GUIDED BY PRESENTED BY Principles of

D R . V. S A I R A M
SAMHITHA
E.VEDA
- D E P T. O F O R A L
Radiographic
MEDICINE
AND RADIOLOGY Interpretation
 TERMINOLOGY :
Interpret : to offer an explanation
Interpretation : an explanation
Radiographic interpretation : an explanation of what is viewed on a radiograph
Diagnosis : the identification of a disease by examination or analysis.
 ROLE OF RADIOGRAPHS
For Clinical Examination
To Confirm/exclude Diagnosis
Treatment planning
During Treatment
Follow up
ESSENTIAL REQUIREMENTS
FOR DENTAL RADIOGRAPHS:
Optimum viewing conditions
Knowledge of what dental radiographs should look like.
Detailed knowledge of radiographic appearance of normal structures and variants
of normal structures.
Detailed knowledge of radiographic appearances of pathological conditions
affecting head and neck
Radiologic interpretation or visual diagnosis is a multistep process that begins with the
identification of an abnormality on an image.
A systematic approach identifies the key features of the abnormality, which are linked to
the mechanisms of disease that determine the radiologic presentation.
A systematic search strategy involves the identification of a list of normal anatomic
structures that would be contained within the image.
A thorough appreciation of normal anatomy and its variants is a vital first step in image
interpretation.
 When an abnormality is detected in an image, the clinician must then focus on
formulating an interpretation or diagnosis of the abnormality.
In a periapical image, the list might include the crown, root structure, pulp chamber and root
canal system, periodontal ligament space, and lamina dura.
In a panoramic image, this strategy might involve identifying the posterior border of the
maxilla, the floor of the maxillary sinus, the zygomatic process of the maxilla, and the orbital
rim.
In a data set of cone beam computed tomography (CBCT) images, normal anatomy would be
reviewed through the entire image volume in the axial, coronal, and sagittal imaging planes.
ANALYSIS OF ABNORMAL
FINDINGS
ANALYTIC OR SYSTEMATIC
STRATEGY
STEP 1: LOCALIZE THE
ABNORMALITY
• Localized or Generalized
The anatomic location of the abnormality and its extent should be described.
If an abnormal appearance affects all the osseous structures of the
maxillofacial region uniformly, generalized disease processes, such as
metabolic or endocrine abnormalities of bone, should be considered.
If the abnormality is localized, is the abnormality unilateral or bilateral?
Abnormal conditions such as fibrous dysplasia are more commonly unilateral,
whereas Paget disease of bone and cherubism are always seen bilaterally in the jaws
.
POSITION IN THE JAWS
Identification of the geometric center or epicenter of a lesion may assist in
determining the cell or tissue types contained within the abnormality in question.
The epicenter can be estimated by identifying the midpoint of the mesial-distal,
superior-inferior, and buccal-lingual extensions of the abnormality.
This estimation may become less accurate with very large lesions or lesions with
poorly defined borders.
The following are a few examples of relating the epicenter of the lesion to the tissue
of origin:
If the epicenter is located coronal to a tooth, the lesion probably is likely to be
odontogenic in origin.
If the epicenter is located superior to the inferior alveolar canal (IAC), the
likelihood is greater that it is of odontogenic origin
If the epicenter is located inferior to the IAC, it is unlikely to be odontogenic
in origin; rather, it is more likely to have arisen from nonodontogenic cell
sources.
If the epicenter is located within the IAC, the lesion is likely neural or
vascular in nature
The probability of lesions arising from cartilaginous sources is greater in the
condylar head region.
If the epicenter is within the maxillary antrum, the lesion is not of odontogenic
origin, as opposed to a lesion that has displaced the antral floor from the alveolar
process of the maxilla
The other reason to establish the exact location of the lesion is that some abnormalities may
be found in very specific locations within the jaws, although location in and of itself should
never be used as the sole characteristic feature when abnormalities are being interpreted.
The following are a few examples of this observation:
• The epicenters of central giant cell lesions are commonly located mesial to the first molar
teeth in the mandible and mesial to the canine teeth in the maxilla in young patients.
• Osteomyelitis occurs more commonly in the mandible and rarely in the maxilla.
• Periapical osseous dysplasia occurs in the periapical regions of teeth(Fig)
 SINGLE OR MULTIPLE
Establishing whether an abnormality is solitary or multiple aids in understanding the disease
mechanism of the abnormality.
Additionally, the list of possible multiple, similarly appearing abnormalities in the jaws is
relatively short.
