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dam was removed the quality of the root filling was 1 The periapical radiolucency was largest in the first
checked with a radiograph exposed with the bisecting- image
angle technique. A postoperative radiograph was then 2 The periapical radiolucency was largest in the second
taken with the paralleling technique (Forsberg 1987c). image or
This radiograph served as a basis for the comparison in 3 Same size of radiolucencies or no radiolucency was
the follow-up examination. The radiographs were present in any image.
exposed with a Philips Oralix X-ray machine operated at Again this examination was repeated after 4 weeks.
65 kV and 7.5 mA, which was equipped with a tubular When the observer selected the same group twice, this
collimator (diameter 5 cm). The focus-film distance was decision was used as the final grouping. In cases with
approximately 22 cm for both techniques. The film used intraobserver disagreement a third reading was per-
was Kodak Ektaspeed EP 12 and EP 22. The exposures formed. In eight cases (two in the root canal treatment
were performed by undergraduate students who had and six in the surgery group) the observers had
already completed their training in oral radiology and disagreed completely with one another (used all three
who where supervised by clinical instructors. The films alternatives). These cases were excluded from that part
were processed in an automatic processor, Philips of the study that dealt with comparison of the projection
Rollomat 820. After five of 68 consecutive cases had techniques. The intra- and interobserver performance
been excluded because of technical errors, the sample was expressed as overall agreement and calculated as a
consisted of 63 pairs of radiographs. kappa index (Cohen 1960, Cockshott & Park 1983) as
The second group consisted of patients who had further described by Fleiss (1971) and Grndahl et al.
received endodontic surgery with apicectomy in the (1987).
Department of Oral Surgery. The exposures were taken McNemars test (Rosner 1995) was used to test
by radiographers in the Department of Oral Radiology, possible differences between the bisecting-angle and the
supervised by an oral radiologist. The X-ray machine paralleling techniques. Statistical significance was
was a Gendex GX operated at 65 kV and 10 mA and the chosen at the 5% level.
films were developed in an automatic processor, Drr
Dental XR 24. This sample consisted of 105 pairs of Results
radiographs taken at the 1-year review. Other data were
as for the first group. Intraobserver agreement
The findings are summarized in Table 1. When evalu-
Evaluation of the cases ating the presence of lesions for the root canal treatment
cases the observers showed kappa values in the range
The radiographs were masked to reveal only the apical 0.790.89 for the bisecting technique and in the range
part of the tooth and the surrounding bone. They were 0.800.85 for the paralleling technique. For the surgery
coded and the two exposed radiographs of the same cases the kappa values were somewhat lower for all
tooth were examined randomly. Three observers (A, B three observers.
and C), all well trained in oral radiology, examined the No significant differences were found when com-
pictures using a viewing box with moderate illumina- paring the kappa values for the two techniques and
tion and a magnifying viewer. They were asked to comparing surgery and root canal treatment cases.
classify the teeth according to: For both the root canal treatment and the surgery
1 Normal periapical condition cases the intraobserver agreement was considerably
2 Periapical radiolucency lower when comparing lesion size for the two tech-
The radiographs were re-examined after 4 weeks. niques. The kappa values varied from 0.38 to 0.71.
In the second part of the investigation the pairs of
corresponding radiographs were compared. Only cases
Interobserver agreement
where a radiolucency had been diagnosed by at least one
of the observers were included, and the samples now The comparison of observers based on their first evalua-
consisted of 30 root canal treatment cases and 51 tion of cases is presented in Table 2. When evaluating
surgical cases, respectively. The two radiographs presence of lesions for the root canal treatment cases the
exposed with different techniques, but also now coded, observers showed kappa values in the range 0.700.72
were compared with regard to the size of the radiolu- for the bisecting technique and in the range 0.580.69
cency. The observers had to determine whether: for the paralleling technique. For the surgery cases the
Table 1 Comparison of first and second evaluation of cases with respect to presence/absence of apical lesion or lesion size. Observers performance
presented as percentage agreement and Cohens kappa
Table 2 Comparison of observers based on their first evaluation of cases with respect to presence of apical lesion or lesion size. Observers perfor-
mance presented as percentage agreement and Cohens kappa
kappa values were somewhat lower for the bisecting For both the endodontic and the surgery cases the
technique and at the same level for the paralleling interobserver agreement was low when comparing
technique. No significant differences were found when lesion size for the two techniques. The kappa values were
comparing the kappa values for the two techniques. in the range 0.250.48.
