EVALUATION OF DIAGNOSTIC VALUES OF DENTAL RADIOGRAPHY IN THE MANAGEMENT OF DENTAL PATHOLOGIES (CASE STUDY OF FEDERAL MEDICAL CENTRE ASABA)

LIST OF TABLES

Table 1:      Age distribution of patients for dental clinical and radiographic exams in Federal Medical Centre Asaba.

Table 2:      Sex distribution of patients for dental clinical and radiographic exams     –

Table 3       Carious Lesions

Table 4:      DentoalveolarAbscess

Table 5:      Chronic periodontitis

Table 6:      Acute Apical periodontitis

Table 7:      Acute Apical pulpitis (reversible pulpitis)

Table 8:      Chronic pulpitis (irreversible pulpitis)

Table 9:      Pericoronitis         –

Table 10:    Retained Root

Table 11     Chronic Gingivitis

Table 12:    Fracture

TABLE OF CONTENTS

Title Page

Approval page

Certification

Dedication

Acknowledgement

List of tables

Table of contents

Abstract

Chapter One

1.0    Introduction

• Background of Study
• Statement of Problem
• Objectives of Study –
• Significance of Study

1.5     Scope of the Study

1.6   Literature Review

Chapter Two

2.0 Theoretical Background

2.1   Anatomy of the Teeth

2.1.1Development and Eruption Teeth

2.1.2Primary Dentition

2.1.3Permanent Dentition

2.2Dental numbering system and notation

2.2.1 Palmer Notation Method

2.2.2FDI World Dental Federation Notation

2.2.3 Universal numbering System (dental)

2.3  Dental pathologies and intra-oral infections

2.3.1 Dental Caries

2.3.2 Periodontitis         –

2.3.3 Pulpitis

2.3.4 Tooth Abscess

2.3.5  Furcation Defect

2.3.6 Pericoronitis

2.3.7 Retained Tooth – Root

2.3.8 Cracked Tooth Syndrome

• Gingivitis

2.3.10 Calculus

• Dental Radiographic Views

2.4.1 Intra-oral radiographic views

2.4.2  Extra– oral radiographic view

Chapter Three:

3.0 Research  Methodology

3.1 Research Design

3.2 Target Population

3.3 Area of Study

3.4 Inclusion Criteria

3.5 Instruments of Data Collection

3.6 Methods of Data Analysis

Chapter Four:

4.0 Results

• Presentation of tables

Chapter  Five:

5.0     Discussion, Summary, conclusion, and recommendation

5.1     Discussion

5.2 Summary of Findings

5.3Conclusion

5.4     Recommendation

5.5 Limitations of the Study

5.6  Areasfor further Studies

References

ABSTRACT

This non-experimental restrospective study was aimed to obtain information on the diagnostic value of dental radiography in the assessment of dental pathologies. And also the findings when dental radiography is compared with clinical examinations. It was conducted at Federal Medical centre Asaba. A total of 130 dental cases were reviewed.The results of this research showed that dental radiography had more diagnostic yield than clinical evalution. It was found that clinical examination had more negative findings compared with negative radiographic findings in all the pathologies assessed. However, the agreement between radiographic and clinical findings was very high. This was contrasted in chronic pulpitis where the agreement between clinical and radiographic findings, and only clinically detected had equal rate of 22.2% compared to 55.5% of only radiographically detected (negative clinical findings).Also in pericoronitis, radiography alone detected highest 62.5%.When the dental cases were distributed according to sex, more females (51.5%) than males (48.5%) had dental pathologies. It also showed that the prevalence of dental pathologies was higher in age range of 21-30 years (23.1%) compared to others.In conclusion, dental radiography was found highly invaluable in the diagnosis of dental pathologies and should be recommended for accurate diagnosis.

CHAPTER ONE

• INTRODUCTION

• BACKGROUND OF STUDY

Dental radiography is the x-ray examination of the teeth and associated structures.  It is the most common radiographic procedure done in cases of dental and maxillofacial disorders.  Dental radiographs on the other hand are the x-ray images of the teeth, bones, and surrounding soft tissues to screen for and help identify pathologies in the teeth, mouth and jaw.  X-ray images can show cavities, cancerous or benign masses, hidden dental structures (such as wisdom teeth), and bone loss.

