Radiographic Diagnosis of:

Caries
Periodontal Disease
Object Localization

Caries

Bitewing Film primarily

Periapical film also used
Low kVp, high contrast
(short scale)
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 Proximal caries susceptible zone

caries

Approximately 50 % demineralization is required for

radiographic detection of a lesion.

The thickness of the tooth buccolingually masks the

carious lesion when it is small.

The actual depth of penetration of a carious lesion is

deeper clinically than radiographically.

Factors affecting caries diagnosis:

Buccolingual thickness of tooth

Two-dimensional film
X-ray beam angle
Exposure factors

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 Radiographic Caries

I M A
A

I = Incipient
M = Moderate
A = Advanced S
S = Severe

Incipient
Interproximal
Caries I

Cone-shaped radiolucent area

Up to half the thickness of

enamel
Treat or no treat ?

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 Incipient
Interproximal I
Caries
Usually not restored:
* Unless patient has high caries activity
* Effective preventive program is enacted.

Histologic examination of an incipient carious lesion

shows that the carious process has penetrated the dentin
although the dentinal tissue is not invaded by bacteria.

Incipient

4
 Moderate
Interproximal
M
Caries

More than half-way through the

enamel (up to DEJ)

10

5
11

12

6
13

Moderate

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 Advanced
Interproximal
Caries A A

From DEJ to half-way through the

dentin

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Advanced

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8
 Advanced

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Advanced

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9
 Advanced

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Incipient
Moderate
Advanced

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10
 Severe
Interproximal
Caries S

More than halfway through the

dentin

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1 2

Severe
Green arrows identify restorative problems: fx (1),
overhang (2), open margin (3)

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 Severe

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Transillumination
Anterior interproximal caries can
usually be diagnosed by directing
bright light through the contact
areas.

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 Occlusal Caries
Must have penetrated into dentin

Diagnosed from clinical exam

Radiographs are not a reliable

diagnostic aid for the detection of
occlusal caries.

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Occlusal Caries

The apex of the triangle is toward the

outer surface of the tooth and the
base is at the dentino-enamel
juncition.
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13
 Occlusal

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Occlusal

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14
 Buccal/Lingual
Caries
Use clinical exam
Can’t determine depth

Appears as round dots

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Buccal/lingual

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15
 Root Caries

Older patients with recession or

periodontitis

Xerostomia may be present

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Root caries

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16
 Root caries

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Root caries may be confused with

cervical burnout (see below).

Cervical Burnout

Cross-section
(red line at right)

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 Cervical burnout
Radiolucency seen above left (arrow) disappears on
periapical film of same tooth (above right).

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Anterior Cervical Burnout

bone level

cervical burnout area

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 Cervical burnout in the
anterior region due to gap
between enamel (red
arrows) and alveolar bone
over root (blue arrows).

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Recurrent Caries

May be due to high caries rate, poor

oral hygiene, failure to remove all the
caries, defective restoration or a
combination.

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 Recurrent Caries

Is not always easy to detect

radiographically:
1. Location of caries lesion
relative to restoration.
2. Angulation of X-ray beam.

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Recurrent caries
(red arrows)

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 Recurrent caries

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Recurrent caries

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 Rampant Caries

* Rapidly progressing
* Usually found in children and teens with
poor diet and inadequate oral hygiene.
* Patients with xerostomia

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22
 Radiation Caries

Found in head/neck radiation therapy

patients with xerostomia

Fluoride used for control

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 Before radiation

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1 year after radiation

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 Mach Band
Optical illusion giving appearance of
increased radiolucency at junction of
differing tissue densities

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Periodontal Disease

Periodontal ligament attachment and

alveolar bony support of the tooth have
been lost.

Junctional epithelium migrates apical to

the CEJ.

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 Periodontal Disease
Bitewings best for diagnosis. Some feel
that paralleling PA’s are best.

Higher kVp recommended (long scale, low

contrast).
Compare images from different
visits (using same technique).

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Limitation of Radiographs

• Two-dimensional representation
of a 3-D anatomic structure.
• Superimposition of the bone and
tooth structures
* Relationship of hard to soft
tissues not evident

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 Limitation of Radiographs

* Presence or absence of periodontal

pockets.
* Early bone loss (<3mm) is not evident.
* Early furcation involvement is not
evident.

