Efficacy of identifying maxillofacial lesions in cone-beam computed tomographs by orthodontists and orthodontic residents with third-party software

doi:10.1016/j.ajodo.2011.10.025

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 141, Issue 4, April 2012, Pages 451-459

https://doi.org/10.1016/j.ajodo.2011.10.025 Get rights and content

Introduction

The purpose of this study was to determine the ability of orthodontists and orthodontic residents to identify nonorthodontic incidental findings and false positives in cone-beam computed tomography scans.

Methods

Two groups of 10 cone-beam computed tomography scans containing equal numbers of scans with no, 1, or several abnormal nonorthodontic lesions were selected from a database. Eight orthodontists and 8 orthodontic residents screened the 2 groups of scans before and after a basic cone-beam computed tomography training course. The paired t test was used for statistical analyses.

Results

In the initial screening, the orthodontists and residents correctly identified 41.1% of the lesions. This lesion-detection rate improved significantly to a mean of 56.7% after the training course (P <0.0005). In parallel with these findings, the mean percentage of correctly identified extragnathic lesions improved significantly, from 22% to 48% (P <0.0005), and correctly identified temporomandibular joint lesions improved from 20% to 55% (P = 0.01) after the training. In contrast, the rate of correctly identified dentomaxillofacial lesions remained largely unchanged before and after the training. Both groups of evaluators had approximately 5 false positives per 10 scans before training and demonstrated significant decreases in false positives after training.

Conclusions

Relative to known error rates in medical radiology, both groups of evaluators had high error rates for missed lesions and false positives before and after training. Given these findings and since the most frequent cause of medical radiology malpractice litigation is due to missed lesions, it is recommended that an appropriately trained radiologist should be involved in reading and interpreting cone-beam computed tomography scans.

Section snippets

Material and methods

This study was approved by the Institutional Review Board at the University of Michigan, Ann Arbor (approval number HUM00016717). Twenty scans were selected by an oral maxillofacial radiologist from a database of CBCT scans at the Department of Oral Radiology. All the scans were taken with the i-CAT (Xoran Technologies and Imaging Sciences International, Hatfield, Pa) CBCT scanner. The images were taken at 120 kVp, 18.66 mAs, with image resolution of 0.4 mm voxels. The 20 scans were divided

Results

All evaluators reported either no or limited experience and no professional training in reading CBCT scans before participating in this study. Since the 2 groups of evaluators screened either the group A or B scans before or after the CBCT training (Fig 1), a statistical analysis was performed to assess whether the scan assignment influenced the outcomes. This analysis showed no significant differences in the mean lesion-detection rates before or after the CBCT training between the 2 groups of

Discussion

A key aspect of our study was the rationale for the 2 groups of examiners selected to evaluate the scans. Current legislation in most states does not require the doctor to demonstrate any particular level of training or competence in reading CBCT scans before owning or using a CBCT unit. Because of this, we chose a “no or minimal experience” baseline knowledge of the examiners in evaluating CBCT images to simulate the rate of lesion detection that could potentially result from the current

Conclusions

Although the use of more than 1 radiologist to serve as a gold standard would have further strengthened our conclusions, our findings show high error rates by orthodontists and residents of missed incidental lesions and false-positive diagnoses during their interpretation of CBCT scans. Although the rates of correctly identified incidental findings, particularly for extragnathic and temporomandibular joint lesions, were significantly improved after training, the 43% total of missed lesion

