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Value of Bite–Wing Radiographs in a Clinical Epidemiological Study and Their

Effect on the DMFS Index

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 Original Paper
Caries Res 2000;34:159–163
Value of Bite-Wing Radiographs in a
Clinical Epidemiological Study and
Their Effect on the DMFS Index
J.H.G. Poorterman a I.H.A. Aartman a J.A. Kieft a H. Kalsbeek b
a Departmentof Social Dentistry and Dental Health Education, Academic Centre for Dentistry, Amsterdam,
The Netherlands; b Division of Child Health, TNO Prevention and Health, Leiden, The Netherlands
Key Words
Bite-wing radiograph · Clinical assessment · DMFS ·
Epidemiology
Abstract
The aim of this study was to determine, for different age
groups, the additional value of bite-wing radiographs
compared to the clinical information, and to calculate
the subsequent effect on the DMFS index. Subjects
were 14, 17, 20, 23 years old, or in the age groups 25–34
and 35–54, who participated in a clinical epidemiologi-
cal survey. After obtaining consent, bite-wings were tak-
en of approximately 25% of the participants (n = 663).
The extra diagnostic yield of the bite-wings varied be-
tween 163 and 700% for approximal dentine caries diag-
nosis of untreated surfaces, and between 233 and 593%
for inadequate restoration judgement for filled surfaces.
The DS score went up by about 20–98%, whereas the
DMFS index increased between 1 and 12%, resulting in
a radiographic correction factor of 1.01–1.12. In conclu-
sion, the considerable increase in the prevalence of ap-
proximal dentinal lesions and inadequate restorations
for all age groups results in higher numbers of surfaces
in need of treatment, but is not accompanied by a sig-
nificant increase in DMFS scores.
Copyright © 2000 S. Karger AG, Basel
쑕 2000 S.Karger AG, Basel
0008–6568/00/0342–0159 $17.50/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com http://BioMedNet.com/karger
Received: March 8, 1999
Accepted after revision: July 16, 1999
A general decline in dental caries prevalence and inci-
dence in most Western countries has been accompanied by
a change in lesion behaviour [Pitts, 1992]. Macroscopic
cavitation is visually detected at a much later stage in the
process [Wenzel et al., 1993], while dentinal lesions ‘hide’
under the enamel. It is presumed that the decline of caries as
well as its change in behaviour are largely due to the in-
creased availability of fluorides [Naylor, 1994]. Thus, clini-
cal examination alone leaves much to be desired when used
as a sole diagnostic method for caries detection and moni-
toring, and for the evaluation of restoration behaviour.
Kidd and Pitts [1990] have reported in a review study
that the use of bite-wing radiographs, as an aid to clinical
diagnosis, is essential if much approximal caries is not to be
missed. Several studies have confirmed that the prevalence
of approximal caries is significantly underestimated when
clinical data are compared with radiographic information.
However, the results show a large range in the number of
additional lesions diagnosed by the radiographic examina-
tion [Mann et al., 1989; de Vries et al., 1990; de Araujo et
al., 1992; Hintze and Wenzel, 1994; Richardson and McIn-
tyre, 1996; Poorterman et al., 1999]. This range might be re-
lated to the different age groups used and the caries preva-
lence of the population under study. In addition, the
bite-wing radiograph reveals significant additional informa-
tion with respect to the quality of approximal restorations
[Kroeze et al., 1990].
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Dr. J.H.G. Poorterman
Academic Centre for Dentistry Amsterdam (ACTA)
Department of Social Dentistry and Dental Health Education
Vrije Universiteit
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Louwesweg 1, NL–1066 EA Amsterdam (The Netherlands)
Tel. +31 20 5188246, Fax +31 20 5188233, E-Mail j.poorterman@acta.nl
 These results may have serious consequences regarding
the outcome of routine epidemiological research in which
no additional diagnostic aids like bite-wing radiographs are
used. In those reports reference is usually made to the pos-
sible undervaluation of the presence of approximal caries,
but to what extent this phenomenon interfered with the re-
sults found is reported to be unknown or assumed to be
small. Therefore, this numerical uncertainty about the epi-
demiological outcome data lacks a solid base for evidence-
based improvements in oral health and oral health care in
the future. On top of that, these figures contain a serious
warning for the standard procedure of visual clinical diag-
nosis in general dental practice. From an earlier study, it can
be concluded that at least for the age groups of the 17- and
23-year-olds clinically sound approximal surfaces and ap-
parently adequate restorations should not be taken at face
value [Poorterman et al., 1999].
Therefore, research should be aimed at gathering more
information about the precise extent of underestimated den-
