Dentomaxillofacial Radiology (2008) 37, 142148 2008 The British Institute of Radiology http://dmfr.birjournals.

org

RESEARCH

Digital enhancement of radiographs for assessment of interproximal dental caries

V Seneadza1, A Koob1, J Kaltschmitt2, HJ Staehle2, J Duwenhoegger3 and P Eickholz*4
Department of Prosthodontics, Department of Conservative Dentistry, Clinic of Oral, Dental and Maxillofacial Diseases, University Hospital Heidelberg, Germany; 2Section of Periodontology, Department of Conservative Dentistry, Clinic of Oral, Dental and Maxillofacial Diseases, University Hospital Heidelberg, Germany; 3Private Practice, Heidelberg, Germany; 4 Department of Periodontology, Center for Dental, Oral, and Maxillofacial Medicine, Hospital of the Johann Wolfgang GoetheUniversity Frankfurt, Germany
1

Objectives: Evaluation of a particular digital caries image-enhancing mode (filter) for its effect on the validity of measurements of caries lesion depth. Methods: Standardized radiographs of 44 extracted teeth exhibiting interproximal caries lesions were obtained. Six radiographs were obtained of each tooth and digitized. Four radiographs were made using D-speed film with and without soft tissue scattering equivalent (STSE) at normal exposure time (0.32 s) and underexposed (0.16 s). Two were made using E-speed film with STSE normally (0.16 s) and underexposed (0.08 s). On each of the 264 radiographs, 4 independent examiners measured the central depth (CD) of 1 carious lesion per tooth both on the unchanged radiographic image and after use of the filter. Histometric CD assessments provided a gold standard for comparison with the radiographic measurements (validity). Repeated measures ANOVA was calculated for validity in relation to examiner, lesion type, filter, film type, exposure time and STSE. Results: The lesion type was identified to statistically significantly influence the validity of CD measurements. Examiner in combination with defect type (P,0.001), filter (P 5 0.017), exposure (P 5 0.027) and film type (P 5 0.044) had an additional albeit small effect. Conclusions: The lesion type significantly influenced the validity of CD measurements: enamel lesions were less underestimated than dentin lesions. Dentomaxillofacial Radiology (2008) 37, 142148. doi: 10.1259/dmfr/51572889 Keywords: dental caries; radiology, diagnostic X-ray; radiographic image enhancement; validity Introduction Diagnosis of posterior approximal carious lesions by means of bitewing radiographs is an approved clinical method.14 Basically, there are two tasks in radiographic caries diagnosis: (i) detection of caries, i.e. assessment of whether caries are present or not (receiver operating characteristic (ROC) analysis)511 and (ii) assessment of the extent of the carious lesion. The latter may be done (i) by assigning lesions to different categories of extent,12 or (ii) by measuring the actual extent (e.g. central depth (CD)).1316 It has been shown that the extent and change over time of carious lesions can be assessed and monitored by the measurement of linear distances in
*Correspondence to: Prof. Dr Peter Eickholz, Poliklinik fu r Parodontologie, ZZMK (Carolinum), Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany; E-mail: eickholz@med.uni-frankfurt.de Received 2 April 2007; revised 22 July 2007; accepted 23 July 2007

vitro.17,18 However, monitoring approximal lesions with serial radiographs is difficult because changes in irradiation geometry are likely to produce artificial changes in the radiographic image.1921 Even if precautions are taken to minimize the changes in irradiation geometry, the radiographic image of a demineralized area tends to underestimate the extent of a lesion in comparison with histological assessment.4,16,2025 Earlier studies have failed to show an improvement in radiographic diagnosis of interproximal dental caries by digital image manipulation.13,15,26,27 However, taking tissue scatter, type of film, and time of exposure into account, some benefit from basic filters has been revealed.14 For caries in particular designed digital manipulations may offer further benefit by adequately adjusting for shortcomings in the quality of the radiographs, or permit contrast enhancement to clarify changes otherwise undetectable to the eye.

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Thus, the purpose of this study was to investigate the validity of linear measurements of interproximal dental carious lesions that could be achieved by a particular digital caries filter in radiographic images according to examiner, lesion type, film type, tissue scatter and time of exposure.

