Advanced diagnostic aids

in
periodontology
Radiographs & imaging
 Introduction
A better understanding of the
periodontal disease process
challenged usefulness of traditional
clinical and radiographic methods for
diagnosis and prompted revision of
outdated diagnostic aids.
DIAGNOSIS

The act or process of identifying or determining

the nature and cause of a disease or an injury

Evaluation of
patient history

Physical
examination

Laboratory
investigations
PRINCIPLES OF DIAGNOSIS

Diagnostic test are assessed in terms of their

sensitivity and specificity

Specificity is the ability of test to clearly

differentiate one disease from other

True negative

Percentage of subjects with truly absent disease

who have a negative test
SENSITIVITY - the ability of a test to detect the disease
whenever it is present

Percentage of subjects with truly present disease who have

positive test

PREDICTIVE VALUE Probablity that the test result agress

with disease status

Positive predictive Negative predictive

value-Probablity of value
disease in a subject with Probabllity of health
positive test results in presence of
negative test results
RADIOGRAPHS
It is the traditional method to asses the destruction of
alveolar bone associated with periodontitis.

CONVENTIONAL RADIOGRAPH CAN BE USED TO

EVALUATE

Bone levels
Bone loss even or angular patterns
Intra(infra) bony defects
Root morphologies topographies
Furcation radiolucencies
Endodontic lesions
Endodontic mishaps
Developmental anomalies
Root length and shape(s) remaining in bone
 CONVENTIONAL
RADIOGRAPHS AND
DIGITAL

INTRA ORAL EXTRA ORAL

IOPA,BITEWINGS
OPGS
&OCCLUSAL
CONVENTIONAL RADIOGRAPHS

INTRA ORAL RADIOGRAPHS

 Intra oral periapical radiographs

Paralleling technique
Also called as right angle or long cone technique.
X-ray film is placed parallel to long axis of tooth and
central ray of x-ray beam is directed at right angle to teeth
& film.
Preferable technique for periodontal use.
 Bisecting angle technique

Central ray is directed at right angles to a plane

bisecting the angle between long axis of teeth &
film.

Projection Maxilla Mandible

Incisors +40 degrees -15 degrees
Canine +45 degrees -20 degrees
Premolar +30 degrees -10 degrees
Molar +20 degrees 2-5 degrees
 Extraoral Periapical Radiograph
(Newman And Friedman 2003)
Limitations with intraoral periapical radiographic imaging:
Advancing age
Anatomical difficulties like large tongue, shallow palate,
restricted mouth opening,
Neurological difficulties, and size of radiographic sensor

Chen et al in 2007 developed a

sensor beam alignment aiming
device for performing
radiographs using this technique
aiming device with placement of the sensor
BITEWING RADIOGRAPHS

Records the coronal part of upper & lower dentition along

with periodontium.

USES
1)To study height & contour of interdental alveolar bone.
(2)To detect interproximal calculus.
(3)To detect periodontal changes

Horizontal bitewing radiographs

useful for proximal caries
detection
limited use in periodontal
treatment and treatment planning if
bone loss is advanced
Vertical bitewing radiographs
film is placed with its long axis at 90 to the placement
for horizontal bitewing radiography,
can be helpful in evaluating periodontium

POSITIONING DEVICES FOR BITEWING

Hawe Paro-Bite Centering Device

a positioning aid is advised to reduce the need for repeat
radiographs and hence the unnecessary x-ray exposure is
reduced
Occlusal Radiographs Intraoral occlusal
radiographs enable viewing of a relatively
large segment of dental arch.

They are useful in patients who are unable to

open mouth wide enough for periapical
radiographs
LIMITATIONS OF RADIOGRAPHS

Conventional radiographs are specific but lack sensitivity

More than 30% of bone mass at alveolar crest must be

lost to be recognized on radiographs

Radiographs provide a 2-dimensional view of a 3-

dimensional situation,
provides only information about inter proximal bone
level.

