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J Oral Rehabil. 2020;00:1–7. wileyonlinelibrary.com/journal/joor
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1© 2020 John Wiley & Sons Ltd
1 | INTRODUCTION
Cone-beam computed tomography (CBCT) examination of the tem-
poromandibular joint (TMJ) has become a recognised tool in case
of suspicion for the presence of osseous changes, after a thorough
history and clinical examination of the patient. CBCT images provide
high spatial resolution in three-dimensional (3D) images, which is de-
sirable in diagnostics and treatment of temporomandibular disorder
(TMD). Of ten, its diagnostic accuracy and reliabilit y are bet ter than
that of two-dimensional (2D) images.1 CBCT provides comparable
diagnostic accuracy with a relatively lower radiation dose and cost
compared with medical computed tomography (CT)2-4 and, at pres-
ent, is considered the technique of choice for evaluating osseous
changes of the TMJ.5
Researchers in the International Network for Orofacial Pain and
Related Disorders Methodology (INfORM; formerly, the International
Received: 23 April 2020
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Revised: 13 Jul y 2020
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Accepted: 27 Ju ly 2020
DOI : 10.1111 /jo or.13 065
ORIGINAL ARTICLE
Web-based educational programme for temporomandibular
joint assessment with cone-beam computed tomography
Durer Iskanderani1,2 | Per Alstergren3 | Ewa Carin Ekberg3 | Xie-Qi Shi1,4 |
Kristina Hellén-Halme1
1Depar tment of O ral and Maxillof acial
Radiol ogy, Facult y of Odontology, Malmö
University, Malmö, Sweden
2Depar tment of O ral and Maxillof acial
Radiol ogy, Facult y of Dentistry, King
Abdulaziz University, Jeddah, Saudi Arabia
3Depar tment of O rofacial Pain and Jaw
Function, Facult y of Odontology, Malmö
University, Malmö, Sweden
4Divisio n of Oral Ma xillofacial Radiolog y,
Depar tment of Clinical Dentis try, Facult y
of Medicine, University of Bergen, Bergen,
Norway
Correspondence
Durer Iskanderani, Department of Oral
and Maxillofacial Radio logy, Faculty of
Odontology, Malmö University, Malmö SE-
205 06, Swe den.
Email: durer.iskanderani@mau.se
Funding information
King Abdulaziz University
Abstract
Objectives: To develop and evaluate an educational web-based programme for tem-
poromandibular joint (TMJ) assessment using cone-beam computed tomography
(CBCT).
Methods: A web-based educational programme was designed for TMJ assessment
using CBCT images. Fifteen CBCT cases of the TMJ (three-dimensional reconstructed
volumes) and an assessment module based on image analysis criteria in the Diagnostic
Criteria for Temporomandibular Disorders (DC/TMD) were added to the programme.
Thirty-six undergraduate dental students were invited to test the programme by as-
sessing all cases twice: before and after 2 months of training. Participants submitted
written subjective evaluations of the programme.
Results: The web-based programme can be accessed on Malmö University webpage
(www.cbct-tmj.mau.se). Despite limited CBCT learning in their undergraduate train-
ing and not using the programme in the 2-month interval, the students were able
to correctly diagnose 80% of the cases at the second assessment. Their diagnoses,
however, did not differ significantly from the first assessment. Overall, the students
were satisfied with the programme and considered it user-friendly.
Conclusion: The web-based educational programme that was developed in the pre-
sent study and tested by dental students could be a useful educational tool for TMJ
assessment using CBCT.
KEYWORDS
cone-beam CT, education, temporomandibular joint, training programme
The pee r review histor y for this arti cle is available at h ttps://publo ns.com/publ o n/10.1111/joor.13065 .
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ISKANDER ANI Et Al .
RDC/TMD Consortium Network) developed the Diagnostic Criteria
for TMDs (DC/TMD) in order to standardise the diagnosis of TMD
globally.6 These criteria have been widely accepted and used as a
valid diagnostic tool for most common conditions of oro-facial pain
and jaw dysfunction. In clinical and research settings, the DC/TMD
allows for identification of patients with a range of simple to complex
TMD presentations.7 Along with DC/TMD, Ahmad et al8 reported
comprehensive and reliable image analysis criteria for assessing the
TMJ, which describe the soft and hard tissue changes that may occur
in the TMJ.
