|Year : 2021 | Volume
| Issue : 11 | Page : 1656-1661
Prevalence of apical periodontitis between root canal-treated and non-treated teeth and between genders: A cross-sectional CBCT study
M Mashyakhy1, M Alkahtany2
1 Department of Restorative Dental Science, College of Dentistry, Jazan University, Jazan, Saudi Arabia
2 Department of Restorative Dental Sciences, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||13-Oct-2020|
|Date of Acceptance||27-Apr-2021|
|Date of Web Publication||15-Nov-2021|
Dr. M Mashyakhy
Department of Restorative Dental Sciences, College of Dentistry, Jazan University, Jazan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Apical periodontitis (AP) is one of the most important prognostic factors in almost all endodontic outcome studies. The high prevalence of AP has been reported in different populations. Aims: The aim of the present study was to investigate (a) the overall prevalence of AP among all permanent teeth, (b) the differences between root canal-treated (RCT) and non-treated teeth in association with AP, and (c) the influence of gender on AP in a Saudi Arabian population using cone-beam computed tomography (CBCT). Materials and Methods: A total of 208 CBCT radiographs (including 5,504 permanent teeth) were investigated. The CBCT machine used in this study was a 3D Accuitomo 170 (Morita, Japan) with the following features: 90 kV, 5–8 mA, 17.5 s exposure time, and 0.25 mm voxel size. The radiographs of the axial, coronal, and sagittal segments of each tooth were acquired to evaluate the presence or absence of RCT teeth and AP. The data were presented as frequencies and percentages. Z test was used to analyze the differences in proportions at the significance level of P < 0.05. Results: The overall prevalence of AP was 4.5% (264 out of 5,504 permanent teeth). AP had the highest frequencies in the mandibular and maxillary first molars (18.4 and 9.3%, respectively) with a higher prevalence in the maxillary teeth. AP was associated with endodontically treated teeth more than the untreated ones (66.3% compared with 33.7%) with a highly significant difference (P < 0.001). AP was more prevalent in females than in males but with no statistically significant difference (P > 0.05). Conclusion: AP had a low prevalence (4.5%) in all permanent teeth and was highly associated with RCT teeth (66.3%). First molars had the highest prevalence of AP. Care must be taken when examining patient radiographs to avoid missing AP, particularly in RCT teeth.
Keywords: Apical periodontitis, CBCT, cross-sectional study, root canal-treated teeth, Saudi population
|How to cite this article:|
Mashyakhy M, Alkahtany M. Prevalence of apical periodontitis between root canal-treated and non-treated teeth and between genders: A cross-sectional CBCT study. Niger J Clin Pract 2021;24:1656-61
|How to cite this URL:|
Mashyakhy M, Alkahtany M. Prevalence of apical periodontitis between root canal-treated and non-treated teeth and between genders: A cross-sectional CBCT study. Niger J Clin Pract [serial online] 2021 [cited 2021 Nov 27];24:1656-61. Available from: https://www.njcponline.com/text.asp?2021/24/11/1656/330474
| Introduction|| |
Apical periodontitis (AP) is a pathological term that describes the local inflammatory response of apical tissues related to the tooth apex because of a microbial infection within the root canal system (RCS)., One of the most important prognostic factors in almost all outcome studies is the presence of AP prior to root canal treatment or retreatment.[3–5] The prevalence of AP has been reported in many cross-sectional studies in different populations with an alarming number ranging from 6.2 to 58% with a substantially different frequency among root canal-treated (RCT) teeth.[6–10] Microorganisms within the RCS are the main cause of AP,, and post-treatment endodontic disease leading to apical lesions can be revealed by radiographic examination. AP is present quite often in RCT teeth,[14–16] although infection in the RCS that can cause AP may occur in treated and non-treated teeth.
