Incidental findings of pathology and abnormality in pretreatment orthodontic panoramic radiographs

Panoramic radiographs, in combination with a clinical examination, are routinely used as an aid to orthodontic diagnosis and treatment planning. The aim of this study was to evaluate the prevalence and location of incidental findings of pathology and abnormalities in pretreatment orthodontic panoramic radiographs. A total of 496 patients (232 girls and 264 boys; mean age 11.2 years, SD 2.33) were randomly selected from the Orthodontic Clinic at the Faculty of Odontology, University of Malm?, Sweden. All radiographic examinations were performed between 1999 and 2003 at the Department of Oral Radiology, Faculty of Odontology, University of Malm?, Sweden. Two independent examiners analyzed the radiographs for abnormalities and diagnoses of pathology. However, caries and findings related to the orthodontic treatment plan, such as eruption disturbances and missing or supernumerary teeth, were not recorded. All radiographs with positive findings were reexamined by a third examiner, a specialist registrar in oral radiology. A total of 56 findings in 43 patients (8.7%) were recorded, and significantly more findings were detected in girls (P = .007). The most common findings were radiopacities (idiopathic sclerosis) in alveolar bone (n = 22), thickening of mucosal lining in sinus maxillaris (n = 15), and periapical inflammatory lesions (n = 10). The majority of the periapical lesions and radiopacities were found in the mandible. In most cases, the findings had no consequence for the orthodontic treatment plan and did not require medical or odontological management. However, the clinician should be aware of the potential to detect pathology and abnormality in pretreatment orthodontic panoramic radiographs.     

Influence of lateral cephalometric radiography in orthodontic diagnosis and treatment planning

Objective:To evaluate the impact of additional lateral cephalometric radiography in orthodontic diagnosis and treatment planning.Materials and Methods:Forty-three patients seeking orthodontic treatment, and for whom pretreatment diagnostic records were available, were randomly selected. Ten qualified orthodontists were involved in this study. The patients'' records included three photographs of the angle trimmed dental casts, digital lateral cephalometric and panoramic radiographs, and standard clinical photographs comprising seven intra- and four extraoral pictures. Records were evaluated in two sessions. At the first session, orthodontists evaluated records without lateral cephalometric radiography (LCR). In the second session, the same information was presented, but with LCR. Between the two sessions the order in which the cases were presented was altered to avoid bias.Results:The percentage of agreement between sessions was lower for diagnosis than for treatment planning. Concerning skeletal classification, the least experienced orthodontist was the least consistent (28%), while the more experienced orthodontist was the more reliable (67%). In terms of treatment modalities, in general there was an agreement of 64%. The most frequent modifications in treatment modalities were seen in Class II malocclusion patients.Conclusions:The results of our study suggest that the majority of Portuguese orthodontists judge that LCR is important to producing a treatment plan. Despite that, it does not seem to have an influence on orthodontic treatment planning.     

Panoramic and restrictive intraoral radiography in comprehensive oral radiographic diagnosis

It has been suggested that information from the panoramic radiograph makes it possible to appropriately select supplementary intraoral radiographs to achieve a comprehensive examination of teeth and surrounding bone with less patient dose but no significant information loss. Number of intraoral radiographs selected, information loss and monetary costs with such a procedure was evaluated in 40 patients. Results show that, on average, 5.1 intraoral radiographs were selected to supplement the panoramic radiograph. Of these, 3.1 contained information different from that in the panoramic radiograph but 2.0 did not. An additional 3.4 ought to have been taken to reach the result of the 'gold standard' achieved from a simultaneous evaluation by two expert observers of panoramic radiographs and full mouth surveys with intraoral radiographs. Sensitivity for the combined use of panoramic and supplementary intraoral radiographs was high (80–96%, depending on type of teeth) as regards periapical lesions and marginal bone loss but low for caries (42–96%). Specificity was high for periapical lesions and caries (95–97%) but low for marginal bone loss (50–92%). In Sweden, patient costs become almost the same for a combination of panoramic radiography and 8.5'intraoral radiographs as for a full mouth survey comprising 20 intraoral radiographs. The radiation dose reduction is 40–50% considering that the dose from a panoramic radiograph approximately corresponds to 2–4 intraoral radiographs. We conclude that using panoramic radiography in combination with selected intraoral radiographs is possible if the radiographic examination is preceded by a thorough clinical examination and the following parameters are correctly evaluated before the examination: patient category, radiation dose, information loss, patient discomfort, time consumption and monetary costs.     

