Efficacy of dental radiographic practices: options for image receptors, examination selection, and patient selection

A R T I C L E S

M any technical factors and treatment philosophies affect the way dental radiology is practiced. Some, like m in im u m tube filtration, are legislated. Others, like proper darkroom techniques, are universally acknowledged as essential. Still others, like the selection of an image receptor and the selection o f the type o f examination, are the subject o f m uch discussion and debate. This article addresses some o f the more controversial options and choices facing dental practitioners by reviewing the standard assessment techniques available to help m ake appropriate decisions, by sum m arizing and analyzing available data, and by offering recommendations fo r practice.

Efficacy of dental radiographic practices: options for image receptors, examination selection, and patient selection Mel L. Kantor, DDS Samuel J. Zeichner, DMD, MA, MS Richard W. Valachovic, DMD Allan B. Reiskin, DDS, DPhil adiographic exam inations con­ methods been used to evaluate the efficacy stitute a significant portion of of d iag n o stic tests in d en tistry .6 T his den ta l h e a lth care services in article illustrates the statistical methods the U nited States. It is estim ated that used to ev alu ate d ia g n o stic efficacy, in 1970, 68 m illion dental radiographic sum m arizes the av ailab le data th at exam inations were conducted, exposing describe the efficacy of d e n tal radio279 million films. By 1978, these figures graphic procedures, and helps clinicians rose to 84 and 412 million, respectively.1 assess the appropriateness of dental XBy 1982, 105 m illion radiographic exam­ ray procedures for specific diagnostic inations were conducted, exposing 380 tasks. m illion films.2 T his constitutes between 36% and 47% of all radiographic exam­ Measures of performances inations taken for diagnostic purposes.2,3 Estimates of n atio n al expenditures for All diagnostic tests (for example, radio­ dental radiography range between $1.0 graphs, electric p u lp test, blood sugar and $2.5 billion annually.4,5 levels) are an attem pt to assess the “true Because of in c re a sin g p u b lic an d status” of patients. Clinicians often accept professional concern about health care test results at face value and assume that expenditures and efficient use of diag­ the test is 100% accurate. T his is rarely nostic tests, m any m edical d iag n o stic the case. Rather, a degree of uncertainty m odalities have been analyzed system­ is associated with every test result. Efficacy atic a lly for d ia g n o stic efficacy an d m easurem ents attem pt to quantify the usefulness. Only recently have standard degree of uncertainty. T hey include

R

sensitivity, specificity, predictive values, and receiver o p e ra tin g c h a ra c te ristic (ROC) analysis. T he evaluation of any diagnostic test requires the know ledge of tw o pieces of inform ation—whether the disease that is being considered is present or absent, and whether the diagnostic test for this disease is positive or negative. W ith this info rm atio n , a “ decision m a trix ” can be constructed th at relates the results of the d ia g n o stic test to the presence or absence of disease. T h e test resu lt (positive or negative) can then be iden­ tified as true or false, depending on the actual status of the patient. An example of a decisio n m a trix is illu s tra te d in Figure 1. W ith a decision m atrix , the p e rfo r­ m ance of a ra d io g ra p h ic test can be expressed in terms of its sensitivity and specificity. The sensitivity is the ability of the test to identify correctly those JADA, Vol. 119, A ugust 1989 ■ 259

ARTICLES

Actual disease state

Positive

Present

Absent

True positive (TP)

False positive (FP)

Fig 1 ■ T he standard d e c isio n m atrix is a tw o -b y -tw o

c o n tin ­

gency table that com ­ Negative

True negative (T N )

False negative (FN)

patients who have the disease. Sensitivity equals the percentage of actual lesions detected. Referring to the decision matrix, sensitivity eq u als true p o sitiv es/(tru e positives + false negatives). T he specificity is the a b ility of the test to identify correctly those patients who are free of disease. Specificity equals the percentage of n o rm a l cases id e n tifie d . W ith the decision m atrix, specificity equals true negatives/(false positives + true nega­ tives). A lth o u g h sensitivity an d specificity are im portant characteristics of a diag­ nostic test, they reflect only the p ro b ­ ability of obtaining a positive test result in subjects known to have a disease or a negative re su lt in h e a lth y patients. However, diagnostic tests are rarely, if ever, perform ed when the actual status of the patient is already known. There­ fore, clinically it is more useful to know the lik e lih o o d th a t a p a tie n t has the disease when the test result is positive, a n d the lik e lih o o d th a t a p a tie n t is diseasefree when the result is negative. T hese p ro b a b ilitie s are know n as the positive predictive value and negative predictive value, respectively. T h e ideal test has a sensitivity, spe­ cificity, positive predictive value, and negative predictive value of 100%. How­ ever, all actual tests have efficacy mea­ surements that are less than 100% (Fig 2). F urth erm o re, there is a reciprocal give-and-take relationship between sen­ sitivity an d specificity. T h e sensitivity of a test may be increased by changing the threshold value that separates normal from disease, b u t then the specificity of th a t test w ill decrease. Also, the predictive values of a test are influenced by the prevalence of the disease in the 260 ■ JADA, Vol. 119, A ugust 1989

pares the actual disease state

w ith

the

test

results.

population. Techniques based on Bayes’ theo rem are a v ailab le to a c co u n t for disease prevalence.7 Another im portant technique for mea­ su rin g ra d io g ra p h ic efficacy is RO C an aly sis. T h is a p p ro a c h p erm its an evaluation of the diagnostic test under clinical conditions, as well as the com­ parison of one type of test to another. T h e R O C analysis correlates the test result with the actual presence or absence of disease. T he results of the analysis may be presented as a curve or as a num ber that represents the area under the curve (Fig 3). The curve for an actual test will lie somewhere between the two, and will have an area between 0.5 and 1. 0 .

The ROC analysis is particularly useful for comparing the efficacy of two or more d ifferen t ra d io g ra p h ic m o d alities by testing for significant statistical differ­ ences between the areas under the curves that represent the competing modalities. The graphic representation of the ROC curve dem onstrates the reciprocal rela­ tio n sh ip between sensitivity and spec­ ificity as the decision criterion varies. A h y p o th e tica l R O C curve for caries detection illu strates this concept (Fig 4). If the decision criterion is very strict (the diagnostician is absolutely certain th a t a lesion is p resen t), then the sensitivity is low and many real lesions will be missed, but the specificity will be high and few or no healthy surfaces will be diagnosed incorrectly as diseased. If the decision criterion is relaxed (the diagnostician is less certain or equivocal a b o u t the presence of a lesion), then the sensitivity will increase b u t at the expense of reduced specificity. T h e selection of a decision threshold depends

on the clinical significance of detecting or m issing the lesion for the specific disease being investigated (for example, breast cancer versus dental caries). Determining the status of the patient, com m only called the “ g round tru th ,” is fundamental to assessing the efficacy of a diagnostic test. However, the ground truth is usually established by some other, independent diagnostic assessment. When com paring im aging systems, the “gold standard” for the ground truth is usually surgical co n firm a tio n o r m icroscopic analysis of b iopsied tissue. However, in som e c lin ic a l situ a tio n s, it is n o t possible to use the gold standard. For example, it is not possible to confirm an in c ip ie n t enam el lesion detected radiographically because confirm ation by tooth preparation or extraction are n o t acceptable altern ativ es. In these instances, the gro u n d tru th may have to be determined by the same diagnostic procedures that are being evaluated. The acceptability of such alternatives to the gold sta n d ard g ro u n d tru th may be enhanced if the test is perform ed by specialists o r by u sin g m u ltip le tests sim u ltan eo u sly an d in c o m b in a tio n .8 In all cases, the ground truth is a defined entity and its accuracy depends on the acceptability to investigators and c li­ nicians who are active in the field. A review of the uses an d abuses of the standard measures of efficacy may be found in papers by Swets8 and Gelfand and Ott.9 Dental radiography is used for initial diag n o sis and p a tie n t fo llo w -u p . Its success depends on m atching the appro­ p riate test to the task at h a n d and conducting the test properly. The rem ain­ der of this article reviews the available data for im age receptor selection and examination selection. Data derived from standard measures of efficacy are em pha­ sized when such data are available. Image receptors

Since the discovery of X rays in 1895, many improvements in equipm ent, film, and technique have resulted in images of greater diagnostic value with signif­ icant reduction in p a tie n t exposure.10 Dentists can choose from am ong three image receptors for intraoral use: D-speed dental film , E-speed dental film , and xeroradiographic plates. T he ap p licatio n of xeroradiography to dentistry began in earnest in the late 1970s11' 12 w ith the developm ent of an intraoral xeroradiography system (Xerox

ARTICLES

110 System, Xerox Medical Systems).13 In 1981, a new E-speed dental film was introduced (Kodak Ektaspeed, Eastman Kodak Co) which required approximately half the exposure of D-speed film (Kodak U ltrasp eed , E astm an Kodak Co) and p ro m ised to deliver the sam e im age quality.14 The performance characteristics and diagnostic yields for these alternative image receptors have been compared with D -speed film , the m ain stay of d en tal radiology since 1955.

