Influence of clinical data on diagnostic hypotheses of intraosseous lesions of the jaws on panoramic images

Abstract

Aim  The present study aimed to evaluate the influence of clinical data on the differential diagnosis of intraosseous lesions visualized on panoramic radiographs.

Methods  The sample comprised 41 panoramic radiographs of individuals presenting intraosseous jaw lesions and conclusive histopathological diagnosis. Three experienced radiologists evaluated the images on two separate occasions: first without clinical information and, after a two-month washout period, with additional data. For each image, the observers were asked to indicate the corresponding pathological category and list up to three differential diagnoses. They also rated their diagnostic confidence level and stated whether further case information was needed to achieve a more accurate radiographic diagnosis. Data were collected and analyzed using McNemar and Wilcoxon tests (α = 0.05), and descriptive analysis was also carried out.

Results  The results revealed no statistically significant differences for the indicated pathological categories (p=0.166) or for the evaluators’ confidence levels (p=0.081). Regarding the diagnostic hypotheses suggested by the observers, with and without clinical data, a higher median value was observed in the second evaluation when clinical data was provided (p=0.023). Different types of clinical information were reported as desirable for ranking the differential diagnosis.

Conclusion  Clinical information contributes to improved performance in establishing diagnostic hypotheses for intraosseous lesions affecting the jaws.

Keywords
Diagnostic imaging; Odontogenic cysts; Odontogenic tumors; Radiography, panoramic

Introduction

Pathologies of different etiologies may affect the maxillofacial region¹, such as fibro-osseous lesions as well as odontogenic cysts and tumors². Most diagnosis are performed during routine panoramic examinations, as these lesions generally take time to cause facial asymmetry. In this scenario, diagnosis depends on well-conducted anamnesis, physical examination and radiographic assessment along with histologic evaluation³,⁴. Additionally, cysts and benign tumors present similar radiographic features and typically manifest as unilocular radiolucent lesions², which can lead to misdiagnosis if only imaging data is considered. Therefore, imaging exams aim to complement clinical observations to improve diagnosis and define the best treatment approach⁵-⁷.

Panoramic radiography is widely used in the dental practice as it enables an overview of the jaws in a single image at a low cost with a low radiation dose⁸,⁹. There are many indications of this imaging exam, and the detection of intraosseous lesions and other pathological conditions is among the most important ones¹⁰-¹². Despite being an affordable modality, panoramic radiography has limitations due to its two-dimensional nature, which can result in the overlap of anatomical structures and susceptibility to distortion, thus restricting the evaluation³. When three-dimensional assessment is necessary, imaging exams such as cone beam computed tomography (CBCT) are well indicated⁹. Nevertheless, considering that, in Brazil, medium and high complexity diagnostic equipment is concentrated in wealthier regions, CBCT may not be as widely available as panoramic radiography¹³.

Radiographic interpretation is enhanced by clinical data, such as the patient’s medical history, ongoing medications, chief complaint and diagnostic hypotheses¹⁴. In countries like Australia, for instance, providing clinical information is mandatory when requesting imaging exams¹⁴ and it is even regulated by some medical authorities¹⁵. In this context, previous studies have demonstrated that clinical data influence diagnostic accuracy across many medical situations, and the lack of such information leads to precarious and biased diagnostic reasoning⁵,¹⁶. However, to the best of the authors’ knowledge, no studies have investigated the influence of clinical data specifically on panoramic images. Therefore, research on this topic is warranted¹⁷.

Although clinical data are essential for radiographic interpretation, dental radiologists often struggle with the limited information provided in imaging exam requests¹⁵. Furthermore, it is important to note that many technological advances such as improvement on diagnostic imaging methods and adoption of electronic health records also justify further investigations¹⁴. Hence, the present study aimed to assess the influence of clinical data on the interpretation of dental radiographs and on the radiologists’ confidence when listing diagnostic hypotheses under different levels of information availability. The null hypothesis of the study was that clinical data would not affect the radiographic report nor influence the radiologist’s confidence level.

