Radiographic diagnosis of dental caries.

The purpose of this report was to respond to aspects of the RTI/UNC systematic review relating to the radiographic diagnosis of dental caries. The systematic review was commissioned as part of the NIH Consensus Development Conference on Diagnosis and Management of Dental Caries Throughout Life. The systematic review evaluated the dental literature from 1966 to 1999. Well-defined search criteria along with clear inclusion and exclusion criteria were used to perform the review. Some of the inclusion and exclusion criteria used in the systematic review may have limited the evidence supporting the use of radiography, especially for the diagnosis of proximal surface caries. The RTI/UNC review only included studies in which sensitivity and specificity were reported or could be derived from the data presented. Studies that used the receiver operating characteristic as a measure of diagnostic accuracy were not included. Although the strength of evidence is considered poor, this does not mean that the use of radiographic methods is of no diagnostic value. It simply means that, using the criteria established by the systematic review, the evidence is inadequate to validate the method. Guidelines should be developed for assessing diagnostic methods that assist researchers in developing study designs that will hold up to critical review.

Comparison of five methods for the derivation of spectra for a constant potential dental X-ray unit.

OBJECTIVES: To compare the diagnostic X-ray spectra derived by different methods for a constant potential dental X-ray unit. MATERIALS AND METHODS: Five methods of deriving X-ray spectra for a constant potential dental X-ray unit were compared: measurement by spectrometer using cadmium-zinc-telluride (CZT) detector, calculation by Monte Carlo simulation, calculation by two different, semi-empirical methods and estimation from transmission data. The dental X-ray set was a Heliodent MD unit (Sirona, Charlotte, NC, USA) operable at 60 or 70 kV. A semiconductor detector was used in the spectrometer measurements and an ionization chamber dosimeter in the transmission measurements. From the five methods, photon-fluence spectra were derived. Based on the photon-fluence spectra, average energies and transmission curves in aluminum were calculated. RESULTS: For all five methods, the average energies were within 2.4% of one another. Comparison of the transmission curves showed an average difference in the range of 1 to 6%. CONCLUSION: All of the five methods of deriving spectra are in extremely good agreement with each other.

Measurement and validation of benchmark-quality thick-target tungsten X-ray spectra below 150 kVp.

Pulse-height distributions of two constant potential X-ray tubes with fixed anode tungsten targets were measured and unfolded. The measurements employed quantitative alignment of the beam, the use of two different semiconductor detectors (high-purity germanium and cadmium-zinc-telluride), two different ion chamber systems with beam-specific calibration factors, and various filter and tube potential combinations. Monte Carlo response matrices were generated for each detector for unfolding the pulse-height distributions into spectra incident on the detectors. These response matrices were validated for the low error bars assigned to the data. A significant aspect of the validation of spectra, and a detailed characterization of the X-ray tubes, involved measuring filtered and unfiltered beams at multiple tube potentials (30-150 kVp). Full corrections to ion chamber readings were employed to convert normalized fluence spectra into absolute fluence spectra. The characterization of fixed anode pitting and its dominance over exit window plating and/or detector dead layer was determined. An Appendix of tabulated benchmark spectra with assigned error ranges was developed for future reference.

Using measured 30-150 kVp polychromatic tungsten x-ray spectra to determine ion chamber calibration factors, Nx (Gy C(-1)).

Two methods for determining ion chamber calibration factors (Nx) are presented for polychromatic tungsten x-ray beams whose spectra differ from beams with known Nx. Both methods take advantage of known x-ray fluence and kerma spectral distributions. In the first method, the x-ray tube potential is unchanged and spectra of differing filtration are measured. A primary standard ion chamber with known Nx for one beam is used to calculate the x-ray fluence spectrum of a second beam. Accurate air energy absorption coefficients are applied to the x-ray fluence spectra of the second beam to calculate actual air kerma and Nx. In the second method, two beams of differing tube potential and filtration with known Nx are used to bracket a beam of unknown Nx. A heuristically derived Nx interpolation scheme based on spectral characteristics of all three beams is described. Both methods are validated. Both methods improve accuracy over the current half value layer Nx estimating technique.