Radiographs do not demonstrate soft tissue - to - hard

tissue relationship hence no information about depth
of soft tissue pocket
STANDARDIZATION OF RADIOGRAPHS

Constant film position film holders, stents

Constant tube geometry - Positioning

devices , Cephalostat
Using paralleling techniques
Using vertical bitewings
Using superimposed mm grid
 Extraoral radiographs
Extraoral radiographs are taken
when large areas of the skull or jaw must be examined
or
when patients are unable to open their mouths for film
placement.

Useful for evaluating large areas of the skull and jaws but
are not adequate for detection of subtle changes such as
the early stages of dental caries or periodontal disease.
Conventional panoramic
imaging/Pantamography
LIMITATIONS OF OPG

Image distortion
Lingual structures would be projected higher than buccal
surfaces
Use of screen film combination results in less details than
intral oral images
Production of ghost images

It can be used as a alternative for intra oral full mouth series when
combined with bite wing radiographs
Tugnait et al. 2000,2005
The periodontal structures of interest noted on periapical
radiographs are also noted on panoramic radiographs.

The radiographic features of interest on a panoramic radiograph

supplemented when necessary by a small number of intra-oral
views, is sufficient for the management of periodontal diseases .

Pepallasi EA et al 2000
Panoramic radiographs may not reveal alveolar bony defects as
accurately as periapical radiographs.

But question is whether there is any additional therapeutic yeild

from greater accuracy from IOPAs
Vazquez et al 2007

Determined the efficacy of panoramic radiographs in

the preoperative planning of posterior mandibular
implants

mental nerve parasthesia following implant

placement in 1527 patients with 2584 implants with
only OPGs as preoperative imaging technique

No permanent sensory disturbances of the inferior

alveolar nerve

Only 2 cases 0.08 %reported paresthesia

Panoramic examination safe preoperative

evaluation tool
 Digital radiography
Digital radiography is a superior alternative for film based imaging

Digital in digital radiography means numeric format of image content as

well as its discreteness

Images are numeric and discrete in two ways

Spatial distribution of picture elements (pixels)

and

In terms of different shades of gray of each of pixels

Collections of individual pixels

Digital image
organized in a matrix of rows and columns
 DIGITAL RADIOGRAPHY
Direct Method
Uses a Charge Couple Device
(CCD) or CMOS sensor linked
with fiberoptic or other wires to
computer system
CCD receptor is placed
intraorally as traditional films ,
images appear on a
computer screen which can be
printed or stored
Indirect Method
This method uses a phosphor
luminescence plate, which is a
flexible film like sensor placed
intraorally & exposed to
conventional x-ray tube.
A laser scanner reads the
exposed plates & reveals
digital image data.
 Direct Digital Imaging
Components
X-ray source
an electronic sensor,
A digital interface card,
a computer with an analog to-
digital converter (ADC),
a screen monitor, software, and a
printer.

Direct digital sensors- charge-coupled device (CCD) or complementary

metal oxide semiconductor active pixel
sensor (CMOS-APS).

array of X-ray or light sensitive pixels

on a pure silicon chip.
Indirect imaging
Photostimulable phosphor radiographic
systems

PSP is scanned with a helium-neon laser

beam. The emitted light is captured and intensifi ed
by a photomultiplier tube and then converted into
digital data.
 ADVANTAGES
image can be instantly viewed by patient & dentist.

Reduction in radiation received by patient by as much

50% to 80%

Images can be altered to achieve task specific image

characteristics for eg. density & contrast can be lowered
for evaluation of marginal bone and increased for
evaluation of implant components.

enables the dental team to conduct remote

consultations.

Computerized images can be stored, manipulated &

corrected for under & overexposure
 DISADVANTAGES
Familarity with digital nature of images and understanding of
principles of image manipulation is required

Lack of infection control.

