45. Diagnosis /Indices - Radiographic Interpretation                                    

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Are Radiographs an accurate method of diagnosing periodontal disease?

  1. Hardekopf J, et al. The "furcation arrow" - A reliable radiographic image? J Periodontol. 58:258 - 261, 1986.

  2. Deas DE, Moritz A., Mealey B et al: Clinical reliability of the furcation arrow as a diagnositc marker. J Periodontol 2006;77;1436-1441

  3. Ortman L, McHenry K, Hausmann E: Relationship between alveolar bone measured by 1251 absorptiometry with abalsysis of standardized radiographs: 2. Bjorn technique: J Periodntol 1982;53:311-314

  4. Buchanan SA, et al: Radiographic detection of dental calculus. J Periodontol. 58:747-751, 1987.

What alveolar crest level represents bone loss on a bitewing radiograph??

  1. Hausman E., Allen K., Clerehugh V. What alveolar crest level on a bite wing radiograph represents bone loss? J Periodontol 1991;62;570-572

Are digital radiographs equivalent to conventional radiographs in revealing bone loss?

  1. Khocht A, Janal M, Harasty L, Chang K: Comparison of direct digital and conventioanl intraoral radiographs in detecting alveolar bone loss. J Am Dent Assoc 2003;134;1468-1475

  2. Bruder G, Casale J, Goren, A, Friedman S; Alteration of computer dental radiography images J Endod 1999;25;275-276

Are panoramic radiographs ever of value in periodontics?

  1. Kasaj A, Vasiliu Ch, Willershausen B. Assessment of alveolar bone loss and angular bony defects on panoramic radiographs. Eur J Med Res. 2008 Jan 23;13(1):26-30.

  2. Persson RE, Tzannetou S, Feloutzis AG, Brägger U, Persson GR, Lang NP. Comparison between panoramic and intra-oral radiographs for the assessment of alveolar bone levels in a periodontal maintenance population. J Clin Periodontol. 2003 Sep;30(9):833-9.

When should cone beam computed tomography (CBCT) be used?

  1. The American Dental Association Council on Scientific Affairs. The use of cone beam computed tomography in dentistry: An advisory statement from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2012;143;899-902

  2. Misch KA, Yi ES, Sarment DP: Accuracy of cone beam computed tomography for periodontal defect measurements.. J Periodontol. 2006 Jul;77(7):1261-6.

  3. Vandenberghe B, Jacobs R, Yang J. Detection of periodontal bone loss using digital intraoral and cone beam computed tomography images: an in vitro assessment of bony and/or infrabony defects. Dentomaxillofac Radiol. 2008 Jul;37(5):252-60.

What if the significance of the lamina dura?

  1. Tibbetts J, Allen K, Hausmann E: Effect of x-ray angulation on radiographic periodontal ligament space width. J Periodontol 63: 114-117, 1992

  2. Greenstein G, Polson A, et al: Associations between crestal lamina dura and periodontal status. J. Periodontol. 52:362-366, 1981.

Can radiographs be used to detect progression of periodontitis?

  1. Selikowitz H-S, et al: Retrospective longitudinal study of the rate of alveolar bone loss in humans using bite-wing radiographs. J. Clin. Periodontol. 8:431-438,1981.

Are radiographs an accurate way to assess healing after periodontal surgery?   Do newer radiographic techniques improve the usefulness of radiographs?

  1. Toback GA, Brunsvold MA, et al. The accuracy of radiographic methods in assessing the outcome of periodontal regenerative therapy. J Periodont 70:1479-1489,1999.

  2. Zybutz M, Rapoport D, Laurell L, Persson GR. Comparisons of clinical and radiographicmeasurements of inter-proximal vertical defects before and 1 year after surgical treatments. J Clin Periodontol 27:179-186, 2000.

  3. Grimard BA, Hoidal MJ, Mills MP, Mellonig JT, Nummikoski PV, Mealey BL. Comparison of clinical, periapical radiograph, and cone-beam volume tomography measurement techniques for assessing bone level changes following regenerative periodontal therapy. J Periodontol. 2009 Jan;80(1):48-55.

  4. Goren AD, Dunn SM, Wolff M, van der Stelt PF, Colosi DC, Golub LM. Pilot study: digital subtraction radiography as a tool to assess alveolar bone changes in periodontitis patients under treatment with subantimicrobial doses of doxycycline. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; Oct;106(4):e40-5. Epub 2008 Aug 20.

How do Radiographic Measurements Compare to Clinical Examination Measurements?

  1. Papapanou PN, Wennstrom JL: Radiographic and clinical assessments of destructive periodontal disease. J Clin Periodontol. 16:609-612, 1989.

  2. Machtei EE, Hausmann E, Grossi SG, Dunford R, Genco RJ. The relationship and clinical changes in the periodontium. J Perio Res 32:661-666, 1997.

  3. Eickholz P, Hausmann E. Accuracy of radiographic assessment of interproximal bone loss in intrabony defects using linear measurements. Euro J Oral Sci 108:70-73, 2000.

  4. Pilgram TK, Hildebolt CF, et al. Relationships between radiographic alveolar bone height and probing attachment level: data from healthy post-menopausal women. J Clin Perio 27:341-346, 2000.

Comparison of Techniques

  1. Reed BE, Polson AM : Relationships between bitewing and periapical radiographs in assessing crestal alveolar bone levels. J. Periodontol. 55:22-27, 1984.

Reviews

  1. Benn DK. A review of the reliability of radiographic measurements in estimating alveolar bone changes. J. Clin. Periodontol. 17:14-21, 1990. (Review)

  2. Jeffcoat MK. Radiographic methods for the detection of progressive alveolar bone loss. J Periodontol 63: (Suppl 4) 367-372, 1992. (Review)

  3. Tugnait A, Clerehugh V, Hirschmann PN. The usefulness of radiographs in diagnosis and management of periodontal diseases: a review. J Dent 28:219-226, 2000. (Review)

  4. Kim IH, Mupparapu M.Dental radiographic guidelines: a review. Quintessence Int. 2009 May;40(5):389-98. Review

Are Radiographs an accurate method of diagnosing periodontal disease?

Topic: Furcation Arrow

Authors: Hardekopf J, et al.                                ARTICLE

Title: The "furcation arrow" - A reliable radiographic image?

Source: J.Periodontol.58:258-261,1986.
Type: Clinical study

Rating: Good

Keywords: Furcation Arrow, Radiograph

Furcation Arrow: Small triangular shadow across the mesial or distal roots of maxillary molars. Indicates class II or class III involvement.

P: To determine whether there is a consistent relationship between furcation arrows on radiographs and proximal bony furcation involvement in maxillary molars.

