radiographic pathology
TRANSCRIPT
Radiographic Radiographic PathologyPathology
““Radiographic appearances are governed by Radiographic appearances are governed by anatomic or physiologic changes in the presence of anatomic or physiologic changes in the presence of the disease processes. Radiographic ‘diagnosis’ is the disease processes. Radiographic ‘diagnosis’ is founded on a knowledge of these alterations, the founded on a knowledge of these alterations, the prerequisite being awareness of disease prerequisite being awareness of disease mechanisms.” (H.M. Worth)mechanisms.” (H.M. Worth)
Method of Radiographic Method of Radiographic Investigation and Film Investigation and Film
AnalysisAnalysis 1. Assess the quality of the film1. Assess the quality of the film
- A) film density (alterations due to exposure or processing A) film density (alterations due to exposure or processing errors).errors).
- B) image geometry (image distortion due to technique B) image geometry (image distortion due to technique errors).errors).
Method of Radiographic Method of Radiographic Investigation and Film Investigation and Film
AnalysisAnalysis 2.2. Examine the total film before concentrating Examine the total film before concentrating
on one specific region.on one specific region. 3.3. Examine the film for the presence of normal Examine the film for the presence of normal
anatomy and assess the shape and density of each anatomy and assess the shape and density of each structure. To accomplish this, one must have structure. To accomplish this, one must have knowledge of the variable appearance that knowledge of the variable appearance that “normal” anatomy may have. “normal” anatomy may have.
Method of Radiographic Method of Radiographic Investigation and Film Investigation and Film
AnalysisAnalysis 4.4. Make sure that the total area of interest is Make sure that the total area of interest is
present in the film. This may require a larger film present in the film. This may require a larger film format. Often a second view at a slightly different format. Often a second view at a slightly different angle or preferentially at right angles is angle or preferentially at right angles is advantageous (e.g. occlusal views). advantageous (e.g. occlusal views).
Method of Radiographic Method of Radiographic Investigation and Film Investigation and Film
AnalysisAnalysis 5.5. Suitable Viewing EquipmentSuitable Viewing Equipment
A) view boxA) view box
B) intense light sourceB) intense light source
C) maskC) mask
D) magnifying glassD) magnifying glass
E) room with subdued lighting E) room with subdued lighting
Method of Radiographic Method of Radiographic Investigation and Film Investigation and Film
AnalysisAnalysis 6.6. Referral for Other Imaging ProceduresReferral for Other Imaging Procedures
A) pantomographA) pantomograph
B) skull radiographyB) skull radiography
C) tomographsC) tomographs
D) sialographyD) sialography
E) arthrographyE) arthrography
F) nuclear medicineF) nuclear medicine
G) CT and MRIG) CT and MRI
Radiographic AnalysisRadiographic Analysis
1.1. Anatomic position of abnormalityAnatomic position of abnormalityA) localized or generalizedA) localized or generalizedB) unilateral or bilateralB) unilateral or bilateralC) monostotic or polystoticC) monostotic or polystoticD) point of origin (epicenter)D) point of origin (epicenter)
I I bone or soft tissuebone or soft tissue IIII in, outside, above, below inferior alveolar in, outside, above, below inferior alveolar
canalcanal IIIIII in, outside of max. antrum/ tooth follicle/ at in, outside of max. antrum/ tooth follicle/ at
apex of apex of toothtooth
Factors Associated with Factors Associated with HypercementosisHypercementosis
LOCAL FACTORSLOCAL FACTORS •• Abnormal occlusal traumaAbnormal occlusal trauma •• Adjacent inflammation (e.g., Adjacent inflammation (e.g.,
pulpal, periapical, pulpal, periapical, periodontal)periodontal) •• Unopposed teeth (e.g., Unopposed teeth (e.g.,
impacted, embedded, without impacted, embedded, without antagonist)antagonist) •• Repair of vital root fractureRepair of vital root fracture SYSTEMIC FACTORSSYSTEMIC FACTORS •• Acromegaly and pituitary Acromegaly and pituitary
gigantismgigantism •• ArthritisArthritis •• CalcinosisCalcinosis •• Paget disease of bone (osteitis Paget disease of bone (osteitis
deformans)deformans) •• Rheumatic feverRheumatic fever •• Thyroid goiterThyroid goiter •• Gardner syndromeGardner syndrome •• Vitamin A deficiency (possibly)Vitamin A deficiency (possibly)
Radiographic AnalysisRadiographic Analysis
2.2. Periphery of the abnormalityPeriphery of the abnormality
- A) discrete borders- A) discrete borders I punched out- no bone reaction IIII corticated- uniform thin RO linecorticated- uniform thin RO line IIIIII sclerotic border- non-uniform RO bordersclerotic border- non-uniform RO border IVIV soft tissue capsule- uniformly thin or irregular width soft tissue capsule- uniformly thin or irregular width
