Acknowledgments

The Australian Dental Association wishes to express its gratitude to the authors for their efforts in the
creation of these guidelines.

Clinical Professor Bernard Koong, BDSc (W.Aust), MSc (OMR)(Toronto), FICD, FADI,
FPFA Oral and Maxillofacial Radiologist.

Dr May Lam, BDSc (Hons)(W.Aust), FRACDS (GDP)

Oral and Maxillofacial Radiology Registrar (Qld)

Dr Tom Huang, BDSc (Hons1)(Qld), DClinDent(DMFR)(Qld)

Oral and Maxillofacial Radiologist

Practical Guide to Dental Radiology

First Edition 2019

Published by the Australian Dental Association, PO Box 520, St Leonards, NSW 1590, Australia
© Australian Dental Association 2019

All rights are reserved. No part of this work may be reproduced or copied in any form or by any means,
electronic or mechanical, including photocopying, without the written permission of the publisher, the
Australian Dental Association

Page 2 |Practical Guide to Dental Radiology

Foreword

This Practical Guide to Dental Radiology is a significant addition to the ADA’s series of Practical Guides to
Dental Equipment and Materials, which provide hands-on information specific to practice in the dental sector.
Radiation technology is an important diagnostic tool in dentistry, hence the need to develop an up-to-date
guide on the available technologies, their use in prescription, their interpretation, their types and application.
While radiation regulation currently varies by state and there is guidance available at the state and national
levels through the various Government Agencies, an overall view of radiology has been missing and this
inaugural edition has been developed to provide a succinct summary of the key aspects of practical radiology
as they relate to dentistry.
Optimal imaging, quality control and interpretation of images is essential in achieving the maximum
diagnostic capability in all dental radiology. This guide is developed with this in mind, and it is hoped that it
will be useful to enhance the understanding of radiation technologies (and how they apply in the surgery) of
all staff working in the clinical area of the dental sector.
Safety is also paramount and dental radiology should only be prescribed and performed by appropriately
trained and qualified dental and medical professionals (and in some states licencing is required). While safety
in radiology is not the main focus of this document, it does address the important issue of how to minimise
the risks of radiation exposure to both patients and to staff alike. To do this effectively requires an
understanding of the advantages and disadvantages of the diagnostic benefits of dental radiology.
The ADA gratefully acknowledges the scientific expertise of Clinical Professor Bernard Koong, Dr May Lam and
Dr Tom Huang, who volunteered their time in developing this comprehensive evidence-based practical guide.
The ADA also acknowledges the ongoing contributions of the volunteers on the ADA Dental Instruments,
Materials and Equipment Committee, who were also involved in the creation of this guide.
Further information regarding regulation, codes and standards of radiology in Australia is available by
consulting the relevant government agency in your state and at the national level, the Australian Radiation
Protection and Nuclear Safety Agency (ARPANSA). You may also like to refer to the ADA’s Policy 6.14
Radiation Safety.
I hope you find this practical guide a valuable resource.

Dr Carmelo Bonanno
Federal President

Practical Guide to Dental Radiology | Page 3

Contents

Foreword 3
Introduction 5
Chapter 1: Intraoral radiology – a review 6
Chapter 2: Panoramic radiographs – a review 10
Chapter 3: Multi-detector CT and cone beam CT 13
Chapter 4: Other advanced techniques: MRI, ultrasound and nuclear medicine 17
Chapter 5: Prescription and radiologic interpretation 19

Page 4 |Practical Guide to Dental Radiology

Introduction
This radiology practical guide is constructed around a series of evidence-based articles on contemporary
radiology in dentistry by Clinical Professor Bernard Koon and Drs May Lam and Tom Huang..

Continued advances in radiology have substantially contributed to diagnosis and management. Clinicians are
continually challenged to be familiar with all available modalities in order to prescribe the optimal radiological
test for their patients.

The first four chapters discuss the various modalities, including intraoral radiography, cone beam computed
tomography, multislice computed tomography and MRI. The final chapter aims to assist the clinician in the
prescription of the appropriate test for the common conditions encountered in practice.

Practical Guide to Dental Radiology | Page 5

Chapter 1: Intraoral radiography - a review
This chapter focuses on intraoral 2D radiography, namely periapical and bitewing radiographs. The table below compares
intraoral radiography technology based upon the type of detector.

Technology
Film radiography Direct capture radiography Indirect capture radiography

CCD (charged coupled device) PSP (photostimulable phosphor) plates.

CMOS (complementary metal
oxide semi-conductor).

Method of image Exposure to an X-ray beam results The X-ray beam causes silicon The surface of the PSP is ionised upon
capture in a latent image recorded on the crystals in the sensor to convert X-ray exposure. When the plate is fed into a
emulsion- coated film. Chemical photons to electrons. The signal is scanner, the latent image is transmitted to
processing generates the transmitted to the computer the computer which depicts the image.
radiographic image which depicts a real time image.

Ease of use Positioning is often more difficult Resembles film radiography and better
and uncomfortable due to sensor tolerated by patients.
bulk and rigidity of the cable.

Radiation dose levels Effective dose commonly ranges Reduced radiation dose due to Depending on exposure settings, PSP
from 5–9 μSv, although 0.1–9 μSv increased sensitivity of sensor radiation dose is less than film, but more
have been reported. compared to film. With optimal than direct capture radiography.
settings, the potential for dose
reductions of up to 40–60% have
been reported.

Risk of overexposure Dark film will alert the operator to Blooming artefacts (i.e. the pixels A useable image will still be produced
overexposure. are ‘burnt out’ and appear black) at high radiation doses. As a result,
will alert the operator to overexposure and increased patient
overexposure. radiation dose may occur without operator
awareness.

Frequency of retakes Chemical processing of film is Higher number of retakes (up to The larger dynamic range of PSP may
and errors technique sensitive, potentially 28%) have been quoted due to a decrease retakes, but the potential of
contributing to retakes. smaller active capture area and unrecognised overexposure must be
difficulty in positioning of a thick considered. Latent image quality may be lost
and rigid sensor. due to the spontaneous release of electrons,
or exposure to ambient lighting. PSP plates
should be scanned no later than 10 minutes
after exposure. Erased plates must be kept in
light-tight containers.

Image resolution ≥ 20 lp/mm 7–15 lp/mm 5–13 lp/mm has been quoted.
(measured in linepairs Theoretically may achieve Lower than film and direct digital
per mm lp/mm) radiography. Visibility of small endodontic
≥ 20 lp/mm, but this is not often
file tips are potentially suboptimal.
possible in practice.

