RADIOGRAPHIC DX Flashcards
ANTERIOR CERVICAL BURNOUT APPEARANCE
The bitewing radiographs confirm the carious exposure and in addition reveal occlusal caries in all the maxillary and mandibular molars with the exception of the upper right first molar. No approximal caries is present.
DIAGNOSIS: The patient has a nonvital lower first molar with a periapical abscess. In addition he has a very high caries rate in a previously almost caries-free dentition.
describe
“CART-P”
C: Caries reaches the Coronal dentine, close to the pulp but with an intact dentine bridge.
A: Amel undermined (occlusal and distal enamel affected, no cavitation).
R: Reduced pulp chamber with Reactionary dentine obliterating pulp horns.
T: Tricky radiolucency (radicular “burn-out” mistaken for caries but isn’t).
P: Pulp vital with no Periapical periodontitis.
Figure 1.5 shows the restored lower first molar 2 months after endodontic treatment. What do you see and what long-term problem is evident?
Lay-Term Mnemonic: “BONDS-CROWN”
B: Bone healing is good around the roots (apices) and between the roots (bifurcation). Full healing is expected in 6 months to 1 year.
O: Original contact point between the back molar (lower right first molar) and nearby teeth is lost.
N: Normal tooth position is affected; the molar has tilted and drifted, causing gaps.
D: Difficult cleaning in the tilted area increases the risk of gum issues (localized periodontitis).
S: Surface at the front of the molar (mesial) is flat and lacks a proper contact point, which can lead to:
Risk of decay on the next tooth (distal surface of the second premolar).
Decay that spreads further down the tooth near the gumline.
C: Contour issues on the biting surface can cause food to get stuck.
R: Restoration of the tooth (like a filling) needs an enhanced ridge to avoid food packing.
O: Over time, the tooth might need a crown because:
Enamel is weakened and much of it is damaged.
A crown could help improve the contact point and strengthen the tooth.
W: While the molar stays tilted, some issues (like contact improvement) cannot be fixed.
N: Next step might involve orthodontic uprighting (straightening the tooth) for a better long-term solution.
Lay-Term Mnemonic: “FIND-CRISP”
F: Full set of developing adult teeth (permanent successors) is present, except the wisdom teeth (third molars).
I: In the lower left area, there’s a sign of early tooth crypt formation (a small cavity where a tooth is developing).
N: Normal upper left front tooth (central incisor) shape is not seen, and its root shape is unclear on the panoramic X-ray.
D: Direction of the tooth (whether it’s closer to the lips or palate) cannot be determined from this view.
C: Closer view (periapical X-ray) shows:
Tooth root is intact but distorted.
Root is developing normally but appears bent (dilacerated).
Tooth crown is pushed towards the lip (labial direction), consistent with the visible swelling in the gums.
R: Radiographs confirm no extra tooth (supernumerary) is present.
I: Incisor’s crown and root are misaligned, with the crown tipped towards the lip and its edge pointing forward.
S: Side (lateral) view confirms the displaced crown position in the gum near the lip (labial sulcus).
P: Position of the root is normal despite the misaligned crown.
Lay-Term Mnemonic: “SPOTS”
S: Sialogram shows Small Spots (punctate sialectasis) of contrast scattered in the salivary gland.
P: Primary duct is visible, but no branches of major or minor ducts are seen.
O: Outlines of the gland appear evenly affected, with changes across the whole gland.
T: These findings resemble chronic salivary gland inflammation (sialadenitis) but are more uniform in distribution.
S: Symptoms and radiographic features are characteristic of Sjögren’s syndrome.
Lay-Term Mnemonic: “REST-LOSS”
R: Restorations are heavy in several teeth.
E: Endodontic treatment (root canal) is present in the lower first molar.
S: Shadowy (poorly defined radiolucency) area about 2 cm long stretches from the second molar’s distal root to the premolar socket.
T: The outline of the inferior dental canal is missing in this region.
L: Lamina dura is still visible in the recent extraction socket but is slightly blurred, suggesting infection or resorption.
O: Observation confirms no sequestra (dead bone) or root fragments in the socket.
S: Socket remains intact but further investigation with a periapical X-ray might provide additional clarity.
S: Signs point to possible bone resorption or infection.
Lay-Term Mnemonic: “CROWN-DEFECT”
C: Crowned left lateral incisor is not root filled.