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Dental imaging has seen a rapid technological advance over the last several years. Not only has most x-ray based diagnostic technology been digitized, with the possibility of low dose 3D computed tomography imaging, but many novel optical imaging techniques have now also been adopted in a more therapeutic imaging of the dental patient. When combining and manipulating such different digital image data, clinicians can now easily plan and simulate treatments on-screen, use 3D printed models and aids to assist in accurate transfer of the virtual planning or even follow-up their treatments over time. However, it seems that knowledge on digital technology is still lacking in clinical practice, which may contribute to errors or slow adoption. The purpose of this article is to bring an overview of the digitalization of dental imaging techniques and inform dental professionals on the digital tools that are available for the follow-up of patient treatments.
Accuracy of Cone-beam Computed Tomographic Image Interpretation by Endodontists and Endodontic Residents
2018, Journal of Endodontics
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Institutional review board approval was obtained from the Institutional Review Board at Louisiana State University (LSU) Health Sciences Center, New Orleans, LA, and informed consent was obtained from all participants in the study. The study design was similar to previous studies by Parker et al (13) and Ahmed et al (12). Eighteen deidentified limited FOV CBCT scans were used in the study.
Limited field cone-beam computed tomography (CBCT) imaging has become a modality frequently used by endodontists to evaluate the teeth and surrounding tissues of their patients. Accurate image interpretation is vital to obtain needed treatment information as well as to discern coincidental findings that could be present. The goal of this study was to determine the accuracy of CBCT volume interpretation when performed by endodontists and endodontic residents.
Eighteen deidentified limited field CBCT scans were obtained and evaluated by an oral and maxillofacial radiologist and an endodontist experienced in reading CBCT images. Their collective findings were combined as the “gold standard” of interpretation for this investigation. Using standard CBCT software, 4 practicing endodontists and 5 second-year endodontic residents evaluated each scan and recorded any notable findings and whether or not each scan warranted referral to a radiology specialist. Their interpretations were then compared with the gold standard to determine accuracy and any significant differences among the groups.
The overall accuracy was 58.3% for endodontists and 64.3% for residents. Paired t tests showed no statistically significant differences in accuracy between the 2 groups for findings in teeth or in bone, but residents were significantly better for maxillary sinus findings. Endodontists agreed with the gold standard 38.9% of the time and residents 49.8% of the time on necessity of referral. The Cohen kappa coefficient showed moderate agreement between the groups.
Endodontists and residents had similar accuracy in CBCT scan evaluation. More training and experience are warranted for both groups in order to maximize image assessment accuracy.
Cone beam computed tomography incidental findings of the cervical spine and clivus: retrospective analysis and review of the literature
2017, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
The aim of this study was to analyze and describe incidental findings in the cervical spine (C-spine) and the clivus encountered in cone beam computed tomography (CBCT) imaging. The wide range of possible anatomic variants and pathoses is discussed in the context of the medical and dental literature to clarify their radiographic appearance and clinical implications as a guide for the oral and maxillofacial radiologist.
A retrospective analysis of radiographic reports was conducted based on CBCT images from 2 oral and maxillofacial imaging centers. Reports documenting incidental findings in the C-spine or the clivus were selected. Data on patient age and sex were collected, and each incidental finding was categorized as degenerative, congenital, or developmental/pathologic. Each finding is discussed with clinical importance and is pictorially presented.
From a total of 7689 CBCT reports, there were 732 incidental findings (9.5%) in the C-spine or the clivus. Most findings were in the C-spine (92.3%), were degenerative in nature (78.7%), and occurred in females in their sixth decade. Logistic regression analysis showed that the odds of presenting with a degenerative incidental finding in the C-spine or the clivus did not differ based on sex but were 5.5 times (95% confidence interval, 3.77-8.04) higher if the patient was aged 50 years or older.
This review is the largest and the first to characterize incidental findings in the C-spine and the clivus. Such findings were reported in 9.5% of radiographic reports. Several presented as uncommon congenital variants that are not usually spotlighted during oral and maxillofacial radiology training.
Association between maxillary sinus pathologies and healthy teeth
2016, Brazilian Journal of Otorhinolaryngology
Citation Excerpt :
Mucous retention cysts are bodies that develop as a result of a blockage of the sinus ostium and usually resolve spontaneously. They are common findings in CBCT images, but cannot be detected without proper training in dental radiology.35 Although they are usually present in asymptomatic patients, it is important to disclose them in CBCT image reports.
The proximity of the roots to the maxillary sinus can create a variety of risks.
To evaluate the relationship between the roots of healthy teeth and the maxillary sinus, as well as the occurrence of sinus pathologies.
Three radiologists analyzed 109 cone beam computed tomography (CBCT) images. The Kappa test was used to assess the intra- and inter-rater agreement. The chi-squared test and prevalence ratio were used to test the hypothesis that roots of healthy teeth in the maxillary sinus favored the occurrence of sinus pathologies (p = 0.01).
Intra- and inter-rater agreement ranged from good to excellent. The chi-squared test demonstrated a statistically significant difference (p = 0.006) between the tooth roots in diseased maxillary sinuses (6.09%) and those in normal sinuses (3.43%). The prevalence ratio test showed a statistically significant higher prevalence of tooth roots in diseased sinuses than in normal sinuses (p < 0.0001). Roots in the maxillary sinus were 1.82 times more associated with diseased sinuses.
Dental roots in the maxillary sinus are almost twice as likely to be associated with diseased sinuses than normal sinuses. Healthy teeth whose roots are inside the maxillary sinus may induce an inflammatory response in the sinus membrane. It is suspected that dental procedures may exacerbate the condition.
A proximidade das raízes com o seio maxilar pode criar uma variedade de riscos.
Avaliar a relação entre as raízes dos dentes hígidos com o seio maxilar, assim como com a ocorrência de doenças sinusais.
Três radiologistas analisaram 109 imagens de tomografia computadorizada de feixe cônico (TCFC). O teste Kappa avaliou a concordância intra e interexaminadores. Os testes de Qui-quadrado e Razão de Prevalência foram utilizados para testar a hipótese de que raízes de dentes hígidos dentro do seio maxilar favorecem a ocorrência doenças sinusais (nível de significância = 0,01).
A concordância intra e interexaminadores variou de boa a excelente. O teste Qui-quadrado mostrou uma diferença estatisticamente significante (p = 0,006) entre as raízes dentárias dentro do seio maxilar patológico (6,09%) e aquelas dentro do seio normal (3,43%). O teste de Razão de Prevalência mostrou uma ocorrência de raízes dentárias dentro de seios patológicos estatisticamente maior do que dentro de seios normais (p < 0,0001). As raízes dentro do seio maxilar foram encontradas 1,82 vezes mais associadas a seios patológicos.
Raízes dentárias dentro do seio maxilar são quase duas vezes mais associadas a seios patológicos do que a seios normais. Dentes hígidos que têm raízes dentro do seio maxilar podem induzir uma resposta inflamatória da mucosa sinusal. Suspeita-se que procedimentos odontológicos possam agravar tal situação.
Agreement among orthodontists experienced with cone-beam computed tomography on the need for follow-up and the clinical impact of craniofacial findings from multiplanar and 3-dimensional reconstructed views
2015, American Journal of Orthodontics and Dentofacial Orthopedics
Citation Excerpt :
Additionally, if certain findings require follow-up, it would be paramount if agreement between clinicians were high, thus reducing the risk of a failed follow-up when necessary. Ahmed et al27 demonstrated that CBCT interpretation skills can be improved through training. However, they only assessed the ability of clinicians to directly identify findings in CBCT imaging and did not assess their ability to determine the clinical significance.
In this study, we aimed to assess interrater and intrarater agreement among orthodontic clinicians in their assessments of reported incidental findings in regard to both the need for additional follow-up and the impact on future orthodontic treatment in large-field maxillofacial cone-beam computed tomography (CBCT) imaging.
The study sample consisted of 18 nonrandomly selected large-field maxillofacial CBCT volumes containing a reported total of 88 radiographic findings. All scans were associated with formal radiologic reports. However, the suggestions of further follow-up were removed from the radiologic reports so as to not bias the 3 evaluating orthodontists in their subsequent decision making. The evaluators had on average 7.6 years of CBCT usage and self-interpretation experience. Reliability was determined by quantifying the level of agreement between the evaluators' assessments for both research questions for all 88 findings using a binary response (yes/no) as the outcome measure. The Cohen kappa statistic was calculated to quantify intrarater and interrater agreement globally for both statements.
Although interrater agreement was considerable, potential decisions with clinical impact were not consistent. This needs to be considered when interpreting maxillofacial incidental findings. Evaluators demonstrated higher levels of agreement for dentoalveolar findings compared with all other extragnathic regions when assessing clinical significance.
Among the evaluators who were considered experienced in CBCT, “fair-to-good” interrater agreement and “excellent” intrarater agreement were demonstrated in terms of the need for further follow-up and their potential impact on future orthodontic treatment.
Incidental findings of skull-base abnormalities in cone-beam computed tomography scans with consultation by maxillofacial radiologists
2015, American Journal of Orthodontics and Dentofacial Orthopedics
Cone-beam computed tomography (CBCT) gives orthodontists and other dental clinicians 3-dimensional information for planning treatment in the craniofacial region. Often overlooked are incidental findings outside the treatment region of interest.
Two patients with incidental findings of skull-base abnormalities are presented. The orthodontic patient was tentatively diagnosed with a notochordal remnant in the clivus; the implant patient exhibited an empty sella turcica.
For the clivus lesion in the orthodontic patient, an artifact was ruled out after a second CBCT image and further distinguished from a fat-containing tumor after magnetic resonance imaging. The impression after magnetic resonance imaging was a notochordal remnant, although chordoma was also included in the differential, warranting a 6-month follow-up magnetic resonance image to confirm the diagnosis. The CBCT study for the implant patient demonstrated an enlarged sella turcica. The impression after the magnetic resonance imaging was an enlarged and partially empty sella with no evidence of a pituitary mass.
Orthodontists and implant surgeons may come across incidental findings outside their area of expertise on CBCT scans, highlighting the importance of appropriate consultation with maxillofacial radiologists. Notochordal remnants may present as nonexpansile intraosseous low-density areas. The challenge in distinguishing these lesions radiographically with chordomas warrants follow-up to confirm a diagnosis. An empty sella is a noteworthy finding because of its potential for endocrine and neuro-ophthalmological disorders despite an asymptomatic presentation.

