RADIOGRAPHIC AIDS IN DIAGNOSIS OF

PERIODONTAL DISEASE

INTRODUCTION:
Radiography is the production of a photographic image of an object
through the use of x – rays.
Radiographs play an integral role in the assessment of periodontal
disease. They provide unique information about the status of the
periodontium and a permanent record of the condition of the bone through
out the course of the disease.Radiogarphs aid the clinician in identifying the
extent of destruction of the alveolar bone , local contributing factors and
features of the periodontium that influence the prognosis .

HISTORY:
The foundation for the discovery of the x – ray dates back as far as the
17th century, when the sciences of magnetism and electricity were started
with the discovery of magnetism. Finally x – ray was discovered by
Wilhelm conard roentgen in November 1895.

RADIOGRAPHIC ASSESSMENT OF PERIODONTAL

CONDITIONS
Radiographs are especially useful in the evaluation of the following:
 Amount of the bone present
 Condition of the alveolar crests
 Bone loss in the furcation areas
  Width of the periodontal ligament space
 Local irritating factors that cause or intensify periodontal disease
o Calculus
o Poorly contoured or over extended restorations
 Root length and morphology of the crown –root ratio
 Anatomic considerations
 Pathologic considerations
o Caries
o Periapical lesions
o Root resorption

LIMITATIONS OF RADIOGRAPHS:
The following are the limitations of radiographs:
1. Radiographs provide two –dimensional view of a three –dimensional
situations. Because the radiographic image fails to reveal the three –
dimensional structure, bony defects overlapped by higher bony walls
may be hidden .Also because of overlapping tooth structure, only the
interproximal bone is seen clearly.
2. Radiographs typically show less severe bone destruction than is
actually present. The earliest (incipient) mildly destructive lesion in
bone do not cause a sufficient change in density to be detectable.
3. Radiographs do not demonstrate the soft-tissue - to - hard-tissue
relationships and thus provide no information about the depth of soft
tissue pockets.
 4. Bone level is often measured from the cemento enamel junction;
however this reference point is not valid in situations in which either
over eruption or severe attrition with passive eruption exists.

For the above cited reasons, although radiographs play an invaluable

role in treatment planning, their use must be supplemented by careful
clinical examination.

RADIOGRAPHIC PROJECTIONS USED TO ASSESS THE

PERIODONTIUM

1. Bitewing technique : horizontal

Vertical
2. Peri apical technique : paralleling
3. Dental panoramic radiographs
4. Digital radiography: including sub traction radiography and
Densitometry analysis

HORIZONTAL BITE WING TECHNIQUE:

Bite wing radiographs are probably the most important images for
establishing the true radiographic picture of the alveolar bone height in most
patients with periodontal disease.
With the teeth in a close approximation of their normal occlusion, the
angulations used (positive 7 to 10 degrees) is favorable to projecting the
image of both the maxillary and mandible posterior teeth in their most
parallel orientation.
Well positioned, well exposed, horizontal bite wings will give
excellent image geometry and will result in the most accurate diagnostic
images of the teeth and the crestal bone.
Horizontal bite wings are usually ordered when the patient has
suspected mild to moderate horizontal bone loss, as determined by the
clinical examination.
If the horizontal bite wings are properly positioned, the clinician
should expect to see:
1. Super imposition of the buccal and lingual/palatal cusps.
2. A sharp or well defined alveolar crestal margin
3. No horizontal “overlap” between adjacent teeth (ie “open”
interproximal spaces with out overlap in the contact areas.)

VERTICAL BITE WING TECHNIQUE :

Vertical bite wings are useful if the patient has demonstrated deep
probing depths on clinical examination and the clinician expects the patient
to have moderate to severe horizontal bone loss.
Vertical bite wings too have some problems; the operator should be
cautioned about two potential problems during image acquisition.

1. The first is that the image receptor (film) oriented vertically will
impinge more readily on the palatal curvature because of the
increased height of the receptor (film). This is especially true if the
 patient has a relatively shallow palatal vault .This impingement
will lead to image distortion.

2. Vertical orientation reduces the image information in an anterior –

posterior dimension because the receptor is narrower in the
horizontal direction in this orientation.

PERIAPICAL TECHNIQUE :

Periapical radiographs make excellent supplemental images for

periodontal bone level determination and are essential for assessing the
crown –root ratio, root morphology, periodontal ligament spaces and the
periapical status.
Two intra oral projection techniques may be used for periapical
radiography: paralleling and the bisecting angle technique.

