Fundamental and Clinical Evaluation of Dual Imaging Plate (DIP) Intraoral Radiography

Fundamental and Clinical Evaluation of Dual Imaging Plate (DIP) Intraoral Radiography | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Fundamental and Clinical Evaluation of Dual Imaging Plate (DIP) Intraoral Radiography Tatsuhiko Sasaki, Tomoyo Nomura, Toshihiko Amemiya, Mutsumi Kishi, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7542071/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives To investigate the clinical applicability of dual-imaging plate (DIP) intraoral radiography by evaluating image quality and diagnostic usefulness under varying X-ray beam angles and exposure conditions. Methods In Experiment 1, aluminum step wedges and rectangular wave charts were used to evaluate the impact of X-ray beam angle and exposure dose on the contrast-to-noise ratio (CNR) and square wave response function (SWRF) across DIP, front imaging plate (FIP), and single imaging plate (SIP) images. In Experiment 2, intraoral radiographs were obtained from 19 adult volunteers, and the diagnostic utility of DIP images was subjectively evaluated. Results Despite angled-beam irradiation and elevated doses, DIP images exhibited a significantly higher CNR than SIP and FIP images, with no significant difference in SWRF curves. In clinical cases, DIP images were consistently rated as superior to FIP images for anatomical structure visibility, with large effect sizes. However, inter-rater agreement was poor, possibly due to individual contrast preferences. Conclusions The DIP method offers enhanced image contrast without sacrificing spatial resolution, even at clinically realistic irradiation angles and dose levels, suggesting its clinical utility for reducing radiation exposure while preserving diagnostic accuracy. contrast-to-noise ratio dual imaging plate intraoral radiography spatial resolution Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 INTRODUCTION In digital intraoral X-ray imaging, both semiconductor and imaging plate (IP) systems are widely used [ 1 – 3 ]. Compared to the semiconductor system, the sensor of the IP system is thinner, more flexible, and curved, making it easier to insert into the oral cavity, and therefore it has become widely adopted in clinical practice [ 4 – 7 ]. In the IP method, irradiated X-rays are absorbed by a photostimulable phosphor on the surface of the IP, and their energy is stored. The accumulated X-ray energy is released as fluorescence when exposed to a laser beam of a specific wavelength, which is then detected to generate an image [ 3 , 8 ]. However, due to the high penetrability of X-rays, many pass through the IP, resulting in the loss of useful image information and unnecessary exposure. To address this issue, dual imaging plate (DIP) intraoral radiography, which overlays two IPs to enhance image information, has been used. By layering the front IP (FIP) and back IP (BIP), the BIP captures X-ray information that passes through the FIP, and combining both images minimizes information loss. As a result, this technique not only reduces noise while maintaining spatial resolution but also decreases exposure [ 9 ]. Therefore, diagnostic performance can be maintained even in low-dose imaging, and the technology is considered to comply with the ALARA principle [ 9 , 10 ]. However, when the main X-ray beam enters the IPs at an angle, distortion can occur in the two images forming the DIP image, potentially leading to synthesis errors or defects. Therefore, its clinical applicability remains insufficiently verified [ 9 ]. In this study, to explore the clinical applicability of the DIP method, we aimed to clarify its effectiveness and challenges by addressing the following two points: 1) Verification of the effects of irradiation angle on DIP images 2) Examination of the diagnostic usefulness of DIP images under clinical conditions MATERIALS AND METHODS Experiment 1: Verification of the Effect of Irradiation Angle on DIP Images To examine the influence of the incident angle of the principal X-ray beam on DIP intraoral radiography, we simulated an intraoral radiographic indicator (Hanshin Engineering, Osaka, Japan) used in clinical practice and set the irradiation angle to the FIP at an inclination of 75° from the vertical. The focal point-to-IP distance was set to 270 mm, reflecting clinical conditions (Fig. 1 ). The X-ray apparatus used was the Xspot-TS dental X-ray system (Asahi Roentgen Ind., Kyoto, Japan). For the subject materials, a circular stepped aluminum piece with 12 steps, each 1 mm thick, was used to measure the noise characteristics (contrast-to-noise ratio [CNR]). Additionally, to evaluate spatial resolution characteristics (square wave response function [SWRF]), a rectangular wave chart (micro chart R-1W100, Huettner Roentgenteste, Bayern, Germany; JIS Z4916-1997) with seven-line pairs (LP/mm) of 1.25, 1.6, 2.0, 2.5, 3.2, 4.0, and 5.0, engraved on a 0.1 mm tungsten plate, was used. For IP, a size 2 Digora Optime Imaging Plate (Soredex, Palo DEx Group Oy, Tuusula, Finland) was used. For DIP intraoral radiography, ten sets of double packaging, each containing two overlapping IPs, were prepared. As a control, ten single-packaged IPs (Single IP [SIP]) were prepared using the conventional method. According to the specifications, the Digora Optime Imaging Plate has a thin iron plate attached to the IP. Therefore, to maximize the dose transmitted through the FIP, the thin iron plate was removed from the FIP only, after which the FIP was overlapped with the BIP and packaged together. The SIP was packaged without modification. During X-ray exposure, a 40-mm acrylic block was placed in front of the subject as a substitute for soft tissue when imaging was performed. The exposure conditions were set at a tube voltage of 70 kV, tube current of 6 mA, and exposure time of 0.1 seconds (Table 1 ). Table 1 Instrumentation and experimental parameters in Experiments 1 and 2 Experiment 1 2 Imaging plate SIP, DIP, FIP DIP, FIP Object rectangular wave chart 19 volunteers Aluminum steps (1–12 mm) Acrylic block Exposure time 0.1 s 0.06 s, 0.08 s, 0.1 s, 0.16 s Irradiation angle 75° Focus-IP distance 270 mm Scanner Digora optime DXR-60 Dose meter RaySafe ThinX X-ray generator Xspot-TS (Tube voltage: 70 kV, Tube current: 6 mA) DIP, dual imaging plate; SIP, single imaging plate; FIP, front imaging plate. Image Processing After imaging, the FIP and BIP were scanned using the Digora Optime system (PaloDEx Group Oy, Tuusula, Finland). For the FIP, the thin iron plate was attached only during scanning. The output format of the images was BMP (8-bit grayscale) with a matrix size of 1,333 × 1,020 pixels and a pixel size of 30 µm × 30 µm. The SIP was scanned in the same manner. For the DIP image, the FIP and BIP images were aligned using the least-squares method, and their density values were averaged to generate the DIP image. Image processing was performed using software developed in Visual Studio 2019 C# (Microsoft Corp., Redmond, WA, USA). Measurement of Noise Characteristics (CNR) The density values of the aluminum steps in the DIP, SIP, and FIP images were measured using ImageJ version 1.53e (National Institutes of Health). Regions of interest (ROI) measuring 50 × 50 pixels were set at step sections with thicknesses of 1 and 5 mm, from which the mean and standard deviation (SD) of the density values were obtained. Based on these measurements, the contrast-to-noise ratio (CNR) was calculated using the following formula (Fig. 2 ): $$\:\text{C}\text{N}\text{R}=\frac{{\text{M}\text{e}\text{a}\text{n}}_{\left(\text{A}\text{l}5\text{m}\text{m}\right)}-{\text{M}\text{e}\text{a}\text{n}}_{\left(\text{A}\text{l}1\text{m}\text{m}\right)}}{\sqrt{\frac{{{\text{M}\text{e}\text{a}\text{n}}_{\left(\text{A}\text{l}5\text{m}\text{m}\right)}}^{2}-{{\text{M}\text{e}\text{a}\text{n}}_{\left(\text{A}\text{l}1\text{m}\text{m}\right)}}^{2}}{2}}}$$ Measurement of Spatial Resolution Using ImageJ, the gray value (count) was measured from the line profile of the rectangular waves on the DIP and SIP/FIP images, and the SWRF was calculated using the following formula (Fig. 3 ). $$\:\text{S}\text{W}\text{R}\text{F}=\frac{{\text{C}\text{o}\text{u}\text{n}\text{t}}_{\text{m}\text{a}\text{x}\left(\text{L}\text{P}\right)}-{\text{C}\text{o}\text{u}\text{n}\text{t}}_{\text{m}\text{i}\text{n}\left(\text{L}\text{P}\right)}}{{\text{C}\text{o}\text{u}\text{n}\text{t}}_{\text{m}\text{a}\text{x}\left(\text{L}\text{P}0\right)}-{\text{C}\text{o}\text{u}\text{n}\text{t}}_{\text{m}\text{i}\text{n}\left(\text{L}\text{P}0\right)}}$$ Experiment 2: Examination of the Diagnostic Usefulness of DIP Images under Clinical Conditions In this study, intraoral X-ray imaging using DIP intraoral radiography was performed on 19 healthy adults under clinical conditions (11 men and 8 women, aged 26–68 years; mean age 40.6 years) with no notable dental history. All participants voluntarily participated in the study and provided informed consent. This study was approved by the relevant ethics committee and was conducted in accordance with the Declaration of Helsinki, as revised in 2008. To ensure consistency with Experiment 1, an X-ray imaging indicator, a dental X-ray unit Xspot-TS, and a size 2 Digora Optime Imaging Plate were used. The imaging sites included the central incisors, canines, and first