Abstract:

The scope of the present study was to develop a computational detection system based on a Deep
Convolutional Neural Network (CNN) algorithm and to evaluate the potential usefulness and accuracy of this
system for the diagnosis and prediction of periodontally compromised teeth. (PCT). By combining a pre-
trained deep CNN architecture and a self-trained network, periapical radiographs were used to determine the
optimal CNN algorithm and weights. diagnostic and predictive accuracy, sensitivity, specificity, positive
predictive value, negative predictive value, receiver operating characteristic (ROC) curve, area under the ROC
curve, confusion matrix, and confidence intervals (95% CI) were calculated using our Deep CNN algorithm
computed based on a Keras framework in Python. The periapical X-ray data set was divided into training (n =
1044), validation (n = 348), and testing (n = 348) data sets. With the deep learning algorithm, the diagnostic
accuracy of PCT was 81.0% for premolars and 76.7% for molars. Using 64 premolars and 64 molars clinically
diagnosed as severe PCT, the accuracy in predicting extraction was 82.8% (95% CI 70.1-91). 2% for
premolars and 73.4% (95% CI, 59.9%-84.0%) for molars. We show that the Deep-CNN algorithm was useful
in assessing the diagnosis and predictability of PCT. Thus, with further optimization of the PCT data set and
improvements in the algorithm, it can be expected that a computer-aided detection system will become an
effective and efficient method for diagnosing and predicting PCT.

Keywords: Artificial intelligence; Machine learning; Periodontal diseases; Supervised machine learning , CNN , Deep
Learning.

Introduction:

Continued progression of PD leads to destruction of all periodontal supporting tissues, including alveolar
bone, gingiva and periodontal ligament around teeth, making PD considered the most common cause of
tooth loss in adults. [1,2]. Periodontal disease (PD), in its acute and chronic forms, is a common oral
lesion and the sixth most common type of inflammatory disease [3]. Many epidemiological and
experimental studies have shown that systemic chronic inflammation caused by periodontal pathogens is
a risk factor or risk indicator for comorbidities such as cardiovascular disease, diabetes mellitus, obesity,
osteoporosis, erectile dysfunction and cancer. shows [4-8]. A variety of non-surgical and surgical
methods have been developed and improved for the treatment of periodontal damaged teeth (PCT) and
supporting structures, as well as numerous studies on regenerated periodontal tissue [9,10]. Despite
therapeutic advances, PCT diagnostic and prognostic methodologies have not yet been significantly
improved. Although panoramic/periapical radiographs and periodontal probes, which are widely used as
objective diagnostic tools for diagnosing and predicting PCT, are used in conventional periodontal
examinations, clinical diagnostic and prognostic judgment depends heavily on empirical evidence [11].
Convolutional neural networks (CNNs), which are the latest, core model of artificial neural networks and
deep learning in computer vision, have developed rapidly since roughly 2010 [12].

Since medical data are digitally stored and accumulated quantitatively and qualitatively, deep CNNs with
computer-aided detection (CAD) systems have clear opportunities to be applied in the medical field, and
this very fast-growing new area of research has yielded impressive results in terms of diagnosis and
prediction in radiological and pathological research [13,14]. Although radiographic image analysis is
conventionally and widely used to diagnose and predict PD, it still tends to be used as an auxiliary means
of clinical diagnosis and prediction, and studies on the diagnosis of PCT using deep CNNs with CAD are
limited [15]. Therefore, most recently reported artificial intelligence performance has been based on deep
learning and was developed mainly for medical image classification [16,17]. Hence, the aim of the
current study was to evaluate the potential utility and accuracy of deep CNN algorithms for PCT
diagnosis and prediction.

