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Kumar et al., Oral Hyg Health 2014, 2:5

http://dx.doi.org/10.4172/2332-0702.1000163

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Different Radiographic Modalities Used for Detection of Common Periodontal

and Periapical Lesions Encountered in Routine Dental Practice
Vandana Kumar*, Kirandeep Arora and Hema Udupa

School of Dentistry, Oral and Maxillofacial Radiology, Kansas City, USA

Abstract
The objective of this article is to review the literature which describes the different radiographic modalities used
for detection of osseous defects due to periodontal and periapical disease. Despite inherent limitations associated
with conventional two-dimensional (2D) intra- and extra-oral radiographs, these continue as the mainstay for
assessments of periodontal and periapical defects. Three dimensional CBCT scans are considered as a useful
complement to these conventional radiographic techniques. This article gives an overview of common periodontal
and periapical lesions encountered in routine clinical practice and various radiographic modalities used for their
detection.

Keywords: Periodontal defects; Bony pockets; Furcation involvement;

Periapical and Bitewing radiographs; Cone Beam CT; Periapical
lesions; Periapical sclerosing osteitis
Introduction
Periodontium consist of cementum, periodontal ligament and
alveolar bone. The term periodontitis/periodontal disease represent a
group of disease that affects the surrounding and supporting tissues of
teeth. Periodontal disease can be broadly classified as gingival diseases
(gingivitis) and periodontitis. Gingivitis presents as inflammation of
the soft tissue surrounding the teeth and is characterized by gingival
swelling, and erythema. Periodontitis is an inflammatory destruction of
the supporting apparatus of the teeth, including cementum, periodontal
ligament and alveolar bone which results in gradual loosening of teeth.
Although periodontitis is always preceded by gingivitis, gingivitis does
not always progress to periodontitis.
Bacterial plaque is the chief causative factor for periodontal disease
and apical migration of this bacterial plaque causes bone destruction
leading to osseous defects. Other factors like stress, occlusal trauma,
smoking, hypertension and diabetes also contribute to greater risk
of periodontal disease [1]. The formation of osseous defect is either
related to occlusal stress on the tooth or to original anatomy of the
alveolar process [2]. In recent research, a strong correlation is found
between periodontal disease and cardiovascular disease [3]. It is
found that bacterial microorganisms that cause periodontitis travel
through the blood stream and have high affinity for the development
of atherosclerotic plaque, notably involving the cardiac and carotid
endothelium, leading to coronary heart disease and vice versa [4].
The pulp cavity is the central part of the tooth that extends into
the root as root canal which opens into the periodontium via apical
foramen and is enclosed all around by dentin. Healthy periapical
tissues exhibit following important features:
1. Periodontal ligament space (PDL) : A thin, continuous radiolucent
line around the outline of the root
2. Lamina dura :A thin, continuous radiopaque line adjacent to the
radiolucent line
3. The trabecular pattern and density of the surrounding cancellous bone
Any changes in the thickness, continuity, density of these
features may suggest the presence of pulpal, periodontal, and various

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pathologic disorders. Advancing pulpal inflammation when exits

the apical foramen will exhibit radiographic signs such as widened
PDL and poorly demarcated periapical low density area due to
demineralization and these changes are typically located at the apex of
the tooth. .Sometimes these lesions extend along the lateral surface of
root due to the presence of the accessory canals. Widening of PDL is
an early sign of periapical inflammation [5-7]. The prevalence of apical
periodontitis associated with root-lled teeth was reported to be as
high as 64.5% in a cross sectional study of populations [8-10]. Early
detection of periodontal and periapical disease and correct assessment
of the bone condition is essential for the diagnosis, treatment planning
and prognosis of periodontal disease [7,11].
Current approaches to diagnose periodontal disease include
probing of gingival tissues and radiographs to evaluate osseous
support and periapical pathosis. Due to lack of stable reference point
and standardization and calibration of periodontal probe reading, it is
not considered a reliable method for evaluation of advanced periodontal
disease. Radiographs provide an overview of the amount of bone present
and serve as a permanent record for future comparison to assess bone loss/
gain. Radiographs are also used effectively in patients having periapical
lesions to determine the extent and severity of the disease.
In the following sections, common periodontal and periapical
osseous defects encountered in routine clinical practice would be
elaborated and various diagnostic imaging methods along with their
associated strengths and limitations would be discussed.

Common radiographic modalities for detection of periodontal

and periapical lesion
The success of periodontal therapy depends on many factors. One

*Corresponding author: Vandana Kumar, school of Dentistry, Oral and Maxillofacial

Radiology, 650E, 25th street Kansas City, Missouri 64108, USA, Tel: 816 235-2664;
E-mail: kumarva@umkc.edu
Received June 23, 2014; Accepted September 17, 2014; Published September
23, 2014
Citation: Kumar V, et al. (2014) Different Radiographic Modalities Used for Detection
of Common Periodontal and Periapical Lesions Encountered in Routine Dental
Practice. Oral Hyg Health 2: 163. doi: 10.4172/2332-0702.1000163
Copyright: 2014 Kumar V, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.

