Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2012; 57:(1 Suppl): 33–39

doi: 10.1111/j.1834-7819.2011.01656.x

The basic principles of radiological interpretation

B Koong*
*Envision Medical Imaging, Subiaco, Western Australia.

ABSTRACT
Radiologic interpretation is a complex process which involves the application of an appropriate algorithm in the study of
radiologic images and the ability to understand the meaning and to weight the various findings, ultimately contributing to
diagnosis. Prerequisites include the knowledge of orofacial radiologic anatomy and the various pathoses which may arise or
manifest in this region of the body. An understanding of the strengths and limitations of the modality employed is also
essential. The process of interrogating radiologic images for abnormalities varies, depending on the modality. This paper
outlines the basic steps involved in the radiologic examination of abnormalities which affect the jaws, primarily in relation
to plain 2-D imaging.
Keywords: Cone beam, radiography, radiology, computed tomography.

appreciation of anatomy three-dimensionally and how

INTRODUCTION
Radiologic interpretation involves the detailed study of
radiologic images, ultimately contributing to diagnosis.
It requires the application of an algorithm which
demands a certain knowledge base and skill set. This
is, in part, dependent on the imaging modality
employed and the region examined. Several essential
prerequisites allow accurate identification of the normal
structures and abnormalities. The ability to understand
the features of an abnormality and to weight these
findings is also crucial.
A thorough discussion of all these points is not within
the scope of this paper and acceptable interpretive
standards can only be achieved with clinically based
programmes. This paper will focus on identifying some
of the key prerequisites and introducing the key steps in
the radiologic interpretation of plain 2-D radiographic
images of the dental and orofacial structures, such as
the intraoral and panoramic radiographic images.
Prerequsites
Radiologic anatomy
The detailed knowledge of anatomy is an obvious
prerequisite for all clinicians. A similar understanding
of the appearance of anatomic structures in radiologic
images is also crucial. This requires a thorough
ª 2012 Australian Dental Association
these structures appear radiologically, depending on the
imaging modality employed. Knowledge of normal
anatomic variants and their radiological appearances is
also vital.
In plain 2-D radiographs, awareness of the angle of
projection and associated geometry is crucial. For exam-
ple, the temporomandibular joint is poorly examined
with the panoramic radiograph,1–3 related to the obliq-
uity of projection and the limitations of tomography.
Obviously, larger field of view 2-D images will
include more structures, requiring a broader knowledge
base. It is also important to understand the differences
in the appearance of anatomic structures in plain 2-D
projections (e.g. intraoral periapical view) compared to
a panoramic radiograph, which is essentially a curvi-
linear tomogram.
The radiologic anatomy as depicted in plain 2-D
images differs from that seen in volumetric radiologic
studies, such as multislice CT and cone beam imaging.
It is essential that the clinician responsible for the
interpretation is able to identify all the anatomic structures
which are depicted in the images. The ability to identify
the presence of an abnormality is severely compromised if
the clinician is not completely familiar with the appear-
ances of all anatomic structures and normal morphologic
variants. It must be emphasized that not all abnormalities
present as obvious opacities or lucencies.
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B Koong
Pathology
It is obvious that the clinician carrying out the interpre-
tation must be aware of the pathoses which may arise or
manifest in the region included in the radiologic study.
Many imaging techniques in dentistry capture a large
proportion of the orofacial structures. Examples include
panoramic and cephalometric projections. To varying
