Reporting of dental status from full-arch radiographs: Descriptive analysis and methodological aspects

Abstract

Aim:
To identify standards, how entities of dental status are assessed and reported from full-arch radiographs of adults.

Methods:
A PubMed (Medline) search was performed in November 2011. Literature had to report at least one out of four defined entities using radiographs: number of teeth or implants; caries, fillings or restorations; root-canal fillings and apical health; alveolar bone level. Cohorts included to the study had to be of adult age. Methods of radiographic assessment were noted and checked for the later mode of report in text, tables or diagrams. For comparability, the encountered mode of report was operationalized to a logical expression.

Results:
Thirty-seven out of 199 articles were evaluated via full-text review. Only one article reported all four entities. Eight articles reported at the maximum 3 comparable entities. However, comparability is impeded because of the usage of absolute or relative frequency, mean or median values as well as grouping. Furthermore the methods of assessment were different or not described sufficiently. Consequently, established sum scores turned out to be highly questionable, too. The amount of missing data within all studies remained unclear. It is even so remissed to mention supernumerary and aplased teeth as well as the count of third molars.

Conclusion:
Data about dental findings from radiographs is, if at all possible, only comparable with serious limitations. A standardization of both, assessing and reporting entities of dental status from radiographs is missing and has to be established within a report guideline.

Full text

of report was operationalized to a logical expression.
RESULTS: Thirty-seven out of 199 articles were evalu-
ated
via
full-text review. Only one article reported all
four entities. Eight articles reported at the maximum 3
comparable entities. However, comparability is impeded
because of the usage of absolute or relative frequency,
mean or median values as well as grouping. Further-
more the methods of assessment were different or not
described sufficiently. Consequently, established sum
scores turned out to be highly questionable, too. The
amount of missing data within all studies remained un-
clear. It is even so remissed to mention supernumerary
and aplased teeth as well as the count of third molars.
CONCLUSION: Data about dental findings from ra-
diographs is, if at all possible, only comparable with
serious limitations. A standardization of both, assessing
and reporting entities of dental status from radiographs
is missing and has to be established within a report
guideline.
© 2014 Baishideng Publishing Group Inc. All rights reserved.
Key words: Research design; Guideline; Dental radiog-
raphy; Epidemiology; Public health; EQUATOR
Core tip: Full mouth dental radiographs are in world-
wide daily use and contain various informations about
dental and oral health of adult patients. This is why it
is often used for epidemiologic research or to augment
clinical data. But, when reported, data is presented in
multifarious ways. Thus no or only little comparison
of research outcome is possible. Existing standards of
evaluation and reporting should be fixed in a report-
ing guideline regarding: number of teeth and implants;
caries, fillings and restorations; root-canal fillings and
apical health; alveolar bone level. Application of sum
scores turned out to be very questionable.
Huettig F, Axmann D. Reporting of dental status from full-arch
Reporting of dental status from full-arch radiographs:
Descriptive analysis and methodological aspects
Fabian Huettig, Detlef Axmann
Fabian Huettig, Detlef Axmann, Department of Prosthodontics
with Section “Medical Materials and Technology” at the Centre
of Dentistry, Oral Medicine, Maxillofacial Surgery of Eberhard-
Karls-University Hospital, D-72076 Tuebingen, Germany
Author contributions: Huettig F and Axmann D established
the search strategy, selection criteria and methodology of report;
Huettig F performed the literature research, selected the articles
and performed the full text review; Axmann D reviewed the data
aquisiton by spot tests; Huettig F wrote and Axmann D reviewed
the paper.
Supported by The “Walter and Anna Koerner-Scholarship”
as part of the Land of Baden-Wurttemberg’s Dentists Chamber
(Stuttgart, Germany) within the cooperation of Tuebingen Uni-
versity and Peking University Dental Schools; by Mrs. Barbara
Welder of Dental Clinics Library at Eberhard-Karls-University
(Tuebingen, Germany); by Lucas M Leister for English proof-
reading
Correspondence to: Dr. Fabian Hüttig, Department of Prosth-
odontics with Section “Medical Materials and Technology” at the
Centre of Dentistry, Oral Medicine, Maxillofacial Surgery of Eb-
erhard-Karls-University Hospital, Osianderstrasse 2-8, D-72076
Tuebingen, Germany. fabian.huettig@med.uni-tuebingen.de
Telephone: +49-7071-2986183 Fax: +49-7071-295917
Received: April 10, 2014 Revised: July 11, 2014
Accepted: August 27, 2014
Published online: October 16, 2014
Abstract
AIM: To identify standards, how entities of dental
status are assessed and reported from full-arch radio-
graphs of adults.
METHODS: A PubMed (Medline) search was per-
formed in November 2011. Literature had to report at
least one out of four defined entities using radiographs:
number of teeth or implants; caries, fillings or restora-
tions; root-canal fillings and apical health; alveolar bone
level. Cohorts included to the study had to be of adult
age. Methods of radiographic assessment were noted
and checked for the later mode of report in text, tables
or diagrams. For comparability, the encountered mode
SYSTEMATIC REVIEWS
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DOI: 10.12998/wjcc.v2.i10.552
World J Clin Cases 2014 October 16; 2(10): 552-564
ISSN 2307-8960 (online)
© 2014 Baishideng Publishing Group Inc. All rights reserved.
World Journal of
Clinical Cases
W
J C C
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radiographs: Descriptive analysis and methodological aspects.
World J Clin Cases 2014; 2(10): 552-564 Available from: URL:
http://www.wjgnet.com/2307-8960/full/v2/i10/552.htm DOI:
http://dx.doi.org/10.12998/wjcc.v2.i10.552
INTRODUCTION
Beside diagnosis support, X-rays are an established
method to follow up treatments with surrogate charac-
teristics, such as: bone loss in implantology, periodontol-
ogy and maxillo-facial surgery, or apical are up and loss
of teeth in endodontology, or caries prevalence in opera-
tive dentistry.
Moreover, it is used for assessment of skeletal
changes focussing orthodontic or temporo-mandibular-
disorders. It is even possible to nd approaches of foren-
sic medicine, i.e., for non-invasive age determination via
orthopantomograms.
The quality of panoramic radiographs has enhanced
during the last years. Namely their sensitivity and specity
to diagnose ndings, as mentioned before, is considered
to be satisfying. Problems of underestimation are dis-
cussed commonly. Nevertheless, determining oral health
by radiographic presentable dimensions of the dental
status is possible. That is why panoramic radiographs are
often used for epidemiologic and retrospective analysis
of dental status and oral health respectively. Recently,
a review subsumed the competence and application of
panoramic radiographs for epidemiologic studies of
oral health[1]. However, it remains uncertain, whether
standards are established to report radiographic ndings
which describe dental status or oral health data in general.