Methods

The research protocol was submitted and approved by the Ethics Committee under protocol number CAAE 36244819.0.0000.5152, and the study was conducted based on the Helsinki Declaration. On the present retrospective study, 50 panoramic radiographs were collected from electronic dental records of patients who attended a Dental Hospital, and which were previously diagnosed with intraosseous jaw lesions. The images included presented intraosseous lesions on the jaws that had undergone incisional or excisional biopsy with definitive histopathological diagnosis. All biopsy samples were analyzed in the same Oral Pathology Laboratory by pathologists with more than 30 years of professional experience. The exclusion criteria were panoramic radiographs acquired after any surgical intervention in the region of interest and images with insufficient quality. All radiographs were acquired in the same digital panoramic X-ray unit (Orthopantomograph OP200D, Instrumentarium, Finland), and the selected images were anonymized for evaluation.

The methodology of the present study was adapted from previous research⁸,¹¹. As proposed by Lim et al.¹¹ (2018), three oral and maxillofacial radiologists with more than 10 years of experience in radiological reports were recruited. They evaluated the radiographs in blocks of 10 images in a secluded room with dim light and could use such tools as zoom, brightness and contrast adjustment during the evaluation process.

Each radiography underwent two stages of evaluation. At first, the examiners assessed the panoramic radiographs without any clinical data other than the patient’s sex and age, like what happens in a radiologist’s routine practice. After a two-month wash out period, the evaluators reassessed the same material (panoramic image with sex and age description) along with at least two additional pieces of clinical information (patient’s ethnicity, chief complaint or time since disease onset). In both evaluation moments, the images were presented in a randomized order.

At each stage, the observers were asked to evaluate the images, indicate the pathological category of the detected lesion and, finally, list up to three ranked differential diagnoses. They also had to rate their diagnostic confidence on a scale from 1 to 5 and indicate whether additional clinical information was needed to reach a final radiographic diagnosis (Table 1).

Table 1
Questionnaire model answered by experts.

Q1	Indicate the pathological category of the detected lesion (Inflammatory lesion, Cyst, Benign Tumor, Malignant tumor, Fibro-osseous lesion, Vascular anomaly, Metabolic disease, Trauma-related lesion)
Q2	List up to three ranked differential diagnoses (from most likely to least likely)
Q3	Rate your diagnostic confidence on a scale from 1 to 5 (5- Very confident; 4- Confident; 3- Partially confident; 2- Not very confident; 1- Not confident at all)
Q4	Indicate whether additional clinical information was desired for the final diagnosis

The answers were then organized for statistical analysis. According to the biopsy-proven diagnosis, the answers regarding the pathological category were dichotomized as either correct or incorrect. For the three ranked differential diagnoses, scores were assigned according to the match with the histopathological diagnosis: Score 3 (if the evaluator’s first hypothesis matched the histopathological diagnosis), Score 2 (if the evaluator’s second hypothesis matched the histopathological diagnosis), Score 1 (if the evaluator’s third hypothesis matched the histopathological diagnosis), and Score 0 (if none of the proposed hypotheses were a match).

The statistical analysis was conducted using Jamovi software (The Jamovi Project, version 1.2.27) and all tests were performed at a significance level of 5%. McNemar test was performed to analyze the pathological category of the detected lesions. Wilcoxon test was used to evaluate the diagnostic hypothesis and confidence level of the evaluators. A descriptive analysis was carried out to address the additional information desired by the specialists.

