David MacDonald

Objectives: Dental practitioners commonly use digital radiography to identify various oral conditions. These conditions may be unexpectedly discovered in an otherwise asymptomatic patient, termed incidental findings (IFs). Digital panoramic radiography (DPR) gives the best overview of the jaw. Furthermore, COVID-19 may have influenced the exposure of dental students to clinical education. The purpose of this study was to assess the prevalence of IFs on dental radiographs and compare the performance of pre-doctoral dental students in different cohorts (prior to, during, and post-COVID-19) in identifying them.Methods: A total of 1598 consecutive radiographs and charts of patients in UBC’s dental clinics were reviewed retrospectively. After the application of inclusion and exclusion criteria, 600 cases remained in the study. Radiographs and patients’ charts were reviewed and assessed for IFs. Chi-square tests were utilized to assess the performance of the students. To validate the precision of the testing method, Positive Predictive Values (PPVs), ‘Specificity’, ‘Sensitivity’, and Negative Predictive Values (NPVs) were utilized.Results: A notable prevalence of IFs was observed in the 600 cases that were reviewed. Dilacerated teeth exhibited the highest prevalence in this study, accounting for 50.3% of the IFs. The PPVs for all groups combined for DPR images exceeded 90% for the majority of the conditions. In contrast, the NPVs for all groups combined for DPR images were below 80% for various conditions, including dilacerated teeth, sclerosing osteitis, exostosis of a mandibular angle, tonsilloliths, styloid complex calcification, triticeous cartilage calcification, maxillary sinus pathology, condylar anomalies, PRIO, caries, and periodontal disorders. The results of this study demonstrated that dental students exhibited an improved ability to diagnose caries and periodontal conditions, although performance varied among cohorts. Notably, the identification of other conditions like impacted and dilacerated teeth saw poorer performance in the cohorts during and post-COVID-19.Conclusion: A thorough examination of these radiographs is highly advisable. Conditions that require more experience for accurate diagnosis are less frequently identified. The ability of pre-doctoral dental students to assess radiographs has been impacted by the constraints imposed by COVID-19, possibly due to online education and reduced clinical training time.

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Objectives: We aimed to determine the prevalence of CCAA detected on DPR’s of individuals over 30 years of age. We assessed if student dentists were able to identify CCAA on DPRs in UBC Dental clinic. Additionally, to associate CCAA on DPR with pre-existing statin indicated conditions, age, sex, hypertension, diabetes mellitus, history of smoking and periodontal bone loss. Methods: In this retrospective study, we reviewed the charts of 700 consecutive subjects over the age of 30 with a DPR from October 2018 to April 2021 from UBC Dental Clinic. We reviewed patients’ medical histories for pre-existing statin-indicated conditions as outlined by the Canadian Cardiovascular Society 2021 Guidelines. We also examined patients’ standard dental panoramic radiographs to determine the prevalence of CCAAs. The proportion of patients on lipid lowering therapy (LLT) was also assessed. Results: Out of 700 consecutive charts reviewed with a DPR, 657 were unique subjects. Since subjects had a DPR acquired more than once, only the most recent DPR was included. Of the 657 DPRs, 358 (55.9%) were considered diagnostic for evaluation of CCAA. 16 were excluded due to undocumented or incomplete medical history. Out of the 641 subjects, 289 (45.1%) were females and 352 (54.9%) were males. The mean age was 60.4±16.0 years for females and 60.9±16 years for males. There was evidence of CCAA on 82 (22.9%) of the 358 DPRs; however only 6 (7%) were identified by the student dentist based on the chart review. In patients with CCAAs, 17/82 (20.7%) were already on LLT for a pre-existing condition and 15/82 (18.3%) were not on LLT despite a pre-existing condition, for the remaining 50/82 (61%) CCAA on DPR was the first evidence of atherosclerosis. Therefore, CCAA on DPR constituted a new diagnosis of atherosclerosis in 61% of subjects. With chi square test, a statistically significant association of CCAA found with increasing age (p0.05), male sex (p0.05), pre-existing condition (p0.05), history of smoking and hypertension (p0.05). Conclusion: CCAA on DPR constitutes a new diagnosis of atherosclerosis in a significant proportion of patients and is an opportunity for risk modifying therapies to prevent future cardiovascular events.

