**RADIOGRAPHY IN PERIODONTOLOGY** **DR ANNA HUGHES/** **Dr Rincon/Prof Abbott** **RADIOGRAPHY IN PERIODONTOLOGY** **DR ANNA HUGHES** / **Dr Rincon** / **Prof Abbott** **AIM OF THE LECTURE** • To understand the diagnostic benefit and biological cost of radiographic imaging • To understand the prerequisites for prescribing a radiological test • Discuss the imaging modalities used in periodontology • Interpreting radiographs for periodontal diagnosis **AIM OF THE LECTURE** - To understand the diagnostic benefit and biological cost of radiographic imaging - To understand the prerequisites for prescribing a radiological test - Discuss the imaging modalities used in periodontology - Interpreting radiographs for periodontal diagnosis The title "BENEFITS OF RADIOLOGY IN PERIODONTOLOGY" is formatted in bold yellow text. The bullet points and the image are not bold. **BENEFITS OF RADIOLOGY IN PERIODONTOLOGY** • Evaluation of health and pathology of hard tissues- teeth and surrounding bone . • Essential aid in diagnosis in addition to the clinical periodontal assessment • Important in determining prognosis • Facilitates treatment planning • Important to exclude non-inflammatory conditions • Prerequisite for pre-surgical planning • Assists in monitoring treatment outcomes  **BENEFITS OF RADIOLOGY IN PERIODONTOLOGY** - Evaluation of health and pathology of hard tissues - teeth and surrounding bone. - Essential aid in diagnosis in addition to the clinical periodontal assessment. - Important in determining prognosis. - Facilitates treatment planning. - Important to exclude non-inflammatory conditions. - Prerequisite for pre-surgical planning. - Assists in monitoring treatment outcomes. Clinical radiograph (periapical X-ray) showing multiple teeth with visible roots and surrounding alveolar bone. The image demonstrates hard tissue structures relevant to periodontal assessment, including tooth morphology and bone levels, consistent with the context of 'Evaluation of health and pathology of hard tissues'. **LIMITATIONS OF RADIOLOGICAL IMAGING** * **Ionizing** radiation mostly only reveals alteration in calcified tissues * **It doesn’t** reveal cellular (disease) activity * **Shows** only **historical** bone destruction * **Limited** value in **soft** tissue analysis * After regenerative procedures, difficult to distinguish between bone graft and regenerated bone. **LIMITATIONS OF RADIOLOGICAL IMAGING** - Ionizing radiation mostly only reveals alteration in calcified tissues. - It doesn’t reveal cellular (disease) activity. - Shows only historical bone destruction. - Limited value in soft tissue analysis. - After regenerative procedures, difficult to distinguish between bone graft and regenerated bone. BIOLOGICAL COSTS and the effects of ionizing radiation Ionizing radiation can induce cellular and chromosomal damage in 2 main ways- - Deterministic effect- dose has to be over a certain threshold to cause damage, severity then increases with dose- fetal abnormality, skin damage, hair loss. - Stochastic effect- not dose dependent but risk increases with higher dose- induction of chromosomal damage which can develop into specific cancers, leukemias ,salivary gland, thyroid, breast, brain.. Can occur years after radiation. - Radiation dose protection principles very important–justification, optimization , (Alara) dose limitation **BIOLOGICAL COSTS and the effects of ionizing radiation** Ionizing radiation can induce cellular and chromosomal damage in 2 main ways: - **Deterministic effect** – dose has to be over a certain threshold to cause damage, severity then increases with dose – fetal abnormality, skin damage, hair loss. - **Stochastic effect** – not dose dependent but risk increases with higher dose – induction of chromosomal damage which can develop into specific cancers, leukemias, salivary gland, thyroid, breast, brain. Can occur years after radiation. - Radiation dose protection principles very important – justification, optimization (Alara), dose limitation. # **PREREQUISITES** - Sound knowledge of anatomy and radiological anatomy in the field of view of your radiograph - Knowledge of the disease conditions you are looking for and its radiographic presentation - The principle of Alara (as low as reasonably achievable) and pros and cons of each imaging modality - Training in taking a good radiograph **PREREQUISITES** - Sound knowledge of anatomy and radiological anatomy in the field of view of your radiograph. - Knowledge of the disease conditions you are looking for and its radiographic presentation. - The principle of Alara (as low as reasonably achievable) and pros and cons of each imaging modality. - Training in taking a good radiograph. **IMAGING MODALITIES IN PERIODONTOLOGY** • Ionizing radiation- intra/extraoral sensors • Bitewings, periapicals, occlusal • Panoramic, cephalometric views • 3D imaging – cone beam computed tomography • Multislice / multidetector computed tomography • Non-ionizing radiation • Ultrasound • MRI - Ionizing radiation – intra/extraoral sensors - Bitewings, periapicals, occlusal - Panoramic, cephalometric views - 3D imaging – cone beam computed tomography - Multislice / multidetector computed tomography - Non-ionizing radiation - Ultrasound - MRI **PERIODONTAL Radiographic** **Examination-WHAT YOU WANT TO LOOK AT** • Bone destruction, bone loss pattern and bone defect morphology. • Roots –anatomy, length, crown/root ratio, hypercementosis • Restorations-deficiencies, caries, overhangs • Calculus if abundant • Pulp/periapical conditions, perio-endo conditions, • Furcations • Periodontal ligament space • Tooth impactions, root remnants, unerupted teeth • Any pathology of the root or adjacent structures • Bone deficiencies - Bone destruction, bone loss pattern and bone defect morphology. - Roots – anatomy, length, crown/root ratio, hypercementosis - Restorations – deficiencies, caries, overhangs - Calculus if abundant - Pulp/periapical conditions, perio-endo conditions - Furcations - Periodontal ligament space - Tooth impactions, root remnants, unerupted teeth - Any pathology of the root or adjacent structures - Bone deficiencies # **INTRAORAL RADIOGRAPHS** * Standard imaging modality for periodontal