M&M: 45 adult human skulls with proximal furcation involvement in maxillary 1st or 2nd molars were used. 66 Degree 1, 53 Degree 2, 43 Degree 3 proximal furcation involvements. An additional 120 proximal furcations without bony involvement served as controls. Furcation classifications were determined independently by two examiners. Each maxillary molar was radiographed radiographed. Film placement was standardized to minimize interproximal overlap and to position the film lingually/palatally on a plane that paralleled the buccal surfaces of the teeth radiographed. Evaluations for the presence of the furcation arrow were made independently by 6 dentists as the radiographs were projected onto a screen. Projected radiographs with identifiable “arrow” images were used.

R: Incidence of furcation arrow image over degree 2 and 3 involvements was significantly greater than that observed over the uninvolved controls. The incidence of the furcation arrow image over the 120 uninvolved proximal furcations was low (18% for mesial and 7% for distal furcations). There was NSD between degree 1 involvement and the controls in the incidence of the furcation arrow image. There was an equal number of furcation arrows observed over mesial and distal furcations. The existence of a buccal furcation involvement of any degree did not influence the appearance of the furcation arrow. The image was no more likely to be observed over Degree 3 involvement than over Degree 2 involvement.

D: As the extent of furcation involvement increased, so did furcation arrow image.  Degree 3 involvement reflected the radiographic image > 50% of the time. The furcation arrow seldom appears over uninvolved furcations, its appearance indicates that there is proximal bony furcation involvement. Absence of arrow does not indicate the absence of a bony furcation involvement.  Root morphology and horizontal angulation of the tube head may be factors in determining whether a given furcation defect will exhibit an arrow.    

BL:  The radiographic presence of the furcation arrow appears to be a reliable diagnostic tool for the clinician when evaluating bony furcation involvement.

Topic: Furcations

Authors: Deas DE, Moritz A., Mealey B                                NO ARTICLE

Title: Clinical reliability of the furcation arrow as a diagnositc marker.

Source: J Periodontol 2006;77;1436-1441

Type: Clinical study

Rating: Good

Keywords: Furcation involvement, periapical, bitewings

B: Traditionally, radiographic assessment in conjunction with clinical probing using a curved explorer or furcation probe has been the chief diagnostic methods used for detecting and characterizing furcation involvement.

P: To evaluate the furcation arrow in a clinical setting, with emphasis on testing the assertion that the radiographic presence of a furcation arrow reliably identifies a furcation invasion.

Questions answered: 1. What is the prevalence of furcation arrow images in the radiographs of maxillary molars with periodontitis? 2. What is the interexaminer agreement on what constitutes a furcation arrow? 3. How does the presence or absence of a furcation arrow correlate with the true clinical status of the furcation? 4. What is the sensitivity and specificity of the furcation arrow as a diagnostic indicator?

M&M: 89 patients were referred between February 2004-June 2005 for treatment of moderate to advanced periodontitis that required surgical access to at least one maxillary posterior sextant. Before surgery, one of five calibrated examiners viewed PA and BW radiographs of the surgical site and recorded the presence or absence of a furcation arrow at each proximal furcation. Before administering anesthesia, the same examiner recorded a Hamp index value of each proximal furcation. After flap reflection and debridement, the examiner recorded a second Hamp index at each proximal furcation. After surgery, each of the four remaining examiners independently reviewed the radiographs for furcation arrows. Descriptive statistical analysis was performed to correlate the appearance of the furcation arrow image to the actual degree of furcation invasion as determined by the intrasurgical Hamp index.

R:

C: Clinical probing, post-anesthetic sounding and surgical access provide more diagnostic data about furcations than the radiographs to the clinicians. The image is difficult to interpret and highly subjective and can correctly predict furcation invasions only 70% of the time when present on the radiograph. In addition, when furcation invasions are truly present, the furcation arrow is seen in <40% of sites.

Topic: standardized radiographs

Authors: Ortman L, McHenry K, Hausmann E                               NO ARTICLE

Title: Relationship between alveolar bone measured by 1251 absorptiometry with analysis of standardized radiographs: 2. Bjorn technique

Source: J Periodntol 1982;53:311-314

Type: Skull study

Rating: Fair

Keywords: standardized radiographs, Bjorn technique


B: Bjorn developed a bone scoring technique using the projected 5x magnification of periapical radiographs on a scale which divides the tooth into 5% portions.

P: To compare the Bjorn and Henrikson (125I absorptiometry) techniques in their ability to detect small bone changes.

Omnell demonstrated that established principles of radiation absorptiometry permitted measurement of alveolar bone mineral mass. Henrikson applied these principles to development of an 125I absorptiometry technique capable of detecting alveolar bone mass changes on the order of 5%. The technique utilizes an essentially monoenergetic radiation beam, a collimating device and a scintillation counter for directly determining the amount of absorbed radiation.

M&M: 4 periodontal defects were created in dried human skulls between 1st and 2nd PM and 1st M of differing sizes, with incremental reduction of approximately 10%. The defects were made either by reducing the buccal wall or creating crater like defects and were measured using both of the techniques utilizing stents for standardization.

R: In initial bone loss, the Bjorn technique consistently underestimated the amount. 53% of the bone as measured by 125I absorptiometry needed to be reduced before the Bjorn technique could detect any loss. In advanced bone loss, the Bjorn technique was shown to overestimate the amount of loss in 2 of the sites and underestimate in the two other sites.

Conclusion: When bone loss is under 30%, the Bjorn technique tends to underestimate how much true loss has occurred and when over 60%, it is inconsistent.

Topic: Radiography

Authors: Buchanan SA, et al                                ARTICLE

Title: Radiographic detection of dental calculus.

Source: J Periodontol. 58:747-751, 1987

Type: Clinical

Rating: Good

Keywords: calculus, radiographs, sensitivity, specificity.


P: To quantify the sensitivity, specificity and observer error associated with radiographic detection of dental calculus on proximal surfaces of teeth in patients with severe periodontitis.

M&M: 18 patients that required extraction of at least 3 teeth because of severe periodontitis participated in the study. Excessively rotated or malpositioned teeth were not included in the study. Radiographic presence of calculus was determined by two examiners. After tooth extractions teeth were prepared and examined microscopically for calculus.

R: 275 proximal tooth surfaces and the corresponding radiographs were available for evaluation. Mean AL was 5.8mm.

Of the 153 surfaces with calculus noted visually, radiographically calculus was detected 43.8% (false negative 56.2%), (low sensitivity).

Of the 73 surfaces with calculus present radiographically, 91.8% were determined calculus present clinically.

Of the 160 surfaces assessed radiographically as calculus absent, 46.3% were verified by visual examination to have no calculus.

