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An evaluation of periapical radiography with a charge-coupled device

Article  in  Dentomaxillofacial Radiology · March 1998

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 Dentomaxillofacial Radiology (1998) 27, 97 ± 101
 1998 Stockton Press All rights reserved 0250 ± 832X/98 $15.00

An evaluation of periapical radiography with a charge-coupled

device
CH Versteeg1, GCH Sanderink1, FC van Ginkel2 and PF van der Stelt1
1
Department of Oral Radiology, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam; 2Netherlands Institute for Dental
Sciences (IOT), Amsterdam, The Netherlands

Objectives: To compare the standards of periapical radiography with a CCD-image receptor

with ®lm.
Methods: Three radiography technicians exposed a total of ®fty teeth from all areas of the
jaws using either size 1 or size 2 ®lm and the Sidexis1 (Siemens, Bensheim, Germany) direct
digital dental radiography system with the appropriate ®lm holders. Image quality was assessed
by two dental radiologists for nine individual criteria and overall, on a three-point scale.
Results: There was a signi®cant di€erence between ®lm and sensor exposures (P50.014). Six
per cent of dental ®lms required retakes compared with 28% with the sensor.
Conclusion: Periapical radiography with a CCD sensor leads to more errors and thus more
retakes than conventional ®lm.

Keywords: radiography, dental; image processing, computer-assisted; quality control

Introduction

Following the introduction of digital intra-oral CCD
sensors, investigation of factors such as image quality,
diagnostic quality and digital image management (e.g.
image manipulation and automated image analysis)
have dominated the literature.1 The clinical handling of
such systems (system management) has to some extent
been taken care of by manufacturers who have
provided specially modi®ed ®lm holders and instruc-
tion manuals. However, little has been published so far
on the geometric standard of images obtained with
intra-oral CCD sensors.2,3 These sensors di€er from
dental ®lm in a number of respects which could cause
some problems in obtaining adequate images. The
sensor is thicker, sti€er and commonly has a smaller
sensitive area than ®lm.1 ± 3 In addition, the sensor is
attached by a cable to the computer. Patient
discomfort from the sensor may also result in a larger
number of retakes. The advantage of real-time imaging
may well turn out to be a disadvantage, as it could
encourage dentists to make more exposures. Sensor
size, patient comfort and operating time are thus
related to the potential number of retakes and
consequently patient dose.
Correspondence: CH Versteeg, ACTA, Department of Oral Radiology,
Louwesweg 1, 1066 EA Amsterdam, The Netherlands
Received 9 September 1997; accepted 26 November 1997
Digital intra-oral sensors have been constructed in
di€erent sizes. Figure 1 compares the Sidexis1 sensor
(Siemens, Bensheim, Germany), with size 1 and 2
®lm. The sensitive area of the sensor is
18.5629.7 mm, less than the 24640 mm of size 1
®lm and 31641 mm of size 2. There may be
advantages in the smaller sensor for posterior teeth
in particular. The sensitive area covers at least one
tooth completely, large enough when only one tooth
has to be imaged. It may also be more comfortable
for the patient than a larger sensor or size 2 ®lm. The
aim of the present study was to compare geometric
image quality of periapical radiographs obtained with
a CCD-sensor and dental ®lm.
Materials and methods
Film holders (X-Act1, Oral Diagnostic Systems,
Amsterdam, The Netherlands) were adapted to create
similar aiming devices for ®lm and sensor. Two holders
were made for the Sidexis1 sensor, one for the
posterior and one for the anterior teeth (Figure 2).
The posterior holder was suitable for all four
quadrants. Two types of ®lm holder were used for
®lm: one for anterior teeth with size 1 ®lm, and a pair
for size 2 ®lm in the posterior region.
 Periapical CCD-radiography
CH Versteeg et al
98
Table 1 Distribution of images of single teeth from 50 patients, by
region, jaw, sequence (film ± sensor or sensor-film), radiography
technician, and period (first 17 patients, second 17 patients and
final 16 patients)
Total Period 1 Period 2 Period 3
Anterior region 18 5 7 6
Premolar region 14 5 4 5
Molar region 18 7 6 5
Upper jaw 27 9 9 9
Lower jaw 23 8 8 7
Film ± Sensor 23 10 7 6
Sensor ± Film 27 7 10 10
Technician A 20 4 9 7
Technician B 15 9 2 4
Technician C 15 4 6 5
Figure 1 Two ®lms (size 2 and 1) and the Sidexis1 sensor. The
sensitive area of the sensor is smaller than both size 2 and 1 ®lm Total 50 17 17 16

Table 2 Nine criteria (1 to 9) used for evaluation of the film and

sensor images
Receptor placement:
Correct horizontal placement (1)
Crown of tooth completely visible (2)
4 mm area of bone around apex (3)
Parallel with occlusal surface (4)
X-ray tube positioning:
Correct horizontal angulation (5)
Tooth upright (6)
Correct vertical angulation (7)
No cone cutting (8)
Remaining factors: no film bending, superimposition of anatomical
structures or unsharpness, correct processing and no other errors of
image quality (9)

