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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 1 | Page : 49-54
Assessment of common errors and subjective quality of digital panoramic radiographs in dental institution, Riyadh
Amara Swapna Lingam1, Pradeep Koppolu2, Rasheed Abdulsalam3, Reddy Lavanya Reddy4, Anupreeta Anwarullah5, Deepak Koppolu6
1 Department of Surgical and Diagnostic Sciences, Dar Al Uloom College of Dentistry, Riyadh, Saudi Arabia; Department of Dentistry, Faculty of Dentistry, Lincoln University College, Kota Bharu, Malaysia
2 Department of Dentistry, Faculty of Dentistry, Lincoln University College, Kota Bharu, Malaysia; Department of Preventive Dental Sciences, Dar Al Uloom College of Dentistry, Riyadh, Saudi Arabia
3 Department of Dentistry, Faculty of Dentistry, Lincoln University College, Kota Bharu, Malaysia
4 Department of Oral Medicine and Radiology, Government Dental College and Hospital, Hyderabad, Telangana, India
5 Department of Conservative Dentistry and Endodontics, GITAM Dental College and Hospital, Visakhapatnam, Andhra Pradesh, India
6 Department of Clinical Research, George Clinical Pvt Limited, Sydney, New South Wales, Australia
Correspondence Address:
Amara Swapna Lingam
Department of Surgical and Diagnostic Sciences, Dar Al Uloom University, Riyadh
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_213_21
Abstract
Aim: The study aims to determine the frequency of positioning errors, record the number of diagnostically inappropriate images, and assess the quality of panoramic radiographs. Materials and Methods: In this study, a total of 2629 patients for whom orthopantomogram were selected out of 3900 new patients between August 2020 and June 2021. The positioning errors of the radiographs were evaluated and categorized into ten groups. The quality of the radiographs is further assessed as “Excellent,” “Diagnostically Acceptable,” and “Diagnostically Unacceptable.” Results: Out of the total radiographs, 32.8% had no errors, and 77.2% of the radiographs had one or more positioning errors. The radiographs were analyzed in detail, and the errors found in the panoramic radiographs were recorded. The most common positioning error observed in the radiograph was error 8, failure to place the tongue close to the palate. Conclusion: The results and evaluation inferred that attention to patient positioning and focusing on reducing diagnostically indecent images could improve the quality of panoramic radiographs. Proper instructions to the patient, patient preparation, appropriate positioning of the patient, and the technician's skill plays a vital role in reducing diagnostic errors in Panoramic Radiography.
Abstract in French Résumé
Objectif: L'étude vise à déterminer la fréquence des erreurs de positionnement, à enregistrer le nombre d'images diagnostiques inappropriées et à évaluer la qualité des radiographies panoramiques. qualité des radiographies panoramiques. Matériaux et méthodes: Dans cette étude, un total de 2629 patients pour lesquels l'orthopantomogramme a été sélectionné. sur 3900 nouveaux patients entre août 2020 et juin 2021. Les erreurs de positionnement des radiographies ont été évaluées et classées en dix groupes. La qualité des radiographies est ensuite évaluée comme “Excellente”, “Diagnostiquement acceptable” et “Diagnostiquement inacceptable”. Résultats: Sur l'ensemble des radiographies, 32,8 % ne présentaient aucune erreur, et 77,2 % des radiographies présentaient une ou plusieurs erreurs de positionnement. Les radiographies ont été analysées en détail, et les erreurs trouvées dans les radiographies panoramiques ont été enregistrées. L'erreur de positionnement la plus courante observée sur l'erreur 8, à savoir le fait de ne pas placer la langue près du palais. Conclusion: Les résultats et l'évaluation ont permis de déduire que l'attention portée au positionnement du patient et la réduction des images indécentes sur le plan diagnostique peuvent améliorer la qualité des radiographies panoramiques. Une bonne communication avec le patient, le technicien passant plus de temps à positionner le patient et la compétence du technicien sont les clés du contrôle et de la réduction des erreurs de diagnostic dans les radiographies panoramiques. et la réduction des erreurs de diagnostic en radiographie panoramique
Mots clés: Artefacts, images fantômes, panoramiques, radiographies
Keywords: Artifacts, ghost images, panoramic, radiographs
Introduction 
In dentistry, the panoramic radiograph is one of the valuable tools in diagnosing various dental and oral problems and is essential to design treatment plans for different dental issues. Achieving a high-quality image without any errors with the least level of radiation exposure is most important in dental practice. Further low-quality radiographs often lead to misinterpretation which, in turn, leads to incorrect diagnosis and treatment.[1] This technique is one of the most indicated radiographic examinations, which provides an overall view of dentomaxillomandibular structures, which is also the most cost-effective for patients.