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Purpose: Recent studies have found visual and tactile examination to be superior in caries diagnosis than conventional intra-oral radiography (mainly bitewings and periapicals). Extra-oral bitewing radiograph (EBW) is a patient-friendly, non-aerosol-generating technique. To date, the sole studies on EBWs have been in-vitro, and though encouraging, they indicate a higher likelihood of false positives. This is the first study in which findings on EBWs was compared with the clinical visual-tactile examination. The aim of our study is to evaluate the role of EBWs in caries diagnosis- by comparing EBW to clinical data retrospectively and comparing caries noted on EBWs to conventional intra-oral bitewing radiographs (IBW)Methods: This retrospective study was done by reviewing records of pediatric patients attending Ridge Meadows Children’s Dentistry, Maple Ridge from 01 Jan 2017 to 21 Jan 2022. To elicit how EBW compares to clinical findings, 193 patient charts were reviewed to compare the treatment planned to the treatment executed. To compare the depth and accuracy of caries diagnosis between 2 imaging modalities (IBW and EBW), 104 preoperative IBW and EBW radiographs were analyzed by 2 independent examiners using International Caries Classification and Management System (ICCMS) classification. Kapa agreement was done for statistical analysis.Results: EBW was found to be comparable to clinical findings of caries with high positive predictive value (PPV) of 98% and negative predictive value (NPV) of 78%. The data comparing caries on IBW and EBW was assessed quadrant wise and moderate agreement was found for contacts in the lower arch and a weak agreement was found for the upper quadrants. Conclusion: Our results suggest that EBWs are a useful diagnostic tool for proximal caries in children with high caries risk.

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Background: Accurate localization of mandibular canals (MC) is important in Dental Implantology to avoid injuries of mandibular nerve inside the canal. Artificial intelligence (AI) has impacts on improving the quality of delivering Implantology. The aim of this study was to compare the accuracy of an AI system with conventional methods in detecting MC during pre-implant planning using cone-beam computed tomography (CBCT) images.Methods: A pilot study of six CBCT scans of a dentate human mandible was initially conducted to explore measurement agreements of manual tracing (coDiagnostiX), AI method (Diagnocat) and histology sections as gold standard. Measurements were conducted in 2nd premolars and 1st and 2nd molars areas bilaterally and coded as LM2, LM1, LP2, RP2, RM1, RM2. Subsequently, a retrospective study of 47 patients’ CBCT scans of their mandibles was analysed for MC localization by 2 examiners using coDiagnostiX, and Diagnocat. Measurements were taken from the midpoint of the superior aspect of the buccal and lingual cortex to the superior aspect of MC in the regions of interest (ROIs). The data was calibrated for intra-examiner and inter-examiner reliability. One-way ANOVA test was used to analyse three sets of measurements in pilot studies and independent samples t-tests were used in retrospective studies.Results: 110 CBCTs were screened, 57 CBCTs were excluded due to different ROIs, 2 CBCTs were excluded in coDiagnostiX due to old Digital Imaging and Communications in Medicine (DICOM) files and 4 CBCTs were excluded in Diagnocat due to metal artifact or extended ROI outside mandible area. Twelve CBCTs in AI software showed incidental findings including thickening of maxillary sinus membrane or dense bone islands in the mandible. No statistically significant difference found in the pilot study among the measurements of three groups except for RM2 (p0.05) likely due to complex anatomy of the area and increased bone thickness. When sample size increased in the retrospective study, no statistically significant difference found between AI and coDiagnostiX in edentulous and dentate groups or both groups combined using independent samples t-test.Conclusion: AI software used in this study is as accurate and predictable as manual tracing software for MC detection.

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Objectives: Lateral Cephalograms (LC) have been used as part of pretreatment records of orthodontic patients for diagnosing and treatment planning. Since LC contains many important anatomical structures, accurate examination of these areas is very important. Incidental findings of clinical significance are believed to be present very commonly on LC and thus orthodontists are more likely to encounter those. The purpose of this study was to find out prevalence of incidental findings in LC taken for orthodontic diagnosis of patients seeking orthodontic treatment at UBC Graduate Orthodontic Clinic. Methods: A total of 1765 consecutive patients’ pretreatment and follow up LCs were inspected retrospectively. The age was restricted to 12-20 years old at the start of the orthodontic treatment. All the LC were checked within Romexis- image capturing software. Each LC was examined in 3 zones in a systematic way: cranium; neck and cervical spine; and dentofacial complex. Additionally, size of Sella Turcica was also measured in Romexis.Results: Overall prevalence of incidental findings was 18.8%. Ponticulus Posticus was the most prevalent finding (10.3%) followed by bridging of Sella Turcica (4.2%). Sella turcica height ranged from 1.1-12.0mm and width ranged from 2.6-15.8mm. There is statistically significant association between incidental findings and sex (chi square statistics 16.315 and p0.05) with males being more likely to present with them. Conclusions: Incidental findings are prevalent on LC radiographs of orthodontic patients. Thus, careful examination of LC beyond area of orthodontists’ interest is very important. Males are more likely to present with incidental findings than females. As far as the individual anomaly is concerned, only Occipital Spur was more likely to be present in males than in females. Ponticulus Posticus and Occipital Spur were highest co-occurring incidental findings in the sample. All except on follow up LC revealed no additional prevalence of incidental findings.