Patient discomfort during placement.

As image can be easily manipulated, it can be misused in legal

proceedings

Grossly overexposed or underexposed images cannot be corrected

 Radiovisiography (RVG)
Duret F et al (1988)

Based on use of CCD

Radio X-ray generator connected to sensor

Visio storage of incoming signals during exposure and
convertion to gray levels
Graphy digital mass storage unit connected to various
video printout devices

latest version

Trophy has released a wireless version

of their RVG intraoral sensor named
the RVG 6500.
Mechanism of image display
Radiographic digital
detector

Conventional radiographic
source used to expose sensor

Detector converts X-rays to

visible image

Image display on monitor

Mouyen F et al (1989):
The RVG system when compared with conventional
uses considerably reduced levels of radiation to
produce an image immediately after exposure..

Adosh L in 1997 in a comparative study for

marginal bone between RVG and after surgical
exploration presented that Majority showed
difference of less than 0.5 mm between two
techniques
A.R. Talaiepour et al in 2005

evaluated the accuracy of RadioVisioGraphy (RVG) in

the linear measurement of interproximal bone loss in
intrabony defects.
Comparison between RVG measures and
intrasurgical estimates were performed in 56 teeth
with intrabony defects

The radiographic measurements overestimated

interproximal bone loss as compared to the
intrasurgical measurements:
 Diagnostic efficacy of digital imaging
with regard to periodontal lesions
Nair et al. 2000 investigated the accuracy of alveolar crestal bone
detection utilizing Ektaspeed Plus film, Sidexis
direct digital images, and brightness-enhanced
digital images. No significant differences were found

Wallace et al 2004 Demonstrated that E film displayed the

highest sensitivity and specificity followed
by PSP and CCD images when observers
were able to adjust digital image contrast
and brightness enhancements.
 Specialized techniques

Introduction of digital radiography applications with meaningful

in dentistry diagnostic utility

Early detection

Quantitative assessment

3 D imaging
 Digital subtraction radiography
Zeidses des Plantes (1935) : 1st demonstrated use of
subtraction imaging
Depends up on conversion of serial radiographs into
digital images.

The serially obtained digital images are

superimposed & image intensities of corresponding
pixels are subtracted

If change has occurred

The brighter area represents gain

Darker area represents loss

This technique facilitates both qualitative &
quantitative visualization of even minor density
changes in bone by removing the unchanged anatomic
structures from image

Base line after one year bone gain

Ortmann (1994)- 5% of bone loss can be
detected.
Diagnostic subtraction radiography (DSR) can
be used for enhanced detection of crestal or
periapical bone density changes and to evaluate
caries progression
STANDARDIZATION

Baseline projection geometry and image density

should be reproduced

bite blocks must be made and attached to the film

holders and the film holder must be reproducibly
aligned to the x-ray beam collimating device
Several image processing techniques are also developed to
reduce the error in DSR

Semiautomated registration Byrd V et al 1998

Automated registration algoritham .Ettinger et al

samarabandhu et al 1994

Computer corrected of distorted projections webber1984

 ADVANTAGES DISADVANTAGES

Overall contrast is
improved no objective description
Trabecular marrow High standardization of x
spaces are visualized rays
Enhancement of low No reduction in exposure
and high density
images
 COMPUTER ASISTED DENSITROMETRIC

IMAGE ANALYSIS SYSTEM

Introduced by Urs Brgger et al 1988
A video camera mesaures the light transmitted through
the a radiograph

Signal are converted to grey scale images

Camera is interfaced with computer and image

processor for storage and mathematic manipulation of
image

Offers an objective method for studying alveolar bone

changes quantitatively

High degree of sensitivity ,accuracy and reproducablity

Urs Brgger et al in 1988

CADIA was more sensitive than subtraction radiography

CADIA was capable of assessing differences in
remodeling activity over 46 weeks after periodontal
surgery
Objective method to quantify alveolar bone density