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Citation: Kumar V, et al. (2014) Different Radiographic Modalities Used for Detection of Common Periodontal and Periapical Lesions Encountered in
Routine Dental Practice. Oral Hyg Health 2: 163. doi: 10.4172/2332-0702.1000163

Page 2 of 11
of the most important factors is an accurate image of morphology
of periodontal bone destruction that would influence the treatment
modality and eventually the outcome of the periodontal therapy. Intraand extra-oral imaging modalities are available to display periodontal
structures. The extraoral panoramic radiograph can be utilized as an
alternative assessment. Though it provides means of viewing larger
area and can be used in assessing periapical lesions like condensing
osteitis, florid osseous dysplasia etc. but has very little diagnostic value
in assessing alveolar bone levels [12]. Patient positioning error and
superimposition of ghost images often result in suboptimal projections
and limit comparisons with follow-up images. Superimposition and
distortion of structures, blurring of anatomical landmark and loss
of detail are the inherent limitations of panoramic radiograph that
reduce their value in evaluation of osseous defects due to periodontal
or periapical disease [13]. Most common two dimensional (2D) intra
oral radiographs used to determine osseous defects are bitewings and
periapical radiographs, with the paralleling extension cone method.
These are easy to acquire, are cheap and have high resolution details [14].
Bitewings present the most favorable imaging geometry for periodontal
bone level assessment; best detection performance is achieved with
horizontal angulation perpendicular to the tooth surfaces, and vertical
angulation with a positive or negative tilt of 12-15 degrees relative to
the perpendicular [15]. Vertical bitewings are used where there is bone
loss > 4 mm [16]. The disadvantage of bitewings is that apices of the
teeth are not visible; therefore, one cannot estimate percentage of bone
loss that has taken place [17]. Full mouth periapical radiographs are
also used to diagnose osseous defects and are found to be more effective
in posterior segment in mandible than in maxilla due to denser bone in
mandible [12]. The disadvantages of full mouth periapical radiographs
are, that they are time consuming, require multiple films and have
low patient tolerance [18]. In comparison to bitewing radiographs,
periapical radiographs also present more geometric distortion [16].
Intraoral digital radiographic imaging offers the clinician an improved
way for periodontal diagnosis and treatment planning. It not only
reduces radiation exposure, [19-22] but also optimizes assessment of
oral structures, improving the accuracy of periodontal diagnosis [23].
However, these 2D intraoral radiographic methods are limited by
overlapping anatomical structures [24,25] difficulty in standardization
[26,27] and by underestimating the size and occurrence of bone defects
[25]. Funnel-shaped or lingually located defects are difficult to detect
in these radiographs [28] and destruction of the buccal plate can be
undiagnosed or undistinguished from lingual defects [29]. Studies have
shown that bone loss can be underestimated by 1.5 mm, with large
variations between examiners with these modalities [30].
For the long term assessment of periapical disease, periapical
radiographs play a vital role in preoperative, post-operative and follow
up appointments. Radiographic signs of apical periodontitis include
radiolucent changes in periradicular trabecular pattern and changed
shape and width of the periodontal ligament (PDL). However, small
periapical lesions < 1 to 2 mm go undetected on periapical radiographs
and the radiographic appearance of periapical lesions is always smaller
than the histologic extent of the lesion [31,32].
To address these issues, Cone beam computed tomography has
been explored because it enables cross-sectional and three dimensional
analyses without distortion similar to multi-slice conventional
tomography (CT) however, it does so with reduced acquisition times,
lower effective radiation doses, and decreased financial burdens when
compared with CT [33,34]. Introduction of CBCT technology presents
the opportunity for 3D assessment of dental and craniofacial anatomy
without the inherent limitations of conventional 2D imaging [35]. That
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is, an assessment can be conducted in all three planes of space without

image distortion, superimposition of structures, and differential
magnification of the image based on geometry. Research comparing
the use of three-dimensional (3D) volumetric images and 2D images in
artificial bone defects has shown that CBCT has sensitivity of 80-100%
in the detection and classification of bone defects, while intra-oral
radiographs present a sensitivity of 63-67% [27,36-38]. CBCT images
are well-known to provide detailed anatomy of the teeth and bones as
well as allow for evaluation of the periapical lesions in multiple planes
and aids in improved detection of the disease [39]. CBCT has a role in
the identification of root canal systems, notably for the identification of
presence or absence of a second mesiobuccal canal (MB2) in maxillary
first molars which are not visible on periapical radiographs [40,41].
Although, CBCT is able to readily detect simulated defects, they
lack clinical applicability because of failure to use an appropriate
reference standard to explain the true presence of disease. Crosssectional imaging does offer a potential means of resolving resorption
(internal or external) and perforations, as literature shows that CBCT
may be useful in this respect with improved sensitivity. A question has
to be asked, however, whether this will have a significant impact on
management of the patient. In the case of perforations by posts, due
regard has to be given to degradation of images by beam hardening
artifact arising from metal post and obturation material like gutta
percha, which may mask features in the roots and surrounding
bone [5,6,42]. Further research is needed addressing the impact on
management decisions and, for now, it seems logical to consider CBCT
only when conventional radiography has been tried and failed to
answer the question and when a significant treatment decision (e.g. to
extract or not) has to be made [43]. The literature shows that a request
for CBCT is justified for the periodontal surgical planning of patients
with severe periodontal diseases such as aggressive periodontitis, for
regenerative or mucogingival surgical planning and for planning of
implant placements. These surgical procedures are costly, difficult to
plan and need precise diagnosis [14]. Periapical radiographs result in
lower radiation doses to the patient and are less costly, hence should be
indicated for simpler cases.
The available intra-oral and extra-oral 2D and 3D radiographic
modalities are invaluable diagnostic tool that can be used effectively
in a wide variety of clinical and research situations. However, like any
other diagnostic procedure involving ionizing radiation, their use
should involve clinical judgment rather than routine practice. Recent
studies have indicated that medical radiation, most notably computed
tomography (CT), now accounts for more radiation exposure to the U.S.
population than background radiation [44,45]. Although CT typically
represent less than 11% of all imaging performed at most universitybased practices, diagnostic CT can account for as much as 70% of
the overall radiation dose generated in radiology departments [46].
The doses from CBCT are significantly lower than conventional CT,
yet are higher than doses from the traditional views used in dentistry
[47-49]. Significant differences in dose for the same examination have
been reported for different CBCT units and significant differences
in dose have been reported for different fields of view (FOVs) or
techniques with the same unit [50-53]. In a study by Roberts et al, the
i-CAT CBCT scanner was investigated for various imaging protocols
commonly used in clinical practice [52]. The effective doses, based
on 2007 (E2007) ICRP guidelines, were 206.2 Sv for full FOV of the
head; 133.9 Sv for a 13 cm scan of the jaw; 188.5 Sv for a 6 cm highresolution scan of the mandible; 93.3 Sv for a 6 cm high-resolution
scan of the maxilla; 96.2 Sv for a 6 cm standard scan of the mandible;
and 58.9 Sv for a 6 cm standard scan of the maxilla [54]. When eight