Actual disease state Present 60

Absent 15

(TP)

(FP)

40

10

Positive 50

F ig 2 ■ H ypothetical decision matrix illu s ­ trates the calcu lation

S tudies have show n th at E-speed film is 1.7 to 2.3 tim es faster, has the sam e or slig h tly lower contrast, and has equal resolution as D-speed film .15-19 Similar studies have shown that a xeroradiograph is approx­ imately three to four times as fast, has less contrast, and has the same or slightly greater resolution as D-speed film .13,20 T he lower contrast of xeroradiography is offset by its unique characteristic of edge enhancement that makes boundaries between slightly different densities more obvious. Both technological advances are subject to processing problem s. E-speed film is less “forgiving” to careless processing th a n is D-speed film , especially w ith m anual processing.14,21 There are slight differences between D-speed and E-speed film even when processed properly. The differences between the two films vary depending on the processing technique (autom atic versus m anual versus rapid chem istry).22,23 T h e investigators con­ cluded that the faster E-speed film was more sensitive to varying conditions but that, when a quality assurance program was in place, either film may be clinically acceptable. X e ro ra d io g ra p h ic p lates sh o u ld be prepared, exposed, and processed within a 5- to 10-m inute in terv al; otherw ise there can be sig n ifican t im age d egra­ dation.24 W ith either technique, a significant num ber of image artifacts could interfere w ith diagnosis or necessitate a reexam­ ination. In a study that com pared the frequency an d sig n ifican ce of im age artifacts for xeroradiography and m an­ u ally processed film (D -speed an d Espeed), xero rad io g rap h y h a d a p p ro x ­ im ately three tim es as m any artifacts than film.25 This ratio would have been even greater had it n o t been th a t the embossed film dot and the m anufacturer’s id e n tific a tio n "K S ” were c o u n te d as artifacts on the dental film . However, not all artifacts result in retakes. In the Receptor characteristics.

Negative 25

(FN)

(TN)

20

5

o f standard m easures o f diagnostic efficacy. In this exam ple there are 75 p a tien ts; 60 p atien ts have disease and 15 p a tie n ts are

Sensitivity

=

TP

40

TP + FN

40 + 20

_

40

diseasefree. H ow ever,

=

0.66 or 66%

60

the test results suggest 50 p o sitiv e cases and 25

n e g a tiv e

cases

am ong the 75 patients.

Specificity

Positive PV

=

Negative PV =

TN

5

5

FP + TN

10 + 5

15

TP

40

40

TP + FP

40 + 10

50

tn

5

5

FN + TN

20 + 5

25

same study, the retake rate resulting from image artifacts was six times greater for xeroradiography than for film. A clinical study that compared xeroradio­ graphs to D-speed films using a subjective fo u r-p o in t ra tin g scale suggested that the x ero rad io g rap h s were esthetically equal or superior to the D-speed image.26 A nother study com pared E-speed with D-speed film for the detection of a rti­ ficially produced (known) lesions in the m arginal alveolar bone of a dry m an­ d ib le .27 T h e R O C an aly sis of the observers’ responses showed that E-speed film performed as well as D-speed film. A sim ila r a p p ro a c h u sin g cadaver specimens and ROC analysis compared xeroradiographs, E-speed, and D-speed films for the detection of calculus and showed no difference am ong these image receptors for th is d ia g n o stic ta sk .28 A d d itio n a lly , th is study show ed th a t dentists rad io graphically detected 55% to 60% of the calculus deposits, although they incorrectly identified calculus on 10% to 28% of the calculusfree surfaces.

= 0.33 or 33%

= 0.80 or 80%

= 0.20 or 20%

In other words, the sensitivity of radiog ra p h ic im ages for the d etectio n of calculus is 55% to 60%, and the specificity is 72% to 90%.

Radiographic efficacy in periodontics.

Radiographic efficacy in endodontics. Radio­ g ra p h y has tw o im p o rta n t roles in endodontics: the identification of bony changes for diagnosis and follow -up, and the confirm ation of root length and file p lacem en t d u rin g the treatm en t phase. T h e results of observer preference studies have been mixed. T w o studies compared films: one showed that D-speed film was preferred over E-speed,29 and the other suggested that both films were equally acceptable.30 Tw o studies com ­ pared xeroradiography w ith film rad i­ ography: one concluded that xeroradio­ g ra p h s were preferab le to E-speed radiographs,31 and the other showed that xeroradiographs and E-speed radiographs were eq u iv ale n t.32 W ith the exception of the last study, however, the authors of these studies did not attem pt to show a difference in the specific diagnostic inform ation provided by each modality.

K antor-O thers : EFFICACY O F R A D IO G R A P H IC PR A C T IC E S ■ 261

ARTICLES

An investigation of xeroradiographs and film for the detection of periapical lesio n s in h u m a n cadaver specim ens showed no difference am ong the three image receptors based on ROC analysis and a histological status.33 T his study also showed that the sensitivity for the ra d io g ra p h ic d etectio n of p e ria p ic a l lesions is 70%, and the specificity is 85% to 90%. A clinical version of this study, based on the sam e analy tic approach, had similar results.34 Tw o studies have assessed the accuracy of determ ining endodontic file placement: one co m p ared E-speed w ith D -speed film ,35 an d the other, xeroradiographs with D-speed film .36 Both studies showed no difference between the experimental im age receptor (E-speed film or xero­ radiographs) and the standard D-speed film for the accuracy of the measurement, based on the actual position of the files.

Fig 3 ■ T h e receiver o p eratin g ch aracteristics (R O C ) grap h is a p lot of the true-positive ratio (s e n sitiv ity ) a g a in st the fa lse positive ratio (1—specificity). T he straight d iagon al (C) represents a diagnostic test that is n o better than chance alone. A perfect test with a sensitivity equal to 1.0 (a true-positive ratio equal to 1.0) and a specificity equal to 1.0 (a fa ls e -p o s itiv e ratio eq u a l to 0) is plotted as a poin t in the upper left corner or as a “ curve” that follow s the left and upper borders of the graph. T he curve for real tests (Ri and R2) w ill lie between curves C and P, and the relative efficacy of Rj and R 2 can be False-positive ratio (1-specificity)

d eterm ined by c a lc u la tin g and co m p a rin g the areas under the curves.

Radiographic efficacy in restorative dentistry.

T he data for the diagnostic efficacy of D-speed film , E-speed film , and xeroradiography for the detection of carious lesions varies m ore th a n th a t for the d iag n o stic tasks discussed previously. Of six studies using extracted teeth with e ith e r n a tu ra l or sim u la te d cario u s lesions, three showed that D-speed film perform ed better than E-speed film ,37' 39 two showed them to be equivalent,40’41 and one showed E-speed and xeroradiography to perform better than D-speed film .42 A ll six stu d ies used sta n d a rd measures of efficacy. A clin ical inv estig atio n th at used a sp lit-m o u th e x p erim en tal design an d assumed that carious lesions are distrib­ uted ra n d o m ly fo u n d n o difference between D-speed and E-speed film for the detection of proxim al surface caries in a clin ical settin g an d found a sig ­ nificant observer variability.43 A second clin ical investigation th at compared xeroradiography with D-speed film and xeroradiography w ith E-speed film , u sin g direct clinical observation of prepared teeth to establish an inde­ p e n d e n t g ro u n d tru th , h ad sim ila r findings.44 A study investigating the effect of lesion size, film speed, an d rad io d e n sity of restorative m aterial on the detection of recurrent caries sim ulated on extracted teeth found no difference between the two films for this diagnostic task.45 In a c lin ic a l study th a t com pared xeroradiography with D-speed film and x e ro ra d io g ra p h y w ith E-speed film , xeroradiography was significantly better 262 ■ JA DA, Vol. 119, A ugust 1989

F ig 4 ■ H y p o th e tic a l receiver o p era tin g ch aracteristic (R O C ) graph for caries detection illu s ­ trates the reciprocal relationship between sensitivity and specificity as the decision criterion varies.