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Objectives: Cone-Beam Computed Tomography (CBCT) was first developed 29 years ago and came into commercial use in 1999 and has over the last decade been increasingly applied to almost every area of dental practice. This is due to 3D visualization of teeth and supporting tissues, high spatial resolution, low radiation, and minimal operating time compared to medical computed tomography. The CBCT images are read by an accompanying viewer or a treatment planning software. Currently, there is little information on comparing accuracy of commercially available implant planning softwares. Therefore, the aim of this study was to assess the accuracy of four popular implant planning software (coDiagnostix, DTX, Simplant, and BlueSkyPlan) by identifying the mandibular canal using the free hand nerve marking tool.Methods: Two De-fleshed human mandibles were acquired for study. Various regions of the mandibles were evaluated including canine, premolars, and molars. Gutta-percha was fixated in buccal and lingual aspects of the aforementioned regions. Mandibles were scanned in low (.30mm voxel size) and high (.18mm voxel size) resolution along with variation of mA values including 3.2, 4, and 5. DICOM files were imported into the four implant planning softwares for analysis. After image analysis, specimen were sectioned with a reverse-cutting saw in all evaluated regions. For gold standard measurements, a digital caliper was used in anatomical sections to measure comparable areas.Results: ANOVA analysis demonstrated that there is no statistical significance between the gold standard and different softwares when calculating for accuracy. When calculating for sensitivity, it appears that coDiagnostix has the highest value out of the four softwares.Conclusions: Varying mA and voxel size values does not impact the accuracy of four different softwares. It appears that coDiagnostix has the highest sensitivity values when using the most common settings for CBCT image acquisition.

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Objectives: To determine whether patient age or patient sex affects the number of errors on dental panoramic radiographs (DPR) in the mixed dentition population. Methods: All DPRs taken at the UBC dental student clinic, during the study period, on 6 to 12-year-old patients were examined. The consecutive case series of 178 DPRs were obtained over a 4.5-year period. The primary reviewer was calibrated on 30 DPRs. Intra- and inter- reviewer reliability was assessed upon completion by examining a random sample of 20 DPRs. A total of 14 errors were examined for on each DPR. Results: A linear regression analysis showed that the number of DRP errors decrease as the patient age increases, but with a p-value of 0.102 this is not statistically significant so we cannot conclude that age has a significant relationship with the number of errors in a DPR. A p-value of 0.44 was obtained when evaluating the difference in the average number of errors per DPR for males and females. We failed to reject the null hypothesis and did not conclude that sex had a significant relationship to the number of errors. When errors were grouped, we rejected the null hypothesis up to 0.011% significance level and concluded that age has a significant relationship to the number of errors in a DPR. Trends for head tilting left and rotating right is likely due to the DPR room design and the door location. Conclusions: Patient age and sex do not significantly affect the number of errors in a DPR in the mixed dentition population. Communication between the operator and patient likely contributes to the presence of DPR errors.

