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98]

Original Article

Unusual Incidental Findings on Intra‑ and Extra‑oral

Radiographs in North Indian Population: A Radiographic Study
Gaurav Goyal, Sarfaraz Padda, Bhawandeep Kaur
Department of Oral Medicine and Radiology, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab, India

Abstract
Aims and Objectives: To detect the prevalence of unusual incidental findings on intra‑ and extra‑oral radiographs in North Indian Population:
A radiographic study. Methods: All the intra‑ and extra‑oral conventional dental radiographs were analyzed for the period of 2 year along with
the radiographic findings related to patient’s chief complaint. Results: A total of 6780 conventional intra‑ and extra‑oral dental radiographs
were screened and 90 radiographs showed incidental findings. A  total of 10 varieties and 95 numbers of incidental findings were noted,
50 (55.55%) affected mandible, and 24 (44.44%) affected maxilla. Out of 90, 44 (48.88%) were bony findings and 46 (51.11%) were dental
findings. Most common type of incidental pathology was idiopathic osteosclerosis. The most uncommon type of incidental pathology was
regional odontodysplasia with 35 (38.88%), 25 (27.77) cases of cysts, 16 cases of supernumerary teeth (17.77%), 9 (10%) cases of sinus
abnormality, 4 (5.40%) of each findings were of odontome, dense in dente, internal resorption, and calcifications. About 1 (1.11%) of each
findings were regional odontodysplasia, focal cemental dysplasia. Conclusions: Conventional radiography is still most commonly used tool
to primarily investigate lesions quickly with low cost to patient and then further diagnostic and advanced radiological or other examinations
can be performed for comparison, periodic follow up, management, and research purposes.

Key words: Conventional radiography, incidental findings, North Indian population

Introduction prognosis is improved; moreover, it may reduce the mortality

Radiographic incidental findings of abnormality refers to
the occult or hidden abnormality that exhibits no clinical
signs and symptoms but is present as an incidental finding
when the radiograph is taken to detect some pathology
related to the patients chief complaint. Commonly, the
radiographs are prescribed when the dentist thinks that
they are likely to offer useful diagnostic information that
will influence the treatment plan. Often some clinical sign
or symptom or finding from the patient’s history indicates
the need for a radiologic examination. The information
obtained from the clinical examination is used first to
select the appropriate radiograph and later to aid in their
interpretation.[1] Radiographic incidental findings in the jaws
include a combination of dental and/or introsseous findings.
The consequences of some these incidental findings may
be quite serious.[2] Therefore, one should avoid limiting
attention to one particular region of the film; rather, all
aspects of each image should be examined systematically.
If the presence of any abnormalities detected in advance, the
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and morbidity rate to some extent.
There are only limited studies that have analyzed the
prevalence of abnormal findings in radiographs ordered
primarily for chief complaint related findings. Most of these
studies described as an isolated case reports on dentigerous
cysts, keratocystic odontogenic tumor (KOT), Gorlin Goltz
syndrome, and maxillary sinus or Temporomandibular
Joint pathologies. Only two studies handled this topic
in patients with pretreatment orthodontic panoramic
radiographs (orthopantomogram [OPG]), whereas in the
present study, patients from all age groups were included. Thus,
Address for correspondence: Dr. Gaurav Goyal,
Department of Oral Medicine and Radiology, Genesis Institute of Dental
Sciences and Research, Ferozepur, Punjab, India.
E‑mail: dr.gaurav867@gmail.com
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which
allows others to remix, tweak, and build upon the work non-commercially,
as long as the author is credited and the new creations are licensed under
the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Goyal G, Padda S, Kaur B. Unusual incidental
10.4103/2277-4696.192974 findings on intra- and extra-oral radiographs in North Indian Population: A
radiographic study. J Dent Allied Sci 2016;5:74-7.

74 © 2016 Journal of Dental and Allied Sciences | Published by Wolters Kluwer ‑ Medknow

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Goyal, et al.: Unusual Incidental radiographic findings

the aim of the present study was to evaluate the prevalence of

incidental findings of abnormalities on conventional dental
radiographs.
Aims and objectives
To detect the prevalence of unusual incidental findings on
intra‑ and extra‑oral radiographs in North Indian population:
A radiographic study.

