Sarbani Deb Sikdar et al

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JAYPEE
REVIEW ARTICLE
Thermography: A New Diagnostic Tool
in Dentistry
1
Sarbani Deb Sikdar,
1
Anshul Khandelwal,
2
Savita Ghom,
2
Rajkumar Diwan,
3
FM Debta
1
Postgraduate Student (2nd year), Department of OMDR, Chhattisgarh Dental College and Research Institute, Rajnandgaon
Chhattisgarh, India
2
Postgraduate Student (1st year), Department of OMDR, Chhattisgarh Dental College and Research Institute, Rajnandgaon
Chhattisgarh, India
3
Associate Professor, Department of OMDR, Chhattisgarh Dental College and Research Institute, Rajnandgaon, Chhattisgarh
India
Correspondence: Sarbani Deb Sikdar, Postgraduate Student (2nd year), Department of OMDR, Chhattisgarh Dental College
and Research Institute, Sundra, Rajnandgaon, Chhattisgarh, India, e-mail: shantusen@gmail.com
JIAOMR
ABSTRACT
The various biochemical processes in the human body generate heat, which must be dissipated. Skin is the major route for heat dissipation using
blood as the heat exchange fluid. Skin temperature is an indicator of aberrations in metabolism, hemodynamics or in neuronal thermoregulatory
processes. Since most of the heat dissipation of skin is by infrared black body emission, skin temperature should be measured without contact, by
monitoring the emitted infrared radiation. This has been the basis of telethermography. Thermography is being used to detect various pathological
conditions in the medical field. There are also various orofacial conditions in which thermography can be used. This paper deals with the history of
thermography and its various uses in dentistry.
Keywords: Telethermography, Liquid crystal thermography, Infrared thermography, Facial telethermography, Black body radiation.
INTRODUCTION
The detection of body warmth, along with touch, may be the first
conscious sensation a newborn baby perceives when handled by
mother. Heat (or warmth) has a profound cognitive impact on
humans. Even the most primitive humans knew that the body of a
dead person is always cold. There are strong associations of life
with warmth, of moderate body temperature with health, and of
high body temperature (fever) with disease.
1
Body heat is generated
by metabolism and by muscular activity, and keeps the core body
temperature at a defined slightly oscillating level (about 37C).
The organisms heat loss depends on ambient factors and results
of conduction, convection IR radiation, and of evaporation
(sweating) from the surface of the skin despite of breathing and
other mechanisms. Inside the organism, heat is transported by
convection (blood flow) and by conduction.
2
Thermography is a
noncontact, nondestructive, and noninvasive investigative method
that utilizes the heat from an object to detect, display and record
thermal patterns and temperatures across the surface of the object.
3
HISTORY
Ancient medicine perceived good health as a state of balance
between the elements. The assessment of body temperature was
an integral part of Greek pre-Hippocratic medicine (600-400 BC),
4
and as early as 400 BC, human body temperature was used as a
medical diagnostic sign. Hippocrates used his right hand to judge
the skin temperature of his sick patients.
5
About 600 years later, Galen (130-210 AD) advanced the
notion that body heat is produced by the biocombustion of food.
Galen also discussed a theory on the feedback between sensory
and motor nerves,
6
which, as we know today, is the primary
mechanism of thermoregulation. About 1400 years later, in 1592,
Galileo Galilei is credited with inventing the semiquantitative air
thermometer (Galileos thermoscope). In 1611, Santorio
Sanctorius, developed the first thermometer. It took, however,
another 300 years before Wunderlich introduced fever measure-
ments as a routine clinical diagnostic procedure (Germany in
1872).
7
Czerny documented the first infrared image of a human subject
in Frankfurt in 1928. The medical use of infrared thermography
started in 1952 in Germany. The physician Schwamm, together
with the physicist Reeh developed a single detector infrared
bolometer for sequential thermal measurement of defined regions
of the human body surface for diagnostic purposes. They founded
the first medical association of thermography in 1954, today still
active as German Society for Thermography and Regulation
Medicine (Deutsche Gesellschaft fr Thermographie und
Regulationsmedizin eV).
.2
CHARACTERISTICS OF THERMAL IMAGES
Thermal images are characterized by their spatial resolution, i.e.
the separation between two nearby spots (the temperatures of which
can be assessed distinctively), and by their thermal resolution, i.e.
the minimum temperature difference that can be measured at two
distinct spots on an image. Another related parameter is the
temporal resolution, i.e. the time delay between a change in
temperature at a certain spot on the monitored area and the
corresponding change on the thermal image.
