OBJECTIVES: The purpose of this study was to evaluate rater agreement and the accuracy of a semi-automated software and its fully automated tool for osteoporosis risk assessment in intraoral radiographs.

METHODS: A total of 567 intraoral radiographs was selected retrospectively from women aged 75-80 years participating in a large population-based study (SUPERB) based in Gothenburg, Sweden. Five raters assessed participants' risk of osteoporosis in the intraoral radiographs using a semi-automated software. Assessments were repeated after 4 weeks on 121 radiographs (20%) randomly selected from the original 567. Radiographs were also assessed by the softwares' fully automated tool for analysis.

RESULTS: Overall interrater agreement for the five raters was 0.37 (95% CI 0.32-0.41), and for the five raters with the fully automated tool included as 'sixth rater' the overall Kappa was 0.34 (0.30-0.38). Intrarater agreement varied from moderate to substantial according to the Landis and Koch interpretation scale. Diagnostic accuracy was calculated in relation to reference standard for osteoporosis diagnosis which is T-score values for spine, total hip and femoral neck and presented in form of sensitivities, specificities, predictive values, likelihood ratios and odds ratios. All raters' mean sensitivity, including the fully automated tool, was 40,4% (range 14,3%-57,6%). Corresponding values for specificity was 69,5% (range 59,7%-90,4%). The diagnostic odds ratios ranged between 1 and 2.7.

CONCLUSION: The low diagnostic odds ratio and agreement between raters in osteoporosis risk assessment using the software for analysis of the trabecular pattern in intraoral radiographs shows that more work needs to be done to optimise the automation of trabecular pattern analysis in intraoral radiographs.

OBJECTIVES: This study aims to investigate if automated analyses of the trabecular pattern in intraoral radiographs independently contribute to fracture risk assessment when other risk factors incorporated in the Fracture Risk Assessment Tool (FRAX) are taken into account. A secondary aim is to explore the correlation between the automated trabecular pattern assessment in intraoral radiographs and Trabecular Bone Score (TBS).

METHODS: A total of 567 intraoral radiographs from older females participating in a large population-based study (SUPERB) based in Gothenburg, Sweden, were selected to analyse trabecular pattern using semi-automated and fully automated software. Associations between trabecular pattern analysis and incident fractures were studied using Cox proportional hazard model, unadjusted and adjusted for FRAX risk factors (previous fracture, family history of hip fracture, smoking, corticosteroids, rheumatoid arthritis, without and with bone mineral density (BMD) of the femoral neck). In addition, the correlation between trabecular pattern analysis and TBS of the lumbar spine was investigated using Pearson correlation analysis.

RESULTS: Neither the unadjusted nor the adjusted trabecular pattern analysis in intraoral radiographs was significantly associated with any fracture or major osteoporotic fracture (MOF). A weak correlation was found between semi-automated trabecular pattern analysis and TBS. No correlation was found between the fully automated trabecular pattern analysis and TBS.

CONCLUSIONS: The present study shows that semi-automated and fully automated digital analyses of the trabecular pattern in intraoral radiographs do not contribute to fracture risk prediction. Furthermore, the study shows a weak correlation between semi-automated trabecular pattern analysis and TBS.

OBJECTIVES: To investigate rater agreement regarding measurements of height and width of the maxilla and mandible using cross-sectional images from CBCT examinations. Furthermore, to explore the association between vertical craniofacial height and alveolar bone morphology.

METHODS: Pre-treatment CBCT scans from 450 patients referred for treatment to a private clinic for orthodontics and oral surgery in Scandinavia were available and of these, 180 were selected. Lateral head images were generated from the CBCT volumes to categorise subjects into three groups based on their craniofacial height. Cross-sectional images of the maxillary and mandibular bodies at three locations in the maxilla and mandible, respectively, were obtained and measured at one height and two width recordings by five raters. One-way analysis of variance with a Tukey post hoc test was performed. A significance level of 5% was used.

RESULTS: Rater agreement was mostly excellent or good when measuring height and width of the maxilla and mandible in cross-sectional CBCT images. For height (of the alveolar bone/bodies), there were statistically significant differences between the low- and the high-angle groups for all the observers when measuring in the premolar and midline regions, both in the maxilla and in the mandible.

CONCLUSION: The high agreement found ensures a reliable measurement technique and confirms the relation between craniofacial height and alveolar bone height and width.

BACKGROUND AND AIMS: Systematic reviews (SRs) are considered to provide reliable estimates, but flaws in designs, methods of monitoring effects, and outcomes have the potential to bias results. There are several tools for assessing risk of bias (RoB), most of them designed for SRs of beneficial effects. To our knowledge, there is no tool that is adapted specifically to assess RoB in studies of adverse effects associated with orthodontic treatment. To address this, the aim of this study was first to introduce a tool for assessment of RoB in studies of adverse effects associated with orthodontic treatment and, second, to apply it in an SR of external root resorption (ERR) associated with orthodontic treatment with fixed appliance.