Examples of lesions that can be multifocal in the jaws are cemento-osseous dysplasia,
odontogenic keratocysts, metastatic malignant lesions, multiple myeloma and leukemic
infiltrates.
STEP 2: ASSESS THE
PERIPHERY AND SHAPE OF
THE ABNORMALITY
Is the periphery well or poorly defined?
A well-defined lesion is one in which most of the periphery is well defined.
In contrast, it is difficult to exactly and reproducibly delineate a poorly defined
periphery
The transition between a lesion and the normal adjacent bone is another important
feature of the periphery to consider.
The periphery of a lesion can display a zone of transition between the abnormal and
normal bone patterns.
For example, a lesion with a thin radiopaque cortex at its periphery displays a
narrow zone of transition.
Lesions with a sclerotic border exhibit a relatively wide zone of transition. Further
analysis of these two types of peripheries or borders can help define the nature of the
lesion.
 WELL-DEFINED BORDERS
Punched-out border.
A punched-out border is one that has a sharp and very narrow zone of transition; there is no
bone reaction immediately adjacent to the abnormality.
 The term punched out points to something similar to punching a hole in a piece of film or
paper with a hole punch.
The border of the resulting hole is well defined and the adjacent bone has a normal appearance
up to the edge of the hole.
This type of border is sometimes seen in multiple myeloma.
Corticated border.
A corticated border is one that displays a thin, uniform, radiopaque line of bone at
the periphery of a lesion.
This is commonly seen with cysts and benign neoplasms or tumors (see Fig. 18.4).
Sclerotic border.
A sclerotic border is one that shows a wider, more diffuse zone of transition
between the lesion and the normal surrounding bone.
The radiopaque border represents reactive bone that is usually not uniform in width.
This border may be seen in periapical osseous dysplasia and may indicate the ability
of the lesion to stimulate the production of surrounding bone
Internal radiolucent “soft tissue” periphery.
A centrally located radiopaque lesion may be surrounded by a radiolucent rim of variable
width. These lesions are described as having a mixed radiolucent and radiopaque internal
structure.
Histologically, the radiolucent rim represents nonmineralized connective tissue and is
sometimes referred to as a “soft tissue capsule.”
 This radiolucent rim may be seen in conjunction with a corticated periphery, as is observed
with odontomas and cementoblastomas
POORLY DEFINED BORDERS
Blending border.
A poorly defined border is one that is difficult to resolve.
The zone of transition is often gradual and wide between the adjacent normal bone trabeculae
and the abnormal-appearing trabeculae of the lesion.
The focus of this observation is on the trabeculae rather than the radiolucent marrow spaces.
 Examples of conditions with this type of margin are sclerosing osteitis and fibrous dysplasia.
Invasive border.
An invasive border is one in which there are few or no trabeculae between the periphery of
the lesion and the normal bone.
Furthermore, the zone of transition is typically wide (Fig. 18.15).
In contrast to the blending border described earlier, the focus of this observation is on the
enlarging radiolucency at the expense of normal adjacent bone trabeculae.
These borders have also been described as permeative because the lesion grows around
existing trabeculae, producing radiolucent, finger-like, or bay-type extensions at the
periphery.
This growth may result in enlargement of the marrow spaces at the periphery (Fig. 18.16).
Invasive borders are usually associated with rapid growth and can be seen with malignant
lesions.
 SHAPE
The lesion may have a particular shape, or it may be irregular. Two examples follow:
A circular or “hydraulic” shape, similar to an inflated or water-filled balloon, is characteristic
of a cyst (see Fig. 18.4).
Scalloping describes a series of contiguous arcs or semicircles that may develop around the
roots of teeth or within adjacent bone or bone cortices.
Scalloping may reflect the mechanism of a lesion's growth (Fig. 18.17). This shape
may be seen in cysts (e.g., odontogenic keratocyst), cyst-like lesions (e.g., simple
bone cysts), and some benign neoplasms.
Occasionally a lesion with a scalloped periphery is referred to as multilocular;
however, the term multilocular is reserved for the description of the internal structure
STEP 3: ASSESS THE INTERNAL
STRUCTURE
The internal appearance of a lesion can be classified into one of three basic categories:
a. totally radiolucent,
b. totally radiopaque, or
c. mixed radiolucent and radiopaque (“mixed density”).
Total radiolucency is characteristic of a lesion where the normal bone has been completely
resorbed. This is commonly seen in cysts (see Fig. 18.4A)
In contrast, total radiopacity implies that the lesion is filled with some sort of mineralized
matrix; this is observed in osteomas.