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Citation: Kumar V, et al. (2014) Different Radiographic Modalities Used for Detection of Common Periodontal and Periapical Lesions Encountered in
Routine Dental Practice. Oral Hyg Health 2: 163. doi: 10.4172/2332-0702.1000163

Page 3 of 11
different dentoalveolar and maxillofacial CBCT units and a 64-slice
multi-detector computed tomography (MDCT) unit were compared
for radiation according to E2007, exposures for large FOV CBCT units
ranged from 68 to 1,073 Sv and for medium FOV CBCT units ranged
from 69 to 560 Sv, whereas for the MDCT unit with a similar FOV,
the exposure was 860 Sv [55]. In a study by Ludlow JB et. al, effective
radiation dosage associated with 2D radiographic modalities based on
E2007 were enumerated as follows [49]:

a) 34.9 Sv for full mouth radiographs (FMX) with photo-stimulable

phosphor (PSP) storage or F-speed film with rectangular collimation
b) 5.0 Sv for four-image posterior bitewings with PSP or F-speed film
with rectangular collimation was ;
c) 14.2 Sv for panoramic Orthophos XG (Sirona Group, Bensheim,
Germany) with charge-coupled device (CCD),
d) 24.3 Sv for panoramic ProMax (Planmeca, Helsinki, Finland) with CCD.

Figure 1a: Bitewing radiographs of right premolar and molar region showing
normal alveolar crest.

These dosages were far less when compared to effective radiation

dosage associated with CBCT/MDCT. Therefore, attention to radiation
hygiene by following the fundamental principle of choosing exposures
As Low As Reasonably Achievable (ALARA) for diagnostic radiology
is imperative. CBCT procedures must be reserved for selected cases
and appropriately collimated down to the chosen region of interest.

Osseous defects as result of periodontal disease

Normal alveolar bone supporting dentition has a characteristic
radiographic appearance. It exhibits a thin opaque cortical bone that
covers the alveolar crest. The height of crest lies at a level approximately
0.5 to 2.0 mm below the level of cementoenamel junction (CEJs) and is
continuous with lamina dura of adjacent teeth (Figure 1a and 1b). Care
must be taken in using CEJ as a reference point in case of over erupted
and severely attrited teeth.

Figure 1b: Bitewing radiographs of right premolar and molar region showing
normal alveolar crest.

Osseous defects as a result of periodontal disease is classified

clinically into horizontal (even) and angular (vertical) defects. In
horizontal bone loss, the height of alveolar bone is symmetrical and
parallel to an imaginary line joining CEJ of adjacent teeth. There occurs
resorption of buccal, lingual cortical walls including the interdental
bone. It can be categorized as mild, moderate or severe, depending on
its extent (Figures 2a, b, c and d).
In the vertical or angular osseous destruction, the bone loss is
unsymmetrical; alveolar crest is not parallel to the level connecting
the CEJ of the adjacent teeth (Figure 3a). These defects develop when
bone loss progresses down the root of the tooth, resulting in deepening
of the clinical periodontal pocket. The early vertical defects appear
as abnormal widening of the PDL space at alveolar crest (Figure 3b).
Further vertical osseous destruction leads to the formation of osseous
defects where the base of the defect is located apically to the alveolar
crest [56,57].
Different classifications of bone defects have been proposed.
Goldman & Cohen (1958) described the morphology of various bone
defects and classified them according to the number of osseous walls
present [58]. Glickman (1964) presented a specific description of
bone deformities produced by periodontal disease, classifying bone
defects as osseous craters, infrabony defects, bulbous bone contours,
hemisepta, inconsistent margins and ledges [57]. Prichard (1967)
expanded this classification by including furcation involvement and
indicated that resorptive lesions may also be complicated by anatomic
aberrations of the alveolar process, i.e., thick marginal ledges, exostosis
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Figure 2a: Bitewings shows mild horizontal bone loss.

Figure 2b: Mandibular anterior periapical radiograph.

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Citation: Kumar V, et al. (2014) Different Radiographic Modalities Used for Detection of Common Periodontal and Periapical Lesions Encountered in
Routine Dental Practice. Oral Hyg Health 2: 163. doi: 10.4172/2332-0702.1000163

Page 4 of 11
mutirooted teeth, eliminating the bone covering the root [60]. This
is further subcategorized as:

Grade 1: Incipient bone loss, radiographic changes are not usually

seen as bone loss is minimal
Grade 2: There is destruction of bone in one or more aspect of
furcation, but part of alveolar bone and periodontium remains intact
to allow partial penetration of the probe. These too may or may not be
seen on traditional radiographs as they get obscured due to overlapping
of roots, angulation of x-rays or due to thick inter- radicular bone.

Figure 2c: Shows moderate horizontal bone loss and maxillary anterior periapical
radiograph.