Cost Comparatively low cost High initial system cost is more Regular replacement of PSP is necessary.
durable than PSP, but physical The lifespans of a PSP have been quoted
damage can occur. between 50–200 uses. Damage to the
phosphor layer (e.g. scratches, folds) may
render the PSP non-useable.

Other advantages Ease of digital storage and transmission of image.

No need for darkroom equipment

Other disadvantages Associated hazardous waste and • Ease of use may potentially increase the number of exposures.
lead foil from film processing. • Infection control may be a problem as the detectors cannot be sterilised. Wiping
with an alcohol-impregnated tissue has been suggested, but it is uncertain to what
degree the sensors tolerate wiping.

Page 6 | Chapter 1: Intraoral radiography

 REDUCING RADIATION EXPOSURE In the following subsections, brief references to cone-beam
computed tomography (CBCT) and multi detector computed
The following summarises some of the ways in which dose tomography (MDCT) are made where relevant. Chapter 3
minimisation can be achieved: addresses volumetric techniques in more detail.
• Adopt the principle of ALARA (as low as reasonably
APPLICATION
achievable).
• Review relevant previous studies prior to further imaging.
Bitewing radiographs
Request from previous clinician if necessary.
• Use the fastest image receptor compatible with the The bitewing (BW) radiograph remains the most optimal
diagnostic task (F-speed film or digital). technique for detecting interproximal caries but may not be
• Benefits associated with the use of lead aprons have been necessary in patients who show no evidence of the disease,
shown to be minimal compared to other methods of dose have open proximal contacts or a low caries risk. Diagnosis
reduction. As such, this could be considered optional unless should be made in conjunction with a clinical examination as
required by relevant governing bodies. low sensitivity (0.24–0.42) and high specificity (0.70–0.97) have
• Thyroid shields have been shown to reduce thyroid radiation been reported. The frequency of their prescription should be
dose. determined based on caries risk assessment and altered as the
• Rectangular collimation has been suggested, substantially individual circumstances of the patient changes with time.
reducing dose. However, it is technically more demanding,
and its use must be balanced against the possibility of Several studies have reported that CBCT may be useful for
repeats, potentially increasing the overall dose delivered. caries detection but is not recommended as the primary
• Use a film positioning device to aid in the parallel alignment technique for caries diagnosis on account of the potential for
of the film with the collimated beam to minimise geometric higher radiation dose, low specificity and beam hardening
distortion and for reproducibility of subsequent radiographs. artefacts when metallic or radiodense restorations are present.
• Use optimal settings to minimise exposure times.
• Minimise the number of images necessary to obtain essential Furcation defects and the more superficial periodontal bone
diagnostic information. can be demonstrated in a BW, which is taken at right angles to
• Optimal film exposure and processing technique. the X-ray beam.
• Implement quality assurance protocols to regularly evaluate
the film processor, image receptor devices and processing Periapical radiographs
chemistry. For periodontal disease, the periapical (PA) radiograph
The justification and selection criteria for intraoral demonstrates a 2D view of periodontal bone and root
radiographic examination have been thoroughly outlined by morphology, with associated limitations. Foreshortening or
various bodies, including the American Dental Association and elongation of the teeth occur, resulting in distortion and
the European Commission. A radiologic examination should be inaccurate assessment of the true horizontal bone height.
undertaken only when it provides additional information
about a condition or planned procedure and/ or influences Image distortion is worse when using a bisecting angle
management or surgical approach. Other factors, including the technique. Limited sensitivity for measuring the degree of
patient’s history and susceptibility to dental diseases should periodontal bone loss, mapping infrabony and vertical defects
also be considered. The benefit must outweigh the and the assessment of furcation involvements have been
accumulated biological risk to the patient. reported. The existence and severity of bone loss demonstrated
in one imaging episode does not indicate active disease.
The clinician needs to prescribe the optimal technique based Therefore, radiological examinations should be correlated with
on clinical indications. The practise of initially prescribing clinical findings, and compared with previous imaging where
conventional examinations (e.g. plain film 2D radiographs) relevant. Increasingly, for more complex cases, the use of
before determining whether 3D volumetric information is volumetric (3D) imaging has been suggested to allow for more
needed has been suggested. However, the limitations of 2D accurate detection, diagnosis, prognosis prediction and
imaging (geometric distortion and projection errors, treatment planning.
overlapping of anatomical structures and image magnification)
have been well documented and may lead to difficulty with For periapical disease, a PA radiograph correlated with clinical
diagnosis and misinterpretation of results. In situations where findings is generally sufficient for most cases. However, the
2D radiography is neither sufficiently sensitive nor specific, or limitations of these 2D views must be recognised. It has been
multiple exposures are required to visualise an area, more shown that MDCT and CBCT are more sensitive for the
advanced techniques should be considered. detection of periapical lesions.

Chapter 1: Intraoral radiography | Page 7

For the initial diagnostic stages of implant planning, PA Other situations requiring volumetric imaging include cases
radiographs may be helpful as a preliminary guide on bone with unresolved symptoms and more serious trauma,
availability and proximity to anatomical structures. However, especially where injuries extend beyond the dento-alveolar
PA radiographs are insufficiently accurate for the final planning complex. MDCT is the modality of choice over CBCT for more
for implant placement. The 3D morphology and relationship to complex cases.
relevant structures is not demonstrated. In this regard,
volumetric imaging techniques are superior and generally The information provided by a PA radiograph may be
accepted as the modalities of choice. insufficient for surgical and/or orthodontic treatment
planning for impacted canines and their relationship to
PA radiographs have been recommended for the measurement adjacent structures. Ultra-low dose CBCT is emerging as a
of baseline bone levels after implant placement. It is obvious modality of choice, as it is able to demonstrate the precise
location and morphology of the tooth, the surrounding
that 2D radiographs only demonstrate the proximal peri-
structures and detection of root resorption of adjacent teeth.
implant bone and optimal paralleling technique is essential.
CBCT and MDCT may be useful in some cases, but are not
Overall, there are increasingly fewer indications for vertex
without their limitations, namely the adjacent artefact.
occlusal views as well as the full mouth series with the advent
of CBCT. Volumetric imaging is discussed in Chapter 3.
For most cases of dental trauma, at least two PA radiographs
with different horizontal and vertical angulations have been VIEWING CONDITIONS
recommended. They may be sufficiently accurate for minor To ensure the highest diagnostic accuracy, it is important to
dental injuries, but low sensitivity in detecting fractures have review radiographs under optimal conditions. Low ambient
been reported. CBCT and MDCT may not be essential for acute lighting (no more than 50 lux), a bright backlight source and
management of minor dento-alveolar trauma. These magnification is recommended for film radiographs. Use of a
techniques, usually low-dose protocol CBCT, should be mask to reduce glare from light boxes around the film is also
considered where 2D radiography is inconclusive. Volumetric helpful. With more steps involved in digital image acquisition
imaging could also be considered in the long-term and display, any component in this process can influence the
management of trauma cases. quality of the final image.

