Indian Journal of Dental Sciences

: 2019  |  Volume : 11  |  Issue : 3  |  Page : 138--142

Comparison of conventional and digital radiographic techniques for the assessment of alveolar bone in periodontal disease

Heena Sharma, Parveen Dahiya, Rajan Gupta, Mukesh Kumar, Sunita R Melwani, Lolakshi Kachroo 
 Department of Periodontics, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh, India

Correspondence Address:
Heena Sharma
Department of Periodontics, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh


Background: Alveolar bone loss at the crest and interdental osseous defects are the frequent outcomes of periodontal disease. Radiographs act as valuable adjunct as they provide essential information regarding the morphology of residual bone and help in determining the prognosis, formulating treatment plan, and establishing the outcome of various therapies. Aims: The aim of the study was to compare the measurements obtained by conventional (intraoral periapical [IOPA] radiographs) and digital radiographs (radiovisiography [RVG]) for the assessment of alveolar bone by utilizing intrasurgical (IS) measurements as the gold standard. Methods: Thirty systemically healthy periodontitis patients with 100 interproximal sites were selected to undergo periodontal flap surgery. IOPA radiographs and RVG were taken before surgery using paralleling cone technique with the help of extension cone paralleling technique (XCP)®. Measurements in case of horizontal and vertical bone loss were taken and compared to IS measurements. Statistical Analysis Used: Analysis of variance and post hoc test were used. Results: No statistically significant difference was found between conventional and digital radiographic method in comparison to IS (IS) method for the assessment of alveolar bone level. Conclusion: Both radiographic methods (conventional and digital) showed statistically nonsignificant results in comparison to IS measurements. Hence, either IOPA radiograph or RVG can be used to visualize the alveolar bone level in periodontal disease.

How to cite this article:
Sharma H, Dahiya P, Gupta R, Kumar M, Melwani SR, Kachroo L. Comparison of conventional and digital radiographic techniques for the assessment of alveolar bone in periodontal disease.Indian J Dent Sci 2019;11:138-142

How to cite this URL:
Sharma H, Dahiya P, Gupta R, Kumar M, Melwani SR, Kachroo L. Comparison of conventional and digital radiographic techniques for the assessment of alveolar bone in periodontal disease. Indian J Dent Sci [serial online] 2019 [cited 2019 Oct 17 ];11:138-142
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Full Text


Alveolar bone loss forms the characteristic feature of destructive inflammatory changes in periodontal disease.[1] Radiographs are used to get a visual image of the bone support around affected teeth, to make out the location and extent of marginal bone loss and the amount of remaining bone support. Radiographs play a very important role toward assessment of determining the prognosis, formulating comprehensive treatment plan, and establishing the outcome of various therapies. Radiographs can be broadly classified as intraoral and extraoral radiographs. Intraoral radiographs include intraoral periapical (IOPA) radiographs, bitewings, and occlusal radiographs while extraoral radiographs include orthopantomographs (OPGs).

Conventional radiography consists of IOPA, bitewing, and panoramic views, which have been used from long-standing period in the field of periodontics. These imaging techniques are generally based on silver halide emulsion technology.[2] In the past decade, computerized digital radiography has been introduced in dentistry. There are several types of digital imaging techniques, including direct digital radiography, indirect digital radiography, and computed radiography. Of the three techniques, direct digital imaging with intraoral sensors is progressively integrated in everyday clinical practice of dentistry.[3]

Radiovisiography (RVG) is one of the direct digital imaging techniques that have become widely accepted as a substitute to film-based radiography because of its superior image quality and by reducing the time needed for processing the radiographic image with low radiation exposure.[4]

The purpose of the present study was to compare the measurements obtained by conventional (IOPA radiograph) and digital radiograph (RVG), by utilizing intrasurgical (IS) measurements as the gold standard to assess their accuracy in evaluating the amount of bone loss.