As there could be considerable percentage of the unacceptable radiographs, it is important to understand the key common errors and reasons for its occurrence in order to ensure good-quality radiographs.[2] Further, diagnostically unacceptable radiographic images will lead to multiple supplementary images which cause increased risk of additional radiation to the individual and could cause adverse effects to the patient.[3]
Low-quality images are often noticed due to the errors made by the technician due to positioning of the patient or due to processing. Before undergoing panoramic radiography of teeth, the patient usually needs to remove accessories such as glasses, jewelry, hairpins, dentures, other removable appliances. It is also observed that radiopaque spots which are the reflections of several structures on the examined areas are possible in the panoramic radiography. This means it is furthermore critical to eliminate these positioning errors to get a high-quality radiographic image.[4] Horizontal and vertical magnification discrepancies and distortion of the images are mainly due to the improper positioning of the subjects.
Using digital imaging leads to the elimination of processing errors making the technician or dentist to focus on the positioning errors to ensure more error free and diagnostically acceptable images.[2]
Hence, this study is aimed to determine the frequency of positioning errors, and diagnostically inappropriate images, and to assess the quality of panoramic radiographs. Our objective is to know the common causes for positioning errors; this knowledge will enable technicians to improve the quality of the images.
Materials and Methods In this study, a total of 2629 patients were considered for whom orthopantomogram is taken out of 3900 new patients between August 2020 and June 2021. The imaging was performed with digital panoramic Orthophos XG system Sirona company used exposure parameters as per manufacturer instruction to validate and correlate the results. All projections were achieved digitally by two technicians with the same level of training and experience of 8 years. The radiographs include patients of all ages, including pediatric patients from 5 to 12 years and elderly patients aged above 60 years. Ethical clearance was obtained from the institutional ethics committee.
Inclusion and exclusion criteria
Patients' radiographs with history of developmental abnormality or fracture to the maxillofacial region or orthognathic surgeries or patients with tumors/cysts were excluded in the study. The rest of the radiographs were included in the study.
All radiographs were analyzed for the presence of positioning errors by two radiology specialists with more than 15 years of experience. The radiographic images were evaluated on the monitor and the frequency of the critical errors was recorded. The standard errors observed by both observers are given below, and the criteria for evaluation and summarization are provided, as shown in [Table 1]. Quality of images, errors, and artifacts were taken into consideration by the observers while assessing the diagnostic accessibility of the radiograph. Repeated images were not included, and in cases where multiple images were taken from the patient, the first image is included in the study and for evaluation.
It is also ensured that each observer also used the three-point quality scale as consistent with National Radiological Protection Board to rate every radiograph's quality and correctness [Table 2].[7] To ensure consistency, interobserver reliability was also tested by reassessment of some of the random radiographic images after a month of the initial assessment of the radiographic image.[8]
The results of the assessment of the panoramic radiographic images are listed and presented with the help of descriptive statistics. All statistical analyses were performed using IBM SPSS Statistics version 25.0 (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA: IBM Corp). A frequency test was used for the statistical analysis. The frequency was tabulated to explain the frequency and probability of each error with P value. Repeatability was assessed by calculating kappa (K) statistic.
The dentists or the technicians were unaware at the time of the radiograph about the study. The images may be regarded as only for representation of day-to-day radiograph image quality. The processing and handling errors were also considered in this study, and the study included images from people of all age groups.
Common errors
Errors in radiographic images result in reduced diagnostic methods, which lead to repeated patient exposure to unnecessary radiations during radiographic investigations of teeth. In the above study and assessment, some common errors are observed in most cases, as listed below.[4]
Results Out of the 2629 panoramic radiographs viewed by the observers, a total of 863 radiographs (32.8%) had no errors and were classified as excellent. However, 1766 (77.2%) of the radiographs showed one or more errors. The most common positioning error observed in the radiograph was error 8, failure to place the tongue close to the palate, which leads to the presence of radiolucent airspace obscuring the roots of the maxillary teeth. In contrast, the least standard error kept was error 10, which was reflected in images [Table 3], [Table 4], [Table 5], [Table 6].
Table 3: Quality assessment of the panoramic radiographs observed in the study
Table 4: Percentage of errors observed by both observers among different age groups
Table 5: Association of different errors observed with different age groups
Table 6: Quality assessment of the panoramic radiographs age wise observed in the studyThe association of different errors observed by both observers with different age groups is mentioned in [Table 4]. Further, the overall kappa statistic for interexaminer proportional agreement is 0.998 [Table 7]. The results of the study also noted that there is no significant statistical difference in the prevalence of diagnostic errors based on gender.[9]
The results exhibit a statistically significant higher error 8 and error 3 among 19-–59-year-old subjects than other age groups. Error 10 is statistically significant in the age group of 5–12 years.
The results from both the observers depict that errors 1 to 9 are majorly found in radiographic images of the subjects between age 19 and 59 years. Error 10 is more predominantly found in the radiographic images of the children [Figure 1] and [Figure 2].