tal caries and its influence on epidemiological measures
such as DMFT and DMFS scores. For example, Mann et al.
[1989] found in a student population (between 14 and 18
years) that 53% of the decayed surfaces in the premolar and
molar region was detected on the radiographs only. They
suggested a multiplying factor of 1.59 that would better as-
sess the actual DMFS value in their study population. How-
ever, such a correction factor is largely dependent on the
caries prevalence, age of the participants, average fluoride
use in the population, the amount of restorative treatment,
etc. Therefore, correction factors should be determined for
various study populations. The clinical data can then be ad-
justed in order to obtain a more precise estimate of the true
caries prevalence, and the use of bite-wing radiographs
might be superfluous.
The aim of the present study was (1) to determine the ad-
ditional value of the bite-wing radiograph compared to the
clinical epidemiological information collected for different
age groups and (2) to calculate the subsequent effect on the
DMFS index.
Materials and Methods
Subjects
Subjects were 560 14-, 537 17-, 285 20- and 429 23-year-old
males and females who participated in a clinical epidemiological sur-
vey conducted in four medium-sized Dutch communities in 1990 and
1993 [Kalsbeek et al., 1996]. All persons were selected based on their
insurance by a so-called ‘Health Insurance Fund’, under which ap-
proximately 60% of the Dutch population was covered at the time.
Furthermore, 974 adults between 25 and 54 years who participated in
160 Caries Res 2000;34:159–163
Table 1. Radiographic criteria for assessment of approximal sur-
faces
0 No radiolucency visible in enamel and/or dentine
1 Radiolucency confined to the enamel
2 A circumscribed radiolucency visible in the dentine (D3 level)
3 An adequate restoration
4 An inadequate restoration (a missing, partly missing or fractured
restoration, marginal over- or underextension, open approximal
contact with risk of food imaction)
5 A restoration in combination with a circumscribed radiolucency
visible in the dentine
6 A missing tooth surface
7 No judgement can be made (due to overlap, orthodontic banding
or dislocated film position)
a clinical epidemiological project in 1995 were included in this study
[Kalsbeek et al., 1998]. Initially, they were divided into three groups
(25–34, 35–44 and 45–54 years), but due to the low number of partic-
ipants in the oldest groups and the fact that the two older groups did
not differ on any characteristic, these were combined.
At the end of the clinical examination, bite-wing radiographs were
taken after the participant’s consent was obtained. Finally, these were
taken of 115 14-year-olds (21%), 120 17-year-olds (22%), 117 20-
year-olds (41%), 119 23-year-olds (28%), and 192 adults (20%). The
main reasons for not taking bite-wing radiographs were (possible)
pregnancy, the fact that radiographs were taken shortly before by the
home dentist, unwillingness to participate or lack of time.
Procedure
Clinical data of the subjects of the present study were collected
during the epidemiological survey. Clinical oral examination was car-
ried out using light, mirror, and a blunt probe for the removal of de-
bris. Enamel lesions were not clinically recorded. An approximal
tooth surface was recorded as decayed when a lesion was present that
expressed itself as a clearly undermined marginal crista or as a dis-
continuity of the enamel. An approximal restoration was recorded as
inadequate based on one or more of the following conditions: (1) the
restoration was missing or fractured, (2) a carious lesion adjacent to
the restoration was visible or tactile, (3) marginal over- or underex-
tension (a1 mm) was visible or tactile, (4) the approximal contact
was insufficient.
The first examiner (J.P.) assessed the bite-wing radiographs of all
participants from the distal surface of the first premolar to the mesial
surface of the second molar based on the radiographic criteria used in
an earlier study (table 1). These radiographic criteria were derived
from the clinical protocol with the objective to be as comparable as
possible with the clinical procedures. The scores ‘0’ and ‘1’ corre-
spond with a sound tooth surface, whereas the scores ‘2’, ‘4’ and ‘5’
are considered surfaces in need of restorative treatment. An extensive
description of the protocol including these criteria can be found else-
where [Poorterman, 1997]. A second examiner (J.K.), also experi-
enced and calibrated in the field of dental epidemiology, judged about
20% of the radiographic material to determine the interobserver
agreement. Cohen’s kappa was used as a measure of reliability. The
agreement proved to be very good (κ = 0.77), according to a standard
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Table 2. Number of participants in the
clinical and radiographic study and the re- Age Year of Clinical study DMFT Radiographic DMFT
spective DMFT score years examination participants (mean B SD) study participants (mean B SD)

