Dentomaxillofacial Radiology (2006) 35, 442446 q 2006 The British Institute of Radiology http:/ /dmfr.birjournals.

org

RESEARCH

The precision of the panoramic mandibular index

K Gungor*,1, ZZ Akarslan1, M Akdevelioglu1, H Erten2 and M Semiz3
Department of Oral Diagnosis, Oral Medicine and Radiology, Gazi University, Faculty of Dentistry, Ankara, Turkey; 2Department of Operative Dentistry and Endodontics, Gazi University, Faculty of Dentistry, Ankara, Turkey; 3Department of Statistics, Selcuk University, Faculty of Art and Sciences, Konya, Turkey
1

Objectives: This study evaluates the precision of the panoramic mandibular index (PMI). Materials and methods: Measurements were made by two observers on both of the left and right sides of the mandible on the radiographs taken from 41 young individuals and the inferior and superior PMI were calculated. Two weeks later the same observers repeated their measurements to assess intrarater reliability. Paired t-test, Pearson correlation coefcients and precision values were calculated to assess levels of association. Results: There was a signicant difference between the rst raters rst and second measurements (intrarater repeatability) for both the inferior and superior PMI, while no signicant difference was observed for the second rater. The intrarater and inter-rater precision values for the inferior PMI were calculated as 0.005319 and 0.005594 for the rst rater and 0.005663 and 0.005594 for the second, respectively. The intrarater and inter-rater precision values for the superior PMI were similar for both observers, calculated as 0.002558, 0.002766; and 0.003046, 0.002766, respectively. The precision of both inferior and superior indices was not very good, but precision gures for the superior PMI demonstrated consistency almost twice better than those for the inferior PMI for both observers. Conclusions: The precision values for the PMI seem to be sufcient according to the results of this study, but they are still questionable and more studies need to be done on this aspect. Dentomaxillofacial Radiology (2006) 35, 442446. doi: 10.1259/dmfr/25346328 Keywords: panoramic; radiography; osteoporosis; mandible Introduction There has been a growing interest in the diagnosis and oral signs of osteoporosis recently. This disease, characterized as a signicant age-related deciency in bone mass with a potential for structural failure,1 affects a large portion of the elderly population. The affected regions of the skeleton become weakened and have an increased risk of fracture.2,3 Besides the persisting bone loss,4 oral manifestations such as alveolar ridge resorption, tooth loss,6 periodontal disease7 and oral bone loss8 could also be associated. Panoramic radiographs are widely used in dental practice for the diagnosis of many dental pathologies. It is possible for dentists to evaluate patients osteoporotic status from these radiographs taken for other purposes. The panoramic mandibular index (PMI) described by Benson et al10 evaluates the cortical thickness normalized for the mandibular size which could be used for the assessment of local bone loss.
*Correspondence to: Kahraman Gungor, Gazi University, Faculty of Dentistry, Department of Oral Diagnosis, Oral Medicine and Radiology, Emek/Ankara 06510, Turkey; E-mail: kahraman@gazi.edu.tr

High repeatability and reproducibility of such indices are important in clinical practice. This is essential in evaluating consistency of diagnosis between different observers and follow-up of patients over a period of time.9 Therefore, the aim of this study was to assess the intrarater repeatability, inter-rater reproducibility and precision based on measures of the PMI. Materials and methods Out of 60 randomly selected panoramic radiographs taken for other diagnostic tasks, 19 were excluded because of undened mental foramen and/or inferior mandibular cortex borders, and measurements were performed on 41 radiographs. Patients consisted of 18 males and 23 females aged between 26 years and 35 years (to ensure full development of the mandible), without any systemic disease affecting skeletal metabolism. All radiographs were taken with Kodak lms (Eastman Kodak Co., Rochester, NY) with the same orthopantomograph OP100 (Trophy Instrumentarium Corp., Finland) at standard positioning and developed in an automatic processor machine (Velopex, Extra-X; Medivance

This study was supported by the scientic research department of Selcuk University.
Received 30 September 2005; revised 23 January 2006; accepted 8 February 2006

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Instruments Limited, London, UK) with fresh chemicals. Evaluation of the radiographs was made independently by two dentists, one Research Assistant and one Assistant Professor working in the Department of Oral Diagnosis, Oral Medicine and Radiology, who were trained and informed about how the measurements were going to be made. The measurements were made according to the following criteria: (1) (2) A line was drawn which passed perpendicular to the tangent to the lower border of the mandible (a) and through the centre of the mental foramen Measurements were made along this line of cortical width (c), the distance between the lower border of the mandible and the inferior margin (I), and superior margin (s) of the mental foramen. Step two was described by Benson et al,10 who introduced the index, and step one was described by Ledgerton et al,9 who used the index in their study.

