J Periodontol • July 2008

Detection of Bone Loss With Different

X-Ray Techniques in Periodontal Patients
Ti-Sun Kim,* Christian Obst,* Sven Zehaczek,* and Claudia Geenen*

Background: Intraoral radiographs can aid in formulating a

more accurate diagnosis of periodontal disease. However, it
must be considered whether a comparable amount of informa-
tion can be obtained with modern panoramic radiographs. The
aim of this study was to determine to what degree the diagnos-
able amount of bone loss in patients with aggressive periodon-
titis or severe chronic periodontitis depends on the type of

T
he main goals of the diagnosis of
x-ray technique used. periodontal disease and the sub-
Methods: A total of 110 subjects (63 females) were in- sequent therapy are to eliminate
cluded in this study. The inclusion criteria were the diagnosis periodontal infection and to reduce the
of aggressive periodontitis (N = 49) or severe chronic peri- risk for future progression of the disease
odontitis (N = 61). In all patients, panoramic radiographs as much as possible.1 To describe the
(panoramic) and intraoral films of all regions (eight to 10 sin- amount of periodontal destruction that
gle exposures) were available. Analysis of the panoramic and has already occurred, the clinician has
intraoral films was carried out with a computer-assisted tech- relied on data from clinical examinations
nique for linear measurement. The amount of bone loss in ref- and radiographs. Determining bone loss
erence to the alveolar crest (AC) and bottom of the bony using intraoral and panoramic radio-
defect (BD) was determined as a percentage of total root graphs is essential for accurate di-
length. agnosis2 and appropriate treatment
Results: Depending on the examined tooth and reference planning.3,4 Among the methods used
point, 47.01% to 81.89% of all subjects showed differences be- to detect alveolar bone dimensions on
tween intraoral and panoramic measurements that were £10% radiographs are Schei or millimeter
of the total root length. For cemento-enamel junction–AC rulers5 and computer analysis of digital
measurements, differences between intraoral and panoramic images.6,7
measurements that were >10% of the total root length were Linear measurements between the
found predominantly in the upper molar and premolar regions. cemento-enamel junction (CEJ) and
In the mandible, differences between intraoral and panoramic the alveolar crest (AC) or the bottom of
measurements that were >10% of the total root length were the bony defect (BD) are used often to
observed for BD and AC at the mesial contour of the central characterize the amount of bone loss in
incisor. osseous periodontal defects.3 The im-
Conclusions: A preorientation with respect to the expected portance of determining the extent of
bone loss is possible using panoramic radiographs. Additional bony lesions has been stated with respect
intraoral films might be helpful where rapid changes of bone to possible outcomes of different regen-
level are expected (e.g., aggressive periodontitis). J Periodon- erative procedures8-10 and for correct
tol 2008;79:1141-1149. periodontal risk assessment.11 In this
context, Molander et al.12 found a high
KEY WORDS
sensitivity for the combination of pano-
Dental radiography; panoramic radiography; periodonitis. ramic radiographs and (on average) five
intraoral single-tooth films with regard
to marginal bone loss and periapical
* Section of Periodontology, Department of Operative Dentistry, University Medical
Hospital, Heidelberg, Heidelberg, Germany. lesions. Furthermore, clinical investiga-
tions showed agreement between direct
bone sounding and assessment of bony
height by analysis of dental radio-
graphs.13-15 With the help of radiographs,