Radiographic evaluation of calculus was not an effective diagnostic method in most surfaces with thin or moderate deposits.


C: Conventional radiographs are a poor diagnostic method for detection of calculus. Radiographic analysis predicted calculus on less than half of the proximal surfaces where deposits were present visually.

What alveolar crest level represents bone loss on a bitewing radiograph??

Topic: Radiographic measurement of bone

Author: Hausman E., Allen K., Clerehugh V.                                 ARTICLE

Title: What alveolar crest level on a bite wing radiograph represents bone loss?

Source: J Periodontol 1991;62;570-572

Type: RCT

Rating: Good

Keywords: bone level, radiographic interpretation


P: Compute the distance from the CEJ to the alveolar crest on radiographs at sites where there was no clinical loss of attachment.

M&M:

R: The mean radiographic CEJ- alveolar crest distance (mm) for the 134 sites with zero loss of clinical attachment was 1.11 ±0.37 mm. at the initial examination and 1.19 ±0.34 mm at the same sites examined 18 months later . The 95% confidence limits were 0.4 mm to 1.9 mm.

BL: No crestal bone loss is consistent with a range of CEJ- alveolar bone crest distance between 0.4 and 1.9 mm as evidenced on bitewing radiographs.

Are digital radiographs equivalent to conventional radiographs in revealing bone loss?

Topic: Radiographic Interpretation

Authors: Khocht A, Janal M, Harasty L, Chang K:                                ARTICLE

Title: Comparison of direct digital and conventioanl intraoral radiographs in detecting alveolar bone loss.

Source: J Am Dent Assoc 2003;134;1468-1475

Type: Clinical Study

Rating: Good

Keywords: conventional radiographs, digital radiographs

P: To compare direct digital (D) and conventional (C) radiographic estimates of alveolar bone under normal clinical use.

M&M: 25 subjects with perio with age range b/w 18-65 years and had full set of PAs and BW for diagnostic purpose and tx planning. All subject had min of 15 teeth without any intraoral pathology or systemic dz. A long cone parallel technique was used to take PAs and a paper sleeve with biting tab was used for BW. Within 4 weeks, a second set PAs and BW was taken with digital system (Shick). The distance from the CEJ (surfaces with non-identifiable CEJs due to restorations or overlapping were excluded) to the interproximal alveolar crest (where the PDL space ends on the root surface) was measured. 3rd molars were excluded. One examiner measured with a plastic ruler on the C x-rays while another examiner measured the D x-rays. Overall % agreement of first and second readings in C x-rays was 99 and it was 92 for the D images. The examiners performed their measurements independently from each other. Each examiner measured the conventional or digital radiographs twice and took two sets of measurements for each subject. The examiners took the second set of measurements without having access to the initial set.


R: Examiner measured 857 PAs and 315 BW image sites match on both radiographic systems.

It seems that digital radiographs impart a constant addition of millimeters to measures taken in the posterior mandibular.

C:  Under normal clinical use and without standardized film positioning, the average bone level measurements varied SS between C and D radiographs in certain regions of the mouth and that the disagreement between these two systems is influenced by the type of image PA or BW as well.


Cr: It is very difficult to take x-rays at the exact same angle with the sensor/film in the exact same place to compare measurements. Also, there may be error in calculating exactly where the CEJ is on the x-ray. The digital sensor is a different size, not flexible, and can be more difficult to position than conventional films. Having the USB cord attached to the digital sensor may interfere with subjects biting down on the BW tabs.

Topic: radiographic alterations

Authors: Bruder G, Casale J, Goren, A, Friedman S                                NO ARTICLE

Title: Alteration of computer dental radiography images

Source: J Endod 1999;25;275-276 DOI: 10.1016/S0099-2399(99)80159-9

Rating: good

Keywords: radiography, distortion, digital images, alterations


P: to determine if digital images could be exported, altered, and then restored without visible signs of alteration

M&M: Images were exported from the computer radiography program, files were altered, then files were restored to the Schick format and printed

D: Digital images are relatively easy to export and alter with the use of a photo editing program. The need to implement technologies to safeguard digital radiography must be addressed to prevent potential abuses.

Are panoramic radiographs ever of value in periodontics?


Topic: Radiographs

Author: Kasaj A., Vasiliu Ch, et al.                                ARTICLE

Title: Assessment of alveolar bone loss and angular bony defects on panoramic radiographs

Source: Eur J Med Res. 2008 Jan 23;13(1):26-30

Type: Prospective study

Rating: Good

Keywords: Panoramic radiographs, angular bony defects, periodontal disease, bone loss

P: To investigate the prevalence and severity of alveolar bone loss and angular bony defects in randomly selected panoramic radiographs.

M&M: 500 panoramic radiographs of adult patients were studied. The mean age of the subjects was 51 years (range 20-80). Panoramic radiographs were placed on an x-ray viewer and evaluated by the same examiner. A calibrated periodontal probe was used to assess horizontal and vertical defects. If the interproximal projection of the CEJ was not identifiable, the apical termination of the restoration or crown margin was used for the measurements. A site was considered as having an angular bony defect if the bottom of the oblique radiolucency was located at least 2mm apical to the most coronal level of the interproximal alveolar bone.

R:

-In majority of subjects (86.7%) had some form of bone loss (horizontal and vertical).

-Angular bony defects were found in 49.8 % of the patients.

-Angular defects were more present in the mandible than in the maxilla, most frequently in the mandibular posterior, and least frequently in the mandibular anterior.

-The mean depth of the angular bony defects was 6.0 mm with the greatest mean depth in the maxillary anterior area (6.8 mm).

-The mean M-D width of the intrabony defects was 2.44 mm, and was most pronounced in maxillary molars (3.1 mm).

-Female subjects exhibited a gradual increase of vertical defect with age whereas in male subjects vertical bone loss was most prevalent in the age group 40-60 years and decreased in the older age group (60% vs. 40%).

-Interradicular molar radiolucencies demonstrated 38.3 % of the subjects and were more frequent in the md (first molar) than mx.


C: This study demonstrated a high prevalence of angular bony defects found on panoramic radiographs suitable for regenerative periodontal treatment.

Topic: Radiography

Authors: Persson RE, Tzannetou S, Feloutzis AG, Brägger U, Persson GR, Lang NP                                NO ARTICLE

Title: Comparison between panoramic and intra-oral radiographs for the assessment of alveolar bone levels in a periodontal maintenance population

Source: J Clin Periodontol. 2003. 30(9):833-9

Type: Clinical study

Rating: Good

Keywords: orthopantomogram; radiographs; alveolar bone level; diagnosis; periodontitis; maintenance population; agreement

P: To assess the level of agreement between intraoral and panoramic radiograph for direct measurements of the distance between the CEJ and the alveolar bone level (BL) as well as the proportional relationship (CEJ-BL/root length) and to explore the symmetry between left and right sided measurements.

