Principles of Radiographic Interpretation Juan F. Yepes DDS, MD, MPH Assistant Professor Division of Oral Diagnosis, Oral Medicine and Oral Radiology University of Kentucky, College of Dentistry Spring 2009

What is that radiologist saying? Well defined and Corticated…..

General Objective The objective of this lecture is to provide step-by-step- analytic process that can be applied to the interpretation of diagnostic images. Proficiency comes with PRACTICE!!! Radiographic interpretation of caries Radiographic interpretation of periodontal disease Radiographic interpretation of benign conditions Radiographic interpretation of malignant conditions

Some definitions….

Radiopaque This refers to the item that is being imaged, i.e. in our case a part of the patient, and means that it blocks the transmission of x rays.

Radiolucent This refers to the item that is being imaged, i.e. in our case a part of the patient, and means that it permits the transmission of x rays.

Dense (Density) In radiology this usually refers to the film, and refers to the ability of the film to block the transmission of light (i.e. blackness)

Well localized The item being reported is limited to a specific area, and does not extend beyond that locality.

Well localized

Poorly localized The item being reported is not limited to a specific area, and extends into surrounding anatomical sites.

Poorly localized

Well defined The edges of the item being reported are reasonably sharp and clearly define the extent of the lesion.

Well defined

Poorly defined The edges of the item being reported are not sharp. The actual borders and thus the exact extent of the lesion are not clearly defined.

Poorly defined

well localized and well defined well localized, but poorly defined The lesion may thus be well localized and well defined or well localized, but poorly defined poorly localized and poorly defined but generally not poorly localized and well defined

Corticated The entity being reported is not only well defined, but has a cortex, i.e. an osseous border, seen as a thin white line.

Corticated

Multilocular The entity being reported is usually well defined and has a cortex, i.e. an osseous border, seen as a thin white line, but is partially or totally subdivided into several loculi.

Multilocular Loculus, loculi: the diminutive of locus. Locus, loci: a place or position

Multilocular Thus, multilocular implies several small places. As we use it, they are joined places.

Multilocular

Osteitis vs Osteomyelitis Both terms mean that there is inflammation of bone.

Osteitis inflammation of bone, involving the haversian spaces, canals, and their branches, and generally the medullary cavity, and marked by enlargement of the bone, tenderness, and a dull aching pain. Dorland’s Illustrated Medical Dictionary 29th ed.

Osteomyelitis inflammation of bone caused by infection, usually by a pyogenic organism, although any infectious agent may be involved. It may remain localized or may spread through the bone to involve the marrow, cortex, cancellous tissue, and periosteum. Dorland’s Illustrated Medical Dictionary 29th ed.

Osteitis inflammation of bone that remains localized, and may be more of a painful inconvenience

Osteitis

Osteomyelitis

Osteitis Rarefying Osteitis Sclerosing Osteitis

Rarefying Osteitis (Periapical lesion U. of K.) Inflammation of bone that results in the removal of bone. The term is not a diagnosis, but a radiologic interpretation that includes abscess, cyst and granuloma.

Rarefying Osteitis (periapical lesion at UK)

Sclerosing Osteitis I use the term sclerosing osteitis, i.e. inflammation of bone (osteitis) that causes sclerosis.

Sclerosing (or condensing) Osteitis

Sclerosing Osteitis

Periosteal Reaction Any involvement of the periosteum by a pathological process that results in the deposition of periosteal new bone.

Inflammation of the Jaws and Periosteal Reactions Sessile Osteomyelitis Periostitis Healing Orthogonal Anemia Sarcoma Sarcoma

Periapical Radiolucency This is merely a description of a finding, and should better be stated as a periapical radiolucent area or line. It does not denote disease. e.g. the maxillary sinus could be a periapical radiolucent area, as could the mental foramen.

What is that radiologist really saying? Well defined and Corticated

Well localized

Well localized The radiologist infers that the appearance is consistent with a slow non-invasive growth, and thus that this is benign.

Poorly localized

Poorly localized The radiologist infers that the appearance is consistent with a faster and invasive growth, and thus that this is malignant, or a spreading infectious/inflammatory lesion.

Well defined

Well defined The radiologist infers that the appearance is consistent with a slow non-invasive growth, and thus that this is benign.

Poorly defined

Poorly defined The radiologist infers that the appearance is consistent with invasive growth, and thus that this is malignant, or infectious/ inflammatory lesion.

Corticated

Corticated The radiologist infers that the appearance is consistent with a slow non-invasive growth, and thus that this is benign.

