Radiographic aids in periodontal disease diagnosis part I

Copyright ©2021 Periowiki.com
Radiographic aids in periodontal
disease diagnosis – part I
1

HISTORY
2
 Radiographs have been used in medicine since
1895 when Wilhelm Conrad Rontgen discovered
the roentgen rays.
 One year later, the radiographic technique was
used by Morton in the diagnosis of periodontal
disease.
 With the Introduction of the concept of focal
infection, radiographs became commonly
accepted in dentistry.

In periodontics, radiographs have
mainly been used to assess?
3
 Loss and destruction of alveolar hone.
 To confirm a clinical diagnosis of trauma from
occlusion.
Niklous P. Lang and Roger W Hill. Radiographs in periodontics. J Clin Periodontol
1977;4:16-28.

Clinical periodontal findings not captured on
radiographs are:
4
 Gingival redness
 Gingival swelling
 Gingival bleeding
 Gingival recession
 Gingival enlargements
 Bleeding on probing
 Probing pocket depth
 Tooth mobility
 Suppuration
Anuja Muley" Advanced Diagnostic Imaging in Periodontal Diseases: A Review"
IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), vol. 18, no. 5,
2019, pp 55-70.

List of detectable features of interest
on radiographs:
Anuja Muley" Advanced Diagnostic Imaging in Periodontal Diseases: A Review" IOSR
Journal of Dental and Medical Sciences (IOSR-JDMS), vol. 18, no. 5, 2019, pp 55-70.
5
Bone levels Open interproximal contacts
,which may be sites for food
impaction
Root canal filllings
Bone loss-horizontal
-angular(vertical)
Root length and shape(s)
embedded in alveolar bone,
root resorption
Perapical periodontitis, cysts,
granulomas
Intra(infra)-bony defects Widened periodontal
ligament space
position of the maxillary sinus
in relation to periodontal
deformity
Furcation radiolucencies root caries Impacted third molars
Local irritating factors-
calculus -radio-opaque
restorative margins,
overhang
Root canal fillings
Retained & fractured roots
Cemental tears
Endodontic mishaps Root
morphologies/topographies
and crown to root ratio
Cysts/tumors
Developmental anamolies

I) INTRODUCTION
1) Radiograph is an adjunct to the clinical
examination, not a
substitute for it.
2) Radiograph is a valuable aid in:-
- diagnosis of periodontal disease
- determination of prognosis
- evaluation of the outcome of treatment
6 Copyright ©2021 Periowiki.com

I) INTRODUCTION
3) Radiograph reveals:-
- calcified tissue alterations
- effects of past cellular experience on the
bone and roots
4) Radiograph does not reveal:-
- current cellular activity

Classification of Oral radiography
8

II) NORMAL INTERDENTAL
SEPTA
Crest of interdental bone normally
parallel to a line drawn between
the cementoenamel junction of
adjacent teeth (arrow).
Note also the radiopaque lamina
dura around the roots and
interdental bone.
When there is a difference in the
level of the CEJs, the crest of the
interdental bone appears

SEPTA
1) Presents a thin, radiopaque border that is
adjacent to the periodontal ligament and at
alveolar crest, referred to as the lamina dura.
2) Lamina dura represents the bone surface lining
the tooth socket
3) Radiographically appears as a continuous white
line, but in reality it is perforated by:-
- blood vessels, lymphatics and nerves

SEPTA
6) The width and shape of the interdental bone
and the angle
of the crest normally vary according to the:-
- convexity of the proximal tooth surfaces
- level of the cementoenamel junction (CEJ)
of the
approximating teeth.
7) If proximal tooth surfaces are prominently
convex, then
interdental septum is wider anteroposteriorly
compared to
teeth with relatively flat proximal surfaces.

Prichard’s 4 criteria
To determine adequate angulation of periapical
radiographs:
1. The radiographs should show the tips of molar
cusps with little or none of the occlusal surface
showing.
2. Enamel caps and pulp chambers should be
distinct.
3. Interproximal spaces should be open.
12

III) DISTORTIONS PRODUCED BY
VARIATIONS IN RADIOGRAPHIC
TECHNIQUE
Alterations in:-
exposure time,
development
time,
type of film and
x ray
angulation
Bone level,
Bone destruction
pattern,
PDL space width,
Marginal contour of
interdental septum
1.

