium, Dent. Radiogr. Photogr. 33: 84-88, 1960. Gilbert. S. G.: Orthodontics and the Panorex Dental X-ray, Bull. Philadelphia Dent. Sot. 28: I l-13, 1962. Grondahl et al.: Diagnosis of Periapical Osteolytic Processes With Orthopantomography and Intraoral Full Mouth Radiography-A Comparison. Sven. Tanklak. Tidskr. 63: 079. 686. 1970. Jung, T.: Gonadal Doses Resulting From Panoramic X-Ray Examinations of the Teeth, ORAL SURG. 19: 745-753, 1965. Kelly. G. P.: Radiographs in Clinical Periodontal Trials, J. Periodontol. 46: 38 l-386, 1975. Kite. 0. W.. ct al.: Radiation and Image Distortion in the Panorex X-Ray Unit, ORAL SURG. 15: 1201-1210, 1962. Kraskc. L. M., and Mazzerella, M. A.: Evaluation of a Panoramic Dental X-Ray Machine, Dent. Prog. 1: 33-41, 1961. Kuba. R. K.. and Beck, J. 0.: Radiation Dosimetry in Panorex Roentgenography. Part 111. Radiation Dose Measurements, ORAL SURG. 25: 393-404, 1968. McCall, J. 0. and Wald, S. S.: Clinical Dental Roentgenology, Periodontal Diseuse, ed. 4, Philadelphia, 1957, W. B. Saunders Company. pp. 262-278. Mitchell. L. D.: Panoramic Roentgenography a Clinical Evaluation, J. Am. Dent. Assoc. 66: 778-786. 1963. Morris, C. R., et al.: Abnormalities Noted on Panoramic Radiographs, ORAI SLRG. 28: 772-782. 1969. Mycrs. D. R.. ct al.: Radiation Exposure During Panoramic
radiographic
surveys
117
Radiography in Children, ORAL SURG. 46: 588-593, 1978 50. Patur, B.: Roentgenographic Evaluation of Alveolar Bone Changes in Periodontal Disease. Dent. Clin. North Am.. nn .. 47-54; 1960. 51. Phillips, J. D., and Shawkat, A. H.: A Study of the Radiographic Appearance of Osseous Defects on Panoramic and Conventional Films, ORAL SURG. 36: 745-749, 1973. 52. Prichard, J.F.: Advanced Periodontal Disease, Surgical and Prosthetic Management. Role of the Roentgenograph in Diagnosis, ed 2, Philadelphia, 1972, W. B. Saunders Comnany, pp. 142-147. 53. Priebe, W. A., et al.: Value of the Radiographic Film in the Different Diagnosis of Periapical Lesions, J. Dent. Res. 32: 675-676, 1953. 54. Ramadan, A. E., and Michell, D. F.: A Roentgenographic Study of Experimental Bone Destruction, ORAL SURG. 15: 934-943, 1962. 55. Raper, H. R.: Practical Clinical Preventive Dentistry Based Upon Periodic Roentgen-Ray Examination, J. Am. Dent. Assoc. 12: 1084-l 100, 1925. 56. Rees, T. D., et al.: Radiographic Interpretation of Periodontal Osseous Lesions, ORAL SURG. 32: I4 I - 153, I97 I. 57. Sandler. H. C., and Stahl, S. S.: Measurement of Periodontal Disease Prevalence, J. Am. Dent, Assoc. 58: 93-97, 1959. Essential to Diagnosis and 58. Smith, R. K.: The X-Ray-An Prognosis of the Child Patient, J. Am. Dent. Assoc. 29: 796-804, 1942. 59. Stafne, E. C.: Oral Roentgenographic Diagnosis. Infections of the Jaw, Philadelphia, 1958, W. B. Saunders Company, pp. 70-74. 60. Suomi, J. D.. ct al.: A Comparative Study of Radiographs and Pocket Measurements in Periodontal Disease Evaluation, J. Periodontol. 29: 3 I l-3 15, 1968. 61. Trithart, A. H., and Donnelly, C. J.: A Comparative Study of Proximal Cavities Found by Clinical and Roentgenographic Examination, J. Am. Dent. Assoc. 40: 33-37, 1950. 62. Updegrave, W. S.: The Role of Panoramic Radiography in Diagnosis, ORAL SURG. 22: 49-57, 1966. 63. Worth, H. M.: Principles and Practice of Oral Radiologic Interpretation. Periodontal Disease, Chicago. 1963, Year Book hledical Publishers, Inc., pp. 285-292.
