A review of the reliability of radiographic measurements in estimating alveolar bone changes Benn DK: A review of the reliability of radiographic measurements in estimating alveolar bone changes. J Clin Periodontol 1990; 17: 14-21. Abstract. Despite their widespread use, dental radiographs have numerous shortcomings for measuring alveolar bone changes. In order to develop guidelines for improving the reliability of radiographic measurements, factors affecting the formation of an image were reviewed. These were considered regarding the design of a clinical monitoring system, capable of detecting the loss of small amounts of alveolar bone crest from serial films. Dentists need a monitoring system to assess whether bone loss is progressing or to judge whether a treatment is successful, 2 models were constructed to predict how long it would take to detect marginal bone loss occurring at a linear rate of 0.1 mm/year. The Ist model assumed a CEJ-crest measurement error of +0.3 mm and the second 40.9 mm, both using a 0.1 mm measuring interval. These error values were derived from the literature. The Ist model predicted it would take between 7 and 13 years for the system to measure a 1.0 mm loss in crest height caused by an actual loss of between 0.7 and 1.3 mm. The 2nd model predicted that a 1.0 mm measurement would occur between I and 19 years, caused by an actual crestal bone loss of between 0.1 and 1.9 mm, From these models, it appears that routine screening. of patients by general dental practitioners for small amounts of bone loss is unlikely to be successful without the use of (i) repositionable stentless film holders, to standardise the irradiation geometry, (ii) a very accurate reproducible measur- ing technique which (ii) will probably require an automatic computer-based measuring system. Previous reports on the measurement of bone loss less than 1.0, ‘mm are most likely measurement errors. A method of selecting radiographic examination time intervals is suggested. Review Article Douglas K. Benn Department of Community Dental Health ang Dental Practice, University College London, UK Key words: radiographs; periodontal disease; ‘measurement error; rate of bone loss; moni- toring systems. Accepted for publication 27 December 1988 Intra-oral dental radiographs are rou- tinely used to assess the status of a veolar bone and to monitor whether there has been changes in bone height since the last radiographic examination. Despite their widespread use, dental radiographs have numerous short- comings for measuring alveolar bone changes. Alveolar bone is a 3-dimensional GD) anatomical structure covering the roots of teeth. It is composed of an outer dense cortical layer covering an inner collection of delicate trabeculae. Since bone is covered by soft tissue, its structure is usually determined in- directly by irradiating it with X-rays and capturing the transmitted photons on a sensing device, such as silver halide film. The resultant 2-dimensional (2D) latent image is chemically processed to pro- duce a grey image which is viewed by backlit illumination. The clinician’s aim is to compare similarly exposed and processed films, separated by an appro- priate time interval, in order to reveal structural changes resulting from phy’ ological or pathological processes. If “small” amounts of “bone loss” can be reliably detected and measured from serial radiographs, then one can state with “confidence” that a demineralising Process has occurred during the time interval between exposures of the films. In order to design a diagnostic moni- toring system for alveolar bone changes, it is necessary to define the measuring precision required, Unfortunately, there is no common agreement as to the pre- cise mechanisms underlying crestal bone loss. Is the bone loss mainly caused by a slow process removing small amounts of mineral or by sudden bursts of activity removing several mill metres at a time (Birkedal-Hansen et al. 1988)? Do bursts encourage further bursts and if so at what intervals (So- cransky ct al, 1984)? This lack of know!- edge makes it difficult to define the re- quired measuring precision of a system by a direct approach. However, it is possible to predict. how different measuring precisions would influence the operation and clinical requirements of a monitoring system, In this way, we may be able to constrain the various design options by considering practical problems which would define what is possible rather than what is just desir- able. The purpose of this paper is () to identify those factors which influence the accuracy of a radiographic measur- ing system, (ii) to calculate the range of time required to detect bone loss with different measurement errors and inter- vals, and (iii) to examine the clinicalimplications for monitoring bone changes. Factors affecting a radiographic monitoring