OralGPT-Plus: Learning to Use Visual Tools via Reinforcement Learning for Panoramic X-ray Analysis

Orthopantomograms (OPGs) are the standard panoramic radiograph in dentistry, used for full-arch screening across multiple diagnostic tasks. While Vision Language Models (VLMs) now allow multi-task OPG analysis through natural language, they underperform task-specific models on most individual tasks. Agentic systems that orchestrate specialized tools offer a path to both versatility and accuracy, this approach remains unexplored in the field of dental imaging. To address this gap, we propose OPGAgent, a multi-tool agentic system for auditable OPG interpretation. OPGAgent coordinates specialized perception modules with a consensus mechanism through three components: (1) a Hierarchical Evidence Gathering module that decomposes OPG analysis into global, quadrant, and tooth-level phases with dynamically invoking tools, (2) a Specialized Toolbox encapsulating spatial, detection, utility, and expert zoos, and (3) a Consensus Subagent that resolves conflicts through anatomical constraints. We further propose OPG-Bench, a structured-report protocol based on (Location, Field, Value) triples derived from real clinical reports, which enables a comprehensive review of findings and hallucinations, extending beyond the limitations of VQA indicators. On our OPG-Bench and the public MMOral-OPG benchmark, OPGAgent outperforms current dental VLMs and medical agent frameworks across both structured-report and VQA evaluation. Code will be released upon acceptance.

Vision-language models (VLMs) remain largely unreliable on panoramic dental radiographs and can rely on learned anatomical priors rather than evidence in the image. This is particularly problematic for tooth localization and spatial reasoning, and fine-tuned dental VLMs can retain the same spatial biases. We present AgenTeeth, a model-agnostic, tool-augmented framework that grounds frozen VLMs using seven specialized dental vision experts. A question-aware orchestrator selects the relevant tools, whose detections are mapped to FDI tooth numbers or anatomical regions and returned as structured findings together with annotated image overlays. A fresh synthesis call then answers the question using this evidence, without fine-tuning the underlying VLM. On MMOral-OPG-Bench, AgenTeeth improves four backbone VLMs by 12.9-23.0 percentage points over their baselines. Our strongest configuration reaches 65.66% on open-ended VQA, compared with 45.35% for OralGPT-Plus. The advantage also holds at matched scale: a frozen Qwen2.5-VL-7B-Instruct with AgenTeeth reaches 48.11%, exceeding OralGPT-Plus built on the same backbone after supervised fine-tuning and reinforcement learning for tool use. We release the framework, all seven expert models, and a dentist-annotated dataset for alveolar bone-loss detection in panoramic radiographs.

Accurate evaluation of multimodal large language models (MLLMs) in dental panoramic radiography (orthopantomogram, OPG) is limited by the lack of fine-grained, clinically reliable benchmarks that reflect expert interpretation. This work introduces PanDent, a large-scale, clinically grounded OPG benchmark built upon fine-grained, expert-validated tooth-level annotations. The dataset comprises 9,524 high-quality OPGs, each associated with comprehensive structured annotations produced by experienced dentists and further validated by an oral and maxillofacial radiologist, providing clinically reliable supervision for tooth-level diagnosis and reasoning. Clinically consistent radiology reports are constructed from expert-validated findings using clinician-defined reporting logic, establishing explicit correspondence between structured clinical evidence and free-text descriptions. This design enables evaluation of whether MLLMs generate reports that are not only linguistically coherent but also clinically consistent with expert-validated tooth-level findings. Experiments are conducted on diverse MLLMs, including state-of-the-art (SOTA) proprietary models, general-domain open-source models, and medical-specific models. Results show that current MLLMs can generate fluent reports, yet fail to produce clinically consistent descriptions, exhibiting substantial errors in fine-grained localization and tooth-level diagnosis. Fine-tuning on PanDent significantly improves structure-language consistency, substantially enhancing visual localization accuracy and diagnostic correctness, and bringing model outputs closer to expert dental interpretation. These results establish PanDent as a rigorous benchmark for evaluating tooth-level clinical reasoning in MLLMs and a valuable resource for clinically grounded dental AI.