The present study included 30 systemically healthy periodontitis patients, consisting of 26 males and 4 females, between the age group of 30 and 65 years who reported to the department of periodontics with 100 interproximal sites (54 mesial and 46 distal). This specific age group was selected because the individuals in this age group commonly present with chronic periodontitis and are capable of maintaining the study protocol. Individuals were selected randomly with no discrimination on the basis of sex, caste, religion, and socioeconomic status. Patients with drifted teeth, with supraerupted teeth, and who were contraindicated for any radiographic procedure were excluded from the study. Informed consent was taken from all the individuals who voluntarily participated in the study.

Clinical parameters (plaque index, pocket depth, and clinical attachment level) were recorded, and scaling and root planing was done. One month after scaling and root planing, the individuals were recalled and those who retained ≥5 mm of pocket depth were subjected for the flap surgery. Before the flap surgery, IOPA radiographs were taken using Kodak E-speed ® film of size 3 cm × 4 cm per size 2 with the help of Gomax X-ray unit operated at 216 Kvp, 12 MPA with a radiation exposure of 0.08 s [Figure 1] while RVGs were taken using GENORAY RVG model Port-X II EZ X-60 operated at 60 Kvp, 12 mA with a radiation exposure of 0.4 s [Figure 2]. Both the radiographs were taken using paralleling cone technique with the help of extension cone paralleling device (XCP) Densply ®. For a fixed occlusal reference, an orthodontic wire of 22 gauge was fixed with the modeling wax on the occlusal surface of the teeth to be examined while taking an IOPA radiograph, RVGs, as well as IS measurements.{Figure 1}{Figure 2}

The following distances were assessed while recording the measurements: (1) for horizontal bone loss: occlusal plane to alveolar crest, occlusal plane to cementoenamel junction (CEJ), CEJ to alveolar crest and (2) for angular bone loss: occlusal plane to base of defect, occlusal plane to CEJ, and CEJ to base of defect.

The IOPA radiographs were mounted on the X-ray viewer and the alveolar bone losses were measured with the help of a digital vernier caliper [Figure 3], and for the RVG, digital radiographic measurements were done using Carestream Health, Inc. ISO Verona Street Rochester, NY 14608 USA [Figure 4]. The IS measurements were taken with the help of UNC-15 probe [Figure 5].{Figure 3}{Figure 4}{Figure 5}

Statistical analysis

The analysis of variance and the post hoc test were used.


The measurements which were taken by IOPA radiograph and RVG were statistically compared with the IS measurements. The results in case of horizontal bone loss showed that both the radiographic methods nonsignificantly underestimated the amount of bone loss as compared to IS method, and similarly, in case of vertical bone loss, the statistical difference between three methods (IOPA, RVG, and IS) was nonsignificant as shown in [Table 1] and [Table 2].{Table 1}{Table 2}


In periodontology, diagnosis has been a massive challenge. It is typically derived from information obtained from patient's medical and dental histories combined with the findings from thorough oral examination. The sum of signs and symptoms associated with the disease and the additional information provided by radiographic imaging and laboratory tests is taken into consideration before arriving to a diagnosis.[5]

However, it is well known that considerable volume of alveolar bone must be destroyed before the bone loss is detectable on radiographs. Specifically, >30% of the bone mass at the alveolar crest must be lost so that a change in bone height will be recognized on radiographs. Therefore, conventional radiographs are very specific but lack sensitivity.[6]

With the advancing years, the new technologies offer many advantages over conventional radiographs. It eliminates the need for film and film processing and it also allows for low radiation exposure. The mean amount of radiation dose used by digital radiograph is 22.3% of the total radiation dose of conventional radiograph.[7] The generated image is available immediately for evaluation on a computer screen and can be manipulated digitally to enhance viewing.

The present study was carried out with the objective to compare conventional and digital radiographic techniques for the assessment of alveolar bone in periodontal disease by utilizing IS method as a gold standard.