doi: 10.1902/jop.2008.070578

1141
Detection of Bone Loss With Different X-Ray Techniques
periodontal changes can be estimated with high spec-
ificity but low sensitivity, characterized by an underes-
timation of the severity of periodontal breakdown,
especially in moderate forms of periodontitis.16,17
However, focusing on chronic periodontitis, the as-
sessment of bone loss with the use of intraoral radio-
graphs resulted in an overestimation of surrounding
bony tissues.17
Although an underestimation of bony height
(£1.4 mm) was observed in previous studies,12,14,15
changes in alveolar bone level measured via intraoral
radiographs yielded small differences that were not
statistically significant (P >0.05)15 compared to bone
sounding or reentry procedures. Only a few stud-
ies16,18 compared the validity of panoramic films to in-
traoral single-tooth films in detecting periodontal bone
loss. In a study16 comparing the accuracy of pano-
ramic and intraoral radiography to open surgery mea-
surement as the gold standard, an underestimation of
bone loss ranging from 13% to 32% for panoramic
films and from 9% to 20% for intraoral single-tooth
films was detected. Persson et al.18 found a high agree-
ment between panoramic and intraoral radiographs
for evaluating the amount of bony height. In the same
study, a symmetry between the left and right sides of
the maxilla and mandible was detected.
There is increasing concern about patient exposure
to radiation, and replacing a series of intraoral films
with a single panoramic radiograph certainly reduces
the amount of exposure. Therefore, the question
arises whether full-mouth radiographs, often exceed-
ing eight to 12 single films, would still be a prerequisite
for the diagnosis of periodontal disease.
Additional objectives of the study were to draw a
comparison between the assessment of different tooth
groups and different bony anatomic reference points
(AC and BD), depending on the x-ray technique used.
This study focused on subjects after the first diag-
nosis of periodontitis to visualize the initial status of
bony defects before the start of periodontal therapy.
Based on the fact that most dental offices still use
conventional x-ray techniques,2 the overall goal of
this study was to find out to what degree the diagnos-
able amount of bone loss in subjects with aggressive
periodontitis (AgP) or severe chronic periodontitis
(sCP) depends on the type of x-ray technique used.
MATERIALS AND METHODS
Subjects
A total of 110 subjects (63 females and 47 males; age
range: 25 to 64 years) were included in this retrospec-
tive study. Inclusion criteria were the diagnosis of sCP
(N = 61) or AgP (N = 49). The subjects provided in-
formed consent to participate in the study, and the
study was conducted in accordance with the Helsinki
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Volume 79 • Number 7
Declaration of 1975, as revised in 2000. Subjects had
a panoramic radiograph taken at the Department of
Oral and Maxillofacial Surgery during their first visit
to the University Hospital of Heidelberg between Jan-
uary 2002 and December 2005. After the primary
diagnosis of a ‘‘periodontal patient’’ had been deter-
mined at the Department of Oral and Maxillofacial
Surgery, the subjects were referred to the Section of
Periodontology (Department of Operative Dentistry);
the periodontal diagnosis was specified with the help
of a clinical periodontal examination and a complete
set of intraoral periapical radiographs. Panoramic ra-
diographs and full-mouth periapical surveys (each
consisting of eight to 10 intraoral single-tooth films in
periapical projection) were digitized and analyzed with
a computer-assisted system for linear measurement.†
Intraoral periapical radiographs were obtained
using commercially available film holders.‡ Intraoral
dental films size two§ were exposed to an x-ray
source.i A single panoramic radiograph¶ was taken
with a panoramic apparatus.# Panoramic radiographs
were taken according to the manufacturer’s standard
protocol to reduce image distortion (especially in the
horizontal dimension) to a minimum. Intraoral and
panoramic radiographs were developed under stan-
dardized conditions** to reduce differences in bright-
ness and contrast to a minimum.
Digitization of Radiographs
Before intraoral or panoramic radiographs could be
measured using a computer-assisted method, every
image had to be transferred or scanned to make it ac-
cessible to digital analysis. This was done by using a
scanner†† with a resolution of 600 · 1,200 dots per inch.
Radiographic Analysis
Under standardized viewing conditions in a darkened
room, the distance from the CEJ to the marginal AC,
the distance from the CEJ to the BD, and the total root
length (CEJ–apex) were determined for each tooth at
two locations (mesial and distal). The apex was de-
fined as the most apically located point of the tooth.
In teeth that had been restored with fillings or crowns,
the most apical limit of the restoration was considered
to be equivalent to the CEJ and was taken as the ref-
erence point. This led to the examination of 2,327
teeth and resulted in 2,327 · four pairs of variates
for sets of periapical radiographs and to the analysis
of 2,159 teeth with a result of 2,159 · four pairs of var-
iates for panoramic radiographs.
† Friacom, Dentsply-Friadent, Mannheim, Germany.
‡ KKD RWT, Kentzler-Kaschner Dental, Ellwangen, Germany.
§ Insight, Eastman Kodak, Rochester, NY.
i Sirona Heliodent DS model 4684606, Sirona, Bensheim, Germany.
¶ Kodak T-MAT G-RA Dental Film panoramic 15 · 30, Eastman Kodak.
# Orthophos model 5968573D3200, Sirona.
** Periomat XR24PRO, Dürr Dental, Bietigheim-Bissingen, Germany.
†† Epson Perfection 1260, Epson, Meerbusch, Germany.
J Periodontol • July 2008 Kim, Obst, Zehaczek, Geenen