AP is usually asymptomatic and routinely found as apical radiolucencies during radiographic examination in regular dental visits. Panoramic and periapical radiographs, with their inherent limitations, are widely used in regular dental examinations to assess and evaluate AP., However, this 2-D technology can distort some important anatomical structures and superimpose and mask important details., In addition, this technology is not consistent in detecting lesions that are limited to the cancellous bone and cannot reach the cortical plates. Cone-beam computed tomography (CBCT) is currently utilized to overcome these limitations. CBCT is a 3-D imaging modality that allows the visualization of dental anatomy in all planes (coronal, sagittal, and axial), which improves its overall diagnostic ability in vivo.,, In addition, CBCT has shown excellent accuracy value in detecting AP; CBCT found lesions that conventional radiography failed to detect.[24–30]
A literature search revealed that only one study using panoramic radiography evaluated the prevalence of AP in a Saudi Arabian population, but no study has used CBCT. Also, a few CBCT studies on AP in different populations were found.,,, Therefore, the aim of the present study was to evaluate the overall prevalence of AP in all permanent teeth among a Saudi Arabian population using CBCT and comparing them to the other studies utilizing the same methodology. Differences between RCT and non-treated teeth in association with AP and the influence of gender on AP were also investigated as secondary objectives.
| Materials and Methods|| |
The sample size for the current cross-sectional study was based on the findings of a previous investigation. The earlier study indicated that around 5.9% of a study sample of 656 had AP. Therefore, with an alpha set at 5% and an addition of 10% for a possibility of dropouts, the sample size using the OPENEPI software was estimated at 105. This radiographic cross-sectional study included the CBCT scans of 208 subjects (100 males and 108 females) with 5,504 permanent teeth. The scans were collected for the patients who attended the College of Dentistry of Jazan University in Saudi Arabia between 2018 and 2020 with a mean age of 28.74 ± 9.56 years. The CBCT scans were obtained for different diagnostic reasons other than endodontics. The institute's ethical approval was attained before commencing the study (CODJU-19682). All permanent teeth were included in the investigation. Fractured teeth, distorted/unclear images, remaining roots, impacted teeth, and deciduous or permanent teeth with immature apices were excluded. The CBCT machine used in this study was a 3D Accuitomo 170 (Morita, Japan) with the following features: 90 kV, 5–8 mA, 17.5 s exposure time, and 0.25 mm voxel size. The software imaging program, i-Dixel 3D (Morita, Japan), was used to process the CBCT radiographs. The scans of axial, coronal, and sagittal segments were acquired to investigate whether the teeth are RCT or not and to evaluate the presence of apical radiolucency in a given tooth. Periapical periodontitis was considered when the low-density area associated with the radiographic apex was at least twice the width of the periodontal ligament space and/or when the disruption of the lamina dura was detected., Twenty CBCT images were evaluated twice with an interval of 2 weeks for reliability. Cohen's kappa test was used, and the results revealed a kappa value of 0.94 with a high significance level (P < 0.001).
The collected data were uploaded in a statistical software program for Windows (SPSS V25; IBM, Chicago, IL). The results were presented as frequencies and percentages. Z test was used to determine the significance of difference in proportions at P < 0.05.
| Results|| |
A total of 5,504 permanent teeth were investigated in this study, of which 246 (4.5%) teeth had AP. In addition, 246 teeth (4.5%) had root canal treatment. Mandibular and maxillary first molars presented the highest frequency of AP (18.4 and 9.3%, respectively). The presence of AP in the maxillary teeth was higher than in the mandibular teeth. As expected, AP was associated with endodontically treated teeth more than untreated teeth (66.3% compared with 33.7%) with a highly significant difference (P < 0.001). The same was observed in the maxillary and mandibular teeth. The prevalence of AP was higher in the females than in males but without significant difference (P > 0.05; [Table 1]).
|Table 1: Overall prevalence of apical periodontitis among teeth according to RCT and gender|
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[Table 2] shows the prevalence of AP among the maxillary teeth. Its prevalence was higher in the maxillary first molars (9.3%) and maxillary centrals (7.8%). All maxillary endodontically treated canine teeth, 94.7% of maxillary second premolars, and 75.0% of maxillary first premolars were significantly associated with AP (all P < 0.001). In general, the prevalence of AP was higher among RCT teeth than untreated teeth with significant difference (P < 0.05; [Table 2]). Mandibular endodontically treated canines and first premolars (100%), mandibular second molars (66.7%), and mandibular first molars (62.9%) were significantly (P < 0.05) associated with AP. It was more associated with untreated mandibular central and lateral incisors unlike maxillary teeth in which AP was more associated with treated teeth. More details are shown in [Table 3].