The asymmetric extraction decision.

Orthodontic study models, intraoral photographs, radiographs and diagnostic set-up casts of four completed adult cases are presented to show the possibilities of atypical treatment planning to correct specific and unusual malocclusions. The cases presented required asymmetric dental extractions in order to achieve the desired treatment results. Three diagnostic procedures were used to assist in making the final treatment decisions; a Bolton tooth size analysis, a space available/space needed assessment, and a pretreatment diagnostic set-up. The completed treatment results closely approximate the original diagnostic predictions, and completely satisfied each patient's chief concern. Most orthodontic practices now treat increasing numbers of non-growing (adult) patients. Traditional extraction considerations must be modified to satisfy the treatment needs of this demanding patient population.     

Longitudinal study of the diagnostic yield of panoramic radiographs in aging edentulous men

Participants in the Veterans Administration Dental Longitudinal Study who were edentulous and for whom longitudinal panoramic radiographs were available were followed through four examination cycles, representing approximately 10 years. It was observed that 13 (39%) of the 33 subjects examined had one or more positive radiographic findings at the initial examination. No changes occurred in the findings noted during the initial panoramic radiographic examination, and no new findings were observed over the study period. Although the initial baseline panoramic examinations yielded several positive radiographic findings, few were of a nature that materially affected the initial treatment plan.     

Diagnosis, screening and treatment of root resorption in orthodontic practices in Greece and Sweden

OBJECTIVE: To evaluate the perception of Greek and Swedish orthodontic practitioners regarding the possible occurrence and prognosis of root resorption occurring during orthodontic treatment and to estimate practitioners' approaches to the diagnosis of preexisting root resorption, screening of prevalence, and treatment planning approach when moderate or severe root resorption is present. MATERIALS AND METHODS: Questionnaires were received from randomly selected Greek (n = 90) and Swedish (n = 106) practitioners. Topics of the questions included (a) the presence of history; (b) the radiographic evaluation of root resorption before, during, and after treatment; (c) the treatment approach of initial prevention and protocols in cases of radiographic diagnosis of root resorption during treatment. RESULTS: Of the respondents, 47.1% of the Swedish practitioners and 32.3% of the Greek practitioners use periapical and panoramic radiographs to diagnose root resorption, mostly in the anterior region. Both groups recognize trauma, root form, and oral habits as predisposing factors. The majority of Swedish orthodontists perform radiographic follow-up in the first 6 months. In contrast, the Greek orthodontists perform it at 1 year or at the end of treatment. The treatment approach for root resorption that is most frequently used by Swedish orthodontists is altering the treatment plan, using light forces, and allowing resting periods, while the Greek orthodontists most frequently use lighter forces and reduce the total duration of the treatment. CONCLUSIONS: Because there is no specific approach offered in the literature, the prevention and treatment reassessment in cases of root resorption relies on individual practitioner perception.     

The radiographic assessment of implant patients: decision-making criteria

Indications for the most frequently used imaging modalities in implant dentistry are proposed based on clinical need and biologic risk for the patient. To calculate the biologic risk, the authors carried out dose measurements. They demonstrated that the risk from a periapical radiograph is 20% of that from a panoramic radiograph. A panoramic radiograph and a series of 4 conventional tomographs of a single-tooth gap in the molar region carry 5% and 13% of the risk from computed tomography of the maxilla, respectively. Panoramic radiography is considered the standard radiographic examination for treatment planning of implant patients, because it imparts a low dose while giving the best radiographic survey. Periapical radiographs are used to elucidate details or to complete the findings obtained from the panoramic radiograph. Other radiographic methods, such as conventional film tomography or computed tomography, are applied only in special circumstances, film tomography being preferred for smaller regions of interest and computed tomography being justified for the complete maxilla or mandible when methods for dose reduction are followed. During follow-up, intraoral radiography is considered the standard radiographic examination, particularly for implants in the anterior region of the maxilla or for scientific studies. In patients requiring more than 5 periapical images, panoramic radiography is preferred.     

