RESEARCH

Diagnostic accuracy of cone beam computed tomography scans

compared with intraoral image modalities for detection of caries
lesions
F Haiter-Neto
1
, A Wenzel
2
and E Gotfredsen
2
1
Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas, Brazil;
2
Department of Oral Radiology, School
of Dentistry, University of Aarhus, Denmark
Objectives: The aim was to compare the caries diagnostic accuracy of two cone beam CT
systems (CBCT) with two intraoral receptors, one digital and one film.
Methods: 100 non-cavitated extracted human teeth were placed with approximal contacts:
each row of teeth comprised 1 canine, 1 first and second premolar, and 1 first and second
molar. Radiographs of each tooth were recorded using two intraoral modalities: Digora-fmx
(Soredex) and film (Kodak Insight), and two CBCT systems: NewTom 3G (Quantitative
Radiology) in three fields of view (FOVs): pixel size of 0.36 mm (FOV 12 inches), pixel size of
0.25 mm (FOV 9 inches), pixel size of 0.16 mm (FOV 6 inches); and 3DX Accuitomo
(Morita), pixel size of 0.125 (FOV 4 cm). The volumetric data from the CBCT systems were
reconstructed and sectioned (0.5 mm) in the mesiodistal tooth plane. Six observers scored
approximal and occlusal surfaces for the detection of caries lesions. The teeth were clinically
sectioned and microscopy served as the validation tool. Two-way ANOVA tested differences
in sensitivity, specificity and overall true score (true positives plus true negatives) between the
modalities.
Results: Microscopy of approximal surfaces found 63% sound, 31% enamel and 6% dentin
lesions; of occlusal surfaces, 6%sound, 59%enamel, 19%dentin lesions and 16%had fillings.
For approximal surfaces, NewTom 12 inch and 9 inch images had significantly lower
sensitivities than Accuitomo (P , 0.02); and NewTom 9 inch and 6 inch had significantly
lower specificities than film and Digora-fmx (P , 0.04). Accuitomo images were not
significantly different from film or Digora-fmx images for any of the tested variables
(P . 0.2). For occlusal surfaces, the Accuitomo presented a higher sensitivity than the other
systems. Specificity and overall true score did not differ (P . 0.06) among the modalities.
Conclusions: In conclusion, the NewTom 3G CBCT had a lower diagnostic accuracy for
detection of caries lesions than intraoral modalities and the 3DX Accuitomo CBCT. The
Accuitomo CBCT had a higher sensitivity than the intraoral systems for detection of lesions
in dentin, but the overall true score was not higher.
Dentomaxillofacial Radiology (2008) 37, 1822. doi: 10.1259/dmfr/87103878
Keywords: radiography; digital; computed tomography; diagnosis; dental caries
Introduction
Intraoral digital radiography has been adopted by
dentists in the last decade and is widely used for caries
diagnosis.
1
Over the past years, the accuracy of different
digital radiography systems for caries detection has been
compared mutually and with conventional film sys-
tems.
26
Cone beam CT (CBCT) is a new technology that uses
a two-dimensional sensor and a cone-shaped beam in
place of the fan-shaped X-ray beam used for conven-
tional CT. The volume data of the human body can be
acquired in a single rotation of the beam and sensor.
7
The characteristics of this scanner type are lower
entrance doses and higher resolution in the axial
*Correspondence to: Professor Francisco Haiter-Neto DDS, PhD, Department
of Oral Diagnosis, Dentomaxillofacial Radiology Area, Av. Limeira 901,
Areiao, Piracicaba, SP 13414-901, Brazil; E-mail: haiter@fop.unicamp.br
Received 22 September 2006; revised 30 January 2007; accepted 9 March 2007
Dentomaxillofacial Radiology (2008) 37, 1822
2008 The British Institute of Radiology
http://dmfr.birjournals.org
direction than conventional CT-scanners.
8
According
to Ludlow et al,
9
CBCT doses vary depending on
brand, device, field of view (FOV) and selected
exposure factors.
The CBCT technique could be applied in several
dental diagnostic areas such as implant treatment,
craniofacial anomalies, endodontic treatment, ortho-
dontics and periodontology.
