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Module 7: Interpretation of Dental Radiographs
Lesson 27: Radiographic Interpretation of Pulpal & Periapical Lesions & Radiopacities & Radiolucencies of the Jaws
Kathleen A. Hock, RDH, MAdEd Dental Hygiene Department
William Rainey Harper College
Module 7: Interpretation of Dental Radiographs
Lesson 27: Radiographic Interpretation of Pulpal & Periapical Lesions & Radiopacities & Radiolucencies of the Jaws
Kathleen A. Hock, RDH, MAdEd Dental Hygiene Department
William Rainey Harper College
Normal Radiographic Pulp Appearance Vascular connective tissue
interspersed with lymphatics Functions:
Blood supply Nutrition Innervation Dentin formation & defense
Radiolucent, well-defined
Alterations in the Pulp Chamber/Canal
Pulpal sclerosis Pulpal obliteration Pulp stone
Pulpal Sclerosis
Pulpal Sclerosis Diffuse calcification of the pulp
chamber/canals Maturing tooth responds to stimuli
(mastication, thermal changes, chemical irritants, slight trauma) by depositing secondary dentin
Results in narrowing of pulp chambers & root canals
Secondary dentin is less permeable, fewer tubules therefore less sensation; serves as pulpal protection No radiographic difference between primary & secondary dentin
No clinical features
Pulpal ObliterationPulpal Obliteration
Pulpal Obliteration Pulpal irritants (attrition, abrasion, caries,
restorations, trauma etc.) stimulate secondary dentin formation Tubules calcify resulting in obliteration of the pulp cavity; dentin impermeable
Defense reaction of the body Radiographically appears as though there is
no pulp chamber or canals; may also appear more radiopaque compared to normal dentin
Non-vital; no treatment
Pulpal Obliteration Pulpal irritants (attrition, abrasion, caries,
restorations, trauma etc.) stimulate secondary dentin formation Tubules calcify resulting in obliteration of the pulp cavity; dentin impermeable
Defense reaction of the body Radiographically appears as though there is
no pulp chamber or canals; may also appear more radiopaque compared to normal dentin
Non-vital; no treatment
Pulp Stones
Pulp Stones Localized masses of calcified material
within dentinal tubules-round, oval or fill canal
Formed by deposits of connective layers of calcium salts
Cause unknown-may be due to minor circulatory disturbances of the pulp vessels
Prevalence: 90% of all teeth in clients age 50-70 years
15% visible radiographically (1 out of 7) No symptoms or treatment
Pulpal Injuries Hyperemia Acute Pulpitis Fractures Displacement of teeth
Hyperemia Dilation & engorgement of pulp; edema;
increased capillary pressure due to prolonged vasodilatation
Pulp stimulation response often caused by hypersensitivity to thermal changes following cavity prep
Reversible; remove irritant & normal circulation established
No radiographic image
Pulpitis Vital but inflamed pulp, usually in
coronal portion of tooth Rigid wall of pulp chamber prevent
vascular dilation so intrapulpal pressure from severe inflammation may result in pulpal death
Degree of pain depends on pressure Pain spontaneous, diffuse Percussion negative Radiograph looks normal
Fractures Crown fractures
Anterior teeth most often involved Result of trauma Radiograph assists in determining
involvement of pulp Root fractures
Less common Anterior teeth most often involved May appear as a radiolucent line or not be
visible at all but enlarge with time
Fractures
Fractures
Fractures Jaw
Mandible most often involved Result of trauma Panoramic is radiographic of choice Appear as radiolucent line Difficult to detect on maxillae
Jaw Fractures
Displacement of the Teeth Luxation
Abnormal displacement Intrusion (into bone) Extrusion (out of bone)
Avulsion Complete displacement Usually result of trauma Use radiograph to
evaluate for splintered bone
Acute Apical Conditions
Acute Apical Periodontitis Acute Apical Abscess
Acute Apical Periodontitis Pulp non-vital or vital (occlusal trauma,
caries) Periapical area inflamed Exudate Throbbing pain No swelling Positive percussion test Slight widening of PDL space
Acute Apical Abscess Nonvital tooth Edema & exudate in PDL space Pain upon percussion Intense pain Swelling may be present; facial cellulitis May result from acute inflammation of pulp or
