Evaluation of common operator errors in panoramic radiography in Trinidad and Tobago: a comparison of formally vs informally trained operators.

AIM: To evaluate and compare the frequency of common operator errors seen on panoramic radiographs in dental private practices and in the dental hospital (taken by informally and formally trained operators, respectively) in Trinidad and Tobago. METHOD: One thousand panoramic radiographs of patients over the age of 10 years were included in this study. These comprised 500 from the dental hospital and 500 from dental private practices. The radiographs were reviewed using standardized criteria to identify the most common operator errors. RESULTS: There were only 21 (4.2%) error free radiographs in the dental private practice sample and 29 (5.80%) in the dental hospital sample. Frequencies of specific errors were significantly higher in the dental private practice sample in each category except for "Chin tipped too low" (Chi-square p < 0.05) CONCLUSION: This study supports the need for the introduction of statutory guidelines with respect to the use of ionizing radiation in dentistry in Trinidad and Tobago and in particular, the implementation of formally assessed dedicated dental radiography training for all operators of dental X-ray equipment.

Mechanisms of Atomization from Rotary Dental Instruments and Its Mitigation.

Since the onset of coronavirus disease 2019, the potential risk of dental procedural generated spray emissions (including aerosols and splatters), for severe acute respiratory syndrome coronavirus 2 transmission, has challenged care providers and policy makers alike. New studies have described the production and dissemination of sprays during simulated dental procedures, but findings lack generalizability beyond their measurements setting. This study aims to describe the fundamental mechanisms associated with spray production from rotary dental instrumentation with particular focus on what are currently considered high-risk components-namely, the production of small droplets that may remain suspended in the room environment for extended periods and the dispersal of high-velocity droplets resulting in formites at distant surfaces. Procedural sprays were parametrically studied with variables including rotation speed, burr-to-tooth contact, and coolant premisting modified and visualized using high-speed imaging and broadband or monochromatic laser light-sheet illumination. Droplet velocities were estimated and probability density maps for all laser illuminated sprays generated. The impact of varying the coolant parameters on heating during instrumentation was considered. Complex structured sprays were produced by water-cooled rotary instruments, which, in the worst case of an air turbine, included droplet projection speeds in excess of 12 m/s and the formation of millions of small droplets that may remain suspended. Elimination of premisting (mixing of coolant water and air prior to burr contact) resulted in a significant reduction in small droplets, but radial atomization may still occur and is modified by burr-to-tooth contact. Spatial probability distribution mapping identified a threshold for rotation speeds for radial atomization between 80,000 and 100,000 rpm. In this operatory mode, cutting efficiency is reduced but sufficient coolant effectiveness appears to be maintained. Multiple mechanisms for atomization of fluids from rotatory instrumentation exist, but parameters can be controlled to modify key spray characteristics during the current crisis.

New dimensions in endodontic imaging: part 1. Conventional and alternative radiographic systems.

Conventional radiographs used for the management of endodontic problems yield limited information because of the two-dimensional nature of images produced, geometric distortion and anatomical noise. These factors often act in combination. This review paper assesses the limitations of periapical radiographs and seeks to clarify three-dimensional imaging techniques that have been suggested as adjuncts to conventional radiographs. These include tuned aperture computed tomography, magnetic resonance imaging, ultrasound, computed tomography and cone beam computed tomography (CBCT). Of these techniques, CBCT appears to be an effective and safe way to overcome some of the problems associated with conventional radiographs.

Epithelioid Haemangioendothelioma of the mandibular gingiva: case report and literature review.

INTRODUCTION: Epithelioid hemangioendothelioma (EHE) is a rare vascular neoplasm that exhibits the potential for recurrence and metastasis but rarely involves the oral cavity. PRESENTATION OF CASE: We report the management and long term follow up of recurrent EHE in a 23- year-old woman. The lesion initially presented as a small area of erythematous gingival swelling with localised bone loss around the lower anterior teeth. It was treated by buccal and lingual stripping of the gingival tissues. The patient suffered local recurrence after 7 years and was treated with a wider surgical excision of the buccal and lingual gingivae, conserving the adjacent teeth and bone with an excellent cosmetic outcome. Over 21 years later, there have been no further recurrences. DISCUSSION: This case highlights the management challenges of EHE and is the only case in the literature to have reported a case of mandibular gingivae with a long review period of 21 years. CONCLUSION: Oral EHE is an unpredictable lesion with a relatively benign course, unlike non-oral EHE where up to one third of cases may metastasise. Because of the propensity to recur locally after excision and curettage, a wide local excision with close clinical follow has been suggested in the literature as the treatment of choice for oral lesions. However, the lack of metastases from oral lesions, the small size, mandibular site and bland histology in this case suggests that a limited soft tissue excision and bone curettage, with long term follow-up would be appropriate for similar gingival lesions in future.

