Radiographic Diagnosis of Dental Caries

Caries
Bitewing Film primarily Periapical film also used Low kVp, high contrast (short scale)

Proximal caries susceptible zone

caries

Approximately 50 % demineralization is required for radiographic detection of a lesion. The thickness of the tooth buccolingually masks the carious lesion when it is small. The actual depth of penetration of a carious lesion is deeper clinically than radiographically.

Factors affecting caries diagnosis:

Buccolingual thickness of tooth Two-dimensional film X-ray beam angle Exposure factors

Radiographic Caries
I M I = Incipient M = Moderate A = Advanced S = Severe A

Incipient Interproximal Caries

Cone-shaped radiolucent area Up to half the thickness of enamel Treat or no treat ?

Incipient Interproximal Caries

Usually not restored:

* Unless patient has high caries activity

Incipient

Moderate Interproximal Caries

More than half-way through the enamel (up to DEJ)

Moderate

Advanced Interproximal Caries

From DEJ to half-way through the dentin

Advanced

Advanced

Advanced

Advanced

Incipient Moderate Advanced

Severe Interproximal Caries

More than halfway through the dentin

Severe

Transillumination
Anterior interproximal caries can usually be diagnosed by directing bright light through the contact areas.

Occlusal Caries
Must have penetrated into dentin Diagnosed from clinical exam Radiographs are not a reliable diagnostic aid for the detection of occlusal caries.

Occlusal Caries

The apex of the triangle is toward the outer surface of the tooth and the base is at the dentino-enamel juncition.

Occlusal

Occlusal

Buccal/Lingual Caries
Use clinical exam Cant determine depth Appears as round dots

Buccal/lingual

Root Caries
Older patients with recession or periodontitis

Root caries

Root caries

Root caries may be confused with cervical burnout

Cervical burnout appears as a collar or wedge-shaped radiolucency on the mesial and distal root surfaces near the CEJ of a tooth. The tissue density at the cervical region of the tooth is less than the regions above and below it. (variable penetration of X-ray)

Burn-Out: *Mainly located at the neck of the tooth (Demarcated above by enamel cap or restoration and below by the alveolar bone) **Usually all teeth are affected esp. smaller premolars. ***it is more obvious when the exposure factors are increased!

Cervical burnout Radiolucency seen above left (arrow) disappears on periapical film of same tooth (above right).

Anterior Cervical Burnout

bone level

cervical burnout area

Cervical burnout in the anterior region due to gap between enamel (red arrows) and alveolar bone over root.

Recurrent Caries
May be due to high caries rate, poor oral hygiene, failure to remove all the caries, defective restoration or a combination.

Recurrent Caries
Is not always easy to detect radiographically: 1. Location of caries lesion relative to restoration. 2. Angulation of X-ray beam.

Recurrent caries (red arrows)

Recurrent caries

Recurrent caries

Rampant Caries

* Usually found in children and teens with poor diet and inadequate oral hygiene. * Patients with xerostomia

Radiation Caries
Found in head/neck radiation therapy patients with xerostomia Fluoride used for control

Before radiation

1 year after radiation

Mach Band
Optical illusion giving appearance of increased radiolucency at junction of differing tissue densities

Periodontal Disease
Periodontal ligament attachment and alveolar bony support of the tooth have been lost. Junctional epithelium migrates apical to the CEJ.

Periodontal Disease
Bitewings best for diagnosis. Some feel that paralleling PAs are best. Higher kVp recommended (long scale, low contrast). Compare images from different visits (using same technique).

Limitation of Radiographs
Two-dimensional representation of a 3-D anatomic structure. Superimposition of the bone and tooth structures * Relationship of hard to soft tissues not evident

Limitation of Radiographs
* Presence or absence of periodontal pockets. * Early bone loss (<3mm) is not evident. * Early furcation involvement is not evident.

Limitation of Radiographs
* PA: X-ray beam alignment will obliterate the presence of extent of furcation involvement. * Facial and lingual aspects of alveolar bone will be superimposed over the furcation.

Benefits
Early radiographic changes: 1.Crestal irregularities. 1.Triangulation 1.Interdental septal bone changes

Periodontitis
Involvement:
Localized Generalized

Periodontitis
Normal Anatomy:
Alveolar crest corticated 1-1.5 mm from crest to CEJ Parallel to line between CEJs Crest is pointed anteriorly

Corticated alveolar crests

CEJ

1-1.5 mm

Alveolar crests more pointed anteriorly

Contributing Factors
Occlusal trauma Open contacts Overhangs, poor contours Calculus Post-extraction defects Systemic involvement (diabetes, blood disorders, hormonal changes, stress, AIDS)

Horizontal bone loss: Parallel to line drawn between adjacent CEJs Vertical (Angular) bone loss: More bone destruction on interproximal aspect of one tooth than on the adjacent tooth

Gingivitis
No bone loss No radiographic signs

Mild Adult Periodontitis Loss of cortical density Rounding off of junction between alveolar crest and lamina dura Blunting of crest anteriorly

Mild adult periodontitis

Moderate Adult Periodontitis

Horizontal bone loss or vertical osseous defects Total extent of bone loss not evident May have slight mobility

Moderate adult periodontitis

(red arrows point to calculus)

Moderate adult periodontitis

Severe Adult Periodontitis

Tooth mobility Extensive horizontal bone loss or vertical osseous defects Furcation involvement

Severe adult periodontitis

Severe adult periodontitis

Severe adult periodontitis

Restorative Materials
Radiopaque: Structures with higher object density, such as amalgam, gold, silver points, pins, gutta percha, porcelain. Radiolucent: Structures with lower object density, such as older composites and bonding agents.

Gold crowns, amalgams

Retention pins

porcelain crowns

Ceramic Crowns

crown crown amalgam

cast post

gutta percha

silver points

Red arrows point to bases Green arrow indicates recurrent caries with fractured restoration

old

Composites

new