1. Introduction to Radiographic Pathology Flashcards
Radiographs in Diagnosis
Diagnostic imaging is an integral part of the ____ process in clinical dentistry.
Radiographs are often obtained as part of a complete ____.
Appropriate radiographic interpretation is used along with ____ information and other tests to formulate a differential diagnosis
• Looking for cancer is our number one mission in our careers
• The most important thing is that it’s an ____ to what our skill sets afford us when
working with patients
• Important to do an interpretation to develop a list of possibilities based off of the
radiograph in order to come up with a list of possibilities, a ____
diagnostic examination clinical addition differential diagnosis
The Diagnostic Process \_\_\_\_ History of Present illness \_\_\_\_ Clinical examination \_\_\_\_ Further examination and testing Formulate a \_\_\_\_
Regular workup for an H&P: ◦ Reads the list
Following the clinical examination > generate radiographs and interpret them
◦ It’s different for every patient; not every patient needs an FMX or Pano, every patient
will be ____!
If no definitive diagnosis we will at least have a differential diagnosis
chief complaint medical history diagnostic imaging differential diagnosis different
Quality of Image
Is the radiograph of diagnostic quality?
n Contrast and density
n Region of interest ( lesion) clearly visible
n Surrounding normal tissue (approx. ____ mm)
n No geometric distortion
n No ____
• First thing: make sure you’re looking at the right patient’s ____
• Make sure it’s the area you’re actually trying to diagnose
• Want to see contrast so you can see changes in density, as opposed a “morass” of gray
(don’t want to see this!)
• Want at least a few mm of good healthy tissue surrounding the lesion > if any of the lesion
extends beyond the border > ____ make an assessment of what the lesion is completely,
or to what organ system it may be advancing upon
• No distortion
◦ It’s easy to ____ and thereby distortion
• Make sure no fingertips, paperclips, aka no artifacts present in the image
2-3 artifacts radiograph cannot overangulate
Quality of Image
Do I need more radiographs? n Which one(s)
n ____, Bitewing, Occlusal, Panoramic, CT/MRI
Shall I obtain ____ radiographs?
What is the expected ____
from the radiographs?
• Once establish that you can make a determination of what the problem is > can you make your DD from that, or do you need another image and extend beyond the field?
• In our generation > ____ images take double the geography of a PA, and you can put them in different locations and you can shoot perpendicular to the arches > more anatomy and more pathology
◦ Unless you have film in the office, you cannot use occlusal anymore
• Prior radiographs
◦ What was the pathology like 3, 6, 12 months ago?
◦ Can use them to observe the trends, and may help in making your diagnosis now
• Writing a radiograph is a ____
◦ If ordering another radiograph, will you get a reasonable yield from ordering another scan? Have to think about radiation exposure!
periapical
prior
diagnostic yield
occlusal
prescription
Type of Images \_\_\_\_ BW Selected \_\_\_\_ Extra-oral views \_\_\_\_ views Advanced Imaging – CT, MR, nuclear medicine etc
FMS
periapicals
panoramic
• • Viewing the radiographs Appropriate viewing conditions n \_\_\_\_ lit room n \_\_\_\_ view box n High \_\_\_\_ monitor n Mask all \_\_\_\_ light n Use a magnifying \_\_\_\_ as appropriate
With actual film you can always rely on the quality and the persistence of the image on film
◦ Sustains itself quite well (unless left in sunlight) Reads the list
◦ Don’t need any other light other than the light used to illuminate the film ◦ ____ you don’t need a magnifying lens
dimly bright resolution extraneous lens digital
Use a systematic process
Knowledge of \_\_\_\_ radiographic anatomy is paramount Distinguish n Normal anatomy n Variations of normal anatomy n Pathoses
- Doesn’t care which system we use, but we have to know the osteological ____ first, then translate that radiographically
- Have to know normal variation to anatomy (there’s a lot of variation!)
- Once you establish all of that, anything that doesn’t fit the bill is ____
normal
anatomy
pathologic
FMX
• ____ images (used to use 20 images back in the day)
18
Normal anatomy
Start with the ____ landmarks
View the radiographs in order through the quadrants from ____ through
lower right
Identify the normal anatomy such as the ____, canals, foramina, cortices, etc.