Grade 3: Inter radicular bone is completely absent allowing probe

to penetrate completely. Traditional radiographs reflect this defect as
a small radiolucency between roots. Grade 3 furcations in maxillary
posterior teeth are difficult to diagnose due to overlapping of roots
Grade 4: Similar to grade 3 but gingival tissue is recessed and is
detected clinically and radiographically.
The vertical bone defects, especially three and four wall defects, are
difficult to detect on a conventional radiograph because buccal/ lingual
cortical plates remain superimposed over the defect. Clinical and
surgical evaluation of these defects is the best mode of determining the
number of the remaining walls. Two wall and one wall defects can be
identified on conventional radiographs. Radiographically, interdental
craters / two wall defects can be identified as band like regions or
inconsistent bone margins (Figure 4), whereas one-wall defect presents
as ramp like appearance, because the inter-dental septal bone slopes
down from the facial/ lingual wall crest of bone towards the crest of the

Figure 2d: shows moderate to severe horizontal bone loss.

and tori. Additional anatomic aberrations of the alveolar process

are isolated areas in which the root is denuded of bone to a varying
extent (dehiscence and fenestrations) [59]. Other classifications were
introduced later and represented the combinations of the existing
descriptions.
Based on the classifications proposed, morphology of bone defects
can be described as follows [56]:
1. Interdental crater/ two wall bony defect is a saucer shape concavity
in the interdental bone confined within facial and lingual walls.
These are the most common osseous defects and are most commonly
found in the posterior segment of the mandible.

Figure 3a: Maxillary right premolar periapical radiograph and maxillary anterior periapical
radiograph.

2. Three- wall bony defect has bony walls on three sides and tooth root
forming the fourth wall
3. Four- wall defect is a circumferential defect that completely
surrounds the root of the tooth.
4. Hemiseptum defect/ One-wall defect is where one bony wall of
the interseptal bone remains after the mesial and distal portions of
the interseptal bone has been destroyed. It is identical to vertical or
angular deformities.
5. Furcation involvement: extension of bone loss between roots of
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Figure 3b: Maxillary right premolar periapical radiograph, shows examples of developing
vertical bone defect on mesial aspect of maxillary right first premolar and distal aspect of
maxillary left central incisor respectively.

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Citation: Kumar V, et al. (2014) Different Radiographic Modalities Used for Detection of Common Periodontal and Periapical Lesions Encountered in
Routine Dental Practice. Oral Hyg Health 2: 163. doi: 10.4172/2332-0702.1000163

Page 5 of 11
the form of the furcation and severity of the lesions that cannot be
obtained from the conventional radiographs or clinical assessments
[61,62]. In another radiographic example presented here, periapical

Figure 4: Maxillary left premolar periapical radiograph showing loss of buccal cortical
plate adjacent to maxillary left premolars. The black arrows indicate the level of buccal
and lingual alveolar crestal level, demonstrating inconsistent bone margins.

Figure 6: Maxillary right molar periapical radiograph showing furcation involvement

of maxillary right first molar, presented as small radiolucency between the roots of
maxillary molar.

Figure 5a: Mandibular left molar bitewing showing one wall defect- hemisptum defect
at mesial aspect of mandibular right first molar.

Figure 7a: Periapical radiograph of maxillary right second premolar showing vertical bone
loss on the distal aspect.

Figure 5b: Mandibular right molar periapical radiograph showing one-wall defectinterdental bone slopes down from facial lingual wall crest of bone towards the crest of
destroyed facial lingual bone.
Figure 7b: Cone beam CT reformatted panoramic image and cross -sectional images
of maxillary right second premolar showing interdental crate.

destroyed facial/ lingual bone (Figure 5a and 5b). Grade 3 and grade
4 furcation involvement of mutirooted teeth can also be revealed on
conventional radiographs as radiolucency between roots (Figure 6).
Vandenberghe et al. observed that the cross-sectional slices from
CBCT data allows better assessment of periodontal bone levels with
an average underestimation of 0.29 mm compared with 0.56 mm
in periapical digital radiographs [38]. Periapical radiograph of the
maxillary right second premolar (Figure7a) exhibits distal vertical
bone loss suggesting interdental crater, whereas CBCT reformatted
panoramic image and cross-sectional images of maxillary right second
premolar (Figure7b) and associated sagittal (Figure 7c) and axial
sections (Figure 7d) clearly exhibits loss of facial and distal walls. The
accuracy of CBCT to diagnose molar furcations has been identified.
CBCT generated data adds substantial amount of information about
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Figure 7c: sagittal section of maxillary right second premolar showing interdental
crater.

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Citation: Kumar V, et al. (2014) Different Radiographic Modalities Used for Detection of Common Periodontal and Periapical Lesions Encountered in
Routine Dental Practice. Oral Hyg Health 2: 163. doi: 10.4172/2332-0702.1000163

Page 6 of 11

Figure 7d: Axial section of maxillary right second premolar showing interdental
crater.

Periapical rarefying osteitis occurs as a result of bone resorption in

the periapical areas surrounded by a sclerotic periphery. Early lesions
presents as a widening of the PDL space followed by a gradual loss of
apical lamina dura. As the lesion grows with resorption and thinning
of associated buccal and lingual cortices and possible expansion of the
region. Periapical radiograph of root canal treated mandibular left
first and second molar (Figure 9a) shows periapical rarefying osteitis
associated with its distal root that extends up to the mesial root of
adjacent mandibular left second molar, involving the interdental bone
between them. The radiograph also suggests the furcation involvement
of mandibular left second molar. Reformatted panoramic images and
cross-sectional views of same teeth (Figure 9b) shows the periapical
rarefying osteitis causing resorption and thinning of buccal cortical
plate on distal aspect of mandibular first molar and clearly exhibits
furcation involvement of mandibular left first and second molars.
Periapical sclerosing osteitis also known as condensing osteitis
or focal sclerosing osteitis occurs as a result of chronic periodontal
and endodontic infections in a tooth. Individual thickening of the
trabeculae is noted within the marrow spaces surrounding the roots
of the affected teeth with sclerosis of periapical bone. This is a result
of surrounding bone attempting to wall off the inflammation or repair
the bone affected by the inflammatory process. Radiographically,
A

Figure 8a: Periapical radiograph of maxillary left first molar showing vertical bone loss
and possible furcation involvement.

radiograph of maxillary left first molar (Figure 8a) shows vertical bone
loss on its distal aspect and possible furcation involvement. CBCT
reformatted panoramic image and cross-sectional images (Figure 8b)
of the same tooth shows clearly the furcation involvement, periapical
radiolucencies and severe bone loss all around it. These defects are very
difficult to detect on conventional radiographs.

