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Challenges in X-ray diagnosis: a review of referrals for specialist opinion

Key Points

  • Identifies the commonest reasons for referral to a dental maxillofacial radiologist.

  • Reviews the commonest diagnoses made by the dental maxillofacial radiologist.

  • Evaluates the service, highlighting the demand for a referral service.


The aim of this study was to determine the common reasons why a dental professional might request a second opinion on a dental radiograph from a Dental and Maxillofacial (DMF) radiologist. The study was a retrospective analysis of consecutive referrals for an opinion received by post or email by one DMF radiologist based in a UK dental hospital. The study period was from March 2009 to November 2015. Referrals came from a mixture of sources: mainly from general dental practitioners and specialists working in primary care, but with some referrals from hospital-based practitioners. An enormous range in diagnoses were made by the DMF radiologist, but the ten most frequent diagnostic categories contributed 57.5% of the total. Normal anatomy and anatomical variations in normal anatomy made up the largest category. Common dental disease was often diagnosed, but idiopathic osteosclerosis and maxillary antrum pathosis were both frequent reasons for seeking a second opinion. This service evaluation may assist in developing curricula for undergraduates and in designing continuing education courses. It also highlights a service that may avoid unnecessary referrals to hospital specialists but which currently is not commissioned by the NHS.

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Figure 1: Variation in normal anatomy: sparse trabeculation on a periapical radiograph of 46.
Figure 2: Variation in normal anatomy: large marrow space on a periapical radiograph taken for 36.
Figure 3: Air overlying the angle of mandible on a panoramic radiograph taken of a 12-year-old female.
Figure 4: Air overlying the anterior maxilla on a periapical radiograph taken for a discoloured 11.
Figure 5: Air overlying the antero-superior part of the ramus of mandible on a panoramic radiograph taken because of pain in the right hand side of her jaw following trauma.
Figure 6: A locule of the maxillary antrum on a periapical radiograph taken for 24.
Figure 7: Maxillary sinus extending down into the interdental bone on a periapical radiograph taken because of sensitivity of 16.
Figure 8: The soft tissues of the external nose on a periapical radiograph.
Figure 9: The submandibular fossa on a periapical radiograph of 48.
Figure 10: The nasopalatine foramen on a periapical radiograph of the central incisors.
Figure 11: The body of the zygoma.
Figure 12: Idiopathic osteosclerosis associated with the root of 4 5.
Figure 13: Idiopathic osteosclerosis associated with the distal root of 36, of fairly typical size and location.
Figure 14: Section of a panoramic radiograph showing an extensive area of idiopathic osteosclerosis associated with 37 and 38 region.
Figure 15: Periapical sclerosing osteitis associated with 46 mesial root.
Figure 16: External resorption of the crown of an unerupted 38 in a 78-year-old female who was asymptomatic but who had a small pus discharge distal to the 37.
Figure 17: Section of a panoramic radiograph of a patient who was complaining of acute tenderness in upper left quadrant with no obvious diagnosis.
Figure 18
Figure 19: Section of a panoramic radiograph, sent in with a request for confirmation that the area above the root-filled 27 was probably a cyst.


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Many thanks to Susanne Perschbacher for providing information about her study in Ontario, Canada, and to John Holroyd (Dental X-ray Protection Services, Public Health England) for information related to panoramic radiography use.

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Correspondence to M. Dave.

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Dave, M., Horner, K. Challenges in X-ray diagnosis: a review of referrals for specialist opinion. Br Dent J 222, 431–437 (2017).

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