Mixed radiolucent and radiopaque lesions are those in which calcified material
(radiopaque) is deposited against a radiolucent background.
A challenging part of this analysis may be deciding whether the perceived calcified
material is located within the lesion itself or is located buccal or lingual to the lesion;
The shape, size, pattern, and density of the calcified material should be examined. For
example, bone can be identified by the presence of a trabecular pattern. Also, the degree of
radiopacity may help.
For instance, enamel is more radiopaque than bone. The following is a list of most radiolucent to
most radiopaque material seen in plain radiographs:
• Air, fat, and gas
• Fluid
• Soft tissue
• Bone marrow
• Trabecular bone
• Cortical bone and dentin
• Enamel
• Metal
POSSIBLE INTERNAL STRUCTURES THAT
MAY BE SEEN IN MIXED RADIOLUCENT
AND RADIOPAQUE LESIONS.
Abnormal Trabecular Patterns
Abnormal bone may exhibit various trabecular patterns that are different from those
that are seen in normal bone.
These variations result from a difference in the numbers, lengths, widths, and
orientations of the trabeculae.
For instance, in fibrous dysplasia, the trabeculae are
usually greater in number, shorter, and not aligned in
response to applied forces to the bone.
Rather, they are randomly oriented, resulting in patterns
described as having orange peel– or ground glass–like
appearances.

Another example is the stimulation of new bone formation

on existing trabeculae in response to inflammation. The
result is thick trabeculae, giving an area a more radiopaque
appearance (see Fig. 18.14).
Internal Septation
Septations represent striations of bone found within a lesion that appear to divide the lesion
into two or more compartments.
The term multilocular is used to describe the resultant compartments.
The origin of this internal bone may be trapped normal bone, such as in ameloblastomas.
In other lesions such as central giant cell lesions, cells within the tumor can manufacture
bone in a recognizable linear pattern.
The appearance of the septa can inform the clinician about the nature and pathogenesis of the
lesion. For instance, septa that are curved and coarse may be seen in ameloblastoma, giving
rise to an internal pattern that is multilocular or “soap bubble” in appearance.
In some cases this tumor contains a few straight, thin septa.
In central giant cell lesions, reactive bone in the form of poorly calcified osteoid may develop,
and appear as low-density and wispy or granular septations in the image.
This pattern reflects small nests of tumor cells or cyst-like formations within the tumor at the
histopathologic level within the ameloblastoma.
The small tumor nests or cyst like areas entrap and remodel the bone around them as they
increase in size (Fig. 18.19A and B).
This pattern may also sometimes be observed in odontogenic kerato cysts. Odontogenic
myxomas also exhibit internal septation.
Dystrophic Calcification
Dystrophic calcification is mineralization that occurs in
damaged soft tissue. It is most commonly seen in calcified lymph
nodes that appear as dense, cauliflower-like masses in the soft
tissue. In chronically inflamed cysts, the calcification may have a
very delicate, particulate appearance without a recognizable
pattern.
Amorphous Bone
This type of dystrophic bone has a homogeneous, dense, poorly
organized structure and is sometimes organized into round or oval
shapes or clumps (see Fig. 18.2).
Tooth Structure
Tooth structure can usually be identified by organization into
enamel, dentin, and pulp chambers. Also, the density of this
material is equivalent to the normal density of tooth structure and
is of greater density than the surrounding bone (see Fig. 18.12).
STEP 4: ASSESS THE EFFECTS
OF THE LESION ON ADJACENT
STRUCTURES
Evaluating the effects of a lesion on adjacent structures allows the dentist to infer
biologic behavior, and this behavior may aid in identification of the disease.
However, having knowledge of disease mechanisms is required.

Teeth, Lamina Dura, and Periodontal Ligament Space

Displacement of teeth is seen more commonly with benign slower-growing space-
occupying lesions. The direction of tooth displacement is significant.
Lesions with an epicenter above the crown of a tooth (i.e., dentigerous cysts and occasionally
odontomas) will displace the tooth apically (see Fig. 18.4A).
The central giant cell lesions arising in cherubism have a propensity to displace teeth in a
mesial (anterior) direction given the epicenters of these lesions (see Fig. 18.3).
Some lesions (e.g., lymphoma, leukemia, Langerhans cell histiocytosis) grow in the papillae of
developing teeth and may push a developing tooth in a coronal direction (Fig. 18.20).
Resorption of teeth usually occurs with a more chronic or slowly growing process (see Fig.
18.4A).
It may also result from chronic inflammation. Although tooth resorption is more commonly
related to benign processes, some malignant tumors, particularly sarcomas, can occasionally
resorb teeth.
