Radiographic interpretation

Confused while writing a report of a radiograph..here's the solution...

1. RADIOGRAPHIC INTERPRETATION Guided by: Dr Vela Desai Dr Beena Varma Dr Neelkanth Patil Dr Rajeev Sharma

2. Radiograph 18-10-2010 2 Photographic image Radiosensitive surface Radiation – X rays/ Gamma rays Radiogram/ shadowgram /roentgenogram

3. Role of radiographs 18-10-2010 3 Clinical examination phase Diagnosis( confirm/exclude) Treatment planning During treatment Follow up Blind screening tool-justify Limitations-replace clinical examination Need for further investigation

4. Radiographs in Diagnosis 18-10-2010 Free PowerPoint Template from www.brainybetty.com 4 Diagnostic imaging is an integral part of the diagnostic process in clinical dentistry. Radiographs are often obtained as part of a complete examination. Appropriate radiographic interpretation is used along with clinical information and other tests to formulate a differential diagnosis

5. Uses of radiographs 18-10-2010 Free PowerPoint Template from www.brainybetty.com 5 Loss of tooth structure Caries(occlusal/proximal) Non carious( attrition,fracture ) Periodontal diseases Endodontic diseases Impacted teeth Trauma Other bone pathologies Implants

6. 18-10-2010 6 Technique Radiography Interpretation Radiology Interpretation: Step by step analytical process that provides an exact idea of the clinical problem and helps to achieve the final diagnosis of any particular lesion.

7. Interpretation 18-10-2010 7 Three steps : Visualization Perception Integration of information Other diagnostic tools-vitality/mobility Pulp tester

8. Clinical examination Type of radiograph Number of radiographs Aids in interpretation Quality assurance Inadequate quality Inadequate number Extraoral radiology Biopsy/treatment-aids in site selection 18-10-2010 8

9. 18-10-2010 FULL MOUTH INTRAORAL RADIOGRAPHS-IOPA & BITEWING 9

10. 18-10-2010 10 Ideal radiograph: Visual : density & contrast Geometric : sharpness/detail, resolution/definition, magnification, distortion Anatomical accuracy of radiographic images Adequate coverage of anatomical region of interest. NEVER INTERPRET A FAULTY RADIOGRAPH

11. Viewing Conditions 18-10-2010 11 This should be done in a quiet, darkened room At least two good, evenly-lit viewing boxes are required A bright light illuminator is required for relatively over-exposed areas Mounted in holder Appropriate size of viewbox to accommodate film Magnifying glass-detailed examination of small regions

12. 18-10-2010 12 A radiograph is a two dimensional image of a three dimensional object. Clark’s rule: The most distant object from the cone(lingual) moves towards the direction of the cone

13. Three-dimensional concept 18-10-2010 13 The radiographic image is simply a Two-dimensional shadowgram of the patient The third dimension must be reconstructed mentally, preferably from two radiographic projections made at right angles (orthogonal projections) to each other Oblique projections may be required to assess anatomically complicated areas

14. Contrast perception: 18-10-2010 14 Ability to distinguish b/w two areas of radiographic image of diff densities-Weber’s law Minimum perceptible difference in gray level is proportional to the brightness level to which the subject is adapted. All areas on a radiograph represented as: Black Grey White

15. MACH BAND EFFECT 18-10-2010 15 Illusion consists of light or dark stripes that are perceived next to the boundary between two regions of an image that have different lightness gradients Spatial high-boost filtering performed by the human visual system on the luminance channel of the image captured by the retina. Mach bands are independent of orientation. This occurs when two circles of uniform brightness are placed side by side, separated by a sharp edge. Just along the edge one colour looks darker than it really is, while the other looks lighter.

16. 18-10-2010 MACH BAND EFFECT 16

17. 18-10-2010 17  False-positive radiological diagnosis of dental caries Manifest adjacent to metal restorations or appliances, between enamel and dentin  Misdiagnosis of horizontal root fractures because of the differing radiographic intensities of tooth and bone.

18. 18-10-2010 18 RADIOLUSCENT- the capability of a substance with a relatively small atomic number to let a large amount of x-rays pass through it, thus producing darkened images on x-ray films. RADIOOPACITY- the capability of a substance to hinder or completely stop the passage of x-rays, display as white/light areas on an exposed x-ray film. RADIOOPAQUE RADIOLUSCENT

19. Properties 18-10-2010 19 Atomic number The higher the atomic number, the more radiopaque the tissue/object: Physical opacity Air, fluid and soft tissue have approximately the same atomic number, but the specific gravity of air is only 0.001, whereas that of fluid and soft tissue is 1 Therefore air will appear black on a radiograph, compared with fluid and soft tissue, which appear more grey

