Radiographic aids in diagnosis of periodontal diseases

1. Radiographic Aids in the
Diagnosis of Periodontal
Diseases
PRESENTED BY :
DR : Abdullah Ali

2. RADIOGRAPH
• Radiograph is an adjunct to clinical examination but not a
substitute for it.
• It reveal alterations in calcified tissues.
• It is a valuable aid in
- Diagnosis of periodontal disease.
- Determination of the prognosis.
- Evaluation of outcome of the
treatment.

3. • Radiograph does not reveal minor destructive changes in
bone . The radiographic image tends to show less severe
bone loss than that actually present. “ Bone loss is
always greater than it appears in the radiograph ”
• Slight radiographic changes in the periodontal tissues
means that the disease has progressed beyond its earliest
stages.
The earliest signs of periodontal disease must be
detected clinically.

4. NORMAL INTERDENTAL SEPTA
Width , shape & the angle of the alveolar crest of inter-dental
septum normally vary according to the convexity of the proximal
tooth surfaces & the level of the CEJ of the approximating
teeth.
The height of the alveolar crest lies at a level 1- 2 mm below CEJ of
adjacent teeth.
Lamina Dura is radioopaque border (white line )adjacent to
periodontal ligament and at alveolar crest. It represents the bone
surface lining the tooth socket.

5. Crest of interdental bone is 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

6. INTRA ORAL PERIAPICAL RADIOGRAPH
(IOPA)
Prichard established following 4 criterias to determine
adequate angulation of periapical radiographs –
• The radiograph should show the tips of molar cusps with little
or none of the occlusal surface showing.
• Enamel caps & pulp chambers should be distinct.
• Inter proximal spaces should be open.
• Proximal contacts should not overlap unless teeth are out of line
anatomically.

7. • Two intraoral projection techniques are used for periapical
radiography-
(i) Paralleling technique. (long cone technique)
(ii) Bisecting angle technique.
Long Cone Paralleling technique is better than bisecting angle . It
cause less distortion & produce more realistic image of the level
of alveolar bone

8. Bitewing Radiographs
Bitewing radiographs are used –
(1) To visualize the crowns of the posterior teeth and the height
of the alveolar bone in relation to the cementoenamel
junctions
(2) To detect interproximal calculus & caries
They more accurately exhibit the bone levels than
periapical views because of projection geometry.

9. • Schematic diagram of
• periapical (A)
• and
• bite-wing (B) radiographs.
• Angulation of the x-ray beam and the film on
the periapical radiograph distort the
distance between the alveolar crest and the
cementoenamel junction (CEJ) (compare a-b
versus a1-b1).
• In contrast, the projection geometry of the
bite-wing radiograph allows a more
accurate depiction (a-b) of the distance
between the alveolar crest and the CEJ (a-b).

10. Radiographic appearance
of periodontal diseases

11. PERIODONTITIS
• Fuzziness & a break in the continuity of the lamina dura at
the mesial or distal aspect of the crest of interdental septum.
These are earliest radiographic changes in periodontitis.
• A wedge shaped radiolucent area at mesial or distal aspect of crest
of septal bone.
• The height of the inter dental septum is reduced and finger like
radiolucent projections extend from the crest in to the septum.

12. Radiographic changes in periodontitis
A, Normal appearance of interdental
bone.
B, Fuzziness and a break in the continuity
of the lamina dura at the crest of the bone
.Also there are wedge-shaped radiolucent
areas at the crest of the interdental bone.
C, Radiolucent projections from the crest
into the interdental bone indicate extension
of destructive processes.
D, Severe bone loss

13. FURCATION INVOLVEMENT
• The slightest change(fuzziness) in the furcation
area should be examined clinically, especially if
there is bone loss on adjacent roots.
• Diminished radiodensity in the furcation area in
which outlines of bony trabeculae are visible
suggests furcation involvement
• Whenever there is marked bone loss in relation to
a single molar root, it may be assumed that the
furcation is also involved.

