More than 50% of dental practitioners are thought to use panoramic radiographs to screen their new adult patients. While the UK Faculty of General Dental Practitioners recommend the use of intra-oral radiographs for the assessment of the adult dentate patient for the presence of caries, periodontal bone loss and apical pathology. One of the aims of this study was to measure the added value of panoramic radiography in new dentate patients attending for routine treatment.
What did they do
37 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.
What did they find
- 740 patients were examined(The majority in 18–24 and 25–34 age groups), 533 were pain free, 207 were experiencing some degree of pain.
- 105 patients (14.2%) had no restorations and 385 (52.0%) had only simple restorations, (1.8%) had teeth with full coronal restorations, and (0.7%) had bridges.
- 310 (42%) patients were found to be caries free at examination, 350 (47.3%) had between one and five caries lesions, 53 (7.2%) had between six and ten caries lesions, 20 (2.7%) had between eleven and fifteen caries lesions.
- A Basic Periodontal Examination( BPE) score of 4 or less in any sextant was recorded for 37 patients (6.2%).
- The dentists reported the presence of partially erupted teeth in 162 (21.9%) cases and 155 (20.9%) patients were assessed as having clinically suspected unerupted teeth.
- 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.
- 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.
They concluded
The study found that there was no support for the use of panoramic radio-graphs in routine screening as there was no net diagnostic benefit to the patient.
Rushton MN, Rushton VE. 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. J Dent. 2012 Apr 27. [Epub ahead of print] PubMed PMID: 22542499
Comment
The authors also pointed out that 5.1% of the panoramic films that were only of benefit because of:- ‘deficiencies regarding the intraoral films, of which 27 were of such low contrast due to spent processing chemistry that they were unreadable and the other 11 were incorrectly positioned so that areas of clinical interest were not imaged’
This is an interesting study coming on the back of the recent reports that linked dental x-rays with meningioma and to me it further highlights the need to only take radiographs following a thorough clinical examination and further that we should favour the use of intra-oral films for caries and periodontal disease diagnosis as recommended by UK Faculty of General Dental Practitioners
Unfortunately, the authors did not give enough information about the equipment and type of panoramic radiography taken. There are many difference among equipments, e.g.
So far, reported studies stated that the quality of panoramic radiographs was considerably lower than standards recently set for primary dental care (1). Also, the the panoramic radiography is a difficult radiographic technique, which needs an experienced operator in order to get high quality radiographs (2) and in the paper analyzed there is no report of the level of training of the operators of the panoramic equipment. Also there are differences between digital and conventional panoramic radiographs. (3)
Hence, considering this, an alternative viable conclusion also can be “there is no support for the use of bad quality panoramic radio-graphs in routine screening as there was no net diagnostic benefit to the patient”
References
1. Br Dent J. 1999 Jun 26;186(12):630-3.
2. Swed Dent J. 2006;30(4):165-70.
3. Clin Oral Investig. 2000 Sep;4(3):162-7.
I was just told today I had to have a panoramic X-ray at my Kaiser Permanente Dental run practice in Portland, Ore., USA, as a new patient. No dentist ever in my past has required this, and no health risk issues with the X-ray or the radiation dosage was discussed by the clinic or lead dentist. I was told I could either do it or find another practice. One or the other.
With regards to your comments, the authors however do raise excellent points questioning the value of a diagnostic procedure for the patient, and the procedure does in fact expose the patient to a dose (albeit and reportedly “acceptable”) of radiation. There are also costs to both the patient and the health care system that may not be justified in terms of health outcomes from having this imaging.
Another paper made a finding that also questioned the need for this diagnositic method and its actual value to the patient. There are larger questions to consider, from a public health dentistry perspective concerning the use of this diagnostic tool to the bottom line of a dental practice, a dental professional or a medical equipment company.
See: BMC Oral Health. 2013 Sep 26;13:48. doi: 10.1186/1472-6831-13-48. Comparison of clinical and dental panoramic findings: a practice-based crossover study.
Moll MA1, Seuthe M, von See C, Zapf A, Hornecker E, Mausberg RF, Ziebolz D. (http://www.biomedcentral.com/1472-6831/13/48)
The authors conclude: “There was no difference between clinical and x-ray findings. However, with regard to the assessment of carious as well as insufficiently filled or prosthetically treated teeth, there was a clear discrepancy between the two methods of investigation. At the same time, DPR findings were inferior to clinical findings in relation to the parameters “carious tooth” and “insufficient filling”. Accordingly, the DPR gives the clinician no additional gain
in information in this area. Therefore, it would have been possible to have dispensed with x-rays. Nevertheless,
additional x-ray findings were found.”
the images are:
Conventional
http://www.imagebanana.com/view/r64t6xuh/Seleccin_999448.png
Digital
http://www.imagebanana.com/view/r64t6xuh/Seleccin_999448.png
[…] No diagnostic benefit from routine screening with panoramic radiographs […]
The studies claiming risk of meningioma were based on patient recall, and if correct (however prone to bias that may be) were done on a population of age that would have had much higher exposures given the equipment of the time. Also worth questioning the protocols at the time of their early childhood years; what were they? Did they get annual panoramic imaging as very young children? Radiation exposures in the early years can carry risks orders of magnitude higher than anything else cumulatively later in life. The results of the report should be considered nearly junk imo. Far too many unanswered questions, it should only spur more studies and less to base current recommendations.