Prevalence of Errors and Number of Retakes in Panoramic Radiography: Influence of Professional Training and Patient Characteristics

ABSTRACT: Panoramic radiography has clinical importance in several dental specialties. The objective of this study was to evaluate the influence of professionals' experience and patient characteristics (age group and dental absence) in the prevalence of errors and the number of retakes in the panoramic radiography.771 panoramic radiographs were evaluated and classified according to the group of patients (children, dentulous adults, total edentulous adults, and anterior edentulous adults) and professionals who performed the technique (novice and experienced). The association between frequency and type of error, group of patients, professionals' experience, and number of retakes was performed by the Chi-square and Fisher's exact test (a=0.05). There was no significant association between the frequency of errors or retakes of the radiograph s and the professionals' experience or patients' characteristics (p<0.05). The errors "turned head" and "tongue not against the palate," "chin tipped low", "chin not resting on the support," "patient movement during exposure," and "lead apron artifact" showed significantly higher frequency of retake (p<0.05). The most frequent type of error was due to the failure to position the tongue against the palate for all patients and both groups of professionals. The frequency of errors in the panoramic radiography occurs regardless of the professionals' experience, and age and dental absence of the patients. Error occurs mainly due to the lack of patient collaboration, and the examination is rarely repeated by the professionals.

RESUMEN: La radiografía panorámica es de importancia clínica en varias especialidades dentales. El objetivo de este estudio fue evaluar la experiencia de los profesionales y las características de los pacientes (grupo etario y ausencia dentaria) en la prevalencia de errores y el número de repeticiones en la radiografía panorámica.771 radiografías panorámicas fueron evaluadas y clasificadas según la grupo de pacientes (niños, adultos desdentados, adultos desdentados totales y adultos desdentados anteriores) y profesionales que realizaron la técnica (novatos y experimentados). La asociación entre frecuencia y tipo de error, grupo de pacientes, experiencia de los profesionales y número de repeticiones se realizó mediante la prueba de Chicuadrado y exacta de Fisher (a = 0,05). No hubo asociación significativa entre la frecuencia de errores o repetición de las radiografías y la experiencia de los profesionales o las características de los pacientes (p <0,05). Los errores "cabeza girada" y "lengua no contra el paladar", "mentón inclinado hacia abajo", "mentón no apoyado en el soporte", "movimiento del paciente durante la exposición" y "artefacto del delantal de plomo" mostraron una frecuencia de repetición significativamente mayor (p < 0,05). El error más frecuente se debió a la falta de posicionamiento de la lengua contra el paladar para todos los pacientes y en ambos grupos de profesionales. La frecuencia de errores en la radiografía panorámica ocurre independientemente de la experiencia de los profesionales, edad y ausencia dentaria del pacientes. El error se produce principalmente por la falta de colaboración del paciente, y los profesionales rara vez repiten el examen.

Automatic exposure compensation and subjective image enhancement in the radiographic diagnosis of caries

Abstract This study aims to assess the influence of high-density material on the radiographic diagnosis of proximal caries in digital systems with automatic exposure compensation, and to evaluate the effect of subjective adjustment of brightness and contrast to undertake this diagnostic task. Twenty bitewing radiographs of forty posterior human teeth with non-cavitated carious lesions, confirmed by micro-CT, were obtained with two digital systems. A porcelain-fused-to-metal crown attached to a titanium implant was inserted into the exposed area, and all the radiographs were repeated. Five radiologists assessed the radiographs and diagnosed proximal carious lesions. Afterwards, the observers were asked to adjust image brightness and contrast, based on their subjective perception, and to reassess the images. Thirty percent of each experimental group was reassessed to test intraobserver reproducibility, totaling 208 images per observer. Intraobserver and interobserver agreements ranged from fair to substantial. Sensitivity, specificity, predictive values, and area under the ROC curve were calculated and compared for each radiographic system, using ANOVA (α = 0.05). Overall, presence of high-density material and adjustment of brightness and contrast did not significantly influence the radiographic diagnosis of proximal caries (p ≥ 0.05). Regarding Digora Optime, adjustment of brightness and contrast significantly increased (p < 0.05) the diagnostic accuracy of proximal carious lesions in the presence of high-density material. In conclusion, the presence of high-density material in the X-rayed region does not influence radiographic diagnosis of proximal caries. However, when it is present in the X-rayed area, subjective adjustment of brightness and contrast is recommended for use with the Digora Optime digital system.

