ORIGINAL ARTICLE

ACTA RADIOLOGICA

Low-Dose Dental Computed Tomography: Significant Dose

Reduction without Loss of Image Quality
P. RUSTEMEYER, U. STREUBUHR & J. SUTTMOELLER
Institute of Anatomy, University of Munster, Germany; Department of Radiology, University of Essen,
Germany, Inspection Station for Radiation Protection, Wennigsen, Germany
Rustemeyer P, Streubuhr U, Suttmoeller J. Low-dose dental computed tomography:
significant dose reduction without loss of image quality. Acta Radiol 2004;45:847853.
Purpose: To measure and reduce the patient dose during computed tomography (CT)
for dental applications.
Material and Methods: Lithium fluoride thermoluminescent dosimeters were implanted
in a tissue-equivalent humanoid phantom (Alderson-Rando-Phantom) to determine
doses to the thyroid gland, the active bone marrow, the salivary glands, and the eye lens.
Dental CT was performed with spiral CT and a dental software package. The usual
dental CT technique was compared with a new dose-reduced protocol, which delivered
best image quality at lowest possible radiation dose, as tested in a preceding study.
Image quality was analysed using a human anatomic head preparation. In addition, the
radiation dose was compared with panoramic radiography and digital volume
tomography (DVT). Eight radiologists evaluated all images in a blinded fashion. A
Wilcoxon rank pair test was used for statistical evaluation.
Results: Radiation dose could be reduced by a factor of 9 (max.) with the new dosereduced protocol (e.g. bone marrow dose from 23.6 mSv to 2.9 mSv; eye lens from
0.5 mSv to 0.3 mSv; thyroid gland from 2.5 mSv to 0.5 mSv; parotid glands from
2.3 mSv to 0.4 mSv). Dose reduction did not reduce image quality or diagnostic
information.
Conclusion: A considerable dose reduction without loss of diagnostic information is
achievable in dental CT. As radiation exposure of the presented low-dose protocol is
expected to be in the same range as DVT, low-dose dental CT might be superior to
DVT, because CT can be used to evaluate soft tissues as well.
Key words: Alderson-Rando-Phantom; dental CT; dose reduction; radiation protection
Peter Rustemeyer, Institut fur Anatomie Westfalische Wilhelms Universitat Munster
Vesaliusweg 2-4 D-48149 Munster Germany (fax. z49 251 8355241, e-mail.
peter.rustemeyer@uni-muenster.de)
Accepted for publication 2 September 2004

The increasing demands on preoperative planning,

due to the expansion of indications for oral implant
placement and craniofacial reconstruction, have led
to increased significance of computed tomography
(CT) in dentoalveolar surgery (11, 21, 27). CT
software that automatically displays reformatted
cross-sectional and panoramic views of the jaw is
commercially available (1). CT often completes or
replaces conventional panoramic radiographs (PR)
(2, 15). Oral surgeons recommend dental CT to
assess height, width, structure, and density of bone
available for implant anchorage within potential
implant sites. For mandibular implant treatment,
accurate localization of the mandibular canal is
necessary if injury to the neurovascular bundle is to

be avoid. It has been demonstrated that tomography provides better visualization of the mandibular
canal than other radiographic methods (16). Therefore CT is frequently used in dental implant
planning despite the considerably higher patient
dose, greater amount of time needed, and higher
costs (6, 16). A new generation of maxillofacial CT
device has recently been developed specifically
for dentistry, namely digital volume tomography
(DVT). It is promoted as offering volume 3dimensional imaging similar to the dental CT
technique but with significantly reduced radiation
exposure to the patient (18).
The dose is of great importance because highly
X-ray sensitive organs such as eye lenses, thyroid
DOI 10.1080/02841850410001402 # 2004 Taylor & Francis