M&M: Intraoral (IO) and panoramic (OPG) images were obtained from 292 patients on maintenance therapy. Two examiners performed measurements on digitally processed images. The distance between the CEJ and marginal BL was measured at the mesial and distal aspects of each tooth. The distance between the CEJ and apex of the tooth was also measured. The proportional distance between CEJ and BL relative to the length of the root was calculated.

R: All measurements between the two examiners showed no statistically significant differences. The largest mean proportional difference between CEJ and BL was seen in the maxillary right posterior segment, suggesting advanced periodontal disease in these sites. The largest difference between IO and OPG reading was observed between measurements for the maxillary anterior sextant, while the smallest difference was seen in the mandibular anterior sextant.

C: The study suggests that BL measurements between IO and OPG radiographs are highly comparable. The mean differences observed for the distance CEJ-BL in proportion to root length were neither statistically nor clinically different. A significant degree of symmetry of alveolar bone loss between the left and right side of the dentition was also found.

When should cone beam computed tomography (CBCT) be used?

Topic: CBCT in dentistry

Authors: The American Dental Association Council on Scientific Affairs.                                NO ARTICLE

Title: The use of cone beam computed tomography in dentistry: An advisory statement from the American Dental Association Council on

Scientific Affairs.

Source: J Am Dent Assoc 2012;143;899-902
Type: Discussion

Rating: Good

Keywords: CBCT, ALARA

ADA Council on scientific affairs 2012: The use of CBCT in dentistry

CBCT imaging provides three-dimensional volumetric data construction of dental and associated maxillofacial structures with isotropic resolution and high dimensional accuracy.

A CBCT scanner uses a collimated x-ray source that produces a cone- or pyramid-shaped beam of x- radiation, which makes a single full or partial circular revolution around the patient, producing a sequence of discrete planar projection images using a digital detector. These two-dimensional images are reconstructed into a three-dimensional volume that can be viewed in a variety of ways, including cross-sectional images and volume renderings of the oral anatomy.

Although CBCT units produce a higher radiation dose than one would receive from a single traditional dental radiograph, the radiation dose delivered typically is less than that produced during a medical multichannel computed tomographic scan. CBCT radiation doses also vary widely according to the device used, x-ray energy and filtration, tolerance for image noise and motion artifacts and the size of the imaging area that is used to acquire volumetric data.

Principles for the safe use of dental and maxillofacial CBCT

- Should be used only after review of pt’s health, and imaging history and thorough clinical examination

- Should be used only after professional justification that the potential clinical benefits will outweigh the risks associated with exposure to ionizing radiation

-The clinician should prescribe traditional dental radiographs and CBCT scans only when he or she expects that the diagnostic yield will benefit patient care, enhance patient safety, sig- nificantly improve clinical outcomes or all of these.

-Should be considered as an adjunct to standard oral imaging modalities

- ALARA (As-low-as-reasonably-achievable) principle

- Should take every precaution to reduce radiation dose and ensure the patient’s safety. The use of thyroid collars and lead aprons is recommended when they do not interfere with the examination.

- Regardless of the primary purpose for the selection of CBCT, the complete image data set must be interpreted by a qualified health care provider. The prescribing clinician should receive a thorough radiological report

- Dental practitioners who use CBCT devices must receive appropriate training and education in the safe use of CBCT imaging systems

- Facilities using CBCT systems should consult a health physicist to perform equipment performance and compliance evaluations initially at installation and then follow a schedule in compliance with local, state and federal requirements

- Staffs of facilities using CBCT should establish a quality control program. This program can be based on the manufacturer’s recommendations


 

Topic: Radiograph

Authors: Misch KA, Yi ES, Sarment DP:.                                 ARTICLE

Title: Accuracy of cone beam computed tomography for periodontal defect measurements.

Source: J Periodontol. 2006 Jul;77(7):1261-6.

Type: Clinical study

Rating: Good

Keywords: Periodontal defect, CBCT

P: To compare linear measurements of periodontal defects using CBCT to traditional methods.

M&M: 2 human dry cadaver skulls with existing horizontal bone loss up to 20% were examined. Infrabony buccal, lingual, and interproximal defects with varying width and height were created with a bur in mandibular molar and premolar regions. Grooves were also placed vertically into the roots from the CEJ to the depth of defect. Gutta percha cones were superglued into the grooves. CBCT (i-cat) and PA radiographs were taken.

Measurements were taken from A) CEJ-depth of pocket, B) CEJ to alveolar crest, C) width of the defect. Impressions of the defects were taken, and all measurements were compared to electronic caliper measurements. The accuracy of impression and caliper measurements were verified using another set of defects with known height and width prepared in cast acrylic blocks. Statistical analysis was done.


R:

All infrabony defects were detected using CBCT and the probe.

Average correlation was 0.4 for direct, 0.53 for PA, 0.62 for CBCT and 0.95 for impressions.

Correlation varied b/w 0.09 and 0.99 within examiners.

NSSD between all the methods for CEJ-depth of pocket, detection of isolated IP defects, and for buccal and lingual defects.

C: CBCT measurements compared well to traditional methods, with the advantage of allowing observation of defects in all directions. Further investigation is needed.


 

Topic: CBCT vs intraoral radiographs

Authors: Vandenberghe B, Jacobs R, Yang J.                                ARTICLE

Title: Detection of periodontal bone loss using digital intraoral and cone beam computed tomography images: an in vitro assessment of bony and/or infrabony defects.

Source: Dentomaxillofac Radiol. 2008 Jul;37(5):252-60.

Type: Skull study

Rating: Good

Keywords: periodontium, crater, furcation involvement, intraoral radiography, cone beam computed tomography

P: To determine the diagnostic values of digital intraoral radiographs and cone beam CT (CBCT) in the determining bone loss, infrabony defects, and furcation involvement.
M&M: A cadaver head with upper and lower jaws fixed with 10% formalin and a dry skull covered with a soft tissue substitute were used to measure 71 selected periodontal defects. To assess bone levels, the CEJ was used as a reference point for the fixed jaws, and gutta-percha fixated onto the buccal and lingual of teeth for the dry skulls. Intraoral radiographs were obtained with standardized bite blocks. CBCT was obtained with I-CAT. For the CBCT the observation were made on a 5.2 mm panoramic reconstruction view and on .4mm thick cross-sectional slices. First part of the study: 43 randomly selected sites with linear or vertical defects were chosen for radiographic and CBCT assessment of the bone loss and compared to the actual measurements. Second part of the study, 11 teeth containing vertical defects or furcation involvement was compared to actual measurements. The defects were categorized by 1, 2, 3 and 4 walls and the furcations by class 1, 2,3. Readings were performed by 3 examiners a medical imaging master and PhD student, and two radiology faculty members.

