Geetha Vijay, Vijay Raghavan

24
JAYPEE
REVIEW ARTICLE
Radiology in Periodontics
Geetha Vijay, Vijay Raghavan
ABSTRACT
The aim is to give a brief account of how to image the periodontal
tissues and to describe in detail the radiological features of
periodontal disease.
Periodontal examination remains incomplete without
accurate radiographs, which play an important role in the
assessment of periodontal disease. An overall assessment of
periodontal tissues is made on the basis of both the clinical
examination and radiographic findings.
The radiographic features of healthy and diseased
periodontal tissues are discussed.
Keywords: Bite-wing, Periodontics, Periapical, Periodontology,
Radiology.
How to cite this article: Vijay G, Raghavan V. Radiology in
Periodontics. J Indian Aca Oral Med Radiol 2013;25(1):
24-30.
Source of support: Nil
Conflict of interest: None declared
INTRODUCTION
Radiography plays a very important part in the diagnosis,
study and treatment of periodontal disease but it has very
serious limitations. It is true that in periodontology,
radiography often reveals evidence which is not forthcoming
from any other method of investigation, but on the other
hand, even gross disease may be present with no
radiographic indication of abnormality.
1
The proper approach to the diagnosis of periodontal
disease is a clinical one with the use of radiographs in every
case, either to support some clinical finding, or to yield
additional evidence when possible.
1
This paper will be directed to the role of conventional
radiographic methods as they remain the most commonly
used imaging methods in clinical dental practice.
CHOICE OF RADIOGRAPHS
The radiographic projections available to study periodontal
tissues include:
a. Periapical,
b. Bite-wing and
c. Panoramic.
Periapical radiograph is the film of choice for the
evaluation of periodontal disease. The paralleling technique
is the preferred periapical exposure method for the
demonstration of the anatomic features of periodontal
disease.
2
Radiographs obtained using paralleling techniques
provides more accurate assessment of height of crestal bone
10.5005/jp-journals-10011-1334
when compared with bisecting the angle technique. As a
result, periapical films using the bisecting technique may
appear to show more or less bone loss than actually present
2
(Figs 1A and B).
Vertical bite-wing radiographs can be used to examine
bone levels in the mouth and are best used as a post-
treatment or follow-up film. Vertical bite-wings have the
advantageous orientation of the interproximal views yet
show the reduced alveolar bone level even when bone loss
has been considerable. Horizontal bite-wing should not be
used to document periodontal disease, as severe bone loss
cannot be adequately visualized on horizontal bite-wing
radiograph
2
(Figs 2A and B). Horizontal bite-wing is best
utilized to demonstrate proximal and secondary caries.
Panoramic radiograph has little diagnostic value in the
identification of periodontal disease. It is useful as a general
survey, but may not show precise details.
A dental panoramic radiograph (DPR) of optimal quality
may offer a dose advantage over large numbers of intraoral
radiographs and may be considered as an alternative if
available. This may be the case when there are concurrent
problems for which radiography is indicatedfor example,
symptomatic third molars, multiple existing crowns/heavily
restored teeth and/or multiple endodontically treated teeth
in a patient new to a practice. However, in view of the
limitations in fine detail on DPRs, supplementary intraoral
radiographs may be necessary for selected sites.
3
Figs 1A and B: Periapical radiographs showing difference in crest
level using different techniques (A) Paralleling (B) Bisecting the angle
A B
Figs 2A and B: Coverage of interdental bone in vertical and
horizontal bite-wing radiographs along with orientation of films in
XCP instrument (A and B) Bite-wing, (C) Horizontal, (D) Vertical
A B
Journal of Indian Academy of Oral Medicine and Radiology, January-March 2013;25(1):24-30
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Radiology in Periodontics
JIAOMR
Full-mouth surveys of paralleling periapical radiographs
have been considered to be a gold standard for periodontal
diagnosis and treatment planning.
4
However, there is no
basis for considering a full-mouth series of paralleling
periapical radiographs to influence periodontal treatment
decisions any more than, say, panoramic radiographs. If a
panoramic radiograph is available, having been exposed for
whatever purpose, that radiograph may alone be sufficient,
5
or a panoramic radiograph may be supplemented by selected
intraoral radiographs which numbered less than four
per patient to reach the gold standard.
