Radiographic Pathology

Radiographic Radiographic PathologyPathology

““Radiographic appearances are governed by Radiographic appearances are governed by anatomic or physiologic changes in the presence of anatomic or physiologic changes in the presence of the disease processes. Radiographic ‘diagnosis’ is the disease processes. Radiographic ‘diagnosis’ is founded on a knowledge of these alterations, the founded on a knowledge of these alterations, the prerequisite being awareness of disease prerequisite being awareness of disease mechanisms.” (H.M. Worth)mechanisms.” (H.M. Worth)

Method of Radiographic Method of Radiographic Investigation and Film Investigation and Film

AnalysisAnalysis 1. Assess the quality of the film1. Assess the quality of the film

- A) film density (alterations due to exposure or processing A) film density (alterations due to exposure or processing errors).errors).

- B) image geometry (image distortion due to technique B) image geometry (image distortion due to technique errors).errors).


AnalysisAnalysis 2.2. Examine the total film before concentrating Examine the total film before concentrating

on one specific region.on one specific region. 3.3. Examine the film for the presence of normal Examine the film for the presence of normal

anatomy and assess the shape and density of each anatomy and assess the shape and density of each structure. To accomplish this, one must have structure. To accomplish this, one must have knowledge of the variable appearance that knowledge of the variable appearance that “normal” anatomy may have. “normal” anatomy may have.


AnalysisAnalysis 4.4. Make sure that the total area of interest is Make sure that the total area of interest is

present in the film. This may require a larger film present in the film. This may require a larger film format. Often a second view at a slightly different format. Often a second view at a slightly different angle or preferentially at right angles is angle or preferentially at right angles is advantageous (e.g. occlusal views). advantageous (e.g. occlusal views).


AnalysisAnalysis 5.5. Suitable Viewing EquipmentSuitable Viewing Equipment

A) view boxA) view box

B) intense light sourceB) intense light source

C) maskC) mask

D) magnifying glassD) magnifying glass

E) room with subdued lighting E) room with subdued lighting


AnalysisAnalysis 6.6. Referral for Other Imaging ProceduresReferral for Other Imaging Procedures

A) pantomographA) pantomograph

B) skull radiographyB) skull radiography

C) tomographsC) tomographs

D) sialographyD) sialography

E) arthrographyE) arthrography

F) nuclear medicineF) nuclear medicine

G) CT and MRIG) CT and MRI

Radiographic AnalysisRadiographic Analysis

1.1. Anatomic position of abnormalityAnatomic position of abnormalityA) localized or generalizedA) localized or generalizedB) unilateral or bilateralB) unilateral or bilateralC) monostotic or polystoticC) monostotic or polystoticD) point of origin (epicenter)D) point of origin (epicenter)

I I bone or soft tissuebone or soft tissue IIII in, outside, above, below inferior alveolar in, outside, above, below inferior alveolar

canalcanal IIIIII in, outside of max. antrum/ tooth follicle/ at in, outside of max. antrum/ tooth follicle/ at

apex of apex of toothtooth

Factors Associated with Factors Associated with HypercementosisHypercementosis

LOCAL FACTORSLOCAL FACTORS •• Abnormal occlusal traumaAbnormal occlusal trauma •• Adjacent inflammation (e.g., Adjacent inflammation (e.g.,

pulpal, periapical, pulpal, periapical, periodontal)periodontal) •• Unopposed teeth (e.g., Unopposed teeth (e.g.,

impacted, embedded, without impacted, embedded, without antagonist)antagonist) •• Repair of vital root fractureRepair of vital root fracture SYSTEMIC FACTORSSYSTEMIC FACTORS •• Acromegaly and pituitary Acromegaly and pituitary

gigantismgigantism •• ArthritisArthritis •• CalcinosisCalcinosis •• Paget disease of bone (osteitis Paget disease of bone (osteitis

deformans)deformans) •• Rheumatic feverRheumatic fever •• Thyroid goiterThyroid goiter •• Gardner syndromeGardner syndrome •• Vitamin A deficiency (possibly)Vitamin A deficiency (possibly)


2.2. Periphery of the abnormalityPeriphery of the abnormality

- A) discrete borders- A) discrete borders I punched out- no bone reaction IIII corticated- uniform thin RO linecorticated- uniform thin RO line IIIIII sclerotic border- non-uniform RO bordersclerotic border- non-uniform RO border IVIV soft tissue capsule- uniformly thin or irregular width soft tissue capsule- uniformly thin or irregular width