Table 1 Characteristics of radiographs obtained from each specimen Film type Ultraspeed D-speed Exposure time Standard exposure 0.32 s 0.32 s Underexposure 0.16 s 0.16 s Standard exposure 0.16 s Underexposure 0.08 s Soft tissue scatter radiation equivalent Without With Without With With With

Materials and methods Preparation of specimens, obtaining radiographs and histometric evaluation have been described in detail before.1315 Hence, only a brief description is given here: 44 extracted human teeth all exhibiting naturally occurring interproximal caries were collected. Six standardized radiographs of each tooth were obtained using specific film holders (Figure 1). Four were made using D-speed film (Ultra SpeedTM, size 2; Eastman Kodak Co., Rochester, NY) with and without soft tissue scatter equivalent (STSE: 9 mm Plexiglas slab)28 at normal exposure time (0.32 s) and underexposed (0.16 s). Two were made using E-speed film (Ekta Speed plusTM, size 2; Eastman Kodak Co.) with STSE normally (0.16 s) and underexposed (0.08 s) (Table 1). After histometric assessment, all lesions were classified according to the radiographic classification for interproximal caries:12 C1, caries within the outer half of the enamel; C2, caries within the inner half of the enamel; C3, caries extending into the outer half of the dentin; and C4, caries extending into inner half of dentin. Histologically, 11 lesions extended into the outer half of the enamel (C1), 15 into the inner half of the enamel (C2), 16 into the outer (C3) and 2 into the inner half of the dentin (C4), respectively. Radiographic evaluation All 264 radiographs were digitized using a flat bed scanner (Friacom-Scanner: Linotype SAPHIR; Friadent AG, Mannheim, Germany) with 60061200 dpi resolution and 10-bit grey values, and thereafter transferred to a computer (Friacom-PC; Friadent AG: PC: 486DX2,

Ektaspeed plus E-speed

Figure 1 Diagram of specimen attached to the film holder (connection by Lego chips 1 and 2) and film holder attached to the X-ray source using the collimator, STSE, soft tissue scattering equivalent (Plexiglas slab)

66 MHz, graphics adapter: ELSA WINNER 1000 PRO; 17 inch monitor, Trinitron Multiscan 17seII; Sony, Tokyo, Japan). Digital manipulations and measurement of linear distances were performed using a computer program (Friacom 2.5, Friadent AG). Underexposed images were not processed in a different way from optimally exposed images. All radiographs were evaluated under 9.56 magnification. The horizontal diameter of the metal ball on the film holder was measured using the measurement tool and thereafter the program automatically adjusted the magnification of the particular radiographic image accordingly (Figure 1). From each of the 264 radiographic images, 2 different versions were created: (i) an unmanipulated digitized image and (ii) an image manipulated by a filter specifically designed to detect dental caries.29,30 This filter is based on segmentation. Two threshold values were calculated: one to exclude metallic restorations and another to exclude background including soft tissue. First, a locally adaptive alpha-trimmed mean filter was used. Then two global threshold methods were applied. (i) Detection of local minima of the grey value histogram. The two lowest and the highest thresholds were used for further operation. (ii) Transformation of the grey value histogram into a gradient grey value histogram. The particular grey value was used as the threshold that showed the highest gradient within the image.29Despite use of the respective filters, examiners were not allowed to enhance images individually. A region of interest (ROI) was selected that contained the whole extent of one particular lesion per tooth (Figure 2). On each version of the image, the CD of one carious lesion per tooth was measured using the Friacom measurement tool, i.e. for each radiograph, the distance was measured twice. To prevent bias, a schedule for assessments was followed. The radiographs were numbered sequentially from 1 to 264. The first measurement was made on the unmanipulated version of radiograph number one, the second measurement on the manipulated version of radiograph number two, and so forth. Thus, the 265th measurement was performed on the filtered image of radiograph number one.1315 Four independent examiners (VS, AK, JD, JK) measured all radiographs. For each specimen, the interproximal surface at which CD should be measured was determined in advance. Thus,
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Figure 2 Digitized radiographic images of specimen number 13 with C1 lesion (arrow). (ah) D-type film (Ultra SpeedTM, size 2; Eastman Kodak Co., Rochester, NY) without soft tissue scatter equivalent (STSE) at normal exposure time ((a) without filter and (b) with filter) and underexposed ((c) without filter and (d) with filter). With STSE at normal exposure time ((e) without filter and (f) with filter) and underexposed ((g) without filter and (h) with filter). (il) E-type film (Ekta Speed plusTM, size 2; Eastman Kodak Co.) with normal STSE ((i) without filter and (j) with filter) and underexposed ((k) without filter and (l) with filter)

