VOLUME 2 | ISSUE 6

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DENTAL LEARNING
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Knowledge for Clinical Practice

AN UPDATE

ON

Bitewing Radiography Technology

Brad Potter, DDS, MS Page 3

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Written for
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An Update on
Bitewing Radiography Technology
ABSTRACT

EDUCATIONAL OBJECTIVES

Unfortunately, dental caries continues to be a primary oral health

issue, which requires a comprehensive consideration of caries risks,
preventative oral health care by the patient and dental professional, and a series of clinical techniques to determine the presence
and extent of caries involvement. Total patient care requires radiographic assessment of dental disease and is considered an essential
tool in this assessment. Bitewing radiographs remain the primary
diagnostic image for intraoral caries assessment with periapical
imaging and extraoral imaging being used as adjunctive tools.
Both film-based and digital intraoral bitewing images continue to
provide the necessary resolution and evidence-based accuracy for
diagnosis, while extraoral techniques require further study.
ABOUT THE AUTHOR
Brad Potter, DDS, MS
Dr. Brad Potter graduated from Northwestern
University School of Dentistry in 1979. After
private practice in general dentistry in Colorado for 10 years, he returned to school at The
University of Texas Health Science Center at
San Antonio where he earned a Certificate and
an M.S. in Dental Diagnostic Sciences. Dr. Potters current appointment is in the Department
of Diagnostic and Biologic Sciences and he also serves as Senior
Associate Dean of Academic Affairs at the University of Colorado
School of Dental Medicine. In addition to his academic roles, he
maintains a private practice in oral and maxillofacial radiology.
He is a diplomate of the American Board of Oral and Maxillofacial Radiology, and a fellow of the American College of Dentists,
International College of Dentists, and the American Academy of
Oral and Maxillofacial Radiology. Dr. Potter can be reached at
Brad.Potter@ucdenver.edu.

The overall goal of this article is to provide the reader with information on the use of radiography for caries detection. On completion of
this article, the participant will be able to:
1. Review the types of oral radiographs used for caries detection
2. Define sensitivity and specificity
3. Contrast and compare the methodology and results for radiographic caries detection
4. List and describe the methods by which radiation exposure is
reduced as well as the relative radiation exposure with different
radiographic methodologies for caries detection.

Introduction

he discovery of X-rays by Rntgen, and early work

by dentists, including Dr. C. Edmund Kells, led to
significant developments and improvements over
time in the ability of clinicians to diagnose medical and later
dental conditions. Since these early developments, advances
in oral radiography have resulted in a wide range of diagnostic options and improved capabilities for the detection of
pathological lesions and other anomalies. The overall goals
of caries detection are to determine whether caries is
present, to determine its extent, and to detect it at an early
stage when it is still susceptible to remineralization with the
use of preventive agents, in particular fluoride. Incipient
carious lesions are confined to enamel and have not yet
breached the dentinoenamel junction (DEJ). Ideally, lesions
will not develop but if they do it is optimal to detect them
while they are still in the outer enamel, at which time there

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DENTAL LEARNING

is the greatest opportunity to remineralize or arrest them.

Paradoxically, incipient lesions are the most difficult to
detect radiographically.1 Options for caries detection in
addition to visual examination include oral radiography,
transillumination, fluorescence and laser fluorescence. At the
current time, visual examination plus oral radiography is the
most commonly used method for caries detection and other
technologies, including panoramic bitewings, are recommended as adjunctive devices.
Radiography for caries detection and the assessment of
the depth of caries present involves the differential attenuation of X-rays through hard tooth structure that is sound or
partially demineralized, with more X-rays passing through
the less dense demineralized tooth structure to reach the
image receptor. Use of a standardized and strict methodology for caries detection is necessary to enable appropriate
preventive and restorative care. In addition to diagnostic
accuracy, a further consideration of importance is the risk
versus benefit of exposure to radiation and risk reduction
through minimization of radiation exposure.
Desirable characteristics for any diagnostic tool require
that a method offer high sensitivity, high specificity and high
reliability. Sensitivity refers to the ability of a test to correctly identify when a condition is present in the case of
dental caries, sensitivity refers to the ability of an image to
correctly identify when a carious lesion is present. Specificity,

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on the other hand, refers to the ability of images to detect

when the tooth is sound and no carious lesion is present.
Low sensitivity results in carious lesions being missed (and
therefore not being treated preventively or restored), while
low specificity would result in treatment of a lesion that in
fact was not present.

