Agreement between panoramic and

intra-oral radiography in the

assessment of marginal bone height
B. Molander*, M. Ahlqwist*, H-G. Grendahl" and L. Hollendert
"Department of Oral Radiology, University of Goteborg, Gothenburg, Sweden and tDepartment of Oral Medicine,
School of Dentistry, University of Washington, Seattle, USA

Received 6 April 1990 and in final form 25 February 1991

Panoramic and intra-oral radiographs from 400 consecutive patients were evaluated for the
assessment of the marginal bone height. Two hundred panoramic radiographs were exposed
with the rotational technique and 200 with the intra-oral X-ray tube technique. Measurements
of the approximal marginal bone level were independently performed by two observers.
Complete agreement between panoramic and intra-oral radiographs was, on average,
obtained in 55% and 49% of the sites, respectively. When the criterion for agreement was
widened to include recordings with a difference of ±1 mm, the agreement was on average
87% irrespective of the techniques compared. The agreement varied with tooth type and
severity of the marginal bone loss. Angular bony defects and furcation involvements were
recorded separately. For angular bony defects there was a variation in agreement from 33% to
46% for the rotational technique and from 35% to 51% for the intra-oral X-ray tube technique
depending on localization. Furcation involvements of the molars were equally recorded in
60% and 59%, respectively, but in only 12% and 28% for the upper premolars. Interobserver
agreement was 58% for the intra-oral radiographs, 60% and 59% for the two panoramic
techniques. Mean intra-observer agreement was 68%, 66% and 68%. It is concluded that
panoramic radiography can often be used for the assessment of marginal bone loss alone,
supplemented when necessary by intra-oral radiographs.

Keywords: Radiography, dental; radiography, panoramic; periodontal bone

Introduction examined, claim that panoramic radiography could be

Compared with a full mouth intra-oral examination,
panoramic radiography, whether performed by the
rotatio~al or the int:a-?ral X-ra~ tube technique, saves
both time and radiation dose -9. Although the two
panoramic methods were introduced at approximately
the same time, the intra-oral X-ray tube technique has
not been adopted to the same extent. It has not been
shown that they perform differently as diagnostic tools,
but the rotational technique is more convenient to use.
In panoramic radiographs, comparison with the other
side can be used to facilitate the evaluation of suspected
lesions, while those extending over a large area are
easier to assess than in a series of overlapping intra-oral
images. Such factors have been advanced in favour of
using panoramic radiographs instead of, or as an
adjunct to, intra-oral radiographs. On the other hand
the site-specific exposures and the higher resolution
support the case for intra-oral radiographs. For these
reasons, differing opinions abound on the diagnostic
value of panoramic radiography'P"!", Some argue
against it as an adjunct to a full-mouth examination
because little information is added 13.19-21 .Others,
despite the unsharpness and distortion and the limited
three-dimensional assessment of the structures
the primary radiographic method and the information
obtained then used to assess the need for
supplementary intra-oral radiographs'S. As a result of
the considerable improvement in dental health in many
countries, a full mouth series may no longer be
necessary. In order to determine the validity of such an
approach, we found it necessary to perform yet another
study comparing panoramic with intra-oral
radiography. Equipment for rotational panoramic
radiography has improved during recent years and
studies using panoramic radiographs produced by the
intra-oral X-ray tube technique are relatively
rareI4.17.23.24 and, when available, based on small
samples. The aim of the present study was to evaluate
the agreement between panoramic and intra-oral
radiography in the assessment of marginal bone loss:
both rotational (RPR) and intra-oral X-ray tube (IPR)
panoramic radiography were examined.
Materials and methods
Panoramic radiographs
RPRs were obtained with an Orthopantomograph
Model OP5 (Siemens, Bensheim, Germany). The

