Clinical Research
Coronal and Intraradicular Appearances Affect
Radiographic Perception of the Periapical Region
Julie W. Strong, DDS, MS,* Karl F. Woodmansey, DDS, MA, John A. Khademi, DDS, MS,k
and John F. Hatton, DMD
Abstract
Introduction: The influence of the radiographic appear-
ances of the coronal and intraradicular areas on periap-
ical radiographic interpretation has been minimally
evaluated in dentistry and endodontics. The purpose
of this study was to evaluate the effects that the coronal
and intraradicular radiographic appearance has on end-
odontists radiographic interpretations of periapical
areas. Methods: In a split-group study design using
an online survey format, 2 pairs of digital periapical
radiographic images were evaluated by 2 groups
(A and B) of endodontist readers for the presence of a
periapical finding. The images in each pair were iden-
tical except that 1 image of each image pairs had coro-
nal restorations and/or root canal fillings altered using
Adobe Photoshop software (Adobe Systems, San Jose,
CA). The periapical areas were not altered. Using a 5-
point Likert scale, the endodontist readers were asked
to Please evaluate the periapical area(s). A Mann-
Whitney U test was used to statistically evaluate the dif-
ference between the groups. Significance was set at
P < .01. Results: There were 417 readers in group A
and 442 readers in group B. The Mann-Whitney U test
showed a significant difference in the responses
between the groups for both image pairs (P < .01).
Conclusions: Because the periapical areas of the image
pairs were unaltered, the differing coronal and intrara-
dicular areas of the radiographs appear to have influ-
enced endodontists interpretations of the periapical
areas. This finding has implications for all radiographic
outcome assessments. (J Endod 2017;43:723727)
Key Words
Dental radiography, diagnosis, endodontics, interpreta-
tion, outcomes, perception
From the *Private Practice, Butte, Montana; Graduate Endodontics and Center for Advanced Dental Education, Saint Louis University, St Louis, Missouri; Illinois Air
National Guard and kPrivate Practice, Durango, Colorado.
Address requests for reprints to Dr John F. Hatton, Graduate Endodontics, Center for Advanced Dental Education, Saint Louis University, 3320 Rutger Street, St Louis,
MO 63104. E-mail address: Hattonjf@slu.edu
0099-2399/$ - see front matter
Copyright 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.01.003
JOE Volume 43, Number 5, May 2017
R adiography is an inte-
gral part of dentistry
and endodontics. Radio-
Signicance
This study asserts that the radiographic appear-
ances of coronal and intraradicular areas inuence
graphic images, in conjunc-
the interpretation of periapical areas. This raises
tion with clinical testing, are
concerns regarding the validity of radiographic
routinely used for end-
outcome assessments of the periapical area that
odontic diagnosis, treat-
have been used as outcome measures for decades
ment planning, treatment,
to assess periapical healing. This effect may be sig-
and as an outcome measure
nicant in previously endodontically treated cases.
for evaluating treatment
Both routine radiographic recall assessments and
efficacy. Interpretation of
radiographic outcome research should consider
radiographic images in-
the potential inuences of coronal and intraradicu-
volves both perceptual and
lar areas.
cognitive skills. Visual in-
spection of the image is a
perceptual skill, whereas reasoning through possible diagnoses and inferring decisions
is a cognitive skill.
Shortly after World War II, a medical study reported inter- and intraobserver var-
iations among radiologists of more than 30% (1). Since then, considerable research
has been performed in medical radiography of the various influences on the perception
of radiographic findings; however, far fewer studies have been performed in dentistry
(213). Most endodontic radiographic research has focused on diagnostic accuracy,
overlooking the directly related but more fundamental perceptual and interpretive
issues (1417). Goldman et als classic study (6) showed that radiographic interpre-
tation is unreliable and that success depends on who is reading the radiograph. Two
previous studies have shown the effects of the coronal and intraradicular areas on the
radiographic assessment of periapical areas (13, 18).
This study examined the effects the coronal and intraradicular areas of dental
radiographic images have on endodontists interpretations of periapical areas. The
null hypothesis was that the coronal and intraradicular areas would not affect the peri-
apical interpretation.
Materials and Methods
This study was performed in accordance with a protocol approved by the Institu-
tional Review Board of Saint Louis University, St Louis, MO (Institutional Review Board
#26444). All patient identifiers were removed from all radiographic images before their
use in the study.
A list of e-mail addresses of potential study participants was compiled for a total of
4386 potential participants. Using a random number technique, the potential partici-
Radiographic Perception of the Periapical Region 723
Clinical Research
pants were randomly assigned to 1 of 2 groups referred to as group A
and group B. This provided a total of 2193 potential participants in
group A and 2193 potential participants in group B.
An invitation to participate in the study was e-mailed to the 4386
potential participants on March 7, 2016. The invitations were hyper-
linked to 2 similar, but slightly different, online questionnaires using
an online survey tool (SurveyMonkey, Palo Alto, CA). One week after
the initial invitation, a second invitation was e-mailed to individuals