Radiographic AnalysisRadiographic Analysis
2.2. Periphery of the abnormality (Continued)Periphery of the abnormality (Continued)
- B) Non- discrete borders- B) Non- discrete borders II blends in with normal anatomyblends in with normal anatomy IIII signs of invasion (e.g. enlargement of adjacent signs of invasion (e.g. enlargement of adjacent
marrow spaces; “finger-like” extensions of marrow spaces; “finger-like” extensions of destruction; multifocal or “skip lesions”destruction; multifocal or “skip lesions”
Radiographic AnalysisRadiographic Analysis
2.2. Periphery of the abnormality (Continued)Periphery of the abnormality (Continued)
C) shape of lesionC) shape of lesion II irregularirregular IIII curved surface or hydrauliccurved surface or hydraulic IIIIII undulating or scallopingundulating or scalloping
Radiographic AnalysisRadiographic Analysis
3.3. Internal StructureInternal Structure-- A. densityA. density
II radiolucent (completely)radiolucent (completely) IIII mixed RL/ROmixed RL/RO IIIIII radiopaque (completely)radiopaque (completely)
Radiographic Analysis Radiographic Analysis (Internal Structure (Internal Structure
Continued)Continued) B) description of RO structuresB) description of RO structures
- I- I bone trabeculae (ground glass, orange peel, bone trabeculae (ground glass, orange peel, cottoncotton wool, etc.)wool, etc.)
- II- II cortical bone (homogeneous)cortical bone (homogeneous)
- III- III bony septum (thin/coarse; straight/curved; bony septum (thin/coarse; straight/curved; prominent/faintprominent/faint
- IV- IV cementum (oval/round; amorphous)cementum (oval/round; amorphous)
- V- V tooth structure (shape; density; pulp chamber; tooth structure (shape; density; pulp chamber; PDL; PDL; lamina dura)lamina dura)
- VI- VI no specific patternno specific pattern
Radiographic Analysis Radiographic Analysis (Internal Structure (Internal Structure
Continued)Continued) C) Comparative radiolucency to radiopacityC) Comparative radiolucency to radiopacity
- E.g. fat, air, gas, fluid, soft tissue, medullary spaces; - E.g. fat, air, gas, fluid, soft tissue, medullary spaces; cancellous bone, cortical bone, cementum, dentin, cancellous bone, cortical bone, cementum, dentin, enamel, metals (from most radiolucent to most enamel, metals (from most radiolucent to most
radiodense)radiodense) D) Identification of RO structuresD) Identification of RO structures
Tooth material; bone; cementum, calcified Tooth material; bone; cementum, calcified cartilage, cartilage, dystrophic calcificationdystrophic calcification
Osteomas in Gardner Osteomas in Gardner SyndromeSyndrome
Radiographic AnalysisRadiographic Analysis
4.4. Behavior as suggested by the effects on the Behavior as suggested by the effects on the surrounding structuressurrounding structures
- A) structures to assess - A) structures to assess II teeth- displacement, resorption, lamina dura, PDL, pulp teeth- displacement, resorption, lamina dura, PDL, pulp
chamber, follicular space, cortex, shape and density of chamber, follicular space, cortex, shape and density of toothtooth IIII surrounding cortical structures- cortex of canals, antrum, etc.surrounding cortical structures- cortex of canals, antrum, etc. IIIIII surrounding cancellous bone- destruction versus bone formation surrounding cancellous bone- destruction versus bone formation
and sclerosisand sclerosis IVIV other structures, e.g. inferior alveolar canal, etc.other structures, e.g. inferior alveolar canal, etc.
Radiographic AnalysisRadiographic Analysis
B) Behavioral characteristics B) Behavioral characteristics
- 1.- 1. DisplacementDisplacement
- 2.- 2. ExpandExpand
- 3.- 3. DestroyDestroy
- 4.- 4. Cause periosteal bone formationCause periosteal bone formation
- 5.- 5. Cause increase in cancellous boneCause increase in cancellous bone
- 6.- 6. Increase in soft tissue massIncrease in soft tissue mass
Radiographic AnalysisRadiographic Analysis
B) Behavioral characteristics (Continued)B) Behavioral characteristics (Continued)
- 7.- 7. Increase in normal width Increase in normal width e.g. Peridontal membrane spacee.g. Peridontal membrane space
-- Inferior alveolar canalInferior alveolar canal
- Pulp chamber- Pulp chamber
- 8.- 8. Cause irregular bone remodelingCause irregular bone remodeling e.g. Resulting in unusual shape or unusual bone e.g. Resulting in unusual shape or unusual bone
pattern pattern
Unique Unique Radiographic Radiographic AppearancesAppearances
““Ground Glass”Ground Glass”
1. Fibrous dysplasia1. Fibrous dysplasia 2.2. HyperparathyroidismHyperparathyroidism
Fibrous dysplasia – PatientAge First and second decadesFirst and second decades
Fibrous dysplasia – Location Maxilla favored
Fibrous dysplasia – Radiographic Appearance
Poorly defined radiographic mass; diffuse Poorly defined radiographic mass; diffuse opacification often described as “ground glass”.opacification often described as “ground glass”.