Results

Of the total 50 panoramic radiographs assessed, 41 met the inclusion criteria, presenting intraosseous lesions with biopsy-proven diagnosis. The age of the participants ranged from 6 to 92 years, with an average age of 39.42 years. The majority of the study population consisted of adults (17-64 years old). Pediatric (aged 16 years and below) and geriatric participants (aged 65 years and above) accounted for 17% of all participants each. The males consisted of 17 participants while female ones accounted for 24 participants, representing a male:female ratio of 0.7:1. Overall, the most prevalent pathological category was cystic lesions, followed in descending order by: benign tumors, fibro-osseous and osseous lesions. Inflammatory lesions and malignant tumors accounted for one lesion each. Table 2 presents the distribution of the sample stratified by sex, age group and histological diagnosis.

Table 2
Distribution of the study population by sex, age group and histological diagnosis

Sex n (%)	Male	17 (41,5%)
	Female	24 (58,5%)
Age group n (%)	Pediatric	7 (17%)
	Adult	16 (66%)
	Geriatric	7 (17%)
Cysts n (%)	Radicular cyst	7 (17,1%)
	Odontogenic keratocyst	5 (12,2%)
	Dentigerous cyst	4 (9,8%)
	Calcifying odontogenic cyst	4 (9,8%)
	Nasopalatine duct cyst	2 (4,9%)
	Glandular odontogenic cyst	1 (2,4%)
Benign tumors n (%)	Ameloblastoma	7 (17,1%)
	Odontoma	2 (4,9%)
	Cementoblastoma	1 (2,4%)
Fibro-osseous lesions n (%)	Periapical cemento-osseous dysplasia	1 (2,4%)
	Florid cemento-osseous dysplasia	1 (2,4%)
	Fibrous dysplasia	1 (2,4%)
	Cemento-ossifying dysplasia	1 (2,4%)
Osseous lesions n (%)	Central giant cell granuloma	1 (2,4%)
	Cherubism	1 (2,4%)
Inflammatory lesion n (%)	Periapical granuloma	1 (2,4%)
Malignant tumor n (%)	Adenoid cystic carcinoma	1 (2,4%)

In order to compare the indicated pathological category between the two assessments, McNemar’s statistical test was carried out. The results revealed no statistically significant differences (p=0.166), and the distribution of correct and wrong answers are displayed in Table 3.

Table 3
Correct and wrong answers regarding the pathologic category that the lesion detected belonged to

Second evaluation
First evaluation		Correct answer	Wrong answer	Total
	Correct answer	63 (94%)	4 (6%)	67
	Wrong answer	9 (16.1%)	47 (83.9%)	56
	Total	72 (58.5%)	51 (41.5%)	123

To analyze the three ranked differential diagnoses suggested by the evaluators, with and without clinical data, Wilcoxon test was carried out. A statistically significant difference was observed (p=0.023), with a higher median value in the second evaluation. Regarding the observers’ confidence level across the evaluations, no significant difference was observed (p=0.081) (Figure 1).

Figure 1
Confidence degree in the diagnostic hypotheses suggested by the evaluators, with and without clinical data.

The additional information desired by the evaluators consisted of eight different data: presence of cortical expansion/facial assimetry, time since disease onset, pulp sensitivity test result, previous dental history, chief complaint, patient’s ethnicity, clinical aspect by inspecion and clinical aspect by palpation. The answers were tabulated, the frequency was recorded and the percentages on both assessments can be seen in Figure 2.

Figure 2
Distribution of information desired by experts.

Discussion

The diagnosis of intraosseous lesions of the jaws is challenging since these lesions often present with non-specific symptoms and radiographic features. In many cases, they are detected incidentally during routine exams, and the correct diagnosis depends on clinical information¹⁸-²⁰. In the presence of clinical data, radiologists can also determine whether the exam performed was appropriate for the diagnosis²¹ or whether additional imaging is suggested. The aim of the present study was to evaluate the influence of clinical data on the interpretation of dental radiographs and to assess the confidence levels of dental radiologists when evaluating images provided with different amounts of patient information. Although the present study only included 41 panoramic radiographs containing intraosseous lesions, the sample can be considered representative. A 25-year retrospective study²² evaluated more than 7,000 intraosseous lesions and reported a sample composition similar to our findings. In that study, cysts were the most prevalent lesions, followed by benign tumors, consistent with our results. Regarding malignant tumors, Dhanuthai et al.²² (2021) observed a prevalence of 1.53%, whereas our sample demonstrated a prevalence of 2.4%. When evaluating the participants’ age, the mean age reported in the present study was 39.42 years, compared to 36.05 years as reported by Dhanuthai et al.²² (2021).

