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Original Article

Comparison between Conventional and Digital Radiography in

Assessing Alveolar Bone Loss: An Original Research
Hemant Mathur, Junaid Ahmed1, Payal Tripathi2, Mohit P. Singh, S. Bhuvaneshwari, Aditi Mathur3, Narender Singh Bansal4
Departments of Oral Medicine and Radiology and 3Periodontology, Pacific Dental College and Hospital, 4Department of Dentistry , RNT Medical College, Udaipur,
Rajasthan, 1Department of Oral Medicine and Radiology, CODS, Mangalore, Karnataka, 2Department of Oral Medicine and Radiology, Career Dental College and
Hospital, Lucknow, Uttar Pradesh, India

Abstract
Aim: The aim of this study was to compare the efficiency of conventional and digital radiography in assessing alveolar bone loss.
Materials and Methods: The study group comprised 50 participants (25 males and 25 females) between 25 and 45 years of age. The participants
were screened for all clinical features of periodontitis. A series of conventional bitewing radiographs of right and left of both maxillary and
mandibular posterior region (15,16,17,25,26,27,35,36,37,45,46,47) were taken for each of 50 patients by examiner 1. Similarly, a series of digital
bitewing radiographs were taken by examiner 2 for each 50 patients by using RVG of Planmeca Dixi 2 B Series. In digital bitewing radiographs,
the measurement was done by examiner 2, using Planmeca Dixi 2 B Digital Software, by dragging the cursor to make a line by joining the linear
points. Bone level less than 2 mm from the cementoenamel junction (CEJ) was considered normal while above that was considered bone loss.
In case of conventional bitewing radiographs, alveolar bone loss was measured by the same examiner by measuring the distance from the CEJ
to the most apical level of crestal bone using a divider and transparent ruler. The above collected data of examiners 1 and 2 were handed over
to examiner 3 for statistical evaluation. Results: Comparison of conventional and digital radiographic techniques in left maxilla, left and right
mandible, and between maxilla and mandible in the total sample and in females aged 25–35 and 36–45 years yielded a significant correlation
while comparison of the two techniques in the right maxilla and between maxilla and mandible in males yielded a nonsignificant correlation.
Conclusion: Direct digital radiography provides an edge over conventional radiography in assessing the periodontal bone destruction.

Keywords: Alveolar bone level, conventional intraoral bitewing radiographs, direct digital radiography, periodontal disease

Introduction distortions with bitewing radiographs are relatively minimal,

Periodontal disease is one of the most extensively occurring
diseases in the general population.[1] Radiographs play an
integral role in the assessment of periodontal diseases, caries,
periapical pathologies, and dentoalveolar fractures. The
radiographic features of periodontal disease are changes in
morphologic features of supporting alveolar bone due to
interproximal crestal bone loss and change in internal density
and trabecular pattern which reflect reduction or an increase
in bone structure. The most used radiographic methods in the
diagnosis of periodontal diseases are panoramic radiography,
bitewings, and periapical radiography.[2]
Conventional radiographs are easy to setup and are cost
effective. Bitewing technique is characterized by its simplicity
and reduction of radiation exposure since fewer films are
needed than when the periapical technique is used.[3] The
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DOI:
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but their diagnostic accuracy is notoriously imprecise.[4]
A recent advance in computer technology has led to the
development of digital imaging, which has made a significant
impact on dental radiographs.[1] Digital radiographic methods
facilitate clinical practice as they eliminate chemical
processing, reduce radiation exposure, and the images can
be manipulated with the use of software.[5] This possibility of
enhancing digital images optimizes diagnosis, unlike the static
Address for correspondence: Dr. Narender Singh Bansal,
Department of Dentistry, RNT Medical College, Udaipur, Rajasthan, India.
E-mail: drnarenbansal@gmail.com
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which
allows others to remix, tweak, and build upon the work non-commercially, as long
as appropriate credit is given and the new creations are licensed under the identical
terms.
For reprints contact: reprints@medknow.com
How to cite this article: Mathur H, Ahmed J, Tripathi P, Singh MP,
Bhuvaneshwari S, Mathur A, et al. Comparison between conventional and
digital radiography in assessing alveolar bone loss: An original research.
J Indian Acad Oral Med Radiol 2018;30:142-7.
Received: 14-11-2017   Accepted: 07-03-2018   Published: 16‑07‑2018