Model training:

Her x-ray datasets and electronic dental records of all periapical teeth were collected, decoded, and
classified to determine the severity of PCT from her three calibrated, board-certified teeth. Reviewed by
peripathologists. All apical radiographs in which the three examiners' diagnoses were inconsistent were
excluded. Teeth with a clinical attachment level (CAL) of less than 3 mm were classified as healthy teeth
when clinically examined with a periodontal index probe standardized by the World Health Organization.
Teeth that bleed on probing during clinical examination and radiographically with CAL <6 mm or bone
loss <4 mm are classified as moderate PCT, teeth with CAL >6 mm and bone loss >4 mm was classified
as severe. PCT. In severe PCT, teeth extracted immediately after clinical and radiological examination or
during the 3-month follow-up period were defined as hopeless teeth. Since the differential diagnosis
between healthy teeth and early PCT was made using only apical radiographs, this study did not diagnose
or distinguish between healthy teeth and early PCT (1,440 × 1,920 pixels) and converted to PNG format.
Did. In addition, all the teeth of the upper jaw were tilted perpendicular to the shape of the teeth of the
lower jaw. A trained VGG19 network was used for preprocessing and the dataset was augmented with the
Keras framework based on the ImageDataGenerator function. This was done randomly with a rotation
range of 15°, a latitude and longitude translation range of 0.1, and a shear range of 0.5, generating 100
images for each tooth for a total of 104,400 training data set images. rice field.

CNN ARCHITECTURE:

CNN is a type of machine learning used in various fields, especially image and speech recognition. Deep
CNN mimics the connectivity patterns of neurons in the visual cortex of animals. A CNN consists of one
or more convolutional, pooling, and fully connected layers. Each convolutional layer responds to stimuli
only in a limited area of the visual field known as the receptive field. This structure differs from
traditional image classification algorithms and other deep learning algorithms. This is because CNNs can
learn filter types handcrafted by traditional algorithms. In this study, we used 16 convolutional layers and
3 fully-connected dense layers. This network is shown in Figure 1. Each convolutional layer was designed
with a core size of 3×3 pixels, the same padding, and a tuned linear unit activation function. The max
pooling layer was designed with 2 × 2 pixel increments. After extracting the feature set from the images
using convolutional layers, we used max pooling layers to reduce the location sensitivity issue and allow
for more general detection capabilities. We then connected three fully connected deep hidden layers of
1,024, 1,024, and 512 nodes, respectively, to remove spatial information and statistically determine the
significant classification of PCT. Dropout, a common regularization method (rescaling the deep CNN
weights to a more effective range), was set to 0.5 and the final output layer was classified by PCT using a
Softmax classifier. rice field. A total of 500 epochs were used and the training network weights were
learned using Stochastic Gradient Descent, Adam's algorithm (learning rate = 0.0001). To achieve better
diagnosis and prediction of PCT, after his 20 epochs of this training phase, fine-tuning was performed to
optimize the weights and improve the results by adjusting the slice hyperparameters. rice field.

Figure 1. Overall architecture of the deep CNN model. A data set of PCT images (224 × 224 pixels) is called input. Each
convolutional layer is followed by a ReLU activation function, a failure, a max pooling layer, and three fully connected layers of
1,024, 1,024, and 512 nodes, respectively. The final output layer performs three classifications using the softmax function. CNN:
convolutional neural network, PCT: periodontal damage tooth, ReLU: rectified linear unit.

STATISTICAL STUDY:

Randomization sequences were generated using the RAND function in an Excel spreadsheet (Microsoft
Corporation, Redmond, WA, USA), which was used to replace the apical radiography dataset with the
training dataset (n=1,044; 60%). ), the validation dataset (n= 348 ; 20%) and the test dataset (n=348 ;
20%). Using the training and validation datasets directly, we analyzed the PCT and supporting structures
to build the optimal weights for the deep CNN algorithm model. Using the test dataset, chi-square,
diagnostic and predictive accuracy, sensitivity, specificity, positive predictive value, negative predictive
value, receiver operating characteristic (ROC) curve, area under the ROC curve (AUC), and confusion I
have computed a matrix deep CNN. Algorithms based on Python's Keras framework (Python 3.9, Python
Software Foundation, Wilmington, DE). 95% confidence intervals (CI) were calculated. P-values less
than 0.05 were considered statistically significant.

