IMAGING IN PERIODONTICS

CONTENTS
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Introduction Radiography Digital radiography Subtractional radiography Computer assisted subtractional radiography Diagnostic Subtractional Radiography DSR Computer Assisted Densitometric Image Analysis CADIA Panoramic imaging Intraoral photographic imaging CT Scan MRI Bone Scanning Conclusion

INTRODUCTION
What is imaging?  Imaging is the action or process of producing images, animations, 3dimensional computer graphics or any other spatial representation of a physical object.

RADIOGARPHS
Radiographs play an important role in assessment of periodontal disease.  They provide unique information about status of periodontium & permanent record of condition of bone throughout the course of disease.

Radiographs are especially helpful in evaluation of following factors –  Amount of bone present.  Condition of alveolar crest.  Bone loss in furcation areas.  Width of periodontal ligament space.  Relationship between alveolar bone margin & CEJ.  Local irritating factors such as calculus & poorly contoured or overextended restorations.  Anatomic considerations in relation to a periodontal deformity.

There are 2 types of radiographs – Intraoral & Extraoral 1- Intraoral radiographs (a) IntraOral Periapical Radiographs- These are radiographs used to view the teeth & periodontium. Prichard established following 4 criterias to determine adequate angulation of periapical radiographs(1)The radiograph should show the tips of molar cusps with little or none of occlusal surface showing.

(2) Enamel caps & pulp chambers should be distinct. (3) Interproximal space should be open. (4) Proximal contacts should not overlap unless teeth are out of line anatomically.  Two intraoral projection techniques are used for periapical radiography (i) Paralleling technique.  (ii) Bisecting angle technique.

(i)

(ii)

Paralleling technique - Also called as “right angle” or “long cone technique”.In this technique x-ray film is placed parallel to long axis of tooth and central ray of x-ray beam is directed at right angle to teeth & film. Bisecting angle technique - In this technique, central ray is directed at right anglesto a plane bisecting the angle between long axis of teeth & film.

(b) Bitewing radiographs – They record the coronal part of upper & lower dentition along with periodontium. Bitewing radiographs are used – (1) To study height & contour of interdental alveolar bone. (2) To detect interproximal calculus. (3) To detect periodontal changes.

(c) Occlusal Radiographs – Intraoral occlusal radiographs enable viewing of a relatively large segment of dental arch. They are useful in patients who are unable to open mouth wide enough for periapical radiographs.

(d) Intraoral Radiographic Survey – It should consists of a minimum of 14 intraoral films & 4 posterior bite-wing films.

Limitations of radiographs
(1) (2)

(3)

(4)

Radiographs provide a 2-dimensional view of a 3-dimensional situation. More than 30% of bone mass at alveolar crest must be lost for a change in bone height to be recognized on radiographs. Radiographs do not demonstrate soft tissue - to - hard tissue relationship & thus provide no information about depth of soft tissue pocket. Bone level is measured from CEJ, this reference point is not valid in situations in which either overeruption or severe attrition exists.

DIGITAL RADIOGRAPHY
A new technology used increasingly in dental offices is digital radiography. The term digital imaging refers to numeric format of image contents as well as its discreteness.

ADVANTAGES
(1) Ability to produce a image that can instantly be viewed by patient & dentist. (2) Reduction in radiation received by patient by as much 50% to 80% when compared to conventional radiography. (3) Images can be altered to achieve task specific image characteristics for eg. density & contrast can be lowered for evaluation of marginal bone and increased for evaluation of implant components. (4) Digital imaging also enables dental team to conduct remote consultations. (5) Computerized images can be stored, manipulated & corrected for under & overexposure.

There are 2 digital radiography methods Direct & Indirect methods (1) Direct Method/RVG - This method uses a Charge Couple Device (CCD) sensor linked with fiberoptic or other wire to computer system. Direct digital radiography obtains ‘real-time’ imaging. CCD receptor is placed intraorally as traditional films & images appear on a computer screen which can be printed or stored.

(2) Indirect Method - This method uses a phosphor luminescence plate, which is a flexible film like radiation energy sensor placed intraorally & exposed to conventional x-ray tube. A laser scanner reads the exposed plates & reveals digital image data.

DISADVANTAGES
(1) (2) (3) (4)

High initial cost of equipments & setup which is approximately $10000 to $15000. Lack of infection control. Patient discomfort during placement. As image can be easily manipulated, it can be misused in legal proceedings.

SUBTRACTION RADIOGRAPHY
This technique relies on conversion of serial radiographs into digital images.  The serially obtained digital images can then be superimposed & resultant composite viewed on a video screen.  This technique facilitates both qualitative & quantitative visualization of even minor density changes in bone by removing the unchanged anatomic structures from image.

COMPUTER ASSISTED SUBTRACTION RADIOGRAPHY

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This technique requires a parallelization technique to obtain a standardized geometry & accurate superimposable radiographs. Radiographs are then scanned using a microphotometer. After superimposition of 2 subsequent radiographs this technique can show differences in relative densities. There is increased detectibility of small osseous lesions compared with conventional radiographs. DISADVANTAGE- Need of identical projection alignment during exposure of sequential radiographs.

DIAGNOSTIC SUBTRACTION RADIOGRAPHY
It is a recently introduced technique combining the use of a positioning device with specialized software designed for digital image subtraction.  This software system applies an algorithm that corrects angular alignment discrepencies & provide flexibility in imaging procedures.

