Interpretation of Periodontal Disease Chapter 34 Interpretation of Periodontal Disease

Dental Radiography Questions How does the image examination aid in detection of periodontal disease? What type of images are preferred to document periodontal disease? What is the appearance of each of the American Dental Association (ADA) periodontal case types when viewed on a dental image?

Dental Radiography Chapter 34 Reading Iannucci & Howerton (pp. 412-425)

Dental Radiography Chapter 34 Outline Interpretation of Periodontal Disease Description of the periodontium Description of periodontal disease Detection of periodontal disease Image interpretation of periodontal disease

Introduction Purpose Iannucci & Howerton (p. 412) To introduce the dental radiographer to the description and detection of periodontal disease To present the image interpretation of periodontal disease, with an emphasis on a description of bone loss, ADA case types, and identification of predisposing factors

Description of the Periodontium Iannucci & Howerton (pp. 412-413) (Fig. 34-1, 34-2, 34-3) Lamina dura Lamina dura appears as a dense radiopaque line in healthy teeth. Alveolar crest This is about 1.5 to 2 mm apical to the CEJ of adjacent healthy teeth. In anterior teeth, the alveolar crest is pointed and sharp and appears to be very radiopaque. In posterior teeth, the alveolar crest appears flat and smooth, and parallel to a line between adjacent cementoenamel junctions. It appears a little less radiopaque than in anterior teeth. The periodontium refers to the tissues that invest and support the teeth.

Description of the Periodontium Iannucci & Howerton (pp. 412-413) (Fig. 34-1) Periodontal ligament space This appears as a thin radiolucent line between the root of the teeth and the lamina dura. It is continuous around the root structure and of uniform thickness in healthy teeth.

Description of Periodontal Disease Iannucci & Howerton (pp. 413-414) Periodontal disease is a group of diseases that affect the tissue around teeth. May range from superficial inflammation of gingiva to destruction of supporting bone and periodontal ligament. The gingiva appears swollen, red, and bleeding, with soft tissue pocket formation. What should normal, healthy gum tissue look like?

Description of Periodontal Disease The image appearance is different. The alveolar crest appears indistinct. Bone loss is seen. May result in severe destruction of bone and loss of teeth.

Detection of Periodontal Disease Clinical Examination Dental Image Examination Dental images must be used in conjunction with a clinical examination.

Detection of Periodontal Disease Iannucci & Howerton (p. 414) Detection requires both clinical and dental image examination. The clinical examination provides information about soft tissue. The image examination provides information about bone.

Clinical Examination Iannucci & Howerton (p. 414) Clinical examination must be performed by the dentist and dental hygienist. Should include evaluation of soft tissue for signs of inflammation such as redness, bleeding, swelling, pus. A thorough clinical assessment must include periodontal probing. Whenever clinical evidence of periodontal disease is present, radiographs must be exposed to obtain maximum diagnostic information. What do the numbers recorded from the periodontal probing mean?

Dental Image Examination Iannucci & Howerton (p. 414) (Figs. 34-4, 34-5) This provides an overview of the amount of bone present. Indicates the pattern, distribution, and severity of bone loss. The periapical image is the image of choice for the evaluation of periodontal disease. The paralleling technique is the preferred periapical exposure method for demonstrating anatomic features of periodontal disease. Bisected periapical images may appear to show less bone loss than is actually present. The paralleling technique accurately records the relationship of the height of the crestal bone to the tooth root.

Dental Image Examination The horizontal bite-wing has limited value in the detection of periodontal disease. Severe interproximal bone loss cannot be adequately visualized on horizontal bite-wing images. The vertical bite-wing image can be used to examine bone levels in the mouth. The panoramic image has little diagnostic value in the detection of periodontal disease.

Radiographic Examination Images alone cannot be used to diagnose periodontal disease. They do not provide information about the condition of soft tissue or early bone changes. They are two-dimensional representations of three-dimensional objects. Buccal and lingual areas may be difficult to evaluate. Bone loss may be difficult to detect in furcation areas.

Interpretation of Periodontal Disease on Dental Images Bone Loss Classification of Periodontal Disease Predisposing Factors

Interpretation of Periodontal Disease on Dental Images All images should be Evaluated for bone loss Examined for other predisposing factors that may contribute to periodontal disease

Bone Loss Iannucci & Howerton (p. 415) (Fig. 34-6) Can be estimated as the difference between the physiologic bone level and the height of remaining bone It can be described in terms of the pattern, distribution, and severity of loss A radiograph allows the dental professional to view the amount of bone remaining rather than the amount of bone lost.

