Comparison of Quantitative Radiomorphometric Predictors of Healthy and MRONJ-Affected Bone Using Panoramic Radiography and Cone-Beam CT.

OBJECTIVES: To determine the most distinctive quantitative radiomorphometric parameter(s) for the detection of MRONJ-affected bone changes in panoramic radiography (PR) and cone-beam computed tomography (CBCT). METHODS: PR and sagittal CBCT slices of 24 MRONJ patients and 22 healthy controls were used for the measurements of mandibular cortical thickness (MCT), fractal dimension (FD), lacunarity, mean gray value (MGV), bone area fraction (BA/TA), trabecular thickness (Tb.Th), trabecular separation (Tb.Sp), trabecular number (Tb.N). MCT was measured in the mental foramen region. While FD and lacunarity were measured on mandibular trabecular and cortical regions of interest (ROIs), the remaining parameters were measured on trabecular ROIs. The independent samples t-test was used to compare the measurements between MRONJ and control group for both imaging modalities (p = 0.05). RESULTS: MCT was the only parameter that differentiated MRONJ-affected bone in both PR and CBCT (p < 0.05). None of the remaining parameters revealed any difference for MRONJ-affected bone in CBCT (p > 0.05). FD, lacunarity, MGV, BA/TA, and Tb.Sp could distinguish MRONJ-affected trabecular bone in PR (p < 0.05). The correspondent ROI for both imaging methods that was reliable for detecting MRONJ-affected bone was the trabecular bone distal to the mental foramen above the inferior alveolar canal (ROI-3). CONCLUSIONS: MCT is a reliable parameter for the discrimination of MRONJ-affected bone in both PR and CBCT images. PR may be used to detect MRONJ-affected trabecular bone using FD, lacunarity, MGV, BA/TA, and Tb.Sp measurements as well.

Effect of Mandibular Angulation on Pre-Implant Site Measurement Accuracy Using CBCT.

PURPOSE: To evaluate the accuracy of available bone width, height, and length measurements on pre-planned implant sites using CBCT images scanned at different angulations of the mandible. MATERIALS AND METHODS: Standard cylindrical holes were prepared on six dry human mandibles and filled with warm gutta-percha to create spherical markers for measurements of available bone width, height, and length. Mandibles were first scanned with a CBCT device in an ideal position with the occlusal plane parallel to the horizontal plane. Then, images of the mandibles were obtained in rotation, tilt, flexion, and extension positions using 5- and 10-degree angulations. Measurements were done on a total of 54 images. Original dimensions of the available bone for planned implant sites were measured with a digital caliper on dry mandibles as the gold standard. The absolute values of the differences between each measurement and the gold standard were obtained for measurement errors. Repeated-measures analysis of variance and Dunnett's multiple comparisons test were used for comparisons (P = .05). Intraobserver and interobserver agreement was calculated using intraclass correlation coefficient (ICC). RESULTS: ICC was excellent for both intraobserver and interobserver reproducibility. No significant difference was found between length and height measurements in ideal position and in rotation, tilt, flexion, and extension movements of mandibles at two different angulations (P > .05). Width measurements revealed a significant difference among ideal measurements and measurements at 10-degree flexion, 10-degree extension, 10-degree rotation, and 10-degree tilted mandibular positions (P < .05). CONCLUSION: The position of the occlusal plane with respect to the floor during the CBCT scan may have a clinically significant effect on dental implant site dimensions.

Use of Fractal Analysis for the Discrimination of Trabecular Changes Between Individuals With Healthy Gingiva or Moderate Periodontitis.