Page 8 | Chapter 1: Intraoral radiography

Display monitor: • Inverting greyscale values has not been found to improve
With advances in commercial display monitor technology, these diagnostic accuracy. Instead, it may hinder dentinal lesion
monitors (with correct specifications – see below) are detectability.
comparable with medical grade monitors for most diagnostic • Pseudo-colour enhancement has not been documented to
purposes. aid diagnosis.

Maximum brightness High luminance profile of ≥300 cd/m2 Storage and transmission:
(room brightness reduces the contrast • The image should be stored in its original, uncompressed
ratio and making small contrast format with an automatic backup function. Minimising
differences more difficult to observe) compression of the radiographic image during
transmission is necessary to avoid loss of relevant data.

Printed copies of radiographs compromise diagnostic accuracy

and are not recommended. They are highly dependent on the
quality of printer and paper and will not demonstrate the same
Calibration Compliance to DICOM Part 14 GSDF optical range as film or high-quality monitors.
standards
INTERPRETATION
Screen properties Size: 20 inches recommended; ranges The importance of applying a methodical approach to
of 17-24” have been quoted radiological interpretation is critical.
Finish: matt finish to minimise the
reflection of ambient lighting Radiological interpretation is discussed in Chapter 5.

Resolution Ideally, 2048 x 1536 pixels (3

megapixels), but at
least 1920 x 1080 (2MP) is indicated.
If incorrect display resolution is
chosen, geometric distortion or
excessive magnification can result.
Contrast ratio ≥500:1
Response time Around 8 milliseconds
Greyscale bit- depth ≥8-bit greyscale (24-bit or
32-bit colour)
Video display Digital (e.g. DVI, displayport)
interface

Graphics card:
• Should be appropriately matched and of high quality to
avoid information loss and inferior quality images.

Image enhancements and manipulation:

• Zoom control may aid in radiologic diagnosis of proximal
carious lesions. It has been suggested that the optimum
magnification should be no more than six times the
original.

• Enhancement of density and contrast may improve

diagnostic accuracy.

Chapter 1: Intraoral radiography | Page 9

Chapter 2: Panoramic radiographs – a review
TECHNOLOGY • Lower resolution compared with intraoral radiography and
Film, direct and indirect digital image receptors are used in computed tomography (CT).
panoramic radiography, with digital receptors becoming
increasingly popular. There are a few differences with • Clinically relevant features may be missed if outside the
regards to the film and detector technology in relation to focal trough.
those employed in intraoral radiography (Chapter 1):
• Real, double and ghost images are always present and
• Film systems: an intensifying screen with rare earth familiarity with their appearances is important in the
elements is used to minimise radiation exposure to the evaluation of anatomical structures and pathoses.
patient. A dose reduction of 50-55% has been quoted in the
• Overlapping of the proximal surfaces of teeth is common,
literature. This is achieved because film is also sensitive to
usually the premolars.
the fluorescent light emitted from the intensifying screen.
This light will either be of a blue or green wavelength and
• Superimposition of the cervical spine over the incisor region
the appropriate film must be matched to the screen. Screen
is usually present.
film combinations with a speed of 400 or greater are
recommended. • Unequal magnification and distortion is found throughout
the image, making linear measurements unreliable.
• Direct digital systems: due to the expense of large Horizontal magnification is much more unpredictable than
detectors, three to four CCD sensors are arranged vertically vertical magnification.
to cover the height of the panoramic X-ray beam, and the
image is constructed in increments. • Objects located more lingually will be projected superiorly
due to the slight craniocaudal orientation of the beam.
• Indirect digital systems: storage phosphor plates of
appropriate size replace screen films in traditional cassettes. The technical aspects are well covered in many texts. Incorrect
positioning on the bite-block, and/or rotation of the patient’s
The radiation dose levels between the three systems are head are two of the most common positioning errors which can
comparable. Although, direct digital radiography can lead to significant geometric distortion and horizontal
produce lower doses than film and storage phosphor magnification/minification of the image.
systems, if the lowest possible setting appropriate to the
patient is chosen. The effective dose has been quoted at a • Magnification of the teeth occur when the jaw has been
range of 3.85–30 μSv. However, much higher doses have lingually positioned in relation to the focal trough, and is
been reported with older film systems. If the patient is a therefore closer to the X-ray source, causing the beam to
child or of a smaller stature, protocols should be pass through it more slowly. Conversely, objects more
appropriately adjusted to reduce the radiation dose buccally placed will appear narrower.
delivered.
• One method to assist in the identification of horizontal
TECHNICAL ASPECTS AND LIMITATIONS distortion is comparing the width of the mandibular first
The panoramic radiograph is produced by using the principles of molars. The smaller side was positioned too close to the
conventional tomography. It is a simple curvilinear form of receptor, while the larger side would have been too close
tomography where the X-ray source and the image receptor to the X-ray source.
simultaneously rotate around the patient’s head, capturing the
structures within the focal trough. Structures outside of this • If the chin is tilted excessively high (chin up), the mandible
zone are significantly distorted, blurred or magnified to the will be distorted with a flat or inverted occlusal plane, and
point where they are not recognisable, ideally leaving only the the hard palate will be superimposed on the roots of the
dentition and adjacent structures in clearest view possible. maxillary teeth. Conversely, if the chin is too low (chin
down), both the condyles and symphyseal region of the
In addition to the usual disadvantages associated with 2D mandible will not be captured and there will be excessive
imaging (geometric distortion and projection errors, overlapping of the dentition.
overlapping of anatomical structures, image magnification
and lack of 3D information), there are additional limitations
unique to panoramic imaging, detailed in most radiology
texts. Some are listed below:

