Title Page

© 2016 The Authors. Published by the British Institute of Radiology

DEFINITION CLASSIFICATION AND RETROSPECTIVE ANALYSIS OF

PHOTOSTIMULABLE PHOSPHOR IMAGE ARTEFACTS AND ERRORS IN INTRAORAL

DENTAL RADIOGRAPHY

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Running head: Image artefacts in PSP plate systems

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Research Article

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Armagan CALISKAN, DDS, DClinDent 1, Ayse Pinar SUMER, DDS, PhD 2

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Specialist in Dentomaxillofacial Radiology, Oral and Dental Health Hospital, Samsun,

Turkey
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Professor, Department of Dentomaxillofacial Radiology, Ondokuz Mayis University, Faculty
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of Dentistry, Samsun, Turkey
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The authors indicate that there is no source of funding or financial interest.

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The study was presented as an oral presentation in the Oral Diagnosis and Maxillofacial
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Radiology Society 6th National Scientific Symposium & 1st International Congress at April 17-19,
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2015 held in Izmir, Turkey.

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Corresponding Author:
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Armagan Caliskan, DDS, DClinDent.

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Oral and Dental Health Hospital, Ilkadim, Samsun, Turkey

Phone: +90 (362) 440 00 45 - 4008

Fax: +90 (362) 440 54 17

E-mail: armagancaliskan@hotmail.com
 Objectives: To detect and determine image error and artefact types in intraoral
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2 radiographs obtained with PSP technology, place them in an appropriate classification and
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retrospectively analyse the PSP specific image errors and artefacts. The causes and solutions
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Methods: The radiographic database of the Ondokuz Mayıs University, Faculty of Dentistry,
11 Department of Dentomaxillofacial Radiology was used for this study. Different types of
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13 image errors and artefacts observed on intraoral radiographs during 2014 and 2015 were

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15 detected and defined. A total of 2100 intraoral radiographs that were individually evaluated

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17 for the distribution of PSP specific image artefacts.
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21 Results: There were 34 image error and artefact types detected and classified into four groups

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23 according to the causative factors. The most common PSP specific image artefacts were found
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25 in fading with a ratio of 44.1% for the ambient light-related group, peeling of the plate
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borders with a ratio of 53.4% for the PSP plate-related group and straight line with a ratio of
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42.2% for the scanner-related group.
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Conclusions: The determination and definition of the image errors and artefacts with the
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34 clarification of their causes and solutions are important for the improvement of radiographic
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36 quality and the reduction of the retake ratio.

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50 Introduction
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53 Photostimulable phosphor (PSP) plates are still widely used as receptors in intraoral
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56 radiography. These image receptors allow indirect digital image acquisition; more
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58 specifically, after the exposure latent image occurs on the plate, it is then converted to a
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 digital radiographic image via a scanning device. Generally, PSP plate based radiographic
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2 systems are named as “Computed Radiography” (CR) and the term “Digital Radiography”
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5 (DR) is preferred for the solid-state detector based imaging. Advantages of computed
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7 radiography include having cordless and flexible plates, having similar structural features to
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10 well-known conventional films, being easily manipulated, the option of changing image
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12 adjustments via software, lower dose requirements, a wide dose latitude, the elimination of
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chemical processes, an ease of storage, share and replication.1-5

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The integration of these relatively new imaging technologies in dental radiographic
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20 practices has brought about innovations that have to be understood for a proper examination.
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22 Incorrect manipulations and technical errors during both acquisition and processing of the
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25 images may cause distinctive radiographic errors and artefacts. Thus, the optimal radiographic
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27 examination for an area of interest cannot be performed, which may lead to a misdiagnosis.
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30 Determining and clarifying the mechanisms of these mistakes is essential in overcoming these
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32 errors and artefacts.
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35 The aim of this study was to detect and determine image error and artefact types in
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intraoral radiographs obtained with PSP technology, place them in an appropriate
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40 classification and retrospectively analyse the detected PSP specific image artefacts.
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42 Evaluation includes a large number of PSP-based radiographs acquired in one University

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45 Dental Hospital. The causes and solutions of the errors and artefacts which are specific to PSP
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47 based intraoral imaging have also been discussed.