Web-based orthodontic instruction and assessment

Orthodontic records-study models, panoramic and cephalometric radiographs, and the patient's facial and intraoral photographs-are used to collect data to establish a diagnosis and to develop problem-solution lists. These records, however, can be damaged or lost when dispensed to students and need to be stored and maintained every year. An orthodontic diagnosis web site, therefore, has been set up using digital records to provide students with an accessible source of complete, good-quality study materials. The web site is also used for clinical examination in orthodontic courses. The effectiveness of the web-based digital records in providing relevant information to students in comparison to the traditional records was evaluated by a randomized controlled trial involving ninety-nine second-year dental students. One group (fifty students) studied two cases from the web site; the other group (forty-nine students) studied the same two cases from traditional orthodontic records. Effectiveness was assessed by comparing test scores and the time spent on the tests by t-statistics. There were no significant differences between means for the two study groups in test performance or time. Attitudes of students toward the web site, assessed from post-test questionnaires, were positive. It was concluded that web-based digital orthodontic records were as effective in teaching clinical orthodontic diagnosis as were conventional records.     

Diagnostic accuracy and observer performance in the diagnosis of abnormalities in the anterior maxilla: a comparison of panoramic with intraoral radiography.

An investigation was undertaken to assess the reliability of radiographic diagnosis of abnormalities of orthodontic significance in the anterior region of the maxilla from intraoral and dental panoramic tomograph (DPT) views. DPT films of 200 patients were scrutinised by two observers on two separate occasions, who also examined intraoral radiographs of the same patients. Sixty-three of these patients were selected because they had previously been diagnosed as presenting with a defined abnormality of orthodontic relevance, such as supernumerary teeth, absent incisors, etc. The remaining cases had been assessed as depicting normal radiographic appearances. Each radiograph was allocated a unique, randomly selected code number as the only means of identification. It was not possible for the observers to match the DPT to the corresponding intraoral films, and this information was only available to the principal investigator (JWF). Both observers were asked to record the presence or otherwise of any abnormalities at each observation of each radiograph, and to record their findings. The overall level of diagnostic accuracy and reproducibility was fairly high, and in general terms the DPT views were as reliable as the intraoral films with regard to the detection of abnormalities; however, there were significant differences between the observers. It was concluded that in many instances supplementary intraoral films would not contribute any additional information compared to the DPT and that selection criteria should be defined for the former.     

The utility of panoramic imaging of the temporomandibular joint in patients with temporomandibular disorders

OBJECTIVE: The objective of this study was to evaluate the utility of panoramic imaging in assessment of patients with temporomandibular disorders (TMDs). STUDY DESIGN: Fifty-five consecutive patients referred for diagnosis and management of facial pain and jaw dysfunction were included. A single examiner completed the history and clinical examination on all patients. All patients received panoramic imaging. On the basis of clinical and radiographic findings, a subset of patients received advanced imaging modalities. The panoramic radiographs were interpreted by 2 examiners; if any disagreement was noted, a third examiner interpreted the radiographs. RESULTS: Seventy-five percent of the patients had complaints of facial pain, and 75% exhibited tenderness in masticatory muscles. Tenderness was present in TM joint regions in 62%. Altered bony anatomy was seen in 43.6% of panoramic radiographs. Panoramic imaging did not lead to changes in clinical diagnosis in any of the patients seen, although the findings on the radiographs did lead to requests for additional imaging studies in 3 cases, one of which was later referred for surgical intervention because of radiographic findings. CONCLUSION: Clinical findings may be of greater relevance leading to the diagnoses associated with TMD and to determination of the need for additional imaging rather than the use of panoramic imaging in all patients with facial pain and TMD.     

