1. Radiographic Interpretation of Dental Caries, Periodontal Disease, and Pulpal and periapical Lesions

2. Interpretation Versus Diagnosis
Explanation of what is viewed on a dental radiograph; the ability to read what is revealed by a dental radiograph
WHEREAS
Diagnosis refers to the identification of disease by examination or analysis
Radiographic interpretation enables the dental professional to play a vital role in the detection of diseases, lesions, and conditions of the teeth and jaws that cannot be identified clinically

3. radiographs are taken to benefit the patient; radiographs must be taken at the beginning of the dental appointment, interpreted, and then used for diagnostic, therapeutic, and educational purposes
Should be reviewed and interpreted immediately in the presence of the patient
If any suspicious or questionable areas are seen on the films, the patient can be examined clinically to obtain additional information or to confirm the problem that is suspected radiographically
Dental radiographs are best interpreted by the dental professional on a view box in a room with dimmed lighting

4. educational tool
By identifying and discussing what is normally found on a dental radiograph. Then the dentist can focus on specific problems or areas of concern

5. INTERPRETATION OF CARIES
To detect dental caries, both a careful clinical examination and a radiographic examination are necessary
A dental examination for caries cannot be considered complete without radiographs
It enable the dental professional to identify carious lesions that are not visible clinically, and allow to evaluate the extent and severity of carious lesions

6. Radiographs are useful in the detection of dental caries because of the nature of this disease process; demineralization and destruction of the hard tooth structures result in a loss of tooth density in the area of the lesion
Decreased density allows greater penetration of x-rays in the carious area, so that the carious lesion appears radiolucent on a dental radiograph

7. The bite-wing radiograph is the radiograph of choice for the evaluation of caries because it provides the dental professional with diagnostic information that cannot be obtained from any other source
Periapical radiograph using the paralleling technique can also be useful

8. Interproximal Caries
Interproximal caries is typically seen at or just below (apical to) the contact point. This area is difficult if not impossible to examine clinically with an explorer
As caries progresses inward through the enamel of the tooth,

9. INCIPIENT INTERPROXIMAL CARIES Class I
Incipient interproximal caries extends less than ½ through the thickness of enamel

10. MODERATE Interproximal CARIES Class II
Extends more than ½ through the thickness of enamel but does not involve the DEJ

11. ADVANCED INTERPROXIMAL CARIES Class III
Extends to or through the DEJ and into dentin but does not extend through the dentin more than ½ the distance toward the pulp

12. SEVERE INTERPROXIMAL CARIES Class IV
Extends through enamel, dentin, and more than ½ the distance toward the pulp
May appear clinically as a cavitation

13. Occlusal Caries
Clinical examination is the method of choice for the detection of occlusal caries
Because of the superimposition of the dense buccal and lingual enamel cusps, early occlusal caries is difficult to see on a dental radiograph; consequently, occlusal caries is not seen on a radiograph until there is involvement of the DEJ

14. INCIPIENT OCCLUSAL CARIES
Cannot be seen on a dental radiograph and must be detected clinically with an explorer

15. MODERATE OCCLUSAL CARIES
Extends into dentin and appears as a very thin RL line
The RL is located under the enamel, little if any radiographic change is noted in the enamel

16. SEVERE OCCLUSAL CARIES
Extends into dentin and appears as a large RL extends under the enamel of the occlusal surface of the tooth
Severe occlusal caries is apparent clinically and appears as a cavitation in a tooth

17. Buccal and Lingual Caries
Because of the superimposition of the densities of normal tooth structure, buccal and lingual caries are difficult to detect on a dental radiograph and are best detected clinically
When viewed on a dental radiograph, caries that involves the buccal or lingual surface appears as a small, circular radiolucent area

18. Root Surface Caries
Only the cementum and dentin located just below the cervical region or the tooth is involved
Bone loss and corresponding gingival recession precede the caries process and result in exposed root surfaces
Clinically, root surface caries is easily detected on exposed root surfaces, the most common locations include the exposed roots of the mandibular premolar and molar areas
On a dental radiograph, root surface caries appears as a cupped-out or crater-shaped RL just below the CEJ, Early lesions may be difficult to detect on a dental radiograph