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53 Materials and Methods

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 The study protocol was approved by the University Institutional Review Board. The
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2 radiographic database of the Ondokuz Mayıs University, Faculty of Dentistry, Department of
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5 Dentomaxillofacial Radiology was used for this study.
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8 Exposures were performed with two Sirona Heliodent Plus dental X-ray machines

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10 with the parameters of 60 kVp and 7 mA (Sirona Dental Systems GmbH, Bensheim,
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13 Germany). All radiographs were obtained with the bisecting angle technique using VistaScan

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15 image plates and scanning procedures were performed with a VistaScan Combi scanner using

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a standard scanning mode that allowed for a 50-µm pixel size and a 10 lp/mm theoretical
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20 spatial resolution (Dürr Dental GmbH & Co. KG, Bietigheim-Bissingen, Germany). The
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22 images were transferred to the HBYS hospital information management system computer
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25 program (Turcasoft Software Ltd., Samsun, Turkey) and evaluated on a 20.1-inch Dome
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27 GX2MP Plus monitor (NDS Surgical Imaging, LLC, San Jose, CA, USA). The evaluation
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30 was performed in the reporting room that has semi-dark lighting condition.
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33 This study consisted of two parts. In the first part, different types of image errors and
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35 artefacts observed on intraoral radiographs during 2014 and 2015 were detected and defined.
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Possible causes and solutions of these errors and artefacts were determined through
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40 consideration of the materials and image acquisition process of faulty radiographs.
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43 In the second part, 2,100 intraoral radiographs collected from the patient records in
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45 September 2015 which is the following month of major revision of the plates being used.
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48 These radiographs were individually evaluated for the absence or presence of all defined
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50 image errors and artefacts. All of the radiographs were evaluated by one observer. Selected 50
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53 radiographs were revaluated after 2 weeks for the determination of intra-observer reliability.
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56 Statistical analyses were performed with IBM SPSS Statistics Version 21 (IBM
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58 Corporation Armonk, New York, USA), and the frequency and percentage of image errors
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and artefacts were determined. Intra-observer reliability was analysed with kappa analyses.
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 Results
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3 Image error and artefact types
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6 There were 34 image error and artefact types detected and classified into four groups
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8 according to the causative factors. The four groups included: (1) operator-and patient-induced,

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11 (2) ambient light–induced, (3) PSP plate–induced, and (4) scanner-induced errors and
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13 artefacts. The first group was formed with 11 errors that were well known from long existing

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techniques already. Following 3 groups were formed with a total of 23 PSP specific image

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18 artefacts and errors.

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21 Operator- and Patient-Induced Errors and Artefacts

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24 Well known projection errors including cone cutting, crown cut-off, apices cut-off,
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incorrect dot position, non-parallel position to an occlusion, shortening, elongation,
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29 superimposition and movement error may be observed with computed radiography because
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31 these errors are independent to image receptor type. A mirror image occurs when positioning
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34 the sheathed plate incorrectly in the mouth or inversely inserting plate into the sheath. Double
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36 exposure of the PSP plate without scanning or improper erasure of a previously acquired
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latent image are causes of a double image.
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Ambient Light–Induced Artefacts and Errors
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Table 1 shows the ambient light–induced artefacts and errors with their definitions,
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47 reasons and preventions. Mentioned artefacts and errors are shown in Figure 1.
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50 PSP Plate–Induced Artefacts and Errors

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53 PSP plate–induced artefacts and errors basically have two main causative factors as
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55 photostimulating luminescence layer damage and dirt on the plate. Table 2 and Figure 2 show
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58 the photostimulating luminescence layer damage related artefacts and errors. Table 3 and
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60 Figure 3 show dirt on the plate related artefacts and errors.
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 Scanner-Induced Artefacts and Errors
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3 Definitions reasons and preventions of the scanner-induced artefacts and errors are
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5 shown in Table 4. The images of mentioned artefacts and errors are shown in Figure 4.
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8 Statistical analysis

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11 Kappa values were found to be between 0.79 and 1 for various image artefacts.
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14 According to these values, a good/very good agreement was found for the intra-observer
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reliability.