Page 10 | Chapter 2: Panoramic radiographs

REDUCING RADIATION EXPOSURE It has been suggested that without 3D imaging, a safety margin
Similar principles to intraoral radiography apply. This was of 6 mm from the mental foramen would be required, which
discussed in Chapter 1. may contribute to suboptimal treatment planning. There are
many factors which influence the accuracy of this method, such
APPLICATION as incorrect patient positioning, distortion, discrepancies
For a relatively low radiation dose, the panoramic radiograph between the shape of the dental arch and focal trough, and
remains a useful overview of the dentoalveolar and surrounding beam angulation. It has been reported that only 17% of
structures. However, a lack of understanding of the substantial measurements from the alveolar crest to the inferior alveolar
limitations can contribute to misdiagnosis. On the other hand, canal have errors within one millimetre. Panoramic imaging is
even with these limitations in mind, it can be sufficient for inferior to volumetric imaging for visualisation of many critical
many situations and procedures. Where clinically appropriate, it anatomical structures. In general, pre-implant volumetric
may be a useful initial test, where relevant further imaging imaging is considered essential.
could then be considered. It may also be useful for patients who
cannot tolerate intraoral radiography, but it is not a substitute The panoramic radiograph is considered to be particularly
for the information that can be obtained from an intraoral useful in the evaluation of the developing dentition and any
radiograph. anomalies. However, it is important to remember that
supernumerary teeth or pathologies are likely to be missed if
Panoramic radiographic imaging is reported to be inadequate not located within the focal trough.
for the diagnosis of dental caries. The intraoral bitewing
radiograph remains the imaging of choice. Some panoramic For the assessment of impacted and/or ectopic canines,
machines offer an ‘extraoral bitewing radiograph’, suggested to panoramic radiography alone is considered to be inadequate
help with patients who are unable to tolerate intraoral due to its limitations including the inability to provide 3D
radiography. Reduced specificity due to ghost artefacts, information on the buccal or palatal position of the tooth. Cone
superimposition of air spaces and overlapping of premolars has beam computed tomography better demonstrates the
been reported. Extraoral bitewing radiographs have been relationship of the impacted canines and adjacent structures,
shown to be inferior to intraoral radiographs. root position and morphology, and possible associated root
resorption. The use of volumetric imaging in treatment
Also, the panoramic radiograph is not the optimal technique for planning is considered to improve outcomes. Ultra-low dose
most other common dentoalveolar diseases. Compared to CBCT protocols are recommended for the younger patient.
intraoral radiographs, it is less sensitive in its ability to detect
periapical lesions, particularly those exhibiting early periapical Even though the temporomandibular joints (TMJ) are seen in
changes. As well, it often underestimates the extent of most panoramic radiographs, it is considered to be an
periodontal osseous defects. Findings on a panoramic insufficient test where there are specific indications for a
radiograph may need to be supplemented with intraoral radiologic examination of these joints. These views are unable
radiographs or 3D imaging as appropriate. to depict the precise morphology of these joints. The typically
oblique projection of these joints together with variations in
The panoramic radiograph has been considered to be condylar angulation contribute to a distorted image. Without
appropriate for most cases of tooth extraction, including the ability to view the articular surface, pathologies such as
removal of third molars. Volumetric imaging should be erosions and osteophytes in the TMJ are detected with low
considered for more complicated or difficult cases, and where sensitivity. CT and magnetic resonance imaging are the optimal
plain film appearances suggest that the tooth is in close techniques for the bony and soft tissue structures of the TMJ
proximity to critical structures, such as the mandibular canal. respectively. These techniques are discussed in Chapter 3.
However, the TMJs are almost always depicted in the
It has been suggested that panoramic imaging could be used for panoramic radiograph and, despite the limitations, their
the initial radiologic assessment in evaluation for the dental appearances should be thoroughly evaluated.
implant, supplemented by 3D imaging techniques.
Panoramic imaging is inadequate and unreliable for
Given its low radiation dose, low cost and easy accessibility, visualisation of sinus anatomy. There is often misinterpretation
some authors suggest that panoramic imaging can be used for of the proximity of the maxillary tooth roots to the sinus due to
pre-implant vertical linear measurements in the posterior the 2D nature of the image and the presence of distortion. In
mandibular region by calculation with the appropriate situations where 3D information is necessary for accurate and
magnification factor and allowing a 2 mm safety margin precise planning (such as in sinus grafting procedures, or
superior to the inferior alveolar canal or other significant evaluating the likelihood of an oroantral communication),
anatomical structures. However, the degree of magnification volumetric imaging is recommended. Sinus disease cannot be
and minification is unpredictable, and other important 3D fully excluded with the panoramic radiograph. However, the
variables such as the prominence of the submandibular fossa or sinuses are demonstrated in these views and due attention
the precise morphology and proximity of the maxillary sinus should be made as significant disease is sometimes
floor cannot be appreciated in these 2D views. demonstrated.
Chapter 2: Panoramic radiographs | Page 11
Although routine panoramic radiographic screening for extra- INTERPRETATION
gnathic occult diseases cannot be recommended, the operator The relatively broad coverage and tomographic nature of the
should be aware of these additional findings, including the panoramic radiograph contributes to challenges in
clinical relevance. For instance, panoramic imaging has a low interpretation. It has been reported that dental students and
sensitivity for detecting calcified atheromas in the carotid dentists face challenges in identifying the radiologic
artery or mandibular cortical erosion in the case of anatomy, positioning errors and pathologies/anomalies
osteoporosis, but the presence of these findings contribute to relating to panoramic images. This highlights the need for
the diagnosis and management of such conditions. Routine advanced and continued education in the interpretation of
panoramic imaging of the patient at set arbitrary intervals is these radiographs. The prerequisites include a thorough
not considered to be justified.
understanding of the limitations, the radiologic anatomy,
orofacial pathology and radiologic features of pathoses. It is
VIEWING CONDITIONS
obvious that a systematic approach must be taken. All
The viewing conditions in relation to panoramic imaging are
structures included in these radiographs must be
similar to that of intraoral radiographs (Chapter 1).
appropriately evaluated. The practitioner presiding over the
study is responsible for the thorough interpretation of the
entire image, not only the region of interest.
Radiologic interpretation is discussed in Chapter 5.

Page 12 | Chapter 2: Panoramic radiographs

Chapter 3: Multi-detector CT and cone beam CT
This chapter focuses on volumetric (3D) imaging; multi-detector and cone beam computed tomography (MDCT and CBCT
respectively).

The following table compares MDCT and CBCT technology.

THE TECHNOLOGY
MDCT CBCT
Method of capture Thinly collimated, fan shaped X-ray beams rotate in a A divergent cone or pyramidal shaped X-ray beam is
helical fashion around the patient to capture multiple directed through the region of interest to an area detector
image slices. A second collimator reduces the scattered on the opposite side of the rotating gantry. Multiple
photons before it contacts the multiple rows of detectors sequential projections are performed as the platform
to improve image quality. The signal is then relayed to moves through a single arc of 180 or 360 degrees. The
the computer for analysis and image construction. multiple images obtained are computed to generate the
final 3D volumetric data.