19. Recurrent Caries
Caries reoccurs because of inadequate cavity preparation, defective margins, or incomplete removal of caries prior to the placement of the restoration
On a dental radiograph, recurrent caries appears as a radiolucent area just beneath a restoration
Recurrent caries occurs most often
beneath the interproximal margins of a restoration

20. Rampant Caries The term rampant means growing or spreading unchecked
Is advanced and severe caries that affects numerous teeth
Rampant caries is typically seen in
children with poor dietary habits or in
adults with a decreased salivary
flow

22. periodontium
The tissues that invest and support the teeth such as the gingiva and alveolar bone.
The radiographic appearance of healthy alveolar bone:
lamina dura: In health, LD around the roots of the teeth appears as a dense RO
Alveolar crest: normal healthy AC located 1.5 to 2.0 mm apical to the CEJ of adjacent teeth
Anterior AC appears pointed and sharp and is normally very RO
Posterior AC appears flat, smooth, and parallel to a line between adjacent CEJ, and appears slightly less RO than anterior AC
Periodontal ligament space: normal PLS appears as a thin RL line between the root of the tooth and the LD
In health, PLS is continuous around the root structure and is of uniform thickness

24. Interpretation OF PERIODONTAL DISEASE
With periodontal Disease, AC is no longer located 1.5 to 2.0 mm apical to the CEJ and no longer appears RO
INSTEAD
AC appears indistinct, and bone loss is seen
Periodontal disease may result in severe destruction of bone and loss of teeth

25. Useful radiographical view
PA with parallel technique and vertical BW radiograph are the film of choice for the evaluation of periodontal disease
With the paralleling technique, the height of CB is accurately recorded in relation to the tooth root
If the bisecting technique is used to expose PA radiographs, a dimensional distortion of bone is seen because of the vertical angulation used. As a result, PA films using the bisecting technique may appear to show more or less bone loss than is actually present
The horizontal BW has limited use in the detection of periodontal disease; severe interproximal bone loss cannot be adequately visualized on horizontal BW radiographs
The panoramic film has little diagnostic value in the identification of periodontal disease and is not recommended to demonstrate the anatomic features of this condition

26. Radiographs are especially helpful in the evaluation of the following points:
Amount of bone present
Condition of the alveolar crests
Bone loss in the furcation areas
Width of the periodontal ligament space
Local initiating factors that cause or intensify periodontal disease
Calculus
Poorly contoured or overextended restorations
Root length and morphology and the crown-to-root ratio
Anatomic considerations
Position of the maxillary sinus in relation to a periodontal deformity
Missing, supernumerary, or impacted teeth
Pathologic considerations
Caries
Periapical lesions
Root resorption

27. Limitation of radiographs
Radiographs may provide an incomplete presentation of the status of the periodontium
Radiographs provide a 2-dimensional view of a 3-dimensional situation. Because the radiographic image fail to reveal the 3-dimensional structure, bony defects overlapped by higher bony walls may be hidden
Also, because of overlapping tooth structure, only the interproximal bone is seen clearly. However, subtle changes in the density of the root structure may indicate bone loss on the buccal or lingual aspect of the tooth
Radiographs typically show less severe bone destruction than is actually present. The earliest mild destructive lesions in bone do not cause a sufficient change in density to be detectable
Radiographs do not demonstrate the soft-tissue-to-hard- tissue relationships and thus provide no information about the depth of soft tissue pockets
Bone level is often measured from the CEJ; however, this reference point is not valid is situation in which either over eruption or sever attrition with passive erupted exists

28. INTERPRETATION OF PERIODONTAL DISEASE
Bone Loss
Radiograph view the amount of bone remaining rather than the amount of bone lost. However, in documenting bone levels, the amount of bone loss that has occurred is recorded rather than the amount of bone that remains
The amount of bone loss can be estimated as the difference between the physiologic bone level and the height of remaining bone

29. PATTERN
The pattern of bone loss can be described as either horizontal or vertical. The CEJ of adjacent teeth can be used as a plane of reference in determining the pattern of bone loss present
Horizontal bone loss occurs in a plane parallel to the CEJ of adjacent teeth
Vertical bone loss (also known as angular bone loss), the bone loss does not occur in a plane parallel to the CEJ of adjacent teeth

