Ahead in Imaging

The British Society of Dental and Maxillofacial Radiology

Ahead in Imaging

The British Society of Dental and Maxillofacial Radiology

A series of short presentations championing service development, quality improvement, education and research within dental and maxillofacial departments across the UK. This will hopefully provide a platform to share ideas, stimulate discussion and inspire collaboration.


1. Orbital trauma; quantitative assessment of bony orbital volume symmetry: CT analysis in the caucasian population

Edward Walker, Leeds Dental Institute

There is a surprising lack of evidence documenting the volumetric symmetry of the bony orbit in the uninjured population. We aim to establish reference values for orbital volume (OV) and symmetry in the 25-40 year old Caucasian population.

A standardised, quantitative method of OV measurement was carried out using CT sinus examinations acquired for indications unrelated to the orbits. Data for 50 patients was recorded in both male and female cohorts (100 patients in total).

There was almost perfect agreement in OV measurements between the two assessors (Kappa: 0.87). Mean left OV was 23.1 ± 2.8 cm3 and mean right OV was 23.3 ± 2.7 cm3. Left and right OV were strongly positively correlated (correlation coefficient: 0.96).

There is strong positive correlation between left and right orbital volumes in Caucasian males and females in the 20-40 year old age group. This data will now be used to determine the significance of orbital volume discrepancies in both custom and stock plate orbital reconstruction groups

2. Orbital USS

3. Rapid diagnostic clinic

Chris Greenall, Swansea

4. Processing opinion requests from GDPs

Dr Anita Sengupta, Manchester University

5. Multi-disciplinary salivary allergy clinic

Niall O’ Neill, Guy’s Hospital

6. MRI in dental imaging

Jimmy Makdissi
Barts' and the 
London Dental Hospital

7. Audit to assess orthopantomogram justification, grading, interpretation and reporting within a dental foundation training practice.

Dr Dary Jones, Educational Supervisor and Associate Dentist, Moorside Dental Practice

An orthopantomogram (OPG) is a very common plain film imaging technique which is used to visualise the entire dentition and jaws. There is a regulatory requirement for radiographs to be reported on which can often be poorly carried out, especially in general practice. Each report should include comments on the structures seen as well as justification and grading of the radiograph. Dentists should develop a systematic approach to radiograph reporting and consider referral to secondary care when an anomaly arises. This audit reviews a sample of OPG radiographs from a dental foundation training practice and suggests a systematic and effective approach to reporting. The results from the reaudit show a comprehensive and robust reporting strategy which has been well received by the reporting dentists.

8. A two cycle audit assessing the quality of radiographic reports for dental pantomogram taken in a district hospital maxillofacial department

Dr (Alessandra) Joelle Booth (DCT)
Dr Rumandeep Dhillon (DCT)
Oral and Maxillofacial Department, Musgrove Park Hospital, Taunton

This audit assess the justification and grading for DPTs taken in a maxillofacial department. It also assesses the completeness of radiographic reports written by clinicians ranging from dental core trainees to consultants. The audit aims to assess the efficacy of recommendations made to improve compliance with justifying and grading DPTs as well as increasing the quality of radiographic reports.

Study design
100 DPTs were selected for a chronological period within the oral and maxillofacial surgery department at Musgrove Park Hospital. The DPTs were assessed to determine whether they were justified and graded. Each radiographic report was assessed to determine if there was a report present, whether this commented on general anatomy, coronal tissues, bone levels and root morphology. The findings were presented at an audit meeting. An action plan was devised including utilising the new FGDP grading criteria and introducing a radiographic reporting form.

In the first cycle of the audit only 74% of DPTs had a report, 75% a grade and 60% a justification. General anatomy was only commented on in 37% of reports; bone levels 23%; coronal tissues 31% and apical disease/root morphology 50%.

An increase was seen in the quality of the reports using the introduced radiographic reporting forms. In the second cycle of the audit 95% of DPTs had a report, 94% a grade and 93% an adequate justification. The quality of the reports also increased, general anatomy was commented on in 72% of reports; bone levels 52%; coronal tissues 60% and apical disease/root morphology 82%. Dental core trainees scored 94% in the overall quality of reports, followed by consultants (63%) and then staff grades (62%).

The results of the audit suggest that the new FGDP grading criteria improves compliance with grading DPTs, additionally, the radiographic report forms aided as a prompt to improve the quality of reports within the department. Following this two cycle audit annual re-audits should be conducted in the department to continue improved compliance with standards set. Despite the improvements, the department is still falling below the required standards of all DPTs being justified, graded and appropriately reported. One of the barriers suggested by clinicians was limited time to complete detailed reports and to overcome this we would recommend the consideration of DPTs being routinely reported by dental and maxillofacial radiologists. 

9. A clinical service evaluation of the use of ultrasound investigations for head and neck pathology in a district general hospital oral and maxillofacial surgery department.

Dr (Alessandra) Joelle Booth - DCT
Dr Nikel Patel – Specialty Doctor
Oral and Maxillofacial Department, Musgrove Park Hospital, Taunton

The aim of this clinical service evaluation was to determine the use of ultrasound investigation within the maxillofacial department, whether subsequent imaging was required for these patients and if ultrasound scans confirmed differential diagnoses.

