Home Dental Radiology Endodontic radiography – what’s displaying the radiograph? The yield of commercial computer screens vs. DICOM calibrated medical screens in endodontic radiography

Endodontic radiography – what’s displaying the radiograph? The yield of commercial computer screens vs. DICOM calibrated medical screens in endodontic radiography

by adminjay


Currently, the best radiological technique for evaluating the periapical area is CBCT. However, the ALARA principles require strict case selection. Thus, referring all patients to a CBCT scan prior to treatment is not recommended. In most clinical situations, the clinician must make a decision based on a combination of clinical and 2D X-ray data. During this research, we attempted to create conditions that mimic the clinical scenario in which the clinician is guided only by an evaluation of the periapical X-ray.

The maxillary posterior region poses several challenges in dental radiography. It is a complex area to interpret on 2-dimensional X-rays due to the superposition of anatomical structures, such as the border of the maxillary sinus, the zygomatic arch, and fused and closely positioned roots [8]. The current analysis compared the ability of DS and CS imaging to detect PDL widening and visualize the root apices of maxillary molar teeth, and the results were significantly in favor of DS for these purposes.

Identification of PDL widening is crucial in endodontic decision-making since it might serve as a diagnostic criterion for the need for endodontic intervention [11]. To observe the PDL in the apical third of the tooth’s root, which is the most important part of the PDL when looking for the presence of widening in endodontics, one must first observe the entire length of the root, even when it is superimposed by other anatomical structures. A 2017 study [1] revealed that medical calibrated screens performed better in the identification of incipient and recurrent caries lesions. A series of studies conducted at the University of Oulu [8] revealed that DS may improve observer performance in the detection of pathology in panoramic radiographs regardless of the room illuminance level. Hirschorn et al. [7] listed 2 major reasons for preferring DS over CS: 1. a commercial grade monitor does not show all of the critical anatomical information, and as the name implies, the CS monitors are intended to display documents to appear like a printed page in office settings; 2. many commercial grade monitors do not have the required dynamic range, while medical grade monitors are calibrated in a way that takes into account the room light and maps the lowest pixel value to the detectable output. A medical-grade monitor typically adjusts the output to compensate for start-up variations in output; it can usually keep a record and keep track of its calibration, and it is typically certified.

The results of the current analysis indicated that there are several important differences in favor of the DS over the CS for visualizing PDL widening and root apices. First, the observers were able to identify more cases of widened PDLs when using the DS (31.4% compared to 17.4% for one observer and 34.8% compared to 21.7% for the other), meaning that cases that were identified by the CS as “not widened” were identified as “widened” by the DS. This could determine an entirely different treatment plan. Second, one observer was able to detect the root apex in 123 patients (77.4%) when using the DS compared to only 89 (56%) when using the CS. Another observer was able to detect the root apices 133 times (83.6%) when using the DS and only 106 (66.7%) when using the CS. Third, the interobserver agreement for the PDL widening test was 0.527 (P < 0.001) for the CS and 0.662 (P < 0.001) for the DS, indicating that a more suitable screen might improve interobserver agreement (although it did not improve interobserver agreement for the visibility test of apices for all of the observers). The issue of interobserver agreement has long been debated in the endodontic radiography literature. In 1972, Goldman et al. [12] showed that even very experienced observers agreed in only 47% of the cases when they examined 253 random X-rays. In 2011, Tewary et al. [12, 13] repeated Goldman et al.‘s experiment using 150 digital random X-rays. The former authors also reported an average kappa value of 0.5. Omer et al. [14] found limited value of radiographs when studying certain aspects of the root canal system and concluded that poor and average intra- and interobserver values in such studies are to be expected. Similar findings emerged in the current study. Since the interobserver agreement was low for some observers, those for whom the kappa value ranged between moderate and substantial were selected. Overall, however, the interobserver agreement in the current study was consistent with that of past studies. Nevertheless, the finding that the DS was able to improve the kappa value for the PDL widening test might suggest that screens that are better in terms of calibration or more suitable for medical purposes might improve the clinician’s ability to detect and diagnose anatomical structures and pathological conditions. Such screens might serve as a better research tool for endodontic radiography studies and improve past kappa values in endodontic radiography research, as shown in this study.

The main limitation of this research is that there is no “gold standard”, such as a CBCT scan, for comparison. This was done as a simulation of the clinical scenario, as stated before.

Additional studies are warranted to evaluate the influence of screen capability on clinician decisions to refer patients to cone beam computed tomography for cases that are difficult to interpret.

In conclusion, the DS showed a significantly greater ability to identify PDL widening and root apices than did the CS in the posterior maxillary region.



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