R: No intra- or interobserver effect was found. No significant differences were found when comparing the radiographs with those on the panoramic reconstruction image of the CBCT. The mean error for bone level measurements was 0.56 mm for radiographs, 0.47 mm for the CBCT panoramic view and 0.29 mm for the .4mm thick cross-sectional slices. SSD between the cross sectional slices and the radiographs. The detection of crater and furcation failed 29% and 44% with radiographs, and 0% with CBCT.

C: CBCT allowed more accurate assessment of periodontal bone loss.


 

What if the significance of the lamina dura?

Topic: Lamina Dura

Authors: Tibbetts J, Allen K, Hausmann E                                ARTICLE

Title: Effect of x-ray angulation on radiographic periodontal ligament space width

Source: J Periodontol 63: 114-117, 1992

Type: Clinical

Rating: Good

Keywords: Periodontal ligament/anatomy and histology; periodontal ligament/radiography.


P: To determine the influence of known changes in x-ray beam angulation anticipated under clinical conditions on the change in radiographic ligament space width. Radiographs of molars and incisors were studied to determine the influence of anatomical factors on changes associated with alteration in x-ray beam angulation


M&M: Pairs of radiographs were taken of incisor and molar locations in whole dried human skulls with known differences in x-ray beam angulation. To be acceptable, radiographs had to meet the following requirements: 1) no overlaps of contact areas of adjacent teeth, 2) visible interdental alveolar bone, 3) no cone-cut in the radiograph, 4) sufficient contrast to read any anatomic structures present. Baseline for vertical angulation was set perpendicular of the long axis of the tooth. For each tooth site, radiographs were taken at 2 vertical angulations: 1) perpendicular to tooth’s buccal surface 0° and 2) 10° off the perpendicular. 5 different horizontal angulations at each of the 2 indicated vertical angulations 1) baseline 0°, 2) -3° and -6° from the perpendicular, 3) +3° and +6° from the perpendicular. Replicate radiographs were taken at 0° and at each of the 2 vertical angulations. The radiographs were converted to digitized images and PDL width measurements were made utilizing a computer program. Data were analyzed separately for the incisor and molar sites.

R: The variation between the mean difference of baseline measurements was compared with that of discrepant-angle combinations, 10/20 pairs of radiographs which differed in horizontal angle only were significantly different from results of baseline replicates. 2/5 groups of pairs of radiographs which differed in vertical angle only were significantly different from results of baseline replicates. 11/20 groups of pairs of radiographs which differed in both vertical and horizontal angulation were significantly different from results of baseline replicates. Mean PDL width differences for incisor locations were SS from the mean baseline PDL width difference, posterior PDL width difference showed no statistical variation from the mean baseline width difference


C: Changes in x-ray angulation resulted in a SS change in radiographic PDL width at incisor locations, no such significant effect was found at molar locations. At molar area, thick bone overlying PDL will tend to reduce the difference in density seen on the radiograph of the ligament space and adjacent interproximal bone. It is suggested the radiographs should be taken with controlled projection geometry when clinical interpretation of change in PDL width is desired.


 

Topic: Lamina dura

Author: Greenstein G, Polson A, et al                               ARTICLE

Title: Associations between crestal lamina dura and periodontal status.

Source: J. Periodontol. 52:362-366, 1981.

Type: RCT

Rating: Good

Keywords: lamina dura, radiographic diagnosis, bitewing radiographs


P:To investigate the association between the radiographic presence of crestal lamina dura and the clinical periodontal status of the corresponding interdental area.


M&M:

R:  NSSD correlations were obtained between PA radiographs, presence of lamina dura and inflammation, PD, or attachment loss. On bitewings, there was a SSD between presence of crestal lamina dura and inflammation (81.9%) versus absence of crestal lamina dura and inflammation (72.5%). No SSD with the other parameters and bitewings. However, there were significant discrepancies on whether the crestal lamina dura was present (agreed 24% of the time) and agreed 89% of the time when absent.

BL: Radiographically, the crestal lamina dura did not appear to be related to the presence or absence of clinical inflammation, BOP, presence of pockets, or loss of attachment.

Can radiographs be used to detect progression of periodontitis?

Topic: Radiographic Interpretation

Authors: Selikowitz H-S, et al:                                ARTICLE

Title: Retrospective longitudinal study of the rate of alveolar bone loss in humans using bite-wing radiographs.

Source: J. Clin. Periodontol. 8:431-438,1981.

Type: Retrospective Study

Rating: Good

Keywords: periodontal disease, human, rates of alveolar bone loss, radiographs

P:  To develop and evaluate a method for measuring the degree of alveolar bone destruction retrospectively using radiographs and to use the method to assess bone loss over periods exceeding 10 years.

M&M:  100 pairs of BW x-rays obtained from patients of 2 general dentists in England on recall q 3 or 6 months for 10 years.  Long cone paralleling technique was used.  3M reader was used to read the x-rays (6.59x magnification).  An unexposed film with two points 0.3mm apart as measured with a travelling microscope was used to standardize measurement on each radiograph. 2 reference points were used--the highest point on the occlusal surface of the crown and the M and D points on the CEJ.  80 of the cases were assessed using an abbreviated index as described by Bjorn 1975 (they found that the arithmetic means of mesial and distal scores from the mand M and PM regions correlated well with the means of the whole dentition). Bone heights were assessed on x-rays taken 10 years apart. 

R:  The percentages of measurable distances between tooth reference points and bone levels varied form 35%, using occlusal measurement point, to 49%, using the CEJ reference point. Bone levels around the 1st PM were the most unreadable.

Average bone loss per year

         Horizontal      Vertical

Occ      0.06mm        0.05mm

CEJ      0.04mm        0.03mm

Annual bone loss measurements fluctuated, some even gained.  Radiographic bone loss underestimates CAL.

BL:  BW's can be used in longitudinal studies of perio dz and can provide important info on the progression of perio disease (since the findings of bone loss were consistent with the rates of attachment loss reported by several other authors that used probes).

Are radiographs an accurate way to assess healing after periodontal surgery?

Do newer radiographic techniques improve the usefulness of radiographs?

Topic: radiographic accuracy

Authors: Toback GA, Brunsvold MA,                                no ARTICLE

Title: The accuracy of radiographic methods in assessing the outcome of periodontal regenerative therapy.