Paired t-tests, Pearson correlation coefcients and precision values were calculated to assess levels of association from the SPSS statistical package program (Release 7.5.1, Standard version; SPSS Inc., Chicago, IL). Results The intraobserver and interobserver mean difference, standard deviations, standard errors, correlation coefcients and precision values were calculated both for inferior and superior indexes based on the independent measurements made by two observers. Inferior PMI There was a statistically signicant difference between the two indexes calculated from the rst observers rst and second readings, according to the paired t-test (P , 0.001); on the other hand, no signicant difference was observed for the second observer (P 0.322). The standard deviation (SD) for intrarater/inter-rater reliability was calculated as 0.03201 and 0.04544; 0.09337 and 0.09478 for the rst and second observer, respectively. The 95% CI of mean difference of interobserver agreement ranged between 20.0578, 20.0168 for the rst and 20.0489, 20.0072 for the second evaluation of the cases. The rst observers intraobserver Pearson correlation coefcient (r 0.901) was higher than the second observers (r 0.819). The intraobserver precision values for the inferior index were higher than for the superior index and were similar for both observers, presented as 0.005319 and 0.005594. The inter-rater precision values were calculated as 0.005663 and 0.005594 for the rst and second observation, respectively. Details are shown in Table 1 and Figure 1. Superior PMI A statistically signicant difference was observed between the two superior indices calculated from the rst observers readings according to the paired t-test (P , 0.001); on the other hand, no signicant difference was observed for the

The superior and inferior PMI were calculated as: Superior PMI: cortex thickness / distance from superior margin of mental foramen to inferior border of mandible Inferior PMI: cortex thickness / distance from inferior margin of mental foramen to inferior border of mandible When the superior border of the inferior mandibular cortex was ill-dened on the radiographs the smallest width of compact cortical bone lying below the mental foramen was measured.9 All measurements were made on the radiographs with a digital calliper (CD-S15; Mitutoyo, Tokyo, Japan), viewed on a viewbox with subdued lighting and obtained values were in millimetres (mm). Two weeks later, the same observers repeated their measurements blinded to cases with randomized radiographs to evaluate intraobserver agreement level.

Table 1 Intra-inter-rater agreement levels of the superior and inferior panoramic mandibular index (PMI) according to the paired t-test, Pearson correlation coefcient (r) and precision values n Mean difference (P-value) Standard deviation of mean difference Standard error of mean difference 95% CI of mean difference r (P-value) Precision

Inferior Intraobserver O1 82 0.0143 O2 82 0.0050 Interobserver O1&O2 Overall 164 0.0327 First 82 0.0373 Second 82 0.0280 Superior Intraobserver O1 82 0.0116 O2 82 0.0045 Interobserver O1&O2 Overall 164 0.0306 First 82 0.0341 Second 82 0.0271 p Statistically signicant

(P , 0.001)p (P 0.322) (P , 0.001)p (P 0.001)p (P 0.009)p (P , 0.001)p (P 0.246) (P , 0.001)p (P , 0.001)p (P , 0.001)p

0.03201 0.04544 0.09391 0.09337 0.09478 0.02462 0.03500 0.06698 0.06753 0.06665

0.00354 0.00502 0.00733 0.01031 0.01047 0.00272 0.00387 0.00523 0.00746 0.00736

(20.0213, 20.0072) (20.1500, 0.0050) (20.0472, 20.0182) (20.0578, 20.0168) (20.0489, 20.0072) (20.0170, 20.0062) (20.0122, 0.0032) (20.0409, 20.0203) (20.0490, 20.0193) (20.0417, 20.0124)

0.901 (P , 0.001)p 0.819 (P , 0.001)p 0.183 (P 0.019)p 0.174 (P 0.118) 0.187 (P 0.093) 0.819 (P ,0.001)p 0.793 (P 0.001)p 0.162 (P 0.038)p 0.142 (P 0.203) 0.176 (P 0.114)

0.005319 0.005594 0.005634 0.005663 0.005594 0.002558 0.002766 0.002911 0.003046 0.002766

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Panoramic mandibular index K Gungor et al

Figure 1 Graphics demonstrating intrarater and inter-rater agreement levels of inferior panoramic mandibular index (PMI). O1 is more consistent than O2 because standard error of mean differences is less than O2s. (a,b) Intrarater agreement levels. (c,d) Inter-rater agreement levels. The decrease of the distance between the two plotted lines on the graphic demonstrates increased consistency

second observer, similar to the inferior index (P 0.246). The standard deviations of intrarater reliability were calculated as 0.02462 for the rst observer and 0.03500 for the second observer. The standard deviation for interrater agreement level was calculated as 0.06753 and 0.06665 for the rst and second observation, respectively. The 95% CI of mean difference of inter-rater agreement ranged between 2 0.0490, 2 0.0193 for the rst and 2 0.0417, 2 0.0124 for the second evaluation. The rst observers intrarater Pearson correlation coefcient (r 0.819) was higher than the second observers (r 0.793). The intrarater and inter-rater precision values were calculated as 0.002558, 0.002766; and 0.003046,
Dentomaxillofacial Radiology

