Radiographic Pathology

1. Radiographic Pathology DENT 512 Lecture 13 *Radiographs not otherwise market courtesy of Dr. D. Sawyer

2. Radiolucent Lesions • Due to loss of bone by aggregation of reactive soft tissue, cyst, or non-calcified tumor • Reactive (PA granuloma or cyst), Developmental, or Neoplastic • Most important signs to look for are expansion, destruction or movement of adjacent structures, pain or paresthesia LR Eversole. Clinical Outline of Oral Pathology: Diagnosis and Treatment. 3rd Edition. 1992.

3. RADIOLUCENT LESION Irregular or Ragged Unilocular Multilocular Concerning for -Malignant Tumor -Osteomyelitis Apical to Non-Vital Tooth -OdontogenicKeratocyst -Ameloblastoma -OdontogenicMyxoma -Glandular Odontogenic Cyst -Central Giant Cell Granuloma -Traumatic Bone Cyst Coronal to Impacted Tooth Likely PA Cyst or PA Granuloma **Cannot rule out other lesions Mimic Periodontal Disease Likely Dentigerous Cyst or Enlarged Follicle **Cannot rule out other lesions Calcifications or Mixed Appearance -OdontogenicKeratocyst -OrthokeratinizedOdontogenic Cyst -UnicysticAmeloblastoma --Ameloblastic Fibroma -Squamous Odontogenic Tumor -Langerhans Cell Histiocytosis -Malignancy Midline between roots of 8 and 9 Teeth Vital Lateral to roots of premolar or canine Teeth Vital Likely Lateral Periodontal Cyst **Cannot rule out other lesions -Calcifying Odontogenic Cyst -Ameloblastic Fibro-odontoma -Calcifying Epithelial Odontogenic Tumor -AdenomatoidOdontogenic Tumor -Central Ossifying Fibroma -Cemento-osseous Dysplasia Likely NPD Cyst **Cannot rule out other lesions

4. Radiopaque Lesions • Due to replacement of normal bone by either more densely ossified bone or lesion producing some type of calcified material • Neoplastic, Reactive, Systemic, Developmental • Most important signs to look for are expansion, destruction or movement of adjacent structures, pain, or paresthesia LR Eversole. Clinical Outline of Oral Pathology: Diagnosis and Treatment. 3rd Edition. 1992.

5. RADIOPAQUE LESIONS Irregular, Ragged, Expansile, and Painful Mixed Radiolucent-Radiopaque Mainly Radiopaque Concerning for Malignancy -Osteosarcoma -Metastatic Bone Producing Tumors Or Osteomyelitis Usually Expansile +/- Expansile Usually Not Expansile Localized -Cemento-osseous Dysplasia Diffuse (quadrant or more) Usually Expansile Usually Not Expansile +/- Expansile -Calcifying Odontogenic Cyst -Odontoma -Ameloblastic Fibro-Odontoma -CEOT -AOT -Osteoma (multiple associated with Gardner’s Syndrome) -Odontoma -Dense Bone Island (usually mandibular molar vital teeth) -Condensing Osteitis (nonvital tooth near root) -Fibrous Dysplasia -Familial GigantiformCementoma -Pagets Disease Usually Painful -Osteoblastoma *can be mixed RL-RO -Cementoblastoma (attached to tooth root)

6. Method of Radiographic Investigation and Film Analysis • 1. Assess the quality of the film • Film density (alterations due to exposure or processing errors) • Image geometry (image distortion due to technique errors)

7. Dr. L. Clark Artifactual pouching of sinus lining giving the appearance of a well-defined lesion

8. Method of Radiographic Investigation and Film Analysis • 2. Just as in performing an intraoral examination, examine the total film before concentrating on one specific region • Avoid missing important findings by being distracted by most obvious finding • 3. Have a good knowledge of “normal” anatomy and assess the shape and density of each structure • Range of normal may be quite variable

9. Method of Radiographic Investigation and Film Analysis • 4. Make sure that the total area of interest is present in the film • This may require a larger film format • Second view at a slightly different angle or preferentially at right angles may be advantageous

10. Method of Radiographic Investigation and Film Analysis • 5. Make sure suitable viewing equipment is available A) view box B) intense light source C) mask D) magnifying glass E) room with subdued lighting

11. Method of Radiographic Investigation and Film Analysis • 6. Is Other Imaging Required? A) pantomograph B) skull radiography C) tomographs D) sialography E) arthrography F) nuclear medicine G) CT and MRI

12. Radiographic Analysis Anatomic position of abnormality: A) localized or generalized B) unilateral or bilateral C) monostotic or polystotic D) point of origin (epicenter) • I bone or soft tissue • II in, outside, above, below inferior alveolar canal • III in, outside of max. antrum/ tooth follicle/ at apex of tooth

13. These lesions are located apically, but is the origin of the lesion the tooth pulp? What kind of clues may show the lesion to be unrelated to the pulp?

