{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T10:10:24Z","timestamp":1778148624538,"version":"3.51.4"},"reference-count":35,"publisher":"MJS Publishing, Medical Journals Sweden AB","license":[{"start":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T00:00:00Z","timestamp":1778112000000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["AOS"],"abstract":"<jats:p>Objective: Bitewing radiographs are essential for caries and marginal bone diagnostics. Diagnostic quality depends on operator technique. This study evaluated patient-level diagnostic quality of sensor-based bitewing examinations to identify operator-related deficiencies.\nMaterial and Methods: In this retrospective, cross-sectional study, 962 bitewing examinations from 31 Swedish public dental practices were randomly selected and evaluated for caries and marginal bone level diagnostic image quality, according to European guidelines. Available panoramic\/periapical images acquired in connection with the bitewing examinations were included in a second quality assessment. Recorded deficiencies included sensor placement, collimation artifacts, and insufficient biting on the sensor holder. Associations between diagnostic quality and sensor size, number of images, age group, jaw, side, and sex were analyzed using \u03c72 test and logistic regression. Three calibrated examiners performed the evaluations.\nResults: The requirements were fulfilled in 5% and acceptable in 43% of the bitewing examinations, increasing to 7% and 45% when including panoramic\/periapical images. Quality was better with larger sensor sizes (p &lt; 0.001), more exposures (p &lt; 0.001), panoramic\/periapical images (p &lt; 0.001), age \u226512 years (p &lt; 0.001), and in the maxilla (p &lt; 0.001). Common errors were incorrect sensor placement (94%), collimation artifacts (57%), and insufficient biting (15%). No differences were found between side or sex. Inter-observer agreement was substantial (Fleiss\u2019 kappa = 0.61; Gwet\u2019s AC1 = 0.62); intra-observer agreement was almost perfect (Cohen\u2019s kappa = 0.88).\nConclusions: Most bitewing examinations, especially in children, fail to meet diagnostic requirements due to deficient operator performance and quality assessment. Panoramic\/periapical images may improve diagnostic quality but should not replace optimized bitewing examinations. Targeted continuing education is required.<\/jats:p>","DOI":"10.2340\/aos.v85.46001","type":"journal-article","created":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T09:16:43Z","timestamp":1778145403000},"page":"245-253","source":"Crossref","is-referenced-by-count":0,"title":["Operator-related low diagnostic quality in bitewing examinations performed with sensors"],"prefix":"10.2340","volume":"85","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-9101-3505","authenticated-orcid":false,"given":"Daniel","family":"Olsson","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8807-3500","authenticated-orcid":false,"given":"Eva","family":"Levring J\u00e4ghagen","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1320-4400","authenticated-orcid":false,"given":"Maria","family":"Garoff","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1183","published-online":{"date-parts":[[2026,5,7]]},"reference":[{"key":"154574","doi-asserted-by":"crossref","unstructured":"Braga MM, Mendes FM, Ekstrand KR. Detection activity assessment and diagnosis of dental caries lesions. Dent Clin North Am. 2010;54(3):479\u201393.","DOI":"10.1016\/j.cden.2010.03.006"},{"key":"154575","doi-asserted-by":"crossref","unstructured":"Pitts NB. The use of bitewing radiographs in the management of dental caries: scientific and practical considerations. Dentomaxillofac Radiol. 1996;25(1):5\u201316.","DOI":"10.1259\/dmfr.25.1.9084279"},{"key":"154576","unstructured":"Papapanou PN, Sanz M, Buduneli N, Dietrich T, Feres M, Fine DH, et al. Periodontitis: consensus report of workgroup 2 of the 2017 World workshop on the classification of periodontal and peri-implant diseases and conditions. J Periodontol. 2018;89 Suppl 1:S173\u201382."},{"key":"154577","unstructured":"Mallya SM, Lam EW. White and Pharoah\u2019s Oral Radiology: Principles and Interpretation. 8th ed. St. Louis: Elsevier (Mosby); 2018."},{"key":"154578","unstructured":"Gr\u00f6ndahl HG. Bitewing radiography and its clinical significance in dental diagnostics. J Dent Radiol. 