system lnradiation geometry Irradiation geometry describes the 3D relationships between the X-ray beam, the tissues and the sensing device which is predominantly silver halide film. It has been demonstrated by several workers (Van Der Linden & Van Aken 1970, Stoner 1974, Grondahl et al. 1984, Sewerin et al. 1987) that changes in the X-ray beam angle relative to the jaws causes a change in the relative 2D re- lationships of the anatomical structures recorded on film. Put simply, unstan- dardised film positioning can produce slightly different images for identical re~ gions of bone, and when comparing sequential films, these artificial changes could be interpreted as evidence of dis- case. In the ideal situation, every radio- graph would contain an excellent view of the interdental crest including the periodontal membrane spaces. However the curvature of the dental arch and the shape of individual roots often prevents this from being a practical goal. Indeed a horizontal movement of the X-ray tube about a vertical axis passing through the first molars is likely to make some periodontal membrane spaces appear while other disappear (Van der Linden & Van Aken 1970). Teeth with flat planar root surfaces, such as mandibular moiars, should be particularly vulnerable to changes in periodontal membrane visibility with alteration of the X-ray beam path However, teeth with conical roots, such as premolars, will appear to have more constant images If one accepts that there is no ideal or correct projection, this means some periodontal membrane spaces may never be visible for a particular patient if a constant irradiation geometry is ‘maintained for a set of serial film ex- posures. For these teeth, there is no possibility of using increasing perio- dontal membrane width as 2 sign of early bone destruction. However, for those teeth with clearly visible mem- brane spaces, the potential for seeing increased membrane width exists. It is important to realize that in any stan- dardised radiograph, it is the irradiation geometry coupled with the anatomical shape of the roots which will determine Reliability of radiographic measurements 15 which structures are visible. Hence, the sensitivity of the system for detecting early marginal bone loss of the cribri- form plate, will be determined by the irradiation geometry and will probably vary from interdental site to interdental site within the same radiograph. Exploring this theme further, one could predict that the most sensitive re- gion in the image for detecting the smallest amount of bone loss would be a clearly defined periodontal membrane space where the central X-ray path has passed tangentially to the approximal root surface. This is because the image contrast between the root, periodontal space and cribriform plate is high, to- gether with relatively simple anatomical feature shapes. If an identical amount of bone loss occurred but “further round” the root so that some dentine ‘was now in the central X-ray path, the chances of producing an image of equi- valent viewing simplicity for the human eye is reduced. If this minimal lesion should now occur in an even more unfa- vourable position, the chances of detec ting it become even more remote due to decreasing contrast. The point to grasp is that the sensitivity of the film record~ ing system has remained constant, as- suming a standardised technique, but that the position of the lesion is the controlling variable in this situation. If this minimal lesion was to increase in size, it would now be more likely to be detected by eye, due to a higher image contrast, in the previously undetectable region where it was obscured by the root. Other factors will also affect the degree of film blackening or density of this lesion feature such as the amount of buccal and lingual cortical plates in the path of the beam. In addition, the sharpness of the transition of the lesion image outline to its surrounding bone and tooth structures will depend on the degree of X-ray scattering from the cheek which tends to blur images. From the above, it would seem that the production of a lesion image on film is a complicated process which will be influenced by many factors. It may well be found that small lesions in a favour- able marginal position will produce a detectable radiographic lesion image which is against conventional clinical expectations. There are 2 reasons to forecast this. Firstly, in vitro work has shown that 0.5 mm deep cortical holes could be detected by the subtraction method (Grondahl et al. 1984). It must not be forgotten: that the subtraction technique is a method for making lesion images, which already exist on the film, visible for human appreciation. There- fore, the subtraction method demon- strates that the film technique is con- siderably more sensitive than is nor- mally expected. Secondly, investigations