14. Multifocal diffuse radiopaque lesions

15. Multifocal bilateral radiolucent lesions

16. Diffuse polyostotic radiographic changes

17. Important location clue: well defined radiolucency UNDERNEATH the IAN What does this location suggest in regards to the likely diagnosis of this lesion?

19. Radiographic Analysis Periphery of the abnormality: A) Discrete borders • I punched out- no bone reaction • II corticated- uniform thin RO line • III sclerotic border- non-uniform RO border • IV soft tissue capsule- uniformly thin or irregular width

21. Multiple myeloma Fitzpatrick SG et al. Diagnostic challenge: multilocular radiolucency of the mandible. JADA 2011;142(4):411-4. • Usually older adulthood • More common in African Americans than Caucasians • May see “punched out” or ill-defined radiolucencies • May have renal failure • Detection of proteins in serum and urine • Sometimes associated with amyloid deposits

23. Radiographic Analysis Periphery of the abnormality (Continued) B) Non- discrete borders • I blends in with normal anatomy • II signs of invasion (e.g. enlargement of adjacent marrow spaces; “finger-like” extensions of destruction; multifocal or “skip lesions” Diffuse radiopaque lesion blending into the surrounding area

24. Invasive radiolucent lesion

25. Radiographic Analysis Periphery of the abnormality (Continued): C) shape of lesion • I irregular • II curved surface or hydraulic • III undulating or scalloping

26. Radiographic Analysis Internal Structure: - A. density • I radiolucent (completely) • II mixed RL/RO • III radiopaque (completely)

27. The radiodensity of a lesion depends on whether bone is being replaced by fibrous tissue or cystic space (radiolucent lesions) or bone is replaced by products of higher density (higher density bone or tooth product in the case or radiopaque lesions)

29. Radiographic Analysis (Internal Structure Continued) Description of RO structures: I bone trabeculae (ground glass, orange peel, cotton wool, etc.) II cortical bone (homogeneous) III bony septum (thin/coarse; straight/curved; prominent/faint)

30. “Ground Glass” Appearance University of Florida Oral Pathology Image Archives

31. “Cotton Wool” Appearance University of Florida Oral Pathology Image Archives

32. Abnormalities of Tooth Structure Abnormalities may be seen in: • Shape • Density • Pulp chamber • PDL • Lamina dura • Cementum structures

39. Hypercementosis: often a symptom of another pathologic cause either local or systemic

40. Factors Associated with Hypercementosis • LOCAL FACTORS • Abnormal occlusal trauma • Adjacent inflammation (pulpal, periapical, periodontal) • Unopposed teeth • Repair of vital root fracture • SYSTEMIC FACTORS • Acromegaly/pituitary gigantism • Arthritis • Calcinosis • Paget disease of bone (osteitis deformans) • Rheumatic fever • Thyroid goiter • Gardner syndrome • Vitmain A deficiency possibly

41. Radiographic Analysis (Internal Structure Continued) Comparative radiolucency to radiopacity: - Most radiolucent to most radiodense: fat, air, gas, fluid, soft tissue, medullary spaces, cancellous bone, cortical bone, cementum, dentin, enamel, metals Identification of RO structures: -Tooth material; bone; cementum, calcified cartilage, dystrophic calcification

42. Gardner’s syndrome University of Florida Oral Pathology Image Archive Photomicrograph from www.pathologyoutlines.com • APC tumor suppressor gene on chromosome 5 • Adenomatous colon polyps, skeletal abnormalities, multiple epidermoid cysts of the skin, desmoid tumors, and increased risk of thyroid carcinoma, pigmented leisons of the ocular fundus • Multiple osteomas of the jaws or sinuses may be seen • Also may have increased odontomas, supernumerary teeth, and impacted teeth

43. Osteomas in Gardner Syndrome

45. Odontoma

48. Predicting behavior based on effects of lesion on surrounding structures Structures to assess: • I teeth- displacement, resorption, lamina dura, PDL, pulp chamber, follicular space, cortex, shape and density of tooth • II surrounding cortical structures- cortex of canals, antrum, etc. • III surrounding cancellous bone- destruction versus bone formation and sclerosis • IV other structures, e.g. inferior alveolar canal, etc.