Treatment outcomes of pulp revascularization in traumatized immature teeth using calcium hydroxide and 2% chlorhexidine gel as intracanal medication

Abstract Objective Pulp revascularization is an effective treatment for immature necrotic teeth. Calcium hydroxide has been used in pulp revascularization as an intracanal medication due to its antimicrobial action and the non-exhibition of crown discoloration and cytotoxicity for stem cells from the apical papilla. Our study aimed to investigate the clinical success and quantitative radiographic changes of root development in immature traumatized teeth using calcium hydroxide plus 2% chlorhexidine gel as intracanal medication. Methodology In this retrospective study, 16 patients were treated with a standardized pulp revascularization protocol. Calcium hydroxide and 2% chlorhexidine gel were manipulated in a 1:1 (v/v) ratio and inserted into root canals with Lentulo spirals (Dentsply Maillefer, Baillaigues, Switzerland). Patients were followed up for a period from 9 to 36 months for the evaluation of clinical and radiological data. Radiographic measurements of root length, root width, apical diameter, and MTA placement from the apex were quantified using software ImageJ. Wilcoxon test and t-test were used, according to nonparametric or parametric data, respectively, for changes over time in root length, root width, and apical diameter. Results Fifteen teeth survived during the follow-up period (93.75%) and met the criteria for clinical success. Although the changes seem to be very small in many cases, significant increases in the average root length (14.28%, p<0.0001), root width (8.12%, p=0.0196), and decrease in apical diameter (48.37%, p=0.0007) were observed. MTA placement from the apex and age at the time of treatment was not significantly associated with the quantitative radiographic outcomes. Conclusions Pulp revascularization in traumatized immature teeth treated with calcium hydroxide plus 2% chlorhexidine gel as intracanal medication had high success and survival rates, showing periodontal healing and resolution of signs and symptoms. However, concerning the continued root development, the outcomes can still be considered unpredictable.

Diagnostic value of magnetic resonance imaging in the analysis of ameloblastoma: report of two cases / Valor diagnóstico da ressonância magnética na análise do ameloblastoma: relato de dois casos

Ameloblastoma is an odontogenic tumor that shares clinical and imaging characteristics with other lesions of the jaws, such as odontogenic keratocyst, which makes the diagnosis difficult.However, in addition to radiographic and tomographic examinations, Magnetic Resonance Imaging (MRI) has been increasingly used, contributing with relevant additional information about thedifferentiation between solid and liquid components of the lesion. This case report was conducted to present two variations of ameloblastoma and discuss the radiographic, tomographic and MRI contribution in the differential diagnosis between ameloblastoma and odontogenic keratocyst. The signal intensity in T1-weighted MRI revealed internal fluid content in both cases, which was important in the differential diagnosis with other intraosseous lesions such as odontogenic keratocysts. This is probably due to the presence of keratin that increases the viscosity of the content and also for an intermediate signal intensity signal in T2-weighted MRI. Therefore, MRI revealed important internal characteristics of the reported lesions, which was very useful in the establishment of the differential diagnosis with other lesions. (AU)

O ameloblastoma é um tumor odontogênico que compartilha características clínicas e de imagem com outras lesões da mandíbula, como o ceratocisto odontogênico, o que dificulta o seu diagnóstico. Entretanto, além dos exames radiográficos e tomográficos, a ressonância magnética (RM) tem sido cada vez mais utilizada, contribuindo com informações adicionais relevantes sobre a diferenciação entre componentes sólidos e líquidos da lesão. Este relato de caso apresenta duas variações de ameloblastoma e discuti a contribuição radiográfica, tomográfica e da RM no diagnóstico diferencial entre o ameloblastoma e o ceratocisto odontogênico. A RM ponderada em T1 revelou conteúdo líquido interno em ambos os casos relatados, o que foi importante no diagnóstico diferencial com outras lesões intraósseas, como os ceratocistos odontogênicos. Isto ocorre devido à presença de queratina aumentar a viscosidade do conteúdo e também gerar um sinal de intensidade intermediária na RM ponderada em T2. Portanto, a RM revelou importantes características internas das lesões relatadas, o que foi muito útil no estabelecimento do diagnóstico diferencial com outras lesões. (AU)

Automatic cephalometric analysis: is it time to switch to a hands-free method?