Pattern Described as either horizontal or vertical Iannucci & Howerton (pp. 415-416) (Figs. 34-7 through 34-10) Described as either horizontal or vertical Horizontal bone loss The loss occurs in a plane parallel to the CEJs of adjacent teeth Vertical bone loss The loss does not occur in a plane parallel to the CEJs of adjacent teeth Vertical bone loss is also referred to as angular bone loss.

Distribution Described as localized or generalized Iannucci & Howerton (pp. 415-417) (Figs. 34-11, 34-12) Described as localized or generalized Localized Occurs in isolated areas Generalized Occurs evenly throughout the dental arches Localized has less than 30% of the sites involved. Generalized has more than 30% of the sites involved and occurs evenly throughout the dental arches.

Severity Can be classified as mild, moderate, or severe Mild bone loss: crestal changes Moderate bone loss: bone loss of 10% to 33% Severe bone loss: bone loss of 33% or more Measured by the clinical attachment loss, distance in mm from the CEJ to the base of the sulcus or periodontal pocket. Measured by a calibrated periodontal probe.

Classification of Periodontal Disease Iannucci & Howerton (p. 416) Based on the amount of bone loss, periodontal disease can be classified as ADA case Type I: gingivitis Type II: early periodontitis Type III: moderate periodontitis Type IV: advanced periodontitis Each disease type has a specific radiographic appearance. Radiographs can also be used to detect the contributing factors of periodontal disease, such as calculus and defective restorations.

ADA Case Type I Gingivitis No associated bone loss No change is seen in bone when viewed on a dental image The crestal lamina dura is present, and the alveolar crest is approximately 1 to 2 mm apical to the CEJ. Bleeding may or may not be present. Only the gingival tissues are affected.

ADA Case Type II Early periodontitis Iannucci & Howerton (p. 417) (Fig. 34-13 through 34-15) Early periodontitis Associated with mild crestal changes The lamina dura becomes unclear and fuzzy and no longer appears to be a continuous radiopaque line. Horizontal bone loss is seen more often. Bleeding may occur with probing, pocket depths resulting from attachment loss may be present, and localized areas of recession may also be seen.

ADA Case Type III Moderate periodontitis Iannucci & Howerton (pp. 417-419) (Figs. 34-16 through 34-20) Moderate periodontitis Is associated with 10% to 33% bone loss. The pattern may be horizontal or vertical, the distribution may be localized or generalized. Furcation involvement may be seen. The alveolar bone level is approximately 4 to 6 mm apical to the CEJs of adjacent teeth. When the bone in the furcation is destroyed, a radiolucent area is evident on the dental image. Clinically, pocketing and attachment loss is evident up to 6 mm. Recession, furcation involvement areas, and slight mobility may also be present.

ADA Case Type IV Advanced periodontitis Iannucci & Howerton (pp. 419-420) (Figs. 34-21, 34-22, 34-23) Advanced periodontitis Associated with more severe bone loss (33% or more) May be vertical, and the alveolar bone level is 6 mm or great from the CEJ. Furcation involvement is readily viewed on posterior images.

Predisposing Factors Predisposing factors and local irritants may contribute to periodontal disease Elimination is important in the management and treatment of periodontal disease Dental images aid in detection of irritants such as Calculus Defective restorations The effects of certain medications, tobacco use, and conditions such as diabetes are all considered risk factors for periodontal disease.

Calculus Results from the mineralization of plaque Iannucci & Howerton (pp. 419, 421-422) (Figs. 34-24 through 34-28) Results from the mineralization of plaque Appears white or light on a dental radiograph Most often appears as a pointed or irregular radiopaque projection extending from proximal root surfaces May also appear as a Ringlike opacity A nodular image projection A smooth opacity on a root surface Stonelike concretion that forms on the crowns and roots of teeth due to the calcification of bacterial plaque.

Defective Restorations Iannucci & Howerton (pp. 419, 422-423) (Figs. 34-29 through 34-35) Faulty restorations may act as food traps and lead to the accumulation of food debris and bacteria They may be detected both clinically and on dental images Dental images may allow identification of restorations with Open or light contacts Poor contour Uneven marginal ridges Overhangs Inadequate margins