Reprint requests to: Dr. A. H. Muhammed c/o Dr. Lincoln R. Manson-Hing University of Alabama School of Dentistry University Station Birmingham, Ala. 35294
D.M.D., MS.,**
The effectiveness of radiographic surveys in detecting basic radiographic signs for the initial examination of patients in a specific dental clinic population was investigated. A sample of 300 patients showed that panoramic periapical and bitewing radiographs are all needed for a complete radiographic evaluation. Panoramic plus bitewings and periapical plus bitewings were the next most effective surveys with either survey being less effective than the other for some radiographic signs.
T he use of x-rays for diagnostic purposes has been well established since the discovery of the rays. Although warnings about radiation hazards and suggestions for radiation protection appear in the dental literature as early as 1914, the general awareness of the need for radiation hygiene is relatively recent. As a result of this awareness, steps have been taken to reduce the amount of radiation resulting from dental radiography. These measures include improved x-ray machines, the use of faster film and screens, and proper selection of radiographic technique. Patients in dental school clinics have been examined radiographically with panoramic, periapical, bitewing, or a combination of the three radiographic surveys.] Panoramic radiographs utilize intensifying screens and require less radiation but they have the disadvantage of having less definition and detail than conventional intraoral periapical and bitewing radiographs.2-4 Depending upon the information desired, one radiographic survey may be preferred or all methods may be employed. This study was designed to determine the method of radiographic examination most effective for the detection of interproximal caries and bone changes in the initial examination of patients in a dental school clinic patient population. *Department of Dental Radiology, School of Dentistry. **Department of Dental Radiology, School of Dentistry, University of Alabama.
MATERIALS
AND METHODS
A Panorex panoramic machine* was used in this study. The film used was 5 by 12 inch DuPont Cronex 2 DC. Kilovoltage peak was varied according to the size of the patient in order to maintain an average radiographic density. Intraoral radiographs were made with a General Electric 1000,t an S. S. White Flexomatic 90,* or a Ritter Explorer 90$ machine using 65 kVp and 10 mA with the exposure time varied to maintain average film density. The intraoral films were double-packet Kodak ultraspeed dental x-ray film. One film was placed in the patient’s chart and the duplicate used for this study. Patients were selected after they had been examined in the oral diagnosis clinic and complete-mouth radiographs had been prescribed. Edentulous patients and patients with facial swellings or a recent history of trauma were excluded from the study. Each patient was radiographed for a completemouth periapical intraoral survey, a set of intraoral bitewings, and one panoramic radiograph. Intraoral radiographic surveys were made by dental students or technicians in accordance with the present clinic policy. Panoramic radiographs were made by the investigators. Panoramic radiographs are normally *Pennwalt S. S. White, Philadelphia, Pa. 19102. Kieneral Electric Medical Systems Division, Milwaukee, 53201, $Ritter Company. Rochester, N. Y. 14603.
Wis.
Comparison of panoramic and intraoral
Fig. 1. The three radiographic surveys. Above, Periapical survey. Below, Panoramic survey.
made by technicians or the investigators in the clinic. Radiographic surveys are illustrated in Fig. 1. Films were processed in a standard, light-tight darkroom equipped with safelights using Morlite 2 and Wratten 6B filters. A Litton automatic processor was used to process all films. Three hundred patients in the school clinic population were examined. Two age groups were used to separate adult patients from patients with erupting teeth: 21 years of age or greater and 20 years of age or less. An attempt was made to obtain equal numbers for each group. Three sets of radiographs were prepared for study: a set of panoramic radiographs, a set of bitewings, and a set of intraoral periapical radiographs. Radiographic surveys in each set of radiographs were numbered and randomized for viewing.