To obtain a fixed reference point, an orthodontic wire of 22 gauge was fixed on the occlusal surface with modeling wax, in accordance to the study performed by Talaiepour et al., in which occlusal plane with a fixed wire was used as a reference point instead of using CEJ as a reference point because it is more accessible, more conspicuous, and better achievable and provides more accurate measurement.[1]

All the measurements were subjected for statistical analysis. The comparison of conventional and digital radiographs was done with IS method for the assessment of following measurements in horizontal bone loss showed nonsignificant difference, as in the measurement from reference point-alveolar crest, conventional and digital radiograph showed mean and standard deviation of 10.74 ± 2.71 and 10.63 ± 2.66, respectively, in comparison to IS method with the mean and standard deviation of 11.34 ± 2.43 with P = 0.235. From reference point to CEJ, the mean and standard deviation of conventional, digital, and IS method is 6.51 ± 0.06, 6.38 ± 1.32, and 6.70 ± 1.52, respectively, with P = 0.278. In case of measurement and from CEJ to alveolar crest, the mean and standard deviation of conventional, digital and IS method is 4.38 ± 2.11, 4.26 ± 2.2,4.67 ± 1.89 respectively, with the P = 0.498 as showed in [Table 1], as compared to IS method measurements with 4.67 ± 1.89 mean and standard deviation, as depicted in [Table 1], showed statistically nonsignificant difference between the comparable radiographic and IS method. Similar results were observed in the study done by Pecoraro et al.[3] and Mellekatte et al. (2014).[8]

Although there are some studies that show that RVG is better than conventional radiograph, Wolf et al. found that all radiographic assessments on the digitized images came close to the IS gold standard when compared to conventional radiographs digitized using flatbed scanner.[9] Khocht et al. also performed a study to estimate the bone levels from digital and conventional radiographs and found that digital images revealed higher number of sites with early-moderate bone loss than the conventional images.[10]

Ashwinirani et al. reported that both IOPA radiograph and RVG underestimated the bone loss in comparison to IS measurements, but they found that RVG was superior to IOPA radiograph for the detection of interdental bone loss.[4] Singh and Singh reported that digital radiographs had superior image recording capabilities as compared to conventional radiographs with the significant statistical difference.[11]

Similarly, in case of vertical bone loss, statistically nonsignificant difference was observed among three methods. From reference point to the base of defect, the mean and standard deviation depicted by conventional and digital radiographs and IS method were 14.76 ± 3.32, 14.71 ± 3.15, and 14.70 ± 3.19, respectively, with P = 0.997. From reference point to CEJ, the mean and standard deviation shown by three methods were 6.53 ± 1.46, 6.35 ± 1.40, and 6.88 ± 1.59 with P = 0.342. From CEJ to base of defect, both the conventional and digital radiographs showed the mean and standard deviation of 8.23 ± 2.52 and 8.25 ± 2.38 as compared to mean and standard deviation of IS method 7.79 ± 2.43 with P = 0.686. These results are similar to the study done by Pecoraro et al.[3]

Although some studies have found the statistically significant difference between the measurements taken by conventional and digital radiograph, we in our study did not find any significant difference between the measurements taken by two radiographic methods in comparison to IS method; this could be due to all the efforts which were made to standardize both the radiographic techniques such as use of XCP ® to avoid any geometric errors and utmost precautions taken such as proper positioning of patient while taking radiographs; proper angulation of X-ray cone could have led to more accurate measurements. Although all the results were found to be nonsignificant, the observations showed that IOPA values were more near to IS method values as compared to RVG values. However, direct digital radiographs (RVG) are preferred, as the imaging software of digital radiographs provides the following advantages as less radiation exposure, immediate digital image display on computer after exposure, its ability to enlarge the radiographs for easy viewing, ability to adjust the contrast for better visualization, ease of taking measurements, the convenience of having immediate access to radiographic records stored in computer, and easy to retrieve, view, and transport data and also save the time by eliminating the need of manual processing of film, which is required for the processing of conventional radiographs. The need for light proof dark room is also omitted.

However, in cases, where direct digital radiographic method is not available for the evaluation of alveolar bone, conventional radiographic techniques such as IOPA radiographs can be used, as the above results of the study did not show any significant difference in the measurements that were taken by conventional and digital radiographic techniques when compared to the IS measurements which were taken as the gold standard. It can be concluded that both the radiographic methods can be used to assess the alveolar bone level.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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