Radiographic Caries Detection

Current radiographic techniques typically used for caries
detection include the use of intraoral bitewings, panoramic
radiographs, and extraoral bitewings from panoramic radiography. In addition to the detection of dental caries, other
indications and uses of bitewings include monitoring the progression (and arrestment/reversal) of carious lesions as well as
assessing existing restorations and periodontal status.
Intraoral Bitewings
Intraoral bitewing radiography has been performed since
the introduction of X-rays in dentistry, primarily for the
detection of proximal carious lesions. The technique derives
its name from the bite tabs that were originally used around
or as an attachment to film, and upon which patients bit to
hold the film in position while the image was being acquired.2
Intraoral bitewings are acquired with traditional film or by
using digital sensors. Detection of carious lesions of differing
depths using bitewing radiography can be found in Figure 1.

Figure 1. Images showing caries at different stages

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An Update on
Bitewing Radiography Technology

Traditional Film
With traditional film, X-rays are attenuated differentially
depending on the photon energy, thickness of the anatomy,
the atomic number of the elements in the tissues, and the
density of the tissue. Once acquired, the resulting film is processed and assessed for pathology. Drawbacks of traditional
film have included the need for processing (developing and
fixing) and the artifacts that can be introduced if the film is
scratched or contaminated (eg, powder from gloves or processing chemicals) or if processing is improperly performed
(Fig. 2). Incorrect processing or inadvertent exposure to
light can result in the necessity for retaking images and
more radiation exposure for the patient. The use of posi-

Figure 2. Artifact error due to inadequate washing during

processing of the film

Figure 3. Vertical bitewing with positioning instrument

OCTOBER 2013

tioning instruments and film holders rather than tabs results

in standardized positioning of bitewing films, increasing
accuracy and reducing the potential for errors (Fig. 3).
The use of high-speed films has reduced radiation exposure significantly, since less exposure time is required due
to modified silver halide crystals being used in the emulsion.3 Studies have confirmed that the diagnostic accuracy
of caries detection with high-speed film is equivalent to that
of lower-speed films with no statistically significant differences. An in vitro study comparing four different speeds of
film and digital oral radiography for detection of mesial and
distal caries in 48 extracted posterior teeth found no statistically significant differences either in interobserver evaluations or in the diagnostic imaging results of E- or F-speed
film or digital radiography.4 In one study, no statistically
significant difference in the diagnostic accuracy of proximal
caries detection was found comparing ultra-speed (highspeed) film with slower film. If, however, developer solution
was older than 3 weeks, high-speed film was actually more
accurate than slower-speed film.5
Digital Intraoral Bitewing Radiography
Digital intraoral bitewing radiography is performed using direct digital sensors or using photostimulable phosphor
(PSP) plates. In the case of PSP plates, image acquisition is
indirect, with the energy absorbed from the X-rays stored in

Figure 4. PSP plates, including with infection control

wraps

DENTAL LEARNING

Figure 5. Positioning error with backward PSP plate, as

well as underexposure of the plate

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the phosphor crystals. The PSP plate is then scanned using

a laser, and the scan converted to electrical signals that are
then processed to create a digital image (Fig. 4).6 PSP plates
are typically the same size as traditional film, and although
they were prone to artifacts as a result of scratching, plates
are now available that are scratch-resistant.7 Poor images
can result from improper handling, including over- or underexposing the PSP plate or placing it backwards (Fig. 5).
As with film, digital intraoral bitewing radiography results
in excellent images (Fig. 6).
Digital sensors (Fig. 7) result in nearly immediate image
display and reduced radiation exposure when compared to