Data were collected by two calibrated observers. Table 1.

All observers were calibrated prior to the study by re-
Percentage of Teeth With Differences
cording data from 10 intraoral films and 10 panoramic
radiographs by using the computer-assisted method. Between Panoramic and Intraoral
Radiographs £10% of Total Root
Statistical Methods
Length (maxilla)
Sampled data were collected using the software pro-
gram for table calculation‡‡ and were transferred to a
Examined Teeth
scientific statistical software program§§ for descrip-
tive analysis. All linear distances were expressed as Reference 2nd 1st 2nd 1st Lateral Central
percentages of total root length. For both x-ray tech- Point Molar Molar Premolar Premolar Canine Incisor Incisor
niques, the median value was calculated for the dis-
BD
tances CEJ–AC and CEJ–BD in all locations.
Mesial 48.85 47.83 53.74 50.00 64.07 62.58 59.67
To describe differences between intraoral and pan-
Distal 57.14 58.74 63.51 50.00 65.82 52.15 61.11
oramic radiographs that were likely to gain clinical
relevance, all measured differences were classified AC
according to the following system: 1) differences be- Mesial 63.08 61.97 69.13 61.79 81.66 68.10 74.03
tween panoramic and intraoral radiographs £10% of Distal 61.42 53.85 61.49 62.30 76.33 72.19 72.78
the total root length = without clinical relevance, mea-
surements were interpreted as being identical with
both techniques; and 2) differences between pano-
ramic and intraoral radiographs >10% of the total root Table 2.
length = with clinical relevance in either direction: pan- Percentage of Teeth With Differences
oramic > intraoral (negative values) and intraoral >
Between Panoramic and Intraoral
panoramic (positive values).
The following null hypothesis was set: the fre- Radiographs £10% of Total Root
quency of measurements with panoramic > intraoral Length (mandible)
is identical to the frequency of measurements with
intraoral > panoramic. To compare the two samples, Examined Teeth
a distribution-free test, the statistical sign test,19 was Reference 2nd 1st 2nd 1st Lateral Central
used. This test is based on the signs of the differences Point Molar Molar Premolar Premolar Canine Incisor Incisor
between paired observations and requires only the as-
sumption of independence of differences between BD
paired observations, a condition believed satisfied. Mesial 63.06 60.40 69.77 56.72 56.34 50.77 52.73
Distal 63.55 54.35 66.67 62.50 60.00 50.36 47.01

RESULTS AC
Descriptive Statistics Mesial 70.91 78.22 81.89 71.76 70.71 57.69 51.46
Distal 80.37 73.27 79.84 78.03 71.63 56.82 57.41
Percentage of agreement between intraoral and
panoramic measurements. Differences between cor-
responding intraoral and panoramic linear measure-
ments that were >10% were clinically relevant per
ral–panoramic measurements are listed in Table 3
definition. Tables 1 and 2 show the percentages of
(maxilla) and Table 4 (mandible). The sign of the me-
teeth that exhibited agreement between intraoral
dian difference (- or +) indicates if larger distances
and panoramic linear measurements. In both jaws,
were measured on panoramic radiographs or on intra-
the amount of agreement was higher for CEJ–AC than
oral single films.
for CEJ–BD. In the maxilla, the highest percentage of
Maxilla: AC. For the linear measurement of CEJ–
agreement was found for the canine region (64.07% to
AC, panoramic measurements consistently showed
81.66%), whereas the least agreement was observed
longer distances than intraoral measurements, which
for the first molars (47.83% to 61.97%). In the mandi-
resulted in negative median of difference values for
ble, the best agreement was detected for the second
mesial and distal sites. These differences were more
premolar (66.67% to 81.89%), whereas the central
or less pronounced depending on the observed tooth.
and lateral incisor showed the smallest percentage
The only exception was found when measuring the
of agreement between intraoral and panoramic radio-
distal contour of central incisors. At this site, distances
graphs (47.01% to 57.69%).
Differences between intraoral and panoramic ‡‡ Excel, Microsoft, Redmond, WA.
measurements. Medians for the differences in intrao- §§ SPSS software, version 12.0, SPSS, Chicago, IL.