molars. Cases with extensive defects, full-crown restorations or prosthetics, periapical lesions, root canal filling, significant eruption anomalies, or crowding were excluded. The exposure conditions were set to a tube voltage of 70 kV and a tube current of 6 mA. Exposure times were 0.08, 0.1, 0.16, 0.06, 0.08, and 0.1 seconds for the maxillary incisors, maxillary canines and premolars, maxillary molars, mandibular anterior teeth, mandibular canines and premolars, and mandibular molars, respectively (Table 1 ). Using the DIP method, a total of 35 cases were obtained, including 7 central incisors, 12 canines, and 16 first molars. Image composition was also performed as in Experiment 1, generating DIP images from the FIP and BIP. For the control, FIP images were used in place of SIP images. In addition, the exposure dose was measured using the RaySafe ThinX (RaySafe, Hovås, Sweden) as the patient entrance dose (incident air kerma [IKA]) at an exposure time of 0.1 seconds and a focal spot-to-IP distance of 150 mm. The IKA was calculated based on these measurements. Subjective Evaluation Subjective evaluations were conducted by seven board-certified dental radiologists in a dimly lit, quiet environment using a 27-inch LCD monitor (BARCO, Brussels, Belgium). To compare and evaluate DIP and FIP images, paired images from the same case were displayed simultaneously (Fig. 4 ). The order of presentation was randomized using the original software developed in Visual Studio 2019 C#, and the evaluators were blinded to whether images were DIP or FIP.. A dental radiologist who did not participate in the evaluation monitored the brightness, contrast, and magnification, which could not be adjusted by the evaluators. There was no time limit for the evaluation. The evaluators compared the DIP and FIP images with respect to eight anatomical features (Table 2 ), including enamel, dentinoenamel junction, alveolar crest, alveolar bone, radix dentis, canalis radices dentis, apex of dental root, and periodontium of dental root. For each feature, one point was awarded to the image judged superior, with a maximum possible score of eight points per image. The subjective evaluation was conducted twice, with a minimal interval of two weeks between sessions. Table 2 List of question items for the subjective evaluation in Experiment 2 Enamelum Dentino-enamel junction Alveolar crest Alveolar bone Radix dentis Canalis radices dentis Apex of dental root Periodontium of the apex of dental root Statistical Analysis In Experiment 1, the normality of each CNR was assessed using the Shapiro-Wilk test. An unpaired t-test was performed when normality was assumed, whereas the Mann-Whitney U test was used when it was not. Additionally, for SWRF, the similarity of the curves in the graph was evaluated [ 9 ]. In Experiment 2, the mean scores from the first assessment of each image by the seven evaluators were used for analysis. The normality of the scores was evaluated using the Shapiro-Wilk test. If normality was assumed, a paired t-test was used; otherwise, the Wilcoxon signed-rank test was conducted. The intraclass correlation coefficient (ICC, Class 1) was used to evaluate inter-rater reproducibility, and ICC (Class 2) was used to evaluate intra-rater reliability. Statistical analyses were performed using SPSS Statistics (version 25.0; IBM Corp., Armonk, NY, US) and DATAtab (DATAtab Team, Austria), with the significance level set at p < 0.05. RESULTS Experiment 1 Even when the incidence angle of the main X-ray beam was not perpendicular, a significant improvement in CNR was observed in DIP images compared to conventional SIP and FIP images (Fig. 5 ). In contrast, no significant difference in CNR was observed between SIP and FIP images. In addition, the spatial resolution (SWRF) curves for DIP, SIP, and FIP images exhibited the same trend across the three methods, and no differences in spatial resolution under different exposure conditions were observed (Fig. 6 ). Experiment 2 According to the subjective evaluations of seven board-certified dental radiologists, DIP images received significantly higher scores than FIP images in all anatomical categories (enamelum, dentinoenamel junction, alveolar crest, alveolar bone, radix dentis, canalis radices dentis, apex of dental root, and periodontium of the apex of dental root) ( p < 0.05) (Fig. 7 ). The effect size (r) was large, at 0.87, indicating that the visibility of DIP images was strongly supported by the evaluators. In the reproducibility analysis, the mean ICC (1,1), which reflects intra-rater reliability, was 0.66, indicating moderate agreement, whereas the ICC (2,1), which reflects inter-rater agreement, was poor (0.07), suggesting differences in observation trends among evaluators. The IKA values at irradiation times of 0.16, 0.1, 0.08, and 0.06 seconds were 1.13, 0.71, 0.56, and 0.42, respectively (Table 3 ). Table 3 Patient entrance dose (incident air kerma [IAK]) with the diagnostic reference level (DRL) for the clinical trial in Experiment 2 Tooth Clinical trial DRL (Adults) DRL (Children) Maxilla Incisor 0.56 1.1 0.8 Canine 0.71 1.2 0.8 Premolar 0.71 1.3 1.0 Molar 1.13 1.9 1.2 Mandible Incisor 0.42 0.9 0.6 Canine 0.56 1.0 0.7 Premolar 0.56 1.1 0.8 Molar 0.71 1.3 1.0 (mGy) DISCUSSION To date, DIP intraoral radiography has only been validated under conditions where the main X-ray beam is directed perpendicularly to the IP. The results of study, aimed at clinical trials, showed that even when the irradiation angle varied, DIP images exhibited higher CNR and better visibility than SIP and FIP images. Additionally, no significant differences in SWRF were observed among the three image types, and the spatial resolution of DIP intraoral radiography was maintained compared with conventional methods. These findings suggest that even under when the main X-ray beam is not perpendicular, DIP images offer technical advantages by reducing noise while enhancing structural clarity. Furthermore, no significant differences in CNR were observed between FIP and SIP images, and their SWRF curves were identical, suggesting that FIP images can serve as a control for DIP images as an alternative to SIP images. Therefore, in the clinical study (Experiment 2), FIP images were used as control images to minimize radiation exposure to the subjects. According to subjective evaluations by dental radiology specialists, DIP images scored significantly higher than FIP images, and the effect size was larger. This is believed to be due to the image quality of DIP images, which reduce noise [ 11 – 13 ], are consistent with radiologists’ visual assessment criteria, leading to higher evaluations. These findings suggest that, compared to conventional methods, DIP images offer superior visibility of anatomical structures and are considered useful in clinical diagnosis. However, while the intra-rater agreement ICC (1,1) was moderate (0.66), the inter-rater agreement ICC (2,1) was low (0.07), indicating that image evaluation may be easily influenced by subjective factors. In this image assessment, a dental radiology specialist who did not participate preset the brightness, contrast, and magnification of the monitor for diagnostic suitability, and these settings could not be adjusted by the evaluators. This factor led to varied preferences among evaluators [ 14 ], resulting in dispersed evaluations. In the future, standardization of assessment criteria and the introduction of objective indicators for image processing will be necessary. In Experiment 2, exposures ranging from 0.42 to 1.13 mGy, which were approximately half the adult diagnostic reference level (DRL) for intraoral X-ray imaging (0.9 to 1.9 mGy), were used (Table 3 ) [ 9 , 15 ]. This demonstrates its potential to provide stable image quality in pediatric intraoral X-ray imaging. The DIP method has clinical significance because of its potential application in pediatric patients. Based on the laws of Bergonié and Tribondeau, children are more sensitive to radiation, making technologies that can minimize radiation exposure while maintaining diagnostic capabilities particularly valuable. In recent years, there has been a global increase in dental caries among children, and in the United States, pediatric dental treatments are increasingly being performed on teeth that have already been treated [ 16 , 17 ]. Given this situation, IP-based intraoral X-ray imaging [ 7 , 18 , 19 ], which causes less discomfort during insertion into the oral cavity compared to CCD sensors and excels in the observation of fillings at low doses, can be applied to bitewing techniques and is expected to have certain advantages. If the effectiveness of the DIP imaging method is clinically established, it may provide an even lower-dose technique for intraoral X-ray imaging, a modality that has been widely used worldwide. DIP imaging allows for a shorter X-ray exposure time. For patients who have difficulty maintaining the IP in position owing to body movement, such as the aforementioned children [ 7 ], patients with cerebral palsy, or those who exhibit tremors, the application of this method is expected to be beneficial. Recently, the use of portable X-ray devices has increased. Because portable X-ray units are often handheld during imaging, capturing images under ideal conditions is difficult [ 20 ], which may result in motion artifacts or positional