who had not opened the hyperlink. The study was closed on March
21, 2016, after 2 weeks of availability. All participants were volunteers.
No incentives were offered.
A total of 6 digital periapical radiographic images were selected for
use in this study. Each image was cropped to consist of a single tooth
with a clearly visible crown, root, and periapical area. Two of the 6 im-
ages served as control images, and 2 served as test images. The 2 test
images were of single-rooted maxillary premolar teeth with ambiguous
periapical areas. Each of the 2 test images were then digitally modified
using Adobe Photoshop software (Adobe Systems, San Jose, CA) to
create 2 test image pairs. Image pair 1 was modified to suggest an
adequate coronal restoration with an inadequate (short) obturation.
Image pair 2 was digitally modified to suggest an adequate coronal
restoration with an adequate obturation (Fig. 1). The periapical areas
remained unaltered in all images and were identical in each image pair.
The study used a split design to allow for comparison of the re-
sponses between each pair of test images. Each respondent was asked
his or her number of years of experience as an endodontist. Both ver-
sions of the online questionnaire included 6 pages with a single radio-
graphic image and the following Likert scale question: Please evaluate
the periapical areas. The 6 images shown on these pages included 2
test images, 1 from each image pair; 2 control images; and 2 addi- were also excluded from participants who failed to score both test im-
tional images that were not scored. Both groups viewed the same con-
trol images and nonscored images, but group A viewed different test
Images Viewed Images Viewed by
by Group A Group B
Image
Pair 1
Original Modified
Image
Pair 2
Modified Original
Figure 1. The 4 test images or 2 image pairs.
724 Strong et al.
images than group B. Each group viewed only 1 image from each image
test pair (Fig. 2). Time was not limited for completion of the question-
naire; however, participants were prevented from returning to previous
pages.
Each image had a 5-point Likert scale (referred to as the confi-
dence scale) associated with it. Using this scale, participants re-
sponded to the following question: Please evaluate the periradicular
area(s). The scale used in this study was as follows: 1, definitely,
or almost definitely, an abnormal feature; 2, probably abnormal;
3, possibly abnormal; 4, an anomalous feature present but probably
normal; and 5, definitely, or almost definitely, normal. Although Lik-
ert scales typically have a neutral option, the selected scale used in the
study did not. The wording for this scale was based on a similar one
used in medical radiography perception research (19).
In addition, the participant was asked the following question for an
action category: What is your recommendation to the patient? The
choices of the 3-point Likert scale were Treatment, Future re-evalu-
ation, or No endodontic treatment/no future re-evaluation.
For result analysis, the 2 control images consisting of obvious
normal and abnormal periapical areas were used to assess partic-
ipants for eligibility. The intent was to ensure that the participant was
focused on the questionnaire and capable of identifying normal and
abnormal periapical areas. Data were excluded from participants
who failed to correctly score the normal and abnormal control images.
Data were excluded if participants identified the normal image as
definitely, or almost definitely, an abnormal feature, probably
abnormal, or possibly abnormal. Data were excluded if participants
identified the abnormal image as an anomalous feature present but
probably normal or definitely, or almost definitely, normal. Data
ages. These screenings effectively were exclusion/inclusion criteria,
such that the remaining data set was considered for analysis (Fig. 2).
Statistical analysis was performed using SPSS for Windows Version
14.0 (SPSS Inc, Chicago, IL). The median and mode were calculated for
the confidence scales of each test image. The medians of the confidence
scales of each image pair were compared using the Mann-Whitney U
test. Significance was set at P < .01 to reject the null hypothesis. Using
the Mann-Whitney U test results, the Cliffs delta effect size of the data
was calculated to evaluate the magnitude of difference between the orig-
inal and modified images of each image pair. The null hypothesis was
that there would be no differences between the images of each image
pair.
Results
There were 417 responses that met the inclusion criteria for group
A for a response rate of 19% and 442 responses that met the inclusion
criteria for group B for a response rate of 20%. The mean/median num-
ber of years of endodontic experience was 14.4/12 for group A and
14.2/11 for group B. Fifty-two (12%) of the readers in group A and
50 (11%) of the readers in group B were endodontic residents.
For image pair 1, the results of the confidence scale resulted in
both a mode and median for group A of possibly abnormal; for group
B, the mode was definitely abnormal, and the median was probably
abnormal (Fig. 3). For image pair 2, the mode and median were
possibly abnormal for group A, and the mode and median were defi-
nitely abnormal for group B (Fig. 4).
Mann-Whitney U statistics compared the median Likert scores of
both image pairs and showed significant differences with actual P values
<.001 (Table 1). The null hypothesis was rejected for both image pairs
because the calculated P value was less than the preselected significance
level (P < .01).
JOE Volume 43, Number 5, May 2017
 Clinical Research
AAE members with e-mail addresses
Enrollment (n= 4,386)
Approached for Enrollment