|Table 2: Prevalence of apical periodontitis among all and RCT maxillary teeth|
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|Table 3: Prevalence of periapical radiolucency among all and RCT mandibular teeth|
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Differences between males and females to the prevalence of AP are presented in [Table 4]. No significant differences were observed in the prevalence of AP between both genders except for maxillary first premolars in which 93.8% of the teeth (n = 15) with AP were found in females and only 6.2% (n = 1) in males.
|Table 4: Prevalence of apical periodontitis according to gender among all maxillary and mandibular teeth|
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| Discussion|| |
This is the first study in a Saudi population utilizing CBCT and it was used in this retrospective cross-sectional study because it is more accurate in detecting AP compared to conventional radiography.,, A study showed a substantial difference among CBCT, periapical, and panoramic radiograph in detecting apical radiolucency in the same teeth (63.3, 35.3, and 17.6%, respectively). The same author found that conventional radiography might underestimate AP prevalence because approximately 30–50% mineralized bone loss is needed for the radiographic detection of a lesion. By contrast, CBCT overestimates the presence of AP and shows a false-positive result in RCT teeth. Small field of view (FOV) is recommended in endodontics to precisely detect apical pathoses. However, we included full head scans in this prevalence study to provide a true convenient sample where the scans were taken for different diagnostic reasons other than endodontics. Small FOV for endodontics were excluded to remove the bias of including scans that already included AP.
We evaluated the prevalence of AP in 5,504 teeth and found that the overall frequency of AP was 4.5%, which is very similar to the other recent studies that utilized CBCT in different populations (3.4, 5.8 and 5.9% in Brazilian, Scottish, and Belgian population, respectively) and lower than a report from Portuguese population 10.4%.
A previous study by Estrela et al. concluded that CBCT imaging modality had a higher sensibility for AP detection and conventional radiographs tend to underestimate the presence of apical radiolucency. However, a recent panoramic radiographic study in a Saudi population from different cities evaluated 926 patients (25,028 teeth) and reported a slightly higher frequency of AP 6.2% compared to our results. In addition, our findings fell within the lower range (1.4–15.1%) of previous studies that used panoramic radiographs,,
The accuracy of CBCT might be related to the nature of the sample and study design, where patients referred for endodontic treatment or teeth with previous RCT may normally present with AP, and once you compared the frequency of AP in these samples, CBCT will show more prevalence because of its accuracy. While this is not the case once the sample was collected from different patients who were exposed to radiography for different diagnostic and treatment purposes. It seems that there is no difference in the frequency of AP detected by panoramic radiography and CBCT, with the panoramic imaging modality having the advantage of being more accessible, cheaper, and giving a complete overview of all the teeth at once.
AP was more frequent in maxillary teeth (5.1%) compared with mandibular teeth (3.8%). Mandibular and maxillary first molars presented the highest frequency of AP (18.4 and 9.3%, respectively). This finding is in agreement with the previous studies., The higher frequency of AP in first molars might be explained by the early eruption of first molars and their complex occlusal and internal root anatomy, which make them more prone to caries and result in difficulties in appreciating their RCT during chemo-mechanical shaping and cleaning.,,
One interesting finding as a secondary finding of this study was that the prevalence of RCT teeth (4.5%, 246 out of 5,504 teeth) among the samples was the same as AP (4.5%). However, the presence of AP was significantly associated with endodontically treated teeth compared with non-treated teeth (66.3 and 33.7%, respectively; P < 0.001). This finding is consistent with three previous CBCT studies,,, which presented a strong association between RCT teeth and AP (55.5, 55.5, and 59.5%, respectively).