Source: J Periodont 70:1479-1489,1999 DOI: 10.1902/jop.1999.70.12.1479

Type: clinical

Rating: good

Keywords: bone regeneration; periodontal disease/therapy; outcome assessment; comparison studies; radiography, dental methods; follow up studies.


P: to determine the ability of 2 forms of radiographic analyses (linear measurements and computer assisted densitometric image analysis, CADIA) to assess postsurgical bone fill in comparison to measured bone fill at a re-entry procedure.


M&M: 15 patients each with 3 separate sites.

R: Of the 45 pairs of radiographs, 24 were excluded, 21 remained, 15 in the mandible and 6 in the maxilla.

C: Linear radiographic measurement significantly underestimate post-treatment bone fill when compared to re-entry data. The linear-CADIA method provided the highest level of accuracy of the 3 methods tested.

D: It cannot be said with confidence that any of the radiographic methods evaluated in this study can serve as a replacement for the data obtained during a re-entry procedure.

No single radiographic method can reproduce similar information consistently

Topic: Radiographs

Author: Zybutz M, Rapoport D, et al.                                ARTICLE

Title: Comparisons of clinical and radiographic measurements of inter-proximal vertical defects before and 1 year after surgical treatments.

Source: J Clin Periodontol 27:179-186, 2000

Type: Clinical

Rating: Good

Keywords: probing bone; probing attachment level; radiographic bone level


B: Radiographic measurements are often used as a substitute for direct clinical measurements requiring surgical re-entry for follow up outcome studies.

P: There were 3 aims of this study:

  1. To assess the reliability of clinical and radiographic measurements of periodontal defects as compared to direct bone measurements during surgery.

  2. To assess associations between selected clinical and radiographic measurements of interproximal defects

  3. To assess if changes identified from probing to bone measurements could reliably be detected by other clinical and radiographic methods.

M&M:

-57 interproximal vertical defects from 29 patients were measured at baseline and 12 months after surgery (OFD or GTR procedures).

-Standardized PA x-rays were taken at both baseline and 12 months after surgery.

-During surgery, direct measurements from the CEJ to bottom of the defect-alveolar bone level (ABL) were taken, and then compared with probing to bone (PB), probing attachment level (PAL) and x-ray measurements.

-Using computer-digitized images, CEJ to bottom of defect (ABLX) and bone crest to bottom of defect (IBDX) were measured.


R:

-Probing to bone is an accurate measure to assess interproximal bone level as compared to ABL.

-Standardized PA’s underestimate bone level and defect depth by approximately 1.4mm.

-Interpretation of the periodontal changes between baseline and 12 months after treatment by probing to bone, or PAL measurements, or from images almost yield identical results (mean difference <0.2mm)

BL: Both radiographic interpretations of changes over time, and measurements of attachment level changes are reliable in assessing treatment outcome of interproximal intra-bony defects when compared to probing to bone changes as the standard method.


 

Topic: Radiography

Authors: Grimard BA, Hoidal MJ, Mills MP, Mellonig JT, Nummikoski PV, Mealey BL                                ARTICLE

Title: Comparison of clinical, periapical radiograph, and cone-beam volume tomography measurement techniques for assessing bone level changes following regenerative periodontal therapy

Source: J Periodontol. 2009 Jan; 80(1):48-55

Type: Clinical study

Rating: Good

Keywords: Bone regeneration, diagnosis, imaging, radiology

P: To compare linear measurements of periodontal defects and treatment outcomesf rom intraoral (IR) and cone-beam volumetric tomography (CBVT) to direct surgical measurements at the time of surgery and at re-entry.

M&M: Subjects from a controlled clinical trial comparing outcomes of DFDBA alone vs. DFDBA and enamel matrix derivative were used in this study. Inclusion criteria were moderate to severe chronic periodontitis, at least one interproximal site with 5mm probing depth, and a vertical defect of greater than 3 mm on an IR. 35 grafts were available for re-evaluation. At he time of surgery (baseline), direct surgical measurements were taken. These measurements were completed at reentry greater than or equal to 6 months later. IR and CBCT were obtained at both surgical time points. Clinical measurements after flap reflection included CEJ to the coronal part of alveolar crest and CEJ to the base of the defect. The surgical measurements were considered the “gold standard” values that the radiographic measurements were compared to. Statistical analysis was performed.

R: 22 defects were present in the mandible, and 13 were in the maxilla, with the majority of defects in the canine/premolar or molar region. Most defects had a combination of defect wall numbers. All of the radiographic measurements from the CEJ to alveolar crest were overestimations of surgical measurements except for the reentry CBVT measurement. All of the remaining measurements (CEJ-base of defect, defect fill, defect resolution) were underestimated compared to direct surgical measurements. The CBVT measurements were closer to surgical measurements than those made from IRs. CBVT was significantly more accurate than IR at ≤1 and ≤2-mm thresholds for almost all hard tissue measurements.

C: For some bony parameters, no significant difference was noted between IR and CBVT measurements compared to surgical measurements. Results suggest that data gathered from CBVT images more accurately reflects bony defect dimensions than data from IR images, and measurements for defect resolution are not significantly different from surgical measurements. CBVT is an equivalent substitution for direct surgical measurements of bony changes occurring after bone replacement graft procedures, especially defect fill and defect resolution.


 

Topic: Radiographic interpretation of alveolar bone changes

Authors: Goren AD, Dunn SM                                ARTICLE

Title: Pilot study: digital subtraction radiography as a tool to assess alveolar bone changes in periodontitis patients under treatment with subantimicrobial doses of doxycycline.

Source: Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; Oct;106(4):e40-5. Epub 2008 Aug 20.
Type: Pilot study

Rating: Fair

Keywords: Digital Subtraction, radiography, alveolar bone changes

B: Digital subtraction radiography is a method of image enhancement, trying to produce 2 radiographic images of the same area of the mouth with the same angulation at different time intervals. The first image can then be subtracted from the second to assess changes that occurred during a particular time period. Minimal changes of loss or gain of hard tissue can be detected that would otherwise be undetectable by visual exam or traditional radiograph.

P: To evaluate the practical application of geometrically corrected digital subtraction radiography (DSR) in a clinical study of alveolar bone response to a 6 months regimen of subantimicrobial doxycycline or a placebo.

M&M: 11 patients were included. Half received low-dose-doxycycline (LDD) 20 mg regime for 6 months and half received placebo. PD and GI recorded at baseline, 3 and 6 months. 2 sites with PD >3 mm were imaged for each patient. Standardized radiographs were taken at 3 and 6 months and baseline radiographs were subtracted from these images.