False-positive ratio (1-specificity)

in identifying actual recurrent carious lesions, but film was significantly better in identifying healthy surfaces.46 In other words, for detecting recurrent carious lesions, xeroradiography has better sen­ sitiv ity th a n film b u t film has better specificity. However, the authors of this study concluded th a t the overall p e r­ form ance of each im age receptor was about the same as the other two receptors, an d th at none of the im age receptors p erfo rm ed p a rtic u la rly w ell for the detection of recurrent carious lesions. T h e d ata suggest th a t the effect of kilovolt (peak) kV(p) on caries detection is small. In a clinical acceptance study, five o u t of e ig h t d en tists fo u n d no difference in diagnostic inform ation in radiographs exposed at 50 and 90 kV(p).47 Another study that used extracted teeth

and ROC analysis found a statistically sig n ificant difference of ab o u t 2% for cario u s lesion d etectio n w ith film s exposed at 50 and 90 kV(p).41 However, it is not likely that this small statistical difference can be extrapolated to a clinical setting. Observer bias and clinical acceptance. Among various available techniques, the criterion for selection sh o u ld be the a b ility to perform a p a rtic u la r d ia g n o stic task. However, the clinician’s subjective reac­ tion to the images may bias the decisions. Four blinded studies have show n that w hen observers are asked to rate the clinical acceptability of radiographs taken w ith both films, E-speed and D-speed radiographs are virtually indistinguish­ able.48-51 Similarly, there is no difference

ARTICLES

in the clinical acceptability of E-speed film and xeroradiographs.52 One study has show n th a t x ero ra d io g ra p h y is preferred to D-speed and E-speed film for some applications and that film is preferred to xeroradiography for other applications.53 Conclusion

O n the basis of the a v ailab le data, xeroradiography and E-speed film are equivalent alternatives to D-speed film for most dental radiographic diagnostic tasks (Table 1). Compared with D-speed film, xeroradiography is three times faster and E-speed film is twice as fast, resulting in one-third and one-half the radiation exp o su re, respectively. T h ese dosesparing alternatives that m aintain diag­ nostic in fo rm atio n m erit serious co n ­ sideration. Xeroradiography is substantially dif­ ferent from film radiography, requires special equipm ent and training of oper­ ators, and a slightly different approach to image interpretation. Intraoral xero­ radiography is not used widely in dental education facilities or am ong practicing clinicians. Unless xeroradiography can

Table 1 . Intraoral image receptors. A p p licatio n

C om parative perform ance

P erio d o n tic E n d o d o n tic R estorative Note:

< worse than;

X eroradiographs X eroradiographs X eroradiographs = equal to;

=

D-speed D-speed D-speed

= =

< = >

E-speed E-speed E-speed

> better than.

film in other circumstances. Examination selection

H istorically, intraoral radiography has been the workhorse of dental radiography. Recently, additional radiographic modal­ ities have su p p lem en ted tra d itio n a l intraoral films. For example, panoramic radiography has increased in popularity since its introduction in the late 1950s. It is estimated that annually, 18% of all dental X-ray units installed are panoramic u n its an d th a t at least 11 m illio n panoram ic films are exposed.4 Addition­ ally, co n v en tio n al skull rad io g rap h y , to m o g ra p h y , co m p u ted to m ography (CT), ultrasound, and magnetic resonance im a g in g (M RI) are being used in the

O n the basis of available data, xeroradiography and E-speed film are equivalent alternatives to D-speed film for most dental radiographic diagnostic tasks. These dose-sparing alternatives that maintain diagnostic information merit serious consideration. be show n clearly su p erio r to D-speed and E-speed film, it is not likely to replace film radiography in general. However, xeroradiography may be a useful adjunct to film for special diagnostic tasks. O n the other hand, E-speed film can be su b stitu ted easily for D-speed film with only slight modifications of expo­ sure tech n iq u e (long cone, added fil­ tration, in addition to shorter exposure times). E-speed is slightly more sensitive to su b o p tim al processing, b u t p ro p er dark ro o m an d p ro cessin g te ch n iq u es should always be used, regardless of film speed. Dentists should consider selecting film speed based on the a n ticip ated a p p li­ cation. For exam ple, given the varied results for caries detection, it may be a p p ro p ria te to use D -speed film for bitew ing radio g rap h s taken p rim arily for caries detection, and to use E-speed

= =

evaluation of facial traum a, sinus and salivary g lan d diseases, and tem poro­ m a n d ib u la r disorders. T h e follow ing sections of th is a rtic le focus on: the comparative performance of panoram ic and intraoral radiography for the detec­ tio n of com m on d e n tal p a th o lo g ic a l conditions—caries, periodontal disease, and periapical lesions; the performance of panoram ic and intraoral films used for the detection of significant occult (hidden) p ath ological conditions; and the comparative performance of various available methods for the evaluation of facial trauma, sinus disease, edentulous patients, and grow th and development of children and adolescents. Radiographic efficacy for detection of common dental pathological conditions. Several

rad io g rap h ic options are available for detecting com m on dental pathological

conditions. These include a full-m outh series (intraoral periapical and bitewing rad io g ra p h s), p an o ra m ic ra d io g ra p h s alone, bitewing radiographs alone, pan­ oram ic plus bitew ing radiographs, and a fu ll-m o u th series p lu s p a n o ra m ic rad io g rap h s. A ccording to one study, approxim ately 27% of dentists routinely use the full-m outh series and 40% rou­ tinely use the panoram ic plus bitewing radiographs as part of their new adult patient exam ination.54 Tw o studies compared panoram ic plus bitewing radiographs with a full-m outh series for the evaluation of alveolar bone height and showed no difference between the two m o d a litie s.55,56 H ow ever, the panoram ic survey alone did not compare favorably with the full-m outh series for this diagnostic task.55 T he ability to detect periapical lesions has been addressed in three investigations. In tw o of these studies, fewer lesions were detected with a panoram ic survey than w ith a full-m outh series.56,57 T he third study reported that an equivalent num ber of periapical lesions could be detected with a panoram ic survey as with a full-m outh series.55 Several studies com pared panoram ic radiography with intraoral films for caries d e te c tio n .55-59 T hese in v e stig a tio n s reported that intraoral films were better than the panoram ic view for the detection of carious lesions. For the detection of other intraosseous abnormalities, the num ber of panoram ic an d in tra o ra l fin d in g s was e q u a l.56,57 O th er studies in v estig a ted w h eth e r a p a n o ra m ic survey y ielded a d d itio n a l fin d in g s over a fu ll-m o u th series.60,61 A lth o u g h the investigators noted th at the p a n o ra m ic e x a m in a tio n pro v id ed additional inform ation, less th an 0.1% of the findings required treatment. However, the aforementioned data from the investigations are not sufficient to determine the efficacy of panoram ic and intraoral radiographs for the detection of pathological conditions. These studies sim ply totaled the num ber of positive findings identified with each technique.