14 1990 560 3.2B3.3 115 4.2B3.7

17 1993 537 4.5B4.1 120 4.8B3.9
20 1990 285 7.3B4.6 117 7.1B4.3
23 1993 429 8.5B5.2 119 9.7B4.9
25–34 1995 373 12.9B5.6 96 12.0B5.4
35–54 1995 601 17.5B5.1 96 15.7B5.0

Table 3. Mean clinical and total number of dentine lesions per person and the respective percentages of unfilled approximal surfaces with a
dentine lesion

Age, Participants Clinical number Clinical % of Total number Total % of Only Clinically and Only Additional
years (surfaces) of dentine lesions surfaces with a of dentine lesions surfaces with a clinically radiographically radiographically radiographic
per person 1 dentine lesion per person 1 dentine lesion scored, % scored, % scored, % value, %

14 115 (2,557) 0.21B0.9 0.94 0.67B1.7 2.5 15.9 22.2 61.9 163
17 120 (2,565) 0.13B0.4 0.62 1.1B2.3 5.0 7.8 4.7 87.5 700
20 118 (2,425) 0.32B0.8 1.6 1.2B2.4 5.2 14.3 15.9 69.8 232
23 119 (2,100) 0.27B0.8 1.5 1.2B2.2 6.2 10.0 14.6 75.4 306
25–34 96 (1,395) 0.23B0.5 1.6 1.3B1.6 8.1 8.0 12.4 79.6 391
35–54 96 (971) 0.18B0.5 1.8 0.68B1.1 5.4 11.5 21.2 67.3 206

1 Mean B SD.

interpretation of Cohen’s kappa [Hunt, 1986]. When the interobserver
agreement was calculated for the separate categories, the agreement
was good for both dentine caries diagnosis (κ = 0.65) and for restora-
tion assessment (κ = 0.62).
Material
Kodak Ektaspeed double-packed films, held in Kwik-Bite film
Holders, were used in combination with a Philips Oralix 65-kV ma-
chine, with an exposure time of 0.5 s. The bite-wing radiographs were
examined with an X-ray desk viewer (Clive Craig Co.) without mag-
nification.
Results
Mean DMFT scores for the total clinical survey popula-
tion and for the group who participated in the radiographic
study, both based on clinical examination alone, are pre-
sented in table 2. The mean number of approximal dentine
lesions in untreated surfaces varied from 0.13 (SD = 0.4;
0.62% of the unfilled surfaces) for the 17-year-olds to 0.32
(SD = 0.8; 1.6%) for the 20-year-olds. This figure ranged
from 0.67 (SD = 1.7; 2.5%) for the 14-year-olds to 1.3 (SD
= 1.6; 8.1%) for the age category 25–34 when clinical and
radiographic judgement were combined (table 3). As a re-
sult, the extra diagnostic yield of the bite-wing radiographs
is calculated as the number of additionally detected approx-
imal lesions divided by the total number of lesions found
clinically. This figure ranged between 163 and 700%.
Based on clinical judgement alone, the mean number of
inadequate restorations varied between 0 for the 14-year-
olds and 0.33 (SD = 0.7; 3.2% of the filled surfaces) for the
age category 35–54. When the radiographic judgements
were included, this number increased to a range between
0.13 (SD = 0.4; 24.2%) for the 14-year-olds and 1.5 (SD =
1.8; 13.3%) for the age category 35–54 (table 4). Excluding
the 14-year-olds, between 233 and 594% extra inadequate
restorations were found when bite-wing radiographs were
used.
The clinically based DMFS scores and related DS scores
are shown in table 5. Between approximately 20 and 100%
additional decayed surfaces were detected for the various
age categories. This resulted in a 1–12% rise in total DMFS
experience. These figures correspond with a correction fac-
tor of 1.01 to 1.12 for adjustment of the clinical DMFS
score. The largest increase in DMFS and DS scores was
found for the 17-year-olds. The number of surfaces in need
of restorative treatment (due to caries or an inadequate
restoration), based on the additional bite-wing radiographic
judgement, was doubled, except for the 14-year-olds.
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Table 4. Mean clinical and total number of inadequate restorations per person and the respective percentages of filled approximal surfaces
with an inadequacy