of the sensitivity of bitewing film for detecting in vitro enamel carious lesions has shown that very shallow 200 um deep lesions can surprisingly be seen on film, but small changes in the ir- radiation geometry can make the lesions appear or disappear (Benn & Watson 1989). Variations of the X-ray path in the horizontal plane will affect periodontal membrane space visibility, but alter- ations of the beam in the vertical plane will probably change the image of the crest bone relative to the adjacent ce- mento-enamel junction (CEJ). Al- though some work has been performed on the influence of variable beam posi- tioning and image changes (Grondahl et al. 1984, Sewerin et al. 1987), no de- tailed work regarding crest outline, infrabony pockets or periodontal mem- brane space variation, has been per- formed at the sub-millimetre level. Un- less we understand how changes in irra- tiation geometry will influence imaging of periodontal tissues, it will be difficult to determine clinically which are real tissue changes and which are method- ological errors. Itis suggested that for in vitro models to closely represent the in vivo situation, dry human skulls be used with at least 2 em of water in the X-ray path, to simulate cheek scattering increasing the image noise. Without this, it is likely that diagnostic systems will appear to have a higher sensitivity or specificity than is achievable in the clinical situ- ation (Grondahl et al. 1987). Sensing devices Restricting our study to X-ray sensing devices, we are currently limited to (a) silver halide film, (b) xeroradiography and (c) solid state silicon chip devices. Silver halide film is a mature tech- nique which will continue to be used for some time yet. Xeroradiography is a comparatively new technique which uses a charged selenium plate placed inside the mouth to detect X-rays. The image is produced as a print for viewing, and appears to contain much more in- formation than a silver halide negative. This is largely due to the edge-enbance-16 Benn ‘ment produced by the xeroradiographic process which artificially increases the rate of transition of light to dark across the boundary of an image feature such as bone crests or amalgam restorations. With the latter, itis a problem since the edge-enhancement can give rise to false regions of secondary caries-like features being produced in the print (White & Gratt 1979, Gratt et al. 1980). Although to the eye the xeroradiograph appears to be a superior image, it needs to be shown by experimentation with stan- dard test skulls that the technique is not adversely affecting the detection of bone compared to conventional films. It will be necessary, using a computer, to measure the rate of gray level gradient changes of an alveolar bone crest over a distance of 0.2 mm in a xeroradiograph compared with a silver halide image. This is to determine if the edge-enhance- ment introduces changes which at this small scale actually reduce sensitivity for detecting small image features. As will be seen later, measurement accu- racy of Standard Deviation (SD)+0.1 ‘mm will be extremely important for de- tecting bone loss, and all components of the system need to be studied for properties which will limit measuring sensitivity. Solid state X-ray sensing devices are now commercially available instead of film (Trophy Ltd., Paris, France). The device, connected to a computer, is placed in the mouth. Immediately after irradiating the patient, an image is formed which can either be stored or printed out. Although the patient dose is about of that required for film, the current sensor has an area } of a number 2 size film, This means that more ex- posures have to be made to cover the same amount of the teeth and bone, increasing the patient dose to about 4 the film dose, assuming strict collima- tion of the beam. With a 6 cm open cone, multiple periapicals will probably produce a similar dose to normal film. However, despite this, solid state sen- sors are significant new devices which ‘when they become larger, will speed the development of automatic image pro- cessing systems for measuring bone loss. Choice of film technique When exposing patients to ionising radiation, a balance has to be achieved between the diagnostic yield of infor- ‘mation produced and the radiation dose absorbed by the patient for any given technique. Panoramic radiographs pro- vide an excellent overview of the jaws with a low radiation dose and it has been suggested that areas of interest, either a region of poor image quality or potential disease, can be supplemented by intra-oral radiographs (Hirschmann 1987). However, it is difficult to accu- rately reproduce the irradiation ge- ometry for these extra-oral films, and only a minority of dentists own these machines. Intra-oral examination of alveolar bone can be performed by either