K antor-O thers : EFFICACY O F R A D IO G R A P H IC PR A C T IC E S ■ 263

ARTICLES

If the totals were similar, the techniques were called equivalent; if the sums were different, the technique th at “revealed m o re ” was co n sid ered the p referred method. Such conclusions are justified o nly if a ll of the fin d in g s rep resen t treatable p a th o lo g ic a l co n d itio n s an d there are no false-positive findings. In any evaluation of alternative diagnostic tech n iq u es it is best to com pare each m ethod to the g ro u n d tru th th a t has been determ ined independently, and to use standard measures of efficacy. Tw o in vitro studies used ROC analysis to determ in e the efficacy of b itew in g radiographs for the detection of carious lesions.62,63 In these studies, extracted teeth were m ounted to sim ulate a dental arch and radiographs were obtained under standardized c o n d itio n s w ith D-speed film. The ground truth was established histologically or by direct visual inspec­ tion. The sensitivity of bitew ing radio­ graphs for the detection of carious lesions was 40% to 65%, and the specificity was 85% to 99%. W hen a tra d itio n a l g o ld stan d ard ground tru th is u n attain ab le, the best available estimate of the actual condition may be used as a substitute. In a recent study, the results of the sim ultaneous interpretation of each patient’s panoramic and full-m outh series (referred to as the consensus radiographic standard) were used to determ ine the relative efficacy of three radiographic surveys (panoramic alone, p a n o ra m ic p lu s b itew in g , an d tra d itio n a l fu ll-m o u th series) for the detection of carious lesions and alveolar changes associated w ith p e rio d o n ta l disease.64 T he sensitivity and specificity of each survey were calculated using the consensus radiographic standard as the ground truth. T h e sensitivities for the d etection of caries for the p an o ram ic survey alone, panoram ic plus bitewing, and the full-m outh series were 18%, 41%, and 70%, respectively, and the specificities were 99%, 99%, an d 98%, respectively. T he low sensitivity for the panoram ic survey alone is a result of poor detection of an terio r carious lesions (0.6%), and only “ fair” detection in the prem olars (26%) and molars (23%). T he sensitivities for the detection of periodontal disease for the panoram ic only, the panoram ic plus bitewing, and the full-m outh series were 95%, 100%, and 90%, respectively, and the specificities were 39%, 24%, and 44%, respectively. T hese data indicate th a t the fu ll-m o u th series is the best exam ination m odality for the detection of carious lesions, and that all surveys 264 ■ JA D A , Vol. 119, A ugust 1989

effectively avoid m isdiagnosing healthy surfaces. For the detection of periodontal disease, the panoram ic and panoram ic plus bitewing modalities are better than the full-m outh series, but they also are m ore likely to m isd iag n o se h ealth y situations as diseased than does the fullm outh series. Radiographic efficacy for the detection of OCCllIt disease. There is a common belief

th a t the larg er v isu al d isp la y of the p a n o ra m ic film com pared w ith the traditional full-mouth series examination is a significant advantage and that the panoram ic exam ination is useful for

pathological conditions.66,67 T h e resu lts of c iv ilia n p a n o ra m ic screening studies for the detection of abnorm alities are sim ilar. A review of 1,066 panoramic radiographs of members of the A m erican D ental A ssociation obtained d u rin g a health screening at an annual session revealed no significant treatable nonodontogenic pathological conditions.68 A survey of 6,780 pan o ram ic ra d io ­ graphs from a university teaching hos­ p ital and affiliated Veterans A dm inis­ tra tio n h o sp ita l, id en tifie d 68 (1%) dentigerous cysts, 64 (1%) residual cysts, 13 (0.2%) incisive canal cysts, and 6 (0.08%)

he belief that dentists have a responsibility to screen all of their patients for occult disease cannot be substan­ tiated from the available data, and is not recommended.

discovering significant occult patholog­ ical conditions. Various populations have been studied in an effort to determine the radiographic yield of occult lesions in asymptomatic subjects w ith panoram ic exam inations. Several of these reports are the results of panoram ic screenings in the military. A 1969 rep o rt on the den tal status of 5,556 US Air Force train ees found numerous missing teeth; teeth with large cario u s lesions r e q u irin g e x tra ctio n ; impacted teeth; periapical, periodontal, follicular radiolucent areas; and a smaller n u m b e r of reta in e d p rim ary teeth; retained roots; supernumerary teeth; and ra d io p a q u e , m ixed-density lesions of an undisclosed natu re.65 Isolated ra d i­ olucent areas were identified in 36 trainees (0.6% of the sample). Included in this category was one ameloblastic odontoma and several traumatic bone cysts. The authors of this study65 noted that 1,900 (36%) of the radiographs showed some finding that would not have been discovered by clinical ex am in atio n or p o sterio r bitew ing rad io g rap h s. Most of these abnorm alities were unerupted, impacted third molars. A dental history m ig h t have in d icated a lik e lih o o d of the situation; and a radiograph m ight have co n firm ed (n o t discovered) the finding. More recent studies on samples of 2,135 and 1,059 US Air Force trainees h ad sim ilar results, and n eith er m en­ tioned finding significant treatable occult

globulom axillary cysts.69 However, the investigators did not consult the clinical records so it is unknow n whether these findings are incidental observations in a screening process or how many patients had signs and sym ptom s th at resulted in the radiographic exam ination. T he ad d itio n of a p an o ram ic ex am ination to the clinical exam ination and selected intraoral radiographs for 1,000 consec­ utive patients at a dental school clinic changed the treatment in only 12 cases and none of the fin d in g s outside the field of an intraoral exam ination required treatment.70 A study conducted for the US Bureau of Radiological Health to establish highyield selection c riteria for p an o ram ic rad io g rap h y show ed th a t w hen the panoram ic rad io g rap h is obtained for a specific reason, the yield is high (this includes the confirm ation of im pacted teeth suspected clinically).61,71 However, the study also show ed th a t w hen a p anoram ic rad io g rap h is obtained for general screening purposes, the yield is low. A recent study based on the benefit plan records of 30 m illion people showed that screening for intrabony tum ors is not cost-effective from neither a financial nor a biological view.5 On the basis of panoramic screening alone, it costs about $8.6 m illio n per po sitiv e m a lig n a n t finding, and about $430,000 per positive benign finding. Additionally, the esti­

A R T I C L E S

Table 2 ■ Radiographic examinations for detection of common dental pathological conditions. C o m parative perform ance

A pplicatio n Intraoral Intraoral Intraoral

P eriodontic E ndodontic R estorative Legend:

= eq u al to;

= > >

Panoram ic* Panoram ic Pan o ram ic

> better th an .

♦Alveolar bone heights only. Requires supplementation with bitewing radiographs for assessment of changes in crestal cortication.

Table 3 ■ Radiographic examinations for various diagnostic tasks. A pplication*

C om parative perform ance

T rau m af m andible m idface

P an o ram ic P an o ram ic

S in u s f

P an o ram ic

E dentulous

Indications

>

M andible series Facial bones series

H istory and signs

<

=

S in u s series

H istory and signs

P an o ram ic

<

=

In trao ral

N o postoperative f ilm i

D evelopm ent

P an o ram ic

<

=

In trao ral

Age and signs

Legend:

= eq u al to;

< w orse th an ;

<

> better than.

* R andom and mass screenings are not an acceptable ap p licatio n of rad io g rap h ic ex a m in atio n since both the risk-benefit and cost-benefit ratios are unfavorable. t C om plete assessm ent of facial trau m a and sinus p athological con d itio n s may req u ire advanced im aging techniques such as tomography, computed tomography, or magnetic resonance imaging. £ If preextraction radiographs are available and extractions were done w ithout complications, then a postoperative rad io g rap hic exam ination may not be necessary. If there were surgical com p licatio n s o r the extractions were done sometime before the fabrication of the first prosthesis then radiographs are advised. Once residual pathological conditions have been ruled out, periodic radiographic réévaluations are not necessary.