1017
Recently, Akdeniz
et al
18
compared caries lesion depth measurements in
approximal surfaces using images obtained with the
Accuitomo CBCT, the Digora-fmx storage phosphor
system and conventional film, and found that CBCT
appears to be a promising tool for monitoring already-
observed small caries lesions. However, there seem to
be no studies published to date investigating the
accuracy of caries lesion detection using CBCT.
The aim of the present study was to compare the
caries diagnostic accuracy of two cone beam CT
systems (CBCT) with two intraoral receptors, one
digital and one film.
Materials and methods
The study was based on 100 non-cavitated extracted
human teeth; 20 canines, 40 premolars and 40 molars.
The teeth were mounted in blocks of silicone, five in a
row with approximal contacts, each row consisting of
four test teeth (one first and second premolar and one
first and second molar) and one non-test tooth, a
canine.
The teeth were radiographed using two intraoral
modalities: Digora-fmx with blue plates (Soredex,
Tuusula, Finland) and Kodak Insight film (Eastman
Kodak Company, Rochester, NY). Standardized con-
ditions were used: Gendex DC X-ray unit (Gendex, Des
Plaines, IL), 65 kVp, 10 mA, 32 cm focustooth
distance, 2 cm toothreceptor distance, rectangular
collimation, paralleling technique. A 12 mm acrylic
plate was placed between the tube and the tooth block
to simulate soft tissue. The films were developed in an
automatic roller processor (XR 24 Nova, Du rr Dental,
Bietigheim-Bissingen, Germany) using automatic
regeneration of developer and fixer solutions (Du rr-
Automat XR, Du rr Dental). The PSP image plates were
stored in light-proof envelopes during the exposure.
The teeth were also recorded using two CBCT
systems: NewTom 3G (Quantitative Radiology,
Verona, Italy) in three FOVs: pixel size 0.36 mm
(FOV 12 inches, low resolution); pixel size 0.25 mm
(FOV 9 inches, medium resolution); pixel size 0.16 mm
(FOV 6 inches, high resolution) at a fixed 110 kVp
setting, automated adjusted milliamperes and a scan
time of 36 s; 3DX Accuitomo (Morita Co. Ltd, Tokyo,
Japan) had a pixel size of 0.125 mm (FOV 4 cm). The
tube voltage was 60 kVp, the tube current 3 mA and
scanning time was 18 s. The volumetric data from the
CBCT systems were reconstructed and sectioned in
0.5 mm in the mesiodistal tooth plane. The images from
each digital system were exported to general software
(CaSco, designed by senior programmer Erik
Gotfredsen, School of Dentistry, University of
Aarhus, Denmark) with image enhancement facilities
to adjust contrast, brightness, gamma curve function
and magnification, and coded to blind the observers. In
this program, the image is displayed at its full size, 1:1
on the monitor, and a scroll bar is used to move from
one side of the image to the other. Six independent
observers scored primary approximal and occlusal
caries lesions in each tooth. The images were organized
in groups of images from a particular exposure setting
and system. The observers viewed the image groups in
random order. They recorded caries lesions using a
5-point confidence rating scale: 1caries definitely
absent; 2caries probably absent; 3unsure if present
or absent; 4caries probably present; and 5caries
definitely present. Whenever a score of 4 or 5 was
recorded, the observer also scored whether the lesion
was observed in enamel alone or in both enamel and
dentin. A period of at least 1 day separated each
viewing session. Surfaces with fillings were excluded.
The digital images were displayed on a 17 inch monitor
placed in a room with subdued light. All observers
assessed all images on the same monitor. The observers
could use the image enhancement facilities as they
pleased. The film radiographs were assessed using a
light box and a two-times magnification X-viewer.
The teeth were individually embedded in acrylic
(Vipcril; Vipi, Sa o Paulo, Brazil) and serially sectioned
into 700 mm thick sections in the mesiodistal direction
using a 200 mm diamond band. The sections were glued
to a glass slide. Two experienced pre-calibrated
observers (different from those examining the radio-
graphic images) examined the tooth sections using a
light microscope at 1216 times magnification. They
classified each tooth surface into one of three cate-
gories: sound, lesion in enamel, or lesion in enamel and
dentin. In case the observers classifications varied, they
performed a joint assessment to establish agreement.