0.002766 for the rst and second observer, respectively. Details are shown in Table 1 and Figure 2. Precision gures for the superior PMI demonstrate consistency almost twice better than those for the inferior PMI for both observers. Discussion PMI is a radiomorphometric method presented in 1991 by Benson et al.10 It is partly based on the Wical and Swoope11 method, which is a theory of the relation of the residual ridge resorption to mandibular height below the inferior

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Figure 2 Graphics demonstrating intrarater and inter-rater agreement levels for superior panoramic mandibular index (PMI). (a,b) Intrarater agreement levels. (c,d) Inter-rater agreement levels. The decrease of the distance between the two plotted lines on the graphic demonstrates increased consistency

edge of the mental foramen. They suggest that despite the alveolar bone resorption above the foramen, the distance from the foramen to the inferior border of the mandible remains relatively constant throughout life. The distance below the foramen in a non-resorbed mandible is approximately one third of the total height of the mandible in that region.11 Thus, the PMI provides a measure of mandibular cortical thickness for normal mandibular size and it could be used for the evaluation of local bone loss in dental practice. In this index, multiple measurements are made and divided by each other, so these could show some intraobserver and interobserver differences; therefore, the repeatability, reproducibility and precision should be evaluated.

Repeatability and reproducibility indicate the agreement between repeated measurements. Repeatability refers to intraobserver and reproducibility refers to interobserver agreement level. Repeatability could be evaluated from repeated measurements made on a series of subjects and calculation of mean and standard deviation of the differences. Since the same method is used, for the best level of agreement the mean difference should be zero. We expect 95% of differences to be less than two standard deviations. If the mean difference differs from zero, it is said that there is some discrepancy between measurements. For a good level of agreement the difference is expected to be very low; as the difference grows the level of agreement tends to be poorer.12
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Precision is expressed as the variance or standard deviation of multiple measurements made on a single subject, thus could be applied to both repeatability and reproducibility. The consistency level increases while the precision values decreases. In this study the precision values ranged between 0.002 and 0.005 for both observers. The precision gures of the superior PMI were almost twofold better than those of the inferior index for both observers. This result is consistent with the results of the study of Ledgerton et al9 in which precision of the measurements made for the inferior and superior PMI were evaluated. We think that the superior border of the mental foramen could be more easily detected by both observers, therefore consistency in the measurements led to increased precision. As seen in Figures 1 and 2, the decrease of the distance between the two plotted lines demonstrates increased consistency. Klemetti et al reported the reproducibility of the PMI as 94%, thus as a high level.13 Our results are consistent with their study. The rst observer was a research assistant working in the Oral Diagnosis, Oral Medicine and Radiology Department with 7 years experience, and the second was an assistant professor with 15 years experience. According to the t-test, a signicant difference was observed between the
References
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rst observers rst and second index values. This is due to the rst observers second measurements being generally higher than the rst measurements (50 of 82 cases). Therefore, these differences create signicant negative differences from zero. The second observers dispersion is larger than the rst observers but the mean of the difference is closer to zero. There is a need for more studies to discuss the repeatability and reproducibility of the index with increased number of observers working in different departments and dentists working in general dental practice with different experience in evaluating radiographs. Devlin et al14 reported a lack of precision due to an extensive variation among nine general dental practitioners for other radiomorphometric indices (Gonion index, Antegonion index, Mental index and Mandibular Cortical index (MCI)). Jowett et al15 reported substantial agreement level between experts and moderate agreement level between students for the MCI, another index in which the appearance of the lower border of the mandibular cortex is evaluated. They concluded that more training and experience in using the index was needed. In conclusion the precision values for the PMI seem to be sufcient according to the results of this study, but there are still questions and more studies are needed for the discussion of this point.

9. Ledgerton D, Horner K, Devlin H, Worthington H. Panoramic mandibular index as a radiometric tool: an assessment of precision. Dentomaxillofac Radiol 1997; 26: 95 100. 10. Benson BW, Prihoda TJ, Glass BJ. Variations in adult cortical bone mass as measured by a panoramic mandibular index. Oral Surg Oral Med Oral Pathol 1991; 71: 349 356. 11. Wical KE, Swoope CC. Studies of residual ridge resorption. Part 1. Use of panoramic radiographs for evaluation and classication of mandibular resorption. J Prosthet Dent 1974; 32: 7 12. 12. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. The Lancet 1986; i: 307 310. 13. Klemetti E, Kolmakov S, Heiskanen P, Vainio P, Lassila V. Panoramic mandibular index and bone mineral densities in postmenopausal women. Oral Surg Oral Med Oral Pathol 1993; 75: 774 779. 14. Devlin CV, Horner V, Devlin H. Variability in measurement of radiomorphometric indices by general dental practitioners. Dentomaxillofac Radiol 2001; 30: 120 125. 15. Jowitt N, MacFarlane T, Devlin H, Klemetti E, Horner K. The reproducibility of the mandibular cortical index. Dentomaxillofac Radiol 1999; 28: 141 144.

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