Radiographic Pathology

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Radiographic Pathology

  1. 1. RadiographicRadiographic PathologyPathology
  2. 2.  ““Radiographic appearances are governed byRadiographic appearances are governed by anatomic or physiologic changes in the presence ofanatomic or physiologic changes in the presence of the disease processes. Radiographic ‘diagnosis’ isthe disease processes. Radiographic ‘diagnosis’ is founded on a knowledge of these alterations, thefounded on a knowledge of these alterations, the prerequisite being awareness of diseaseprerequisite being awareness of disease mechanisms.” (H.M. Worth)mechanisms.” (H.M. Worth)
  3. 3. Method of Radiographic InvestigationMethod of Radiographic Investigation and Film Analysisand Film Analysis  1. Assess the quality of the film1. Assess the quality of the film - A) film density (alterations due to exposure or processingA) film density (alterations due to exposure or processing errors).errors). - B) image geometry (image distortion due to techniqueB) image geometry (image distortion due to technique errors).errors).
  4. 4. Method of Radiographic InvestigationMethod of Radiographic Investigation and Film Analysisand Film Analysis  2.2. Examine the total film before concentrating onExamine the total film before concentrating on one specific region.one specific region.  3.3. Examine the film for the presence of normalExamine the film for the presence of normal anatomy and assess the shape and density of eachanatomy and assess the shape and density of each structure. To accomplish this, one must havestructure. To accomplish this, one must have knowledge of the variable appearance thatknowledge of the variable appearance that “normal” anatomy may have.“normal” anatomy may have.
  5. 5. Method of Radiographic InvestigationMethod of Radiographic Investigation and Film Analysisand Film Analysis  4.4. Make sure that the total area of interest isMake sure that the total area of interest is present in the film. This may require a larger filmpresent in the film. This may require a larger film format. Often a second view at a slightly differentformat. Often a second view at a slightly different angle or preferentially at right angles isangle or preferentially at right angles is advantageous (e.g. occlusal views).advantageous (e.g. occlusal views).
  6. 6. Method of Radiographic InvestigationMethod of Radiographic Investigation and Film Analysisand Film Analysis  5.5. Suitable Viewing EquipmentSuitable Viewing Equipment A) view boxA) view box B) intense light sourceB) intense light source C) maskC) mask D) magnifying glassD) magnifying glass E) room with subdued lightingE) room with subdued lighting
  7. 7. Method of Radiographic InvestigationMethod of Radiographic Investigation and Film Analysisand Film Analysis  6.6. Referral for Other Imaging ProceduresReferral for Other Imaging Procedures A) pantomographA) pantomograph B) skull radiographyB) skull radiography C) tomographsC) tomographs D) sialographyD) sialography E) arthrographyE) arthrography F) nuclear medicineF) nuclear medicine G) CT and MRIG) CT and MRI
  8. 8. Radiographic AnalysisRadiographic Analysis  1.1. Anatomic position of abnormalityAnatomic position of abnormality A) localized or generalizedA) localized or generalized B) unilateral or bilateralB) unilateral or bilateral C) monostotic or polystoticC) monostotic or polystotic D) point of origin (epicenter)D) point of origin (epicenter)  II bone or soft tissuebone or soft tissue  IIII in, outside, above, below inferior alveolar canalin, outside, above, below inferior alveolar canal  IIIIII in, outside of max. antrum/ tooth follicle/ at apex ofin, outside of max. antrum/ tooth follicle/ at apex of toothtooth
  9. 9. Factors Associated withFactors Associated with HypercementosisHypercementosis LOCAL FACTORSLOCAL FACTORS  •• Abnormal occlusal traumaAbnormal occlusal trauma  •• Adjacent inflammation (e.g., pulpal, periapical,Adjacent inflammation (e.g., pulpal, periapical, periodontal)periodontal)  •• Unopposed teeth (e.g., impacted, embedded, withoutUnopposed teeth (e.g., impacted, embedded, without antagonist)antagonist)  •• Repair of vital root fractureRepair of vital root fracture  SYSTEMIC FACTORSSYSTEMIC FACTORS  •• Acromegaly and pituitary gigantismAcromegaly and pituitary gigantism  •• ArthritisArthritis  •• CalcinosisCalcinosis  •• Paget disease of bone (osteitis deformans)Paget disease of bone (osteitis deformans)  •• Rheumatic feverRheumatic fever  •• Thyroid goiterThyroid goiter  •• Gardner syndromeGardner syndrome  •• Vitamin A deficiency (possibly)Vitamin A deficiency (possibly)