extents, cone beam scans include the paranasal sinuses,
pharyngeal air spaces, skull base, cervical spine and
upper neck. It is imperative that clinicians responsible for
the interpretation are familiar with the diseases which are
potentially associated with these structures.
As an example, in order to interpret an image or scan
of a temporomandibular joint, the clinician must be
familiar with the possible diseases which can affect this
joint, ranging from internal derangement and degener-
ative disease to the erosive arthropathies, synovial
chondromatosis, chondrocalcinosis, vascular lesions
and various tumours. The radiologic presentations of
these conditions differ and can often be differentiated
radiologically. The application of the correct modality
is also critical and it is worth pointing out that cone
beam imaging is often not necessarily the optimal
technique for these joints. Lack of knowledge of the
potential diseases which can affect this joint, especially
when the optimal modality is not employed, can lead to
suboptimal outcomes (Fig. 1).
Imaging modality
There are numerous imaging techniques which can be
applied in the radiologic examination of the orofacial
Fig 1. Opacities associated with the right TMJ typical of chondro-
calcinosis.
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structures, including intraoral and other plain 2-D
views, the panoramic tomograph, multislice CT, cone
beam imaging, MRI, ultrasound and nuclear medicine.
While modern dentistry can no longer rely on intraoral
and panoramic radiography alone, relatively new
modalities such as cone beam imaging must be applied
judiciously. Importantly, there are other advanced
techniques which may be more appropriate and should
also be considered. The radiations dose levels delivered
vary substantially between cone beam machines, some
of which can be higher than multislice CT (when
appropriate protocols are employed).4
The significant differences of the strengths and
limitations of all these modalities are not within the
scope of this paper. However, of note are the
substantial limitations of the commonly used pano-
ramic radiograph. The orofacial structures depicted in
this view are not necessarily sufficiently well demon-
strated and can lead to erroneous interpretations. Cone
beam imaging has been a relatively new technique
which is increasingly employed. Persons engaged in the
interpretation of these scans must be thoroughly
familiar with the limitations of this modality, including
beam hardening, noise, low signal, metal artefact and
poor soft tissue contrast resolution and the effect of
motion artefact.4 The effects of the various protocols
using the same equipment must also be understood.
Viewing conditions
Optimal viewing conditions are necessary to allow
identification of all the key features in an image,
including normal anatomy. The subtle absence of a
normal structure can be a key finding leading to
identification of a significant abnormality. Ambient
light must be kept to a minimum and extraneous light
from a viewing box should be obscured.
The ability to optimally view every aspect of an
image is crucial. Digital images viewed on a computer
monitor can be easily manipulated, including magnifi-
cation and windowing. The quality of the monitor is
crucial and is not infrequently the weakest link in the
dental practice. For traditional analogue images, optical
magnification and using a brighter light source for
darker regions can be critical.
The interpretation of plain 2-D radiographic digital
images printed on paper can be problematic. The
quality of the printer and paper are crucial. Even
high quality photographic paper generated from a high
quality printer does not demonstrate the same optical
range as film or high quality monitors. The interpreta-
tion of 2-D digital images is optimally performed on
high quality monitors or on high quality film. When
images are transferred electronically, the level of
compression of images must be minimized or avoided
so that crucial data is not lost. Volumetric data such as
ª 2012 Australian Dental Association
 Basic principles of radiological intepretation