Dental radiography provides diagnostic information  on caries, plaque retention factor, furcation defects, subgingival calculus and other pathologies.  In diagnosing periodontal diseases, radiographs, play an important role since critical information such as alveolar bone level, widening of periodontal ligament, crestal bone height and irregularity and crown root ratio cannot be found in clinical examination¹

Clinical and radiographic examinations play an integral role in the diagnosis of periodontal disorders as well as in the choice of treatment and in follow-up examination². Features visualized are dependent on the radiographic view.  Bitewing and periapical radiography are both useful tools for this purpose³.  In addition to intra-oral radiography, panoramic radiography has been used as adjunct to the examination of marginal bone tissue⁴.  Panoramic radiography compares favourably with intra-oral radiography in the assessment of marginal bone level⁵.

Very few radiographic studies⁵ have elucidated the diagnostic yield on alveolar vertical bone defects and furcation involvements.

Caries epidemiological studies have traditionally been based on clinical examination alone⁶.  Several studies have confirmed that the prevalence of proximal carries is significantly under estimated when clinical data are compared with the radiographic information.  Dental radiography are claimed to be of great importance, particular for the detection of proximal caries in contacting posterior surfaces⁷.

Plague – induced periodontal diseases are mixed infections associated with relatively specific groups of indigeneous oral bacteria⁸.  Susceptibility to these diseases is highly variable and depends on host responses to periodontal pathogens⁹.  Although bacteria cause plague – induced inflammatory periodontal diseases, progression and clinical characteristics of these disease are influenced by both acquired and genetic factors that can modify susceptibility to infection¹⁰.

To arrive at a periodontal diagnosis, the dentist must rely upon such factors as:

1. Presence or absence of clinical signs of inflammation (eg bleeding upon probing).
2. Probing depts.;

• Extent and pattern of loss of clinical attachment and bone.

1. Patent’s medical and dental histories, and
2. Presence or absence of miscellaneous signs and symptoms, including pain, ulceration and amount of observable plague and calculus

Plague – induced periodontal diseases have traditionally been divided into two general categories based on whether attachment loss has occurred: gingivitis and periodontitis.  Gingivitis is the presence of gingival inflammation without loss of connective tissue attachment.  Periodontitis can be defined as the presence of gingival inflammation at sites where there has been a pathological detachment of collagen fibers from cementum and the junctional epithelium has migrated apically.  In addition, inflammatory events associated with connective tissue attachment loss also lead to the resorption of coronal portions of tooth – supporting alveolar bone¹¹.

This research is aimed at gathering information about the additional value of radiographic examination compared to clinical examination in assessing caries and other dental pathologies.  This will give information about the precise extent of underestimated pathologies when only clinical criteria is used.

• STATEMENT OF PROBLEM

1. There is sparse literature support on the diagnostic value of dental radiography in the assessment of dental pathologies.
2. The impressions based on clinical examination and radiological outcomes in the diagnosis and management of dental pathologies have not been evaluated in the area under study.
   • OBJECTIVES OF STUDY
3. To obtain information on the diagnostic value of dental radiography in the assessment of dental pathologies.
4. To compare the impressions based on clinical examination with radiological outcomes in the diagnosis and management of dental pathologies in federal medical centre Asaba.

• To determine the age and sex distribution of patients for dental clinical and radiographic exams in FMC Asaba
  • SIGNIFICANCE OF STUDY

1. This will help dental surgeons in planning initial, corrective and supportive phases of therapy.
2. The result of this study will help in the definitive management of patient with dental and maxillofacial disease.
   • SCOPE OF THE STUDY

The study surveyed dental radiography examinations in federal medical centre Asaba, Delta state.  It covers all patient’s dental records from 1^st January 2011 – 1^st March 2012.

1.6   LITERATURE REVIEW

RADIOGRAPHY IN THE ASSESSMENT OF DENTAL CARIES

Detection and diagnosis of the carious process are perhaps the most common reasons for dental radiography.However, with changes in the caries profiles within certain segments of the younger age groups¹² and increases in the number of older dentate adult¹³ radiographs are now being obtained for many different reasons for patients in all age groups and at all levels of risk. Bader and others¹⁴ have produced an excellent review of all current systems fordetecting dental caries, including radiography.