PARALLELING TECHNIQUE:

The x-ray film is supported parallel to the long axis of the teeth and
the central ray of the x-ray beam is directed at right angles to the teeth and
film.

BISECTING –ANGLE TECHNIQUE:

 Here the film is positioned as possible to the lingual surface of the
teeth, resting in the palate (or) in the floor of the mouth.
The plane of the film and the long axis of the teeth form an angle,
with its apex at the point where the film is in contact with the teeth. This
angle is bisected by an imaginary line & two congruent angles are formed. A
central ray will bisect the imaginary line which is perpendicular to the
imaginary bisector.

THE BEST TECHNIQUE FOR THE DIAGNOSIS OF

PERIODONTAL DISEASE

PARALLELING TECHNIQUE:
It will demonstrate more accurately the features of periodontitis. It
provides a better view of alveolar margin & reveals the actual depth of
periodontal lesion in relation to root of the tooth.

BISECTING –ANGLE TECHNIQUE:

It shows greater destruction of the alveolar bone than is actually
present, because the central ray is directed obliquely to the long axis of the
teeth, which provides dimensional distortion.
Hence the Paralleling technique is the best for evaluating periodontal
disease.

RADIOGRAPHIC ANATOMY OF THE PERIODONTIUM

Interdental septum and crestal lamina dura:
 The interdental septum or septal bone is located between the roots of
adjacent teeth. It is therefore more clearly visualized than bone that is
located on the buccal or lingual aspect of the tooth.
The shape of the interdental septum is a function of the morphology of
the contiguous teeth. Teeth that are quite convex on the approximating
surfaces (ie, cup shaped) will give rise to wider interdental space in a
mesiodistal dimension. This will result in flatter, broader septa of larger
mesiodistal width.
Teeth that are present with a flatter, less convex interproximal profile
will tend to produce narrower interdental spaces.
This results in formation of a “septal peak” and is most commonly
seen in anterior regions.
Loss of this architecture results in “blunting” or loss of septal height
and may indicate early periodontitis.
The normal radiographic appearance of the alveolar crest is
characterized by the presence of cortical bone. This crestal cortication
appears as a thin but distinct radiopaque line contiguous with the lamina
dura of the adjacent teeth.
In the posterior regions, the junction of the alveolar crest with the
lamina dura is box- like, forming a sharp distinct angle.
In the mandibular anterior region, the alveolar crest between adjacent
teeth is normally spear-shaped or knife-like.
In the maxillary anterior region, the alveolar crest may be rounded.
In all regions, the normal alveolar crest lies 1 to 2 mm subjacent to the
CEJ the adjacent teeth and parallels adjacent CEJ’s.

Periodontal ligament space:

 The periodontal ligament space often can be discerned on routine
radiographs as a thin radiolucent line interposed between the root and the
radiopaque line that outlines the root.
This radiopaque line is the image of the cribriform plate or alveolar
bone proper. This radiographic image is known as the lamina dura, which is
continuous with the crestal lamina dura, which is the radiopaque line at the
most superior aspect of the interdental septum.
Widened PDL space is suggestive of occlusal trauma. Widening of the
periodontal ligament space is also seen in vertical root fractures, in
progressive systemic sclerosis and occasionally as a manifestation of
periodontal pathology.

BONE DESTRUCTION IN P ERIODONTAL DISEASE

PATTERN OF BONE DESTRUCTION:

Horizontal bone loss:

It is the term used to describe the radiographic appearance of loss in

height of the alveolar bone around multiple teeth; the crest is still horizontal
(ie parallel with the occlusal plane) but is positioned apically more than a
few millimeters from the line of cemento enamel junctions
(CEJ’S). Horizontal bone loss may be mild, moderate, severe, depending on
it’s extent.
 Mild bone loss may be defined as approximately 1 mm of attachment
loss, and moderate loss is any thing greater than 1 mm up to the mid point of
the length of the roots or to the furaction level of the molars.
Severe loss is any thing beyond this point and has often has evidence
of furcation involvement of multi rooted teeth.
In horizontal bone loss, the crest of the buccal and lingual cortical
plates and the intervening interdental bone has been resorted.

Vertical osseous defects:

It occurs in oblique direction leaving a hollowed out trough in the

bone alongside the root.
They are classified on the basis of number of osseous walls as One,
Two & Three wall defect.
The interproximal crater is a two – walled, trough like depression that
forms in the crest of the interdental bone between adjacent teeth.
The infrabony defect is a vertical deformity with in bone that extends
apically along the root from the alveolar crest. This usually develops from
bone loss extending down the root of the tooth and in its early form appears
as abnormal widening of the periodontal ligament space at the CEJ.