Figure 6. PSP plate images

Figure 7a and b. Sensors

Examples of typical CMOS and CCD sensors

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An Update on
Bitewing Radiography Technology

film acquisition. These types of sensors use charge coupled

devices (CCDs) or complementary metal oxide semiconductors (CMOS), or they include an active pixel in the CMOS
technology and are then referred to as CMOSP. Direct digital acquisition results in images being available on the computer screen for viewing in a matter of seconds. However,
care must be taken when placing sensors, as with traditional
film, to ensure accurate positioning. Other considerations
are that the sensors are rigid and the size of the sensors being used may make them uncomfortable for certain patients.
Recent designs for sensors include some that are smaller
than earlier versions as well as having rounded edges. These
modifications have resulted in greater patient comfort and

improved positioning of the sensor (reducing the risk of it

being moved by the patient to a more comfortable position).
Earlier versions resulted in discomfort relative to traditional
film.8 Bitepieces that fit over the sensor are similar to bitewing tabs and help to hold the sensor in position (Fig. 8).
For optimal results, arm and ring positioning devices should
also be used (Fig. 9).
Advantages of digital radiography versus traditional film
radiography include ease of use (no developing or fixing is
required) and potential reductions in radiation exposure, as
well as the ability to digitally archive and digitally enhance
the images (for example, altering the brightness and contrast
to view suspect areas or different anatomical structures).

Diagnostic Accuracy of Intraoral Bitewing

Radiography
In general, bitewing radiographs offer low sensitivity
for the detection of occlusal caries compared to use of the
International Caries Detection and Assessment System
(ICDAS) (a visual methodology) and laser fluorescence. In
extracted primary molars, Neuhaus et al found that ICDAS

TABLE 1. Sources of radiograph errors

Figure 8. Sensor and use of tab

Poor positioning of the receptor

Overexposure
Underexposure
Improper handling of sensors/PSP plates
Improper handling of film
Scratching of receptor surface
Film contamination (eg, glove powder)
Incorrect film processing

Figure 9. Sensor and use of positioning arms and rings

Bitewing using sensor in a mannequin

OCTOBER 2013

Inadvertent exposure of film to light

DENTAL LEARNING

and laser fluorescence devices offered greater accuracy for

occlusal caries detection.9 In other studies of occlusal caries detection, a bitewing radiograph was found to be less
accurate than other methods. Diniz et al studied occlusal
caries in permanent molars in an in vivo study, comparing
the use of ICDAS, bitewing radiography, laser fluorescence
and a fluorescence camera. Histological comparison was
used as the gold standard after extraction. Visual inspection (ICDAS) was found to be more accurate than bitewing
radiography and the fluorescence camera.10 Another study
using the same detection methods for occlusal surfaces in
primary molars found that bitewings offered the highest
specificity at the D1 lesion level. However, overall, for the
detection of both enamel and dentinal lesions, bitewing
radiography offered less specificity and sensitivity than the
other methods used.11 On proximal surfaces in extracted
primary molars (n=135), Chawla et al compared caries detection with laser fluorescence, digital radiography
and transillumination. Histology sections were used as
the gold standard against which specificity and sensitivity
were measured. Visual inspection was the most accurate
detection method for dentinal lesions and the second most
accurate for enamel plus dentinal lesions, while digital
radiography was most accurate for dentinal lesions and
the second most accurate method for enamel plus dentinal
lesions. Transillumination and laser fluorescence were less
accurate than either digital radiography or visual inspection. Although visual inspection was found to be the most
accurate, these were proximal lesions and in vivo this
would be possible only if sufficient spacing was present or
if interproximal wedges were used.12 Bitewing radiographs
were found in another study to be more accurate than
visual inspection of visible proximal lesions once the lesion
reached beyond the outer third of the dentin.13
Given that bitewings are primarily indicated for the
detection and monitoring of proximal caries in the presence
of contact points (ie, where the surfaces are not accessible
for visual inspection), the more interesting question is the diagnostic accuracy of intraoral bitewing radiography for the
detection of proximal caries.

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Proximal Caries Detection with Intraoral Bitewing