Rapid advances in digital and web technologies, and their use in
education, have focused attention on alternative methods of educa-
tion. Thus, a web-based approach has become a feasible and prac-
tical form of learning. Besides allowing choice of time and place of
learning, web-based approach provides learners with an interactive
self-learning tool.
The application of CBCT imaging in dental practice is increas-
ing; consequently, it raised a demand for more education about this
technique. Studies on pre- and/or post-doctoral dental education
using CBCT imaging reported some gaps; one of them was image
interpretation.9,10 Thus, a web-based learning programme on CBCT
interpretation might be an efficient and practical way to increase
the knowledge and adjunct the educational process. Several studies
have emphasised the advantages of web-based learning in dental
education.11-13 Howerton et al14 reported similar learning outcomes
between computer-assisted and conventional learning methods with
the computer-assisted method being preferred by students.
Various CBCT online training programmes are available to support
dental education in radiology, and they are useful and show high ef-
ficacy in delivering knowledge.15 -18 Our research team recently pub-
lished a training programme on the detection of TMJ osseous changes
using predefined 2D multiplane CBCT reconstructions.18 Thus, the
purpose of this study was to develop and evaluate the usefulness of a
web-based educational programme for TMJ assessment using CBCT.
2 | MATERIALS AND METHODS
2.1 | Radiographic examination
Fifteen CBCT cases of the TMJ were retrieved, to meet the scope
of the study, from the Faculty of Odontology database at Malmö
University, Malmö, Sweden. The CBCT volumes were acquired with a
Veraviewepocs 3D F40 scanner (J. Morita Corp., Kyoto, Japan) using
the manufacturer's recommended scanning protocol (90 kV, 5 mA, and
9.4 s). All images were exposed with a 40 × 40 mm field of view, 180°
rotation, and reconstructed with a voxel size of 0.125 mm, 1 mm slice
thickness and 1 mm slice interval. For each case, the three orthogo-
nal volumes (axial, coronal and sagittal) were exported separately and
then imported to the Synedra image viewer (Synedra Information
Technologies, Innsbruck, Austria). In the viewer, all cases were an-
onymised and the image stacks were converted to the JPEG file format
in order to be compatible with web browsers.
2.2 | Study participants
Thirt y-six undergraduate dental students in their final year at the
Faculty of Odontology, Malmö University were recruited to this
study. None of the students had previous training in interpretation
of CBCT images of the TMJ.
2.3 | Radiographic assessment
The assessment module for the TMJ osseous changes was struc-
tured according to DC/TMD image analysis criteria.8 The mod-
ule describes the criteria in the following sequence: changes in
the condylar head, the articular eminence and condylar position.
Assessment of the condylar head involves observing gross hypo-
plasia or hyperplasia, flattening of the ar ticular surface, any subcor-
tical sclerosis or cysts, surface erosion, osteophy tes, generalised or
subcortical sclerosis, loose joint body, deviations in form and bony
ankyloses. Assessment of the articular eminence involves observ-
ing flattening of the articular eminence, subcortical sclerosis and
surface erosion. For the condylar position, assessment involves de-
termining whether the joint condyle is in an anterior, posterior or
centric position with normal or reduced joint space. One of three di-
agnoses is then set: no degenerative joint disease, indeterminate for
degenerative joint disease or degenerative joint disease (Table 1).
2.4 | Programme development
The web-based programme was designed with the help of profes-
sional web designers using three open-source web frameworks:
Laravel, React/Redux and d3. The bulk of the programme was built
using the PHP-based Laravel framework to implement back-end
functionality (eg user accounts, application programming inter face
endpoints and database and content management) as well as front-
end user and admin HTML pages.