1994;22(4):213\u201322."},{"key":"154579","unstructured":"European guidelines on radiation protection in dental radiology: the safe use of radiographs in dental practice. Publications Office; 2004. Available from: https:\/\/op.europa.eu\/en\/publication-detail\/-\/publication\/ea20b522-883e-11e5-b8b7-01aa75ed71a1 (accessed April 25, 2026)"},{"key":"154580","unstructured":"Eliasson S, Lavstedt S, Wouters F, Ostlin L. Quality of intraoral radiographs sent by private dental practitioners for therapy evaluation by the Social Insurance Office. Swed Dent J. 1990;14(2):81\u20139."},{"key":"154581","unstructured":"Svenson B, Eriksson T, Kronstr\u00f6m M, Palmqvist S. Quality of intraoral radiographs used for prosthodontic treatment planning by general dentists in the public dental health service. Swed Dent J. 1995;19(1\u20132):47\u201354."},{"key":"154582","doi-asserted-by":"crossref","unstructured":"Hyv\u00f6nen M, Jaakkola A, Tanner T, P\u00e4kkil\u00e4 J, K\u00e4mppi A, Patinen P, et al. Quality and findings of bitewing radiographs among twenty-year-old conscripts in Finland. Int J Dent. 2021;2021:8894917.","DOI":"10.1155\/2021\/8894917"},{"key":"154583","doi-asserted-by":"crossref","unstructured":"Wenzel A, M\u00f8ystad A. Work flow with digital intraoral radiography: a systematic review. Acta Odontol Scand. 2010;68(2):106\u201314.","DOI":"10.3109\/00016350903514426"},{"key":"154584","doi-asserted-by":"crossref","unstructured":"Ozdemir S, Parlaky\u0131ld\u0131z Gokce A, Unver T. Simulation of three intraoral radiographic techniques in pediatric dental patients: subjective comfort assessment using the VAS and Wong-Baker FACES Pain Raiting Scale. BMC Oral Health. 2020;20(1):33.","DOI":"10.1186\/s12903-020-1011-2"},{"key":"154585","doi-asserted-by":"crossref","unstructured":"Juneja S, Dalvi S, Aggarwal R, Sukhija M, Singh S, Bansal S. Assessment of perception of pain with E-Speed film, CCD sensor and photostimulable phosphor plates for intraoral radiographs in children using three pain rating scales. Indian J Dent Res. 2024;35(1):54\u20138.","DOI":"10.4103\/ijdr.ijdr_78_23"},{"key":"154586","doi-asserted-by":"crossref","unstructured":"Bahrami G, Hagstr\u00f8m C, Wenzel A. Bitewing examination with four digital receptors. Dentomaxillofac Radiol. 2003;32(5):317\u201321.","DOI":"10.1259\/dmfr\/14212871"},{"key":"154587","doi-asserted-by":"crossref","unstructured":"Berkhout WE, Sanderink GC, Van der Stelt PF. Does digital radiography increase the number of intraoral radiographs? A questionnaire study of Dutch dental practices. Dentomaxillofac Radiol. 2003;32(2):124\u20137.","DOI":"10.1259\/dmfr\/97410196"},{"key":"154588","doi-asserted-by":"crossref","unstructured":"Nysether S, Hansen BF. Errors on dental bitewing radiographs. Community Dent Oral Epidemiol. 1983;11(5):286\u20138.","DOI":"10.1111\/j.1600-0528.1983.tb01895.x"},{"key":"154589","doi-asserted-by":"crossref","unstructured":"Svenson B, Eriksson T, Kronstr\u00f6m M, Palmqvist S. Image quality of intraoral radiographs used by general practitioners in prosthodontic treatment planning. Dentomaxillofac Radiol. 1994;23(1):46\u20138.","DOI":"10.1259\/dmfr.23.1.8181659"},{"key":"154590","unstructured":"Hell\u00e9n-Halme K, Johansson PM, H\u00e5kansson J, Petersson A. Image quality of digital and film radiographs in applications sent to the Dental Insurance Office in Sweden for treatment approval. Swed Dent J. 2004;28(2):77\u201384."},{"key":"154591","doi-asserted-by":"crossref","unstructured":"Rodgers GD, Sharif MO, Smith AB, Kellett M, Brunton PA. Making the grade? Modification of dental radiograph quality ratings. Prim Dent Care. 2011;18(3):119\u201324.","DOI":"10.1177\/2050168411os1800307"},{"key":"154592","unstructured":"Espelid I, Mej\u00e0re I, Weerheijm K; EAPD. EAPD guidelines for use of radiographs in children. Eur J Paediatr Dent. 2003;4(1):40\u20138."},{"key":"154593","doi-asserted-by":"crossref","unstructured":"Fleiss JL, Nee JC, Landis JR. Large sample variance of kappa in the case of different sets of raters. Psychol Bull. 1979;86(5):974\u20137.","DOI":"10.1037\/0033-2909.86.5.974"},{"key":"154594","doi-asserted-by":"crossref","unstructured":"Gwet KL. Large-sample variance of Fleiss generalized kappa. Educ Psychol Meas. 2021;81(4):781\u201390.","DOI":"10.1177\/0013164420973080"},{"key":"154595","doi-asserted-by":"crossref","unstructured":"Dawid AP, Skene AM. Maximum likelihood estimation of observer error-rates using the EM algorithm. J R Stat Soc Series C Appl Stat. 1979;28(1):20\u20138.","DOI":"10.2307\/2346806"},{"key":"154596","doi-asserted-by":"crossref","unstructured":"McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb). 