Widening of the periodontal ligament space may be seen with a number of abnormalities.
 It is important to observe whether the widening is localized or generalized, irregular or uniform.
As well, the adjacent lamina dura should be assessed to determine its condition.
For instance, orthodontic movement of teeth results in generalized widening of the
periodontal ligament space around tooth roots, but the lamina dura remains intact.
Malignant lesions can rapidly grow down and invade the ligament space, resulting
in irregular widening, and destruction of the lamina dura (Fig. 18.21).
Surrounding Bone Reaction
Some abnormalities can stimulate a bone reaction at the periphery.
An example is the cortex of a cyst or the often sclerotic border seen in cemento osseous dysplasia
as previously described.
The corticated border of a cyst is not actually part of the cyst but is a bone reaction that develops
in response to the cyst as it enlarges.
Identification of peripheral bone formation provides a behavioral characteristic suggesting that the
abnormality has the ability to stimulate an osteoblastic reaction.
Periapical rarefying osteitis can also stimulate a sclerotic bone reaction (see Fig. 18.14), as can
some metastatic prostate and breast lesions.
Inferior Alveolar Canal and Mental Foramen
Changes to the IAC can be characteristic of specific disease processes.
Superior displacement of the IAC is strongly associated with fibrous dysplasia when the
epicenter occurs inferior to the canal.
Widening of the IAC with the maintenance of a cortical boundary may indicate the presence of
a benign lesion of vascular or neural origin within the canal (see Fig. 18.7).
Irregular widening with cortical destruction may indicate the presence of a malignant neoplasm
growing down the length of the canal.
Cortical Bone and Periosteal Reactions
The cortical boundaries of bone may remodel in response to the growth of a lesion within the
maxilla or mandible.
A slowly growing lesion may allow time for the surface periosteum to manufacture new bone, so
that the resulting expanded bone surface appears to have maintained an outer cortex (see Fig.
18.4B).
In contrast, a rapidly growing lesion outstrips the ability of the periosteum to respond, and the
cortex may be lost (Fig. 18.22).
The remodeled external shape of the mandible or maxilla can provide information on the
growth pattern of the entity. For instance, a tumor such as ossifying fibroma often has a
concentric growth pattern with a clear epicenter.
Whereas a bone dysplasia such as fibrous dysplasia, will enlarge the bone with a growth
pattern that is along the bone without an obvious epicenter (Fig. 18.23).
Exudate from an inflammatory lesion can stimulate the periosteum to lay down new bone(Fig.
18.24)
When this process occurs more than once, an onion skin type of pattern can be seen. This pattern is
most commonly seen in inflammatory lesions and more rarely in tumors such as leukemia and
Langerhans cell histiocytosis.
Other examples of patterns of reactive periosteal bone formation include a spiculated new bone
formed at right angles to the surface cortex, which is seen with metastatic lesions of the prostate
gland or in a radiating pattern of spiculated bone seen in osteosarcoma (Fig. 18.25) or a hemangioma.
STEP 5: FORMULATE AN
INTERPRETATION
The preceding steps enable the dentist to collect a series of radiologic findings in an
organized and systematic fashion.
Now the significance of each observation must be determined and weighted.
The ability to give more significance to some observations over others comes with
experience.
After an initial working interpretation has been reached, ambiguities are resolved
either by searching for more features or by putting more weight on one feature or the
other.
 Analysis of Intraosseous Lesions
Step 1: Localize the Abnormality
• Anatomic position (epicenter)
• Localized or generalized
• Unilateral or bilateral
• Single or multifocal
Step 2: Assess Periphery and Shape of the Abnormality
Periphery
Well defined
• Punched out
• Corticated
• Sclerotic
• Soft tissue capsule
Poorly defined
• Blending
• Invasive
Shape
• Circular
• Scalloped
• Irregular
Step 3: Analyze the Internal Structure
• Totally radiolucent
• Totally radiopaque
• Mixed radiolucent and radiopaque (describe pattern)
Step 4: Assess the Effects of Lesion on Surrounding Structures
• Teeth, lamina dura, periodontal ligament space
• Inferior alveolar nerve canal and mental foramen
• Maxillary antrum
• Surrounding bone density and trabecular pattern
• Outer cortical bone and periosteal reactions
Step 5: Formulate an Interpretation
A diagnostic algorithm such as that shown in Fig. 18.26 can aid in this decision-making
process.
Following this algorithm, the observer makes decisions regarding which general disease
category the entity fits into and then proceeds to smaller, more specific categories.