Both sides of each tooth section were examined. A
caries lesion was defined as present when an opaque
white or brown discoloration was observed in an area
at risk of caries.
Data analysis
For each observer with each radiographic modality,
parameters expressing various aspects of accuracy
(sensitivity, specificity, positive and negative predictive
values, and overall true score (true positives plus true
negatives)) were computed by validating the results
achieved with the radiographic examination against
those from the histological examination. To obtain
these accuracy parameters, the radiographic scores
from the confidence scale were dichotomized into:
sound 5 caries definitely absent, caries probably absent,
unsure if caries is present or absent; and lesion 5 caries
probably present and caries definitely present (this was
done for scores assigned to both enamel and dentin). Two
CBCT for caries lesion detection
F Haiter-Neto et al 19
Dentomaxillofacial Radiology
diagnostic thresholds were analysed. The first analysis
was performed to detect all lesions in approximal
surfaces: sound surfaces vs surfaces with lesions (whether
enamel or enamel plus dentin). The second analysis was
performed to detect dentinal lesions in approximal and
occlusal surfaces: sound surfaces or surfaces with shallow
lesions vs surfaces with dentinal lesions. The tooth
surface was the statistical unit. The parameters sensitiv-
ity, specificity, positive predictive value, negative pre-
dictive value and overall true score were analysed
separately using two-way ANOVA with the factors
observer and radiographic modality at both diagnostic
thresholds. The pair-wise comparisons between the
modalities were made using post hoc t-tests. The level of
statistical significance was P , 0.05.
Results
The true status of the 160 approximal surfaces
according to histological examination was 63% sound
surfaces, 31% with enamel carious lesions and 6% with
dentin lesions. 13 occlusal surfaces had fillings (16%),
6% had no lesions, 59% had lesions in the enamel and
19% had dentin lesions.
Table 1 presents mean sensitivities, specificities,
positive and negative predictive values and overall true
score for each modality for the diagnostic threshold
detection of lesions in approximal surfaces. Sensitivity
was significantly lower for NewTom 12 inch and 9 inch
when compared with Accuitomo (P , 0.02). NewTom
6 inch did not differ from the other modalities.
NewTom 9 inch and 6 inch had significantly lower
specificities than Insight film and Digora-fmx
(P , 0.04), among which there were no differences
(P . 0.05). The positive predictive values for the
NewTom FOV 12 inch and 9 inch were significantly
lower than the other systems (P , 0.03). The negative
predictive values were significantly lower for all three
NewTom FOVs than for Accuitomo (P , 0.04).
Overall true score (true positives plus true negatives)
was significantly lower for all NewTom FOVs (12
inches, 9 inches and 6 inches) than for Accuitomo and
Insight film (P , 0.05). Between Accuitomo and the
intraoral systems, and between film and Digora-fmx,
no differences were found for any parameter (P . 0.2).
Table 2 presents mean sensitivities, specificities,
positive and negative predictive values and overall true
score for each modality for the diagnostic threshold
detection of dentinal lesions in approximal and occlusal
surfaces. Accuitomo had a significantly higher sensitiv-
ity than the other digital systems (P , 0.001). Film and
Digora-fmx presented the lowest sensitivity values,
which did not differ between them (P 5 1), but which
were significantly lower than all three NewTom FOVs
and Accuitomo (P , 0.001). Specificity did not differ
significantly among the modalities (P . 0.06). Digora-
fmx obtained positive predictive values significantly
lower than film and Accuitomo (P , 0.03). The
negative predictive values were not significantly differ-
ent between the three NewTom FOVs (P . 0.93), nor
when the three FOVs were compared with the other
modalities, while Accuitomo obtained significantly
higher values than the intraoral systems (P , 0.01).
There were no differences among the systems in overall
true score (P . 0.15).
Discussion
In the present study, we selected teeth with rather small
clinical demineralizations and non-cavitated surfaces
since we believe that if diagnostical differences between
radiographic systems are to be found, their accuracy in
detecting subtle pathological changes should be tested.