Radiography
In combination with visual inspection, bitewing radiography has been found to be diagnostically accurate for the
detection of proximal caries. Studies have compared the
use of faster-speed film versus slower-speed film and the
accuracy of traditional film bitewing radiography versus
digital intraoral bitewing radiography. In a comparison
of proximal caries diagnostic accuracy with traditional
X-ray films (Ektaspeed Plus) and digital radiography with
a charge-coupled (CMOS) sensor, an assessment by 6 observers of the proximal surfaces of 40 extracted teeth using
these techniques led to the conclusion that these techniques
were similar, with no statistically significant differences in
diagnostic accuracy for the film or low- or high-resolution
digital radiographs (P = 0.70).14 In contrast, in a study
comparing the use of E- or F-speed film with digital
radiography (CCD) for the detection of proximal caries
in the mixed dentition, with 5 pediatric dentists assessing
270 proximal surfaces in extracted teeth (primary canine
to first permanent molar), it was found that the diagnostic accuracy of the clinicians, using a 4-point scale, was
greater with the use of E- or F-speed film than with digital
radiography. However, the accuracy of some of the observers increased the second time they viewed the direct digital
images. Comparisons were made with histology sections of
all observed teeth to determine the actual versus diagnosed
proximal caries.15 Another study, involving 48 extracted
posterior permanent teeth, found no statistically significant
differences in the diagnostic accuracy of traditional bitewing film and digital intraoral radiographs for the detection of proximal caries.16
Hintze et al assessed the diagnostic accuracy of proximal enamel caries and occlusal dentinal caries detection
using D- or E-speed film or digital radiography. The study
included 122 proximal surfaces assessed by 3 observers
and 65 occlusal surfaces assessed by 2 observers. The
evaluations were also compared with histology sections
of all sampled teeth. No statistically significant differences
were found in the accuracy of any of the methods stud-

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An Update on
Bitewing Radiography Technology

ied, although all were found to be of very limited value

in detecting proximal enamel caries and of some value in
the detection of dentinal occlusal caries.17 In a study of 56
premolar surfaces, two different E-speed films, two CCD
digital radiography brands and two PSP digital radiography brands were compared. No statistically significant
differences were found in the diagnostic accuracy of any of
the methodologies used.18
The diagnostic fidelity of both traditional film and digital
radiographic images is influenced by the manner in which
these receptors are handled and processed. Artifacts with
traditional film include areas on the film that have been

scratched, where deposits were present during processing

(eg, powder from gloves), and due to contamination by
developer and fixer. In digital radiography, image processing can result in artifacts that appear to be pathological
lesions, as confirmed in a 2011 audience participation test
at a specialist radiographic conference.19 Therefore, regardless of the method used, attention to detail and following a
standard protocol are essential.
In summary, overall studies of film and intraoral digital
bitewing radiography support the accuracy of both techniques for the detection and monitoring of proximal caries
lesions.20,21,22,23

Figure 10. Overlapping proximal surfaces on a panoramic radiograph

OCTOBER 2013

DENTAL LEARNING

Panoramic and Extraoral Panoramic Bitewing

Radiography
Traditional panoramic radiography provides an overview of the maxilla and mandible in 1 two-dimensional
image. Panoramic radiography, however, is known to have
low diagnostic capabilities for the detection of proximal caries, in part due to the overlapping of proximal surfaces on
the radiograph and to decreased resolution when compared
to intraoral imaging (Fig. 10). Several studies have been
conducted comparing the diagnostic accuracy of extraoral
and intraoral radiography.
Akkaya et al conducted an in vivo trial with 79 participants and 3 observers, to compare the diagnostic accuracy
of panoramic and intraoral full mouth radiographs for
the detection of proximal caries throughout the dentition.
Receiver operating characteristic curve analysis (ROC) was
used to compare accuracy (Fig. 11). The results showed
that panoramic radiography was not as diagnostic for the
assessment of premolar and molar teeth when compared to
intraoral imaging. Supplemental bitewing radiography was
required for proximal caries assessment in premolar and
molar teeth, and supplemental anterior periapicals were also
recommended for complete diagnoses. A full mouth series
was comparable to this combination.24
Flint et al assessed the diagnostic yield of intraoral and

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panoramic radiographs in the detection of dental pathology

in 30 Air Force personnel. Panoramic surveys were the least
accurate based on the consensus of radiographs by the observing general dentists. Bitewings were required in addition
to panoramic survey for diagnostic accuracy with respect
to caries.25 A third study also found diagnostic ability to be
low for proximal caries detection, whether or not the images were filtered, in comparison to traditional and digital
intraoral bitewing radiographs.26

Extraoral Panoramic Bitewing Radiography

Recently, bitewing images produced by panoramic
machines have been introduced, which involves the use of
software programs and in some cases different hardware configurations. This technique offers the production of screening
bitewing images for patients who have difficulty tolerating intraoral film, plates, or sensors. These images, while appearing

TABLE 2. Panoramic versus intraoral radiographs

Panoramic radiographs
Akkaya et al

Panoramic radiographs less

diagnostic for posterior teeth
than intraoral bitewings
Supplemental bitewings
required