Deas et al 1991

on monitoring the relationship of CALs and CADIA, found

that prevelance of progressive lesions as detected by
radiograph is higher than previous accepted data

CADIA is still used in research purposes for detecting

quantitatively the alveolar bone density
Computer-Based Thermal Imaging

Compare the rewarming rates of normal and

inflamed human gingiva

gingival temperature measurement Valuable

objective method for the diagnosis of periodontal
diseases

Infra-red thermography provides a non-invasive

method
 Probeye Thermal Imaging Systems

The camera's lOx lens provides a

spatial resolution of 0.1 mm at a
distance of approximately 15 cm from
the gingiva.

composed of indium antimonide

which detects wave lengths from 2000
nm to 5600 nm

Technique is no more in use

Extra oral digital imaging
 Conventional tomography
Designed to image a slice or plane of tissue

Accomplished by blurring the images lying outside

the plane of interest

It consists of an x ray tube and radiographic film

rigidly connected which moves about a fixed axis
and fulcrum

As exposure begins tube and film move in opposite

direction simultaneously .

Objects located with in the fulcrum remain in fixed

positions and are viewed clearly
Used less frequently with the
introduction of:

MRI , CT and Cone beam imaging

OPG is a variant of conventional

Tomography
 Computed tomography
Godfrey Hounsfield and Allan MacLeod Cormack (1979) shared Nobel
prize

Consists of a x ray tube emitting

finely collimated x ray beam
directed through the patient to a
series of scintillating detectors or
ionizing chambers

Detectors form a continuous ring

and x-ray tube moves in a circle
with in the ring

Patients lie stationary and x ray

tube rotates one turn .Then the
table will move 1 to 5 mm to next
scan
 HELICAL CT

Introduced in 1989

The gantry containing x ray tube and detectors continuously

revolve around the patient ,where as patients table advances
through the gantry.

Result is acquisition of a continuous helix of data.

DETECTORS

Gas filled ion chambers xenon

Solid state detectors cadmium tungstate
CT Image construction

Computer algorithms use photon counts to construct

digital CS images

Images are displayed in individual blocks

-----VOXELS

Each square of the image is matrix----PIXELS

Each pixel is assigned a CT number representing

tissue density

CT number HOUNSFIELD units

Range -1000 to 1000

ADVANTAGES

Eliminates superimposition of images of

structures outside area of interest

High contrast resolution differences between

tissues that differ in density < 1% - can be
distinguished

Images can be viewed in axial coronal and

sagittal planes
Naito T et al. 1998, Pistorius A et al. 2001.
Used Computed tomography (CT) in studies in
relation to periodontal defects.

CT does not offer any favourable cost benefit, dose

exposure or therapeutic yield advantage in periodontal
practice and is unlikely to find a routine
 CONE BEAM COMPUTED TOMOGRPHY
Developed in 1982 for angiography

Utilizes cone shaped source of ionizing

radiation & 2D area detector fixed on a rotating
gantry .

Multiple sequential images are produced in one

scan

Rotates 360 around the head

Scan time typically < 1 minute

 Image acquisition involves a Rotational
scan of a x ray source and reciprocating
area detector moving synchronously
around patients head

Many exposures are made at fixed

intervals to form basic images.