evaluation, mostly diagnostic of interdental bone changes * Periapical and bitewings use various sized films / digital sensors intraorally attached to a localising ring. * Not as accurate as 3D imaging but much lower radiation dose. * Ideally aim to standardize technique- exposure time, film size, angulation - Standard imaging modality for periodontal evaluation, mostly diagnostic of interdental bone changes - Periapical and bitewings use various sized films / digital sensors intraorally attached to a localising ring. - Not as accurate as 3D imaging but much lower radiation dose. - Ideally aim to standardize technique – exposure time, film size, angulation  Labelled diagram showing three types of film holders and positioning devices used in dental radiography. The image displays three distinct plastic instruments against a light blue background: a blue 'Anterior' holder on the left with an oval ring, a yellow 'Posterior' holder in the center with a rectangular bite block, and a red 'Bitewing' holder on the right with a curved arm design. **Periapical views** * Various sized small digital sensors positioned ideally parallel to the tooth being examined-ideal for viewing the whole root, used for evaluating periapical and periodontal/peri-implant status -even with holders you can over- or underestimate calculations   - Various sized small digital sensors positioned ideally parallel to the tooth being examined – ideal for viewing the whole root, used for evaluating periapical and periodontal/peri-implant status – even with holders you can over- or underestimate calculations Radiograph showing multiple teeth with visible roots and surrounding bone structure. The image appears to be a periapical view used for evaluating dental health. Another radiograph displaying teeth with clear root structures and periodontal spaces. This image is likely used for assessing periapical and periodontal status as mentioned in the text. **BITEWING RADIOGRAPHS** Used for caries detection and early crestal bone loss More accurate than PAs because x-ray projection more perpendicular to teeth but records only coronal third of tooth Ideally no overlap of teeth, cusp tips clear  Used for caries detection and early crestal bone loss More accurate than PAs because x-ray projection more perpendicular to teeth but records only coronal third of tooth Ideally no overlap of teeth, cusp tips clear Clinical radiograph (bitewing) showing upper and lower posterior teeth. The image demonstrates the typical appearance of bitewing radiographs used for caries detection and early crestal bone loss assessment. • How do you it's a good intraoral radiograph? **Clear Cusps of molars** • Enamel and pulp chambers seen and distinct. • Interproximal spaces should be open. • Interproximal contacts should not overlap (unless crowding present) - How do you know it's a good intraoral radiograph? - Clear cusps of molars - Enamel and pulp chambers seen and distinct. - Interproximal spaces should be open. - Interproximal contacts should not overlap (unless crowding present) # LIMITATIONS OF PA AND BWS- 2D IMAGES * Superimposition * Buccal/lingual bone and roots ### Effect of varying the angulation- Vertical and horizontal shifting of the x-ray tube will change the configuration of the PDL space, furcation, interdental bone, position of roots - Superimposition - Buccal/lingual bone and roots #### Effect of varying the angulation Vertical and horizontal shifting of the x-ray tube will change the configuration of the PDL space, furcation, interdental bone, position of roots An endodontic infection? Or a severe periodontal infection   An endodontic infection? Or a severe periodontal infection? Clinical radiograph (X-ray) showing two adjacent teeth. The image is used to illustrate potential endodontic or periodontal infection findings. Educational diagram illustrating the diagnosis of combined endodontic-periodontal lesions. It includes a schematic cross-section of tooth anatomy with color-coded areas and a technical X-ray beam visualization labeled 'Periodontal pocket' and 'Film'. The title 'Diagnosis: Combined Endo-Perio?' indicates its purpose in differentiating between endodontic and severe periodontal infections. • Or a root perforation?   - Or a root perforation? Radiograph showing two teeth with radiopaque root fillings. The caption asks if this represents a 'perfect rootfilling'. Cross-sectional CT image of a tooth with a radiopaque root filling. The caption questions whether the structure shown is a 'root perforation'. <span style="font-size: 1.5em; font-weight: bold; text-align: center;">RADIOGRAPHIC TECHNIQUE</span> <span style="font-size: 1.5em; font-weight: bold; font-style: italic; text-align: center;">DISTORTIONS- by vertical/horizontal</span> <span style="font-size: 1.5em; font-weight: bold; font-style: italic; text-align: center;">shifting</span> <span style="text-decoration: underline;">BISECTION TECHNIQUE:</span> Increases projection Bone closer to crown Distortion of facial and Lingual bone Long cone technique better <span style="text-decoration: underline;">MESIAL OR DISTAL SHIFTING</span> Changes the shape of interdental bone Changes PDL space width Changes lamina dura Furcation involvement changes  #### Distortions – by vertical/horizontal shifting **Bisection technique:** - Increases projection - Bone closer to crown - Distortion of facial and lingual bone - Long cone technique better **Mesial or distal shifting:** - Changes the shape of interdental bone - Changes PDL space width - Changes lamina dura - Furcation involvement changes A composite diagram illustrating radiographic distortions caused by vertical and horizontal shifting. The image is split into two panels: the top panel shows a 'Periapical radiograph' with an angled X-ray beam demonstrating how bone closer to the crown (labeled b) appears distorted compared to the crown (a). The bottom panel shows a 'Bite-wing radiograph' with a parallel X-ray beam, depicting mesial or distal shifting effects on the interdental bone, PDL space, lamina dura, and furcation involvement. **Long cone parallel technique**  **Long cone parallel technique** Labeled diagram illustrating the 'Long cone parallel technique' for dental