R: Radiolucency (dark oval area) fills the middle of the root, replacing its width and connecting to the periodontal ligament.
O: Outlined defect margins are smooth and sharply defined.
W: Well-maintained bone level above the defect with no horizontal or vertical bone loss.
N: Nearly all root dentine below the crown and gum line is missing.
D: Decayed upper left central incisor is root filled, with filling close to the ideal length but with a curved apex.
E: Evidence of radiolucency around the apex, especially on the mesial side, where the lamina dura is missing.
F: Filled canine has mesial caries and an indistinct apical lamina dura, but no obvious dark area (radiolucency) at the apex.
E: Every defect in the film provides clues about dental issues, with lamina dura changes indicating potential bone or root problems.
C: Combined findings suggest a need for further assessment of structural integrity and treatment.
T: Timely intervention is essential to address decay, root health, and the radiolucent defect.
Lay-Term Mnemonic: “SOCKET-FRAG”
S: Socket of the first molar is indistinct, with no clear boundaries.
O: Observed lamina dura is resorbed, likely due to inflammation or infection.
C: Cortex remains intact buccally and palatally, masking the tract of a fistula.
K: Keeping focus on the floor of the sinus (antrum), a 3 mm root fragment is visible lying on it.
F: Failed root canal treatment in the second molar has caused:
Loss of apical lamina dura.
Small periapical radiolucency.
R: Root pin perforates the distal root, contributing to the problem.
A: Antrum’s floor and socket’s radiodensity aid in identifying the issue.
G: Goal: Assess for removal of the root fragment and address inadequate treatment.
Lay-Term Mnemonic: “LUX-INJURY”
L: Luxation: Severe intrusion of the maxillary right permanent incisor.
U: Unclear periodontal ligament space: Indistinct or obliterated in some areas.
X: X-ray confirms no visible crown or root fractures.
I: Immature root: Wide open apex indicates incomplete development.
N: Notable feature: Circular dark spots (radiolucent areas) on the crown, which are well-defined and smooth.
J: Just the crown is affected by these peculiar well-demarcated areas.
U: Unique feature suggests possible developmental or structural anomalies.
R: Radiographic findings emphasize careful monitoring and treatment planning.
Y: Young tooth requires attention to avoid further complications.
Lay-Term Mnemonic: “IMPACT-BONE”
I: Impacted lower third molars are vertically positioned against soft tissue, not the second molars.
M: Molars are of normal size with no visible abnormalities.
P: Patient is fully dentate, with no restorations or cavities visible on the film.
A: Adjacent bone surrounding the molars appears to have normal density.
C: Closely related: The roots of the molars are positioned near the inferior dental nerve canal.
T: There is darkening around the canal but no narrowing or deflection of its bony wall.
B: Bony canal does not contact or pass through the tooth roots.
O: Overall, the findings suggest no immediate concerns regarding nerve involvement.
N: Normal anatomical features indicate standard monitoring or treatment options.
E: Emphasize careful planning if surgical intervention is needed.
Lay-Term Mnemonic: “ANKYLOSE-ROOT”
A: Ankylosis: The tooth is fused to the bone, with no normal periodontal ligament.
N: No alveolar growth around the tooth, leading to infraocclusion (tooth sits lower than others).
K: Key cause: Damage to the periodontal ligament during avulsion, preventing proper repair.
Y: Years of replacement resorption have extensively destroyed the middle and apical root.
L: Lateral voids in the root canal filling indicate possible poor-quality root filling, allowing bacterial contamination.
O: Ongoing inflammatory resorption has sped up root destruction.
S: Space maintenance: Despite issues, the tooth preserved the gap for 3 years.
E: Extraction is necessary to prevent further distortion of the alveolar ridge.
Osseointegration means the implant is firmly connected to the bone, both structurally and functionally.
The implant is stable, has no symptoms, and looks healthy on the X-ray.
Bone is closely attached to the implant all the way along its length.
The top of the implant (head) is level with or just above the surrounding bone.
Signs of failure to watch for:
The implant becoming loose or mobile.
Dark areas (radiolucency) around the implant on the X-ray.
Bone loss around the implant over time.
All permanent incisors are present and are well-separated from the roots of the baby teeth (primary teeth).
The roots of the upper primary central incisors show resorption, which is normal for the patient’s age.
The upper left primary central incisor has an increased periodontal ligament space and is slightly displaced.
No other abnormalities are visible on the radiograph.