RADIOGARAPHIC INTERPRETATON AS APPLIED TO

THE PERIODONTAL PATIENT
Furcation defects:
 Loss of bone in the furcation of molar teeth may occur as a result of
periodontitis, endodontic infection, and root perforation during dental
procedures or occlusal trauma.
The radiographic changes are more commonly seen in the mandibular
molars as they have only two roots. Because most maxillary molars have
three roots, early changes in their furcation areas are more difficult to assess.
Bone loss in the facial furcation may occasionally be detected on
radiographs but the superimposition of the palatal root makes such detection
difficult. Defects occurring between the mesiobuccal and the palatal roots
and between the distobuccal and the palatal roots are easier to detect radio
graphically.

Root morphology:
The radiograph is the only method, short of direct observation, of
visualizing the morphology of the roots.
They are a number of radiographic parameters that may be of clinical
significance, including the length of the root trunk, root length, root
divergence or convergence, root resorption and root shape.
Radiographs reveal root resorption, either idiopathic or as a result of
orthodontic movement. Clinically significant root resorption may jeopardize
the prognosis of the affected teeth. For this reason, it is suggested that adult
orthodontic patients receive a pre treatment radiographic series and periodic
films through out treatment to detect such changes.
Radiographic examination may reveal other root anomalies such as
germination or fusion, root dilacerations etc
Calculus:
Clinically significant calculus deposits are seen on routine
radiographic examination. However the radiograph is not a sensitive
indicator of calculus. Buchanan and co workers report that radiographic
evaluation of calculus did not co relate well with its presence. These authors
conclude that conventional radiography is not a very discriminating method
of calculus detection.
When any radiographic sub gingival calculus is observed, it is usually
indicative of very heavy deposits.
The clinician should not interpret the absence of radiographic calculus
as indicative of an absence of calculus clinically, because most calculus
deposits will not be present radio-graphically.

GENERAL RADIOGRAPHIC CHANGES IN

PERIODONTITIS
 Fuzziness & a break in the continuity of the lamina dura at the mesial
or distal aspect of the crest of the interdental septum -earliest
radiographic change.
 Wedge-shaped radiolucent area is formed at the mesial or distal aspect
of the crest of the septal bone
 Finger like projection (radiolucent) extends across the crest into the
septum.
 The height of the interdental septum is progressively reduced.

EARLY PERIODONTITS :
 Inflammation must be present for some time to result in early
radiographic signs of periodontal disease.
The first of these early signs is loss of the relatively radiopaque
appearance of the interproximal alveolar crest.
Fuzziness and break in the continuity of the lamina dura of the
interdental septum can be seen.
It results from the extension of the gingival inflammation in to the
bone, causing widening of vessel channels and reduction in calcified tissue.
Normally the interproximal crest between bicuspids and molars is
normally flat and originates approximately 1 to 1.5 mm apical to the CEJ.
The interproximal alveolar crestal bone in anterior teeth has the same
CEJ location of origin but tapers to a point in the cervical embrasure space.
The earliest radiographic signs of periodontal disease can be
suspected when the alveolar crests lose their normal architecture and the
cortex of the crestal bone is lost, resulting in an irregular, diffuse appearance
of the crestal bone edge.
When the inflammatory space invades the PDL space, widening of
this radiolucent zone begins at the crest of the interseptal bone. Early
widening of the PDL space can be visualized as a triangle with its sides
formed by the root surface and alveolar bone, the base toward the occlusal
plane, and the apex pointed apically.

MODERATE PERIODONTITS:

Progression of the diseases process beyond the alveolar crest

eventually will result in loss of the supporting alveolar bone.
 Bone loss in progressive periodontitis can occur in many different
configurations.
The radiographic classification of bone loss in adult periodontitis can
be divided in to: horizontal and vertical bone loss.
Horizontal bone loss can be either: localized or generalized
Mild, moderate or severe

Vertical bone loss (osseous defects) can be:

Interproximal crater
Infrabony defect
Interproximal hemiseptal defect
Inconsistent bony margins

When the interproximal alveolar crest migrates apically but remains

parallel to the line connecting the CEJ of the neighbouring teeth, horizontal
bone loss can be diagnosed.
Horizontal bone loss can be classified as localized when it occurs in
only one area, or in more than one area that are isolated from one another.
Generalized bone loss occurs when the alveolar crest appears apically
positioned on several teeth in a quadrant, an arch, or the entire dentition.
Horizontal bone loss can also be classified as mild, moderate and
severe. This radiographic classification of degree is some what arbitrary
because even a slight variation in vertical angulations of the x-ray beam will
change the apparent position of the bone.
Actively progressing horizontal bone loss will exhibit a crestal bone
margin that is diffuse and non corticated. Also, the sharp angle normally
formed by the crestal cortex and the lamina dura of adjacent teeth in a
healthy periodontium will be rounded in patients with periodontitis.

