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