The case assessment pages were developed using JavaScript li-
braries: for the user interface—Reac t, as the web framework; and
for state management—Redux. The pages were built as a single-page
JavaScript-driven application with no page reloads bet ween
cases, rather than as a series of separate HTML pages. Each case
is presented on a separate screen. The CBCT examination screen
(Figure 1A) presents a series of high-resolution JPEG images for each
of the three volumes, similar to what would be viewed in the clinical
situation, while keeping bandwidth requirements and loading times
low. The assessment module allows only dichotomous responses,
presence/absence for each criterion. After assessing all criteria,
users must set a diagnosis to proceed to next c ase. User instructions
and list of the assessment criteria can be accessed via a button at
the bottom of each case screen and when the curser points to a cri-
terion or diagnosis, an explanation appears in a window to the left
(Figure 1A). Reference findings were compiled through consensus by
a team of three senior specialists in oral and maxillofacial radiology,
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ISKA NDERA NI Et Al.
each with more than 10 years of experience in evaluating TMJs on
CBCT images. A final programme feature used JavaScript library d3
to build an interactive matrix, which was based on all responses to
the cases compared with reference findings. It describes user per-
formance at the end of all cases for user learning (Figure 1B).
The administration page was designed to give the authors con-
trol over the programme setup with safeguards for guaranteeing data
integrit y. The programme was divided into four phases, which the
authors unlocked successively via the administration page; thus, limit a-
tions were placed on the users, to mitigate the risk of manual mistakes.
2.4.1 | Phase I: Preparation
An online account for each study participant was created, and radio-
graphic images for each case were uploaded to the programme. Each
time a user started the programme, and the cases were presented in
a new, randomised order with all personal, clinical and radiograph-
related data anonymised. None of the cases could be related to an
underlying disease or malignancy, and they covered a wide range of
osseous changes in the TMJ; some healthy cases were also included.
The programme was designed to lock all website elements after a user
started the programme to guarantee data consistency.
2.4.2 | Phase II: The first assessment and training
One author (DI) introduced participants to the web-based programme
in an oral presentation using case examples and illustrations to de-
scribe the design of the programme, how to use it, and the criteria
for diagnosing osseous changes in the TMJ. Participants were then
assigned login credentials and asked to make a first assessment of
the programme. All participants evaluated the cases independently
on their own computers. Case assessment was not time limited, and
responses were saved in real time on a remote server, which let the
participants exit the programme and resume at any time.
When participants had finished their assessment of the cases,
they were shown the interactive results matrix (Figure 1B). By clicking
on a response in the matrix, they could see the case and compare their
response with the reference findings. In the 2 months following this
first assessment, participant s were allowed to use the programme to
train diagnoses of osseous changes in the TMJ whenever they chose.
TABLE 1 The criteria and diagnoses used in the web-
based programme for assessing osseous changes of the
temporomandibular joint on cone-beam computed tomography
images; structured according to Ahmad et al8
Criteria/number of cases for each criterion according to the
reference standard
Condylar head
1. Condylar hypoplasia: condylar morphology is normal but the
size is small from all dimensions. This is associated with either an
increase in the joint space in a normal articular fossa or a small
articular fossa/0.
2. Condylar hyperplasia: condylar morphology is normal but the size
is large in all dimensions. This is associated with either lack of joint
space in a normal articular fossa or an enlarged articular fossa to
accommodate the large condyle/0.
3. Articular surface flattening: a loss of the rounded contour of the
su rfa ce /6.
4. Subcor tical sclerosis: any increased thickness of the cortical plate
in the load-bearing areas relative to the adjacent non-load-bearing
areas/4.
5. Subcor tical cyst: a cavity below the articular surface that deviates
from normal marrow pattern/6.
6. Surface erosion: loss of continuit y of articular cor tex/10.
7. Osteophyte: marginal hypertrophy with sclerotic borders and
exophytic angular formation of osseous tissue arising from the
su rfa ce /6.
8. Generalised sclerosis: no clear t rabecular orientation with no
delineation bet ween the cortic al layer and the trabecular bone that
extends throughout the condylar head/3.