Materials and Methods

This prospective study was conducted in the Department of
Oral Medicine and Radiology, Genesis Institute of Dental
Sciences and Research, after getting the approval from Ethical
Committee.
To evaluate the prevalence of incidental findings of Figure 1: Intraoral X-ray film showing idiopathic osteoscelrosis
abnormalities, all the intra‑  and extra‑oral conventional
dental radiographs were screened along with the radiographic
findings related to patient’s chief complaint. Radiographs
were not prescribed as a screening tool. All radiographic
examinations performed during January 2013–January 2015
at the Department of Oral Medicine and Radiology were
included in the study. Intra‑ and inter‑examiner accuracy and
reproducibility for each of the radiograph was done to increase
the authenticity of the study.
Exclusion criteria
Radiopaque lesions associated with dental caries, deep Figure 2: Panoramic radiograph showing idiopathic osteoscelrosis
restorations, or tooth extraction regions were not diagnosed
as idiopathic osteosclerosis, since they could be the result
of condensing osteitis or residual condensing osteitis, when
located in a tooth extraction region. Lesions located in tooth
extraction regions could also be the result of alveolar sclerosis.
Exostoses of the torus type were excluded by evaluating the
intraoral photographs.

Results
The patients in this study were advised radiographs
as a part of routine investigative procedures for their
chief complaints such as panoramic radiographs (OPG)
for orthodontic and periodontics work up, intraoral
periapical (IOPA) radiographs for evaluating periapical
region, lateral oblique for third molar and so on. A  total
of 6780 conventional intraoral and extraoral dental
radiographs were screened and ninety radiographs showed
incidental findings. A total of 10 varieties and 95 numbers
of incidental findings were noted. Out of 8962 radiographs,
4546 were of males and 2234 were of females. Out of
6780 radiographs, 90  (0.013%) radiographs showed
incidental findings. Out of these 95 incidental findings,
51  (53.68%) affected males and 44  (46.31%) affected
females. Out of 90, 44 (48.88%) were bony findings and
46 (51.11%) were dental findings. Most common type of
incidental pathology was idiopathic osteosclerosis with
35 cases (38.88%) [Figures 1 and 2], 25 (27.77%) cases of
cysts [Figure 3], 16 cases of supernumerary teeth (17.77%),
Figure 3: Panoramic radiograph showing Stafne bone cyst
9  (10%) cases of sinus abnormality, 4  (4.40%) of each
findings were of odontome, dense in dente, internal
resorption and calcifications, 1  (1.11%) of each findings
were regional odontodysplasia, focal cemental dysplasia.
The most common type of incidental pathology was idiopathic
osteosclerosis  (38.88%). The most uncommon type of
incidental pathology found was regional odontodysplasia.
The second most common type of incidental pathology that
was encountered was 25  (27.77%) cases of cysts, out of
which 15 were KOT; 4 were dentegerous cysts; 3 were Stafne
cysts [Figure 3]; and 3 were radicular cysts. The third type of
incidental pathology was 16 (17.77%) cases of supernumerary
teeth. Out of these 16 supernumerary teeth, 10 were in
maxillary anterior region and remaining 6 were in mandibular

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Goyal, et al.: Unusual Incidental radiographic findings