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Purpose: Taurodontism was thought to be associated mainly with oro-facial syndromes butstudies in normal Chinese and Brazilian adult populations have shown that this trait is relativelycommon. We hypothesize that taurodontism is a variation of normal root morphology that maybe present in an adolescent population as an incidental finding.Methods: Digital dental panoramic radiographs (DPRs) taken of 124 adolescents aged between15 and 20 years old (male: female; 59:65), attending the University of British Columbia’sFaculty of Dentistry Clinic between July 2006 and June 2019 were examined. Unrestored firstand second permanent molars with closed apices were measured digitally and a taurodont ratioindex was obtained using the Shifman and Chanannel criteria.Results: The total number of teeth examined was 992 and the proportion of taurodont teeth was16.6%. Of the 124 cases, 68 (54.8%) had at least one taurodont tooth. There were 43 cases withbilateral taurodont teeth. Taurodontism had a higher predilection for females (63.1%) ascompared to males (45.8%). This difference was significant for all molars with a P valueranging from P = .003 to P = .043, where P .05, except for the upper left second permanentmolar (tooth #27) and the lower left second permanent molar (tooth #37). The extent oftaurodontism was mostly mild.Conclusions: Our results suggest that mild taurodontism is relatively common in the localadolescent population similar to what was reported elsewhere. The ability to identify these teethand diagnose them early can help inform treatment planning decisions.

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Purpose: Cone Beam Computed Tomography (CBCT) is an advanced but new imaging technique used in dentistry. Although it already has acquired a substantial literature, that literature does not include evidence-based evidence both for its indications-for-use and for its efficacy in comparison to the conventional approach to diagnosis and treatment planning. Aims: To determine the pattern of prescription of CBCT by all UBC dental programs with particular regard to the field-of-view (FOV). To determine whether the CBCT prescriptions by the Graduate Endodontics Program were compliant with the joint American-Academy-of-Oral-and-Maxillofacial-Radiology and American-Academy-of-Endodontics (AAOMR/AAE) position statement (viz guidelines). To determine by reference to the EPR whether CBCT changed the original diagnosis and/or treatment plans based on the initial clinical examination and the conventional radiographic.Methods: Ethics approval certificates H14-02191 and H15-03507 were granted for this retrospective study. All CBCT prescriptions were audited. The audit revealed that CBCT prescriptions by the Graduate Endodontics program were for a wide range of clinical reasons and worthy of further study. The pattern of prescription of CBCT was reviewed, by reference to electronic patient record (EPR), to determine whether it was compliant with the AAOMR/AAE guidelines. The statistical test, Chi-square was used. Results: All but one CBCT in the audit were for small and medium-sized FOVS. All 128 CBCT prescriptions (in 110 consecutive patients) were AAOMR/AAE-guidelines compliant. CBCT identified significantly more features than conventional radiography (p0.001), particularly with regards to the identification of periapical lesions (p = 0.002), missed canals (p 0.001), vertical root fractures (p = 0.004) and complex anatomy (p = 0.008). The significant results were seen with respect to change in diagnosis (p0.001), change in treatment plan (p 0.005). The AAOMR/AAE recommendations were found to be incomplete.Conclusion: CBCT permitted the identification of more numbers of periapical lesions, missed canal, complex anatomy and vertical root fracture than initially observable on conventional radiography. This study is perhaps the first to ‘road-test’ the AAOMR/AAE guidelines in an authentic clinical environment. It identified an important hiatus in these guidelines; they did not consider missed/extra canals in teeth which required endodontic re-treatment.

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Purpose: Cone beam computed tomography (CBCT) has become the standard of care for many applications in the specialty of periodontics. CBCT is now taken for almost all implant related cases and there is also a clear shift towards higher resolution images. However, the increased radiation dosage from a higher resolution images must be accompanied by valid clinical justification. Aims: The first aim was to conduct an audit of all CBCT prescriptions at the UBC Faculty of Dentistry with a focus on implant related prescriptions. Concurrently, all implant related prescriptions were evaluated for compliance with the current guidelines. The second aim was to evaluate whether altering the mA and kVp values will result in measurement differences on CBCT images. Materials and Methods: Ethics approval was granted for the retrospective portion of this study (Certificates H18-01536 and H19-02001). All CBCT prescriptions were audited from Jan. 1, 2015 to Aug. 31, 2018. However, the prescriptions originating from the Graduate Periodontics and Prosthodontics programs were examined more thoroughly. A major finding from the audit was a shift towards higher resolution images for the small FOV. An in vitro experiment was conducted to determine whether changing the imaging parameters and scatter would affect the measured distance between two adjacent implants placed in a model. Results: Almost all the CBCT scans prescribed in the Periodontics and Prosthodontics departments were prescribed for the purposes of implant treatment planning. In Graduate Periodontics and Prosthodontics, 95% and 94% of the prescriptions, respectively, were compliant with the guidelines published by the AAOMR and the AAP. Manipulation of the imaging parameters did affect the measured distance between the two implants when specific mA and kVp values were compared. The scatter and metal artifacts from the addition of a third implant did not have any effect on the measured distance.Conclusion: CBCT was used judiciously for implant treatment planning in both the Graduate Periodontics and Prosthodontics department. Manipulation of CBCT parameters had a statistically significant effect on the measured distance between two adjacent implants but the potential scatter and metal artifacts from the addition of third implant did not.