20. 18-10-2010 Free PowerPoint Template from www.brainybetty.com 20 Thickness The thicker the tissue/object, the greater the attenuation of X-Rays and the more white the image . When two tissues/objects are superimposed, the composite shadow formed by these will appear more opaque than either of the two separate tissues Bone(14 ; 1.8)

21. Image analysis 18-10-2010 21 Identify normal anatomic landmarks Knowledge of normal v/s abnormal Attention to all regions on the film systematically Three circuits

22. First visual circuit: intraoral images 18-10-2010 22 Periapical before bitewing images Right maxilla to left; left mandible to right One anatomic structure at a time Eg : posterior maxilla-maxillary sinus,tuberosity,zygomatic process Normal anatomy bones, canals, foramina Check for symmetry

23. Use a systematic process 18-10-2010 23 Go back to the first quadrant and look at the trabecular pattern. Is it: Normal Symmetrical when compared to the contralateral side Sparse Dense In the direction of anatomical stress Altered

24. 18-10-2010 TRABECULAR PATTERN 24 Step ladder Fish net Granular

25. Second visual circuit 18-10-2010 Free PowerPoint Template from www.brainybetty.com 25 Examination of bone: Height of alveolar bone Crest relative to teeth Loss of height-more than 1.5 mm-periodontal disease Cortication Lamina dura + PDL space + tooth roots Carcinoma-erosion of alveolar crest+ ill defined borders.

26. 18-10-2010 Free PowerPoint Template from www.brainybetty.com 26

27. Third visual circuit 18-10-2010 27 Examination of dentition & associated structures Number, Sequence, appearance, root structure Crowns –defective enamel, caries Intreproximal areas & restorations Pulp chambers-size, content Bone- radioluscent / radioopaque lesions Restoration Proximal caries Pulp Dentin

28. Check individual teeth 18-10-2010 Free PowerPoint Template from www.brainybetty.com 28 Enamel, [ amelogenesis imperfecta , mulberry molar, etc.] The dentin, [dens invaginatus or evaginatus , denticles etc.] T Pulp chamber [ dentinogenesis imperfecta , odontogenesis imperfecta , odontodysplasia , taurodontism , individual obliteration of nerve canals, etc.] Apical area [root resorption, lucencies or opacities] periodontal ligament space [widened in early osteosarcoma (localized), scleroderma ( generalized) [ absent in hyperparathyroidism] Amount of bone support.

29. Routine assessment of radiographs 18-10-2010 29 Ensure that the radiograph is the one of the patient being examined, check the date, opd /no. Ensure two orthogonal projections are available. The radiographic views are named according to the direction the primary beam enters and leaves the tissue and the body part being examined The position of the patient during exposure should be known, and left/right markers should be identified The radiograph should be of high technical quality with respect to positioning, centring , collimation, exposure and development, and should be free from artefacts .

30. 18-10-2010 Free PowerPoint Template from www.brainybetty.com 30 Every shadow visible must be evaluated to determine whether it is: A feature of normal anatomy A composite structure formed by superimposition of structures An artefact produced by inaccurate positioning A pathologic lesion: must be ruled out first

31. 31 Interpretation is an orderly process Normal variation Abnormal Developmental abnormalities Acquired abnormalities Cyst Benign neoplasia Vascular analomy Metabolic Inflammatory lesion Malignant neoplasia Bone dysplasia Trauma

32. Why describe the lesion? 18-10-2010 Free PowerPoint Template from www.brainybetty.com 32 The radiographic description can give us indications of: Tissue of origin Biological behavior Prognosis Treatment concerns Diagnosis or a Differential Diagnosis

33. Describing the Lesion 18-10-2010 Free PowerPoint Template from www.brainybetty.com 33 1 . Size 2. Shape 3. Location 4. Density 5. Borders 6. Internal Architecture 7. Effect on adjacent structures

34. Aunty Minnie Approach 18-10-2010 34 Aunt Minny represents an abnormality which looks like one that the evaluator has seen before, or been told about. It would be difficult to recognise new findings using this approach Cousin Harry represents an abnormality which the evaluator has not seen for a long time, but would like to see Uncle Fred represents an abnormality which is often present

35. 18-10-2010 Free PowerPoint Template from www.brainybetty.com 35 One only sees on a radiograph what one already knows

36. Size 18-10-2010 36 Measure the lesion with a ruler. If you must estimate, use surrounding structures as guide Measure in two dimensions , width and height in mm or cm

37. Shape 18-10-2010 Odontogenic keratocyst 37 Regular shapes like Round, Triangular, Rhomboid etc. Irregular shape like circular, fluid filled(hydraulic)-cyst Scalloped- multilocular app.