Mechanical loading stimulates differentiation of periodontal osteoblasts in a mouse osteoinduction model: effect on type I collagen and alkaline phosphatase genes.

The effects of mechanical loading on the osteoblast phenotype remain unclear because of many variables inherent to the current experimental models. This study reports on utilization of a mouse tooth movement model and a semiquantitative video image analysis of in situ hybridization to determine the effect of mechanical loading on cell-specific expression of type I collagen (collagen I) and alkaline phosphatase (ALP) genes in periodontal osteoblasts, using nonosseous cells as an internal standard. The histomorphometric analysis showed intense osteoid deposition after 3 days of treatment, confirming the osteoinductive nature of the mechanical signal. The results of in situ hybridization showed that in control periodontal sites both collagen I and ALP mRNAs were expressed uniformly across the periodontium. Treatment for 24 hours enhanced the ALP mRNA level about twofold over controls and maintained that level of stimulation after 6 days. In contrast, collagen I mRNA level was not affected after 24 hours of treatment, but it was stimulated 2.8-fold at day 6. This increase reflected enhanced gene expression in individual osteoblasts, since the increase in osteoblast number was small. These results indicate that (1) the mouse model and a semiquantitative video image analysis are suitable for detecting osteoblast-specific gene regulation by mechanical loading; (2) osteogenic mechanical stress induces deposition of bone matrix primarily by stimulating differentiation of osteoblasts, and, to a lesser extent, by an increase in number of these cells; (3) ALP is an early marker of mechanically-induced differentiation of osteoblasts. (4) osteogenic mechanical stimulation in vivo produces a cell-specific 2.8-fold increase in collagen gene expression in mature, matrix-depositing osteoblasts located on the bone surface and within the osteoid layer.

Analysis of sensitivity and specificity of a new digital subtraction system: an in vitro study.

OBJECTIVE: The purpose of this study was to compare a new digital subtraction system with conventional radiograph images for the detection of periapical and periodontal bone lesions. STUDY DESIGN: Periapical and periodontal bone lesions were simulated with cortical bone chips of varying sizes placed on a human dry mandible. Radiographic film images were acquired from varying projections and were subsequently digitized, registered, and subtracted. Four clinicians evaluated the subtracted images, and sensitivity and specificity were calculated. RESULTS: The mean sensitivity and specificity of the Diagnostic Subtraction Radiography system for detecting bone lesions of all sizes with varying projection geometry were 87.90% and 85.23%, respectively. The corresponding results for conventional radiograph images were 47.54% and 97.38%. The difference in sensitivity was statistically significant, whereas the difference in specificity was not. CONCLUSIONS: These results indicate that, even when radiographs are taken from disparate projection geometries, the Diagnostic Subtraction Radiography system is capable of excellent discrimination between healthy and disease states in this in vitro model.

Clinical validation of a new subtraction radiography technique for periodontal bone loss detection.

BACKGROUND: Diagnostic subtraction radiography (DSR) is a new digital radiographic image subtraction method designed to enhance detection of crestal or periapical bone density changes and to help evaluate caries progression in teeth. In this clinical study, the performance of the DSR method was evaluated for its ability to detect periodontal bone loss and was compared with that of conventional evaluation of radiographs and the standardized cephalostat-guided image acquisition and subtraction technique (LRA) which served as the "gold standard." METHODS: In each of 25 subjects with alveolar crestal bone loss created by periodontal surgery, one set of DSR radiographs and one set of LRA radiographs were obtained before and after the surgery. Subtraction images were then generated by both the proprietary DSR and the LRA techniques. Four viewers evaluated the paired film sets and both subtraction image sets using a 5 point confidence scale to determine the presence or absence of crestal bone loss. Receiver operating characteristics (ROC) statistical procedures were applied to analyze the diagnostic accuracy and statistical differences between the three imaging modalities. RESULTS: The DSR subtraction viewing generated an ROC area of 0.882. For 2 of the viewers this represented a statistically significant gain (P <0.05) over the conventional viewing of the radiographs which had an average ROC area of 0.730. In comparison, the LRA method achieved an area of 0.954. The differences between the LRA and the DSR subtraction methods were not statistically significant, but the statistical power for claiming equality was low ranging from 0.2 to 0.6. CONCLUSIONS: The use of the DSR technique in clinical radiographic image acquisition and subsequent subtraction analysis clearly enhanced the accuracy of alveolar crestal bone loss detection when compared to conventional film viewing. Because this methodology is less resource demanding than LRA and the film exposure techniques and computer-based image analysis skills may be acquired with only a few hours of training, the DSR has potential in clinical practice.

