what else could this be? differential overview exploring...

What Else Could This Be? Exploring Diagnostic

QuandariesDavid Landwehr D.D.S., M.S.

Capital EndodonticsMadison, WI

Metabolic

Infectious

Neoplastic

Developmental

Differential Overview

NervesVeins

Glandular elements

Arteries

Bone

Odontogenic epithelium

Smooth Muscle

Radiology limitations

One piece of Subjective diagnostic information

Who is Reading the Radiograph ?

Goldman M, Pearson A, Darzenta N. Reliability of radiographic interpretations. Oral

Surg  1974; 38(2):340.

Who is Reading the Radiograph ?

Goldman M, Pearson A, Darzenta N. Reliability of radiographic interpretations. Oral

Surg  1974; 38(2):340.

Interexaminer agreement ~ 50%Intraexaminer agreement ~ 75 - 80 %

Who is Reading the Digital Radiograph ?

100% agreement < 25%5 agree ~ 50%

Intraobserver reliability range 41 % - 85 % Average 68 %

Tewary S, Luzzo J, Hartwell G. Endodontic radiography: who is reading the digital radiograph? J Endod. 2011 Jul;37(7):

919-21.

Radiology limitations

Sensitivity 0.65Specificity 0.78

Overall accuracy 70.2%Bohay RN. The sensitivity, specificity, and reliability of radiographic

periapical diagnosis of posterior teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000 May;89(5):639-42.

Bone loss will not be detected if the lesion is only in cancellous

bone

PA lesion when bone loss extends to the junction of the cortical and

cancellous bone

Radiology limitations

Bender IB, Seltzer S: Roentgenographic and direct observation of experimental lesions in bone. Part I. J Am Dent

Assoc  1961; 62:152.

Radiology limitations

Certain teeth are more prone to exhibit

radiographic changes than others, depending

on their anatomic location

Bender IB, Seltzer S: Roentgenographic and direct observation of experimental lesions in bone. Part II. J

Am Dent Assoc  1961; 62:708.

Radiology limitations

Lesions were always larger than the radiographic image, especially in the molar region

Shoha RR, Dowson J, Richards AG. Radiographic interpretation of experimentally produced bony lesions. Oral Surg Oral Med

Oral Pathol. 1974;38(2):294-303.

Lesions were evident on the radiograph before junctional bone or cortical plate was involved

Radiology limitations

7.1% mineral bone loss to produce a radiolucency

Lesions 1-7 mm didn’t produce a lesion in cancellous bone

Bender IB. Factors influencing the radiographic appearance of bony lesions. J Endod 1982 Apr;8(4):161-70.

Cone-Beam Computed

Tomography (CBCT)

Recommendation 2:

Limited FOV CBCT should be considered the imaging modality of choice for diagnosis in patients who present with contradictory or

nonspecific clinical signs and symptoms associated with

untreated or previously endodontically treated teeth

CBCTCBCT is accurate in detecting apical

periodontitis

Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic

and periapical radiography for detection of apical periodontitis.vJ Endod 2008 Mar;34(3):273-9.

De Paula-Silva FW, Wu MK, Leonardo MR, da Silva LA, Wesselink PR. Accuracy of periapical radiography and cone-

beam computed tomography scans in diagnosing apical periodontitis using histopathological findings as a gold

standard. J Endod 2009 Jul;35(7):1009-12.

CBCTCBCT devices demonstrated poor accuracy in detecting simulated lesions smaller than

0.8 mm in diameter

fair to good accuracy when simulated lesion diameter was between 0.8–1.4 mm

excellent accuracy when simulated lesions were larger than 1.4 mm in diameter

Tsai P, Torabinejad M, Rice D, Azevedo B. Accuracy of cone-beam computed tomography and periapical radiography in detecting small periapical lesions.

J Endod 2012 Jul;38(7):965-70.

Edwards R, Altalibi M, Flores-Mir C. The frequency and nature of incidental findings in cone-beam computed tomographic scans of

the head and neck region: a systematic review. J Am Dent Assoc 2013 Feb;144(2):161-70.

