2/24/2023

RADIOGRAPHIC
INTERPRETATION OF
LESIONS RELATED TO THE
TEETH AND THEIR
SUPPORTING STRUCTURES

There are two important aspects to be

considered:
1. Films of high radiographic quality should be
used (regarding technique, exposure and
processing)

2. Systemic approach to viewing the radiograph

(General overview and evaluation of the entire
radiograph then evaluation of the tooth crown
and root in addition to its supporting structures)

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RADIOGRAPHIC EVALUATION OF DIFFERENT

LESIONS RELATED TO THE TEETH AND THEIR
SUPPORTING STRUCTURES
I. RADIOGRAPHIC ASSESSMENT OF CARIES:
- Appear radiolucent due to demineralization and
decreased density allowing more penetration of x-ray in
the carious area.
- Detectable only when there has been enough
demineralization to allow the lesion to be differentiated
from enamel and dentine ( 50% demineralization)
- Can be seen in periapical radiographs but bite-wing
radiographs are more satisfactory when diagnosing inter-
proximal caries(proper film technique and processing +
open contacts)
- Panoramic radiographs are of limited value in caries
detection
- Acquire different shapes and occur in crown or root

Proximal caries susceptible zone

caries
(between contact and free gingival margin)

Approximately 50 % demineralization is required for

radiographic detection of a lesion. As seen in the
occlusal view, above right, the thickness of the tooth
buccolingually masks the carious lesion when it is
small (in any type of caries).
The actual depth of penetration of a carious lesion
is deeper clinically than radiographically.

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Sequence for radiographic diagnosis of caries:

- Trace the outline of the enamel cap, the enamel dentine
junction, the neck, and the cervical 1/3 of the root.
- Alterations in the outline of the tooth may appear as:
a. Radiolucent triangular shadows caused by cavities
in enamel inter-proximally with the apex of the
triangle seen at the DEJ, as caries spreads into dentine
another triangle is seen, with its base along the DEJ this
time and its apex directed towards the pulp.
b. Radiolucent saucer-shaped radiolucencies in
dentine at the occlusal (and interproximal) surfaces
or oval round areas seen in the smooth buccal and
lingual surfaces.
c. Radiolucent saucer-shaped shadow in the root
caused by root caries.

Radiographic Appearance of Caries

Types of caries seen radiographically:

1. Interproximal Caries .
2. Occlusal Caries.
3. Buccal and Lingual [Palatal] Caries.
4. Root Surface Caries.
5. Rampant Caries.
6. Recurrent Caries.
7. Radiation Caries.

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1. Interproximal caries
(between the contact area and free gingival margin)
Inter-proximal Caries Classification
(according to the depth of penetration into enamel and dentine)

I M A
A

I = Incipient (Stage I)
M = Moderate (Stage II)
A = Advanced (Stage III) S
S = Severe (Stage IV)

1. Incipient
interproximal Caries

An incipient interproximal lesion is seen

in enamel only and it extends less than
to half the thickness of enamel.

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I- Inter-proximal Caries
A] Incipient Caries:

2. Moderate
interproximal Caries

A moderate interproximal lesion is seen in

enamel only and it extends more than
halfway through the enamel but not
involving the DEJ.

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I- Inter-proximal Caries
B] Moderate lesions:

3. Advanced
interproximal Caries

A
A
An advanced interproximal lesion involves both
enamel and dentine. It extends through the DEJ into
dentine but only involves less than half the
thickness of dentine in the direction towards the
pulp.

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I- Inter-proximal Caries
C] Advanced lesions:

4. Severe interproximal
Caries

A severe interproximal lesion also involves

enamel and dentine. It extends through
dentine more than half the distance towards
the pulp.

