International Endodontic Journal (1997) 30, 115123

Periapical radiolucencies as evaluated by bisecting-angle and paralleling radiographic techniques

J. F O R S B E RG & A . H A L S E
Department of Oral Radiology, School of Dentistry, University of Bergen, rstadveien 17, N-5009 Bergen, Norway

Summary
Two groups of patients were included in the study. The rst group consisted of patients who received root canal treatment of single-rooted teeth (n=63). The completed roof llings were exposed to two different radiographic techniques, the paralleling and the bisecting-angle technique. The second group consisted of 1-year review radiographs of patients who had received apicectomies of single-rooted teeth (n=105). Three observers examined the radiographic images. First, they were asked to identify teeth with a normal apical condition and those with an apical radiolucency. Thereafter pairs of radiographs were compared; cases judged as normal by all observers were excluded. The observers were now asked to ascertain whether the apical radiolucency was largest in the rst image, the apical radiolucency was largest in the second picture or both radiolucencies were the same size. Both intraobserver and interobserver agreement, calculated as Cohens kappa, was high with respect to the presence of lesions within both samples and it was at the same level for both radiographic techniques. The evaluation of the size of the lesions proved to be more inconsistent. Kappa values were in the range 0.380.71 for intraobserver comparisons and in the range 0.250.48 for interobserver comparisons. No signicant difference was found between the size of lesions as recorded by the two techniques (P > 0.05). It is concluded that, when correctly adjusted the bisectingangle technique and the paralleling technique provide similar diagnostic results. Keywords: dental radiology, endodontics.

dento-alveolar region the paralleling or the bisectingangle technique may be used. Earlier, the use of the bisecting-angle technique was most predominant, while the paralleling technique has come into more widespread use during the last 20 years. Clinical experience seems to be the main factor inuencing the choice of technique, but some comparative research data is available. For the diagnosis of caries, for example, the techniques have been compared (Leijon & Marken 1968, Tveit et al. 1991) and there is a tendency for the paralleling technique to give the most accurate results. The same nding has been made for the diagnosis of alterations in the marginal periodontium (Sewerin et al. 1987, Hausmann et al. 1989, Jenkins et al. 1992). For alterations of the pulp and the apical periodontium there are less data available. Studies on recorded tooth length as well as on working length and root lling length (Van de Voorde & Bjorndahl 1969, Bhakdinaronk & Manson-Hing 1981, Forsberg 1987a,b,c) have generally concluded that the paralleling technique is preferable. The effects of the radiographic technique upon the depiction of periapical pathology have not been thoroughly investigated. In a recent laboratory study (Forsberg & Halse 1994) clear indications were found that the paralleling technique provided the most valid information about the extent of the periapical, pathological process. The aim of the present study was to compare the value of the two techniques for the diagnosis of changes in the periapical region under clinical conditions.

Material and methods Selection of patients and radiographic techniques

Introduction
For the radiographic diagnosis of problems within the
Correspondence: Dr J. Forsberg, Department of Oral Radiology, School of Dentistry, University of Bergen, rstadveien 17, N-5009 Bergen, Norway.
1997 Blackwell Science Ltd

Two different groups of patients were included in this study. The rst group consisted of patients who received root canal treatment in the Department of Cariology and Endodontics, School of Dentistry, University of Bergen. The completed root lling was examined radiographically using two different techniques. Before the rubber 115

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J. Forsberg & A. Halse 1 The periapical radiolucency was largest in the rst image 2 The periapical radiolucency was largest in the second image or 3 Same size of radiolucencies or no radiolucency was present in any image. Again this examination was repeated after 4 weeks. When the observer selected the same group twice, this decision was used as the nal grouping. In cases with intraobserver disagreement a third reading was performed. In eight cases (two in the root canal treatment and six in the surgery group) the observers had disagreed completely with one another (used all three alternatives). These cases were excluded from that part of the study that dealt with comparison of the projection techniques. The intra- and interobserver performance was expressed as overall agreement and calculated as a kappa index (Cohen 1960, Cockshott & Park 1983) as further described by Fleiss (1971) and Grndahl et al. (1987). McNemars test (Rosner 1995) was used to test possible differences between the bisecting-angle and the paralleling techniques. Statistical signicance was chosen at the 5% level.

