Preface_i_Clinical_Manual_for_Oral_Medic (1)

Appendices 537

Langerhans cell disease
Metastatic carcinoma
29. Salt and pepper appearance:
Osteoblastic metastatic carcinoma
Hyperparathyroidism
Fibrous dysplasia
Osteoradionecrosis
30. Scalloped appearance
Odontogenic Keratocyst
Central giant cell granuloma
Traumatic bone cyst
31. Shattered wind shield appearance
Fibrous dysplasia
32. Soap bubble appearance (Figure
AP 1.4)
Hemangioma
Aneurysmal bone cyst
Cherubism
Ameloblastoma
Giant cell lesion of hyperpara-
thyroidism
Central giant cell granuloma
Odontogenic cysts like odonto- Figure AP 1.4: Soap
genic keratocyst bubble appearance

Arteriovenous malformation
33. Stepladder appearance
Thalassemia
Sickle cell anemia
34. Sunray appearance (sun burst)
Osteosarcoma
Ewings sarcoma
Central hemangioma
Chondrosarcoma
Burkitt’s lymphoma
35. Tennis racket appearance
Odontogenic myxoma
36. Washer effect
Compound odontome (intermediate stage)
(well- defined radiolucent area composed of number of radiopaque
washer like cross-sections of developing teeth)
37. Wheel spoke pattern
Benign cementoblastoma

538 Clinical Manual for Oral Medicine and Radiology

LIMITATIONS OF RADIOLOGY

(WITH SPECIFIC REFERENCE TO INTRAORAL RADIOGRAPHS

AND ORTHOPANTOMOGRAPHY)

The dentomaxillofacial complex is susceptible to disease that manifests
early as subtle changes in bone density and geometry. These changes
can be detected by imaging. Conventional film based dental radiography
is the defacto standard for clinical and research examination of the oral
hard tissues.

Radiographic imaging is necessary only when the patient will
potentially benefit by the discovery of clinically useful information on
the radiograph. After concluding that the patient requires a radiograph
the dentist should consider the most appropriate radiographic technique
based on the anatomic relationship, size of field, radiation dose and the
inherent limitations of the imaging technique used.

All x-ray transmission based radiographs suffer the limitation in that
they are 2 dimensional projections of intrinsically complex 3 dimensional
anatomies. The result is that buccal- lingual structures are
indistinguishable. There is currently no traditional method of dental
radiography that permits viewing internal dental anatomy without
superimposition of other structures.

Soft tissues are not diagnostically imaged and for practical reasons
the exposure settings, dose and level of detail are relatively fixed and
represents a significant compromise. With these methods there is an
acknowledged lack of sensitivity for detecting and quantifying small,
subtle changes in the hard tissues.

CRITERIA FOR SELECTING AN APPROPRIATE RADIOGRAPH

Orthopantomogram

1. Orthopantomogram is preferred over intraoral periapical radiograph
as a screening modality [to evaluate eruption status of teeth, to
evaluate gross abnormalities of the maxilla, mandible and condylar
process).

2. When required field of imaging is large.
3. When exposure to the patient is a factor.
4. When great image resolution is not a factor

Appendices 539

INHERENT LIMITATIONS OF AN IOPA RADIOGRAPH

Periapical full mouth radiographs though more accurate than OPG in the
dental area. It leaves a large area of maxillofacial skeleton unimaged
and thus many lesions remain undetected.

INHERENT LIMITATIONS OF ORTHOPANTOMOGRAPHY

1. Technique sensitive
A. Patients with slumped heads and placement of neck forwards,
causes a large opaque artifact in the midline caused by super
imposition of cervical spine. These superimpositions can hide
lesions particularly in the midline.
B. If the chin is tipped too low – teeth are severely overlapped
and symphyseal region may be cut off in the film.
C . Patient should be instructed to swallow and hold tongue against
the palate, Eliminating air spaces, there by allowing optimum
visualization of apices of maxillary teeth.

2. Fine anatomic detail is not obtained
3. Cannot detect small carious or periapical lesion.
4. Proximal surfaces of premolars typically overlap.
5. Uneven magnification and geometric distortion.
6. Clinically important structures that lie outside the plane of focus

[focal trough] may appear distorted or may not be imaged at all.