1143
Detection of Bone Loss With Different X-Ray Techniques Volume 79 • Number 7

Table 3.
Descriptive Statistics: Median
Differences (maxilla)

Median Difference Intraoral–Panoramic

CEJ–AC CEJ–BD

Reference Point Mesial Distal Mesial Distal

2nd molar -3.99 -5.31 -0.74 0.48

1st molar -3.02 -3.90 0.68 -2.06

2nd premolar -4.22 -6.78 2.29 -0.09

1st premolar -3.72 -5.22 3.62 5.42
Canine -3.60 -0.82 -2.54 -0.42

Lateral incisor -1.80 -0.29 -1.42 0.26

Central incisor -0.45 1.38 2.51 1.73

Table 4.
Descriptive Statistics: Median
Differences (mandible)

Median Difference Intraoral–Panoramic

CEJ–AC CEJ–BD

Reference Point Mesial Distal Mesial Distal Figure 1.

Percentages of subjects with different CEJ–BD measurements
2nd molar -4.38 -1.54 -2.89 0.57 (panoramic versus intraoral radiographs, maxilla) in distal and mesial
sites. Columns are shaded for significant differences between
1st molar -1.12 -2.36 -0.54 1.04 panoramic and intraoral; for statistical values, refer to Table 5.
2nd premolar -0.26 0.66 -1.29 1.67
graphs exceeded the corresponding intraoral mea-
1st premolar -0.27 1.48 -2.13 2.73
surements for both mesial and distal sites in first
Canine 2.53 0.09 -1.12 0.40 and second molars, which resulted in negative median
of difference values (intraoral - panoramic) for mesial
Lateral incisor -0.06 0.93 0.11 -0.45
and distal sites in the molar area (Table 4).
Central incisor 1.24 0.55 0.86 2.24 Mandible: BD. With regard to the measurement of
CEJ–BD, medians of differences between panoramic
and intraoral measurements for the first and second
measured on intraoral radiographs tended to be lon- molars were not as pronounced as for CEJ–AC mea-
ger than panoramic distances (Table 3). surements (Table 4).
Maxilla: BD. With regard to the measurement of Analytical Statistics
CEJ–BD, no clear tendency toward longer linear dis- After calculating the percentages of teeth with clini-
tances was found for either of the two radiographic cally relevant deviation of linear measurements on
techniques (Table 3). panoramic and intraoral radiographs, the Dixon and
Mandible: AC. With regard to the mandible, dis- Mood statistical sign test was used to test the null hy-
tances measured on panoramic radiographs were pothesis that there is no specific direction for under- or
predominantly longer in mesial sites (exception: ca- overestimation of linear distances with one of the two
nine and central incisor), whereas in distal sites intra- radiographic methods. Figures 1 through 4 illustrate
oral measurements led to higher values (exceptions the results for the different reference points and tooth
were first and second molars) (Table 4). However, locations. Parameters of statistical testing are pre-
the median distances CEJ–AC on panoramic radio- sented in Table 5.