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I- Inter-proximal Caries
D] Severe lesions:

Incipient
Moderate
Advanced

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Advanced

Severe lesion

2. Occlusal caries
Occlusal caries does not usually appear radiographically
unless the lesion penetrates into dentine involving the DEJ,
this is because of the superimposition of the dense buccal
and lingual enamel cusps on the carious radiolucent lesion.
Occlusal caries can be classified as :
1. Incipient: Occurs in enamel only and usually cannot be seen
radiographically
2. Moderate: Extends into dentine and seen as a thin RL line
under the DEJ
3. Severe: Extends into dentine and seen typically as a broad-
based radiolucent zone under the DEJ

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2. Occlusal Caries
Moderate lesions:

Occlusal caries: seen when penetrates into dentine

2. Occlusal Caries
Moderate (YELLOW) and severe (RED) lesions:

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3. Buccal and Lingual caries

- Buccal and lingual caries are difficult to detect

radiographically due to the superimposition of
normal tooth structure.
- When apparent radiographically, it appears as a
well defined oval or round radiolucency whose
depth and exact location cannot be determined
from the radiograph.

Severe interproximal

Advanced
interproximal

Buccal/lingual caries: diagnosed clinically

and cannot determine its depth

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Buccal and Lingual [Palatal] Caries

4.Root caries:
Cemental or radicular
Caries.
Involves cementum
and dentine

Root caries: older

patients with
periodontitis or
gingival recession
(appear saucer-shaped)

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Root Surface Caries

"Cemental caries", "Radicular caries" or "Senile caries“
- It involves both cementum & dentin (buccal, lingual and interprox)
-  in older age (gingival recession + periodontitis + loose contacts) .
- They are most commonly found in the mandibular molar & premolar
region. Usually affects patients with xerostomoa
- Small lesions  "notched" RL. - Larger lesions  ill-defined
"saucer-like “.

Limitations of radiographs in diagnosis of caries:

- Carious lesions are always larger clinically than radio-graphically.
- Technique variations can affect the image of the carious lesion.
- Varying the horizontal angulation can make a lesion
confined to enamel appear to have progressed into dentine.
- The presence of recurrent caries may also be obscured
completely by the restoration due to superimposition.
- Caries detection is improved with a lower kvp which provides
higher contrast.
- The radiograph is a two dimensional image therefore limiting :
a. The actual site of a carious lesion whether buccal or lingual.
b. The bucco-lingual extension of a lesion.
c. The distance between the lesion and the pulp horns.

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5. Rampant Caries

Extensive and rapidly progressing

caries usually found in children and
teens with poor diet and inadequate
oral hygiene

Rampant caries

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6. Recurrent Caries
Recurrent caries is found around the
margins of existing restorations.
May be due to unusual susceptibility of the
patient to caries, poor oral hygiene, failure
to remove all of the caries during cavity
preparation, a defective restoration or a
combination of the above.

Recurrent caries
(red arrows)

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7. Radiation caries: Numerous large cervical

carious lesions

Radiolucencies misinterpreted as
dental caries
1. Cervical Burn out

2. Restorative and Base Materials

3. Developmental/acquired defects in enamel

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1. Cervical Burnout (misinterpreted as caries)

Cervical burnout is an apparent wedge-shaped
radiolucent artifact found just below the CEJ on the
mesial and distal root surfaces due to anatomical
variation (concave root formation posteriorly) or a gap
between the enamel and bone covering the root
(anteriorly). Mimics root caries. Posteriorly, this
radiolucency usually disappears when another film of
the region is examined.

In general, caries does NOT occur on the root of

the tooth unless there is loss of alveolar bone and
gingival tissue due to recession or periodontitis.

Posterior cervical burnout. The invagination of the

proximal root surfaces allow more x-rays to pass
through this area, resulting in a more radiolucent
appearance on the radiograph (over exposure of the
lateral surface of teeth between enamel and alveolar
bone). X-rays directed at a different angle usually pass
through more tooth structure and the radiolucency
disappears.

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Radiolucency seen at left (arrow) disappears on periapical

film of same tooth. This is cervical burnout. Caused by over
exposure of the lateral portion of the teeth between enamel
and alveolar crest.

Anterior cervical burnout: The space between the

enamel and the bone overlying the tooth will appear
more radiolucent than either the enamel or the bone-
tooth combination.

bone level

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Cervical burnout in the

anterior region due to gap
between enamel (red
arrows) and alveolar bone
over root (blue arrows).

Appears as a RL band
across the cervical neck of
anterior teeth.