Dentomaxillofac. Radiol., 1991, Vol. 20, August 155

Radiography of the marginal bone: B. Molander et al.
screen-film combination used was Titan 2 HS
(Siemens, Erlangen, Germany) screen and X-Omat L
(Eastman Kodak, Rochester, NY, USA) film. Radio-
graphs were judged acceptable on the basis of an
average density of 1.0 in the area of the alveolar bone,
and the absence of any overall asymmetry or marked
distortion of the anterior teeth.
The IPRs were obtained as lateral views, as
described by Durner"', by means of a Stat-Oralix
(Philips, Eindhoven, The Netherlands). A gradient
filter was added to the applicator for lateral views?".
The screen-film combination was a single Trimax 23M
screen and OM 1 (Eastman Kodak) film inserted in
Cronex Lo-Dose Bagger System (Du Pont, de
Nemours, Frankfurt-am-Main, Germany). The screen
and the film were sealed under vacuum in a light-proof
polyethylene bag. Although one criterion for
acceptable image quality was that all teeth had been
imaged, those radiographs of patients with narrow
dental arches where the central incisors were not visible
were not rejected; in these patients, the central incisors
will occasionally be outside the X-ray beam due to a
more medial position of the applicator. As the image
density varied widely between different regions of the
same radiograph, the only requirement was that it
could be studied with aid of a light-box with variable
luminance. Since enlargement and distortion also vary
between different parts of the jaws and between
different patients, there were no requirements for
uniform enlargement over the entire image.
Intra-oral radiographs
The intra-oral examination comprised 16 periapical and
four posterior bitewing radiographs and was taken
using a 60-65 kVp, a focus to object distance of 20-
28 em, Ektaspeed (Eastman Kodak, Rochester, NY)
film, and paralleling technique. The criteria for accept-
able image quality were that the radiographs covered
all the teeth and their surrounding bone without
obvious projection errors. The requirement for image
density was the same as for RPR.
Patients
The examinations were performed on 423 consecutive
patients referred to the Radiology Department at the
Clinic of Odontology, Gothenburg, Sweden. Intra-oral
radiographs were taken on all patients. In addition,
RPRs were taken on the first 213 patients and the IPRs
on the subsequent 210 patients. Radiographs from 23
patients, 13 RPRs and 10 IPRs, did not meet the
criteria because of severe projection and positioning
errors. The mean age of the patients examined with the
RPRs was 42.8 ± 15.3 years and 47.9 ± 15.9 years for
those with the IPRs. The difference was statistically
significant (P<O.OOl). The mean number of teeth was
22.4±5.8 and 21.7±5.5, respectively, but the differ-
ence was not statistically significant (P>0.05).
Diagnostic evaluation
The radiographs were interpreted by two observers.
Each observer read half the images. To decrease the
influence of possible changes in observer performance
over time, half of the panoramic images were evaluated
first, followed by the second half of the intra-oral
156 Dentomaxillofac. Radiol., 1991, Vol. 20, August
radiographs. The reading order was then reversed. The
marginal bone height was measured at all proximal
surfaces (excluding the third molars) to the nearest
miIlimetre with the cernento-enamel junction and the
crestal bone as measuring points. The measuring point
of the crestal bone was the most coronal edge of the
unbroken lamina dura. If the points were not clearly
visible, their positions were estimated. Measurements
were made on the bitewing and anterior periapical
radiographs from the full mouth series. Specially
prepared transparent rulers were used with line
increments of 1.0 mm for intra-oral radiographs and 1.3
mm for the RPRs to compensate for an average vertical
enlargement of 1.3 calculated from the radiation beam
geometry. In order to estimate the enlargement of the
IPRs, a radiograph was exposed on a dry skull with
small steel balls 3.5 and 2.8 mm in diameter, placed in
the cervical regions of the incisors, premolars and
molars. The vertical enlargement (parallel to the long
axes of the teeth) was measured to the nearest 0.1 mm
with a magnifying glass. Two different transparent
rulers were made, one for the molars with line
increments of 2.0 mm and one with 1.4 mm for the
other teeth. A distance of :!S 1 mm between the
cemento-enarnel junction and the crestal bone was
regarded as an intact bone level. Angular bony defects,
2 mm or deeper, and furcation involvements were
recorded separately. The agreement between
panoramic and intra-oral radiographs was calculated as
the percentage of sites, angular bony defects, and
furcation involvements, which were recorded equally in
both panoramic and intra-oral images. The percentages
of sites with agreement for bone level measurements
and the different degrees of disagreement, were
calculated for every patient together with the mean
values and the 95% confidence limits. To examine
whether the severity of the bone loss or age could
influence the comparison of the two panoramic
techniques a multiple linear regression analysis was
performed with age, percentage of intact sites and
choice of panoramic technique as the variables. Panor-
amic and intra-oral radiographs were evaluated jointly
by the two observers in order to find any possible
reasons for their disagreements over angular
bony defects and furcation involvements. Inter- and
intra-observer agreements for bone level measure-
ments were assessed from 15 radiographs of each of the
panoramic techniques and 15 sets of intra-oral radio-
graphs.
Results
The marginal bone level was measured in 8968 sites in
the RPRs and in 8702 sites in the IPRs. Table I shows
the mean value and the 95% confidence limits for the
Table I Comparison of rotational and intra-oral tube panoramic
techniques for agreement with intra-oral radiography in the
measurement of marginal bone height
Difference Rotational Intra-oral X-ray tube
(mm) technique technique
(n =200) (n = 200)
±O 55.4±3.6 49.4±2.9
±I 87.8±2.3 86.2 ± 1.8
±2 95.5± 1.3 95.7±0.9
Values are mean ± 95% confidence limits of percentage of sites.
 Radiography of the marginal bone: B. Molander et al.

