Presentation 1

Module 7: Interpretation of Dental Radiographs

Lesson 27: Radiographic Interpretation of Pulpal & Periapical Lesions & Radiopacities & Radiolucencies of the Jaws

Kathleen A. Hock, RDH, MAdEd Dental Hygiene Department

William Rainey Harper College

Module 7: Interpretation of Dental Radiographs

Lesson 27: Radiographic Interpretation of Pulpal & Periapical Lesions & Radiopacities & Radiolucencies of the Jaws

Kathleen A. Hock, RDH, MAdEd Dental Hygiene Department

William Rainey Harper College

Normal Radiographic Pulp Appearance Vascular connective tissue

interspersed with lymphatics Functions:

Blood supply Nutrition Innervation Dentin formation & defense

Radiolucent, well-defined

Alterations in the Pulp Chamber/Canal

Pulpal sclerosis Pulpal obliteration Pulp stone

Pulpal Sclerosis

Pulpal Sclerosis Diffuse calcification of the pulp

chamber/canals Maturing tooth responds to stimuli

(mastication, thermal changes, chemical irritants, slight trauma) by depositing secondary dentin

Results in narrowing of pulp chambers & root canals

Secondary dentin is less permeable, fewer tubules therefore less sensation; serves as pulpal protection No radiographic difference between primary & secondary dentin

No clinical features

Pulpal ObliterationPulpal Obliteration

Pulpal Obliteration Pulpal irritants (attrition, abrasion, caries,

restorations, trauma etc.) stimulate secondary dentin formation Tubules calcify resulting in obliteration of the pulp cavity; dentin impermeable

Defense reaction of the body Radiographically appears as though there is

no pulp chamber or canals; may also appear more radiopaque compared to normal dentin

Non-vital; no treatment

Pulpal Obliteration Pulpal irritants (attrition, abrasion, caries,

restorations, trauma etc.) stimulate secondary dentin formation Tubules calcify resulting in obliteration of the pulp cavity; dentin impermeable

Defense reaction of the body Radiographically appears as though there is

no pulp chamber or canals; may also appear more radiopaque compared to normal dentin

Non-vital; no treatment

Pulp Stones

Pulp Stones Localized masses of calcified material

within dentinal tubules-round, oval or fill canal

Formed by deposits of connective layers of calcium salts

Cause unknown-may be due to minor circulatory disturbances of the pulp vessels

Prevalence: 90% of all teeth in clients age 50-70 years

15% visible radiographically (1 out of 7) No symptoms or treatment

Pulpal Injuries Hyperemia Acute Pulpitis Fractures Displacement of teeth

Hyperemia Dilation & engorgement of pulp; edema;

increased capillary pressure due to prolonged vasodilatation

Pulp stimulation response often caused by hypersensitivity to thermal changes following cavity prep

Reversible; remove irritant & normal circulation established

No radiographic image

Pulpitis Vital but inflamed pulp, usually in

coronal portion of tooth Rigid wall of pulp chamber prevent

vascular dilation so intrapulpal pressure from severe inflammation may result in pulpal death

Degree of pain depends on pressure Pain spontaneous, diffuse Percussion negative Radiograph looks normal

Fractures Crown fractures

Anterior teeth most often involved Result of trauma Radiograph assists in determining

involvement of pulp Root fractures

Less common Anterior teeth most often involved May appear as a radiolucent line or not be

visible at all but enlarge with time

Fractures

Fractures

Fractures Jaw

Mandible most often involved Result of trauma Panoramic is radiographic of choice Appear as radiolucent line Difficult to detect on maxillae

Jaw Fractures

Displacement of the Teeth Luxation

Abnormal displacement Intrusion (into bone) Extrusion (out of bone)

Avulsion Complete displacement Usually result of trauma Use radiograph to

evaluate for splintered bone

Acute Apical Conditions

Acute Apical Periodontitis Acute Apical Abscess

Acute Apical Periodontitis Pulp non-vital or vital (occlusal trauma,

caries) Periapical area inflamed Exudate Throbbing pain No swelling Positive percussion test Slight widening of PDL space