Figure 9a: Periapical radiograph of mandibular left first and second molar showing
periapical rarefying osteitis and possible furcation involvement of second molar.

Osseous defects as result of periapical disease

Osseous destruction as a result of periapical disease could be
classified broadly as of inflammatory and non-inflammatory origin.
Inflammatory periapical lesions can produce osseous changes around
the apex of a tooth as a result of either pulpal necrosis or due to extensive
periodontal disease causing destruction of the periapical tissues.
Periapical lesions causing osseous defects present radiographically as
radio-lucency, opacity or a combination of both around the root of
the tooth. These are often incidental findings during routine dental
imaging studies, or may be seen as manifestations of other diseases
of odontogenic and non odontogenic origin, including cysts and
neoplasms. Radiolucent or low density presentations are categorized as
periapical rarefying osteitis, including periapical abscess, granuloma,
and cyst/ tumor while the radiopaque presentations are categorized as
periapical sclerosing osteitis and idiopathic osteosclerosis.
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Figure 9b: Reformatted panoramic image and cross-sectional views of mandibular

left first and second molar showing periapical rarefying osteitis that causes resorption
and thinning of buccal cortical plate.

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Citation: Kumar V, et al. (2014) Different Radiographic Modalities Used for Detection of Common Periodontal and Periapical Lesions Encountered in
Routine Dental Practice. Oral Hyg Health 2: 163. doi: 10.4172/2332-0702.1000163

Page 7 of 11
condensing osteitis appears as a uniformly dense radiopaque mass
adjacent to the apex of the tooth with well-defined margins combined
with loss of apical lamina dura and widening of the PDL. Periapical
radiograph (Figure 10a) and reformatted images and cross-sectional
views (Figure 10b) and sagittal section (Figure 10c) of root canal treated
mandibular left first molar demonstrates periapical sclerosing osteitis
involving apices of mesial and distal roots.
Idiopathic osteosclerosis or dense bone island or enostosis are
localized areas of increased radiopacities that occur due to unknown
etiology. They occur in the periapical areas, extend beyond the apices
of associated teeth and can also be found in the edentulous areas.
Radiographically, these present as well-defined, densely homogeneous,
non expansile radiopacity with normal PDL space and lamina dura
when in close proximity to the apex of a tooth. (Figures 11a,11b,11c-1
and 11c-2). They are asymptomatic and are found incidentally during
routine dental imaging.

Figure 10c: Cross-sectional views of root canal treated mandibular left first molar
showing periapical sclerosing osteitis.

Non-inflammatory periapical lesion are a group of non-neoplastic

lesions collectively called as benign fibro osseous lesions. Normal
bone is replaced by fibrous connective tissue containing abnormal
cementum or bone. Osseous dysplasia (OD) or cemento-osseous
dysplasia (COD) is an example of fibro-osseous disease that occurs
commonly in jaws. These lesions are confined to dentulous or

Figure 11a: Periapical radiograph of mandibular right second premolar showing

enostosis on its mesial aspect.

Figure 10a: Periapical radiograph of root canal treated mandibular left first molar
showing periapical sclerosing osteitis.

Figure 11b: Cropped panoramic image of mandibular right first molar showing
enostosis at its apical region.

C1

Figure 10b: Cross-sectional views of root canal treated mandibular left first molar
showing periapical sclerosing osteitis.

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Figure 11c-1: Reformatted panoramic view showing enostosis or idiopathic

osteosclerosis between mandibular right second premolar and first molar.

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Citation: Kumar V, et al. (2014) Different Radiographic Modalities Used for Detection of Common Periodontal and Periapical Lesions Encountered in
Routine Dental Practice. Oral Hyg Health 2: 163. doi: 10.4172/2332-0702.1000163

Page 8 of 11
edentulous portions of the jaws. In 2005, WHO described three clinical
presentations of OD/ COD : periapical OD/COD, focal OD/COD and
florid OD/COD. Radiographically, these lesions exhibit osteolytic,
intermediate and mature stages. The osteolytic stage appears as welldefined radiolucencies at the apices of associated teeth. These can be
easily confused as pulpal disease; however, the affected teeth are vital
and typically are asymptomatic (Figure 12a). Intermediate stage lesions
appear partly radiolucent and partly radiopaque with the initiation of
hard tissue (bone or cementum) formation in the center of the lesion
(Figure 12b). Mature stage lesions appears completely radiopaque
(Figure 12c).
Apical scar results from endodontic treatment of periapical
granuloma or abscess, which generally tend to resolve the lesion,
but sometimes the granulation tissue produces excessive collagen
fibers that results in a dense tissue scar. This remains as a permanent,
asymptomatic periapical lesion and appear as a well circumscribed
radiolucency on the radiograph (Figure 13a and 13b). Surgical defect/
apical scar also results from failure of osseous tissue formation
following surgery at the apex of the tooth. This defect appears as a low
density region at apex of the tooth on a radiograph [63].

Figure 12b: Periapical Radiograph of mandibular anterior teeth with Intermediate

stage of cemento-osseous dysplasia.

Resorption is another common periapical condition associated

with either a physiologic or a pathologic process resulting in a loss of
dentin, cementum, and/or bone [64]. Resorption of the roots of the
permanent teeth is a pathological process originating either internally
or externally based on the surface of tooth being resorbed.