R: Average PD in baseline was 4.6 mm and 4.9 mm for LDD and placebo group respectively. NSD between LDD and placebo at 3 months for both GI and PD. GI showed no change between 3 and 6 months. For PD, LDD appeared to remain stable between 3 and 6 months, whereas the placebo showed in increase in PD between 3-6 months (average change of 0.3 mm). Comparing the bone height gained/lost, the LDD group at 6 months showed on average less alveolar bone loss compared with placebo. 3/6 patients showed bone gain.

BL: Digital subtraction radiography has potential as a clinical method for evaluation of changes in alveolar bone level.


 

How do Radiographic Measurements Compare to Clinical Examination Measurements?


Topic: Radiograph

Authors Papapanou PN, Wennstrom JL                                ARTICLE

Title: Radiographic and clinical assessments of destructive periodontal disease.

Source: J Clin Periodontol. 16:609-612, 1989.

Type: Clinical study

Rating: Good

Keywords:

P: To compare results from radiograph and clinical estimations of the amount of periodontal tissue destruction.


M&M: 191 subjects (35-80 years old), 4,682 tooth sites were examined for periodontal disease using radiographic and clinical means. At all proximal tooth surfaces, assessment was made radiographically by measuring the distance from CEJ to the coronal level of alveolar bone on PAs (anteriors) and BWs (posteriors) and clinically by recording the CAL w/ a calibrated periodontal probe.

R:

C: The amount of periodontal destruction is not necessarily underestimated in radiographs, but no definite conclusion regarding the over or under-estimation of the alveolar bone loss should be made with either method.

Topic: measuring disease progression

Authors: Machtei EE, Hausmann E, Grossi SG, Dunford R, Genco RJ.                                 NO ARTICLE

Title: The relationship and clinical changes in the periodontium.

Source: J Perio Res 32:661-666, 1997.

Type: Longitudinal study

Rating: Fair

Keywords: disease progression, attachment loss, correlation

P: To evaluate the correlation between changes in CAL and alveolar bone loss in untreated pts with moderate to advanced periodontitis (longitudinal study).

M&M: 79 pts (44 female, 35 male) with IP CAL  6mm and PD  5mm, CAL and relative attachment level (RAL: a disk probe attached to the Florida probe. The occlusal table or incisal edge is used as a landmark from which all attachment measurements are being made) were measured at 6 sites on each tooth with Florida probe at baseline and every 3 months for one year. Radiographs were taken at the baseline and 1 year. Crestal bone height was analyzed using image enhancement technique.

R: Mean CAL change was 0.16mm, mean change in crest height was 0.16 mm. Mean percentage of IP active sites was 12.9% and 13.7% for radiographic and clinical measurements, respectively. Correlation analysis failed to demonstrate a significant correlation between CAL and radiographic bone loss. Measurement error may play a role in affecting this correlation.

D: Changes in CAL and radiographic crestal bone height progress independently over a short period of time, but seem to level off long term. Author suggests using both methods for longitudinal monitoring of dz progression and response to therapy, while for cross-sectional evaluation and long-term prospective studies, either or both variables may be used as independent but correlated measurements of destructive periodontitis. Even though same mean value for both parameters, they don't correlate according to site based correlation analysis or patient based analysis. This may be due to measurement error, or maybe one occurs prior to the other (ej. bone loss before CALoss).

C: CAL and crestal bone height seem to progress somewhat independently over a short period of time, however, in the long term, these differences seem to level off. For longitudinal monitoring disease progression and response to therapy both CAL and radiographic changes may be needed.

Cr: x-rays non-standardized

Topic: Radiographs

Authors: Eickholz P, Hausmann E                                ARTICLE

Title: Accuracy of radiographic assessment of interproximal bone loss in intrabony defects using linear measurements.

Source: Euro J Oral Sci 108:70-73, 2000

Type: Clinical

Rating: Good

Keywords: alveolar bone loss; digital radiography; linear measurements; surgical measurements; periodontal diagnosis


P: 1) To assess the accuracy of linear measurements of interproximal bone loss on radiographs using a computer- assisted technique and 2) to identify factors influencing the accuracy of this method

M&M: 22 patients with untreated periodontal disease participated in the study. After initial treatment, vertical bitewing radiographs were taken to assess vertical bone loss. Before surgery PI, GI, PD and AL were assessed in 6 sites per tooth and during surgery after FTF reflection distances from CEJ to apical extension of bony defect (BD) and alveolar crest (AC) to BD were recorded. Linear measurements of CEJ-BD were performed by a computer assisted method. Factors that could affect the measurements accuracy (angulation difference, patient. Height of one-, two- and three-wall component) were investigated.

R: 33 radiographs with 34 IP defects were obtained. The radiographic analyzing technique significantly underestimated the amount of interproximal bone loss compared to surgical measurements (CEJ-BD by 1.4+/-2.6mm). The discrepancy between computer-assisted radiological measurements and surgical assessments was modulated by factors, such as vertical angulation difference, height of the two- walled component, and individual patients. The particular model explained 79% of the variation of the explanatory variable.

C: Within the limits of the present study, the following conclusions may be drawn: 1) the computer-assisted analysis of linear distances on radiographs underestimated the amount of inter- proximal bone loss as assessed by surgical measurements; and 2) it appears that there are no major differences between different computer- assisted analyses in underestimating interproximal alveolar bone loss.


 

Topic: Post-menopausal women

Author: Pilgram TK, Hildebolt CF, et al                                ARTICLE

Title: Relationships between radiographic alveolar bone height and probing attachment level: data from healthy post-menopausal women.

Source: J Clin Perio 27:341-346, 2000.

Type: RCT

Rating: Good

Keywords: post-menopausal women, radiographic appearance, diagnosis, attachment level, HRT


P: To determine cross-sectional and longitudinal relationships between radiographic alveolar bone height and probing attachment level in a healthy postmenopausal women population.


M&M:

  1. 81 patients in good oral health, perio pockets < 5mm, were part of an estrogen replacement interventional treatment.

  2. Pts received annual prophylaxis. Probing measurements with pressure sensitive probe at 6 sites.

  3. Vertical bitewings were digitized and 6 linear measurements made from CEJ to alveolar crest. Procedures performed at baseline and every year for 3 yrs.

  4. Data was analyzed by site and by patient

R:

  1. Moderately strong correlation between cross-sectional measurements in probing attachment level and radiographic alveolar bone height

  2. Correlations were stronger for patient data than for site data

  3. No relationships were found between longitudinal changes in alveolar bone height and attachment level in either the site data or patient data.

  4. Some sites gained attach and bone height. Estrogen may cause small gains in alveolar bone more likely result of systemic changes in bone health.