BACKGROUND: The aim of this study is to evaluate the capability of fractal analysis to discriminate the changes in the trabecular structure of interdental bone between individuals with healthy gingiva or moderate periodontitis using digital images. METHODS: Two groups of patients were included according to the probing depth, bleeding on probing, and clinical attachment level. The first group (n = 50) consisted of individuals with healthy gingiva, whereas the other group consisted of patients with moderate periodontitis (n = 50). Periapical images obtained with a storage phosphor plate system during clinical examination were used for the fractal dimension (FD) calculations. Two rectangular regions of interest (ROIs) were placed at mandibular posterior interdental bone areas. The mean of the two ROIs was used to calculate mean FD by using the box-counting method. Student t test was used for the comparison of the FDs of the two groups (P = 0.05). RESULTS: The mean FD of patients with periodontitis was 0.83, whereas it was 1.02 for the patients with healthy gingiva. A significant difference was obtained in the mean FD values of healthy individuals and patients with moderate periodontitis (P <0.05). CONCLUSION: Fractal analysis can quantitatively discriminate the trabecular integrity alterations induced by periodontitis and therefore can be recommended for the diagnosis and monitoring of changes in trabecular architecture associated with periodontitis.

Oral health and oral quality of life in inactive patients with familial Mediterranean fever without amyloidosis.

OBJECTIVES: The aim of this study was to investigate oral and general health-related quality of life (QoL) in patients with familial Mediterranean fever (FMF) disease. METHODS: In this cross-sectional study, 45 patients with FMF, 50 age- and sex-matched healthy controls (HC), and 50 patients with Behçet's disease (BD) as the disease control group were included. FMF disease activity was evaluated by using the FMF-severity score, as well as with erythrocyte sedimentation rate (ESR), and serum C-reactive protein and fibrinogen levels. Oral health-related QoL and general QoL were evaluated using oral health impact profile-14 (OHIP-14) and Medical Outcomes Short-Form Health Survey Questionnaire 36 (SF-36), respectively. RESULTS: Only the numbers of extracted teeth (4.13±4.72 vs. 1.55±3.6) and filled teeth (2.33±3.19 vs. 0.66±1.46) were significantly higher in FMF group compared to HC group (p=0.005 and p=0.013, respectively). OHIP-14 score was significantly higher in FMF and BD groups compared to HC group. In FMF patients, OHIP-14 score was positively correlated with the number of extracted teeth (r=0.38, p=0.010), while the number of carious teeth was positively correlated with ESR (r=0.43, p=0.003). When FMF patients were sub-classified according to disease severity, no significant difference was observed with respect to oral health status. CONCLUSIONS: In patients with FMF, some of the parameters of oral health status were found to be worse compared to HC group. Tooth loss appears to be to be a critical factor contributing to impaired oral QoL. In general, oral health status in FMF patients is better than in BD patients.

Pixel intensity and fractal dimension of periapical lesions visually indiscernible in radiographs.

INTRODUCTION: The purpose of the study was to analyze pixel intensity (PI) and fractal dimension (FD) values in radiographs of chemically created but visually undetectable periapical lesions. METHODS: Artificial lesions were created by applying 70% perchloric acid to the sockets of left and right first premolars in 12 cadaver mandibles. For preparation of relatively small lesions, the acid was applied for 30 and 60 minutes. Before and after each acid application, radiographs were taken (60 kVp, 7 mA, and 1.5 mm Al equivalent filtration for 0.12 second) with storage phosphor plates. An optical bench was used to standardize projection geometry. Image plates were scanned immediately after exposure, and the acquired images were saved uncompressed in TIF format. Six observers evaluated the images by using a 5-grade scale, and the images scored as "definitely absent" by all observers were used for the calculations of PI and FD. Box-counting FDs and differences in mean PI were computed for regions of interest at the apical areas of each premolar. Repeated-measures analysis of variance, Tukey test, and Pearson correlation coefficient test were used for statistical analysis. RESULTS: A significant difference was found in FD values after both acid application periods (P < .05), whereas a difference in PI was detected only in images obtained after 60-minute acid application (P < .05). There was a negative correlation between FD and PI values (-0.754, P < .05). CONCLUSIONS: Calculation of FD can be a tool for the early detection of periapical lesions given the presence of baseline radiographs.

Detection of artificial demineralization bordering different types of laminate veneers using visual inspection and storage phosphor radiography.