p h e n o m e n o n (w hich rarely re q u ires trea tm en t), b u t less h e lp fu l in the detection of more significant pathological conditions such as mucosal thickening, bony changes, and m alignancy.81-83 In many instances of facial traum a and sinus disease, the p atien t’s clinical signs and symptoms indicate that a more sophis­ ticated im aging technique such as CT or MRI may be preferable. Dentists who treat children and ado­ lescents need to identify not only dental disease b u t situations interfering w ith norm al grow th and developm ent th at req u ire treatm ent. Some professionals believe that a “baseline” panoramic film is appropriate.84,85 Some developmental anom alies such as m issing, im pacted, an d su p e rn u m e ra ry teeth occur w ith sufficient frequency m aking it reasonable to evaluate asym ptom atic children.8^87 Several schemes that use selected intraoral views timed to the developmental status of the patient have been recommended as high-yield altern ativ es to the p a n ­ o ram ic su rv ey .88,89 Several p u b lish e d rep o rts c o n c ern in g false-positive and false-negative findings a ttrib u ta b le to the inherent characteristics of the p a n ­ oram ic im age suggest th at caution be used in interpreting the panoramic film w hen assessing developm ental a n o m ­ alies.90-98 Conclusion

m ated nu m b er of m alignancies found per m illio n screened is approxim ately the sam e as the estim ated n u m b er of malignancies induced by the radiographic screening pro ced u re.5 T h is study also show ed th a t in tra o ra l film s were sig ­ n ific a n tly b e tte r for the d etection of intraosseous lesions than were the p an ­ oramic radiographs. Radiographic efficacy of various imaging methods for other clinical applications, i t

is widely believed that panoram ic radio­ graphs are particularly useful in prosthodontics, oral and maxillofacial surgery, and pediatric dentistry. Panoram ic radiographs of edentulous patients are often obtained to rule out pathological conditions before fabrication of complete dentures, as well as to provide inform ation helpful to their fabrication. Studies of panoram ic surveys of eden­ tulous patients have shown that approx­ imately 40% to 60% of these radiographic exam inations disclose positive findings such as retain ed ro o t tips, u n eru p ted and impacted teeth, and isolated radio-

lucent and radiopaque lesions72,73; that these findings affect treatment in approx­ im ately 7% to 34% of the p a tie n ts.61,73 These data suggest that the preprosthetic radiographic evaluation of the asym p­ tom atic edentulous patient has a high yield th at may resu lt in the detection of tre a ta b le p a th o lo g ic a l c o n d itio n s. However, in one study, the panoram ic view was 25% less efficacious than the in tra o ra l p e ria p ic a l survey for this purpose.74 Once the baseline radiographic exam ination is obtained, periodic reex­ am ination in the asymptomatic patient is u n lik e ly to yield any ad d itio n a l findings.75,76 For the oral and maxillofacial surgeon treating facial traum a, various studies have show n the panoram ic film to be equal w ith or superior to the standard m an d ib u lar series for the detection of m an d ib u lar fractures,77-79 b u t of little a d d itio n a l value in the detectio n of midfacial fractures.80 Panoram ic exam­ ination for sinus pathological conditions is slightly better than the standard Waters view for d e tec tin g m ucous re te n tio n

In providing the best care to patients, dentists should select the radiographic exam ination modality that will contrib­ ute most to ap p ro p riate diagnosis and treatment (Tables 2, 3). M ost of the d ata suggest th a t the p anoram ic plus bitew ing exam ination is n o t an a d eq u a te su b stitu te for the traditional intraoral radiographic exam­ in a tio n for the d etectio n of com m on dental diseases—caries, periodontal dis­ ease, and periapical disease—in patients for w hom the re su lts of a c lin ic a l ex a m in a tio n in d ic a te the need for a com prehensive rad io g rap h ic ex am in a­ tion. T h e belief th a t d e n tists have a re sp o n sib ility to screen a ll of th e ir p a tie n ts for o c c u lt disease c a n n o t be substantiated from the available data, and is not recommended. T he panoramic radiograph may be useful in assessing edentulous patients; however, intraoral film s may be even m ore valuable. In the evaluation of facial traum a and sinus disease, the panoram ic view appears to be useful for the detection of m andibular fractures, but is inadequate for assessing

K antor-O thers : EFFICACY O F R A D IO G R A P H IC PR A C T IC E S ■ 265

ARTICLES

midfacial traum a and significant sinus p ath o lo g ical cond itio n s. D eterm ining the dental development of young patients can be accomplished easily w ith selected in trao ral rad io g rap h s taken at proper age intervals. Patient selection

U n til recen tly , d e n tists d id n o t have specific guidelines for the selective use of radiographs. A lthough some recently p u b lish e d textbooks recom m end th a t radiographs be ordered on the basis of the patient’s needs,99-101 other textbooks suggest th a t a fu ll-m o u th series be a required or routine p art of a complete in itia l p a tie n t e x a m in a tio n .102"105 T he majority of dental schools still prescribes a predeterm ined standard radiographic examination for most patients, although during the last 10 years there has been an increase in the n u m b er of schools that order radiographs based on patient needs.106 T h e A m erican D en tal A ssociation recommendations published in 1984 state that “ it is im p o rtan t to recognize that each patient is different from the next, so should radiographic exam ination be individualized for each patient” and that “ decisions re g a rd in g the use of ra d i­ ography should be based on the deter­ m ination of need arising from clinical examination and the dental and medical history of the patient.” 107 Although these recom m en d atio n s set the a p p ro p ria te tone for the use of rad io g rap h s, they do not provide specific inform ation that is useful to the clinician. During the past decade, several inves­ tigators have developed selection criteria for p an oram ic61,108 an d in trao ral ra d i­ o g ra p h y 109,110 th a t id en tify the m ost appropriate rad io g rap h ic exam ination modality for specific clinical signs and symptoms. T he Food and Drug Admin­ istration’s Center for Devices and Radio­ logical H e a lth has sponsored a series of expert panels to address the efficacy of radiographic exam inations in a variety of medical and dental applications. The Dental R adiographic P atien t Selection Criteria Panel’s final report has recently been published,111 offering specific, but flexible, guidelines for prescribing dental radiographs for the asymptomatic routine patient. T he recommendations take into account the patient’s developmental age, relative risk for d e n ta l disease, an d w hether the e x a m in a tio n is p a rt of a new or recall ap p o in tm e n t. T he FDA panel’s report has been adopted by the 266 ■ JADA, Vol. 119, August 1989

ADA an d has been incorporated in its updated recommendations published in 1989.112

Conclusion T h e re is n o a rb itra ry ra d io g ra p h ic examination that is appropriate for every p a tie n t. C o n trary to som e p u b lish e d textbooks and common opinion, a fullm o u th survey is not a requirem ent of every complete dental examination. Summary and recommendations

Dental radiography is used for various diagnostic tasks that include the detection of caries, p e ria p ic a l a n d p e rio d o n ta l disease, detection of in trabony lesions of the face and jaws, evaluation of sinuses and trauma, preprosthetic planning, and detection of developmental abnormalities. Recent data perm it in itial assessments of the efficacy of selected radiographic procedures for some of the aforem en­ tioned diagnostic tasks. Such assessments are essential in light of increasing public and professional concern about health care expenditures and efficient use of diagnostic tests. Additionally, these data provide the basis for certain recommen­ dations regarding clinical radiographic practice: —R adiographic exam inations should be tailored to the p a tie n t’s individual status and should be based on high-yield selection criteria. —Even under optim al conditions, the diagnostic yield from dental radiographs is limited, and radiographs should never be considered a substitute for a complete history and clinical examination. —T h e panoram ic radiograph should have a limited role in dental care delivery. G eneral dentists may avoid the capital expense and operating costs of a p a n ­ oram ic m achine w ith o u t concern that they are providing suboptimal care. —O n the basis of the evidence of the efficacy of E-speed film for the radiog ra p h ic d etectio n of com m on den tal p a th o lo g ic a l co n d itio n s, clin ic ia n s should feel confident adopting the faster film for most applications, knowing that diagnostic yield will be maintained and patient exposure reduced.

------------- J iADA ------------T he conclusions presented in this article are those drawn by the authors and do not necessarily represent the policy of the institutions w ith w hich the authors are affiliated, nor the policy of the American Dental Association.

In fo r m a tio n a b o u t th e m an ufacturers o f th e products m entioned in this article may be available from the author. Publication of the names o f products or m anufacturers does n ot im p ly endorsem ent by the American Dental Association.