Acute Apical Abscess Nonvital tooth Edema & exudate in PDL space Pain upon percussion Intense pain Swelling may be present; facial cellulitis May result from acute inflammation of pulp or

from an area of chronic infection such as a granuloma Widening of PDL or normal appearance if less than 10 days

Establish drainage

Chronic Apical Conditions Periapical granuloma Periapical cyst Chronic periapical abscess Condensing osteitis

Periapical Granuloma Most common apical condition

developing from pulpitis Localized mass of chronically

inflamed granulation tissue at apex of nonvital tooth

Defense tissue Will heal if irritant removed via

RCT May give rise to cyst or abscess

Periapical Granuloma Asymptomatic but history or

prolonged sensitivity to heat or cold

Radiographically Begins as widened PDL space Round or ovoid radiolucency, may not

be real dark; may see bone trabeculation

No lamina dura visible between root apex & apical lesion

Periapical Granuloma

Periapical Abscess Localized collection of pus resulting from

pulpal death Low grade, long standing inflammatory

reaction May develop from acute abscess or granuloma Usually asymptomatic due to drainage through

PDL(fistula track); may see parula Drainage & RCT Round or ovoid radiolucency with poorly

defined margins Lamina dura not visible

Periapical Abscess

Periapical Cyst Abnormal pathologic space within the

bone lined with epithelium & usually filled with fluid

Arises from preexisting granulomas Asymptomatic Pressure may cause resorption of

surrounding bone Most common cyst of the jaw (50-70% of all cysts in oral cavity)

Periapical Cyst Percussion, vitality & mobility

negative Radiolucent (very dark), bounded

by radiopaque border Develops over long period of time

Periapical Cyst

Condensing Osteitis Chronic focal sclerosing

osteomyelitis Well-defined radiopacity visible

below apex of nonvital tooth with history of long-standing pulpitis

Proliferation of bone resulting from low-grade infection

Bone reaction to inflammatory stimulation

Condensing Osteitis Mandibular first molar most commonly

involved Tooth asymptomatic & nonvital Radiolucent area circumscribed by

radiopaque area which remains even if tooth extracted Considered a physiologic reaction of bone to inflammation so no treatment indicated

Condensing Osteitis

Other Apical Conditions Periapical Cemental Dysplasia Hypercementosis Sclerotic Bone

Periapical Cemental Dysplasia

Benign, slow-growing connective tissue proliferation of unknown etiology originating from cellular elements of the periodontal ligament Destroys the lamina dura & replace trabecular bone with fibrous tissue mass

Visible around vital teeth

Periapical Cemental Dysplasia Most common in middle-aged

females especially African-Americans

Mandibular anteriors are most common location

Three stages Radiolucent Mixed Radiopaque

Hypercementosis Excess deposits of secondary

cementum on root surfaces No clinical signs or symptoms Results from:

Supraeruption Inflammation Trauma Idiopathic

Hypercementosis Apices appear enlarged & bulbous Lamina dura & periodontal

ligament space appear normal Teeth vital; no treatment required

Hypercementosis

Sclerotic Bone Osteosclerosis Well-defined radiopacity visible below

apices of vital, noncarious teeth Cause unknown but not believed to be associated with inflammation

Not attached to tooth & varies in size & shape

Margins irregular or diffuse Asymptomatic

Sclerotic Bone

Resorption Physiologic: normal

shedding or deciduous teeth

Pathologic: regressive alteration of tooth structure observed when a tooth is subjected to abnormal stimuli External Internal

External Resorption Affects apices of teeth Apices appear blunted & roots shorter Causes

Apical inflammation Tumors/cysts Reimplantation of teeth Excessive trauma/abnormal mechanical

forces Impacted teeth Idiopathic

External Resorption Lamina dura

& PDL intact No mobility or other clinical signs

No treatment

External Resorption

Internal Resorption Occurs within crown or

root Possible causes

Trauma Pulp capping Round/ovoid

radiolucency in crown or root

Asymptomatic May appear as pink spot RCT may be used if

tooth not weakened or extraction

Internal Resorption

Misinterpreted Nonpathological Apical Conditions

Terminal stage of root formation Widened PDL space

Usually result of trauma-occlusal, ortho, injury

Superimposition of radiolucent structures over teeth apices