Software programs are used to reconstruct

3D images
Image reconstruction
INTERFACE CONE-BEAM CT MANAGEMENT SOFTWARE
 INDICATIONS
Evaluation of the jaw bones
Implant placement and evaluation
evaluation TMJ
Bony & Soft tissue lesions
Periodontal assessment
Endodontic assessment
Alveolar ridge resorption
Orthodontic evaluation
Airway assessment
Need for 3D reconstructions
superimposition
 CT V/S CBCT
Conventional CT scanners
make use of a fan-beam and
Provides a set of consecutive
slices of image
Conventional CT makes use
of a lie-down machine with a
large gantry.
Greater contrast resolution &
More discrimination between
different tissue types (i.e. bone,
teeth, and soft tissue
Utilize a cone beam, which radiates
from the x-ray source in a cone
shape, encompassing a large
volume with a single rotation.
a sitting-up machine of smaller
dimensions
Commonly used for hard tissue
Ease of operation
Dedicated to dental
Both jaws can be imaged at the same
time
Lower radiation burden
Artifacts arising from metal artifacts that arise from metallic
restorations are more severe using restorations are less severe with the i-CAT
conventional CT.
Kelly A. Misch et al . 2006
Compared radiographs with CBCT
Results: Three-dimensional capability of CBCT offers a significant
advantage in linear measurements for periodontal defect
All defects can be detected and quantified.

Mol A and Balasundaram 2008

Evaluated The NewTom 9000 CBCT scanner
Results: Better diagnostic and quantitative information on periodontal
bone levels in three dimensions than conventional radiography can be
obtained

B. BEZAK et al 2010
Assessed reliability and accuracy of Cone Beam Computed Tomography
(CBCT) against CAL
.
CBCT measurement protocol is reliable.
Accuracy of CBCT measurements correlates with CAL gold standard
measurements.
 Brently A. et al 2009

Compared the measurements from digital IR and

CBVT images to direct surgical measurements for the evaluation of
regenerative treatment outcomes.

Compared to direct surgical measurements,

CBVT significantly more precise and accurate than IRs.

CBVT may obviate surgical reentry as a technique

for assessing regenerative therapy outcomes
Walter C et al..2011-

Suggests that cone-beam CT may provide detailed

information about furcation involvements in
patients with chronic periodontitis and so may
influence treatment planning decisions
 . MICRO CT
Microtomography KNOW AS Industrial CT Scanning
uses X-rays to create cross-sections of a 3D-object

The term micro the pixel sizes of the cross-sections are in the
micrometer range

Used in animal studies

analysis of bone biopsies without destruction
of samples
 Denta scan

DentaScan is a unique computer software program

provides computed tomographic (CT) imaging of the

mandible and maxilla in three planes of reference:
axial, panoramic, and oblique sagittal

.
 Uses

visualization of internal bone morphology in

three dimensions ; precise treatment
planning
In cross sectional view, observation regarding
bone quality, density can be made
pre-operative planning of endosseous
dental implants and subperiosteal implants
to visualize the bony structures pre-
operatively
 Dentascan CT provides information of the
internal structures that cannot even be gained
by direct intra-operative visualization

the precise location of the mandibular canal

the location of the floor of the maxillary sinuses

Dr Urvashi shah, Dr Subraya bhat

Utilization of denta-scan for treatment planing in

patients with infra-bony defects

Infra-bony defects better visualized by denta-scan

compared to intra-oral radiographs
 SIMPLANT

Computer program for assessing

oral implant site

Uses raw data from CT along with

advanced computer graphics

Advantages:
assessment of bone volume,
bone height &quality
proper length of implant can be
selected
Clear visualization of inferior
alveolar canal
 Digital tomosynthesis (DTS)
Digital tomosynthesis (DTS) is a limited-angle tomographic
technique

only small rotation angles (a few tens of degrees) with a small

number of discrete exposures are used.

provides some of the tomographic benefits of computed tomography

(CT)
at reduced dose and cost
K Ogawa et al 2010

Developed a new dental panoramic radiographic

system
based on a tomosynthesis method

This system allowed the extraction of an optimum-

quality panoramic image regardless of
irregularities in patient position

the authors could freely reconstruct a fine image

of arbitrary planes
C Beda in 2010
proposed the Use of both DTS and CBCT
reconstruction methods as an integrated solution
for providing tomographic data in dental
application
OPTICAL COHERENCE TOMOGRAPHY
Optical coherence tomography (OCT) is an
optical signal acquisition and processing method