premolar‑molar region. The fourth type of incidental pathology The second most common incidental findings in our study
was sinus abnormality 9 (10%) cases. came out to be cyst, i.e., 27.77%. Out of various cyst KOT
had highest incidental radiographic findings because of its
Discussion propensity to grow along the internal aspect of the jaws,
causing minimal expansion.[6] The relatively slight expansion
Detection of incidental finding is not a deliberate procedure
common with these cysts probably contributes to their either
to find out one. However, its presence is appreciated during
late or incidental detection. As considerable numbers of
radiographic evaluation of the patient for the purpose which
KCOTs are asymptomatic and their clinical signs often fail
is not related to the incidental finding of abnormality. Hence,
to appear, these lesions are mostly detected in the late stage,
these are found on routine radiographic evaluations. Most
which occasionally allow them to reach a large size. The
common abnormalities usually found in bone are radiolucent,
radiographic appearance of KCOT may resemble that of many
mixed, or radiopaque lesions associated with the teeth and
other odontogenic lesions. If it is associated with a crown of an
introsseously in the jaws and may present as an incidental
unerupted tooth, it may be indistinguishable radiographically
findings on radiographs apart from the chief symptom of a
from dentigerous cyst.[7]
patient.
Dentigerous cysts are the second most common cysts occurring
Idiopathic osteosclerosis is an asymptomatic, nonexpansive,
in the jaws. A dentigerous cyst is formed as a result of fluid
and localized increase of bone radiopacity caused by an increase
accumulation in the reduced enamel epithelium surrounding an
in the width of the bone trabeculae at the expense of medullary
unerupted tooth. These cysts typically present as well‑defined
space. It is usually located in the mandibular premolar region.
pericoronal radiolucencies either superior or lateral to the
The lesion has benign characteristics and seems not to increase
unerupted tooth. Dentigerous cysts involving the posterior
over time. As described by DS MacDonald‑Jankowski
maxillary teeth tend to grow into and fill the maxillary sinus and
in 1999, [3] the radiographic appearance of idiopathic
hence are discovered late. Posterior mandibular dentigerous
osteosclerosis is a localized, well‑defined nonexpansile
cysts commonly extend well into the ramus. There are often
radiopacity, generally round or ovoid in shape; but sometimes
no clinical symptoms, with the exception of swelling once the
irregular. The results were in consistence to our study, as all
cyst reaches a considerable size.[8,9] Ramesh and Pabla[10,11]
cases we had encountered of idopathic osteosclersosis had well
found dentigerous cyst and Stafne bone defect as an incidental
demarked borders. On occasion, osteoscelrosis may be very
findings on a dental radiograph. Cysts definitely require
large sometimes occupying almost the whole height of the
histopathologic confirmation and enucleation which was
body of the mandible. The cause of idiopathic osteosclerosis
carried out in these cases.
is obscure. It is asymptomatic, uniformly radiopaque foci of
dense bone, usually with distinct outlines, that are apparently The supernumerary teeth are more commonly encountered
not the sequelae of infection or systemic disease. It has also clinically as well as radiographically. The impacted
been claimed that many radiopacities described as idiopathic supernumerary tooth requires disimpaction to avoid cyst
osteosclerosis may be developmental variations of normal formation or development of malocclusion.[12]
bony architecture, unrelated to local stimuli, which can arise
The maxillary sinuses are of particular importance to dentist
at any age and at any location in the jaws.[4] When the lesion
because of their proximity to dental structures. Part or all of
is present in the alveolous between first and second premolar,
the paranasal sinuses may appear on radiographs made for
its occurrence is generally described as a sequela of retained
dental purposes, including maxillary periapical, panoramic
roots. These retained roots are resorbed and replaced by
and lateral or posteroanterior cephalometric skull radiographs.
sclerotic bone or fragments of the roots are surrounded and
Antral polyp rarely causes any signs or symptoms and is
obliterated by the condensed bone.[5] Bondemark et al.[6] found
often noticed as an incidental finding on radiographs made
22 cases of idiopathic osteosclerosis. Idiopathic osteosclerosis
for other purposes. It usually requires no treatment because
does not require any treatment. Diagnosing idiopathic
they customarily resolve spontaneously without any residual
osteosclerosis accurately is a difficult task, since this lesion
effect on the antral mucosa and periodic follow up may be
may be radiographically mistaken for exostosis, including
required. One case of thickening of mucosal lining was seen
torus mandibularis and palatinus, residual condensing osteitis,
in peripheral nervous system which is frequently regarded as
alveolar calcification after exodontia (whether complicated or
nonpathologic; even if in some cases, it can be associated with
not), bone architectural change in response to occlusal trauma
symptoms. One case of antrolith was found in IOPA, antroliths
on an inclined tooth, particularly on mandibular second molars,
usually occur within the maxillary sinus and thus are positioned
when the first molars are missing. The lesion may even be
above the floor of maxillary antrum in periapical, occlusal or
mistaken for a radiographic projection over bone of a soft
panoramic radiographs.[13,14]
tissue calcification. The mere presence of teeth, their carious
lesions, occlusal traumas and infectious processes, as well as Most odontomas (70%) are associated with abonormalities
the primary teeth shedding process, may also cause bone tissue such a impaction, malpositioning, diastema, aplasia,
architectural changes, adding to the abovementioned enostoses malformation, and devitalization of adjacent teeth and should
and dense bone islands. be removed as early as possible.[15,16] Early identification of

