2. DENT5102, Spring, 2007 Unit2. Restorative Materials Unit3. Dental Caries Unit5. Periodontal and Periapical Unit6. General Principles of Interpretation in Osseous Structures

3. DENT5102 quiz #1 is posted at the following web address: http://www1.umn.edu/dental/courses/dent_5 102/Quiz1/quiz07.htmlhttp://www1.umn.edu/dental/courses/dent_5 102/Quiz1/quiz07.html.

4. Restorative Materials According to radiographic density beginning with most radiopaque Group I. Gold alloys, amalgam,silver Gr.II. Gutta percha, zinc oxyphosphate or other base materials, composite with opacifier, rubber base impression material, calcium hydroxide with opacifier Gr.III. Porcelain

5. Restorative Materials (Cont.) Gr. IV. Radiolucent. Calcium hydroxide, composite, resin

14. Dental Caries Severity 1 st degree (early, incipient, enamel only) 2 nd degree (moderate, to DEJ) 3 rd degree (advanced, into dentin) 4 th degree (extensive, extending to pulp)

15. Caries Progression

16. Dental Caries (Cont.) Location Occlusal, incisal Lingual, palatal Buccal, facial Proximal (mesial, distal) Cemental (root) Recurrent

17. Dental Caries Most common location for proximal caries: just apical to the contact area.Enamel caries is usually triangular in shape, occasionally rounded. Radiographically, occlusal caries can be seen only when it is in dentin (3 rd degree).

19. Incipient Caries

27. Dental Caries (Cont.) Cemental (root)

30. Dental Caries (Cont.) Recurrent

32. Recurrent Caries Caries immediately next to a restoration Inadequate margins or excavation Metallic restorations often hide Clinical examination

34. Dental Caries (Cont.) Adumbrasion (cervical radiolucency, cervical burnout).

36. Adumbration Between CEJ and alveolar crest Diffuse radiolucency Ill-defined borders Presence of the edge of root Clinical evaluation

37. Caries: Xerostomia Therapeutic radiation Sjogren’s syndrome Caries begins at cervical region Extensive decay

41. Periodontal And Periapical Diseases

42. Periodontal Disease

43. Usefulness of Radiographs Amount of bone present Condition of alveolar crest Bone loss in furcation areas Width of periodontal ligament Local factors: calculus, overhanging restorations Crown/root ratio

44. Limitations of Radiographs No indication of morphology of bony defects No indication of successful management No indication of hard/soft tissue relationship, I.e., depth of pockets

45. Normal Alveolar Crest 1.0-1.5 mm apical to cemento-enamel junction Parallel to line joining the CEJ of adjoining teeth Smooth Continuation of lamina dura, has the same radiopacity

50. Severity or Extent of Bone Loss

51. Evidence of Early Periodontitis Localized erosion of crest of bone Blunting of crest- anterior teeth Loss of sharp angle between lamina dura and crest Widening of pdl near crest

54. Local Factors Calculus Overhanging restorations Poor restoration contours

55. Calculus

57. Overhanging Restoration

58. Buccal VS Lingual Bone Loss

61. Direction Of Bone Loss Horizontal Bone Loss: Crest of bone is parallel to CEJ line between adjoining teeth. The remaining bone is still horizontal but may be positioned apically.

63. Direction Of Bone Loss Vertical bone loss Crest of remaining bone is not parallel to the CEJ line between adjoining teeth ( displays an oblique angulation to the CEJ line )

66. Bone Loss In Bifurcation/trifurcation Areas

69. Bitewing Radiographs Most Reliable For Crestal Bone Evaluation

72. Generalized Periodontal Disease

73. Juvenile Periodontitis (Early-onset Periodontitis, Rapidly Progressing Periodontitis) Occurs in healthy individuals between puberty and age 25 Amount of bone loss is not consistent with local factors and oral Hygiene habits. Rate of bone loss is 3-4 times faster than in typical periodontitis

74. Juvenile Periodontitis(cont.) Typically affects crestal bone of first molars and incisors. Eventually affects greater # of teeth. Bone loss is progressive and frequently bilaterally symmetrical. Many teeth show vertical bone loss. Host neutrophil dysfunction has been demonstrated by several investigators.

77. Papillon-Lefevre Syndrome Autosomal recessive trait Hyperkeratosis of palms and soles Occasional keratosis of other skin surfaces Calcification in falx cerebri Severe destruction of alveolar bone involving all deciduous and perm. teeth Exfoliation of teeth

83. Langerhans’ Cell Histiocytosis (Histiocytosis X) Complex of three diseases: Eosinophilic granuloma (usually solitary) Hand-Schuller-Christian disease Letterer-Siwe disease Due to abnormal proliferation of Langerhans’ cells or their precursors

84. Eosinophilic Granuloma of Bone Most common in children and young adults Usually single radiolucency Skull, mandible, vertebra and long bones commonly involved Painful, mobile teeth and gingival lesions

85. Hand-Schuller-Christian Disease Most cases reported in children under 10 years. Has been reported in older individuals Skeletal and soft tissues may be involved Classic triad of symptoms: “punched out” destructive bone lesions unilateral or bilateral exophthalmos diabetes insipidus Complete triad occurs in 25% of patients

86. Hand-Schuller-Christian (Cont.) Oral manifestations include: loose teeth exfoliated teeth gingivitis loss of alveolar bone / advanced periodontitis Sharply outlined multiple radiolucent lesions in skull, jaws and other bones

87. Letterer-Siwe Disease Acute, disseminated form of disease Usually occurs before age 3. Most patients die Involves several bones and organs Skin rash Intermittent fever, enlargement of liver and spleen, lymphadenopathy common Destructive radiolucencies in jaws Loosening and premature loss of teeth

88. Hand-Schuller-Christian Disease

90. Other Diseases Influencing Course Of Periodontal Disease Diabetes mellitus Leukemia

91. Periapical Inflamatory Lesions Bone destruction around apex of tooth, mostly secondary to pulp exposure due to caries or trauma. Bacterial invasion of pulp produces toxic metabolites which escape to the periapical bone through apical foramen and cause inflammation. The following may occur:

92. Periapical Inflamatory Lesions Periapical granuloma: Localized mass of chronic granulation tissue containing PMN’s, lymphocytes, plasma cells.

