International Scholarly Research Network

ISRN Dentistry
Volume 2011, Article ID 363578, 4 pages
doi:10.5402/2011/363578

Research Article
Are Panoramic Radiographs Reliable to Diagnose Mild Alveolar
Bone Resorption?

Larissa Semenoff,1 Tereza Aparecida Delle Semenoff,2 Fabio Luiz Miranda Pedro,2 Evaristo
Ricci Volpato,3 Maria Aparecida de Andrade Moreira Machado,4 Álvaro Henrique Borges,2
and Alex Semenoff-Segundo5
1 Department of Radiology, Especialista em Radiologia, UNIDERP, Rua Ceará 333, 79003-010 Campo Grande, MS, Brazil
2 Department of Endodontics, Dental School, University of Cuiabá, Avenida Beira Rio 3100, 78065 900 Cuiabá, MT, Brazil
3 Department of Pediatric Dentistry, Dental School, University of Cuiabá, Avenida Beira Rio 3100, 78065 900 Cuiabá, MT, Brazil
4 Department of Pediatric Dentistry, Orthodontics and Community Health, Bauru School of Dentistry, University of São Paulo, Al.

Octávio Pinheiro Brisola, 9-75, 17012-901 Bauru, SP, Brazil

5 Discipline of Hospital Dentistry, University of Cuiabá, Rua Professora Azélia de Mamoré de Melo,

no. 318, Ap. 63, 78005-700 Cuiabá, MT, Brazil

Correspondence should be addressed to Alex Semenoff-Segundo, semenoff@uol.com.br

Received 23 January 2011; Accepted 21 March 2011

Academic Editor: G. Sjogren

Copyright © 2011 Larissa Semenoff et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

It is extremely important to assess variations between the most used radiographs in dental practice, since minimum distortion on
obtained images may change diagnosis, treatment plan, and prognosis for the patient. For this, the distance between the enamel-
cementum junction and the alveolar bone crest was measured on conventional and digitized periapical, bitewing, and panoramic
radiographs and compared among them. From a total of 1484 records, 39 sets of radiographs that fulfilled the inclusion criteria
of the study sample were selected. The measurements were grouped according to the intensity of bone loss. Statistically significant
difference was found in the averages of the measurements assessed in radiographs with absence of bone loss between conventional
panoramic and periapical radiographs, between digitized panoramic and periapical radiographs and between digitized bitewing
and panoramic radiographs. By analyzing the results of this work and considering the research protocol used, one can conclude
that small losses in height of alveolar bone crest observed in panoramic radiographs should be cautiously evaluated, as they may
be overestimated.

1. Introduction size of the root trunk, root divergences, and presence of lat-
eral or periapical lesions and combined lesions (endodontic-
Radiographic examination is part of routine dental treat- periodontal) [2]. Bitewings by their turn present good
ment, with periapical, bitewing, and panoramic radiographs reading precision at the alveolar crest and cementum-enamel
being the most commonly used. These are conventional junction areas, and thus, provide reliable information in
radiographs, which are capable of diagnosing fractures, comparison to clinical findings [3]. Intraoral radiographs are
pathologic lesions and development abnormalities. Such also important for the diagnosis and monitoring of marginal
radiographs might be employed in epidemiologic surveys to bone levels [4].
large populations, being their cost-benefit relation for the The panoramic radiograph is excellent for visualization
patient in aiding the definition of a diagnosis and prognosis of general structures of the face. This radiograph is also
very satisfactory [1]. performed when difficulties in performing Intraoral radio-
Periapical radiographs are indicated to assess the width graphs are experienced. However, frequent distortions to
of periodontal ligament, bone trabecular pattern and density, mesial-distal measurements are observed, limiting a more
2 ISRN Dentistry

precise evaluation mainly to the anterior segment and

maxillary molars areas [4].
New diagnostic image exams have been recently intro-
duced to dental practice, such as digital radiographs and
computed tomography. More modern technologies allow
three-dimensional visualization of images of the maxillofa-
cial complex, leading to a more precise planning and exe-
cution of the dental treatment with better predictability [5].
However, the high cost of equipments and consequently the
exams is still a very relevant disadvantage to be considered,
which frequently reduces their employment [6]. Another (a)
obstacle to be overcome is related to the lack of utilization
of digital reading systems by great part of dentists.
Thus, it is very important to evaluate existent variations
among the most commonly employed radiographic exami-
nations used at dental settings, once minimum distortions
may change diagnosis, treatment plan, and prognosis for
patients.