The sensitivity value for detecting lesions in approximal
surfaces was between 0.13 and 0.21, meaning that all
systems failed to detect the smallest enamel lesions. These
Table 1 Mean sensitivities, specificities, positive and negative predictive values and overall true score for each image modality (Digora-fmx,
Insight film, NewTom 12 inch, NewTom 9 inch, NewTom 6 inch and Accuitomo) for the detection of lesions in approximal surfaces
Means Digora-fmx Film NewTom 12 inch NewTom 9 inch NewTom 6 inch Accuitomo
Sensitivities 0.17 0.18 0.13 0.14 0.18 0.21
Specificities 0.91 0.92 0.88 0.85 0.84 0.89
Positive predictive 0.56 0.62 0.42 0.43 0.50 0.60
Negative predictive 0.65 0.66 0.64 0.63 0.65 0.66
True score 0.64 0.65 0.61 0.59 0.61 0.64
Table 2 Mean sensitivities, specificities, positive and negative predictive values, and overall true score for each image modality, Digora-fmx,
Insight film, NewTom 12 inch, NewTom 9 inch, NewTom 6 inch and Accuitomo for detection of dentinal lesions in approximal + occlusal
surfaces
Means Digora-fmx Film NewTom 12 inch NewTom 9 inch NewTom 6 inch Accuitomo
Sensitivities 0.31 0.31 0.44 0.44 0.44 0.58
Specificities 0.93 0.95 0.92 0.90 0.89 0.90
Positive predictive 0.38 0.53 0.46 0.43 0.43 0.57
Negative predictive 0.92 0.92 0.93 0.93 0.93 0.95
True score 0.87 0.88 0.87 0.85 0.85 0.86
CBCT for caries lesion detection
20 F Haiter-Neto et al
Dentomaxillofacial Radiology
findings are in accordance with previous studies on caries
diagnostic accuracy in radiographs.
19
At the diagnostic
threshold for lesions in dentin in both approximal and
occlusal surfaces, sensitivity values increased to 0.31
0.58. The statistical test unit in our study was the tooth
surface. More surfaces from the same tooth may not be
independent variables, but we believe that this is not a
serious bias and does not weaken the results.
CBCT is a new radiographic modality for dental
imaging, and all new diagnostic methods should be
compared with imaging systems already in clinical use
to evaluate whether their accuracy is comparable with
the well-estimated systems. Therefore, film and the
Digora-fmx storage phosphor system were included in
this study to serve as reference. Film and Digora-fmx
showed no differences in our study in any parameter for
caries diagnostic accuracy. These results are in accor-
dance with previous reports comparing conventional
and digital intraoral receptors.
1,2,1922
Akdeniz et al
18
compared the Accuitomo (3DX) CBCT, Digora-fmx
and Insight film for measuring depth of approximal
caries lesions. The authors found that the Accuitomo
images provided more accurate lesion depth estimates
with less variation when compared with measurements
performed on the sections of the tooth than did the
intraoral images and therefore suggested that CBCT
appears to be a promising tool for monitoring small
caries lesions. The aim of our study was to detect
lesions, not to monitor already-observed lesions, and
for this purpose no differences in overall true score, true
positive plus true negative scores, were found between
the Accuitomo CBCT and the intraoral systems. When
the statistical analysis included occlusal lesions in
dentin, the Accuitomo demonstrated higher sensitivities
than the intraoral systems, but still no differences
among the systems were found in the overall true score.
The teeth images from the CBCT systems were
examined in the mesiodistal plane. There is, of course,
the possibility of also performing sections in other
planes with the CBCT software. The teeth can be cut in
only one direction, however, and we chose the
mesiodistal plane to validate approximal surfaces. In
such tooth sections, both approximal and occlusal
surface demineralization may be seen. We therefore
also examined the CBCT sections in the mesiodistal
plane since otherwise there would be no truth to
validate against.
A few other studies have evaluated the diagnostic
performance of CBCT systems. Mengel et al
23,24
investigated the accuracy and quality representation
of periodontal and peri-implant defects using the
Accuitomo CBCT system, intraoral radiography,
panoramic radiography and CT. They advocated the
use of CBCT since these images showed the best image
quality regarding periodontal and peri-implant defects.