OBJECTIVE: The objective of this study is to compare the diagnostic accuracy of visual inspection (VI) and storage phosphor plate (SPP) radiography for the detection of artificial demineralization bordering different laminate veneers. MATERIALS AND METHODS: Twenty human maxillary canine teeth were prepared. All-ceramic (A) and hybrid ceramic (H) laminate veneers were fabricated and luted. Veneered teeth were covered except for a circular window on the proximal surface bordering restorations. Teeth were kept in acetic acid buffer to create demineralization and imaged with a SPP system. Ten observers evaluated all teeth first visually then with SPP images for the presence/absence of demineralization. Teeth were examined using scanning electron microscopy (SEM) as well. The accuracy was expressed as the area under the ROC curves (A(z)). Pair-wise comparisons were performed using two-way ANOVA and post hoc t test (p = 0.05). Fleiss kappa (κ) was used for agreement. RESULTS: SPP radiography was better than the VI for both veneers (p = 0.004). The A(z)s of two veneers were different for both VI (p < 0.005) and SPP (p < 0.005). SEM evaluation revealed lesions confined to enamel. κ was fair for H, and fair to moderate for A. Agreement was higher for the radiographic evaluation for both veneers. CONCLUSION: Enamel demineralizations bordering hybrid and ceramic laminate veneers can be detected better with SPP radiography than VI and detectability was better for all-ceramic veneers than the hybrid ceramic ones. CLINICAL RELEVANCE: Early detection of enamel demineralizations bordering laminate veneers would result in time-saving and less-invasive treatment methods; therefore, SPP radiography may be recommended in clinically suspicious cases since it provides better diagnostic accuracy.

Changes in the fractal dimension, feret diameter, and lacunarity of mandibular alveolar bone during initial healing of dental implants.

PURPOSE: To evaluate the combination of fractal dimension (FD), lacunarity, and Feret diameter (FeD) to quantitatively characterize structural changes of mandibular alveolar bone around dental implants during initial healing. MATERIALS AND METHODS: Three standard-sized regions of interest (ROIs) (mesial and distal crest and apical area) around implants and three ROIs of the same size in the alveolar bone on the contralateral side were analyzed on digital panoramic images. FD was calculated using the box-counting method, and lacunarity was calculated using the FracLac plugin of Image J software. FeD was measured in the same ROIs. Comparisons of the groups were done with the Dunnett test. RESULTS: Forty-two implants in the posterior mandibles of 21 patients were used for FD measurements. A total of 189 ROIs was segmented into binary images. Mean FD values for mesial, distal, and apical ROIs around implants were 1.26, 1.36, and 1.4, respectively. The mean FD of alveolar bone around premolars/molars was 1.39 for all ROIs. The mean FeD for mesial, distal, and apical ROIs around implants was 7.63, 7.86, and 8.02, respectively, whereas it ranged between 7.88 and 8.13 for premolar teeth. Mean lacunarity values for mesial, distal, and apical ROIs around implants were 0.53, 0.51, and 0.48, respectively. Lacunarity values for ROIs around premolars ranged between 0.45 and 0.50. No significant differences were observed in FD, FeD, or lacunarity measurements between ROIs around implants and around teeth. CONCLUSIONS: The satisfactory healing of bone following implant placement may be monitored by calculating FD, lacunarity, and FeD using digital panoramic images. Although preliminary, these values may alert the practitioner to any implants with loss of stability.

Diagnostic accuracy of Digora Optime storage phosphor plates for proximal subsurface demineralization: effect of different exposure times.

OBJECTIVE: The aim of this study was to compare the diagnostic accuracy of F-speed film and storage phosphor plate (SPP) exposed with different exposure times for the detection of artificial enamel subsurface demineralization. STUDY DESIGN: Standard enamel windows of extracted premolars were exposed to a demineralizing solution. All teeth were radiographed before and after acid application with F-speed films and SPPs. Films were exposed for 0.25 seconds and SPPs were exposed using 4 exposure times. Receiver operating characteristic analysis was used for diagnostic accuracy (A(z)). RESULTS: Significant differences were obtained among A(z)s of 0.08- versus 0.12-seconds and 0.10- versus 0.12-second exposed SPPs (P < .05). A(z)s of films were higher than the SPPs exposed with 0.08, 0.10, and 0.12 seconds (P < .05). No difference was found between the A(z)s of the 2 systems when SPPs were exposed for 0.16 seconds (P > .05). CONCLUSIONS: Diagnostic accuracy of films and SPPs was not impaired when exposure time was 36% reduced for the latter; however, diagnosis was impaired when reduced 52%.