38. 18-10-2010 Scalloped/ Multilocular-Ameloblastoma 38

39. Location 18-10-2010 39 Is the lesion localized or generalized? Unilateral or bilateral (submandibular fossa ), fibrous dysplasia Where is the lesion in relation to other structures and anatomic landmarks? Use terms such as: Mesial , Distal Inferior, Superior Posterior , Anterior

40. Soft tissues or jaws: 18-10-2010 40 Epicentre -coronal to tooth- odontogenic epithelium Epicenter of the lesion is above the mandibular canal-> odontogenic in origin Epicentre ->below IAC->non odontogenic (likely) Cartilaginous lesions, osteochondromas -> condyles If the epicenter of the lesion is in the sinus , not odontogenic in origin-alveolar process of maxilla

41. Density 18-10-2010 41 Is the lesion Radiopaque, Radiolucent, or Mixed Density Remember that opacity is relative to the adjacent structures. If the lesion is of mixed density, describe the appearance

42. Radioluscent to radioopaque structures 18-10-2010 42 Air,fat,gas Fluid Soft tissue Bone marrow Trabecular bone Cortical bone Enamel Metal

43. Internal architecture 18-10-2010 Free PowerPoint Template from www.brainybetty.com 43 Is the lesion uniform? Internal structures such as septae or loculations Septae –residual bone-long strands/walls Loculations are individual compartments(2) Soap bubble app- OKC Giant cell granuloma -wispy, granular Odontogenic myxoma -straight, thin Tooth-like elements- cementum

44. Fibrous dysplasia 18-10-2010 44 More in number Shorter Aligned in response to stress Randomly oriented Ground glass/orange peel app

45. 18-10-2010 Free PowerPoint Template from www.brainybetty.com 45

46. 18-10-2010 Calcified lymph nodes-tuberculosis 46 Inflammatory lesion-new bone formation-thick trabeculae -more radioopaque Dystrophic calcifications-damaged soft tissue masses- calcified lymph nodes-cauliflower like masses Ewing’s sarcoma-onion skin app

47. Borders 18-10-2010 47 Well or poorly demarcated Punched out-sharp- (no bony reaction )- multiple myeloma Corticated-uniform-periphery- (thin opaque border ) cyst Sclerotic (wide, uneven opaque border ) Periapical cemental dysplasia Radioluscent (periphery)+ corticated Odontoma , cementoblastoma

48. 18-10-2010 Free PowerPoint Template from www.brainybetty.com 48 Periapical cemento osseous dysplasia Residual cyst Well defined borders

49. Ill defined borders 18-10-2010 Free PowerPoint Template from www.brainybetty.com 49 Gradual transition-normal app bone & abnormal app trabaculae - sclerosing osteitis Invasive border-bone destruction-malignancy

50. Jaw – examine the lesion in the jaw: 18-10-2010 Free PowerPoint Template from www.brainybetty.com 50 · Site – location, extent, solitary, multi-focal or generalised · Size and shape – measure and describe. This may require one or more views. · Symmetry – examine contralateral site. Bilateral symmetry is suggestive of a normal variant · Border – sclerosis, resorption, lack of continuity · Contents – lucent or opaque. Homogenous or varying density · Association with other structures. Teeth displaced or resorbing

51. Effect on adjacent structures 18-10-2010 Free PowerPoint Template from www.brainybetty.com 51 Lesions behaviour & impact on surrounding structures-identification of disease Inflammatory disease-bone resorption/formation. A Space Occupying lesion creates its own space by displacing other structures , such as teeth, maxillary sinus , inferior alveolar canal, etc .

52. 18-10-2010 Free PowerPoint Template from www.brainybetty.com 52 Epicentre above crown of teeth-follicular cysts-teeth apically Lesion- ramus of mandible- cherubism -anterior direction Papilla of developing tooth-lymphoma Widening of PDL, broken lamina dura-periapical /periodontal abscess Root resoption-periodontitis , trauma, tumors Reactive bone-periphery of lesion-benign slow growth

53. 18-10-2010 Free PowerPoint Template from www.brainybetty.com 53 Inferior alveolar canal Superior displacement-fibrous dysplasia Widening of IAN-cortical boundary intact-benign vascular/neural lesion Irregular widening with cortical destruction, complete length of canal-malignant neoplasm

54. Outer cortical bone/ periosteal reactions 18-10-2010 54 Slow growing-new bone-expanding lesion-outer cortical bone maintained Rapidly growing- periosteum does not respond-missing cortical plate Exudate from inflammatory lesion-lift periosteum off surface of the surface of cortical bone- periosteum lay down new bone. Onion skin app- leukaemia , langerhan’s cell histiocytosis Spiculated new bone- osteogenic sarcoma

55. Formulation of radiographic interpretation 18-10-2010 Free PowerPoint Template from www.brainybetty.com 55 Organised fashion Single observation Diagnosis