Flint et al

Panoramic radiographs less

accurate than intraoral
imaging

Akarslan et al

Panoramic radiographs have

lower caries diagnostic ability
than intraoral radiographs

Extraoral bitewings

Figure 11. Example of ROC Curve

10

Kaburoglu et al

Intraoral bitewings significantly superior to extraoral

bitewings or panoramic
radiography

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An Update on
Bitewing Radiography Technology

similar to intraoral bitewings, frequently exhibit horizontal

overlap of the premolar contacts and often lack the resolution
necessary to clearly define the true extent of caries.
Diagnostic Accuracy
In a study comparing extraoral bitewing radiography,
traditional high-speed film radiography, and panoramic
radiography, 80 extracted molar and premolar teeth were
evaluated by 3 observers twice for the detection of mesial
and distal caries, and the diagnoses compared with gold
standard histology sections of the teeth. The assessment
of accuracy used the Receiver Operating Characteristics
(ROC) test, which considers both sensitivity and specificity
curves. No statistically significant differences in accuracy
were found between the extraoral bitewings and extraoral
panoramic radiographs. Statistically significant differences

TABLE 3. Methods for reducing radiation exposure

Rectangular collimation
X-ray filter
Lead aprons
Lead collar

in diagnostic accuracy were found between intraoral and

extraoral bitewing radiographs, with intraoral bitewing
radiography found to be significantly superior to the use of
extraoral bitewing and panoramic radiography and with
similar results found for each observer and between observers.27

Radiation Exposure
Acquiring clinically justified radiographs also involves consideration of the risks and benefits of radiation exposure. The
ALARA (As Low As Reasonably Achievable) principle serves
as a guideline to all diagnostic imaging in dentistry.
Methods to reduce exposure to radiation also include
using lead aprons during imaging and using rectangular collimation. Lead collars, which protect the thyroid, should also
be used, except when taking panoramic radiographs as they
obstruct taking these radiographs.28 Significant reductions
in radiation result from these precautions. Acquiring as few
radiographs as necessary for diagnosis and only when they
are needed, selecting radiograph imaging that results in less
exposure to radiation and taking care to use a precise technique to avoid retakes all helps to reduce potential radiation
exposure.29
When acquiring intraoral bitewing radiographs, appropriate collimation and filtration of the X-ray beam will reduce

Take only essential radiographs

Use of positioning arms and rings
Avoid overexposure
Avoid underexposure
A precise technique
Select methods with least exposure
High-speed if traditional film
Automated film processors

OCTOBER 2013

Figure 12. Rectangular collimation

11

DENTAL LEARNING

exposure to radiation. There are two types of collimation

rectangular and circular. Rectangular collimation reduces the
X-ray beam exposure area considerably compared to circular
collimation, decreasing scatter (Fig. 12). Reducing scatter
will improve image quality, aiding diagnosis and reducing the likelihood of a retake being necessary. Higher-speed
traditional bitewing films have reduced the time required to
take the radiograph, reducing exposure compared to older,
slower-speed (D) films. Automated film processors also help
to reduce processing errors and the need for retakes.
With earlier versions of panoramic film radiography versus film bitewings, the reduction in radiation exposure was
up to 50%; however, the use of faster-speed films and digital
imaging has reduced these differences. Also, although panoramic radiographs result in less radiation exposure than a
full-mouth series, for caries detection supplemental bitewing
radiographs are necessary to improve caries diagnoses, and
extraoral panoramic bitewing radiography is less accurate
than intraoral radiography.30 Compared to traditional bitewing radiographs, digital bitewing radiography in principle
offers a lower radiation dose. Care must be taken to capture
images that offer diagnostic ability and to avoid retakes by
following sound protocols, and all principles of ALARA
should be followed when performing oral radiography.

Conclusion
Radiographic imaging is an integral tool in the assessment and diagnosis of dental caries. The evidence clearly
shows that with prudent and careful consideration of its
use, intraoral bitewing imaging is still the modality of choice
when assessing the presence and extent of caries in proximal tooth structure. While techniques such as panoramic
bitewing imaging are being further developed to use in
diagnosis, it remains to be seen if the evidence will support
its exclusive use for complete diagnoses.

