How many times have you been fooled by an optical illusion, seeing a vase where there is the profile of two faces, or a slightly odd-looking duck where there is actually also an obscure image of a rabbit? It can often be a concern in healthcare when it comes to reading intraoral and extraoral images.
In many cases, a radiograph can be read as clear as day by a clinician who is appropriately trained to read it. However, there are circumstances where the process may be more prone to error.
In the case of “interpretation”, clinicians must account for the potential for human error, and identify steps that can be taken to reduce radiographic misinterpretation.
Identifying misdiagnoses
As with all other areas of dentistry, radiographs should only be read by individuals that are adequately trained and competent, and have the skills and experience to read them safely.[i], [ii] However, radiologic errors are still possible. These can be divided into cognitive and perceptual mistakes. Cognitive errors account for 20-40% of problems, where an abnormality is identified, but the significance is incorrectly understood or reported. Perceptual errors are more common, occurring in 60-80% of instances, where the professional fails to identify an abnormality, but it is deemed visible in retrospect.[iii]
The literature has also discussed the impact of cognitive biases. These could include the likes of confirmation, availability and overconfidence bias.[iv] Clinicians should record their interpretations of radiographs in great detail. If an opportunity to improve is identified later in the treatment process, the interpretations can then be revisited, and potentially used to inform any changes to the radiographic workflow.
Some steps are being taken to reduce the likelihood of cognitive and perceptual errors, including the development of AI systems. However, many clinicians feel that current AI development in dental imaging is not mature enough and requires improvement before it is implemented in clinical routine.[v]
Planning ahead
If radiographs are misinterpreted, clinicians may be more likely to misdiagnose and overtreat a patient.
Take the diagnosis of caries, the most common noncommunicable disease worldwide,[vi] as an example. A carious lesion appears radiolucent in a radiographic image, differentiating it from healthy portions of the dentition.[vii] However, instances of cervical burnout, Mach band effect, background density effect, the use of radiolucent restorative material and dental anomalies (such as dental enamel hypoplasia) may all create radiolucent but non-carious aspects of the dentition, causing misdiagnosis following the review of a bitewing radiograph,vii and prompt subsequent unnecessary treatment.
The impact of a radiolucent restorative material is particularly interesting. In this instance a previous restoration is wrongly perceived as a cause for concern. This misidentification may bring about unnecessary overtreatment.
Restorative materials may be difficult to differentiate from carious lesions due to their thickness, density, atomic number, and the X-ray beam energy creating an image that may be misinterpreted.vii In particular, adhesive systems that are not sufficiently radiopaque may result in radiolucent images suggestive of secondary caries, gaps or a lack of material at the tooth/resin interface.[viii] If, based on this information, a dental restoration is removed, patients may undergo unnecessary removal of healthy dental tissue, risking the health of the dental pulp.viii
To avoid misdiagnosis and overtreatment in this circumstance, two things can be done. The clinician reading the radiograph should look for the well-defined and smooth outlines that are illustrative of a radiolucent restorative material.vii Otherwise, the dental professional placing the initial restoration may choose a radiopaque solution that altogether minimises the risk of misinterpretation.
Both instances require clinicians to develop their knowledge of each modern workflow.
Choosing the right material
Clinicians providing restorative care could choose effective, radiopaque materials, such as the award-winning* Scotchbond Universal Plus Adhesive from Solventum, formerly 3M Health Care. It is the first radiopaque universal adhesive, reducing the risk of overtreatment, which also bonds and seals caries-affected dentine effectively, supporting minimally invasive dentistry. Clinicians can see an instant impact to their restorative workflows, and the Scotchbond Universal Plus Adhesive has now been formulated to add greater control and predictability over its outstanding predecessor.
The misinterpretation of radiographic images is detrimental to patient health, and should be avoided at all costs. By constantly reviewing their workflows, clinicians may be able to identify opportunities to change and improve their care.
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*Dental Advisor awards 2024, Top Universal Bonding Agent, Scotchbond Universal Plus Adhesive https://www.dentaladvisorawards.com/products/3m-tm-scotchbond-tm-universal-plus-adhesive
About Solventum
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[i] Care Quality Commission, (2023). Dental mythbuster 3: Dental radiography and X-rays. (Online) Available at: https://www.cqc.org.uk/guidance-providers/dentists/dental-mythbuster-3-dental-radiography-x-rays [Accessed July 2024]
[ii] Care Quality Commission, (2023). Regulation 12: Safe care and treatment. (Online) Available at: https://www.cqc.org.uk/guidance-providers/regulations/regulation-12-safe-care-treatment [Accessed July 2024]
[iii] Brady, A. P. (2017). Error and discrepancy in radiology: inevitable or avoidable?. Insights into imaging, 8, 171-182.
[iv] Rehder, O., Noack, M. J., Zirkel, C., & Wicht, C. (2021). Recognition and prevention of cognitive biases and judgment errors in diagnostics and dental therapy. Animal-assisted therapy in the dental practice, 3, 231-237.
[v] Putra, R. H., Doi, C., Yoda, N., Astuti, E. R., & Sasaki, K. (2022). Current applications and development of artificial intelligence for digital dental radiography. Dentomaxillofacial Radiology, 51(1), 20210197.
[vi] World Health Organization, (2017). Sugars and dental caries. (Online) Available at: https://www.who.int/news-room/fact-sheets/detail/sugars-and-dental-caries [Accessed July 2024]
[vii] Secgin, C. K., Gulsahi, A., & Arhun, N. (2016). Diagnostic challenge: Instances mimicking a proximal carious lesion detected by bitewing radiography. Oral Health Dent. Manag, 15, 1-5.
[viii] de Moraes Porto, I. C. C., Honório, N. C., Amorim, D. A. N., de Melo Franco, Á. V., Penteado, L. A. M., & Parolia, A. (2014). Comparative radiopacity of six current adhesive systems. Journal of Conservative Dentistry and Endodontics, 17(1), 65-69.