Ro'a' ional In'ro- or01 X...roy 'ubi the IPRs 33.4%. The difference was significant
Centro l inC'sort me.ial 48
(P<0.05).
cent ral ine tsor t di.'al ~I

la' ero l incisor, melia l ~4

Since both the severity of the bone loss as well as the
loterol incis or, dis tal 46 patient's age could possibly be confounding factors in
Conine ,mesial ~9 the comparison of the two panoramic techniques, a
CanIne , di. tal so multiple linear regression analysis was performed. Age,
FiJl t p~r , mes ial ~

Firt ' premolar , distal
Second prima tar ,IM'I+OI
second premola r,d ~ to l
First motor t melia l
fi nt makx'i dis ta l
SKon d moJor, mesial
second mokN'1 distal
100 .,. S Itu 0 0
a sites, was 0.88 ± 2.23% (95% confidence limits). The
Roto tlonal
C, ntrol inc.ISOf', mes ia l
Clinlro' ine;,.or I distal
Latt rol inCit or I mesi al
Lattrol inciaor, dis tat
Conine , tnKic:l 1
Corunt diltol
Fir, t premolar, mnial
Fint premolor, dit tol
S tcond pramo lor, mni QI
S.e()(ld premolQr I d is ta l
f irs l molar, moial
Fir" molar, dit tol
Stcond molOt . mu iol
Second molar I d ilt o l
o ". Sit..
b amounts of calculus.
Figure I Agree ment and disagr ee men t bet ween pa nora mic and intra -
or al rad iograp hs for measurem en ts o f margi nal bo ne level by toot h
type . a . Maxilla jaw: b. mandible jaw . • . Agree ment : . disagree-
ment - a larg er bo ne loss reco rded in pa noram ic rad iogra phs; O .
disag ree ment - a large r bone loss recorde d in intra -ora l rad iographs.
Values are percent age of sites
percentages of sites which were in agreement in
panoramic and intra-oral radiographs and those where
different degrees of disagreement were found. For the
RPRs average agreement was 55.4 ± 3.6% and for
48 percentage of intact sites and panoramic technique
47 could explain 78% (r 2 = 0.777) of the agreement
between panoramic and intra-oral radiographs but the
only variable reaching statistical significance was per-
so centage of intact sites (P=O.OOOI). The estimated
39 mean difference between the two panoramic tech-
.,. S itn 100 niques with respect to percentage of sites with agree-
ment, taking account of age and percentage of intact
Intro -oral X-roy tube
RPRs were in better agreement with the intra-oral
radiographs than the IPRs, but the difference was not
significant (P=0.44).
There was agreement in ::::;30% of the sites for 37
(18.5%) patients examined with the rotational tech-
nique and 38 (19%) patients with the intra-oral X-ray
tube technique. Several factors were identified that
may have made the measurements more difficult in one
radiograph compared with the other. A large number
of angular bony defects were recorded in 30 patients
examined with RPRs and in 27 patients with IPRs.
There were extensive dental restorations in 11 and 29
100
patients respectively, while five and three had large
Figure 2 shows the relation between panoramic and
Rotational Intra - oral X.roy tube
n n
~9 An'erior ' .. '1'1 tnQalUO Be
3~ Premolar. rnoul la 47
~9 MolCJ" moli llo 39
48 Antertor IHIt'!
mandlbl,
89

IPRs 49.4±2.9%. The agreement varied from 48% to

77% of the total number of sites for the RPRs and from 32 Premolar, mandlblt 69

38% to 64% for the IPRs (Figure 1), depending on the

~
type of teeth. For some sites, the largest amount of ~~ Motors monchbla

bone loss was recorded on the intra-oral radiographs, tOO -t. Defeet, 0 0 -t. Defach 100
for others on the panoramic radiographs, but, overall,
was more often in the former. The mean percentage of a
sites where the difference between the two techniques
was at most ± 1 mm was 87.8 ± 2.3% for the RPRs and Rotation al Intra -orol X. roy tubl
86.2 ± 1.8% for the IPRs.
Premolar, mo. iUa
As agreement was found to decrease with increasing '6 II

bone loss (Table II) the percentage of intact sites (bone

level es 1 mm from cementoenamel junction) in the two 12~ Molars rna.llla 8~
groups was estimated; in the RPRs it was 41.8% and in
62 48
Table II Comparison of rotational and intra-oral X-ray tube
panoramic techniques for agreement with intra-oral radiography in 100 o 0 100
terms of marginal bone loss .,. In.ol.... rn.nl l .,. Involvement.