All ultrasound scans ordered for patients in the oral and maxillofacial surgery department from October 2019-2020 were included in this study as collated from the hospital imaging ordering system (Ordercomms). Clinical records on the electronic hospital records system (Epro), ultrasound requests and radiology reports were assessed to determine clinical justification for imaging and outcomes. Radiographic reports were conducted by the radiology department and cross-reported by a second radiologist where required. The online radiology viewing platform was analysed for each patient to determine if they had further subsequent imaging in six months following their ultrasound scan and if so what type of imaging was utilised. Differential diagnosis was taken from clinical records and radiographic requests and compared to histological or clinical outcomes.

113 patients underwent ultrasound imaging following referral. the average time a between ultrasound imaging requests and the scan was 15 days for patients. Of patients referred 73% were imaged within two weeks of the referral (referrals were not separated into two week or routine prior to analysis). The main reason for referral was palpable lymph nodes (27%), parotid swellings (21%), suspected malignancy (17%) and submandibular swellings (15%). 14% of those who had an ultrasound also underwent fine needle aspiration (FNA) to aid diagnosis. 39% required further imaging in the six months following their ultrasound scan. As shown in figure 3, the majority of these patients went on to have an MRI (20 patients), a repeat ultrasound (9 patients) or a CT (7).

Ultrasound imaging has limitations and this service evaluation found that 39% of patients required further subsequent imaging, most commonly MRI or a second US with FNA. This was mainly due to the fact that the primary ultrasound imaging did not provide a definitive diagnosis in these cases. A suitable use for ultrasound is surveillance of lymph nodes, especially when combined with FNA1. 

1. de Bondt RB, Nelemans PJ, Hofman PA, Casselman JW, Kremer B, van Engelshoven JM, Beets-Tan RG. Detection of lymph node metastases in head and neck cancer: a meta-analysis comparing US, USgFNAC, CT and MR imaging. Eur J Radiol. 2007 Nov;64(2):266-72. doi: 10.1016/j.ejrad.2007.02.037. Epub 2007 Mar 27. PMID: 17391885.


 10. The impact of CBCT imaging on oral surgery treatment plans

Presenting author: Dr Neelam Rathod
Authors: Dr Neelam Rathod, Dr Dhurrika Raveendran, Dr Jennifer Parrish, Mr Kandasamy Ganesan

CBCT images are increasingly becoming a vital tool for assessment and planning of various oral surgery procedures, offering low-dose exposure and ease of acquisition. With the introduction of a CBCT device at Southend University Hospital, this audit evaluates compliance and impact on the management of various oral surgical procedures. 

To determine whether CBCT images were requested in accordance with SEDENTEXCT guidance and the impact the images had on the planning of various oral surgery procedures. 

Material and Methods
A retrospective review of 143 electronic records was carried out for all CBCT scans conducted between October 2019 and November 2020. Data was collected in relation to patient demographics, indications for CBCT images and treatment plans before and after the CBCT scans were taken. 

98.6% of the CBCT scans requested were justified appropriately in accordance with the SEDENTEXCT guidelines and were commonly requested for pre-surgical assessment of unerupted teeth (38%), assessment of cysts (20.4%) and, where radiographs suggested an intimate relationship between a mandibular third molar and ID canal, for surgical planning of management (32.7%). In 35% of cases, the CBCT scans contributed towards a significant change in treatment plan including: surgical removal or coronectomy of third molars (17%); surgical intervention or conservative management (8%); change in the number of teeth for removal (6%) and change in the type of surgery (4%).

CBCT images are a pivotal tool in determining the extent of surgical intervention and the most conservative approach that can be used for various oral anomalies and pathologies.

11. Radiographic reporting of cone beam computed tomography imaging in an oral and maxillofacial department

Tim Browning, Speciality doctor oral and maxillofacial surgery Russells Hall Hospital
Luis Bruzual, Consultant Oral Surgeon Russells Hall Hospital

SEDENTEXCT guidelines support reporting of dento-alveolar images by a specially trained DMF radiologist or adequately trained dentally qualified clinician.

Those images containing craniofacial structures (usually larger than 8x8 cm) should be evaluated by specially trained DMF radiologist or clinical radiologist.

Retrospective data collection for a 3 month period evaluating if images have a report recorded by an appropriately trained professional

Total of 49 images evaluated, only 1 in 5 radiographs (21%) reported by an appropriately trained professional. Majority of these were 5x5cm and 8x8cm imaging which could be reported by adental professional with the correct training.

Guidelines including those from CQC, IR(ME)R as well as SEDENTEXCT clearly state that all imaging should have a report by an appropriately trained clinician. This Audit highlighted a lapse in reporting which was mainly due to small volume dento-alveolar imaging. On discussion with the radiology department a plan was implemented including appropriate training of oral and maxillofacial department to facilitate reporting of dental-alveolar CBCT imaging. A pathway was established for joint reporting of larger imaging or those including craniofacial structures.