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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 26  |  Issue : 1  |  Page : 34-41

In vivo comparison of Kodak E-speed film and direct digital imaging system for assessment of interproximal bone loss


1 Department of Oral Medicine and Radiology, College of Dental Sciences, Davangere, Karnataka, India
2 Department of Oral Medicine and Radiology, Rungta College of Dental Science and Research, Rungta Educational Campus, Bhilai, Chhattisgarh, India
3 Department of Oral Medicine and Radiology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Haryana, India

Date of Submission11-Mar-2014
Date of Acceptance14-Jul-2014
Date of Web Publication26-Sep-2014

Correspondence Address:
Mellekatte C Neetha
Department of Oral Medicine and Radiology, College of Dental Sciences, Pavilion Road, Davangere - 577 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.141849

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   Abstract 

Aims: To evaluate the diagnostic accuracy of direct digital radiography as compared to a conventional radiographic film for the assessment of interproximal bone loss with intrasurgical measurements as the gold standard. Materials and Methods: A total of 100 patients, with untreated moderate-to-advanced periodontal disease, were included in the study. The presurgical radiographs were made using a Kodak E-speed film and a Dexis digital sensor simultaneously, for sites with interproximal bone loss. At the time of surgery, the distance from the cementoenamel junction to the bone defect (CEJ-BD) was measured for 331 interproximal defects. The radiographs were randomized and then linear measurements were taken for the same sites in both conventional and digital radiographs. Stastistical Analysis: Comparison between the conventional, digital, and intrasurgical measurements was done statistically using the Student's t-test. The agreement and correlation among the methods was assessed using the weighted Kappa measure of agreement and Pearson's correlation, respectively. Results: The results showed that the conventional (5.15 ± 2.19 mm) and digital analyzing techniques (5.13 ± 2.19 mm) underestimated the interproximal bone loss, as compared to the intrasurgical measurements (6.07 ± 2.05 mm) (p < 0.001). The difference between conventional and digital radiographic methods was found to be statistically insignificant (p = 0.92). Conclusion: Under normal clinical use, the alveolar bone levels revealed on intraoral direct digital radiographs and Kodak E speed film were almost same. Therefore, the digital radiographic system can be routinely used in clinical practice as an alternative to conventional film.

Keywords: Dexis, direct digital radiography, interproximal bone loss, in vivo comparative study, linear measurement


How to cite this article:
Neetha MC, Shashikanth MC, Kalappanavar AN, Ali IM, Shambulingappa P. In vivo comparison of Kodak E-speed film and direct digital imaging system for assessment of interproximal bone loss . J Indian Acad Oral Med Radiol 2014;26:34-41

How to cite this URL:
Neetha MC, Shashikanth MC, Kalappanavar AN, Ali IM, Shambulingappa P. In vivo comparison of Kodak E-speed film and direct digital imaging system for assessment of interproximal bone loss . J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2020 Feb 18];26:34-41. Available from: http://www.jiaomr.in/text.asp?2014/26/1/34/141849


   Introduction Top


Alveolar bone loss associated with periodontitis can be assessed conventionally using dental radiographs. Over the past few years, systems that generate radiographic digital images without the need for radiographic film are available.These digital radiographic systems contain a solid state detector, sensitive to x-rays, and they have many positive attributes over the silver halide film.

The Dexis charge coupled device (CCD)-based direct digital imaging system is one of the systems available for use in intraoral radiography. The Dexis digital system has been stated to have a superior image quality after it has been tested for various tasks like caries detection, [1] endodontic file length determination, [2] and in the detection of marginal defects of composite restorations. [3] To date, the utility of Dexis digital imaging for periodontal bone loss has not been reported. A few studies that have been conducted to evaluate alveolar bone loss use other direct digital imaging devices, [4],[5] a storage phosphor system, [6] and digitized conventional radiographs, [7],[8],[9],[10],[11],[12],[13] and most of these were performed in vitro.

Therefore, the present study was undertaken to compare the diagnostic performance of the Dexis digital radiographic system with that of conventional radiography for the assessment of interproximal bone loss in vivo, utilizing surgical measurements as the gold standard.