This finding is best explained by the presence of microorganisms within the RCS of RCT teeth as a consequence of the inability of clinicians to perform adequate endodontic treatment., In addition, outcome studies have reported many factors associated with failed RCT, including poor root canal filling, missed canals, remaining intercanal infection, improper coronal seal, and iatrogenic errors, which lead to the presence or persistence of AP.[45–49]
The influence of gender on AP was also investigated in the present study, and the results showed no association between gender and the presence of AP. We found that females tend to have a higher frequency of AP compared with males with no statistically significant difference (P > 0.05) except for maxillary first premolars, in which 15 teeth with AP were found in females and only one tooth with AP was found in males. Another study in the same population used panoramic radiography and reported no differences in gender in association with AP. Other studies utilized CBCT in Belgium, Brazilian, Scottish populations and found no substantial difference in the prevalence of AP between males and females. Our findings and other previously mentioned studies showed that gender appears to have no influence on the presence or absence of apical pathology.
The main limitation of the present study is its nature as a cross-sectional evaluation of a given situation at a certain point in time in the investigated population. This type of study lacks important information, including the preoperative diagnosis of a tooth, time since the treatment was done, the quality of the treatment, and the skills of the practitioner, which affect the outcome; therefore, a cause-effect relationship cannot be established. However, these types of studies notify about illnesses that represent the real clinical situations which need to be addressed and managed properly by establishing preventive measures.
Based on our findings and in comparison with the previous studies that utilized both conventional or CBCT imaging modalities, we could recommend not to expose a patient for CBCT for the sake of finding apical pathosis. Instead, panoramic radiograph should be the first line in examining the patient for a comprehensive diagnosis then periapical radiography and/or small FOV CBCT if more details are needed.
New retrospective studies comparing the prevalence of AP using panoramic radiography and CBCT of the same patients are recommended to detect the accuracy of detection of apical pathoses.
| Conclusion|| |
The overall prevalence of AP and RCT teeth was 4.5%, and AP was highly prevalent in the first molars. The frequency of AP was highly associated with RCT teeth 66.3%. Gender had no significant influence in the presence of AP. CBCT and conventional radiography of a patient should be carefully evaluated for the presence of AP, especially in RCT teeth.
MM and MA participated in the design of the study, data collection, interpretation of the data and drafted the manuscript. All authors read and approved the final manuscript.
We would like to thank Dr. Rawan Alfaifi, Dr. Fatimah Hadi, and Dr. Hashimah Alhazmi for their help in collecting and organizing the data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nair PN. Apical periodontitis: A dynamic encounter between root canal infection and host response. Periodontol 2000 1997;13:121–48.
Abbott PV. Classification, diagnosis and clinical manifestations of apical periodontitis. Endod Top 2004;8:36–54.
Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod 1990;16:498–504.
Marquis VL, Dao T, Farzaneh M, Abitbol S, Friedman S. Treatment outcome in endodontics: The Toronto study. Phase III: Initial treatment. J Endod 2006;32:299–306.
Liang Y-H, Li G, Wesselink PR, Wu M-K. Endodontic outcome predictors identified with periapical radiographs and cone-beam computed tomography scans. J Endod 2011;37:326–31.
Al-Nazhan SA, Alsaeed SA, Al-Attas HA, Dohaithem AJ, Al-Serhan MS, Al-Maflehi NS. Prevalence of apical periodontitis and quality of root canal treatment in an adult Saudi population. Saudi Med J 2017;38:413–21.
Meirinhos J, Martins JNR, Pereira B, Baruwa A, Gouveia J, Quaresma SA, et al
. Prevalence of apical periodontitis and its association with previous root canal treatment, root canal filling length and type of coronal restoration-A cross-sectional study. Int Endod J 2020;53:573–84.
Huumonen S, Suominen AL, Vehkalahti MM. Prevalence of apical periodontitis in root filled teeth: Findings from a nationwide survey in Finland. Int Endod J 2017;50:229–36.
Chala S, Abouqal R, Abdallaoui F. Prevalence of apical periodontitis and factors associated with the periradicular status. Acta Odontol Scand 2011;69:355–9.