Marginal Rotational Intra-oral X-ray tube b

bone loss (mm) technique technique
Figure 2 Pe rcent age of agree ment and disagreemen t bet wee n pa n-
o 82 78 o rarn ic and intra -oral radiog ra phs for record ings of a. angu lar bon y
1 51 45 defects and b. furcation involveme nts by ja w region. • . Agreemen t:
2 38 32 • . disagr ee mcnt - angular bo ny defects and furcat ion invo lveme nts
3 28 32 recor ded onl y in pa no ramic radiograp hs: O . disag ree ment - angular
4 25 28 bony defects and furcation involvement s reco rded o nly in intra-ora l
>4 17 21 radiographs. n = tot al nu mber of reco rdings for ea ch site. Value s
Values are percentage of sites with agreement. within eac h histogra m arc per cent age of to tal

Dentomaxillofac. Radial., 1991, Vol. 20, August 157

Radiography of the marginal bone: B. Molander et al.

Table III Disagreement between panoramic and intra-oral radio- ment were 66% and 69% (mean 68%), 63% and 69%
graphs in the recording of angular bony defects in terms of the
reasons established in the joint evaluation
(mean 66%) and 65% and 71% (mean 68%). Inter- and
A intra-observer agreements for all three techniques were
over 90% when sites with a difference of ± 1 mm were
Reasons Rotational Intra-oral
technique radiographs
included. Another indicator of observer performance is
the agreement between each pair of techniques each
FP (%) FN (%) FP (%) FN (%) achieved in their measurements of marginal bone loss.
Difference in projection 5 24 1 15 For the rotational technique, it was 56% for one
Unsharpness I 30 0 0 observer and 62% for the other, while for the intra-oral
Difference in contrast 1 0 0 6
Observer variations 2 2 6 8
X-ray tube technique it was 51% for both.

Reasons Intra-oral X-ray Intra-oral radio-

tube technique graphs
Discussion
FP (%) FN (%) FP (%) FN (%)
Difference in projection 4 35 o 15
The mean age of the patients examined with RPR was
Unsharpness 1 7 o 0 lower and the mean percentage of intact sites was
Difference in contrast I I o 1 higher than those examined with IPR. This may explain
Observer variations 5 II 6 13 the differing levels of agreement with the intra-oral
FP. false positives: FN. false negatives. radiographs. However, when these two factors were
kept constant, there was no significant difference
between them.
intra-oral radiographs for angular bony defects and The marginal bone level has often been measured
furcation involvement. There was a variation in agree- with specifically designed rulers'" and then expressed
ment for the former from 33% to 46% in the RPRs and as a proportion of root length. However, some authors
from 35% to 51% in the IPRs, depending on the tooth believe that absolute measurements are more valid 28- 3o
examined. Furcation involvement in molars was equal- and we chose to use these because they ought to reflect
ly recorded in 60% and 59% respectively, but in only the effect of the periodontal disease unaffected by the
12% and 28% of upper premolars. length of the root. However, as the exact enlargement
Tables III and IV show the results of the joint of the teeth in the panoramic radiographs could not be
evaluation for possible reasons for the disagreements calculated for all regions in every patient, they could
over angular bony defects and furcation involvements. not always be performed accurately. This may have
The most common were projection differences and decreased the actual level of agreement between the
observer variation defined as when no obvious causes two radiographic techniques.
could be found. A large number of those with RPR In evaluating diagnostic methods, it is desirable that
were due to unsharpness. When assessed jointly the the true status of the patients is known, but this is not
disagreements were mainly due to false-negative read- often possible in radiographic studies of dental disease.
ings in one of the two types of radiograph. However, studies have been performed, as here, where
Interobserver agreement was 58% for the intra-oral only the agreement between panoramic and intra-oral
radiographs, 60% for the RPRs and 59% for the IPRs. radiographs has been determined. In order to improve
The corresponding values for the intra-observer agree- on this approach, Balis'? and Douglass et al." used a
consensus evaluation made from all the radiographs as
a gold standard. Balis also combined the radiographic
Table IV Disagreement between panoramic and intra-oral radio- evaluation with a clinical examination. Ahlqwist et al. II
graphs in the recording of furcation involvements in terms of the used intra-oral radiographs as the source of validation
reasons established in the joint evaluation data. Difficulties in evaluating radiographic methods
A from agreement between them stem from the large
observer variation which, in many cases, is larger than
Reasons Rotational Intra-oral radio-
technique graphs
the differences between the methods themselves.
Although knowledge of their diagnostic accuracy is
FP (%) FN (%) FP (%) FN (%) incomplete, radiography is usually considered essential
Difference in projection 5 16 o 13 in the diagnosis and treatment planning of periodontal
Unsharpness 2 28 o o disease": 33. Basically, there are only two methods
Difference in contrast 2 o o 9
available, panoramic and intra-oral radiography.
Observer variations I 7 5 13
Should it have turned out that the results from the
8 panoramic radiographs totally agreed with those from
the intra-oral images, then it could be argued that the
Reasons Intra-oral X-ray Intra-oral radio- methods were interchangeable. However, such a result
tube technique graphs can never be attained because of intra- and interobser-
FP (%) FN (%) FP (%) FN (%) ver variation and the results must therefore be evalu-
Difference in projection o 27 o 24 ated against this. Agreement between the imaging
Unsharpness 1 I o o modalities in this study was not very different from
Difference in contrast o I o 4 both intra- (68%) and interobserver (58%) agreement.
Observer variations I 15 1 22 Differences in marginal bone level between the two
FP. false positive: FN. false negative. radiographs were rarely larger than ± 1 mm, but did