6
It has been shown
that if seven periapical radiographs supplement a panoramic
oral radiograph then the effective radiation dose exceeds
that of a full-mouth series of periapicals,
7
but if the number
is less than four, then there is a reduction in radiation
exposure and yet the gold standard in terms of information
can be achieved.
In the interpretation of the periodontal tissues, it is
important to note that images of excellent quality are
essentialperhaps more so than in other dental specialities
because of the fine detail that is required. Also, exposure
factors should be reduced when using film-based techniques
to avoid burn out of the interdental crestal bone.
8
RADIOGRAPHIC FEATURES OF HEALTHY
ALVEOLAR BONE
In health, the lamina dura around the roots of the teeth
appears as a dense radiopaque line.
2
The normal healthy alveolar crest is located approximately
1.5 to 2 mm apical to the cementoenamel junctions of adjacent
teeth. As the age advances, due to passive eruption, there is
some radiographic evidences of increase in the distance
between the amelocemental junction and the alveolar crest.
Radiographically it is difficult or impossible to determine
precisely the normal position of the alveolar crest for any
particular age.
In the anterior region, the alveolar crest appears sharp
and pointed. In the lower incisor area, the sharp crests are
normally covered by dense bone which is actually a
continuation of the lamina dura. The absence of cortex in
this area nearly always indicates that disease is, or has been,
present
1
(Fig. 3).
In the posterior regions, the alveolar crest appears flat
and smooth. They are sometimes covered with a thin layer
of dense cortical bone, which may be seen as a thin white
line. These bony cortices are more often absent, however,
even in normal cases, and are usually noted only in young
persons. Bicuspid and molar areas which show no cortex
may be regarded as normal if the level and density of the
crests are normal. Alveolar crests, when flat, meet with the
lamina dura at the necks of the teeth, forming well-defined
right angles. A rounding of these angles always indicates a
pathologic process (Fig. 4).
The normal periodontal ligament space appears as a thin
radiolucent line between the roots of the tooth and the lamina
dura. In health, the periodontal ligament space is continuous
around the root structure and is of uniform thickness.
Periodontal membrane shadows can be seen only on the
mesial and distal aspects of the teeth. There are slight
differences in thickness of the periodontal membranes in
different persons, but there is uniformity in any one person
except in the presence of disease.
1
BENEFITS OF RADIOGRAPHS IN
PERIODONTAL DISEASE
Despite its limitations, periodontal examination is
incomplete without accurate radiographs, which can show
most bony changes in association with periodontal disease
(Flow Chart 1).
Radiographs provide the following information
concerning periodontal disease:
Early Radiographic Changes in Periodontitis
Although the radiograph is not sensitive enough to detect
the earliest signs of periodontal disease, it is still an essential
part of the clinical examination. Glickman
9
listed the
following sequence of early radiographic changes that occur
in periodontitis:
Crestal irregularities
Triangulation
Interseptal bone changes.
Crestal Irregularities
The crest of the interdental bone becomes rough and
irregular along with indistinctness and interruption in the
continuity of the lamina dura seen along the mesial or distal
aspect of the interdental alveolar crest (Fig. 5).
Triangulation
Triangulation is the widening of periodontal membrane
space along either mesial or distal aspect of the interdental
crestal bone. The sides of the triangle are formed by
lamina dura and the root and the base is toward the crown
(Fig. 6).
Interseptal Bone Changes
One of the earliest radiographic signs of periodontitis is the
finger-like radiolucent projections extending from the crestal
bone into the interdental alveolar bone (Fig. 7). These
projections are result of a deeper extension of the
inflammation from the connective tissue of the gingiva. They
represent widened blood vessel channels within the alveolar
bone that allow for the passage of inflammatory fluid and
cells into the bone.