Modification and benchmarking of MCNP for low-energy tungsten spectra.

The MCNP Monte Carlo radiation transport code was modified for diagnostic medical physics applications. In particular, the modified code was thoroughly benchmarked for the production of polychromatic tungsten x-ray spectra in the 30-150 kV range. Validating the modified code for coupled electron-photon transport with benchmark spectra was supplemented with independent electron-only and photon-only transport benchmarks. Major revisions to the code included the proper treatment of characteristic K x-ray production and scoring, new impact ionization cross sections, and new bremsstrahlung cross sections. Minor revisions included updated photon cross sections, electron-electron bremsstrahlung production, and K x-ray yield. The modified MCNP code is benchmarked to electron backscatter factors, x-ray spectra production, and primary and scatter photon transport.

Combining periodic and continuous sodium hypochlorite treatment to control biofilms in dental unit water systems.

BACKGROUND: This study evaluated the efficacy of combined intermittent and continuous treatment with diluted sodium hypochlorite, or NaClO, to improve dental unit water quality in a clinical setting. METHODS: In this prospective study, 10 dental units were fitted with separate water reservoir systems. Dental units were maintained with weekly rinses with 1:10 NaClO. Treatment water consisted of 750 milliliters of tap water and one drop of undiluted commercial bleach. Bacterial contamination in the effluent coolant water was assayed via microbiologic culture on a weekly basis. At the end of the study, scanning electron microscopy of the inner surfaces of the dental unit waterlines corroborated the results. RESULTS: All 10 dental units consistently delivered water with less than 10 colony-forming units per milliliter, or CFU/mL, with a mean bacterial contamination of less than 1 CFU/mL. Baseline scanning electron microscopy demonstrated biofilm formation. Scanning electron microscopy at the end of the study demonstrated the lack of features consistent with biofilm formation. Although tri-halomethanes were detected in output water, all samples were below Environmental Protection Agency limits for drinking water. CONCLUSIONS: Weekly treatment with 5.25 percent NaClO diluted 1:10, and concomitant use of chlorinated treatment water (3 parts per million chlorine) consistently attained the proposed American Dental Association goal of fewer than 200 CFU/mL in the unfiltered output. The effects of continuous treatment on dentin and enamel bond strength may require further evaluation. CLINICAL IMPLICATIONS: The success of this protocol suggests that optimal attainment of dental water quality goals may require a combination of approaches.

Validation of an in-office dental unit water monitoring technique.

The authors conducted a study to determine the sensitivity, specificity and accuracy of HPC Samplers (Millipore Corp.) as compared with that of R2A agar and HPC agar when used to monitor dental unit water, or DUW, quality. Results were either a pass (200 colony-forming units per milliliter, or CFU/mL, or less) or a fail (greater than 200 CFU/mL). Of the 408 tests conducted, the results of the HPC Sampler agreed with R2A agar 377 times, for an accuracy rate of 92.6 percent. The authors recommend that clinicians consider using HPC Samplers, as they are a user-friendly, economical means of monitoring compliance of DUW quality.

Computer-assisted densitometric image analysis (CADIA) of previously sealed carious teeth: a pilot study.