848

P. Rustemeyer et al.

gland, and the parotid glands are close to the

examination area and active bone marrow is
directly within the scanning area. Dose reduction
without losing image quality is therefore important.
The purpose of this study was to identify the dose
during dental CT and to find out if it is possible to
reduce the dose by changing the standard examination conditions (tube amperage, rotation time, pitch
factor) without losing image quality, e.g. through
increasing noise in the picture. This question arose
because the two structures, jaw bone and teeth,
which are of interest for preoperative planning,
are high contrast organs and should therefore be
suitable for imaging with a significantly lower dose.
Similar studies have recently been carried out in CT
of the thorax (7, 8).
Material and Methods
The present investigation was carried out with a
spiral CT Somatom Plus 4 (Siemens, Erlangen,
Germany) with special application software for
dental CT. The investigation took place in spiral
mode on a donated corpse laid on its back with
fixed head. For examination of the lower jaw the
plane was set parallel to the basis of the corpus
mandibulae. The scan distance included the entire

corpus mandibulae with the processus alveolaris

and the neck of the teeth. Layer thickness and
reconstructive interval were 1 mm each, the spiral
algorithm was slim (180 LI-Algorhythm, decisive
for the z-profile) and tube voltage was set to
120 kV. In protocol 1, which corresponded to the
standard exposition data, tube current was 165 mA,
rotation time 1s, and pitch 1 mm. The axis dose of
the chosen examination parameters was 68 mGy for
one rotation (measured in air). In protocol 2, which
proved the best image quality at the lowest possible
radiation dose in our preceding study (22), the tube
current was 50 mA, the rotation time 0.7 s, and the
pitch 2 mm, which is a pitch factor of 2.
With the help of an appropriate axial layer
through the alveolar crest, a graph was drawn
corresponding to the jaw structure and the average
reconstructive plane. Parallel to the graph, 5
panorama cuts of 2-mm thickness each were also
drawn. The program automatically generated 50
so-called paraxial cuts vertical to the average
layer of the panorama cut with a thickness of at
least 2 mm and a length of 25 mm. After a single
calculation and adjustment of the magnifying
factor, the secondary reconstructions were shown
in the original scale 1:1 (1).
PR was done using the panoramic radiograph

Fig. 1. A. Axial layer with a line following the jaw bone and corresponding paraxial cuts, 120 kV, 165 mA, pitch 1, rotation time 1s.
B. Axial layer with a line following the jaw bone and corresponding paraxial cuts, 120 kV, 50 mA, pitch 2, rotation time 0.7s.
Acta Radiol 2004 (8)

Low-Dose Dental Computed Tomography

PM 2002 CC (Planmeca, Helsinki, Finland) (400

film-foil combination, 80 KV, 180 mAs, 2.5 MM
AI-Filter).
The dose of the jaw bone, dental CT, and PR was
calculated on an Alderson-Rando-Phantom (Alderson Research Laboratories Inc., Stamford, Conn.,
USA) with thermoluminescent dosimeters (TLD100, lithium fluoride rods of size 16166 mm,
analysis by Harshaw TLD Analyser, model 2080
(Bicron, Paris, France). Nine TLDs were placed in
definite positions: the right and the left eye, right
and left corpus mandibulae, the vertebral bone
marrow at the level of the corpus mandibulae, right
and left lobe of the thyroid gland, and right and left
parotid gland. Ten measurements were carried out
and meansSD were calculated. The same phantom with identical positions of the dosimeters was
used for the CT and PR measurements. The PR was
adjusted to the jaw area.
The effective dose was calculated with ICRP 60
(1990) (13). The effective layer thickness (z-profile)
was calculated from collimation and pitch factor
using a 180 LI spiral algorithm (slim mode) (19).
The inaccuracy was lower than the layer thickness
tolerance.
Comparative analysis of the pictures was performed independently by eight radiologists blinded
to each other. A rank scale from 1 (very good) to 6
(insufficient) was used to judge differentiation of the
lower jaw cortical bone, general picture quality, and
visibility of the bone and soft part tissue structures.
The results of the picture analysis were established
with the Wilcoxon rank pair test (Pv0.05). The
bony structure was measured according to height
and width of the lower jaw on eight definite
positions in the alveolar area (four each in the
pre-/molar area on both sides). In addition, the
diameter of the mandibular canal was determined.
The CT results were compared with the results of
height and width of the alveolar crest taken directly
from the specimen.

