Periodontal disease involves the loss of periodontal ligament attachment and alveolar bone support around teeth. Radiographs are useful but limited for diagnosing periodontal disease, as they provide only a two-dimensional view and structures can be superimposed. Early signs on radiographs include crestal irregularities, triangulation of the periodontal ligament space, and interdental bone changes. Periodontitis can range from localized to more severe and generalized forms with increased bone loss and mobility. Contributing risk factors include occlusal trauma, open contacts, overhangs, calculus, and systemic health issues.

1. Periodontal Disease
Islam Kassem
Consultant oral & maxillofacial surgeon
ikassem@dr.com

2. Periodontal Disease
Periodontal ligament attachment and
alveolar bony support of the tooth have
been lost.
Junctional epithelium migrates apical to
the CEJ.

3. Periodontal Disease
Bitewings best for diagnosis. Some feel
that paralleling PA’s are best.
Higher kVp recommended (long scale, low
contrast).
Compare images from different
visits (using same technique).

4. Limitation of Radiographs
• Two-dimensional representation
of a 3-D anatomic structure.
• Superimposition of the bone and
tooth structures
* Relationship of hard to soft
tissues not evident

5. Limitation of Radiographs
* Presence or absence of periodontal
pockets.
* Early bone loss (<3mm) is not evident.
* Early furcation involvement is not
evident.

6. Limitation of Radiographs
* PA: X-ray beam alignment will
obliterate the presence of extent of
furcation involvement.
* Facial and lingual aspects of alveolar
bone will be superimposed over the
furcation.

8. Benefits
Early radiographic changes:
1. Crestal irregularities.
2. Triangulation
3. Interdental septal bone changes

9. Periodontitis
Involvement:
Localized
Generalized

12. Periodontitis
Normal Anatomy:
Alveolar crest corticated
1-1.5 mm from crest to CEJ
Parallel to line between CEJ’s
Crest is pointed anteriorly

13. Corticated alveolar crests

14. CEJ
1-1.5 mm

15. Alveolar crests more
pointed anteriorly

16. Contributing Factors
• Occlusal trauma
• Open contacts
• Overhangs, poor contours
• Calculus
• Post-extraction defects
• Systemic involvement (diabetes,
blood disorders, hormonal
changes, stress, AIDS)

17. Horizontal bone loss: Parallel to line
drawn between adjacent CEJ’s
Vertical (Angular) bone loss: More
bone destruction on interproximal
aspect of one tooth than on the
adjacent tooth

18. Gingivitis
No bone loss
No radiographic signs

19. Mild Adult Periodontitis
Loss of cortical density
Rounding off of junction
between alveolar crest and
lamina dura
Blunting of crest anteriorly

20. Mild adult periodontitis

21. Moderate Adult Periodontitis
Horizontal bone loss or vertical
osseous defects
Total extent of bone loss not evident
May have slight mobility

22. Moderate adult periodontitis
(red arrows point to calculus)

23. Moderate adult periodontitis

24. Severe Adult Periodontitis
Tooth mobility
Extensive horizontal bone
loss or vertical osseous
defects
Furcation involvement

25. Severe adult periodontitis

26. Severe adult
periodontitis

27. Severe adult periodontitis

28. Restorative Materials
Radiopaque: Structures with higher object
density, such as amalgam, gold, silver
points, pins, gutta percha, porcelain.
Radiolucent: Structures with lower object
density, such as older composites and
bonding agents.

29. Gold crowns, amalgams

30. Retention pins

31. porcelain
crowns
Ceramic Crowns

32. crown
crown
amalgam
cast post
gutta percha
silver points

36. Red arrows point to bases
Green arrow indicates recurrent caries with
fractured restoration

37. old Composites new

41. Thank you
ikassem@dr.com