Detector type Solid state detectors Flat panel detector or image intensifier/CCD sensor

Patient positioning Supine Standing, sitting or supine

Image reconstruction A back projection algorithm (most commonly the

Feldkamp algorithm) is applied to reconstruct the
volumetric images with a computer.

Radiation dose levels In imaging of the jaws, effective dose ranges of 280- Reported range of 5-1,073 μSv. Not all CBCT scans deliver
1,410 μSv have been quoted. While there is variation low radiation doses. It is highly dependent on the type of
between different types of scanners, imaging protocols unit and the protocols employed.
substantially alter the doses delivered. Anecdotally, doses
lower than those reported in the literature can be
achieved.

The difficulty in making comparisons between CBCT units and between the different imaging modalities has been
documented. A smaller field of view (FOV) in one unit may not necessarily deliver less radiation than a larger FOV in
another unit. While ultra-low dose CBCT units, with appropriate low dose protocols, can deliver doses comparable to
some panoramic radiographs, other types of CBCT units may deliver doses greater than a well optimised low-dose
MDCT.

Scan times Substantially faster than CBCT in the imaging of orofacial Scan times are generally substantially longer than MDCT,
structures. with a typical range of 10-40 seconds. Scan times can be
shorter for low resolution scans.

Spatial resolution Sub-millimeter imaging (as small as 0.5 mm) is possible Usually higher spatial resolution than MDCT due to
to generate high-spatial resolution images. smaller voxel sizes, with a reported range of 0.076-0.4
mm. However, image resolution and quality range widely
(refer to ‘Disadvantages’ below), potentially lower than
MDCT.

Chapter 3: Multi-detector CT and cone beam CT | Page 13

TECHNICAL ASPECTS ADVANTAGES
MDCT machine operation should only be undertaken by 3D volumetric imaging overcomes the limitations of 2D
an appropriately trained radiographer/radiologist. imaging (superimposition, geometric distortion and
magnification). The data from a single scan can be
The technical aspects of CBCT has been covered in various reformatted to be viewed along the axial, coronal, sagittal
texts. Adequate training is essential, including a thorough or any other plane (multiplanar reformatted images).
understanding on the influence of protocols on image Surface rendering facilitates viewing of the data as 3D
quality and radiation safety. The basic principles of virtual 'models'.
reducing radiation exposure were discussed in Chapter 1.
The following highlight some of the key issues in relation Compared with 2D plain films, CBCT and MDCT have
to CBCT: both been found to be more accurate in measurements
in any dimension. Several studies have found CBCT and
• Field of view: MDCT linear measurements (over lengths comparable
– Selecting the smallest FOV for the region of to a tooth) to be accurate within 1mm.
interest (ROI) will improve the image quality and
potentially significantly reduce radiation dose. CBCT potential advantages:
• Easier accessibility, usually lower cost and smaller
– Large volume CBCT generally produce moderate physical footprint than MDCT.
resolution scans which may not be sufficient for
fine detailed tasks such as examining nondisplaced • Potentially lower radiation dose than MDCT. It must be
tooth fractures or small root canals. High noted CBCT scans can deliver relatively large radiation
resolution small FOV CBCT may be more dose levels, potentially higher than a low dose MDCT
appropriate in such cases. Higher resolution scans scan (refer to ‘The technology’ on page 13).
are generally associated with higher radiation
doses. • High osseous/calcified structure spatial resolution due
to smaller voxel size, which can better depict bony
– The FOV is limited by the size of the detector. trabeculae, root structure etc.
Some units are capable of scanning a ROI which is
MDCT potential advantages:
larger than the FOV of the machine by stitching
multiple scans together. However, this will result in • A more powerful and flexible imaging modality.
an increased radiation dose and acquisition time.
One scan with an appropriate larger FOV machine • Visualisation of soft tissues and scans with or without
is therefore generally recommended over stitching intravenous contrast may be critical in some cases.
of multiple scans.
• High contrast resolution, such that tissues with even
• Voxel size: Smaller voxel sizes capture less X-ray 1% difference in physical density can be identified.
photons, which results in images with more noise.
Most CBCT units compensate for this by increasing the • Improved image quality due to better signal-to-noise
radiation dose. ratio.

• Frame rate: The more basis projection images DISADVANTAGES

captured, the more data available for reconstruction. CBCT is subject to more detrimental effects on image
This improves spatial and contrast resolution, quality than MDCT:
decreases noise and reduces metallic artefacts.
• Increased noise compared to MDCT:
However, it increases patient dose, and also increases
– A result of Compton scattering. The amount of
scan times with associated potential for motion
scattered radiation is proportional to the
artefact.
volume of tissues in the X-ray beam, and can be
• Trajectory arc: Reduction in the rotation arc from 360 reduced by decreasing the FOV.
to 180 degrees will reduce the radiation dose by 50%.
• Poor soft tissue contrast:
However, this will have a corresponding decrease in
– The contrast resolution is limited to bony or
image quality.
calcified structures. CBCT has less overall
• X-ray generation: Using a pulsed X-ray beam to contrast resolution than MDCT.
coincide with detector sampling will reduce patient
• Beam hardening:
exposure by up to 50%.
– Preferential absorption of lower energy photons
through dense objects results in distortion of

