Diagnostic challenges of dental radiographs and adjunctive methods of caries identification

In this monthly feature, Dr. Gordon Christensen addresses the most frequently asked questions from Dental Economics readers. If you would like to submit a question to Dr. Christensen, please send an e-mail to info@pccdental.com.

I am a mature practitioner, having practiced for 30 years. Early in my career, bitewing and periapical radiographs provided relatively good observation and identification of initial dental caries, and I did not miss many lesions. However, now I find that I often miss initial caries, and I am embarrassed on subsequent recall appointments to find significant, large lesions that I overlooked on earlier appointments. It seems to me that the current expensive digital sensors should offer better diagnostic capabilities than I am seeing. I am convinced that the analog radiographs that I used early in my career were much more diagnostic. What has happened to dental radiographs? What can I do to better identify initial caries?

Your observations are shared by the majority of mature practitioners. Many younger practitioners have not noticed the inadequacy of periapical and bitewing radiographs because they do not have a historical perspective relative to the problem you described. I recently received a typical example from an excellent general practitioner in the eastern part of the US (figures 1 and 2).

Upon initial examination of the radiograph, only a few minor lesions were observed. When the dentist excavated the caries in the maxillary second molar, the extreme depth of the lesion was able to be seen. This is not an abnormal finding. In spite of the ability to manipulate digital images through magnification, coloring, texturing, and change of contrast, most small lesions and some large lesions are often missed.

In this column, I will discuss the problems caused by the inadequacy of dental radiographs and present some relatively effective ways to partially overcome these problems. It is my intent to continue to motivate manufacturers of digital sensors to improve the diagnostic capabilities of their products.

Figure 1: Note the lack of any clearly identifiable presence of deep carious lesions on this current-generation digital radiograph.

Figure 2: On making the initial opening of the mesial surface of the second maxillary molar, the extreme depth of the lesion is evident.

Clinical problems associated…

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