10
Geetha Vijay, Vijay Raghavan
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JAYPEE
Flow Chart 1: Role of radiographs in periodontal disease
at a glance
Fig. 5: Crestal irregularities
(arrow)
Fig. 3: Appearance of crestal bone in anterior and
posterior region
Fig. 4: Alveolar crest meet the
lamina dura at right angle on distal
of 2nd premolar and rounded
angle on mesial of 1st molar
Evaluation of Bone Loss
The radiograph is used indirectly to determine the amount
of bone loss attributed to periodontal disease. Actually, the
radiograph indicates the amount of bone remaining and not
the amount of bone loss.
10
The amount of bone loss can be estimated as the
difference between the physiologic bone level and the height
of remaining bone (Fig. 8).
Bone loss can be determined in terms of distribution,
pattern and severity.
Distribution
When the bone loss occurs in isolated areas, with less than
30% of the sites involved, it is described as localized bone
loss.
When the bone loss is evenly distributed throughout the
dental arches, with more than 30% of the sites involved, it
is called generalized bone loss (Fig. 9).
Pattern
When the bone loss occurs on a plane that is parallel to a
line drawn from CEJ of a tooth to that of an adjacent tooth,
it is called horizontal bone loss (Fig. 10).
When the bone loss occurs on a plane that is at an angle
to a line drawn from CEJ of a tooth to that of an adjacent
tooth, it is called vertical or angular bone loss (Fig. 11).
Severity
Bone loss viewed on a dental radiograph can be classified
as slight, moderate, or severe. The severity of bone loss can
be defined as follows:
Slight bone loss: 1 to 2 mm
Moderate bone loss: 3 or 4 mm
Severe bone loss: 5 mm or greater.
2
Fig. 7: Interseptal bone
changes; arrow pointing
to widened blood vessel
channel s wi thi n the
alveolar bone
Fig. 8: Evaluation of amount of
bone loss
Fig. 6: Arrow pointing to widening of
periodontal ligament space near the
crest of interdental bone (triangulation)
Journal of Indian Academy of Oral Medicine and Radiology, January-March 2013;25(1):24-30
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Radiology in Periodontics
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Fig. 9: Generalized bone loss Fig. 10: Horizontal
bone loss
Fig. 11: Vertical
bone loss
Furcation Involvement
Extension of the periodontal pocket between the roots of
multirooted teeth is called furcation involvement.
Radiographs can be helpful in locating furcation
involvement; however, the furcation involvement will not
be seen unless the bone resorption extends apically beyond
the furcation. Mandibular molar furca is much more sharply
defined (Fig. 12) than the maxillary molar furca, mainly
because the palatal root is not superimposed over the furca
as with the maxillary molar
10
(Fig. 13).
Widening of the PDL space at the apex of the inter-
radicular bony crest of the furcation is strong evidence that
the periodontal disease process involves the furcation.
If sufficient bone loss has occurred on the lingual and buccal
aspects of a mandibular molar furcation, the radiolucent
image of the lesion becomes prominent.
Predisposing Factors
A number of predisposing factors or local irritants contribute
to periodontal disease. Dental radiographs play a major role
in the detection of local irritants, such as calculus and
defective restorations.
Calculus
Calculus appears radiopaque on a dental radiograph.
Although calculus may have a variety of appearances on
dental radiographs, it most often appears as pointed or
irregular radiopaque projections extending from the
proximal root surfaces (Fig. 14). Calculus may also appear
as ringlike radiopacity encircling the cervical portion of a
tooth, (Fig. 15) a nodular projection, or a smooth radiopacity
on a root surface.
2
The diagnosis of absence or presence of calculus
deposits should not be based on radiographic interpretation,
since small deposits are not visible in radiographs.
11
Caries/Defective Restorations
Gross proximal caries will lead to plaque accumulation and
may act as an aggravating factor in periodontal disease
(Fig. 16). Root surface caries may also be seen in conjunction
with periodontal bone loss.
3
Faulty dental restorations act as potential food traps and
lead to accumulation of food debris and bacterial deposits.
Defective restorations act as contributing factors to
periodontal disease. Radiographs are useful in detecting
defective margins of restorations
12
(Fig. 17). However, if
there is excessive vertical or horizontal angulation of the
central X-ray beam, there is a risk of underestimating, but
not overestimating the size of the defective margin.