Size of lesions as recorded by the bisecting-angle and irrespective of the radiographic technique (Table 1). It is
the paralleling techniques probable that greater difficulties will arise in diagnosing
the apical region after cutting the root tip during the
Some examples of the radiographic reproduction of surgical procedure than at a well-defined root apex with
periapical lesions in pairs of radiographs exposed at the untouched periapical tissue.
same time with the bisecting-angle and the paralleling Evaluation of cases with respect to the lesion size
techniques are shown in Figs 1 and 2. (Table 1) yielded poor agreement between the two obser-
With one exception, there were no significant differ- vations. A probable reason is the considerably greater
ences between the two techniques in reproducing the difficulty in comparing the size of lesions in pairs of
size of periapical lesions (Table 3). radiographs exposed with different radiographic tech-
niques than taking a decision on one radiograph of
lesion/no lesion. It is reasonable to assume that the
Discussion
presence of scar tissue also complicated the reading of
Absence of periapical radiolucencies has been used as a some of the surgery cases.
significant criterion for therapeutic success in root canal The percentage agreement and Cohens kappa were
treatment and apical surgery (Goldman et al. 1972, Reit generally lower between observers than for the corre-
& Grndahl 1983, Zakariasen et al. 1984, Molven & sponding intraobserver value (Table 2), regardless of the
Halse 1988, Grung et al. 1990). Decreased or increased fact that all three observers had long experience as
size of the periapical lesion over time after treatment is a dental radiologists. Reit (1987) has reported previously
criterion for expected success or failure respectively that radiographic periapical diagnosis is subjected to
(Molven et al. 1987, Halse et al. 1991). considerable interexaminer variation. He also found
A variety of studies have dealt with intra- and inter- that the benefits of calibration programmes for reducing
examiner agreement on the presence of periapical interobserver variation are limited. This stresses the
lesions. These studies show large intraobserver variation need for well defined criteria for the radiographic
(Brynolf 1970, Goldman et al. 1972, Molven 1976, diagnosis of periapical lesions. Since the paralleling
Abdel Wahab et al. 1984) and even greater interob- technique is considered to be the most standardized of
server variation (Goldman et al. 1974, Reit & Grndahl the two techniques, more consistent findings might have
1983, Abdel Wahab et al. 1984, Halse & Molven 1986, been expected, than observed in the present study.
Kaffe & Gratt 1988, Stheeman et al. 1996). However, In radiographs the geometrical distorsion will in-
none of these examinations have analysed the influence fluence the reproduced dimension of a subject. Both the
of the radiographic technique on the reproduced size bisecting-angle and the paralleling techniques, even
of periapical lesions. In this study the intra- and inter- when correctly adjusted, will create magnification of the
examiner agreement on both the presence of lesions apical structures. In addition, because of the different
and the size of lesions as read from radiographs angulation of the central beam, different anatomical
exposed with different radiographic techniques were structures may overlap the apical area resulting in a
evaluated. different radiographic appearance of the lesion (Fig. 3).
The percentage agreement and Cohens kappa, when An earlier in vitro examination on single-rooted teeth
recorded, were higher for all three observers for the root with a simulated periapical lesion has clearly indicated
canal treatment cases than for the surgical cases that the paralleling technique provides more valid infor-
mation about the size of a pathological process than the
Table 3 Intraobserver agreement of number of cases with largest
bisecting-angle technique (Forsberg & Halse 1994).
reproduction of the periapical lesion comparing the bisecting-angle
and the paralleling techniques However, in this laboratory study the simulated
periapical lesion was made small and circular. The
No. of cases
Root canal treatment Surgery
border of it was also well defined and there was no
overlapping of skeletal structures. Clinically, periapical
Observer A B C A B C
lesions will vary in size and shape. In this study the size
Bisecting-angle 7 6 4 10 3 7
technique of the lesions were generally larger compared with the
Paralleling technique 8 9 6 8 12 13 simulated lesion. Owing to the different vertical angula-
Observer B, surgery cases: bisecting-angle versus paralleling tions of the two radiographic techniques the beams will
technique; touch the surface of a lesion at different points and
McNemars test 2.07, P<0.05. thereby influence the extension of the lesion reproduced.
Fig. 1 Pairs of radiographs showing root canal treated teeth. Each pair of radiographs was
exposed at the same time with the bisecting-angle (A) and the paralleling (B) techniques. In
the upper horizontal row the lesion is reproduced largest in the bisecting-angle radiograph
(A). In the middle row both techniques reproduced the lesion to the same size and in the
lower row the lesion is projected largest in the paralleling radiograph (B).
Fig. 2 Pairs of radiographs showing apicected teeth. Each pair of radiographs was
exposed at the same time with the bisecting-angle (A) and the paralleling (B) techniques.