Furthermore, Misch et al
25
compared interproximal
periodontal defects using the i-CAT CBCT (Imaging
Sciences International, Hatfield, PA), intraoral F-speed
film and CT, and the authors reported that CBCT
obtained better results than the other systems with the
advantage of allowing observation of periodontal
defects in all directions.
No studies have previously evaluated the NewTom
3G CBCT for its ability to detect caries lesions. The
NewTom has three FOVs, allowing a full craniofacial
examination with the largest field while the smallest
FOV is 6 inches in diameter. As can be expected, the
NewTom has an appreciably lower spatial resolution
than the Accuitomo system, for which the FOV is 4 cm
in diameter. The consistent finding in our study
between the two CBCT systems was that the 3DX
Accuitomo had a higher overall true score for lesions in
approximal surfaces and a higher sensitivity for
dentinal lesions than the NewTom in all FOVs. There
were very few dentinal lesions in approximal surfaces,
but there were more and deeper occlusal lesions in
dentin in our tooth sample, and deeper lesions may be
easier to differentiate regardless of the radiographic
modality, which may explain why no differences were
found in the overall true score between the two CBCT
systems when detecting lesions in dentin.
Clinicians who perform NewTom CBCT examinations
for other diagnostic tasks may appreciate the finding that,
overall, NewTom obtained a lower diagnostic accuracy
than the intraoral systems for caries detection since it
indicates that they should not spend their time looking for
small caries lesions, even though the images of the teeth
are available. If an Accuitomo examination has been
performed for other diagnostic reasons it may, on the
other hand, be reasonable to carefully examine the teeth
that are included in the examination for caries lesions,
even though this may mean that the examiner must spend
more time reconstructing and sectioning the volume data.
It is undeniable that CBCT produces lower entrance
doses and higher resolution in the axial direction than
medical CT scanners. The entire scanning of a region to
be examined is performed with only one rotation and
application of a cone beam in a 360 rotation exposure,
which produces, according to Ludlow et al,
9
a dose of
approximately 45 mSv, 135 mSv and 477 mSv for the
NewTom (FOV 12 inch), i-CAT and CBCT Mercuray,
respectively. The CBCT scanners thus produce lower
doses in comparison with medical CTscanners, for which
dose values are in the range of 3641200 mSv for a
mandibular scan and 1003324 mSv for a maxillary scan,
according to European Guidelines on radiation protec-
tion in dental radiology.
26
Once the large imaging fields
permit simultaneous imaging of the complete base of the
skull as well as maxillofacial anatomy extending from the
frontal process to the base of chin, these images may
substitute for cephalometric and panoramic images.
Despite the possible advantages in diagnostic outcome
of CBCT, it should be borne in mind that it still results in
higher radiation doses than conventional imaging alter-
natives and intraoral examinations. The effective doses
for conventional imaging are in the range of 18.3 mSv for
an intraoral exam, 430 mSv for panoramic and 23 mSv
for a lateral cephalometric examination.
26
It is critical
CBCT for caries lesion detection
F Haiter-Neto et al 21
Dentomaxillofacial Radiology
that the potential patient benefits from a radiographic
examination be balanced against the risk of exposure to
ionizing radiation,
27
especially in paediatric patients
because children are assumed to carry any radiation
burden for a longer time than adults and the developing
organs are more sensitive to radiation effects. According
to a recent editorial by Farman,
28
the principle of
ALARA (As Low As Reasonably Achievable) is still
fundamental for diagnostic radiology and CBCT proce-
dures should be reserved for selected cases. The profes-
sional radiological society must develop guidelines for
the use of CBCT once there is enough evidence on
the diagnostic outcome compared with conventional
methods.
In conclusion, the 3G NewTom CBCT had a lower
diagnostic accuracy for detection of caries lesions than
intraoral modalities and the 3DX Accuitomo CBCT.
The Accuitomo CBCT had a higher sensitivity than the
intraoral systems for detection of lesions in dentin, but
the overall true score was not higher.
Acknowledgments
To DDS Ribamar Azevedo and Bruno Azevedo, who
permitted the use of the 3DX Accuitomo in their private oral
radiology clinic. To DDS Andrea Pontual, who helped
sectioning the teeth
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