13,14
Crown-Root Ratio
Tooth stability is influenced by the amount of leverage
placed on the periodontium. The type of leverage is
dependent on the amount of tooth that is within bone (clinical
root) in relation to the amount of tooth not within bone
Fig. 12: Furcation clearly seen as radiolucency
at site of furcation in a lower molar
Fig. 13: Furcation not seen in maxillary molar
because of superimposition of palatal root
Fig. 14: Calculus appears
as radiopaque projections
from proximal surface
Geetha Vijay, Vijay Raghavan
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JAYPEE
Fig. 15: Calculus appears as ring-
like radiopacity
Fig. 16: Deep proximal caries
causing periodontal disease
Fig. 17: Defective restoration
causing triangulation
(clinical crown). An increase in length of the clinical crown
produces unfavorable leverage on the periodontium
10
(Fig. 18).
Activity of the Destructive Process
The approximate activity of the destructive process of
periodontal disease can be evaluated by comparing
standardized radiographs taken over regular intervals. When
the interdental septal bone crest is rough and irregular and
the alveolar bone below the crest is devoid of any suggestion
of bone opacity, it is most likely that the resorptive process
is active. Nutrient canals indicate active and even rapid bone
resorption. If a smooth surface of the alveolar bone with
condensation of remaining alveolar bone is seen in the
presence of bone loss, a static destructive process or slowly
destructive process is indicated
10
(Fig. 19).
Root Resorption
External root resorption is sometimes seen in conjunction
with periodontal diseases. Its identification is important
because of its implications for tooth prognosis (Fig. 20).
Hypercementosis
A direct causal relationship with periodontal diseases is not
proven, but hypercementosis is seen occasionally on teeth
with bone loss. It may be a response to inflammation or to
the increased occlusal loading on a tooth with attachment
loss
3
(Fig. 21). Hypercementosis appears as a bulbous
enlargement of the root, most commonly seen in relation to
the apical half of the root.
Prognosis
Radiographic information is part of the diagnostic data that
are used in determining the prognosis.
The prognosis is reasonably good if:
The destructive process is not generalized
Only a limited amount of bone has been lost
Corrective etiologic factors can be identified
The patients general health is good
The patient is motivated to save the remaining teeth and
is capable of performing all routine and specialized
home-care procedures as dictated by the extent and
distribution of the periodontal disease.
LIMITATIONS OF THE RADIOGRAPH
Radiographs may provide an incomplete presentation of the
status of the periodontium. Some of the important limitations
of radiographs are:
They do not provide information about the health of soft
tissues, and the condition of gingiva cannot be predicted
from the radiographic appearance of alveolar crest.
Fig. 18: Crown-root ratio Fig. 19: Presence of sclerotic
margin at crest suggests
static destructive process
Fig. 20: Root resorption of 2nd molar in the
presence of chronic periodontal disease
Journal of Indian Academy of Oral Medicine and Radiology, January-March 2013;25(1):24-30
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Radiology in Periodontics
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Radiographs provide two-dimensional views of three-
dimensional situations. They often fail to disclose
osseous destruction particularly that confined to the
buccal or lingual surfaces of teeth.
Radiographs typically show less severe bone destruction
than is actually present.
Bone level is often measured from the cementoenamel
junction; however, this reference point is not valid in
situations where there is overeruption or where there is
severe attrition with passive eruption.
15
Radiographs do not demonstrate the soft tissue to hard
tissue relationship and thus provide no information about
the depth of soft tissue pockets. However, if a radiopaque
material, such as gutta-percha is inserted into the pocket,
the base of the pocket can usually be recorded on the
radiograph (Fig. 22).
Tooth mobility: Radiographs do not record tooth
mobility. However, in most cases, a widening of
periodontal ligament space on the radiograph does
indicate an increase in tooth mobility (Fig. 23).
They do not specifically distinguish between the
successfully treated cases and the untreated cases.
16
CHRONIC PERIODONTITIS
17
Both A localized and B generalized chronic periodontitis
are characterized by pocket formation and/or gingival
recession, both clinically detectable without radiographs.