Efficacy of panoramic radiography in dental diagnosis and treatment planning

We compared treatment decisions based on a clinical examination alone with decisions based on an examination plus a panoramic radiograph to determine whether the panoramic radiograph increased the diagnostic yield and consequently affected treatment. Provisional treatment plans, based on a screening clinical examination alone (n = 33), or on a screening clinical examination plus panoramic radiograph (n = 43), were compared with final treatment plans based on a complete diagnostic assessment (including all necessary radiographs). For this analysis, the final treatment plan was considered correct and used as the gold standard. The two groups used in the comparison were equivalent in age, gender, and final treatment plan needs. The availability of a panoramic radiograph did not improve the accuracy with which provisional treatment plans predicted the number of teeth requiring composites, amalgams, crowns, or extraction, nor did it improve the accuracy of the assessment of the periodontal status (Wilcoxon rank sum, alpha = 0.05). The proportion of patients who had an intra-oral full-mouth series as part of the complete diagnostic work-up was essentially the same for both groups (58% and 60%, respectively); the availability of the panoramic film did not reduce the need for full-mouth series radiographs for the development of the final treatment plans.     

Panoramic radiographic examination of edentulous jaws.

Many dentists routinely make panoramic radiographs of edentulous patients who request replacement dentures. A study was conducted in patients who attended a Jordanian dental school seeking a new set of dentures. Patients who had at least one set of complete dentures and were treated elsewhere, were included in this study. Any patient whose clinical findings suggested a need for further radiographic study was excluded. Of 286 patients (572 edentulous arches), only three were found to have impacted molars that required extraction and altered the treatment plan. The use of radiography in dentistry generates a large expense and there are risks of radiation hazards. The routine use of radiographs for patients who wear complete dentures and need replacement dentures should be discouraged. A thorough history must be obtained and a careful clinical examination must be performed for the diagnosis and treatment planning.     

Internal root resorption associated with inadequate caries removal and orthodontic therapy

This case report presents a case of internal root resorption originating from inadequate caries removal and orthodontic therapy in maxillary right lateral incisor in a 13-yr-old female. A preoperative, panoramic radiograph taken at the orthodontic office showed no evidence of resorption, however, the composite restoration in the coronal portion was inadequate. During 4 months of nickel titanium orthodontic wire activation, the patient suffered spontaneous pain. Periapical radiographs revealed internal root resorption in the middle third of the root. Endodontic treatment was accomplished and coronal restorations were completed with composite resin. Periodical radiograph examination as well as orthodontic treatment was continued. The tooth was clinically and radiographically healthy at the 18-month follow-up. The importance of the preoperative radiographic examination as well as radiographs during orthodontic treatment is affirmed.     

A study to determine the added value of 740 screening panoramic radiographs compared to intraoral radiography in the management of adult (>18 years) dentate patients in a primary care setting

Objectives

To measure the added value of panoramic radiography in new dentate patients attending for routine treatment.

Methods

Thirty-seven general dental practitioners using panoramic radiographs routinely were recruited. Twenty dentate patients were identified prospectively by each participating dentist if they were new to the practice, attending for an examination and requesting any treatment deemed necessary. A panoramic radiograph was taken with appropriate intraoral radiographs in line with national guidelines. Each dentist completed a radiological report for the panoramic radiograph only and these 20 reports were forwarded to the researchers along with the 20 panoramic radiographs, their accompanying bitewing and periapical radiographs and twenty completed clinical assessment sheets.