one or two posterior bitewings for each side or by a 20 film complete-mouth survey. It hhas been calculated that there is a 12x reduction in the risk of radiation-in- duced cancer using 2 bitewings com- pared to a complete-mouth survey (Un- erhill et al. 1988). A patient who has suffered less than 4 mm of crestal bone loss will have adequate visualisation of the maxillary and mandibular interden- tal regions, from the distal surface of the canine to the distal surface of the second molar, using a single horizontal bitewing. For patients with more exten- sive bone loss, vertical bitewing films can be used. Periapical views, although showing more root, are unlikely to re- veal any more useful information, es- pecially in the large and growing pro- portion of patients who have no caries or minimal restorations and are unlikely to have pulpal pathology. From a popu- lation-screening viewpoint, it would seem sensible for dentists to consider routinely using only a single number 2 size horizontal bitewing per side which could be supplemented by a second bite- wing if the jaw is long. Patients with signs of posterior marginal bone loss are likely to have anterior crestal loss which would be an indication for radio- graphing the anterior teeth. If active marginal bone loss or caries is sus- pected, then obviously the number and type of radiographs should be varied to ‘match the clinical needs. Clinical processing of latent images Although film fogging due to poor dar- K-room procedures is a potential prob- lem, it is relatively easy in the clinical situation to obtain consistently good- quality images with only moderate ef- fort, as described in standard text books. However, there is a need to in- vestigate experimentally the stability of image features over the normal operat- ing range of condi the clinical setting. Although there are existing manufacturers’ recommen- dations, these have been produced for human subjective viewing and interpret- ation, With computers capable of objec- tively recording individual film areas (pixels) as small as 0.05 by 0.05 mm, it is necessary to be able to state what are the processing conditions required to stabilise the latent film image features It may well be that itis not the computer system optics which limit the feature resolution but the practical problems in standardising the irradiation and pro- cessing of films, Reliability of determining reference points and measuring distances between them Conventionally, bone loss is measured in relation to the distance between the CEJ and the alveolar crest. If the dis- tance is greater than a preset limit, which varies in the literature from greater than 1.0 mm (Lennon & Davies 1974, Hugoson & Rylander 1982, Mann etal. 1985), greater than 1.5mm (Davies et al. 1978), greater than 2.0 mm (Hoov- er et al. 1981, Kronauer et al. 1986), to over 3,0 mm (Blankenstein et al. 1978, Latchman et al. 1983), then bone loss has occurred. What should this initial threshold be for detecting bone loss? From the previous discussion above on irradiation geometry, it would seem un- likely, even in a perfectly healthy mouth with no bone loss, that bone crests in different parts of the mouth would all be projected to the same distance from the CEJ. If the physiological distance of the CE! to alveolar crest is set at 1.5 mm and geometric projection errors of 0.5 mm produce a range of 1.00 to 2.00 mm CE3-crest distances, then a number of areas will be incorrectly classified as having suffered bone loss, while others will have “gained” 0.5 mm. This latter group will be likely to suffer from false negative reporting until at least 0.5 mm of bone has been lost. As- suming that a linear loss of bone of 0.1 mm per year was occurring, ignoring measurement errors, it would take 5 years of bone loss to reach the critical 1.5 mm threshold to detect bone loss. It would seem sensible from this argument to abandon an initial distance threshold for indicating disease has occurred if small amounts of bone loss are to be detected. Instead, the initial CEJ-crest. distance would be used as the reference for measuring further loss. If the initial radiographs are taken when the perma-nent teeth are erupted and occluding at about 11-12 years of age, this would seem to provide a reliable base-line for measuring bone loss using a standard- ised film holder technique. Although such an approach would remove the problem of setting an initial disease distance threshold, there is still a need to decide what increase of CEJ- crest distance can be accepted with con- fidence to indicate bone loss has oc- curred. To select this, one needs to look at the measuring error of the system and then its effect on detecting disease. First, the accuracy of determining the CEJ and the alveolar crest should be considered. If these 3D anatomical structures could be projected