Dr. Kantor is former assistant professor, section o f oral radiology, Sch ool of Dentistry, U niversity o f N orth C arolina, C hapel H ill; Dr. Zeichner is former senior staff fellow , diagnostic systems branch, N a tio n a l In stitu te o f D en tal R esearch, N a tio n a l Institutes of H ealth, Bethesda, MD; Dr. Valachovic is former assistan t professor, departm ent o f oral diagnosis and radiology, Harvard School of Dental M ed icin e, B oston; and Dr. R eisk in is professor, division of oral radiology, School of Dental Medicine, U niversity of Connecticut, Farmington. Drs. Kantor and V alachovic are currently at the U niversity o f Connecticut in Farmington; Dr. Zeichner is currently at C o lu m b ia U n iv e r sity in N ew York. A ddress requests for reprints to Dr. Kantor at the division of oral radiology, School of Dental Medicine, L6062, University of Connecticut Health Center, Farming­ ton, C T 06032. 1. Manny EF, Carlson KC, McClean PM, R achlin JA , S e g a l P, Story PC. An overview o f d en ta l radiology. Rockville, MD: N ational Center for Health Care Technology, 1980; (D H H S FDA publication). 2. Mettler FA. D iagn ostic radiology: usage and trends in the U nited States, 1964-1980. R adiology 1987;162:263-6. 3. Brown RF, Shaver JW, Lamel DA. The selection o f patients for x-ray exam ination. R ockville, MD: B ureau o f R a d io lo g ic a l H ealth , Food and D ru g Administration, 1980; DHEW publication no. (FDA) 80-8105. 4. Brooks SL, Lireka LP. Basic concepts in the selection of patients for dental x-ray exam inations. Rockville, MD: Center for Devices and R adiological H ealth, Food and Drug Administration, 1985; D H H S publication no. (FDA) 85-8249. 5. Zeichner SJ, Ruttim ann UE, Webber RL. Dental radiography: efficacy in the assessment of intraosseous lesions of the face and jaws in asymptomatic patients. R adiology 1987;162:691-5. 6. D o u g la s CW, M cN eil BJ. C lin ica l d e c isio n a n a ly s is m eth od s a p p lie d to d ia g n o stic tests in dentistry. J Dent Educ 1983;47:708-12. 7. H am burg M. Statistical analysis for decision m aking. 2nd ed. New York: Harcourt Brace Jovanovich, 1977:78-83. 8. Swets JA. Measuring the accuracy of diagnostic systems. Science 1988;240:1285-93. 9. G elfand DW, Ott DJ. M ethodologic c o n sid ­ e ra tio n s in c o m p a r in g im a g in g m eth od s. A JR 1985;144:1117-21. 10. R ichards A G , C o lq u itt W N . R ed u ction in dental x-ray exposures du rin g the p ast 60 years. JADA 1981;103:713-8. 11. Gratt BM, Sickles EA, Parks CP. Xeroradiography of dental structures—I. Preliminary inves­ tig a tio n s . O ral Su rg O ral M ed Oral P a th o l 1977;44:148-52. 12. Gratt BM, Sickles EA, Parks CR. Xeroradiography of dental structures—II. Im age analysis. Oral Surg Oral Med Oral Pathol 1978;46:156-65. 13. G ratt BM, W hite SC, Sickles EA, Jerom in LS. Im agin g properties of intraoral dental xeroradiography. JADA 1979;99:805-9. 14. Silha RE. T h e new Kodak Ektaspeed dental x-ray film. Dent Radiogr Photogr 1981;54:32-5. 15. T h u n th y K H , W ein b erg R. S e n sito m etric co m p a r iso n o f d en tal film s of g ro u p s D and E. Oral Surg Oral Med Oral Pathol 1982;54:250-2. 16. T am ura T , Kuroda M, Kashiwado N , et al.

ARTICLES

C h aracteristics o f h ig h sp eed d en tal x-ray film . Josai Shika Daigaku Kiyo 1982;11:103-7. 17. Frykholm A. Kodak Ektaspeed—a new dental x-ray film . D entom axillofac Radiol 1983;12:47-9. 18. Kaffe I, Littner MM, Kuspet ME. Densitometric evaluation of intraoral x-ray films: Ektaspeed versus U ltr a sp e ed . O ral Su rg O ral M ed O ral P a th o l 1984;57:338-42. 19. H avu k a in en R, Servom aa A. C haracteristic curves of dental x-ray film . Oral Surg M ed Oral Pathol 1986;62:107-9. 20. Gratt BM, Sickles EA, G ould R G , Jerom in LS, White SC. Xeroradiography of dental structures— IV. Image properties o f a dedicated intraoral system. Oral Surg Oral Med Oral Pathol 1980;50:572-9. 21. K ogon S, S tep hens R , R eid J, M acD on ald J. T he effects o f processing variables on the contrast of type D and type E dental film. Dentom axillofac Radiol 1985;14:65-8. 22. D iehl R, Gratt BM, G ould RG. Radiographic quality control m easurem ents com paring D-speed film , E-speed film , and xeroradiography. Oral Surg Oral Med Oral Pathol 1986;61:635-40. 231 Kaffe I, Gratt BM. E-speed dental film processed w ith rapid chemistry: a com parison w ith D -speed film. Oral Surg Oral Med Oral Pathol 1987;64:36772. 24. Gratt BM, Kashima I, Sickles EA. Time-delay im age degradation w ith dental xeroradiography. Oral Surg Oral Med Oral Pathol 1982;54:696-700. 25. Gratt BM, Sickles EA, Littm an RI. Comparison of dental xeroradiography and co n v en tio n a l film tech n iq u es for the frequency and sig n ifica n ce of im age artifacts. Oral Surg Oral Med Oral P athol 1985;60:546-52. 26. Gratt BM, Sickles EA, Armitage GC. U se of dental xeroradiographs in periodontics—comparison w ith c o n v e n tio n a l ra d io g ra p h s. I P e r io d o n to l 1980;51:1-4. 27. G ron d a h l K, G ro n d a h l H -G , O lv in g A . A com p arison o f Kodak Ektaspeed and U ltraspeed film s for the detection of periodontal bone lesions. Dentom axillofac Radiol 1983;12:43-6. 28. W hite SC, Gratt BM, Hollender L. Comparison of xeroradiographs and film for detection of calculus. D entom axillofac Radiol 1984;13:39-43. 29. Kleier DJ, Benner SJ, Averbach RE. T w o dental x-ray film s com pared for rater preference u sin g endodontic views. Oral Surg Oral Med Oral Pathol 1985;59:201-5. 30. D o n n e lly JC, H a rtw ell G R , J o h n so n WB. C lin ica l ev a lu a tio n o f Ektaspeed film for u se in endodontics. J Endod 1985;11:90-4. 31. Barkhordar RA, N icholson RJ, N guyen N T , Abbasi J. A n ev a lu a tio n o f xeroradiograp hs and radiographs in length determination in endodontics. Oral Surg Oral Med Oral Pathol 1987;64;747-50. 32. Barkhordar RA, Kempler D. A com parison betw een xeroradiography and co n v en tio n a l radi­ ograp h y in the d ia g n o sis o f e n d o d o n tic lesio n s. Oral Surg Oral Med Oral Pathol 1988;66:480-93. 33. W hite SC, Hollender L, Gratt BM. Comparison o f x ero ra d io g ra p h s and film for d e te c tio n o f periapical lesions. J Dent Res 1984;63:910-3. 34. G ratt BM, W hite SC, L ucatorto FM, Sapp JP, Kaffe I. A clinical comparison of xeroradiography and c o n v e n tio n a l film for the in ter p r e ta tio n of periapical structures. J Endod 1986;12:346-51. 35. G irsch W J, M atteson SR , McKee M N . An evaluation o f Kodak Ektaspeed periapical film for use in endodontics. J Endod 1983;9:282-8. 36. S an M arco PA , M on tgom ery S. U se o f xeroradiography for length determ ination in end­ o d o n tic s. O ral Su rg O ral M ed O ral P a th o l 1984;57:308-14. 37. O kano T , H u a n g H-J, Nakamura T . D ia g ­ nostic accuracy o n detection o f proxim al enam el