Therefore, the crestal portion of the PDL space will appear widened.
Osseous bony defects one may affect one tooth, several teeth, or one or more
areas of a single tooth.

Interproximal crater:
The most common bony defect found in moderate periodontal disease
is the interproximal crater.
These defects occur as two walled troughs or channels traversing the
interproximal alveolar crest from one tooth to the adjacent tooth.

Infrabony defect:
Is a vertical deformity within the bone that extends apically along the
root from the alveolar crest. A two-walled infrabony defect-has one side
wall remaining and one side wall lost.

ADVANCED PERIODONTTIS:
Extensive, generalized horizontal bone loss and vertical bony defects
associated with tooth mobility and drifting are strong indicators that affected
teeth are at risk of being lost.
Such a situation qualifies as severe or advanced periodontal disease.
Surgery often reveals even more extensive destruction than that
suggested by the radiographs.
Severe periodontitis often involves the formation of bony defects in
the furcation of multirooted teeth.
 Teeth susceptible to furcation involvement are maxillary and
mandibular molars, maxillary first premolars and any other teeth possessing
more than one root.
Early radiographic evidence of furcation involvement is decreased
radiodensity in the furcation area.
Also when there is marked bone loss in relation to one single molar
root, then furcation involvement is there.

RADIOGRAPHIC CHANGES IN AGGRESSIVE

PERIODONTITIS

Localized form:
Localized aggressive periodontitis is associated with attachment loss
involving the incisors and first molars.
The bone loss is rapid, up to 3 to 4 times that seen in chronic
periodontitis.
In localized aggressive periodontitis there is localized angular bone
loss in relation to the molars and incisors.

Generalized form:
Generalized aggressive periodontitis can involve variable number of
teeth, from at least three to all of the dentition, and by definition is not
confined to the first molars and incisors.
This rapidly progressing disease usually affects individuals under 30
years of age.
 In generalized form aggressive form, there is bone loss involving
several teeth and the rapid bone loss may be of the vertical or angular or
horizontal pattern.
RADIOGRAPHIC APPEARANCE OF THE PERIODONTAL
ABSCESS
Periodontal abscess appears as a discrete area of radiolucency along
the lateral aspect of the root.
A periodontal abscess is a rapidly progressing, destructive lesion that
usually originates in a deep soft tissue pocket.
It occurs when the coronal portion of the pocket is occluded or when
foreign material gets lodged between the tooth and the gingiva.
In the early stages there is a break in the continuity of the lamina dura.
When the lesion persists a radiolucent region appears, often superimposed
over the root of a tooth.

RADIOGRAPHIC CHANGES IN TRAUMA FROM

OCCLUSION

Traumatic occlusion causes degenerative changes in response to

occlusal pressures that are greater than the physiologic tolerances of the
tooth’s supporting tissues.
These lesions occur as a result of malfunction caused by excessive
occlusal force on teeth or by normal forces on a periodontium compromised
by bone loss.
 Radiograpically, There are changes in lamina dura, morphology of
alveolar crest, width of the periodontal space & density of the surrounding
cancellous bone.
There is widening of the periodontal ligament (PDL) space, widening
of the lamina dura, and an increase in the number and size of the trabeculae.
More advanced traumatic lesions-result in deep angular bone loss.
Root resorption may be due to excessive forces on the periodontium caused
by orthodontic appliances.

RADIOGRAPHIC CHANGES OF SKELETAL

DISTURBANCES MANIFESTED IN THE JAWS

Skeletal disturbances may produce changes in the jaws that affect the
interpretation from periodontal aspect.

1. Osteites fibrosa cystica :

 Caused by advanced primary or secondary
hyperparathyroidism.
 Osteoclastic resorption of bone with fibrous replacement
 Generalized loss of lamina dura.