The methodology employed in the present study was adapted from previous investigations⁸,¹¹that compared the radiographic features of intraosseous jaw lesions provided by panoramic images and CBCT. However, these studies reported different results of diagnostic accuracy provided for each imaging modality. While Mao et al.⁸ (2021) demonstrated that CBCT images improve the diagnostic accuracy of radiological reports, Lim et al.¹¹(2018) found no statistical differences between the imaging exams in terms of diagnostic hypothesis raised. Based on these findings, the authors of this study¹¹ argued that clinicians should consider the diagnostic information that is warranted when requesting an imaging exam. Given that panoramic radiograph may be more available and affordable than CBCT, especially in countries like Brazil¹³, these results are important for guiding clinical decision-making.

Even though the present methodology resembled the one applied in the aforementioned studies⁸,¹¹, our investigation differed in two key aspects: we included only panoramic images, given to its clinical realism and accessibility, and performed the analysis in two different moments, with and without clinical information. This design was based on studies included in a previous systematic review¹⁴ that assessed the impact of clinical data on outcomes such as accuracy, confidence levels and perceived relevance on medical diagnosis. Although such studies are common in the medical field, dental research lacks this type of investigation. For this reason, radiologists of the present study were provided with different amounts of clinical information in two distinct assessments, both based exclusively on panoramic images.

The results of the present study showed a significant improvement in the radiologists’ diagnostic performance after clinical information was provided, with the median score increasing from 1 (without clinical data) to 2 (with clinical data). Similarly, several reports included in the systematic review by Castillo et al.¹⁴(2021) demonstrated that patient information improves diagnostic accuracy across many medical conditions. Our findings also demonstrate that clinical data influences the ranked differential diagnoses. This might be explained by the fact that differentiating lesions such as odontogenic keratocyst and ameloblastoma, whose radiographic features are often similar²³, relies on detecting cortical expansion, which can clinically manifest facial asymmetry. However, while clinical information may partially offset the limitations of panoramic radiographs for diagnostic purposes, its influence on treatment plan was not assessed in the present study and our findings must be interpreted with caution. Since it has already been reported that CBCT images change surgical planning for other dental procedures²⁴,²⁵, such as implant planning and third molar extraction, future research could investigate if CBCT images change treatment plan for intraosseous lesions of the jaws.

Regarding the radiologists’ confidence levels in both assessments, no significant differences were observed. These findings contrast with those presented by previous reports¹⁴, in which clinical data improved diagnostic confidence. This discrepancy may be partially explained by the context where the studies were conducted. In countries like Australia, the provision of clinical data is mandatory when requesting imaging exams¹⁴, meaning that radiologists are used to evaluating diagnostic images with this information. Another possible explanation relates to the distinct indications for the imaging exams assessed. While the present study relied on images obtained for dental purposes, previous reports¹⁴ were based on foot radiographs and abdominopelvic computed tomography requested for medical reasons.

It is well known that panoramic radiograph has great applicability in dentistry and requires a systematic approach for the correct identification of anatomical landmarks²⁶, since it presents distortion and superimposition of structures³. To overcome these technical limitations, and to avoid measurement bias, the present study included the analysis by three radiologists with more than 10 years of professional experience in the reporting of intraosseous lesions. On the other hand, the great experience of the evaluators might have been important so that the confidence levels in the ranked differential diagnosis did not present a statistical difference between the two assessments. Previous studies²⁷,²⁸have demonstrated that observer experience has a positive impact on intra-observer reliability levels for the detection of caries and periapical lesions. Therefore, our findings cannot be generalized for early-career radiologists and general practitioners, and recruiting evaluators with different levels of experience could be addressed by future investigations. Moreover, if the lesions had been assessed using different imaging modalities across the two evaluations, the results might have differed, as previous research⁸ has reported that radiologists’ confidence when interpreting CBCT images is higher compared to panoramic radiographs.