Check for ____
• Choose a systematic review that’s comfortable for you
◦ You can start with symmetry first and then look at 1-32 last, whatever process you
like!
anatomical
upper right
bones
symmetry
Landmarks in the Maxilla
Intermaxillary suture
Soft tissue of the nose
Incisive foramen
• Anterior maxillary image (this is on film bc of the curvature in the corners!)
• This is not completely symmetrical > it’s off center (has 7, 8, 9, and 10)
• Midline = inter maxillary suture
◦ Has opaque periphery, cortical thickening, and then the lucency that is wider and the bone is not as close there
• There’s a shadow here (an opacity) which is transparent > cartilage of the nose > almost always superimposed
• Incisive foraman is tougher to see, it’s sort of down in here
• Cannot see cementum on a normal tooth, but you can with hypercementosis
yay
Landmarks in the Maxilla
Incisive foramen
• The midline suture is more to the patient’s left bc the image is off-center
• Squinting your eyes
◦ When you look at a radiograph, and after
you observe what’s going on, then squint your eyes > gets peripheral nonsense out of the way and then you can focus on some details (such as carious lesion on D of #8, or the incisive foramen)
yay
Landmarks in the Maxilla
Nasopalatine canal
• Here’s the incisive area (doesn’t point at it), but the midline is here, but at the arrows you can see the nasopalatine canal which empties into the incisive foramen
◦ Why are there linear opacities? It’s a tube, and the photons in a tube go tangential to the end of the tube/the sides of the tube > there’s more bone for the photons to go through > don’t get to the detector and therefore it’s ____
◦ The thicker the bone is where the photons travel through it > less photons get through > the image will be more opaque/whiter in that area
• You see a root canal, a post, and a bulld-up on #8
• On #9 and #10 you cannot see the pulp canal
◦ When you don’t see canals, and some
bone loss > typically means that they have calcified over time and chronic ____ (could’ve been a boxer, or fell, etc.); these teeth are generally ____
◦ #10 also has PA combination of opaque and lucent lesion probably related to the pulp not living anymore
whiter/opaque
trauma
okay
Landmarks in the Maxilla
Lateral fossa
• Easiest place to look for LF > over the ____ (top-right image) > you see a lot of lucency in the area, and the tooth is healthy (no trauma, etc.)
◦ Why is it Lucent under normal circumstances?
‣ Anterior maxilla is a little bit ____ bt the incisor and canine
• There’s a concavity on the labial plate of the maxilla, but the palatal plate is thick; the distance bt the labial plate and palatal plate is less over the max lat incisors (???) > nothing blocking the photons getting to the film > lucent (and normal!) > this is the lateral fossa!
maxillary lateral incisor
thinner
Landmarks in the Maxilla
Nasal Fossa
• Nasal fossa = nasal cavity
• A hole in the anterior part of face, under our noses
• Surrounded by bone (1-2mm), but in certain spots where photons go through > goes
through more of that thin bone, and it now looks opaque!
◦ This is the border of the nasal fossa/cavity
◦ The orange is the nasal septum, and unless you have a cold, there will be air that’s in
the cavity that will be ____!
• When look at an angle shot (canine #6), we have #4 and #5 that are going over the curve
of the arch that will be overlapped
◦ The pink area is the lateral fossa (nice lucency)
◦ The floor of the nose is also visible from this view
‣ What’s posterior and lateral to the nose > ____
‣ Can also see an anatomic landmark > inverted Y
• Often a board question: somewhere in the vicinity of the ____ > distinguishes bt the ____ posteriorly, and the ____ anteriorly
lucent maxillary sinus max canine sinus nasal cavity
Landmarks in the Maxilla
Nasolabial fold & maxillary sinus
• Here is the sinus in this shot, and the nasal cavity is here, and here is the inverted Y
• The red arrows show the nasolabial fold of the cheek (highlighted in blue in the L image), and
deep to that you see the floor of the maxillary sinus (the opacity surrounding the sinus)
◦ The roots stick into the sinus, but they’re covered with ____ (lamina dura; the roots are
not ____!)
