Differential Diagnosis of Periapical Radiopacities Dr Mohammed Malik Afroz

Format Enumeration of Periapical Radiopacities Radiographic Appearance Differential Diagnosis Conclusion

Specific Learning Objective To know the different periapical radiopacities Methods to differentiate between each radiopacity Radiographic features of them

Enumeration of Periapical Radiopacities Solitary Radiopacities – Multiple Radiopacities – Exostoses and tori Osteoma Retained root Osteosclerosis Socket sclerosis Foreign objects in the jaws Condensing osteitis Garré's osteomyelitis Hypercementosis Odontoma – complex and compound Periapical cemental dysplasia (calcified stage) Cementoblastoma (calcified stage) Cementifying and ossifying fibromas (calcified stage) Florid osseous dysplasia (diffuse cementosis)

Solitary Radiopacities – Exostosis and Tori Exostoses are small, irregular overgrowths of bone developing on the surface of the alveolar bone. They consist primarily of compact bone and produce an ill-defined radiopacity Torus mandibularis — lingual aspects of the mandible, in the premolar/molar region • Torus palatinus — either side of the midline towards the posterior part of the hard palate

Differential Diagnosis Tori are present in the lingual or palatal aspect Exostosis are seen as radiopacities which are outside the periosteal bone. Are less dense in nature Enostosis – these are seen as frank radiopaque lesions and are very dense. Can be diagnosed clinically.

Osteomas are benign tumors of oral cavity. Seen in young adults Solitary Radiopacities – Osteoma Osteomas are benign tumors of oral cavity. Seen in young adults Asymptomatic, solitary lesions Compact or Endosteal osteoma — consists of dense lamellae of bone and including the so-called ivory osteoma seen in the frontal sinus Cancellous or Periosteal osteoma — consists of trabeculae of bone.

Differential diagnosis Not assocaited with a dental infection Causes tooth displacement Very radiopaque in nature

Retained Roots May be seen as accidental findings in old patients Clinically the ridge may be totally healed or may have a flabby tissue When radiograph is taken there may be a root piece. Radiographically has pulp chamber and density of dentin which help in diagnosing the condition.

Osteosclerosis Is seen as a radiopacity in the periapical region of the teeth. It may involve one teeth or seen between any 2 teeth. If it is due to trauma from occlusion – traumatic osteosclerosis Idiopathic osteosclerosis – when no cause can be established. Differential Diagnosis – seen as a periapical scleosis. Using localization method can help to identify, where in a periapical infection is always attached to the tooth while osteoclerosis is not. Involved tooth is vital.

Socket Sclerosis Seen in adults. M > F Due to an old infected tooth which initiates growth in adjacent bone and causes the resorption of periodontal ligament space. In this condition the root directly fuses with the bone.

Differential Diagnosis – socket sclerosis Condensing osteitis osteosclerosis history reveals a highly infectious tooth. The tooth may have lost its crown structure totally or partially. Radiograph does not show any radiolucency surrounding the roots suggesting direct bony fusion. Tooth root is seen as a hazy picture surrounded by the trabeculae of the teeth.

Foreign Object in the Jaw Seen as a frank radiopacity not confirming to the human biology Usually has a relevant shape. Needs to have caution where direct relation to opacity cannot be established Idiopathic osteosclerosis Socket sclerosis Residual sclerosis

Condensing Osteitis – Chronic Focal Sclerosing Osteomyelitis Young adults – M > F. Common in first molars The involved tooth is carious. Patient gives a history of long standing periapical infection. History of inadvertent (illogical) use of antibiotics Seen as diffuse radiopacity surrounding the periapical radiolucency of the involved tooth.

Differential Diagnosis – Condensing Osteitis Idiopathic osteosclerosis Antibioma Tori Exostosis Can be best judged by localization technique where anatomical landmarks change while the infection is always connnected to the tooth.

Garre’s Osteomyelitis There is focal gross thickening of periosteum with peripheral reactive bone formation resulting from mild irritation or infection Seen in young adults; M > F There is mild pain, swelling and tooth ache. History of long standing dental infection Classical ‘ Onion Skin Appearance’ Clinical bony hard swelling

Differential Diagnosis Chronic periapical abscess Periapical granuloma Classic presence of Onion Skin Appearance

Hypercementosis Excess of cementum deposition at the apex of the tooth. The radiodensity of the lesion is equal to the dentin Surrounds all of the tooth and is followed by a radiolucent rim of periodontium Involved tooth is vital. Involves multiple teeth. This is an accidental findings on routine radiographs. Differential Diagnosis – Idiopathic osteosclerosis Condensing osteitis osteoma

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