Does a combination of two radiographs increase accuracy in detecting acid-induced periapical lesions and does it approach the accuracy of cone-beam computed tomography scanning?

INTRODUCTION: The purpose of this study was to determine whether the use of a combination of 2 images (storage phosphor plates [SPPs] and F-speed films [Eastman Kodak, Rochester, NY]) with a 10° difference in horizontal beam angulation resulted in better detectability of chemically created periapical defects than when only 1 image was used and whether a detectability as good as that achieved by limited cone-beam computed tomography (LCBCT) scanning could be achieved. METHODS: Lesions were created by 1, 1.5, and 2 hours of acid application apical to extracted teeth in jaw specimens. After repositioning, teeth were radiographed with Accu-I-Tomo LCBCT, Digora Optime SPP system, and F-speed films. The SPPs and films were exposed at 0° and 10° horizontal angulations. The diagnostic accuracy (Az) was compared using 2-way analysis of variance; pair-wise comparisons were performed using the post hoc t test. Kappa was used to measure interobserver agreement. RESULTS: A combination of 2 exposures with a 10° difference in horizontal angulation caused an increase, although not statistically significant, in the accuracy of both films and SPPs for all acid durations (P > .05) compared with when only 1 exposure was used. The accuracy did not approach that of LCBCT. CONCLUSIONS: Using a combination of 2 exposures instead of 1 did not significantly increase the accuracy in detecting acid-induced lesions at the apices of single-rooted premolars. The accuracy of LCBCT was superior.

Image resolution and exposure time of digital radiographs affects fractal dimension of periapical bone.

OBJECTIVES: The aim of this study was to evaluate the effect of exposure time and image resolution on fractal dimension (FD) of periapical bone on images obtained using a storage phosphor plate (SPP) system. MATERIALS AND METHODS: Periapical images of premolar and molar teeth on both sides of ten dry human mandibles were obtained with Digora Optime (Soredex Corp., Helsinki, Finland) SPP system. The SPPs were exposed with three exposure times (0.05, 0.12, and 0.30 s) and scanned immediately after exposure with high and super resolutions. FD was calculated using public domain software (ImageJ with FracLac plug-in) on two non-overlapping region of interest (ROIs) on premolar and molar periapical bone areas of each radiograph using differential box-counting method. The ROIs on corresponding images were of the same size and position. FDs were compared using two-way ANOVA and Tukey-Kramer multiple comparison tests (p = 0.05). RESULTS: Images obtained with super resolution scans gave significantly higher FD values compared to high-resolution scanning for all exposures (p < 0.0001). FD values were decreasing with increase in exposure time for both resolutions (p < 0.0001). The highest FD was found for images with super resolution and shortest exposure time, which exhibited the highest noise. CONCLUSIONS: FD analysis seems not so robust method as it was believed previously. It shows significant changes with image resolution and exposure time. CLINICAL RELEVANCE: Exposure time and scanning resolution of SPPs should be carefully chosen when evaluating the change in FD of alveolar bone for various bone disorders.

Fractal analysis of periapical bone from lossy compressed radiographs: a comparison of two lossy compression methods.

The aim of the study was to evaluate the effect of two lossy image compression methods on fractal dimension (FD) calculation. Ten periapical images of the posterior teeth with no restorations or previous root canal therapy were obtained using storage phosphor plates and were saved in TIF format. Then, all images were compressed with lossy JPEG and JPEG2000 compression methods at five compression levels, i.e., 90, 70, 50, 30, and 10. Compressed file sizes from all images and compression ratios were calculated. On each image, two regions of interest (ROIs) containing healthy trabecular bone in the posterior periapical area were selected. The FD of each ROI on the original and compressed images was calculated using differential box counting method. Both image compression and analysis were performed by a public domain software. Altogether, the FD of 220 ROIs was calculated. FDs were compared using ANOVA and Dunnett tests. The FD decreased gradually with compression level. A statistically significant decrease of the FD values was found for JPEG 10, JPEG2000 10, and JPEG2000 30 compression levels (p < 0.05). At comparable file sizes, the JPEG induced a smaller FD difference. In conclusion, lossy compressed images with appropriate compression level may be used for FD calculation.