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Goyal, et al.: Unusual Incidental radiographic findings
internal resorption is vital, it may be transient and self‑limiting
or progressive, if endodontic treatment is started early or in
time it halts the resorption. Most cases of dense in dente are
discovered fortuitously and can be identified even before tooth
erupts. Failure of early identification may result in premature
tooth loss or they require root canal treatment.[16]
Thus, the data acquired from the findings of this study put forward
that radiologist should not only interpret characteristic findings of
the pathological conditions related to the chief complaint of the
patient but also analyze coincidental findings. Moreover, this is
not the one time activity but it is an ongoing process.
Conclusions
Various incidental findings in radiographic images are to be
expected. Dental findings were the encountered more common
than bone findings. In the present study, we had incidentally
reported maximum cases idopathic osteosclerosis followed
to KOT. Idopathic osteosclerosis lesions can arise at any age,
at any location, and usually requires no treatment other than
diagnosis by recognition. As KOT shows relatively slight
expansion common with cysts probably contributes to their
either late or incidental detection. As considerable numbers
of KOTs are asymptomatic and their clinical signs often fail
to appear, these lesions are mostly detected in the late stage.
Hence, the detailed and elaborate reports prepared by oral and
maxillofacial radiologists may bring many important aspects,
which can simply be overlooked, into clinicians’ attention.
Therefore, to detect more and more incidental finding, a
thorough radiographic examination should be accomplished
by applying a step by– step analytic process in a systematical
order to enhance the scrutiny of all parts of images which
can maximize the likelihood of detecting all abnormalities.
A thorough review of all radiographic images will ensure early
diagnosis and management of incidental pathologies while a
good documentation of significant anatomical variations will
provide important preoperative information.
Financial support and sponsorship
Nil.
Journal of Dental and Allied Sciences  ¦  Jul-Dec 2016  ¦  Volume 5  ¦  Issue 2
Conflicts of interest
There are no conflicts of interest.
References
1. White SC, Pharoah MJ, editors. Principles of radiographic interpretation.
In: Oral Radiology. Principles and Interpretation. 5th  ed. St. Louis:
Mosby; 2004. p. 281‑96.
2. Brooks SL, Atchison KA. Guidelines for prescribing dental radiographs.
In: White  SC, Pharoah  MJ, editors. Oral Radiology. Principles and
Interpretation. 5th ed. St. Louis: Mosby; 2004. p. 265‑77.
3. MacDonald‑Jankowski  DS. Idiopathic osteosclerosis in the jaws of
Britons and of the Hong Kong Chinese: Radiology and systematic
review. Dentomaxillofac Radiol 1999;28:357‑63.
4. Geist  JR, Katz  JO. The frequency and distribution of idiopathic
osteosclerosis. Oral Surg Oral Med Oral Pathol 1990;69:388‑93.
5. Wood NK, Goaz PW. Solitary radiopacities not necessarily contacting
teeth. In:Wood NK, Goaz PW. Oral and Maxillo-facial lesions. 5th ed. St
luis: Mosby; 1996. p. 488-92.
6. Bondemark  L, Jeppsson  M, Lindh‑Ingildsen  L, Rangne  K. Incidental
findings of pathology and abnormality in pretreatment orthodontic
panoramic radiographs. Angle Orthod 2006;76:98‑102.
7. White SC, Pharoah MJ. Cysts of the jaws. In: White SC Pharoah MJ.
Oral Radiology. Principles and interpretation. 5th ed. St Lous, Mosby;
2004. p. 394-6.
8. Farah CS, Savage NW. Pericoronal radiolucencies and the significance
of early detection. Aust Dent J 2002;47:262‑5.
9. Gonzalez SM, Spalding PM, Payne JB, Giannini PJ. A dentigerous cyst
associated with bilaterally impacted mandibular canines in a girl: A case
report. J Med Case Rep 2011;5:230.
10. Ramesh  A, Pabla  T. Incidental findings on dental radiographs:
Dentigerous cyst. J Mass Dent Soc 2009;58:42.
11. Ramesh A, Pabla T. Incidental findings on dental radiographs: Stafne
bone defect. J Mass Dent Soc 2009;58:42‑3.
12. Rai HC, Shetty DC, Kumar A, Dua M. Incidental finding of jaw
lesions- a case report and its review of literature. The Internet Journal of
Pathology 2011;11:21-2.
13. Ruprecht A, Lam  EW. Paranasal sinuses. In: White  SC, Pharoah  MJ,
editors. Oral Radiology. Principles and Interpretation. 5th ed. St. Louis:
Mosby; 2004. p. 576‑84.
14. Petrikowski  CG. Diagnostic imaging of temporomandibular joint.
In: White SC Pharoah  MJ, editors. Oral Radiology. Principles and
Interpretation. 5th ed. St. Louis: Mosby; 2004. p. 552.
15. Blasberg B, Greenberg MS. Temporomandibular Disorders. In: Burkets
Oral Medicine Diagnosis and treatment. 10th ed. Ontario: BC Decker;
2003. p. 271-306.
16. White  SC, Pharoah  MJ, editors. Benign tumors of the jaws. In: Oral
Radiology. Principles and Interpretation. 5th  ed. St. Louis: Mosby;
2004. p. 425‑7.
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Review Article