849

protocols (mean 2.9 mm). No significant difference

was found between the two CT protocols on the left
side (CT protocol 1: mean 2.6 mm, CT protocol 2:
mean of 2.5 mm).
The paraxial secondary reconstructions (Fig. 3A,
B), according to the cut layers in Fig. 1, show the
diameter of the corpus mandibulae. The cortical
boundary was preserved exactly all around. Height
and width of the lower jaw bone were easy to
measure. No significant difference between the two
CT protocols was observed. Accordingly, height
and width of the alveolar crest (bone volume)

Results
There was no difference in contrast and visibility
of the cortical boundary and the bony structure
between the two protocols according to the
mandible (Fig. 1A, B) (Pv0.05). The panorama
cuts (Fig. 2A, B) of the line in Fig. 1 showed a
readily recognizable bony structure as well as the
cross-section of the mandibular canal. There was no
significant difference between the images of the two
protocols. The diameter of the right mandibular
canal was identical when measured with both CT

Fig. 2. A. Panoramic cut along the line in Fig. 1A, 120 kV,
165 mA, pitch 1, rotation time 1s. B. Panoramic cut along the
line in Fig. 1B, 120 kV, 50 mA, pitch 2, rotation time 0.7s.
Acta Radiol 2004 (8)

850

P. Rustemeyer et al.

Fig. 3. A. Representative paraxial reconstructed cuts (image 18) corresponding to the scout in Fig. 1A (120 kV, 165 mA, pitch 1, rotation time 1s). B. Representative paraxial reconstructed cuts (image 18) corresponding to the scout in Fig. 1B (120 kV, 50 mA, pitch 2,
rotation time 0.7s).

were determined virtually identically by the eight

radiologists. Table 1a and b demonstrates the
average results for the bone volume measured by
the eight radiologists compared with the results
taken directly from the specimen. The measurements of height and width of the alveolar crest
show no significant difference between the two CT
protocols (Wilcoxon rank pair test, P~0.05). The
Table 1. Average bone volumes compared with the results taken
directly from the specimen of the alveolar crest (Wilcoxon rank
pair test: Pv0.05)
CT-protocol 1

CT-protocol 2

Height of the alveolar crest (mm)

13.5
13.75
12.5
12.25
12.5
12.75
13.25
13.25
11.0
10.75
10.25
10.50
10.5
10.25
11.5
11.75
Width of the alveolar crest (mm)
10.5
10.0
9.75
9.75
9.0
8.75
9.0
9.0
9.0
8.5
9.25
9.0
9.5
9.75
10.5
10.5

Acta Radiol 2004 (8)

Specimen
14.0
13.0
13.0
12.5
11.5
11.0
11.0
12.0
10.5
10.0
9.0
9.0
9.0
9.0
10.0
10.5

size measured with the dental CT also corresponded

well with the size measured on the specimen.
There was no difference in image quality between
the two protocols (Table 2). The slightly higher
noise in the images taken with protocol 2 was not
considered as intrusive. No restriction of the
diagnostic meaning could be found.
Table 3 gives the measured doses for the dental
CT protocols and the PR from this study. In
addition, reported values from the literature
regarding CT examinations, PR, and DVT are
given. In the usual dental CT protocol (CT protocol
1), the dose was up to 9 times higher than the dosereduced protocol (CT protocol 2) (Table 3). Within
the scanning area at the measurement points, the
dose during PR was lower than 1/100 of the dose
during dental CT with standard parameters (CT
protocol 1). Calculation of the effective dose is
3.4 mSv for the dental CT protocol 1 (literature
Table 2. Average of independent image quality evaluation of
eight radiologists
Evaluation (ranking)
Diagnostic criteria
Visibility of bone structure
Judgement over cortical boundary
Differentiation of soft tissue
General image quality