BL: Even a healthy mouth is relatively dynamic and may experience sporadic, temporary changes in attachment level and alveolar bone height which are resolved without affecting one another.

Comparison of Techniques

Topic: Radiographic Interpretation

Authors: Reed BE, Polson AM                                ARTICLE

Title: Relationships between bitewing and periapical radiographs in assessing crestal alveolar bone levels.

Source: J. Periodontol. 55:22-27, 1984

Type: Retrospective Study

Rating: Good

Keywords:

P: To study the relationship between measurements of the level of alveolar bone crest obtained from PA’s vs. BW’s of the same interproximal areas.

M&M:  210 patients, 14 PA’s and 4 BW’s were taken on each individual using long cone paralleling tech with Rinn method of positioning the film.  Evaluated all interproximal bone levels from the distal of 2nd molar to distal of canines using projected images and mm rulers.  PA and BW measurements were compared under 5.9x magnification.

R: 50% of mesial & distal surfaces were SSD from each other with BW measures being larger than PA’s 94% of time. The maxilla was less reproducible than the mandible, maxillary cuspids, mandibular 1st premolars, and mandibular 1st molar did not have a SSD between BW & PA for mesial or distal surfaces. The mean % difference between all BW and PA measures was 14.3%.

BL: BW and PA techniques give SSD values in assessing crestal bone levels.  Author recommends these techniques not be used interchangeably.

Reviews

Topic: radiographic reliability

Authors: Benn DK. J.                                NO ARTICLE

Title: A review of the reliability of radiographic measurements in estimating alveolar bone changes.

Source: Clin. Periodontol. 17:14-21, 1990.

Type: review

Rating: good

Keywords: radiographs; periodontal disease’ measurement error; rate of bone loss; monitoring systems.

P: to identify those factors which influence the accuracy of radiographic measurement, to calculate the range of time required to detect bone loss with different measurement errors and intervals, to examine the clinical applications for monitoring bone changes.

D:

Factors affecting a radiographic monitoring system:

C: the current measurement techniques are insufficiently sensitive to measure true bone loss until at least 1mm BL has occurred. Radiography is an accurate method for longitudinal monitor of alveolar bone loss. However, it will not provide evidence of current disease. More accurate methods need to be developed.


 

Topic: Radiographs

Author: Jeffcoat MK.                                ARTICLE

Title: Radiographic methods for the detection of progressive alveolar bone loss.

Source: J Periodontol 63: (Suppl 4) 367-372, 1992

Type: Review

Rating: Good

Keywords: Bone resorption/diagnosis; bone/radiograph; periodontal disease/diagnosis; radiography, digital subtraction; periodontitis/diagnosis; periodontal attachment


P: To review radiographic techniques for the assessment of periodontal disease progression. Also to address the relationship of bone loss as detected by digital subtraction radiography and periodontal disease progression as measured with a sensitive automated periodontal probe.


M&M: 30 patients with untreated periodontal disease & pockets of > 5mm at the experimental site, and 8 healthy patients without bone loss or periodontal disease (any patient with systemic disease was excluded). This study looked at 5 posterior sites in each patient using an automated probe to measure attachment levels at 0,2,4,6 months & DSR to detect progressive bone loss at 0 and 6 months. The Automated probe-instrument retracts when a force of 35gm felt at base of pocket. Standardized radiographs were taken at baseline and 6 months.

R:

-No site in a control patient lost bone or attachment over the 6 months of the study.

-According to DSR, 38% of sites in 76% of the patients were considered to have active bone loss.

-When probing attachment level was assessed, 35% of sites were considered active, observed in 79% of patients.

-A concordance of the results of the subtraction radiography and automated probing attachment level examinations was found in 82.1% of sites, showing these patients had active loss of attachment.


C: There is a high degree of concordance between sites of disease activity detected by automated probing & digital radiography.


Topic: Radiography

Authors: Tugnait A, Clerehugh V, Hirschmann PN                                ARTICLE

Title: The usefulness of radiographs in diagnosis and management of periodontal diseases: a review

Source: J Dent 28:219-226, 2000

Type: Review

Rating: Good

Keywords: dental radiography, periodontal disease, diagnosis, management, clinical effectiveness


P: To review the periodontically significant information obtainable from conventional radiographs and the stages during patient management when this information may assist care.


C: Role of radiographs in the assessment and diagnosis of a periodontal condition: Radiographs provide information about the bone levels and pattern of bone loss that cannot be gained through clinical examination. Position of bony crest, horizontal or vertical bone loss, and location of vertical defects can be identified. Subjective information on bone quality can be gained as well as crown to root ratio. Distance from the CEJ to the bone crest between 0.4-2mm (according to some studies even 3mm) is considered normal with no clinical attachment loss, but clinical estimation of attachment loss is more accurate and precedes radiographic bone loss. Furcation involvements, calculus deposits and anatomical defects such as enamel pearls can also be seen in radiographic images. Bone loss is underestimated in initial periodontal disease, relatively accurate in moderate disease, and overestimated in the advanced stages. The addition of bite wings to panoramic and periapical radiographs increases the detection rate of vertical and furcation defects. Radiographs are highly specific but of limited sensitivity, therefore they are not suitable means of detecting calculus. Radiation risk is lower for a panorex than a full mouth periapical series.

Role of radiographs in management of periodontal diseases: Radiographs are useful in all phases of periodontal treatment. They provide information in the initial therapy (bone loss, determination of hopeless teeth, apical status, and status of restorations) as well as before surgical therapy. In supportive therapy there are no specific intervals for repetition of the radiographs. They depend on the type of periodontal disease (aggressive, chronic) and on the clinical findings during the maintenance visits.

Value added by radiographs: Literature is limited in this field. Treatment decisions are altered when radiographs are taken into account with the clinical findings mostly in relation to extractions, restorative and prosthodontic treatment (43, 40 and 31% respectively) and less in periodontal treatment (15.6%).


B: Conventional radiographs provide information relevant to the diagnosis and management of the periodontal diseases. This information assists in the overall management of the patients. It is less obvious to what extent radiographs truly influence the treatment provided and its ultimate success. It is possible that clinical assessments alone are appropriate for some groups of patients, with radiographs used as a second phase diagnostic test in specific situations or sites rather than routinely due to the risk of exposure to unneeded radiation.

Topic: Radiographic Guidelines

Authors: Kim IH, Mupparapu M                                ARTICLE

Title: Dental radiographic guidelines: a review.

Source: Quintessence Int. 2009 May;40(5):389-98.
Type: Review

Rating: Good

Keywords: Guidelines, dental radiographic


P: To review history of dental radiographic guidelines and rationale for existence.  The literature was also reviewed for its utilization and the North American and European guidelines were compared.

D: 

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