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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 9  »  Diagnosing periapical lesions - disagreement and borderline cases
Diagnosing periapical lesions - disagreement and borderline cases
Introduction - Materials and methods.



A. Halse, O. Molven & I. Fristad
Section of Oral Radiology and Section of Endodontics, School of Dentistry, University of Bergen, Bergen, Norway.

Introduction.
Weak visual signals may often, in addition to producing false negative recordings, cause uncertainty to the observer when attempting to make a radiological diagnosis. In addition, early signs of disease, remnants of disease and certain morphological features in bone are difficult to distinguish (Kohler & Zimmer 1967). Endodontists, like other clinicians, are repeatedly faced with such problems. In the evaluation of the apical periodontium, marked visual signals may leave the ob server unclear as to whether the structures represent normal morphology or pathological alterations. Strategies for the radiographic diagnosis of periapical pathosis take this uncertainty into account through calibration of the observers and plans for handling of borderline and disagreement cases (Molander et al. 1998, Trope et al. 1999, Molven et al. 2002a).
Three diagnostic strategies for evaluation of periapical findings are currently in use in epidemiological studies and follow-up investigations. They are: a classification based on the radiographic appearances of the periodontal ligament space (Halse & Molven 1986, Sjogren et al. 1990,Tronstad et al. 2000, Chugal et al. 2001); the periapical index (PAI), a five-group system related to observations made by Brynolf (Orstavik et al. 1986, Trope et al. 1999, Sidaravicius et al. 1999); and a strict definition of periapical disease (Petersson et al. 1989, Weiger et al. 1997, Kvist & Reit1999).
Observers’doubts during evaluation and inter-observer deviations are handled differently in these strategies. In the classification based on radiographic appearances, both disagreement cases and selected borderline cases are discussed jointly during the study, both to reveal diagnostic problems and obtain agreement (Halse&Molven1986, Molven et al.2002a). Using the PAI scoring system, observers are told to assign a higher score when in doubt, and deviations between observers are adjusted or eliminated by approaches to determine ‘true scores’ (Orstavik et al. 1986,Trope et al. 1999). Joint evaluations have also been used (Sidaravicius et al.1999).The use of a strict definition of periapical disease implies that pathoses should only be recorded when observers are sure. Disagreement cases are discussed and agreed jointly (Kvist & Reit1999).
The number of uncertain and disagreement cases or cases subjected to joint evaluations may vary in different studies and are not always given. Irrespective of method, however, decisions in difficult diagnostic situations for man important element of recording and classifying the disease. Such problem cases ought to be presented to other clinicians and researchers. In her thesis on correlation between histological and roentgenological characteristics of the periapical region of maxillary incisors, Brynolf (1967) presented a series of illustrative cases. Supplementary material was presented in another publication (Brynolf 1979). In more recent papers by other investigators, the radiographic picture in deviating cases has not been presented, and thus the refined analyses are not left open for discussion b y others.
We decided, therefore, to present borderline and disagreement cases taken from a methodological study (Molven et al. 2002a). The aim of this paper is to discuss problems related to such cases.

Materials and methods.
The original material, 257 cases, and the methods are presented elsewhere (Molven et al. 2002a). Full agreement between the three observers was found for 73% of the cases, and agreement between three different pairs of observers was 82, 85 and 86%, respectively.
Atotalof32cases (12%) were subjected to joint discussion. They were: three cases that had been given different diagnoses by the three observers; eight cases that had not been given diagnoses owing to substandard radiographs, either by the radiologist (AH) alone or by the two endodontists (OM and IF); 21 cases selected by one of the observers (OM) amongst cases with initial agreement between two observers. Guidelines for selection were:
  1. each observer should be represented with deviations from the two others,
  2. each classification group should be represented as a deviating diagnosis,
  3. special attention should be given to difficulties encountered with the diagnosis of apical periodontitis,
  4. different tooth groups and both jaws should be included.
The observers met three times during the methodological study (Molven et al. 2002a) for evaluation and discussion of disagreement and borderline cases.