1144
J Periodontol • July 2008
Figure 2.
Percentages of subjects with different CEJ–AC measurements
(panoramic versus intraoral, maxilla) in distal and mesial sites. Columns
are shaded for significant differences between panoramic and intraoral;
for statistical values, refer to Table 5.
In the maxilla, measurements on panoramic radio-
graphs exhibited longer distances for CEJ–AC in sig-
nificantly more subjects for all molar (P <0.01) and
premolar (P <0.05) sites as well as in the mesial canine
site (P <0.05) compared to intraoral measurements.
Shorter distances for CEJ–BD were found on pano-
ramic radiographs in significantly more subjects com-
pared to intraoral measurements for the first premolar
(P <0.05) and the mesial contour of the central incisor
(P <0.05).
In the mandible, significant differences between the
two techniques did not appear as often as in the max-
illa. The distances CEJ–AC were shorter on pano-
ramic radiographs in significantly more subjects
compared to intraoral measurements for the mesial
contour of the canine (P <0.05) and the central incisor
(P <0.05). The distance CEJ–BD was shorter on pan-
oramic radiographs in significantly more subjects
(P <0.05) compared to intraoral measurements for
the mesial contour of the central incisor. The linear
Kim, Obst, Zehaczek, Geenen
Figure 3.
Percentages of subjects with different CEJ–BD measurements
(panoramic versus intraoral, mandible) in distal and mesial sites.
Columns are shaded for significant differences between panoramic
and intraoral; for statistical values, refer to Table 5.
distance CEJ–AC was longer on panoramic radio-
graphs in significantly more subjects (P <0.001) com-
pared to intraoral measurements for the mesial
contour of the second molar.
DISCUSSION
The present study was designed to compare two ra-
diographic techniques to estimate the degree of bone
loss in subjects with sCP or AgP so that an appropriate
treatment plan could be developed. A precise diagno-
sis is a prerequisite for these patients because they
may experience rapidly advancing states of bone
loss.20 In the dental practice, intraoral and panoramic
radiographs are the most established imaging tech-
niques.3 For periodontists, a radiographic status with
usually 10 to 14 intraoral pictures in periapical projec-
tion geometry, taken in parallel technique with the
central beam oriented perpendicular to the tooth
axis, is helpful to define the amount of bone loss for
an accurate initial diagnosis and during follow-up.
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Detection of Bone Loss With Different X-Ray Techniques Volume 79 • Number 7

Table 5.
Analytical Statistics: Reference Points
and Tooth Locations With Significant
Differences Between Panoramic
and Intraoral Radiographs

Reference P Longer
Jaw Point Tooth z Value Distance
Upper AC distal 2nd molar 3.714 <0.001 Panoramic
AC mesial 2nd molar 2.165 <0.01 Panoramic
AC distal 1st molar 3.077 <0.01 Panoramic
AC mesial 1st molar 3.674 <0.001 Panoramic
AC distal 2nd premolar 5.298 <0.001 Panoramic
AC mesial 2nd premolar 2.507 <0.05 Panoramic
AC distal 1st premolar 4.866 <0.001 Panoramic
AC mesial 1st premolar 3.209 <0.01 Panoramic
AC mesial Canine 2.514 <0.05 Panoramic
BD distal 1st premolar 2.561 <0.05 Intraoral
BD mesial 1st premolar 2.343 <0.05 Intraoral
BD mesial Central incisor 2.575 <0.05 Intraoral

Lower AC mesial 2nd molar 4.066 <0.001 Panoramic

AC mesial Canine 2.186 <0.05 Intraoral
AC mesial Central incisor 2.121 <0.05 Intraoral
BD mesial Central incisor 2.080 <0.05 Intraoral