Figure 2 X-Act1 ®lm holders for ®lm and sensor. The two
positioners on the left are for the anterior region, the two on the
right for the posterior region. The second and fourth holders were
modi®ed for use with the sensor by replacing the actual ®lm holder
with the original Sidexis1 component
Periapical radiographs were obtained of 50 patients
selected at random from those attending the Depart-
ment of Radiology, ACTA (Academic Centre for
Dentistry Amsterdam). One tooth was exposed in
each patient using both imaging techniques, the order,
®lm-sensor or sensor-®lm was chosen at random.
The study was approved by the Medical Ethics
Committee and the patients gave informed consent.
The sensor dose was 50% of the dental ®lm dose and the
®lm used was Ektaspeed Plus (Eastman, Rochester, NY,
USA). Three experienced radiography technicians took
the radiographs. Prior to the study, they practiced taking
sensor images on a phantom head. The 50 exposures are
listed in Table 1. Each technician radiographed at least
one of each type of tooth in each jaw.
The images were evaluated by two dental radiolo-
gists (CHV, GCHS) using the nine criteria shown in
Table 2. Each radiograph was also given an overall
rating as excellent (no errors present), acceptable
(errors present which did not detract from the
diagnostic quality) or unacceptable (errors present
which made the radiograph diagnosti®cally unaccep-
table).
MANOVA statistics were based on the mean of the
nine criteria for each exposure. Errors were scored 1
and absence of errors 2. The exposures were divided
into three time periods: exposures 1 to 17, period 1,
exposures 18 to 34 period 2 and exposures 35 to 50
period 3. The variables for MANOVA were: imaging
technique (®lm or sensor), image sequence (®lm-sensor
or sensor-®lm), period, technician and radiologist.
Results
The percentage of errors of receptor placement are
given in Table 3. The sensor showed a substantial
proportion of criterion 1 (incorrect horizontal place-
ment) and criterion 2 (crown partially missing) errors.
Failure to meet criterion 3 (4 mm area around the apex)
was found with both receptors, in all cases in the four
posterior regions. Both receptors were not always
placed completely parallel to the occlusal surface
(criterion 4), but this fault did not detract from the
diagnostic utility of the image. Figure 3 shows examples
of the main problems with sensor placement. Horizontal
placement was dicult, especially in the molar region

(Figure 3a). The edges of incisors were missing most of
the time (Figure 3b). In Figure 3c, less than 4 mm of
periapical bone has been imaged.
The percentage of errors in positioning the X-ray
tube and the other remaining factors are given in Table
4. Correct horizontal angulation (criterion 5) was
relatively dicult in the upper jaw with both ®lm
and sensor. With the sensor, most faults were in the
molar region. Tooth upright (criterion 6) was almost
Periapical CCD-radiography
CH Versteeg et al
99
never a problem: those mistakes that were made,
occurred in the upper jaw. Vertical angulation
(criterion 7) was as often incorrect for ®lm as for the
sensor. Cone cutting (criterion 8) occurred more often
with ®lm than with the sensor. The most frequent of
the remaining errors (criterion 9) was superpositioning
of anatomical structures, such as roots of molar teeth
and the zygomatic arch and was found most often with
®lm, in the maxillary molar region. Figure 4 shows an

Table 3 Errors of receptor placement. Values are percentage of the total 50 teeth imaged
Criterion Receptor Jaw Region Total
Upper Lower Anterior Premolar Molar
1. Film 2 1 3 0 0 3
Sensor 9 13 1 4 17 22
2. Film 1 4 2 0 3 5
Sensor 18 19 28 3 6 37
3. Film 2 3 0 4 1 5
Sensor 8 4 0 6 6 12
4. Film 7 4 7 3 1 11
Sensor 11 3 3 5 6 14
For de®nitions of criteria 1 ± 4, see Table 2

Table 4 Errors of X-ray tube positioning and the remaining image quality factors. Values are expressed as a percentage of the total 50 teeth
imaged
Criterion Image Receptor Jaw Region Total
Upper Lower Anterior Premolar Molar
5. Film 16 2 7 6 5 18
Sensor 23 1 7 4 13 24
6. Film 5 0 0 3 2 5
Sensor 2 0 1 0 1 2
7. Film 5 4 3 0 6 9
Sensor 4 6 5 0 5 10
8. Film 10 9 8 3 8 19
Sensor 4 0 0 0 4 4
9. Film 15 2 0 7 10 17
Sensor 7 0 2 2 3 7
For de®nition of criteria 5 ± 9, see Table 2

a b c

Figure 3 Examples of errors of sensor placement. (a) missed distal apex of tooth 36 due to incorrect horizontal placement. (b) missing incisal
edge of tooth 21. (c) less than 4 mm of surrounding periapical bone on tooth 16
 Periapical CCD-radiography
CH Versteeg et al
100
example of the most frequent problem with the sensor,
horizontal angulation.
Table 5 shows percentages of excellent, acceptable
and unacceptable images. The average percentage of
retakes recommended was 6% for ®lm, all in the upper
jaw, in comparison with 28% for the sensor, where
most of the unacceptable exposures were in the
posterior region.
Analysis of variance revealed no signi®cant differ-
ences between periods (P40.395), sequence (P40.936),
or technicians (P40.354). The di€erence between ®lm
and sensor images was signi®cant: ®lm images were
much better (P50.014). There was also some di€erence
between the two radiologists (P50.049). A ®rst order
interaction e€ect was found (P50.001) between
imaging technique (s for sensor, f for ®lm) and
radiologist (1 or 2), indicated by the following means:
xs1=1.84, xs2=1.87, xf2=1.88, xf1=1.92. Although the
mean value of radiologist 1 was lower for sensor
images than of radiologist 2 but the reverse for ®lm,
both rated image quality better with ®lm than with the
sensor.
Discussion