An update on dental imaging.

This paper reviews recent advances and current trends in dental radiology. Developments in the design of dental x-ray equipment which improve both radiation hygiene and image quality are described. Also discussed are new features which broaden the scope of intra-oral and panoramic radiological diagnosis in the general dental practice setting. The article concludes with the main recommendations from the latest guidelines on quality standards for radiography, selection criteria and quality assurance in general practice.

Radiographic diagnosis of root resorption in relation to orthodontics.

The literature regarding external root resorption in relation to orthodontics and its radiographic diagnosis is reviewed, including a summary of the more common radiographic techniques available. Sample cases are presented which demonstrate the need for good radiographic technique and an awareness of the limitations of certain radiographs. A provisional diagnosis of external root resorption may need to be confirmed by further radiographic views where appropriate.

An evaluation of the diagnostic yield from bitewing radiographs of small approximal and occlusal carious lesions in a low prevalence sample in vitro using different film types and speeds.

AIM: To compare diagnostic yield in caries diagnosis from D- and E-speed films. DESIGN: A laboratory study. SETTING: A UK dental school between 1992 and 1994. MATERIALS AND METHODS: 96 extracted teeth containing approximal and occlusal lesions, but representing a low caries prevalence sample, were set in occluding dental arches. Bitewing radiographs were taken and interpreted by 5 examiners for the presence or absence of caries. Each examiner was also asked which film image he or she subjectively liked best. MAIN OUTCOME MEASURES: The teeth were subsequently sectioned and histologically examined to validate diagnostic decisions. RESULTS: For all film types the percentage of lesions with caries histologically in dentine correctly identified radiologically (sensitivity) was low (approximal caries 8-22%; occlusal caries 0-30%). The number of sound dentine sites correctly identified (specificity) was high (approximal caries 98-100%; occlusal caries 79-100%). There were no significant differences between D- and E-speed films. Sensitivity was unaffected by each examiner's subjective preference for a particular film. The variation in sensitivity of diagnosis was due to differences between examiners. CONCLUSIONS: The reluctance of many GDPs to use E-speed film because they 'do not like the image' cannot be endorsed or supported. Both E-speed film types examined can be recommended for use in general practice.

Haemangioma of the body of the mandible: a case report.

We present a case of haemangioma of the mandible in a 46-year-old woman. The radiological appearance was of a unilocular radiolucency that looked similar to other more common lesions of the mandible. This case shows that a potentially life-threatening haemangioma can present as an apparently benign cyst-like unilocular radiolucency, and highlights the need to include haemangioma in many differential diagnoses, and the importance of taking all radiological features into account.

Basic principles for use of dental cone beam computed tomography: consensus guidelines of the European Academy of Dental and Maxillofacial Radiology.

OBJECTIVES: To develop "basic principles" on the use of dental cone beam CT by consensus of the membership of the European Academy of Dental and Maxillofacial Radiology. METHODS: A guideline development panel was formed to develop a set of draft statements using existing European directives and guidelines on radiation protection. These statements were revised after an open debate of attendees at a European Academy of Dental and Maxillofacial Radiology (EADMFR) Congress in June 2008. A modified Delphi procedure was used to present the revised statements to the EADMFR membership, utilising an online survey in October/November 2008. RESULTS: Of the 339 EADMFR members, 282 had valid e-mail addresses and could be alerted to the online survey. A response rate of 71.3% of those contacted by e-mail was achieved. Consensus of EADMFR members, indicated by high level of agreement for all statements, was achieved without a need for further rounds of the Delphi process. CONCLUSIONS: A set of 20 basic principles on the use of dental cone beam CT has been devised. They will act as core standards for EADMFR and, it is hoped, will be of value in national standard-setting within Europe.

The potential applications of cone beam computed tomography in the management of endodontic problems.