7
There are two commonly used methods of obtaining thermal
images. A relatively inexpensive semiquantitative contact method
that uses liquid crystals and is named liquid crystal thermography
(LCT), and a quantitative infrared-detecting noncontact method
known as area telethermometry, electronic thermography, infrared
Journal of Indian Academy of Oral Medicine and Radiology, October-December 2010;22(4):206-210
207
Thermography: A New Diagnostic Tool in Dentistry
telethermography (ITT), or digital infrared telethermographic
imaging (DITI).
4,7
Skin temperature can be measured at a single instance in time
(static thermography) or in a series of many sequential instances
(dynamic thermography). The latter type of measurement represents
the dynamics of the thermal behavior of the given spot, spots, or
areas of a thermal image. These measurements are named dynamic
spot thermometry and dynamic area thermometry, respectively.
The dynamic phenomena measured can be of a transient or of a
periodic nature. In the former case, we observe a trend of warming
or cooling until a thermal equilibrium is reached. Periodic
modulation of skin temperature manifests physiological
thermoregulation, which is characterized by oscillations around a
certain average value of temperature.
8
LIQUID CRYSTAL THERMOGRAPHY
Liquid crystal area thermometers use flexible rubber sheets within
which cholesteric crystals are embedded. There are several layers
of the crystals in the commercial sheet materials, which are
mounted in a frame (a thin box) which has a clear side parallel to
the sheets. In addition, there may be provision for inflating the
sheets while in the frame, so that the heat-sensitive surface
conforms better to the bodys contours. Those liquid crystal elastic
sheets are applied to the surfaces of the body. After placement,
the crystals change from their neutral color at room temperature,
in response to the surface temperature of the body with which
they are in contact. The color distribution over these sheets
represents the temperature distribution over the area of skin in
contact with the sheet. The resultant color display is then
photographed (usually using polaroid photography which gives
an instant hard copy of the image). It is this photograph that
becomes the thermogram, which is used for diagnostic evaluation.
7
Some advantages of liquid crystal thermography are systems
being portable with no electric requirements, and are considerably
less expensive than electronic telethermography units. But there
are various disadvantages, including low thermal sensitivity
(0.3-1C). In addition, the process is technique sensitive, requiring
carefully timed skin contact to record a reproducible temperature
distribution. Moreover, the spatial resolution of the liquid crystal
display is poor (<5 mm). The main drawback being, that the
temperature of the bodys surface cannot be reliably measured by
any device that makes contact with the skin.
4
Since skin has a
relatively low heat capacity, its temperature is likely to change on
contact with a cooler or warmer object.
In spite of its severe limitations, liquid crystal thermography
has been claimed to yield meaningful results in the evaluation of
thermal abnormalities of the face due to orofacial disorders.
9
Thus,
to make the measurement of skin temperature free of many artifacts,
it is highly advantageous to determine skin temperature without
any contact between the skin and the monitoring device. The only
way the surface temperature of skin can be measured without
contact is by remotely measuring the infrared black body radiation
that it emits.
INFRARED TELETHERMOGRAPHY
Thermal or infrared energy is an energy, not visible because its
wavelength is too long for the sensors in our eyes to detect. It is
the part of the electromagnetic spectrum that we perceive as heat.
Unlike visible light, in the infrared spectrum everything with a
temperature above absolute zero emits infrared electromagnetic
energy. Even cold objects, such as ice cubes, emit infrared
radiations. The higher the temperature of the object the greater
the infrared radiations emitted.
3
In 1899, Max Planck suggested that the energy emitted by any
object is quantized. Planck formulated a theoretical function to
quantitatively describe the spectrum of black body radiation.
Plancks basic assumption was, that the energy (0) of each emitted
quantum is a product of some universal constant (h) and the
frequency () associated with it (0 =h
~
). The frequency is equal
to the speed of light (c) divided by the wavelength () (
~
=c/).
The value of that universal constant, h, could be derived from the
experimental data.
10,12
Thermography is a noncontact, nondestructive test method that
utilizes a thermal imager to detect, display, and record thermal
patterns and temperatures across the surface of an object. Since
infrared radiation is emitted by all objects based on their
temperatures, according to the black body radiation law, thermo-
graphy makes it possible to see ones environment with or
without visible illumination. The amount of radiation emitted by
an object increases with temperature; therefore thermography
allows one to see variations in temperature.
3,7
Plancks quantitative treatment has permitted us to calculate
the black body photon fluxes of any energy for any temperature,
or to determine temperature by measuring the black body radiation.
Since the maximum flux of black body radiation at human skin
temperature (30-36C) is in the infrared part of the spectrum (about
9-10 m), clinical black body radiative thermometry, or
telethermometry, must preferably use detection systems, sensitive
in that region of the infrared spectrum.