OCCLUSAL AND INTERPROXIMAL CARIES

Numerous studies have assessed the ability to diagnose occlusal caries from radiographs, both conventional and digital. In a recent study employing a receiver operating characteristics(ROC) analysis, occlusal and approximal surfaces were radiographed with 6 charged coupled device (ccd) sensor systems and 2 film-based systems.¹⁵ four trained observers interpreted the radiographs, and the caries were validated histologically. The systems yielded auc measurements ranging from 0.74 to 0.90, with the filmbasedSystems scoring generally higher . Of interest is that using 4 rather than 2 films in bitewing examinations (overlapping films) appeared to add  little to the diagnostic value of the exam.¹⁶In another study, the ability of 276 dental practitioners to detect  interproximal demineralization using bitewing radiographs was contrasted with microradiographic assessment (the gold standard).¹⁷ Sensitivity (± standard deviation) was moderate (54% ± 14) and specificity was high (97% ± 5) (AUC of 0.88). Apparently, differences in incidence of caries in different age groups affected radiographic prescribing and the value of ordering such tests: bitewings prescribed for children under 12 years of age added little information to the decision-making process, but for children older than 12 this type of imaging was of value in detecting inter proximal lesions.¹⁸

SECONDARY CARIES

The foremost reason for replacement of restorations is the presence of secondary or recurrent decay. In a study appraising the performance of conventional radiography in detecting recurrent decay, 91% of the noncarious restored teeth were detected, but only 53% of the failed restorations were found.¹⁹ An ROC value of 0.78 was calculated, and the authors suggested that careful clinical assessment of existing restorations was required before a definitive diagnosis of recurrent decay could be made.

The ability to detect recurrent decay from radiographs was examined with Class II amalgam  restorations in an in vitro design.²⁰ Seventy-seven teeth were grouped according to the state of the filling: fillings without failure (controls),fillings with secondary caries and fillings with onlymarginal defects. The teeth were examined  radiographically and clinically. A false-positive rate of 12% and a true positive rate of 47% were obtained for radiographic examination only. When a clinical examination was added to the diagnostic procedures, the false-positive rate was 3% and the true-positive rate 64%. The authors concluded that for secondary caries, radiographic diagnosis alone was insufficient to attain an acceptable degree of certainty and should always be supplemented by a thorough clinical examination.²⁰ In a separate study, dentist were asked to examine 77 teeth radiographically, visually and with the aid of a probe and  indicate if they would replace the restoration in each tooth.²¹ Only 5% of the teeth with no secondary decay were considered as requiring restoration replacement, but 36% of the teeth with small secondary lesions were indicated for replacement. In that study,²⁰ as in several others involving simulated clinical situations,²¹ there was a great deal of variation between and within the observers.

CARIES IN PRIMARY TEETH

One study investigated the ability to detect decay in primary teeth using a variety of imaging methods;²² the results from intraoral and extraoral film systems are described here. Sixty-four extracted primary teeth with a total of 85 carious lesions were examined; 8 trained

observers used a 5-point scale to indicate whether they thought caries was present. Using ground sections as the gold standard, the authors employed ROC analysis to determineaccuracy of diagnosis. The AUC scores were 0.70 for intraoral film and 0.64 for panoramic views. The authors suggested that intraoral films were better than panoramic images for detecting interproximal lesions, although the difference was less pronounced when occlusal lesions were assessed^.22

A study investigating the DIAGNODent device (KaVo,

Lake Zurich, Ill.) reported kappa values for radiographic detection of decay in primary teeth; intra-observer agreement was 0.58 and inter-observer agreement was 0.56.²³ According to the Landis and Koch²⁴ scoring system for kappa values, these can be considered to represent moderate agreement; in overall terms, however, they cannot be considered substantially better than the values attained with conventional radiographic imaging .

ROOT CARIES

Because adults now retain more teeth as they grow older, the prevalence of root caries has increased.²⁵ Unfortunately, few tests have proven of value in detecting such lesions.Lesion colour has been used, but it has little validity.²⁶ Softness of the lesion, as determined by use of an explorer, has been validated with microbiological tests and has shown promise.²⁶ However, further research is required to develop tests for what will be an area of increasing diagnostic need.

RADIOGRAPHY IN THE ASSESSMENT OF PERIODONTAL DISEASE

Dental radiography is an important procedure for diagnosing and monitoring periodontal disease through appraisal of alveolar bone levels. Both panoramic and periapical radiographs are employed, and a wealth of research has been done in this area. The introduction of subtraction imaging techniques has been especially important in monitoring periodontal disease.