During differential diagnosis, it is important to categorize the pathological group to which the lesion belongs and determine whether it is of odontogenic or non-odontogenic origin²⁹-³¹. In oral pathology, lesions can be classified as cysts, benign or malignant tumors, fibro-osseous lesions, vascular anomalies, metabolic diseases or trauma-related conditions, and several of these categories may present similar radiographic features, such as radiolucent appearance²,²³. Although clinical data like facial asymmetry may aid to differential diagnosis²³, the present study revealed no statistically significant differences in the categorization of pathological groups between the two assessment moments. This outcome might be attributed to the sample size or to the extent of the lesions evaluated, since larger lesions can cause damage to the adjacent structures that are detectable on panoramic radiographs. Furthermore, Staal et al.¹⁷ (2022) demonstrated that the lack of clinical data leads to an increased number of diagnostic hypotheses raised by the radiologists, which was not assessed by the present study but may be explored in future investigations.

The absence of clinical information provided by dentists is common in radiology practice³². Despite this, Pitman³³ (2017) revealed that clinical data can reduce errors on the radiographic interpretation and assist in treatment follow-up³³,³⁴. The present study investigated which clinical data would be useful by evaluators to support the diagnosis, and different types of information were indicated. As expected, fewer data were requested in the second assessment, since some information had already been provided through clinical history. For example, facial asymmetry may help differentiate odontogenic keratocyst from ameloblastoma²³. Along these lines, knowledge of the patient’s ethnicity and the result of pulp sensitivity test may suggest the diagnosis of periapical cemento-osseous dysplasia in the anterior mandible rather than a radicular cyst³⁵. Therefore, providing clinical data when requesting imaging exams may enhance radiologists’ diagnostic performance, as supported by our findings.

The study sample consisted of panoramic radiographs, a two-dimensional examination, and therefore the evaluators were unable to assess the real extent and margins of the lesion³,⁹. For this reason, the most requested information in the first evaluation was regarding the expansion of the region of interest. In the second assessment, this information was often contained in the patient’s complaint of facial asymmetry, and when it was not included in the medical record, it was considered necessary by the observers. The results would be divergent if the research sample consisted of CBCT images, since it provides more information to aid diagnoses⁸. To assess the role of clinical data on interpreting different imaging exams, Maizlin and Somers¹⁵(2019) evaluated order requests for medical ultrasonography (US) and radiograph, and have found that clinical information was significantly more relevant for interpreting radiographic examinations as compared with US. Consequently, this highlights the need for further studies with different imaging exams obtained for dental purposes.

The study concluded that clinical data contribute to improved diagnostic interpretation of intraosseous lesions of the jaws in panoramic images, potentially favoring patient’s treatment plan. Further studies incorporating other complementary imaging exams may provide relevant insights regarding diagnostic accuracy, examiner reliability, and report quality.

Acknowledgments

This study was partially supported by FAPEMIG, Minas Gerais State Agency for Research and Development, CAPES, Coordination of Higher Education and Graduate Training (Finance Code 001) and CNPq, National Council for Scientific and Technological Development.

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• Data availability:
  No datasets were generated or analyzed during the current study.

Edited by

• Editor:
  Dr. Altair A. Del Bel Cury

Data availability

No datasets were generated or analyzed during the current study.

Publication Dates

• Publication in this collection
  03 Aug 2026
• Date of issue
  2026

History

• Received
  17 Apr 2025
• Accepted
  02 Dec 2025