30. Horizontal bone loss
Vertical bone loss

31. distribution

32. Severity
The severity of bone loss is measured as a percentage of loss of the normal amount of bone:
Mild bone loss: crestal changes
Moderate bone loss: bone loss of 10-33%
Sever bone loss: bone loss of 33% or more

33. Classification of periodontal disease
American Dental Association classified periodontal disease as follows:
ADA Case Type I (gingivitis)
ADA Case Type II (early periodontitis)
ADA Case Type III (moderate periodontitis)
ADA Case Type IV (advanced periodontitis).
Radiographs can also be used to detect the contributing factors of periodontal disease, such as calculus and defective restorations.

34. ADA CASE TYPE I
There is no bone loss associated with type I disease (gingivitis), and therefore, no radiographic change in the bone is seen

35. ADA CASE TYPE II
Mild crestal changes

36. ADA CASE TYPE III The bone loss about 10-33%
The pattern of bone loss may be horizontal or vertical; the distribution may be localized or generalized. Furcation involvement, or the extension of periodontal disease between the roots of multi-rooted teeth, may also be seen with type III disease
When the bone in the furcation area is destroyed, a radiolucent area is evident on the dental radiograph

37. ADA CASE TYPE III

38. ADA CASE TYPE IV
The bone loss is severe about 33% or more

39. Predisposing Factors for periodontal diseases
CALCULUS
DEFECTIVE RESTORATIONS

40. CALCULUS Calculus appears RO on a dental radiograph
Although calculus may have a variety of appearances, it most often appears as pointed or irregular RO projections extending from the proximal root surfaces

41. CALCULUS
Calculus may also appear as a ring-like RO encircling the cervical portion of a tooth, a nodular, or a smooth RO on a root surface

42. DEFECTIVE RESTORATIONS
Faulty dental restorations act as potential food traps and lead to the accumulation of food debris and bacterial deposits
They can be detected both clinically and radiographically
Radiographs show restorations with open or loose contacts, poor contour (Fig. 31—26), uneven marginal ridges (Fig. 31—27), overhangs (Fig. 31—28), and inadequate margins (Fig. 31—29), all of which may contribute to periodontal disease.

44. Radiographical features of pulpal lesions
Pulpal sclerosis
Pulpal obliteration
Pulp stones

45. Pulpal sclerosis
Is a diffuse calcification of the pulp chamber and pulp canals of teeth that results in a pulp cavity of decreased size
Pulpal sclerosis is associated with aging
No clinical features are associated with pulpal sclerosis AND of little clinical significance unless endodontic therapy is indicated

46. Pulpal Obliteration
Some conditions (attrition, abrasion, caries, dental restorations, trauma, and abnormal mechanical forces) may act as irritants to the pulp and stimulate the production of secondary dentin, which results in obliteration of the pulp cavity
On a dental radiograph, a tooth with
pulpal obliteration does not appear to have
a pulp chamber or pulp canals
Teeth with pulpal obliteration are non
vital and do not require treatment

47. Pulp Stones
Pulp stones are calcifications that are found in the pulp chamber or pulp canals of teeth
The cause is unknown
Pulp stones appear as round, ovoid, or cylindrical RO; some pulp stones may conform to the shape of the pulp chamber or canal
Pulp stones may vary in shape, size, and number. Pulp stones do not cause symptoms and do not require treatment

49. PERIAPICAL LESIONS Lesion that is located around the apex of a tooth
The use of dental radiographs is particularly important in the identification of periapical problems
On dental radiographs periapical lesions may appear either RL or RO

50. Periapical RLS
Periapical granuloma, cysts, and abscesses are common periapical RL that can be seen on dental radiographs
These lesions cannot be diagnosed by their radiographic appearances alone; instead, diagnosis is based on the clinical features and radiographic and microscopic appearances
Because it is impossible to distinguish between these three periapical lesions based on their radiographic appearance, the dental radiographer should refer to these lesions simply as “periapical RL”

