A comparison of the horizontal and vertical bitewing images in detecting approximal caries and interdental bone loss in posterior teeth: A diagnostic accuracy randomized cross over clinical trial

Background/purpose: Horizontal bitewing radiographs are widely and frequently used in dentistry and are very reliable in diagnosing proximal caries and interproximal alveolar bone level. However, it is challengeable in detecting interproximal root caries, horizontal and/or vertical alveolar bone loss, and furcation involvements. The aim of this article was to assess the accuracy of vertical bitewing images in the diagnosis of caries and alveolar bone level compared to the horizontal bitewing technique. Materials and methods: Each one of the 20 patients had eight bitewing radiographs to get four horizontal bitewing (control) and four vertical bitewing (experimental) images for the same posterior area; a steel wire (3 mm) was used on the sensor plate to help measure the magnification later on. The radiographs were processed digitally and were evaluated for caries by two expert restorative specialists and for bone loss by two experienced periodontists. They were also compared to the “gold standard,” which is using of both clinical and radiographic examination for diagnosis. They were blinded to each other during images evaluation. Results: Of the 20-patient sample size, 70% were male and 30% were female, with a mean age of 29.9. The average number of radiographs taken to achieve four standard bitewing radiographs was 5.9 ± 1.7 for vertical bitewings and 5.3 ± 1.3 for horizontal bitewing radiograph. The measurements from the cementoenamel junction (CEJ) to the level of crestal bone didn't show a significant difference between the horizontal and vertical bitewing radiographs. The detection of furcation area in the molar teeth was much higher in the vertical bitewing (100%) compared to the horizontal bitewing (57.5%) (P < 0.0001). Conclusion: The vertical bitewing radiograph has the upper hand over the horizontal bitewing radiograph in the detection of furcation involvement, caries detection, and alveolar bone loss. Therefore, it is highly recommended to use vertical bitewing in caries and patients with periodontal disease rather than the conventional horizontal bitewing.