Diagnostic quality versus patient exposure

with five panoramic screen-film

combinations
Joseph A. Dilmbrosio,* Thomas G. Schi$.** William D. McDavid,*** and
Olaf E. Langland, Bufalo, N.Y.. St. Louis. MO., and San Antonio, Texas

SCHOOL OF DENTISTRY, STATE UNIVERSITY OF NEW YORK AT BUFFALO, WASHINGTON UNIVERSITY

SCHOOL OF DENTAL MEDICINE, AND THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER

Five film-screen combinations were used to make five density-matched panoramic radiographs of a
tissue-equivalent phantom skull using the Midwest /Morita Panoral x-ray machine. The radiographs were
evaluated as to their diagnostic quality by twenty dental radiologists. The results demonstrate that proper
screen-film selection can significantly reduce patient exposure without compromising diagnostic quality.
(ORAL SURG. ORAL MED. ORAL PATHOL. 61:409-411, 1986)

I n dental radiology it is desirable to produce images
of high diagnostic quality with a minimal amount of
ionizing radiation. There are several screen-film
combinations currently available for use in panoram-
ic radiography, each capable of meeting these crite-
ria. These combinations include both conventional
systems and the newer rare earth phosphors. It has
been demonstrated that rare earth intensifying
screens in combination with suitable films can
produce radiographs of good diagnostic quality with
a reduction in patient dose.‘-I6 The purpose of this
study was to examine the most commonly used
screen-film combinations along with several of the
newer screens and films to determine which pro-
duced the best diagnostic quality with the least
amount of radiation exposure to the patient.
MATERIALS AND METHODS
A tissue-equivalent phantom consisting of a
human skull encased in plastic (3M Company, St.
Paul, Minn.) was mounted on a tripod and placed in
the proper position (optimal focal trough) in the
*Department of Oral Medicine, School of Dentistry,
versity of New York at Buffalo.
**Department of Diagnosis and Radiology, Washington
ty School of Dental Medicine.
***Department of Dental Diagnostic Science, The University
Texas Health Science Center.
Midwest/Morita Panoral unit (American Midwest,
Des Plaines, Ill., manufactured by J. Morita Corp.,
Kyoto, Japan). This was accomplished by taping four
metal washers at selected locations (maxillary sinus,
infraorbital rim, crown of right maxillary lateral
incisor, and root tip of right mandibular second
molar) and taking pilot films to locate the position
that minimized radiographic distortion (Fig. 1).
The Panoral machine is equipped with a fixed
rotation time (15 seconds) and separate variable
controls for kilovolts peak and milliamperage. A
Panoral flexible cassette was used to make a stan-
dard film at 85 kVp and 10 mA; Kodak X-omatic
regular screens (BaSO,:SrEu) were used with Kodak
XRP film (Eastman Kodak Co., Rochester, N.Y.).
Density was measured in the center of each of the
four washers listed above by means of a densitometer
(model 301, X-Rite Co., Grand Rapids, Mich). This
radiograph served as a baseline to which subsequent
film-screen combinations were compared.
Several exposures were then made with each of
four additional film screen combinations:
l DuPont Cronex Hi Plus screens (DuPont de
Nemours and Co., Wilmington, Del. (CaWO,)
State Uni- with Kodak XRP film
l Kodak Lanex regular screens (GdO,S:Tb) with
Universi-
Kodak OG film
of l Kodak Lanex regular screens with Kodak T-
Mat G film

409
410 D’Ambrosio et al. Ordi Sllrg.

April, 1986

Fig. 1. Tissue-equivalent phantom with metal washers affixed to mark locations for densitometer
readings.

Table I. Pertinent data for the five screen/film combinations examined

Nominal Nominal Relative Mean rank
Screen Film kW mA exposure by viewers

Kodak X-omatic regular Kodak XRP 85 10.0 1.oo 1.75

Dupont Cronex Hi Plus Kodak XRP 85 5.0 0.58 3.10
Kodak Lanex regular Kodak OG 85 3.0 0.36 3.80
Kodak Lanex regular Kodak T-Mat G 85 2.5 0.3 I I .85
Kyokko special Kodak XRP 85 2.5 0.31 4.50