dam was removed the quality of the root lling was checked with a radiograph exposed with the bisectingangle technique. A postoperative radiograph was then taken with the paralleling technique (Forsberg 1987c). This radiograph served as a basis for the comparison in the follow-up examination. The radiographs were exposed with a Philips Oralix X-ray machine operated at 65 kV and 7.5 mA, which was equipped with a tubular collimator (diameter 5 cm). The focus-lm distance was approximately 22 cm for both techniques. The lm used was Kodak Ektaspeed EP 12 and EP 22. The exposures were performed by undergraduate students who had already completed their training in oral radiology and who where supervised by clinical instructors. The lms were processed in an automatic processor, Philips Rollomat 820. After ve of 68 consecutive cases had been excluded because of technical errors, the sample consisted of 63 pairs of radiographs. The second group consisted of patients who had received endodontic surgery with apicectomy in the Department of Oral Surgery. The exposures were taken by radiographers in the Department of Oral Radiology, supervised by an oral radiologist. The X-ray machine was a Gendex GX operated at 65 kV and 10 mA and the lms were developed in an automatic processor, Drr Dental XR 24. This sample consisted of 105 pairs of radiographs taken at the 1-year review. Other data were as for the rst group.

Results Intraobserver agreement

The ndings are summarized in Table 1. When evaluating the presence of lesions for the root canal treatment cases the observers showed kappa values in the range 0.790.89 for the bisecting technique and in the range 0.800.85 for the paralleling technique. For the surgery cases the kappa values were somewhat lower for all three observers. No signicant differences were found when comparing the kappa values for the two techniques and comparing surgery and root canal treatment cases. For both the root canal treatment and the surgery cases the intraobserver agreement was considerably lower when comparing lesion size for the two techniques. The kappa values varied from 0.38 to 0.71.

Evaluation of the cases

The radiographs were masked to reveal only the apical part of the tooth and the surrounding bone. They were coded and the two exposed radiographs of the same tooth were examined randomly. Three observers (A, B and C), all well trained in oral radiology, examined the pictures using a viewing box with moderate illumination and a magnifying viewer. They were asked to classify the teeth according to: 1 Normal periapical condition 2 Periapical radiolucency The radiographs were re-examined after 4 weeks. In the second part of the investigation the pairs of corresponding radiographs were compared. Only cases where a radiolucency had been diagnosed by at least one of the observers were included, and the samples now consisted of 30 root canal treatment cases and 51 surgical cases, respectively. The two radiographs exposed with different techniques, but also now coded, were compared with regard to the size of the radiolucency. The observers had to determine whether:

Interobserver agreement
The comparison of observers based on their rst evaluation of cases is presented in Table 2. When evaluating presence of lesions for the root canal treatment cases the observers showed kappa values in the range 0.700.72 for the bisecting technique and in the range 0.580.69 for the paralleling technique. For the surgery cases the
1997 Blackwell Science Ltd, International Endodontic Journal, 30, 115123

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Table 1 Comparison of rst and second evaluation of cases with respect to presence/absence of apical lesion or lesion size. Observers performance presented as percentage agreement and Cohens kappa No. of cases Root canal treatment cases, presence of lesions Observer A Observer B Observer C Surgery cases, presence of lesion Observer A Observer B Observer C Root canal treatment cases, size of lesion Observer A Observer B Observer C Surgery cases, size of lesion Observer A Observer B Observer C Bisecting Agreement Kappa Paralleling Agreement Kappa Bisecting/paralleling Agreement Kappa

63 63 63

90 92 95

0.80 0.79 0.89

90 94 92

0.80 0.85 0.83

105 105 105

82 85 90

0.61 0.71 0.80

80 82 84

0.62 0.63 0.69

30 30 30

63 70 83

0.45 0.55 0.70

51 51 51

71 61 82

0.54 0.38 0.71

Table 2 Comparison of observers based on their rst evaluation of cases with respect to presence of apical lesion or lesion size. Observers performance presented as percentage agreement and Cohens kappa No. of cases Root canal treatment cases, presence of lesions A vs. B A vs. C B vs. C Surgery cases, presence of lesion A vs. B A vs. C B vs. C Root canal treatment cases, size of lesion A vs. B A vs. C B vs. C Surgery cases, size of lesion A vs. B A vs. C B vs. C Bisecting Agreement Kappa Paralleling Agreement Kappa Bisecting/paralleling Agreement Kappa