radiography. The image shows an X-ray tube on the right emitting 'X-RAYS' (indicated by dashed lines) towards a tooth and film assembly on the left. Key components are labeled: 'TUBE' at the top of the x-ray source, 'FILM' at the bottom receiving the image, and a long black cone connecting them to minimize magnification errors. # Tube Shift Techniques ## Vertical Shift * Increased angle * Decreased angle  #### Vertical Shift - Increased angle - Decreased angle Diagram illustrating Tube Shift Techniques for Vertical Shift. Three panels show radiographic interpretations: left panel labeled 'Increased angle' shows a diverging beam geometry; middle panel shows standard alignment; right panel labeled 'Decreased angle' shows converging beam geometry. Each panel includes labels for Film, CR (Computed Radiography), Li (Incisor/Lower Incisors), and Bu (Molar/Upper Molars). **Tube Shift Techniques** **Horizontal shifts** ♦ **Mesial** ♦ **Distal** ♦ Used to separate objects that are otherwise superimposed over each other ♦ Can help to indicate the "3rd dimension"   #### Horizontal shifts - **Mesial** - **Distal** - Used to separate objects that are otherwise superimposed over each other - Can help to indicate the "3rd dimension" Schematic diagram illustrating the concept of horizontal tube shifts in radiography. It shows a central object (representing teeth or bone) with two diverging X-ray beams originating from different angles, labeled 'D' (Distal) and 'M' (Mesial). The diagram visually demonstrates how shifting the X-ray source horizontally alters the projection of objects relative to each other. Clinical radiograph demonstrating the application of tube shift techniques. The image displays a dental region where superimposed anatomical structures are shown to be separated by varying the angle of the X-ray beam, visualizing the 'third dimension' effect described in the text. # PANORAMIC RADIOLOGY * **Extraoral rotating x-ray source and image receptor** moves around the patients head- produces a curved image of patients jaws, teeth, TMJ. * Useful as a screening tool, especially if intraoral views not possible/uncomfortable. * Problems- image magnification, ghost and double images, distortion, superimposition, low resolution * **Lower radiation dose** compared to full mouth periapical radiographs - **Extraoral rotating x-ray source and image receptor** moves around the patient's head – produces a curved image of patient's jaws, teeth, TMJ. - Useful as a screening tool, especially if intraoral views not possible/uncomfortable. - Problems – image magnification, ghost and double images, distortion, superimposition, low resolution - **Lower radiation dose** compared to full mouth periapical radiographs Variations in panoramic machines - magnifications are uneven and unpredictable Image distortions, variable shortening and elongations , lingual objects more superior  Variations in panoramic machines – magnifications are uneven and unpredictable Image distortions, variable shortening and elongations, lingual objects more superior Clinical radiograph showing a panoramic dental X-ray with multiple circular metallic objects (likely calibration markers or artifacts) aligned along the lower jaw. The image demonstrates uneven magnification and distortion as described in the accompanying text. **Occlusal radiographs- used in perio to locate impacted /unerupted teeth ( also in dental trauma, locate bone lesions , fractures)** C Anterior occlusal radiograph of ... researchgate.net MEDizzz - Sialolithiasis seen in ... medizzy.com Mandibular occlusal view, the a... openi.nlm.nih.gov View Image jisppd.com View Image ijdentlasers.org View Image ijsonline.com View Image ijdr.in    **Occlusal radiographs** – used in perio to locate impacted / unerupted teeth (also in dental trauma, locate bone lesions, fractures) Anterior occlusal radiograph showing the maxillary and mandibular anterior teeth in a top-down view. The image displays the crowns and roots of the front teeth with surrounding bone structures visible. Clinical photograph demonstrating the positioning for an occlusal radiograph. A patient is shown in profile with their head tilted back against a headrest, while a hand holds a rectangular radiographic film or sensor horizontally across the lower jaw (mandible). A composite figure containing multiple panels of dental radiographs sourced from various websites (e.g., researchgate.net, medizzy.com). It includes an anterior occlusal radiograph, a view labeled 'MEDizzz - Sialolithiasis seen in...', and a mandibular occlusal view with an arrow pointing to a specific finding. **CEPHALOMETRIC RADIOLOGY** • More useful in orthodontic therapy and orthognathic surgery • Occasionally used in perio for full arch implant rehabilitation  - More useful in orthodontic therapy and orthognathic surgery - Occasionally used in perio for full arch implant rehabilitation Clinical radiograph showing a cephalometric analysis. The image contains two panels: the left panel is a lateral (side view) radiograph of the skull demonstrating the profile, nasal cavity, maxilla, and mandible; the right panel is an anterior-posterior (frontal view) radiograph of the skull showing the facial bones and dental arches. **All 2D and OPG have significant limitations** 1. Superimposition of structures 2. Geometric alteration o Elongation & foreshortening, even with holders 3. Anatomic obstacles o Unable to show complex root morphology 1. Superimposition of structures 2. Geometric alteration - Elongation & foreshortening, even with holders 3. Anatomic obstacles - Unable to show complex root morphology # **Cone Beam Computed Tomography** * Introduced into the dental field in 1998, rapidly growing in popularity. * Uses a cone beam to capture image in one rotation around a patient- less radiation compared to mdct * Spatial resolution lower than 2D images but higher by 2-8 times than a MDCT. * Radiation dose higher than an OPG by 5-10 times (machines in envision) * But low contrast resolution (poor for soft tissues and low density structures) big problems with movement and metallic artifacts.  - Introduced into the dental field in 1998, rapidly growing in popularity. - Uses a cone beam to capture image in one rotation around a patient – less radiation compared to MDCT - Spatial resolution lower than 2D images but higher by 2-8 times than a MDCT. - Radiation dose higher than an OPG by 5-10 times (machines in envision) - But low contrast resolution (poor for soft tissues and low density structures) – big problems with movement and metallic artifacts. Radiographic image (likely a CBCT slice) demonstrating the subject of the slide, Cone Beam Computed Tomography. The grayscale medical image shows anatomical structures with high spatial resolution, consistent with the text description of being higher than MDCT. **MultiDetector Computed Tomography** Already commonly used in medicine- fan beam x-rays to take axial slices from top to bottom. Superior soft tissue contrast compared with cone beam. Less accessible for dentists, high cost and radiation dose ( up to 15 times more than a CBCT) Already commonly used in medicine – fan beam x-rays to take axial slices from top to bottom. Superior soft tissue contrast compared with cone beam. Less accessible for dentists, high cost and radiation dose (up to 15 times more than a CBCT) **When is VOLUMETRIC ANALYSIS useful IN PERIO** * To determine the extent and pattern of periodontal bone loss, including infrabony defects, dehiscences, fenestrations * Furcation morphology ie width of entrance, pattern of bone loss in furcations * Root morphology * Root fractures * Periapical status * Origin of infection * Pre-surgical/ implant planning * Pre-ortho in thin phenotypes/ perio patients * **BUT INTRAOPERATIVE ANALYSIS MOST ACCURATE** - To determine the extent and pattern of periodontal bone loss, including infrabony defects, dehiscences, fenestrations - Furcation morphology – i.e. width of entrance, pattern of bone loss in furcations - Root morphology - Root fractures - Periapical status - Origin of infection - Pre-surgical / implant planning - Pre-ortho in thin phenotypes / perio patients - **BUT INTRAOPERATIVE ANALYSIS MOST ACCURATE** **USES IN TREATMENT PLANNING AND IMPLANT PLACEMENT** * Software available to manipulate the axial images into other plains and views (sagittal , coronal..) MPR or multiplanar reformation * Software can be used to plan and form an implant surgical guide pre-op along with computer assisted treatment planning * CBCT not useful to monitor peri-implant bone loss (metallic artifacts )- OPG and periapicals better for interproximal bone evaluation - Software available to manipulate the axial images into other planes and views (sagittal, coronal…) – MPR or multiplanar reformation - Software can be used to plan and form an implant surgical guide pre-op along with computer assisted treatment planning - CBCT not useful to monitor peri-implant bone loss (metallic artifacts) – OPG and periapicals better for interproximal bone evaluation # Approximate radiation doses * **IO PA/ BW** = 2 uSv * **OPG** = 20 uSV * **CBCT** = 40-80 uSv * **Chest xray** = 14 uSv * **Background radiation** in the **UK** = 7 uSv/daily * **Flight-UK to US** = 80 uSv - **IO PA / BW** = 2 uSv - **OPG** = 20 uSv - **CBCT** = 40-80 uSv - **Chest x-ray** = 14 uSv - **Background radiation** in the **UK** = 7 uSv/daily - **Flight – UK to US** = 80 uSv MRI • Radiofrequency pulse used in a chamber with a static magnetic field • Excellent for TMJ and soft tissue analysis • However expensive, claustrophobic, severely affected by metal artifacts • Increasing interest in developing its use for perio because of ability to differentiate between healthy and inflamed soft tissue - Radiofrequency pulse used in a chamber with a static magnetic field - Excellent for TMJ and soft tissue analysis - However expensive, claustrophobic, severely affected by metal artifacts - Increasing interest in developing its use for perio because of ability to differentiate between healthy and inflamed soft tissue # ULTRASOUND - Uses sound ways and a tranducer to generate an image. large transducer head limits current application to TMJ, salivary glands, lymph nodes, head and neck muscles, thyroid gland, carotid vessels - Smaller transducersmore useful intraorally and currently being developed – useful for teeth and implant soft tissue measurements. - Not affected by metal artifacts so useful for peri-implant evaluation. - Useful for cosmetic injectables ( fillers ) to avoid vascular occlusion and evaluate longevity and migration of fillers. - Uses sound waves and a transducer to generate an image. - Large transducer head limits current application to TMJ, salivary glands, lymph nodes, head and neck muscles, thyroid gland, carotid vessels - Smaller transducers more useful intraorally and currently being developed – useful for teeth and implant soft tissue measurements. - Not affected by metal artifacts so useful for peri-implant evaluation. - Useful for cosmetic injectables (fillers) to avoid vascular occlusion and evaluate longevity and migration of fillers. **FILLER COMPLICATIONS-VASCULAR OCCLUSION AND TISSUE NECROSIS**  **FILLER COMPLICATIONS – VASCULAR OCCLUSION AND TISSUE NECROSIS** Clinical photo demonstrating a complication of dermal filler injection. The image shows the lower face and upper lip area with distinct, dark discoloration (ecchymosis) and tissue necrosis. The affected region follows an anatomical distribution corresponding to the angular artery or lateral nasal branches, suggesting vascular occlusion leading to ischemia. This visual serves as evidence for 'FILLER COMPLICATIONS-VASCULAR OCCLUSION AND TISSUE NECROSIS'. **NORMAL RADIOGRAPHICAL FEATURES ON A 2D IMAGE (PA and BWS)** - Interdental bone/septa width varies between different teeth, but should be **radiopaque** and smooth and horizontal. - Alveolar crest 0.5 to 2 mm to CEJ, - Lamina dura –dense cortical bone– appears as a white line, which may or not be continuous - Periodontal ligament space may be widened if the teeth are mobile - Buccal/lingual bone not possible to examine on 2D imaging–buccal bone deficiencies may be present in health (dehiscences/fenestrations) - If teeth have supraerupted, distance between CEJ and crestal bone is more   **Normal Radiographical Features on a 2D Image (PA and BWS)** - Interdental bone/septa width varies between different