an interferometric technique, employing near-

infrared light.
Layperson's explanation

a technique for obtaining

sub-surface images of
translucent or opaque
materials at a resolution
equivalent to a low-power
microscope.
 OCT is well-suited for periodontal diagnosis

pocket morphology, and attachment level are digitally

recorded
Xiang et al. (2009)
OCT imaging can offer three-dimensional imaging of periodontal
soft tissues and bone
quantitative at a very highofresolution . and character of
information thickness
the active
Identify gingiva, root surface
periodontitis beforeirregularities, andbone
significant alveolar theloss
distribution of subgingival calculus
occurs.

Reliable method for determining attachment level

Otis L.L et. al. 2004

demonstrate the capacity of OCT to

determine gingival thickness and the shape and contour
of the alveolar crest.
 TACT-tuned aperture CT
Based on the principles of tomosynthesis

Low cost,low dose ,3D Imaging stystem

Series of radiographs taken from different

angles

Soft ware (work bench) stacks the basic

images and reconstruct in to multi planar
images

Caries detection
Vertical root fracture
Helps to detect osseous defects around implants
Detection and localization of osseous changes in crestal
bone
Onanong Chai-U-Dom in 2002

Compared the potentials of conventional and TACT DSR

detecting simulated bone-gain in periodontal defects, in
vitro
TACT-DSR provide greater sensitivity and technique
flexibility in detecting periodontal bone-gain than standard
DSR.

Nair M K et al in 2002

Compared the diagnostic efficacy of tuned-aperture

computed tomography (TACT) and conventional two-
dimensional direct digital radiography (DDR) in an in vitro
environment for detecting bone loss in mid-buccal and
lingual crests.

TACT-IR performed significantly better than DDR

 SMALL VOLUME CT
Form of CBCT

utilizes small field high resolution detector to

generate high resolution 3D volume

Generally comparable to size of intraoral

radiographs

van Daatselaar 2003

based on comparison made between a full CT
geometry and a local CT geometry.

local CT of dental structures appears to be a

promising diagnostic instrument.
 MRI Magnetic resonance imaging

does not involve the use of ionizing radiation

it involves the behaviour of protons in a

magnetic field.

Hydrogen protons are used to create the MR

image.

The image itself is another example of a

tomograph or
sectional image that at first glance resembles a
CT

Used for imaging intracranial and soft tissue

lesions,
 The patient is placed within a very strong
magnetic field (usually between 0.51.5 Tesla)

patients hydrogen protons, behaves like

magnets to produce the net magnetization
vector (NMV ) which aligns itself readily
with the longaxis of the magnetic field

Radiowaves are pulsed into the patient by the

body coil transmitter at 90 to the magnetic
field

Hydrogen atoms to resonate(store energy )

When radio frequency is turned off ,the stored energy is released

from body and detected as a signal in a coil in scanner

Reconstruction of image
USES IN HEAD AND NECK REGION

Assessment of intracranial lesions involving particularly the posterior cranial

fossa, the pituitary and the spinal cord.

Investigation of the salivary glands

Tumour staging

Investigation of the TMJ to show both the bony and soft tissue components

Implant assessment

Schara et al 2009
In an invitro study evaluated the used the use of MRI to characterize
inflammation and healing process in periodontal tissues

It was concluded that MRI can characterize the type and healing process of
inflammation
BONE SCANNING or RADIONUCLIDE
IMAGING
IN contrast to X-ray, CT, MRI which require
structural or anatomic changes to be recorded,this
technique assesses biochemical alteration in body

It Is a nuclear scanning test that identifies new

areas of bone growth or breakdown.

It can be done to evaluate damage to the alveolar

bones,and monitor conditions that can affect the
periodontium (including infection and trauma)
 radioactive tracer eg. 99m technetium pertechnetate
substance is injected into a vein in the arm.