This is not an infallible method because any algorithm may occasionally fail, since lesions
sometimes do not behave as expected.
Decision 1: Normal or Abnormal
The clinician should determine whether the entity of interest is a variation of
normal or an abnormality.
This is a crucial decision because variations of normal do not require treatment or
further investigation.
Therefore the clinician must develop an in-depth knowledge and appreciation for
the variations in the appearances of normal anatomy. The importance of this cannot
be overstated.
Decision 2: Developmental or Acquired
If the area of interest is abnormal, the next step is to decide whether the radiographic
characteristics represent a developmental abnormality or an acquired change.
For example, the observation that a tooth has an abnormally short root leads to the pertinent
question, “Did the tooth develop a short root, or did the root develop to a normal length and then
become shorter?”
If the answer is the latter, the process must be external root resorption (an acquired abnormality).
If the tooth merely developed a short root, the pulp canal should not be visible to the very end of
the root because of normal apex development.
In contrast, external root resorption may shorten the root, but the canal remains visible to the end
of the root (Fig. 18.27).
Decision 3: Disease Classification
If the abnormality is acquired, the next step is to select the most likely disease category for
the acquired abnormality.
The disease category can be established by observing the features and how they reflect a
particular disease mechanism. The categories may include inflammation, cysts, benign
neoplasia, malignant neoplasia, bone dysplasia, vascular abnormalities, metabolic diseases, or
physical changes such as fractures (i.e., trauma).
The analysis should strive to narrow the interpretation to one of these disease categories; this
directs the next course of action for continued investigation, referral, and treatment.
This may also be a good time to bring the clinical information— such as patient history and
clinical signs and symptoms—into the decision making process.
This additional information may help the clinician to refine the interpretation to a short list (a
differential interpretation) of diseases within the category.
Decision 4: Ways to Proceed
After a disease category or a differential interpretation of diseases is determined, the clinician
must decide how to proceed.
This decision may require further imaging, biopsy, observation (watchful waiting), or definitive
treatment.
For example, if a lesion fits into the category of malignant neoplasia, the patient first should be
referred to an oral and maxillofacial radiologist for possible advanced imaging to further
characterize and stage the lesion.
Advanced imaging may also help to determine an optimal site for biopsy and treatment.
With advanced training or experience in diagnostic imaging, the dentist may be better
able to name one specific abnormality or at least make a short list of abnormalities from
one or two of the disease categories.
It is important to recognize, however, that imaging is but one diagnostic test available to
the dentist, and it is not infallible.
It is therefore important for the dentist to understand the limitations of imaging and
recognize its value alongside other clinical information and diagnostic testing that may
be ordered.
WRITING A DIAGNOSTIC
IMAGING REPORT
General Patient Information
This section appears at the beginning of the report, and includes the patient's name,
age, sex, and any alphanumeric identification such as a clinic or medical registration
number. Also, the name of the referring clinician (if applicable) and the date of the
report are also included.
Imaging Procedure
This section summarizes the imaging procedures provided along with the date of the
examination.
Clinical Information
This is an optional section that includes pertinent clinical information regarding the
patient's condition provided by the referring clinician or by the clinician dictating the
report if a clinical examination was made before the radiologic examination. The
clinical information should be brief and should summarize the information
pertaining to the abnormality in question.
Findings
This section comprises an objective detailed list of observations made from the
diagnostic images.
This can follow the previously presented step-by-step analysis of the anatomic
location, extent of the lesion, periphery and shape, internal structure, and effects on
surrounding structures.
This section does not include a radiologic interpretation.
Interpretation
The collected observations from the radiologic image or images allow the dentist to
elucidate their meaning, and this is called an interpretation.
If additional information from the patient history is available or if clinical or other
diagnostic information is available together with the radiologic interpretation results, a
diagnosis can be made.
In some instances, however, the radiologic features can be pathognomonic of a disease, in
which case the interpretation is the diagnosis.
When possible, the clinician should endeavor to provide a definitive interpretation of the
abnormality that has been imaged.
When this is not possible, a short list of abnormalities or a differential interpretation (listed
in order of likelihood) is acceptable.
This list should not, however, be exhaustive; ideally it should be limited to diseases within
one or perhaps two disease categories at most.
In some situations, advice regarding additional studies, when required, and treatment may be
included.
Last, the name and signature of the clinician composing the report is included.
CONCLUSION
The use of a systematic approach to both feature identification and image
interpretation is a core skill in the practice of dentistry, and one that all
dentists, be they generalists or specialists, must learn and perform
competently.