No results, neither in Pubmed/Medline, EQUATOR-
Network (www.equator-network.com) or Cochrane Li-
brary could be identified searching a relevant guideline.
Therefore, this systematic review was launched, to find
out, which approaches are commonly used, to assess and
report the entities: decay, missing, restorative, endodontic
and periodontal status as surrogate dimensions of oral
health (Table 1).
MATERIALS AND METHODS
Search and identication/inclusion and exclusion
A Medline/PubMed search was performed for articles
reporting findings from full arch radiographs, focused
on oral health and dental status of adults. This search
was conducted in November 2011. No time limit was
set. Panoramic X-ray or a full-mouth radiographic survey
with periapical radiographs of all remaining teeth were
denied as “Full arch radiograph”. In the following, the
term “radiograph” will be only used in this sense.
To nd and include such papers the following search-
string was constructed stepwise and applied finally as:
(“radiographic study” or “panoramic”) and (“oral health”
or “dental status” or “dental health” or “dentition”) not
(children OR review OR edentulous)
The following inclusion and exclusion criteria were
set for a full text review of findings: All peer-reviewed
reports with dental ndings obtained from full arch ra-
diographs are included, even if there had been additional
clinical examination or patient chart reviews. These re-
ports had to focus on at least one surrogate of “dental
status” or “oral health” (Table 1), whereas reports han-
dling edentulous or partially edentulous patients were
disregarded.
Only articles written in English were included. Stud-
ied cohorts had to be of adult age, respectively the mean
age had to be at least 18 years.
If it was not determinable in the abstract, which kind
of radiography was applied or which variables of dental
status were reported, the article was included to full-text
review.
Excluded was all literature handling radiometric issues
only [i.e., bone density, cephalometric angles of jaw and
joint, subjected to soft-tissues (carotis, lymphal-nodes)]
or focusing on specific teeth/tooth types only (such as
caries in third molars) as well as anthropologic analysis.
Articles were also excluded, if they turned out to report
on the basis of bitewing radiographs or specific single
radiographs to fulll their objective.
Denition of variables of interest
Every previously included paper was reviewed towards
the report of at least one out of the following eight
variables (Ⅰa-Ⅳ), which reflect the surrogates listed in
Table 1. If inclusion was validated, information about: (1)
Bibliography and focus of study; (2) Number of patients
studied and country of origin; (3) Number and kind of
radiographs studied was noted first. Then the materials
and method section (MMS) and results were checked for
the following 8 variables of interest:
Ⅰa: remaining/miss-
ing teeth (also included in DMFT/S);
Ⅰb: implants or
implant-loss; Ⅱa: llings (also included in DMFT/S); Ⅱ
b: decay/caries (also included in DMFT/S); Ⅱc: restora-
tions (i.e., crowns); Ⅲa: root canal treatment; Ⅲb: apical
status; Ⅳ: alveolar bone level on teeth or implants.
These variables were recorded by their mode of re-
port. Further statistical analyses applied to these variables
within the articles were disregarded, due to the differ-
ent focus of the studies. Regarding the application of
these variables, it was noted if additional arrangements,
exclusion or inclusion criteria towards the report were
mentioned by the authors. For example: how to handle
the “third molars”, supernumerary teeth or teeth not de-
picted clearly on radiographs.
If a variable was mentioned in the section “methods”
but not reported, it was mentioned not reported “(NR)”.
If a variable was not mentioned within the method sec-
tion, it was noted as not dened “(ND)”. Furthermore it
was recorded, if the authors applied a special method of
evaluation and how it was described or whom they cited.
A “?” was assigned to indicate an assumption by the
reviewers throughout the data, whenever there was no
clear statement within the context of the article. For lon-
Huettig F
et al
. Reporting of dental status from radiographs
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gitudinal studies, the different comparisons between the
dates of results were not considered, as far as no other
way of report was applied. Information about removable
dentures had been neglected, because these are generally
not allowed to be seen on radiographs at all. If results of
a study or cohort were published twice, rst, the longer
observation period and, secondly, the higher impact fac-
tor in year of publication gave favor for inclusion.
Operationalization of ndings
The report of variables
Ⅰ to Ⅳ was reduced to a simple
logic expression. Every expression, shown in Table 2, can
be translated with the following “keys-words” and abbre-
viations: “ND” or “NR” indicates “not dened” or “not
reported”.
“N” = “number”; “[]” = “of/in”; “()” = “expressed
as”; “/” = “by presenting values”; “,” = “and”; “+” =
“with”; “G” = “in group (s)”; “F” = frequency, “%” =
percentage, “SD” = standard deviation, “Q” = quartiles,
“rg” = range, “al” = “all patients/teeth/surfaces”, “tot”
= “total”, “pat” = “patient(s)”, “grades” = “declared
graduation or scaling of measurements”, “FDP” = “xed
dental prosthesis”.
Variable
Ⅰ refers to “r” = remaining, “m” = missing
or “f ” = lost/failed teeth. Variables Ⅱ-Ⅳ always refer
to affected patients, teeth, lesions, surfaces or sites. Fol-
lowing groups were standardized: age, gender, jaw, tooth-
type, age-group, grades (of a previously dened classi-
cation).
If authors introduce special groupings (i.e., diseased/
healthy, baseline/follow-up and so on), it was abbreviated
“spec” for “special”. This was mandatory due to the dif-
ferent outcome-variables of the studies.
For dental terms following abbreviations were used:
“ABL” = “alveolar bone level/loss”, “apH” = “apical
health”, “RCF” = “root canal filled”, “FDI” = “FDI-
tooth code”, “FDP” = “xed dental prosthesis”.
Two examples of this operationalization: The fol-
lowing expression in the column “Ⅱb Caries/Decay”:
“N[surface](mean, SD)[pat]/G[age, gender]” is translated
to “The number of carious surfaces is expressed as mean
and standard deviation in a patient, by presenting values
in groups of age and gender”.
Another exemplary expression in the column “Ⅲa
RCT” is “N[pat + teeth](F)” translated to “Number of
patients with affected teeth is expressed as frequency”.
Subsumption
All included papers were ordered according to their
objective. Bibliography as well as number and origin of
patients were described by frequency distributions. To
discuss the consistency, the ndings were subsumed for
all papers towards each entity of interest. Therefore cited
methods of radiographic evaluation were full-text re-
viewed, as far as these were written in English or German
and obtainable via library services.
RESULTS
Following Figure 1, thirty-seven studies were evaluated
and can be found in Table 2.
The years of publication of all results are shown in
Figure 2. In whole 27447 (median = 191) X-rays have
been evaluated and reported within 37 studies including
27772 (median = 215) patients. Figure 3 shows the shares
of patients towards their origin. Ninety-four percent of
the patients studied were from United States and Europe.