radiographic
surveys
109
complete mouth survey. Middle, Bitewing
Radiographs were viewed under standardized conditions using a uniformly illuminated viewbox masked to obtain an illuminated area the same size as the radiograph to be read. All light in the room was eliminated except the viewbox and a small lamp at a distance of six feet behind the observer. The dim light from the small lamp allowed vision of the numbers on the data sheet. Two dentists independently interpreted each radiographic survey. All radiographic surveys were randomized for each observer in different orders. Sample radiographs depicting typical pathologic conditions were shown to each observer prior to his reading the experimental radiographs. The experimental radiographs were examined for proximal caries, periapical changes, and periodontal bone changes, and other bone alterations, such as foreign
I IO
Muhammed and Manson-Hing Radiograph
Interpreter’s
Date ~
number
I. -- lnterproximal caries - Indicate location 2. -- Periapical Lesion - Shade in lesion.
3. -- Periodontal
Name
in pencil. ‘Z?t,
Bone
l9!!Eb
FURCATION INVOLVEMENT Shade in
HORIZONTAL BONE LOSS Draw level of crest
VERTICAL BONE LOSS Shade in
Avg. % Bone Loss -0
-25 -50 -75 -100 4. -- Other
Draw and locate
changes
on chart
or list if outside
of teeth
area
RECORD -l
Right
Average
32 131 Other
periodontal
bone
]30]29/261271261
changes,
structures
25 124123
2.
Form
used by
]22/21120119116]
Left
17
or lesions
Submandibular salivary gland Foreign body (nose orbit) MUCOUS retention phenomenon Calcified stylohyoid ligament Osteosclerosis Impacted teeth and unerupted
Fig.
loss 0, 25, 50, 75, 100%
defect in maxillary
antrum
Osteoma Ectopic calcification Lymph node calcification
Other: teeth
readers
bodies, root apices, cysts, etc. Data were collected on forms, a sample of which is shown in Fig. 2. The number of interproximal carious lesions in the anterior and posterior segments was totaled for each patient for each radiographic survey. The anterior segment consisted of incisor and cuspid teeth and included the distal surfaces of the cuspid teeth. The number of periapical lesions in the anterior and posterior segments was collated. The level of periodontal bone support was recorded, with the cementoenamel junction and the root apex serving as reference points. The average degree of bone resorption was graded as 0, 25, 50, or 100 percent. Other changes, structures, or lesions of diagnostic interest were recorded. The Student t test was used to test for statistically significant differences between the amount of evidence of pathologic changes observed in the three types of radiographic surveys. The level of significance was set at the 5 percent level for all tests of significance. In addition to comparing the evidence
to record radiographic observations of pathologic changes detected by each type of survey, data from periapical surveys and bitewing surveys were combined and compared with data from panoramic surveys. Also, data from periapical surveys were combined with data from bitewing surveys and compared with the combined data from panoramic surveys and bitewing surveys. RESULTS
There were 300 patients in the sample. The number of male and female patients with and without pathologic findings detected by radiographic survey was collated. No statistically significant differences were observed between surveys when the Student t test was applied. Data about interproximal caries detected by radiographic survey and location for the two observers are presented in Table I. Periapical radiolucencies detected by radiographic surveys and their locations as interpreted by two observers are shown in Table II. The number of patients with alveolar bone loss according to type of
Volume
Comparison of panoramic and intraoral
5-t
Number
radiographic
I. Mean number of interpoximal for two observers
carious lesions detected by radiographic
Table
III
survey and location
Observer No. I
Periapical Bitt-wing Panoramic Perinpical Panoramic
Observer No. 2
Anterior caries
Sumer I 2. 3. 4. 5.
surveys
I
2.69 0.00 1 .OO 2.69 I.01
plus bite-wing plus bite-wing
Posterior caries
k 3.39
0.70 1.25 0.44 1.38 1.32
f 2.09 k 3.39 + 2.08
Table II. Periapical radiolucencies detected by radiographic two observers
Survq,
I
k + -t k i-
:
Anterior caries
1.20 1.80 0.85 1.84 1.79
2.63 0.00 1.03 2.64 1.05
t
3.34
i i t
2.13 3.36 2.16
Posterior caries 0.79 I.22 0.57 1.39 1.32
2 + t i k
1.29 1.74 0.98 1.78 1.76
surveys and their location as interpreted by
Posterior
1
Anrerior
Ma’y
Po/l(rjr-1
Toral
Observer No. I I. 2. 3. 4. 5.