Previous studies have shown that occlusal dental caries can be arrested with sealants. Radiographic monitoring must be performed to ensure success. Standardized sequential bitewing radiographs over a 10-year interval of four patients who had sealed composite restorations placed without caries removal were digitized and analyzed using the CADIA algorithm. CADIA values for the 10-year period were analyzed using Analysis of Variance (ANOVA), and showed no significant change in radiographic density for this interval (P > 0.05), which is suggestive of arrested dental caries.

A comparison of sealer placement techniques in curved canals.

Sealer placement techniques have not been examined in teeth with curved canals prepared with Lightspeed instruments. Three traditional methods of placing sealer were studied, using 45 extracted human single-rooted teeth, divided into 3 groups of 15. Root canal preparations were made with Light-speed nickel-titanium, engine-driven instruments. AH26 sealer was applied with either K-file, lentulo spiral, or master gutta-percha cone. Radiographs were taken after sealer placement and analyzed for amount of canal sealer fill. The teeth were then obturated with laterally condensed gutta-percha, chemically cleared, photographed, and analyzed for total canal wall sealer coverage. The results showed a statistically significant difference in canal sealer fill among the three groups before obturation, but there was no statistical difference in canal wall coverage among the three groups after obturation. None of the examined methods exceeded an average of 62.5% wall coverage of sealer after obturation. This suggests that complete wall coverage after obturation may not be possible.

Effect of nickel-titanium engine-driven instrument rotational speed on root canal morphology.

Thirty-six mesial canals in 18 extracted human mandibular molars were randomly allocated to three experimental groups. Specimens were prepared and evaluated using a modified Bramante technique. Teeth were sectioned at the midroot and apical regions. Canals were prepared with the Lightspeed instruments rotating at 750, 1300, or 2000 rpm. Digitized uninstrumented and instrumented canal images were compared via subtraction software. There was no significant difference (p <0.05) among the three experimental groups in the amount of dentin removed, canal transportation, or the ability of the instrument to remain centered in the canal.

Video-based teleradiology for intraosseous lesions. A receiver operating characteristic analysis.

Immediate access to off-site expert diagnostic consultants regarding unusual radiographic findings or radiographic quality assurance issues could be a current problem for private dental practitioners. Teleradiology, a system for transmitting radiographic images, offers a potential solution to this problem. Although much research has been done to evaluate feasibility and utilization of teleradiology systems in medical imaging, little research on dental applications has been performed. In this investigation 47 panoramic films with an equal distribution of images with intraosseous jaw lesions and no disease were viewed by a panel of observers with teleradiology and conventional viewing methods. The teleradiology system consisted of an analog video-based system simulating remote radiographic consultation between a general dentist and a dental imaging specialist. Conventional viewing consisted of traditional viewbox methods. Observers were asked to identify the presence or absence of 24 intraosseous lesions and to determine their locations. No statistically significant differences in modalities or observers were identified between methods at the 0.05 level. The results indicate that viewing intraosseous lesions of video-based panoramic images is equal to conventional light box viewing.

Absolute measures of image quality for the Sens-A-Ray direct digital intraoral radiography system.

To study the noise characteristics of the Sens-A-Ray (Regam Medical Systems AB, Sundsvall, Sweden) system, 20 radiographs were obtained at each of three different exposure levels at 70 and 90 kVp with a homogeneous x-ray field. Exposures were measured with an ionization chamber. Noise power spectra were calculated over three areas within each radiograph, and ensemble averages were subsequently found from 60 data files at each exposure level. Noise equivalent quanta were calculated with the noise power spectra and modulation transfer function data from previous studies. Finally, the detective quantum efficiency was calculated by dividing the noise equivalent quanta by the estimated incident photon fluence at the different exposures. The system has a maximum detective quantum efficiency of approximately 0.030 at 70 kVp and 0.025 at 90 kVp. A broad maximum exists at approximately 2 cycles/mm, indicating that the signal-to-noise ratio is most favorable at this spatial frequency.

A comparison of root canal preparations using Ni-Ti hand, Ni-Ti engine-driven, and K-Flex endodontic instruments.