2. Material and Methods

The study was approved by the IRB of the Public Health
School of the Mato Grosso State Department (Protocol no.
367/08). One thousand four hundred and eighty four charts
from a private practice located in Jaciara, Mato Grosso
were selected. Seventy four of those presented panoramic
(Figure 1(a)), bitewing (Figure 1(b)), and periapical radio- (b)
graphs (Figure 1(c)).
Inclusion criteria for the patients were presence of a set
of good quality radiographs, availability to go through the
digitization process, well-defined images at the anatomic
neck (cementum-enamel junction) and alveolar bone crest at
the level of first and second mandibular molars, and presence
of at least one adjacent tooth and satisfactory positioning of
the tooth in the dental arch.
Exclusion criteria were radiographs performed in differ-
ent dates, images that did not allow adequate evaluation,
no automated radiographic development employed, and
presence of accentuated angulations of mandibular molars
in relation to adjacent teeth.
Thirty-nine radiograph sets followed the inclusion cri-
teria for the study and were digitized using a photographic
scanner (HP Scanjet G4000 series, Barueri, SP, Brazil), (c)
attached to a laptop (Toshiba-Satellite A-10-S129, Hong Figure 1: Illustrative figures of the images manually measured:
Kong, China). The images were manipulated using a dental panoramic (a), bitewing (b) and periapical radiographs (c).
radiology software (Radiomemory, Belo Horizonte, MG,
Brazil). Reddy in 1997 reported the advantages of image
digitizing in Dentistry, due to precision of performed Memory. Every measurement was performed in a dark
measurements and due to the possibility of using softwares environment aiming better visualization of images.
to treat the images. The distance between the anatomic tooth neck of the
In order assure the standardization of analyses, all the second mandibular molar on the mesial portion and the
measurements were performed by a single evaluator, being bone crest of the side presenting the greatest apical bone
previously calibrated for the study. The agreement between loss in height (right or left) was the chosen measurement for
the performed evaluations was measured by the student comparison between the set of radiographs.
paired t-test, being 0.986 with a standard error of 0.08 mm. The observed measurements for both conventional and
The measurements of the conventional radiographs were digitized radiographs were classified according to the fol-
performed with aid of a table negatoscope and a millimeter lowing categories: 0–2 mm (absence of bone loss), 3–5 mm
ruler, while the digitized radiographs were evaluated through (moderate bone loss), and ≥6 mm (advanced bone loss) and
a specific software for radiograph measurements, Radio compared among them.
ISRN Dentistry 3