Periapical Bitewing Panoramic Periapical Panoramic
plus bitweing plus bitewing
21 0 I7 21 17
14 0 21 I4 21
I3 0 8 I3 8
IO 0 8 IO 8
54 58 54
II 0 9 II 9
I2 0 IO I2 IO
57 0 54 57 55
5x 0
Observer No. 2 I. 2. 3. 4. 5.
Periapical Bitewing Panoramic Periapical Panoramic
plus bitewing plus bitewing
21 0 15 21 I5
13 0 20 I3 21
Ill. Number of patients with alveolar bone loss according to type of bone loss and the types of radiographic surveys
Table
Survey
Horizontal
Verlical
Furcation
1
Toral
Observer No. 1 I. 2. 3. 4. 5.
Periapical Bitewing Panoramic Pcriapical Panoramic
I. 2. 3. 4. 5.
Periapical Bitewing Panoramic Periapical Panoramic
plus bitewing plus bitewing
206 247 222 259 265
plus bitewing plus bitewing
213 250 221 264 266
I8 21 IO 27 31
7 3 2 8 4
231 271 234 294 300
I4 21 II 26 32
6 3 3 7 5
733 274 235 298 303
Observer No. 2
bone loss and the types of radiographic surveys is shown in Table III. The number and sex of patients with alveolar bone loss and the degree of alveolar bone loss detected by radiographic surveys as interpreted by two observers are shown in Table IV. Data concerning impacted and unerupted teeth detected by radiographic surveys and their locations as interpreted by two observers are shown in Table V.
The number of teeth with periodontal membrane changes as detected by radiographic surveys and their locations as interpreted by two observers are shown in Table VI. The bitewing survey does not properly depict periodontal membrane change; therefore periapical plus bitewing and panoramic plus bitewing surveys detect the same periodontal membrane changes as periapical and panoramic
I 12 Muhammed
and Munson-Hing
Oral Surg. .lUlj. 19x2
Table IV. Number and sex of patients with alveolar bone loss and the average degree of bone loss detected by radiographic surveys
I ~~
;~------
Survq
~
PUilC!Z/.\
MU/?.\
F~rwlr.\
Prrcmr of pcrtirnts
Avrriqe dqrer Oh.srrver
I. 2. 3. 4.
Periapical Bitcwing Pnnorllmic Pcriapical plus bitewing 5. Panoramic plus bitewing
Periapical Bitewing Panoramic Periapical plus bitewing 5. Panoramic plus bitewing
(I/
purrcnrs
/
.-iwrugr
’
ilC,lp~
7x 95 XY 99
12.22 87.96 X2.41 91 .hl
No. I 19.44 24.3 I 22.45 25.46
IO3
95.37
26.62
79 9X xx IO1
73. IS 90.74 x I .4x 93.52
No. 2 19.68 25.00 22.22 25.93
I34 IS7 133 163
69.79 79.17 69.21 84.90
IX.XX 70.83 I X.62 22.92
IO4
96.30
26.85
162
84.38
22.53
Obsrrvvr I. 7. 3. 4.