2012;22(3):276\u201382.","DOI":"10.11613\/BM.2012.031"},{"key":"154597","doi-asserted-by":"crossref","unstructured":"Pullin M, Gurrin L, Vukcevic D. Statistical models for repeated categorical ratings: the R package rater. R J. 2023;15(3):93\u2013118.","DOI":"10.32614\/RJ-2023-064"},{"key":"154598","doi-asserted-by":"crossref","unstructured":"Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159\u201374.","DOI":"10.2307\/2529310"},{"key":"154599","unstructured":"Proffit WR, Fields HW, Larson B, Sarver DM. Contemporary Orthodontics. 6th ed. St. Louis: Elsevier; 2019. p. 77."},{"key":"154600","doi-asserted-by":"crossref","unstructured":"Herman HD, Ashkenazi M. Quality of bitewing radiographs in children in relation to the type of film holder used. Eur Arch Paediatr Dent. 2013;14(3):141\u20136.","DOI":"10.1007\/s40368-013-0033-8"},{"key":"154601","doi-asserted-by":"crossref","unstructured":"K\u00fchnisch J, Anttonen V, Duggal MS, Spyridonos ML, Rajasekharan S, Sobczak M, et al. Best clinical practice guidance for prescribing dental radiographs in children and adolescents: an EAPD policy document. Eur Arch Paediatr Dent. 2020;21(4):375\u201386.","DOI":"10.1007\/s40368-019-00493-x"},{"key":"154602","doi-asserted-by":"crossref","unstructured":"Preethi N, Chikkanarasaiah N, Bethur SS. Genotoxic effects of X-rays in buccal mucosal cells in children subjected to dental radiographs. BDJ Open. 2016;2:16001.","DOI":"10.1038\/bdjopen.2016.1"},{"key":"154603","doi-asserted-by":"crossref","unstructured":"Elkhateeb SM, Aloyouny AY, Omer MMS, Mansour SM. Analysis of photostimulable phosphor image plate artifacts and their prevalence. World J Clin Cases. 2022;10(2):437\u201347.","DOI":"10.12998\/wjcc.v10.i2.437"},{"key":"154604","doi-asserted-by":"crossref","unstructured":"\u00c7al\u0131\u015fkan A, Sumer AP. Definition, classification and retrospective analysis of photostimulable phosphor image artefacts and errors in intraoral dental radiography. Dentomaxillofac Radiol. 2017;46(3):20160188.","DOI":"10.1259\/dmfr.20160188"},{"key":"154605","doi-asserted-by":"crossref","unstructured":"Mendon\u00e7a RP, Estrela C, Bueno MR, Carvalho TCASG, Estrela LRA, Chilvarquer I. Principles of radiological protection and application of ALARA, ALADA, and ALADAIP: a critical review. Braz Oral Res. 2025;39:e14.","DOI":"10.1590\/1807-3107bor-2025.vol39.014"},{"key":"154606","doi-asserted-by":"crossref","unstructured":"Granata C, Sofia C, Francavilla M, Kardos M, Kasznia-Brown J, Nievelstein RA, et al. Let\u2019s talk about radiation dose and radiation protection in children. Pediatr Radiol. 2025;55(3):386\u201396.","DOI":"10.1007\/s00247-024-06009-0"},{"key":"154607","doi-asserted-by":"crossref","unstructured":"Dean S, Rathod R, Bansal H. Enhancing diagnostic quality of intra-oral radiographs through targeted training interventions and super user integration. Cureus. 2025;17(3):e80076.","DOI":"10.7759\/cureus.80076"},{"key":"154608","doi-asserted-by":"crossref","unstructured":"Hegde S, Gao J, Vasa R, Cox S. Factors affecting interpretation of dental radiographs. Dentomaxillofac Radiol. 2023;52(2):20220279.","DOI":"10.1259\/dmfr.20220279"}],"container-title":["Acta Odontologica Scandinavica"],"original-title":[],"link":[{"URL":"https:\/\/medicaljournalssweden.se\/actaodontologica\/article\/download\/46001\/53799","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/medicaljournalssweden.se\/actaodontologica\/article\/download\/46001\/53799","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T09:17:26Z","timestamp":1778145446000},"score":1,"resource":{"primary":{"URL":"https:\/\/medicaljournalssweden.se\/actaodontologica\/article\/view\/46001"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,7]]},"references-count":35,"URL":"https:\/\/doi.org\/10.2340\/aos.v85.46001","relation":{},"ISSN":["1502-3850","0001-6357"],"issn-type":[{"value":"1502-3850","type":"electronic"},{"value":"0001-6357","type":"print"}],"subject":[],"published":{"date-parts":[[2026,5,7]]}}}