TECHNIQUE
2. Therefore, standardized reproducible techniques
are required to obtain reliable radiographs for pre-
treatment and post-treatment comparisons.

TECHNIQUE
3. Grid:- calibrated in millimeters
-Helpful for comparing bone levels in radiographs
taken under similar conditions.

TECHNIQUE
4. Angulation
Long-cone paralleling technique – projects the most
realistic image
of the level of the
alveolar bone.

TECHNIQUE
4. Angulation
Bisection-of-the-angle technique – Increases the
projection
- makes the bone margin appear closer to the
crown, the facial
margin more than the lingual margin, creating the
illusion
that the lingual bone margin has shifted apically.

TECHNIQUE
4. Angulation
Long-cone paralleling
technique
Bisection-of-the-angle
technique
Knotted wire = lingual margin
Smooth wire = facial margin
Knotted wire = lingual margin
Smooth wire = facial margin

Transition from the bisecting-angle to the
long-cone technique in periodontics
19
 Superimposition and distortion of tooth-bone relationships
could hereby be diminished (Patur & Glickman 1962, Regan &
Mitchell 1963).
 Projection of the zygomatic process onto the buccal
roots of the upper molars is eliminated (Fitzgerald 1947b).
 If the film is not placed parallel to the object, the parts of
the object located at the longest distance from the film will
be distorted (Richards 1949, 1961, Updegrave 1951).
 Increased distance between the X-ray source and tbe
object will improve the quality of the picture because of
less divergent rays (Richards 1949, Patur 1960).

TECHNIQUE
4. Angulation
Long cone paralleling technique:- if the cone is
mesially or distally shifted without changing the
horizontal plane, then the x-rays are projected
obliquely resulting in:-
radiographic changes in the:-
- Interdental bone shape
- PDL space width
- Lamina dura appearance

Technical aspects of intraoral
radiography.
21
a) Radiograph showing lower contrast and
density
at 2-min developing time as compared
with a lO-min developing time.
b) Using old developer results in a fuzzy
and
washed out image.
c) Influence of kilovoltage on the quality of
the
radiograph. Lower kilovoltage (40 KV)
results in
an image of higher contrast and density

Technical aspects of intraoral
radiography.
22
Influence of exposure
time as radiographic
image.
Too high exposure time
results in a too dense
image with high
contrast resulting in:
"burn out" of the
interproximal alveolar
crest.

TECHNIQUE
Periapical radiograph
Bitewing radiograph
23

TECHNIQUE
Periapical radiograph –
clearly underestimates the amount
of bone loss.
Bitewing radiograph –
Because of appropriate projection
geometry, the alveolar crest height
is accurately depicted.
24

IV) BONE DESTRUCTION IN PERIO-
DONTAL DISEASE
1) Radiograph does not reveal minor destructive
changes in bone.
2) Therefore, slight radiographic changes in the
periodontal tissues mean that the disease has
progressed beyond its earliest stages.
3) The earliest signs of periodontal disease must
be detected clinically.

DONTAL DISEASE
A) BONE LOSS
1. Amount
2. Distribution
B) PATTERN OF BONE
DESTRUCTION

DONTAL DISEASE
A) BONE LOSS – The difference between the alveolar
crest height and the radiographic appearance ranges from
0mm to 1.6mm, mostly accounted for by x-ray
angulation.
1. Amount –
i) For determining the amount of bone loss in
periodontal disease, radiograph is an
indirect method.

DONTAL DISEASE
A) BONE LOSS –
1. Amount –
ii) The amount of bone loss is estimated to be the
difference between the physiologic bone level
of the patient and the height of the remaining
bone.

DONTAL DISEASE
A) BONE LOSS –
1. Amount –
iii) The distance from the CEJ to the alveolar
crest seems to be of 2mm, this distance may
be greater in the older patients (According
to most studies conducted in adolescents).