AIM: To provide core information on cone beam computed tomography (CBCT) technology and its potential applications in endodontic practice. SUMMARY: CBCT has been specifically designed to produce undistorted three-dimensional information of the maxillofacial skeleton as well as three-dimensional images of the teeth and their surrounding tissues. This is usually achieved with a substantially lower effective dose compared with conventional medical computed tomography (CT). Periapical disease may be detected sooner using CBCT compared with periapical views, and the true size, extent, nature and position of periapical and resorptive lesions can be assessed. Root fractures, root canal anatomy and the true nature of the alveolar bone topography around teeth may be assessed. CBCT scans are desirable to assess posterior teeth prior to periapical surgery, as the thickness of the cortical and cancellous bone can be accurately determined as can the inclination of roots in relation to the surrounding jaw. The relationship of anatomical structures such as the maxillary sinus and inferior dental nerve to the root apices may also be clearly visualized. KEY LEARNING POINTS: CBCT has a low effective dose in the same order of magnitude as conventional dental radiographs. CBCT has numerous potential applications in the management of endodontic problems.

Evaluation of common operator errors in panoramic radiography in Trinidad and Tobago: a comparison of formally vs informally trained operators / La evaluación de los errores comunes de los operadores de radiografía panorámica en Trinidad y Tobago comparación de los operadores adiestrados formalmente frente a los adiestrados informalmente

AIM: To evaluate and compare the frequency of common operator errors seen on panoramic radiographs in dental private practices and in the dental hospital (taken by informally and formally trained operators, respectively) in Trinidad and Tobago. METHOD: One thousand panoramic radiographs of patients over the age of 10 years were included in this study. These comprised 500 from the dental hospital and 500 from dental private practices. The radiographs were reviewed using standardized criteria to identify the most common operator errors. RESULTS: There were only 21 (4.2%) error free radiographs in the dental private practice sample and 29 (5.8%) in the dental hospital sample. Frequencies of specific errors were significantly higher in the dental private practice sample in each category except for "Chin tipped too low" (Chi-square p < 0.05) CONCLUSION: This study supports the need for the introduction of statutory guidelines with respect to the use of ionizing radiation in dentistry in Trinidad and Tobago and in particular, the implementation of formally assessed dedicated dental radiography training for all operators of dental X-ray equipment.

OBJETIVO: Evaluar y comparar la frecuencia de los errores comunes de los operadores, observados en las radiografías panorámicas en las clínicas dentales privadas y en el hospital de odontología (tomadas por operadores adiestrados formalmente e informalmente, de forma respectiva) en Trinidad y Tobago. MÉTODO: Mil radiografías panorámicas de pacientes de más de 10 años de edad, fueron incluidas en este estudio. Las mismas comprendían 500 provenientes del hospital odontológico y 500 provenían de las prácticas privadas de dentistas. Las radiografías fueron examinadas a partir de criterios estandarizados, a fin de identificar los errores más comunes de los operadores. RESULTADOS: Hubo sólo 21 (4.2%) radiografías sin errores en la muestra de la clínica dental privada, y 29 (5.8%) en la muestra del hospital de odontología. Las frecuencias de errores específicos fueron significativamente más altas en la muestra de la clínica dental privada en cada categoría, salvo el caso del "mentón inclinado excesivamente hacia abajo" (Chi-cuadrado p < 0.05) CONCLUSIÓN: Este estudio subraya la necesidad de introducir pautas reglamentarias con respecto al uso de la radiación ionizante en la cirugía dental en Trinidad y Tobago, particularmente en lo que concierne al adiestramiento especializado en radiografía dental, formalmente evaluado, para todos los operadores de equipos de rayos x para el trabajo dental.

Salivary duct strictures: nature and incidence in benign salivary obstruction.