Prrwtlt PuliPnt,\
surveys alone. The analysis was done for the total number of teeth with periodontal changes. There were 50 to 147 teeth with evidence of endodontic treatment detected by radiographic surveys. Since anterior bitewings were not utilized, comparisons between bitewings and other surveys were not made for anterior teeth. There were no statistically significant differences between any surveys for anterior or posterior teeth for this radiographic sign. There were ten to twenty-two teeth with hypercementosis as detected by radiographic surveys. The bitewing survey was not included in the analysis. There were no statistically significant differences between the other radiographic surveys and between observers. Analysis of eleven to twenty-one root tips detected by radiographic surveys showed no statistically significant differences between surveys for the total number of root tips detected. Analysis of two to four observations of foreign bodies, zero to four observations of mucous retention phenomena in the maxillary sinus, zero to three observations of cystlike lesions, three to five observations of odontomas, zero to seventeen observations of mandibular tori, zero to two observations of supernumerary teeth, zero to four observations of teeth with follicular enlargements, and one to three observations of fourth molars among the surveys showed no statistically significant differences between surveys. The data for zero to twenty-two observations of osteosclerosis, zero to thirty-nine observations of ectopic calcifications, and zero to twelve observations of calcified stylohyoid ligaments among the surveys
showed some statistically significant differences between surveys. The ranking of surveys according to the greatest number of radiographic signs detected and the surveys with statistically significant differences are shown for each radiographic sign in Table VII. DISCUSSION
In this study, only the detection of interproximal carious lesions was considered. Identification of the radiographic survey that shows the greatest number of interproximal carious lesions is desirable, since radiographs have been shown to be the most effective method of detecting these lesions and the radiographic surveys use different amounts of radiation. The periapical plus bitewing survey detected the most lesions and the panoramic survey used alone was the least effective in the detection of anterior and posterior interproximal lesions. For anterior caries, periapical radiographs depicted greater numbers of carious lesions than panoramic surveys. Since the bitewing survey did not evaluate carious lesions in anterior teeth, the periapical plus bitewing survey was similarly more effective than the panoramic plus bitewing surveys. The analysis of posterior caries showed that the periapical plus bitewing, panoramic plus bitewing, and bitewing surveys were the most effective in detecting these lesions, and there were no statistically significant differences among or between them. When used with posterior bitewings, the panoramic survey detected less total caries than the periapical
Comparison of panoramic and intraoral Table
V.
radiogruphic
surveys
113
impacted and unerupted teeth detected by radiographic surveys and their locations
I- _ Snrw,’
Third molar
Ma-\-i/la
Mandible Premolar
Cuspid
Fourth molar
Third molur
I
-r---IF=’ Prrnrolar
C‘uxpid
molar
Tofal
Observer No. I I. 2. 3. 4.
Periapical Bitewing Panoramic Pcriapical plub bitcwing 5. Panor;imic pluh bitcwing
109 104 I I2 119
2 2 3 2
2 2 3 2
0 0 0 0
112 81 115 134
0 0 0 0
7 I 7 7
4 0 5 4
136 190 245 178
I32
3
3
0
136
0
7
5
2X6
I, 2. 3. 4.
109 9x I IO II6
2 2 3 2
2 2 3 2
0 0 0 0
113 61 II2 121
0 0 0 0
7 I 7 7
4 0 5 4
231 I64 240 252
II7
3
3
0
122
0
7
5
7.57
Observer No. 2 Periupical Bitcwing Panoramic Periapical plus bitcwing 5. Panoramic plus bitewing
Table VI. Number of teeth depicting periodontal membrane changes as detected by radiographic surveys and their locations Mandible Premolar
Incisor Observer No. I
I. 2. 3. 4.
Pertapical Bitcwing Panoramic Periapical plus bitewing 5. Panoramic plus bitewing
29 0 21 29
I 0 3 2
6 0 I 6
II 0 I II
8 0 I 8
12 0 4 I2
67 0 31 68
21
3
2
I
I
4
32
I. 2. 3. 4.
29 0 21 29
I 0 3 I
6 0 I 6
I2 0 I I2
8 0 I 8
I2 0 4 I?
6X 0 31 68
21
3
I
I
I
4
31
Observer No. 2 Periapical Bitcwing Panoramic Periapical plus bitewing S. Panoramic plus bitewing -__--
plus bitewing survey. The difference was not totally due to the much greater effectivenessof the periapical radiographs in detecting anterior caries, since the data show that the periapicals and panoramic radiographs when used with bitewings detect more posterior lesions than the bitewing radiographs alone. The increased caries detection by combination surveys over bitewings indicates that the panoramic and periapical radiographs assist the diagnostician in observing some caries not seen clearly in bitewings. Less sharpness of the radiographic image is a basic reason why carious lesions are more difficult to detect on panoramic surveys. Image overlap of the
shadows of interproximal tooth surfaces is another factor that reduces the panoramic survey readability, since the panoramic x-ray beam direction is fixed while the intraoral radiograph can be made with operator-selected x-ray beam directions. Other studies which have compared panoramic and intraoral radiographs for the detection of interproximal caries include those of Stewart and Bieser,5 Ohba and Katayama,h and Stephens and associates.7 The present study agrees with these investigators in showing that the panoramic radiograph alone is not as effective as other surveys in detecting interproxima1lesions, that the panoramic plus bitewing survey
Oral Surg.