the examiners knew where to look and only one surface per radiographic image was evaluated. Furthermore, the examiners knew in advance that all specimens clinically exhibited caries. All examiners had been calibrated in advance of the experimental assessments. They had measured radiographs from an earlier study. The measurements were compared with already existing histometric measurements. Significant deviations were discussed with the principal investigator (PE). The examiners were trained to have validity better than 0.5 mm before they were allowed to start the experimental assessments. One examiner (B) was experienced in assessing dental caries on radiographs from an earlier study.15 Another examiner (D) was experienced in evaluating radiographs for periodontal bone loss from another study.31 Statistical analysis In this study, images were analysed as models. The radiographic image (n 5 528) was defined as
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the statistical unit. To estimate the validity of the measurements on the different modifications of the radiographic images, the radiographic CD measurements were compared with the histometric CD assessments that served as a gold standard.1315 The means of the differences between histometric and the radiographic assessments using the different examiners as the betweensubjects variable were compared using a repeated measures ANOVA. The following factors were entered into analysis: filter, type of lesion (C1/C2/C3/C4; enamel/ dentin), type of film, time of exposure, STSE (n 5 528). Identification of factors that significantly influenced the dependent variable triggered pair-wise comparisons with the paired t-test (between examiners for the different lesion types) or group-wise comparisons with the independent t-test (filter, exposure, film type). Owing to the need for multiple comparisons, an adjustment according to Bonferroni was required. Statistical analysis was performed using SystatTM for Windows version 10.0 (Systat Inc., Evanston, IL).

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Table 2 Histometric and radiographic measurements of the central depth (CD) of 44 carious lesions (meanstandard deviation (SD)), and differences between the histometric and radiographic measurements for the different image (filter) and film characteristics Measurements Histometric Examiner Radiographic
All radiographs D to histometry D-type/standard exposure D to histometry D-type/underexposure D to histometry D-type/STSE/standard exposure D to histometry D-type/STSE/underexposure D to histometry E-type/STSE/standard exposure D to histometry E-type/STSE/underexposure D to histometry

MeanSD 1.340.89 A Without filter With filter

0.910.62 0.440.78 0.900.64 0.450.76 0.930.64 0.420.77 0.910.65 0.440.79 0.990.68 0.360.78 0.920.58 0.430.86 0.810.55 0.530.75 0.940.65 0.410.76 1.000.65 0.350.75 0.940.59 0.410.77 0.930.69 0.420.79 0.990.72 0.360.79 0.910.68 0.440.82 0.870.58 0.480.67

B Without filter With filter

1.140.64 0.210.77 1.290.66 0.050.69 1.090.53 0.250.80 1.170.72 0.170.84 1.120.70 0.230.86 1.150.67 0.200.71 1.000.52 0.340.70 1.200.69 0.150.71 1.230.65 0.120.67 1.220.74 0.120.76 1.170.72 0.170.76 1.190.64 0.150.66 1.260.72 0.090.73 1.130.69 0.220.72

C Without filter With filter

0.780.43 0.570.77 0.790.38 0.560.79 0.750.29 0.600.79 0.780.46 0.570.73 0.800.49 0.550.84 0.800.45 0.550.73 0.770.48 0.580.78 0.770.51 0.580.75 0.770.50 0.580.70 0.760.48 0.590.71 0.720.34 0.630.76 0.780.58 0.570.82 0.790.65 0.550.79 0.800.47 0.550.75

D Without filter With filter

0.920.51 0.430.74 0.930.56 0.410.71 0.860.52 0.490.72 1.050.51 0.290.84 0.920.51 0.430.70 0.940.49 0.410.79 0.820.44 0.520.71 1.040.59 0.310.73 1.020.60 0.320.72 1.030.62 0.310.73 1.180.66 0.170.79 1.020.56 0.320.70 1.040.57 0.310.78 0.930.55 0.420.71

Results Table 2 gives the meanstandard deviation (SD) of histometric and radiographic CD measurements and differences between histometric and radiographic measurements for the different examiners (A, B, C, D), digital manipulations (no filter/filter), exposures, film types (D-speed/E-speed) as well as STSE (yes/no). Repeated measures ANOVA identified the defect type to statistically significantly influence the validity of CD measurements (Table 3). Classification into C1, C2 and dentin lesions, as well as into enamel and dentin lesions, influenced the validity (Table 3). The different examiners themselves did not significantly influence the statistical validity of CD measurements. However, examiner in combination with defect type (P,0.001), filter (P 5 0.017), exposure (P 5 0.027) and film type (P 5 0.044) had a significant effect (Table 3). The validity of the different examiners for different defect

types is given in Table 4. Tables 5ac give the validity of the different examiners according to filter, exposure and film type. Whereas for examiner A and C there was no effect from filter or exposure, examiner B and D exhibited increased validity after use of filter and standard exposure (Table 5a,b). Film type did not affect the validity of examiner C. All other examiners exhibited better validity using D-speed films.