ASSESSMENT OF MAXILLOFACIAL TRAUMA

1. Periapical radiographs and occlusal films though useful in imaging
fractures of alveolar processes, because of high resolution. In
some instances, it may be difficult to obtain these radiographs as a
result of extent of injury and level of discomfort associated with
mouth opening / jaw opening.

2. Injuries sustained in the midline of the maxilla /mandible may not be
imaged well in an OPG because of super imposition of the cervical
spine.

3. Zygomatico temporal suture often lies in the middle of the zygomatic
arch and may simulate a fracture.

4. Air spaces between dorsum of tongue and soft palate simulate a
fracture.

5. IOPA radiographs and OPG’S do not reveal the third dimensions of
a fracture. If the x-ray beam meets the fracture plane ‘enface’ it

540 Clinical Manual for Oral Medicine and Radiology

may not demonstrate the fracture. The beam must be aligned to
meet the edge of the fracture plane at 90° or multiple projections
may be necessary to reveal the fracture.

ASSESSMENT OF TEMPOROMANDIBULAR JOINT DISORDERS
1. OPG is considered a screening projection; subtle changes in the
articulating surfaces cannot be assessed.
2. Glenoid fossa cannot be seen in plain radiographs because there is
superimposition of skull base and zygomatic arch.
3. Because of the geometry of the OPG projection, the
temporomandibular joints are distorted such that the medial condylar
pole is projected superiorly which sometimes gives an erroneous
impression of a condylar shape abnormality.
4. Condylar position and function cannot be assessed because the
mandible is in a slightly open and protruded position in an OPG.

ASSESSMENT OF ALVEOLAR BONE FOR IMPLANTS
It is mandatory to evaluate adequacy of height of bone, thickness of
bone, relative position of medullary and cortical bone and relative position
of anatomic structures like mandibular canal, maxillary sinus to the implant
site.

1. IOPA radiograph and OPG can supply information only regarding
the vertical dimension of bone at the proposed implant site.

2. Only cross sectional imaging can provide details about the anatomical
landmarks in relation to path of insertion of implant and anchorage
for the implant.

ASSESSMENT OF MAXILLARY SINUS
1. IOPA film provides a detailed view of only the floor of the maxillary
antrum.
2. OPG provides view of both maxillary sinuses and parts of inferior,
posterior and anteromedial walls.
3. IOPA radiographs reveal only a small part of the maxillary sinus,
hence they alone are not enough for reliable diagnosis of pathology
within the antra.
4. OPG reveals cyst like findings better than cloudiness and sclerotic
changes. [Soikonnen 1990; Akesson 1992]

Appendices 541

ASSESSMENT OF PERIODONTAL DISEASES
1. OPG produces image distortion, hence not useful for detailed
analysis of teeth and periodontium.
2. In a bitewing radiograph the extent of bone loss is not always
visible, also the entire root and apex is not visible.
3. IOPA radiograph and OPG provide a 2D picture of 3D structures
4. Super imposition of one structure over the other
5. Extent of periodontal lesions under/over estimated.
6. Soft tissue landmarks and soft tissue attachment cannot be viewed.
7. Periodontal disease activity cannot be assessed
8. Small changes in angulations of the x-ray beam can produce large
change in the resultant image.

ASSESSMENT OF CARIOUS LESIONS
1. Bite wings have limited success in caries diagnosis. 60% of lesions
detected and 20% of non-carious tooth surfaces are diagnosed
as having caries. [White 1984; Douglas 1986]
2. Due to projection factors, IOPA radiographs tend to under/over
estimate degree of osseous destruction. [Akesson 1992]
3. Early carious lesions are difficult to detect especially so when they
are confined to the enamel
4. Paralleling technique for obtaining IOPA increases the chances of
detecting caries of both anterior and posterior teeth.
5. Pulp exposure cannot be determined by radiographs, only clinical
evidence can substantiate the radiographic impression.
6. Occlusal carious lesions limited to the enamel is not ordinarily
detected
7. Because of superimposition of heavy cuspal enamel over the
fissured [carious] areas.
8. Super imposition of buccal carious lesions covers the occlusal area–
simulating occlusal caries.
9. Approximately 40% of demineralization is required for radiographic
detection of a lesion.