Correlating panoramic, bitewing and periapical radiographs with probing depths, researchers have found substantial inter-observer variation.²⁷ Probing depth was the most accurate method (within 5% of the true value), whereas periapical radiography was more accurate than panoramic or bitewing radiography. Panoramic radiography had a lower mean accuracy than bitewing radiography. The underestimation of bone loss ranged from 13% to 32% in panoramic radiographs, 11% to 23% in bitewing radiographs and 9% to 20% in periapical radiographs. A separate study found that periapical radiographs were superior to panoramic views for measuring bone loss in the mandible, although both performed equally well in imaging the maxilla.²⁸  Molander²⁹ found inter-observer agreement of 58% for intraoral radiographs and 60% for panoramic systems. On average, agreement between the systems was obtained for 55% of the sites. The conclusion offered was that panoramic views provide an acceptable amount of information for diagnostic purposes but should be supplemented with intraoral views when assessment of disease progression over time is the main purpose of radiographic monitoring at specified periodontal sites. periapical radiographs supplementing such views may be called for, given that agreement between periapical and panoramic radiographs may not be high. Image enhancement per se may be insufficient to improve the value of the diagnostic procedures. One study³⁰ compared 3 imaging modalities to assess vertical bony defects — plain bitewing, enhanced bitewing and digital bitewing radiography. A total of 75 dentitions were examined, and the results of 2 observers were analyzed with ROC analysis.All 3 methods produced ROC AUC values lower than 0.80, and

the authors concluded that neither of the enhancement approaches improved detection of the targeted periodontal condition.

RADIOGRAPHY IN ENDODONTIC PROCEDURES

 Detection of Periapical Lesions

The search for periapicalpathosis is typically undertaken

by means of periapical radiography for patients with a history of irreversible pulpitis. An important aspect of this application is the effectiveness of radiography in detecting periapicalpathosis and measuring lesion size. A change in lesion size remains one of the most important parameters for determining lesion activity and therefore guiding management decisions. The resolution of periapicalpathosis may be difficult to confirm if there is substantial variation across observers . Generally speaking, agreement regarding the presence or absence of periapical lesions is greater than agreement on lesion size. In a study of 105 teeth, agreement among 3 observers for the presence and size of periapicalradioluency was assessed.Agreement regarding the presence or absence of a lesion was high;however, intra-observer and inter-observer agreement levels for lesion size were less consistent, with kappa values ranging from 0.38 to  0.71 for intra-observer comparisons and from 0.25 to 0.48 for inter-observer comparisons.³²

A larger study was undertaken with 80 diseased teeth and 60 normal (control) teeth, each rated by 6 observers.³³ The observers were asked first to determine if periapical abnormality was present and then to provide an indication of their confidence in the decision rendered. The simple measure of accuracy (as a percentage) was 70.2%; specificity (0.78) was higher than sensitivity (0.65). Intraobserver reliability (0.65) was higher than inter-observer reliability (0.54), although both measures of reliability could be considered only marginal.³³

The identification and assessment of lesion size appears to be influenced by the technology employed. A comparison between digital and conventional radiography (Ektaspeed film [Eastman Kodak, Rochester, N.Y.] and CCD imaging) involved 14 observers measuring ³¹ lesions. Conventional imaging was consistently the less effective method,³⁴ although its performance was acceptable for clinical applications. For example, when tomographic imaging (Scanora system, Soredex, Milwaukee, Wis.) was contrasted with conventional periapical radiography, the sensitivity of the latter was 70% and the specificity 77%.³⁵Other studies have obtained different values for specificity and sensitivity. In a study targeting the identification of bony lesions, 98 general practitioners examined 32 radiographsto diagnose such lesions.³¹ The clinicians correctly identified 81% of all lesions present; they also indicated that 55% of the radiographs had lesions, whereas no lesions were found when the clinicians examined the teeth using the gold standard (i.e., periapical radiographs). Theselesions were therefore false-positives. Although no lesions were missed, the false-positive rate was high.

Canal Length and File Length

The use of radiography for most endodontic techniques is well described; however, many assumptions about the accuracy and reproducibility of these procedures remain untested. One group studied the accuracy of root canal measurements obtained with files in cadaver specimens.³⁶They asked 9 observers to judge file sizes (10 and 15) in molars and premolars. Inter-observer agreement on the adjustment in file length needed was 68% when adjustmentsof up to 0.5 mm were needed, 18% when adjustments from 0.5 to 1.0 mm were needed and 14% when adjustments greater than 1.0 mm were needed. Apparently, no correction for chance agreement was undertaken.