For nine journals no Impact Factor (IF) was noted
at Journal Citation Report (JCR) of “Web of Knowledge”
(www.webofknowledge.com). The 5-year IF in 2010 of
all JCR-listed and evaluated journals was median = 2.23,
range: 0.89-6.39, SD = 1.16. So the included articles rep-
resent an extract of high ranked journals, regarding an
average IF of about 1.3 (median = 1.2, mean = 1.5) for
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Table 1 Entities of dental status and their surrogates in oral health: Left column notes the entities of dental status, which can be
assessed from a full-arch radiograph
Focused entities Subject of clinical dentistry Surrogate of oral health
Alveolar bone loss, furcation and
vertical bony defects
Periodontology, implantology Periodontitis/inammation, risk of tooth loss
Fillings/inlays Operative dentistry Oral hygiene, caries, decay, risk for massive llings/partial crowns
Massive lling/partial crown Operative dentistry, prosthodontics Risk of root canal treatment, risk for crown-treatment
Crowns and xed dental prosthesis/
pontics
Prosthodontics, periodontology Massive decay (even of healthy teeth), risen risk for caries and
endodontic problems, risk for bone loss and fracture (missing teeth),
missing teeth
Root canal lling and root posts Operative dentistry, endodontology,
prosthodontics
High number of life events of intervention, risk of tooth loss by fracture/
inammation, need for crown
Apical lesion Endodontology, oral surgery High risk of tooth loss, poor root canal treatment, inammation
Missing teeth Prosthodontics, implantology High number of life events of interventions, former inammations,
trauma, hypodontia, malocclussion
Implants Periodontology, prosthodontics Missing teeth, higher risk for inammation (periimplantitis), occlusal
rehabilitation
Edentoulism Prosthodontics, oral surgery High number of life events, no further risk of odontogenic inammation
(caries, periodontitis, apical lesions)
Their possible relation as a surrogate of oral health is shown in the right column. The involved subjects of Dental Medicine are noted in the middle column.
Reading the table from top to down, it has to be considered, that surrogates include content of cells above.
Huettig F
et al
. Reporting of dental status from radiographs

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Table 2 Evaluated articles and encountered mode of report: All full-text reviewed articles are sorted by the year of publication
Ref. Number of X- Ⅰa: Number of teeth Ⅱa: Fillings Ⅱb: Caries Ⅱc: Restorations Ⅲa: RCF Ⅲb: apF Ⅳ: ABL
rays evaluated
Helenius-
Hietala et al[17]
2011b
212 N[r-teeth](mean,SD)[pat] ND N[pat] (mean)/G[spec] ND ND NR mm(mean,SD)/pat;
meanABL[pat]/G[spec];
N[teeth+G[ABL]]
(mean,SD)/G[spec]
Yoshihara et
al[40] 2011a
177 N[r-
teeth](mean,SD)[pat]/
G[spec,gender]
ND ND ND ND ND ND
Andersen et
al[28] 2011b
52 N[r-teeth](mean,SD,
median,Q)[pat]/G(age)
ND ND ND Combined: N[teeth](mean,SD,median,Q)[pat]/G[age];
N[teeth](F,%)[toothtype]/G[age]
ND
Seppänen et
al[18] 2011b
84 N[r-teeth](median,rg)
[pat]
ND N[pat](F,%)[all pat],
G[spec]
ND ND ND N[pat](F)[ND]/G[spec]
Willershausen
et al[9] 2011d
2374? N[r-teeth](mean?)/
G[age,spec], N[m-
teeth](mean)/G[age]
N[teeth](mean,SD)[pat]/
G[spec], N[pat](%)/G[age]
N[teeth](mean,SD)[pat]/
G[spec], N[pat](%)/
G[age]
N[teeth](mean,SD)[pat]/
G[spec]; N[pat](%)/
G[age]
N[teeth](mean,SD)[pat]/
G[spec], N[pat](%)/
G[age]
ND ND
Kirkevang et
al[22] 2009b
470 N[r-
teeth](median,rg)[pat]/
G[age]
N[teeth+1,2,3 surfaces
](median,range)[pat]/
G[age,toothtype]
N[teeth](median,rg)[pat]/
G[age,tooth-type]
ND ND ND ND
Saeves et al[10]
2009d
93 N[m-teeth](mean)[pat]/
G[age,spec]
N[teeth](mean)[pat]/
G[age,spec]
ND “Some” N[teeth](%)[all teeth];
N[pat](F)[spec]
ND ND
Tarkkila et
al[13] 2008b
161 N[r-teeth]
(mean,SD)[pat]/G[spec]
Combined with clinical examination: N[DMFT,DT,FT]
(mean,SD)[pat]/G[spec]
ND NR NR ND
Buhlin et al[49]
2007b
51 N[r-teeth]
(mean,SD)[pat]/
G[spec,all]
N[DMFS](mean,SD)[pat]/G[spec,all];
N[DMFT](mean,SD)[pat]/G[spec,all]
ND ND N[lesions](F,%)[pat]/
G[spec]
N[pat](F,%)/G[grade]
Nalçaci et al[26]
2007d
190 N[r-,m-teeth]
(mean,SD)[pat]/
G[gender,tooth-type]
N[teeth](median,SD)[pat]/
G[gender,all]
N[teeth](median,SD)
[pat]/G[gender,all]
N[FPD](F,%)/
G[gender,jaw]
N[teeth](SD,median)[pat]
N[teeth](median,SD)
[pat]/G[gender,all]
N[teeth](median,SD)[pat]/
G[gender,all]
N[pat](median, SD)[ND
ABL]/G[gender]
Huumonen et
al[3] 2007b
95 N[m-teeth](F)/G[spec] ND N[teeth](F)/G[spec];
N[ndings?](F)/G[spec]
ND N[teeth](F)/G[spec] N[teeth](F)/G[spec]; N[pat](F)/G[spec]
Jansson et al[36]
2006c
191? N[r-teeth]
(mean,SD)[pat]/
G[spec]
ND ND ND ND ND N[pat](F)/G[spec]
Tabrizi et al[11]
2006c
20 N[r-teeth]
(F,mean,SD)[pat]
N[DMFS,DMFT](mean,SD)[pat]/G[spec] Included to DMFT? ND ND ABL(mean)[pat]
Skudutyte-
Rysstad et al[30]
2006d
146 ND ND ND ND N[pat+tooth](F,%)[all];
N[pat]/N[teeth](F);
N[teeth](F,%)/G[spec]
N[pat+tooth](F,%)[all];
N[teeth](F)[grade];
N[pat]/N[teeth](F);
N[teeth](F,%)[all]/G[spec]
ND
Peltola et al[31]
2006a
307 NR via DMFT NR via DMFT
N[pat](F)[DMFT = 0]/
G[spec]
N[lesions](mean,SD)
[pat]/G[spec]
ND N[teeth](mean,SD)[pat]/
G[spec]
N[lesions](mean,SD)[pat]/
G[spec]
NR
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Ma et al[2] 2005a1232 N[pat+m-teeth](%)/