Aim: To evaluate the reliability of the automatic cephalometric analysis in relation to the semi-automatic method. Methods: Fifty lateral cephalometric radiographs were selected and two dental surgeons performed the Steiner and Tweed analyses independently using the semi-automatic method on the Radiocef Studio 2® software suite (Radiomemory, Belo Horizonte, MG, Brazil), and the automatic method on the Kodak Dental Imaging Software (Carestream Health, Rochester, NY, USA). After thirty days, 30% of the sample was re-evaluated to assess intra-observer agreement. Ten angular and linear measurements of both analyses were selected, averaged for both observers and compared using Student's t-test with a significance level of 5% (α=0.05). Intra and inter-observer agreement were assessed through Intraclass Correlation Coefficient. Results: Intra-observer reproducibility was excellent for all measurements and inter-observer reproducibility was excellent for most of them. Significant differences (p<0.05) were found between automatic and semi-automatic methods for all measurements. Most of the measurements were significantly higher (p<0.05) with the automatic method. Conclusion: Semi-automatic cephalometric analysis can not be replaced with a completely automatic method

Aspectos tomográficos de ameloblastoma multicístico de células granulares: relato de caso / Computed tomography imaging features of multicystic granular cell ameloblastoma: a case report

O ameloblastoma multicístico é uma variante clínica do ameloblastoma, muitas vezes localmente agressivo, com significante aumento de morbidade e mortalidade. O ameloblastoma é frequentemente assintomático, sendo identificado incidentalmente durante exames odontológicos de rotina. Trata-se de uma lesão de crescimento lento e persistente, podendo ser notada, em alguns casos, uma expansão gradual da mandíbula, produzindo assimetria facial. Ameloblastomas raramente apresentam um comportamento maligno. A avaliação clínica inclui uma revisão cuidadosa da história clínica do paciente, bem como exame físico da cabeça e pescoço. Modalidades de imagens radiográficas são úteis para localizar a lesão, avaliar suas dimensões e os efeitos sobre as estruturas adjacentes. O manejo da lesão representa um desafio para todos os profissionais envolvidos na área de cirurgia de cabeça e pescoço. Assim, o objetivo deste trabalho foi descrever as características tomográficas de um ameloblastoma multicístico de células granulares em um paciente do sexo masculino, leucoderma, de 40 anos de idade...

Multicystic ameloblastoma is a clinical variant of ameloblastoma. It is often locally aggressive with significant impact on patient morbidity and mortality. Ameloblastoma is often asymptomatic and is usually detected as an incidental finding during routine dental examinations. It presents slow and persistent growth; in some cases a gradual expansion of the jaw producing facial asymmetry may be noticed . Although the occurrence is rare, ameloblastomas can exhibit malignant behavior and metastasize. Clinical evaluation includes careful review of the patient's medical history and physical examination of the head and neck region. Radiographic imaging techniques are useful for locating the lesion, estimating its dimensions and assessing its effects on adjacent structures. Management of ameloblastoma is a challenge for all involved in the field of head and neck surgery. The aim of this paper was therefore to describe the tomographic features of a multicystic granular cell ameloblastoma in a 40-year-old white male patient...

Gardner's syndrome suggested by radiographic findings / Síndrome de Gardner sugerida por achados radiográficos

Gardner's syndrome (GS) is a hereditary disorder characterized by multiple osteomas, enostosis, epidermoid cysts, subcutaneous desmoid tumors and multiple gastrointestinal polyps. Given the variety of clinical manifestations, the triad of symptoms that better characterizes the GS is composed by polyps of the colon, multiple osteomas and tumors of soft tissue. The osteomas are most common in the frontal bone and mandible. A significant feature of GS is the progression to malignancy of the intestinal polyps in almost 100% of patients. Early detection of GS allows for an excellent prognosis and may be a lifesaving event. Thus, the aim of this case report was to describe the radiographic aspects of GS in the dentomaxillofacial region and to discuss with the current scientific literature.

A síndrome de Gardner (SG) é uma desordem caracterizada por múltiplos osteomas, enostosis, cistos epidermoides, tumores desmoides subcutâneos e múltiplos pólipos gastrointestinais. Considerando a variedade de manifestações clínicas, a tríade dos sintomas que melhor caracterizam a SG é composta por pólipos do cólon, múltiplos osteomas e tumores de tecido mole. Os osteomas são mais comuns no osso frontal e mandíbula. Uma característica significativa da SG é a progressão maligna dos pólipos intestinais em aproximadamente 100% dos pacientes. A detecção precoce da SG favorece um excelente prognóstico e pode salvar vidas. Então, o objetivo deste relato de caso foi descrever os aspectos radiográficos da SG na região dento-maxilo-facial e discutir com a literatura científica atual.

Gray scale inversion in digital image for measurement of tooth length

The aim of this study was to assess the applicability of gray scale inversion in performing digital linear endodontic measurements. Standardized digital images were taken of 40 extracted human permanent single-rooted teeth with K-files size 15 placed at different lengths in the root canal, using the CDR Wireless® digital system. All images were treated with Positive, a digital tool that inverts the grayscale value. Eight radiologists measured the distance between the lower limit of the rubber stop and the tip of the file on both original and positive images. After 15 days, they repeated this procedure in 50% of the image samples. The intra- and inter-examiner agreement was analyzed by intraclass correlation test, and the comparison between the two image groups and the actual lengths by the Student's t-test (α=0.05). Intra- and inter-examiner evaluation showed high reproducibility (r>0.95) of both original and positive images. No statistically significant differences (p>0.05) were found between measurements performed on original and positive images, but both differed significantly from the actual lengths (p<0.05). Gray scale inversion has low applicability in measuring endodontic files, since it did not improve the accuracy of measurements.