RESULTS:

Basic function:
Baseline characteristics of the study population are shown in Table 1. A total of 651 subjects participated
in the study, including 363 (55.8%) males and 288 (44.2%) females. By age, the lowest number was in
the 20s (n=22; 3.4%), and the highest was in the 60s (n=216; 33.2%). The data set consisted of a total of
1,740 apical radiographs of 447 (25.7%) maxillary premolars, 450 (25.9%) maxillary molars, 403
(23.2%) mandibular premolars, and 440 (25.3%) mandibular molars. was 264 (15.2%) premolars and 394
(16.9%) molars were diagnosed as healthy teeth, 265 (15.2%) premolars and 297 (17.1%) molars were
diagnosed with moderate PCT, 322 (18.5%) premolars and 298 (17.1%) molars were diagnosed. %)
molars diagnosed with severe PCT. Diagnosis of PCT

Figure 2 shows the confusion matrix with and without normalization showing the results of PCT
classification. The diagonal elements are the number of points where the predicted label was identical to
the actual label, while the off-diagonal elements were misinterpreted by the classifier. The higher the
classification score and the darker the shade of blue, the more accurate the diagnosis. In premolars, the
overall diagnostic accuracy was 81.0%, with the highest diagnostic accuracy in severe PCT (82.8%) and
the lowest in moderate PCT (77.3%). In molars, the overall diagnostic accuracy was 76.7%, with the
highest diagnostic accuracy in severe PCT (81.3%) and the lowest in moderate PCT (70.3%).

CHARACTERISTIC TRAINING VALIDATION TEST DATASET P VALUE

S DATASET DATASET

PATIENTS 351(100) 149(100) 151(100) -

SEX

MALE 190(54.1) 88(59.1) 85(56.3) 0.590

FEMALE 161(45.9) 61(40.9) 66(43.7)

AGE GROUP(YR)

20-29 11(3.1) 6(4.0) 5(3.3)

30-39 12(3.4) 12(8.1) 14(9.3)

40-49 44(12.5) 21(14.1) 24(15.9) 0.349

50-59 111(31.6) 41(27.5) 39(25.8)

60-69 121(34.5) 46(30.9) 49(32.5)

>=70 52(14.8) 23(15.4) 20(13.2)

TEETH 1044(100) 348(100) 348(100) -

POSITION
 MAXILLA 0.914

PREMOLAR 261(25.0) 87(25.0) 99(28.0)

MOLAR 264(25.3) 91(26.1) 95(27.3)

MANDIBLE 0.690

PREMOLAR 253(24.2) 81(23.3) 69(19.8)

MOLAR 266(25.5) 89(25.6) 85(24.4)

CLASSIFICATION
OF DIAGNOSIS

HEALTHY 0.319
TEETH
151(14.5) 53(15.2) 60(17.2)
PREMOLAR
182(17.4) 60(17.2) 52(14.9)
MOLAR
0.325
MODERATE PCT
169(16.2) 52(14.9) 44(12.6)
PREMOLAR
180(17.2) 53(15.2) 64(18.4)
MOLAR
0.615
SEVERE PCT
194(18.6) 64(18.4) 64(18.4)
PREMOLAR
168(16.1) 66(19.0) 64(18.4)
MOLAR

Table 1. Study population and baseline characteristics of the patients and teeth

Desperate Tooth Prediction:

The accuracy of the extracted predictions was evaluated and compared between CNN and blinded board-
certified periodontologists. His 64 premolars and 64 molars in the test dataset were diagnosed with severe
his PCT. For premolars, the deep CNN had an accuracy of 82.8% (95% CI, 70.1%-91.2%) and an AUC
of 82.6% (95% CI, 71.1%-91.1%), although periodontist response was values of 79.7% (95% CI, 66.7%-
88.5%) and 79.3% (95% CI, 67.4%-88.4%), respectively. Thus, although deep CNN had higher AUC
values for her, there was no statistically significant difference in prediction accuracy between the two
methods (P = 0.150). For molars, the deep CNN had an accuracy of 73.4% (95% CI, 59.9%-84.0%) and
an AUC of 73.4% (95% CI, 60.9%-83.7%), but periodontologist response values of 76.6% (95% CI,
63.2%-86.5%) and 76.4% (95% CI, 64.1%-86.1%), respectively. Thus, his AUC values for periodontists
were higher, but similar to premolars, there was no statistically significant difference in prediction
accuracy between the two methods (P = 0.151, Table 2 ).

