Radiographic interpretation


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Radiographic interpretation

  1. 1. RADIOGRAPHIC INTERPRETATIONGuided by:Dr Vela DesaiDr Beena VarmaDr Neelkanth PatilDr Rajeev Sharma
  2. 2. Radiograph2  Photographic image  Radiosensitive surface  Radiation – X rays/ Gamma rays  Radiogram/shadowgram/roentgenogram 11/15/2011
  3. 3. Role of radiographs3  Clinical examination phase  Diagnosis( confirm/exclude)  Treatment planning  During treatment  Follow up  Blind screening tool-justify  Limitations-replace clinical examination  Need for further investigation 11/15/2011
  4. 4. Radiographs in Diagnosis4  Diagnostic imaging is an integral part of the diagnostic process in clinical dentistry.  Radiographs are often obtained as part of a complete examination.  Appropriate radiographic interpretation is used along with clinical information and other tests to formulate a differential diagnosis Free PowerPoint Template from 11/15/2011
  5. 5. Uses of radiographs5  Loss of tooth structure  Caries(occlusal/proximal)  Non carious(attrition,fracture)  Periodontal diseases  Endodontic diseases  Impacted teeth  Trauma  Other bone pathologies  Implants Free PowerPoint Template from 11/15/2011
  6. 6. 6  Technique Radiography  Interpretation Radiology  Interpretation: Step by step analytical process that provides an exact idea of the clinical problem and helps to achieve the final diagnosis of any particular lesion. 11/15/2011
  7. 7. Interpretation7  Three steps:  Visualization  Perception  Integration of information  Other diagnostic tools-vitality/mobility  Pulp tester 11/15/2011
  8. 8. 8  Clinical examination  Quality assurance  Type of radiograph  Inadequate quality  Number of  Inadequate number radiographs  Extraoral radiology  Aids in interpretation  Biopsy/treatment- aids in site selection 11/15/2011
  10. 10. 10 Ideal radiograph:  Visual : density & contrast  Geometric : sharpness/detail, resolution/definition, magnification, distortion  Anatomical accuracy of radiographic images  Adequate coverage of anatomical region of interest. 11/15/2011
  11. 11. Viewing Conditions11  This should be done in a quiet, darkened room  At least two good, evenly-lit viewing boxes are required  A bright light illuminator is required for relatively over-exposed areas  Mounted in holder  Appropriate size of viewbox to accommodate film  Magnifying glass-detailed examination of small regions 11/15/2011
  12. 12. 12  A radiograph is a two dimensional image of a three dimensional object.  Clark’s rule: The most distant object from the cone(lingual) moves towards the direction of the cone 11/15/2011
  13. 13. Three-dimensional concept13  The radiographic image is simply a Two-dimensional shadowgram of the patient  The third dimension must be reconstructed mentally, preferably from two radiographic projections made at right angles (orthogonal projections) to each other  Oblique projections may be required to assess anatomically complicated areas 11/15/2011
  14. 14. Contrast perception:14  Ability to distinguish b/w two areas of radiographic image of diff densities-Weber’s law  Minimum perceptible difference in gray level is proportional to the brightness level to which the subject is adapted.  All areas on a radiograph represented as:  Black  Grey  White 11/15/2011
  15. 15. MACH BAND EFFECT15  Illusion consists of light or dark stripes that are perceived next to the boundary between two regions of an image that have different lightness gradients  Spatial high-boost filtering performed by the human visual system on the luminance channel of the image captured by the retina.  Mach bands are independent of orientation.  This occurs when two circles of uniform brightness are placed side by side, separated by a sharp edge. Just along the edge one colour looks darker than it really is, 11/15/2011 while the other looks lighter.