onto a 2D dot of very small size, it could be stated with a high degree of confidence that the CEJ-crest distance was dependant solely on the precision of our ruler or other measuring device in recording distance. Unfortunately, this is not the case and often the CEJ isa diffuse image feature or may even appear as a double structure on some maxillary molars. Similarly, the alveolar crest may have 2 diffuse image quality in the region required and a degree of “judgement” is required in identifying it. These diffuse image reference points are likely to be a cause of measurement error (Fig. 1). It is possible to give an estimate of this problem by assuming a single Standard Deviation (SD) error of +0.1 mm in identifying the position of the CEJ and a similar error for the crest The SD of the CEJ-crest distance is £0.14 mm, derived from the square root of the sum of the CEJ SD squared and the crest SD squared. The 95% con- fidence level in measuring this distance is 1.96 SD, or in this case, approximately £03 mm. If one assumes a 0.1 mm/ year rate of linear bone loss, the 95% confidence limits of the measuring error can be calculated (Table 1). In order to detect bone loss, the observed measure- ‘ments must be outside the error limit. If the threshold for detection has been set at 1.0 mm, bone loss will be reported at a minimum of 7 years and a maximum of 13 years. One should also be cautious regarding the under-reading errors which could be mistakenly inter- preted during the first 2 years as evi- dence of bone deposition. These figures should be borne in mind when designing clinical trials for detecting small amounts of bone loss. Although in the model, a mean rate of 0.1 mm of bone loss pet year was Reliability of radiographic measurements 17 assumed, in an individual patient, bone resorption could be slower, faster or even intermittent. However, itis imposs- ible to record these variations as separ ate entities, since serial films show the total change over a period of time which is equivalent to a mean rate. When de- signing a radiographic measuring sys- tem, the smallest amount of bone loss which can be reliably measured deter- mines the accuracy. For the model, it was felt that a mean rate of 0.1 mm/ year was a good test for a system, since ‘any method which could accurately de- tect this amount of bone loss would cover the whole clinical spectrum of slow to fast rates of resorption, together with bursts The above model relates to a high precision measuring system, but how does it compare with real clinical sys- tems? A study using occlusal regi tration of the film holders and a compu- terised plotter, reported a SD +0.16 mm. for repeated measurements of radio- graphs with distinct CEJs and crestal alveolar bone (Goodson et al. 1984) This figure is very close to the assumed Table 1, Predicted range of error values for 0.1 mm of actual bone loss per year with +0.3 mm CEJ-crest measurement error error in Table 1. However, despite the very rigorous clinical technique, 12% of the measurement sites were excluded from the study, since they fell outside the error limits, ‘Another study reported that 82% of CEl-crest_ measurements repeated on the same radiographs, had an error range of 0 to 0.4 mm using a 0.1 mm ‘measuring interval (Teiwik et al. 1984). Using areas in a tail of a normal distri- bution, these error measurements imply a SD+0.45 mm assuming a mean of 0. This figure agrees well with the SD+ 0.44 mm reported in a recent paper (Pa- papanou et al. 1988) and another of SD+£0.37 mm (Albandar et al. 1986). If one calculates the 95% confidence level for these larger errors, they are approxi- mately +0.9 mm, which is 3 times the size of our first model. This could result in a measurement of 1.0 mm bone loss being reported by the system between | and 19 years (Table 2). It would seem that the measurement errors in most of the current manual ‘measuring systems are too high to detect small amounts of bone loss over a short Table 2. Predicted range of error values for 0.1 mm of actual bone loss per year with 9 mm CEl-crest measurement error ‘Actual Measurement error ‘Actual Measurement error cumulative CEI-crest distance cumulative CEJ-crest distance Year _loss (mm) £03 mm Year _ loss (mm) £09 mm. ft Ol =0.2 1 4 =08 04 Lory 2 02 01 2 02 =07 os Ld 3 03 0 3 03 =06 06 12 4 04 on 4 o4 —05 07 13 3 05 02 3 05 04 08 La 6 06 03 6 06 —03 09 Ls. 7 07 04 7 oF =02 Lo 16 8 08 05 8 08 —01 1 17. 1 Neamt eet i \ B 13 10" 19 19 10 16 2818 Benn SS DENTINE| ENAMEL ~ cer CREST ESTIMATED S.D. OF MEASUREMENT mm : COMBINED S.D.