Completed: 17/3/19

DENTAL RADIOLOGY: A GUIDE TO RADIOGRAPHIC INTERPRETATION

CVE CSPOD1902

Dr. Anthony Caiafa

Learning Outcomes

• Obtain skills in interpreting dental radiographs

• Use these new skills to confidently diagnose more oral pathology and to offer more predictable
treatment outcomes for your patients
• Increase your dental caseload and thus lift practice profitability

Interpreting dental radiographs

1. Determine which teeth imaged

a. Place finger on convex side of dot
b. Decide if maxillary or mandibular teeth
c. Rotate so maxillary roots dorsal
d. Decide which left and right – left side of
2. Investigate any radiolucencies by taking radiographat slightly
different angle
a. Lesion if still periapical, otherwise incidental/mental
farmen
3. Compare width of root canal with adjacent and contralateral
teeth
a. Take radiograph at same angle on other side – to avoid
affecting root width

Normal structures:

• Normal alveolar bone – gray and uniform, slightly darker than tooth roots
o Uniform unless near tooth root/mental foramen
o Slightly, regularly mottled
o Completely fill area between roots and cementoenamel junction
• Root canals
o All of same diameter
• No radiolucent areas in teeth/bone
o Regular, thin radiolucent line around roots = periodontal space
o Thick horizontal radiolucent line parallel to ventral cortex of mandible = tubular mandibular
canal
o Middle and caudal mental foramina near apices of 1st 3 PMs – circular radiolucency
o Fibrocartinlaginous mandibular symphysis between first two incisors – radiolucent line on
rostral mandibular views
o Palatine fissures – paired radiolucent areas caudal to 1st and 2nd incisors
o Widening of periodontal space at apex of canines
Completed: 17/3/19

• Thin white line over maxillary canines and premolars – confluence of bones between palate and
maxilla
• Artefactual superimposed radiolucencies
o Visualisation of foramina/holes over an apex
o Regular margins compared to irregular in true radiolucencies
o Only on one root – more likely on several roots in real radiolucencies
o

Common diseases:

• Periodontal disease – alveolar bone loss

o Bacterial infection + inflammatory
host response causing
osteoclastic bone resorption
o RG: crestal bone height loss to
below cementoenamel junction
▪ Exposure of furcation
o Types of bone loss
▪ Horizontal – bone loss to
similar level across an
arcade
▪ Vertical/angular – single area of
recession below surrounding bone
• Remaining bone often has
horizontal bone loss =>
combo
o Evident >30-50% lost mineralisation
o Can be hidden by superimposition
o Ensure true radiolucency as opposed to
superimposed
▪ Multiple roots mostly affected
▪ Often irregular margins
▪ Take another radiograph at slightly
different angle
• Endodontic dz - tooth nonvitality/inflammation of
root canal system (root canal, pulp chamber,
dentinal tubules), often 2ary infection of periapical
tissues (periodontal ligament, alveolar bone)
o Signs
▪ Periradicular rarefaction
▪ Wide periodontal spake
▪ Thickened/discontinuous lamina dura
▪ Periradicular opacities
▪ Internal resorption
▪ External root resorption
o Ddx
▪ neoplasia
▪ Cysts
Completed: 17/3/19

▪ Normal anatomy/superimposition
o Pathogenesis
▪ Death of pulp due to infection
▪ Death of dentin-producing odontoblasts
▪ Less 2ary dentine laid down -> narrower canal compared to adjacent teeth
▪ Can cause increased dentine production -> narrow root, esp. if also
periodontally diseased
• Feline odontoclastic resorptive lesions (FORLs) – resorption of tooth until no tooth left
o Types
▪ Type 1: no bone replacement
• Due to inflammation (periodontal ds, ginigivostomatitis)
• Well-defined periodontal space, normal root in areas unaffected by
lesion
• Extract only affected root by routine extraction
▪ Type 2: bone replacement
• Localised gingivitis
• Gingival inflammation 2ary to FORL
• Replacement resorption – diff density to normal teeth
• Dentoalveolar anklyosis and no root canal
• Ghost roots in late stages
• Crown amputation required of whole tooth as long as no root canal
o 65% incidence cats >6yo
o Radiography important as determination between type 1 and type 2 changes type of
extraction needed
▪ Most lesions only visible on radiography
o Ddx:
▪ Caries
▪ Neoplasia
▪ Metabolic dz
▪ Trauma
• Denoalveolar ankylosis – lack of periodontal space
• Caries – acid degradation of mineralised dental tissues (enamel, dentin)
o Radiolucent areas in crown/root
o Mostly in dogs, occlusal surfaces of molar teeth/interproximal areas
o 40% mineral lost in tooth before change identifiable
• Cysts – radiolucent areas with smooth bony edges
o Dentigerous – on crown of unerupted tooth
o Can displace teeth
• Benign neoplasia
o Cause tooth mvt
o Expansive tumors can cause bone to pull away
• Malignant neoplasia
o Irregular, ragged, bone destruction
o Mottled texture
o Spiked root apices due to root resorption
o Complete loss of bone around teeth later in dz
o Cortical spicules if cortex involvement
Completed: 17/3/19