2.2. Periphery of the abnormality (Continued)Periphery of the abnormality (Continued)

- B) Non- discrete borders- B) Non- discrete borders II blends in with normal anatomyblends in with normal anatomy IIII signs of invasion (e.g. enlargement of adjacent signs of invasion (e.g. enlargement of adjacent

marrow spaces; “finger-like” extensions of marrow spaces; “finger-like” extensions of destruction; multifocal or “skip lesions”destruction; multifocal or “skip lesions”


2.2. Periphery of the abnormality (Continued)Periphery of the abnormality (Continued)

C) shape of lesionC) shape of lesion II irregularirregular IIII curved surface or hydrauliccurved surface or hydraulic IIIIII undulating or scallopingundulating or scalloping


3.3. Internal StructureInternal Structure-- A. densityA. density

II radiolucent (completely)radiolucent (completely) IIII mixed RL/ROmixed RL/RO IIIIII radiopaque (completely)radiopaque (completely)

Radiographic Analysis Radiographic Analysis (Internal Structure (Internal Structure

Continued)Continued) B) description of RO structuresB) description of RO structures

- I- I bone trabeculae (ground glass, orange peel, bone trabeculae (ground glass, orange peel, cottoncotton wool, etc.)wool, etc.)

- II- II cortical bone (homogeneous)cortical bone (homogeneous)

- III- III bony septum (thin/coarse; straight/curved; bony septum (thin/coarse; straight/curved; prominent/faintprominent/faint

- IV- IV cementum (oval/round; amorphous)cementum (oval/round; amorphous)

- V- V tooth structure (shape; density; pulp chamber; tooth structure (shape; density; pulp chamber; PDL; PDL; lamina dura)lamina dura)

- VI- VI no specific patternno specific pattern

Radiographic Analysis Radiographic Analysis (Internal Structure (Internal Structure

Continued)Continued) C) Comparative radiolucency to radiopacityC) Comparative radiolucency to radiopacity

- E.g. fat, air, gas, fluid, soft tissue, medullary spaces; - E.g. fat, air, gas, fluid, soft tissue, medullary spaces; cancellous bone, cortical bone, cementum, dentin, cancellous bone, cortical bone, cementum, dentin, enamel, metals (from most radiolucent to most enamel, metals (from most radiolucent to most

radiodense)radiodense) D) Identification of RO structuresD) Identification of RO structures

Tooth material; bone; cementum, calcified Tooth material; bone; cementum, calcified cartilage, cartilage, dystrophic calcificationdystrophic calcification

Osteomas in Gardner Osteomas in Gardner SyndromeSyndrome


4.4. Behavior as suggested by the effects on the Behavior as suggested by the effects on the surrounding structuressurrounding structures

- A) structures to assess - A) structures to assess II teeth- displacement, resorption, lamina dura, PDL, pulp teeth- displacement, resorption, lamina dura, PDL, pulp

chamber, follicular space, cortex, shape and density of chamber, follicular space, cortex, shape and density of toothtooth IIII surrounding cortical structures- cortex of canals, antrum, etc.surrounding cortical structures- cortex of canals, antrum, etc. IIIIII surrounding cancellous bone- destruction versus bone formation surrounding cancellous bone- destruction versus bone formation

and sclerosisand sclerosis IVIV other structures, e.g. inferior alveolar canal, etc.other structures, e.g. inferior alveolar canal, etc.


B) Behavioral characteristics B) Behavioral characteristics

- 1.- 1. DisplacementDisplacement

- 2.- 2. ExpandExpand

- 3.- 3. DestroyDestroy

- 4.- 4. Cause periosteal bone formationCause periosteal bone formation

- 5.- 5. Cause increase in cancellous boneCause increase in cancellous bone

- 6.- 6. Increase in soft tissue massIncrease in soft tissue mass


B) Behavioral characteristics (Continued)B) Behavioral characteristics (Continued)

- 7.- 7. Increase in normal width Increase in normal width e.g. Peridontal membrane spacee.g. Peridontal membrane space

-- Inferior alveolar canalInferior alveolar canal

- Pulp chamber- Pulp chamber

- 8.- 8. Cause irregular bone remodelingCause irregular bone remodeling e.g. Resulting in unusual shape or unusual bone e.g. Resulting in unusual shape or unusual bone

pattern pattern

Unique Unique Radiographic Radiographic AppearancesAppearances

““Ground Glass”Ground Glass”

1. Fibrous dysplasia1. Fibrous dysplasia 2.2. HyperparathyroidismHyperparathyroidism

Fibrous dysplasia – PatientAge First and second decadesFirst and second decades

Fibrous dysplasia – Location Maxilla favored

Fibrous dysplasia – Radiographic Appearance

Poorly defined radiographic mass; diffuse Poorly defined radiographic mass; diffuse opacification often described as “ground glass”.opacification often described as “ground glass”.