References
1. Pine CM, ten Bosch JJ. Dynamics of and diagnostic
methods for detecting small carious lesions. Caries Res.
1996; 30: 3818.

12

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2. Cawson RA, Odell EW. Cawsons essentials of oral

pathology and oral medicine. New York: Churchill Livingstone; 2002.
3. ibid.
4. Alkurt MT, Peker I, Bala O, Altunkaynak B. In vitro
comparison of four different dental X-ray films and direct
digital radiography for proximal caries detection. Oper
Dent. 2007 Sep-Oct;32(5):504-9.
5. Syriopoulos K, Velders XL, Sanderink GC, van Ginkel FC,
van Amerongen JP, van der Stelt PF. The effect of developer age on the detection of approximal caries using three
dental films. Dentomaxillofac Radiol. 1999 Jul;28(4):208-13.
6. Wenzel A. Digital imaging for dental caries. Dent Clin
North Am. 2000; 44: 31938.
7. Bedard A, Davis TD, Angelopoulos, C. Storage phosphor plates: How durable are they as a digital dental radiographic system? J Contemp Dent Pract. 2004;5:57-69.
8. Versteeg CH, et al. An evaluation of periapical radiography with a charge-coupled device. Dentomaxillofac Radiol.
1998;27:97-101.
9. Neuhaus KW, Rodrigues JA, Hug I, Stich H, Lussi A. Performance of laser fluorescence devices, visual and radiographic examination for the detection of occlusal caries in
primary molars. Clin Oral Investig. 2011 Oct;15(5):635-41.
10. Diniz MB, Boldieri T, Rodrigues JA, Santos-Pinto L,
Lussi A, Cordeiro RC. The performance of conventional
and fluorescence-based methods for occlusal caries detection: an in vivo study with histologic validation. J Am Dent
Assoc. 2012 Apr;143(4):339-50.
11. Souza JF, Boldieri T, Diniz MB, Rodrigues JA, Lussi A,
Cordeiro RC. Traditional and novel methods for occlusal
caries detection: performance on primary teeth. Lasers
Med Sci. 2013 Jan;28(1):287-95.
12. Chawla N, Messer LB, Adams GG, Manton DJ. An in vitro comparison of detection methods for approximal carious lesions in primary molars. Caries Res. 2012;46(2):161-9.
13. Ekstrand KR, Luna LE, Promisiero L, Cortes A, Cuevas
S, Reyes JF, Torres CE, Martignon S. The reliability and
accuracy of two methods for proximal caries detection
and depth on directly visible proximal surfaces: an in vitro
study. Caries Res. 2011;45(2):93-9.
14. Abreu M Jr, Mol A, Ludlow JB. Performance of RVGui

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Bitewing Radiography Technology

sensor and Kodak Ektaspeed Plus film for proximal caries

detection. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2001 Mar;91(3):381-5.
15. Uprichard KK, Potter BJ, Russell CM, Schafer TE, Adair
S, Weller RN. Comparison of direct digital and conventional radiography for the detection of proximal surface
caries in the mixed dentition. Pediatr Dent. 2000 JanFeb;22(1):9-15.
16. Peker I, Toraman Alkurt M, Altunkaynak B. Film tomography compared with film and digital bitewing radiography
for proximal caries detection. Dentomaxillofac Radiol. 2007
Dec;36(8):495-9.
17. Hintze H, Wenzel A, Jones C. In vitro comparison
of D- and E-speed film radiography, RVG, and visualix
digital radiography for the detection of enamel approximal and dentinal occlusal caries lesions. Caries Res.
1994;28(5):363-7.
18. Syriopoulos K, Sanderink GC, Velders XL, van der
Stelt PF. Radiographic detection of approximal caries: a
comparison of dental films and digital imaging systems.
Dentomaxillofac Radiol. 2000 Sep;29(5):312-8.
19. Brettle D, Carmichael F. The impact of digital image processing artifacts mimicking pathological features associated with restorations. Br Dent J. 2011 Aug
26;211(4):167-70.
20. Wenzel A. A review of dentists use of digital radiography and caries diagnosis with digital systems. Dentomaxillofac Radiol. 2006;35(5):307-14.
21. Senel B, Kamburoglu K, Ucok O, et al. Diagnostic
accuracy of different imaging modalities in detection of
proximal caries. Dentomaxillofac Radiol. 2010;39(8):501-11.
22. Pontual AA, de Melo DP, de Almeida SM, et al. Comparison of digital systems and conventional dental film for
the detection of approximal enamel caries. Dentomaxillofac Radiol. 2010;39(7):431-6.
23. Castro VM, Katz JO, Hardman PK, et al. In vitro comparison of conventional film and direct digital imaging
in the detection of approximal caries. Dentomaxillofac
Radiol. 2007;36(3):138-42.
24. Akkaya N, Kansu O, Kansu H, Cagirankaya LB, Arslan