teeth, but should be **radiopaque** and smooth and horizontal. - Alveolar crest 0.5 to 2 mm to CEJ. - Lamina dura – dense cortical bone – appears as a white line, which may or not be continuous. - Periodontal ligament space may be widened if the teeth are mobile. - Buccal/lingual bone not possible to examine on 2D imaging – buccal bone deficiencies may be present in health (dehiscences/fenestrations). - If teeth have supraerupted, distance between CEJ and crestal bone is more. Clinical radiograph (PA or BWS view) showing two adjacent teeth with visible roots and surrounding bone. The image demonstrates normal interdental bone/septa width, alveolar crest position relative to CEJ, lamina dura as a white line around the root, and periodontal ligament space. Schematic cross-sectional diagram illustrating normal periodontal anatomy. It shows the crown, root, alveolar bone, lamina dura, and periodontal ligament space. A dotted line indicates measurement from CEJ to crestal bone (MBL), used to explain supraeruption features mentioned in the text.   Clinical photo of a dental specimen showing alveolar bone defects. The image includes labels pointing to 'Dehiscence' (bone loss on the facial surface) and 'Fenestration' (a window-like defect on the lingual/palatal surface). The teeth roots are visible below the bone. Intraoral clinical photo showing gingival recession exposing root surfaces. There is visible loss of attached gingiva and potential bone dehiscence or fenestration in the interproximal area between two teeth. # Interpreting bone destruction in periodontal disease Periodontal bone loss starts at the alveolar crest Initial phase, reduced density of cortical bone Slight radiographic changes in bone height means progression to early stages of periodontitis * Hence the earliest signs are easier to detect clinically by probing * X-ray underestimates bone loss compared with clinical assessment * Average distance from CEJ to interproximal alveolar crest is 1.5 to 2 mm hence bone loss is determined by measuring the distance from the crest to the CEJ  Interpreting bone destruction in periodontal disease Periodontal bone loss starts at the alveolar crest. Initial phase, reduced density of cortical bone. Slight radiographic changes in bone height means progression to early stages of periodontitis. - Hence the earliest signs are easier to detect clinically by probing. - X-ray underestimates bone loss compared with clinical assessment. - Average distance from CEJ to interproximal alveolar crest is 1.5 to 2 mm hence bone loss is determined by measuring the distance from the crest to the CEJ. Clinical radiograph (X-ray) showing teeth and surrounding alveolar bone. The image demonstrates the anatomy referenced in the text, specifically the interproximal area between teeth where bone loss is measured from the Cemento-Enamel Junction (CEJ) to the alveolar crest. **SEVERITY and the Classification stages** - **Mild** - stage I (less than 15%) - **Moderate** - stage II (15-33%) - Stage III and Stage IV (extends to mid 1/3 and beyond) - Advanced bone loss - stage III - IV - % of bone loss and root length **Severity and the Classification Stages** - **Mild** - stage I (less than 15%) - **Moderate** - stage II (15-33%) - Stage III and Stage IV (extends to mid 1/3 and beyond) - Advanced bone loss - stage III - IV - % of bone loss and root length **Severity and the radiographic report in your perio eform** * Mild- less than 33% bone loss * Moderate – between 33 and 66% * Severe- more than 66% * Pattern- horizontal / vertical * Distribution- localized or generalized. **Severity and the Radiographic Report in Your Perio Eform** - Mild - less than 33% bone loss - Moderate – between 33 and 66% - Severe - more than 66% - Pattern - horizontal / vertical - Distribution - localized or generalized.  Clinical photo: Bitewing radiograph showing a dental arch with two rows of teeth. The image demonstrates diagnostic features of Stage 1 Periodontal Disease, specifically noting that the radiographic bone loss is limited to the coronal third of the alveolar bone (<15%). **Stage 2 Periodontal Disease (mandibular + maxillary left posterior) bitewing radiograph: Radiographic bone loss limited to the coronal third (15%-33%). Image provided by authors.**  **Stage 2 Periodontal Disease (mandibular + maxillary left posterior) bitewing radiograph:** Radiographic bone loss limited to the coronal third (15%-33%). Image provided by authors. Bitewing radiograph showing a section of upper and lower teeth. The image displays significant dental restorations including amalgam fillings and crowns. Key findings include vertical bone loss visible between the roots of the mandibular molars, characteristic of periodontal disease. Normal implant bone levels **Fig. 23** Mucositis (maxillary anterior incisor) periapical radiograph: Alveolar crest levels appear radiopaque. Bone level appears normal at level of implant platform. Image provided by authors. **19**  Normal implant bone levels **Fig. 23** Mucositis (maxillary anterior incisor) periapical radiograph: Alveolar crest levels appear radiopaque. Bone level appears normal at level of implant platform. Image provided by authors. Periapical radiograph showing a dental implant in the maxillary anterior region with adjacent natural teeth. The image demonstrates normal bone levels around the implant platform, as indicated by the caption. # Peri-implantitis **Fig. 29. Peri-implantitis, Lack of Keratinized Tissue Etiology (mandibular right premolar)** periapical radiograph: Alveolar crest levels appear diffuse. Horizontal bone loss pattern noted. Image provided by authors. **Fig. 27. Peri-implantitis, Bacterial Etiology (maxillary anterior incisor)** periapical radiograph: Alveolar crest levels appear radiopaque. Severely reduced abrupt vertical bone loss noted at mesial and distal aspect of implant housing. Image provided by authors.   