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Introduction: Cone-beam computed tomography (CBCT) became commercially available 20 years ago and has been applied to almost every area of dental practice. This is due to its better spatial resolution, lower radiation dose, and smaller footprint than computed tomography (CT). However, the current CBCT unit still has much higher radiation dose than the standard conventional 2D dental imaging. Since there is no known safe lower radiation dose limit, radiation must be ‘as-low-as-reasonably-achievable’ (ALARA).Aims: To profile the orthodontic patient pool since the inception of the Orthodontics Graduate Program at UBC to determine the number and the reason for whom CBCTs were prescribed. To compare the orthodontic diagnostic efficiency of two different 3D reconstruction methods of the CBCT images. Methods: Ethics was approved for a retrospective review of orthodontic cases and for review by orthodontic instructors of randomized multiplanar reformatting (MPR) and curved CBCT image sets. 15 datasets of similar appearing impacted maxillary canines were reconstructed into MPR and curved screenshots. The instructors were asked to disclose their length of orthodontic service and prior experience reviewing CBCT datasets. They were asked to review the screenshots to determine factors that could affect treatment such as the position of the impacted canine, presence of root resorption and dilacerated roots. Results: The review revealed 35 prescribed CBCTs that were mostly taken to investigate impacted teeth (29 cases). Of the 15 orthodontists, although the 6 females had on average 16 years of experience to their 9 male colleagues (on average of 26 years), this was not significant (P = 0.142). Furthermore, they all have some experience at reviewing MPR reconstructions which was almost identical for either sex, around 6 years; 2 males and 2 females had considerably more experience. All appeared more comfortable with the MPR rather than the curved reconstructions.Conclusions: The number of prescribed CBCT images is low because the program policy follows the “Image Gently” guidelines and the ALARA principles. So far, orthodontists are more comfortable with the MPR rather than the more panoramic-like curved reconstruction. This simply may reflect the fact that the former is the default reconstruction for most CBCT units.

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Purpose: Cone Beam Computed Tomography (CBCT) is an advanced but new imaging technique used in dentistry. Although it already has acquired a substantial literature, that literature does not include evidence-based evidence both for its indications-for-use and for its efficacy in comparison to the conventional approach to diagnosis and treatment planning. Aims: To determine the pattern of prescription of CBCT by all UBC dental programs with particular regard to the field-of-view (FOV). To determine whether the CBCT prescriptions by the Graduate Endodontics Program were compliant with the joint American-Academy-of-Oral-and-Maxillofacial-Radiology and American-Academy-of-Endodontics (AAOMR/AAE) position statement (viz guidelines). To determine by reference to the EPR whether CBCT changed the original diagnosis and/or treatment plans based on the initial clinical examination and the conventional radiographic.Methods: Ethics approval certificates H14-02191 and H15-03507 were granted for this retrospective study. All CBCT prescriptions were audited. The audit revealed that CBCT prescriptions by the Graduate Endodontics program were for a wide range of clinical reasons and worthy of further study. The pattern of prescription of CBCT was reviewed, by reference to electronic patient record (EPR), to determine whether it was compliant with the AAOMR/AAE guidelines. The statistical test, Chi-square was used. Results: All but one CBCT in the audit were for small and medium-sized FOVS. All 128 CBCT prescriptions (in 110 consecutive patients) were AAOMR/AAE-guidelines compliant. CBCT identified significantly more features than conventional radiography (p0.001), particularly with regards to the identification of periapical lesions (p = 0.002), missed canals (p 0.001), vertical root fractures (p = 0.004) and complex anatomy (p = 0.008). The significant results were seen with respect to change in diagnosis (p0.001), change in treatment plan (p 0.005). The AAOMR/AAE recommendations were found to be incomplete.Conclusion: CBCT permitted the identification of more numbers of periapical lesions, missed canal, complex anatomy and vertical root fracture than initially observable on conventional radiography. This study is perhaps the first to ‘road-test’ the AAOMR/AAE guidelines in an authentic clinical environment. It identified an important hiatus in these guidelines; they did not consider missed/extra canals in teeth which required endodontic re-treatment.

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