COMPUTER ASSISTED DENSITOMETRIC IMAGE ANALYSIS SYSTEM(CADIA)
In this system a video camera measures the light transmitted through a radiograph & the signals from the camera are converted in to gray scale images with the help of image processor & a computer that allows storage and mathematical manipulation of images. AdvantagesHigher sensitivity High degree of reproductivity and accuracy

PANORAMIC IMAGING – PANTOMOGRAPHY
It is an extraoral radiographic technique used for providing a single tomographic image of facial structure that includes both maxillary and mandibular dental arches and their supporting structures. OPG provide an overall radiographic picture of distribution and severity of bone destruction in periodontal disease.

DISADVANTAGES OF PANORAMIC IMAGING
Not useful as periapical radiography for detecting small carious lesion and fine structure of marginal periodontium.  Presence of overlapping stuctures eg. cervical spine.

INTRAORAL PHOTOGRAPHIC IMAGING
This technology gives patient inside look at their teeth and a better image and understanding of their oral health.  It chiefly makes use of intraoral photographs for diagnosis, prevention & treatment of periodontal diseases.

ADVANTAGES  It gives patients a sense of ownership of their mouth.  It enhances patient acceptance of treatment & recommendations.  Easy comparison of pre & post-operative status. Types Of Intraoral Photographic Imaging (1) Traditional 35 mm intraoral camera. (2) Intraoral Video Imaging System

TRADITIONAL 35 MM INTRAORAL CAMERA
In newer cameras all functions are performed electronically, allowing the dentists to take excellent images without changing camera settings.  Components(1) Lens (2)Shutter release (3)F-stop (Aperture setting) (4)Film (5)Flash

INTRAORAL VIDEO IMAGING SYSTEM
   (1) (2) (3) (4) (5) (6)

These systems have been in use in dentistry since 1990s. Images obtained can be viewed on monitor, stored on a computer disc or printed on a hard copy. ComponentsMicrocamera, contained in a slender handpiece. Lighting Automatic iris Focussing mechanism Monitor Printer

(1) (2)

(3)

According to advancements in technology, intraoral video imaging systems can be divided asIst generation systems based on analog technology IInd generation systems based on hybrid technology (Between analog & digital technology ). IIIrd generation systems based on digital technology.

COMPUTED TOMOGRAPHY SCAN – CT SCAN

CT (computed tomography), uses special x-ray equipment to obtain image data from different angles around the body and then uses computer processing of the information to show a cross-section of body tissues and organs. CT scanner consists of a radiographic tube that emits finely collimated, fan-shaped x-ray beam directed to a series of ionization chambers. While the gantry containing x-ray tube & detectors revolve around the patient, the table on which the patient is lying continuously advances through the gantry.

Advantages Over Conventional Radiography
   

Claimed to be 100 times more sensitive than conventional x-rays. It completely eliminates the superimposition of images. Differences between tissues that differ in physical density by less than 1% can be distinguished. Images can be seen in axial, coronal, or sagittal planes, depending on diagnostic task referred as “multiplaner reformatted imaging”.

MAGNETIC RESONANCE IMAGING
MRI is an non invasive method which uses radiofrequency waves and a strong magnetic field rather than x-rays to provide clear and detailed pictures of internal organs & tissues.

EQUIPMENTS

The conventional MRI unit is a closed cylindrical magnet in which the patient must lie totally still for several seconds at a time and consequently may feel "closed-in" or truly claustrophobic. However, new "patient-friendly" designs rapidly coming into routine use. The "short-bore" systems are wider and shorter and do not fully enclose the patient. Some newer units are open on all sides, however the image quality may vary.

Advantages Over CT
 

Absence of radiation exposure. High contrast sensitivity to tissue differences makes it more suitable for imaging periodontal soft tissues. MRI can generate cross-sectional views in any plane while CT is limited to axial , coronal or sagittal planes only.

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DisadvantagesLonger imaging times(20 to 45 minutes) Alveolar bone is better visualized by CT scan. Expensive than CT. It is contraindicated in first 1-2 months of pregnancy Restorations ,braces or bridges may distort the image. Can’t be used in patients having metallic implants like pacemaker, cerebral aneurysm clips.

BONE SCANNING or RADIONUCLIDE IMAGING

In contrast to X-ray, CT, MRI which require structural or anatomic changes to be recorded, this technique assesses biochemical alteration in periodontium. Its a nuclear scanning test that identifies new areas of bone growth or breakdown. It can be done to evaluate damage to the alveolar bones, and monitor conditions that can affect the periodontium (including infection and trauma)

PROCEDURE

For a bone scan, a radioactive tracer eg. 99m technetium pertechnetate substance is injected into a vein in the arm. The tracer then travels through the bloodstream and into the bones. Areas that absorb little or no amount of tracer appear as dark or "cold" spots, which may indicate a lack of blood supply to the bone (bone infarction) or the presence of certain types of cancer.

Areas of rapid bone growth or repair absorb increased amounts of the tracer and show up as bright or "hot" spots in the pictures. Hot spots may indicate the presence of a tumor, a fracture, or an infection. Other radioactive isotopes used are – iodine(131 I), gallium(67 Ga) & selenium(74Se).

LIMITATIONS
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Can’t differentiate between normal & abnormal bone growth. Takes longer time (about 1 hour). Contraindicated in pregnancy. Bone scanning should be performed before any test that use barium

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CONCLUSION

Conventional and advanced imaging systems have proven a boon for diagnosis in periodontology .Further advancements are also expected in near future. But these systems are technique sensitive & not free from mechanical errors so a clinician should also consider clinical signs & symptoms while reaching to final diagnosis for a periodontal condition.

REFERENCES
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Clinical Periodontology IXth edition -Newman;Takei;Carranza Clinical periodontology & Implant Dentistry -Jan Lindhe;Thorkild Karring;Niklaus P.Lang Dental Hygeine – Concepts,cases & competencies - Deniel & Harfst Oral Radiology-Principles & Interpretation -S.C.White;M.J. Pharoah

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