• Congested sinus may make it look more opaque
bone
exposed
Landmarks in the Maxilla
Zygomatic Process and Maxillary Sinus
• You see the floor of the maxillary sinus, and this sinus is a little bit more opaque (allergies, congestion); the partition in the sinus = ____ (the sinus can be compartmentalized)
• Zygomatic process of the maxilla
◦ In an intra oral radiograph is either ____ or ____ opacity
◦ Usually always above first or second molars, but doesn’t have to be
◦ Origin of the zygomatic arch that will go posteriorly
◦ As you go posteriorly, it should be more opaque bc you’re superimposing the
zygomatic arch over the maxilla
• Coronoid process of the mandible
◦ This area is the worst bc there are so many overlapping structures > hard to detect what’s normal and what’s not
• Maxillary tuberosity
◦ Most ____ structure in the maxilla
bony septum
U-shaped
J-shaped
posterior palpable
Landmarks in the Maxilla
Maxillary tuberosity
Coronoid process of the mandible Pterygoid Hamulus
Pterygoid hamulus (doesn’t have an image)
◦ What’s posterior to the tuberosity? The ____. And hanging off one of
the pterygoid plates is the hamular process (the medial one)
◦ Once you start seeing the tuberosity rolling posteriorly, you see a ____ >
that’s the hamular notch
hamular notch
v-shape
Mandibular symphysis occlusal
Genial tubercles Mental Ridge
An occlusal film
◦ Larger, and more ____ available to assess
◦ Shooting the image from under your mandible, 90 degrees to it, and you get an image like this
Can see the genial tubercles, can see the lingual foramen (kind of just points all in this area), and the mental ridge (the anterior projection on the mandible)
Not great for assessing the ____, but great for ____ areas
◦ Can also see a benign tumor
‣ Has same density as tooth structure
‣ This is an odontoma (-oma means a benign tumor)
information
dentition
osseous
Landmarks in the Mandible
Inferior border of the mandible
• On a PA can see the inferior border of the mandible ◦ When normal: uniformly ____ and thick
opaque
Landmarks in the Mandible
Submandibular gland fossa
• Right at that mandible (doesn’t point anywhere) and deep to it lives the submandibular salivary gland
◦ There’s a concavity on the lingual plate of the mandible in the posterior region is the fossa where the ____
‣ Similar situation to the lateral fossa in the maxilla > here another concavity is created between two plates > less bony structure for the photons to go through and it will be a little bit darker
• The large black arrow is the mylohyoid ridge, which is the roof the SM fossa itself
submandibular gland
Landmarks in the Mandible
Mental Foramen and Inferior Alveolar Canal
• Mental foramen is a hole in the bone around the apices of the lower ____, and it’s the ____ of the inf alveolar canal
• The arrows on the left there is a lucency which is the mental foramen, and the right image is the inferior alveolar canal
• For PA pathology of dentition: the normal has to be ruled out bc some diseases can present with pulpal death and with a lucency that’s sitting over the apex > but depending on where the mental foramen it can be over the apex of the tooth and mimic the pathology as an abscess; in this case you want to take another image to rule that out
lower premolars
anterior end point
Landmarks in the Mandible
External oblique ridge
Internal oblique ridge
• Yellow arrow = ext oblique ridge
◦ When this area is thin > a sign of ____
• Red = internal oblique ridge = the mylohyoid ridge
• The lucency is the submandibular gland fossa below the IOR
• The apices of 31 are below the mylohyoid ridge > if there’s an infection in this case, the
infection would come out under the mylohyoid > swollen in neck and will have an airway problem; but if 30 developed an infection > above the MH ridge > infection would be in the mouth (under the tongue) separated by the mylohyoid muscle
pathology
Restorations \_\_\_\_ Amalgam \_\_\_\_ Stainless Steel \_\_\_\_ Porcelain Composites \_\_\_\_ • All restorations can show up on a radiograph • Amalgam and gold will the "gold-standard" on opaque (will look the whitest) • Some composites may be radiolucent • Gradation from top-to-bottom: most white to least white
gold
titanium
gutta percha
cements and liners
Restorations
Metallic Restorations
Bases and liners
• L: 3-unit bridge with a Pontic that may be gold/semi-precious metal and you have porcelain overtop (not as opaque as the framework)