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: The authors report no commercial, proprietary, or financial interest in the products or companies described in this article.

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Original articleEfficacy of identifying maxillofacial lesions in cone-beam computed tomographs by orthodontists and orthodontic residents with third-party software

Introduction

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Discussion

Conclusions

Am J Orthod Dentofacial Orthop

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Oral Maxillofac Surg

Am J Orthod Dentofacial Orthop

Am J Orthod Dentofacial Orthop

Am J Orthod Dentofacial Orthop

Semin Orthod

Am J Orthod Dentofacial Orthop

Semin Orthod

Current status of cone beam computed tomography imaging in orthodontics

Dentomaxillofac Radiol

Superimposition of 3D cone-beam CT models of orthognathic surgery patients

Dentomaxillofac Radiol

Error in radiology: classification and lessons in 182 cases presented at a problem conference

Radiology

Incidental findings of pathology and abnormality in pretreatment orthodontic panoramic radiographs

Angle Orthod

Evaluation of panoramic radiographs taken at the initial visit at a department of paediatric dentistry

Dentomaxillofac Radiol

Clinical experience with cone beam volumetric imaging: report of findings in 381 cases

US Dent

Clinical and economic impact of incidental thyroid lesions found with CT and MR

AJNR Am J Neuroradiol

Original article
Efficacy of identifying maxillofacial lesions in cone-beam computed tomographs by orthodontists and orthodontic residents with third-party software