9. Loose joint body: a well-defined c alcified structure (s) that is not
continuous with the disc or osseous structures of the joint/1.
10. Deviation in form: condylar deviation in form is def ined as a
departure from normal shapes, such as concavity in the outline
of the cortical plate, and not attributable to flattening, erosive
changes, osteophytes, hyper or hypoplasia/3.
11. Bony ankylosis: continuous osseous structure between the
condyle and temporal bone associated with no discernible joint
space and no translation of the condyle in the open mouth views/0.
Fossa/eminence
12. Articular surface flattening: a loss of the rounded contour of the
su r f a c e/ 7.
13. Subcor tical sclerosis: any increased thickness of t he cortical
plate in the load-bearing are as relative to the adjacent non-load-
bearing areas/7.
14. Surface erosion: loss of continuity of cortical margin/8.
Condylar position
15. Concentric position with normal joint space/7.
16. Concent ric position with decreased joint space/4.
17. Anterior position/3.
18. Posterior position/4.
Diagnosis/number of cases for each diagnosis according to the
reference standard
A No degenerative joint disease/3
i. Normal relative size of the condylar head; and
ii. No subcortic al sclerosis or articular surface flattening; and
iii. No deformation due to subcortical cyst , surface erosion,
osteophyte, generalised sclerosis or loose calcified bodies.
B Indeterminate for dege nerative joint disease/1
(Continues)
i. Normal relative size of the condylar head; and
ii. Subcortical sclerosis with/without articular surface flattening; or
iii. Articular surface flattening with/without subcortical sclerosis;
and
iv. No deformation due to subcortical cyst, surface erosion,
osteophyte, generalised sclerosis or loose calcified bodies.
C Degenerative joint disease/11
i. Deformation due to subcor tical c yst, surface erosion, osteophyte,
generalised sclerosis or loose calcified bodies.
TABLE 1 (Continued)
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ISKANDER ANI Et Al .
2.4.3 | Phase III: The second assessment
At the 2-month follow-up, participants were asked to make a second
assessment of all cases in the programme.
2.4.4 | Phase IV: Going public
Following an acceptable user assessment, we opened the programme
to the public. In this phase, users did not need to sign up for an account.
2.5 | Programme evaluation
At the end of Phase III, the participants were asked to subjectively
evaluate their experience of using the programme on a form. The
questions concerned accessibility, design, radiographic image quality,
the results matrix, knowledge gained and the web-based learning ap-
proach as a teaching method (Table 2). Responses were made using a
5-point Likert scale: 1 = extremely satisfied, 2 = moderately satisfied,
3 = neutral, 4 = moderately unsatisfied and 5 = extremely unsatisfied.
2.6 | Statistical analysis
The web-based programme stored the results of each participant on
a Microsoft Excel 2016 spreadsheet. The Statistical Package for the
Social Sciences (IBM SPSS, version 23 for Windows) was used to ana-
lyse participants’ diagnostic performance and subjective evaluation of
the programme. The changes in the diagnosis responses between the
first and second assessments were analysed using the Sign test19 with
the level of significance set to 0.05.
3 | RESULTS
A web-based educational programme for the assessment of TMJ
osseous changes in CBCT images, based on the DC/TMD image
analysis criteria,8 was developed and can be accessed on Malmö uni-
versity webpage (www.cbct-tmj.mau.se). The programme consist s of
15 TMJ cases presented as 3D reconstructed CBCT volumes, along
with the assessment module (Figure 1A).
Figure 2 presents the overall percentage of participants’ correct
diagnosis response for all cases, at the first and second assessments.
Figure 3 shows the changes in overall percentage of correct diag-
nosis responses between the two assessments, for all par ticipants
and cases. In most cases, the diagnostic performance improved;
however, the differences in correct diagnoses between the two as-
sessments (76% at assessment 1 and 80% at assessment 2) were not
significant (P = 0.1-1.0).