Age, Participants Clinical number Clinical % of Total number Total % of Only Clinically and Only Additional
years (surfaces) of inadequate surfaces with an of inadequate surfaces with clinically radiographically radiographically radiographic
restorations inadequate restorations an inadequate scored, % scrored, % scored, % value, %
per person 1 restoration per person 1 restoration

14 115 (62) 0.0 0.0 0.13B0.4 24.2 0.0 0.0 100.0 –

17 120 (194) 0.06B0.3 4.6 0.28B0.7 15.5 6.7 23.3 70.0 233
20 118 (268) 0.09B0.4 3.4 0.47B1.6 18.3 10.2 8.2 81.6 444
23 119 (577) 0.13B0.6 2.6 0.91B1.9 18.2 11.5 2.9 85.6 594
25–34 96 (735) 0.25B0.6 3.1 1.3B1.7 15.8 14.7 5.2 82.2 404
35–54 96 (1,004) 0.33B0.7 3.2 1.5B1.8 13.3 14.9 9.0 76.1 319

1 Mean B SD.

Table 5. Increase in DMFS score, number of decayed surfaces (DS) and number of surfaces in need of treatment (TNS) after radiographic ad-
justment

Age DMFS DMFS Correction DS DS Correction TNS TNS Correction

years (clinical) (final) factor (clinical) (final) factor (clinical) (final) factor

14 6.50 6.86 1.06 1.76 2.12 1.20 1.83 2.34 1.28

17 8.02 8.95 1.12 0.95 1.88 1.98 1.09 2.23 2.05
20 12.49 13.23 1.06 1.14 1.88 1.65 1.30 2.42 1.86
23 19.39 20.21 1.04 1.34 2.16 1.61 1.61 3.17 1.97
25–34 27.36 28.30 1.03 1.30 2.24 1.72 1.58 3.52 2.23
35–54 40.92 41.28 1.01 1.18 1.54 1.31 1.72 3.20 1.86