142 © 2018 Journal of Indian Academy of Oral Medicine & Radiology | Published by Wolters Kluwer - Medknow
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Mathur, et al.: Conventional and digital bitewing comparison

images of conventional films, which cannot be manipulated

or enhanced.[2]
The present study was conducted to evaluate and compare
the diagnostic efficacy of digital radiographs against that of
conventional radiographs for assessing interproximal bone
loss under normal clinical conditions.
Aims and objectives
The aim of the study was to evaluate and compare the
diagnostic efficacy of digital radiographs against that of
conventional radiographs for assessment of interproximal
bone loss.
The objectives of the study were first to evaluate and compare
the amount of bone loss between conventional and digital
radiography; the second objective was to measure the average Figure 1: Conventional bitewing
bone loss in different age groups, in maxillary and mandibular
region, and in relation to gender.

Materials and Methods

The study was conducted in Pacific Dental College and
Hospital, Udaipur. Total number of patients were 50
(25 males and 25 females), aged between 25 and 45 years,
selected from the outpatient section of the department.
The participants were screened for all clinical features of
periodontitis which included probing pocket depth  >5  mm,
periodontal attachment loss, gingival recession, presence of
suppuration, and tooth mobility. Bone loss was recorded on
three surfaces per quadrant which included the mesial and
distal surface of the first molar and mesial surface of the
second molar.
Ethical clearance was obtained from the ethical committee of Figure 2: Gnatus intraoral X-ray machine
the institution to conduct the study.
Patients with right and left first and second molars in both
maxillary and mandibular arches aged between 25 and 45 years
were included in the study. The exclusion criteria of the study
were patients contraindicated for radiography, noncooperative
and syndromic patients, patients having fixed and removable
prosthesis in posterior region, and patients having malocclusion
with supraerupted or drifted teeth.
After obtaining the duly signed consent, a series of
conventional bitewing radiographs  [Figure  1] of right
and left of both maxillary and mandibular posterior
region (15,16,17,25,26,27,35,36,37,45,46,47) were taken for
each of the 50  patients by examiner 1 using Gnatus dental
X‑ray unit operated at 70 kvp and 8 mA with radiation
exposure of 0.8  seconds  [Figure  2]. The film used was
Kodak E–speed, No.  2 of size 31  ×  41  mm  (Ekta speed, Figure 3: Measurement being recorded on scale
Eastman Kodak Rochester, USA) and processing of film was
done manually  (time and temperature and visual method). of digital bitewing radiographs  [Figure  4] were taken by
Radiographs were mounted on an X‑ray viewer and alveolar examiner 2 for all 50 patients by using RVG of Planmeca Dixi
bone loss was measured by the same examiner from CEJ to 2 B Series [Figure 5] and Gnatus dental X‑ray unit operated
the most apical level of crestal bone. This was done by using at 70 kvp and 8 mA with a radiation exposure of 0.3 seconds.
a divider and transparent ruler [Figure 3]. Similarly, a series To ensure maximum hygiene, the sensor was covered with a

Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 30  ¦  Issue 2  ¦  April‑June 2018 143
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Mathur, et al.: Conventional and digital bitewing comparison
Figure 4: Digital bitewing
plastic sleeve, and for each new patient a new plastic cover
was used. The system used in our study contained a charge
coupled device (CCD) sensor. The measurement in RVG was
done by examiner 2 using Planmeca Dixi 2 B Digital Software
by dragging the cursor to make a line by joining the linear
points. Bone level less than 2 mm from the CEJ was considered
normal while above that was considered as bone loss.
The above collected data of examiners 1 and 2 were handed
over to examiner 3 for statistical evaluation.
Results
The data derived for each of the group was analyzed by paired
t‑test, Post Hoc test, and Pearson correlation test.
For all tests, a P value of <0.05 (5%) was considered significant.
P‑value of <0.01 (1%) was considered highly significant.
This study was conducted to compare the depth of
alveolar bone loss by conventional radiography and digital
radiography using bitewing technique. The present study
was conducted among 50 patients with chronic periodontitis.
Bitewing radiographs were taken for all the four quadrants
and alveolar bone loss was measured at three sites per
quadrant. Paired t‑test was used to compare the alveolar bone
loss measured by conventional and digital radiographs. For
alveolar bone loss measured for right maxilla, the mean score
for conventional radiographs was 3.52  mm with standard
deviation of ±0.62 while it was 3.83 mm ± 0.63 for digital
radiographic technique. When both the techniques were
compared no significant difference  (P  value 0.061) was
observed [Table 1].
In the left maxilla, conventional radiographs showed a
mean bone loss of 3.39  mm while it was 3.70  mm for the
digital radiographic technique. Comparison of conventional
and digital radiographs showed statistically significant
difference (P value 0.037) [Table 1].
The mean bone loss in right mandible was 3.52 mm ± 0.53 in right
mandible for conventional radiograph and 3.837 mm ± 0.57
144 Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 30  ¦  Issue 2  ¦  April‑June 2018
Figure 5: RVG equipment
Table 1: Comparison of conventional and digital
radiographic technique in the left and right maxilla
Conventional Radiographs Digital Radiographs
Left side Right side Left side Right side
Mean 3.397 3.52 3.703 3.83
Standard 0.5629 0.6272 0.5474 0.6309
Deviation
P‑value of right side is 0.61 which is statistically nonsignificant while of
left side is 0.037, which is statistically significant
for digital radiographs. Statistically significant difference
(P value 0.029) was observed when both the techniques were
compared [Table 2].
Significant difference  (P  value 0.047) was observed on
comparison of conventional and digital radiographs in the left
mandibular quadrant with mean bone of 3.5 mm and 3.77 mm
for conventional and digital radiographs, respectively [Table 2].
Overall comparison of bone loss was done for maxilla
independent of age and sex. Mean alveolar bone loss observed
in maxilla was 3.45  mm for conventional radiographs
and 3.76  mm for digital radiographs with a P value of
0.005 [Table 3].
Mean bone loss of 3.508 mm and 3.803 mm was observed
in mandibular sites for conventional and digital radiographs,
respectively. Statistically significant difference (P value 0.003)
was seen when both the techniques were compared [Table 3].
Paired t‑test was applied to determine which technique was
better for determination of alveolar bone loss. Mean bone loss of
6.9 mm was observed for conventional radiographic technique
whereas a mean bone loss of 7.6 mm was observed by digital
radiographic technique. Significant difference (P value 0.002)
was seen when both the techniques were compared [Table 4].
Mean bone loss of 3.51  mm and 3.80  mm was observed
in maxillary sites in males by conventional and digital
radiographic techniques. Application of paired t‑test showed
a statistically nonsignificant difference  (P  value  =  0.076)
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Mathur, et al.: Conventional and digital bitewing comparison
between both the techniques [Table 5]. Similar results were
seen in mandibular sites with mean bone loss of 3.56 mm and
3.82 mm (P value = 0.082) [Table 5].
A similar comparison was done to compare both the techniques in
females. A statistically significant difference (P value = 0.029)
with mean bone loss of 3.4 mm and 3.72 mm was observed in
female maxillary sites [Table 5]. The mandibular sites showed
an average bone loss of 3.45 mm and 3.78 mm by conventional
and digital radiographic techniques [Table 5]. This result was
statistically significant with a P value of 0.012.
Fifty patients were further divided into two groups on the basis
of age into 25–35 years and 36–45 years. In the age group
of 25–35  years, mean bone loss of 3.41  mm and 3.72  mm
was observed by conventional and digital radiographic
technique. This was statistically significant with P value of
0.019 [Table 6]. In the age group of 35–45 years, the mean bone
loss of 3.54 mm and 3.84 mm was observed by conventional
and digital radiographic technique, respectively. This was
statistically significant (P value = 0.047) [Table 6].
Discussion
Radiographs play an integral role in the assessment of
periodontal disease. They provide unique information about
the status of the periodontium and a permanent record of
the condition of the bone throughout the disease course.
Radiographs aid the clinician in identifying the extent of the
destruction of alveolar bone, local contributing factors, and
feature of the periodontium that influence the prognosis.
The diagnosis of the periodontal diseases is primarily based
on clinical examination. The clinical findings of periodontal
osseous destruction can be confirmed by radiographic
examination, but radiographs on their own cannot help in
diagnosis. They are adjunct to the clinical examination not the
substitute. They also help in the assessment of recurrence of
disease progression by comparative evaluation.
Table 2: Comparison of conventional and digital
radiographic technique in left and right mandible
Conventional Radiographs Digital Radiographs
Left side Right side Left side Right side
Mean 3.5 3.517 3.77 3.837
Standard 0.5085 0.5318 0.524 0.5744
Deviation
P‑value of right side is 0.029 while of left side is 0.047, both are statistically
significant
Table 3: Comparison of conventional and digital radiographic technique in maxilla and mandible
Maxilla
Conventional Radiographs Digital Radiographs
Mean 3.458 3.767
Standard Deviation 0.5941 0.5891
P‑value of maxilla is 0.005 while of mandible is 0.003, both are statistically significant
Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 30  ¦  Issue 2  ¦  April‑June 2018
In the present study, participants with crowded teeth were
excluded as these teeth show a significantly higher bone loss as
compared to noncrowded teeth (Jensen et al. 1989)[6] because
in periodontal patients local crowding and tooth angulation
predisposes to increased bone loss.
In contrast to the study by Albander et al. (1985),[7] the present
study observed that the mandibular sites showed a higher
amount of bone loss compared to maxillary sites. The mean
bone loss in maxilla was 3.4 mm and 3.7 mm by conventional
and digital radiographic technique, whereas 3.7  mm and
3.8 mm bone loss was observed in mandibular sites when both
the radiographic techniques were compared.
The present study evaluated the mean bone loss by conventional
and digital radiographs in various age groups. Age group of
25–35 years showed mean bone loss of 3.41 mm and 3.72 mm
by conventional and digital radiographic method whereas
age group of 36–45 years showed a mean loss of 3.54 mm
and 3.84  mm by both the techniques. These results are in
accordance with a study by Aass et al. in 1994[8] that showed
that the frequency of participants with radiographic alveolar
bone loss increased significantly with age.
In our study, the results showed that overall the digital
bitewing images averaged 0.6 mm greater bone loss than the
conventional images with a significant P value. Whereas in a
study conducted by Kotch et al. (2003),[9] digital radiography
measured 0.3 mm greater bone loss than conventional bitewing
with a significant P value, which is relatively consistent with
our results. Given the overall difference between conventional
and digital radiographs, we wanted to know if this difference
was consistent across all sextant of the mouth. Therefore, we
computed paired t‑test for each of the sextant available, and
our results showed measurement differences in RVG and
conventional radiographs in all 4 sextant of the jaw.
RVG showed more bone loss in both maxilla and mandible than
conventional radiographs, however, in maxilla both methods
showed almost similar measurement with a mean difference
of 0.3  mm only, which is in accordance with the study by
Kotch et al.  (2003).[9] Digital radiographs only in posterior
mandibular region indicated bone loss, and measurements of
bone loss in posterior maxillary region were similar between
the two radiographic methods.
Li  (2007)[10] stated that, as such there was no significant
difference in conventional and digital radiographs, digital
radiographs had measurement accuracy than conventional
radiographs while measuring alveolar bone loss.
Mandible
Conventional Radiographs Digital Radiographs
3.508 3.803
0.5159 0.5462
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Mathur, et al.: Conventional and digital bitewing comparison