errors during exposure. Therefore, by reducing the X-ray exposure time, the DIP method can decrease image blurring and offer the advantage of lowering the radiation dose to unintended areas. Additionally, in situations where panoramic imaging or CT cannot be performed, intraoral X-ray imaging is used as an alternative diagnostic method [ 21 ]. When extensive imaging is required, the low radiation dose and high diagnostic capability of the DIP method are significant advantages. CONCLUSIONS X-ray images taken at non-perpendicular angles showed significantly higher CNR in DIP images compared to SIP and FIP images, while the spatial resolution curves were identical. Under clinical conditions, DIP images, when compared to the conventional method (FIP images), contributed to improved visibility of anatomical structures. This study has also validated the foundational research necessary to apply DIP intraoral radiography in clinical practice and clarified the diagnostic usefulness of DIP imaging in a clinical setting, representing a significant contribution. Declarations Conflict of interest Not applicable. Ethics approval and consent to participate This study was conducted using data for which approval (EP23D017) was obtained from the Ethics Committee of Nihon University School of Dentistry. All procedures were performed in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent Additional informed consent was obtained from all patients, and their identifying information was included in this article. Funding This work was supported by JSPS KAKENHI under Grant Nos. JP 25K11047, Grant from Dental Research Center, Nihon University School of Dentistry (DRC(B)-2025-20) and Sato Fund, Nihon University School of Dentistry(SATO-2023-20) Author Contribution Author Contribution StatementDMFR requires that for all submitted papers:•all the authors have made substantive contributions to the article and assume full responsibility for its content; and•all those who have made substantive contributions to the article have been named as authors. The International Committee of Medical Journal Editors recommends the following definition for an author of a work, which we ask our authors to adhere to:Authorship be based on the following 4 criteria [1]:•Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND •Drafting the work or revising it critically for important intellectual content; AND •Final approval of the version to be published; AND •Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Please list below all authors of this work and a brief description of how they each contributed towards your submission:Author nameContributionTatsuhiko SasakiThe author contributed to design of the study, data acquisition, interpretation of the data, and preparation of the initial draft.Tomoyo NomuraThe author contributed to data acquisition, interpretation of the data, and editing draft.Toshihiko AmemiyaThe author contributed to management and coordination responsibility for the research activity planning, provision of study materials, data acquisition, interpretation of the data and editing draft.Mutsumi KishiThe author contributed to data acquisition, interpretation of the data, and editing draft.Ko DezawaThe author contributed to design of the study, data acquisition, interpretation of the data, and editing draft.Kunihiko SawadaThe author contributed to design of the study, data acquisition, interpretation of the data, and editing draft. Ken-ichiro EjimaThe author contributed to design of the study, data acquisition, interpretation of the data, and editing draft. Kazuya HondaThe author contributed to design of the study, data acquisition, interpretation of the data, and editing draft. Yoshinori AraiThe author contributed to management and coordination responsibility for the research activity planning, designing computer program and editing draft. Kunihito MatsumotoThe author designed and directed the study, and contributed to the final version of the manuscript Please continue on further pages if needed. 1 The International Committee of Medical Journal Editors, Roles and Responsibilities of Authors, Contributors, Reviewers, Editors, Publishers, and Owners: Defining the Role of Authors and Contributors, http://www.icmje.org/roles_a.html Acknowledgements The authors would like to thank Editage ( www.editage.com ) for the English language editing. Data Availability References Farrier SL, Drage NA, Newcombe RG, Hayes SJ, Dummer PMH. A comparative study of image quality and radiation exposure for dental radiographs produced using a charge-coupled device and a phosphor plate system. Int Endod J. 2009;42:900–7. https://doi.org/10.1111/j.1365-2591.2009.01598.x . Berkhout E, Sanderink G, van der Stelt P. Digital intra-oral radiography in dentistry. Diagnostic efficacy and dose considerations. Oral Radiol. 2003;19:1–13. https://doi.org/10.1007/BF02493286 . White SC, Pharoah MJ. Oral radiology: principles and interpretation. 8th ed. St. Louis (MO): Elsevier; 2018. Wenzel A, Møystad A. Work flow with digital intraoral radiography: a systematic review. Acta Odontol Scand. 2010;68:106–14. https://doi.org/10.3109/00016350903514426 . Gonçalves A, Wiezel VG, Gonçalves M, Hebling J, Sannomiya EK. Patient comfort in periapical examination using digital receptors. Dentomaxillofac Radiol. 2009;38:484–8. https://doi.org/10.1259/dmfr/82025587 . Wenzel A, Frandsen E, Hintze H. Patient discomfort and cross-infection control in bitewing examination with a storage phosphor plate and a CCD-based sensor. J Dent. 1999;27:243–6. https://doi.org/10.1016/S0300-5712(98)00063-3 . Juneja S, Dalvi S, Aggarwal R, Sukhija M, Singh S, Bansal S. Assessment of perception of pain with E-speed film, CCD sensor and photostimulable phosphor plates for intraoral radiographs in children using three pain rating scales. Indian J Dent Res. 2024;35:54–8. https://doi.org/10.4103/ijdr.ijdr_78_23 . Kalathingal SM, Shrout MK, Comer C, Brady C. Rating the extent of surface scratches on photostimulable storage phosphor plates in a dental school environment. Dentomaxillofac Radiol. 2010;39:179–83. https://doi.org/10.1259/dmfr/28972644 . Watanabe K, Imanishi Y, Kato M, Kimoto H, Sekiguchi T, Amemiya T, et al. Preliminary evaluation of dual imaging plate intraoral radiography. J Oral Sci. 2022;64:69–73. https://doi.org/10.2334/josnusd.21-0454 . European Commission. Radiation protection no 136: European guidelines on radiation protection in dental radiology: The safe use of radiographs in dental practice. 2004. http://ec.europa.eu/energy/sites/ener/files/documents/136.pdf . Accessed 20 Aug 2025. Tsuda N, Tanaka N, Akasaka T, Yabuuchi H, Morishita J. Dose reduction in general radiography for adult patients by use of a dual-side-reading photostimulable phosphor plate in a computed radiography system. Radiol Phys Technol. 2014;7:310–5. https://doi.org/10.1007/s12194-014-0268-z . Workman A, Cowen AR. Improved image quality utilizing dual plate computed radiography. Br J Radiol. 1995;68:182–8. https://doi.org/10.1259/0007-1285-68-806-182 . Monnin P, Holzer Z, Wolf R, Neitzel U, Vock P, Gudinchet F, et al. An image quality comparison of standard and dual-side read CR systems for pediatric radiology. Med Phys. 2006;33:411–20. https://doi.org/10.1118/1.2163392 . Nascimento EH, Gaêta-Araujo H. Influence of brightness and contrast adjustments on the diagnosis of proximal caries lesions. Dentomaxillofac Radiol. 2018;47:20180100. https://doi.org/10.1259/dmfr.20180100 . Japan Network for research and information on medical exposure [J-RIME]. National diagnostic reference level in Japan. (2020) – Japan DRLs 2025-, https://j-rime.qst.go.jp/report/JapanDRLs2025_ja.pdf . Accessed 20 Aug 2025. Kazeminia M, Abdi A, Shohaimi S, Jalali R, Vaisi-Raygani A, Salari N, et al. Dental caries in primary and permanent teeth in children worldwide, 1995 to 2019: a systematic review and meta-analysis. Head Face Med. 2020;16:22. https://doi.org/10.1186/s13005-020-00237-z . Dye BA, Hsu KL, Afful J. Prevalence and measurement of dental caries in young children. Pediatr Dent. 2015;37:200–6. Kamburoglu K, Kolsuz E, Murat S, Yuksel S, Ozen T. Proximal caries detection accuracy using intraoral bitewing radiography, extraoral bitewing radiography and panoramic radiography. Dentomaxillofac Radiol. 2012;41:450–9. https://doi.org/10.1259/dmfr/30526171 . Aydin KC, Demirel O, Özcan M. Comparison of two digital intraoral radiography imaging systems as a function of contrast resolution and exposure time. Minerva Stomatol. 2020;69:148–52. https://doi.org/10.23736/S0026-4970.19.04286-9 . Berkhout WE, Suomalainen A, Brüllmann D, Jacobs R, Horner K, Stamatakis HC. Justification and good practice in using handheld portable dental X-ray equipment: a position paper prepared by the European Academy of DentoMaxilloFacial Radiology (EADMFR). Dentomaxillofac Radiol. 