93. Periapical Granuloma Radiographically, widening of PDL or variable size of periapical radiolucency may be present

94. Periapical Granuloma

96. Periapical Abscess Periapical abscess: When pus forms in the area. It may develop directly as an acute process or develop in a pre- existing granuloma. Radiographically, appears identical to granuloma.

97. Periapical Granuloma Or Abscess Can one differentiate between the two on the basis of radiographs alone?

98. Periapical Inflamatory Lesions Radicular cyst (periapical cyst): Cell rests of Mallasez (remnants of epithelial root sheath of Hertwig) proliferate due to inflamatory stimulus of a granuloma or an abscess and provide the epithelial lining. What is the definition of a cyst? “A cyst is an epithelium lined cavity which is filled with fluid or semi-solid material”. Radicular cyst is the ONLY cyst related to non-vital pulp.

103. Periapical Inflamatory Lesions Can you definitively differentiate between a periapical granuloma, abscess or radicular cyst on the basis of radiograph alone?

105. Periapical Inflamatory Lesions(co) Condensing osteitis ( chronic sclerosing osteomyelitis or osteitis). Occasionally, the reaction to periapical inflammation is predominantly osteoblastic, I.e., more sclerotic bone is formed (radiopaque mass). This usually occurs in children or young adults when the resistance is high. Most common location is mandibular 1 st molar.

106. Condensing Osteitis

107. (Idiopathic) Osteosclerosis

108. Osteosclerosis How do you differentiate between osteosclerosis and condensing osteitis? In osteosclerosis, the pulp is vital. There are no clinical signs or symptoms. No treatment is necessary. Condensing osteitis is secondary to pulp exposure. Patient is symptomatic. Endodontic treatment or extraction is indicated.

109. Calcific Degeneration (Calcific Metamorphosis) Secondary to Trauma to the Tooth

110. Calcific Degeneration

112. Radiographic Evidence Of Non-vital Teeth Widening of apical PDL or periapical radiolucency ( associated with indication of pulp exposure) Discontinuity of lamina dura Displacement of lamina dura Condensing osteitis Calcific degeneration (metamorphosis) Radiographic indication of pulp exposure

113. Radiographic Evidence Of Non-vital Teeth Widening of apical PDL or periapical radiolucency ( associated with indication of pulp exposure)

114. Radiographic Evidence Of Non-vital Teeth Discontinuity of lamina dura

115. Radiographic Evidence Of Non-vital Teeth Displacement of lamina dura

116. Radiographic Evidence Of Non-vital Teeth Condensing osteitis

117. Radiographic Evidence Of Non-vital Teeth Calcific degeneration (metamorphosis)

118. Radiographic Evidence Of Non-vital Teeth Radiographic indication of pulp exposure

120. Periapical Cemental Dysplasia Also called Cementoma. Localized alteration in periapical area. Osseous structure is replaced by fibrous tissue, cementum-like material, abnormal bone or combination of these. Pulp is vital. Patient is asymptomatic. There are no clinical signs. No treatment is required. Mean age is 39 years.

121. Periapical Cemental Dysplasia 85% patients are females. 3 times more common in African-americans. Most commonly seen in mandibular anterior areas. May be multiple. May be bilateral. Well-defined radiolucency, opacity or mixed.

125. Periapical Cemental Dysplasia Stage I ( Osteolytic stage ) Stage II ( Osteo or cementoblastic stage) Stage III ( mature stage )

126. Stage II

127. Stasge III

128. Multiple

130. Apical Scar (Fibrous Scar ) Variation in healing process. Normally surgical site fills with blood clot which organizes and eventually mineralizes and remodels like surrounding bone. Occasionally, normal mineralization and remodelling fails to occur. Patient is asymptomatic and no treatment is required.

131. Apical Scar (Fibrous Scar )

134. Periapical Lesions (Bhaskar) Periapical granuloma 48% Radicular cyst 43% Periapical abscess 1.1% Residual cyst 3.5% Apical scar 3.0% Periapical cemental dysplasia 1.7% Rare lesions 1.0%

135. Rare Periapical Lesions(Bhaskar) Central giant cell granuloma Traumatic (simple) bone cyst Hyperparathyroidism

136. Periapical Lesions (LaLonde and Leubke) Periapical granuloma 45.2% Radicular cyst 43.8% Periapical abscess 3.0% Other periapical lesions 8.0%

137. General Principles of Interpretation in Bone

138. Relative Radiodensity Radiolucency Radiopacity Mixed (radiolucency and radiopacity)

139. Peripheral Outline Borders Well-defined or Ill- defined, Smooth or Ragged?

140. Expansion of Cortical Plates Indication of Rate of Growth of Lesion

141. Effects on Adjacent Structures Resorption of roots of teeth Mandibular canal ( pain, anesthesia, paresthesia?)

142. Location Mandible Maxilla Anterior Posterior

143. Multiple-single

144. Age

145. Sex