   Materials and Methods Top


This is an in vivo comparative study where an E-speed plus film (Ekta speed Plus Size 2, Eastman Kodak, Rochester, New York) and digital sensors (Dexis Digital Imaging Systems) were compared for the assessment of the linear measurements of interproximal bone loss. All the measurements were done after randomization and compared with the intrasurgical measurements as the gold standard. A total of 100 subjects with moderate-to-advanced untreated periodontal disease, who were to be scheduled for periodontal treatment and patients willing for radiographic examination were included in the study. Patients with any contraindications for surgery, pregnant patients, and patients presenting with fixed prosthesis or class II amalgam restorations at the region of interest were excluded. Signed informed consent was obtained from the patients before including them in the study and ethical clearance was obtained from the Institutional Ethical Committee.

After completion of the initial periodontal treatment, including oral hygiene instruction and scaling, a radiographic examination was done for the teeth exhibiting interproximal bone loss, using the paralleling cone technique. For the radiographic examination, a sealed film package, without lead foil, was placed in front of the Dexis charge-coupled device detector for simultaneous x-ray exposure [Figure 1] and [Figure 2]. In this manner, the geometry of the images recorded with both the imaging modalities was standardized. Prior to exposure of the E-speed film, the lead foil was removed from the film packages in the dark room, under safe lighting, and sealed with black adhesive tapes of polyvinyl, to prevent any light leakage during radiographic examination. A pilot study was carried out to ascertain the optimal exposure time for a combined E-speed film and Dexis intraoral sensor exposure. The optimal exposure time determined was 0.6 seconds, with a 65 kilovoltage peak, and 8 milliamperes.
Figure 1: Dexis charge-coupled device and Kodak E-speed film on the film holder for simultaneous exposure

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Figure 2: Patient positioning for simultaneous exposure

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After exposure, the digital images were immediately displayed on the monitor. Subsequently, the images were numbered for identification. The exposed E-speed films were stored in a lightproof box and placed in the dark room until they were processed. All the films were processed manually in a well-equipped, light-proof, dark room, as described by White and Pharaoh. [14] The processing solution were prepared and used according to the manufacturer's directions. All the exposed films were processed in four increments.

Immediately before surgery, the probing Pocket Depth (PD) and Clinical Attachment Level (CAL) were measured to the nearest 0.5 mm, using a straight periodontal probe (PCPUNC 15, Hu-Friedy, Chicago, III). Next, the distance from the cementoenamel junction (CEJ) to the most apical extension of the bony defect (BD) was measured to the nearest 0.5 mm, using the same probe after reflection of a full thickness flap [Figure 3]. All the clinical measurements were performed by one examiner. For all the defects, two surgical assessments were performed at the interproximal defects - the mesiobuccal and mesiolingual, and distobuccal and distolingual measurements. The highest score of both the measurements was considered.
Figure 3: Intrasurgical measurement of interproximal bone loss

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The CEJ was defined as the most apical extent of the enamel that interfaced with both the root surfaces of the interproximal space. This location was defined by two features:

  • Interface between the enamel and root surface, as indicated by a change in density
  • Location of a definite change in contour between the crown and root along the lateral border of the tooth.


Surfaces with a non-identifiable CEJ due to overlapping or restorations were excluded.

The most coronal point that showed a continuous width of periodontal ligament space was defined as the bottom of the BD. If the periodontal ligament space was difficult to identify then the point on the root surface crossed by the projection of the alveolar crest was taken as the landmark. If more than one bony contour could be identified then the most apical contour that crossed the root surface was defined as the BD.