The results of our study showed that in the normal clinical
use significant difference exists between alveolar bone loss
measurements on digital and conventional radiographs
in several regions in the mouth. This difference between
the two imaging systems may be attributed to variation
in measurement, which were done manually in case of
conventional radiographs and digitally in case of digital
radiographs because RVG was showing 0.6 mm greater bone
loss than conventional radiographs while comparing the
total samples. These variations may be due to flexibility of
the conventional radiograph film and sensor used in digital
radiograph.
Over the past few years, system that can generate radiographic
digital images without the need for radiographic film
have become available for use in clinical practice and are
gaining popularity. Electronic probing system, subtraction
radiography, CADIA  (computer‑assisted densitometric
image analyses system), dark field microscopy, DNA probes,
immunodiagnostic methods have been developed in recent
times, which help in the precise diagnosis of periodontal
diseases.
Khocht (2003)[9] pointed that digital radiography offers many
advantages over conventional methods. It eliminates the
need for film and film developing and allows lower radiation
exposure. The generated image is available immediately for
evaluation on a computer screen and can be manipulated
Table 4: Overall comparison of conventional and digital
radiographic technique
  Mean Standard Deviation P Significance
Conventional 6.96 1.059 0.002
radiographs
Digital 7.57 1.079
radiographs
digitally to enhance viewing. In addition, digital tools are
available to record electronic measurement and to cut, paste,
and colorize the image. The image can be easily filed and
retrieved from the hard disk or removable storage medium,
or the images can be transferred electronically to third party
carriers.
Apart from this they also have other advantages such as
immediate observation of radiographic images. Only few
digital radiography devices, e.g.,  charged coupled devices,
provide immediate viewing. However, phosphorus plate
technology requires placement of irradiated sensor in a
processing device to scan and put the information into a
computer so that the image can be viewed. In conventional
radiographic techniques, the delay in reading the image usually
forces the clinician to change his gloves and do something else
till the radiograph develops.[3]
Along with advantages, there are disadvantages as well. They
include cost of the devices as well as converting previous
records to digital, which are very high, thickness and rigidity
of sensor that makes the patient uncomfortable, and loss or
breakage of sensor, which can prove very costly.
The clinical implication of radiography in the diagnosis of
periodontal diseases are two‑fold; to visualize the initial status
of the bone tissue and to illustrate changes in bone tissue
overtime when there are so many radiographic techniques – the
clinician is in a dilemma as to which technique should be
used. Therefore, this study is an attempt to help the clinician
select the radiographic method in the detection and imaging
of periodontal osseous destruction.
Within the limitation of our study, we recommend that the
S direct digital radiography provides an edge over conventional
radiography to assess the periodontal bone destruction,
however, the cost of RVG results in its limited use by clinicians
in their clinic.