multislice CT is ideally interpreted by interrogating all

the data with a computer.
Ultimately, a lesion must be entirely included in a
field of view or scan. If this is not the case initially (e.g.
in a periapical or panoramic view) preliminary inter-
pretation should still be carried out, which can be
useful in deciding which modality is optimal in further
evaluation.
Optimal imaging is assumed and the technical aspects
of imaging are well discussed in many texts.

Radiologic intepretation
Radiologic interpretation is essentially based upon the
understanding of disease processes and the behaviour of
diseases in a specific anatomic region. By carefully
applying a series of steps, the key features of a lesion Fig 2. Cone beam corrected sagittal image demonstrating the cortical
erosions typical of an infiltrative lesion such as lymphoma.
can be identified. Combined with knowledge of the
specific radiologic characteristics of various lesions, this
can contribute substantially to diagnosis.
multislice CT and cone beam techniques, differ to that
It is desirable that the diagnostic imaging and
which is employed for intraoral and panoramic images.
interpretation is completed prior to biopsy. Appropri-
Volumetric data should be evaluated in multiple
ate interpretation can be useful in identifying the
appropriate planes and windows, depending on the
optimal and ⁄ or safe site(s) for biopsy. It is also critical
structures involved and potential associated diseases.
that some lesions are excluded prior to biopsy or
Evaluation of volumetric data in one plane can result in
surgical intervention. Of note are the vascular malfor-
misinterpretation and non-identification of the presence
mations. In addition, surgical procedures and biopsies
of disease.
can substantially alter the radiological appearances of a
In addition, there are commonly known specific
lesion, usually by introducing inflammatory changes,
radiologic features which suggest the presence of
potentially compromising diagnosis and management.
disease. For example, a wide stylo-mandibular notch
The ability to perform morphologic analyses and
is a feature which suggests presence of a mass related to
plan surgical procedures with a specific imaging
the deep lobe of the parotid salivary gland.
technique is different to the skill set required to evaluate
the same data set for the presence of disease and the
interpretation of the radiologic features of a lesion. Radiologic evaluation of a lesion
The following describes a series of steps which assists in
Recognizing the presence of an abnormality the identification of the important radiologic features,
highlighting the behaviour and nature of a lesion. These
The practitioner is responsible for the entire volume of
features identified are also important from a surgical
information of a scan and all structures in the field of
standpoint.
view, not just for the primary focus of the study.
The process of interrogating radiologic images for
1. Location
abnormalities varies, depending on the modality. While
the actual sequence in which the evaluation of an image Before focusing on the precise location of a lesion, the
is carried out may vary, the entire image must be entire field of view or scan should be evaluated for
methodically and thoroughly studied. Every normal other possible related lesions. That is, the disease may
anatomical structure that should be within the field of be multifocal or generalized. If there is more than one
view must be specifically identified and evaluated, lesion, it is important to note if the lesions are
including its normal boundaries and internal appear- monostotic or polyostotic and unilateral or bilateral.
ances. This is critical since not all lesions are obvious. For example, Gorlin-Goltz syndrome (nevoid basal cell
For example the absence of a cortical boundary of a carcinoma syndrome) needs to be considered if multiple
structure in a panoramic radiograph, cone beam or cystic lesions are identified.
multislice CT can reflect the presence of significant A key point of this step is to attempt to identify the
disease (Fig. 2). point at which the lesion originated. This is often the
The algorithm and skill set required to thoroughly anatomic centre of a lesion (e.g. the centre of a spherical
evaluate volumetric data, including those captured with lesion). However, the origin of a lesion is not always at
ª 2012 Australian Dental Association 35
B Koong
the anatomic centre. A lesion arising from the maxillary
alveolar process expanding into maxillary sinus is an
example. Being filled with air, the maxillary sinus
allows for much easier expansion than the alveolar
bone. Hence, most of the volume of this lesion is within
the sinus. In these cases, the anatomic centre is not the
origin. This highlights the importance of understanding
the involved anatomy.
The location and extent of the lesion can provide
useful information about the likely tissues involved. For
example, a lesion in the posterior body of the mandible
which arises from below the mandibular canal is
unlikely odontogenic. Detailed information regarding
the location and extent of a lesion is also critical in
relation to surgical planning and biopsy.
2. Shape and contour
The shape of the lesion can provide useful information
on the lesion. True cysts such as the dentigerous cyst are
generally spherical or ovoid. In contrast, an odonto-
genic cyst often demonstrates a scalloped peripheral
morphology. An osteoma usually presents as a smooth
convex bony prominence while an osteochondroma
tends to present with a more irregular surface. A bone
island typically demonstrates an irregular outline
(Fig. 3).
3. Border
The first part of this step is to identify if the border of a
lesion is well defined or poorly defined. Generally, a
well-defined border suggests that the lesion is likely
slower growing. It should be noted that similarly well-
Fig 3. Periapical radiograph depicting a bone island.
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defined lesions generally appear less defined in the
maxilla than the mandible, especially in plain 2-D
views. This is related to the trabecular architecture and
also the thickness of the bone.
If a lesion is well defined, this border has to be further
examined and subcategorized. Most well-defined bor-
ders fall into one of the following descriptions:
(1) A sharp demarcation between normal and abnor-
mal with no other features. This is often referred to as
‘punched out’. Multiple myeloma is a classical example.
(2) A corticated border. This describes a sharp
opaque usually curved line (Fig. 4).
(3) A sclerotic border. This refers to an opaque
border which is thicker and less uniform than a
corticated border. Most chronic inflammatory bony
lesions demonstrate sclerotic margins, which reflect the
reaction of the surrounding trabecular bone to the
inflammatory lesion (Fig. 5). However, other lesions
including cement-osseous dysplasia and some malig-
nant lesions can also demonstrate sclerotic margins.
(4) A surrounding lucent margin. This usually refers
to opaque and mixed-density lesions where the lucent
margin reflects presence of soft tissue surrounding the
lesion (Fig. 6).
If a lesion has an ill-defined border, further analysis is
necessary to decide which of the following two best
describes it:
(1) A gradual change from abnormal to normal.
Inflammatory lesions, unless extremely chronic, dem-
onstrate these borders (Fig. 5).
(2) An aggressive margin. Malignant lesions classi-
cally demonstrate these borders. Aggressive and infil-
trative margins include the appearance of extension
Fig 4. A cropped panoramic radiograph depicting the corticated
border of a radicular cyst and associated inferior deflection of the
mandibular canal.
ª 2012 Australian Dental Association

