RADIOGRAPHSRADIOGRAPHSININ

THE DIAGNOSISTHE DIAGNOSISOFOF

PERIODONTAL DISEASEPERIODONTAL DISEASE

RADIOGRAPHSRADIOGRAPHS

Diagnosis of periodontal diseaseDiagnosis of periodontal disease

Determination of prognosis Determination of prognosis

Evaluation of outcome of treatment plan.Evaluation of outcome of treatment plan.

YETYET

Radiograph is an Radiograph is an adjunct to clinicaladjunct to clinical examination but not a substitute for it.examination but not a substitute for it.

RADIOGRAPHRADIOGRAPHADJUNCT ADJUNCT NOT NOT A SUBSTITUTEA SUBSTITUTE

Radiograph reveals alterations in calcified Radiograph reveals alterations in calcified tissue tissue

it does not reveal current cellular activity it does not reveal current cellular activity

BUTBUT

shows the effects of past cellular shows the effects of past cellular experience on the bone & roots.experience on the bone & roots.

NORMAL INTERDENTAL SEPTANORMAL INTERDENTAL SEPTA

In normal radiographs a thin layer of In normal radiographs a thin layer of opaque cortical bone often covers alveolar opaque cortical bone often covers alveolar crest.crest.

The height of the crest lies at a level 1-1.5 The height of the crest lies at a level 1-1.5 mm below CEJ of adjacent teeth.mm below CEJ of adjacent teeth.

Between posterior teeth alveolar crest is Between posterior teeth alveolar crest is parallel to a line connecting adjacent CEJparallel to a line connecting adjacent CEJ

NORMAL INTERDENTAL SEPTANORMAL INTERDENTAL SEPTA

Alveolar crest in anterior teeth is pointed Alveolar crest in anterior teeth is pointed A well mineralized cortical outline of A well mineralized cortical outline of alveolar crest indicates absence of alveolar crest indicates absence of periodontitis activity.periodontitis activity.Alveolar crest is continuous with the Alveolar crest is continuous with the lamina dura lamina dura Radiographic changes in periodontal Radiographic changes in periodontal disease is based mainly on the disease is based mainly on the appearance of interdental septa appearance of interdental septa

PRICHARD’S 4 CRITERIA FOR PRICHARD’S 4 CRITERIA FOR RG RG WITH GOOD ANGULATIONWITH GOOD ANGULATION

The radiograph should show the tips of The radiograph should show the tips of molar cusps with little or none of the molar cusps with little or none of the occlusal surface showing.occlusal surface showing.

Enamel caps & pulp chambers should be Enamel caps & pulp chambers should be distinct.distinct.

Inter proximal spaces should be open.Inter proximal spaces should be open.

Proximal contacts should not overlap Proximal contacts should not overlap unless teeth are out of line anatomically.unless teeth are out of line anatomically.

WHAT TO CHECK IN A WHAT TO CHECK IN A RADIOGRAPHRADIOGRAPH

Amount of bone loss.Amount of bone loss.Condition of alveolar crests.Condition of alveolar crests.Bone loss in furcation areas.Bone loss in furcation areas.Width of PDL space.Width of PDL space.Calculus & overextended restorationsCalculus & overextended restorationsRoot length & morphology & crown to Root length & morphology & crown to root ratio.root ratio.Peri apical lesionsPeri apical lesions

BONE DESTRUCTIONBONE DESTRUCTIONPERIODONTAL DISEASEPERIODONTAL DISEASE

Radiograph does not reveal minor Radiograph does not reveal minor destructive changes in bone destructive changes in bone

So slight radiographic changes means the So slight radiographic changes means the disease has progressed beyond its earliest disease has progressed beyond its earliest stages.stages.

Difference between clinical & radiographic Difference between clinical & radiographic alveolar crest is 0-1.6 mm.alveolar crest is 0-1.6 mm.

AMOUNT OF BONE LOSSAMOUNT OF BONE LOSS

Radiograph is an indirect method for Radiograph is an indirect method for determining the amount of bone loss. determining the amount of bone loss.

WHYWHY

It shows the amount of bone remaining It shows the amount of bone remaining rather than amount lost.rather than amount lost.

The amount of bone loss is difference The amount of bone loss is difference between the physiologic bone level & the between the physiologic bone level & the height of remaining bone.height of remaining bone.

PATTERN OF BONE PATTERN OF BONE DESTRUCTIONDESTRUCTION

In periodontal disease, the interdental In periodontal disease, the interdental septa undergo changes that affect the septa undergo changes that affect the

Lamina duraLamina dura

Crestal radiodensityCrestal radiodensity

Size & shape of medullary spacesSize & shape of medullary spaces

Height & contour of the boneHeight & contour of the bone

PATTERN OF BONE PATTERN OF BONE DESTRUCTIONDESTRUCTION

Horizontal bone loss Horizontal bone loss

Vertical bone loss Vertical bone loss

Interdental Craters Interdental Craters

Changes in the facial & lingual surfaces of Changes in the facial & lingual surfaces of bone cannot be seen in the radiograph bone cannot be seen in the radiograph because this can be obscured by dense because this can be obscured by dense root structure.root structure.