• L: maxilla has amalgams on the molars, and the premolar has semi-precious metal/ gold with porcelain over top, with a post located within the canal
• L: external oblique ridge is relatively thin, so potentially an ____ patient
• Under restorations you can have ____
◦ Sometimes you can see and sometimes you cannot
◦ On #19 this may be a base, there may be a difference in opacity
older
bases and liners
Restorations
Implant restorations
____ is not as opaque as semi-precious metal for the prosthetic, and less opaque is the porcelain overlying the framework
Can see calculus deposit due to lack of ____
The different opacities indicate different types of restorative materials
titaniums
hygiene
Restorations
Stainless steel post Amalgam from apicoectomy
• Can see gutta percha in the base of the canal, but not as opaque as the ____
• Apicoectomy
◦ At the ____ of a tooth, and you’re removing it and you place a filling in it’s place ◦ Typically use ____, but sometimes unless you protected the area you see a
residue of amalgam ____ (can see here)
‣ Nothing terrible to the patient, but it’s still there
stainless steel post
apex
titanium
particles
Restorations
Porcelain Gold
Gutta percha Stainless steel
These caps and crowns are made differently, no ____ is probably used here Can see the stainless steel post and gutta percha once again
Can see a cast post here (probably gold)
Can see the incisive foramen
metal
Restorations
Composites: Radiolucent and Radiopaque
• Older composites have no filler that’s ____, when you look at them they look like caries
• As opposed to the newer ones that have the ____ filler
radioopaque
opaque
Restorations
Posterior composites
• Examples of amalgams and a ____
composite
CT –bone windows
• Can see the highlights: thickness of ____ of mandible
◦ I’m guessing he meant the opacities here
• Looking from “toes to nose”
• In L maxillary sinus > bony growth
• The spine is located ____
• Can see some soft tissue, but this window is mostly used to
examine ____
cortex
posteriorly
bone
CT- soft tissue windows
• For the soft tissue window > the bone is an opaque mess, but you can see all the ____ changes
soft tissue
MRI
• Soft tissue water and fat are ____ and the cortical bone is now ____
• R: image of a condyle
• L: looking at same image a different way
◦ The marrow space is a little opaque, and the cortex is purely lucent/ purely dark
◦ The base of the brain is now ____ (bc of the MRI)
opaque
dark
lucent
Use a systematic process Go back to the first quadrant and look at the trabecular pattern. Is it: n \_\_\_\_ n Symmetrical when compared to the contralateral side n \_\_\_\_ n Dense n In the direction of \_\_\_\_ stress n Altered
normal
sparse
anatomical stress
Use a systematic process
• Here is a panoramic
◦ It is a decent image, but the L condyle is a cm from the top, and the R condyle is farther
from the top (head was tilted) > already knows it’s not symmetric, but the midline is okay
• The bone looks very Lucent, and not much trabeculation
◦ The inferior border cortex of mandible is ____
◦ No distinct external oblique ridge
• An ____ patient with anemia or osteoporosis that’s generalized to the bone
• A lot of remnants and missing teeth
• Can sometimes see the spine (on the R can see it here)
thinner
older
Use a systematic process Check the \_\_\_\_ of the interdental bone \_\_\_\_ are the optimal projection for proximal bone heights Look at n \_\_\_\_ n Bone height n \_\_\_\_ of the bony crest
height
bitewings
cortication
shape
Use a systematic process
• Goes through his systematic process: always checks the bone first, and then finishes with the teeth
◦ Can have your own process
• No ____ lesions are present here
osseous
Use a systematic process Check the teeth n Count n Check enamel, dentin, and pulp n \_\_\_\_ roots n Compare anatomy n Check \_\_\_\_ (bitewings are optimal) • \_\_\_\_ is not mentioned here! • Can do it all in any order you like
count
anatomy
cementum
Count the teeth
• There is a sideways L on the R side > why?: in a panoramic, there are ____ and ____ images; the virtual image sometimes on a pano can be categorized as a ghost
◦ The L on the bottom right is metal/lead, and it shoots across and shows up on the other side as a ____ image
◦ The same applies for the R
◦ Make sure you rule out ghost images on pano’s as well!