This study revealed certain speci®c problems in

Figure 4 Example of an error on X-ray tube positioning. Incorrect
horizontal angulation of tooth 26
obtaining adequate images with a CCD-based sensor.
Horizontal positioning in the molar region in particular
was dicult. Although the patient felt comfortable, the
technicians found it hard to assess its position. In the
anterior region, the incisal edges were missed most of
the time, due to the design of the holder. Although this
may be of minor importance, it should be easy for the
manufacturers to improve the design. The sensor could
move vertically in the posterior holder. The operator
should be aware of this problem, or the manufacturer
should modify the holder so that they are suitable for
two quadrants instead of four. The small horizontal
dimensions of the sensor make it easy to rotate.
Consequently, the operator should pay special atten-
tion to the correct horizontal angulation.
In this study, a rectangular collimator was used.
Cone cutting occurred more often with ®lm than with
the sensor, possibly due to the bigger size 2 ®lm. Very
small areas of both ®lm and sensor were sometimes
missed, but this did not detract from the diagnostic
quality of the ®lm. Bending of the ®lm, unsharpness
and inferior image quality were not recorded as speci®c
faults by the radiologists.
In the present study, a high percentage (28%) of the
sensor images were unacceptable. Similar results were
found in an initial study of the Radiovisiography1
system, where the repeat rate was 25%.2 Retaking a
sensor exposure is easier than with a conventional
radiograph. The sensor can be kept in position after
the exposure and its position is easily adjusted.
Assuming that all 28% of the original images that
are retaken are acceptable, then this still means a dose
reduction compared with ®lm.
The fact there was no di€erence in image quality
over the three time periods of this study suggests there

Table 5 Overall evaluation of film and sensor images. Values are expressed as a percentage of the total 50 teeth imaged
Standard Image Receptor Jaw Region Total
Upper Lower Anterior Premolar Molar
Excellent Film 16 27 15 12 16 43
Sensor 12 13 6 13 6 25
Acceptable Film 32 19 19 13 19 51
Sensor 26 21 29 5 13 47
Unacceptable Film 6 0 2 3 1 6
Sensor 16 12 1 10 17 28
For de®nition of standard, see Materials and methods

was no improvement in the skill of the technicians in
handling the sensor. This may be due to the fact that
this work was carried out over a relatively short time
period and that with greater experience the proportion
of excellent sensor exposures would increase.
Three sizes of image receptor were used in this study.
Although the comparison of di€erent sizes has most
likely in¯uenced the results, the ®lm sizes were chosen
because they are the most commonly used in daily
practice.
Although patient comfort was not speci®cally
studied, the technicians noted that they felt comfor-
table with the sensor in position. Similarly, the
operating time, that is the time to position and expose
the sensor, was not recovered, but the technicians
considered it was similar to ®lm.
If the purpose of a radiograph is to examine a single
tooth, then the CCD-based intra-oral sensor may be a
convenient and rapid solution. If the X-ray ®eld is
References
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digital intra-oral radiography in clinical dentistry. J Dent 1997;
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4. Rushton VE, Horner K. The impact of quality control on
radiography in general dental practice. Br Dent J 1995; 179:
254 ± 261.
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Periapical CCD-radiography
CH Versteeg et al
101
collimated further, then the dose will also be lower.
Using a small sensor in the posterior region may
always be a problem. This suggests a need for larger
sensors for posterior regions. Such sensors have been
introduced but it needs to be established if they are
comfortable for patients and produce adequate images.
In dental radiography, ®lm-holding, beam-alignment
devices should be used to improve image quality.2,4 ± 7
Whatever system is used, retaking any radiograph will
double the radiation dose to the patient. The obvious
answer to this problem is educational with a suitable
quality assurance programme.4 ± 6,8 Mastering a CCD-
sensor requires time and e€ort.
In conclusion, periapical radiography with a CCD-
sensor leads to more errors, and thus more retakes
than with conventional ®lm. Although repeating a
sensor image means that the dose may still be lower
than that for a single ®lm, this should not be taken as a
licence for a less than excellent technique.
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the standards of radiography in general dental practice. Br Dent
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6. Langlais RP, Langland OE. Risks from dental radiation in 1995.
CDA Journal 1995; 23: 33 ± 39.
7. Pitts. Film-holding, beam-aiming and collimating devices as an
aid to standardization in intra-oral radiography: a review. J
Dent 1984; 12: 36 ± 46.
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479 ± 483.