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Table 5 shows the frequency and percentage of the PSP specific image artefacts. The

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most common image artefacts were found in fading with a ratio of 44.1% for the ambient

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24 light–induced group, peeling of the plate borders with a ratio of 53.4% for the PSP plate–
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induced group and straight line with a ratio of 42.2% for the scanner- induced group.
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29 Discussion
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32 The intraoral radiographic errors and artefacts that form with film-based radiology are
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35 very well known. However, according to our knowledge, there are few studies that have
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37 determined and classified the image errors and artefacts specific to PSP technology,6-12 and
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40 only two of these are associated with dental practices.11,12 Therefore, we aimed to
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42 comprehensively determine and classify intraoral radiographic image errors and artefacts of
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PSP plates, which is a relatively new and popular imaging system.
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47 The electrons that are captured via the F centres after exposure are metastable.1,13 This
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50 means that these captured electrons may spontaneously release from the F centres over time.
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52 High temperature and increased ambient light intensity and duration accelerate the release and
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55 have harmful effects on the latent image, especially on the underexposed PSP plates.
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57 Clinically, the most important reason of release is delayed scanning and ambient light
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60 exposure of the unsheathed plate. This behaviour of the PSP plates may cause a significant
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 signal loss which results a decrease in the signal-to-noise ratio and an increase in the mean
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2 gray value.14,15 The image deterioration starts with the fading or its partial forms like non-
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5 uniform image density or text pattern associated with the ambient conditions. Following
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7 fluctuating signal loss creates a noisy image. However, darker image areas are affected more
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10 from the ambient light.15 Weak signals, which are generated by low energy photons, are lost
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12 first as a result of excessive delayed scanning and ambient light exposure. These usually
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correspond with the radiopaque parts and periphery of the image. The shining artefact occurs

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17 on these specific areas together with a significantly noisy image. Shetty et al.6 suggested that
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19 the intensity of the photons is decreased with the distance from the central beam. Therefore,
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22 recognizing the image loss first on the peripheral image is probably related with the lower
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24 intensity of the photons that expose the periphery of the plate compared to the centre of the
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27 plate.
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30 Although the manufacturer recommends an ambient light intensity of up to 1,000
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32 lux,16 a semi-dark room is recommended for scanning,1,2,14 and plate scanning delays should
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not be more than 10 minutes.15 The current study revealed a result of 44.1% for fading
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37 artefacts. However, these images are generally retrievable with the adjustment tools provided
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39 with the imaging software. The reason for this greater result is due to the removal of the plate
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42 from its sheath after the exposure to prevent contamination. In our department, a black
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44 cardboard that covers the imaging plate is routinely placed into all of the sheaths for an extra
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precaution to protect the PSP plate from both ambient light and mechanical stress.
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50 Mechanical stress of the plate is basic factor for the photostimulating luminescence
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52 layer damage. Excessive bending, pressure, friction, biting, aging and effects of the rollers
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have been reported as possible reasons for this damage.1,6 Handling of the plate during any
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57 image acquisition steps, especially during the scanning step and wiping the plate have been
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59 considered as main causative factor for scratches.17,18 Kalathingal et al.18 suggested handling
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 of the plates with gloves in all steps and cleaning them with soft cloth instead of gauze only if
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2 a visible dirt is seen on the plate surface for the prevention of scratches. Chiu et al.11
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5 suggested that the saliva contamination related to an inadequate sheath may have a peeling
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7 effect on the plate borders. The friction between the plate and foil cassette might be the main
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10 cause of this plate damage. The disinfectant solutions and skin oil combined with
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12 contaminants have been reported as possible permanent damage agents. 1 However, in the
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present study, no permanent damage was observed on any plate associated with these agents.