  10. 10. Radiographic AnalysisRadiographic Analysis  2.2. Periphery of the abnormalityPeriphery of the abnormality - A) discrete borders- A) discrete borders  I punched out- no bone reaction  IIII corticated- uniform thin RO linecorticated- uniform thin RO line  IIIIII sclerotic border- non-uniform RO bordersclerotic border- non-uniform RO border  IVIV soft tissue capsule- uniformly thin or irregular widthsoft tissue capsule- uniformly thin or irregular width
  11. 11. Radiographic AnalysisRadiographic Analysis  2.2. Periphery of the abnormality (Continued)Periphery of the abnormality (Continued) - B) Non- discrete borders- B) Non- discrete borders  II blends in with normal anatomyblends in with normal anatomy  IIII signs of invasion (e.g. enlargement of adjacentsigns of invasion (e.g. enlargement of adjacent marrow spaces; “finger-like” extensions ofmarrow spaces; “finger-like” extensions of destruction; multifocal or “skip lesions”destruction; multifocal or “skip lesions”
  12. 12. Radiographic AnalysisRadiographic Analysis  2.2. Periphery of the abnormality (Continued)Periphery of the abnormality (Continued) C) shape of lesionC) shape of lesion  II irregularirregular  IIII curved surface or hydrauliccurved surface or hydraulic  IIIIII undulating or scallopingundulating or scalloping
  13. 13. Radiographic AnalysisRadiographic Analysis  3.3. Internal StructureInternal Structure -- A. densityA. density  II radiolucent (completely)radiolucent (completely)  IIII mixed RL/ROmixed RL/RO  IIIIII radiopaque (completely)radiopaque (completely)
  14. 14. Radiographic Analysis (InternalRadiographic Analysis (Internal Structure Continued)Structure Continued)  B) description of RO structuresB) description of RO structures - I- I bone trabeculae (ground glass, orange peel, cottonbone trabeculae (ground glass, orange peel, cotton wool, etc.)wool, etc.) - II- II cortical bone (homogeneous)cortical bone (homogeneous) - III- III bony septum (thin/coarse; straight/curved;bony septum (thin/coarse; straight/curved; prominent/faintprominent/faint - IV- IV cementum (oval/round; amorphous)cementum (oval/round; amorphous) - V- V tooth structure (shape; density; pulp chamber; PDL;tooth structure (shape; density; pulp chamber; PDL; lamina dura)lamina dura) - VI- VI no specific patternno specific pattern
  15. 15. Radiographic Analysis (InternalRadiographic Analysis (Internal Structure Continued)Structure Continued)  C) Comparative radiolucency to radiopacityC) Comparative radiolucency to radiopacity - E.g. fat, air, gas, fluid, soft tissue, medullary spaces;- E.g. fat, air, gas, fluid, soft tissue, medullary spaces; cancellous bone, cortical bone, cementum, dentin,cancellous bone, cortical bone, cementum, dentin, enamel, metals (from most radiolucent to mostenamel, metals (from most radiolucent to most radiodense)radiodense)  D) Identification of RO structuresD) Identification of RO structures Tooth material; bone; cementum, calcified cartilage,Tooth material; bone; cementum, calcified cartilage, dystrophic calcificationdystrophic calcification
  16. 16. Osteomas in Gardner SyndromeOsteomas in Gardner Syndrome
  17. 17. Radiographic AnalysisRadiographic Analysis  4.4. Behavior as suggested by the effects on theBehavior as suggested by the effects on the surrounding structuressurrounding structures - A) structures to assess- A) structures to assess  II teeth- displacement, resorption, lamina dura, PDL, pulpteeth- displacement, resorption, lamina dura, PDL, pulp chamber, follicular space, cortex, shape and density of toothchamber, follicular space, cortex, shape and density of tooth  IIII surrounding cortical structures- cortex of canals, antrum, etc.surrounding cortical structures- cortex of canals, antrum, etc.  IIIIII surrounding cancellous bone- destruction versus bone formationsurrounding cancellous bone- destruction versus bone formation and sclerosisand sclerosis  IVIV other structures, e.g. inferior alveolar canal, etc.other structures, e.g. inferior alveolar canal, etc.