The processed radiographs were randomly coded and mounted on a mount in such a way that the identification of the films was totally concealed. The conventional radiographic measurements were done using the profile projector (Model V-12, Nikon Corporation, Japan), which projected the radiographic images at a magnification of 10x [Figure 4]. The radiographs were viewed on the viewing screens provided with a linear encoder (crossed lines) engraved on fine-grain ground glass. This linear encoder was connected to a digital micrometer (DP 200, Nikon, Japan) that was capable of automatically displaying the readings of two-dimensional measurements with an accuracy of 0.001 mm.
Figure 4: Profile projector used for conventional radiographic interpretation

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For measurements, the long axis of the tooth was oriented to the long axis of the linear encoder and the distance from the CEJ to the BD was measured on both the mesial and distal aspects by coinciding the crossed lines at the CEJ first, and then the crossed lines were brought to the bottom of defect (BD). The distance between the two points was automatically displayed on the micrometer [Figure 5].
Figure 5: Conventional radiographic measurement of interproximal bone loss

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The same examiner determined all the digital radiographic measurements. The images were viewed on the monitor of a personal computer and the viewing conditions for the film and digital images were made as similar as possible. The landmarks, CEJ and BD, were marked on the screen and the distance between the points was measured digitally using the Dexis software program, with an accuracy of 0.1 mm [Figure 6]. After 10 days, both the conventional and digital radiographs were reassessed using the same viewing conditions. This would help to assess for any intraobserver variability that might have occurred between the two sessions.
Figure 6: Dexis digital radiographic measurement of interproximal bone loss

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To estimate the accuracy and validity of the radiographic measurements, the distances that were measured on the conventional and digital radiographs were compared to the gold standard of the surgical assessments. The mean value and the difference between the conventional and the digital measurements were compared with the intrasurgical measurements, using the Student's t-test (unpaired). Agreement in the assessment of interproximal bone loss by various methods was measured using the weighted Kappa measure of agreement. The Pearson's correlation was computed to examine the correlation between the various methods. The reproducibility of the two methods (intraobserver reliability) was assessed by comparing the mean difference between the first and second measurements using the paired t-test.


   Results Top


Out of a 100 subjects studied 50 were females and 50 were males and the age ranged from 17 years to 50 years. A total of 186 teeth were evaluated separately for both the mesial (165) and distal (166) surfaces resulting in 331 interproximal surfaces. The linear distance from the CEJ to BD at each interproximal surface was measured using the conventional, digital radiographic method, and the surgical method.

The mean and standard deviation in the measurement of distance from the CEJ to BD for all the three methods is shown in [Table 1]. Both conventional and digital measurements significantly (P < 0.001) underestimated the amount of interproximal bone loss, when compared to the intrasurgical measurements (in mm). The conventional measurements underestimated the surgical measurements by a mean value of −0.92 and a standard deviation of ±0.40, the differences ranged from −2.5 to 0.00. The digital measurements underestimated the surgical measurements by a mean value of −0.94 and a standard deviation of ±0.41, the difference ranged from −2.5 to −0.20.
Table 1: Mean intrasurgical and radiographic (conventional and digital) measurements of 331 interproximal lesions

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The mean difference between the conventional and digital radiographic methods was 0.02 ± 0.08 with a range of −0.2 to 0.20 and the difference was statistically nonsignificant (P = 0.92).

Furthermore, when the mean of the difference between the conventional and intrasurgical assessment (C-S) and the mean of difference between digital and intrasurgical measurements (D-S) were analyzed statistically, no significant difference was noted (P = 0.56) [Table 2].
Table 2: Comparison of conventional and digital radiographic measurements with intrasurgical measurements

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The contingency tables were created by cross-tabulating the bone level measurements from the conventional, digital, and surgical methods by the number of sites assigned to each of the seven bone level categories: <4 mm, 4-6 mm, 6-8 mm, 8-10 mm, 10-12 mm, 12-14 mm, and >14 mm. Next, the agreement in the assessment of bone level by various methods was measured using the weighted Kappa measure of agreement. On comparison of the conventional and surgical methods there was agreement in 136 sites (41.1%) and disagreement in 195 sites (58.9%), which indicated a fair agreement between the methods (Kappa value 0.49) [Table 3]. When the digital and surgical methods were compared, there was an agreement in 139 sites (42%) and disagreement in 192 sites (58%), which indicated a fair agreement between the methods (Kappa Score 0.48) [Table 4]. There was agreement between the conventional and digital methods in 320 sites (96.7%) and disagreement in 11 sites (3.3%), which indicated a very good agreement between the methods (Kappa value of 0.95) [Table 5].
Table 3: Contingency analysis of surgical measurements by conventional measurements in terms of bone level assessment