63 63 63

87 87 86

0.72 0.72 0.70

79 86 84

0.58 0.69 0.62

105 105 105

70 83 75

0.51 0.65 0.50

79 83 83

0.59 0.66 0.66

30 30 30

60 57 50

0.39 0.35 0.25

51 51 51

59 67 57

0.37 0.48 0.34

kappa values were somewhat lower for the bisecting technique and at the same level for the paralleling technique. No signicant differences were found when comparing the kappa values for the two techniques.
1997 Blackwell Science Ltd, International Endodontic Journal, 30, 115123

For both the endodontic and the surgery cases the interobserver agreement was low when comparing lesion size for the two techniques. The kappa values were in the range 0.250.48.

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J. Forsberg & A. Halse irrespective of the radiographic technique (Table 1). It is probable that greater difculties will arise in diagnosing the apical region after cutting the root tip during the surgical procedure than at a well-dened root apex with untouched periapical tissue. Evaluation of cases with respect to the lesion size (Table 1) yielded poor agreement between the two observations. A probable reason is the considerably greater difculty in comparing the size of lesions in pairs of radiographs exposed with different radiographic techniques than taking a decision on one radiograph of lesion/no lesion. It is reasonable to assume that the presence of scar tissue also complicated the reading of some of the surgery cases. The percentage agreement and Cohens kappa were generally lower between observers than for the corresponding intraobserver value (Table 2), regardless of the fact that all three observers had long experience as dental radiologists. Reit (1987) has reported previously that radiographic periapical diagnosis is subjected to considerable interexaminer variation. He also found that the benets of calibration programmes for reducing interobserver variation are limited. This stresses the need for well dened criteria for the radiographic diagnosis of periapical lesions. Since the paralleling technique is considered to be the most standardized of the two techniques, more consistent ndings might have been expected, than observed in the present study. In radiographs the geometrical distorsion will inuence the reproduced dimension of a subject. Both the bisecting-angle and the paralleling techniques, even when correctly adjusted, will create magnication of the apical structures. In addition, because of the different angulation of the central beam, different anatomical structures may overlap the apical area resulting in a different radiographic appearance of the lesion (Fig. 3). An earlier in vitro examination on single-rooted teeth with a simulated periapical lesion has clearly indicated that the paralleling technique provides more valid information about the size of a pathological process than the bisecting-angle technique (Forsberg & Halse 1994). However, in this laboratory study the simulated periapical lesion was made small and circular. The border of it was also well dened and there was no overlapping of skeletal structures. Clinically, periapical lesions will vary in size and shape. In this study the size of the lesions were generally larger compared with the simulated lesion. Owing to the different vertical angulations of the two radiographic techniques the beams will touch the surface of a lesion at different points and thereby inuence the extension of the lesion reproduced.
1997 Blackwell Science Ltd, International Endodontic Journal, 30, 115123

Size of lesions as recorded by the bisecting-angle and the paralleling techniques

Some examples of the radiographic reproduction of periapical lesions in pairs of radiographs exposed at the same time with the bisecting-angle and the paralleling techniques are shown in Figs 1 and 2. With one exception, there were no signicant differences between the two techniques in reproducing the size of periapical lesions (Table 3).

Discussion
Absence of periapical radiolucencies has been used as a signicant criterion for therapeutic success in root canal treatment and apical surgery (Goldman et al. 1972, Reit & Grndahl 1983, Zakariasen et al. 1984, Molven & Halse 1988, Grung et al. 1990). Decreased or increased size of the periapical lesion over time after treatment is a criterion for expected success or failure respectively (Molven et al. 1987, Halse et al. 1991). A variety of studies have dealt with intra- and interexaminer agreement on the presence of periapical lesions. These studies show large intraobserver variation (Brynolf 1970, Goldman et al. 1972, Molven 1976, Abdel Wahab et al. 1984) and even greater interobserver variation (Goldman et al. 1974, Reit & Grndahl 1983, Abdel Wahab et al. 1984, Halse & Molven 1986, Kaffe & Gratt 1988, Stheeman et al. 1996). However, none of these examinations have analysed the inuence of the radiographic technique on the reproduced size of periapical lesions. In this study the intra- and interexaminer agreement on both the presence of lesions and the size of lesions as read from radiographs exposed with different radiographic techniques were evaluated. The percentage agreement and Cohens kappa, when recorded, were higher for all three observers for the root canal treatment cases than for the surgical cases
Table 3 Intraobserver agreement of number of cases with largest reproduction of the periapical lesion comparing the bisecting-angle and the paralleling techniques No. of cases Root canal treatment Observer Bisecting-angle technique Paralleling technique A 7 8 B 6 9 C 4 6 A 10 8 Surgery B 3 12 C 7 13