+ 0,14 Fig. 1. Errors in identifying anatomical reference points. The positional errors made in identifying the CEJ and alveolar crest measuring points add together, producing an ertor in the CEJ to crest distance. An error of one SD+£0.1 mm in the position of each point will produce a combined SD error-+0.14 mm in the CEJ-crest distance. At the 95% confidence level, this measurement error increases to ++0.3 mm, time period. There is also a risk of inter- preting negative measurement errors as bone gain. This could be taken as an indication of a reparative phase in the natural history of the disease processes. Unless measurement errors of SD+0.14 mm or less can be achieved, it seems unlikely that the existence of a disease process removing small amounts of bone over many years can either be proved or disproved Intervals for routine radiographic ‘examinations The current radiographic examination interval is determined more by office routine than by the patients” dental sta- tus or anticipated diagnostic yield. Jen- sen et al. (1987) found that the average bitewing interval was 18 months and related to a 9-monthly recall period. In another study, it was found that in pa- tients aged over 15 years, only 8% had radiographs taken for periodontal diag- nosis (Osman et al. 1986), In the current state of ignorance con- cerning the progression rates of the periodontal diseases, should there be one fixed interval or variable periods for routine screening periods? Using the bone loss figures in Tables | and 2, it would seem illogical to have bitewings taken every year. However, if a baseline set of bitewings were taken at 12 years of age, which coincides with the time of peak caries incidence on approximal surfaces of first permanent molars, and a further set | year later, rapid bone loss or caries progression should be detect- able (Kronmiller et al. 1988). However, if neither disease was detected, one could be confident, providing it was possible to achieve the higher measuring Precision in Table 1, that if bone loss was occurring, it would be less than or equal to 0.2 mm/year. On that basis, it would be safe to delay taking further bitewings for a further 24 months or the end of year 3 from the baseline, If at the end of this period no approximal caries or bone loss was detected, a 36- ‘monthly monitoring period could be in- stituted (Joseph 1987). Bursts of bone loss with an expected magnitude of at least 1.0 mm should be detected with high reliability by the system precision defined above. Since bursts are supposed to be random events with a very short active period of only a few days, it is difficult to see how the detection of a single burst should alter the radiographic monitor- ing interval. Should further bitewings be taken at 3 months after the discovery of the burst, even though the burst may have occurred up to 3 years previously just after the last radiographs were made? What is the prognostic signifi- cance of discovering a solitary burst? Perhaps the only practical approach to take is to ensure that this is not a sign of systemic disease by taking another 2 bitewings in 3 months. If no further bone loss is detected, the patient is re- turned to a 2-year monitoring period, and provided a disease-free status is maintained a 3-year period is ultimately adopted, There is currently insufficient infor- mation, due to unreliable techniques, to choose the correct time intervals. How- ever it is possible to avoid routine inter- vals which are not of diagnostic rel- evance. Objective feature representations The positional errors in identifying the CEJ, alveolar crest or any other refer- ence point, is due to a lack of agreed objective criteria for definition of these features in imaging terms. It is insuf- ficient to state that one has measured from the alveolar crest, if measurements of sub-millimetre precision are required. Instead it will be necessary to use com- puter imaging techniques to describe a feature in terms of its area, grey level gradients and any other characteristics which will make the identification of reference points highly reproducible to ideally a maximum error of +0.1 mm about a central point. A simple example of an image feature representation could be an alveolar crest defined as a region with a certain grey level gradient between an interdental space and the bone. The correctness of this representation can be tested for uniqueness and continuity (Cohen & Feigenbaum 1982). By uniqueness is ‘meant that for each different image of a crest, a unique value of the represen- tation should exist to describe the crest.However, it is also important to have continuity where similar crest images have similar values in the represen- tation. Representations which produce image features which change drastically with small alterations in an image should be avoided. In practical terms, an image represen- tation can be tested for uniqueness by repeatedly applying it automatically to the same radiograph. Every image will vary slightly due to electronic noise, but the boundary of the crest as outlined by the computer should change very little if the representation is