CT-protocol 1 CT-protocol 2
3.0
2.25
3.25
2.5

2.75
2.25
3.25
2.5

Low-Dose Dental Computed Tomography

851

Table 3. Measured energy dosage on an Alderson-Rando-Phantom (mGystandard deviation). CT-P1~CT protocol 1 (120 kV,
165 mA, rotation time 1s and pitch~1). CT-P2~CT protocol 2 (120 kV, 50 mA, pitch~2, rotation time 0.7 s)
Dosage (mGy)

Right eye
Left eye
Right corpus mandibulae
Left corpus mandibulae
Vertebral bone marrow at the
level of the corpus mandibulae
Right lobe of thyroid gland
Left lobe of thyroid gland
Right parotid gland
Left parotid gland

CT-P 1

CT-P 2

Lit. (14)

OPG

0.50.06
0.50.02
20.71.06
22.60.54
23.61.4

0.20.02
0.30.02
2.70.06
2.80.14
2.90.28

0.6
0.6
18.8
17.1

0.07
0.08
0.18
0.16
0.19

0.31
0.31
0.198

0.4
0.4
1.450.11
1.450.11
0.9750.42

2.50.28
2.50.30
2.30.36
1.80.22

0.5z0.04
0.50.04
0.40.08
0.40.02

1.7
1.7
9.6
10.8

0.09
0.09
0.36
0.41

0.04
0.04
0.29
0.29

0.78
0.78
1.30.1
1.30.1

2.55.3 mSv) (4, 24), 0.4 mSv for the dose-reduced

protocol 2, and 0.04 mSv for the PR (literature
0.038 mSv) (6). In the literature, the effective dose
during DVT is calculated to be 0.110.5 mSv (5,
17).
Calculation of the effective layer thickness for the
Somatom Plus 4 (spiral algorithm: slim) resulted in
1.08 mm (for a collimation of 1 mm and a pitch of
1 mm (pitch factor 1)). On increasing the pitch to
2 mm (pitch factor 2), the effective layer thickness
rose to 1.27 mm. In CT protocol 2 the effective
layer thickness was therefore 0.19 mm (18%) wider.
Discussion
For dental implant planning in the upper and lower
jaw, CT has become a widely employed modality
and has been recommended as the method of
choice. A disadvantage of the conventional radiological methods, PR and spiral tomography, is
that the pictures are magnified and distorted.
In addition, it is not possible to show a second
diagnostically important plane without an additional dose.
A decisive disadvantage of the dental CT is the
relatively high dose needed. The doses measured in
this study were in accordance with the results
known from the literature (14), (Table 3).
Our presented protocol allows a maximum dose
reduction of a factor of 9 without loss of picture
quality. This factor is expected in theory because of
the changed examination parameters (mAs product
and pitch factor).
This relationship is also valid for the measured
doses within the scanning area if the standard
deviation is taken into account. For organs,
polluted only by scattered radiation (e.g. in the
area of the eye lens), a factor of 9 cannot be
confirmed by the measurements. This is caused by
ground noise of the thermoluminescent dosimeter,

Lit. (6)

DVT (17)