2015;44:20140343. https://doi.org/10.1259/dmfr.20140343 . Dave M, Coulthard P, Patel N, Seoudi N, Horner K. Letter to the editor: Use of dental radiography in the COVID-19 pandemic. J Dent Res. 2020;99:1112. https://doi.org/10.1177/0022034520923323 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7542071","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":521914363,"identity":"3a306f97-2aac-4168-8e20-076a76056689","order_by":0,"name":"Tatsuhiko Sasaki","email":"","orcid":"","institution":"Nihon University School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Tatsuhiko","middleName":"","lastName":"Sasaki","suffix":""},{"id":521914364,"identity":"6cd99e4f-3d1a-413d-8bdc-0973c804b047","order_by":1,"name":"Tomoyo Nomura","email":"","orcid":"","institution":"Nihon University School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Tomoyo","middleName":"","lastName":"Nomura","suffix":""},{"id":521914365,"identity":"4adbb751-201b-46bb-9904-2d22cd75bf77","order_by":2,"name":"Toshihiko Amemiya","email":"data:image/png;base64,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","orcid":"","institution":"Nihon University School of Dentistry","correspondingAuthor":true,"prefix":"","firstName":"Toshihiko","middleName":"","lastName":"Amemiya","suffix":""},{"id":521914367,"identity":"7f616053-ef21-4333-b6e0-a33be041d21f","order_by":3,"name":"Mutsumi Kishi","email":"","orcid":"","institution":"Nihon University School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Mutsumi","middleName":"","lastName":"Kishi","suffix":""},{"id":521914369,"identity":"6c4e6087-f190-4c1d-b300-d804fe0662c5","order_by":4,"name":"Ko Dezawa","email":"","orcid":"","institution":"Nihon University School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Ko","middleName":"","lastName":"Dezawa","suffix":""},{"id":521914371,"identity":"1cda9cfe-936b-4547-a937-41f8125a0306","order_by":5,"name":"Kunihiko Sawada","email":"","orcid":"","institution":"Nihon University School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Kunihiko","middleName":"","lastName":"Sawada","suffix":""},{"id":521914373,"identity":"e2842d33-e3cf-49d5-b314-7f8c761df3a3","order_by":6,"name":"Ken-ichiro Ejima","email":"","orcid":"","institution":"Nihon University School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Ken-ichiro","middleName":"","lastName":"Ejima","suffix":""},{"id":521914374,"identity":"6b24e141-4b20-425f-9748-c0a032946852","order_by":7,"name":"Kazuya Honda","email":"","orcid":"","institution":"Nihon University School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Kazuya","middleName":"","lastName":"Honda","suffix":""},{"id":521914375,"identity":"ffec3590-748b-47f8-b9df-262c3e965e76","order_by":8,"name":"Yoshinori Arai","email":"","orcid":"","institution":"Nihon University School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Yoshinori","middleName":"","lastName":"Arai","suffix":""},{"id":521914376,"identity":"a51df1cf-1859-443f-955a-90d1a84982f4","order_by":9,"name":"Kunihito Matsumoto","email":"","orcid":"","institution":"Nihon University School of Dentistry","correspondingAuthor":false,"prefix":"","firstName":"Kunihito","middleName":"","lastName":"Matsumoto","suffix":""}],"badges":[],"createdAt":"2025-09-05 08:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7542071/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7542071/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92530141,"identity":"110b3e6d-b57e-40be-887f-1090ecef0e72","added_by":"auto","created_at":"2025-09-30 16:36:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60388,"visible":true,"origin":"","legend":"","description":"","filename":"FundamentalandClinicalEvaluationofDualImagingPlateDIPIntraoralRadiography.docx","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/656ec095873473bfa01d47d9.docx"},{"id":92530143,"identity":"78494c7c-b55f-46f0-8ae5-cd13b6b9a9d7","added_by":"auto","created_at":"2025-09-30 16:36:47","extension":"json","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":12652,"visible":true,"origin":"","legend":"","description":"","filename":"134eb47e45ee4be695c9ce230729a2ef.json","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/170b42a29420c1abcb69635c.json"},{"id":92530147,"identity":"7c4ffb5c-b60b-4d7e-83c1-e9d1f55aecbb","added_by":"auto","created_at":"2025-09-30 16:36:47","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74899,"visible":true,"origin":"","legend":"","description":"","filename":"134eb47e45ee4be695c9ce230729a2ef1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/acc29bfef6de242e3cb2258e.xml"},{"id":92530152,"identity":"57e3d0b2-a0fc-4a66-954f-cdcf0c053fa4","added_by":"auto","created_at":"2025-09-30 16:36:47","extension":"zip","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4537269,"visible":true,"origin":"","legend":"","description":"","filename":"Fig.17TIFF.zip","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/0707d29a66c8ec3566384f7d.zip"},{"id":92530148,"identity":"b84a6d02-b8bd-43aa-ad46-d911fcd44619","added_by":"auto","created_at":"2025-09-30 16:36:47","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":70496,"visible":true,"origin":"","legend":"","description":"","filename":"134eb47e45ee4be695c9ce230729a2ef1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/a34726dda634f6fed7687f1d.xml"},{"id":92530151,"identity":"3d68f0a0-a50d-496b-afd7-2be1ee4411a1","added_by":"auto","created_at":"2025-09-30 16:36:47","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":81460,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/7235b5f162d09ae159f7bf8a.html"},{"id":92531939,"identity":"cb1b5ade-9a7c-461a-888c-403f7be48b9e","added_by":"auto","created_at":"2025-09-30 16:44:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":993548,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of X-ray generator, subject, and IP\u003c/p\u003e\n\u003cp\u003eThe distance between the IP and X-ray focal spot was 270 mm. The incidence angle of radiography to the IP was 75°.\u003c/p\u003e\n\u003cp\u003eIP, imaging plate; DIP, dual imaging plate; SIP, single imaging plate.\u003c/p\u003e","description":"","filename":"Fig.1.tif.png","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/069b3c66e439a0c14c500719.png"},{"id":92530142,"identity":"0c272260-a0b2-402e-8f1b-8e16cc64f944","added_by":"auto","created_at":"2025-09-30 16:36:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2205201,"visible":true,"origin":"","legend":"\u003cp\u003eAluminum step phantom used for measuring CNR in Experiment 1\u003c/p\u003e\n\u003cp\u003eThe DIP (a), SIP (b), and FIP (c) images were obtained using an exposure time of 0.1 seconds. The CNR for each image was calculated from the mean and standard deviation of the image intensity at the 1-mm and 5-mm steps.\u003c/p\u003e\n\u003cp\u003eCNR, contrast-to-noise ratio; DIP, dual imaging plate; SIP, single imaging plate; FIP, front imaging plate.\u003c/p\u003e","description":"","filename":"Fig.2.tif.png","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/a944e111dfd7fa052450f1f1.png"},{"id":92531940,"identity":"ceadbe07-46a5-4264-9137-e206b6947fe0","added_by":"auto","created_at":"2025-09-30 16:44:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2329994,"visible":true,"origin":"","legend":"\u003cp\u003eLine pair gauge used for the measurement of the SWRF in Experiment 1\u003c/p\u003e\n\u003cp\u003eThe DIP (a), SIP (b), and FIP (c) images were obtained using an exposure time of 0.1 seconds.\u003c/p\u003e\n\u003cp\u003eSWRF, square wave response function; DIP, dual imaging plate; SIP, single imaging plate; FIP, front imaging plate.\u003c/p\u003e","description":"","filename":"Fig.3.tif.png","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/7f207bfad357082f073bd8a6.png"},{"id":92531942,"identity":"916b1e88-006a-498b-9263-436ad540ab8c","added_by":"auto","created_at":"2025-09-30 16:44:47","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":5683186,"visible":true,"origin":"","legend":"\u003cp\u003eImages used for the subjective evaluation of the DIP and FIP in Experiment 2\u003c/p\u003e\n\u003cp\u003eThe DIP (a) and FIP (b) images are shown, with their enlarged views indicating the distal root.\u003c/p\u003e\n\u003cp\u003eBased on the subjective evaluation, DIP image (a) received a significantly higher score than FIP image (b) (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eDIP, dual imaging plate; FIP, front imaging plate.\u003c/p\u003e","description":"","filename":"Fig.4.tif.png","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/5af72cc76053821aee0f9b3d.png"},{"id":92530145,"identity":"0ed8d9c4-6258-49e5-af5c-746f848a9ff8","added_by":"auto","created_at":"2025-09-30 16:36:47","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":869034,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the CNR obtained using the SIP, DIP, and FIP in Experiment 1 (* \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05)\u003c/p\u003e\n\u003cp\u003eCNR, contrast-to-noise ratio; DIP, dual imaging plate; SIP, single imaging plate; FIP, front imaging plate.\u003c/p\u003e","description":"","filename":"Fig.5.tif.png","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/e292d1bacb6b9733ca8384ee.png"},{"id":92530149,"identity":"c07ef94e-e270-4d11-8e5b-c1cf6e85d586","added_by":"auto","created_at":"2025-09-30 16:36:47","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1256103,"visible":true,"origin":"","legend":"\u003cp\u003eAssessment of spatial resolution using the SWRF in Experiment 1\u003c/p\u003e\n\u003cp\u003eSWRF, square wave response function; DIP, dual imaging plate; SIP, single imaging plate; FIP, front imaging plate.\u003c/p\u003e","description":"","filename":"Fig.6.tif.png","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/96cdb1eb4a951f774b30b1c5.png"},{"id":92531941,"identity":"84bc4025-cf6e-4cb0-8c7a-53ed8c5eecf6","added_by":"auto","created_at":"2025-09-30 16:44:47","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":264116,"visible":true,"origin":"","legend":"\u003cp\u003eScore differences in the subjective evaluation in Experiment 2 (* \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05)\u003c/p\u003e\n\u003cp\u003eDIP, dual imaging plate; FIP, front imaging plate.