I 14 Muhammed and Manson-Hing
July. 1982 VII. Surveys in order of greatest amount of radiographic signs detectable for each sign (surveys with statistically significant differences are underlined)
Table
PA + BW
PA
I’X + BW
PX
P/\ t BW
PX t BW
is-<
PA
+++++ PA PA+BW PX t BW PA + BW _..__.._.__.._.._.._..~..~..~....~.. +++++ ++ PX + BN PA + BW
++ PX RU
Px+Bw PX
PA
HU
PA
PX
PA + BW PX + BW
P.A P.A t BW
I’X + BW BW’
BW PX
PX PA
PA+BW
PA
PX t BU r,x
PX
BW
pi-+
H-i.
PXtBW PA t BW PA PX PX t BW
I’X
i,i- 1 -ii,-
is not much less effective than the periapical plus bitewing survey, and that the advantage of the periapical survey in detecting lesions is mainly in the anterior region. Hurlbert and Wuehrmann4 studied a group of patients similar to the patients used in this study and found that the difference between the panoramic plus bitewing and the periapical plus bitewing surveys was mainly due to the ability of the intraoral radiographs to detect small carious lesions. Thus, if the diagnostic objective is to detect carious lesions the panoramic plus bitewing will probably be as effective as other surveys. If small lesions must be identified, then additional types of examination will be needed in the anterior region. In the present investigation there were no data permitting the identification of false positive and false negative responses. However, Horton and associates8 found that there were no significant differences in false negative or false positive responses in interpreting caries in radiographs. The incidence of periapical radiolucencies in this study was 14.3 percent, and this is in general
__
PA+BW
PA t BW PA PA + BW PX+BW PX
PX
_
PA PX PX t BW P4 + BW P:4 i,i,. ~. ii--------
PX __
_. _.
PA
BW
PX PX+BW PX PA PA t BW _. _. P,I t B%
BU BW BW BW
PA t BW
BW
Bb
agreement with other studies.9-‘J Periapical radiolucencies were seen more frequently in mandibular teeth than in maxillary teeth and more frequently in the anterior than in the posterior region. These findings support the results of Alattar and associates,‘* Lilly and colleagues,14 and Johnson.‘s The greater frequency of periapical radiolucencies in the anterior area has been attributed by some authors to the fact that this segment of both the maxilla and the mandible is more prone to trauma. The comparison between radiographic surveys revealed that the periapical survey showed more periapical radiolucencies than the panoramic survey. However, there was no significant difference between these surveys. The bitewing survey does not depict the apices of teeth; thus there is no increase in periapical radiolucency detection when the bitewing is combined with other radiographs. Changes in the periodontal tissues were measured for different radiographic signs. The incidence of horizontal bone loss seen in patients in this study was 79.9 percent. Other studies have shown incidences of 64.0 percentI and 68.77 percent.16 The panoramic
Vulume
54
Comparison of panoramic and intraoral
plus bitewing survey identified the greatest number of patients with horizontal bone loss. The periapical plus bitewing survey showed a slightly smaller number, but there was no statistically significant difference between the surveys. The bitewing survey was more efficient in identifying patients with horizontal bone loss than the panoramic or periapical surveys, and there was some indication that the combination of surveys was more efficient than bitewings alone. The incidence of vertical bone loss among patients in this study was 7.13 percent. Marshall-Day and Shourie’” reported an incidence of 3 1.07 percent. The panoramic plus bitewing survey showed the greatest number of cases with vertical bone loss. The periapical plus bitewing survey showed a slightly smaller number of cases with vertical bone loss, but there was no statistically significant difference between the surveys. All other surveys showed a smaller number of cases with vertical bone loss and were significantly different from the combination-type surveys. The incidence of furcation changes in patients in this study was 1.7 percent. Marshall-Day and Shourie16 found no such changes in their study of 177 patients. The periapical plus bitewing survey showed the most furcation changes; however, the number found was small and there were no significant differences between surveys for this radiographic sign. The degree of alveolar bone loss for the entire dentition was estimated as an average percentage loss. The data revealed that the panoramic plus bitewing survey showed the greatest amount of alveolar bone loss and the periapical survey the least amount. There was no significant difference between the combined surveys and the bitewing survey, but the analysis shows that these three surveys depicted more bone loss than the panoramic or periapical survey alone. Other studies have compared panoramic and periapical radiographic surveys for the detection of bone 10ss.“.‘~ The present study agrees with these investigations in showing that the panoramic survey produces a higher bone loss score than the periapical survey; however, in another studyI orthopantomographs and periapical surveys were found to be equally effective in estimating bone loss. The present study also shows that a combination of bitewings with panoramic or periapical radiographs is significantly better than either of the surveys alone in evaluating the average degree of bone loss. There were more periodontal membrane changes found in the mandible than in the maxilla. This may be due, to some extent, to the superimposition of the xygomatic arch on maxillary molar areas. The periapical survey detected the most membrane changes.