DONTAL DISEASE
A) BONE LOSS-
2. Distribution-
i) The distribution of bone loss is an important
diagnostic sign.
ii) It points to the location of destructive local
factors in different areas of the mouth and in
relation to different surfaces of the same tooth.

DONTAL DISEASE
B) PATTERN OF BONE DESTRUCTION-
1) In periodontal disease, the interdental septa
undergo changes that affect:-
- lamina dura
- crestal radiodensity
- medullary space size and shape
- bone height and contour.

DONTAL DISEASE
2) Interdental septa changes may present as:-
- horizontal bone loss
- angular or vertical bone loss

DONTAL DISEASE
3) A radiograph does not reveal :-
i) Does not reveal facial and lingual bone surface extent of
involvement.
ii) Bone destruction of facial & lingual surfaces is obscured
by the dense root structure.

DONTAL DISEASE
3) iii) Angular bone loss on mandibular molar is partially
obscured by dense mylohyoid ridge.
34

DONTAL DISEASE
4) Craterlike interdental defects:-
i)A radiograph does not indicate its internal morphology or
depth.
ii)Dense cortical facial and lingual plates of interdental bone
obscure destruction of the intervening cancellous bone. Thus a
deep craterlike defect between the facial and lingual plates might
not be depicted on conventional radiographs.

DONTAL DISEASE
4) Craterlike interdental defects:-
iii) To record destruction of the interproximal cancellous bone
radiographically, the cortical bone must be involved.
iv) A reduction of only 0.5 to 1.0 mm in the thickness of the
cortical plate is sufficient to permit radiographic
visualization of the destruction of the inner cancellous
trabeculae.

DONTAL DISEASE
5) Troughlike defect:-
i)Interdental lesion that extends to the
facial and ligual surfaces in a
troughlike manner.
ii)Could be difficult to appreciate
radiographically.

DONTAL DISEASE
6) One interconnecting osseous lesion:-
i) Formed by two adjacent interdental lesions connecting
on the radicular surface
ii) Along with clinical probing of these lesions, the use of
a radiopaque pointer placed in these radicular defects
will demonstrate the extent of the bone loss.

DONTAL DISEASE
6) One interconnecting osseous lesion

DONTAL DISEASE
7) Gutta percha packed around the teeth increases the
usefulness of the radiograph for detecting the
morphologic changes of osseous craters and
involvement of the facial and lingual surfaces.
40

V)RADIOGRAPHIC APPEARANCE
OF PERIODONTAL DISEASE
A) Periodontitis
1) Fuzziness and a break in the
continuity of the lamina dura:-
-Earliest radiographic change
in periodontitis.
-Presence of an intact crestal
lamina dura may be an indicator
of periodontal health, whereas its
absence lacks diagnostic
relevance.
2) A wedge- shaped
radiolucent area
-PDL space widening
- Apex area is pointed
in the direction of the
root, this is produced
by resorption of the
bone of the lateral
aspect of the
interdental septum.
3) Fingerlike
radiolucent projections
- From the crest into
the interdental septum
indicate extension of
destructive processes.
4)
Severe
bone
loss

B) Interdental Craters
1) Seen as irregular areas of reduced radiopacity on the
alveolar bone crests.
2) Are not sharply demarcated from the rest of the bone,
with which they blend gradually.
3) Radiographs do not accurately depict the morphology
or depth of interdental craters, which sometimes appear
as vertical defects.

C) Furcation Involvement
1) As a general rule, bone loss is always greater than it
appears in the radiograph.
2) Variations in the radiographic technique may obscure
the presence and extent of furcation involvement. A
tooth may present marked bifurcation involvement
in one film but appear uninvolved in another.
3) Radiographs should be taken at different angles to reduce
the risk of missing furcation involvement.

1) As a general rule, bone loss is always greater than it
appears in the radiograph.
2) Variations in the radiographic technique may obscure
the presence and extent of furcation involvement. A
tooth may present marked bifurcation involvement
in one film but appear uninvolved in another.
3) Radiographs should be taken at different angles to reduce
the risk of missing furcation involvement.