Song M, Park M, Lee C-Y, Kim E. Periapical status related to the quality of coronal restorations and root fillings in a Korean population. J Endod 2014;40:182–6.
Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol 1965;20:340–9.
Sundqvist G. Ecology of the root canal flora. J Endod 1992;18:427–30.
Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. J Endod 2008;34:273–9.
Saunders WP, Saunders EM, Sadiq J, Cruickshank E. Technical standard of root canal treatment in an adult Scottish sub-population. Br Dent J 1997;182:382–6.
De Moor RJ, Hommez GM, De Boever JG, Delme KI, Martens GE. Periapical health related to the quality of root canal treatment in a Belgian population. Int Endod J 2000;33:113–20.
Lopez-Lopez J, Jane-Salas E, Estrugo-Devesa A, Castellanos-Cosano L, Martin-Gonzalez J, Velasco-Ortega E, et al
. Frequency and distribution of root-filled teeth and apical periodontitis in an adult population of Barcelona, Spain. Int Dent J 2012;62:40–6.
Van der Veken D, Curvers F, Fieuws S, Lambrechts P. Prevalence of apical periodontitis and root filled teeth in a Belgian subpopulation found on CBCT images. Int Endod J 2017;50:317–29.
Katebzadeh N, Hupp J, Trope M. Histological periapical repair after obturation of infected root canals in dogs. J Endod 1999;25:364–8.
Bender IB, Seltzer S. Roentgenographic and direct observation of experimental lesions in bone: II. 1961. J Endod 2003;29:707–12; discussion 701.
American Association of Endodontists; American Academy of Oral and Maxillofacial Radiology. Use of cone-beam computed tomography in endodontics Joint Position Statement of the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:234–7.
LeQuire AK, Cunningham CJ, Pelleu GBJ. Radiographic interpretation of experimentally produced osseous lesions of the human mandible. J Endod 1977;3:274–6.
Patel S, Brown J, Pimentel T, Kelly RD, Abella F, Durack C. Cone beam computed tomography in Endodontics-A review of the literature. Int Endod J 2019;52:1138–52.
Nair MK, Nair UP. Digital and advanced imaging in endodontics: A review. J Endod 2007;33:1–6.
Lofthag-Hansen S, Huumonen S, Gröndahl K, Gröndahl H-G. Limited cone-beam CT and intraoral radiography for the diagnosis of periapical pathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:114–9.
Low KMT, Dula K, Burgin W, von Arx T. Comparison of periapical radiography and limited cone-beam tomography in posterior maxillary teeth referred for apical surgery. J Endod 2008;34:557–62.
Abella F, Patel S, Duran-Sindreu F, Mercade M, Bueno R, Roig M. Evaluating the periapical status of teeth with irreversible pulpitis by using cone-beam computed tomography scanning and periapical radiographs. J Endod 2012;38:1588–91.
Pope O, Sathorn C, Parashos P. A comparative investigation of cone-beam computed tomography and periapical radiography in the diagnosis of a healthy periapex. J Endod 2014;40:360–5.
Venskutonis T, Daugela P, Strazdas M, Juodzbalys G. Accuracy of digital radiography and cone beam computed tomography on periapical radiolucency detection in endodontically treated teeth. J Oral Maxillofac Res 2014;5:e1.
Estrela C, Bueno MR, Azevedo BC, Azevedo JR, Pecora JD. A new periapical index based on cone beam computed tomography. J Endod 2008;34:1325–31.
Leonardi Dutra K, Haas L, Porporatti AL, Flores-Mir C, Nascimento Santos J, Mezzomo LA, et al
. Diagnostic accuracy of cone-beam computed tomography and conventional radiography on apical periodontitis: A systematic review and meta-analysis. J Endod 2016;42:356–64.
Paes da Silva Ramos Fernandes LM, Ordinola-Zapata R, Hungaro Duarte MA, Alvares Capelozza AL. Prevalence of apical periodontitis detected in cone beam CT images of a Brazilian subpopulation. Dentomaxillofac Radiol 2013;42:80179163. doi: 10.1259/dmfr/80179163.