\u003c/p\u003e","description":"","filename":"Fig.7.tif.png","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/da197e3448f7ae7680c8efdd.png"},{"id":97673458,"identity":"f97a69b3-e6b9-4188-b546-1da84b1b590d","added_by":"auto","created_at":"2025-12-08 09:40:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":14328917,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7542071/v1/36ea301c-1e66-4672-a869-a0cbf279deb3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Fundamental and Clinical Evaluation of Dual Imaging Plate (DIP) Intraoral Radiography","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIn digital intraoral X-ray imaging, both semiconductor and imaging plate (IP) systems are widely used [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Compared to the semiconductor system, the sensor of the IP system is thinner, more flexible, and curved, making it easier to insert into the oral cavity, and therefore it has become widely adopted in clinical practice [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the IP method, irradiated X-rays are absorbed by a photostimulable phosphor on the surface of the IP, and their energy is stored. The accumulated X-ray energy is released as fluorescence when exposed to a laser beam of a specific wavelength, which is then detected to generate an image [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, due to the high penetrability of X-rays, many pass through the IP, resulting in the loss of useful image information and unnecessary exposure.\u003c/p\u003e\u003cp\u003eTo address this issue, dual imaging plate (DIP) intraoral radiography, which overlays two IPs to enhance image information, has been used. By layering the front IP (FIP) and back IP (BIP), the BIP captures X-ray information that passes through the FIP, and combining both images minimizes information loss. As a result, this technique not only reduces noise while maintaining spatial resolution but also decreases exposure [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Therefore, diagnostic performance can be maintained even in low-dose imaging, and the technology is considered to comply with the ALARA principle [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, when the main X-ray beam enters the IPs at an angle, distortion can occur in the two images forming the DIP image, potentially leading to synthesis errors or defects. Therefore, its clinical applicability remains insufficiently verified [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, to explore the clinical applicability of the DIP method, we aimed to clarify its effectiveness and challenges by addressing the following two points:\u003c/p\u003e\u003cp\u003e1) Verification of the effects of irradiation angle on DIP images\u003c/p\u003e\u003cp\u003e2) Examination of the diagnostic usefulness of DIP images under clinical conditions\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eExperiment 1: Verification of the Effect of Irradiation Angle on DIP Images\u003c/p\u003e\u003cp\u003eTo examine the influence of the incident angle of the principal X-ray beam on DIP intraoral radiography, we simulated an intraoral radiographic indicator (Hanshin Engineering, Osaka, Japan) used in clinical practice and set the irradiation angle to the FIP at an inclination of 75\u0026deg; from the vertical. The focal point-to-IP distance was set to 270 mm, reflecting clinical conditions (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe X-ray apparatus used was the Xspot-TS dental X-ray system (Asahi Roentgen Ind., Kyoto, Japan). For the subject materials, a circular stepped aluminum piece with 12 steps, each 1 mm thick, was used to measure the noise characteristics (contrast-to-noise ratio [CNR]). Additionally, to evaluate spatial resolution characteristics (square wave response function [SWRF]), a rectangular wave chart (micro chart R-1W100, Huettner Roentgenteste, Bayern, Germany; JIS Z4916-1997) with seven-line pairs (LP/mm) of 1.25, 1.6, 2.0, 2.5, 3.2, 4.0, and 5.0, engraved on a 0.1 mm tungsten plate, was used.\u003c/p\u003e\u003cp\u003eFor IP, a size 2 Digora Optime Imaging Plate (Soredex, Palo DEx Group Oy, Tuusula, Finland) was used. For DIP intraoral radiography, ten sets of double packaging, each containing two overlapping IPs, were prepared. As a control, ten single-packaged IPs (Single IP [SIP]) were prepared using the conventional method. According to the specifications, the Digora Optime Imaging Plate has a thin iron plate attached to the IP. Therefore, to maximize the dose transmitted through the FIP, the thin iron plate was removed from the FIP only, after which the FIP was overlapped with the BIP and packaged together. The SIP was packaged without modification. During X-ray exposure, a 40-mm acrylic block was placed in front of the subject as a substitute for soft tissue when imaging was performed. The exposure conditions were set at a tube voltage of 70 kV, tube current of 6 mA, and exposure time of 0.1 seconds (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInstrumentation and experimental parameters in Experiments 1 and 2\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExperiment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImaging plate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSIP, DIP, FIP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDIP, FIP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObject\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003erectangular wave chart\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 volunteers\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAluminum steps (1\u0026ndash;12 mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAcrylic block\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExposure time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.1 s\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.06 s, 0.08 s, 0.1 s, 0.16 s\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIrradiation angle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e75\u0026deg;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFocus-IP distance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e270 mm\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eScanner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eDigora optime DXR-60\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDose meter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eRaySafe ThinX\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eX-ray generator\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eXspot-TS (Tube voltage: 70 kV, Tube current: 6 mA)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eDIP, dual imaging plate; SIP, single imaging plate; FIP, front imaging plate.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eImage Processing\u003c/h2\u003e\u003cp\u003eAfter imaging, the FIP and BIP were scanned using the Digora Optime system (PaloDEx Group Oy, Tuusula, Finland). For the FIP, the thin iron plate was attached only during scanning. The output format of the images was BMP (8-bit grayscale) with a matrix size of 1,333 \u0026times; 1,020 pixels and a pixel size of 30 \u0026micro;m \u0026times; 30 \u0026micro;m. The SIP was scanned in the same manner. For the DIP image, the FIP and BIP images were aligned using the least-squares method, and their density values were averaged to generate the DIP image. Image processing was performed using software developed in Visual Studio 2019 C# (Microsoft Corp., Redmond, WA, USA).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMeasurement of Noise Characteristics (CNR)\u003c/h3\u003e\n\u003cp\u003eThe density values of the aluminum steps in the DIP, SIP, and FIP images were measured using ImageJ version 1.53e (National Institutes of Health). Regions of interest (ROI) measuring 50 \u0026times; 50 pixels were set at step sections with thicknesses of 1 and 5 mm, from which the mean and standard deviation (SD) of the density values were obtained. Based on these measurements, the contrast-to-noise ratio (CNR) was calculated using the following formula (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e):\u003c/p\u003e\u003cp\u003e\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:\\text{C}\\text{N}\\text{R}=\\frac{{\\text{M}\\text{e}\\text{a}\\text{n}}_{\\left(\\text{A}\\text{l}5\\text{m}\\text{m}\\right)}-{\\text{M}\\text{e}\\text{a}\\text{n}}_{\\left(\\text{A}\\text{l}1\\text{m}\\text{m}\\right)}}{\\sqrt{\\frac{{{\\text{M}\\text{e}\\text{a}\\text{n}}_{\\left(\\text{A}\\text{l}5\\text{m}\\text{m}\\right)}}^{2}-{{\\text{M}\\text{e}\\text{a}\\text{n}}_{\\left(\\text{A}\\text{l}1\\text{m}\\text{m}\\right)}}^{2}}{2}}}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eMeasurement of Spatial Resolution\u003c/h3\u003e\n\u003cp\u003eUsing ImageJ, the gray value (count) was measured from the line profile of the rectangular waves on the DIP and SIP/FIP images, and the SWRF was calculated using the following formula (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equb\" name=\"EquationSource\"\u003e\n$$\\:\\text{S}\\text{W}\\text{R}\\text{F}=\\frac{{\\text{C}\\text{o}\\text{u}\\text{n}\\text{t}}_{\\text{m}\\text{a}\\text{x}\\left(\\text{L}\\text{P}\\right)}-{\\text{C}\\text{o}\\text{u}\\text{n}\\text{t}}_{\\text{m}\\text{i}\\text{n}\\left(\\text{L}\\text{P}\\right)}}{{\\text{C}\\text{o}\\text{u}\\text{n}\\text{t}}_{\\text{m}\\text{a}\\text{x}\\left(\\text{L}\\text{P}0\\right)}-{\\text{C}\\text{o}\\text{u}\\text{n}\\text{t}}_{\\text{m}\\text{i}\\text{n}\\left(\\text{L}\\text{P}0\\right)}}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eExperiment 2: Examination of the Diagnostic Usefulness of DIP Images under Clinical Conditions\u003c/p\u003e\u003cp\u003eIn this study, intraoral X-ray imaging using DIP intraoral radiography was performed on 19 healthy adults under clinical conditions (11 men and 8 women, aged 26\u0026ndash;68 years; mean age 40.6 years) with no notable dental history. All participants voluntarily participated in the study and provided informed consent. This study was approved by the relevant ethics committee and was conducted in accordance with the Declaration of Helsinki, as revised in 2008.