Table 3 presents participants’ evaluation of the web-based pro-
gramme. In general, more than 90% of the participants were mod-
erately or extremely satisfied and thought that the programme was
easy to access and had a user-friendly design, while more than 65%
were moderately or extremely satisfied with the radiographic image
quality and results matrix. Seventy-six per cent of the participant s
were moderately or extremely satisfied with the knowledge gained
after using the programme and with its value as a learning tool.
FIGURE 1 A screenshot of the web-based programme for temporomandibular joint interpretation on cone-beam computed tomography
images (CBC T). A, case assessment page showing the reconstructed 3D CBCT images (sagittal, coronal, and axial) and the list of assessment
criteria; when the cursor points to a criterion or a diagnosis, an explanation appears in a window to the left. B, User result matrix that
compares user and reference responses for all cases
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ISKA NDERA NI Et Al.
4 | DISCUSSION
When investigating volumetric CBCT images, the observer can scroll
through the entire volume in many viewing plans in order to visualise
the image data set and answer a clinical question. Thus, the images
provide ex tensive and detailed information. Therefore, a thorough
knowledge of CBCT anatomy, anatomic variations, tissue abnormali-
ties and pathologies is prerequisites to CBCT image interpretation,
which is not commonly part of general dental education.
Recently, we devel oped a training pr ogramme that describes TM J
osseous changes but incorporated predefined 2D multiplane CBCT
reconstructions. General dental practitioners who participated
TABLE 2 Form for evaluating how participants experienced the web-based programme
Level of satisfaction
Extremely
satisfied
Moderately
satisfied Neutral
Moderately
unsatisfied
Extremely
unsatisfied
1. The programme contents were easy to
access.
○ ○ ○ ○ ○
2. The programme's design was well-
organised and user-friendly.
○ ○ ○ ○ ○
3. Image resolution was high and the
anatomical landmarks were clearly visible.
○ ○ ○ ○ ○
4. The results matrix was understandable and
made it easy to track the answers.
○ ○ ○ ○ ○
5. The programme challenged your previous
knowledge in such a way that your
understanding was widened.
○ ○ ○ ○ ○
6. The web-based learning approach makes
learning faster, easier and interactive
(accessible anytime, anywhere).
○ ○ ○ ○ ○
FIGURE 2 The overall percentage of
participants’ correct diagnosis response,
for all cases at each assessment
FIGURE 3 The changes in overall
percentage of correc t diagnosis responses
between the two assessments for all
participants
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ISKANDER ANI Et Al .
in the previous programme reported the programme to be helpful
training material.18 Its limitation, however, was the use of predefined
2D images instead of the entire CBCT volume. Thus, the present
project was to resolve this limitation by developing a pedagogical
web-based programme for CBCT interpretation of the TMJ using
3D reconstructed images that mimic the clinical situation with the
ability of the obser ver to scroll though the volume in 3D plans. This
interpretation was based on the recommendation of INfORM6; that
(the DC/TMD) has been recognised as a standardised and valid diag-
nostic tool for TMDs. The goal of the present study was to develop a
comprehensive, self-learning and interactive platform for the inter-
pretation of degenerative joint disease using the CBCT examination
as an educational tool. It was proposed to be useful to anyone inter-
ested in the subject such as a general clinician, under or postgradu-
ate dental student, or specialist for training, calibrating an observer
and/or increasing knowledge about the subject.
The web-based training approach provides ease and flexibility of
learning so that users are unlimited in time and place of learning. The
presented programme can be used on a range of devices, including
laptops, iPads/tablets and smartphones. Also, it has the advantages
of knowledge deliver y in multiple formats (eg 3D images and inter-
active assessment modules), and storage of results between learning
sessions to enable tracking of performance (ie the user can pause the
programme and continue at any time). Thus, this programme could,
in a long run, reduce ef fort, cost and time of the teaching process.
Mitov et al13 recommended the online dental learning approach as a
valuable tool for self-learning. The Clark12 study suggested that in-
corporating the web-based learning approach into dental education
would be beneficial.