In the upper horizontal row the lesion is largest in the bisecting-angle radiograph (A). In
the middle row both techniques reproduced the lesion to the same size and in the lower
row the lesion is largest in the paralleling radiograph (B).
Although numerous studies based on radiographic periapical tissue (Andreasen & Ruud 1972) and in
examination have been published evaluating success autopsy material (Brynolf 1967). However, none of
or failure of root canal therapy and apical surgery these combined examinations has presented informa-
(Strindberg 1956, Bergenholtz et al. 1973, Molven tion on whether the reproduced size correlated with the
1976, Kerekes & Tronstad 1979, Reit & Grndahl 1983, true size of periapical lesions. Fouad et al. (1992)
Molven & Halse 1988, Halse et al. 1991, Molven et al. concluded that the morphology of the jaws of most
1996), little attention has been paid to the influence of experimental animals was not suitable for standardized
the radiographic technique on the depiction of periapical radiographs. Andreasen & Ruud (1972) examined the
pathological changes (Forsberg & Halse 1994). Peri- correlation between histology and radiography in
apical lesions have been studied in animals using both assessment of healing after endodontic surgery. They
radiography and histology (Allard & Strmberg 1979, found a number of radiographic variables correlated to
Fouad et al. 1992), clinically by biopsies of apices and the histological findings by periapical inflammation or
presence of fibrous scar tissue. The radiographically technique upon prediction of tooth length in intraoral radiography.
reproduced size of the lesions compared with the histo- Oral Surgery, Oral Medicine and Oral Pathology 51, 1007.
BR Y N O L F l (1967) A histological and roentgenological study of the
logical appearance was not examined in this study. periapical region of human upper incisors (Thesis). Odontologisk
Brynolf (1967), in her study of the periapical region in Revy 18, (Suppl. 11).
autopsy material, concluded that the changes in the BR Y N O L F l (1970) Roentgenologic periapical diagnosis 1.
Reproducibility of interpretation. Svenska Tandlkarfrbundets
radiographic groups tallied well with those in the histo-
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periapical region of maxillary incisors, which in relation radiology. Skeletal Radiology 10, 8690.
to the vertical plane are about 1520 angulated. CO H E N J (1960) A coefficient for agreement for normal scales.
Education Psychological Measurement 20, 3746.
Therefore, in this region the angle between the tooth
FO R S B E R G J (1987a) Radiographic reproduction of endodontic
axis and the film will be moderate irrespective of the working length comparing the paralleling and the bisecting-angle
radiographic technique. techniques. Oral Surgery, Oral Medicine and Oral Pathology 64,
During recent years many studies have been 35360.
FO R S B E R G J (1987b) A comparison of the paralleling and bisecting-
performed using digital subtraction radiography in
angle radiographic techniques in endodontics. International Endo-
diagnosing dental caries and bone lesions. There is no dontic Journal 20, 17782.
indication that this technique provides a better validity FO R S B E R G J (1987c) Estimation of the root filling length with the paral-
than conventional radiographic examination in leling and the besecting-angle techniques performed by under-
graduate students. International Endodontic Journal 20, 936.
diagnosing caries (Halse et al. 1994) but it seems to be
FO R S B E R G J, HA L S E A (1994) Radiographic simulation of a periapical
useful for detection of small substance loss in the lesion comparing the paralleling and the bisecting-angle techniques.
marginal periodontium (Kullendorf et al. 1992, Wenzel International Endodontic Journal 27, 1338.
et al. 1992). Promising results have also been obtained FO U A D A, WA L T O N R, RI T T A N B (1992) Induced periapical lesions in
ferret canines: Histologic and radiographic evaluation. Endodontics
for diagnosing alteration in the apical periodontium and Dental Traumatology 8, 5662.
(Pascon et al. 1987, Kullendorf et al. 1988). Because of FL E I S S JL (1971) Measuring nominal scale agreement among many
the difficulties in determining the size of periapical raters. Psychological Bulletin 76, 37882.
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Whos reading the radiograph? Oral Surgery, Oral Medicine and Oral
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bisecting-angle and the paralleling radiographic tech- agreement in estimating changes in periodontal bone from conven-
niques will give the same result in diagnosing periapical tional and subtraction radiographs. Journal of Clinical Peridontology
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that the paralleling technique produces more identical GR U N G B, MO L V E N O, HA L S E A (1990) Periapical surgery in a
Norwegian county hospital: follow-up findings of 477 teeth. Journal
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area after root canal treatment and apical surgery. pathosis. Journal of Endodontics 12, 5348.
HA L S E A, ES P E L I D l, TV E I T AB, WH I T E S (1994) Detection of mineral
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