l KYOKKO special screens (KYOKKO Screens,
Kasei Optonix, Ltd., Tokyo, Japan)
(BaFCl:Eu) with Kodak XRP film
In all exposures the kilovolt peak was kept con-
stant while the milliamperage was adjusted to
produce films with densities matching those of the
standard film in the four locations mentioned. Rela-
tive values of radiation exposure to patients for each
film-screen combination were measured with an
ionization chamber (model 1015, MDH Industries,
Monrovia, Calif.). The probe was mounted in front
of the film cassette and allowed to rotate with the
cassette during the exposure (Table I).
All films were developed in a Kodak RP X-Omat
automatic processor operated according to the man-
ufacturer’s instructions. The reliability of the pro-
cessing technique was monitored during the process-
ing session with a sensitometer (Radiation Measure-
ments Inc., Middleton, Wis.).
Five panoramic films of matching densities (one
from each of the film-screen combinations) were
then arranged on single light-source viewboxes in a
darkened room and masked with black matted paper
to eliminate glare and extraneous light. The twenty
raters for the study were faculty members and
postdoctoral students well qualified and highly expe-
rienced in the evaluation of panoramic radiographs.
Each was asked to rank order the five films, from
most diagnostic to least, with regard to relative
densities of enamel, dentin, and bone and overall
diagnostic quality. Statistical analysesI were per-
formed to determine if there were significant differ-
ences among the five film-screen combinations.
RESULTS
The five screen-film combinations subjected to
clinical evaluation are summarized in Table I. The
combinations are listed in order of decreasing expo-
sure to the patient. When the rankings of the five
systems were analyzed statistically, the Kendall
Coefficient of Concordance was 0.58, indicating a
high degree of agreement among the twenty raters.
The Friedman two-way analysis of variance yielded a
p value of 0.000, indicating that there were sign&
cant differences among the radiographs. When the
Wilcoxon matched-pairs, signed-ranks test was run,
the following results were noted:
1. The most preferred systems were the Kodak
Volume 6 I Five panoramic screen-film combinations 41 I
Number 4

X-Omatic regular screens with XRP film and the 6. Lawrence DL: Kodak X-omatic and Lanex screens and
Kodak films for medical radiography. Med Radiogr Photogr
Kodak Lanex regular screens with T-Mat G film. 53: 2-10, 1977.
There was no significant difference in the rankings of 7. Halse A, Hedin M: May fast screen-film combinations be
these two systems, even though the latter was pro- used for cephalometry? Br J Orthod 5: 189-192, 1978.
8. Hurlburt C: Screen-film combinations used for cephalometric
duced with 31% of the exposure to the patient radiography. ORAL SURG ORAL MED ORAL PATHOL 46:
required for the former. These two systems were 721-724, 1978.
rated significantly better than the three other sys- 9. Hurlburt CE: Faster screen/film combinations for cephalo-
metric radiography. ORAL SURG ORAL MED ORAL PATHOL 52:
tems with all p values less than 0.005. 661-665. 1981.
2. The DuPont Hi Plus/XRP combination was IO. Kaugers GE, Fatouros P: Clinical comparison ofconventional
significantly preferred to the KYOKKO special/ and rare earth screen-film systems for cephalometric radio-
graphs. ORAL SURG ORAL MED ORAL PATHOL 53: 322-325,
XRP system, but neither of these systems was 1982.
statistically distinguishable from the Lanex regular/ I I. Forsgren L, Julin P: Radiation dose reduction in panoramic
OG combination. radiography. Swed Dent J 6: 225-231, 1982.
12. Reiskin AB, Hummel E, Kirchhof RT, Freedman AB: Rare
CONCLUSIONS earth imaging in dental radiology. J Prev Dent 4: 7-13,
1977.
This study demonstrates that proper screen-film 13. Ponce AZ. McDavid WD, Morris CR: Adaptation of the
Panorex II for use with rare earth screen-film combinations.
selection in panoramic radiography can significantly ORAL SURF ORAL MED ORAL PATHOL (In press.)
reduce radiation exposure to the patient and preserve 14. Ponce AZ, McDavid WD, Morris CR: The use of Kodak
diagnostic quality. T-Mat G film in rotational panoramic radiography. ORAL
SURG ORAL MED ORAL PATHOL (In press.)
15. Hurlburt CE, Coggins LJ: Rare earth screens for panoramic
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