OBJECTIVES: The aim of this study was to establish the incidence and character of salivary duct strictures by carrying out a 10 year retrospective review. Salivary gland obstruction is most commonly caused either by salivary calculi or duct strictures. These strictures or stenoses develop secondarily to inflammation in the duct wall and may be single or multiple. METHODS: All reports of sialographic examinations performed on patients referred to the Dental Radiology Department in a London Dental Hospital between 1995 and 2004 were reviewed and those patients with symptoms of salivary obstruction identified. In total, 1362 sialograms using the conventional hand injection technique with water-soluble contrast media were performed on 1349 patients with obstructive symptoms during the 10-year period. RESULTS: Of the 1362 sialograms performed, the reports revealed that 877 (64.4%) showed evidence of benign intraductal obstruction. The remaining 485 (35.6%) were normal. 642 of the cases (73.2%) revealing obstruction were reported to be due to salivary calculi, 198 due to duct strictures (22.6%) and the remaining 37 (4.2%) were considered to be due to mucous plugs. Detailed analysis of the patients with strictures showed they were more common in women with a mean age of 52 years. Single strictures were evident in 66.7% of cases while 33.3% showed multiple stenoses. Strictures were more common in the parotid duct (75.3%). 7% of patients presented with bilateral stenoses. CONCLUSION: This is the largest review of duct strictures to be reported. It has shown that ductal stricture formation accounts for almost 25% of cases of benign salivary obstruction and appears to have been an under-recognized condition. Strictures more commonly affect parotid ducts and are typically found in the fourth, fifth or sixth decades, particularly in women.

Comparison of ultrasound, digital and conventional radiography in differentiating periapical lesions.

OBJECTIVES: To carry out an in vivo comparative pilot study to evaluate the efficacy of ultrasound, digital (DR) and conventional plain film-based imaging (PF) in the differential diagnosis of periapical lesions. METHODS: Fifteen patients aged between 13 years and 40 years with periapical lesions associated with anterior maxillary or mandibular teeth requiring endodontic surgery were selected and consented for the study. Pre-operative periapical radiographs (PF) and charge coupled device (CCD) DR were obtained. Measurements and provisional diagnoses of the apical areas were made by three specialist observers (two dental radiologists and one endodontist) on three separate occasions. Pre-operative ultrasound examinations were then performed and the images assessed by two specialist observers (ultrasonographer and endodontist) for the size, contents, vascular supply and a provisional diagnosis made as to whether the lesion was a cyst or granuloma. Endodontic surgery was performed including curettage of the apical tissues to enable histopathological investigation, which provided the gold standard diagnosis. All measurements and findings were compared and statistically analysed. RESULTS: On PF and DR the periapical lesions were readily identified but observers were unable to differentiate granuloma from cyst using either modality. Dimensional measurements were subject to greater interobserver variation on DR than on PF. Where sufficient buccal cortical bone had been resorbed, ultrasound imaging was straightforward but underestimated the size of the lesions compared with PF and DR. In all 15 cases, the ultrasound diagnosis agreed with the histopathological gold standard. CONCLUSIONS: PF and DR enable diagnosis of periapical disease existence, but not of its nature; while ultrasound underestimates the extent of disease, but can provide accurate information on the pathological nature of the lesion.

What happens if you delay scanning Digora phosphor storage plates (PSPs) for up to 4 hours?

OBJECTIVES: To assess, both objectively and subjectively, the effects of different combinations of storage conditions and delaying scanning for up to 4 h on digital images captured using Digora phosphor storage plates (PSPs). METHOD: Standardized images were obtained of an aluminium step wedge and dry mandible in acrylic using GE 1000 and phosphor storage plates (PSPs) from the Digora (Soredex) digital system. 12 plates were exposed and immediately scanned to produce the baseline gold standard. The plates were re-exposed and stored using three different storage combinations--(A) ambient temperature, (R) refrigeration and (S) low humidity, and then scanned after 10 min, 30 min, 1 h, 2 h, 3 h or 4 h. The objective analysis was carried out by pixel density measurements and the data analysed statistically using analysis of variance. Subjective analysis was carried out by three oral radiologists and the results analysed using the Mann Whitney U-test. RESULTS: Objective analysis showed loss of pixel density after 4 h using all storage combinations. Subjectively, this loss of density was not evident. CONCLUSION: There is a loss of image density at 4 h when using Digora PSPs which can not be detected clinically, but could compromise multisite research.

Osteopetrosis--a review and report of two cases.

We present a brief review of the rare condition of osteopetrosis together with two case reports of this disease in the same family affecting the jaws. The first in a 41-year-old woman, and the second in her 39-year-old brother. Plain films and computed tomography showed marked sclerosis of the affected bones with obliteration of the medullary cavities and thickening of the cortices as well as multiple absent and unerupted teeth. In addition radiographs showed discrete mixed radiopaque/radiolucent areas consistent with the appearance of fibro-cemento-osseous dysplasia, but which may also represent part of the overall spectrum of bone changes in osteopetrosis.