\u003c/p\u003e\u003cp\u003eTo ensure consistency with Experiment 1, an X-ray imaging indicator, a dental X-ray unit Xspot-TS, and a size 2 Digora Optime Imaging Plate were used. The imaging sites included the central incisors, canines, and first molars. Cases with extensive defects, full-crown restorations or prosthetics, periapical lesions, root canal filling, significant eruption anomalies, or crowding were excluded.\u003c/p\u003e\u003cp\u003eThe exposure conditions were set to a tube voltage of 70 kV and a tube current of 6 mA. Exposure times were 0.08, 0.1, 0.16, 0.06, 0.08, and 0.1 seconds for the maxillary incisors, maxillary canines and premolars, maxillary molars, mandibular anterior teeth, mandibular canines and premolars, and mandibular molars, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Using the DIP method, a total of 35 cases were obtained, including 7 central incisors, 12 canines, and 16 first molars. Image composition was also performed as in Experiment 1, generating DIP images from the FIP and BIP. For the control, FIP images were used in place of SIP images.\u003c/p\u003e\u003cp\u003eIn addition, the exposure dose was measured using the RaySafe ThinX (RaySafe, Hov\u0026aring;s, Sweden) as the patient entrance dose (incident air kerma [IKA]) at an exposure time of 0.1 seconds and a focal spot-to-IP distance of 150 mm. The IKA was calculated based on these measurements.\u003c/p\u003e\n\u003ch3\u003eSubjective Evaluation\u003c/h3\u003e\n\u003cp\u003eSubjective evaluations were conducted by seven board-certified dental radiologists in a dimly lit, quiet environment using a 27-inch LCD monitor (BARCO, Brussels, Belgium). To compare and evaluate DIP and FIP images, paired images from the same case were displayed simultaneously (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The order of presentation was randomized using the original software developed in Visual Studio 2019 C#, and the evaluators were blinded to whether images were DIP or FIP.. A dental radiologist who did not participate in the evaluation monitored the brightness, contrast, and magnification, which could not be adjusted by the evaluators. There was no time limit for the evaluation.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe evaluators compared the DIP and FIP images with respect to eight anatomical features (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), including enamel, dentinoenamel junction, alveolar crest, alveolar bone, radix dentis, canalis radices dentis, apex of dental root, and periodontium of dental root. For each feature, one point was awarded to the image judged superior, with a maximum possible score of eight points per image. The subjective evaluation was conducted twice, with a minimal interval of two weeks between sessions.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eList of question items for the subjective evaluation in Experiment 2\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"1\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnamelum\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDentino-enamel junction\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlveolar crest\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlveolar bone\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRadix dentis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCanalis radices dentis\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApex of dental root\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeriodontium of the apex of dental root\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eIn Experiment 1, the normality of each CNR was assessed using the Shapiro-Wilk test. An unpaired t-test was performed when normality was assumed, whereas the Mann-Whitney U test was used when it was not. Additionally, for SWRF, the similarity of the curves in the graph was evaluated [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Experiment 2, the mean scores from the first assessment of each image by the seven evaluators were used for analysis. The normality of the scores was evaluated using the Shapiro-Wilk test. If normality was assumed, a paired t-test was used; otherwise, the Wilcoxon signed-rank test was conducted. The intraclass correlation coefficient (ICC, Class 1) was used to evaluate inter-rater reproducibility, and ICC (Class 2) was used to evaluate intra-rater reliability. Statistical analyses were performed using SPSS Statistics (version 25.0; IBM Corp., Armonk, NY, US) and DATAtab (DATAtab Team, Austria), with the significance level set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eExperiment 1\u003c/h2\u003e\u003cp\u003eEven when the incidence angle of the main X-ray beam was not perpendicular, a significant improvement in CNR was observed in DIP images compared to conventional SIP and FIP images (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). In contrast, no significant difference in CNR was observed between SIP and FIP images. In addition, the spatial resolution (SWRF) curves for DIP, SIP, and FIP images exhibited the same trend across the three methods, and no differences in spatial resolution under different exposure conditions were observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eExperiment 2\u003c/h3\u003e\n\u003cp\u003eAccording to the subjective evaluations of seven board-certified dental radiologists, DIP images received significantly higher scores than FIP images in all anatomical categories (enamelum, dentinoenamel junction, alveolar crest, alveolar bone, radix dentis, canalis radices dentis, apex of dental root, and periodontium of the apex of dental root) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). The effect size (r) was large, at 0.87, indicating that the visibility of DIP images was strongly supported by the evaluators.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn the reproducibility analysis, the mean ICC (1,1), which reflects intra-rater reliability, was 0.66, indicating moderate agreement, whereas the ICC (2,1), which reflects inter-rater agreement, was poor (0.07), suggesting differences in observation trends among evaluators.\u003c/p\u003e\u003cp\u003eThe IKA values at irradiation times of 0.16, 0.1, 0.08, and 0.06 seconds were 1.13, 0.71, 0.56, and 0.42, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient entrance dose (incident air kerma [IAK]) with the diagnostic reference level (DRL) for the clinical trial in Experiment 2\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTooth\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eClinical trial\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDRL\u003c/p\u003e\u003cp\u003e(Adults)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDRL (Children)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eMaxilla\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncisor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCanine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePremolar\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMolar\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eMandible\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncisor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCanine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePremolar\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMolar\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e(mGy)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTo date, DIP intraoral radiography has only been validated under conditions where the main X-ray beam is directed perpendicularly to the IP. The results of study, aimed at clinical trials, showed that even when the irradiation angle varied, DIP images exhibited higher CNR and better visibility than SIP and FIP images. Additionally, no significant differences in SWRF were observed among the three image types, and the spatial resolution of DIP intraoral radiography was maintained compared with conventional methods. These findings suggest that even under when the main X-ray beam is not perpendicular, DIP images offer technical advantages by reducing noise while enhancing structural clarity.\u003c/p\u003e\u003cp\u003eFurthermore, no significant differences in CNR were observed between FIP and SIP images, and their SWRF curves were identical, suggesting that FIP images can serve as a control for DIP images as an alternative to SIP images. Therefore, in the clinical study (Experiment 2), FIP images were used as control images to minimize radiation exposure to the subjects.