11
An additional important
reason for using 8 to 12 m detectors is the fact that, unlike in
other regions of the infrared spectrum, skin is >98% emissive in
that region. When skin is partly reflective, as it is below 8 m,
12
the detected infrared emission may represent artifacts due to
reflected infrared radiation that originated from some
environmental source.
Noncontact clinical thermometry did not become a reality with
the advent of quantum physics. Because of the low energy and
low intensity of the radiation emitted by the body at skin
temperature, biological telethermometry was not practical until
the development of sensitive and precise detectors of infrared
radiation.
13
INFRARED DETECTORS
Because of the low intensity of human skins black body radiation,
precise measurement (<1% precision) of the infrared emission
from small areas of skin (e.g. 1 mm
2
) within a reasonable short
timeperiod (say, 30 msec) requires photon (quantum) detectors
(e.g. rapidly responding photoconductive devices), which produce
electrical pulse each time they absorb infrared photon. These pulses
can be amplified and counted individually, or they can be integrated
into an instantaneously measurable electric current. Detectors that
require thermal equilibrium with the measuring device (bolo-
meters)
14
are inadequate for clinical use. Although modern
bolometers with a very low heat capacity can be fabricated into
Sarbani Deb Sikdar et al
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two dimensional arrays and produce high resolution thermal images
at a rate of 30 per second,
15
they cannot operate adequately at skin
temperature,
16
especially when neuronal response times, involved
in rapid thermoregulatory processes are to be studied.
17
Photoconductive quantum detectors are analogous to
thermoresistive electronic thermometers. The photoconductive
semiconductors most commonly used for photon detection in the
8 to 14 m region are three-metal alloys, such as mercury-
cadmium-telluride (HgCdTe).
18
HgCdTe detectors have high
efficiency combined with a low noise (low dark current), allows
the determination of skin temperature of areas less than 10 mm
2
at
a distance of 100 cm from the camera with a precision of a
millidegree.
18
Infrared Radiation Measurement in Medical Field
Using an appropriate detector, skin temperature can be measured
remotely at a single spot (telethermometry or radiation thermo-
metry), or provides quantitative information on the temperature
distribution over a large area of skin (telethermometry or
telethermography). Clinical telethermography systems consist of
infrared detector with its appropriate amplifier-digitizer and
readout electronics, a microcomputer, and a video display.
18
The detectors must be sensitive to infrared radiation in the 8 to
12 m region. Three configurations of infrared detectors can be
used for telethermography: A single element infrared detector, a
linear array of infrared detectors and a two-dimensional array of
detectors.
Infrared radiations emitted by the face enters the lens of the
camera, passes through a number of rapidly spinning prisms
(or mirrors), which sequentially reflect the infrared radiations
emitted from different subareas of the field of view onto the
infrared sensor. The sensor converts the reflected infrared
radiations into electrical signals. An amplifier receives the electric
signals from the sensor and boosts them to electric potential signals
of a few volts, that can be converted into digital values. These
values are then fed into a computer. The computer uses this input,
together with the timing information from the rotating mirrors, to
reconstruct a digitized thermal image from the temperature values
of each subarea of the field of observation. These digitized images
can be analyzed with appropriate image analysis software or stored
on a computer disk for later reference.
8
FACIAL TELETHERMOGRAPHY
The pattern of radiative heat dissipation over the human body is
normally symmetrical. It has been shown that, in normal subjects,
differences in skin temperature on selected points from side-to-
side are small (about 0.2C).
19
The significant difference between
the absolute facial temperature of men vs women has also been
observed. Men were found to have higher temperatures over the
25 anatomic zones measured on the face (e.g. orbit, upper lip,
lower lip, chin, cheek, etc.) than women.
20
Whereas the right-
versus-left-side temperature differences (termed static area DT
values) between many specific facial regions in asymptomatic
individual subjects were shown to be low (<0.3C). The area DT
values were found to be >0.5C in a wide variety of chronic facial
pain disorders.
21
There are certain guidelines to be followed while taking a facial
telethermography as advised by J apanese Society of Thermology.
1. Keep the testing room free of wind. Turn off air conditioners.
2. Keep sources emitting high-temperature infrared away from
the subject. Place a screen between any heater and the subject.
3. Keep control room temperature at over 25C. Record room
temperature and humidity when taking each thermal image.
4. Stabilize the environment for at least 20 minutes before
examination in the winter.
5. Instruct the subject to refrain from smoking for at least 4 hours
before thermographic examination.
6. Note the following items as subject-related information in the
medical record including name, sex, age, chief complaint,
history of tobacco use, history of alcohol consumption,
handedness, painful position, abnormal position, region of cold
sensitivity, past medical history, present clinical history,
presence of medical treatment and detail of medical treatment,
diagnostic entity, body temperature, time when the thermal
image is taken, room temperature, room humidity, and wall
temperature.