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Table 4: Contingency analysis of surgical measurements by digital measurements in terms of bone level assessment

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Table 5: Contingency analysis of conventional measurements by digital measurements in terms of bone level assessment

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When comparison of the conventional or digital with surgical measurements was done in terms of deviation in measurements of the bone height, there was absolute agreement on only one site (0.3%) between conventional and surgical measurements, and none of the sites on the digital radiographs showed absolute agreement, and when the criterion for agreement had widened to include sites with a difference of 0.1-1.5 mm there were 306 sites (92.4%) on the conventional radiographs and 311 sites (93.9%) on the digital radiographs showing agreement with the surgical measurements [Table 6].
Table 6: Comparison of conventional and digital measurements with surgical measurements in terms of deviation in measurements of bone height

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The comparison of conventional and digital measurements was done in terms of deviation in measurements of bone height. There was absolute agreement in 163 sites (49.2%) and when the criteria for agreement was widened to include recording with a difference of ±0.5 mm there was agreement in all the 331 sites (100%) [Graph 1]. [Additional file 1]

The Pearson's correlation was computed to examine the correlation between the various methods. There was a significant correlation of r = 0.98 between the conventional and surgical methods (p < 0.001) and digital and surgical (P < 0.001) methods, which indicated that the difference between the conventional and surgical, as well as digital and surgical measurements was consistent. The correlation between the conventional and digital measurements was very strong with r = 0.99 (P < 0.001), which indicated that the two radiographic methods maintained consistent ordering of observations [Table 7].
Table 7: Correlation between various measurements

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Reproducibility of the two methods (intraobserver reliability) was assessed by comparing the mean difference between the first and second measurements. For the conventional radiographic method the mean difference between the two measurements was −0.02, which was statistically insignificant (P value = 0.06). Agreement between the first and second assessments was seen in 90.33% of the sites and 9.67% showed disagreement. For the digital radiographic method the mean difference between the two measurements was 0.01, which was statistically insignificant (P value = 0.34). Agreement between the first and second assessments was seen in 84.9% of the sites and 15.1% of the sites showed disagreement [Table 8].
Table 8: Measure of repeatability

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   Discussion Top


A total of 331 interproximal surfaces were evaluated using conventional and digital radiographic methods, which were exposed simultaneously, to obtain identical projection geometry. The lead foil from the film packets was removed and the film was placed in front of the sensor for simultaneous exposure. Price C, [15] Versteeg et al., [16] and Kaeppler et al. [6] reported that the low-contrast resolution of the film, with and without lead foil, was comparable. Therefore, we assumed that the removal of the lead foil neither affected the visibility of the anatomical structures nor the accuracy of the measurements made in the study. In our study we employed the long cone paralleling technique of periapical radiography, as the sample studied comprised of patients with moderate-to-advanced bone loss and the technique enabled extensive coverage of the alveolar bone level in the apical direction.

The crestal bone level has often been measured using relative measurements, expressed as a proportion of tooth or root length. [17],[18] However, some authors believe that absolute or direct millimetric measurements are more valid. [19],[20],[21] We chose to use the absolute or direct millimetric measurement because it had to reflect the effect of the periodontal disease unaffected by the length of the root, and use of the millimeter might also have a better reproducibility and readability as compared to the relative measurements.

The present study showed that both the radiographic techniques underestimated the amount of interproximal bone loss when compared to the intrasurgical measurements and the difference was highly significant (P < 0.001) [Table 2]. To the best of our knowledge, no in vivo study has been conducted comparing interproximal bone loss measurements made on conventional and direct digital radiographs with those of surgical measurements. Therefore, the results of our study cannot be directly compared to any other study. However, our observations are similar to studies reported by Eickholz et al. (1996) [8] and Eickholz et al. (1998), [9] where the radiographs were digitized and assessed and also studies by Hildebolt et al. [22] and Scaf G, [23] which were in vitro assessments. The tendency of radiographs to underestimate the distance between the cementoenamel junction and the alveolar bone may be related to the presence of craters or depressions in the alveolar bone, which do not show on the radiographs when the buccal and lingual cortical plates are intact. Furthermore, the lingual bone, which is closer to the film, is often seen prominently on a radiograph, making small defects in the facial bone or ridge, which is farther away and less prominent. However, in more than 90% of the sites, the difference has been within 1.5 mm; the observed underestimation in our study may have little or no clinical significance [24] [Table 6]. There is evidence that the radiographic measurement of horizontal bone loss underestimates the gold standard to a lesser extent as compared to the assessment of vertical defects. [11] This may account for the difference in the underestimation of bone loss between studies dealing strictly with vertical defects and those assessing both vertical and horizontal bone loss.