Other radiographic appearances include ill-defined Other radiographic appearances include ill-defined radiolucency (early lesion).radiolucency (early lesion).
Fibrous dysplasia – Other Features
Slow growing and asymptomatic; causes cortical Slow growing and asymptomatic; causes cortical expansion; may stop growing after puberty; a cosmetic expansion; may stop growing after puberty; a cosmetic problem treated by recontouring. Variants: monostotic problem treated by recontouring. Variants: monostotic – one bone affected; polystotic –more that one bone – one bone affected; polystotic –more that one bone affected; Mc Cune-Albright syndrome includes: affected; Mc Cune-Albright syndrome includes: fibrous fibrous dysplasia plus cafdysplasia plus café au lait macules and é au lait macules and endocrine endocrine abnormalities (e.g. precocious puberty in abnormalities (e.g. precocious puberty in females); Jaffe-females); Jaffe- Lichtenstein syndrome – multiple Lichtenstein syndrome – multiple bone lesions of fibrous dysplasia and skin bone lesions of fibrous dysplasia and skin pigmentations; rare.pigmentations; rare.
Giant Cell Lesion of (Primary)
Hyperparathyroidism Predominant region – None Other radiographic appearances – Multilocular,
indistinct borders Additional features – Polydipsia; polyuria; serum
calcium levels ↑; serum phosphate levels ↓; serum alkaline phosphatase levels ↑
Giant Cell Lesion of (Primary)
Hyperparathyroidism Predominant gender – F 7:1 Usual age (years) – 30-60 Predominant jaw - Mandible
Hyperparathyroidism - Primary Calcium – Increased Phosphorus – Decreased Alkaline phosphatase - Increased
Giant Cell Lesion of (Secondary)
Hyperparathyroidism Predominant region – None Other radiographic appearances – multilocular,
indistinct borders Additional features – History of kidney disease;
serum calcium levels normal to ↓; serum phosphate levels↑; serum alkaline phosphatase levels ↑
Giant Cell Lesion of (Secondary)
Hyperparathyroidism Predominant gender – F 2:1 Usual age (years) – 50-80 Predominant jaw - Mandible
Hyperparathyroidism - Secondary Calcium – Normal to decreased Phosphorous – Increased Alkaline phosphatase - Increased
“Cotton Wool”
1. Paget disease (osteitis deformans) 2. Periapical cemento-osseous dysplasia 3. Gardner syndrome (Osteoma) 4. Gigantiform cementoma
Paget Disease – Patient Age Over 40 years of age
Paget Disease – Location
Maxilla favored, bilateral and symmetric
Paget Disease – Radiographic Appearance
Diffuse lucent to opaque bone changes; opaque lesions described as “cotton wool”; hypercementosis, loss of lamina dura, obliteration of periodontal ligament space, and root resorption may be seen.
Paget’s disease – Other Features
Patients may develop pain, deafness, blindness, and headache because of bone changes; initial complaint may be that denture is too tight; diastemas may develop;
complications of hemorrhage early,
infection and fracture late; alkaline
phosphate elevated; etiology unknown but affects bone metabolism.
Periapical Cemento-Osseous Dysplasia
Cause: Reactive Age/Race/Sex: Fifth decade; F>M; African-
American (Black) Location: Anterior mandible Clinical Features: Asymptomatic lesion (s),
often multiple; teeth are vital.
Periapical Cemento-Osseous Dysplasia
Radiographic Features: Well-defined radiolucency to radiopacity (depending on stage of lesion) at the area of the tooth apex; often more than one tooth involved; usually mandibular incisors
Microscopic Features: Fibrous connective tissue and calcifications
Treatment: None Diagnostic Process: Radiographic
OsteomaOsteoma Osteomas are benign lesions of bone that Osteomas are benign lesions of bone that
in many cases represent developmental in many cases represent developmental growths rather than true neoplasms.growths rather than true neoplasms.