To develop a learning tool, we believe that using recognised cri-
teria, based on evidence from well-conducted researches, is bene-
ficial. Since the criteria are valid and reliable tool and are accepted
internationally, therefore, it could help to provide knowledge in a
standardised way. Hellen-Halme et al20 and our research team in
the previous study18 reported the usefulness of using Ahmad et al8
criteria. Both teams assumed that it could increase the diagnostic
outcome among obser vers for magnetic resonance imaging (MRI)
and CBCT evaluations of the TMJ, respectively. Our results showed
good participant performance in the assessment module. One cri-
terion, ‘deviation in form’, was poorly understood and affected the
diagnostic response in case # 7 (Figure 3). Perhaps, it was being con-
fused with other condylar changes in form. A similar situation oc-
curred in the previous 2D training programme.18
All students in their final year were invited; however, the re-
sponse rate was 61%, with only 5 of 36 participants have done
some training. The assessment session was designed to be one hour
at most, and therefore, the number of cases was limited to 15. We
believe that evaluating radiographs for more than an hour can be
tiring, and thereby, the results would be affected. Prior par ticipants’
knowledge of CBCT interpretation was limited as little involvement
of CBCT imaging during undergraduate dental education. Thus, a
thorough oral presentation was delivered to them. However, when
the programme opened to the public, user instructions and a de-
scription of the diagnostic criteria were provided. The participants
were correct in their diagnosis by 76%, which is a good performance
at the first assessment and could indicate that the programme is
understandable. A similar performance was observed in the second
assessment by 80% correct diagnosis, which could suggest that they
reasonably grasp the presented knowledge without a noticeable im-
provement; therefore, they may need more practice. Hellen-Halme
et al20 developed a comparable web-based programme for examin-
ing soft tissue changes in the TMJ using MRI and following Ahmad
et al8 criteria.
During a case assessment, the participant can enlarge the 3D recon-
structed volumes by clicking on the lower right corner of the selected
plane as well as scrolling through the volume (Figure 1). We think that
our programme presents cases in a well-organised manner with an in-
teractive portion and was easy and time-efficient. These reasons could
explain the overall encouraging attitude of the participants towards
the programme. They appreciated the web-based learning method and
were satisfied with the contents of the programme. The participants
were, however, less satisfied with the results matrix. A web-based pro-
gramme for anatomical interpretation in maxillofacial CBCT images
showed comparable results for the participants’ performance after
using the programme with a highly positive perception.16,17
A limitation of this study was that the authors have developed
and evaluated the programme according to their knowledge of TMD.
In addition, not all DC/TMD image analysis criteria were represented
in the programme's cases. However, the satisfaction of most of the
participants can be a strength.
TABLE 3 Students subjective evaluation of the web-based programme for diagnosing osseous changes of the temporomandibular joint
on cone-beam computed tomography images (n = 36 undergraduate dental students, after the second assessment)
Extremely satisfied
(%)
Moderately satisfied
(%) Neutral (%)
Moderately unsatisfied
(%)
Extremely
unsatisfied (%)
Accessibility 53 45 2 - -
Design 67 26 7 - -
Radiographic image quality 45 29 24 2 -
Results matrix 26 38 19 10 7
Knowledge gained 33 43 17 7 -
Web-based learning
approach
40 36 17 5 2
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ISKA NDERA NI Et Al.
The present study, in line with several previous studies, points
out numerous benefits of the web-based learning approach. In ad-
dition, it shows that similar educational materials could be advanta-
geous for the education of radiographic interpretation.
5 | CONCLUSION
The web-based educational programme that was developed in the
present study and tested by dental students could be a useful edu-
cational tool for TMJ assessment using CBCT.
ACKNOWLEDGMENTS
The authors thank Daniel Dunér and Jonatan Alvarsson for their
work in developing the web-based programme. This study was fi-
nancially supported by King Abdulaziz University.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.
ORCID
Durer Iskanderani https://orcid.org/0000-0001-5593-0553
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How to cite this article: Iskanderani D, Alstergren P, Ekberg EC,
Shi X-Q, Hellén-Halme K. Web-based educational programme
for temporomandibular joint assessment with cone-beam
computed tomography. J Oral Rehabil. 2020;00:1–7. ht t p s :// do i .
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