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102]

Original Article

Assessment of digital enhancement filters

in the radiographic determination of alveolar
bone level
Matheus Lima Oliveira, Luciana Moraes1, Jonathan Nicholas Santos Pereira1, Guilherme Monteiro Tosoni1
Department of Oral Diagnosis, Piracicaba Dental School, University of Campinas, Piracicaba, 1Department of Oral Diagnosis and Surgery,
Araraquara Dental School, So Paulo State University-UNESP, Araraquara, SP, Brazil

A B S T R A C T

Context: Recent studies have emphasized the advantages of digital radiographic imaging systems for periodontal evaluation. Because
digital enhancement filters are designed to improve image quality, the real impact of such improvement on diagnostic accuracy needs
to be evaluated for different clinical tasks. Aims: To assess the efficacy of digital enhancement filters in the radiographic determination
of the alveolar bone level. Materials and Methods: Twenty-four digital periapical radiographs were obtained from mandibular sites
with alveolar bone loss. Two enhancement filters-perio and invert-were applied separately and jointly on all radiographic images. The
alveolar bone level was measured by consensus agreement of two examiners in 55 sites on the standard and enhanced radiographic
images. A single examiner obtained the actual measurements on the dry mandible by using a periodontal probe and a digital caliper.
For each assessment site, three measurements were obtained and averaged. One-way analysis of variance for differences between
the actual measurements and radiographic image groups was performed ( = 0.05). Results: The digital radiographic measurements
overestimated the actual by approximately 0.2 mm. There was no statistically significant difference between radiographic image
groups. Furthermore, none of them differed from the actual measurements. Conclusion: Under the tested conditions, the perio
and invert enhancement filters did not interfere with the efficacy of the radiographic images, which were accurate in determining the
alveolar bone level.

Key words: Alveolar bone loss, digital dental accuracy, dimensional measurement accuracy, radiographic image enhancement

Introduction about the periodontal support and alveolar bone level

along the progression of the disease, and contributes
significantly to the diagnosis and treatment plan.[3] The
Periodontal disease is a multifactorial and chronic infectious
determination of the alveolar bone height is an important
process that begins with an inflammation of the gingival
step in such assessment, which consists of obtaining the
tissues surrounding the teeth and becomes more severe
distance between the cement-enamel junction (CEJ) and
by resorbing the underlying bone. Although the clinical
the alveolar crest (AC).[4]
examination reveals characteristics of the periodontal
condition, it has to be complemented by radiographic
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DOI: Cite this article as: Oliveira ML, Moraes L, Santos Pereira JN, Tosoni GM.
10.4103/2321-3841.170610 Assessment of digital enhancement filters in the radiographic determination
of alveolar bone level. J Oral Maxillofac Radiol 2015;3:79-82.

Address for correspondence: Dr. Matheus Lima Oliveira, 901, Limeira Avenue, 13414-903 Piracicaba, SP, Brazil.
E-mail: matheuso@unicamp.br