Table 1: Distribution of mean measured distances according to the accessible procedure, decrease in price of panoramic radio-
type of radiograph. graphs, exam convenience, as the film is positioned outside
patients’ mouth, and professionals’ intention to reduce X-
Bone loss (in millimeters)
Type of radiograph ray exposure, as a single exposure for panoramic radiographs
Absent Moderate Advanced during a check-up substitutes multiples exposures required
Conventional periapical 1.70 ± 0.48∗ 3.78 ± 0.85 7.10 ± 1.28 for periapical and bitewing radiographs [2, 9, 10].
Digitized periapical 1.70 ± 0.45∂ 3.76 ± 0.84 7.20 ± 1.50 In a study performed by Papapanou and Wennstrom
Conventional bitewing 1.90 ± 0.56 3.57 ± 0.96 6.60 ± 1.65 [10], in 1989, clinical measurements were compared to
Digitized bitewing 1.78 ± 0.37† 3.64 ± 1.02 6.60 ± 1.75 radiographic evaluations obtained from periapical and
Conventional panoramic 2.50 ± 0.84∗ 3.89 ± 1.28 8.00 ± 2.30 bitewing radiographs. Greater discrepancies were found to
Digitized panoramic 2.59 ± 0.89∂† 3.98 ± 1.18 8.00 ± 2.30 patients presenting larger periodontal destruction. On the
∗
Significant difference between conventional periapical and panoramic
other hand, Li et al. [4] (2007) reported that the severity of
radiographs (P = .03). marginal bone loss did not affect measurements precision
∂ Significant difference between digitized periapical and panoramic radio- when comparing clinical and radiographic measurements,
graphs (P = .01). regardless the intensity of the marginal bone loss. Another
† Significant difference between digitized bitewing and panoramic radio-
study following this same research focus [4] compared
graphs (P = .02).
panoramic with periapical and bitewing radiographs in
patients presenting aggressive and advanced periodontitis,
and the results presented differently from the present
The observed variations were submitted to the analysis of study. This disparity in results certainly occurred as the
variance with Bonferroni correction at a level of significance included patients presented large bone loss. Another point
of 5%. for discussion and disagreement is related to the fact that
the evaluation criteria for differences among the groups also
3. Results differ. It is also important to point out that in this study the
different results were observed for the small bone loss group,
The average of bone loss in millimeters was determined after which highlights proper care required when analyzing early
the radiographs were distributed into groups according to bone loss in patients possibly presenting periodontitis.
the measured bone loss, followed by the standard deviation. The present study observed statistical significant differ-
These data are presented on Table 1. ences only in cases of bone loss lower than 2 mm, contradict-
In this table, differences were searched between the ing previously reported studies [2, 5, 8]. When comparing
obtained average measurements within the conventional or the conventional radiographs, it was observed that the
digitized radiograph groups or between them. It was found average bone loss assessed on the periapical radiographs
that the average of measurements of the groups presenting was 32% lower than the data obtained from the panoramic
moderate or advanced bone loss did not present any statis- radiographs.
tical significant difference within either the conventional or The analysis of the digitized radiographs followed the
digitized radiograph groups. same pattern presented on the conventional ones. However,
Among the radiographs presenting no bone loss, statisti- during the digitized assessment, bitewings also presented
cal significant differences were observed between the averages inferior bone loss averages when compared to the panoramic
observed on the conventional periapical and panoramic images. The precision of measurements in digitized radio-
radiographs (P = .03), between the measurements of the dig- graphs probably decreased the variation of central tendency
itized periapical and panoramic radiographs (P = .01), and measurements (standard deviation and standard error),
between the digitized bitewing and panoramic radiographs resulting in statistical differences between them. The results
(P = .02). presented might have had some influences by the sample
size; however, the inclusion criteria for case selection pro-
There were no statistical significant differences on the vide consistency to the results. Other researches compared
mean measurements between conventional and digitized measurements of marginal alveolar bone loss using digitized
radiographs according to the type of radiograph. radiographs incorporating color or not [4] and digitized
radiographs with original or inverted colors [7], and no
4. Discussion statistical significant difference was reported for both cases.
The assessment of mandibular molars was the choice in
The radiographic examination, besides its limitations, is the present study, as the cementum-enamel junction and the
a fundamental tool to diagnosis and to follow up the alveolar bone crest are easily assessed and consequently the
evolution of performed treatments, especially for patients distance between them [7]. It is highlighted that the sample
under periodontal therapy [1, 4, 7]. Periapical and bitewing was composed by teeth positioned on an adequate plane in
radiographs are the most indicated to identify alterations on relation to adjacent teeth.
sustaining periodontal tissues, mainly for alterations involv- In relation to the radiographs, they were all taken at the
ing bone loss [3, 8, 9]. However, some factors are related same day for each patient; film holders were used and they
to the greater utilization of panoramic radiographs, such as were developed using automatic developers at only three
increased number of radiology centers resulting in a more radiologic centers. Although these steps are important for the
4 ISRN Dentistry

measurements accuracy [1], it is known that nonstandard- [11] A. T. Merchant, W. Pitiphat, J. Parker, K. Joshipura, M. Keller-
ized periapical and bitewing radiographs might not change man, and C. W. Douglass, “Can nonstandardized bitewing
the research measurements [11]. radiographs be used to assess the presence of alveolar bone
The results of this study presented great clinical relevance loss in epidemiologic studies?” Community Dentistry and Oral
in demonstrating that small losses at bone level observed Epidemiology, vol. 32, no. 4, pp. 271–276, 2004.
on panoramic radiographs should be cautiously interpreted
once they might be overestimated. The same losses were
significantly lower when observed on bitewing and periapical
radiographs, which present good similarity with clinical
inspection [4, 5, 10].

5. Conclusion
By the analyses of the data of the present study and consid-
ering the employed research protocol, it can be concluded
that small loss in height of alveolar bone crest observed on
panoramic radiographs might be carefully considered, once
they can be overestimated.

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