Multilocular

Multilocular The radiologist infers that the appearance is consistent with a slow non-invasive growth, is not fluid-filled, and that this is a benign, non-cystic growth, i.e. a benign neoplasm.

Clinical Examination Radiographs are prescribed when the dentist thinks that they are likely to offer useful diagnostic information that will influenced the TREATMENT plan. Clinical information should be used first to select the type of radiographs and later to aid in their interpretation. ADQUIRING APPROPRIATE DIAGNOSTIC IMAGES Quality of the Diagnostic Image Is the image distorted? Are the contrast and density adequate?

Clinical Examination ADQUIRING APPROPRIATE DIAGNOSTIC IMAGES Quality of the Diagnostic Image Number and Type of Available Images Initially the clinical examination indicates the number and types of films required. The interpretation of these films in turn may suggest additional imaging. Advanced techniques available (CBCT, MRI, ultrasound, CT, etc)

Clinical Examination ADQUIRING APPROPRIATE DIAGNOSTIC IMAGES Quality of the Diagnostic Image Number and Type of Available Images Viewing Conditions Ambient light in the viewing room should be reduced. Intraoral radiographs should be mounted in a film holder. Light from the viewbox should be of equal intensity across viewing surface Use of magnifier

Image Analysis Systematic Radiographic Examination Profound knowledge of normal anatomy and normal variations. Best learning method  Indentify NORMAL anatomy in every film Do not limit your attention to only one particular are on the film Intraoral Images Periapical films before bitewings Same sequence Bone first, bone of the alveolar process second, dentition last Extraoral radiography  Panoramic films (lateral skull projections)

Bone Alveolar Bone Dentition

Analysis of the Intraosseous Lesions The preferred method of radiographic interpretation is STEP by STEP This procedure helps ensure recognition and collection of all the information contained in the image and in turn improves the accuracy of the interpretation. Localize the abnormality Localized or Generalized Position in the jaws Single or multifocal Size and shape

Analysis of the Intraosseous Lesions Localize the abnormality Localized or Generalized Position in the jaws Single or multifocal Size Assess the periphery and shape Well defined ? Corticated ? Borders Shape

Analysis of the Intraosseous Lesions Corticated Well defined Step 2  Assess the periphery and shape

Analysis of the Intraosseous Lesions Non - Corticated Well defined Step 2  Assess the periphery and shape

Analysis of the Intraosseous Lesions Step 2  Assess the periphery and shape Step 3: Analyze the internal structure Totally radiolucent Totally radiopaque Mixed density

Analysis of the Intraosseous Lesions Step 3: Analyze the internal structure Totally radiolucent Totally radiopaque Mixed density

Analysis of the Intraosseous Lesions Step 3: Analyze the internal structure Totally radiolucent Totally radiopaque Mixed density

Analysis of the Intraosseous Lesions Step 3: Analyze the internal structure Totally radiolucent Totally radiopaque Mixed density

Analysis of the Intraosseous Lesions Step 4: Analyze the effects of the lesion on surround structures Teeth, lamina dura, and periodontal ligament space Surrounding bone density and trabecular bone pattern Inferior alveolar canal and mental foramen outer cortical bone and periostial reactions

Analysis of the Intraosseous Lesions Step 4: Analyze the effects of the lesion on surround structures Teeth, lamina dura, and periodontal ligament space Surrounding bone density and trabecular bone pattern Inferior alveolar canal and mental foramen outer cortical bone and periostial reactions

Analysis of the Intraosseous Lesions Step 4: Analyze the effects of the lesion on surround structures Teeth, lamina dura, and periodontal ligament space Surrounding bone density and trabecular bone pattern Inferior alveolar canal and mental foramen outer cortical bone and periostial reactions

Analysis of the Intraosseous Lesions Step 4: Analyze the effects of the lesion on surround structures Teeth, lamina dura, and periodontal ligament space Surrounding bone density and trabecular bone pattern Inferior alveolar canal and mental foramen outer cortical bone and periostial reactions

Analysis of the Intraosseous Lesions Step 4: Analyze the effects of the lesion on surround structures Teeth, lamina dura, and periodontal ligament space Surrounding bone density and trabecular bone pattern Inferior alveolar canal and mental foramen outer cortical bone and periostial reactions

Analysis of the Intraosseous Lesions Step 5: Formulate a radiographic interpretation Decision 1 Normal Abnormal Decision 2 Developmental Acquired Decision 3 Classification: Cyst, benign tumor, malignant tumor, etc.. Decision 4 Ways to proceed: Further imaging, treatment, biopsy, or observation RADIOLOGY REPORT