OBJECTIVE: Bitewing radiographs are essential for caries and marginal bone diagnostics. Diagnostic quality depends on operator technique. This study evaluated patient-level diagnostic quality of sensor-based bitewing examinations to identify operator-related deficiencies. MATERIAL AND METHODS: In this retrospective, cross-sectional study, 962 bitewing examinations from 31 Swedish public dental practices were randomly selected and evaluated for caries and marginal bone level diagnostic image quality, according to European guidelines. Available panoramic/periapical images acquired in connection with the bitewing examinations were included in a second quality assessment. Recorded deficiencies included sensor placement, collimation artifacts, and insufficient biting on the sensor holder. Associations between diagnostic quality and sensor size, number of images, age group, jaw, side, and sex were analyzed using χ2 test and logistic regression. Three calibrated examiners performed the evaluations. RESULTS: The requirements were fulfilled in 5% and acceptable in 43% of the bitewing examinations, increasing to 7% and 45% when including panoramic/periapical images. Quality was better with larger sensor sizes (p < 0.001), more exposures (p < 0.001), panoramic/periapical images (p < 0.001), age ≥12 years (p < 0.001), and in the maxilla (p < 0.001). Common errors were incorrect sensor placement (94%), collimation artifacts (57%), and insufficient biting (15%). No differences were found between side or sex. Inter-observer agreement was substantial (Fleiss' kappa = 0.61; Gwet's AC1 = 0.62); intra-observer agreement was almost perfect (Cohen's kappa = 0.88). CONCLUSIONS: Most bitewing examinations, especially in children, fail to meet diagnostic requirements due to deficient operator performance and quality assessment. Panoramic/periapical images may improve diagnostic quality but should not replace optimized bitewing examinations. Targeted continuing education is required.
Olsson et al. (2026) studied this question.