MATERIALS AND METHODS: The approach with domains supported by signalling questions was used for the tool. Domains and signalling questions were tailored to the review questions of the SR of studies of ERR after orthodontic treatment using periapical radiography or cone beam computed tomography. Duplicate study selection, data extraction, and RoB assessment using the tool, followed by meta-analyses, were performed.

RESULTS: Using the tool for the assessment of RoB identified shortcomings and report deficiencies of primary studies concerning the presentation of orthodontic treatment, identification of ERR, and analysis of outcomes. RoB assessment resulted in 12 of 32 studies read in full text being included. Reported severe ERR varied across studies between 2 and 14 per cent for all incisors and 10 and 29 per cent for maxillary incisors. Results of ERR related to patients' age and sex, orthodontic diagnosis, and treatment were contradictory. Quality of evidence evaluated by GRADE was low due to study limitations, imprecision, and inconsistency of study results.

CONCLUSIONS: As the tool and its application highlight important issues to consider when planning, conducting, and reporting research, the tool may have a valuable role for quality enhancement of future studies of outcomes of orthodontic treatment. The tool may also serve for authors when planning SRs. Our SR identified a need for studies that use rigorous methodology and transparent reporting.

REGISTRATION: PROSPERO (ID = CRD42018084725).

Objective To explore and identify the attitudes of dentists, patients and medical specialists regarding implementation of osteoporosis risk assessment into Swedish primary dental care. Background Osteoporosis is a major health problem leading to fragility fractures. As shown in academic-based research, dental radiological examination can be used for osteoporosis risk assessment. A substantial number of patients undergo radiographic examinations in primary dental care each year, but little is known about implementation of osteoporosis risk assessment in this setting. Materials and methods A qualitative research approach using focus group discussions and manifest content analysis was applied. Five focus groups with dentists and representatives from patient support groups and a single individual interview with one medical specialist were included in the sample. Results From the manifest content analysis, three categories emerged: (a) barriers to change in practice, (b) benefits to change in practice, and (c) needs and requirements prior to change in practice. Most participants felt that there was insufficient knowledge of osteoporosis as well as a heavy existing workload. A concern was expressed about medical practitioners' willingness to take on responsibility for patients referred by dentists. Representatives from patient support groups highlighted a lack of knowledge about osteoporosis among both the general public and the medical professionals. Clear guidelines and improved communication channels between stakeholders would have to be established to ensure a smooth treatment path for patients. Conclusion Despite interest in osteoporosis risk assessment in primary dental care, there are political, workflow and educational barriers that must be overcome for successful implementation.

The REduce research Waste And Reward Diligence statement has highlighted how weaknesses in health research can produce misleading results and waste valuable resources. Research on diagnostic efficacy in the field of dentomaxillofacial radiology (DMFR) is no exception to these criticisms and could be strengthened by more robust study designs, consistent use of a core set of outcome measures and completeness in reporting. Furthermore, we advocate that everyone participating in collaborative research on clinical interventions subscribes to the importance of methodological quality in how imaging methods are used. The aim of this paper, therefore, is to present a guide to conducting high-quality research on diagnostic efficacy in DMFR.We initially propose a framework inspired by the hierarchical model of efficacy of Fryback and Thornbury, highlighting study designs, measures of analysis, completeness of reporting and established guidelines to assist in these aspects of research. Bias in research, and measures to prevent or limit it, are then described.It is desirable to climb the Fryback and Thornbury "ladder" from technical efficacy, via accuracy and clinical efficacy, to societal efficacy of imaging methods. Efficacy studies on the higher steps of the ladder may be difficult to perform, but we must strive to answer questions of how useful our methods are in patient management and assess benefits, risks, costs, ethical and social issues. With the framework of six efficacy levels as the structure and based on our experience, we present information that may facilitate quality enhancement of diagnostic efficacy research in DMFR.

Objectives: To evaluate measurability and reliability of measurements of root length and marginal bone level in CBCT, periapical (PA) and bitewing (BW) radiographs. Methods: CBCT of both jaws, PA of maxillary incisors and posterior BW radiographs of 10 adolescents (mean age 13.4) were selected. The radiographs comprised part of the baseline examinations of a trial of orthodontic treatment. Six raters assessed measurability and measured root length and marginal bone level. Three raters repeated their assessments. Measurability was expressed as frequency of interpretable sites and reliability as intraclass correlation coefficient (ICC). Results: Measurability was 100 % in CBCT and 95 % in PA of maxillary incisors for root length measurements. For marginal bone level, measurability was 100 % in CBCT, 76 % in PA and 86 % in posterior BW. Mean ICC for interrater reliability for root length measurements in CBCT was 0.88 (range 0.27-0.96 among different teeth) and 0.69 in PA of maxillary incisors. For marginal bone level measurements, mean ICC was 0.4 in CBCT, 0.38 in PA of maxillary incisors and 0.4 in posterior BW. Intrarater reliability varied among methods, root length or marginal bone level and among raters, except for root length measurements in CBCT, which presented high reliability (above 0.8) for all raters. Conclusions: As measurability and reliability were high for root length measurements in CBCT, this may be the method of choice for scientific analyses in orthodontics. For clinical praxis, we recommend PA following the "as low as diagnostically acceptable" principle, as clinical decisions seem to be influenced only when severe root resorption occurs.