Figure 2: Patient midline asymmetry causing an increase in right mandibular ramus mesiodistal width Discussion The images evaluated in the present study were from new patients who visited the dental college and had orthopantomogram between August 2020 and June 2021. The purpose of the study is to determine the frequency of positioning errors and to record the percentage of diagnostically unacceptable images.
Due to the limited dimensions of the image layer in the panoramic radiography, minor errors in the positioning are manifested as distortions. It is because of unequal horizontal and vertical magnification or overlap of teeth or loss of image sharpness.
In this study, it is noticed that the most common positioning error in the radiographs was error 8, failure to place the tongue close to the palate, which leads to the presence of radiolucent airspace obscuring the roots of the maxillary teeth.[10] The above most common error is in concordance with the results from the evaluation of both observers. And in correlation with other studies, Wafa′a AL-Faleh reported 81.8% of this error in his study.[6] It is sometimes because the patients might not understand the instructions clearly or misunderstand or ignore the instructions provided by the technician. This error occurred averagely in 17.90% of observations of the radiographs in this study.
The least standard error observed in this study is the ghost or reflected images. This error happens when the object or anatomic structure is located between the source and the center of rotation and has a sufficient density to attenuate the beams. Sometimes, jewelry can also lead to ghost image formation. It is also observed that occasionally unilateral jewelry might be mistaken for a radio-opaque disease entity. Further, few anatomical bony structures can cause superimposed double real images, and any hair clips or accessories lead apron artifacts that may lead to the appearance of ghost images, which are magnified in the panoramic radiographic image.[11] This error on an average of both evaluations was found in 2.20% of the radiographs in this study. The second most error observed in this study is that the patient's head is tilted downward, positioned as chin back, and forehead in front, leading to condyles cut off, lower root apices blurring. This result is almost matching to the other studies.[8] To rectify this error, the vertical plane of occlusion should be positioned parallel to the floor.
The results of this study are also in agreement with other studies in terms of other positioning errors. It is because many times, multiple errors were observed in one image, and this could be due to technicians spending less time on patient preparation and positioning.[12]
The results also inferred that there is no significant statistical difference among different types of errors between males and females. Further, the error no. 8 caused by failure to place the tongue close to the palate, which lead to the presence of radiolucent airspace obscuring the roots of the maxillary teeth was significantly high among 13 to 18years age group while the error no 3 where the patient's head tilting downwards with chin down recorded more among 19-59 years age group. However, ghost images are more significantly noticed in the pediatric group of 5–12 years.
The fundamental benchmark or standard is that the rate of diagnostically unacceptable images should not cross 10% of the total images of the study,[13] whereas it is observed in this study that this rate is approximately 15%. The guidelines also suggest that the rate of the total number of excellent images should not be <70%. Hence from the results of this study, it is observed that this standard is highly challenging and needs continuous improvement in the training of the technicians to ensure the proper positioning and instruction of the patient.[14]
Good-quality radiography helps in making a correct diagnosis. It further maximizes the benefits to the patient by balancing against the radiation risk and the financial outlay.[13],[15] From the results of this study, it is observed that it might be appropriate to realign the quality standards in the guidelines by focusing more on the reduction of diagnostically unacceptable images rather than an increase of excellent images.[10],[13],[16] This rethinking of the quality assessment criteria may likely improve quality by reducing radiographic image rejection rates and leading to an increase in “excellent” radiographs.
In this study, while evaluating the radiograph, the clinical situation of the patient is not considered. It is possible that the panoramic radiography is not suitable for some patients with clinical conditions due to swelling, facial asymmetry, or physical structure. In these scenarios, the proper positioning is not always possible, and the radiograph error is inevitable. This factor has a significant effect on the overall assessment of the study as it can increase the percentage of diagnostically unacceptable images.[17],[18]
Conclusion An inadequate and diagnostically unacceptable orthopantomogram will conceal the nature, size, and location of the pathology and cause unnecessary burden and stress to the patients and the dentists by causing unwanted exposures to the patient and often delaying the treatment.
The technicians must understand the causes of positioning errors and ensure proper patient preparation and positioning to prevent most positioning errors. From the findings, it is inferred that proper communication with the patient, the technician spending more time positioning the patient, and the technician's skill are the keys in controlling and reducing diagnostic errors in panoramic radiography.
The value of any diagnostic assessment is based on understanding the diagnosis's indications and noting the limitations of imaging. The focus should be on improvement in the quality of panoramic radiographs and reduction in diagnostically unacceptable images.
Institutional review board statement
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of College of Dentistry, Dar Al Uloom University, Riyadh, KSA (COD/IRB/2020/5).
Informed consent statement
Informed consent was obtained from all subjects involved in the study.
Data availability statement
The data presented in this study are available upon request.
Acknowledgments
The authors extend their appreciation to the Deanship of Postgraduate and Scientific Research at Dar Al Uloom University, Riyadh, KSA, for supporting this work.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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