Discussion The relatively largest contribution of the radiographs

All age groups in this study suffer from a considerable
underestimation of the prevalence of approximal carious le-
sions at the D3 level in untreated surfaces and a similar un-
derestimation of the number of inadequate restorations in
filled surfaces, based on clinical examination alone. Clear-
ly, the bite-wing radiograph detects more approximal le-
sions and inadequate restorative treatment than the naked
eye. The magnitude of this effect seems somewhat age-re-
lated. A relatively small contribution of the bite-wing radio-
graphs is found for the youngest group of 14-year-olds. This
is not surprising, since three out of four posterior teeth only
recently arrived in the oral cavity and the average time to
develop a dentinal lesion is at least 3–4 years. Even then,
the prevalence of approximal caries lesions is almost tripled
and, on average, every ten 14-year-olds share six dentinal
lesions between them. On top of that, it is worrisome to find
that almost one quarter of the approximal restorations is
deemed inadequate for this age group. For the older groups,
this percentage fluctuates around 16%.
with respect to caries detection is found for the 17-year-
olds. However, in absolute numbers, in this age group about
one dentine lesion per person is detected, fairly consistent
with three out of five other age groups. Clearly, this large
percentage is due to the very small number of clinically ob-
served approximal dentine lesions in this adolescent age
group. At first sight, their often apparently sound dental sta-
tus seems to benefit from long-term caries reducing mea-
sures. With bite-wing radiographs, however, more than half
of this clinically caries-free age group has in fact one or
more lesions in the dentine [Poorterman et al., 1999].
In table 2 the radiographic subgroup and the entire clini-
cal study population are compared with respect to their
DMFT score. Some differences can be noticed, especially
in the 14- and 23-year-old age groups. After the clinical ex-
amination the participants were asked if bite-wing radio-
graphs could be made. The main reasons for unwillingness
to participate have already been mentioned in the ‘Materials
and Methods’ section. Apparently, the 23-year-olds with a
higher DMFT score are more willing to participate. Perhaps
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the participants with a clinically very low DMFT were not
convinced of any personal benefit, although 25% of the
clinically caries-free in this age group have dentinal lesions
on the bite-wing radiograph [Poorterman et al., 1999]. The
14-year-olds constitute a different problem. First of all, their
parents played a role in the consent procedure. Probably,
they are more protective when their children have apparent-
ly better teeth. Secondly, quite a few participants in that age
group wore orthodontic appliances, which interfere with an
adequate clinical judgement. Furthermore, in that case no
bite-wing radiographs were taken. Since a relationship ex-
ists between high socio-economic status and both a low
clinical DMFT score and the use of orthodontics, it is not
surprising that we found a somewhat higher mean DMFT
score for the 14-year-old radiographic participants. Whether
this difference affects the generalizability of the results for
these age groups can therefore not easily be answered.
Whether or not exposing participants in an epidemiolog-
ical survey to (unnecessary) X-rays is controversial. How-
ever, planning and preparation of epidemiological research
and the realization of fieldwork are usually time-consuming
and therefore expensive. Thus, when the results produced
without the use of radiographs lack accuracy, such surveys
can just as well be contested from a society perspective.
Generally, it is advocated that radiographs should not be
used for purely epidemiological purposes, unless the films
are also clinically justified and available to clinicians who
are caring for the individuals concerned [Kidd et al., 1993].
In the present study, this ethical dilemma was overcome by
a combination of the participants’ consent and the use of
double-packed bite-wing radiographs, of which one copy
was returned by mail. Now new figures on this topic are
presented, the clinical data can be adjusted and the use of
bite-wing radiographs might be superfluous in the future.
This also meets a growing awareness in the public regarding
the potential danger of (dental) radiation.
It has been a point of discussion in several studies
whether bite-wing radiographs add significantly to the clin-
ical diagnosis. As to the percentage of undiagnosed approx-
imal lesions and inadequate restorations found in this study
this seems to be the case. The overall underestimation re-
sults in significantly higher numbers of decayed surfaces
and surfaces in need of restorative treatment, in that way
underlining its clinical value. Whether this phenomenon
then seriously affects the epidemiologic DMFS index by
adding a radiographic factor in the D component is ques-
tioned. Due to the large figures of underestimated approxi-
mal caries prevalence one would like to think so. However,
calculating the relative increase in the DMFS index, the ra-
diographic information leads to a rise of about 5%, varying
only slightly between the age groups (except for the 35- to
54-year-olds). This is due to the fact that, in general, at a
younger age the decayed and filled occlusal surfaces and at
an older age the restorations already present are responsible
for the major contribution to the DMFS index. Therefore, if
the clinical DMFS score should be adjusted at all, the cor-
rection factor based on the additional radiographic informa-
tion of the approximal surfaces only varies from 1.01 to 1.12.

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