Multiclass classification confusion matrix:

Recent studies have investigated the potential usefulness and accuracy of artificial intelligence
approaches in interpreting medical images such as clinical photographs, X-rays, computed tomography
(CT), magnetic resonance imaging (MRI), and positron emission tomography scans. There are several In
particular, the Deep-CNN algorithm is the most widely used, with promising results. As a result,
supervised deep learning based on the CNN algorithm was performed in this study using a pre-labeled
apical X-ray dataset. We also confirmed that the diagnostic and predictive accuracy of the results was
comparable to that of a certified periodontist. In this study, we found that the deep CNN algorithm has
higher diagnostic accuracy for identifying His PCT in premolars than in molars. Although we excluded
aberrant anatomical variations to minimize complication as much as possible, these results suggest that
anterior premolars, which usually have one root, are more common than two-rooted mandibular or three-
rooted maxillary molars. This may be due to the high efficiency of deep learning for molars. In addition,
there was a tendency to judge that the PCT is more severe. The overall diagnostic accuracy of his PCT in
severe was the highest, and the pre-trained deep CNN algorithm was optimized for detecting his PCT in
severe. Further research on the mechanisms underlying deep CNN algorithms is needed. Distinguishing
between PD and caries is very important, and edge detection needs to be done properly in the case of
destructive PD to improve diagnosis and prediction.PCT accuracy. Unlike traditional shallow learning
algorithms, deep CNN algorithms can automatically learn hierarchical feature representations and detect
regional patterns from her PCT images with multiple convolutional and hidden layers. Wang reported that
deep CNN algorithms can efficiently perform edge detection with only two convolutional layers and he
one fully connected hidden layer. Therefore, deep CNN architecture was chosen for use in this study due
to its structurally powerful advantages in solving the detection problem. The deep CNN algorithm used in
the current study was developed based on the VGG-19 network architecture. Consisting of 16
convolutional layers and 2 fully connected layers, this architecture is well-suited for deep learning and
highly effective in solving object detection and image classification problems in complex non-medical
image data.
Figure 2.Multiclass classification confusion matrix with and without normalization using a deep CNN classifier. The diagonal
elements are the number of points where the predicted label was identical to the actual label, while the off-diagonal elements
were misinterpreted by the classifier. The higher the diagonal value and the darker the shade of blue, the more accurate the
diagnosis of premolars in healthy, periodontally damaged teeth (A, B) with or without normalization. (C, D) Molars without/with
normalization.

However, because of the need to classify black-and-white PCT images that are similar in size and shape,
the VGG-19 network architecture has the potential for poor learning efficiency without correction, which
can lead to poor learning efficiency. A potential problem was considered. Greatly increases overfitting.
Therefore, we modify the VGG-19 network architecture to adjust the number and hyperparameters of
convolutional and hidden layers, such as the number of epochs, stack size, loss function, optimizer,
momentum, and learning rate, to deal with overfitting. , allowing for possible and efficient deep learning
performance. Rapid and accurate diagnosis and prediction are key components of PD treatment, and
optimization of speed and accuracy is an ongoing research challenge in CAD. There are three main
factors that complicate this task. The first limitation of this study is that relatively few images of his PCT
were used, including premolars and molars. To achieve good artificial intelligence performance in deep
learning, the design of the deep CNN algorithm itself is important, but so is the use of high-quality
training datasets. In a recent study to detect diabetic retinopathy, 54 ophthalmologists repeatedly read his
130,000 fundus photographs. In another study of

VARIABLES ACCURACY(%, AUC(%,95% CI) DIFFERENCE(%, 95% P

95% CI) CI) VALUE

PREMOLAR 3.3(-1.2-7.8) 0.150

DEEP CNN 82.8(70.1-91.2) 82.6(71.1-91.1)

PERIODO
NTIST 79.9(66.7-88.5) 79.3(67.4-88.4)

MOLAR 2.9(-1.0-6.9) 0.151

DEEP CNN 73.4(59.9-84.0) 73.4(60.9-83.7)