G[tooth-type]; N[m-
teeth](%)[tooth-type]
ND ND ND ND ND ND
Olze et al[14]
2005d
275 NR NR NR ND ND ND ND
Cabrera et al[4]
2005c
1417 N[pat](F)/G[m-
teeth,spec]
ND ND ND ND ND ND
Rosenquist et
al[5] 2005b
452 N[pat](F)[G[m-teeth]/
G[spec]
N[pat](F)[G[m-teeth]/G(spec) ND N[pat](F)[teeth]/G[spec] N[pat](F)[grade]/G(spec)
Montebugnoli
et al[44] 2004c
113 NR via pantomography
index
ND NR via Pantomography
index
ND ND NR NR
Abou-Raya et
al[46] 2002a
50 N[pat+m-teeth](%)/
G[spec]
ND NR via Pantomography
index
ND ND NR via pantomography
index
NR via pantomography
index
Enberg et al[21]
2001a
137? N[r-teeth]
(mean,SD)[pat]/
G[gender,age,spec]
ND N[teeth](mean,SD)[pat]/
G[gender,age,spec]
ND N[teeth](mean,SD)[pat]/
G[gender,age,spec]
N[teeth](mean,SD)[pat]/
G[gender,age,spec]
N[teeth](F,%)[pat]/
G[gender,age-group,spec]
Närhi et al[6]
2000a
396 N[pat+r-teeth]; N[r-teeth]
(mean,SD)[pat]/
G[gender,jaw,spec]
ND N[teeth]; N[teeth]
(mean,SD)[pat]/
G[gender,spec]
ND absN[teeth],
N[teeth](mean,SD)[pat]/
G[gender,spec]
N[teeth],
N[teeth](mean,SD)[pat]/
G[gender,jaw,spec]
N[teeth](mean,SD)[pat,grade]
/G[gender, spec]
Aartman et
al[43] 1999a
211 N[r-teeth]
(mean,SD)[pat]/
G[spec]
ND N[teeth](mean,SD) [pat]/
G[spec]
ND N[teeth](mean,SD)[pat]/
G[spec]
ND ND
Taylor et al[38]
1998b
362 N[r-teeth?](median)/
G[spec]
ND ND ND ND ND N[pat](F,%)[grades]/G[spec,
age-group];
Grau et al[48]
1997c
126 NR via pantomography
index
ND NR via pantomography
index
ND NR via pantomography
index
NR via pantomography
index
NR via pantomography
index
Peltola et al[19]
1993c
990? N[pat](%)[DMFT = 0] N[DMF](mean,SD)[pat]/
G[age]
N[teeth](mean,SD,rg)[pat] ND N[pat](%) N[pat](%) N[pat+ND G[ABL]](F,%)
Hakeberg et
al[33] 1993c
180 N[m-teeth]
(mean,SD,rg)[pat]/
G[spec,gender,age]
N[surfaces](mean,SD,rg)[p
at]/G[spec, gender,age]
N[surfaces](mean,SD,rg)
[pat]/G[spec,gender,age]
ND N[m-teeth]
(mean,SD,rg)[pat]/
G[spec,gender,age]
N[lesions](mean,SD,rg)[pat]
/G[spec,gender,age]
N[lesions](mean)[pat]/
G[grade,spec]
Corbet et al[24]
1992b
165 N[m-teeth]
(mean,SD)[pat]/G[age];
N[m-teeth](%)[FDI]
ND ND N[pontics,cantileve
r,crowns](%)[FDI];
N[FPD](%)[units]; N[uni
ts,retainers](mean,SD)[all
FPD]
ND ND ND
Lindqvist et
al[15] 1989d
50 N[r-teeth](mean,rg)[pat] N[pat+”seriously decayed teeth”](F,%) N[teeth,pat](F);
N[“Inadequate”
RCF](F,%)
N[pat](F)/G[lesions] N[pat](F,%)/
G[“periodontits”];
N[pat?](F)[spec]
Stermer
Beyer-Olsen et
al[37] 1989c
141 ND ND ND ND N[teeth](F), N[pat](F,%) N[teeth,RCF-teeth](F),
N[pat](F,%)
N[pat](F,%)
Grover et al[7]
1982a
5000 N[pat](F,%)/G[m-teeth] Combined for all carious as N[ndings,pat](F,%) ND N[ndings,pat](F,%) N[pat+G[periodontits]](F,%)
Langland et
al[16] 1980b
2921 ND ND N[pat+lesion?](F,%) N[pat+FPD](F,%) N[pat+tooth](F,%) N[pat+lesion?](F,%) N[pat+G[periodontits]](F,%)
Meister et al[25]
1977b
5783 ND ND ND N[pat+FPD](F,%) ND N[ndings](F,%) N[pat+G[periodontits]](%)
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. Reporting of dental status from radiographs

Dental Journals listed in the JCR in 2011.
All modes of report are shown-according to the scheme of operationalization-in Table 2. The following subheadings subsume these ndings and focus on the methodic of
radiographic assessment.
Missing/remaining teeth and implants
Thirty/37 (81%) of all studies reported remaining and/or missing teeth. Four articles intended a report of these values within their material and method section, but did not so. Be-
side mean-and median values, two articial approaches were found: Ma et al[2] reported the prevalence of missing tooth types (rst molars). Other authors gave the number of abso-
lute frequency of missing teeth within their studied cohort[3]. In addition to this the following groupings were found: “< 10 missing teeth”[4], “0, 1-5, 6-14, 15-20, > 20 missing teeth”[5],
“1-7, 8-20, 21-32 teeth”[6], “1-2, 3-5, 6-9, 10-14, 15-20, 21-27 missing teeth”[7], “0, 1-11, 21-12, 22-27, 28-31, 32”[8].
This approach of grouping allowed the authors mentioned above to report only the “number of patients” within their established groups. Before 1990 absolute frequencies
were reported more frequently. Due to the variety of dentition, especially existence of 3rd molars, the problem of report is thoroughly discussed below.
Only 3 articles considered and reported dental implants. That is why this column is not shown in Table 2. The modes of report were: “N[pat + implants](%)/G[age]”[9],
“N[implants](F)[all pat]/G[spec]”[3] and worded “some”[10].
Caries, llings and restorations
Due to the clinical DMFT-index decayed (carious) and lled (restored) teeth are often pooled and mixed up. Six authors did so-three out of these using the DMFT/DMFS-
Index[11-13]. Overall 19 out of 37 papers mentioned to evaluate “carious problem”, “-lesions”, “-teeth” or “defective teeth”. One did not report their announced ndings[14] and
two remained unclear[15,16]. Four authors got more specic towards their assessment by mentioning the following criteria: “deep caries cavities”[17], “carious pulpal exposure le-
sions”[18], “lesions clearly perforating the enamel and clear radiolucencies under old llings were recorded. Enamel caries was excluded”[19], “gross carious lesions … in posterior
teeth”[7].