The panoramic radiograph is of poor quality due to incorrect head positioning:
The lower jaw (mandible) appears bowed down.
The lower front teeth are foreshortened.
Spinal shadows are prominent, affecting clarity.
The midline teeth appear blurry because of superimposition.
The patient’s head was twisted, causing:
One side of the film (right) to show wider molar crowns than the other (left).
Radiographic findings:
Extensive bone loss around the lower right and left second molars.
Bone loss and decay (caries) in the furcation of the lower left second molar.
Furcation involvement on both lower first molars, but they are less mobile compared to the second molars.
A better quality film (postoperative) demonstrates how the radiograph should have appeared.
First permanent molar:
Extensively decayed (carious).
Root filling present, but only one canal (palatal canal) is filled with gutta percha or silver point, extending 2 mm beyond the apex.
Buccal roots are not clearly visible and appear unfilled.
Overextended root filling is close to the sinus (antrum), which extends between the roots of the first molar and second premolar.
No apical radiolucency is visible.
Second premolar:
Root-filled with the filling stopping just short of the apex, which is ideal.
A small apical radiolucency is present, surrounded by the lamina dura.
First premolar:
Decay (caries) visible below the crown.
Second molar:
Contains a large pinned amalgam filling.
Lay-Term Explanation in Dot Points:
Tooth Findings:
The canine and premolars are filled and have no decay.
There is significant tooth wear on the front teeth (anteriorly).
The second molar has had a root canal, and a broken instrument is visible in one of its front (mesial) root canals.
Radiograph Issues:
The X-ray does not show the full area:
The third molar (wisdom tooth) is missing from the image.
The root tips and surrounding tissues are not visible.
Part of the X-ray is cut off because the tube head was positioned too far forward (an issue called “coning off”).
The sensor or film was not placed far back enough in the mouth.
Technical Challenges:
A paralleling technique was used, which makes the canals look parallel, but this has caused the two mesial canals to overlap.
It is unclear which canal contains the broken instrument.
Next Steps:
A better-quality X-ray is needed to clearly identify where the broken instrument is.
This is important if a decision is made to remove the broken piece during further treatment.
Note:
Lay-Term Explanation in Dot Points:
Original Film (Left):
The first X-ray does not clearly show the details, such as the fractured instrument or the condition of the surrounding tissues.
Improved Film (Right):
The second X-ray, taken from the mesial side, is better positioned.
It clearly shows the fractured instrument and confirms there is no infection or dark area (radiolucency) around the root tip.
The shape of the amalgam filling in the third molar can now be properly evaluated.
Mesial-Buccal-Distal (MBD) Rule:
When the X-ray beam is moved to the mesial, the buccal canal (closer to the cheek) appears to move to the distal (away from the middle).
The fractured instrument appears to move mesially on the X-ray, meaning it is located in the mesiolingual root canal (closer to the tongue).
Clinical Relevance:
Identifying the exact location of the broken instrument is critical for planning its removal or further treatment.
The improved film provides clearer details, making it easier to assess the condition of the tooth and restoration.
Lay-Term Explanation in Dot Points:
Additional Investigation:
Check the patient’s temperature to assess the spread and severity of the infection.
A raised temperature can indicate the systemic impact of the infection and whether there’s a large amount of pus or risk of the infection spreading.
In this case, the patient’s temperature is 37.2°C, which is within the normal range and suggests no severe systemic involvement.
Radiograph Usefulness:
A radiograph is not helpful in this case because:
Delayed radiographic changes: It can take up to 3 weeks for signs of infection to show on an X-ray after the tooth’s nerve (pulp) dies.
Misleading features:
In areas where the maxillary sinus overlaps the root tips, the normal space around the root (periodontal ligament) can look wider and mimic signs of infection.
Why Tests of Vitality are Better:
Tests that check if the tooth is alive (vital) are more reliable in identifying the problem tooth.
There’s already little doubt about the diagnosis in this case, so a radiograph would add limited value.
Conclusion:
Focus on temperature monitoring and vitality testing rather than relying on radiographs, which may be unnecessary or even misleading in this situation.
The panoramic radiograph is displayed in Figure 50.2. What does it show?
The dental panoramic radiograph shows that the
upper lateral incisors are missing with no evidence of supernumerary teeth or other lesions in this region. All other teeth are present including the unerupted third molars. This confirms the diagnosis that the upper lateral incisors are developmentally absent.