10. It is a challenging task to differentiate cervical burn out from proximal
caries.

11. It is difficult to differentiate between, buccal lingual caries on a
radiograph

INDEX

A Child
Abscess behavior 70-73
drug dosage 73
dento-alveolar 112
furcal 112 Clubbing 28, 29
gingival 102 Collimators 265
periapical 111 Computed tomography
periodontal 102
Acute radiation syndrome 273 assembly 407
Antibiotic prophylaxis advantages, disadvantages
conditions indicated 67, 68
dental procedures indicated 410
uses 411
69, 70 Concrescence 45
regimen 69 Conjunctiva, examination 27
Antral polyp 247, 248 Contrast media 416
Antrolith 246, 247 Contrast radiography 415
ANUG management 477 Cyanosis (peripheral, central) 28
Arthrography 422 Cyst
Artifacts, radiographic 368 periapical 115
Atypical odontalgia 223, 224
D
B
Biopsy 486 Degenerative neuromuscular
Bisecting angle technique 306 disorders 58
Bitewing radiographs 295, 315
Blood pressure 26 Dental caries 33-35, 104
Bone loss (horizontal, angular, classification 104, 105
enamel caries 108
vertical) 402, 403 dentinal caries 109
Bruxism 57
Burning mouth syndrome 220 Dentinal hypersensitivity 472
Diagnosis
C
Calculus 41, 43, 95 differential 52
Cassettes 299, 300 final 52, 53
provisional/clinical 52
Digital radiography 428, 435
Disability
developmental, acquired 55

544 Clinical Manual for Oral Medicine and Radiology

Dosimetry pilocarpine 523
film badges, ionization piroxicam 494
prednisolone 511
chamber, TLD badge rofecoxib 497
serratiopeptidase 500
281, 282 tetracycline 503
Drugs triamcinolone 510
valdecoxib 498
acyclovir 515 Dry socket 472
Dysplasia 140
alprazolam 517
amitriptyline 518 E
Enamel hypoplasia 45
amoxycillin 501 Exostoses 44
Extra oral radiography
aspirin 494
baclofen 522 lateral oblique views 333,
334
betamethasone 509
lateral skull view 328
carbamazepine 520 PA view 329, 330
celecoxib 498 reverse Towne’s view 331
submentovertex view 332
cephalexin 505 TMJ views 335-337
Water’s view 330
chlorzoxazone 508
clavulanic acid 502 F
Filters 363, 364
clotrimazole 513 Fractures

desensitising tooth pastes Bennet classification 167
525 condyle, coronoid 173
dentoalveolar 166
diazepam 516 Ellis classification 166, 167
Le Fort I 169
diclofenac sodium 493 Le Fort II 170
doxepin 519 Le Fort III 171
mandible 173, 174
doxycycline 504 nasal complex 169
orbital 169
erythromycin 503 zygomatic complex 168
fluconazole 514 Fusion 45

gabapentin 521

ibuprofen 491
ketoconazole 513

ketorolac 495

levamisole 523
methocarbamol 507

metronidazole 506

minocycline 505
mouth washs 526

nimesulide 496

nortriptyline 519
nystatin 512

paracetamol/acetaminophen

492
parecoxib 499

Index 545

G cutaneous/nails 145, 146
oral 146
Gemination 45 Localisation techniques
Gingiva 46 buccal object rule 343, 344
Miller’s technique 341
bleeding 94, 95 tube shift/ SLOB/ Clark’s
color 88, 89
enlargement 90-93 technique 345, 346
recession 97 Lymph nodes
Gingivitis
acute 100 examination 179-182
chronic 101 draining sites 183-185
Grids 266-268 neoplastic diseases 187, 188

H M

Herring bone effect 363 Magnetic resonance imaging
HIV advantages, disadvantages
415
accidental exposure 86 assembly 412
clinical evaluation, oral uses 414

manifestations 75- 84 Maxillary sinus
Hypertension 27, 28 carcinoma 249, 250
functions 240
I
Intensifying screens 300 Missing teeth (anodontia, oligo-
Intraoral radiographs dontia, hypodontia) 32

composition 298, 299 Mobility 97, 98
types, sizes 294 MPDS 222, 223, 475
Intraoral periapical radiograph
indications 294, 303 N

L Natal and neo-natal teeth 46
Neuralgia
Lamina dura 375
Leukoplakia glossopharyngeal 225
trigeminal 219, 220
hairy 80
malignant potential 140 O
staging 144
types 139, 140 Occlusal radiographs 296, 317
Lichen planus Occlusion

