IMAGING IN PERIODONTICS

CONTENTS
 Introduction
 Radiography
 Digital radiography
 Subtractional radiography
 Computer assisted subtractional radiography
 Diagnostic Subtractional Radiography DSR
 Computer Assisted Densitometric Image Analysis CADIA
 Panoramic imaging
 Intraoral photographic imaging
 CT Scan
 MRI
 Bone Scanning
 Conclusion
 INTRODUCTION
 What is imaging?
 Imaging is the action or process of
producing images, animations, 3-
dimensional computer graphics or any other
spatial representation of a physical object.
 RADIOGARPHS
 Radiographs play an important role in
assessment of periodontal disease.
 They provide unique information about
status of periodontium & permanent record
of condition of bone throughout the course
of disease.
Radiographs are especially helpful in evaluation of
following factors –
 Amount of bone present.
 Condition of alveolar crest.
 Bone loss in furcation areas.
 Width of periodontal ligament space.
 Relationship between alveolar bone margin &
CEJ.
 Local irritating factors such as calculus & poorly
contoured or overextended restorations.
 Anatomic considerations in relation to a
periodontal deformity.
 There are 2 types of radiographs –
Intraoral & Extraoral
1- Intraoral radiographs
(a) IntraOral Periapical Radiographs- These are
radiographs used to view the teeth &
periodontium.
Prichard established following 4 criterias to
determine adequate angulation of periapical
radiographs-
(1)The radiograph should show the tips of molar
cusps with little or none of occlusal surface
showing.
(2) Enamel caps & pulp chambers should be distinct.
(3) Interproximal space should be open.
(4) Proximal contacts should not overlap unless teeth
are out of line anatomically.
 Two intraoral projection techniques are used for
periapical radiography-
 (i) Paralleling technique.
 (ii) Bisecting angle technique.
(i) Paralleling technique - Also called as “right
angle” or “long cone technique”.In this technique
x-ray film is placed parallel to long axis of tooth
and central ray of x-ray beam is directed at right
angle to teeth & film.
(ii) Bisecting angle technique - In this technique,
central ray is directed at right anglesto a plane
bisecting the angle between long axis of teeth &
film.
(b) Bitewing radiographs – They record the coronal
part of upper & lower dentition along with
periodontium.
Bitewing radiographs are used –
(1) To study height & contour of interdental
alveolar bone.
(2) To detect interproximal calculus.
(3) To detect periodontal changes.
(c) Occlusal Radiographs – Intraoral occlusal
radiographs enable viewing of a relatively
large segment of dental arch.
They are useful in patients who
are unable to open mouth wide enough for
periapical radiographs.
(d) Intraoral Radiographic Survey – It should
consists of a minimum of 14 intraoral films &
4 posterior bite-wing films.
Limitations of radiographs
(1) Radiographs provide a 2-dimensional view of a
3-dimensional situation.
(2) More than 30% of bone mass at alveolar crest
must be lost for a change in bone height to be
recognized on radiographs.
(3) Radiographs do not demonstrate soft tissue - to
- hard tissue relationship & thus provide no
information about depth of soft tissue pocket.
(4) Bone level is measured from CEJ, this reference
point is not valid in situations in which either
overeruption or severe attrition exists.
 DIGITAL RADIOGRAPHY
A new technology used increasingly in dental
offices is digital radiography.
The term digital imaging refers to numeric format
of image contents as well as its discreteness.
 ADVANTAGES
(1) Ability to produce a image that can instantly be
viewed by patient & dentist.
(2) Reduction in radiation received by patient by as much
50% to 80% when compared to conventional
radiography.
(3) Images can be altered to achieve task specific image
characteristics for eg. density & contrast can be lowered
for evaluation of marginal bone and increased for
evaluation of implant components.
(4) Digital imaging also enables dental team to conduct
remote consultations.
(5) Computerized images can be stored, manipulated &
corrected for under & overexposure.
There are 2 digital radiography methods -
Direct & Indirect methods
(1) Direct Method/RVG - This method uses a Charge
Couple Device (CCD) sensor linked with
fiberoptic or other wire to computer system.