Pelton et al[20] classied caries lesions within a reliability study of panoramic and periapical radiographs as “C1: radiographically viewed that involved the enamel, but did not
penetrate the dentin; C2: … involved the enamel and the dentin, but not the pulp; C3: … said to involve the pulp”.
Two other authors explained more concrete: “Caries was judged to be present in the radiograph when a clearly dened reduction in mineral content of the proximal, occlusal,
and/or restored surfaces was evident”[6], and “(Caries was) present when the lesion reached the dentin proximally or occlusally or was found at restored surfaces”[21].
Kirkevang et al[22] used a method published by Wenzel[23] described as follows: “A surface was assessed as having a caries lesion if a radiolucency, exhibiting the shape of a
caries lesion and observed at a caries-susceptible site”, and augmented with “extended into dentine; radiolucencies conned to the enamel were ignored”.
In the same article Kirkevang et al[22] gave concrete information about llings: “Registrations were performed on mesial, distal and occlusal or incisal surfaces. Fillings in pits
and ssures in oral and buccal surfaces were not registered”.
Tabrizi et al[11] stated “Restorations and dental caries were also calculated for each participant”, but owes the data by presenting only DMFT-values.
Reporting is also structured by using absolute frequencies of patients with “lesions”[18,19], or “affected teeth” in all patients[3]. In addition to this, following groupings were found: “0,
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Pelton et al[20]
1973d
200 ND ND N[ndings](F)/
G[jaw,spec]
ND ND ND ND
Christen et
al[27] 1967b
1338 ND ND ND “Many ill tting crowns” ND N[pat+tooth](F) N[pat+”gross
periodontits”](F,%)
Lilly et al[8]
1967d
1285 N[pat](F,%)/G[r-teeth] ND ND ND N[teeth](F)/G[tooth-
type]; N[pat,canals](F)
N[teeth](F)G[spec] ND
The date is followed by a discretionary index for the 5 year Impact Factor of the journal in 2010 (a < 1.5; b < 3; c > 3; d: None). Please see caption: Operationalization of ndings in “Materials and Methods” section to decipher con-
tent in columns
Ⅰa-Ⅳ. Column Ⅱb “Implants” is not shown for a comprehensive view and due to the lack of noteworthy reports. RCF: Root-canal-llings; apF: Apical ndings; ABL: Alveolar bone loss; ND: Not dened; NR: Not
reported.
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. Reporting of dental status from radiographs

< 5, > 5 defective teeth”[5], “0, 1-2, ≥ 3 carious lesions”[19].
Restorations were reported six times[9,10,16,24-26], but 2 articles
did insufficiently[10,27]. Within three out of seven articles
restorations, llings and decay were merged[5,11,15].
Root canal llings and apical health
Identification of root canal filled teeth was taken for
granted in 15 out of the 18 papers. Within 3 papers it
was claried in more detail within the MMS as “ongoing
or completed root canal treatment, …, pulp amputa-
tion”, “teeth with pulp amputation, endodontic fillings,
or both”[3,6,21]. One article merged root canal llings and
apical health[28].
Seventeen further articles focused on apical health.
The periapical index (PAI) by Orstavik et al[29] was used
for diagnosis of periapical health by only three authors,
who regarded the PAI-scores 3-5 as positive nding[3,28,30].
For Peltola et al[31] “A radiolucency measuring > 2 mm
in the apical bone was considered to be an apical rarefac-
tion”. Nalçaci et al[26] cited Soikkonen et al[32] method: “A
periapical lesion, interpreted as apical periodontitis, was
recorded if there was a clearly discernible local widening
of the apical periodontal membrane space”. But, this ap-
proach is not described within this referred citation (han-
dling edentulous patients at all). Hakeberg et al[33] divided
“Periradicular destructions … into three different classes
according to size; 1 = pathologically altered lamina dura
and radiolucency less than 2 mm, 2 = radiolucency of
2-10 mm, 3 = radiolucency > 10 mm”[33], and set grade
2 as cut-off for affection. The earliest grading found was
in Lilly et al[8] 1967: “less than 5 mm and 5-10 mm apical
translucency”[8].
The remaining ve articles only mentioned to evalu-
ate “apical radiolucencies”[17], “periapical lesions”[5], with-
out further criteria or mentioning additions like: “radicular
cysts as well as sclerotic periapical lesions indicating con-
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PubMed search in November 2011 using string:
("radiographic study" OR "panoramic") AND ("oral health" OR "dental status"
OR "dental health" OR "dentition") NOT (children OR review OR edentulous)
199 results
144 excluded 55 full text review
15 excluded 37 evaluated
Focuse or age (84) Language (38) Case-report (22) Not available (4)
Dental status not
described by one
of the 4 entities (11)
Age, focus (1)
Duplicate (2)
No report from X-ray (1)
Figure 1 Flow chart of review strategy and nally evaluated articles: The ow chart shows the systematic exclusion of search results towards the nally
evaluated studies. The primary reasons for exclusion are mentioned including the number of concerned articles.
Number of articles
1970 1980 1990 2000 2010
Year of publication
35
30
25
20
15
10
5
Figure 2 Distribution of included and excluded articles: Distribution of
the 37 evaluated (green) and 159 excluded (red) studies of the search re-
sults ordered by their date of publication. Shaded fractions represent the 4
articles which were not available as full text version.
1.4% Finland (9)
0.1% Denmark
0.8% The Netherlands
0.4% Italy
0.7% Turkey
0.2% Egypt
0.7% Japan
62.0%
United States (7)
Norway (3)
8.1%
Sweden (7)
10.3%
Germany (3)
10.3%
5.2%
Hong Kong (2)
Figure 3 Shares of patients in the 37 evaluated studies with respect to the
country of origin: The number of contributing studies is noted in brackets
behind the country. Preponderance of United States is due to two reports of
“mass X-ray evaluation” in the years 1977 and 1982. If these two are left out of
consideration the median value of studied subjects in a paper is 212 (mean =
485).
Huettig F
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. Reporting of dental status from radiographs

densing osteitis”[6,21], or “sign of osteolysis”[12].
Alveolar bone level
The most various methods in assessment and reporting
were found for alveolar bone level.
Metric measurements were used by ve authors[6,7,17,21,33].
In addition to this following groupings were found: “≥ 6
mm, ≥ 4 mm”[17], “> 1-3 mm, > 3-6 mm, > 6 mm”[6], “<
2 mm, 2-4 mm, > 4 mm”[33]. “< 4 mm = moderate peri-
odontitis, > 4 mm = severe periodontits”[7].
To relativize metric measures the following formula
for alveolar bone loss is used: “total bone height divided
by total root length [the distance from the radiographic
apex to the cemento-enamel junction (CEJ)] multiplied
by 100.”, and applied i.e., by Tabrizi et al[11].