Discussion At the present time, bitewing radiographs are the most feasible in vivo method of scoring caries progression.3,21,32,33 The clinical decision whether to excavate caries should be made based on cavitation rather than histological lesion depth.4 However, conventional radiographs do not give reliable information about cavitation and, thus, the need for invasive treatment.12

Table 3 Repeated measures ANOVA of the differences between the histometric assessments and radiographic measurements of central depths (CDs) on the digitized but unchanged and the manipulated radiographic images (statistical unit: radiograph) Dependent variable: histometric minus radiographic measurement CD (mm) Source Between subjects Defect type Dentin Filter Exposure Film type STSE Error Within subjects Examiner Examiner 6 defect type Examiner 6 filter Examiner 6 exposure Examiner 6 film type Examiner 6 STSE Examiner 6 dentin Error Sum of squares 167.15 11.32 1.25 1.15 0.85 0.05 616.37 0.23 2.10 1.12 1.01 0.88 0.71 0.51 166.44 DF 1 1 1 1 1 1 521 3 3 3 3 3 3 3 1563 F-ratio 141.29 9.57 1.06 0.97 0.72 0.04 0.70 6.58 3.51 3.15 2.76 2.22 1.60 P 0.000 0.002 0.304 0.326 0.397 0.836 0.550 0.000 0.015 0.024 0.041 0.084 0.188

GreenhouseGeisser epsilon (GG): 0.9303. HuynhFeldt epsilon (HF): 0.9466. DF, degrees of freedom; STSE, soft tissue scatter radiation equivalent
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Table 4 Histometric and radiographic measurements of central depth (CD) of carious lesions (meanstandard deviation (SD) and differences between histometric and radiographic measurements for the different examiners and lesion types (enamel/dentin; C1/C2/C3/C4) Measurements Examiner C1 lesions Histometric Radiographic D to histometry C2 lesions Histometric Radiographic D to histometry Enamel lesions Histometric Radiographic D to histometry C3 and C4/dentin lesions Histometric Radiographic D to histometry MeanSD A 0.500.21 0.790.24 20.280.34 1.230.47 0.870.45 0.360.67 0.960.53 0.840.37 0.120.65 1.960.97 1.060.88 0.900.78 MeanSD B MeanSD C MeanSD D

0.970.33 20.470.42 1.120.50 0.110.68 1.060.45 20.100.65 1.340.88 0.620.77

0.700.19 20.200.28 0.730.35 0.500.59 0.720.30 0.240.60 0.860.64 1.100.77

0.900.31 20.400.34 0.890.38 0.340.60 0.900.36 0.060.63 1.110.75 0.850.73

C1, caries within the outer half of the enamel; C2, caries within the inner half of the enamel; C3, caries extending into the outer half of the dentin; C4, caries extending into inner half of dentin

Table 5a Histometric and radiographic measurements of central depth (CD) of carious lesions (meanstandard deviation (SD) and differences between histometric and radiographic measurements for the different examiner and filter (no/yes) Measurements Examiner Histometric No filter Radiographic D to histometry Filter Radiographic D to histometry MeanSD A 1.340.89 0.910.62 0.440.78 0.940.65 0.410.82 1.140.64 0.210.77 1.200.69 0.150.80 0.780.43 0.570.77 0.770.51 0.580.82 0.920.51 0.430.74 1.040.59 0.310.80 MeanSD B MeanSD C MeanSD D

Table 5b Histometric and radiographic measurements of central depth (CD) of carious lesions (meanstandard deviation (SD) and differences between histometric and radiographic measurements for the different examiner and exposures Measurements Examiner Histometric Standard exposure Radiographic D to histometry Underexposure Radiographic D to histometry MeanSD A 1.340.89 0.930.64 0.420.85 0.920.63 0.430.75 1.210.69 0.130.82 1.130.64 0.220.75 0.770.47 0.570.81 0.770.47 0.570.78 1.030.57 0.320.83 0.930.54 0.410.71 MeanSD B MmeanSD C MeanSD D

Table 5c Histometric and radiographic measurements of central depth (CD) of carious lesions (meanstandard deviation (SD) and differences between histometric and radiographic measurements for the different examiner and film type Measurements Examiner Histometric D-speed Radiographic D to histometry E-speed Radiographic D to histometry
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MeanSD A 1.340.89 0.950.65 0.400.77 0.880.59 0.470.86