Effect of tube potential and image receptor on the detection of natural proximal caries in primary teeth.

The aim of this study was to assess the detection of proximal caries in primary teeth at three different tube potentials using Ektaspeed films, storage phosphor plates (SPPs), and a charge-coupled device (CCD). Fifty-three extracted human primary molars with natural proximal caries were radiographed with three different imaging modalities--Digora Optime SPP system, RVGui CCD system, and Ektaspeed films--at 50-, 65-, and 70-kV tube potentials. Three observers scored the resultant images for the presence or absence of caries. The definitive diagnosis was determined by stereomicroscopic assessment. The diagnostic accuracy for each imaging modality was expressed as the area under the receiver operating characteristic curves (A(z)). Differences among the A(z) values were assessed using two-way ANOVA and t tests. Kappa was used to measure inter- and intra-observer agreement. Higher accuracy was found for SPPs compared to film and CCD images at all tube potentials. Accuracy was significantly different only at 50-kV tube setting in favor of SPPs (p < 0.05). Inter- and intra-observer agreement was high for all systems. A SPP system can be recommended for dental peadodontic clinics particularly with 50-kV tube potential for the diagnosis of proximal caries since further advantages include the elimination of chemical processing, image enhancement, and a better low-contrast detectability performance.

The influence of bonding agents on the decision to replace composite restorations.

UNLABELLED: This in vitro study evaluated the validity of the decision to replace of a restoration based upon the radiolucent zone beneath a resin composite. MATERIALS AND METHODS: Class II cavities were prepared on the approximal surfaces of 40 molars. The teeth were divided into four groups. Clearfil SE Bond, PQ1 or Single Bond was applied in the experimental groups. No bonding agent was used in the control group. Following the restorations, digital radiographs were obtained and independently evaluated by two oral radiologists and two specialists in restorative dentistry to determine the need for replacement. The coronal portions of the teeth were then sectioned and the interfaces between the restorations and cavity walls were examined using an optical light microscope. Possible adhesive pooling and voids were examined under a light microscope. Inter-examiner reliability was evaluated with the Cohen's kappa (kappa) test. Sensitivity, specificity and negative and positive predictive values were calculated. Kruskal-Wallis, followed by the Mann-Whitney U-test, determined differences among the pooling thicknesses of the different adhesives. RESULTS: Various sensitivity and specificity degrees were obtained from the groups in which different adhesive systems were used. The PQ1 adhesive system was the best for identifying well-adapted restorations with the highest true non-replacement diagnosis (TND = 0.70). Clearfil SE Bond had the highest false positive scores. Adhesive pooling was significantly different in the experimental groups of the current study (p < 0.05). CONCLUSION: Replacement decisions for a resin composite restoration based upon digital images frequently resulted in false-positive or negative decisions.

LCD and CRT display of storage phosphor plate and limited cone beam computed tomography images for the evaluation of root canal fillings.

The aim was to compare quality of liquid crystal display (LCD) and high resolution cathode ray tube (CRT) screens for the evaluation of length and homogeneity of root canal fillings in storage phosphor plate (SPP) and limited cone beam computed tomography (LCBCT) images. Endodontic treatment was performed to 17 extracted permanent lower incisor teeth. Images of each tooth positioned in a dried mandible were obtained with Digora SPP and Accu-I-Tomo LCBCT systems. Six observers scored the quality of all images on CRT and LCD screens. Results were compared using McNemar's and Cochran's Q tests (p < 0.05). The differences among the LCBCT and SPP images were determined by binomial test. No significant difference was found between ratings of CRT and LCD displays (p > 0.05). Agreement among observers' scores was higher with CRT display. Within the limits of this ex vivo study, differences between LCD and CRT monitors for the evaluation of root canal fillings are clinically insignificant independent on whether conventional radiographs, captured by means of image plates, or cone beam images are being displayed.

Differences in aluminum equivalent values of endodontic sealers: conventional versus digital radiography.