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Dirt on the plate blocks the stimulating laser light, which is necessary for the
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20 phosphorescence and signal acquisition. The image from this area is seen as radiopaque
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22 because of no signal acquisition and takes the form of a blocking agent. Dirt on the black side
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25 does not produce an artefact, only the dirt on the active side of the plate creates the image
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27 artefact. Dust particles, glove powder contamination and body oil are the reported agents for
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30 dirt on the plate.1 The manufacturer recommends the use of image plate cleaning wipes for
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32 cleaning and disinfection.19 These disposable wipes containing 4 g of isopropyl alcohol and
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the manufacturer recommends 15–30 seconds of application time for adequate effectiveness.
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37 Image plates must also be dried after cleaning.
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40 Dust particles and dirt on the narrow scanning window of the scanner may block the
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42 stimulating laser light at the same place on every fast scan cycle. Also, acquired visible light
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45 from the constant part of every fast scan cycle, resulting from phosphorescence, may not
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47 reach the photomultiplier tube because of dust and dirt on the parabolic mirrors or light
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50 collector. These blockages cause a focal no-signal area and a loss of image acquisition. These
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52 always happen at the same focal area on the fast scan direction if the blocking agent is fixed.
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A repeat of this blockage during whole scanning procedures of the plate generates a
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57 radiopaque straight line on the radiographic image, which is parallel to the slow scan
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59 direction. The zigzagged line is probably related to minimal movement of the blocking agent
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 because of scanner vibration during the process or the effect of plate movement elements. All
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2 of the images processed on the same scanning socket of the scanner show the same image
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5 artefact exactly at the same place unless the blocking dust particles and dirt are cleaned or
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7 have spontaneously moved. Additionally, an air spray of the dental units may be used for
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10 removing dust particles and dirt on the narrow scanning window without removing the parts
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12 of the scanner.
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15 The intensity and duration of the stimulating laser light determine the amount of

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phosphorescence and hence, the amount of signal acquisition.13 If the stimulating laser light is
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20 applied to the image receptor erratically, a brighter radiographic image is seen on the
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22 longer-exposed part of the plate.6 This is a possible reason for the ridging artefact. This
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25 artefact is not seen on subsequent scanning procedures.
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28 Foil cassette and plate size mismatch may be effective in occurring skipped image
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30 part. Using smaller sized foil cassette and forcing the sliding button during scanning
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33 procedure may have a pushing effect on the plate being scanned. Additionally, software,
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35 conveying belt or roller malfunctions during plate scanning may cause this artefact.
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38 Plate size determination errors are rare artefacts. Combining error is almost always
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seen with multiple plate scanning including an occlusal-sized plate and may be related to
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43 sliding the occlusal plate with the hand from the extra socket area instead of using the size
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45 four foil cassette. The rarity and lack of repetition of certain errors and artefacts, also bring
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48 about difficulty in explaining these mechanisms. Possible unforeseen software-associated
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50 malfunctions might be the main causative factors for these image errors and artefacts.
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53 Conclusion
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 The wide usage of this imaging modality necessitates that the features of the PSP
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5 image errors and artefacts.
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8 The most common image errors and artefacts were peeling of the plate borders, fading,

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10 straight line, scratches and dust particles on the plate. The determination and definition of the
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13 image errors and artefacts with the clarification of their causes and solutions are important for

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15 the improvement of radiographic quality and the reduction of the retake ratio.

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 References
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2 1. Ludlow JB, Mol A. Digital imaging. In: White SC, Pharoah MJ (eds). Oral radiology:
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Physicists in Medicine. 2006.

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 Figure Legends
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3 Figure 1: (a) ambient light related fading on the left bitewing radiograph; (b) non-
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5 uniform image density on the left bitewing radiograph; (c) text pattern on the mandibular left
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8 posterior periapical radiograph; (d) circled area indicates the associated writing part which

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10 causes text pattern artefact on the radiograph c. (e) fading and noisy image on the maxillary
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13 right posterior periapical radiograph; (f) significant noisy image and shining areas because of

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15 total signal loss on the right bitewing radiograph.

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18 Figure 2: (a and b) mandibular right posterior periapical radiograph and the plate used

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20 for image acquisition of radiograph a. Straight arrows show cracking, arrows with dashes
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23 show scratch, arrows with dots show peeling of the plate border. Additionally, adhesive
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25 contamination and associated image artefact is seen on the right bottom of image and plate.
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28 (c) Biting related multiple radiopaque dots on the maxillary occlusal radiograph. (d) The
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30 arrow shows the crescent shaped bending on the left bitewing radiograph.
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33 Figure 3: (a) dust particles related multiple radiopaque dots on the maxillary right
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posterior periapical radiograph; (b) Glove powder related radiopaque clusters on the maxillary
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38 right posterior periapical radiograph; (c) circled area of the maxillary anterior periapical
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radiograph indicates radiopaque fingerprint appearance; (d and e) maxillary anterior
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43 periapical radiograph and the plate used for image acquisition of radiograph d. Notice the
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45 accumulation of radiopaque dots superimposed over the left lateral incisor and dirt on the
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48 plate which is related adhesive contamination and dust accumulation.
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51 Figure 4: (a) horizontal radiopaque straight lines and vertical ridging pattern on the
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53 maxillary left posterior periapical radiograph. (b) zigzagged radiopaque line on the right
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56 bitewing radiograph related with minimal movement of the blocking agent. (c) vertical
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58 skipped image part at the level of third molars on the left bitewing radiograph. (d) well
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 defined mixed radiopacity at the left bottom corner of the right mandibular posterior
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2 periapical radiograph related with peeling of the conveying belt.
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61
62
63
64
65
Figure 1 Click here to download Figure Figure 1.tif