Other radiographic appearances include ill-defined Other radiographic appearances include ill-defined radiolucency (early lesion).radiolucency (early lesion).

Fibrous dysplasia – Other Features

Slow growing and asymptomatic; causes cortical Slow growing and asymptomatic; causes cortical expansion; may stop growing after puberty; a cosmetic expansion; may stop growing after puberty; a cosmetic problem treated by recontouring. Variants: monostotic problem treated by recontouring. Variants: monostotic – one bone affected; polystotic –more that one bone – one bone affected; polystotic –more that one bone affected; Mc Cune-Albright syndrome includes: affected; Mc Cune-Albright syndrome includes: fibrous fibrous dysplasia plus cafdysplasia plus café au lait macules and é au lait macules and endocrine endocrine abnormalities (e.g. precocious puberty in abnormalities (e.g. precocious puberty in females); Jaffe-females); Jaffe- Lichtenstein syndrome – multiple Lichtenstein syndrome – multiple bone lesions of fibrous dysplasia and skin bone lesions of fibrous dysplasia and skin pigmentations; rare.pigmentations; rare.

Giant Cell Lesion of (Primary)

Hyperparathyroidism Predominant region – None Other radiographic appearances – Multilocular,

indistinct borders Additional features – Polydipsia; polyuria; serum

calcium levels ↑; serum phosphate levels ↓; serum alkaline phosphatase levels ↑

Giant Cell Lesion of (Primary)

Hyperparathyroidism Predominant gender – F 7:1 Usual age (years) – 30-60 Predominant jaw - Mandible

Hyperparathyroidism - Primary Calcium – Increased Phosphorus – Decreased Alkaline phosphatase - Increased

Giant Cell Lesion of (Secondary)

Hyperparathyroidism Predominant region – None Other radiographic appearances – multilocular,

indistinct borders Additional features – History of kidney disease;

serum calcium levels normal to ↓; serum phosphate levels↑; serum alkaline phosphatase levels ↑

Giant Cell Lesion of (Secondary)

Hyperparathyroidism Predominant gender – F 2:1 Usual age (years) – 50-80 Predominant jaw - Mandible

Hyperparathyroidism - Secondary Calcium – Normal to decreased Phosphorous – Increased Alkaline phosphatase - Increased

“Cotton Wool”

1. Paget disease (osteitis deformans) 2. Periapical cemento-osseous dysplasia 3. Gardner syndrome (Osteoma) 4. Gigantiform cementoma

Paget Disease – Patient Age Over 40 years of age

Paget Disease – Location

Maxilla favored, bilateral and symmetric

Paget Disease – Radiographic Appearance

Diffuse lucent to opaque bone changes; opaque lesions described as “cotton wool”; hypercementosis, loss of lamina dura, obliteration of periodontal ligament space, and root resorption may be seen.

Paget’s disease – Other Features

Patients may develop pain, deafness, blindness, and headache because of bone changes; initial complaint may be that denture is too tight; diastemas may develop;

complications of hemorrhage early,

infection and fracture late; alkaline

phosphate elevated; etiology unknown but affects bone metabolism.

Periapical Cemento-Osseous Dysplasia

Cause: Reactive Age/Race/Sex: Fifth decade; F>M; African-

American (Black) Location: Anterior mandible Clinical Features: Asymptomatic lesion (s),

often multiple; teeth are vital.

Periapical Cemento-Osseous Dysplasia

Radiographic Features: Well-defined radiolucency to radiopacity (depending on stage of lesion) at the area of the tooth apex; often more than one tooth involved; usually mandibular incisors

Microscopic Features: Fibrous connective tissue and calcifications

Treatment: None Diagnostic Process: Radiographic

OsteomaOsteoma Osteomas are benign lesions of bone that Osteomas are benign lesions of bone that

in many cases represent developmental in many cases represent developmental growths rather than true neoplasms.growths rather than true neoplasms.

They are composed of woven and lamellar They are composed of woven and lamellar bone.bone.