The aims of this study were to compare film and digital radiography in assessing the radiopacities of root canal sealers and to establish the relation in aluminum equivalent values of different methods. Standard disks of 5 different sealers were exposed together with an aluminum step wedge by using occlusal films and storage phosphor plates. Optical density of the sealers was evaluated by transmission densitometry, and mean gray values were determined by digital analysis. The data were analyzed by using two-way analysis of variance (P = .05). Pairwise comparisons were made by using Tukey post hoc and paired t tests (P = .05). The order from the most radiopaque to the most radiolucent sealer was the same for both methods; however, aluminum equivalent values determined by transmission densitometry were significantly higher (P < .01). Aluminum equivalent values of the 2 radiographic methods were 7%-20% different. The International Standards Organization standard for the radiopacity of dental root canal sealing materials needs modifications for digital systems.

Measurement accuracy and perceived quality of imaging systems for the evaluation of periodontal structures.

The aim of this study was to compare the subjective diagnostic quality of F-speed film images and original and enhanced storage phosphor plate (SPP) digital images for the visualization of periodontal ligament space (PLS) and periapical (PB) and alveolar crestal bone (CB) and to assess the accuracy of these image modalities for the measurement of alveolar bone levels. Standardized images of six dried mandibles were obtained with film and Digora SPPs. Six evaluators rated the visibility of anatomical structures using a three-point scale. Alveolar bone levels were measured from the coronal-most tip of the marginal bone to a reference point. Results were compared by using Friedman and Wilcoxon signed-ranks tests. The kappa (kappa) statistic was used to measure agreement among observers. The measurements were compared using repeated measures analysis of variance and Bonferroni tests (P = 0.05). A paired t test was used for comparison with true bone levels (P = 0.05). Enhanced SPP images were rated superior, followed by film and then the original SPP images, for the evaluation of anatomical structures. The value of kappa rose from fair to substantial after the enhancement of the SPP images. Film and enhanced SPP images provided alveolar bone lengths close to the true bone lengths. Enhancement of digital images provided better visibility and resulted in comparable accuracy to film images for the evaluation of periodontal structures.

Comparison of conventional and digital radiography for radiometric differentiation of dental cements.

OBJECTIVE: To test the efficacy of conventional radiometry with indirect digital image analysis in the assessment of the relative radiopacity of dental cements used as liners or bases compared to human enamel and dentin. METHOD AND MATERIALS: Disks of 15 different dental cements, 5 mm in diameter and 2 mm thick, were exposed to radiation together with 2-mm-thick disks of enamel and dentin and an aluminum step wedge. Density was evaluated by digital transmission densitometry and with the histogram function of an image analysis program following digitization of the radiographs with a flatbed scanner. RESULTS: A higher number of dental cements were discriminated from both dentin and enamel with conventional radiographic densitometer. All the cements examined, except Ionoseal (Voco) and Ionobond (Voco), were more radiopaque than dentin. With both methods, Chelon-Silver (3M ESPE) had the highest radiopacity and glass-ionomer cements the lowest. CONCLUSION: Radiodensity of dental cements can be differentiated with a high probability with the conventional radiometric method.

Effect of various digital processing algorithms on the measurement accuracy of endodontic file length.

OBJECTIVE: The aim of this study was to compare the accuracy of endodontic file lengths after application of various image enhancement modalities. STUDY DESIGN: Endodontic files of three different ISO sizes were inserted in 20 single-rooted extracted permanent mandibular premolar teeth and standardized images were obtained. Original digital images were then enhanced using five processing algorithms. Six evaluators measured the length of each file on each image. The measurements from each processing algorithm and each file size were compared using repeated measures ANOVA and Bonferroni tests (P = 0.05). Paired t test was performed to compare the measurements with the true lengths of the files (P = 0.05). RESULTS: All of the processing algorithms provided significantly shorter measurements than the true length of each file size (P < 0.05). The threshold enhancement modality produced significantly higher mean error values (P < 0.05), while there was no significant difference among the other enhancement modalities (P > 0.05). Decrease in mean error value was observed with increasing file size (P < 0.05). CONCLUSIONS: Invert, contrast/brightness and edge enhancement algorithms may be recommended for accurate file length measurements when utilizing storage phosphor plates.