Page 14 | Chapter 3: Multi-detector CT and cone beam CT

 objects, appearance of bands or streaks (extinction In recent years, there has been an increase in the use
or missing value artefacts) which can contribute to of CBCT in dentistry, primarily related to improved
misinterpretation of the scan. The size of the understanding of the application, accessibility and dose
patient’s head as well as the density of the object considerations. While a few authors consider that it
also contribute to the degree of beam hardening. has largely replaced MDCT for dentistry, the limitations
of CBCT require consideration and it is not the optimal
• Motion artefacts: modality for many cases. Understanding of the
– Occurs if the patient is unable to keep still for the strengths and limitations of both CBCT and MDCT is
entire scan time. This is a common problem as necessary for selection of the most appropriate
CBCT scan times are generally substantially longer radiologic test. In some instances, other modalities
than with MDCT. Selection of a shorter scan time such as MRI, ultrasound or nuclear medicine may be
may reduce this, but a decrease in scan time optimal.
reduces image quality.
The indications for a CBCT/MDCT image has been
• Metal streaking artefacts: outlined by various bodies. These position statements
– The absorption of nearly the entire X-ray beam and guidelines will alter as the research in this field
energy by metallic structures results in an opaque continues. The prescription of volumetric imaging, in
streak. This may obscure key structures. relation to intraoral radiography (IOR) and OPG has
been discussed in preceding chapters. The following
• Cone-beam effect: discusses the more common application of CBCT and
– The peripheries of the image are subject to more MDCT in dentistry:
image distortion, streaking artefacts and greater • Despite its increased sensitivity for the detection of
noise. dental caries, CBCT has low specificity and is associated
with a higher radiation dose than
• Moire artefact:
bitewing radiography. As such, it is not recommended
– Too few basis projection images occur resulting in
as the primary imaging technique for dental caries.
undersampling of the object.
Also, metallic artefacts and beam hardening from
adjacent restorations render CBCT inadequate for
• Scanner related artefacts:
caries detection.
– Appears as a circular streak, often due to poor
calibration or imperfections in scanner detection.
• MDCT and CBCT are more accurate than IORs and OPGs
at identifying the severity of periodontal bone loss and
• Inaccurate bone density estimation:
infrabony defects, detecting furcation involvements
– The grey values in CBCT cannot be quantified as
and providing information on root morphology. With
Hounsfield units (HU), which measure the relative
the associated contribution to diagnosis and prognosis,
density of body tissues based on a calibrated grey-
it has been suggested that treatment time and cost
level scale. This is possible with MDCT.
may be reduced with the better ability to make
The main limitations of MDCT are the potential for higher appropriate treatment decisions on whether to extract
radiation doses, and reduced accessibility. In some cases, or maintain periodontally compromised teeth.
the MDCT image quality of teeth and osseous structures is However, it remains important that 3D imaging for
comparable or better than CBCT scans. However, high periodontal disease should only be applied when
resolution small FOV CBCT scans for persons who are not clinically indicated.
particularly large (with no motion artefact) produce higher
quality images of the jaws and teeth than MDCT scans. • CBCT and MDCT have been shown to be more sensitive
in the detection of periapical lesions. However, IOR
may suffice in many cases. Several authors consider
APPLICATION that limited FOV, high resolution CBCT should only be
In general, the prescription of 3D imaging should only considered in cases where there are contradictory
be carried out in cases where lower dose imaging clinical and radiographic signs and symptoms, non-
techniques are not able to provide the information specific or persistent pain, complex root morphology or
required for diagnosis and treatment planning. Without extra canals, surgical planning and suspected vertical
specific indications, 3D imaging for routine screening is root fracture not detectable with 2D radiography. The
not recommended. application of MDCT and MRI must also be considered.

Chapter 3: Multi-detector CT and cone beam CT | Page 15

• Rood JP1, Shehab BA.
• Potentially more complicated or difficult extraction • MDCT has been recommended over CBCT for more
cases may require volumetric imaging, particularly complex, serious or significant cases, especially where
when plain film suggests the tooth is in close there is potential soft tissue involvement. The list
proximity to critical structures, such as the includes benign or malignant tumours, cysts,
mandibular canal or maxillary sinus. While the undiagnosed pain, facial fractures, cellulitis,
presence of any of Rood and Shehab’s1 criteria may osteomyelitis or osteonecrosis of the jaw. Other tests,
warrant further radiologic examination, it has been
including MRI, ultrasound and nuclear medicine must
shown that the absence of these radiologic signs
also be considered.
does not preclude a close relationship with the
inferior alveolar nerve. Diagnostic imaging, including
• CBCT use in orthodontics for diagnosis and treatment
3D imaging, should only be performed where it has
the potential to contribute to diagnosis, prognosis, planning is becoming increasingly popular, but due
treatment planning or influences a planned consideration should be given to the increased lifetime
procedure. risk of radiation exposure in children/adolescents. Not all
CBCT scans are low dose (refer to ‘The Technology’ on
• Most authors consider that volumetric imaging page 13). The appropriate low dose CBCT unit together
should be used in implant planning. Where required, with appropriate protocols must be employed. Common
virtual planning and fabrication of computer- applications include assessment of impacted canines,
generated surgical guides can be performed, based root resorption, tooth position and morphology, and
on the scan data sets. craniofacial anomalies.

• When indicated, volumetric imaging has been • It has been reported that volumetric imaging is more
recommended for the assessment of sinus anatomy accurate than 2D plain radiographs in the evaluation for
or pathology, and the preoperative assessment for obstruction in the upper airways and craniofacial
sinus augmentation or grafting procedures. Plain film
structures. Radiological tests, including 3D imaging,
imaging for paranasal sinus disease is insufficient.
should be prescribed only where it has the potential to
Presently, MDCT remains the most commonly used
contribute to diagnosis, prognosis, treatment planning or
modality for paranasal sinus disease, considered to
be the optimal technique by most clinicians and influences a planned procedure.
surgeons.

• MDCT and MRI are appropriate for the evaluation of

the bony and soft tissue structures of the TMJ INTERPRETATION
respectively. Some consider that CBCT may be more • The interpretation of CBCT or MDCT scans require a
suitable if soft tissue imaging is not required due to higher level of knowledge and skill sets than plain film.
its high bony spatial resolution and reported lower Prerequisite knowledge includes radiologic anatomy,
radiation, but factors affecting the image quality orofacial pathology, radiologic features of pathoses and a
must be considered (refer to the aforementioned thorough understanding of the limitations of the
‘Disadvantages’), especially beam hardening and the technique. Appropriate image interrogation is critical.
relatively low signal-to-noise ratio associated with Some authors recommend that these scans should be
CBCT scans. Inappropriate selection of the imaging interpreted by persons with sufficient advanced training.
modality can lead to misdiagnosis and a delay in
Interpretation is discussed in Chapter 5.
appropriate management.

1 Rood JP, Shehab BA. The radiological prediction of inferior alveolar nerve injury during third molar surgery. The British
journal of oral & maxillofacial Surgery 1990 Feb;28(1):20-5.