Direct digital radiography obtains ‘real-time’
imaging.
CCD receptor is placed intraorally as traditional
films & images appear on a computer screen
which can be printed or stored.
(2) Indirect Method - This method uses a phosphor
luminescence plate, which is a flexible film like
radiation energy sensor placed intraorally &
exposed to conventional x-ray tube.
A laser scanner reads the exposed plates & reveals
digital image data.
DISADVANTAGES
(1) High initial cost of equipments & setup which
is approximately $10000 to $15000.
(2) Lack of infection control.
(3) Patient discomfort during placement.
(4) As image can be easily manipulated, it can be
misused in legal proceedings.
 SUBTRACTION RADIOGRAPHY
 This technique relies on conversion of serial
radiographs into digital images.
 The serially obtained digital images can then
be superimposed & resultant composite
viewed on a video screen.
 This technique facilitates both qualitative &
quantitative visualization of even minor
density changes in bone by removing the
unchanged anatomic structures from image.
 COMPUTER ASSISTED
SUBTRACTION RADIOGRAPHY
 This technique requires a parallelization technique to
obtain a standardized geometry & accurate
superimposable radiographs.
 Radiographs are then scanned using a
microphotometer.
 After superimposition of 2 subsequent radiographs
this technique can show differences in relative
densities.
 There is increased detectibility of small osseous
lesions compared with conventional radiographs.
 DISADVANTAGE- Need of identical projection
alignment during exposure of sequential radiographs.
DIAGNOSTIC SUBTRACTION
RADIOGRAPHY
 It is a recently introduced technique
combining the use of a positioning device
with specialized software designed for
digital image subtraction.
 This software system applies an algorithm
that corrects angular alignment
discrepencies & provide flexibility in
imaging procedures.
COMPUTER ASSISTED
DENSITOMETRIC IMAGE
ANALYSIS SYSTEM(CADIA)
In this system a video camera measures the light
transmitted through a radiograph & the signals
from the camera are converted in to gray scale
images with the help of image processor & a
computer that allows storage and mathematical
manipulation of images.
Advantages-
Higher sensitivity
High degree of reproductivity and accuracy
PANORAMIC IMAGING –
PANTOMOGRAPHY

It is an extraoral radiographic technique used for

providing a single tomographic image of facial
structure that includes both maxillary and
mandibular dental arches and their supporting
structures.
OPG provide an overall radiographic picture of
distribution and severity of bone destruction in
periodontal disease.
 DISADVANTAGES OF
PANORAMIC IMAGING
 Not useful as periapical radiography for
detecting small carious lesion and fine
structure of marginal periodontium.
 Presence of overlapping stuctures eg.
cervical spine.
 INTRAORAL PHOTOGRAPHIC
IMAGING
 This technology gives patient inside look at
their teeth and a better image and
understanding of their oral health.
 It chiefly makes use of intraoral photographs
for diagnosis, prevention & treatment of
periodontal diseases.
 ADVANTAGES
 It gives patients a sense of ownership of their
mouth.
 It enhances patient acceptance of treatment
& recommendations.
 Easy comparison of pre & post-operative
status.
Types Of Intraoral Photographic Imaging
(1) Traditional 35 mm intraoral camera.
(2) Intraoral Video Imaging System
TRADITIONAL 35 MM
INTRAORAL CAMERA
 In newer cameras all functions are performed
electronically, allowing the dentists to take excellent
images without changing camera settings.
 Components-
(1) Lens
(2)Shutter release
(3)F-stop (Aperture setting)
(4)Film
(5)Flash
 INTRAORAL VIDEO IMAGING
SYSTEM
 These systems have been in use in dentistry since 1990s.
 Images obtained can be viewed on monitor, stored on a computer disc or printed
on a hard copy.
 Components-
(1) Microcamera, contained in a slender handpiece.
(2) Lighting
(3) Automatic iris
(4) Focussing mechanism
(5) Monitor
(6) Printer
 According to advancements in
technology, intraoral video
imaging systems can be divided
as-
(1) Ist generation systems based on
analog technology
(2) IInd generation systems based on
hybrid technology (Between
analog & digital technology ).