Observer B, surgery cases: bisecting-angle versus paralleling technique; McNemars test 2.07, P<0.05.

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Fig. 1 Pairs of radiographs showing root canal treated teeth. Each pair of radiographs was exposed at the same time with the bisecting-angle (A) and the paralleling (B) techniques. In the upper horizontal row the lesion is reproduced largest in the bisecting-angle radiograph (A). In the middle row both techniques reproduced the lesion to the same size and in the lower row the lesion is projected largest in the paralleling radiograph (B).

1997 Blackwell Science Ltd, International Endodontic Journal, 30, 115123

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Fig. 2 Pairs of radiographs showing apicected teeth. Each pair of radiographs was exposed at the same time with the bisecting-angle (A) and the paralleling (B) techniques. In the upper horizontal row the lesion is largest in the bisecting-angle radiograph (A). In the middle row both techniques reproduced the lesion to the same size and in the lower row the lesion is largest in the paralleling radiograph (B).

1997 Blackwell Science Ltd, International Endodontic Journal, 30, 115123

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Fig. 3 Pairs of radiographs showing anatomical structures overlapping the periapical lesions. Each pair of radiographs was exposed at the same time with the bisecting-angle (A) and the paralleling (B) techniques. Upper row, overlapping by the mental ridge in A; lower row, overlapping by the external nose in A.

Although numerous studies based on radiographic examination have been published evaluating success or failure of root canal therapy and apical surgery (Strindberg 1956, Bergenholtz et al. 1973, Molven 1976, Kerekes & Tronstad 1979, Reit & Grndahl 1983, Molven & Halse 1988, Halse et al. 1991, Molven et al. 1996), little attention has been paid to the inuence of the radiographic technique on the depiction of periapical pathological changes (Forsberg & Halse 1994). Periapical lesions have been studied in animals using both radiography and histology (Allard & Strmberg 1979, Fouad et al. 1992), clinically by biopsies of apices and
1997 Blackwell Science Ltd, International Endodontic Journal, 30, 115123

periapical tissue (Andreasen & Ruud 1972) and in autopsy material (Brynolf 1967). However, none of these combined examinations has presented information on whether the reproduced size correlated with the true size of periapical lesions. Fouad et al. (1992) concluded that the morphology of the jaws of most experimental animals was not suitable for standardized radiographs. Andreasen & Ruud (1972) examined the correlation between histology and radiography in assessment of healing after endodontic surgery. They found a number of radiographic variables correlated to the histological ndings by periapical inammation or