Chronic periodontitis can be divided into localized, if less
than 30% of available sites display clinical attachment loss,
and generalized if more than 30% of sites display clinical
attachment loss. This differentiation is made on the basis of
clinical findings and so radiographs are not required,
although radiographs may be used. In some clinical
situations restorations may impede the accessibility of the
periodontal probe into a pocket and/or may obscure the CEJ
and so compromise the clinical assessment of the presence
and severity of chronic periodontitis. In such a situation
radiographic evidence of alveolar bone loss may be helpful.
Similarly, subgingival calculus or root surface topographies
or malformations may impede the passage of the periodontal
probe. In these situations radiographic evidence of alveolar
bone loss may be helpful as it may direct the attention of
the examining clinician to probe carefully sites or teeth with
evident radiographic bone loss.
AGGRESSIVE PERIODONTITIS
15
Aggressive periodontitis refers to periodontal disease of an
aggressive and rapid nature that usually occurs in patients
younger than 30 years. Aggressive periodontitis is
subclassified into localized aggressive periodontitis and
generalized aggressive periodontitis. The cause of
aggressive periodontitis is not known; however, specific
bacterial pathogens, especially Actinobacillus actino-
mycetemcomitans, functional defects of polymorphonuclear
leukocytes, exuberant immune responses, and inheritable
factors have been implicated.
Clinical Presentation
Localized aggressive periodontitis is associated with
attachment loss involving the incisors and first molars. In
this form, the amount of bone loss correlates with the time
of tooth eruption, in that the teeth that erupt first (incisors
and first molars) have the most bone loss. This disease
usually commences around puberty and the bone loss is
rapid. Of interest is the fact that there are usually very few
signs of soft tissue inflammation or plaque accumulation
despite the presence of deep bony pockets. Often the patient
will present with drifting and mobile incisors and early loss
of first molars.
Generalized aggressive periodontitis can involve a
variable number of teeth, from the least three to all of the
dentition, and by definition is not confined to the first molars
and incisors. This rapidly progressing disease usually affects
individuals younger than 30 years.
Radiographic Appearance
The radiographic appearance of the bone loss in localized
aggressive periodontitis typically consists of deep vertical
Fig. 22: Radiograph with gutta-percha to record
the base of pocket
Fig. 21: Hypercementosis of premolars with
moderate interdental bone loss
Fig. 23: Widening of periodontal
membrane space around a
tooth may indicate mobility
Geetha Vijay, Vijay Raghavan
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defects. Maxillary teeth are involved slightly more often
than mandibular teeth, and strong left-right symmetry is
common. The generalized form of aggressive periodontitis
can involve several teeth or all the dentition and the rapid
bone loss may be of the vertical or horizontal pattern.
PERIO-ENDO LESION
This entity is an incompletely understood phenomenon that
may present clinically in a variety of ways. It refers to teeth
(typically molars) that have concurrent clinical and radio-
logical signs of disease of periodontal and pulpal origin.
3
Perio-endo lesion occurs when an infection involves
both pulp chamber and periodontal ligament space
simultaneously (Fig. 24). It may arise as a result of:
1. Infection in a necrotic pulp draining via the periodontal
ligament (usually in the presence of existing periodontal
disease).
2. Toxins from pulp reaching PL space via lateral or
accessory canals, especially in the furcation region.
3. The root having been perforated by pin or post.
CONCLUSION
Dental radiographs play an integral role in the assessment
of periodontal disease. Periodontal examination is
incomplete without accurate radiographs.
An overall assessment of the periodontal tissues is based
on both the clinical examination and radiographic findings
the two investigations complement one another.
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ABOUT THE AUTHORS
Geetha Vijay
Professor and Head, Department of Periodontics, Vydehi Institute of
Dental Sciences and Research Center, Bengaluru, Karnataka, India
Vijay Raghavan (Corresponding Author)
Professor, Department of Oral Medicine and Radiology, Seema
Dental College and Hospital, Rishikesh, Uttarakhand, India
e-mail: drvijayr53@gmail.com Fig. 24: Perio-endo lesion