Dutta A, Smith-Jack F, Saunders WP. Prevalence of periradicular periodontitis in a Scottish subpopulation found on CBCT images. Int Endod J 2014;47:854–63.
Zhang M-M, Liang Y-H, Gao X-J, Jiang L, van der Sluis L, Wu M-K. Management of apical periodontitis: Healing of post-treatment periapical lesions present 1 year after endodontic treatment. J Endod 2015;41:1020–5.
Patel S, Wilson R, Dawood A, Mannocci F. The detection of periapical pathosis using periapical radiography and cone beam computed tomography-Part 1: Pre-operative status. Int Endod J 2012;45:702–10.
Ordinola-Zapata R, Bramante CM, Duarte MH, Ramos Fernandes LMPS, Camargo EJ, de Moraes IG, et al
. The influence of cone-beam computed tomography and periapical radiographic evaluation on the assessment of periapical bone destruction in dog's teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:272–9.
Kruse C, Spin-Neto R, Evar Kraft DC, Vaeth M, Kirkevang L-L. Diagnostic accuracy of cone beam computed tomography used for assessment of apical periodontitis: An ex vivo histopathological study on human cadavers. Int Endod J 2019;52:439–50.
Al-Omari MA, Hazaa A, Haddad F. Frequency and distribution of root filled teeth and apical periodontitis in a Jordanian subpopulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:e59-65.
Kabak Y, Abbott PV. Prevalence of apical periodontitis and the quality of endodontic treatment in an adult Belarusian population. Int Endod J 2005;38:238–45.
Mashyakhy M, Chourasia HR, Halboub E, Almashraqi AA, Khubrani Y, Gambarini G. Anatomical variations and bilateral symmetry of roots and root canal system of mandibular first permanent molars in Saudi Arabian population utilizing cone- beam computed tomography. Saudi Dent J 2019;31:481-6.
Mashyakhy M, Chourasia HR, Jabali A, Almutairi A, Gambarini G. Analysis of fused rooted maxillary first and second molars with merged and C-shaped canal configurations: Prevalence, characteristics, and correlations in a Saudi Arabian Population. J Endod 2019;45:1209-18.
Baruwa AO, Martins JNR, Meirinhos J, Pereira B, Gouveia J, Quaresma SA, et al
. The influence of missed canals on the prevalence of periapical lesions in endodontically treated teeth: A cross-sectional study. J Endod 2020;46:34-9.e1.
Karabucak B, Bunes A, Chehoud C, Kohli MR, Setzer F. Prevalence of apical periodontitis in endodontically treated premolars and molars with untreated canal: A cone-beam computed tomography study. J Endod 2016;42:538–41.
Siqueira JFJ, Magalhaes KM, Rocas IN. Bacterial reduction in infected root canals treated with 2.5% NaOCl as an irrigant and calcium hydroxide/camphorated paramonochlorophenol paste as an intracanal dressing. J Endod 2007;33:667–72.
Nair PN, Sjogren U, Krey G, Kahnberg KE, Sundqvist G. Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: A long-term light and electron microscopic follow-up study. J Endod 1990;16:580–8.
Ray HA, Trope M. Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J 1995;28:12–8.
Nair PNR. On the causes of persistent apical periodontitis: A review. Int Endod J 2006;39:249–81.
Tronstad L, Asbjornsen K, Doving L, Pedersen I, Eriksen HM. Influence of coronal restorations on the periapical health of endodontically treated teeth. Endod Dent Traumatol 2000;16:218–21.
Siqueira JFJ. Aetiology of root canal treatment failure: Why well-treated teeth can fail. Int Endod J 2001;34:1–10.
Ng Y-L, Mann V, Gulabivala K. Outcome of secondary root canal treatment: A systematic review of the literature. Int Endod J 2008;41:1026–46.
Ahlqwist M, Halling A, Hollender L. Rotational panoramic radiography in epidemiological studies of dental health. Comparison between panoramic radiographs and intraoral full mouth surveys. Swed Dent J 1986;10:73–84.
[Table 1], [Table 2], [Table 3], [Table 4]