  18. 18. Radiographic AnalysisRadiographic Analysis  B) Behavioral characteristicsB) Behavioral characteristics - 1.- 1. DisplacementDisplacement - 2.- 2. ExpandExpand - 3.- 3. DestroyDestroy - 4.- 4. Cause periosteal bone formationCause periosteal bone formation - 5.- 5. Cause increase in cancellous boneCause increase in cancellous bone - 6.- 6. Increase in soft tissue massIncrease in soft tissue mass
  19. 19. Radiographic AnalysisRadiographic Analysis  B) Behavioral characteristics (Continued)B) Behavioral characteristics (Continued) - 7.- 7. Increase in normal widthIncrease in normal width  e.g. Peridontal membrane spacee.g. Peridontal membrane space -- Inferior alveolar canalInferior alveolar canal - Pulp chamber- Pulp chamber - 8.- 8. Cause irregular bone remodelingCause irregular bone remodeling  e.g. Resulting in unusual shape or unusual bone patterne.g. Resulting in unusual shape or unusual bone pattern
  20. 20. Unique RadiographicUnique Radiographic AppearancesAppearances
  21. 21. ““Ground Glass”Ground Glass”  1. Fibrous dysplasia1. Fibrous dysplasia  2.2. HyperparathyroidismHyperparathyroidism
  22. 22. Fibrous dysplasia – Patient Age  First and second decadesFirst and second decades
  23. 23. Fibrous dysplasia – Location  Maxilla favored
  24. 24. Fibrous dysplasia – Radiographic Appearance  Poorly defined radiographic mass; diffuse opacificationPoorly defined radiographic mass; diffuse opacification often described as “ground glass”.often described as “ground glass”.  Other radiographic appearances include ill-definedOther radiographic appearances include ill-defined radiolucency (early lesion).radiolucency (early lesion).
  25. 25. Fibrous dysplasia – Other Features  Slow growing and asymptomatic; causes corticalSlow growing and asymptomatic; causes cortical expansion; may stop growing after puberty; a cosmeticexpansion; may stop growing after puberty; a cosmetic problem treated by recontouring. Variants: monostoticproblem treated by recontouring. Variants: monostotic – one bone affected; polystotic –more that one bone– one bone affected; polystotic –more that one bone affected; Mc Cune-Albright syndrome includes:affected; Mc Cune-Albright syndrome includes: fibrousfibrous dysplasia plus cafdysplasia plus café au lait macules andé au lait macules and endocrineendocrine abnormalities (e.g. precocious puberty inabnormalities (e.g. precocious puberty in females); Jaffe-females); Jaffe- Lichtenstein syndrome – multiple boneLichtenstein syndrome – multiple bone lesions of fibrous dysplasia and skin pigmentations;lesions of fibrous dysplasia and skin pigmentations; rare.rare.