Areas that absorb little or no amount of tracer appear as

dark or "cold" spots, which may indicate a lack of blood
supply to the bone (bone infarction) or the presence of
certain types of cancer

Areas of rapid bone growth or repair absorb increased

amounts of the tracer and show up as bright or "hot"
spots in the pictures. Hot spots may indicate the presence
of a tumor, a fracture, or an infection.
Other radioactive isotopes used are iodine(131 I), gallium(67 Ga) &
selenium(74Se)

scintillation camera is used to capture photons and then

convereted to light and to voltage signal

Signal is constructed to planar image that shows radionuclide

in the image
 Advanced nuclear
imaging
Single photon emission computed
tomography

Positron emission tomography

Positive bone scans are detected in beagle
dogs with advanced experimental
periodontitis kaplan 1975 ,Jeffcoat et al
1985

Jeffcoat et al1985 There exist a significant

association with high intake of 99mTC and
bone loss in moderate to severe periodontitis

Sensitivity of 83 % and specificty of 84 %

Reddy et al 1991 scintillation camera images

following radiopharmaceutical
administration is accurate in detecting bone
loss
IMPLANT IMAGING
 2012

In 2000, the American Academy of Oral and Maxillofacial Radiology

(AAOMR) recommended some form of cross-sectional
imaging be used for implant cases

conventional cross-sectional tomography be

the method
 PRINCIPLES OF IMAGING FOR

DENTAL-IMPLANT ASSESSMENT

Images should have appropriate diagnostic quality and not

contain artifacts that compromise anatomic-structure
assessments
Images should extend beyond the immediate area of interest
to include areas that could be affected by implant placements

Practitioners should have appropriate training in operating radiographic

equipment and competence in interpreting images from the modality
used
Initial examination
Preoperative site specific imaging

match imaging findings to the prosthetic

plan
Postoperative imaging
 DICOM Standard
The Digital Imaging and Communications in
Medicine

facilitate communications between imaging

devices and systems.

By dictating specific data and interface

: requirements, DICOM ensure that devices--
particularly devices made by different
suppliers--can communicate with one another.
DICOM address five primary areas of functionality:
 RADIOGRAPHS IN PERIODONTAL
DISEASE DIAGNOSIS & MANAGEMENT

Tugnait et al 2000

Considered a provoking review

EF CORBET, DKL HO, SML LAI 2009

Radiographs only inform with respect to diagnosis for a

small proportion of periodontal conditions

Radiographs play a pivotal role is in treatment planing

Imaging approaches, such as cone-beam computed (digital

volume) tomography,show some usefulness

Will probably remain a research tool without much clinical

application
Full-mouthsurveys of paralleling periapical radiographs have
been considered to be a gold standard for periodontal
diagnosis and treatment planning
or
a panoramic radiograph supplemented by selected intra-
oral radiographs , numbered less than four per patient
reach the gold standard
 EXPOSURE FROM X RAYS
IOPA F speed ,rectangular collimator- 0.001mSV

IOPA E speed round collimator --.004mSV

Full mouth .080mSV

Panoramic .009 mSv

Cone Beam .068 mSv

Hospital CT 0.6 mSv

 TO CONCLUDE.

Radiography must not be a substitute for clinical

investigation

X-rays as a component of periodic examinations cannot be

condoned.

Radiographic examination in clinical periodontology is only

justified if changes in treatment plans from those treatment
plans developed on the basis of clinical examination
supplemented by any already available radiographs are
anticipated
Advanced imaging systems like CTs,CBCTs,
have enabled better visualization of periodontal structures
and pathologies in3D thus helping in better diagnosis and
treatment planning

The cost factor and other technical difficulties have limited

their cliniclal utility but their utility as a research tool is
unquestionable

FURTHER IMPROVEMENT S ARE WARRANTED IN

FIELD OF DIGITAL IMAGING

And in near future these imaging techniques will become

routine diagnostic tools
THANK YOU