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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 7  |  Issue : 3  |  Page : 146-149

Common errors on panoramic radiograph: A time to reflect and review and not to sweep them under the carpet!


Department of Oral Medicine and Radiology, ACPM Dental College, Dhule, Maharashtra, India

Date of Web Publication22-Aug-2016

Correspondence Address:
Ujwala Rohan Newadkar
Department of Oral Medicine and Radiology, ACPM Dental College, Dhule - 424 003, Maharashtra
India
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DOI: 10.4103/0976-433X.188802

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  Abstract 

Introduction: There are a multitude of factors that may lead to a reduction of the diagnostic quality of panoramic radiographs. Errors in taking radiographs increase patient's radiation exposure, and also waste time and money. Inspecting the frequency and mechanism of producing errors will result in less retakes. Therefore, the aim of the study is to identify the most common positioning and technical errors in the panoramic radiographs taken in department of oral Medicine and Radiology of our institute. Materials and Methods: 2000 panoramic radiographs were photographed and reviewed under identical conditions, on a computer screen. Radiographs were evaluated by oral and maxillofacial radiologist, and frequency of errors was recorded. Results: Out of 2000 Panoramic radiographs there were 220 radiographs (11%) which were error free and 1780 radiographs (89%) with errors. The most common error observed in this sample was failure to place the tongue on the palate (48.7%) followed by chin tipped too low or too high (21.1%). Dark room errors accounted for 2.7% radiographs due to the processing errors resulting as dark and light radiographs as well scratches on them. The least frequent errors observed were the presence of radio-opaque artifacts caused by failure to remove metallic accessories, prostheses and the use of the lead apron during exposure and processing error (2.4%). Few radiographs had more than one error. Conclusion: Frequency of errors seen on panoramic radiographs are relatively high, thus training the operators, discussing the technical errors in case of occurrence are highly essential to maximize the quality of panoramic radiographs. Also clinicians need to be able to recognize the cause of the various film faults so that appropriate corrective action can be taken.

Keywords: Errors, panoramic radiograph, positioning


How to cite this article:
Newadkar UR, Chaudhari L, Khalekar YK. Common errors on panoramic radiograph: A time to reflect and review and not to sweep them under the carpet!. SRM J Res Dent Sci 2016;7:146-9

How to cite this URL:
Newadkar UR, Chaudhari L, Khalekar YK. Common errors on panoramic radiograph: A time to reflect and review and not to sweep them under the carpet!. SRM J Res Dent Sci [serial online] 2016 [cited 2021 Jan 16];7:146-9. Available from: https://www.srmjrds.in/text.asp?2016/7/3/146/188802


  Introduction Top


Dental panoramic tomography has become a very popular radiographic technique in dentistry. The main reasons for this are as follows:

  • All the teeth and their supporting structures are shown on one film
  • The technique is reasonably simple
  • The radiation dose is relatively low, particularly with modern DC units with rare-earth intensifying screens – the dose is equivalent to about 3–4 periapical radiographs.


The diagnostic value of these films is increased considerably if clinicians are aware of their limitations and apply a systematic approach to their interpretation.[1] “The hardest thing to see is what is in front of your eyes.” The value of panoramic radiograph is reduced when they are of poor diagnostic quality. This poor quality usually is not a result of an inherent limitation with the equipment, but rather is a result of errors made by the operators during patient positioning and processing.[2] Therefore, the aim of the study is to identify the most common positioning and technical errors in the panoramic radiographs taken in the Department of Oral Medicine and Radiology of our institute.


  Materials And Methods Top


A total number of 2000 panoramic radiographs of patients above 10 years old were taken in this study. The radiographs were taken by the same technician with the same equipment of panoramic unit (advanced medical system) in the radiology department of our institute, operating at 70 kVp and 10 mA. Exposure time was 18 s. Radiographs related to patients with mental or physical disorders were not included in this study. The radiographs were photographed using a Sony Cybershot 10.1 megapixel digital camera (model DSC-W170) in a room, with subdued lighting and imported to a laptop. The radiographs were reviewed under identical conditions, on a computer screen (Compaq Presario CQ40 laptop with 14.1-inch screen, 1280 × 800 screen resolution, 32-bit color mode). Each radiograph was assessed for the errors [Table 1]. Radiographs were evaluated by one oral and maxillofacial radiologist, and frequency of errors was recorded according to the criteria described by Langland et al. [Table 2].[3]
Table 1: Classification of errors