FS
O
O
R
P
D
E
T
C
E
R
R
O
C
N
U
Figure 2 Click here to download Figure Figure 2.tif

FS
O
O
R
P
D
E
T
C
E
R
R
O
C
N
U
Figure 3 Click here to download Figure Figure 3.tif

FS
O
O
R
P
D
E
T
C
E
R
R
O
C
N
U
Figure 4 Click here to download Figure Figure 4.tif

FS
O
O
R
P
D
E
T
C
E
R
R
O
C
N
U
Table 1

Error/artefact
Definition Reason Prevention
name
Fading Brighter radiographic Ambient light exposure of the
image than usual which is unsheathed plate because of
almost always correctable delayed scanning, tolerable
with image adjustment spontaneous releasing of the
tools electrons that form the latent
image and reduced output signal
that causes incorrect initial image

FS
density optimization

Non-uniform Two or more radiographic Partial ambient light exposure of

image density areas on the image that the plate generally because of the

O
exhibit different densities overlapped unsheathed plates and
for same structures fading on the exposed area Plates should not be removed

O
from their sheaths until just
Text pattern A readable text part on the Hanging on the exposed and before the scanning procedure
radiographic image due to unsheathed plate overlapped with and unsheathed plates should

R
the density differences the paper which patient not be overlapped with
information written on it. Light anything, advice from the

P
transition on the unwritten part of manufacturers must be
paper and fading on the associated considered for the ambient
image area. Absorption and light intensity and plates
D
normal density on the written part should be scanned as soon as
possible after exposure
E
Noisy image Grainy image that exhibits Spontaneous releasing of
random density variations electrons that creates
T

for the same structural uncorrectable changes to the

areas latent image due to delayed
C

scanning and too much ambient

light intensity and exposure
E

Shining Pure white areas generally Total loss of the gained signal at
R

formed at the central of the associated areas due to

radiopaque structures and excessive spontaneous releasing
R

peripheral borders of the

image
O

Table 1: Ambient light–induced artefacts and errors

C
N
U
Table 2

Error/Artefact
Definition
name
Cracking Linear, irregular radiopaque
line, mostly at the occlusion
level of the bitewing
radiographs. Generally, a
polyester base of the plate is
bent irreversibly on the
associated area
Reason Prevention
Excessive bending and rough
manipulation which generate
irreversible damage on the
photostimulating luminescence
layer and polyester base

Scratches Small, smooth linear opacities Photostimulating luminescence

anywhere on the image
Peeling of the Corruption and irregularity at
FS
layer damage without bending of
the polyester base
Gentle manipulation by the
Peeling of the protective and
operator to the plate at each

O
plate borders the borders of radiographic photostimulating luminescence
step of the image
image and plate layer of the PSP plate borders as a
acquisition and controlled
result of friction when the plate is

O
biting of the bitewing and
placed into the foil cassette(a
occlusal radiographs
special plate carrier of the

R
VistaScan Combi Plus scanner)

Bite-marks Small multiple irregular Pressure to the plate when the

P
radiopaque dots on the patient bites strongly
radiographic image and small
pits on the plate surface
D
Crescent A crescent-shaped radiopacity Tension on the sheath and plate
shaped on the image and a crescent- when patients bite the bite block
E
bending shaped bending at the improperly
corresponding area of the plate
T
C

Table 2: Photostimulating luminescence layer damage related PSP plate–induced artefacts and errors.
E
R
R
O
C
N
U
Table 3