• 15 is missing… and there are four molars!
◦ ____ third molar of #17, and an embryologic supernumerary of #32
virtual
absolute
ghost
supernumerary
Check enamel, dentin, cementum, and pulp
• After the bone, check for the teeth themselves
• Green arrow = caries
◦ Composite w/o filler can look like this!
• Red = caries on the cervical area
• Yellow = caries on the root
• Bone height is lower than we would like > some perio disease
• PDL look okay, and the lamina dura (the opaque line around the PDL) look good as well
• The bone looks normal
• Just a raised black dot on the film (not actually on the tooth)
yay
Check enamel, dentin, cementum, and pulp
• A BAD image (overexposed) but pretty revealing for what we’re going to talk about: cementum!
• Bulbous roots on mostly #19: ____ ◦ A board question
hypercementosis
Describing the Abnormality
- ____
- ____
- ____
- ____
- ____
- ____
- ____
BLISSAD
size shape location density borders internal architecture affect on adjacent structures
Why describe the lesion? The radiographic description can give us indications of: n \_\_\_\_ of origin n Biological behavior n \_\_\_\_ n Treatment concerns n \_\_\_\_ or a Differential Diagnosis
tissue
prognosis
diagnosis
- Size
Measure the lesion witha ____. If you must estimate, use surrounding structures as your guide
Measure in ____ dimensions, width and height in mm or cm, as appropriate
• Digitally can measure, there are algorithms into the computer engineering now and they are accurate (can do on CAT scans and MRIs as well)
ruler
two
- Size
• Maybe it’s 5-6 mm in diameter
• A little bit elliptical and elongated, with a tear drop anterior or inferior projection on the PA
film
• Well defined lesion
• Parts of it have a corticated border > signature feature for a benign lesion (not a malignant
lesion)
◦ Body tries to wall it off and grows bone surrounding the lesion (with cancer the body
doesn’t have time to do that)
yay
2. Shape Regular n \_\_\_\_ n Triangular n \_\_\_\_, etc. Irregular shape
round
rhomboid
- Shape
• A panoramic
• Normal bone on the right mandible, but abnormal on the left mandible:
◦ Well circumscribed radiolucent lesion, which has eroded the surrounding structures and expanded (cannot tell us lateral and medial, but can tell us top and bottom)
◦ ____ in shape
◦ Not affecting any teeth (bc absence of teeth
elliptical
- Shape
• A round lesion around a cm
• Well-defined and a corticated border
• Isn’t pushing teeth apart
• Nice lucency which means it’s less dense and less bone
• Border around it > signature feature of it being ____ (same applies to the last slide)
◦ However, benign lesions can have histopathologic malignant changes within the lining epithelium even though most of it is normal
benign
- Location
Is the lesion localized or generalized? Unilateral or bilateral
Where is the lesion in relation to other structures and anatomic landmarks?
Use terms such as: n Mesial, Distal
n Inferior, Superior n Posterior, Anterior
• Is there ____ (localized) or ____ on either side of the midline (generalized)
• Above or below the inferior alveolar canal?
◦ Significant pathologic prognoses based on that
one
multiple
- Location
If the epicenter of the lesion is above the mandibular canal, the likelihood is that the lesion is ____ in origin.
____ lesions are found nearer to the condyles.
If the epicenter of the lesion is in the sinus, it probably is not ____ in origin.
• Be specific in your identification and description of where these lesions are
• Reads the bullets
odontogenic
cartilaginous
odontogenic
- Location
• Unusual oval, well-defined and is circumscribed by a prominent and uniformly thick that is opaque (sclerotic) that is surrounding a Lucent type of lesion
◦ Does the white opaque make the darkness look more lucent? Or vice-versa? Yes and yes, they influence each other
• This is above the gonial angle, the cortex is intact, and it is located below the inferior alveolar canal
◦ It’s not impinging on the canal
◦ This is pathognomonic for a ____ bone cavity
‣ Below the canal, corticated, and usually comes from the SM salivary gland
‣ If it’s above the canal it’s not this, if it’s within the canal is a ____ disease
‣ Unilateral lesion
stafne
neurologic
- Density
Is the lesion Radiopaque, Radiolucent, or Mixed Density
Remember that opacity is ____ to the adjacent structures.