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Table 2: Positioning errors and the resultant identifying features on panoramic radiograph

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Errors related to film radiographs, such as static electricity or exposure and darkroom, were also assessed. The frequencies of individual errors on all radiographs were evaluated. In cases of doubt about the presence of errors, a second radiologist was consulted and after collecting the opinions and reaching a consensus, the errors in question were registered. Statistical analysis was carried out using Statistical Package for the Social Sciences 15.0 software (SPSS Inc., Chicago, IL, USA).


  Results Top


Panoramic radiographs of 2000 patients (female: 1090 and male: 910) were evaluated. There were 220 radiographs (11%) which were error-free and 1780 radiographs (89%) with errors. The most common error observed [Table 3] and [Graph 1 [Additional file 1]] in this sample was failure to place the tongue on the palate (48.7%), followed by chin tipped too low or too high (21.1%). Darkroom errors accounted for 2.7% of radiographs due to the processing errors, resulting in dark and light radiographs as well as scratches on them. The least frequent errors observed were the presence of radiopaque artifacts caused by failure to remove metallic accessories, prostheses, and the use of the lead apron during exposure and processing error (2.4%). A few radiographs had more than one error.
Table 3: Frequency distribution of positioning errors

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  Discussion Top


Most commonly seen error in this study was the presence of palatoglossal air space. This result is similar to other studies.[4],[5],[6],[7],[8],[9] It results when the patient does not raise the tongue against the palate [Figure 1]. The resulting air in the mouth is visible on the radiograph as a band of radiolucency over the maxillary teeth. This can reduce the diagnostic quality of the roots and its surrounding structures. The possible explanation for this error may be a lack of communication between the operator and the patients because of different languages. The technician may find difficult to instruct the patients to swallow and to keep the tongue on the roof of the mouth. Another explanation is that the patients sometime may misunderstand the instructions, putting only the tip of the tongue on the palate, or the patients do not pay much attention to the instruction given by the operator.[10]
Figure 1: Palatoglossal air space in the maxillary anterior region

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Rotation of the head leads to discrepancies in horizontal magnification of integral structures and interferes with diagnostic interpretation. Careful attention must be paid to the position of the light beam marker for the mid-sagittal plane and FH plane before the exposure is carried out. If the patient's chin is tilted downward, the arches will appear constricted. The condyles will appear closer together and may be cut off at the top of the film. The overall appearance will be that of a “Cheshire cat grin” due to the accentuated Curve of Spee [Figure 2]. If the patient's chin is tilted upward, the image of the arches will be one of the overall flattening or elongations. The condyles will be farther apart and may be cut off at the sides of the film. The general appearance is that of a wide “grimace” [Figure 3] due to a flattened Curve of Spee.{Figure 2}
Figure 3: Patient's chin is tilted upward leading to appearance as that of a wide “grimace” due to a flattened Curve of Spee

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The focal trough of the panoramic machines is a three-dimensional curved zone, and it is important for obtaining high-quality images. Conversely, this same panoramic quirk could suggest the presence of a condition that did not really exist. For example, if the apices of the mandibular incisors were missing [Figure 4], the clinician could suspect external resorption. The limited dimension of the focal trough, carelessness of operators, and the age of the panoramic unit affect the occurrence of some errors.[9]
Figure 2: Patient's chin is tilted downward leading to appearance of a “Cheshire cat grin” due to the accentuated Curve of Spee

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The operator must assure that the patient has removed dental appliances, earrings, eyewear, facial and oral piercing jewelry, and necklaces before making a panoramic exposure. Frequently, the patient will be wearing a chain or necklace that cannot be seen beneath clothing. Similarly, placing the lead apron too high on the patient's neck or bunching it at the shoulders will obstruct the beam enough to cast a ghost image of the shielding material.