2015 Journal of Oral and Maxillofacial Radiology | Published by Wolters Kluwer - Medknow 79
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Oliveira, et al.: Radiographic image enhancement in periodontology
Technological advances have brought positive alternatives
to the radiographic examination, by means of digital
radiography. Importantly, radiographic digital imaging
eliminates chemical processing, allows for image
postprocessing, can be electronically transmitted and may
require less radiation than analogue film.[5] Digital image
processing corresponds to any computer-aided editing
with the purpose of enhancing aspects of the image
not readily apparent in its original form and providing
images with diagnostically important information. [6]
Each digital radiographic imaging system works with
specific accompanying software that provides a range of
enhancement filters.
The VistaScan storage phosphor plate system (Drr Dental,
Beitigheim-Bissingen, Germany) is a digital radiographic
imaging equipment that is capable of capturing images
with high spatial and contrast resolutions: Twenty line pairs
per millimeter (L p/mm) and 16 bits, respectively. The
software DBSWIN (Drr Dental) acquires and manages
the radiographic images, and presents several enhancement
filters, in addition to some specifically intended for
periodontal, endodontic and caries evaluation. Among
the image enhancement possibilities, there are two filters
known as perio and Grey Scale Inversion (henceforth,
invert). The former is a high-pass filter and was developed
to enhance periodontal structures by accentuating the
transition in density levels after mathematical recomputation
of pixels,[7,8] and the latter inverts the image grey scale,
changing the pixels of low value (dark) to high value (bright)
and vice-versa.[9] Caution is needed in the application of
such filters, since their efficacy has not been scientifically
proven for all diagnostic tasks. Thus, the aim of this paper
is to assess the efficacy of the perio and invert filters in
the radiographic determination of the alveolar bone level.
Materials and Methods
This study was designed according to the local Institutional
Research Ethics Committee and carried on after its approval
(protocol # 01387512.4.0000.5416). Thirteen partially
edentulous dry human mandibles presenting one or more
sites of alveolar bone loss <2 mm were selected. Exclusion
criteria were cervical restorations, and any damage on AC
and/or CEJ. Twenty-four periapical radiographs were
obtained from these sites by paralleling technique using
VistaScan size 2 storage phosphor plates and a Gendex
765DC Intraoral X-ray Unit (Gendex, Des Plaines, IL,
USA) adjusted at 65 kVp, 7 mA, and 0.125 s. An acrylic
plate (20-mm thick) was placed between the X-ray tube
and the mandible as soft-tissue equivalent material, and
80 Journal of Oral and Maxillofacial Radiology / September-December 2015 / Vol 3 | Issue 3
the focal spot-to-image receptor distance was fixed at
32.5 cm. The VistaScan Combi Plus Scanner (Drr Dental,
Beitigheim-Bissingen, Germany) captured the latent image
on the phosphor plates using the computer software
DBSWIN 5.1.1. All plates were scanned with a spatial
resolution of 20 L p/mm and contrast resolution of 16 bits,
and stored as TIFF files. In addition, two enhancement
filters-perio and invert-were applied separately and jointly
on all radiographic images, resulting in a total of four
groups of image: No filter (henceforth, Standard), perio,
invert, perio + invert [Figure 1].
The CEJ and the AC were determined by consensus
agreement of two observers, who measured the distance
between those anatomical landmarks in 55 sites on the
radiographic images. The observers were senior dental
students who had successfully accomplished oral radiology
and periodontology classes and were previously trained and
calibrated to make the measurements. The radiographic
measurements were done in a low-light room with the aid
of a digital ruler and a 23-inch widescreen LED monitor
with a spatial resolution of 1920 1080 pixels (Philips
236VL, Amsterdam, Netherlands). At least 1-week interval
elapsed between the assessments of each image group
and the observers were allowed to adjust the contrast
and brightness in all of them. A single and independent
examiner obtained the actual measurements by using a
digital caliper (Mitutoyo CD-12 PSX, Kawasaki, Japan)
to measure the distance between the tip of a Williams
periodontal probe and a rubber stop, after being placed on
the physical AC and CEJ, respectively. For each assessment
site, three measurements were obtained and averaged both
on the radiographic image and on the dry mandible.
One-way analysis of variance (ANOVA) for differences
between the actual measurements and radiographic image
Figure 1: Digital radiographic images (a: Standard, b: Perio, c: Invert,
d:Perio + invert)
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Oliveira, et al.: Radiographic image enhancement in periodontology
groups was performed. The significance level was set at
5% ( = 0.05).
Results
As shown in Figure 2, the mean values, in millimeter,
( standard deviation) of the actual measurements were
3.00 0.84 and the measurements obtained from the
Standard, perio, invert and perio + invert radiographic
images were, respectively, 3.26 1.32, 3.25 1.33,
3.27 1.34, 3.24 1.34. The radiographic measurements
overestimated the actual by approximately 0.2 mm.
Table 1 shows that the ANOVA did not detect statistically
significant difference between the radiographic image
groups. Furthermore, none of the groups was significantly
different from the actual measurements (P = 0.771).
Discussion
Digital image receptors have shown to be more accurate for
periodontal diagnosis than analogue film. Vandenberghe
et al.[10] showed that both the photostimulable phosphor