Peri-implantitis **Fig. 29. Peri-implantitis, Lack of Keratinized Tissue Etiology (mandibular right premolar)** periapical radiograph: Alveolar crest levels appear diffuse. Horizontal bone loss pattern noted. Image provided by authors. **Fig. 27. Peri-implantitis, Bacterial Etiology (maxillary anterior incisor)** periapical radiograph: Alveolar crest levels appear radiopaque. Severely reduced abrupt vertical bone loss noted at mesial and distal aspect of implant housing. Image provided by authors. Periapical radiograph showing a dental implant in the mandibular right premolar region with adjacent natural teeth. The image demonstrates diffuse alveolar crest levels and a horizontal bone loss pattern around the implant, consistent with peri-implantitis due to lack of keratinized tissue. Periapical radiograph showing a dental implant in the maxillary anterior incisor region. The image displays radiopaque alveolar crest levels and severely reduced abrupt vertical bone loss at the mesial and distal aspects of the implant housing, indicating bacterial etiology peri-implantitis.  Clinical radiograph demonstrating severe periodontal disease in the mandibular and maxillary right posterior regions. The image shows significant vertical bone loss affecting multiple teeth, with furcation involvement noted as Class II and Class III. **Occlusal trauma-widened PDL space, thickened lamina dura**  **Occlusal trauma - widened PDL space, thickened lamina dura** Periapical radiograph showing mandibular anterior teeth exhibiting signs of occlusal trauma. The image displays a wear facet on the occlusal surface of the central incisor, along with visibly widened periodontal ligament (PDL) spaces and thickened lamina dura. STAGE | CAL PERSPECTIVE | POCKET PERSPECTIVE --- | --- | --- | | | Stage I | CAL 1-2 mm | 4 mm POCKET Stage II | CAL 3-4 mm | 5 mm POCKET Stages III & IV | CAL 5 mm + | 6 mm + POCKET | | | BONE LOSS PERSPECTIVE 1-15% 15-33% 33 to 100% Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins  | STAGE | CAL PERSPECTIVE | POCKET PERSPECTIVE | BONE LOSS PERSPECTIVE | | --- | --- | --- | --- | | Stage I | CAL 1-2 mm | 4 mm POCKET | 1-15% | | Stage II | CAL 3-4 mm | 5 mm POCKET | 15-33% | | Stages III & IV | CAL 5 mm + | 6 mm + POCKET | 33 to 100% | Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins A composite medical figure illustrating periodontal disease stages from three perspectives. The left section contains a labeled diagram showing a tooth cross-section with a periodontal probe, correlating 'CAL PERSPECTIVE' (Clinical Attachment Loss) and 'POCKET PERSPECTIVE' measurements across Stage I (CAL 1-2 mm / 4 mm pocket), Stage II (CAL 3-4 mm / 5 mm pocket), and Stages III & IV (CAL 5 mm+ / 6 mm+ pocket). The right section displays a clinical radiograph of teeth with yellow arrows pointing to bone loss, accompanied by a legend quantifying bone loss percentages: 1-15%, 15-33%, and 33 to 100%. A copyright notice for Wolters Kluwer Health | Lippincott Williams & Wilkins is visible at the bottom.    Dental radiograph showing Stage I periodontal disease severity. The image displays a bracket indicating shallow bone loss relative to the root length. Dental radiograph demonstrating Stage III periodontal disease. A bracket highlights moderate to severe bone loss extending further down the root compared to Stage I. Dental radiograph illustrating advanced stages (III and IV) of periodontal disease. A bracket indicates extensive bone loss approaching or exceeding the root apex. **Radiographic Interpretation-** **MORPHOLOGY OF BONE LOSS** • Bone loss type • Horizontal bone loss • Vertical bone loss Assessing bone loss more difficult on 2D images   **Radiographic Interpretation - Morphology of Bone Loss** - Bone loss type - Horizontal bone loss - Vertical bone loss Assessing bone loss more difficult on 2D images. Clinical radiograph showing horizontal bone loss pattern. The image displays the crowns and roots of several teeth with a distinct lack of vertical bone height variation between them. The alveolar crest appears as a relatively flat line parallel to the root surfaces, characteristic of generalized periodontal disease. Clinical radiograph illustrating vertical bone loss (angular defect). This image shows significant bone destruction on one side of the tooth socket, creating an angular or 'cup' shaped defect extending down the root surface, rather than a uniform horizontal recession.  Periapical radiograph showing maxillary right anterior teeth exhibiting periodontal disease. The image demonstrates vertical (angular) bone loss where the alveolar crest levels are indistinct and not parallel to the cementoenamel junctions (CEJs) of the adjacent teeth. **Vertical/angular/intrabony/infrabony/crater bone defects- different types**    **Vertical/angular/intrabony/infrabony/crater bone defects - different types** Radiograph showing a vertical bone defect around the roots of molar teeth. The alveolar bone crest is significantly reduced in height on one side of the tooth compared to the other, creating a deep pocket of missing bone extending vertically down the root surface. Radiograph demonstrating an angular bone defect (specifically a vertical or intrabony defect) between two premolar teeth. There is a distinct V-shaped loss of bone depth on the interproximal surface of the mesial root of the right tooth, indicating localized periodontal destruction. Radiograph illustrating an infrabony/crater bone defect in the posterior mandible. The bone loss appears as a saucer-like depression or crater located within the horizontal plane of the alveolar bone, rather than extending vertically down the root like the defects shown in the other images. **PATTERN OF INTRABONY DEFECTS; 1,2, 3 WALLED DEFECTS** **NUMBER OF REMAINING WALLS**  **Pattern of Intrabony Defects; 1, 2, 3 Walled Defects** **Number of Remaining Walls** A labeled medical diagram illustrating the 'PATTERN OF INTRABONY DEFECTS' and classifying them by the 'NUMBER OF REMAINING WALLS'. The image displays four distinct cross-sectional views of periodontal bone defects (labeled A, B, C, D). Panel A shows a shallow crater-like defect. Panel B depicts a one-walled vertical defect. Panel C illustrates a two-walled angular defect. Panel D demonstrates a three-walled bony defect where only the base remains. # **CRATER DEFECTS** Buccal and lingual plate higher than the base of a defect- difficult to detect on 2D imaging- may appear as more radiolucent except if B/L bone very thick <div><img>Images of