  16. 16. 16 MACH BAND EFFECT 11/15/2011
  17. 17. 17  False-positive radiological diagnosis of dental caries  Manifest adjacent to metal restorations or appliances, between enamel and dentin  Misdiagnosis of horizontal root fractures because of the differing radiographic intensities of tooth and bone. 11/15/2011
  18. 18.  RADIOLUSCENT-the capability of a substance with a relatively small atomic number to let a large18 amount of x-rays pass through it, thus producing darkened images on x-ray films. RADIOOPAQUE RADIOLUSCENT  RADIOOPACITY-the capability of a substance to hinder or completely stop the passage of x-rays, display as white/light areas on an exposed x-ray film. 11/15/2011
  19. 19. Properties19  Atomic number  The higher the atomic number, the more radiopaque the tissue/object:  Physical opacity  Air, fluid and soft tissue have approximately the same atomic number, but the specific gravity of air is only 0.001, whereas that of fluid and soft tissue is 1  Therefore air will appear black on a radiograph, compared with fluid and soft tissue, which appear more grey 11/15/2011
  20. 20. 20  Thickness  The thicker the tissue/object, the greater the attenuation of X-Rays and the more white the image .  When two tissues/objects are superimposed, the composite shadow formed by these will appear more opaque than either of the two separate tissues  Bone(14;1.8) Free PowerPoint Template from 11/15/2011
  21. 21. Image analysis21  Identify normal anatomic landmarks  Knowledge of normal v/s abnormal  Attention to all regions on the film systematically  Three circuits 11/15/2011
  22. 22. First visual circuit: intraoral22 images  Periapical before bitewing images  Right maxilla to left; left mandible to right  One anatomic structure at a time  Eg: posterior maxilla-maxillary sinus,tuberosity,zygomatic process  Normal anatomy bones, canals, foramina Check for symmetry 11/15/2011
  23. 23. Use a systematic process23  Go back to the first quadrant and look at the trabecular pattern. Is it:  Normal  Symmetrical when compared to the contralateral side  Sparse  Dense  In the direction of anatomical stress  Altered 11/15/2011
  24. 24. Fish net Step ladder Granular24 TRABECULAR PATTERN 11/15/2011
  25. 25. Second visual circuit25  Examination of bone:  Height of alveolar bone  Crest relative to teeth  Loss of height-more than 1.5 mm-periodontal disease  Cortication  Lamina dura + PDL space + tooth roots  Carcinoma-erosion of alveolar crest+ ill defined borders. Free PowerPoint Template from 11/15/2011
  26. 26. 26 Free PowerPoint Template from 11/15/2011
  27. 27. Third visual circuit27  Examination of dentition & associated structures  Number, Sequence, appearance, root structure  Crowns –defective enamel, caries  Intreproximal areas & restorations  Pulp chambers-size, contentRestoration Dentin Proximal caries  Bone-radioluscent/radioopaque lesions Pulp 11/15/2011
  28. 28. Check individual teeth28  Enamel, [amelogenesis imperfecta, mulberry molar, etc.]  The dentin, [dens invaginatus or evaginatus, denticles etc.] T  Pulp chamber [dentinogenesis imperfecta, odontogenesis imperfecta, odontodysplasia, taurodontism, individual obliteration of nerve canals, etc.]  Apical area [root resorption, lucencies or opacities]  periodontal ligament space [widened in early osteosarcoma (localized), scleroderma ( generalized) [ absent in hyperparathyroidism]  Amount of bone support. Free PowerPoint Template from 11/15/2011
  29. 29. Routine assessment of radiographs29  Ensure that the radiograph is the one of the patient being examined, check the date, opd/no.  Ensure two orthogonal projections are available.  The radiographic views are named according to the direction the primary beam enters and leaves the tissue and the body part being examined  The position of the patient during exposure should be known, and left/right markers should be identified  The radiograph should be of high technical quality with respect to positioning, centring, collimation, exposure and development, and should be free from artefacts. 11/15/2011
  30. 30. 30  Every shadow visible must be evaluated to determine whether it is: A feature of normal anatomy  A composite structure formed by superimposition of structures  An artefact produced by inaccurate positioning  A pathologic lesion: must be ruled out first Free PowerPoint Template from 11/15/2011
  31. 31. Interpretation is an orderly process Normal Abnormal variation Developmental Acquired abnormalities abnormalitiesCyst Benign Malignant Inflammatory Bone Vascular Metabolic Trauma neoplasia neoplasia lesion dysplasia analomy31
  32. 32. Why describe the lesion?32  The radiographic description can give us indications of:  Tissue of origin  Biological behavior  Prognosis  Treatment concerns  Diagnosis or a Differential Diagnosis Free PowerPoint Template from 11/15/2011
  33. 33. Describing the Lesion33 1. Size 2. Shape 3. Location 4. Density 5. Borders 6. Internal Architecture 7. Effect on adjacent structures Free PowerPoint Template from 11/15/2011