Angle’s malocclusion 38-40
canine relation 41

546 Clinical Manual for Oral Medicine and Radiology

Occupation 15 manual 354
Oedema 29 Processing solutions

Oral cancer developer 358
fixer 359
risk factors 157 Prognosis 54
signs, symptoms 157 Pulpitis 110, 119
Pulse 24
TNM staging 161, 162
Oral submucous fibrosis R

clinical features 150 Radiation caries 277, 278
clinical staging 154, 155 Reducing solution 371
malignant potential 155 Rumination 56
Oroantral fistula 245, 246
Orthopantomography 338
Osteomyelitis 115
Osteoradionecrosis 278

P S

Pallor 28 Salivary glands
Pain examination, major 227, 228
examination, minor 228
types 213, 214 sialolith 232, 233
Paralleling technique 312 tumors 236
Penny test 352
Periodontal pocket 46, 96 Schamroth’s window test 28
Periodontium 87 Scintiscans 429
Periodontitis Sclera, examination 27
Sialography 417
aggressive/rapidly progressive Sinusitis 244
102 Sjögren’s syndrome 235
Stains (extrinsic, intrinsic) 43
chronic 101 Stereoradiography 347, 348
HIV associated 79 Supernumerary teeth (mesiodens,
juvenile 101
pre-pubertal 101 paramolar, distomolar)
Pica 57 44, 45
Pouching 57 Supplemental teeth 45
Pregnancy Syndromes
first trimester 61, 62 adrenogenital 464
second trimester 62, 63 Aldrich 467
third trimester 63 Apert 447
general guidelines 64 Ascher 455
drugs and effects 64-66 baby bottle 455
Processing of films basal cell nevus 455
automatic 357

Index 547

Beckwith hypoglycemia 465 mobius 466
Behcet 470 Mohr 453
myofascial pain-dysfunction
Bing Neel 468
459
B-K mole 456 occulodento-digital 452
Block-Slitz Berger 451 orofacial-digital 452
Papillon-Lefevre 460
Caffey Silver 451 Parry-Romberg 461
Peutz-Jeghers 458
Chediak Higashi 469 Pierre Robin 461
Costen 471 Plummer Vinson 468
popliteal pterygium 452
Cowden 457 Raeder 466
Reiter 461
cranio carpo tarsal 448 Rieger 453
CREST 470 Robinow 450
Rubinstein-Taybi 462
Crouzon 449 Saethre Chotzen 454
Scheuthauer Marie-Sainton
cryptophthalmos 449
Cushing 464 462
Senear Usher 463
Down 457 Sjögren’s 458
Stevens-Johnson 463
Eagle 467 Treacher Collins 456
ectrodactyly ectodermal 449 Trotter 463
Van Buchem 463
Ehlers-Danlos 470 Van Der Woude 463
Weber Cockayne 463
Ellis- van Creveld 448 William 454
Fanconi 469
T
Frey 466
Temperature 25
Gardner 457 Temporomandibular Joint
Goltz-gorlin 450
auscultation 201
Gorham 457 disorders 206-212
TENS 476
Grinspan 458 Test
Heerfordt 467 Minor starch-iodine 486
patch 485
Horner 466

Hurler 464
Hutchinson Gilford 453

James Ramsay Hunt 467

jaw winking 466
Lazy leukocyte 468

malabsorption 469

Marfan 458
Marin Amat 466

median cleft face 459

median cleft palate 451
Melkersons Rosenthal 467

MEN 459

Menke 465
Miescher 460

548 Clinical Manual for Oral Medicine and Radiology

Schirmer 485 W
toluidine blue 485
Thermography 439 Wasting diseases
Tooth nomenclature, Zigmondy attrition 36
abfraction 37
Palmer system 32 abrasion 36
Tooth nomenclature, FDI system erosion 36
perimolysis 37
32
Tooth nomenclature, ADA system X

32 Xerostomia 229, 230
Treatment plan 53 X-ray
Turner’s hypoplasia 45
production 256, 257
U properties 257, 258
tube construction 258-261
Ulcer
aphthous 82, 127, 128
examination 122-126
traumatic 126

V Y
Vitality tests 51, 488 Y line 382