Any of these methods can be combined. Interpreta-

Figure 4.
Percentages of subjects with different CEJ-AC measurements
(panoramic versus intraoral, mandible) in distal and mesial sites.
Columns are shaded for significant differences between panoramic
and intraoral; for statistical values, refer to Table 5.
Nevertheless, studies13,21,22 showed that the assess-
ment of bone height from intraoral radiographs usually
underestimates the extent of alveolar bone loss or the
depth of vertical defects.
Recently, panoramic radiographs have also be-
come a standard technique in most dental offices
because the quality of panoramic pictures has im-
proved18,23 and a large amount of information can
be obtained while exposing the patient to a compara-
tively low level of ionizing radiation.24,25 One of the
main limitations of panoramic radiographs is the po-
tential for image distortion.3
Conventional radiographic diagnosis in dentistry is
limited to a two-dimensional picture of a three-dimen-
sional periodontal defect that has a very complex
morphology.26 The two-dimensional mapping of an
intraoral region on a periapical radiograph is always
very susceptible to angulation errors.
Radiographs are used to assess bone support in
three major ways: interpretation of the radiograph
image, measurement, and image processing.26,27
tion of the radiographic image by transillumination
on a view-box is the method most frequently used
in clinical practice. Measurements taken from the ra-
diograph allow quantification of the extent of bone
loss along the root surface using simple methods,
such as a grid or a Schei ruler,5 or computer-assisted
techniques.6,28-33 Image-processing techniques
are used primarily in research and exploit infor-
mation contained in the radiograph that is too
subtle to be seen by the unaided eye.26,27
Various radiographic projections have been de-
signed to increase the likelihood of obtaining different
types of information.3,27 Because each radiograph
carries with it some exposure to ionizing radiation,
the practitioner must make the most of the diagnostic
potential of any radiographic view.26 Periapical films
are extremely susceptible to operator error, especially
in the maxillary molar regions.30,31 In the dental of-
fice, the use of paralleling-positioning devices has
helped to reduce the likelihood of misangulation.34
In the past, the indication for panoramic radio-
graphs was mainly limited to the measurement of
bone height in implant-receiving sites, whereas it
was not recommended for assessment of the alveolar
bone level in periodontal disease.35 Panoramic radio-
graphs provide a large quantity of information with a
single exposure that reduces the level of ionizing
radiation significantly compared to the multiple