O objetivo deste estudo foi avaliar a aplicabilidade da inversão da escala de cinza na realização de mensurações endodônticas lineares digitais. Quarenta dentes unirradiculares humanos extraídos foram radiografados com limas K tamanho 15 posicionadas no canal radicular em diferentes comprimentos, usando o sistema digital CDR Wireless®. Todas as imagens foram tratadas com Positive, uma ferramenta digital que inverte os valores da escala de cinza. Oito radiologistas mediram a distância entre o limite inferior do stop de borracha e a ponta da lima endodôntica nas imagens originais e positivas. Após quinze dias, eles repetiram esse procedimento em 50% da amostra. A concordância intra- e interobservador foi analisada pelo teste de correlação intraclasse e a comparação entre os dois grupos de imagem e os valores reais, pelo teste t-Student (α=0,05). A análise intra- e interobservador apresentou elevada reprodutibilidade (r>0,95) das imagens original e Positive. Não foi encontrada diferença (p>0,05) entre as medidas realizadas nas imagens original e positiva, mas ambas diferiram dos valores reais (p<0,05). A inversão da escala de cinza tem baixa aplicabilidade na realização de mensuração endodôntica, considerando que as medidas não se apresentaram mais acuradas.

Terceiro molar intrassinusal: relato de caso / Intra-sinusal third molar: case report

Ectopic tooth eruption into an area other than the oral cavity is rare. Nasal septum, mandibular condyle, coronoid process and infratemporal fossa space have been reported as frequent locations for ectopic tooth eruption. Ectopic teeth located within the maxillary sinus may be asymptomatic, found only in routine examinations. Headache, sinusitis and nasal obstruction are some of the associated symptoms. The differential diagnosis includes foreign bodies (rhinolith), infections (syphilis and tuberculosis), benign lesions (hemangioma, osteoma, calcified polyp) and malign lesions (osteosarcoma). Upper third molars located within the maxillary sinus may be associated with the development of mucocele or dentigerous cyst. The aim of this paper was to describe the case of a 24-year old female patient with an ectopic right upper third molar in the maxillary sinus. A hyperdense area was observed with sinus obliteration, consistent with mucous material.

Erupção ectópica dos dentes em outras regiões além da cavidade oral é rara. O desenvolvimento ectópico desses dentes tem sido relatado no septo nasal, côndilo mandibular, processo coronoide e no espaço da fossa infratemporal. Dentes ectópicos localizados no seio maxilar podem ser assintomáticos, descobertos em exames radiográficos de rotina. Dentre os sintomas associados estão cefaleia, sinusite e obstrução nasal. Corpos estranhos (rinólitos), processos infecciosos (sífilis ou tuberculose), lesões benignas (hemangioma, osteoma, pólipos calcificados) e malignas (osteossarcoma) podem ser considerados no diagnóstico diferencial de dentes ectópicos. Os terceiros molares superiores, quando localizados no seio maxilar, podem estar associados ao desenvolvimento de mucocele, assim como de cistos dentígeros. Dessa forma, o objetivo deste artigo foi relatar o caso de uma paciente do gênero feminino, com 24 anos de idade, em que se observou terceiro molar superior direito com localização intrassinusal associado a uma área de hiperdensidade média, causando parcial obliteração do seio maxilar, compatível com material mucoide.

Bone mineral density on conventional and digitized images under different parameters of digitization and storage

Aim: To assess the bone mineral density on conventional and digitized images, comparing whether different parameters of digitization and storage change these values. Methods: Twenty radiographs were taken from five partially dentulous dry mandibles with an aluminum 7-mm stepwedge placed on the superior edge of the film. After processing, the films were digitized with are solution of 600 and 2,400 d.p.i. and saved as TIFF and JPEG files. On every conventional and digitized image, circular regions of interest were selected for densitometry and radiographic contrast analysis. Results: Pearson’s correlation coefficient showed a significant and strong mean gray values association between digitized and conventional images, differing from radiographic contrast that did not show a significant association. A NOVA did not reveal a statistically significant difference in bone density and radiographic contrast among the four digitized image groups, but the conventional image contrast was significantly lower. Conclusions: Bone mineral density did not differ in both conventional and digitized images. The parameters of image compression and resolution, tested in this study, did not change the results of densitometry and digitization process increased the radiographic contrast.