\u003c/p\u003e\u003cp\u003eAccording to subjective evaluations by dental radiology specialists, DIP images scored significantly higher than FIP images, and the effect size was larger. This is believed to be due to the image quality of DIP images, which reduce noise [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], are consistent with radiologists\u0026rsquo; visual assessment criteria, leading to higher evaluations. These findings suggest that, compared to conventional methods, DIP images offer superior visibility of anatomical structures and are considered useful in clinical diagnosis. However, while the intra-rater agreement ICC (1,1) was moderate (0.66), the inter-rater agreement ICC (2,1) was low (0.07), indicating that image evaluation may be easily influenced by subjective factors. In this image assessment, a dental radiology specialist who did not participate preset the brightness, contrast, and magnification of the monitor for diagnostic suitability, and these settings could not be adjusted by the evaluators. This factor led to varied preferences among evaluators [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], resulting in dispersed evaluations. In the future, standardization of assessment criteria and the introduction of objective indicators for image processing will be necessary.\u003c/p\u003e\u003cp\u003eIn Experiment 2, exposures ranging from 0.42 to 1.13 mGy, which were approximately half the adult diagnostic reference level (DRL) for intraoral X-ray imaging (0.9 to 1.9 mGy), were used (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. This demonstrates its potential to provide stable image quality in pediatric intraoral X-ray imaging. The DIP method has clinical significance because of its potential application in pediatric patients. Based on the laws of Bergoni\u0026eacute; and Tribondeau, children are more sensitive to radiation, making technologies that can minimize radiation exposure while maintaining diagnostic capabilities particularly valuable.\u003c/p\u003e\u003cp\u003eIn recent years, there has been a global increase in dental caries among children, and in the United States, pediatric dental treatments are increasingly being performed on teeth that have already been treated [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Given this situation, IP-based intraoral X-ray imaging [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], which causes less discomfort during insertion into the oral cavity compared to CCD sensors and excels in the observation of fillings at low doses, can be applied to bitewing techniques and is expected to have certain advantages. If the effectiveness of the DIP imaging method is clinically established, it may provide an even lower-dose technique for intraoral X-ray imaging, a modality that has been widely used worldwide.\u003c/p\u003e\u003cp\u003eDIP imaging allows for a shorter X-ray exposure time. For patients who have difficulty maintaining the IP in position owing to body movement, such as the aforementioned children [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], patients with cerebral palsy, or those who exhibit tremors, the application of this method is expected to be beneficial.\u003c/p\u003e\u003cp\u003eRecently, the use of portable X-ray devices has increased. Because portable X-ray units are often handheld during imaging, capturing images under ideal conditions is difficult [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], which may result in motion artifacts or positional errors during exposure. Therefore, by reducing the X-ray exposure time, the DIP method can decrease image blurring and offer the advantage of lowering the radiation dose to unintended areas. Additionally, in situations where panoramic imaging or CT cannot be performed, intraoral X-ray imaging is used as an alternative diagnostic method [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. When extensive imaging is required, the low radiation dose and high diagnostic capability of the DIP method are significant advantages.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eX-ray images taken at non-perpendicular angles showed significantly higher CNR in DIP images compared to SIP and FIP images, while the spatial resolution curves were identical. Under clinical conditions, DIP images, when compared to the conventional method (FIP images), contributed to improved visibility of anatomical structures. This study has also validated the foundational research necessary to apply DIP intraoral radiography in clinical practice and clarified the diagnostic usefulness of DIP imaging in a clinical setting, representing a significant contribution.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of interest\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eThis study was conducted using data for which approval (EP23D017) was obtained from the Ethics Committee of Nihon University School of Dentistry. All procedures were performed in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and the Helsinki Declaration of 1975, as revised in 2008 (5).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003cp\u003eAdditional informed consent was obtained from all patients, and their identifying information was included in this article.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was supported by JSPS KAKENHI under Grant Nos. JP 25K11047, Grant from Dental Research Center, Nihon University School of Dentistry (DRC(B)-2025-20) and Sato Fund, Nihon University School of Dentistry(SATO-2023-20)\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor Contribution StatementDMFR requires that for all submitted papers:\u0026bull;all the authors have made substantive contributions to the article and assume full responsibility for its content; and\u0026bull;all those who have made substantive contributions to the article have been named as authors. The International Committee of Medical Journal Editors recommends the following definition for an author of a work, which we ask our authors to adhere to:Authorship be based on the following 4 criteria [1]:\u0026bull;Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND \u0026bull;Drafting the work or revising it critically for important intellectual content; AND \u0026bull;Final approval of the version to be published; AND \u0026bull;Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Please list below all authors of this work and a brief description of how they each contributed towards your submission:Author nameContributionTatsuhiko SasakiThe author contributed to design of the study, data acquisition, interpretation of the data, and preparation of the initial draft.Tomoyo NomuraThe author contributed to data acquisition, interpretation of the data, and editing draft.Toshihiko AmemiyaThe author contributed to management and coordination responsibility for the research activity planning, provision of study materials, data acquisition, interpretation of the data and editing draft.Mutsumi KishiThe author contributed to data acquisition, interpretation of the data, and editing draft.Ko DezawaThe author contributed to design of the study, data acquisition, interpretation of the data, and editing draft.Kunihiko SawadaThe author contributed to design of the study, data acquisition, interpretation of the data, and editing draft. Ken-ichiro EjimaThe author contributed to design of the study, data acquisition, interpretation of the data, and editing draft. Kazuya HondaThe author contributed to design of the study, data acquisition, interpretation of the data, and editing draft. Yoshinori AraiThe author contributed to management and coordination responsibility for the research activity planning, designing computer program and editing draft. Kunihito MatsumotoThe author designed and directed the study, and contributed to the final version of the manuscript Please continue on further pages if needed. 1 The International Committee of Medical Journal Editors, Roles and Responsibilities of Authors, Contributors, Reviewers, Editors, Publishers, and Owners: Defining the Role of Authors and Contributors, http://www.icmje.org/roles_a.html\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eThe authors would like to thank Editage (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.editage.com\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.editage.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) for the English language editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFarrier SL, Drage NA, Newcombe RG, Hayes SJ, Dummer PMH. A comparative study of image quality and radiation exposure for dental radiographs produced using a charge-coupled device and a phosphor plate system. Int Endod J. 2009;42:900\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1365-2591.2009.01598.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1365-2591.2009.01598.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerkhout E, Sanderink G, van der Stelt P. Digital intra-oral radiography in dentistry. Diagnostic efficacy and dose considerations. Oral Radiol. 