C2

Figure 12c: Cropped panoramic radiograph with multiple areas of radiopacities

surrounded by a radiolucent rim representative of the mature stage of cement-osseous
dysplasia.

Figure 11c-2: Axial and sagittal views showing enostosis between mandibular right
second premolar and first molar.

Figure 13a: Sagittal section showing apical scar at root canal treated maxillary right
second premolar.

Figure 12a: Periapical radiograph of mandibular anterior with multiple radiolucencies

at the apices representative of early or osteolytic stage of periapical cemento-osseous

dysplasia.

Oral Hyg Health

ISSN: 2332-0672 JOHH, an open access journal

Internal resorption is an inflammatory process initiated within the

pulp space with loss of dentin and possible invasion of the cementum

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Citation: Kumar V, et al. (2014) Different Radiographic Modalities Used for Detection of Common Periodontal and Periapical Lesions Encountered in
Routine Dental Practice. Oral Hyg Health 2: 163. doi: 10.4172/2332-0702.1000163

Page 9 of 11
[64]. External root resorption occurs when odontoclasts resorb the
external surface of the tooth root involving the cementum, dentin
and sometime extending to the pulp. Various contributory etiologic
factors have been proposed for internal root resorption , but trauma
is found to be the most common etiological factor (43%), followed by
carious lesions (25%) [65]. Etiology behind the external root resorption
is unknown, however, other causes have been attributed such as
reimplantation, trauma, and pressure from adjacent unerupted teeth
and related pathological conditions such as odontogenic and nonodontogenic tumors.
Early lesions of internal resorption are usually asymptomatic and
often recognized clinically through routine full mouth radiographs.
They appear as localized, oval shape radiolucent enlargement within
the pulp chamber or the root canal, as demonstrated in the periapical
radiograph (Figure 14a) and the axial view of the same tooth (Figure
14b). In internal resorption, the outline of the root canal is usually
distorted and the root canal and the radiolucent resorptive defect
appear to be contiguous. External inflammatory root resorption is
always accompanied by the resorption of the bone seen as a loss of
lamina dura around the apex in addition to that of the root (Figure 15
and 16). External root resorption can also occur along the lateral aspect
of the roots due to presence of an unerupted adjacent tooth. When the
defect is external, the root canal outline appears normal and can usually
be seen running through the radiolucent defect.

Figure 14b: Axial view of maxillary left lateral incisor showing internal root resorption.

Figure 15: Periapical radiograph showing external root resorption at apical region of
maxillary right canine.

Figure 13b: Cross-sectional views of root canal treated maxillary right first premolar
showing apical scar at its apex.

Figure 16: Periapical radiograph of maxillary right lateral incisor showing external root
resorption at its apical region.

The early diagnosis of the internal and external root resorptions

is difficult based on a conventional radiograph only. CBCT has been
found to be successful in evaluating the true nature and severity of
resorption lesions [66,67].
Figure 14a: Periapical radiograph of maxillary left lateral incisor showing internal

root resorption.

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There are many other inflammatory, developmental, and benign

and malignant cystic and neoplastic lesion that result in periapical
osseous defects, those are described elsewhere.

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Citation: Kumar V, et al. (2014) Different Radiographic Modalities Used for Detection of Common Periodontal and Periapical Lesions Encountered in
Routine Dental Practice. Oral Hyg Health 2: 163. doi: 10.4172/2332-0702.1000163

Page 10 of 11

Conclusion
Osseous defects from periodontal and periapical lesions are far
more common and are detected routinely as incidental findings.
Establishing an accurate diagnosis is always crucial. Intra-oral periapical
and bitewing radiographs are superior to extra-oral panoramic
radiographs in detecting periodontal and periapical osseous lesions.
Three dimensional CBCT scans are considered as a useful complement
to these conventional radiographic techniques. Diagnostic benefit and
dose detriment tradeoffs are important considerations in choices of
radiographic procedures. It is imperative that CBCT be fully justified
over conventional techniques for each given case before CBCT is
applied for detection of periodontal and periapical lesions.
References

19. van der Stelt PF (2000) Principles of digital imaging. Dent Clin North Am 44:
237-248.
20. Sanderink GC (1993) Imaging: new versus traditional technological aids. Int
Dent J 43: 335-342.
21. Mol A (2000) Image processing tools for dental applications. Dent Clin North
Am 44: 299-318.
22. Vandre RH, Webber RL (1995) Future trends in dental radiology. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 80: 471-478.
23. Kaeppler G, Vogel A, Axmann-Krcmar D (2000) Intra-oral storage phosphor
and conventional radiography in the assessment of alveolar bone structures.
Dentomaxillofac Radiol 29: 362-367.
24. Mol A, Balasundaram A (2008) In vitro cone beam computed tomography
imaging of periodontal bone. Dentomaxillofac Radiol 37: 319-324.

1. Baljoon M, Natto S, Abanmy A, Bergstrm J (2005) Smoking and vertical bone

defects in a Saudi Arabian population. Oral Health Prev Dent 3: 173-182.

25. Eickholz P, Hausmann E (2000) Accuracy of radiographic assessment of

interproximal bone loss in intrabony defects using linear measurements. Eur
J Oral Sci 108: 70-73.

2. Manson JD (1976) Bone morphology and bone loss in periodontal disease. J

Clin Periodontol 3: 14-22.

26. Jeffcoat MK (1994) Current concepts in periodontal disease testing. J Am Dent

Assoc 125: 1071-1078.

3. Holmlund A, Holm G, Lind L (2006) Severity of periodontal disease and number

of remaining teeth are related to the prevalence of myocardial infarction and
hypertension in a study based on 4,254 subjects. J Periodontol 77: 1173-1178.