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Limitation of Radiographs

* PA: X-ray beam alignment will

obliterate the presence of extent of
furcation involvement.
* Facial and lingual aspects of alveolar
bone will be superimposed over the
furcation.

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Benefits

Early radiographic changes:

1.Crestal irregularities.
2.Triangulation
3.Interdental septal bone changes

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 Periodontitis

Involvement:
Localized
Generalized

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58

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Periodontitis
Normal Anatomy:
Alveolar crest corticated

1-1.5 mm from crest to CEJ

Parallel to line between CEJ’s

Crest is pointed anteriorly

60

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 Corticated alveolar crests

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CEJ

1-1.5 mm

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 Alveolar crests more
pointed anteriorly

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Contributing Factors
• Occlusal trauma
• Open contacts
• Overhangs, poor contours
• Calculus
• Post-extraction defects
• Systemic involvement (diabetes,
blood disorders, hormonal
changes, stress, AIDS)

64

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 Horizontal bone loss: Parallel to line
drawn between adjacent CEJ’s

Vertical (Angular) bone loss: More

bone destruction on interproximal
aspect of one tooth than on the
adjacent tooth

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Gingivitis

No bone loss
No radiographic signs

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 Mild Adult Periodontitis

Loss of cortical density

Rounding off of junction
between alveolar crest and
lamina dura
Blunting of crest anteriorly

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Mild adult periodontitis

68

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 Moderate Adult Periodontitis
Horizontal bone loss or vertical
osseous defects

Total extent of bone loss not evident

May have slight mobility

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Moderate adult periodontitis

(red arrows point to calculus)

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 Moderate adult periodontitis

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Severe Adult Periodontitis

Tooth mobility
Extensive horizontal bone
loss or vertical osseous
defects
Furcation involvement

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 Severe adult periodontitis

73

Severe adult
periodontitis

74

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 Severe adult periodontitis

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Restorative Materials
Radiopaque: Structures with higher object
density, such as amalgam, gold, silver
points, pins, gutta percha, porcelain.

Radiolucent: Structures with lower object

density, such as older composites and
bonding agents.

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 Gold crowns, amalgams

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Retention pins

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 porcelain
crowns

Ceramic Crowns

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crown

crown
amalgam

cast post

gutta percha
silver points

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82

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83

84

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 Red arrows point to bases
Green arrow indicates recurrent caries with
fractured restoration
85

old Composites new

86

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87

88

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89

Object Localization
Radiographic Definition
Closer to film = sharper
Right-Angle Technique (Occlusal)
Buccolingual location
Buccal Object Rule (SLOB)
Two films; different horizontal
or vertical angulations

90

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 Radiographic definition

91

Right Angle (Occlusal) technique

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 Buccal Object Rule
Same Lingual Opposite Buccal
(Compares object movement with tubehead movement)

Two films are needed. There must be a change in the

horizontal or vertical angulation of the x-ray beam to get
movement of the image of the object on the film.

93

When using the SLOB rule, the direction of the beam must be
opposite to the way the tubehead is moved.

Horizontal Tube Shift: When the tubehead is moved mesially,

the beam must be directed more distally (from the mesial). If
the tubehead is moved distally, the direction of the beam must
be more towards the mesial (from the distal).

Vertical Tube Shift: The SLOB rule also works for movement of
the tubehead in a vertical direction. When the tubehead is
raised, the beam is directed down and when the tubehead is
lowered, the beam is directed upward.

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 Buccal Object Rule
Same Lingual Opposite Buccal
(requires two films)

95

Horizontal movement of the x-ray beam

incisors
canine

premolar

molar

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 Vertical movement of the x-ray beam

Maxillary PA

BW

Mandibular PA

97

canine premolar

tubehead
restoration
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 Tubehead movement
Lingual object
Buccal object

premolar molar

99

100

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 molar premolar

tubehead

101

canine

tubehead

102

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 premolar
incisor canine

tubehead

103

Buccal

Lingual

104

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105

106

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107

108

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 BW

tubehead
PA

109

110

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111

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