teeth showing crater defects, one intraoperative and one on a dental model</div></div>   **Crater Defects** Buccal and lingual plate higher than the base of a defect - difficult to detect on 2D imaging - may appear as more radiolucent except if B/L bone very thick. Images of teeth showing crater defects, one intraoperative and one on a dental model. Clinical photo showing an intraoperative view of a crater defect. The image displays the gingival tissue retracted to reveal the alveolar bone between teeth. The text describes this condition as having buccal and lingual plates higher than the base of the defect, making it difficult to detect on 2D imaging. Photo of a dental model demonstrating crater defects. It shows multiple teeth with visible gaps or defects in the surrounding gum line (alveolar ridge), illustrating the anatomical structure described in the text regarding the relationship between the bone plates and the defect base. RADIOPAQUE HORIZONTAL LINE FOR LABIAL OR LINGUAL BONE LEVEL  Radiopaque Horizontal Line for Labial or Lingual Bone Level Clinical dental radiograph showing the anterior maxillary region with two vertical arrows pointing to a distinct radiopaque horizontal line within the alveolar bone. This visual finding demonstrates the labial or lingual bone level. DISTRIBUTION Localised less than 30% Generalised more than 30% Distribution - Localised less than 30% - Generalised more than 30% FURCATION DEFECTS * In multirooted teeth, hard to see bone loss in furcations on 2D images because of superimpositioning of bone and roots * Variations in radiolucency may help detect bone loss * Inverted J shape on maxillary molars- sign of distal furcation bone loss * Unless the radiograph is standardised and reproducable, very hard to compare before and after treatment/ deterioration. * CBCT more accurate as a diagnostic tool but not recommended for follow-up and monitoring Furcation Defects - In multirooted teeth, hard to see bone loss in furcations on 2D images because of superimpositioning of bone and roots. - Variations in radiolucency may help detect bone loss. - Inverted J shape on maxillary molars - sign of distal furcation bone loss. - Unless the radiograph is standardised and reproducible, very hard to compare before and after treatment/deterioration. - CBCT more accurate as a diagnostic tool but not recommended for follow-up and monitoring. # Interpretation of Furcation defects in 2 D imaging ## Fig. 23-18 Various stages of furcation involvement as depicted on periapical images. (a) The radiograph shows a slight radiolucency in the most coronal aspect of the furcation of tooth 46. (b) This periapical radiograph shows radiolucency in the furcation of tooth 36 that reaches the middle-third of the root. Different crestal bone levels may mimic no radiolucency in the furcation of tooth 37. (c) This radiograph exhibits a radiolucency of the furcation of tooth 26 that extends up to the apex of the respective roots. ## Fig. 23-19 A periapical image demonstrating a radiolucent triangle superimposed over the distal roots of tooth 26 and demonstrating the hooks of the "**J**" shaped radiolucency on the distal root of tooth 27, both of which indicate bone destruction extending into the furcation of the respective regions (**yellow circles**). ## Fig. 23-20 This periapical image shows an extended radiolucency from the alveolar crest to the periapical region of tooth 46. This points towards the presence of periodontal and periapical inflammatory pathologies (**perio-endo lesion**).       Interpretation of Furcation Defects in 2D Imaging **Fig. 23-18** Various stages of furcation involvement as depicted on periapical images. (a) The radiograph shows a slight radiolucency in the most coronal aspect of the furcation of tooth 46. (b) This periapical radiograph shows radiolucency in the furcation of tooth 36 that reaches the middle-third of the root. Different crestal bone levels may mimic no radiolucency in the furcation of tooth 37. (c) This radiograph exhibits a radiolucency of the furcation of tooth 26 that extends up to the apex of the respective roots. **Fig. 23-19** A periapical image demonstrating a radiolucent triangle superimposed over the distal roots of tooth 26 and demonstrating the hooks of the "**J**" shaped radiolucency on the distal root of tooth 27, both of which indicate bone destruction extending into the furcation of the respective regions (**yellow circles**). **Fig. 23-20** This periapical image shows an extended radiolucency from the alveolar crest to the periapical region of tooth 46. This points towards the presence of periodontal and periapical inflammatory pathologies (**perio-endo lesion**). Periapical radiograph showing a slight radiolucency in the most coronal aspect of the furcation of tooth 46. Periapical radiograph showing radiolucency in the furcation of tooth 36 that reaches the middle-third of the root. Different crestal bone levels may mimic no radiolucency in the furcation of tooth 37. Periapical radiograph exhibiting a radiolucency of the furcation of tooth 26 that extends up to the apex of the respective roots. Composite figure illustrating various stages of furcation involvement across multiple teeth, with accompanying descriptive text explaining each stage. Periapical radiograph highlighting a radiolucent triangle over the distal roots of tooth 26 and J-shaped radiolucency on the distal root of tooth 27, indicating bone destruction in the furcation regions (marked by yellow circles). Periapical radiograph showing an extended radiolucency from the alveolar crest to the periapical region of tooth 46, indicative of perio-endo lesion. **PERIODONTITIS RADIOGRAPHIC APPEARANCE** * Depends or radiographic technique, tube angulation and film placement * **Also** depends on anatomical variations **thickn**ess and density of inter**de**ntal bone, posiTion of teether * Presence of an intact lamina dura indicates health but its absence doesn't mean disease * Furcations may appear as a wedge shaped radiolucent area **mesial and or distal with apex pointing to the crown**   **Periodontitis Radiographic Appearance** - Depends on radiographic technique, tube angulation and film placement. - **Also** depends