4) furcation involvement
indicated by:-
triangular radiolucency.
or
by slight thickening of
the periodontal space in
furcation area.
45

5) To assist in the radiographic detection of furcation
involvement, the following diognostic criteria suggested:
i) The slightest radiographic change in the furcation area
should be investigated clinically, especially if there is
bone loss on adjacent roots.
ii) Diminished radiodensity in the furcation area in which
outlines of bony trabeculae are visible suggests
furcation involvement.
iii) Whenever there is marked bone loss in relation to a single molar root, it
may be assumed that the furcation is also involved.

D) Periodontal Abscess
1) Appears as a discrete area of radiolucency along the
lateral aspect of the root.
Right central incisor

D) Periodontal Abscess
2) However, the radiographic picture is often not typical
because of many variables, such as following:
i) Stage of lesion ii) The extent of bone
destruction and the
morphologic changes of the
bone
iii) The location of the
abscess
In the early stages the acute
periodontal abscess is extremely
painful but presents
no radiographic changes
Lesions in the soft tissue wall of a
periodontal pocket are less likely
to produce radiographic changes
than those deep in the supporting
tissues.
Abscesses on the facial or lingual
surface are obsured by the
radiopacity of the root
Interproximal lesions are more
likely to be visualized
radiographically .

E) Clinical Probing
1) Radiographs taken with periodontal probes or other
indicators (eg – Hirschfeld pointers) placed into the
anesthesized pocket show true extent of the bone lesion.
2) The use of radiopaque indicators is an efficient
diagnostic aid for the clinician to better visualize every
aspect of the defect.

E) Clinical Probing
This view does not The radiograph of same
show facial bone loss maxillary cuspid with
with maxillary gutta percha points
cuspid placed in the facial
pocket to indicate bone loss

F) Localized Aggressive Periodontitis
Characterized by the a combination of the following
radiographic features:
1. Bone loss may occur initially in the maxillary and
mandibular incisors and/or first molar areas, usually
bilaterally and results in vertical, arclike destuctive
patterns.
2. Loss of alveolar bone may become generalized as the
disease progresses but remains less pronounced in the
premolar areas.
51

G) Trauma from Occlusion
1) TFO can produce radiographically detectable changes
in the:-
- lamina dura
- morphology of the alveolar crest
- width of the PDL space
- density of the surrounding cancellous bone.

2) Traumatic lesions manifest more clearly in faciolingual
aspects, because mesiodistally the tooth has added
stability provided by the contact areas with adjacent teeth.
Therefore, slightest variations in the
proximal surfaces may indicate greater changes in the
facial and lingual aspects.

3) The initial phase of TFO:-
Radiographically:-
- Widened periodontal space
- Increased density of surrounding bone caused by new
bone formation in response to increased occlusal forces.

4) The repair phase of TFO:-
- Radiographically, is manifested by a widening of the
PDL space, which may be generalized or localized.

5) More advanced traumatic lesions:-
In terminal stages, these lesions extend around the root
apex, producing a wide, radiolucent periapical image
(cavernous lesions).
6) Although TFO produces many areas of root resorption,
these areas usually of a magnitude insufficient to be
detected radiographically.

7) The radiographic changes as stated to be associated with
TFO, are not pathognomonic of TFO and must be
interpreted in combination with clinical findings,
particularly tooth mobility, presence of wear facets,
pocket depth and analysis of occlusal contacts and habits.

a) Loss of continuity of the
lamina dura (arrows)
associated with coronal and
apical widening of the
periodontal membrane
space.
b) Widening of the periodontal
memhrane space and root
fractures as a result of
heavy bruxism.
c) Root resorption following
rapid orthodontic movement.
d) Hypercementosis associated
with trauma from occlusion
(S. P. Ramfjord, University of
Michigan, Ann Arbor, USA).

VI) ADDITIONAL RADIOGRAPHIC
CRITERIA
1. Radiopaque horizontal line across the roots:-
Arrows indicate the horizontal
line which demarcates the
portion of the root where the
labial or lingual bony plate
has been partially or completely
destroyed from the remaining
bone supported portion.