Rosenquist[5,12] decided to use a modied criterion of
Lindhe[34]: “< 1/3 of the root length, > 1/3 of the root
length, and horizontal loss supporting tissues, > 1/3 of
the root length, angular bony defects and/or furcation
involvement” which is similar to Nyman et al[35] cited by
Tabrizi et al[11]. Two authors used a relative root length,
but went for an overall approach and added a criterion
for “diseased” via their amount of ndings: “≥ 30% of
the sites with ≥ 1/3 bone loss”[36] and “including one or
more teeth”[37].
Semiquantitative approaches were found specified:
“classied as extension to: (1) to the coronal third of the
root; (2) the middle third of the root; and (3) the apical
third of the root”[18,21]. Graduations apart from thirds
exist also: i.e., as an ordinal scale with ve grades: “0%,
1%-24%, 25%-49%, 50%-74%, or ≥ 75%”[38] or with
only one cut-off point as: “one-fourth or more of the
normal bone height”[37].
A direct measurement of ABL-percentages was de-
veloped by Schei et al[39] and used by only one author[38].
For two authors “A healthy horizontal bone level was
considered to be 2 mm”[21,31]. Huumonen et al[3] graded
into “(1) No bone loss, bone level within 2-3 mm of the
cemento-enamel junction area; (2) Slight bone loss, bone
level at the cervical third of theroots; and (3) Moderate to
advanced bone loss, bone level between the middle third
of the roots at or beyond the apex”[3]. Slightly different
graduation-starting out the same with level 0-Nalçaci et
al[26] continues: “(1) Moderate bone loss, bone level at
the middle third of the roots; (2) Advanced bone loss,
bone level at the apical third of the roots; and (3) Severe
bone loss, bone level at or beyond the apex”, but did not
mentioned a cut-off. So it remains unclear (ND) what the
reported “horizontal bone loss” is intended to be.
In three cases the results were presented with previously
not defined expressions like “periodontal problem”[18] or
undefined graduations like “Slight marginal bone loss …
and vertical bone loss”[19]. The denition lacks what ex-
actly is supposed to mean “affected” in this context. Like-
wise less helpful is a more historical graduation we came
over: “If considerable bone loss was seen, this was called
‘gross periodontal disease’. If there was pronounced ‘ar-
clike’ bone loss limited to the molar and incisor regions,
this was designated as periodontosis”[25].
One methodical article on forensics was coping with
the calculation of DMFT and DFT-Index. They stated
within their material and method section to grade ABL
of 2nd premolars towards the criteria “0, less than half of
first third, up to third of root, more than a third”. But
the ndings were not reported at all[14].
DISCUSSION
The diversity of assessments and report modes is found
to be alarming. The applied search strategy covers only a
small, but high-ranked, sample of articles handling radio-
graphic ndings. It has to be assumed, that diagnosis and
report of the entities studied here are not standardized at
all, as it is for clinical dental status, namely the DMFT-,
CPITN-, PI-, or BOP-Index for example.
In the following, each above mentioned and studied
entity is discussed critically towards assessment and re-
port. Further consequences are subsumed.
Number of teeth and implants
The method to identify teeth from a radiograph is quite
simple. Not so the communication of amounts and values.
Commonly, every time when the descriptive level of
absolute frequencies (i.e., number of affected patients) is
not used, the calculation has to be relative to a standard-
ized data-set (i.e., all patients studied, all patients with
root canal treatment). It gets even more complicated,
if the complete dentition is handled as an entity: When
median-or mean values are used, the calculation base has
to be clear. For the rst: including the third molars to the
calculation, or not? For the second: how to handle miss-
ing or supernumerary teeth? For the third: are edentulous
patients excluded[17,40], or included to the calculation-or
have there been other selection criteria like “at least 15
remaining own teeth”[9]?
Unfortunately this was not clear for 9 out of the 37
studied papers. Twenty-three included, 4 excluded, the
third molars for evaluation. Two articles presented both
approaches. Due to the variety of third molars dental
history (retention, extraction) it make sense-similar to
DMFT Index-to exclude these, if these are not primary
focus of a study. Please follow the subheading “report of
values” below, where more inherent details are addressed.
Against the backdrop of costly dental implants as a
routine therapy after about 40 years now, their presence
in oral status should be reported. Their number can give
not only important dental input, but also ideas towards
the financial background of an individual patient, a
group, a whole cohort or even the social system.
Carious lesions, llings and restorations
The detection of carious lesions within radiographs is
discussed and researched by operative dentistry, foremost.
Searching “detecting caries and X-ray” via Pubmed/Med-
line results around 100 ndings. The denitions used by
the authors studied herein are inconsistent. This is why
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a clear statement which denition can be used as a gold
standard to assess a tooth as affected by caries, would be
favorable. We found the approach of Pelton and Bethart
the most reproducible[20].
As fillings are made from radiopaque resin, cement,
compomer, or metal, these can be easily seen on radio-
graphs. If a restoration material is only slightly radiopaque,
like silicate ceramic, the used adhesive composite or luting
cements is clearly visible. However, the size of restora-
tions can only be guessed, due to the 2-dimensional pro-
jection. But, the amount of decay could be derived from
the ratio of lling and remaining coronal tooth substance.
These remarks are valid for xed restorations (crowns,
pontics) too. For all of these 3 ndings, the mode of re-
port as a comparable number and the report of missing
values has to be standardized.
Root canal llings
Root canal fillings can be recognized just as easily as a
tooth or restoration itself can be, because radiopaque
materials are used around the world very commonly. Two
authors judged the quality of root canal llings[3,30]. If the
quality or length of root canal llings should be regarded
or not, remains to be discussed by endodontologist.
Works about the potential already exist[41]. Furthermore
the existence of root canal posts has to be taken into ac-
count. Some of these are either not radiolucent (Fiber-
posts) or radiopaque and due to their form not possible
to distinct from a perfect root canal lling.
Regarding the reporting mode as frequency or per-
centage is same as discussed for missing/remaining teeth.
Furthermore reporting authors should care about the
problem that the number of teeth is easier to compare
than the number of roots or even root canals. Moreover
the values of root canal treatments should be reported
separately from apical affection(s) of a tooth or root.
Apical health
Beside the controversy of detection capability with peri-
apical and panoramic radiographs (augmented with the
problem: digital vs analog), the key point is to diagnose
the affection in awareness of healthy variations-without
a clinical examination. This is analog to the detection
of caries. The method of the PAI by Orstavik et al[29] is
a good example for standardization and should be used
more often. This 5-grade assessment tool is based on
standardized pictures. It might be most reliable if used
with a cut-off at Grade 3.