OCTOBER 2013

U. Comparing the accuracy of panoramic and intraoral radiography in the diagnosis of proximal caries. Dentomaxillofac Radiol. 2006 May;35(3):170-4.
25. Flint DJ, Paunovich E, Moore WS, Wofford DT, Hermesch CB. A diagnostic comparison of panoramic and
intraoral radiographs. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 1998 Jun;85(6):731-5.
26. Akarslan ZZ, Akdevelio lu M, Gngr K, Erten H. A
comparison of the diagnostic accuracy of bitewing, periapical, unfiltered and filtered digital panoramic images for
approximal caries detection in posterior teeth. Dentomaxillofac Radiol. 2008 Dec;37(8):458-63.
27. Kamburoglu K, Kolsuz E, Murat S, Yksel S, Ozen T.
Proximal caries detection accuracy using intraoral bitewing radiography, extraoral bitewing radiography and
panoramic radiography. Dentomaxillofac Radiol. 2012
Sep;41(6):450-9.
28. National Council on Radiation Protection and Measurements. Radiation Protection in Dentistry. NCRP Report No.
145. Bethesda, MD. NCRP 2003, Revised 2004;14-27.
29. Williamson GF. Intraoral Radiography: Positioning and
Radiation Protection. Academy of Dental Therapeutics
and Stomatology, Chesterland, OH, 2007.
30. Molander B, Ahlqwist M, Grndahl HG. Panoramic
and restrictive intraoral radiography in comprehensive oral radiographic diagnosis. Eur J Oral Sci. 1995
Aug;103(4):191-8.

Webliography
American Dental Association. Dental radiographs.
Benefits and safety. Available at: http://www.ada.org/
sections/scienceAndResearch/pdfs
Federal Drug Administration. The Selection of Patients
for Dental Radiographic Examinations. (2012). Retrieved
on June 6, 2013, from http://www.fda.gov/RadiationEmittingProducts/RadiationEmittingProductsand
Procedures/ MedicalImaging/MedicalX-Rays/ucm116504.
htm#patient_selection_criteria

13

DENTAL LEARNING

CEQuiz
1. The overall goal of caries detection is to __________.
a. determine whether caries is present
b. determine the extent of caries
c. detect caries at an early stage
d. all of the above
2. When photostimulable phosphor (PSP) plates are used for images, their acquisition is __________.
a. indirect
b. direct
c. inferior to traditional film
d. none of the above
3. Radiography for caries detection and assessment involves the
differential __________ of X-rays through hard tooth structure
that is sound or partially demineralized.
a. reflection
b. attenuation
c. scattering
d. refraction
4. High-speed traditional films involve the use of __________ in the
emulsion.
a. modified silver halide crystals
b. modified silver iodide crystals
c. modified silver bromide crystals
d. none of the above
5. Sensitivity refers to the ability of a test to correctly identify
when a condition is __________.
a. present
b. absent
c. ameliorating
d. none of the above
6. Specificity refers to the ability of images to detect __________.
a. the extent and severity of a lesion
b. the absence of a lesion
c. the presence of anomalies
d. all of the above
7. Intraoral bitewing radiography has been performed since the
introduction of X-rays in dentistry, primarily for the detection of
__________ lesions.
a. periapical
b. proximal carious
c. occlusal carious
d. b and c

14

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Visa, MasterCard, and American Express.