Error/Artefact
Definition Reason Prevention
name
Dust particles Radiopaque dots anywhere on Dust particles on the plate surface
on the plate the image which stay fixed during the
scanning procedure

Glove powder Granular radiopaque clusters Accumulation of glove powder to

contamination on the image the plate surface with the
contribution of sweat and body oil
Careful manipulation by
the operator and regular
Fingerprint A radiopaque fingerprint Body oil and dirt on the fingers of

FS
cleaning of the plates with
appearance on the the operator
appropriate materials
radiographic image

Adhesive An irregular radiopaque area Adhesive contamination from the

O
contamination that is generally near the short adhesive band of the sheath while
edges of the plate sleeving the plate and dust
accumulation over this adhesive

O
area

R
Table 3: Dirt on the plate related PSP plate–induced artefacts and errors.

P
D
E
T
C
E
R
R
O
C
N
U
Table 4

Error/artefact
Definition Reason Prevention
name
Lines parallel Straight A radiopaque straight line Dust particles and dirt on the
to the slow scan line on the radiographic image, narrow scanning window of
direction which is parallel to the slow the scanner which stay fixed
scan direction during scanning

Zigzagged A radiopaque zigzagged line Dust particles and dirt on the

line on the radiographic image, narrow scanning window of
which is parallel to the slow the scanner which move
scan direction slightly during scanning

FS
Ridging Multiple radiolucent lines Momentary changes of the
with an increasing distance, stimulating laser light
which are seen parallel to intensity, the loss of

O
the fast scan direction synchronization between fast
scan cycles and image plate
transition, which causes more

O
or less stimulating laser light
exposure

R
Skipped image A skipped image part, which Synchronization failure
part is parallel to the fast scan between the stimulation of

P
direction the laser beam on the fast
Periodic control,
scan direction and
cleaning and
progression of the plate on
calibration of the
D the slow scan direction via
scanning device,
rollers and a conveying belt
using appropriate
E
foil cassette for
Peeling of the An irregular but well Peeling of the conveying belt
each plate size,
conveying belt defined mixed appearance surface and positioning the
T

careful and gentle

usually seen at one corner of
the image with different
C
peeled part between the plate
manipulation
and narrow scanning window
during scanning

shapes
procedure
E

Erasure A double image, which has Improper erasure and reuse

artefact the same characteristics as of the plate for another
an image acquired as a result radiograph
R

of a double exposure
R

Plate size Combining A large image that occurs Panoramic- or

determination with collection of the cephalometric-sized plate
errors images from the separate scanning determination of
O

plates of same scanning the scanner by mistake when

procedure the area between multiple intraoral-sized
C

the plates is seen as white plates are scanned

Bisection Two separate images from Smaller plate size

N

one plate scanning, which is determination, faulty power

the continuation of each supply or other malfunctions
U

other with the software

Incomplete Smaller radiographic image Stopping the scanning

scanning dimension when procedure when the scanner
corresponding to its plate reaches the excessive cone
cutting area

Table 4: Definitions reasons and preventions of the scanner-induced artefacts and errors
Table 5

Artefact group Artefact type Frequency

Absolute Relative(%)
Fading 926 44.1%
Non-uniform image density 382 18.2%
Ambient light–induced
Text pattern 17 0.8%
artefacts and errors
Noisy image 160 7.6%
Shining 32 1.5%

Cracking 339 16.1%

FS
Photostimulating Scratch 871 41.5%
luminescence layer Bite-marks 22 1%
damage Peeling of the plate borders 1121 53.4%
PSP plate–induced Crescent shaped bending 143 6.8%

O
artefacts and errors
Dust particles on the plate 737 35.1%

O
Glove powder contamination 195 9.3%
Dirt on the plate
Fingerprint 1 0.04%
Adhesive contamination 164 7.8%

R
P
Lines parallel to the Straight line 887 42.2%
slow scan direction Zigzagged line
D 184 8.8%
Ridging 4 0.2%
Skipped image part 0 0%
Scanner-induced
Peeling of the conveying belt 31 1.5%
E
artefacts and errors
Erasure artifact 0 0%
T

Combining 3 0.1%
Plate size
Bisection 3 0.1%
determination errors
C

Incomplete scanning 11 0.5%

E

Table 5: The classification, frequency and percentage of the PSP specific image artifacts.
R
R
O
C
N
U