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technique upon prediction of tooth length in intraoral radiography. Oral Surgery, Oral Medicine and Oral Pathology 51, 1007. BR Y N O L F l (1967) A histological and roentgenological study of the periapical region of human upper incisors (Thesis). Odontologisk Revy 18, (Suppl. 11). BR Y N O L F l (1970) Roentgenologic periapical diagnosis 1. Reproducibility of interpretation. Svenska Tandlkarfrbundets Tidskrift 63, 33944. CO C K S H O T T WP, PA R K WM (1983) Observer variation in skeletal radiology. Skeletal Radiology 10, 8690. CO H E N J (1960) A coefcient for agreement for normal scales. Education Psychological Measurement 20, 3746. FO R S B E R G J (1987a) Radiographic reproduction of endodontic working length comparing the paralleling and the bisecting-angle techniques. Oral Surgery, Oral Medicine and Oral Pathology 64, 35360. FO R S B E R G J (1987b) A comparison of the paralleling and bisectingangle radiographic techniques in endodontics. International Endodontic Journal 20, 17782. FO R S B E R G J (1987c) Estimation of the root lling length with the paralleling and the besecting-angle techniques performed by undergraduate students. International Endodontic Journal 20, 936. FO R S B E R G J, HA L S E A (1994) Radiographic simulation of a periapical lesion comparing the paralleling and the bisecting-angle techniques. International Endodontic Journal 27, 1338. FO U A D A, WA L T O N R, RI T T A N B (1992) Induced periapical lesions in ferret canines: Histologic and radiographic evaluation. Endodontics and Dental Traumatology 8, 5662. FL E I S S JL (1971) Measuring nominal scale agreement among many raters. Psychological Bulletin 76, 37882. GO L D M A N M, PE A R S O N AH, DA R Z E N T A N (1972) Endodontic succes Whos reading the radiograph? Oral Surgery, Oral Medicine and Oral Pathology 33, 4327. GO L D M A N M, PE A R S O N AH, DA R Z E N T A N (1974) Reliability of radiographic interpretations. Oral Surgery, Oral Medicine and Oral Pathology 38, 28793. GR N D A H L K, GR N D A H L HG, WE N N S T R M J, HE I J L L (1987) Examiner agreement in estimating changes in periodontal bone from conventional and subtraction radiographs. Journal of Clinical Peridontology 14, 749. GR U N G B, MO L V E N O, HA L S E A (1990) Periapical surgery in a Norwegian county hospital: follow-up ndings of 477 teeth. Journal of Endodontics 16, 4117. HA L S E A, MO L V E N O (1986) A strategy for the diagnosis of periapical pathosis. Journal of Endodontics 12, 5348. HA L S E A, ES P E L I D l, TV E I T AB, WH I T E S (1994) Detection of mineral loss in approximal enamel by subtraction radiography. Oral Surgery, Oral Medicine and Oral Pathology 77, 17782. HA L S E A, MO L V E N O, GR U N G B (1991) Follow-up after periapical surgery: the value of the one-year control. Endodontics and Dental Traumatology 7, 24650. HA U S M A N N E, AL L E N K, CR I S T E R S S O N L, GE N C O L (1989) Effect of X-ray beam vertical angulation on radiographic alveolar crest level measurement. Journal of Periodontal Research 29, 819. JE N K I N S SM, DU M M E R PMH, AD D Y M (1992) An in vitro study of the inuence of X-ray beam angulation on the radiographic images of the amelocemental junction and simulated alveolar crest. Journal of Oral Rehabilitation 19, 62937. KA F F E I, GR A T T BM (1988) Variations in the radiographic interpretation of the periapical dental region. Journal of Endodontics 14, 3305. KE R E K E S K, TR O N S T A D L (1979) Long-term results of endodontic treatment performed with a standardized technique. Journal of Endodontics 5, 8390.
1997 Blackwell Science Ltd, International Endodontic Journal, 30, 115123

presence of brous scar tissue. The radiographically reproduced size of the lesions compared with the histological appearance was not examined in this study. Brynolf (1967), in her study of the periapical region in autopsy material, concluded that the changes in the radiographic groups tallied well with those in the histological groups. However, she examined only the periapical region of maxillary incisors, which in relation to the vertical plane are about 1520 angulated. Therefore, in this region the angle between the tooth axis and the lm will be moderate irrespective of the radiographic technique. During recent years many studies have been performed using digital subtraction radiography in diagnosing dental caries and bone lesions. There is no indication that this technique provides a better validity than conventional radiographic examination in diagnosing caries (Halse et al. 1994) but it seems to be useful for detection of small substance loss in the marginal periodontium (Kullendorf et al. 1992, Wenzel et al. 1992). Promising results have also been obtained for diagnosing alteration in the apical periodontium (Pascon et al. 1987, Kullendorf et al. 1988). Because of the difculties in determining the size of periapical lesions with conventional radiographic techniques it is possible that digital subtraction radiography in the future will be a valuable complement in follow-up controls after endodontic treatment and apical surgery. The conclusion of the present investigation is that the bisecting-angle and the paralleling radiographic techniques will give the same result in diagnosing periapical radiolucencies. As earlier investigations have shown that the paralleling technique produces more identical images by repeated exposures, we recommend that this technique be generally used for review of the periapical area after root canal treatment and apical surgery.

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