27. Misch KA, Yi ES, Sarment DP (2006) Accuracy of cone beam computed
tomography for periodontal defect measurements. J Periodontol 77: 1261-1266.

4. Kebschull M, Demmer RT, Papapanou PN. (2010) Gum bug, leave my heart
alone!--epidemiologic and mechanistic evidence linking periodontal infections
and atherosclerosis. Journal of dental research 89: 879-902.
5. Rohlin M, Akerblom A (1992) Individualized periapical radiography determined
by clinical and panoramic examination. Dentomaxillofac Radiol 21: 135-141.
6. Morton TH Jr (1979) Differential diagnosis of periapical radiolucent lesions.
Dent Clin North Am 23: 519-541.
7. Langen HJ, Fuhrmann R, Diedrich P, Gnther RW (1995) Diagnosis of infraalveolar bony lesions in the dentate alveolar process with high-resolution
computed tomography. Experimental results. Invest Radiol 30: 421-426.
8. Segura-Egea JJ, Jimenez-Pinzon A, Rios-Santos JV, Velasco-Ortega E,
Cisneros-Cabello R, et al. (2008) High prevalence of apical periodontitis
amongst smokers in a sample of Spanish adults. International endodontic
journal 41: 310-316.
9. Lopez-Lopez J, Jane-Salas E, Estrugo-Devesa A, Castellanos-Cosano L,
Martin-Gonzalez J, et al. (2012) Frequency and distribution of root-filled teeth
and apical periodontitis in an adult population of Barcelona, Spain. International
dental journal 62: 40-46.
10. Jimnez-Pinzn A, Segura-Egea JJ, Poyato-Ferrera M, Velasco-Ortega E,
Ros-Santos JV (2004) Prevalence of apical periodontitis and frequency of rootfilled teeth in an adult Spanish population. Int Endod J 37: 167-173.
11. Lin LM, Pascon EA, Skribner J, Gngler P, Langeland K (1991) Clinical,
radiographic, and histologic study of endodontic treatment failures. Oral Surg
Oral Med Oral Pathol 71: 603-611.
12. Akesson L, Hkansson J, Rohlin M (1992) Comparison of panoramic and
intraoral radiography and pocket probing for the measurement of the marginal
bone level. J Clin Periodontol 19: 326-332.

28. Ramadan AB, Mitchell DF (1962) A roentgenographic study of experimental

bone destruction. Oral Surg Oral Med Oral Pathol 15: 934-943.
29. Rees TD, Biggs NL, Collings CK (1971) Radiographic interpretation of
periodontal osseous lesions. Oral Surg Oral Med Oral Pathol 32: 141-153.
30. Hirschmann PN (1987) Radiographic interpretation of chronic periodontitis. Int
Dent J 37: 3-9.
31. Pope O, Sathorn C1, Parashos P2 (2014) A comparative investigation of conebeam computed tomography and periapical radiography in the diagnosis of a
healthy periapex. J Endod 40: 360-365.
32. Tsai P, Torabinejad M, Rice D, Azevedo B (2012) Accuracy of cone-beam
computed tomography and periapical radiography in detecting small periapical
lesions. J Endod 38: 965-970.
33. Chau AC, Fung K (2009) Comparison of radiation dose for implant imaging
using conventional spiral tomography, computed tomography, and cone-beam
computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107:
559-565.
34. Ekestubbe A, Thilander A, Grndahl K, Grndahl HG (1993) Absorbed doses
from computed tomography for dental implant surgery: comparison with
conventional tomography. Dentomaxillofac Radiol 22: 13-17.
35. Lamichane M, Anderson NK, Rigali PH, Seldin EB, Will LA. (2009) Accuracy
of reconstructed images from cone-beam computed tomography scans. Am J
Orthod Dentofacial Orthop 136(2):156.e1-6; discussion 156-7. doi: 10.1016/j.
ajodo.2009.04.006
36. Fuhrmann RA, Bcker A, Diedrich PR (1997) Furcation involvement:
comparison of dental radiographs and HR-CT-slices in human specimens. J
Periodontal Res 32: 409-418.

13. Mol A (2004) Imaging methods in periodontology. Periodontol 2000 34: 34-48.

37. Fuhrmann RA, Wehrbein H, Langen HJ, Diedrich PR (1995) Assessment of

the dentate alveolar process with high resolution computed tomography.
Dentomaxillofac Radiol 24: 50-54.

14. de Faria Vasconcelos K, Evangelista KM, Rodrigues CD, Estrela C, de Sousa

TO, et al. (2012) Detection of periodontal bone loss using cone beam CT and
intraoral radiography. Dentomaxillofac Radiol 41: 64-69.

38. Vandenberghe B, Jacobs R, Yang J (2007) Diagnostic validity (or acuity) of 2D

CCD versus 3D CBCT-images for assessing periodontal breakdown. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 104: 395-401.

15. van der Stelt PF, Ruttiman UE, Webber RL, Heemstra P (1989) In vitro study
into the influence of X-ray beam angulation on the detection of artificial caries
defects on bitewing radiographs. Caries Res 23: 334-341.

39. Lofthag-Hansen S, Huumonen S, Grndahl K, Grndahl HG (2007) Limited

cone-beam CT and intraoral radiography for the diagnosis of periapical
pathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 103: 114-119.

16. Reddy MS (1992) Radiographic methods in the evaluation of periodontal

therapy. J Periodontol 63: 1078-1084.

40. Vizzotto MB, Silveira PF, Arus NA, Montagner F, Gomes BP, da Silveira
HE. (2013) CBCT for the assessment of second mesiobuccal (MB2) canals
in maxillary molar teeth: effect of voxel size and presence of root filling.
International endodontic journal 46: 870-876.