Wolf et al. [12] reported an overestimation of 0.48 mm and Kim et al. [13] reported an overestimation of 0.26 mm and 0.35 mm, using two different methods of computer-assisted analysis. Kaeppler et al., [6] reported an overestimation of 0.59 mm on the storage phosphor system, when compared to the true distance on the skull. The digital manipulations used and the deviation in projection geometry may be ascribed for the overestimation of bone loss in these studies.

Both the radiographic systems were equally good for assessment of interproximal bone loss [Table 2] and [Table 5]. This was similar to the results of other studies evaluating the diagnostic accuracy of the Dexis digital system for caries detection, [1] endodontic file length determination, [2] and for the detection of marginal defects of composite restorations, [3] where they had concluded that the performance of the Dexis digital system was comparable to conventional films.

This is probably the first study where the Dexis digital radiographic system has been used for the assessment of interproximal bone loss. Our observations are similar to Kaeppler et al., [6] who reported that the intraoral storage phosphor was equivalent to conventional radiography in the assessment of alveolar bone structures. Vandenberghe et al. [25] and de Faria Vasconcelos et al. [26] found that measurement of the periodontal bone levels and defects made on Cone beam computed tomography (CBCT) and intraoral radiography were comparable. However, by using CBCT it was possible to analyze buccal and lingual/palatal surfaces and it also allowed better visualization of the morphology of the defect. Eickholz et al. (1996) [8] and Eickhloz et al. (1998) [9] observed that the computer-assisted method was more valid than the conventional loupe for estimation of the extent of bone loss. Russell et al. [4] reported that RVG video prints were inferior to conventional radiographs for the assessment of marginal bone level in periodontal diseases. Khocht et al., [5] after comparing the direct digital and conventional intraoral radiographic estimates of alveolar bone levels reported that both the radiographic systems significantly differed in revealing the alveolar bone level.

There was a significant correlation of r = 0.98 between C-S and D-S (p < 0.001) [Table 7], which indicated that the difference between the radiographic and surgical measurements was consistent. Shrout et al. [7] similarly reported that digital radiographic measurements and direct measurements made on the skull were highly correlated. The correlation between the conventional and digital measurements was very strong with r = 0.99 (P < 0.001), which indicated that the two radiographic methods maintained a consistent ordering of observations. Khocht [5] also observed a very strong correlation between conventional and digital measurements. This is in contrast to the observations made by Renvert et al., [27] who reported that there was poor correlation between conventional and surgical measurements.

The intraobserver variability was slight for both the methods and it was statistically insignificant [Table 8]. Similar results have been reported by Hammerle et al., [24] Hildebolt et al., [10] and Wolf et al., [12] who observed that the intraobserver variations were minimal.

On the basis of the observations of the study the linear measurements of the interproximal bone level made on Kodak E-speed film and Dexis digital radiographs significantly underestimated the intrasurgical measurements and both the methods were less accurate for the assessment of the interproximal bone level. However, the diagnostic accuracy of the Kodak E-speed film and Dexis digital system was comparable for the assessment of interproximal bone loss. Therefore, the Dexis digital system could be considered to be equivalent to conventional radiography. The only real change or 'Paradigm shift' that digital technology would bring to dentistry was its ability to process images electronically. Future research may be directed to evaluate the potential clinical benefits of various image processing/manipulation facilities featured in digital radiographic systems. This may, in turn, help to make better diagnoses and better treatment decisions.


   Acknowledgment Top


The authors express gratitude to the Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India, for the support and help rendered during the study.

 
   References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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