Associations Between Eye-Movement Patterns, Pupil Dynamics, and the Interpretation of a Single Mixed-Dentition Panoramic Radiograph Among Dental Students: An Exploratory Eye-Tracking Study

Eye tracking can provide quantitative indices of visual exploration and cognitive processing during radiographic image interpretation. This study examined eye-movement patterns and pupil dynamics and their associations with task performance while fifth-year dental students interpreted a single mixed-dentition panoramic radiograph under free-viewing conditions. Task performance was defined as the number of correctly identified pre-specified items (three radiographic findings plus two interpretive items: dental age estimation and the presence/absence of congenital anomalies). Eye-movement patterns were classified into four groups: clockwise (R, 29.6%), counterclockwise (L, 44.4%), saccadic (S, 16.7%), and concentrated (C, 9.3%). Clockwise scan paths were associated with higher task scores and more globally distributed fixations than other patterns (<i>p</i> < 0.001). Linear mixed-effects modeling suggested that task scores increased up to 120 s of viewing time, whereas longer viewing times were not associated with further improvements. Furthermore, ordinal logistic regression analysis revealed that higher task scores were significantly associated with a smaller mean pupil area across the entire viewing time, combined with a larger pupil area specifically during fixations, suggesting more selective allocation of cognitive resources. These findings indicate associations between global scan structure, time allocation, pupil dynamics, and task performance in this single-image setting. Generalization to overall diagnostic competence or other radiographs requires replication using multiple panoramic images and a broader range of verified findings.