17. de Toledo BE, Barroso EM, Martins AT, Zuza EP (2012) Prevalence of
Periodontal Bone Loss in Brazilian Adolescents through Interproximal
Radiography. Int J Dent 2012: 357056.
18. Tugnait A, Carmichael F (2005) Use of radiographs in the diagnosis of
periodontal disease. Dent Update 32: 536-538, 541-2.

Oral Hyg Health

ISSN: 2332-0672 JOHH, an open access journal

41. Abuabara A, Baratto-Filho F, Aguiar Anele J, Leonardi DP, Sousa-Neto

MD. (2013) Efficacy of clinical and radiological methods to identify second
mesiobuccal canals in maxillary first molars. Acta odontologica Scandinavica
71: 205-209.

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Citation: Kumar V, et al. (2014) Different Radiographic Modalities Used for Detection of Common Periodontal and Periapical Lesions Encountered in
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Page 11 of 11
42. Marmary Y, Kutiner G (1986) A radiographic survey of periapical jawbone
lesions. Oral Surg Oral Med Oral Pathol 61: 405-408.
43. Horner K (2013) Cone-beam computed tomography: time for an evidencebased approach. Prim Dent J 2: 22-31.
44. Theodorakou C, Walker A, Horner K, Pauwels R, Bogaerts R, et al. (2012)
Estimation of paediatric organ and effective doses from dental cone beam CT
using anthropomorphic phantoms. Br J Radiol 85: 153-160.
45. Schauer DA, Linton OW (2009) NCRP Report No. 160, Ionizing Radiation
Exposure of the Population of the United States, medical exposure--are we
doing less with more, and is there a role for health physicists? Health physics
97: 1-5.
46. Smith-Bindman R, Miglioretti DL, Larson EB (2008) Rising use of diagnostic
medical imaging in a large integrated health system. Health Aff (Millwood) 27:
1491-1502.
47. Ludlow JB, Davies-Ludlow LE, Brooks SL (2003) Dosimetry of two extraoral
direct digital imaging devices: NewTom cone beam CT and Orthophos Plus DS
panoramic unit. Dentomaxillofac Radiol 32: 229-234.
48. Ludlow JB, Davies-Ludlow LE, Brooks SL, Howerton WB (2006) Dosimetry of 3
CBCT devices for oral and maxillofacial radiology: CB Mercuray, NewTom 3G
and i-CAT. Dentomaxillofac Radiol 35: 219-226.
49. Ludlow JB, Davies-Ludlow LE, White SC. (2008) Patient risk related to common
dental radiographic examinations: the impact of 2007 International Commission
on Radiological Protection recommendations regarding dose calculation.
Journal of the American Dental Association 139:1237-1243.
50. Hirsch E, Wolf U, Heinicke F, Silva MA (2008) Dosimetry of the cone beam
computed tomography Veraviewepocs 3D compared with the 3D Accuitomo in
different fields of view. Dentomaxillofac Radiol 37: 268-273.
51. Ludlow JB, Ivanovic M (2008) Comparative dosimetry of dental CBCT devices
and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 106: 106-114.
52. Roberts JA, Drage NA, Davies J, Thomas DW (2009) Effective dose from cone
beam CT examinations in dentistry. Br J Radiol 82: 35-40.
53. Suomalainen A, Kiljunen T, Kaser Y, Peltola J, Kortesniemi M (2009) Dosimetry
and image quality of four dental cone beam computed tomography scanners
compared with multislice computed tomography scanners. Dento maxillo facial
radiology 38: 367-378.
54. Roberts JA, Drage NA, Davies J, Thomas DW (2009) Effective dose from cone
beam CT examinations in dentistry. Br J Radiol 82: 35-40.

55. Ludlow JB, Ivanovic M (2008) Comparative dosimetry of dental CBCT devices
and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 106: 106-114.
56. Pepelassi EA, Tsiklakis K, Diamanti-Kipioti A (2000) Radiographic detection
and assessment of the periodontal endosseous defects. J Clin Periodontol 27:
224-230.
57. Newman MG, Takei HH, PKlokkevold PR, Carranza FA (2006) Caranzas
Clnical Periodontology. (10 ed). W.B. Saunders Co.: St. Louis.
58. Goldman HM, Cohen DW (1958) The infrabony pocket: classification and
treatment. Journal of periodontology 29: 272-276.
59. Prichard JF (1967) The etiology, diagnosis and treatment of the intrabony
defect. J Periodontol 38: 455-465.
60. Karn KW, Shockett HP, Moffitt WC, Gray JL (1984) Topographic classification
of deformities of the alveolar process. J Periodontol 55: 336-340.
61. Qiao J, Wang S, Duan J, Zhang Y, Qiu Y, et al. (2014) The accuracy of
cone-beam computed tomography in assessing maxillary molar furcation
involvement. J Clin Periodontol 41: 269-274.
62. Walter C, Weiger R, Zitzmann NU (2010) Accuracy of three-dimensional
imaging in assessing maxillary molar furcation involvement. J Clin Periodontol
37: 436-441.
63. Langlais R, Langland O, Nortje CJ (1995) Diagnostic imaging of the jaws: Lea
& Febiger.
64. Albini Riccioli G (1973) Glossary of endodontic terms drawn up by the
endodontic study group. Mondo Odontostomatol 15: 465-468.
65. Calikan MK (1997) Prognosis of permanent teeth with internal resorption: a
clinical review. Endod Dent Traumatol 13: 75-81.
66. Cohenca N, Simon JH, Mathur A, Malfaz JM (2007) Clinical indications for digital
imaging in dento-alveolar trauma. Part 2: root resorption. Dental traumatology:
official publication of International Association for Dental Traumatology 23:
105-113.
67. Patel S, Dawood A, Wilson R, Horner K, Mannocci F (2009) The detection and
management of root resorption lesions using intraoral radiography and cone
beam computed tomography - an in vivo investigation. International endodontic
journal 42: 831-838.

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