  26. 26. Giant Cell Lesion of (Primary) Hyperparathyroidism  Predominant region – None  Other radiographic appearances – Multilocular, indistinct borders  Additional features – Polydipsia; polyuria; serum calcium levels ↑; serum phosphate levels ↓; serum alkaline phosphatase levels ↑
  27. 27. Giant Cell Lesion of (Primary) Hyperparathyroidism  Predominant gender – F 7:1  Usual age (years) – 30-60  Predominant jaw - Mandible
  28. 28. Hyperparathyroidism - Primary  Calcium – Increased  Phosphorus – Decreased  Alkaline phosphatase - Increased
  29. 29. Giant Cell Lesion of (Secondary) Hyperparathyroidism  Predominant region – None  Other radiographic appearances – multilocular, indistinct borders  Additional features – History of kidney disease; serum calcium levels normal to ↓; serum phosphate levels↑; serum alkaline phosphatase levels ↑
  30. 30. Giant Cell Lesion of (Secondary) Hyperparathyroidism  Predominant gender – F 2:1  Usual age (years) – 50-80  Predominant jaw - Mandible
  31. 31. Hyperparathyroidism - Secondary  Calcium – Normal to decreased  Phosphorous – Increased  Alkaline phosphatase - Increased
  32. 32. “Cotton Wool”  1. Paget disease (osteitis deformans)  2. Periapical cemento-osseous dysplasia  3. Gardner syndrome (Osteoma)  4. Gigantiform cementoma
  33. 33. Paget Disease – Patient Age  Over 40 years of age
  34. 34. Paget Disease – Location  Maxilla favored, bilateral and symmetric
  35. 35. Paget Disease – Radiographic Appearance  Diffuse lucent to opaque bone changes; opaque lesions described as “cotton wool”; hypercementosis, loss of lamina dura, obliteration of periodontal ligament space, and root resorption may be seen.
  36. 36. Paget’s disease – Other Features  Patients may develop pain, deafness, blindness, and headache because of bone changes; initial complaint may be that denture is too tight; diastemas may develop; complications of hemorrhage early, infection and fracture late; alkaline phosphate elevated; etiology unknown but affects bone metabolism.
  37. 37. Periapical Cemento-Osseous Dysplasia  Cause: Reactive  Age/Race/Sex: Fifth decade; F>M; African- American (Black)  Location: Anterior mandible  Clinical Features: Asymptomatic lesion (s), often multiple; teeth are vital.
  38. 38. Periapical Cemento-Osseous Dysplasia  Radiographic Features: Well-defined radiolucency to radiopacity (depending on stage of lesion) at the area of the tooth apex; often more than one tooth involved; usually mandibular incisors  Microscopic Features: Fibrous connective tissue and calcifications  Treatment: None  Diagnostic Process: Radiographic
  39. 39. OsteomaOsteoma  Osteomas are benign lesions of bone that in many casesOsteomas are benign lesions of bone that in many cases represent developmental growths rather than truerepresent developmental growths rather than true neoplasms.neoplasms.  They are composed of woven and lamellar bone.They are composed of woven and lamellar bone.  The most common locations are the facial bones andThe most common locations are the facial bones and skull and they are most common in the 40-50 ageskull and they are most common in the 40-50 age group.group.  Most osteomas are exophytic growths but they mayMost osteomas are exophytic growths but they may arise within bone.arise within bone.
  40. 40. OsteomaOsteoma  Multiple osteomas are seen in Gardner syndrome, aMultiple osteomas are seen in Gardner syndrome, a polyposis syndrome, which has significant malignantpolyposis syndrome, which has significant malignant complications and oral manifestations.complications and oral manifestations.  Osteomas are generally slow-growing tumors of littleOsteomas are generally slow-growing tumors of little clinical significance except when they cause obstructionclinical significance except when they cause obstruction or produce cosmetic problems.or produce cosmetic problems.  Osteomas do not undergo malignant changeOsteomas do not undergo malignant change
  41. 41. ““Sunburst Radiopacities”Sunburst Radiopacities”  OsteosarcomaOsteosarcoma  Intraosseous HemangiomaIntraosseous Hemangioma
  42. 42. Osteosarcoma – Clinical FeaturesOsteosarcoma – Clinical Features  Third and fourth decades; can occur in eitherThird and fourth decades; can occur in either jaw although some studies indicate is morejaw although some studies indicate is more common in mandible; juxtacortical subtypecommon in mandible; juxtacortical subtype arises from periosteum.arises from periosteum.