MeanSD B

MeanSD C

MeanSD D

1.190.67 0.160.85 1.130.65 0.210.85

0.770.45 0.580.76 0.790.51 0.560.85

1.000.57 0.280.73 0.930.51 0.360.74

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Since standardized radiographs are essential for monitoring approximal carious lesions,2123 a standardized orthoradial projection was provided in the present study. If regression or progression of carious lesions is to be monitored, further information is required. It must be taken into account that radiographic images tend to underestimate the real extent of demineralization.1315,17,18,25 Some recent studies failed to show that radiographic images statistically significantly underestimated histometric measurements.4,16 However, it also has to be kept in mind that the radiographic measurements (0.470.17 mm) of Young and Featherstone4 underestimated the histometric gold standard (0.580.19 mm), but the difference failed to reach statistical significance for the sample of 13. The sample may be too small to reveal a statistically significant difference and artificially created lesions may be easier to measure. Furthermore, the reported difference between radiographic and histometric measurements are within the range that was observed for examiner B using the filter in this study. Other authors found a digital radiographic system not to underestimate CD when compared with the histological gold standard. However, this observation could be made only for two of four examiners. Obviously the examiner is a strong factor influencing the validity of radiographic CD measurements in caries lesions.16 If dentin lesions are to be monitored in particular, underestimation of the real extent should be minimized, which may be achieved using digital enhancement.14,15 All radiographs were evaluated under 9.56 magnification because earlier research has revealed that the representation of radiographic images at higher magnifications facilitates accuracy.13,32 The type of carious lesion had a significant influence on the validity of CD measurements. Whereas the depths of C1 lesions were overestimated, the underestimation of dentin lesions (C3 and C4) was stronger than that of C2 lesions. This confirms observations made in earlier studies.1315 Using ROC analysis, other authors have also observed that accuracy depends on lesion type: dentin lesions were easier to detect than enamel lesions.7,10 The different examiners themselves did not have a statistically significant influence on the validity of CD measurements. However, examiner in combination with defect type, filter, exposure and film type had a significant effect. Examiners B and D were able to take advantage from optimal exposure and D-speed film, and from image enhancement (filter). Both examiners were already experienced in the radiographic assessment of caries (B) or evaluation of radiographs in general (D). This observation confirms the findings of other authors who report that oral radiologists (people specifically trained to evaluate radiographs and use digital enhancement) take more benefit from digital filtering.10,24,25,34 Other authors had found increased validity after automatic digital

enhancement of radiographs with inadequate exposure. However, all six examiners in this study were trained oral radiologists.35 The influence of film type should not be overestimated: the mean differences between D- and E-speed film were 0.07 mm to 0.08 mm (Table 5c). These small differences are certainly not clinically relevant. Using ROC analyses, many studies failed to find differences regarding accuracy of caries assessment between different film types: D-/E-speed,59 E-/Fspeed.8,10,11 However, even in ROC analysis there is some conflicting evidence regarding the comparison of accuracy for the detection of approximal caries using different film types. For specific E-speed films (Ektaspeed/Ektaspeed Plus) some authors report significantly different accuracy7 while some do not.6 Furthermore, in comparing D-, E- and F-speed films, statistically significant superior performance of the Espeed film was observed by some authors,36 whereas other authors failed to detect statistically significant differences between Ektaspeed Plus and F-speed films.26 For examiners B and D, use of the filter resulted in a reduced underestimation of CD measurements in C1 and C2 lesions compared with digitized but unmanipulated images. Also for dentinal lesions, the study showed a significant effect of the applied filter on the validity of CD measurements in the hand of experienced examiners. Thus, the increased validity provides means with which to monitor dentinal lesions. However, the lowest validity of CD measurements was observed for dentinal lesions. Monitoring a radiographic C3 lesion still carries a risk of underestimating the depth of the lesion and thereby for pulpal reactions within the observation interval. However, the use of the filter may reduce this risk and thereby increase the options to monitor dentinal caries. The validity achieved in this study was better for each examiner and parameter than the validity observed in earlier studies with conventional radiographic films (mean difference between histometric gold standard and radiographic CD measurement: 0.52 mm to 0.80 mm,14 and a CCD system (0.61 mm to 0.91 mm)).15 The worst validity (0.63 mm) was observed for examiner C using the filter in D-speed film with STSE under standard exposure. Examiner B achieved the best validity (0.05 mm) without filter under optimal film conditions (D-speed, without STSE, standard exposure) (Table 2). A difference to the earlier studies14,15 was that only radiographs of teeth that were histologically exhibiting caries were entered into this study. All examiners were aware of the fact that all radiographs depicted caries and they knew on which side of the tooth the carious lesion could be found. Thus, variability and decreased validity due to uncertainty about whether caries is present or not could be excluded. Lesion type significantly influenced the validity of CD measurements: enamel lesions were less underestimated than dentin lesions.

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