2003;19:1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/BF02493286\u003c/span\u003e\u003cspan address=\"10.1007/BF02493286\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWhite SC, Pharoah MJ. Oral radiology: principles and interpretation. 8th ed. St. Louis (MO): Elsevier; 2018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWenzel A, M\u0026oslash;ystad A. Work flow with digital intraoral radiography: a systematic review. Acta Odontol Scand. 2010;68:106\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3109/00016350903514426\u003c/span\u003e\u003cspan address=\"10.3109/00016350903514426\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGon\u0026ccedil;alves A, Wiezel VG, Gon\u0026ccedil;alves M, Hebling J, Sannomiya EK. Patient comfort in periapical examination using digital receptors. Dentomaxillofac Radiol. 2009;38:484\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1259/dmfr/82025587\u003c/span\u003e\u003cspan address=\"10.1259/dmfr/82025587\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWenzel A, Frandsen E, Hintze H. Patient discomfort and cross-infection control in bitewing examination with a storage phosphor plate and a CCD-based sensor. J Dent. 1999;27:243\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0300-5712(98)00063-3\u003c/span\u003e\u003cspan address=\"10.1016/S0300-5712(98)00063-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJuneja S, Dalvi S, Aggarwal R, Sukhija M, Singh S, Bansal S. Assessment of perception of pain with E-speed film, CCD sensor and photostimulable phosphor plates for intraoral radiographs in children using three pain rating scales. Indian J Dent Res. 2024;35:54\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/ijdr.ijdr_78_23\u003c/span\u003e\u003cspan address=\"10.4103/ijdr.ijdr_78_23\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKalathingal SM, Shrout MK, Comer C, Brady C. Rating the extent of surface scratches on photostimulable storage phosphor plates in a dental school environment. Dentomaxillofac Radiol. 2010;39:179\u0026ndash;83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1259/dmfr/28972644\u003c/span\u003e\u003cspan address=\"10.1259/dmfr/28972644\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatanabe K, Imanishi Y, Kato M, Kimoto H, Sekiguchi T, Amemiya T, et al. Preliminary evaluation of dual imaging plate intraoral radiography. J Oral Sci. 2022;64:69\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2334/josnusd.21-0454\u003c/span\u003e\u003cspan address=\"10.2334/josnusd.21-0454\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEuropean Commission. Radiation protection no 136: European guidelines on radiation protection in dental radiology: The safe use of radiographs in dental practice. 2004. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://ec.europa.eu/energy/sites/ener/files/documents/136.pdf\u003c/span\u003e\u003cspan address=\"http://ec.europa.eu/energy/sites/ener/files/documents/136.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 Aug 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsuda N, Tanaka N, Akasaka T, Yabuuchi H, Morishita J. Dose reduction in general radiography for adult patients by use of a dual-side-reading photostimulable phosphor plate in a computed radiography system. Radiol Phys Technol. 2014;7:310\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12194-014-0268-z\u003c/span\u003e\u003cspan address=\"10.1007/s12194-014-0268-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorkman A, Cowen AR. Improved image quality utilizing dual plate computed radiography. Br J Radiol. 1995;68:182\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1259/0007-1285-68-806-182\u003c/span\u003e\u003cspan address=\"10.1259/0007-1285-68-806-182\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMonnin P, Holzer Z, Wolf R, Neitzel U, Vock P, Gudinchet F, et al. An image quality comparison of standard and dual-side read CR systems for pediatric radiology. Med Phys. 2006;33:411\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1118/1.2163392\u003c/span\u003e\u003cspan address=\"10.1118/1.2163392\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNascimento EH, Ga\u0026ecirc;ta-Araujo H. Influence of brightness and contrast adjustments on the diagnosis of proximal caries lesions. Dentomaxillofac Radiol. 2018;47:20180100. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1259/dmfr.20180100\u003c/span\u003e\u003cspan address=\"10.1259/dmfr.20180100\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJapan Network for research and information on medical exposure [J-RIME]. National diagnostic reference level in Japan. (2020) \u0026ndash; Japan DRLs 2025-, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://j-rime.qst.go.jp/report/JapanDRLs2025_ja.pdf\u003c/span\u003e\u003cspan address=\"https://j-rime.qst.go.jp/report/JapanDRLs2025_ja.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 Aug 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKazeminia M, Abdi A, Shohaimi S, Jalali R, Vaisi-Raygani A, Salari N, et al. Dental caries in primary and permanent teeth in children worldwide, 1995 to 2019: a systematic review and meta-analysis. Head Face Med. 2020;16:22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s13005-020-00237-z\u003c/span\u003e\u003cspan address=\"10.1186/s13005-020-00237-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDye BA, Hsu KL, Afful J. Prevalence and measurement of dental caries in young children. Pediatr Dent. 2015;37:200\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKamburoglu K, Kolsuz E, Murat S, Yuksel S, Ozen T. Proximal caries detection accuracy using intraoral bitewing radiography, extraoral bitewing radiography and panoramic radiography. Dentomaxillofac Radiol. 2012;41:450\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1259/dmfr/30526171\u003c/span\u003e\u003cspan address=\"10.1259/dmfr/30526171\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAydin KC, Demirel O, \u0026Ouml;zcan M. Comparison of two digital intraoral radiography imaging systems as a function of contrast resolution and exposure time. Minerva Stomatol. 2020;69:148\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.23736/S0026-4970.19.04286-9\u003c/span\u003e\u003cspan address=\"10.23736/S0026-4970.19.04286-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBerkhout WE, Suomalainen A, Br\u0026uuml;llmann D, Jacobs R, Horner K, Stamatakis HC. Justification and good practice in using handheld portable dental X-ray equipment: a position paper prepared by the European Academy of DentoMaxilloFacial Radiology (EADMFR). Dentomaxillofac Radiol. 2015;44:20140343. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1259/dmfr.20140343\u003c/span\u003e\u003cspan address=\"10.1259/dmfr.20140343\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDave M, Coulthard P, Patel N, Seoudi N, Horner K. Letter to the editor: Use of dental radiography in the COVID-19 pandemic. J Dent Res. 2020;99:1112. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0022034520923323\u003c/span\u003e\u003cspan address=\"10.1177/0022034520923323\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"contrast-to-noise ratio, dual imaging plate, intraoral radiography, spatial resolution","lastPublishedDoi":"10.21203/rs.3.rs-7542071/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7542071/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eTo investigate the clinical applicability of dual-imaging plate (DIP) intraoral radiography by evaluating image quality and diagnostic usefulness under varying X-ray beam angles and exposure conditions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn Experiment 1, aluminum step wedges and rectangular wave charts were used to evaluate the impact of X-ray beam angle and exposure dose on the contrast-to-noise ratio (CNR) and square wave response function (SWRF) across DIP, front imaging plate (FIP), and single imaging plate (SIP) images. In Experiment 2, intraoral radiographs were obtained from 19 adult volunteers, and the diagnostic utility of DIP images was subjectively evaluated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eDespite angled-beam irradiation and elevated doses, DIP images exhibited a significantly higher CNR than SIP and FIP images, with no significant difference in SWRF curves. In clinical cases, DIP images were consistently rated as superior to FIP images for anatomical structure visibility, with large effect sizes. However, inter-rater agreement was poor, possibly due to individual contrast preferences.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe DIP method offers enhanced image contrast without sacrificing spatial resolution, even at clinically realistic irradiation angles and dose levels, suggesting its clinical utility for reducing radiation exposure while preserving diagnostic accuracy.\u003c/p\u003e","manuscriptTitle":"Fundamental and Clinical Evaluation of Dual Imaging Plate (DIP) Intraoral Radiography","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-30 16:36:42","doi":"10.21203/rs.3.rs-7542071/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"51c3e221-32cc-429c-8c18-b4a7dccd6c65","owner":[],"postedDate":"September 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-06T11:08:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-30 16:36:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7542071","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7542071","identity":"rs-7542071","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}