PERIODONTIST 76.6(63.2-86.5) 76.4(64.1-86.1)

Table 2. Pairwise Comparison of Deep CNN Algorithms and Periodontists for Predicting Desperate Teeth

For skin cancer diagnosis, 18 doctors systematically read her 130,000 digital skin images of over 200 skin
diseases as training data. The rapid evolution of unsupervised or semi-supervised deep learning
algorithms that do not use pre-trained datasets, such as Generative Adversarial Networks (GANs) and
reinforcement learning, has made the training dataset itself less important. I'm here. Nonetheless,
maintaining and protecting high-quality datasets remains critical to deep learning approaches. Therefore,
to overcome the limitation of the number of images required for deep learning, we collected only the
highest quality images that were most clearly classified by her three experienced periodontists.
Additionally, transfer learning and preprocessing techniques, including image amplification and
enhancement, were used to avoid overfitting and normalize the model. Another limitation is the
impossibility of fully diagnosing and predicting PD using only two-dimensional apical radiographs.
Radiological and clinical data such as patient history, clinical probing depth, CAL, bleeding on probing,
mobility, percussion, and electropulp tests should be comprehensively considered for more accurate
diagnosis and prediction of PD. there is. Therefore, a deep CNN algorithm using only periapical
radiographs does not provide sufficient evidence, but can be used as a diagnostic and prognostic reference
for PCT. Nevertheless, his three-dimensional deep CNN algorithm using CT and MRI data was
implemented in this study, and models associated with this algorithm were further developed and refined
in this study. 3D deep CNN algorithms are even more useful for advanced and effective diagnosis and
prediction. As a final caveat, much of the previous deep CNN research used scaled-down, low-resolution
medical images instead of high-resolution large matrix images due to limitations in computational power,
storage space, cost, and training time. was doing. Images used in the current study have also been cropped
and scaled to 224 × 224 pixels for convenience. Therefore, it is likely that the use of low-resolution
datasets in this study reduced the diagnostic and predictive accuracy of PCT. Deep learning algorithms
are currently being developed and improved with amazing accuracy in diagnosis and prediction,
especially in the fields of radiology and pathology.
Conclusions:
We have shown that the Deep CNN algorithm is useful for evaluation PCT diagnosis and predictability.
Therefore, further optimization of the PCT data set yields Algorithm improvements hold promise for
computer-aided recognition systems To be an effective and efficient method for diagnosing and
predicting PCT.

References:

[1].Lee JH, Oh JY, Choi JK, Kim YT, Park YS, Jeong SN, et al. Trends in the incidence of tooth
extraction due to periodontal disease: results of a 12-year longitudinal cohort study in South Korea. J
Periodontal Implant Sci 2017;47:264-72.
[2].Lee JH, Lee JS, Choi JK, Kweon HI, Kim YT, Choi SH. National dental policies and socio-
demographic factors affecting changes in the incidence of periodontal treatments in Korean: A nationwide
populationbased retrospective cohort study from 2002-2013. BMC Oral Health 2016;16:118.
[3].Tonetti MS, Jepsen S, Jin L, Otomo-Corgel J. Impact of the global burden of periodontal diseases on
health, nutrition and wellbeing of mankind: a call for global action. J Clin Periodontol 2017;44:456-62.
[4].Martins SH, Novaes AB Jr, Taba M Jr, Palioto DB, Messora MR, Reino DM, et al. Effect of surgical
periodontal treatment associated to antimicrobial photodynamic therapy on chronic periodontitis: A
randomized controlled clinical trial. J Clin Periodontol 2017;44:717-28.
[5].Ainamo J, Barmes D, Beagrie G, Cutress T, Martin J, Sardo-Infirri J. Development of the World
Health Organization (WHO) community periodontal index of treatment needs (CPITN). Int Dent J
1982;32:281-91
[6].Sklan JE, Plassard AJ, Fabbri D, Landman BA. Toward content based image retrieval with deep
convolutional neural networks. Proc SPIE Int Soc Opt Eng 2015;9417.
[7].Rajpurkar P, Irvin J, Zhu K, Yang B, Mehta H, Duan T, et al. CheXNet: radiologist-level pneumonia
detection on chest X-rays with deep learning. arXiv e-print 2017;arXiv:1711.05225.
[8].Rajpurkar P, Hannun AY, Haghpanahi M, Bourn C, Ng AY. Cardiologist-level arrhythmia detection
with convolutional neural networks. arXiv e-print 2017:arXiv:1707.01836
[9].Graziani F, Karapetsa D, Alonso B, Herrera D. Nonsurgical and surgical treatment of periodontitis:
how many options for one disease? Periodontol 2000 2017;75:152-88.
[10].Lee JH, Lee JS, Park JY, Choi JK, Kim DW, Kim YT, et al. Association of lifestyle-related
comorbidities with periodontitis: a nationwide cohort study in Korea. Medicine (Baltimore)
2015;94:e1567.
[11].Lee JH, Choi JK, Kim SH, Cho KH, Kim YT, Choi SH, et al. Association between periodontal flap
surgery for periodontitis and vasculogenic erectile dysfunction in Koreans. J Periodontal Implant Sci
2017;47:96-105.
[12].Lee JH, Oh JY, Youk TM, Jeong SN, Kim YT, Choi SH. Association between periodontal disease
and noncommunicable diseases: A 12-year longitudinal health-examinee cohort study in South Korea.
Medicine (Baltimore) 2017;96:e7398.
[13].Choi JK, Kim YT, Kweon HI, Park EC, Choi SH, Lee JH. Effect of periodontitis on the development
of osteoporosis: results from a nationwide population-based cohort study (2003-2013). BMC Womens
Health 2017;17:77.
[14].Lee JH, Kweon HH, Choi JK, Kim YT, Choi SH. Association between periodontal disease and
prostate cancer: results of a 12-year longitudinal cohort study in South Korea. J Cancer 2017;8:2959-65.
[15].Kim TS, Obst C, Zehaczek S, Geenen C. Detection of bone loss with different X-ray techniques in
periodontal patients. J Periodontol 2008;79:1141-9.
[16].Litjens G, Kooi T, Bejnordi BE, Setio AA, Ciompi F, Ghafoorian M, et al. A survey on deep
learning in medical image analysis. Med Image Anal 2017;42:60-88.
[17].Garcia-Hernandez JJ, Gomez-Flores W, Rubio-Loyola J. Analysis of the impact of digital
watermarking on computer-aided diagnosis in medical imaging. Comput Biol Med 2016;68:37-48.
[18].L. Jin, T. Tian, D. Liu, H. Mao and H. Liu, "·Reconstituting Organ-Level Periodontal Soft Tissue on
a Chip," 2021 21st International Conference on Solid-State Sensors, Actuators and Microsystems
(Transducers), 2021, pp. 707-710, doi: 10.1109/Transducers50396.2021.9495506.
[19].A. V. Demidov, E. V. Udaltsova and S. M. Gerashchenko, "Development of the System for
Assessment of Periodontal Tissue State," 2021 Ural Symposium on Biomedical Engineering,
Radioelectronics and Information Technology (USBEREIT), 2021, pp. 0027-0029, doi:
10.1109/USBEREIT51232.2021.9455109.
[20].T. Kabir et al., "An End-to-end Entangled Segmentation and Classification Convolutional Neural
Network for Periodontitis Stage Grading from Periapical Radiographic Images," 2021 IEEE International
Conference on Bioinformatics and Biomedicine (BIBM), 2021, pp. 1370-1375, doi:
10.1109/BIBM52615.2021.9669422.
[21].S. Islam, A. Kim, G. Hwang and S. H. Song, "Smart Tooth System for In-Situ Wireless PH
Monitoring," 2021 21st International Conference on Solid-State Sensors, Actuators and Microsystems
(Transducers), 2021, pp. 755-758, doi: 10.1109/Transducers50396.2021.9495706.
[22].J. Hyttinen, P. Fält, H. Jäsberg, A. Kullaa and M. Hauta-Kasari, "Computational Filters for Dental
and Oral Lesion Visualization in Spectral Images," in IEEE Access, vol. 9, pp. 145148-145160, 2021,
doi: 10.1109/ACCESS.2021.3121815.