158 Dentomaxillofac. Radiol., 1991, Vol. 20, August


increase with increasing bone loss (Table II). One
reason for this might be that the patients in the latter
category also might have had larger numbers of dental
restorations that made the measurements more diffi-
cult. Angular bony defects and furcation involvements
were not easy to record in both panoramic and intra-
oral radiographs. When the radiographs were judged
simultaneously, it was found that this was mainly due to
projection differences.
It is difficult to compare the present results with
those of previous studies, due to the wide variation in
both radiopraphic and evaluation techniques. In some
studies1o,I ,17,34, because many of the measuring
points were not clearly visible on the radiographs, a
large number of non-measurable surfaces were dis-
counted from the comparison. We wanted, however, to
use the panoramic radiographs in the more usual way,
where an estimation of the bone level is made even
though not all the measuring points are clearly
depicted. Observations cannot be excluded in evaluat-
ing a diagnostic method if the method is not satisfac-
tory, unless the number of excluded observations is also
used to describe the performance of the method. In
some studies l 7 , 35 , this type of evaluation has been
used. Rohlin et al. 34 compared rotational panoramic
with intra-oral periapical and found an agreement for
the upper arch of 66% and for the lower of 74%. These
high values may have been reached because measure-
ments were performed only on those sites judged as
readable in both sets of radiographs, 60% of the total
sites in the upper arch and 72% in the lower. In
addition, they used a ruler with larger line increments
than in our study which also could explain the better
results. Drizhal et al. 36 found 616 out of 761 teeth with
marginal bone loss when using intra-oral radiographs,
but only detected 451 of these teeth with rotational
panoramic radiographs. Fifty-three teeth were found in
the latter with marginal loss that had not been detected
in the intra-oral radiographs. It can be calculated from
these figures that the agreement for all teeth between
the two image modalities was 71 %. This is also a better
result than in the present study, but could be due to the
fact that bone loss was only recorded when present, and
not its extent. Grondahl et al. 37 found an agreement of
50% between periapical and rotational panoramic
radiographs for similar measurements of marginal bone
level. Our slightly better results could be a reflection of
improvements in panoramic technique. Although the
image quality is still lower than in intra-oral radio-
graphs, the agreement between the two is so high that it
often should be possible to use panoramic radiographs
to assess marginal bone loss. There are differences
between the two panoramic techniques for individual
teeth but the mean difference seems to be small when
differences between the groups of patients is taken into
account, and it would appear that marginal bone level
is recorded equally well with both. It is rather the easier
patient handling than differences in image quality that
makes the rotational technique the more advantageous.
The information obtained from panoramic radiographs
can serve as a guide for deciding upon supplementary
intra-oral radiography, a view that is not shared by
most other authors. The general opinion seems to be
that intra-oral radiographs should be the technique of
choice for dental radiographic examinations and panor-
amic radiographs used restrictively'": 13,18.20,21,36".
Radiography of the marginal bone: B. Molander et al.
Acknowledgements
This study was supported by grants from the Swedish
National Institute of Radiation Protection (Project SSl
P 283-84, 283-86, 283-87).
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Address: Dr Bjorn Molander. Department of Oral Radiology,
University of Gothenburg, Box 33070, S-400 33 Goteborg, Sweden.