  43. 43. Osteosarcoma – Radiographic Appearance  Poorly defined lucency with spicules of opaque material’ “sunburst” pattern may be seen; juxtacortical lesion appears as radiodense mass on the periosteum
  44. 44. Osteosarcoma – Other Features  Swelling, pain, or paresthesia are diagnostic features; patients may have vertical mobility of teeth and asymmetric (uniformly) widened periodontal ligament space; prognosis fair to poor, good prognosis for juxtacortical lesions
  45. 45. Hemangioma (White & Pharoah)Hemangioma (White & Pharoah)
  46. 46. “Onion-Skin”  1. Proliferative periostitis  2. Ewing sarcoma  3. Langerhans cell disease
  47. 47. PROLIFERATIVE PERIOSTITIS  Also known as Periostitis Ossificans or Garrè’s Osteomyelitis  Proliferative Periostitis represents a periosteal reaction to the presence of inflammation  The affected periosteum forms several rows of reactive vital bone that parallel each other and expand the bone
  48. 48. PROLIFERATIVE PERIOSTITIS  Mean age is approximately 13 years with no gender predilection.  Most frequent cause is dental caries.  Most arise in the mandibular premolar/molar region with involvement of the lower border.  Most cases are unifocal.
  49. 49. PROLIFERATIVE PERIOSTITIS: Radiographic Features  Appropriate radiographs reveal radiopaque laminations of bone that roughly parallel each other and underlying cortical surface.  If bony destruction is seen in association with the cortical surface or new periosteal bone, then clinical should consider the possibility of a neoplastic process, e.g. Ewing sarcoma.
  50. 50. PROLIFERATIVE PERIOSTITIS  Treatment & Prognosis:  Treatment consists of the elimination of the source of infection via endo or extraction.  Resolution typically occurs in 6 to 12 months following successful treatment of the infection.
  51. 51. Ewing Sarcoma – Patient Age  Children and young adults
  52. 52. Ewing Sarcoma – Location  Mandible favored
  53. 53. Ewing Sarcoma – Radiographic Appearance  Diffuse lucency; poorly defined; periosteal reaction; “onion-skin”, may be present; may be multilocular.
  54. 54. Ewing Sarcoma – Other Features  Swelling, pain, or paresthesia may be present; prognosis is poor; malignant cell is of unknown origin but may be of neuroendocrine origin; rare tumor.
  55. 55. Ewing Sarcoma  Predominant gender – M 2:1  Usual age (years) – 5-24 (peak 14-18)  Predominant jaw – Rare in maxilla  Additional features – Metastasizes to lymph nodes, lungs, and other bones, rapid course  Other radiographic appearances – Onionskin growth of periosteal bone, sunburst.
  56. 56. Soft Tissue Radiopacities  1. Amalgam tattoo  2. Sialolith  3. Calcified lymph nodes  4. Phlebolith  5. Tonsillolith  6. Osseous/Cartilaginous choristoma  7. Calcinosis cutis  8. Myositis ossificans  9. Other foreign bodies
  57. 57. Amalgam TattooAmalgam Tattoo
  58. 58. SIALOLITHS
  59. 59. CALCIFIED LYMPH NODES
  60. 60. PHLEBOLITHS
  61. 61. ANTROLITHS
  62. 62. CREST Syndrome C- calcinosis R- Raynaud’s phenomenon E- esophageal dysmotility S- sclerodactyly T- telangiectasia (Also presence of anticentromere antibodies)
  63. 63. FOREIGN BODIES

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