Page 16 | Chapter 3: Multi-detector CT and cone beam CT

Chapter 4: Other advanced techniques: MRI, ultrasound and
nuclear medicine *
THE TECHNOLOGY reconstruction algorithms to form axial slices, similar to a CT
Magnetic resonance imaging image.
The basis of MRI imaging modality is a magnetic field generated
around a patient which aligns spinning nuclei, the majority of • Positron emission tomography (PET): Is an imaging
which are protons, electromagnetically with the field flux. A technique using positron emitting radionuclides (e.g. 11C,
radiofrequency pulse is then applied, causing some of the nuclei 13N, 15O, 18F) which are usually combined with
to absorb energy (resonate), where protons spin in a higher pharmaceuticals such as glucose or amino acids, to assess
energy state. When the pulse is turned off, relaxation occurs, metabolic processes in the body. After a set period of time,
protons return to the lower energy state and the stored energy positron emission decay occurs, and two photons are
is released, which is detected by a receiver coil in the MRI produced which travel in opposite directions. A PET camera
system. These signals are then used to generate the image. has a ring of detectors which can map the photons that
arrive at the same time and this information is used to
Ultrasonography produce a functional image of organs and tissues.
This application uses ultrasonic energy (in the range of 7.5– 30
MHz) to obtain a topographical map of tissue interfaces at • There are now hybrid imaging systems where the nuclear
differing depths in the body. A transducer converts electrical medicine images are co-registered with CT or MRI images
energy into sonic energy using piezoelectric crystals. The (i.e. SPECT/CT, PET/CT and PET/MRI) allowing for combined
transducer is held against the body part of interest. This morphological and functional imaging.
ultrasonic beam interacts with the various tissues which all
have different acoustic impedance. Some of the sonic waves
will reflect (echo) back to the transducer, generating an electric ADVANTAGES
signal which is used to produce the diagnostic image. Each MRI
tissue has a characteristic echo pattern, allowing detection of • No ionising radiation.
tissue boundaries or pathological changes within the tissue.
• Excellent soft tissue contrast compared to X-ray based
Real-time imaging is possible, as the processing of these echoes
techniques due to the higher water content in soft tissues.
occur at a rapid enough rate to allow perception of motion.
Certain anatomical and pathological structures with greater
vascularity and permeability can be enhanced by intravenous
Nuclear medicine
paramagnetic contrast agents such as gadolinium.
A functional imaging technique, which detects abnormal
metabolic processes in the body, rather than anatomical/
morphological changes, which may not be discernible in the Ultrasonography
early stages of some diseases. • No ionising radiation.
• Good soft tissue discrimination and sensitivity for superficial
• Radionuclide imaging: evaluates tissue function by utilising
mass lesions.
radioactive atoms or molecules (radionuclides) which emit
gamma rays (e.g. Technetium 99m). These radionuclides are • Colour Doppler sonography for evaluation of blood flow is
combined with a pharmaceutical to form a radiotracer possible.
which is distributed to various parts of the body based on • May be a useful alternative for patients who are
their chemical properties. A gamma camera captures the contraindicated for MRI.
emitted photons, converting them to light, then into a
voltage signal for image reconstruction. Nuclear medicine
• Evaluates physiologic alterations of tissues.
• Single photon emission computed tomography (SPECT): Is a
method for acquiring tomographic slices through a patient, • Identify early changes of some diseases not demonstrated in
where a single or dual headed gamma camera rotates other techniques.
around the patient detecting emitted gamma rays. This data • PET has very high spatial resolution and is able to detect very
is processed via filtered back-projection or iterative small lesions.

* B Koong, M Lam. With contributing authors: Dr Jerry Moschilla, Radiologist & Nuclear Medicine Specialist and
C Clinical A/Prof Michael Bynevelt, Neuroradiologist.
• Chapter 4: Other advanced techniques: MRI, ultrasound and nuclear medicine * | Page 17
DISADVANTAGES
MRI Ultrasonography
• Ferromagnetic objects may move, overheat and therefore • Commonly used in the orofacial region for the evaluation of
injure the patient when in the vicinity of the magnetic field. salivary gland, cervical lymph nodes and neck lumps.
Therefore, this modality is contraindicated for some patients
• Ultrasound guided fine needle aspiration and core biopsies.
with some implanted metallic objects or medical devices.
• Metals used in dentistry will not move but may distort the • Other applications in this region include evaluation of the
image in its vicinity. Titanium implants only cause minor thyroid glands and carotid vessels.
degradation of the image.
• Longer scan times. Nuclear medicine
• Osteoblastic metastatic neoplasms involving bone.
• May not be suitable for claustrophobic patients.
• SPECT has been used to assess mandibular growth in patients
• The use of gadolinium-based contrast media must be used
with caution in those with renal impairment as this has been with asymmetry. The limited specificity of these studies must
associated with nephrogenic systemic fibrosis. Gadolinium be considered. Correlation with CT and/or MRI is useful.
deposition within regions of the brain has recently been • The extent of medication-induced osteonecrosis of the jaw
discovered and is currently being investigated. (MRONJ).
• Gallium and radio labelled white cell radionuclide and SPECT/
Ultrasonography
CT imaging is useful in diagnosing base of skull osteomyelitis.
• Difficulty in imaging deeper structures and structures
obscured by bone. • PET/CT imaging is useful for skeletal imaging for assessment
of primary bone tumours, locating metastases in bone and
Nuclear medicine detecting osteomyelitis. It is often correlated with post
• Associated with ionising radiation. contrast CT or MRI scans.
• PET/CT is particularly useful for staging squamous cell
APPLICATION IN THE OROFACIAL REGION
carcinoma and other head and neck malignancies.
MRI
• Evaluating of soft tissue anatomy and pathology,
characterisation and extent of lesions e.g. evaluating for INTERPRETATION
perineural spread of tumours. Radiologists, neuro-radiologists, maxillofacial radiologists and
• Additional characterisation of soft tissue components of nuclear medicine specialists perform the interpretation of these
bone lesions. studies.
• Considered the gold standard in the assessment of the soft
tissues of the temporomandibular joint, particularly the
articular disc position. Also demonstrates joint effusions,
synovitis, marrow oedema, and changes in the adjacent
masticatory muscles.
• Implant dentistry: Identifying the location of inferior alveolar
neurovascular bundle where multislice CT or cone beam CT is
not able to demonstrate the location of the mandibular
canal.

Page 18 | Chapter 4: Other advanced techniques: MRI, ultrasound and nuclear medicine *
Chapter 5: Prescription and radiologic interpretation

This chapter summarises the prescription of the various Other conditions affecting the jaws:
imaging techniques in relation to the more common • For example, cysts, tumours, osteomyelitis, etc.
conditions/clinical situations encountered in dentistry. An • MDCT is usually the technique of choice. CBCT may suffice for
introduction to the key responsibilities and principles some lesions.
involved in radiological interpretation is also included.