CBCT Sensitivity

1.3 - 2.9 incidental findings per CBCT

24 - 93 % of scans had incidental findings

1029 scans looked at by 3 observers for changes in maxillary

sinus

prevalence of pathology was 56.3 %

CBCT Sensitivity

Ritter L, Lutz J, Neugebauer J, Scheer M, Dreiseidler T, Zinser MJ, Rothamel D, Mischkowski RA. Prevalence of pathologic findings in the maxillary sinus in cone-

beam computerized tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011 May;111(5):634-40.

Clinicians’ experience level appears to be correlated with their

ability to correctly diagnose periapical disease in CBCT

volumes

CBCT Limitations

Parker JM, Mol A, Rivera EM, Tawil PZ. Cone-beam Computed Tomography Uses in Clinical Endodontics: Observer Variability in

Detecting Periapical Lesions. J Endod 2017 Feb;43(2):184-187.

Remember

• Common things occur more often *** • Same lesion can have different presentations • Similar clinical presentations can have different

treatments and potential outcomes• Patient can have more than a single pathology

Remember

• 90% ≠ 100%

• Smaller lesions- unilocular• Larger lesions- multilocular

• These lists have crossover and omissions

Systematic Differential Diagnosis

of Periapical Pathology

Unilocular

Multilocular

MULTILOCULAR RADIOLUCENCIES

Odontogenic keratocyst***Ameloblastoma***

Central giant cell granuloma**

MULTILOCULAR RADIOLUCENCIES

Keratocystic Odontogenic Tumor***Ameloblastoma***

Central giant cell granuloma**

Keratocystic Odontogenic Tumor

• 3-11% of all cysts• Infancy to old age (rare before 10)• Mn in 60-80%• Posterior body and ramus

Keratocystic Odontogenic Tumor

• Usually asymptomatic- pain, drainage, swelling with larger lesions

• Grow in AP direction• 25-40% will have impacted tooth • Recurrence

Ameloblastoma

• Tumor of Odontogenic epithelium• Incidence • Expansion is frequent• Resorption of roots common• Slow growing

Ameloblastoma• Locally invasive • Usually benign• Wide age range (rare before 10)• Equal prevalence 3rd-7th decade• M=F• 80% Mn (usually posterior)

Ameloblastoma

• Often asymptomatic• Painless swelling or

expansion• Can grow to large size• Pain/ paresthesia

MULTILOCULAR RADIOLUCENCIES*

Ameloblastic fibromaOdontogenic myxoma

Central odontogenic fibromaCalcifying epithelial odontogenic tumor

Orthokeratinized odontogenic cystLateral periodontal cyst (botryoid type)

Calcifying odontogenic cyst

MULTILOCULAR RADIOLUCENCIES*

Ameloblastic fibromaOdontogenic myxoma

Central odontogenic fibromaCalcifying epithelial odontogenic tumor

Orthokeratinized odontogenic cystLateral periodontal cyst (botryoid type)

Calcifying odontogenic tumor

MULTILOCULAR RADIOLUCENCIES*

Central hemangioma/arteriovenous malformationAneurysmal bone cyst

CherubismHyperparathyroidism (brown tumor)

Intraosseous mucoepidermoid carcinoma

Isolated

Multifocal

Multifocal

Cemento-osseous dysplasia***

Nevoid basal cell carcinoma syndrome**Multiple myeloma**

Cherubism*Hyperparathyroidism*

Langerhans cell histiocytosis*

Periapical Cemento-osseous Dysplasia

• Early lesions will be radiolucent but with time this will change

• Anterior Mn• More common multiple, solitary

possible

Periapical Cemento-osseous Dysplasia

• Female (10:1)• 70% African American• Initial Dx between 30-50 years of

age (almost never before 20)• Vital pulps• Asymptomatic

Radiolucent

MixedRadiopaque

Torus or exostosisRetained root tip

Condensing osteitisIdiopathic osteosclerosis

RADIOPACITIES: WELL-DEMARCATED BORDERS***

Well Defined

Poorly Defined

RADIOLUCENCIES: ILL DEFINED

Periapical granuloma or cyst***Focal osteoporotic marrow defect***

Osteomyelitis**Bisphosphonate-associated osteonecrosis**

Drug Related Osteonecrosis of the Jaw?