CLINICAL EXAMINATION AND RADIOGRAPHY IN THE ASSESSMENT OF DENTAL PATHOLOGIES.

Several studies have been done to compare the detectability of clinical examination with dental radiograph in assessing dental caries.

Lawrence et al ³⁷ in a study done in the state of Rio de janeiro, Brazil, found that lesion progression from the outer half of enamel into the outer half of the dentin takes approximately 3-4 years (assuming a constant rate overtime) in school children (mean age 14.1years at baseline) from fluoridated areas who exhibited high caries activity. Although clinical examination remains the basic detection system for dental caries, several studies have shown that it is not very accurate in detecting carious lesions in approximal surfaces³⁷

PITTS³⁸ concluded that clinical examinations alone generally detected less than 50% of the total approximal lesions found with clinical plus radiographic examination. The results of the present study are in line with these conclusions. For the diagnosis of integrity of approximal surfaces, temprorary tooth separation with an elastic separator or some other apparatus seems to be better than other conventional methods. Regarding the detection of non-cavitated lesions, clinical examination used alone detected 41.3% and bitewing radiography detected about 61% of the total number of approximal non-cavitated lesions that have been identified after tooth separation.

These findings differ from the results obtained by Machiukieneet al³⁹ who found that 75% of approximal non cavitated lesions were detected by clinical examination alone and 55% by radiographs. With respect to the detection of cavitated lesions, clinical examination alone detected 46.4% and bitewing radiography detected about 85.5% of the total number of approximalcavitated lesions that were detected after tooth separation. Those findings are close to the results obtained by Machiulkieneet al⁶⁰ who reported that 56% of the total number of approximal non cavitated lesions was detected by clinical examination alone and 85% of approximalcavitated lesions was detected by radiographs. However, in that study the authors did not separate the approximal surfaces to confirm the presence or absence of carious lesions.

De Vrieset al⁴⁰ in a study on patients under the age of 12 years, concluded that omission of radiographic examination did not result in a substantial loss of information. However, for patients above this age the authors advised the adjunctive use of radiography for diagnosis of caries of approximal surfaces.

Radiographic multiplication/adjusting/correction factor has been calculated by Mann et al⁴¹ to compensate for the clinically undetected proximal caries. The above is a numerical value derived by dividing the sum total of the clinically detected caries plus additional radiographically detected proximal caries by the number of caries detected clinically. This value when multiplied by the clinically detected caries in a given population for whom radiographs have not been taken, help to compensate for the clinically under-estimated proximal caries to reflect the actual decayed-surface (D-S) and decayed – missing- filled surfaces (DMFS) scores. However, such a factor is dependent on various factors like caries prevalence, age of the participants, amount of restorative treatment etc. therefore, it was proposed that correction factors should be determined for various study population.

Choi⁴² reported carious detectablity of clinical examination in occlusal and buccolingual surface was higher than that of panoramic examination, however it was statistically insignificant. In proximal surfaces carious detectability of panoramic examination was higher than that of clinical examination, and it was statistically significant. When the two examination methods were combined additional detection of caries was possible (26.7% in occlusal, 48.2% in proximal, 33.3% in bucco lingual surface, and 38.% totally).

An et al⁴³ compared the detectability of clinical examination with panoramic radiograph.Panoramic examination revealed 24.2% of dental caries which had been detected only in clinical examination was 5.2%.These results are in agreement with the finding of Shin et al, that panoramic radiography showed a higher detection rate of 23.1% for dental caries than clinical examination^44.

Biswas et al⁴⁵ described the characteristics and types of the impacted mandibular third molar at the highest risk for pain and pericoronitis using clinical and radiographic analysis. A total of 239 volunteers, including 147 (61.5 %) male and 92 (38.5%) female patients presenting with acute pericoronitis, participated in the study. The mean age of the participants was 28 years (range 16-40 years). The analysis of type, angulations and eruption level of the mandibular third molar were achieved by using I.O.P.A. X-ray and in few cases, lateral oblique of mandible. While mesioangular impaction was the most frequent angulation (44.4%), horizontal impaction was quite less (11%). Vertical impaction (27.6%) was slightly higher than distoangularimpaction(15.9%) and aberrant(0.8%).

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