8. The __________ affects the attenuation of X-rays used for

traditional film.
a. photon energy
b. thickness of the anatomy and density of the tissue being
radiographed
c. atomic number of the elements in the tissues being
radiographed
d. all of the above
9. The use of positioning instruments and film holders rather than
tabs results in __________.
a. standardized positioning of bitewing films
b. increased accuracy
c. reduced potential for errors
d. all of the above
10. Studies have confirmed that the diagnostic accuracy of caries
detection with high-speed film is __________ to that of lowerspeed films, with no statistically significant differences.
a. inferior
b. equivalent
c. superior
d. none of the above
11. __________ lesions are the most difficult to detect radiographically.
a. Dentinal
b. Advanced
c. Incipient
d. Pulpal
12. PSP plates are __________.
a. typically the same size as traditional film
b. now available as plates that are scratch-resistant
c. prone to chemical contamination
d. a and b
13. Digital sensors result in __________.
a. nearly immediate image display
b. indirect image acquisition
c. reduced radiation exposure when compared to film acquisition
d. a and c
14. __________ is an advantage of digital radiography versus traditional film radiography.
a. Ease of use
b. Potential reductions in radiation exposure
c. The ability to digitally archive and enhance images
d. all of the above

VOLUME 2 | ISSUE 6

An Update on
Bitewing Radiography Technology

CE QUIZ
15. __________ can cause an artifact on traditional film images.
a. Scratches on the film
b. Powder on the film from gloves
c. Contamination by fixer and developer
d. all of the above
16. Proximal caries diagnostic accuracy with traditional high-speed
X-ray films and digital radiography with a charge-coupled sensor
have overall been found to be __________.
a. equally accurate diagnostically
b. inferior to PSP
c. differentially accurate
d. none of the above

23. Panoramic bitewing images offer the production of bitewings for

patients who have difficulty tolerating __________.
a. intraoral film
b. plates
c. sensors
d. all of the above
24. __________ is/are a frequent occurrence with panoramic
bitewing images.
a. Horizontal overlap of the premolar contacts
b. Vertical overlap of the molar contact
c. Artifacts
d. all of the above

17. The diagnostic fidelity of traditional film and digital radiographic

images is influenced by __________.
a. the manner in which these receptors are handled and processed
b. the size of the lesion
c. the X-ray beam
d. none of the above

25. Intraoral bitewing radiography has been found to be __________

to the use of extraoral bitewing and panoramic radiography.
a. significantly superior
b. significantly inferior
c. equivalent
d. none of the above

18. Receiver operating characteristic curve analysis is used to

compare the __________ of radiography techniques.
a. images
b. accuracy
c. cost
d. all of the above

26. The ALARA principle is related to radiation exposure and stands

for __________.
a. As Low As Reasonably Accessible
b. As Low As Reasonably Achievable
c. As Light As Reasonably Achievable
d. none of the above

19. Panoramic radiography is known to have low diagnostic

capabilities for the detection of proximal caries, in part
due to the __________.
a. overlapping of proximal surfaces on the radiograph
b. size of the film
c. decreased resolution when compared to intraoral imaging
d. a and c

27. Lead collars __________.

a. protect the thyroid
b. should be used when taking any radiograph
c. should be used except when taking panoramic radiographs
as they obstruct the taking of these radiographs
d. a and c

20. If using panoramic radiography, __________ are required for

proximal caries assessment in premolar and molar teeth.
a. supplemental periapical radiographs
b. supplemental bitewing radiographs
c. supplemental lateral films
d. all of the above
21. Bitewing images produced by panoramic machines __________.
a. involve the use of software programs
b. in some cases involves different hardware configurations
c. are necessary
d. a and b
22. Reducing scatter __________.
a. improves image quality
b. aids diagnosis
c. reduces the likelihood of a retake being necessary
d. all of the above

OCTOBER 2013

28. Using __________ is a method to reduce exposure to radiation.

a. a lead apron
b. a lead collar
c. rectangular collimation
d. all of the above
29. __________ collimation reduces the X-ray beam exposure
area considerably compared to __________ collimation.
a. Circular; vertical
b. Circular; rectangular
c. Rectangular; circular
d. Rectangular; oblique
30. Compared to __________, __________ in principle offer a lower
radiation dose.
a. digital bitewing radiography; traditional bitewing radiographs
b. traditional bitewing radiographs; digital bitewing radiography
c. traditional bitewing radiographs; chest X-rays
d. none of the above

15

An Update on
Bitewing Radiography Technology

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eview the types of oral radiographs used for caries detection

R
Define sensitivity and specificity
Contrast and compare the methodology and results for radiographic caries detection
List and describe the methods by which radiation exposure is reduced as well as the relative
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16

VOLUME 2 | ISSUE 6