(3) IIIrd generation systems based on
digital technology.
COMPUTED TOMOGRAPHY
SCAN – CT SCAN
 CT (computed tomography), uses special x-ray
equipment to obtain image data from different angles
around the body and then uses computer processing
of the information to show a cross-section of body
tissues and organs.
 CT scanner consists of a radiographic tube that emits
finely collimated, fan-shaped x-ray beam directed to a
series of ionization chambers.
 While the gantry containing x-ray tube & detectors
revolve around the patient, the table on which the
patient is lying continuously advances through the
gantry.
Advantages Over Conventional
Radiography
 Claimed to be 100 times more sensitive than
conventional x-rays.
 It completely eliminates the superimposition of
images.
 Differences between tissues that differ in physical
density by less than 1% can be distinguished.
 Images can be seen in axial, coronal, or sagittal
planes, depending on diagnostic task referred as
“multiplaner reformatted imaging”.
 MAGNETIC RESONANCE
IMAGING
MRI is an non invasive method which uses
radiofrequency waves and a strong magnetic
field rather than x-rays to provide clear and
detailed pictures of internal organs & tissues.
 EQUIPMENTS
 The conventional MRI unit is a closed cylindrical
magnet in which the patient must lie totally still
for several seconds at a time and consequently
may feel "closed-in" or truly claustrophobic.
However, new "patient-friendly" designs rapidly
coming into routine use.
 The "short-bore" systems are wider and shorter
and do not fully enclose the patient. Some newer
units are open on all sides, however the image
quality may vary.
Advantages Over CT
 Absence of radiation exposure.
 High contrast sensitivity to tissue differences makes it more
suitable for imaging periodontal soft tissues.
 MRI can generate cross-sectional views in any plane while
CT is limited to axial , coronal or sagittal planes only.
 Disadvantages-
 Longer imaging times(20 to 45 minutes)
 Alveolar bone is better visualized by CT scan.
 Expensive than CT.
 It is contraindicated in first 1-2 months of pregnancy
 Restorations ,braces or bridges may distort the image.
 Can’t be used in patients having metallic implants like
pacemaker, cerebral aneurysm clips.
BONE SCANNING or
RADIONUCLIDE IMAGING
 In contrast to X-ray, CT, MRI which require
structural or anatomic changes to be recorded,
this technique assesses biochemical alteration in
periodontium.
 Its a nuclear scanning test that identifies new
areas of bone growth or breakdown. It can be
done to evaluate damage to the alveolar bones,
and monitor conditions that can affect the
periodontium (including infection and trauma)
 PROCEDURE
 For a bone scan, a radioactive tracer eg.
99m technetium pertechnetate substance is
injected into a vein in the arm. The tracer
then travels through the bloodstream and
into the bones.
 Areas that absorb little or no amount of
tracer appear as dark or "cold" spots, which
may indicate a lack of blood supply to the
bone (bone infarction) or the presence of
certain types of cancer.
 Areas of rapid bone growth or repair absorb
increased amounts of the tracer and show up
as bright or "hot" spots in the pictures. Hot
spots may indicate the presence of a tumor,
a fracture, or an infection.
 Other radioactive isotopes used are –
iodine(131 I), gallium(67 Ga) &
selenium(74Se).
LIMITATIONS
 Can’t differentiate between normal & abnormal bone growth.
 Takes longer time (about 1 hour).
 Contraindicated in pregnancy.
 Bone scanning should be performed before any test that use barium

 9
 CONCLUSION
 Conventional and advanced imaging systems
have proven a boon for diagnosis in
periodontology .Further advancements are also
expected in near future.
 But these systems are technique sensitive & not
free from mechanical errors so a clinician should
also consider clinical signs & symptoms while
reaching to final diagnosis for a periodontal
condition.
 REFERENCES
 Clinical Periodontology IXth edition
-Newman;Takei;Carranza
 Clinical periodontology & Implant Dentistry
-Jan Lindhe;Thorkild Karring;Niklaus P.Lang
 Dental Hygeine – Concepts,cases &
competencies - Deniel & Harfst
 Oral Radiology-Principles & Interpretation
-S.C.White;M.J. Pharoah