An 8-year-old girl is referred to you for an orthodon- tic opinion. She has an anterior crossbite.
The radiograph shows a normal dentition. The developmental age matches the patient’s chronological age. All permanent successors are present and appear to be in favourable positions. There is not yet any evidence of third molar development, as is normal at this age. Though the panoramic view is not suitable for detailed diagnosis, there seems to be some mesial bone loss on the lower left central incisor.
The initial films showed severe bone loss around the first molar and localized loss near the premolars, consistent with periodontal disease, but the panoramic X-ray revealed unusual patterns, including conical root morphology, sinus erosion, and lingual bone loss. These findings ruled out periodontitis, and a biopsy confirmed Langerhans’ Cell Histiocytosis, a rare condition causing bone destruction.
Lay-Term Explanation in Dot Points:
Top Film Findings (Figure 52.1):
Severe bone loss is seen behind the first molar.
The lamina dura (the thin white line around the root) is missing around the back root, extending into the area where the roots split (furcation) and near the root tip (apex).
No signs of calculus (hardened plaque) are visible.
Lower Film Findings:
A curved area of bone loss is visible near the first and second premolars.
The lamina dura and crest of the bone remain intact, showing less severe damage.
The bone loss matches the probing depths, suggesting that the findings are consistent with clinical examination.
No signs of calculus are visible.
Clinical Implication:
The top film indicates severe periodontal disease around the first molar, while the lower film shows localized bone loss near the premolars but without significant structural compromise.
Treatment should address the bone loss and maintain periodontal health.
BUT AFTER TAKING OPG:
hy the Panoramic X-Ray was Taken:
It was taken to check for other affected areas and to investigate the unusual pattern of bone loss.
Findings from the Panoramic X-Ray (Figure 52.2):
The lower left third molar is missing.
Both lower second molars have cone-shaped roots (conical root morphology).
There is a shallow bone defect in front of (mesial to) the lower left second molar, raising suspicion of aggressive periodontitis, particularly in a juvenile localized pattern.
Radiographic Features That Suggest It’s Not Periodontitis:
Upper teeth:
The upper molar area shows poorly localized bone destruction and a “fuzzy” furcation, unlike typical periodontitis.
The bone around the apex of the tooth is not clearly defined, but the tooth is still alive (vital), which is unusual for periodontitis.
The maxillary sinus (antrum) above the molars has an indistinct floor, with signs of erosion, and a dark area (radiolucency) is visible above the molar roots.
The erosion and indistinct sinus floor make this more concerning than periodontitis.
Lower teeth:
The smooth, rounded shape of bone loss near the premolars does not match the usual pattern of periodontitis.
The lamina dura and alveolar crest are intact between the premolars, indicating that the bone loss is not between the teeth (not interdental).
The bone loss is limited to the lingual (tongue side) bone and does not affect the buccal side, which is unusual for periodontitis.
Conclusion:
The findings from the panoramic radiograph, combined with the unusual patterns of bone loss, confirm that this is not periodontitis.
A biopsy was taken, and the diagnosis is Langerhans’ Cell Histiocytosis, a rare condition that can mimic periodontal disease but involves bone destruction caused by abnormal immune cells.
Clinical Relevance:
Early identification of these unusual features helps differentiate between periodontitis and more serious systemic conditions, ensuring timely diagnosis and treatment.
The panoramic radiograph shows loss of the white line that forms the bony floor of the left maxillary sinus (antrum), which remains intact on the right side. A domed radiopaque lesion fills most of the left maxilla and sinus, with a thin white border at its upper edge, alongside supernumerary teeth and clear lesion margins.
Lay-Term Explanation in Dot Points:
Differential Diagnosis for the Lesion:
Most likely a dentigerous cyst due to its dome-shaped appearance, thin bony margin, and association with the unerupted second premolar.
Other possibilities include odontogenic tumors (e.g., ameloblastoma, adenomatoid odontogenic tumor), a radicular cyst (unlikely due to vital teeth), or an antral cyst (unlikely because of bone involvement).
Treatment Recommendations:
For the pain, remove caries in the first molar and place a temporary filling.
For the cyst, enucleation (removal of the cyst lining) is recommended to complete treatment in one visit, as it’s more effective for children. Adjacent teeth can be preserved if vitality is maintained.
Surgical Details and Follow-Up:
Enucleation may include removing the unerupted tooth and connecting the cyst cavity to the sinus for healing if necessary.