into the adjacent bone and enlargement of adjacent
marrow spaces. Irregular widening of the periodontal
ligament space with focal destruction of the lamina
dura is also another example of the leading edge of an
infiltrative lesion spreading around tooth roots.
Fig 5. A periapical radiographic image depicting a periapical inflam-
matory lesion.
Fig 6. A cropped panoramic view depicting an odontome.
Fig 7. Fibrous dysplasia of the right posterior maxillary alveolar process, better visualized in the axial multislice CT image than in the cropped
panoramic radiograph.
ª 2012 Australian Dental Association
Basic principles of radiological intepretation
4. Internal appearances
The internal appearance of a lesion provides important
clues as to the likely nature of the lesion. Initially, it is
useful to identify if the lesion is completely opaque or
complete lucent.
For completely opaque lesions, the density and
degree of homogeneity or heterogeneity should be
identified together with any consistent pattern. A
classical fibrous dysplasia is internally homogenous
with ground glass appearances (Fig. 7). A bone island is
usually internally homogenous and isodense with
cortical bone. Osteomyelitis can demonstrate heterog-
enous internal appearances with focal areas of rarefac-
tion and sclerotic regions.
A complete lucent lesion seen in plain 2-D imaging
could reflect presence of air ⁄ gas, fluid or soft tissue.
Typically, air ⁄ gas and fat will appear more lucent than
fluid and soft tissue in plain 2-D radiography. It is
important that this is understood in relative terms. For
example, in a panoramic radiograph, a fluid-filled cyst
within the maxillary sinus will appear relatively opaque
while a fluid-filled cyst with the mandible will appear
lucent. Cone beam imaging can clearly differentiate
between air and soft tissue but cannot differentiate
between fluid and soft tissue and different types of soft
tissue. Multislice CT has far superior soft tissue
contrast resolution and can demonstrate density differ-
ences between different types of soft tissues. Multislice
CT is often able to differentiate between soft tissue and
fluid, although the effects of beam hardening need to be
considered when evaluating the internal attenuation
characteristics of intrabony lucent lesions. It is impor-
tant to note that soft tissues are best evaluated with
MRI.
There are also lesions which demonstrate both lucent
and opaque internal appearances. In these cases, it is
important to try to identify the nature of the opacities
e.g. bony, odontoid or dystrophic calcification. In
addition, the pattern of the opacities is also important
as many lesions often demonstrate a certain pattern.
For example, an ameloblastoma classically demon-
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B Koong
Fig 8. A periapical view depicting the superior aspect of a keratocystic
odontogenic tumour. Note the right angle appearance of the superior
border in relation to the tooth roots, which is not usually seen with
radicular cysts.
strates coarse curvilinear internal septae while giant cell
lesions often reveal much finer septae.
5. Adjacent anatomic structures
The way in which the normal anatomic structures
influence the pattern growth and spread of a lesion and
the effects that a lesion has on these adjacent anatomic
structures as the lesion enlarges are both important
features which require detailed analysis.
For example, a radicular cyst would displace the
mandibular canals while an inflammatory lesion does
not usually display this characteristic (Fig. 4). Tooth
displacement is a characteristic of a lesion with mass
effect, usually benign in nature. The way in which the
periapical bone is effaced provides important clues as to
the likely nature of the lesion (Fig. 8). Some lesions,
such as an ameloblastoma and a giant cell lesion
demonstrate a propensity to resorp tooth roots. The
resorption of roots require time, which is not a typical
feature with malignant lesions. Malignant lesions tend
to destroy the bone surrounding the tooth. While
destruction of cortical boundaries can occur with a
variety of lesions, including inflammatory lesions, it
requires special attention as malignant lesions often
demonstrate this characteristic (Fig. 2). Periosteal
new bone formation is often seen in more extensive