Table 5: Comparison of conventional and digital radiographic technique in maxilla and mandible among males and
females
Maxilla Mandible
Conventional Radiographs Digital Radiographs Conventional Radiographs Digital Radiographs
Male Female Male Female Male Female Male Female
Mean 3.51 3.40 3.80 3.72 3.56 3.45 3.82 3.78
Standard Deviation 0.639 0.55 0.617 0.56 0.567 0.46 0.585 0.51
P‑value of maxilla among males is 0.076 while among females is 0.029, which is statistically significant only in females
P‑value of mandible among males is 0.082 while among females is 0.012, which is statistically significant only in females

Table 6: Comparison of conventional and digital radiographic technique in 25-35 years and in 36-45 years
25-35 years 36-45 years
Conventional Radiographs Digital Radiographs Conventional Radiographs Digital Radiographs
Mean 3.41 3.72 3.54 3.84
Standard Deviation 0.943 0.977 1.15 1.16
P‑value of individuals of age between 25 and 35 years is 0.019 while for individuals between the age group of 36 and 45 years is 0.047, both are statistically
significant

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Mathur, et al.: Conventional and digital bitewing comparison
Summary and Conclusion
The present study compared the efficacy of digital radiographs
in measuring the alveolar bone loss. A  total of 50  patients
were evaluated  (25  males and 25  females) who were aged
between 25 and 45  years of age. Alveolar bone loss was
measured from the CEJ to the most apical level of marginal
bone on the readable surfaces. Seven hundred and twenty
image sites were examined using conventional and digital
bitewing radiographs showing more bone loss using digital
radiographs in all the 4 sextant of the jaws than conventional
radiograph. The data obtained were recorded in tabloid form
and statistically analyzed using paired t‑test, Post Hoc test, and
Pearson correlation test. After analyzing the data following
conclusions were drawn:
Under normal clinical use, significant difference
existed between alveolar bone measurements on
digital and conventional radiographs in several regions of
the mouth.
Thus, it could be said that the digital radiograph had an upper
hand compared to conventional radiographs in terms of
measurement of alveolar bone loss. Although RVG is superior
in measuring the alveolar bone loss compared to conventional
radiographs, its cost must be taken into account, which is quite
high than the conventional radiograph.
Financial support and sponsorship
Nil.
Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 30  ¦  Issue 2  ¦  April‑June 2018
Conflicts of interest
There are no conflicts of interest.
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