Abbreviations: IOR – intraoral radiography; OPG – panoramic

radiographs; CBCT – cone beam computed tomography; MDCT Orofacial pain:
– multidetector (multislice) computed tomography; MRI – • Dentoalveolar inflammatory disease is a common cause –
magnetic resonance imaging. clinical findings combined with IOR and/or OPG are sufficient
for diagnosis in most cases.
PRESCIPTION OF THE OPTIMAL IMAGING • Dentoalveolar inflammatory lesions contributing to orofacial
pain cannot be fully excluded with IOR and OPG.
TECHNIQUE - A SUMMARY:
The various imaging techniques, including the associated • MDCT or CBCT should be considered if the cause of pain is
radiation dose levels delivered, have been discussed in the not identified clinically and with 2D imaging.
preceding chapters. The following summarises the indications • Volumetric imaging should be considered if other causes for
in relation to the conditions and clinical scenarios which are the orofacial pain is suspected, e.g. sinus disease.
more commonly encountered in dentistry: • MRI should be considered if diagnosis is not made following
volumetric imaging.
Dental caries:
• Bitewing radiographs remain the optimal technique – the
limitations, especially in relation to sensitivity, are noted and Dental implants:
clinical correlation is essential. • IOR and OPG may be useful for initial assessment.
• OPGs are considered inadequate – caries cannot be fully • Pre-implant MDCT or CBCT must be considered.
excluded.
• MRI may be used to identify the location of the inferior
• CBCT is associated with increased sensitivity, but decreased alveolar nerve where the mandibular canal borders are not
specificity. Artefact related to restorations is another demonstrated with MDCT or CBCT.
limitation.

Periodontal disease: Dental extractions/exposure procedures:

• OPG provides a good overview. The associated limitations • IOR and OPG are appropriate for most cases.
compared to the IOR are recognised. • Volumetric imaging could be considered for more
• IOR demonstrates periodontal bone levels and root complicated cases or where the tooth is potentially in close
morphology, but is less accurate than CBCT and MDCT. relationship to significant anatomic structures, e.g. the
Limited sensitivity in relation to vertical defects and mandibular canal.
furcations have also been demonstrated. • Third molar and related morphology including the
• CBCT and MDCT provide 3D information, which allows for relationships with the mandibular canal are better
more accurate diagnosis and treatment planning. Could be demonstrated with volumetric imaging. The indication for
considered for cases with moderate to severe periodontal CBCT or MDCT is based upon clinical parameters, potential
disease. intra-surgical implications and the OPG appearances.
• Ultra-low dose CBCT should be considered for
Periapical inflammatory disease: impacted/ectopic canines.
• A periapical radiograph and clinical findings are sufficient for
most cases.
• OPG is less sensitive for detecting periapical lesions. Dental trauma:
• CBCT and MDCT are more sensitive, should be considered in • PA radiographs with different horizontal and vertical
cases with contradictory findings or non-specific/unresolved angulations has been recommended.
pain. • CBCT and MDCT should be considered where 2D imaging is
• In rare instances, MRI can be considered where the clinical inconclusive, for complex/severe cases of dentoalveolar
suspicion for periapical inflammatory lesion is high, but this is trauma and where jaw fractures are suspected. MDCT is the
not demonstrated with MDCT/CBCT. technique of choice for more involved facial bone fractures.

Chapter 5: Prescription and radiologic interpretation| Page 19

Paranasal sinuses: Some of the key points, based upon these two publications, are
• OPGs are inadequate – sinus disease cannot be fully excluded summarised:
with this technique.
Prerequisites:
• Volumetric imaging (particularly MDCT) is recommended for • Radiologic anatomy: An in-depth knowledge of anatomy and
the assessment of sinus disease. their normal variants is critical. Knowledge of the
appearances of all normal structures will aid in identifying
TMJ:
the presence of pathology.
• OPGs are inadequate – arthropathy cannot be fully excluded
with this technique. • Pathology: Knowledge of the pathology which may occur in
all regions included in the field of view or scan, as well as the
• MDCT is optimal for the evaluation of the bony structures. radiologic appearances of these lesions, is obviously of
MDCT also demonstrates the soft tissues and the articular importance.
disc may be visualised.
• Imaging modality: Understanding the strengths and
• CBCT demonstrates the bony structures – image degradation limitations of the various imaging techniques impacts on the
related to beam hardening must be considered. interpretation of the studies. Examples include the
• MRI is optimal for the evaluation of the soft tissues related to tomographic nature of OPGs and beam hardening seen in
the TMJs. MRI is also optimal in the evaluation for effusion, CBCT scans.
synovitis and marrow oedema. Bony structures are also • Viewing conditions: The lighting conditions and display
demonstrated although the lower spatial resolution is quality of the monitor can have a significant influence on the
recognised. accuracy of the radiologic interpretation. This was covered in
Chapter 1 of this series.
Soft tissue lesions:
• CBCT does not demonstrate the soft tissues sufficiently well. Identifying the presence of disease
• MDCT or MRI could be considered. Ultrasound may be • A methodical approach during evaluation of the entire image
useful, especially for more superficial lesions. or dataset is critical.
• The interrogation of volumetric data requires a different skill
RADIOLOGIC INTERPRETATION set to that for plain 2D films.
All structures included in any imaging must be appropriately
evaluated. The practitioner presiding over the radiologic study Radiologic evaluation of a lesion(s)
is responsible for the thorough interpretation of the entire An algorithm should be followed to identify the relevant
image, not only the region of interest. Should the entirety of radiologic features. Below is an example:
the lesion not be included in the initial scan, preliminary 1. Location
interpretation should still be carried out, which can be useful in
deciding the optimal imaging technique for further evaluation. 2. Shape and contour
Studies have demonstrated the challenges that dentists 3. Border
encounter in relation to the interpretation of OPGs and CBCT
4. Internal appearances
scans.
5. Adjacent anatomical structures
Volumetric data requires a different level of knowledge and
Lesions will not always present classically, nor will they
skill for interpretation. Several authors recommend that CBCT
necessarily demonstrate all the typical features. As a result, it
scans should be interpreted by persons with sufficient is necessary to weigh the identified features. For example, a
advanced training. lucency at the apex of a tooth is often inflammatory in nature.
However, a malignant lesion may also present as a lucent
The following publications introduce the key principles of lesion apically and weight must be given to the marginal
radiologic interpretation: appearances.

Koong B. The basic principles of radiological interpretation. CONCLUSION

Aust Dent J. 2012;57 Suppl 1:33–9. As advances in diagnostic imaging continue, it is increasingly
essential that clinicians remain up-to-date in order to prescribe
Koong B. Diagnostic imaging of the periodontal and implant
the optimal radiological test for their patients. The practitioner
patient. In Lang PL & Lindhe J (eds.), Clinical
presiding over the radiologic study is responsible for the
periodontology and implant dentistry (6th edition., examination in its entirety and should ensure that it is
574-608). UK: Wiley Blackwell. interpreted by appropriately skilled persons.

Page 20 |Chapter 5: Prescription and radiologic interpretation

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