CRITERIA
2. Vessel canals in the alveolar bone:-
-Vessel canals appear as linear and
circular radiolucent areas.
-These canals indicate the course
of the vascular supply of bone and
are normal radiographic findings.
-Since they are so prominent,
particularly in the mandibular
anterior region, that they might be
confused with radiolucency resulting
from periodontal disease.
60

CRITERIA
3. Differentiation between treated and untreated periodontal
disease:-
- Clinical examination is the basic determinant
- However, radiographically detectable alterations in the normally
clear-cut peripheral outline of the septa are corroborating
evidence of destructive periodontal disease.

VII) SKELETAL DISTURBANCES
MANIFESTED
IN THE JAWS
1) Osteitis fibrosa cystica (Recklinghausen’s disease of bone):-
- Generalized disappearance of
lamina dura.
- Diffuse, granular mottling, scattered
cystlike radiolucent areas throughout
the jaws.
Periapical view
Occlusal view
of brown tumors
in patient with
hyperparathyroidism

MANIFESTED
IN THE JAWS
2) Pagets’s disease:-
- Normal trabacular pattern replaced by hazy, diffuse
meshwork of
closely knit, fine trabecular markings
- Diminution in the prominence of lamina dura
- Scattered radiolucent areas may contain irregularly
shaped
radiopaque zones.

MANIFESTED
IN THE JAWS
3) Fibrous dysplasia:-
- Lamina dura – obliterated
- Ground-glass appearance – cancellous spaces may be
enlarged, with distortion of the normal trabecular pattern
- Small radiolucent area at a root apex or
- Extensive radiolucent area with irregularly arranged
trabecular markings.

MANIFESTED
IN THE JAWS
4) Langerhans cell histiocytosis (Gaucher’s disease)
- Single or multiple radiolucent areas, which may be
unrelated to the teeth
or
- May entail destruction of the tooth supporting bone

MANIFESTED
IN THE JAWS
5) Multiple myeloma:-
- Numerous radiolucent areas occur when the jaws
are involved
66

MANIFESTED
IN THE JAWS
6) Osteopetrosis (marble-bone disease, Albers-Schonberg disease)
- Outlines of the roots may be obscured by diffuse radiopacity of
the jaws
- In less severe cases the increased density is confined to the bone
in relation to the nutrient canals and the lamina dura.

MANIFESTED
IN THE JAWS
6) Osteopetrosis (marble-bone disease, Albers-Schonberg disease)
- Increased density of the jaws,
- Narrow inferior alveolar nerve canal

MANIFESTED
IN THE JAWS
7) Scleroderma
- Typical uniform widening of the periodontal ligament
- Thickening of the lamina dura

MANIFESTED
IN THE JAWS
8) Osteosarcoma :-
- A uniform widening of the PDL can be an early sign
70

MANIFESTED
IN THE JAWS
8) Osteosarcoma :-
- A uniform widening of the PDL can be an early sign
71

MANIFESTED
IN THE JAWS
9) Squamous cell carcinoma or metastatic carcinoma
Irregular destruction of the periodontal bone without tooth
displacement

MANIFESTED
IN THE JAWS
The intraosseous tumors are all osteolytic (A through D), mostly with ill-defined borders (A, C, D)
and sometime causing pathologic fracture (C, D). There is no corticated border in a relatively well-
defined tumor (B). Scattered calcification can be seen in a few of the tumors (C). In contrast to
marked bone destruction, root resorption of the involved teeth is lacking, thus showing a typical
radiographic pattern—floating teeth (D).
73

VIII) DIGITAL INTRAORAL RADIOGRAPHY
Two major digital intraoral systems :-
First system:-
uses charge-coupled devices (CCDs) or
Complementary metal oxide semiconductor (CMOS)
receptors
as detectors.

First system:-
These detectors are placed in the patient’s mouth and
are linked by a wire to the computer
On radiation exposure, virtually in real time, the
radiographic image appears on the computer
screen.
The detector is then moved to the next position and
so on until the whole area of interest is imaged.