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Fig 9. An axial multislice CT image depicting periosteal response
related to an inflammatory lesion.
inflammatory lesions affecting the jaws, such as oste-
omyelitis (Fig. 9).
Interpretation of the findings
Many lesions can demonstrate similar features. In
addition, many lesions do not always present classically
and demonstrate only a few or even just one of its
typical features. Therefore, the next critical step is for
the observer to weight the various features identified.
This requires knowledge of the classical radiologic
features of the possible pathoses and experience in the
application of this information.
For example, fibrous dysplasia does not always
present with classical ground glass internal appearance
and can appear quite heterogenous internally. How-
ever, in these cases, the nature of the expansion often
remains typical which assists the observer in differen-
tiating it from other lesions which can otherwise appear
similar, such as the cement-ossifying fibroma.
A lucent lesion located at the apex of a tooth root is
often inflammatory in nature. However, malignant
lesions at root apices are also lucent. Furthermore,
some can indeed demonstrate adjacent sclerosis which
can appear similar to the reactive sclerosis often seen in
inflammatory lesions. In these cases, the invasive nature
of margins and the irregular way in which the adjacent
lamina dura and periodontal ligament spaces are
destroyed are critical features.
Classification
One of the final steps in radiologic interpretation
involves the classification of the lesion. While it is
tempting to rush to provide a specific diagnosis, it is
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important that the thought process focuses initially on
classifying the lesion into a broad category, e.g.
inflammatory, fibro-osseous, cyst, benign or malignant
tumour, vascular etc. This step allows the observer to
finally re-evaluate all key features identified and reduces
the likelihood that a key feature is not considered, e.g.
the serpiginous appearance of the mandibular canal
typical of a vascular malformation. It is often useful to
also consider the patient’s age and ethnicity (if known)
at this stage. Once the lesion has been classified into the
broader categories, the observer will then be able to
decide upon the most likely nature of the lesion.
CONCLUSIONS
It is important to reiterate the importance of employing
a methodical approach to radiologic interpretation.
Sole reliance upon a classical appearance of a lesion and
use of the ‘Aunt Minnie’ style of interpretation (looks
like the lesion the observer last encountered or saw in a
book) is insufficient and can lead to erroneous inter-
pretation and misdiagnosis.
In dentistry, the observer is often also the clinician. In
these instances, the observer can easily develop a
preconception as to the likely diagnosis and thorough
evaluation of the radiologic study is not performed. An
example is when there is a clinically suspicious
periapical inflammatory lesion where radiologic inter-
pretation ends as soon as a lucent appearance is noted
periapically. A thorough radiologic evaluation to
identify the features of an inflammatory lesion is then
not performed, which can contribute to misdiagnosis.
Like other facets of dentistry and diagnosis, knowl-
edge combined with appropriate training and guided
ª 2012 Australian Dental Association
Basic principles of radiological intepretation
experience is critical in the development of competent
radiological interpretive skills. The author hopes that
this paper has been effective in introducing an algo-
rithm for radiologic interpretation and raising associ-
ated pertinent issues. Equally important, it is also hoped
that this paper inspires those involved in radiologic
interpretation to continue development of their indi-
vidual skills and to be cautious where the imaging is
beyond their interpretive skill set.
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3. Schmitter M, Gabbert O, Ohlmann B, et al. Assessment of the
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Address for correspondence:
Professor Bernard Koong
Envision Medical Imaging
Suite 5
178 Cambridge Street
Subiaco WA 6014
Email: bkoong@iinet.net.au
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