radiographic
surveys
I I5
The survey was more than twice as efficient as the panoramic survey and was of significant statistical difference. The bitewings did not show any membrane changes, and thus the combination types of survey were not different from the periapical and panoramic surveys alone. The differences between surveys disagrees with Horton and colleagues8 study that compared a periapical plus bitewing survey with a panoramic survey of 100 patients and found no significant differences between the surveys. There were ninety-eight patients with impacted or unerupted teeth in this study, resulting in an incidence of 32.7 percent. Other studies have reported 25.2, 45, and 22.3 percent.‘~“~‘~ Most of the impacted or unerupted teeth were in the third molar region, but a number were also located in the premolar or cuspid regions. The panoramic plus bitewing survey identified the most impacted or unerupted teeth with the periapical plus bitewing showing a few less cases. The bitewing survey revealed a considerably smaller number of these teeth and was the only survey statistically significantly different from the other surveys. Three other entities showed differences among surveys. These were twenty-two cases of osteosclerosis, twelve calcified stylohyoid ligaments, and thirtyeight ectopic calcifications. For all of these conditions, the panoramic survey was significantly better than the periapical and bitewing surveys. There were many more teeth with root canal fillings in the maxilla than in the mandible, and this agrees with the findings of other investigators.‘3,‘4 Hypercementosis was found only in posterior teeth. There were more premolar teeth with hypercementosis than molar teeth. The data support the findings of Christen and associates9 and Gardner and Goldstein.2o The bitewing survey detected no teeth with hypercementosis. The periapical survey discovered more teeth with hypercementosis than the panoramic survey, but the difference was not statistically significant. All retained root tips were located in the molar region, which supports the results of others.‘3~2’~2’ Most investigators attribute this root tip distribution to the greater difficulty in extracting posterior teeth. The periapical survey discovered more root tips than the panoramic survey, and the panoramic more than the bitewing survey; however, there were no significant differences between radiographic surveys in the detection of root tips. The results of this study show that the best surveys for over-all evaluation are the panoramic plus bitewing and periapical plus bitewing surveys. When bitewings are not used, the effectiveness of either the
I 16
Muhammed and Manson-Hing
panoramic or periapical survey is significantly reduced for many radiographic signs. The periapical plus bitewing and panoramic plus bitewing surveys are statistically significantly different for anterior caries (the former being more effective), for periodontal membrane changes (the former being more effective), for osteosclerosis (the latter being more effective), for calcified stylohyoid ligaments (the latter being more effective), and for ectopic calcifications (the later being more effective). For a complete radiographic evaluation, a survey must include periapical, panoramic, and bitewing radiographs. Other studie@*.” which have also indicated this finding suggest that the inclusion of the panoramic radiograph is due to the radiograph examining a larger area of the patient’s mandible and maxilla. In these studies, 46 additional findings in 140 patients, 160 additional findings in 3,059 patients, and 23 additional findings in 100 patients were discovered on panoramic radiographs. CONCLUSIONS