Randomization and
Allocation

Group A-2193 Randomized Group B-2193 Randomized Excluded (n=914)

Excluded (n=893)
2,193 e-mails sent 2,193 e-mails sent Did not open email
Did not open email
1,300 e-mails opened 1,279 e-mails opened
605 Assessed for eligibility 623 Assessed for eligibility Excluded (n=656)
Excluded (n=695)
Did not complete survey Did not complete survey

Control Images used as Control Images used as

Inclusion Criteria Inclusion Criteria
Excluded (n=188) Excluded (n=181)
Failed control image Failed control image
interpretation interpretation

"Normal" "Abnormal" "Normal" Abnormal"

Analyzed (n=417) Analyzed (n=442)

Identical periapical area

Images viewed by Group A participants Images viewed by Group B participants

Test
Images

Identical periapical area

Figure 2. A flow diagram of the methodology.

Using the Cliffs delta, effect sizes were calculated to evaluate the
magnitude of the differences between the original and modified images
for each image pair. The Cliffs delta for image pair 1 was +0.51, and for
image pair 2 it was +0.55.
Discussion
It should be emphasized that the periapical areas were identical in
both image pairs and that participants were instructed to Please eval-
uate the periradicular area(s). The results suggest that because the
periapical areas of the image pairs were identical, the differences be-
tween the interpretations of the image pairs can be directly attributed
to the coronal and intraradicular differences of the radiographic images.
An effect size is a quantitative measure of the strength of a phenom-
enon (20). The Cliffs delta is a nonparametric effect size measure that
quantifies the amount of difference between 2 groups of observation
beyond P value interpretation (21). The effect size for the Cliffs delta
ranges from 1.0 to +1.0, with a value of 0.0 designating zero effect
(21). The calculated effect sizes (+0.51 and +0.55) strongly suggest
that radiographic interpretations of the periapical areas by endodontists
can be biased by the radiographic appearances of the coronal and intra-
radicular areas. Because the radiographic images had ambiguous periap-
ical areas, the judgments regarding these areas were not straightforward.
Endodontists (and residents) who participated in this study appear to
have interpreted a greater prevalence of apical disease when associated
with questionable coronal and intraradicular radiographic findings.
Morgental et al (13) used an Adobe Photoshop image alteration
technique to compare periapical evaluations. They had 10 Brazilian
general dentists compare original radiographic images with images
digitally modified to either fully mask the root area or the periapical re-
gion. Although their experimental technique differed substantially from
the Photoshop alteration technique used in this study, they had remark-
ably similar findings. They concluded that root filling quality substan-
tially affects periapical diagnoses.