The most common locations are the facial The most common locations are the facial bones and skull and they are most bones and skull and they are most common in the 40-50 age group.common in the 40-50 age group.

Most osteomas are exophytic growths but Most osteomas are exophytic growths but they may arise within bone.they may arise within bone.

OsteomaOsteoma

Multiple osteomas are seen in Gardner Multiple osteomas are seen in Gardner syndrome, a polyposis syndrome, which syndrome, a polyposis syndrome, which has significant malignant complications has significant malignant complications and oral manifestations.and oral manifestations.

Osteomas are generally slow-growing Osteomas are generally slow-growing tumors of little clinical significance except tumors of little clinical significance except when they cause obstruction or produce when they cause obstruction or produce cosmetic problems.cosmetic problems.

Osteomas do not undergo malignant Osteomas do not undergo malignant changechange

““Sunburst Radiopacities”Sunburst Radiopacities”

OsteosarcomaOsteosarcoma Intraosseous HemangiomaIntraosseous Hemangioma

Osteosarcoma – Clinical Osteosarcoma – Clinical FeaturesFeatures

Third and fourth decades; can occur Third and fourth decades; can occur in either jaw although some studies in either jaw although some studies indicate is more common in indicate is more common in mandible; juxtacortical subtype mandible; juxtacortical subtype arises from periosteum.arises from periosteum.

Osteosarcoma –Radiographic Appearance

Poorly defined lucency with spicules of opaque material’ “sunburst” pattern may be seen; juxtacortical lesion appears as radiodense mass on the periosteum

Osteosarcoma – OtherFeatures

Swelling, pain, or paresthesia are

diagnostic features; patients may have vertical mobility of teeth and asymmetric (uniformly) widened periodontal ligament space; prognosis fair to poor, good prognosis for juxtacortical lesions

Hemangioma (White & Hemangioma (White & Pharoah)Pharoah)

“Onion-Skin”

1. Proliferative periostitis 2. Ewing sarcoma 3. Langerhans cell disease

PROLIFERATIVE PERIOSTITIS

Also known as Periostitis Ossificans or Garrè’s Osteomyelitis

Proliferative Periostitis represents a periosteal reaction to the presence of inflammation

The affected periosteum forms several rows of reactive vital bone that parallel each other and expand the bone


Mean age is approximately 13 years with no gender predilection.

Most frequent cause is dental caries. Most arise in the mandibular premolar/molar

region with involvement of the lower border. Most cases are unifocal.

PROLIFERATIVE PERIOSTITIS: Radiographic

Features Appropriate radiographs reveal radiopaque

laminations of bone that roughly parallel each other and underlying cortical surface.

If bony destruction is seen in association with thecortical surface or new periosteal bone, then

clinical should consider the possibility of a neoplastic process, e.g. Ewing sarcoma.


Treatment & Prognosis: Treatment consists of the elimination of the

source of infection via endo or extraction. Resolution typically occurs in 6 to 12 months

following successful treatment of the infection.

Ewing Sarcoma – Patient Age

Children and young adults

Ewing Sarcoma – Location

Mandible favored

Ewing Sarcoma –Radiographic Appearance

Diffuse lucency; poorly defined; periosteal reaction; “onion-skin”, may be present; may be multilocular.

Ewing Sarcoma – Other Features

Swelling, pain, or paresthesia may be present; prognosis is poor; malignant cell is of unknown origin but may be of neuroendocrine origin; rare tumor.

Ewing Sarcoma

Predominant gender – M 2:1 Usual age (years) – 5-24 (peak 14-18) Predominant jaw – Rare in maxilla Additional features – Metastasizes to lymph

nodes, lungs, and other bones, rapid course Other radiographic appearances – Onionskin

growth of periosteal bone, sunburst.

Soft Tissue Radiopacities

1. Amalgam tattoo 2. Sialolith 3. Calcified lymph nodes 4. Phlebolith 5. Tonsillolith 6. Osseous/Cartilaginous choristoma 7. Calcinosis cutis 8. Myositis ossificans 9. Other foreign bodies

Amalgam TattooAmalgam Tattoo

SIALOLITHS

CALCIFIED LYMPH NODES

PHLEBOLITHS

ANTROLITHS

CREST Syndrome

C- calcinosis

R- Raynaud’s phenomenon

E- esophageal dysmotility

S- sclerodactyly

T- telangiectasia

(Also presence of anticentromere antibodies)

FOREIGN BODIES

Radiographic Pathology

Health & Medicine

Transcript of Radiographic Pathology