Confusing is the usage of “lesion” or “finding” in
contrast to “affected tooth”, because i.e., a lower rst mo-
lar may have 2 apical or carious lesions (mesial and distal),
but is only 1 affected tooth. As for the above-mentioned
root-canal fillings, at this point of time no consensus
could be found. But, we found one possibility for clari-
cation: “For multi-rooted teeth, the root presenting the
highest PAI-score and the quality of the corresponding
root lling was used”[30].
Alveolar bone loss
The “radiographic alveolar bone loss” is one classical
research dimension of periodontology and implantol-
ogy. Thereby it has been of interest for ages-expressed
in hundreds of publications. Thus radiographic assess-
ment of this entity is just as many-faceted. Two general
approaches could be identified: metric measuring and
proportions of bone height towards root length. The lat-
ter might be the better choice due to the variety of root
length by anatomy and radiographic projection. More-
over, approaches including the age dependence of bone
loss are described[42].
Beside bone level, furcation and vertical defects might
be taken into account, too. The authors do not want to
judge, which way is the best. But, even if a standard can
be found in the future, also the cut off values for healthy
and affected shall be dened by the authorities (see caption
“grading and cut-offs”). Until then, the authors find the
relative approach coping with the “rst third of the root”,
described by Nyman et al[35], the most reliable.
Missing values/misinterpretation
Depiction problems of X-rays may lead to missing val-
ues, because it is not always possible to state a nding (i.e.,
the vertical alveolar bone height by overlapped projection
of two teeth, carious lesion at a lling by a “burn out”
artifact). Only 5 papers mentioned depiction problems
right in their material and methods section as follows: “If
the image of the permanent teeth was blurred, supple-
mentary digital intraoral radiographs were taken of these
teeth”[28], “For areas poorly visible in the panoramic
radiograph, intraoral radiographs were made”[6,26,37], “A
tooth was judged as non-measurable if the CEJ or bone
crest could not be identied properly because of overlap-
ping caries or restorations. In cases where any one of the
dental or bony landmarks could not be identied on one
aspect (mesial or distal), the tooth was excluded”[11]. Pro-
jection artifacts may also lead to misinterpretation, which
is mostly ruled out by the use of 2 examiners and/or reli-
ability assurance. Such problems were solved differently:
“In case of disagreement between the observers, their
mean is used in the calculation”[43].
“Only panoramic radiographs that displayed the
whole dentition without asymmetry, distortion or error
in patient positioning were included”[2], “The radiographs
were assessed twice, the rst time by each dentist sepa-
rately and next time by all in cooperation”[10].
One article announced within materials and method
section: “Missing values were registered with suitable so-
called ‘missing values”[9], but-it was true for all articles
above mentioned, these values were not reported.
One of the articles revealed depiction problems while
studying the X-rays and stated: “A total of 54 teeth, most
often maxillary pre-molars, were excluded”[11].
Discussions about sensitivity and specifity of pan-
oramic radiographs were only anecdotal, not concrete.
Montebugnoli et al[44] dropped an important sentence,
which was unfortunately not discussed further or towards
their findings: “Other factors that could affect the out-
comes include differences in the way of measuring …
dental status (the measures used to assess the oral status
seem to be related to the strength and signicance of the
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associations reported)”[44].
Beside this, Langland et al[16] mentioned within their
comparative study in 1980: “Discrepancies in the percent-
ages of periodontal disease may be attributed to variance
in the classication of each disease entity each year ….”[16]
and also Grover et al[7] did so in 1982: “Several discrepan-
cies in ndings … explained by variance … in diagnostic
methods”. One author explicitly complained about the
absence of guidelines and stated: “We found it difcult
to clearly dene what a short root was and how to dene
early obliteration of the pulp. There are no guidelines
in the literature, which dened what is a short root, and
what is obliteration. For that reason it was difficult to
compare our data with earlier studies”[10].
In summary, it has to be pointed out again, that pan-
oramic radiographs can be regarded as sufficient diag-
nosis instrument. During the past 5 years digital imaging
made great strides. But, sufficient comprehensive data
about quality progress is not published yet. Nonetheless,
the assessment of dental findings within a radiograph
is restricted by anatomical deviations of oral structures,
such as dislocation or rotation of teeth. That implies
missing data are common in radiographic based studies-
especially for alveolar bone loss, apical health and caries.
The option of an “indiscernible/unclear” criteria will
reduce bias since rstly, no accidental attribution as “af-
fected” or “healthy” have to take place, secondly an idea
about overall image quality is given.
Such missing values may be handled statistically, but
have to be reported and how these were regarded in cal-
culation.
Report of values: Mean and median, absolute
frequencies and percentages
The number of remaining and missing teeth is reported
most frequently (see caption “missing/remaining teeth
and implants”). But even in this case, comparability is dif-
cult due to the different modes of reporting. 4 authors
decided for the report of median-number, 16 for mean,
6 for absolute frequencies. The same utilization can be
found across the other studied entities: caries, root-canal-
lled teeth, apical lesions and even alveolar bone level.
For the report of frequencies the use of median val-
ues can be assigned as the better choice due to its lower
susceptibility towards extreme single values and the non-
normal distribution of remaining and missing teeth in pa-
tients. To clarify the distribution of data we recommend
the report of both: mean and medium value, augmented
with SD, range and quartiles.
Dichotomization, groups, grades and cut-offs
A grouping of age, ndings, measures are often necessary
for further analyses, especially to calculate odd-ratios or
only to compare such “self-made” groups. Grouping with
a cut-off allows additionally to report absolute and rela-
tive frequencies of teeth or patients, instead of mean or
median values. Examples for the last mentioned would be
“1-10 missing teeth” or “< 20 remaining teeth”. Especially
the rationales behind the cut-offs points are questionable.
Sometimes these are set following previous analysis of the
same sample, such as: “Each group comprised one-third
of the dentate subjects in the baseline study”[6], or “Each
dental index was dichotomized at the mean value”[44]. It
can also be empirical reasons as: “The cut-off point (<
45 and > 45 years) was selected in accordance with the in-
troduction of a new social-security law”[21]. However, cut-
off points for “healthy” and “diseased” varied, especially
if diagnosis of alveolar bone height and apical lesions are
dichotomized for analyses, graphic art and report.
With such intervention to data, these are not univer-
sally valid anymore. Further comparability is hindered, if
the crude data are not available from the paper.
The DMFT and other sum scores
Three authors reported DMFT-values[11-13]. One team
reported only the number of patients (one time as per-
centage, one time as an absolute frequency) with a DMFT
value of zero[19,31]. The DMFT would be helpful for a com-
parison with existing epidemiological data, but it hinders
to extract missing/remaining teeth if only given as a sum
score. If not separated by the author, no more informa-
tion can be extracted from the DMFT; the DMFS is even
worse. Furthermore alveolar bone level and apical health
are not covered within this (exclusively) clinical index.