This study used a modified Bramante technique and new digital subtraction software to compare root canals prepared by nickel-titanium (Ni-Ti) hand, Ni-Ti engine-driven, and stainless steel hand endodontic instruments. Sixty mesial canals of extracted human mandibular molars were randomly divided into five groups. The roots were embedded in clear resin and cross-sectioned in the apical and mid-root areas. In group A, canals were instrumented using a quarter turn/pull technique with K-Flex files. In group B, canals were prepared with Ni-Ti hand files (Mity files) using the same technique as in group A. Group C was prepared with NT Sensor engine-driven files. Group D canals were prepared with Ni-Ti Canal Master "U" hand instruments. Group E was prepared with engine-driven Ni-Ti Lightspeed instruments. Digitized images of the uninstrumented canals were compared with images of the instrumented canals. Engine-driven Ni-Ti instruments (Lightspeed and NT Sensor file) and hand instrumentation with the Canal Master "U" caused significantly less canal transportation (p < 0.05), remained more centered in the canal (p < 0.05), removed less dentin (p < 0.05), and produced rounder canal preparations than K-Flex and Mity files. Engine instrumentation with Lightspeed and NT Sensor file was significantly faster than hand instrumentation (p < 0.05).

A simple method for measuring MTF in direct digital intraoral radiography. Technical note.

Conventional methods for measuring the modulation transfer function require the exposure of a narrow slit or straight edge followed by computationally intense data analysis. An alternative method applicable to digital systems uses the standard deviation of gray levels within different frequency regions of a bar pattern. To verify that this method gave reliable results, measurements performed for two systems for intraoral radiography with the use of this method have been compared with modulation transfer function values calculated from Fourier transformations of line spread functions measured for the two systems. The almost identical results confirm the consistency of both sets of modulation transfer function measurements and demonstrate the utility of the bar pattern method for performing rapid measurements.

Color coding of radiographic changes over time by means of image addition.

Differences between sequential radiographs may be displayed in color if the individual radiographs are transformed into monochromatic images and then added. Information in regions where the radiographs are identical is retained whereas differences are emphasized by the color coding that comes about in a quantitative manner from the gray level values in the sequence of radiographs. By using the three additive primary colors, red, blue, and green, two or three radiographs from a sequence may be added. Every possible state of a bone disease, progression, regression, or any combination, will produce a different and specific color code. Different development cycles are described, and the color coding that appears when color image addition is performed is analyzed. The color addition technique should constitute a useful substitute or alternative to subtraction.

Resolution as defined by line spread and modulation transfer functions for four digital intraoral radiographic systems.

Line spread functions for four commercially available systems for direct digital intraoral radiography were determined from images of a slit of negligible width. From the fitted line spread functions presampling modulation transfer functions were calculated. The four systems were the Sens-A-Ray (Regam Medical System AB, Sundsvall, Sweden), the VIXA/Visualix (Gendex, Chicago Ill.), the RVG (Trophy Radiologic, Paris, France), and the Flash Dent (Villa Sistemi Medicale srd, Buccinasco, Italy). Digital intraoral radiography is in a state of rapid development, and detectors as well as computer hardware and software are continually modified and improved resulting in successively changing system parameters. As this occurs the present work provides a method that may be used to determine comparable data on future systems.

Radiographic determination of canal length direct digital radiography versus conventional radiography.

This research compared the length determination images produced by Trophy and Regam direct digital radiographic systems with conventional E-speed radiographs. Size #15 K files were placed in the canals of 19 teeth of cadaver specimens and radiographed in a geometrically standardized bench device. Three evaluators estimated the length adjustment necessary to position the file at the apex. The mean estimated adjustment lengths were compared with the true, anatomically determined adjustment lengths. Statistical analysis with analysis of variance and the Student-Newman-Keuls test indicated no significant difference between direct digital thermal print images and conventional radiographs (p > 0.10). Length adjustment estimates with conventional radiographs were significantly more accurate than Regam high-resolution computer monitor images (p < 0.01). Additionally, it was determined that length adjustment estimates were significantly more accurate when the file was placed short of the apex (p < 0.001). The clinical relevance of these differences is discussed.