correct. Conti- nity of the representation can be exam- ined by using images produced by irra~ diating dry skulls with a known small angular variation of the X-ray beam relative to the jaws. Here the images will have slight variations in the crest shape due to irradiation geometry changes. ‘An image representation for crests ex- hibiting continuity will produce a com- puter outline of the crests which will match the changes caused by the ir- radiation geometry changes. If the rep- resentation chosen is poor, large changes in the crest outline chosen by the computer will occur, despite there being little variation in the radiographic images. A more extensive discussion of this topic is outside the scope of this paper. Existing computer systems Currently, the image subtraction ‘method has a large following as a re- search tool and even as a potential clin- ical monitoring method (McHenry et al 1987, Jeffcoat et al. 1987, Braegger et al. 1988). However, this technique suffers from 2 major weaknesses. Firstly, there is no computational representation for any anatomical features in the images. This means there is no objective descrip- tion for alveolar crests, periodontal membranes, CEJs or any other struc- tures. As a direct consequence, absolute standardisation is required in the X-ray machine output, irradiation geometry, film emulsion, film processing and im- aging system, in order to guarantee that when 2 images are subtracted, only dis- cease changes are shown as light or dark patches in the subtracted image. The interpretation of these patches is de- pendent on clinical subjective assess- ment which is error prone, whereas ob- jective image representations have the potential for automatic feature meas- Reliability of radiographic measurements 19 urements. The current image subtrac- tion techniques are computer-assisted subjective methods and should not be confused with fully automatic systems. The second drawback of the subtrac- tion method is that in an attempt to achieve a very high degree of standardi- sation, occlusal moulds are required for every patient. This will almost certainly preclude the subtraction method from becoming a routine general dental oper- ative procedure. Even with a great deal of research effort, the published results leads one to suspect that the subtraction method has a high risk of introducing artificial dis- ease changes into the images (McHenry et al. 1987, Braegger et al. 1988, Benn 1988). Possible solutions In order to monitor alveolar bone loss more accurately, standardised film hol- ders are needed to reduce irradiation ‘geometry errors in the images. These holders should be simple and quick to use, enabling general dental prac- titioners to obtain longitudinal series of films for their own patients. The author has designed a stentless repositionable film holder which is currently undergo- ing clinical trials. If it transpires that a significant pro- portion of the population does suffer from slow rates of crestal bone loss, it will be impossible to monitor this by looking at radiographs. This is due to the time required to make manual high- precision measurements using magnifi- cation methods at the chairside, and to the probability of subjective errors. The solution will be to develop automatic computer-based monitoring systems. Providing that the correct objective computer representations are chosen for the image features, which are absent in the subtraction technique, there is every hope that computers will be successful tools in monitoring bone loss. Conclusions The accurate measurement of small amounts of alveolar bone lost slowly over several years requires a monitoring system with small errors in determining the anatomical reference points and a small measurement interval. Evidence suggests that the current measurement techniques are insufficiently sensitive to measure true bone loss until at least 1.0 mm has occurred. Researchers are probably reporting measurement errors as bone loss or gain. In order to design a clinical monitoring system suitable for use by general dental practitioners, more accurate and simple to use tech niques are needed. These will require stentless repositionable film holders and an automatic computer-based measur- ing system. Radiography reveals evidence of changes caused by past disease and at best will allow us to divide patients into various risk categories. It may also aid clinicians in assessing the effect of new treatments to prevent or repair bone damage over comparatively long per- iods of time. It will not provide evidence of current disease, since it is incapable of detecting macromolecular changes which are best detected by biochemical techniques. Radiography is a cheap, quick and within certain limits, an accu- rate method for longitudinal monitor- ing of alveolar bone loss. However, having identified our