1. To identify useful radiographic signs in the initial evaluation of a dental clinic patient, a complete radiographic survey, made with present-day clinical conditions, must include periapical, panoramic, and bitewing radiographs. 2. The panoramic plus bitewing survey is deficient in identifying small anterior caries and small periodontal membrane changes. 3. The periapical plus bitewing survey is deficient in identifying osteosclerosis, calcified stylohyoid ligaments, and ectopic calcifications. 4. Either the panoramic, the periapical, or the bitewing survey, used alone, is deficient for the evaluation of many radiographic signs. 5. The panoramic plus bitewing survey is the most effective survey for identifying patients with alveolar bone loss changes as well as impacted or unerupted teeth. 6. The periapical plus bitewing survey is the most effective survey for identifying interproximal caries and periodontal membrane changes. REFERENCES I. Henry, J. L., and Gracia. D. A.: Use of Radiographic ProJectrons in Dental Schools in the United States and Canada, J. Am. Dent. Assoc. 97: 947-948, 1978. 7. Van Aken. J., and Van der Linden, L. W.: The Integral Absorbed Dose in Conventional and Panoramic Complete Mouth Examinations, ORAL SURG. 22: 603-616. 1966. 3. Manson-Hing, L. R., and Greer, D. F.: Radiation Exposure and Distribution Measurements for Three Panoramic X-Ray Machines. ORAL SLIKG. 44: 3 13-321, 1977. 4. Hurlburt. C. E., and Wuehrmann, A. H.: Comparison 01 Interproximal Carious Lesion Detection in Panoramic and
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Radiography in Children, ORAL SURG. 46: 588-593, 1978 50. Patur, B.: Roentgenographic Evaluation of Alveolar Bone Changes in Periodontal Disease. Dent. Clin. North Am.. nn .. 47-54; 1960. 51. Phillips, J. D., and Shawkat, A. H.: A Study of the Radiographic Appearance of Osseous Defects on Panoramic and Conventional Films, ORAL SURG. 36: 745-749, 1973. 52. Prichard, J.F.: Advanced Periodontal Disease, Surgical and Prosthetic Management. Role of the Roentgenograph in Diagnosis, ed 2, Philadelphia, 1972, W. B. Saunders Comnany, pp. 142-147. 53. Priebe, W. A., et al.: Value of the Radiographic Film in the Different Diagnosis of Periapical Lesions, J. Dent. Res. 32: 675-676, 1953. 54. Ramadan, A. E., and Michell, D. F.: A Roentgenographic Study of Experimental Bone Destruction, ORAL SURG. 15: 934-943, 1962. 55. Raper, H. R.: Practical Clinical Preventive Dentistry Based Upon Periodic Roentgen-Ray Examination, J. Am. Dent. Assoc. 12: 1084-l 100, 1925. 56. Rees, T. D., et al.: Radiographic Interpretation of Periodontal Osseous Lesions, ORAL SURG. 32: I4 I - 153, I97 I. 57. Sandler. H. C., and Stahl, S. S.: Measurement of Periodontal Disease Prevalence, J. Am. Dent, Assoc. 58: 93-97, 1959. Essential to Diagnosis and 58. Smith, R. K.: The X-Ray-An Prognosis of the Child Patient, J. Am. Dent. Assoc. 29: 796-804, 1942. 59. Stafne, E. C.: Oral Roentgenographic Diagnosis. Infections of the Jaw, Philadelphia, 1958, W. B. Saunders Company, pp. 70-74. 60. Suomi, J. D.. ct al.: A Comparative Study of Radiographs and Pocket Measurements in Periodontal Disease Evaluation, J. Periodontol. 29: 3 I l-3 15, 1968. 61. Trithart, A. H., and Donnelly, C. J.: A Comparative Study of Proximal Cavities Found by Clinical and Roentgenographic Examination, J. Am. Dent. Assoc. 40: 33-37, 1950. 62. Updegrave, W. S.: The Role of Panoramic Radiography in Diagnosis, ORAL SURG. 22: 49-57, 1966. 63. Worth, H. M.: Principles and Practice of Oral Radiologic Interpretation. Periodontal Disease, Chicago. 1963, Year Book hledical Publishers, Inc., pp. 285-292.
Reprint requests to: Dr. A. H. Muhammed c/o Dr. Lincoln R. Manson-Hing University of Alabama School of Dentistry University Station Birmingham, Ala. 35294