  34. 34. Aunty Minnie Approach34  Aunt Minny represents an abnormality which looks like one that the evaluator has seen before, or been told about.  It would be difficult to recognise new findings using this approach Cousin Harry represents an abnormality which the evaluator has not seen for a long time, but would like to see Uncle Fred represents an abnormality which is often present 11/15/2011
  35. 35. 35 Free PowerPoint Template from 11/15/2011
  36. 36. Size36  Measure the lesion with a ruler. If you must estimate, use surrounding structures as guide  Measure in two dimensions, width and height in mm or cm 11/15/2011
  37. 37. Shape37 Regular shapes like Round, Triangular, Rhomboid etc. Irregular shape like circular, fluid filled(hydraulic)-cyst Scalloped-multilocular app. Odontogenic keratocyst 11/15/2011
  38. 38. 38 Scalloped/Multilocular- Ameloblastoma 11/15/2011
  39. 39. Location39  Is the lesion localized or generalized?  Unilateral or bilateral (submandibular fossa), fibrous dysplasia  Where is the lesion in relation to other structures and anatomic landmarks?  Use terms such as:  Mesial, Distal  Inferior, Superior  Posterior, Anterior 11/15/2011
  40. 40. Soft tissues or jaws:40  Epicentre-coronal to tooth-odontogenic epithelium  Epicenter of the lesion is above the mandibular canal->odontogenic in origin  Epicentre->below IAC->non odontogenic(likely)  Cartilaginous lesions, osteochondromas - >condyles  If the epicenter of the lesion is in the sinus, not odontogenic in origin-alveolar process of 11/15/2011 maxilla
  41. 41. Density41  Is the lesion Radiopaque, Radiolucent, or Mixed Density  Remember that opacity is relative to the adjacent structures.  If the lesion is of mixed density, describe the appearance 11/15/2011
  42. 42. Radioluscent to radioopaque42 structures  Air,fat,gas  Fluid  Soft tissue  Bone marrow  Trabecular bone  Cortical bone  Enamel  Metal 11/15/2011
  43. 43. Internal architecture43  Is the lesion uniform?  Internal structures such as septae or loculations  Septae –residual bone-long strands/walls  Loculations are individual compartments(2)  Soap bubble app- OKC  Giant cell granuloma-wispy, granular  Odontogenic myxoma-straight, thin  Tooth-like elements-cementum Free PowerPoint Template from 11/15/2011
  44. 44. Fibrous dysplasia44  More in number  Shorter  Aligned in response to stress  Randomly oriented  Ground glass/orange peel app 11/15/2011
  45. 45. 45 Free PowerPoint Template from 11/15/2011
  46. 46. 46  Inflammatory lesion-new bone formation-thick trabeculae-more radioopaque  Dystrophic calcifications-damaged soft tissue masses- calcified lymph nodes-cauliflower like masses  Ewing’s sarcoma-onion skin app 11/15/2011 Calcified lymph nodes-tuberculosis
  47. 47. Borders47  Well or poorly demarcated  Punched out-sharp- (no bony reaction)- multiple myeloma  Corticated-uniform-periphery- (thin opaque border) cyst  Sclerotic (wide, uneven opaque border) Periapical cemental dysplasia  Radioluscent(periphery)+ corticated Odontoma, cementoblastoma 11/15/2011
  48. 48. Periapical cemento Residual cyst osseous dysplasia Well defined borders48 Free PowerPoint Template from 11/15/2011
  49. 49. Ill defined borders49  Gradual transition-normal app bone & abnormal app trabaculae- sclerosing osteitis  Invasive border-bone destruction-malignancy Free PowerPoint Template from 11/15/2011
  50. 50. Jaw – examine the lesion in the jaw:50 · Site – location, extent, solitary, multi-focal or generalised · Size and shape – measure and describe. This may require one or more views. · Symmetry – examine contralateral site. Bilateral symmetry is suggestive of a normal variant · Border – sclerosis, resorption, lack of continuity · Contents – lucent or opaque. Homogenous or varying density · Association with other structures. Teeth displaced or resorbing Free PowerPoint Template from 11/15/2011
  51. 51. Effect on adjacent structures51  Lesions behaviour & impact on surrounding structures-identification of disease  Inflammatory disease-bone resorption/formation.  A Space Occupying lesion creates its own space by displacing other structures, such as teeth, maxillary sinus, inferior alveolar canal, etc. Free PowerPoint Template from 11/15/2011
  52. 52. 52  Epicentre above crown of teeth-follicular cysts- teeth apically  Lesion-ramus of mandible-cherubism-anterior direction  Papilla of developing tooth-lymphoma  Widening of PDL, broken lamina dura- periapical/periodontal abscess  Root resoption-periodontitis, trauma, tumors  Reactive bone-periphery of lesion-benign slow growth Free PowerPoint Template from 11/15/2011
  53. 53. 53  Inferior alveolar canal  Superior displacement-fibrous dysplasia  Widening of IAN-cortical boundary intact- benign vascular/neural lesion  Irregular widening with cortical destruction, complete length of canal-malignant neoplasm Free PowerPoint Template from 11/15/2011
  54. 54. Outer cortical bone/periosteal54 reactions  Slow growing-new bone-expanding lesion- outer cortical bone maintained  Rapidly growing-periosteum does not respond- missing cortical plate  Exudate from inflammatory lesion-lift periosteum off surface of the surface of cortical bone-periosteum lay down new bone.  Onion skin app-leukaemia, langerhan’s cell histiocytosis  Spiculated new bone-osteogenic sarcoma 11/15/2011