patient as having suffered excessive rates of bone loss, we will need further as yet undeveloped tests to observe how our new therapies are performing. Acknowledgements Iam most grateful to Professor Aubrey Sheiham for his advice and guidance in the preparation of this paper. Zusammentassung Ein Uberblickiber die Zuverlssigheit rinige- nographischer Messungen bei der Beurteilang der Verdnderungen des alveoliren Knochens ‘Trotz weitverbreteter Anwendung beim Ab- lesen alveolirer Knochenverdnderungeo, sind Zahnrdntgenaufnalnmen mit zahlreichen Mangeln behafiet. Um Richtlinien 2ur Ver~ besserung der Zuverlissigkeit réntgenogra- phischer Messungen zu entwickeln, wurden Faktoren besprochen, die das Entstchen cines Bildes beeinflussen. Diese Faktoren wurden im Hinblick auf die Konstruktion eines klini- schen Uberwachungssystems gesichtct, das imstande ist den Verlust geringer Mengen al- veoliren Knochens bei Réntgenaufnahme- Serien zu entdecken, Zahnirzte bendtigen cin Beurtcilungssystem das erlaubt, die Progres- sion des Knochenveriustes festzustellen oder auch, um die Beurtelung des Behandlungser- folges zu erméglichen, Zur Voraussage, wie lange es dauern wirde einen linearen Kno- chenverlust von 0.1 mm pro Jabr zu ent- decken, wurden 2 Mogelle konstruiert. Beim ersten Modell wurde beim Messen der alveo- laren Knochenleiste cin Messirrtum von £03 mm angenommen und beim zweiten von +0.9 mm ~ bei beiden war ein Messab-20 Benn stand von 0.1 mm vorhanden. Diese Irrtums- werte warden dem Sehriftum entnommen, Die nach dem ersten Modell vorgenommenen Messungen sagten voraus, dass es bei diesem ‘System zwischen 7 und 13 Jahre dauern wit de, um einen HOhenverlust des Alveolarkam- ‘mes von 1.0 mm zu messen, dem der tatsich- liche Verlust von zwischen 0.7 und 1.3 mm zugrunde liegt. Die Messungen nach dem zweiten Modell kamen zu der Voraussage, dass cine 1.0 mm Knochenverlustmessung zwischen 1-19 Jahre dauern wide, verur- sacht durch einen tatsdchlichen Verlust des Knéchernen Alveolarkammes zwischen 0.1 und 1.9 mm. Diesen Modeliversuchen kann centnommen werden, dass es kaum wabr- scheinlich ist, dass routinemaissige Reihenun- tersuchungen von Patienten in der zahnarzti- chen Allgemeinpraxis zur Entdeckung gerin- ger Knochenverluste erfolgversprechend sein knnen, wenn nicht (i) wiedereinsetzbare sta bile Filmhalter zur Standardisierung der Strahlengeomettie und (i) cine sehr genaue Messtechnik. die (il) wahrscheinlich ein au- {omatisches Mess-System auf Computerbasis beinhaltet, angewandt wird. Bei friheren Mitteilungen iber Knothenverlust-Messun- 1gen unter 1,0 mm handelt es sich wahrschein- lich um Messichler. Es wird eine Methode dder Wahl zur Enmittlung zetlicher Abstinde ‘wischen ROnigenuntersuchungen —vorge- schlagen Une revue de laluérature concernant la fiai- lué des mesures radiographiques pour estimer les variations osseuses alolaires Maleré leur utilisation tr répandue, le ra- diographies dentaires ont de nombreuses li- miations dans l'évaluation des changements de os alvéolaie. Afin de développer des li- anes de conduite pour ameéliorer la fiabilité des mesures radiographiques, des facteur fMuengant la formation d'une image ont ét@ revus, Ils ont été considérés en analysant un projet de systéme clinique capable de détecter la perte de petites quantités d'os de la eréte alvéolaire & partir de films en série. Les den- listes ont besoin d'un systéme d'analyse leur Permettant de voir st la perte osseuse est en progression ou de juger si un traitement & séussi. Deux modéles ont &t@ construits pour prédire le temps nécessaire un taux linéaire de 0.1 mm par an. Le premier admet une erreur de mesure de la jonction émail-cément au rebord alvéolaite de +0.3 mm tandis que le second accepte +0,9 mm, les deux modéles utilisant un intervalle de mesure de 0.1 mm. Ces valeurs d'erreur ont été puisées dans la littérature. Le premier modele prévoyait qu’ faudrait entre 7et 13 années au systéme pour ‘mesurer une perte osseuse verticale de 1.0 ‘mm (causé par une perte réelle de 0.7 a 1.3 mm). Le second prévoyait que ostte mesure prendrait entre let 19 années (perteréele de 0.1 & 1.9 mm). I! semble donc que les visites de dpistage de petite perte osseuseeffectuées par les pénéralistes ont peu de chance de suc- és sans Iutilisation (1) d’un systéme porte- films permettant de standardiser la géométrie de Virradiation, (2) d'une technique de mesu- re parfaitement imitable (3) qui devrait vrai- semblablement nécessiter un systéme auto- ‘matique de mesure assité d'un ordinateur. Des mesures de pertes osseuses inférieures & | mm, rapportées précédemment, sont proba- blement dues a des erreurs de mesure. Une méthode de sélection des intervalles de temps lors d’un examen radiographique est sug- corde. References Albandar, J. M., Rise, J, Gjermo, P. & Johansen, J. R. 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