51. PERIAPICAL GRANULOMA
Is a localized mass of chronically inflamed granulation tissue at the apex of a non- vital tooth
It results from pulpal death and necrosis and is the most common sequela of pulpitis
A periapical granuloma may give rise to a periapical cyst or abscess. A tooth with a periapical granuloma is typically ASYMPTOMATIC but has a previous history of prolonged sensitivity to heat or cold
Treatment include endodontic therapy or removal of the tooth along with curettage of the apical region
On a dental radiograph a periapical granuloma is initially seen as a widened periodontal ligament space at the root apex. With time, the widened periodontal ligament space enlarges and appears as a round or ovoid RL, and LD is not visible between the root apex and the apical lesion

53. PERIAPICAL CYST (radicular cyst)
Lesion develops over a prolonged period of time; cystic degeneration takes place within a periapical granuloma and results in a periapical cyst
Results from pulpal death and necrosis
Periapical cysts are the most common of all tooth-related cysts and comprise 50 to 70% of all cysts in the oral region
Periapical cysts are typically asymptomatic
Treatment may include endodontic therapy or extraction of the tooth as well as curettage of the apical region
On a dental radiograph the typical periapical cyst appears as a round or ovoid RL

55. PERIAPICAL ABSCESS
Is a localized collection of pus in the periapical region of a tooth that results from pulpal death. Periapical abscesses may be acute or chronic
Acute periapical abscess has features of an acute pus-producing process and inflammation, may result from an acute inflammation of the pulp or an area of chronic infection, such as a periapical granuloma
Chronic periapical abscess has features of a long-standing, low-grade, pus-producing process, may develop from an acute abscess or a periapical granuloma
An acute periapical abscess is painful — the pain may be intense, throbbing, and constant. The tooth is non vital and is sensitive to pressure, percussion, and heat. Early radiographic changes include an increased widening of the periodontal ligament space
WHILE
Chronic periapical abscesses are usually asymptomatic because the pus drains through bone or the periodontal ligament space. Clinically, a gumboil may be seen in the apical region of the tooth at the site of drainage. Appears as a round or ovoid apical RL with poorly defined margins, and LD cannot be seen between the root apex and the radiolucent lesion.
Treatment includes drainage and endodontic therapy or extraction

57. Periapical Ros
Condensing osteitis, sclerotic bone, and hypercementosis are a few of the common periapical RO that can be seen on dental radiographs
Unlike periapical RLs, periapical ROs can be diagnosed based on their radiographic appearance, clinical information, and patient history

58. CONDENSING OSTEITIS (chronic focal sclerosing osteomyelitis)
Is a well-defined RO that is seen below the apex of a non vital tooth with a history of long-standing pulpitis
The opacity represents a proliferation of periapical bone that is a result of a low-grade inflammation or mild irritation; pulpal necrosis
May vary in size and shape and does not appear to be attached to the tooth root
The most common periapical RO observed in adults
Most frequently involved is the mandibular 1st molar
Teeth associated with condensing osteitis are non vital and typically have a large carious lesion or large restoration
Because condensing osteitis is believed to represent a physiologic reaction of bone to inflammation, no treatment is necessary

60. SCLEROTIC BONE (osteosclerosis or idiopathic periapical osteosclerosis)
A well-defined RO that is seen below the apices of vital, noncarious teeth
The cause of sclerotic bone is unknown; however, it is not believed to be associated with inflammation
The lesion is not attached to a tooth and varies in size and shape
The margins may appear smooth or irregular and diffuse
The borders are continuous with adjacent normal
bone, and no RL outline is seen
Sclerotic bone is asymptomatic and is usually discovered during routine radiographic
examination

61. HYPERCEMENTOSIS Is the excess deposition 0f cementum on root surfaces
Results from supra-eruption, inflammation, or trauma; sometimes there is no obvious cause
Appear as an excess amount of cementum along all or part of a root surface
The apical area is most often affected and appears enlarged and bulbous
Root areas affected by hypercementosis are separated from periapical bone by a normal appearing PLS, & surrounding LD appears normal
No signs or symptoms are associated with hypercementosis; most cases are discovered during routine radiographic examination
Teeth affected by hypercementosis are vital and do not require treatment