Cervical Burn out

absorbs less x-rays than the areas

above [crown covered by enamel]
& below [root covered by alveolar
bone]
May be also due to poor
horizontal angulations

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Cervical Burn out and root caries

Cervical Burn out. Root caries

2. Restorative and Base Materials

1. Amalgam & gold restorations  RO.
2. Older silicate & plastic restorations  RL (often underlined by a RO
base).
3. Anterior composite restorations RO.
4. Zinc oxide-eugenol & zinc phosphate cements RO (contain Zn).
5. Older calcium hydroxide  RL but the newer ones  RO (Additives).

N.B. well-defined, smooth, classic outline of the cavity +

dental history & clinical examination will differentiate
between the restorations & caries.

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3. Developmental/acquired defects in enamel

-Developmental defects, particularly enamel hypoplasia, can

simulate caries radiographically.

-Pits & fissures (if stained) on the facial and lingual (identified by
clinical examination)

-The attrition cavity on the occlusal or incisal surfaces of teeth may

appear as dental caries on the radiograph.

-Abrasion  V-shaped depression simulate carious lesions on the

radiograph.

ENAMEL HYPOPLASIA:
Enamel hypoplasia is a defect in the
enamel due to disturbance of
ameloblastic function during
amelogenesis. The etiology of such
a disturbance may be either genetic
or
environmental
in nature.

Enamel defects
may resemble
caries
radiographically.

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ABRASION - blue arrows point to an example of tooth brush abrasion

that affects the root surface of a tooth and may be confused with root
surface caries. On a dental radiograph, tooth brush abrasion appears as
a well-defined horizontal radiolucency along the cervical region of a
tooth. A clinical examination can help confirm this diagnosis.

Attrition

Or the mechanical wearing down of

teeth, which may be mistaken for
dental caries on a radiograph.
Attrition may be seen on the incisal
or occlusal surfaces of deciduous or
permanent teeth.

Clinical examination enables the

dental professional to distinguish
attrition from caries.

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II. RADIOGRAPHIC ASSESSMENT OF

THE PULP:

Being soft tissue, the pulp appears radiolucent

radio-graphically. Information is thus obtained
from observing presence of radio-opacities
(calcifications) or changes in the size and shape
of the pulp chamber and root canals.

Radiographic changes of the pulp:

1. Calcifications of the pulp:
a. Pulp stones: Pulp stones are
foci of calcification in the dental Pulp stones
pulp. The occur commonly,
mostly in adults but may also be
seen in children. They appear as
single or multiple opacities
within the pulp chamber or root
canal of one or more teeth with
the pulp usually retaining its
normal outline. They occur in
all tooth types but more
commonly in molars.

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b. Pulpal sclerosis or calcific degeneration of the pulp:

Seen as small flecks of radio-
opacities within the pulp
chamber and root canals. In
contrast to pulp stones,
pulpal sclerosis is a diffuse
process. Although its
specific reason is unknown,
its appearance strongly
correlates with age. May also
occur as a stage in the
degenerative process of the Pulpal sclerosis
pulp associated with irritants
as deep cavities or trauma.

c. Pulp obliteration:
- Obliteration of the pulp of a single tooth occurs due to
a non-lethal injury to the tooth as a blow, thus it is
usually seen in anterior teeth. It may also be provoked
by irritants like progressive caries, erosion, attrition, or
dental restorative procedure. The pulp recedes and is
replaced by secondary dentine until no pulp space is
present radio-graphically. If complete pulp obliteration
occurs the tooth is symptomless.
- Obliteration of the pulp of multiple teeth by secondary
dentine occurs normally as a part of the aging process,
or associated with a pathologic condition like
dentinogenesis imperfecta. Pulp recession occurs until
the chamber and root canals are no longer visible.

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Secondary to carious
Pulp lesions and deep
restorations
obliteration

Obliteration
Pulp obliteration stimulated by
provoked by severe
aging attrition

2. Internal resorption: Inflammatory hyperplasia

of the pulp:
Seen as destruction of the tooth starting within the
pulp chamber or root canals. Occurs by a vital pulp,
if the pulp becomes non vital, the resorption stops.
The cause can be a lethal insult to the pulp as a
deep restoration, a large cavity or trauma. Resorption
may continue till the pulp tissue is only covered by
enamel and a pink color is visible clinically. If
proliferation of the external surface occurs, pulp
death follows.
Radio-graphically: Radiolucency continuous with
the root canal or pulp chamber.

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Internal resorption

THANK YOU

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