Results

740 panoramic, 1418 bitewing and 325 periapical radiographs were assessed by the researchers. Only 32 panoramic films provided any additional diagnostic value when compared to intraoral films when guidelines had been observed resulting from the poor technical and processing quality of the accompanying intraoral films. Assessment of the number of caries and periapical lesions and the degree of periodontal bone loss from the intraoral films provided a greater diagnostic yield at the p < 0.001 level of significance. The research found that dentists underestimated the number of caries lesions present and level of periodontal bone loss when compared to the researchers but overestimated the presence of periapical pathology, at the level of significance at p < 0.001.

Conclusions

The study found that there was no support for the use of panoramic radiographs in routine screening as there was no net diagnostic benefit to the patient.     

A comparison of combinations of clinical and radiographic examinations in evaluation of a dental clinic population

Panoramic periapical anterior and posterior bitewing radiographic, mirror-explorer, and transillumination clinical examinations were performed on 300 patients. Various combinations of the radiographic and clinical examination techniques were compared in terms of their ability to diagnose caries, alveolar bone loss, calculus, periapical bone lesions, impacted teeth, root tips, and miscellaneous conditions. A mirror-explorer clinical examination with panoramic and posterior bitewing radiographs and either anterior bitewing radiographs or transillumination proved to be as efficient in the initial examination of patients as the mirror-explorer clinical examination with periapical and posterior bitewing radiographs.     

The use of panoramic radiography in the evaluation of asymptomatic adult dental patients

This article examines the efficacy of panoramic radiography alone and in combination with intraoral films as part of the "full-mouth" radiographic evaluation of asymptomatic dental patients in the diagnosis of dental caries and periodontal disease. Three full-mouth radiographic surveys--the panoramic alone, the panoramic plus posterior bitewing, and the periapical plus posterior bitewing--are compared. Two forms of measurement--comparative and incremental--were used to identify the radiographic survey with the highest single diagnostic yield when measured against the consensus standard. The findings show that the panoramic radiograph alone exhibits very low sensitivities to dental caries, ranging from 0.6% on anterior teeth to 25.6% on premolars. Even when posterior bitewing radiographs are added to the panoramic films, the sensitivities are significantly below those of the full-mouth periapical and bitewing survey. In contrast, the sensitivities of all three radiographic surveys in the diagnosis of periodontal disease are quite high, ranging from 87% to 96%, so that differences are not clinically significant. However, specificities tended to be low for periodontal disease and high for caries. Thus, for dental caries and (to a lesser extent) periodontal disease, the panoramic radiograph was inferior to the full-mouth intraoral series in its ability to correctly detect evidence of the disease.     

The diagnostic value of panoramic radiographs in children aged nine to ten years

The increased awareness of the possible harmful effects of ionizing radiation has resulted in concern at the number of panoramic radiographs taken in General Dental Practice. A study has been carried out to examine the diagnostic value obtained from panoramic radiographs taken at 9-10 years of age. Nine-hundred-and-eighty-two radiographs were examined and 261 (26.5 per cent) showed findings which would be of significance in orthodontic diagnosis and treatment planning.     

Radiographic recommendations for the transitional dentition: comparison of general dentists and pediatric dentists

A survey which included brief case histories and intraoral photos of four transitional dentitions, including examples of ectopic and delayed eruption, as well as carious lesions, was mailed to a random sample of 2000 general dentists and 1000 pediatric dentists. Radiographic options were listed, from which each dentist was to indicate all films needed for each child's examination. Surveys were returned by 1273 (43%) dentists, including 713 (36%) general dentists and 560 (56%) pediatric dentists. The pediatric dentists took significantly more diagnostic radiographs than did the general dentists for each of the four transitional dentition cases. Pediatric dentists were more likely than the general dentists to take panoramic films and combinations which included panoramic films, bite-wing radiographs and periapical films. The most frequently ordered combinations were bite-wing radiographs plus panoramic films and bite-wing radiographs plus anterior periapical films. General dentists recommended bite-wing radiographs films only more frequently than did pediatric dentists. In view of the results of this study and the USDHHS guidelines for radiographic examinations, (1987) education must be provided for both general dentists and pediatric dentists regarding appropriate radiographic examinations for transitional dentition patients.