le sio n s in non screen rad io g ra p h ic perform ance. Oral Surg Oral Med Oral Pathol 1985;59:543-7. 38. Sanderink GCH, Scholte CM. A comparison b etw een tw o d e n ta l film s an d tw o film -screen com binations in detecting low contrast defects and in itia l caries. D entom axillofac R adiol 1985; 14:11322 . 39. L undeen RC, M cD avid W D, B arnw ell GM. Proxim al surface caries detection with direct-exposure and rare earth screen/film im aging. Oral Surg Oral Med Oral Pathol 1988;66:734-45. 40. K ogon SL, Stephens R G , R eid JA, D onner A. Ektaspeed and a screen /film system compared w ith U ltra sp eed in th e in ter p r e ta tio n o f early p r o x im a l caries. J C an D en t A ssoc 1984;50:397401. 41. Svenson B, Grondahl H-G, Petersson A, O lving A. A ccuracy o f r a d iograp h ic caries d ia g n o sis at different k ilo v o ltages and tw o film speeds. Swed Dent J 1985;9:37-43. 42. White SC, Hollender L, Gratt BM. Comparison o f xeroradiographs and film for detection of proximal surface caries. JADA 1984;108:755-9. 43. Kantor ML, Reiskin AB, Lurie AG. A clinical com parison o f x-ray film s for detection of proximal surface caries. JADA 1985;lll;967-9. 44. W hite SC, Gratt BM, Bauer JG. A clin ica l comparison o f xeroradiography and film radiography for the detection of proxim al caries. Oral Surg Oral Med Oral Pathol 1988;65:242-8. 45. Matteson SR, P h illips C, Kantor ML, Leinedecker T. T he effect of lesion size, restorative material and film speed o n the detection of recurrent caries. Oral Surg Oral Med Oral Pathol (in press) 1989. 46. Gratt BM, W hite SC, Bauer JG. A clin ica l comparison o f xeroradiography and film radiography for the detection of recurrent caries. Oral Surg Oral Med Oral Pathol 1988;65:483-9. 47. A n tok u S, R u sse ll W J, Beach D R , Kihara T . E ffect o f c o n tr o lla b le param eters on oral radiographs (I). Quintessence Int 1984;15:71-6. 48. Reynolds RL. A clinical evaluation of Kodak E ktaspeed dental x-ray film . J O kla D ent A ssoc 1982;73:13-4. 49. K augars G E, H arm on FJ, K augars CC. A com parison o f D- and E-speed intraoral film. Gen Dent 1984;32:316-7. 50. H orton PS, S ip p y FH , K ohout FJ, N elson JF, K ienzle GC. A c lin ic a l com p arison of speed group D and E dental x-ray films. Oral Surg Oral Med Oral Pathol 1984;58:104-8. 51. Frommer H H , Jain RK. A comparative clinical study o f g ro u p D and E dental film . O ral Surg Oral Med Oral Pathol 1987;63:738-42. 52. L u d lo w JB, H ill R A , H ayes CJ. U se of a “sandw ich” technique to control im age geometry in clin ica l studies com paring intraoral xeroradio­ graphs and E-speed film. Oral Surg Oral Med Oral Pathol 1988;65:618-25. 53. G ratt BM, W hite SC, H a lse A. C lin ica l recom m endations for the use of D -speed film , Espeed film , and xeroradiography. JADA 1988; 117:60914. 54. Matteson SR, Morrison WS, Stanek EJ, Phillips C. A survey o f radiographs obtained at the initial dental ex a m in a tion and patien t selection criteria for bitew ings at recall. JADA 1983;107:586-90. 55. M uham med A H , M anson-H ing LR. A com ­ parison o f panoram ic and intraoral radiographic surveys in evaluating a dental c lin ic p op u lation . Oral Surg Oral Med Oral Pathol 1982;54:108-17. 56. Stephens RG, Kogon SL, Reid JA, Ruprecht A. A comparison of panorex and intraoral surveys for routine dental radiography. J Can Dent Assoc 1977;43:281-6. 57. Davies EE, Meister F, Lommel TJ. Panoramic versus periapical surveys—a comparison of findings

on freshman dental students. Dent Radiogr PhotQgr 1977;50:41-7. 58. Ohba T , Katayama H . Comparison of ortho­ pantom ography w ith conventional periapical dental ra d io g ra p h y . O ral Su rg O ral M ed O ral P a th o l 1972;34:524-30. 59. Hurlburt CE, W uehrmann AH. C om parison of interproxim al carious lesion d etection in p a n ­ oram ic and standard intraoral radiography. JADA 1976;93:1154-8. 60. W hite SC, Weissman DD. Relative discernment of lesions by intraoral and panoram ic radiography. JADA 1977;95:1117-21. 61. White SC, Forsythe AB, Joseph LP. Patientselection criteria for panoram ic radiography. Oral Surg Oral Med Oral Pathol 1984;57:681-90. 62. M ilem an P. R ad iograp h ic caries d ia g n o sis and restorative treatm ent d ecisio n m ak in g. G ro­ ningen: Drukkerij Vanden Deren BV, 1985. 63. Espelid I. R adiographic diagnosis and treat­ m ent decision on app roxim al caries. C om m u nity D ent Oral E pidem iol 1986;14:265-70. 64. V alachovic RW, D ouglass CW, R eisk in AB, C hauncey H H , M cNeil BJ. T h e use of panoram ic rad iograp h y in th e e v a lu a tio n o f a sy m p to m a tic a d u lt d ental p atien ts. O ral Surg O ral M ed Oral Pathol 1986;61:289-96. 65. Morris CR, Marano PD, Swim ley DC, R unco JG. Abnormalities noted on panoram ic radiographs. Oral Surg Oral Med Oral Pathol 1969;28:772-82. 66. L angenderfer WR, W ilson SR , H aw ley RJ, M ayhew RB, Infeld P, H ouston GD. A n analysis o f pantom ographs from US Air Force recruits. Gen Dent 1985;33:224-8. 67. Burgess JO. A panoramic radiographic analysis o f A ir Force basic trainees. Oral Surg O ral Med Oral Pathol 1985;60:113-7. 68. Langland OE, Langlais RP, Morris CR, Preece JW . P a n o ra m ic r a d io g r a p h ic survey o f d e n tists p articip atin g in ADA health screen ing programs: 1976, 1977, and 1978. JADA 1980;101:279-82. 69. Alattar MM, Baughm an RA, C ollett WK. A survey o f p an oram ic radiographs for e v a lu a tio n of normal and pathologic findings. Oral Surg Oral Med Oral Pathol 1980;50:472-8. 70. Barrett AP, Waters BE, Griffiths CJ. A critical evaluation of panoram ic radiography as a screening procedure in dental practice. Oral Surg Oral Med Oral Pathol 1984;57:673-7. 71. W hite SC, Forsythe AB. H ig h -y ield criteria for panoram ic radiography. R ockville, MD: Bureau o f R a d io lo g ica l H ea lth , Food and D ru g A d m in ­ istration, 1982; D H H S pu b lication no. (FDA) 828186. 72. Perrelet LA, Bernhard M, Spirgi M. Panoramic ra d io g ra p h y in th e e x a m in a tio n of e d e n tu lo u s patients. Oral Surg Oral Med Oral Pathol 1977;37:4948.

73. Keur JJ. Radiographic screening of edentulous patients: sense or nonsense? A risk benefit analysis. Oral Surg Oral Med Oral Pathol 1986;62:463-7. 74. Scandrett FR, T ebo H G , M iller JT , Q uigley MB. R a d io g r a p h ic e x a m in a tio n o f e d e n tu lo u s patients. Oral Surg Oral Med Oral Pathol 1973;35:26674. 75. Lloyd PM, Gambert SR. Periodic oral exam ­ in ation and panoram ic radiographs in edentulous eld e r ly m en . O ral Surg O ral M ed O ral P a th o l 1984;57:678-80. 76. G arcia R I, V alachovic RW, C hauncey H H . L o n g itu d in a l stu d y o f the d ia g n o stic y ie ld o f panoram ic radiographs in a gin g edentu lous men. Oral Surg Oral Med Oral Pathol 1987;63:494-7. 77. Chayra GA, Meador LR, Laskin DM. C om ­ p arison o f p an oram ic and standard rad iograp h s for the d iagn osis o f m andibular fractures. J Oral M axillofac Surg 1986;44:677-9.