SunitinibSunitinib inhibits cellular signaling by

targeting multiple receptor tyrosine kinases (RTKs)

These include all receptors for platelet-derived growth factor (PDGF-Rs) and

vascular endothelial growth factor receptors (VEGFRs)

DenosumabHuman monoclonal antibody for the

treatment of osteoporosis, bone metastases, rheumatoid arthritis, multiple

myeloma, and giant cell tumor of bone

Targets RANKL (RANK ligand), a protein that acts as the primary signal for bone

removal

Bevacizumab

Recombinant IV humanized mAb binds to VEGF

Block angiogenesis through inhibition of cell proliferation and

vessel sprouting

RADIOLUCENCIES: ILL DEFINED*

Metastatic tumorsOsteoradionecrosisMultiple myeloma

Primary intraosseous carcinomas odontogenic or salivary

RADIOLUCENCIES: ILL DEFINED*

OsteosarcomaChondrosarcomaEwing's sarcoma

Other primary bone malignancies: fibrosarcoma, lymphoma

Desmoplastic fibroma of boneMassive osteolysis

NICO (neuralgia-inducing cavitational osteonecrosis)

Unilocular Well Defined

Isolated Radiolucencies

UNILOCULAR RADIOLUCENCIES:

PERIAPICAL

Periapical granuloma***Periapical cyst***

Periapical cemento-osseous dysplasia (early)**

Periapical scar*Dentin dysplasia type I *

UNILOCULAR RADIOLUCENCIES:OTHER LOCATIONS

Developing tooth bud***

Lateral radicular cyst**Nasopalatine duct cyst**Lateral periodontal cyst**

Residual (periapical) cyst**Odontogenic keratocyst**

Central giant cell granuloma**Stafne bone defect**

THICKENED PERIODONTAL LIGAMENT

Periapical abscess***Current orthodontic therapy***

Increased occlusal function**Systemic sclerosis (scleroderma)Sarcoma or carcinoma infiltration

Radiology Limitations

“interpreting the lamina dura continuity, shape and density, and the periodontal ligament width and shape

proved to be the best radiographic features”

Kaffe I, Gratt BM. Variations in the radiographic interpretation of the periapical dental region. J Endod 1988 Jul;14(7):330-5.

Can have PA radiolucency or PDL changes and

inflamed tissue in root canal

Yamasaki M1, Kumazawa M, Kohsaka T, Nakamura H, Kameyama Y. Pulpal and periapical tissue reactions after experimental pulpal exposure in rats. J

Endod 1994 Jan;20(1):13-7.

Radiology limitations

CBCT Limitations

PDL spaces of a healthy teeth demonstrated significant

variation when examined by CBCT

Pope O, Sathorn C, Parashos P. A comparative investigation of cone-beam computed tomography and periapical radiography in the diagnosis of a healthy periapex. J Endod 2014 Mar;40(3):360-5.

Diagnosis: Necrotic Pulp, Symptomatic Apical Periodontitis

45 year old male

No significant medical history

“ I can’t sleep and have had extreme sensitivity to heat, cold

and pressure for 10 days”

Pulp contents necrotic

Root canal treatment completed in a single session

without complication

Patient reported immediate improvement - follow up

phone call11 month recall

11 month recall

THICKENED PERIODONTAL LIGAMENT

Periapical abscess***Current orthodontic therapy***

Increased occlusal function**Systemic sclerosis (scleroderma)Sarcoma or carcinoma infiltration

SYSTEMIC SCLEROSIS

Probably immunologically mediatedRare (19/million/year)

Dense collagen depostition in large amounts F>M (3-5 times more likely)

AdultsInsidious onset… Raynaud’s Phenomenon

SYSTEMIC SCLEROSIS

Organ involvement subtle at first

Fibrosis of lungs, heart, kidneys, GI tract leads to organ failure

(usually within 3 years of Dx)

Nerves Veins

Glandular elements

ArteriesBone

Odontogenic epithelium

Smooth MuscleMINDPerfection is not attainable, but if we chase

perfection we can catch excellence

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