14. Furcation involvement
indicated by triangular
radiolucency in bifurcation
area of mandibular first
molar

15. Periodontal abscess
Appears as discrete area of radiolucency along the
lateral aspect of the root .
Its appearance depends on the
Stage of the lesion & Location of the abscess
Localized Aggressive Periodontitis
Bone loss in the incisors & first molars
Bilateral , angular /vertical defects and arc like destructive
patterns in first molar region

16. Localized aggressive periodontitis ---
Radiographs showing localized, vertical, angular bone loss
associated with the maxillary and mandibular first molars and the
central incisors.

17. TRAUMA FROM OCCLUSION
• Increased width of the periodontal space.
• Thickening of the lamina dura and sometimes condensation of
perialveolar cancellous bone.
• A vertical/angular bone loss.

18. Skeletal disturbances manifested in
the jaws
• Osteitis Fibrosa Cystica
• Paget’s disease
• Fibrous Dysplasia
• Langerhan’s cell histiocytosis
• Multiple Myeloma
• Osteopetrosis/Marble bone disease
• Scleroderma

19. ADVANCES IN RADIOGRAPHIC
ASSESSMENT
• DIGITAL RADIOGRAPHY
• SUBTRACTION RADIOGRAPHY
• C.A.D.I.A. (Computer Assisted Densitometric Image
Analysis)
• CONE BEAM COMPUTED TOMOGRAPHY(C.B.C.T)

20. DIGITAL RADIOGRAPHY
ADVANTAGES:
(1) Ability to produce a image that can instantly be viewed by
patient & dentist.(rapid image capture & display)
(2) Reduction in radiation received by patient by as much 50%
to 80% when compared to conventional radiography.(low x-
ray exposure)
(3) Images can be altered to achieve task specific image
characteristics eg. density & contrast can be lowered for
evaluation of marginal bone and increased for evaluation of
implant components.
(4) Digital imaging also enables dental team to conduct remote
consultations( in tele diagnosis & video conferencing)
(5) Computerized images can be stored, manipulated &
corrected for under & overexposure
(6) Edge enhancement

21. There are 2 digital radiography methods -
1.Direct method
2. Indirect method.
1. Direct Method/RVG (radio visio graphy )-
This method uses a Charge Couple Device (CCD) sensor linked
with fiberoptic or other wire to computer system.
CCD receptor is placed intraorally as traditional films & images
appear on a computer screen which can be printed or stored.
2. Indirect Method - This method uses a phosphor luminescence
plate, which is a flexible film like radiation energy sensor placed
intraorally & exposed to conventional x-ray tube.
A laser scanner then reads the exposed plates & reveals digital
image data.

22. SUBTRACTION
RADIOGRAPHY
• Radiographs are taken with identical
exposure geometry – serial radiographs
• This technique relies on conversion of serial radiographs into
digital images.
• The serially obtained digital images can then be superimposed
& resultant composite viewed on a video screen.
• This technique facilitates both qualitative & quantitative
visualization of even minor density changes in bone by
removing the unchanged anatomic structures from image.

23. DIAGNOSTIC SUBTRACTION
RADIOGRAPHY
• This technique combines the use of a positioning device with
specialized software designed for digital image subtraction.
• This software system applies an algorithm that corrects angular
alignment discrepencies & provide flexibility in imaging procedures.

24. Computer Assisted Densitometric Image
Analysis. (CADIA)
Video camera measures the light transmitted through radiograph
and the signals from the camera are converted to gray scale
images.
The camera is interfaced with an image processor and a
computer that allow the storage and mathematical manipulation
of the images.
Advantages:
Measures quantitative changes in bone density over time.
Higher sensitivity, reproducibility and accuracy as compared to
Digital substraction analysis.

25. Cone-Beam Computed Tomography(CBCT)
• Very accurate three-dimensional imaging technique
• Much less radiation exposure as compared to
conventional CT Scans.
• Very useful technique for implant patients.

26. CONCLUSION
• Conventional and advanced imaging systems have
proven a boon for diagnosis in periodontology.
Further advancements are also expected in near
future.
• These systems are technique sensitive & not free
from mechanical errors so a clinician should also
consider clinical signs & symptoms while reaching to
final diagnosis for a periodontal condition.