A biopsy of the cyst lining should be taken to confirm the diagnosis after treatment.
A dentigerous cyst is a fluid-filled sac that forms around the crown of an unerupted tooth, caused by fluid accumulation between the enamel and reduced enamel epithelium, and it is typically treated through surgical removal (enucleation) or decompression to prevent further growth and complications.
7 yo
Lay-Term Explanation in Dot Points:
Permanent Teeth:
All permanent teeth are present, except for the wisdom teeth (third molars).
The patient’s dental development matches their age.
First Permanent Molars:
These teeth show structural defects visible on the X-ray, with irregular enamel outlines.
The back part of the pulp (distal pulp horns) has extra dentine (reactionary dentine) as a response to the defect.
Tooth Health:
The X-ray is not detailed enough to show small issues, but there are no large cavities visible.
The unerupted second molars look normal, with no obvious problems in shape or enamel structure.
A suspicious mixed-density lesion near the roots of the second premolar and first molar, with early bone loss and a radiopaque area behind the first premolar, suggests cemento-osseous dysplasia, confirmed by old X-rays showing gradual progression, requiring root canal or extraction for the nonvital molar, preventive care to avoid osteomyelitis, and further X-rays to rule out other conditions like tumors or fibrous dysplasia.
Lay-Term Explanation in Dot Points:
Restorations (Fillings):
The first premolar has a small filling.
The second premolar and first and second molars have large fillings, with no signs of new decay.
Bone and Root Issues:
Early bone loss is visible where the roots of the first molar split (bifurcation).
A dark area (radiolucency) is seen at the tip of the second premolar root, extending toward the mesial root of the first molar.
The thin white line (lamina dura) around the root tips of the second premolar and first molar mesial root is missing.
Unusual Finding:
There is a bright, irregular white area (radiopaque) behind the root of the first premolar, which appears well-defined.
What to do next: Take additional X-rays, including a panoramic radiograph and oblique lateral views, to clearly define the lesion’s margins, assess all teeth and bone structures, and rule out conditions like fibro-osseous or cemento-osseous lesions, odontogenic tumors, or bone disorders.
Why: The current X-ray shows a suspicious dark area (radiolucency) around the second premolar and first molar that doesn’t match a simple infection or cyst, and the affected second premolar appears vital, making further investigation necessary.
Findings from the panoramic X-ray: The X-ray reveals a mixed-density lesion extending across the lower jaw, centered on root tips, but with no bone expansion, tooth displacement, or nerve involvement, helping narrow down the diagnosis.
Diagnoses Excluded: Chronic osteomyelitis is unlikely due to the absence of pain, sinuses, or infection signs, and Paget’s disease and fibrous dysplasia are excluded because their typical presentation (e.g., jaw expansion or maxilla involvement) is not present. Metastatic malignancy is also ruled out due to the characteristic radiographic appearance of florid osseous dysplasia.
Diagnosis Confirmation and Management: Reviewing old X-rays confirmed the lesion as cemento-osseous dysplasia, with evidence of gradual progression over years, while the patient’s pain was traced to the nonvital first molar, requiring root canal treatment or extraction. Preventive care, caries control, and antibiotic coverage for extractions are crucial to avoid osteomyelitis in the affected bone.
Cemento-osseous dysplasia is a condition where the normal bone in the jaw is replaced with a mix of fibrous tissue and cementum-like material. It usually occurs near the roots of teeth and can appear as dark areas (radiolucency) or mixed dark and light areas on X-rays.
Causes in Lay Terms:
The exact cause is unknown, but it is thought to result from abnormal healing or bone remodeling in response to minor trauma, inflammation, or genetic predisposition.
It is more common in middle-aged women, especially those of African or Asian descent, and is often found incidentally during routine X-rays as it typically causes no symptoms.
Cemento-osseous dysplasia is a condition where the normal bone in the jaw is replaced with a mix of fibrous tissue and cementum-like material. It usually occurs near the roots of teeth and can appear as dark areas (radiolucency) or mixed dark and light areas on X-rays.
Causes in Lay Terms:
The exact cause is unknown, but it is thought to result from abnormal healing or bone remodeling in response to minor trauma, inflammation, or genetic predisposition.
It is more common in middle-aged women, especially those of African or Asian descent, and is often found incidentally during routine X-rays as it typically causes no symptoms.