SEQUENCE OF CHANGESSEQUENCE OF CHANGESPERIODONTITISPERIODONTITIS

Fuzziness & a break in the continuity of Fuzziness & a break in the continuity of the lamina dura at interdental septumthe lamina dura at interdental septumA wedge shaped radiolucent area at crest A wedge shaped radiolucent area at crest of septal bone. of septal bone. Destruction extends across the crest of Destruction extends across the crest of inter dental septum & the height is inter dental septum & the height is reduced reduced The height of the inter dental septum is The height of the inter dental septum is progressively reduced progressively reduced

FURCATIONFURCATION

The slightest change in the furcation area The slightest change in the furcation area should be examined clinically, especially if should be examined clinically, especially if there is bone loss on adjacent roots.there is bone loss on adjacent roots.

Diminished radiodensity in the furcation area in Diminished radiodensity in the furcation area in which outlines of bony trabeculae are visible which outlines of bony trabeculae are visible suggests furcation involvement suggests furcation involvement

Whenever there is marked bone loss in Whenever there is marked bone loss in relation to a single molar root, it may be relation to a single molar root, it may be assumed that the furcation is also involved.assumed that the furcation is also involved.

Radiographic appearances of the Radiographic appearances of the periodontal abscessperiodontal abscess

discrete area of radiolucency along the discrete area of radiolucency along the lateral aspect of the root lateral aspect of the root

BUT NOT SEEN ALWAYSBUT NOT SEEN ALWAYS

Stage of the lesion Stage of the lesion

Extent of bone destruction & morphology Extent of bone destruction & morphology of bony changes of bony changes

Location of the abscess Location of the abscess

LJPLJP

Bone loss in the incisors & first molarsBone loss in the incisors & first molars

Bilateral , angular defects, arclike Bilateral , angular defects, arclike destructive patterns.destructive patterns.

Bone loss becomes generalized as the Bone loss becomes generalized as the disease progresses.disease progresses.

TFOTFO

TFO produces radiographic changes in:TFO produces radiographic changes in:– lamina duralamina dura– Morphology of the alveolar crestMorphology of the alveolar crest– Width of the PDL space andWidth of the PDL space and– Density of the surrounding cancellous boneDensity of the surrounding cancellous bone

TFOTFO

Radiographic signs of TFO may include Radiographic signs of TFO may include the following:the following:

Increased width of the periodontal space,Increased width of the periodontal space,

thickening of the lamina dura along the thickening of the lamina dura along the lateral aspect of the root, in the apical lateral aspect of the root, in the apical region, and in bifurcation areas.region, and in bifurcation areas.

A "vertical" rather than "horizontal" A "vertical" rather than "horizontal" destruction of the inter dental septumdestruction of the inter dental septum

Skeletal disturbances Skeletal disturbances manifested in jawsmanifested in jaws

Osteitis Fibrosa CysticaOsteitis Fibrosa Cystica

Paget’s disease Paget’s disease

Fibrous Dysplasia Fibrous Dysplasia

Langerhan’s cell histiocytosis Langerhan’s cell histiocytosis

Multiple Myeloma Multiple Myeloma

Osteopetrosis/Marble bone disease Osteopetrosis/Marble bone disease

Scleroderma Scleroderma

OSTEITIS FIBROSA CYSTICAOSTEITIS FIBROSA CYSTICA

Seen in advanced hyperparathyroidism. Seen in advanced hyperparathyroidism. Results in osteoclastic resorption of bone Results in osteoclastic resorption of bone with fibrous replacement & hemorrhage with fibrous replacement & hemorrhage with hemosiderin deposition.with hemosiderin deposition.

Brown tumor→ Diffuse, granular, mottling, Brown tumor→ Diffuse, granular, mottling, scattered cyst like radiolucent areas scattered cyst like radiolucent areas throughout the jaw & generalized throughout the jaw & generalized disappearance of lamina dura.disappearance of lamina dura.

PAGETS DISEASEPAGETS DISEASE

Normal trabecular pattern is replaced by a Normal trabecular pattern is replaced by a hazy, diffuse meshwork & generalized loss hazy, diffuse meshwork & generalized loss of lamina dura.of lamina dura.

FIBROUS DYSPLASIAFIBROUS DYSPLASIA

Ground glass appearance of bone Ground glass appearance of bone with obliteration of lamina dura.with obliteration of lamina dura.

HISTIOCYTOSISHISTIOCYTOSIS

Results from disturbances in immuno Results from disturbances in immuno regulation but changes seen are multiple regulation but changes seen are multiple radiolucent areas, which may be unrelated radiolucent areas, which may be unrelated to teeth or loss of tooth supporting bone.to teeth or loss of tooth supporting bone.

MULTIPLE MYELOMAMULTIPLE MYELOMA

Numerous radiolucent areas in jaws.Numerous radiolucent areas in jaws.

OSTEOPETROSISOSTEOPETROSIS

diffuse radio opacity of jaws which diffuse radio opacity of jaws which obscure the roots of teeth.obscure the roots of teeth.

SCLERODERMASCLERODERMA

periodontal ligament is uniformly periodontal ligament is uniformly widened at the expense of the widened at the expense of the surrounding alveolar bone.surrounding alveolar bone.