7. Check the first thermal image again at the end of the sequence
to confirm the reproducibility of images and changes over time.
8. J udge the interoral condition and perform periodontal
inspection.
9. Hold the frontal region and chin of the subject and set a thermo-
camera at a consistent distance from the subject.
10. Instruct the subject to remain seated during image acquisition.
11. Inform the subject to keep water in mouth for 5 seconds before
image acquisition.
12. Instruct the subject on edge-to-edge occlusion and on the
prohibition of mouth respiration during image acquisition.
22
Applications of Thermography in Dentistry
Detection of Infra-alveolar Nerve Deficit
The thermal imaging of the chin has been shown to be an effective
method to assess inferior alveolar nerve deficit.
23
Subjects with
no inferior alveolar nerve deficit show a symmetrical thermal
pattern, with an area DT of +0.1C (0.1C SD) w (), while
patients with inferior alveolar nerve deficit had an area DT of
+0.5C (0.2C SD) on the affected side.
23
The observed
vasodilatation seems to be due to blockage of the vascular neuronal
vasoconstrictive messages, since the same effect on the
thermological pattern could be invoked in normal subjects by
temporary blockage of the inferior alveolar nerve, using a 2%
lidocaine nerve block injection.
24
TMJ Disorders
TMJ pain patients were found to have asymmetrical thermal
patterns with increased temperatures over the affected TMJ region
of their face and mean area DT values of +0.4C (0.2C SD).
25
Specifically, painful TMJ patients with internal derangement and
painful TMJ osteoarthritis were both found to have asymmetrical
thermal patterns and increased area temperatures over the affected
TMJ region of their faces, with mean area TMJ DT of +0.4C
(0.2C SD). In addition, a study of mild-to-moderate TMD
Journal of Indian Academy of Oral Medicine and Radiology, October-December 2010;22(4):206-210
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Thermography: A New Diagnostic Tool in Dentistry
patients indicated that area DT values correlated with the level of
the patients pain symptoms.
26
Chronic Orofacial Pain Patients
A new classification system of facial area DT measurements was
introduced.
21
This system classifies telethermographs as normal
when selected anatomic area DT values range from 0.0 to
0.25C, hot when area DT is > 0.35C, and cold when area
DT is <+0.35C. When a selected anatomic area DT value is
(0.26-0.35C), the finding is classified asequivocal. The results
have been tabulated in Table 1.
Detection of Herpes Labialis in Prodromal Phase
During the prodromal phase, all patients showed an increase in
temperature with the mean localized change in temperature (DtC)
being 1.1C 0.3C over a mean thermographically positive area
of 126 mm
2
34 mm
2
even when the patient was asymptomatic.
After 72 hours of treatment with acyclovir cream, majority of the
patients returned to normal with no clinical or thermographical
evidence of infection.
27
COMPARISON OF THERAPEUTIC MODALITIES
Infrared thermography promises to become a research tool for
an objective assessment of anti-inflammatory treatment efficacy.
A double-blind, placebo-controlled study was done to evaluate
the effect of GaAlAs diode laser on wound healing and pain
reduction in patients after extraction of impacted lower third
molars by infrared thermography. The patient treated by active
laser reported more pain and swelling during the first week after
tooth extraction than the patient treated by placebo laser.
However, the comparison of thermograms of patients treated by
placebo and active laser showed the acceleration of wound
healing after extraction in the patient treated with GaAsAl diode
laser.
28
Other Uses in Dentistry
A thermogram can offer precise images for:
1. Diagnosis of bone and nerve disorders
2. Articular pain in arthritis, osteoarthritis, rheumatoid arthritis
3. Muscular pain, hyper- or hypotonic reactions
4. Monitoring endodontic treatments
5. Tissues reactions to new dental materials
6. Diagnosis of any kind of maxillofacial inflammation
7. Chronic and acute periodontitis
8. Sinus disease
9. Cancers in maxillofacial territory
10. Myofascial pain syndrome
11. Neuralgia.
ADVANTAGES OF THERMOGRAPHY
The various advantages of thermography are:
1. Noninvasive technique
2. Easy seating examination
3. Minimal examination time (2-3 minutes)
4. Nonexpensive technique
5. Obvious differences in color changes (gradient 0.05C).
6. Its real time enables very fast scanning of stationary targets
and capturing of fast changing thermal patterns.
CONCLUSION
In dentistry, thermography can become important because of
accurate measurement of regional temperature (0.05C
differences). Thermography may be useful in elaborating of a right
diagnosis on an inflammatory reaction from maxillofacial territory.
After treatment, thermograms can give important relations about
the treatment methods and their efficiency. Thermograms can be
saved in a database, on compact disc or printed on a special or
regular paper.
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