which becomes more apparent through the considerably lower doses outside the scanning area.
The suitable parameter for ascertaining the
individual risk is the effective dose. Comparison
of our measurements gives a relation of 1:8.5
between the dose-reduced CT protocol 2 and the
standard CT protocol 1. This is the expected
theoretical result.
When developing the dose-reduced protocol we
have tried to keep layer thickness as low as possible
and to accept greater noise instead. Artifacts caused
by noise could easily be suppressed because of the
naturally strong picture contrast due to the great
difference in density of the various structures
concerned. With the spiral algorithm slim (180
LI), the effective layer thickness increases only
slightly (approximately 0.2 mm) when the pitch is
doubled (pitch factor 2). Changing the profile of the
layer thickness has no meaning in practical use. It is
possible, however, that the slightly greater effective
layer thickness leads to increasing layer thickness
artifacts in the horizontal plane, which can be
disregarded in this case because the effects are
outside the measurable area (20). For the vertical
plane, the theoretical inaccuracy through layer
widening is a maximum of 0.2 mm and therefore
within the tolerance of the method. Consequently,
no differences were found in the anatomical
representation of the jaw bone in the measurements
of the specimen.
Reducing the tube power is the most important
measure for reducing the dose (25). The geometric
relationships in the image remain unchanged. The
noise is slightly increased, but the high organ
contrast allows us to use a filter to suppress this.
Unfortunately, the previous standard CT scanners
do not allow a tube current reduction of any size.
That is why we had to take extra measures for dose
reduction, such as increasing the pitch factor and
reducing the rotation time. Our low-dose protocol
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852

P. Rustemeyer et al.

delivers considerably lower radiation exposure than

other low-dose protocols reported in the literature
(9, 10, 17).
Using examination protocols with dose-reduction
parameters, dental CT is a method that can be used
in almost every patient. Furthermore, there are only
small artifacts, especially for existing dental work.
This is one important advantage compared to
magnetic resonance imaging (MRI) methods,
which show considerable artifacts due to the
metal of already existing dental implants (12, 25,
26). Patients with cardiac pacemakers or some
metal prostheses cannot be examined. In addition,
the considerably longer acquisition time for MRI
examinations leads to artifacts caused by movement
and inaccuracies. Furthermore, up to now the
precise original anatomic representation is only
proved for dental CT (3). With a similar radiation
exposure and effective dose DVT is not really
superior to the low-dose dental CT. CT can be used
to evaluate soft tissues in addition, whereas DVT is
limited to diagnostic information of bony structures.
In conclusion, our results favor use of the lowdose protocol when scanning bony structures.
Further technical modifications, modifications that
allow scanning with considerably lower tube power,
should be carried out. This is especially important
for examination of children with for example
progenie or deformities (23), where a fraction of
the tube current would be sufficient for producing
outstanding good images due to the considerably
smaller body diameter with a therefore significantly
lower attenuation of the X-rays. Today, few CT
scanners allow an appropriate dose reduction because
of the construction of generator and regulations.

7.

8.

9.
10.

11.
12.
13.

14.

15.

16.

17.

References
18.
1. Abrahams JJ. Anatomy of the jaw revisited with a
dental CT software program. Am J Neuroradiol
1993;14:97990.
2. Bahat O. Treatment planning, placement of implants
in the posterior maxillae: report of 732 consecutive
Nobelpharma implants. Int Oral Maxillofac Impl
1993;8:15161.
3. Calvalcanti MGP, Yang J, Ruprecht A, Vannier MV.
Validation of spiral computed tomography for dental
implants. Dentomaxillofac Radiol 1998;27:32933.
4. Clark DE, Danforth RA, Barnes RW, Burtch ML.
Radiation absorbed from dental implant radiography:
a comparison of linear tomography, CT scan and
panoramic and intra-oral techniques. J Oral Implantol
1990;16:15664.
5. Conen M, Kemper J, Mobes O, Pawelzik J, Modder U.
Radiation dose in dental radiology. Eur Radiol
2002;12:6347.
6. Danforth RA, Clark DE. Effective dose from radiation
absorbed during a panoramic examination with a new
Acta Radiol 2004 (8)

19.
20.
21.