Kantor-Others : EFFICACY OF RADIOGRAPHIC PRACTICES ■ 267

ARTICLES

78. J o h n s t o n C C , D o ris P E . C lin ic a l tr ia l o f p a n to m o g ra p h y for ev alu atio n of m a n d ib u la r traum a. A nn E m erg Med 1980;9:415-8. 79. N o ik u ra T , S h in o d a K, A ndo S. Im age visibility o f m a x illo - f a c ia l fr a c tu re s in c o n v e n tio n a l a n d p a n o ra m ic ra d io g ra p h y . D e n to m a x illo fa c R ad io l 1978;7:35-42. 80. M o ila n e n A. M id fa c ia l fr a c tu re s in d e n ta l pa n o ra m ic rad io g rap h y . O ra l S u rg O ral Med O ral P athol 1984;57:106-10. ‘81. O h b a T , K atay am a H . C o m p a riso n of p a n ­ o r a m ic r a d io g r a p h y a n d W a te r’s p r o je c tio n in d ia g n o s is o f m a x illa r y s in u s d isea se. O ra l S u rg O ral Med O ra l P a th o l 1976;42:534-8. 82. O h b a T . V alue an d lim ita tio n of p an o ram ic ra d io g ra p h y in th e d ia g n o s is o f m a x illa ry s in u s pathosis. In t J O ral S urg 1977;6:211-4. 83. H a id a r Z. D ia g n o s tic lim ita tio n s of o r th o ­ p a n to m o g ra p h y w ith lesio n s o f th e a n tru m . O ral S urg O ral M ed O ra l P a th o l 1978;46:449-53. 84. M yers D R . D e n ta l r a d io lo g y fo r c h ild re n . D ent C lin N o rth Am 1984;28:37-45. 85. Myers D R , B arenie J T , Bell RA. T h e diagnostic v a lu e o f a s e c o n d p a n o ra m ic r a d io g ra p h d u r in g the developin g d en titio n . J Pedod 1984;8:160-4. 86. P ilo R, Kaffe I, A m ir E, S arn at H . D iagnosis of developm en tal d e n tal anom alies, u sin g p an o ram ic radiographs. ASDC J D ent C h ild 1987;54:267-72. 87. B u e n v ia je T M , R a p p R . D e n ta l a n o m a lie s in c h ild r e n : a c lin ic a l a n d r a d io g r a p h ic survey. ASDC J D ent C h ild 1984;51:42-6. 88. V a la c h o v ic R W , L u r ie A G . R is k - b e n e fit c o n s id e r a tio n s in p e d o d o n tic ra d io lo g y . P e d ia tr D ent 1980;2:128-46. 89. W hite SC. R ad iatio n in dentistry for children. J Pedod 1984;8:242-56. 90. Bean L R , A kerm an WY. In trao ral o r pan o ram ic radiography? D ent C lin N o rth A m 1984;28:47-55.

91. T r o n je G . Im a g e d is to rtio n in ro ta tio n a l p a n o ra m ic ra d io g ra p h y . D e n to m a x illo fa c R adiol 1982:Suppl 3). 92. M cDavid W D, T ro n je G , W elander U, M orris CR, N u m m ik o sk i P. Im a g in g characteristics of seven p a n o r a m ic x -ra y u n its . D e n to m a x illo fa c R a d io l 1985:(Suppl 8). 93. K augars G E, C o llett WK. P a n o ra m ic ghosts. O ral S urg O ral M ed O ral P ath o l 1987;63:103-8. 94. F a rm a n A G , P h e lp s R , D ow ns JB . A rtifac t o r pathosis? Problem so lv in g for p an o ra m ic dental radiology. Q uintessence In t 1983;14:55-65. 95. S e w e rin I. A rtif a c ts d u e to m o v e m e n t in ro ta tio n a l p a n o ra m ic ra d io g ra p h y . A ngle O rth o d 1983;53:165-71. 96. M atteson SR, L u p to n CR, M orrison WS. Effect o f p a n o ra m ic focal tro u g h to p o g ra p h y o n ra d io g r a p h ic im a g in g o f s u p e r n u m e r a r y te e th in the an te rio r region. J O ral M axillofac S urg 1982;40:3189. 97. M cV an ey T P , K a lk w a rf K L. M isd ia g n o s is o f a n im p a c te d s u p e r n u m e r a r y to o th fro m a p a n o g ra p h ic ra d io g ra p h . O ral S urg O ral Med O ral P ath o l 1976;41:678-81. 98. T esin i DA, Ficarelli JP . S upernum erary tooth? O ral S urg O ral Med O ral P a th o l 1978;46:463-4. 99. L an g lais R P, B ricker SL, C ottone JA, Baker BR. O ra l d ia g n o sis, o ra l m e d ic in e a n d tre a tm e n t p la n n in g . P h ilad e lp h ia : WB Saunders, 1984. 100. S tu rd e v a n t CM , B a rto n R E , S ockw ell C L , S tric k la n d W D. T h e a rt a n d science o f o p e ra tiv e dentistry. St. L ouis: CV M osby, 1985. 101. P in k h a m JR , C asam assim o PS, Fields HW , M cT igue D J, N ow ak A J. P ediatric dentistry: infancy th ro u g h adolescence. P h ila d e lp h ia : WB Saunders, 1988. 102. M itc h e ll D F, S ta n d is h SM, F ast T B . O ra l d ia g n o sis/o ral m edicine. 3rd ed. P h ilad e lp h ia : Lea

8c Febiger, 1978. 103. C randell CE. C om prehensive care in dentistry. L ittleton, MA: PSG P u b lish in g , 1979. 104. C a s ta ld i C R , B rass GA. D e n tistry fo r the adolescent. P h ilad e lp h ia : WB S aunderj, 1980. 105. K err D A, A sh M M , M illa rd H D . O ra l diagnosis. St. L ouis: CV Mosby, 1983. 106. K a n to r M L. R a d io g ra p h ic e x a m in a tio n of com prehensive care p a tie n ts in U.S. and C anadian d e n ta l schools. O ra l S u rg O ral M ed O ral P a th o l 1988;65:778-81. 107. A m e ric a n D e n ta l A ss o c ia tio n C o u n c il o n D e n ta l M a te ria ls , I n s tru m e n ts , a n d E q u ip m e n t. R eco m m en d atio n s in ra d io g ra p h ic practices, 1984. JADA 1984;109:764-5. 108. K ogon SL , S te p h e n s R G . Selective ra d io g ­ ra p h y instead of screening p a n to m o g ra p h y —a ris k / ben efit e v alu atio n . J C an D ent Assoc 1982;48:2715. 109. Brooks SL. A study of selection criteria for in trao ral d e ntal rad io g rap h y . O ral S urg O ra l M ed O ral P ath o l 1986;62:234-9. 110. C ale AE, K augars G E. R eduction in bitew ing ra d io g ra p h s for p a tie n ts w ith n o clin ic al sig n s of dental caries. G en D ent 1987;35:292-4. 111. T h e D ental R ad io g ra p h ic P a tie n t Selection C rite ria P a n e l a n d J o s e p h L P . T h e s e le c tio n of p a tie n ts for x-ray e x am ination: dental ra diographic e x a m in a tio n s. R o c k v ille , MD: C e n te r for Devices a n d R ad io lo g ica l H e a lth , F ood a n d D ru g A d m in ­ is tra tio n , 1988; D H H S p u b lic a tio n no. (FDA) 888273. 112. A m e ric a n D e n ta l A ss o c ia tio n C o u n c il o n D e n ta l M a te ria ls , In s tr u m e n ts , a n d E q u ip m e n t. R e c o m m e n d a tio n s in ra d io g r a p h ic p ra c tic e s: a n update, 1988. JAD A 1989;118:115-7.

Self-Assessment Questions 1. The measure of the ability of a diagnostic test to correctly identify patients who are diseasefree is the a) sensitivity b) specificity c) positive predictive value d) negative predictive value

3. What percentage of carious lesions

5. A full-mouth survey is not a require­

that are actually present will be detected radiographically? a) 10% to 25% b) 50% to 65% c) 80% to 95%

m ent for every com plete dental examination. a) true b) false

2. For most dental radiographic diag­

4. Panoramic radiography should be

nostic tasks, E-speed film is _________ to D-speed film. a) inferior b) equivalent c) superior

used to screen all patients for occult disease. a) true b) false

268 ■ JADA, Vol. 119, A ugust 1989

Answers are found in the People 8c Meetings section.