on anatomical variations **thickness** and density of inter**dental** bone, position of teeth. - Presence of an intact lamina dura indicates health but its absence doesn't mean disease. - Furcations may appear as a wedge shaped radiolucent area **mesial and or distal with apex pointing to the crown**. Clinical radiograph (X-ray) showing a section of the jaw with multiple teeth. The image demonstrates the 'Periodontitis Radiographic Appearance' mentioned in the text, specifically illustrating the bone structure and interproximal areas between teeth. Close-up clinical radiograph focusing on the furcation area of multi-rooted teeth. This visual corresponds to the bullet point describing 'Furcations may appear as a wedge shaped radiolucent area mesial and or distal with apex pointing to the crown', clearly showing the dark triangular voids indicating bone loss at the root bifurcation. **HEALING AFTER TREATMENT**   **Healing After Treatment** A composite radiograph (X-ray) showing multiple teeth. The central tooth has a large, bright white restoration (filling). A yellow arrow points to the root area of this tooth, indicating a specific region of interest likely related to the healing process mentioned in the title. A second set of dental radiographs showing similar teeth and restorations as the upper row. These images appear to be follow-up scans demonstrating the healing progress after treatment. **Some Systemic conditions can present with periodontal manifestations radiographically** * OSTEITIS FIBROSA * PAGET'S DISEASE * FIBROUS DYSPLASIA * HISTIOCYTOSIS * OST EOPETROSIS * SCLERODERMA * MALIGNANCY * CARCINOMA OF THE JAW * OSTEOSARCOMA  Some Systemic conditions can present with periodontal manifestations radiographically - OSTEITIS FIBROSA - PAGET'S DISEASE - FIBROUS DYSPLASIA - HISTIOCYTOSIS - OSTEOPETROSIS - SCLERODERMA - MALIGNANCY - CARCINOMA OF THE JAW - OSTEOSARCOMA A composite radiograph displaying four quadrants of dental X-rays (likely periapical or bitewing views) showing teeth and alveolar bone. The image serves as a visual example for the slide's topic: systemic conditions presenting with periodontal manifestations radiographically. The radiographs show various tooth structures and root areas relevant to diagnosing conditions such as osteitis fibrosa, Paget's disease, fibrous dysplasia, histiocytosis, osteopetrosis, scleroderma, malignancy, carcinoma of the jaw, and osteosarcoma. Distribution  Distribution Dental panoramic radiograph (orthopantomogram) showing the maxillary and mandibular arches. Multiple red arrows point to areas of generalized horizontal alveolar bone loss along the roots of both upper and lower teeth, indicating periodontitis. Some teeth show restorations (radiopaque fillings). The image includes an 'R' marker in the bottom-left corner. **Recommendations for Periodontal disease assessment** * **OPG** is sufficient for an overview- occasionally and alternatively full-mouth periapicals can be used. * Additional intraoral views can be used for more detail on bone levels and root morphology- however limited detail on furcation and intrabony defects. * **CBCT/MDCT** provides a lot more detail if accuracy is important in evaluation of prognosis and treatment planning- but not recommended for follow-up examinations #### Recommendations for Periodontal disease assessment - **OPG** is sufficient for an overview – occasionally and alternatively full-mouth periapicals can be used. - Additional intraoral views can be used for more detail on bone levels and root morphology – however limited detail on furcation and intrabony defects. - **CBCT/MDCT** provides a lot more detail if accuracy is important in evaluation of prognosis and treatment planning – but not recommended for follow-up examinations. **When is VOLUMETRIC ANALYSIS useful IN PERIO** * To determine the extent and pattern of periodontal bone loss, including infrabony defects, dehiscences, fenestrations * Furcation morphology ie width of entrance, pattern of bone loss in furcations * Root morphology * Root fractures * Periapical status * Origin of infection * Pre-surgical/ implant planning * Pre-ortho in thin phenotypes/ perio patients #### When is volumetric analysis useful in perio - To determine the extent and pattern of periodontal bone loss, including infrabony defects, dehiscences, fenestrations - Furcation morphology i.e. width of entrance, pattern of bone loss in furcations - Root morphology - Root fractures - Periapical status - Origin of infection - Pre-surgical / implant planning - Pre-ortho in thin phenotypes / perio patients #To conclude * **Justification**- Prescribe radiological exam only if clinical exam does not provide sufficient diagnostic information * **Optimization**- Follow the lowest dose protocol to achieve the diagnosis Keep updated in theories and techniques of radiological assessment #### To conclude - **Justification** – Prescribe radiological exam only if clinical exam does not provide sufficient diagnostic information - **Optimization** – Follow the lowest dose protocol to achieve the diagnosis Keep updated in theories and techniques of radiological assessment. - THANK YOU! - RECOMMENDED READING - Lindhes Clinical Periodontology and Implant Dentisty 7th edition Chapter 23. <table> <thead> <tr><th>Periodontal and Implant Radiology</th></tr> </thead> <tbody> <tr> <td> Joseph P. Fiorellini, DMD, DMSc^a,^b^*, Dennis Sourvanos, BBDH, DDS^a,^b, Hector Sarimento, DMD, MSOB^a,^b, Nadeem Karimbux, DMD, MMSc^a,^b, Kevin W. Luan, BDS, MSOB, MEd^a,^b^c^ </td> </tr> </tbody> </table> Dent Clin N Am 65 (2021) 447–473 https://doi.org/10.1016/j.cden.2021.02.003 0011-8532/21/© 2021 Elsevier Inc. All rights reserved. - THANK YOU! **RECOMMENDED READING** Lindhe's Clinical Periodontology and Implant Dentistry 7th edition Chapter 23. **Periodontal and Implant Radiology** Joseph P. Fiorellini, DMD, DMSc^a,^b^*, Dennis Sourvanos, BBDH, DDS^a,^b, Hector Sarimento, DMD, MSOB^a,^b, Nadeem Karimbux, DMD, MMSc^a,^b, Kevin W. Luan, BDS, MSOB, MEd^a,^b^c^ Dent Clin N Am 65 (2021) 447–473 https://doi.org/10.1016/j.cden.2021.02.003 0011-8532/21/© 2021 Elsevier Inc. All rights reserved. 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