22.
23.

generation machine. Oral Surg Oral Med Oral Pathol

Oral Radiol Endod 2000;89:23643.
Diederich S, Lenzen H, Puskas Z, Koch AT, Yelbuz
TM, Eameri M, et al. Niedrigdosiscomputertomographie des Thorax. Experimentelle und Klinische Untersuchungen. Radiologe 1996;36:47582.
Diederich S, Thomas M, Semik M, Lenzen H, Roos N,
Weber A, et al. Screening for early lung cancer with lowdose spiral computed tomography: results of annual
follow-up examinations in asymptomatic smokers. Eur
Radiol 2004;16.
Ekestubbe A, Grondahl K, Grondahl H-G. Quality of
preimplant low-dose tomography. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 1999;88:73844.
Ekestubbe A, Grondahl K, Ekholm S, Johansson P E,
Grondahl HhyphenG. Low-dose tomographic techniques for dental implant planning. Int J Oral Maxillofac
Impl 1996;11:6509.
Ericson S, Bjerklin K. The dental follicle in normally
and ectopical erupting maxillary canines: a computed
tomography study. Angle Orthod 2001;71:33342.
Gray CF, Redpath TW, Smith FW, Staff RT. Advanced
imaging: magnetic resonance imaging in implant dentistry. Clin Oral Impl Res 2003;14:1827.
Hunt JG, da Silva FC, Mauricio CL, dos Santos DS.
The validation of organ dose calculations using voxel
phantoms and Monte Carlo methods applied to point
and water immersion sources. Radiat Prot Dosimetry
2004;108:859.
Kassebaum DK, Stoller NE, McDavid WD, Goshorn B,
et al. Absorbed dose determination for tomographic
implant site assessment techniques. Oral Surg Oral Med
Oral Pathol 1992;73:5029.
Lam WW, Ruprecht A, Jang J. Comparison of twodimensional orthoradially reformatted computed tomography and panoramic radiography for dental implant
treatment planning. J Prosthet Dent 1995;74:426.
Lindh C, Petersson A. Radiologic examination for
location of the mandiblar canal: a comparison between
panoramic radiography and conventional tomography.
Int J Oral Maxillofac Implants 1989;4:24953.
Mah JK, Danforth RA, Bumann A, Hatcher D. Radiation
absorbed in maxillofacial imaging with a new dental
computed tomography device. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2003;96:50813.
Mozzo P, Procacci C, Tacconi A, Martini PT, Andresis
IA. A new volumetric CT machine for dental imaging
based on the cone-beam technique: preliminary results.
Eur Radiol 1998;8:155864.
Polacin A, Kalender WA, Marchal G. Evaluation of
section sensitivity profiles and image noise in spiral CT.
Radiology 1992;185:2935.
Preda L, Di-Maggio EM, Dore R, et al. Use of spiral
computed tomography for multiplanar dental reconstruction. Dentomaxillofac Radiol 1997;26:32731.
Preda L, La Fianza A, Di Maggio EM, Dore R,
Schifino MR, Campani R, et al. The use of spiral
computed tomography in the localization of impacted
maxillary canines. Dentomaxillofac Radiol 1997;26:
23641.
Rustemeyer P, Streubuhr U, Hohn HP, Rustemeyer R,
Eich HAT, John-Mikolajewski V, et al. Niedrigdosis
Dental-CT. ROEFO 1999;171:1305.
Santler G, Karcher H, Ruda C. Indications and limitations of three-dimensional models in cranio-maxillofacial
surgery. J Craniomaxillofac Surg 1998;26:1116.

Low-Dose Dental Computed Tomography

24. Scaf G, Lurie AG, Mosier KM, Kantor ML,
Ramsby GR, Freedman ML. Dosimetry and cost of
imaging osseointegrated implants with film-based
and computed tomography. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 1997;83:418.
25. Schorn C, Visser H, Hermann KhyphenP, Alamo L,
Funke M, Grabbe E. Dental-CT: Bildqualitat
und Strahlenexposition in Abhangigkeit von den

853

Scanparametern. ROEFO 1999;170:13744.

26. Shafiei F, Honda E, Takahashi H, Sasak T. Artifacts
from dental casting alloys in magnetic resonance
imaging. J Dent Res 2003;82:6026.
27. Williams MYA, Mealey BL, Hallmon WW. The
role of computerized tomography in dental implantology. Int J Oral Maxillofac Implants 1992;7:
37380.

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