2. Pagets disease :
 Normal trabecular pattern is lost replaced by hazy diffuse mesh
work
 Lamina dura absent
 3. Fibrous dysplasia :

Small radiolucent area at root apex or extensive radiolucent

area with irregularly arranged trabecular pattern

4. Scleroderma :
Periodontal ligament is uniformly widened at the expense of the
surrounding alveolar bone.

ADVANCED RADIOGRAPHIC TECHNIQUES:

Techniques have been developed that enhance our ability to “see”

small changes overtime in the bone
These are:
1. Xero – radiography
2. Computer assisted densitometric image analysis (CADIA)
3. Substraction radiography
4. Computer tomography( CT )
5. Radiovisiography

XERO –RADIOGRAPHY:

It is a diagnostic x – ray imaging system which uses the xerographic

copying process to record x – ray images.
 Xeroradiographic images are different from conventional film images
because they have greater exposure latitude and a property termed “edge
enhancement” by which fine structures eg. Bony trabeculae are made more
visible.
For dental xero- radiographs, the images are recorded on selenium
alloy photo receptive plates which are carried in light proof cassettes
especially designed for dental applications.
The xero – radiographic processor charges a photo – receptive plate
and inserts in to a light proof cassette. After being placed in a disposable
sterile plastic bag, positioned and exposed in the patient’s mouth, the
cassette is reinserted into the xero – radiographic processor using black
liquid toner for development. The system produces a dry permanent xero –
radiographic image in 20 seconds.
The used photo receptor is then reconditioned and may be reused
repeatedly.

Advantages:
 Greater imaging speed.
 Increased speed of interpretation.
 Does not require use of silver.
 Lower radiation exposure.
COMPUTER ASSISTED DENSITOMETRIC IMAGE
ANALYSIS SYSYEM (C.A.D.I.A)

In this system a video camera measures the light transmitted through a

radiograph and the signals from the camera are converted into gray levels.
 The camera is interfaced with an image processor and a computer that
allows the storage and mathematical manipulation of images. In this method
bone changes are presented in terms of C.A.D.I.A. Units which are related to
gray level changes.
Advantages:
1. Bone loss may be detected
A. When only 1% - 5% of mineral is lost
B. When there is as little as 0.5mm of bone loss along the tooth
root.
C. When there is less than 1 mm of bone loss

2. Useful in determining whether bone loss has been lost or gained

between periodontal examinations.

SUBSTRACTION RADIOGRAPHY:

The advent of digital substraction radiography has allowed for the first
quantitative assessment of attachment loss in 3 dimensions.
In digital substraction radiography, a standardized radiographic image
is obtained before the appearance of an anatomical image, such as crestal
bone loss, and is subtracted from a subsequent standardized radiograph.
The resultant substraction image is that of the isolated structure that
has undergone the change. By definition, the structures that have not
changed will subtract out and appear as neutral gray, bone loss will appear
darker gray and areas of bone gain will appear lighter gray. Once the
subtraction image is stored it may be electronically contrast enhanced to
display the final image to its best advantage.

Advantages:

1. A high degree of co relation between changes in alveolar bone

determined by substraction radiography and attachment level changes
in periodontal patients after therapy.
2. Increased detectability of small osseous lesions compared with the
conventional radiographs.

RADIOVISIOGRAPHY (RVG):

Direct Digital Radiography (Radiovisiography - RVG)

Also called a film less radiography, radiovisiography uses an intra

oral detector similar in concept to a miniature video camera to capture
radiographic images of the diagnostic area. It depends on the concept of
Charged Couple Device (CCD) consisting of pure selenium chip.
RVG is used in detecting the bony lesion & determining the
difference in identification of buccal and lingual lesion. Defects on the
lingual area will be depicted than those on the buccal.It demonstrate
superiority in its diagnostic accuracy. It has a better diagnostic value in the
detection of early pathological conditions.
MAGNETIC RESONANCE IMAGING (MRI) :
The human body contains almost 70 % of water, of which hydrogen is
a major component. The nucleus of a hydrogen atom consists of a single
proton.
In this technique of imaging the patient is placed in a large magnet
and electromagnetic energy temporarily changes the alignment and
orientation of the hydrogen protons with in the body.
The area being examined is then subjected to radiofrequency waves.
These waves allow for indirect detection of the magnitude and molecular
characteristics of the magnetized hydrogen protons. Using this information,
a computer can generate an image.
The use of this imaging technique in the field of periodontics is still in
the developing stage.

CONCLUSION

Radiography is the standard for diagnosis of dental disease, although

it lacks the sensitivity to demonstrate the earliest changes of diagnostic
significance. But looking in to the future, advanced radiographic techniques
like digital imaging and substraction radiography help to better demonstrate
subtle changes in diagnostic information.

REFERENCES
1. The clinical approach to radiologic diagnosis , DCNA 1994
2. Oral radiology - white and pharaoh , 5th edition
3. Fundamentals of periodontics – Kornman and Wilson
4. Clinical periodontology - Carranza , 9th edition by Saunders.