56. 18-10-2010 56 Decision 1: Normal V/S Abnormal Decision2: Developmental V/S Acquired Decision 3: Classification Decision 4: Ways To Proceed

57. Decision 1: Normal V/S Abnormal 18-10-2010 Free PowerPoint Template from www.brainybetty.com 57 Structure of interest Variation of normal/represents abnormality

58. Decision 2: Developmental V/S Acquired 18-10-2010 Free PowerPoint Template from www.brainybetty.com 58 Area of interest: abnormal Radiographic characterstics : location, periphery, shape, internal structure, effect on surrounding structures Indicates developmental/acquired-external root resorption

59. Decision 3: Classification 18-10-2010 Free PowerPoint Template from www.brainybetty.com 59 Abnormality Appropriate category Treatment plan

60. Decision 4: Ways To Proceed 18-10-2010 Free PowerPoint Template from www.brainybetty.com 60 Analyse images Further imaging like CT, MRI Biopsy Treatment

61. SOFT TISSUE. 18-10-2010 Free PowerPoint Template from www.brainybetty.com 61 The examination of the radiographic appearance of soft tissue is all too often overlooked. This is particularly true on panoramic radiographs. If the clinical examination determines that soft tissue requires radiographic examination, kVp be reduced when the patient is exposed. Soft tissue structures in the maxillofacial region are often tongue, soft palate, tip and ala of the nose

62. Correct terminology 18-10-2010 62 One examines a radiograph and NOT an X-ray. Bear in mind that an X-ray can not be seen. An X-ray is a photon / beam of energy. One does not see infection at the apex of a tooth. What one does see is the well / poorly demarcated radiolucency /opacity, x mm by y mms in size at the apex of tooth number X. For the same reason one does not speak about a PAP in radiology.

63. 18-10-2010 Free PowerPoint Template from www.brainybetty.com 63 Periodontal bone loss is not periodontitis per se. Stay away from brand names. We do not have a panorex machine here. Use the word PANORAMIC radiograph or PAN. In radiologic terminology, a PA is a postero -anterior view.

64. EXISTING DIAGNOSTIC RADIOGRAPHS 18-10-2010 Free PowerPoint Template from www.brainybetty.com 64 An effective way to reduce unnecessary radiation to the patient is to avoid retaking [recent] radiographs that already exist. It is the clinician's responsibility to obtain these records from earlier health providers where possible.

65. The diagnostic process is far from infallible. In any diagnostic procedure there are four possible outcomes:- 18-10-2010 Free PowerPoint Template from www.brainybetty.com 65 1. True positive: The disease is present and correctly identified. 2. False positive: The disease was absent but something on the radiograph convinced the clinician that it was present. 3. True negative: No disease present and correctly determined. 4. False negative: Disease is present but not detected. Occurs much too often

66. RADIOGRAPHIC RECORDS 18-10-2010 66 The value of radiographs as a part of the integral records of a patient cannot be overstated. Good radiograph is difficult to match with written records and the radiograph is more indisputable than a written statement in a court of law provided the name of the patient is indicated as well as the date. However, this is not a call to expose the patient to ionizing radiation merely for the sake of documentation. One may not retake radiographs for the sake of improving one's grades. Radiographs legally must be kept for at least 5 years; some authorities state 7 years.

67. DOCUMENTATION 18-10-2010 Free PowerPoint Template from www.brainybetty.com 67 Clear medico-legal requirement for documentation of interpretation. Signed and dated radiographic report must be written with patient's record. Clinically useful in treatment planning and case presentation.

68. Radiographic report 18-10-2010 Free PowerPoint Template from www.brainybetty.com 68 Patient & general information Imaging procedure Clinical information Findings Radiographic interpretation

69. RADIOGRAPHIC PRESCRIPTION 18-10-2010 Free PowerPoint Template from www.brainybetty.com 69 Licensed dentist may prescribe radiographs Examination appropriate radiographic views Maximum amount of information Minimum amount of ionizing radiation.

70. CONCLUSION 18-10-2010 70

71. References 18-10-2010 Free PowerPoint Template from www.brainybetty.com 71 White and pharoah,principles and interpretation.IV edition,pg281-296 W&P. Ch.14. Oral and Maxillofacial Imaging. Farman and NortjeNeill Serman.2000 Dr. Parish P. Sedghizadeh . Radiographic pathology of the head and neck. Brocklebank L, Dental Radiology, Oxford University Press 1997. Deforge DH and Colmery BH, An Atlas of Dental Radiology, Iowa State University Press 2000

72. THANK YOU 18-10-2010 72 ... when you have eliminated the impossible , whatever remains, however improbable, must be the truth. Sir Arthur Conan Doyle, (Sherlock Holmes) British mystery author & physician (1859 - 1930)