Survey of radiography and radiation protection in general dental practice in Uganda.

OBJECTIVES: To carry out the first survey in Uganda of all dentists and all public health dental officers (PHDO) to assess the status of dental radiography and radiation protection. METHODS: All 74 dentists and 76 PHDOs in Uganda were sent a postal questionnaire including 33 questions relating to various demographic details, radiographic equipment and radiographic techniques, including processing and radiation protection. A second questionnaire was sent to non-respondents after 3 months. RESULTS: Eighty-two per cent of dentists responded and 83% of PHDOs. Seventy per cent of the dentists and 100% of the PHDOs were trained in Uganda. Seventy-five per cent of the dentists and 30% of the PHDOs had access to one of the approximately 30 X-ray machines in the country. The majority of the equipment did not comply with current recommendations in Europe. Fifty-one per cent of dentists used machines with mechanical timers, 28% used machines with no visual warning signal and 17% used equipment with no audible warning signal. Most of the equipment was over 30 years old and only 15% of dentists knew when the equipment was last serviced. The most relevant finding of the surveys was the level of 'don't know' responses to many questions from both groups. CONCLUSIONS: The lack of knowledge regarding dental radiography and radiation protection plus the condition of most equipment in Uganda is a matter of concern. Standards of care are considerably lower than in developed countries requiring improved undergraduate training, provision of postgraduate courses and Ugandan governmental or international financial assistance.

Survey of dental radiographic services in private dental clinics in Damascus, Syria.

OBJECTIVES: To perform a radiographic survey of private dental clinics in Damascus, Syria using a postal questionnaire to produce recommendations for improving the quality of dental radiographic services and education in Syria. METHODS: Three hundred private dental clinics in Damascus were surveyed using a postal questionnaire (in English and Arabic) containing 27 questions on demographic information, equipment, techniques, selection criteria, frequency of examinations, and undergraduate/ postgraduate education. RESULTS: Two hundred and two (67%) dentists responded of which 95% graduated in Syria. The results showed a general lack of knowledge and understanding of dental radiography. Sixty four per cent did not know the kVp setting of their equipment, 73% used D-speed film, 57% did not use film holders and beam aiming devices, 25% did not use a viewing box. In addition, 45% of known equipment operated at 50 kVp or less and 16% was over 20 years old. No meaningful selection criteria existed with a wide variation in type and frequency of radiographs used for different clinical conditions. Syrian undergraduate training in dental radiology was minimal and there was no postgraduate education in the speciality. CONCLUSIONS: Several areas of the radiographic service in Damascus fall short of current recommendations on good practice. Recommendations are made to improve the service, the quality of undergraduate education and to establish postgraduate education.

Interpretation of skull radiographs for facial fractures by medical staff working in UK emergency departments: a pilot study.

OBJECTIVES: This was a pilot study to determine the ability of hospital doctors (1) to assess the technical quality of occipitomental (OM) radiographs and (2) to identify facial fractures. METHOD: Twenty-two doctors from four UK Accident and Emergency (A&E) departments participated in a two part study: Part A was a postal questionnaire containing questions on demographic data, educational background, selection criteria, assessing radiographs and radiation protection; and Part B was a clinical viewing session to interpret 20 randomized OM radiographs divided into four groups; technically good and poor without fractures, and technically good and poor with fractures. RESULTS: Study participants ranged from junior house officers to senior consultants. There was considerable variation in educational background and radiographic interpretation instruction at undergraduate and postgraduate level. OM radiographs constituted 10% of all skull radiographs examined per week, yet only 40% of the doctors felt confident when assessing technical quality. The majority of participants had only a limited knowledge of radiation protection legislation. During the viewing session, only 50% of the participants correctly identified those radiographs with fractures and those with technique errors. There was no significant difference between house officers and other grades of staff. A higher level of seniority did not equate with greater interpretative ability. Subjective confidence in assessing film quality did not correlate with the actual film viewing. CONCLUSION: Only half of the A&E doctors taking part in the study were able to correctly assess film quality and identify facial fractures on OM radiographs. If the pilot sample is representative, then the findings are of considerable concern.