Radiographic Pathology

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

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Method of Radiographic Investigation and Film
Analysis

• 1. Assess the quality of the film
• A) film density (alterations due to exposure or
  processing errors).
• B) image geometry (image distortion due to
  technique errors).

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Method of Radiographic Investigation and Film
Analysis

• 2. Examine the total film before concentrating on
  one specific region.
• 3. Examine the film for the presence of normal
  anatomy and assess the shape and density of each
  structure. To accomplish this, one must have
  knowledge of the variable appearance that
  normal anatomy may have.

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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. Often a second view at a slightly
  different angle or preferentially at right angles
  is advantageous (e.g. occlusal views).

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Method of Radiographic Investigation and Film
Analysis

• 5. Suitable Viewing Equipment
• A) view box
• B) intense light source
• C) mask
• D) magnifying glass
• E) room with subdued lighting

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Method of Radiographic Investigation and Film
Analysis

• 6. Referral for Other Imaging Procedures
• A) pantomograph
• B) skull radiography
• C) tomographs
• D) sialography
• E) arthrography
• F) nuclear medicine
• G) CT and MRI

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Radiographic Analysis

• 1. 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

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Factors Associated with Hypercementosis

• LOCAL FACTORS
• Abnormal occlusal trauma
• Adjacent inflammation (e.g., pulpal,
  periapical, periodontal)
• Unopposed teeth (e.g., impacted, embedded,
  without antagonist)
• Repair of vital root fracture
• SYSTEMIC FACTORS
• Acromegaly and pituitary gigantism
• Arthritis
• Calcinosis
• Paget disease of bone (osteitis deformans)
• Rheumatic fever
• Thyroid goiter
• Gardner syndrome
• Vitamin A deficiency (possibly)

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Radiographic Analysis

• 2. 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

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Radiographic Analysis

• 2. 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

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Radiographic Analysis

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

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Radiographic Analysis

• 3. Internal Structure
• - A. density
• I radiolucent (completely)
• II mixed RL/RO
• III radiopaque (completely)

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Radiographic Analysis (Internal Structure
Continued)

• B) 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
• - IV cementum (oval/round amorphous)
• - V tooth structure (shape density pulp
  chamber PDL lamina dura)
• - VI no specific pattern

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Radiographic Analysis (Internal Structure
Continued)

• C) Comparative radiolucency to radiopacity
• - E.g. fat, air, gas, fluid, soft tissue,
  medullary spaces cancellous bone, cortical
  bone, cementum, dentin, enamel, metals (from
  most radiolucent to most radiodense)
• D) Identification of RO structures
• Tooth material bone cementum, calcified
  cartilage, dystrophic calcification

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Osteomas in Gardner Syndrome
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Radiographic Analysis

• 4. Behavior as suggested by the effects on the
  surrounding structures
• - A) 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.

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Radiographic Analysis

• B) Behavioral characteristics
• - 1. Displacement
• - 2. Expand
• - 3. Destroy
• - 4. Cause periosteal bone formation
• - 5. Cause increase in cancellous bone
• - 6. Increase in soft tissue mass

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Radiographic Analysis

• B) Behavioral characteristics (Continued)
• - 7. Increase in normal width
• e.g. Peridontal membrane space
• - Inferior alveolar canal
• - Pulp chamber
• - 8. Cause irregular bone remodeling
• e.g. Resulting in unusual shape or unusual bone
  pattern

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Unique Radiographic Appearances
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Ground Glass

• 1. Fibrous dysplasia
• 2. Hyperparathyroidism

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Fibrous dysplasia PatientAge

• First and second decades

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Fibrous dysplasia Location

• Maxilla favored

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Fibrous dysplasia Radiographic Appearance

• Poorly defined radiographic mass diffuse
  opacification often described as ground glass.
• Other radiographic appearances include
  ill-defined radiolucency (early lesion).

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Fibrous dysplasia Other Features

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

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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 ?

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Giant Cell Lesion of (Primary)
Hyperparathyroidism

• Predominant gender F 71
• Usual age (years) 30-60
• Predominant jaw - Mandible

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Hyperparathyroidism - Primary

• Calcium Increased
• Phosphorus Decreased
• Alkaline phosphatase - Increased

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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 ?

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Giant Cell Lesion of (Secondary)
Hyperparathyroidism

• Predominant gender F 21
• Usual age (years) 50-80
• Predominant jaw - Mandible

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Hyperparathyroidism - Secondary

• Calcium Normal to decreased
• Phosphorous Increased
• Alkaline phosphatase - Increased

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Cotton Wool

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

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Paget Disease Patient Age

• Over 40 years of age

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Paget Disease Location

• Maxilla favored, bilateral and symmetric

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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.

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Pagets 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.

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Periapical Cemento-Osseous Dysplasia

• Cause Reactive
• Age/Race/Sex Fifth decade FgtM African-
  American (Black)
• Location Anterior mandible
• Clinical Features Asymptomatic lesion (s),
  often multiple teeth are vital.

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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

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Osteoma

• Osteomas are benign lesions of bone that in many
  cases represent developmental growths rather than
  true neoplasms.
• They are composed of woven and lamellar bone.
• The most common locations are the facial bones
  and skull and they are most common in the 40-50
  age group.
• Most osteomas are exophytic growths but they may
  arise within bone.

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Osteoma

• Multiple osteomas are seen in Gardner syndrome, a
  polyposis syndrome, which has significant
  malignant complications and oral manifestations.
• Osteomas are generally slow-growing tumors of
  little clinical significance except when they
  cause obstruction or produce cosmetic problems.
• Osteomas do not undergo malignant change

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Sunburst Radiopacities

• Osteosarcoma
• Intraosseous Hemangioma

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Osteosarcoma Clinical Features

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

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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

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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

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Hemangioma (White Pharoah)
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Onion-Skin

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

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PROLIFERATIVE PERIOSTITIS

• Also known as Periostitis Ossificans or Garrès
  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

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PROLIFERATIVE PERIOSTITIS

• 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.

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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
  the cortical surface or new periosteal bone, then
  clinical should consider the possibility of a
  neoplastic process, e.g. Ewing sarcoma.

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PROLIFERATIVE PERIOSTITIS

• 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.

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Ewing Sarcoma Patient Age

• Children and young adults

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Ewing Sarcoma Location

• Mandible favored

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Ewing Sarcoma Radiographic Appearance

• Diffuse lucency poorly defined periosteal
  reaction onion-skin, may be present may be
  multilocular.

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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.

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Ewing Sarcoma

• Predominant gender M 21
• 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.

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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

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Amalgam Tattoo
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SIALOLITHS

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CALCIFIED LYMPH NODES
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PHLEBOLITHS
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ANTROLITHS
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CREST Syndrome

• C- calcinosis
• R- Raynauds phenomenon
• E- esophageal dysmotility
• S- sclerodactyly
• T- telangiectasia
• (Also presence of anticentromere antibodies)

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FOREIGN BODIES
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