They are composed of woven and lamellar They are composed of woven and lamellar bone.bone.
The most common locations are the facial The most common locations are the facial bones and skull and they are most bones and skull and they are most common in the 40-50 age group.common in the 40-50 age group.
Most osteomas are exophytic growths but Most osteomas are exophytic growths but they may arise within bone.they may arise within bone.
OsteomaOsteoma
Multiple osteomas are seen in Gardner Multiple osteomas are seen in Gardner syndrome, a polyposis syndrome, which syndrome, a polyposis syndrome, which has significant malignant complications has significant malignant complications and oral manifestations.and oral manifestations.
Osteomas are generally slow-growing Osteomas are generally slow-growing tumors of little clinical significance except tumors of little clinical significance except when they cause obstruction or produce when they cause obstruction or produce cosmetic problems.cosmetic problems.
Osteomas do not undergo malignant Osteomas do not undergo malignant changechange
““Sunburst Radiopacities”Sunburst Radiopacities”
OsteosarcomaOsteosarcoma Intraosseous HemangiomaIntraosseous Hemangioma
Osteosarcoma – Clinical Osteosarcoma – Clinical FeaturesFeatures
Third and fourth decades; can occur Third and fourth decades; can occur in either jaw although some studies in either jaw although some studies indicate is more common in indicate is more common in mandible; juxtacortical subtype mandible; juxtacortical subtype arises from periosteum.arises from periosteum.
Osteosarcoma –Radiographic Appearance
Poorly defined lucency with spicules of opaque material’ “sunburst” pattern may be seen; juxtacortical lesion appears as radiodense mass on the periosteum
Osteosarcoma – OtherFeatures
Swelling, pain, or paresthesia are
diagnostic features; patients may have vertical mobility of teeth and asymmetric (uniformly) widened periodontal ligament space; prognosis fair to poor, good prognosis for juxtacortical lesions
Hemangioma (White & Hemangioma (White & Pharoah)Pharoah)
“Onion-Skin”
1. Proliferative periostitis 2. Ewing sarcoma 3. Langerhans cell disease
PROLIFERATIVE PERIOSTITIS
Also known as Periostitis Ossificans or Garrè’s Osteomyelitis
Proliferative Periostitis represents a periosteal reaction to the presence of inflammation
The affected periosteum forms several rows of reactive vital bone that parallel each other and expand the bone
PROLIFERATIVE PERIOSTITIS
Mean age is approximately 13 years with no gender predilection.
Most frequent cause is dental caries. Most arise in the mandibular premolar/molar
region with involvement of the lower border. Most cases are unifocal.
PROLIFERATIVE PERIOSTITIS: Radiographic
Features Appropriate radiographs reveal radiopaque
laminations of bone that roughly parallel each other and underlying cortical surface.
If bony destruction is seen in association with thecortical surface or new periosteal bone, then
clinical should consider the possibility of a neoplastic process, e.g. Ewing sarcoma.
PROLIFERATIVE PERIOSTITIS
Treatment & Prognosis: Treatment consists of the elimination of the
source of infection via endo or extraction. Resolution typically occurs in 6 to 12 months
following successful treatment of the infection.
Ewing Sarcoma – Patient Age
Children and young adults
Ewing Sarcoma – Location
Mandible favored
Ewing Sarcoma –Radiographic Appearance
Diffuse lucency; poorly defined; periosteal reaction; “onion-skin”, may be present; may be multilocular.
Ewing Sarcoma – Other Features
Swelling, pain, or paresthesia may be present; prognosis is poor; malignant cell is of unknown origin but may be of neuroendocrine origin; rare tumor.
Ewing Sarcoma
Predominant gender – M 2:1 Usual age (years) – 5-24 (peak 14-18) Predominant jaw – Rare in maxilla Additional features – Metastasizes to lymph
nodes, lungs, and other bones, rapid course Other radiographic appearances – Onionskin
growth of periosteal bone, sunburst.
Soft Tissue Radiopacities
1. Amalgam tattoo 2. Sialolith 3. Calcified lymph nodes 4. Phlebolith 5. Tonsillolith 6. Osseous/Cartilaginous choristoma 7. Calcinosis cutis 8. Myositis ossificans 9. Other foreign bodies
Amalgam TattooAmalgam Tattoo
SIALOLITHS
CALCIFIED LYMPH NODES
PHLEBOLITHS
ANTROLITHS
CREST Syndrome
C- calcinosis
R- Raynaud’s phenomenon
E- esophageal dysmotility
S- sclerodactyly
T- telangiectasia
(Also presence of anticentromere antibodies)
FOREIGN BODIES