If the lesion is of mixed density, describe the appearance
relative
Density: as noted in CT
• Looking from “toes to nose”
• The L max sinus you see a uniform density (similar to soft tissue density) so it’s probably soft
tissue
◦ The opaque is bone
◦ There’s no ____ border surrounding it, so this is not a lesion from the bone or within
the bone, and it’s all soft tissue (the opaque layer is border of the nose and lateral wall of the sinus)
opaque
- Borders
Well or poorly demarcated Punched out (no ____ reaction)
Corticated (thin ____ border)
Sclerotic (wide, ____ opaque border)
Hyperostotic (increased ____ of trabeculation)
bony
opaque
uneven
density
- borders
• Maxillary anterior centered on #11
◦ Maxillary sinus
◦ At apex of 11: lucency of the bone (yellow arrow) which doesn’t have a border and not
well-defined
‣ Crescent shaped hugging the apex a little bit
• The lesion over #9 (???) has an opaque border surrounding it
◦ Long-standing benign lesion, while the lesion with #11 is most likely benign but ____ in
lifespan (body hasn’t had long enough to form bone)
◦ Malignancies do not have ____ either, but don’t jump to conclusions!
shorter
borders
- Borders
• Trapezoidish crop out of a lateral skull view of a patient
• Punched out lesions without a corticated border
◦ (Cannot really tell what he’s exactly pointing at bc the image is so washed on the recording, gg)
◦ Pathognomonic for ____
‣ These lesions are ____, while the other cases are benign
multiple myeloma
malignant
- Borders: Distinct and lucent
• Lower anterior
• Some extra teeth, and one hasn’t erupted
• There’s a mass (large arrow) that has the same density of tooth structure
◦ Made up of embryological tooth structure
◦ Border is sort of defined that is corticated/sclerotic ◦ Not a true oval/circle
◦ Pushing 25 root away
◦ An example of an ____
odontoma
- Internal architecture
Is the lesion ____?
Internal structures such as septae or loculations
n ____ are bony walls
n ____ are individual compartments
Tooth-like elements Radiolucent rim
Use terms such as: cotton wool, ground glass, wispy, orange peel, etc.
• Tries to avoid the terms in the last bullet because it may pigeon hole yourself into certain diagnoses
uniform
septae
loculations
- Internal architecture: Ground glass
• Lesion looks like ____, that is filled with bone (not teeth) ◦ Inferior border of cortex is almost non-existent
opacified glass
- Internal architecture: soap bubble
• Looks like soap bubbles
◦ A pathognomonic description for a pathology
◦ This lesion is ____ the roots (not pushing them) ◦ A benign lesion, but acts ____
◦ The mandible had to be resected
• Internal structures can change from uniform solid to a soap bubbley appearance
eroding
aggressively
- Effect on adjacent structures
Space occupying lesions ____ other structures
displace
- Effect on adjacent structures
A Space Occupying lesion creates its own space by displacing other ____, such as teeth, maxillary sinus, inferior alveolar canal, etc.
• Lesions can occupy spaces and can push anything around if they’re there long enough
structures
- Effect on adjacent structures
• Opaque, bony lesion in the left maxilla and left maxillary sinus ◦ ____ the teeth and pushing everything apart
‣ Pushing the teeth down and the mandible open
eroding
- Effect on adjacent structures
• CAT scan on same patient the lesion is pushing into the orbit and pushing into the ____, and left palate
◦ Very expansive
left nasal cavity
Clinical challenge of soft tissue calcification diagnosis
• Opacity located in the mandible under the premolars ◦ 3 x 5 mm opacity that is well-circumscribed
• Take an ____ and change the view, it is actually a stone/calcification in the floor of the mouth in the submandibular duct (Wharton’s)
occlusal
Differential diagnosis
• Soft tissue
◦ Could be a lymph node, calcifications in the neck, salivary gland calcifications ◦ If you can’t palpate it, change the ____ on the radiograph
angle