Diagnosis and Management of Periodontal Disease in Children

and Adolescents: A Brief Review
Vineet Kini, Raju Umaji Patil1, Tushar Pathak, Amit Prakash2, Bharat Gupta
Department of Periodontics, MGM Dental College and Hospital, Navi Mumbai, 1Department of Pedodontics and Preventive Dentistry, STES Sinhgad Dental College and
Hospital, Pune, Maharashtra, 2Department of Orthodontics, Peoples College of Dental Sciences, Bhopal, Madhya Pradesh, India

Abstract
Periodontal disease when occurring in children leads to premature tooth loss, affecting the quality of life. Thus, screening pediatric and
adolescent patients early, for periodontal disease is deemed imperative to its early management for improved prognosis. Chronic periodontitis
(CP) has slow rate of progression, whereas aggressive periodontitis (AP) affecting children and young adults has rapid rate of progression. The
management of AP in particular is affected by bacterial virulence of Aggregatibacter actinomycetemcomitans and Porphyromonas gingivalis
in plaque leading to rapid attachment and bone loss around the affected teeth. Nonsurgical treatment, use of appropriate antimicrobial therapy,
and surgical correction of defects is required to mitigate disease followed by a comprehensive supportive periodontal therapy. This review
visits the current understanding of periodontal disease, its management in pediatric and adolescent patients.

Key words: Adolescent, aggressive periodontitis, children, chronic periodontitis, periodontitis

Introduction of progression serving as a criteria for diagnosis. CP with slow

The most prevalent periodontal diseases are plaque‑associated
gingivitis and periodontitis. Plaque‑associated gingivitis being
inflammation of the marginal gingiva, whereas in periodontitis,
there is loss of tooth‑attached fibers and alveolar bone in the
affected teeth.[1] American Academy of Periodontology (AAP)
classification of periodontal disease  (1989) based on the
World Workshop in Clinical Periodontics  (1989), have
recognized the Early Onset Periodontitis complex. Early
onset periodontitis was divided into prepubertal periodontitis,
juvenile periodontitis, and rapidly progressive periodontitis
based mainly on early age of onset of the disease and rapid rate
of progression of attachment loss.[2] Adult onset periodontitis
has slow rate of progression with the onset of disease in
adulthood.[2] The International Workshop for a Classification
of Periodontal Diseases and Conditions (1999) changed the
classification and categorized plaque‑induced periodontal
disease into aggressive periodontitis (AP) for early‑onset
periodontitis, and chronic periodontitis (CP) for adult onset
periodontitis.[3,4] This classification currently followed by The
AAP (1999) is based on an infection/host response paradigm
in which the age of onset not being a consideration but the rate
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rate of progression and no site specificity, with attachment and
bone loss consistent with local irritating factors (plaque and
calculus) usually occurs in adults but can affect children as
well, whereas AP occurs mostly in children and young adults
with rapid attachment loss and bone destruction inconsistent
with the amount of dental calculus and plaque with increased
proportions of A. actinomycetemcomitans and P. gingivalis.
In AP, there is marked molar incisor site specificity, history
of familial aggregation, phagocyte abnormalities, hyper
responsive macrophage phenotype including increased levels
of prostaglandin E2 and interleukin (IL)‑1β. Progression of
attachment loss and bone loss may be self‑arresting.[2‑4]
Address for correspondence: Dr. Raju Umaji Patil,
Department of Pedodontics and Preventive Dentistry, STES Sinhgad Dental
College and Hospital, S. No. 44/1, Vadgaon Budruk, Off Sinhgad Road,
Pune ‑ 411 041, Maharashtra, India.
E‑mail: rupat13@yahoo.com
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which
allows others to remix, tweak, and build upon the work non-commercially,
as long as the author is credited and the new creations are licensed under
the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Kini V, Patil RU, Pathak T, Prakash A,
10.4103/2277-4696.192978 Gupta B. Diagnosis and management of periodontal disease in children and
adolescents: A brief review. J Dent Allied Sci 2016;5:78-83.

78 © 2016 Journal of Dental and Allied Sciences | Published by Wolters Kluwer ‑ Medknow