Sometimes, errors could occur beyond the operator's control in patients having facial asymmetry, short and heavy neck, very overweight, unusually tall, and the inability of following the instructions.[9] These situations make it difficult to position the patient properly in the X-ray machine. The operator must be careful in positioning these patients. Although errors beyond the operator's control may occur, most errors are within the control of the operator and could be reduced by paying more attention to taking the radiographs. Thus, the errors seen on panoramic radiographs were relatively high and the errors in patient positioning were the most frequent errors. It seems that the operator skill can decrease the frequency of errors and help produce high-quality radiographs. It is important to monitor the panoramic images regularly and identify errors and suggests methods to avoid these errors. Poor quality generally results in the need to retake images which have several consequences, the most serious of which is additional radiation dose to the patient. Given the 2007 recommendations of the International Commission on Radiological Protection which result in an upward reassessment of fatal cancer risk from oral and maxillofacial radiographic examinations,[11] it is important that retakes are kept at a minimum. Other consequences are increased cost and extended examination times. The effect of additional cost significantly increases the financial burden of patients.

The limitations of this study include assessment of conventional panoramic radiographs taken in the institute only. Furthermore, to avoid the processing errors, use of digital radiography can be the way out. Radiographs produced with older machines may increase error rates because with extended use; the location of the focal trough could change, necessitating recalibration if suboptimal images are consistently produced.[12]


  Conclusion Top


From the results of the study, the frequency of errors seen on panoramic radiographs is relatively high; thus, training the operators and discussing the technical errors in case of occurrence are highly essential to maximize the quality of panoramic radiographs. Further, clinicians need to be able to recognize the cause of the various film faults so that appropriate corrective action can be taken. Repeating a radiograph, without first establishing the cause of the error, may result in the error simply being perpetuated.

Acknowledgment

The authors would like to thank Dr. Rohan Newadkar and the members of the Department of Oral Medicine and Radiology for their supports.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Whaites E. Essentials of Dental Radiography and Radiology. 3rd ed. UK: Churchill Livingstone, Elsevier Science Limited; 2003. p. 161.  Back to cited text no. 1
    
2.
White SC, Pharaoh MJ. Oral Radiology: Principles and Interpretation. 5th ed. Philadelphia: Mosby; 2004. p. 200-17.  Back to cited text no. 2
    
3.
Langland OE, Langlais RP, Preece JW. Principles of Dental Imaging. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2002. p. 219-60.  Back to cited text no. 3
    
4.
Akarslan ZZ, Erten H, Güngör K, Celik I. Common errors on panoramic radiographs taken in a dental school. J Contemp Dent Pract 2003;4:24-34.  Back to cited text no. 4
    
5.
Rushton VE, Horner K, Worthington HV. The quality of panoramic radiographs in a sample of general dental practices. Br Dent J 1999;186:630-3.  Back to cited text no. 5
    
6.
Granlund CM, Lith A, Molander B, Gröndahl K, Hansen K, Ekestubbe A. Frequency of errors and pathology in panoramic images of young orthodontic patients. Eur J Orthod 2012;34:452-7.  Back to cited text no. 6
    
7.
Schiff T, D'Ambrosio J, Glass BJ, Langlais RP, McDavid WD. Common positioning and technical errors in panoramic radiography. J Am Dent Assoc 1986;113:422-6.  Back to cited text no. 7
    
8.
Dhillon M, Raju SM, Verma S, Tomar D, Mohan RS, Lakhanpal M, et al. Positioning errors and quality assessment in panoramic radiography. Imaging Sci Dent 2012;42:207-12.  Back to cited text no. 8
    
9.
Mohtavipour ST Haghighat JS, Dalili Z, Somayeh N, Mohtavipour SS, Narenjisani M, et al. Common errors in digital panoramic radiographs taken in Rasht dental school. J Dentomaxillofac Radiol Pathol Surg 2013;2:32-6.  Back to cited text no. 9
    
10.
Pandey S, Pai KM, Dhakal A. Common positioning and technical errors in panoramic radiography. J Chitwan Med Coll 2014;4:26-9.  Back to cited text no. 10
    
11.
Ludlow JB, Davies-Ludlow LE, White SC. Patient risk related to common dental radiographic examinations: The impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculation. J Am Dent Assoc 2008;139:1237-43.  Back to cited text no. 11
    
12.
Razmus TF, Glass BJ, McDavid WD. Comparison of image layer location among panoramic machines of the same manufacturer. Oral Surg Oral Med Oral Pathol 1989;67:102-8.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 4], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
Materials And Me...
Results
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