1146
J Periodontol • July 2008
exposures of a full-mouth periapical survey. There-
fore, the question arises whether, at least for a specific
intraoral region, the periapical radiograph could be re-
placed by a panoramic radiograph, thus minimizing
the overall dose of ionizing radiation for the patient.
Jenkins et al.36 estimated the effective radiation
dose of a radiographic protocol that consisted of a
panoramic view with supplementary periapical radio-
graphs in periodontal patients. They found that, for
the majority of patients, the effective dose of a com-
plete series of periapical radiographs would have
been less than the dose from a panoramic-plus-peri-
apicals approach. In contrast to our study, Jenkins
et al.36 did not compare linear measurements of peri-
odontal bone loss on panoramic and periapical radio-
graphs; the examiners only judged a panoramic
image to be adequate or inadequate for periodontal
diagnosis.
In our study, the linear measurements on pano-
ramic radiographs exhibited longer distances for
CEJ–AC in significantly more subjects (P <0.05) in
all maxillary molar and premolar sites as well as in
the mesial maxillary canine site compared to intraoral
radiographs. Shorter distances for CEJ–BD could be
found in significantly more subjects (P <0.05) on the
panoramic radiographs compared to the intraoral
projections for the first premolar and the mesial con-
tour of the central incisor. These results are in contrast
to the study by Persson et al.,18 who found the largest
differences between intraoral and panoramic mea-
surements in the maxillary anterior region. In agree-
ment with the study by Persson et al.,18 we also
noted that differences between linear measurements
on intraoral and panoramic radiographs were smaller
for the mandibular posterior sextants than for the
maxillary posterior sextants.
The differences between our data and the study of
Persson et al.18 concerning linear measurements
may be explained by the fact that they used a differ-
ent panoramic apparatus,ii which resulted in differ-
ences concerning the focal trough and the patient
positioning within the machine.
In the mandible, significant differences between
both techniques did not appear as often as in the max-
illa. The distances for CEJ–AC were shorter on the
panoramic projections compared to intraoral pictures
for the mesial contour of the canine and the central
incisor.
The linear measurements in the present study re-
ferred to two different bony reference points: AC
and BD. AC characterizes the most coronal bony con-
tour of the periodontal defect, and BD defines the most
apical portion of vertical intrabony defects. For the
teeth with significant differences between intraoral
and panoramic measurements in the maxilla, CEJ–
AC was always larger on the panoramic radiographs,
Kim, Obst, Zehaczek, Geenen
whereas CEJ–BD was larger on the intraoral radio-
graphs.
This finding can be interpreted in the following
ways. For BD, intraoral radiographs allow a more pre-
cise and, therefore, further apically located identifica-
tion of this point, whereas panoramic radiographs fail
to show the vertical defect in its entire depth. For AC,
panoramic radiographs fail to show the most coro-
nally located bony structures of the AC (especially
in the spongious maxillary bone); therefore, the dis-
tance CEJ–AC is longer compared to intraoral radio-
graphs.
One possible source of error were the difficulties in
identifying the chosen reference points with an ade-
quate reproducibility. This was primarily bone related,
such as the correct position of the AC or the BD, and
secondarily tooth related concerning the identifica-
tion of the CEJ. The bone-related problems arise from
a lack of information as a result of possible interprox-
imal defects that may not be visualized because of the
presence of a buccal or lingual cortical plate, which
leads to an underestimation of detectable bone loss.17
Using two relative techniques to determine site-
specific bone loss, the main source of error was the in-
ability to detect the apex of the root and the inability to
distinguish different landmarks in the maxillary pre-
molar region as a result of overprojections and over-
lap of teeth in this area.18 This occurred mainly with
the panoramic radiographs.
Persson et al.18 compared intraoral radiographs
and panoramic radiographs in 292 periodontal main-
tenance subjects. They demonstrated a high agree-
ment between both imaging techniques (intraclass
correlation coefficients between 0.53 and 0.79) and
suggested that panoramic radiographic readings
may, at least in part, substitute for full-mouth periap-
ical radiographs. In contrast to our study, Persson
et al.18 measured radiographs of periodontal mainte-
nance patients who showed no signs of active peri-
odontal inflammation. The subjects who participated
in our study were at the beginning of the anti-infective
stage of therapy and, therefore, still had active peri-
odontal infections that may have complicated the defi-
nition of bony reference points compared to patients in
the maintenance phase; this could at least partly ex-
plain the differences between our data and the results
of Persson et al.18
CONCLUSIONS
In patients with sCP or AgP, panoramic radiographs of-
ten under- or overestimate linear distances. Therefore,
it is important to quantify the amount of bone loss com-
pared to the more accurate periapical radiographs.
Although in ;50% to 80% of all teeth, depending on
ii Planmeca PM 2002 CC Proline, Helsinki, Finland.
1147
Detection of Bone Loss With Different X-Ray Techniques
their location within the maxillary and mandibular
arch, the difference between the two imaging tech-
niques had no clinical relevance, the remaining 20%
to 50% of teeth exhibited a pronounced difference in
linear distances that were >10% of the total root length.
Depending on the location of interest, statistically
significant differences (Table 5) were observed be-
tween the imaging techniques. The most obvious
and statistically significant differences between the
two techniques were found for the following regions:
maxillary molar area (first and second) (larger dis-
tances measured with panoramic; P <0.001); maxillary
premolar area (first and second) (larger distances
measured with panoramic; P <0.001); and mandibular
central incisors (especially the mesial root contour)
(larger distances measured with intraoral; P <0.05).
Based on the results of our study, we do not recom-
mend replacing a complete set of intraoral periapical
radiographs exclusively with a panoramic radiograph
in patients with sCP or AgP. For patients with moder-
ate or superficial forms of periodontitis, panoramic ra-
diographs may be an alternative to a complete set of
intraoral radiographs with regard to a possible reduc-
tion in radiation exposure.
ACKNOWLEDGMENT
The authors report no conflicts of interest related to
this study.
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Correspondence: Dr. Ti-Sun Kim, Section for Periodontol-
ogy, Department of Operative Dentistry, University Med-
ical Hospital, Heidelberg, INF 400, 69120 Heidelberg,
Germany. Fax: 49-6221-565074; e-mail: ti-sun_kim@med.
uni-heidelberg.de.
Submitted November 7, 2007; accepted for publication
January 7, 2008.
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