OBJECTIVES: To evaluate tooth development and calculate dental maturity score in prematurely born children and to compare the findings with full-term born children. MATERIAL AND METHODS: Nine-year-old preterm children were selected from the Swedish Medical Birth Register. One group consisted of 36 extremely preterm children (born before week 29), and the other included 38 very preterm children (born during weeks 29 to 32). Panoramic radiography was performed on each child and the preterm children were compared with 42 full-term born children. Five observers independently assessed the tooth development stages for all teeth in the left mandible (31-37) on the panoramic radiographs according to the method described by Demirjian et al. (Hum Biol 45:211-227, 1973). Data from tooth development stages were compiled and converted into a dental maturity score for each group. Kappa values were calculated for intra- and inter-observer agreement. RESULTS: When the different development stages for each individual tooth were compared, all observers presented a significant delay in the maturity of tooth 37 for the extremely preterm group (p </= 0.002). The extremely preterm group had a significantly lower dental maturity score than the full-term group, as assessed by each observer (p </= 0.006). Kappa values for inter-observer agreement varied between 0.31 and 0.71 depending on tooth and intra-observer agreement was between 0.16 and 1.0. CONCLUSIONS: At age 9, the extremely preterm children had a general delay in tooth development. CLINICAL RELEVANCE: The increased survival rate of extremely preterm babies adds a new group of children to society. Dental clinicians should be aware that the delay in tooth development could impact the timing of orthodontic diagnostics and potential treatment.

Background: Fragility fracture related to osteoporosis among postmenopausal women is a significant cause of morbidity. The care and aftercare of these fractures are associated with substantial costs to society. A main problem is that many individuals suffer from osteoporosis without knowing it before a fracture happens. Dentists may have an important role in early identification of individuals with osteoporosis by assessment of dental radiographs already included in the dental examination. The aim of this study was therefore to investigate postmenopausal women's preferences for an osteoporosis risk assessment in primary dental care. Results: Most respondents (129 of 144 (90%)) were willing to pay for an osteoporosis risk assessment in primary dental care. The overall mean willingness to pay (WTP) including respondents that denoted none or zero WTP was 44.60 Euro (CI 95% 38.46-50.74 Euro) (median 34.75 Euro). A majority (80.6%) of the respondents that denoted WTP also gave a motivation for their answer. The two most common reasons denoted for being willing to pay for osteoporosis risk assessment were the importance of early diagnosis and preventive care to avoid fractures (41.0%) and the importance of knowledge of a risk of osteoporosis (26.4%). A majority of respondents (67.8%) considered it valuable if dental clinics would offer osteoporosis risk assessment. Conclusions: Postmenopausal women seem to find it valuable to be offered osteoporosis risk assessment in primary dental care and are willing to pay for such a risk assessment. From a societal perspective early diagnosis of osteoporosis by risk assessment in primary dental care could prevent osteoporotic related fractures and benefit women's health and quality of life, as well as have a major impact on the health-care budget in terms of cost-savings.

Apical Root Resorption (ARR) of the maxillary incisors is an adverse effect in patients during treatment with orthodontic appliance. Limited number of prospective investigations on ARR in patients with Removable Orthodontic Appliance (ROA) is available and the reliability of assessments of ARR in periapical radiographs has not been evaluated. The aims were to investigate 1) Observer agreement regarding assessment of ARR in radiographs obtained during treatment with ROA in children and 2) The extent and severity of ARR in children during treatment with ROA. Material and Methods One hundred ten children, with Angle class II malocclusion or anterior cross bite suitable for treatment with ROA were consecutively recruited. Periapical radiographs of maxillary incisors were obtained before (T0) and after six month of treatment (T1). The contour of the roots was scored as 0, 1, 2, 3 or 4 according to a modified Levander and Malmgren index, by five observers. Score 0 represent normal root contour, score 4 severe root resorption. Inter- and intra-observer agreement was calculated as overall agreement and kappa values. Results In the 110 patients, 49 females, 61 males, the mean age was 10.6 years. Totally 439 roots were available for assessment. Kappa values for pair wise inter-observer agreement during treatment ranged between -0.01 and 0.27. Kappa values for intra-observer agreement ranged between -0.09 and 0.45 before treatment and -0.22 and 0.48 after treatment. Conclusion Reliability in assessing root morphology/resorption in periapical radiographs obtained in children during treatment with removable appliance is low. ARR seems to be of minor extent, however, the low reliability indicates difficulties in evaluating the severity and thereby the clinical importance in this young patient group.