  55. 55. Formulation of radiographic55 interpretation  Organised fashion  Single observation  Diagnosis Free PowerPoint Template from 11/15/2011
  56. 56. 56  Decision 1: Normal V/S Abnormal  Decision2: Developmental V/S Acquired  Decision 3: Classification  Decision 4: Ways To Proceed 11/15/2011
  57. 57. Decision 1: Normal V/S Abnormal57  Structure of interest  Variation of normal/represents abnormality Free PowerPoint Template from 11/15/2011
  58. 58. Decision 2: Developmental V/S Acquired58  Area of interest: abnormal  Radiographic characterstics: location, periphery, shape, internal structure, effect on surrounding structures  Indicates developmental/acquired-external root resorption Free PowerPoint Template from 11/15/2011
  59. 59. Decision 3: Classification59  Abnormality  Appropriate category  Treatment plan Free PowerPoint Template from 11/15/2011
  60. 60. Decision 4: Ways To Proceed60  Analyse images  Further imaging like CT, MRI  Biopsy  Treatment Free PowerPoint Template from 11/15/2011
  61. 61. SOFT TISSUE.61  The examination of the radiographic appearance of soft tissue is all too often overlooked.  This is particularly true on panoramic radiographs.  If the clinical examination determines that soft tissue requires radiographic examination, kVp be reduced when the patient is exposed. Soft tissue structures in the maxillofacial region are often tongue, soft palate, tip and ala of the nose Free PowerPoint Template from 11/15/2011
  62. 62. Correct terminology62  One examines a radiograph and NOT an X-ray. Bear in mind that an X-ray can not be seen. An X-ray is a photon / beam of energy.  One does not see infection at the apex of a tooth. What one does see is the well / poorly demarcated radiolucency/opacity, x mm by y mms in size at the apex of tooth number X. For the same reason one does not speak about a PAP in radiology. 11/15/2011
  63. 63. 63  Periodontal bone loss is not periodontitis per se.  Stay away from brand names. We do not have a panorex machine here. Use the word PANORAMIC radiograph or PAN.  In radiologic terminology, a PA is a postero- anterior PowerPoint Template from Free view. 11/15/2011
  64. 64. EXISTING DIAGNOSTIC RADIOGRAPHS64  An effective way to reduce unnecessary radiation to the patient is to avoid retaking [recent] radiographs that already exist. It is the clinicians responsibility to obtain these records from earlier health providers where possible. Free PowerPoint Template from 11/15/2011
  65. 65. The diagnostic process is far from infallible. In any diagnostic procedure there are four possible outcomes:-65 1. True positive: The disease is present and correctly identified. 2. False positive: The disease was absent but something on the radiograph convinced the clinician that it was present. 3. True negative: No disease present and correctly determined. 4. False negative: Disease is present but not detected. Occurs much too often Free PowerPoint Template from 11/15/2011
  66. 66. RADIOGRAPHIC RECORDS66  The value of radiographs as a part of the integral records of a patient cannot be overstated.  Good radiograph is difficult to match with written records and the radiograph is more indisputable than a written statement in a court of law provided the name of the patient is indicated as well as the date.  However, this is not a call to expose the patient to ionizing radiation merely for the sake of documentation.  One may not retake radiographs for the sake of improving ones grades. Radiographs legally must be kept for at least 5 years; some authorities state 7 years. 11/15/2011
  67. 67. DOCUMENTATION67  Clear medico-legal requirement for documentation of interpretation.  Signed and dated radiographic report must be written with patients record.  Clinically useful in treatment planning and case presentation. Free PowerPoint Template from 11/15/2011
  68. 68. Radiographic report68  Patient & general information  Imaging procedure  Clinical information  Findings  Radiographic interpretation Free PowerPoint Template from 11/15/2011
  69. 69. RADIOGRAPHIC69 PRESCRIPTION  Licensed dentist may prescribe radiographs  Examination appropriate radiographic views Maximum amount of information Minimum amount of ionizing radiation. Free PowerPoint Template from 11/15/2011
  70. 70. 70 CONCLUSION 11/15/2011
  71. 71. References71  White and pharoah,principles and interpretation.IV edition,pg281-296  W&P. Ch.14. Oral and Maxillofacial Imaging. Farman and NortjeNeill Serman.2000  Dr. Parish P. Sedghizadeh. Radiographic pathology of the head and neck.  Brocklebank L, Dental Radiology, Oxford University Press 1997.  Deforge DH and Colmery BH, An Atlas of Dental Radiology, Iowa State University Press 2000 Free PowerPoint Template from 11/15/2011
  72. 72. THANK YOU72 ...when you have eliminated the impossible, whatever remains, however improbable, must be the truth. Sir Arthur Conan Doyle, (Sherlock Holmes) British mystery author & physician (1859 - 1930) 11/15/2011