(PSP) and charge coupled device (CCD) digital imaging
systems are adequate for periodontal diagnosis, with
notable dose reduction. However, caution is needed when
using CCD sensors at high exposure times to avoid image
deterioration by blooming effects.
Figure 2: Mean values (black squares) and standard deviation (horizontal
dashes), in millimeter, of the actual and radiographic measurements (standard,
perio, invert and perio + invert images)
Table 1: One-way ANOVA for CEJ-AC distance data
according to radiographic image groups and actual
measurements
Source of variation df Sum of Mean
squares square
Measurements 4 2.818 0.704
Residual 270 420.845 1.559
Total 274 423.663
df: Degrees of freedom, ns: Nonsignificant, ANOVA: Analysis of variance,
CEJ: Cemento-enamel junction
Journal of Oral and Maxillofacial Radiology / September-December 2015 / Vol 3 | Issue 3
The efficacy of digital enhancement filters on radiographic
images has been studied in the scientific literature since
the introduction of digital imaging systems.[11] Digital
enhancement filters are developed with the aim of
allowing for better accuracy in the diagnostic process,
by supposedly improving the image quality. Some filters
are only available for specific software applications, but
the majority of them are more commonly widespread.
Despite the fact that the perio filter, assessed in the
present study, is available exclusively at the DBSWIN
software, it is a sharpening filter that contrasts the
edges of the structures.[8] This can also be verified on
a subjective evaluation of the Figure 1b. On the other
hand, the invert filter (also known as negative or positive)
can be easily found in several digital image editing
software applications.
Studies have shown that enhancement filters have great
acceptance by examiners, who demonstrate significant
satisfaction with their use in the evaluation of periodontal
structures.[12] Remarkably, that is a subjective analysis
and not always related to the accuracy of diagnostics
outcomes.[13] The results of our ex vivo study revealed a
nonstatistically significant overestimation of the distance
between the CEJ and AC, since all digital radiographic
measurements were about 0.2 mm greater than the actual
ones, irrespective of the enhancement mode. It can be
justified by the geometry-related inherent magnification
observed on the periapical paralleling technique. The
distance between the object and the image receptor
coupled with the divergent cone-shaped X-ray beam
enlarges the projected image. Considering the fact that
this study aimed to reproduce a clinical situation and made
use of human mandibles, it is important to highlight the
thickness of the alveolar and cortical bone on the lingual
aspect of the mandible, when studying the results. Though
numerically noteworthy, the observed overestimation is
presumably clinically irrelevant.
Studies evaluating some task-specific enhancement filters
from the VistaScan system are controversial. Haiter-Neto
et al.[14] evaluated the caries 1 and caries 2 filters (intended
for caries lesion detection) and concluded that both cannot
be recommended for detection of proximal caries lesions.
de Azevedo Vaz et al.[7] demonstrated that the perio, endo,
caries 1 and caries 2 filters were not accurate for measuring
F P peri-implant bone level, and only the Standard images,
the fine and emboss filters provided satisfactory results.
0.452 0.771 ns Conversely, Oliveira et al.[15] stated that the endo filter
(intended for endodontic purposes), associated with high
spatial and contrast resolutions is recommended for the
determination of file lengths.
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Oliveira, et al.: Radiographic image enhancement in periodontology
The invert is a very popular filter and its usefulness has
been evaluated for different diagnostic tasks. Similarly
to our study, Scaf et al.[16] and Oliveira et al.[9] evaluated
periodontal bone loss and endodontic measurements,
respectively, in Standard and invert digital radiographic
images and concluded that both images were reliable, with
no significant difference in the diagnostic accuracy. In
contrast, Castro et al.[17] demonstrated that the diagnostic
accuracy of the invert in the detection of proximal caries
did not differ from Standard images and both had a very
poor performance. Additionally, de Molon et al.[18] showed
that measurements of periodontal bone defects in grey
scale-inverted digital images obtained with CCD sensors
were inferior to analogue film.
In the present study, the separate and joint use of the perio
and invert filters did not contribute for better accuracy in
the measurement of the alveolar bone level, which is in
disagreement with Vandenberghe et al.,[19] who achieved
better results after applying the perio filter on 12-bit
images. It can possibly be explained by the higher contrast
resolution of our images (16 bits) that may have favored
the radiographic image of the alveolar bone crest to be
even subtler. Nevertheless, perio, invert and perio + invert
images were not significantly different from the standard
images and actual values, what demonstrates that any
of them can provide reliable measurements. The wide
availability of digital enhancement filters does not exempt
the radiographic technique from having the technical
principles carefully observed.
Conclusion
The perio and invert enhancement filters did not interfere
with the efficacy of PSP-based radiographic images, which
were accurate in determining the alveolar bone level.
Financial support and sponsorship
The study was funded by FAPESP, a research foundation of
the State of So Paulo, Brazil (process no: 2012/08744-6).
Conflicts of interest
There are no conflicts of interest.
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