Second system:-
Uses photostimulable phosphor (PSP) plates as
detectors.
PSP plates resemble film with one of the sides lined
with a PSP coating.
When interacting with x rays, PSP stores energy
which then releases on stimulation by light of an
appropriate wavelength.

Second system:-
PSP plates are placed an exposed similar to regular
film.
The exposed plates are placed on a plate scanner
and scanned by a laser beam and the radiographic
image appears on the computer screen.

 Once captured and displayed, computer software can be used to
enhance the digital image and increase its diagnostic efficacy.
 Exposure adjustment provides a balanced image that utilizes the
complete scale of gray levels and does not suppress diagnostic
information A sharpening (edge enhancement) filter increases the
definition and separation of adjacent structures.
 Inversion filters provide a negative of the image that sometimes
might reveal disease not seen on the positive image.

 The ability to magnify the image allows close
examination of the area of interest and detection of occult
disease.
 Different image qualities allow better detection of dental
disease. For example, high-contrast images favor caries
detection, whereas low-contrast images permit a more
accurate depiction of the alveolar crest.
 Digital images can be adjusted such that the contrast of
the interproximal contacts can be enhanced for caries
detection while the remainder of the image is not altered.

 Advantages of intraoral digital radiography:-
speed of image capture and display;
low x-ray exposure;
ability to manipulate the image and maximize diagnostic efficacy;
use of digital tools, such as linear, angular, and density
measurements; improved patient education;
ease of storage,
transfer, and copying;
seamless integration with electronic patient record management or
other software.
Most studies conclude that the aid provided by digital radiographs in
the diagnosis of common dental diseases such as caries is similar to
that of conventional radiographs.

 Although contrast and brightness adjustments can be
used to refine the image, they cannot correct a grossly
overexposed or underexposed projection.
 The ease of digital image acquisition should not replace
correct detector placement and exposure techniques.
 Image enhancement should be used with caution and
should be task oriented. For example, increased contrast
might aid in caries diagnosis but lead to underestimation
of the alveolar bone crest height.
 If properly used, intraoral digital radiography offers great
benefits in the diagnosis of dental disease

IX)ADVANCED IMAGING MODALITIES
Cone beam computed tomography (CBCT)
CBCT offers many advantages over conventional
radiography, including the accurate three
dimensional imaging of teeth and supporting
structures. Although not recommended for every
dental patient,
CBCT avoids the problems of geometric
superimposition and unpredictable magnification
and can provide valuable diagnostic information in
periodontal evaluation.

IX)ADVANCED IMAGING MODALITIES
Cone beam computed tomography (CBCT)
 Periapical and bite-wing radiographs provide
information mostly for the interdental bone.
However, a three-wall defect that
preserves the buccal and/or lingual cortices can be
difficult to diagnose, and the buccal, lingual and
furcational periodontal bone levels are hard to
evaluate in conventional radiographs.
When clinical examination raises concerns for such
areas, CBCT imaging can add diagnostic value.

References
 Fermin A. Carranza and Henry H. Takei. Chapter 31
RADIOGRAPHIC AIDS IN THE DIAGNOSIS OF PERIODONTAL
DISEASE. In: Carranza’s Clinical periodontology 9th edition.
 Niklous P. Lang and Roger W Hill. Radiographs in periodontics. J
Clin Periodontol 1977;4:16-28 (slides 20, 21,58).
 Anuja Muley" Advanced Diagnostic Imaging in Periodontal
Diseases: A Review" IOSR Journal of Dental and Medical Sciences
(IOSR-JDMS), vol. 18, no. 5, 2019, pp 55-70.
 Dr. Rasila Sainu, Dr .R.Madhumala, Dr. Thouseef .A. Majeed,
Dr.R.Saranyan Ravi Dr.N.Sayeeganesh, Dr.D.Jayachandran.
Imaging Techniques in Periodontics: A Review Article. J .Biosci
Tech,Vol 7(2),2016,739-747 (slide 8).

85
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