from an area of chronic infection such as a granuloma Widening of PDL or normal appearance if less than 10 days
Establish drainage
Chronic Apical Conditions Periapical granuloma Periapical cyst Chronic periapical abscess Condensing osteitis
Periapical Granuloma Most common apical condition
developing from pulpitis Localized mass of chronically
inflamed granulation tissue at apex of nonvital tooth
Defense tissue Will heal if irritant removed via
RCT May give rise to cyst or abscess
Periapical Granuloma Asymptomatic but history or
prolonged sensitivity to heat or cold
Radiographically Begins as widened PDL space Round or ovoid radiolucency, may not
be real dark; may see bone trabeculation
No lamina dura visible between root apex & apical lesion
Periapical Granuloma
Periapical Abscess Localized collection of pus resulting from
pulpal death Low grade, long standing inflammatory
reaction May develop from acute abscess or granuloma Usually asymptomatic due to drainage through
PDL(fistula track); may see parula Drainage & RCT Round or ovoid radiolucency with poorly
defined margins Lamina dura not visible
Periapical Abscess
Periapical Cyst Abnormal pathologic space within the
bone lined with epithelium & usually filled with fluid
Arises from preexisting granulomas Asymptomatic Pressure may cause resorption of
surrounding bone Most common cyst of the jaw (50-70% of all cysts in oral cavity)
Periapical Cyst Percussion, vitality & mobility
negative Radiolucent (very dark), bounded
by radiopaque border Develops over long period of time
Periapical Cyst
Condensing Osteitis Chronic focal sclerosing
osteomyelitis Well-defined radiopacity visible
below apex of nonvital tooth with history of long-standing pulpitis
Proliferation of bone resulting from low-grade infection
Bone reaction to inflammatory stimulation
Condensing Osteitis Mandibular first molar most commonly
involved Tooth asymptomatic & nonvital Radiolucent area circumscribed by
radiopaque area which remains even if tooth extracted Considered a physiologic reaction of bone to inflammation so no treatment indicated
Condensing Osteitis
Other Apical Conditions Periapical Cemental Dysplasia Hypercementosis Sclerotic Bone
Periapical Cemental Dysplasia
Benign, slow-growing connective tissue proliferation of unknown etiology originating from cellular elements of the periodontal ligament Destroys the lamina dura & replace trabecular bone with fibrous tissue mass
Visible around vital teeth
Periapical Cemental Dysplasia Most common in middle-aged
females especially African-Americans
Mandibular anteriors are most common location
Three stages Radiolucent Mixed Radiopaque
Hypercementosis Excess deposits of secondary
cementum on root surfaces No clinical signs or symptoms Results from:
Supraeruption Inflammation Trauma Idiopathic
Hypercementosis Apices appear enlarged & bulbous Lamina dura & periodontal
ligament space appear normal Teeth vital; no treatment required
Hypercementosis
Sclerotic Bone Osteosclerosis Well-defined radiopacity visible below
apices of vital, noncarious teeth Cause unknown but not believed to be associated with inflammation
Not attached to tooth & varies in size & shape
Margins irregular or diffuse Asymptomatic
Sclerotic Bone
Resorption Physiologic: normal
shedding or deciduous teeth
Pathologic: regressive alteration of tooth structure observed when a tooth is subjected to abnormal stimuli External Internal
External Resorption Affects apices of teeth Apices appear blunted & roots shorter Causes
Apical inflammation Tumors/cysts Reimplantation of teeth Excessive trauma/abnormal mechanical
forces Impacted teeth Idiopathic
External Resorption Lamina dura
& PDL intact No mobility or other clinical signs
No treatment
External Resorption
Internal Resorption Occurs within crown or
root Possible causes
Trauma Pulp capping Round/ovoid
radiolucency in crown or root
Asymptomatic May appear as pink spot RCT may be used if
tooth not weakened or extraction
Internal Resorption
Misinterpreted Nonpathological Apical Conditions
Terminal stage of root formation Widened PDL space
Usually result of trauma-occlusal, ortho, injury
Superimposition of radiolucent structures over teeth apices