Within our review other indices could be found: six
authors cited Mattila et al[45]: “Association between dental
health and acute myocardial infarction” and their sum
score of a “Total Dental Index” or “Pantomographic
Index”[6,12,18,46]. This is also cited as panoramic tomogra-
phy score, which is “the sum of radiolucent periapical
lesions, third-degree caries lesions, vertical bone pockets,
radiolucent lesions in furcation areas[47]” and was applied
by Montebugnoli et al[44]. Even if published and cited in
high-ranked journals, we found this system neither com-
prehensible in development nor validated for multipur-
pose application. Its focus is both: infective oral lesions
in a combination of oral and radiographic evaluation as
well as from radiographic assessment itself. Furthermore
the description of index does not contain either meth-
ods of oral nor radiographic assessment for its entities.
Despite of this fact, the sum of total dental index (TDI)
can reach values “between zero and 10”[45]. Nevertheless,
the scale of this cited index varies between publication
due to modification by the authors: “0-14”[48], “0-8”[49],
“0-10”[18,50], 0-15[6]. Seppänen et al[18] used a classication
of the sum scores “good, moderate and poor” which
was not established by Mattila et al[45] 1989 as cited in this
very article. Montebugnoli et al[44] decided to dicromize
“each dental index … at the mean value”. Buhlin et al[49]
separated the index according to the statement “TDI of
0 or 1 are considered to have good oral health and those
with TDI 4-8 have poor”. Especially these inconstan-
cies left this tool highly questionable. However, further
investigation is needed for a concluding evaluation of
this approach. Beside, and discussed for the DMFT, a
sum score-with such complexity of terms-might not be
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useful for report. Foremost because, the values of each
contained entity are not given to the reader and for future
comparison.
Limitations of this report
This report is only based on articles indexed at PubMed/
Medline. The variety of applied approaches was expected
to grow if further databases (i.e., EMBASE or MED-
PILOT) are searched. Although this might harden the
presented conclusion, it would not rise the informative
content of this report.
Detailed information about type of X-ray and lms
used as well as acts of calibration of examiners was not
included to this review. We took into account, that jour-
nal reviewers have already checked the applied interven-
tion and found these appropriate. Furthermore, the wide-
spread use of dental radiographs implies standardization
on a reasonable level and quality. Findings in adults were
favored, due to the variety of radiographic studies and
dentition in children and adolescents. The variety of the
mixed dentition is in fact a problem of standardization.
The authors are aware that for every entity studied within
this review, hundreds of other articles exist and there
might be even standards scientists agree on. But, this can
only be figured out by further systematic reviews-one
for each entity and a nal harmonization in a reporting
guideline. Such a general guideline would support the
authors preparing their studies and manuscripts as well as
the scientists to compare data.
Only one article covered all entities studied in this re-
view[26]. Nevertheless, all researches would have been en-
abled to report all these entities. Evidently it is often not
of interest to report about i.e., alveolar bone loss while
presenting results about the prevalence of apical lesions.
Nonetheless, such data would contrast and illustrate nd-
ings by thorough information about the studied cohort.
More accompanied information could be conveyed about
dental status of studied subjects. Thus, comparability and
multi-variate analyses would be simplied generally. The
authors think it would be worthwhile to have an easy re-
porting system of all entities. Today’s possibilities to pro-
vide such data digital via online publication would enable
authors and publishers to share data without expensive
printed pages.
There are established but not generally accepted and
enforced standards to assess and report ndings from ra-
diographic surveys. Thereby comparability of published
ndings is only possible with chief limitations. There is
need to agree on standardized assessment and diagnosis
first, and about the mode of report secondly. An easy
and validated multi-term report-system of dental status
would allow a widespread application, especially for den-
tal public health and epidemiology. In consequence: there
is need for a reporting guideline.
COMMENTS
Background
Reporting standards are necessary to compare research outcomes especially
in medical science. Full-mouth radiographic surveys allow information about the
dental status. These are: number of teeth, caries, llings/restorations, root canal
treatments/lling, apical health and alveolar bone loss. But ndings have to be
evaluated and reported in such a way, that a comparison between published
results is possible. There is no reporting guideline, yet. Which mode of report
could be proper is neither nally discussed nor published. The paper shows
shortcommings in current acquisition and presentation of data, hereinafter it
recommends suitable methodical approaches.
Research frontiers
Dental radiology, epidemiology, research methodology in dentistry and medical
statistics for oral health variables.
Innovations and breakthroughs
Only 8 out of 37 scientically papers are at the maximum comparable towards
3 out of 7 entities of dental status. Evaluation of radiographs differ is widely.
Reporting with statistical tools like mean and median or grouping and dichoto-
mization did not allow further comparison, due to a lack of raw data. Also sum
scores or indices like Decayed, Missing and Filled Teeth (DMFT) impede com-
parability of data. Thus no standard could be identied. Besides, missing values
are underreported.
Applications
A guideline of standards for evaluation, report and cut-off points is needed. So
far it can be advised, that: (1) depicting problems and resulting missing values
are reported; (2) it must be stated, if third molars are included or not when re-
porting the number of missing or remaining teeth; (3) implants should be taken
into account; (4) sum scores are only present with crude data of the study. In
case of DMFT the decayed teeth, missing teeth, lled teeth and decayed and
lled teeth should be given separately, too; (5) apical health should be evalu-
ated with a validated tool preferably the Peri-Apical-Index; (6) alveolar bone
loss should be evaluated and reported in exact percentage or “in thirds” (Lindhe)
not in absolute millimeters; (7) all distributions of data are presented with mean
and medium value, augmented with SD, range and quartiles; and (8) the reader
is given the rational for grouping or a cut-off point if data is dichotomized.
Terminology
“Full-arch radiographs” are radiographs taken mostly in dental ofce and de-
picting all teeth (including the complete root) of a human dentition. Mostly a so
called “panoramic radiograph” is taken; but also a survey with intraoral radio-
graphs can be applied. “Apical health” describes the situation around the tip of
the tooth root inside the bone of the jaw. This area might be retreat for bacteria
causing a painless infection, which is relevant for systemic health and inam-
mation parameters. Such infections can be detected by radiographs. “Alveolar
bone loss” describes the loss of jaw bone around teeth. The amout of lost bone
correlates with the infection of tissues around teeth, which is a multifactorial
disease promoted by bacteria. As seen in the radiograph the occurrence of a
a so called “periodontitis” (inammation of the gums) can be anticipated by the
loss of bone. “DMFT” is the World Health Organization-standard to report a
clinically assessed dental status. It is namely the sum of Decayed, Missing and
Filled Teeth in a dentition. “Reporting guideline” is a standardization for scien-
tic reporting of ndings. Today many such guideline exists in Medicine (www.
equator-network.com).
Peer review
It is a well organized and written paper.
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564 October 16, 2014
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Huettig F
et al
. Reporting of dental status from radiographs

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