JOE Volume 43, Number 5, May 2017 Radiographic Perception of the Periapical Region 725
Clinical Research
Figure 3. Data table from image pair 1.
In medical radiology interpretation studies, action categories are
often used instead of a Likert scale to assess confidence in the call and
make recommendations for a future course of action such as earlier
follow-ups or biopsy (22). For this study, we piloted asking for an action
category, which required making a decision as to a course of action,
including treatment. Although the results of the action category strongly
supported the studied effect, we received multiple e-mails expressing a
general objection to making a decision as to a course of action without
subjective and objective patient information. Based on the level of
Figure 4. Data table from image pair 2.
726 Strong et al.
responses as opposed to the amount of responses, we believe asking
for action categories based on radiographic findings in isolation may
not be appropriate, and, therefore, the data are not reported.
It must be recognized that this study design has limitations and var-
iables. The respondents to the questionnaire were a fraction of the prac-
ticing endodontists in the United States, such that those who responded
to the questionnaire introduced a self-selection bias into the results. Of
the respondents who completed the survey, 369 (30%) were excluded
because of incorrect responses to the normal and abnormal
JOE Volume 43, Number 5, May 2017

TABLE 1. Mann-Whitney U Test and Effect Size
Statistic Image pair 1 Image pair 2
n 417 442
z 13.287 14.550
Mann-Whitney U test 45,391.500 41,073.000
Asymptotic significance .000 .000
(2-tailed)*
Cliffs delta 0.51 0.55
*Significant at P # .01.
control images. These images were designed to cull respondents who
merely clicked through the survey without seriously evaluating the im-
ages. Although these control images were selected to assess a basic
threshold of radiographic interpretation, we cannot know whether re-
spondents were unable to correctly identify what our Delphi panel
determined as obviously normal and abnormal images or whether 2. Webber RL, Stark L. Fitting an image to the eye: a conceptual basis for preprocessing
they just clicked through the survey. Our inclusion criteria were
somewhat loose in that data from the normal control image were
only excluded if participants identified it as definitely, or almost defi-
nitely, an abnormal feature; probably abnormal; or possibly
abnormal. For the abnormal control image, data were only excluded 5. Goldman M, Pearson AH, Darzenta N. Endodontic success whos reading the
if participants identified the abnormal image as an anomalous
feature present but probably normal or definitely, or almost defi-
nitely, normal (Fig. 2).
Another limitation is that participants were asked to make a de-
cision based on a single radiograph. Because Brynolf (14) showed
that increasing the number of radiographic images improves diag-
nostic acumen, the participants diagnostic abilities were limited
by viewing a single radiograph. The results of this study are also
constrained by the surveys questionnaire format. Furthermore, the
viewing conditions, equipment, and environment were not standard-
ized.
In addition to experimental variables, behavior in any experi-
mental situation is also affected by a second set of variables classified
as demand characteristics. Demand characteristics are when partic-
ipants form an interpretation of the experiments purpose and subcon-
sciously change their behavior to fit that interpretation (23). Demand
characteristics cannot be eliminated from an experiment but can be
dealt with. Using a between-subjects design rather than a within-
subjects design is one way to minimize this psychological effect (24).
Despite the experiments limitations and variables, the authors contend
that the split or between-subjects design of this study and the relatively
large sample size mitigated many limiting variables with the possible
exception of self-selection bias.
Conclusion
The results of this study assert that the radiographic appearances
of the coronal and intraradicular areas influence the interpretation of
periapical areas. These results raise concerns regarding the validity
of all radiographic outcome assessments of the periapical area that
have been used as outcome measures for decades and, in particular,
periapical healing. This effect may be especially significant in previously
endodontically treated cases. Both routine radiographic recall assess-
ments and radiographic outcome research should now consider the
potential influences of the coronal and intraradicular areas.
This study shows the effectiveness of this experimental design for
studying radiographic image perception in dentistry. Further studies on
radiographic perception are needed to better understand the role image
perception plays in dental radiography.
JOE Volume 43, Number 5, May 2017
Clinical Research
Acknowledgments
The authors thank the Saint Louis University Center for
Advanced Dental Education for support of this project, Professor
Kevin Berbaum for his assistance with the studys design, Dr Jacob
Frazier for providing the images used in the study, and Mr Dan Kil-
foy for his Web survey assistance. The authors also wish to thank the
participants in this study.
Performed as part of Julie W. Strongs master of science degree
at Saint Louis University.
The authors deny any conflicts of interest related to this study.
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