o Diagnosis: histology
▪ Send w/ pics, RGs, note type and extent of bone involvement
▪ Malignancy w/o bone involvement rare in later stages – check before starting
therpay
o Ddx:
▪ Osteomyelitis
▪ Metabolic/periodontal/endodontic bone dz

• Oral trauma
o Fractures
▪ Even after reparation, fracture will be evident on RG
▪ Complicated by root fractures
• Iatrogenic
o Retained tooth roots after extraction attempt
▪ No signs except
• Pain
• Abscess formation
Completed: 17/3/19

▪ Ensure post-operative RGs

Changes to tooth with age:

• Decrease in canal width – due to 2ary dentin being

laid around root canal
o Protect root canal from damage
o More significant if heavy chewing of hard
objects
• Toot dvlpt
o Pulp starts v. wide w v. thin dentine
▪ Harder to extract – more susceptible
to fractures
o Apex remains open until 9-10mo

Endodontic disease: tooth nonvitality/inflammation of

root canal system (root canal, pulp chamber, dentinal
tubules), often 2ary infection of periapical tissues (periodontal ligament, alveolar bone)

• Signs

->always completely extract tooth with viable root canal!

o Periradicular rarefaction
o Wide periodontal spake
o Thickened/discontinuous lamina dura
o Periradicular opacities

Cyst: closed sac lined with epithelium that contains fluid

and become infected/neoplastic or damage surrounding

structures.

Dental RGs:

• Reveals
28% pathology
undiagnosed
dogs, 40% cats,
extrapathology
50% diagnosed
dogs, 54% cats
• 30% teeth had pathologies
• LLM1 and RLM1 are mot common

Positioning techniques:
Completed: 17/3/19

• Ensure final images have maxillary roots face upwards, mandibular roots downwards, nose
pointing to right for right teeth, etc.
• Bisecting angle – for anterior teeth
o Aim x-ray at 90 to film then drop 30-35 from vertical
• Lateral view
o To assess apical pathology
• Tube shift rule/ SLOB/Clark’s rule – superimposition rule
o If structures are going to superimpose, shift 30deg angle
rostrally
▪ Esp for UPM4
o Same lingual, opposite buccal: anything lingual goes same
direction as tube shift, anything buccal goes the opposite
direction
o Superimposition by zygomatic arch, esp. in cats – large eyes and low zygoma
▪ Drop collimator to more horizontal position
▪ Will cause root elongation
• Modified BAT – make tube more horizontal (30)
• Sternal recumbency for maxillary views
• Dorsal recumbency for mandibular views
Completed: 17/3/19
Completed: 17/3/19

Normal RG:

• Mandible = ladder-like trabecular pattern

• Maxilla = irregular trabecular pattern
• Radicular groove – double radiographic
shadow along l of
o Distal aspect of mesial root
o Furcation area
o Mesial aspect of distal root

Normal dog anatomy:

• Maxilla
o Palatine fissure (paired) – bundles from palatine n. + a. entering into nasal cavity
o Teeth
▪ Dentine – 65% hydroxyapatite + 35% collagen
• Overlies and protects pulp cavity
• Living tissue – gets repaired
• Innervated
▪ Gingiva – adheres to tooth at interface between root and crown
• Neurovascular tissue (superior/inferior alveolar nn., aa., vv.
Completed: 17/3/19

• In Pulp cavity
• Branch in exa
▪ Alveolus socket -
▪ Cementum – type of dentine that allows PDL fibres to attach to root of tooth
• Overlies root of tooth
• Mostly acellular
• Type I collagen + hydroxyapatite
▪ Pulp – neurovascular + fibrous tissue
• Nourishes dentine
• Odontoblasts lining – replace lost dentine
▪ Enamel - <1mm (D, C) – 98% hydroxyapatite
• Non-living
• Not repaired if lost
• Only in crown
• Mineralisation req enamelins and amelogenius in ECM
• Formed by ameloblasts
o Thomes’ fibres – processes projecting into unmineralized
enamel
▪ Apex – point of entry of neurovascular supply to the tooth
• RG apex not necessarily = biological apex
▪ PDL space – radiolucent space where PDL attaches to apex of tooth
• Allows shock absorption
• Widening of space indicates pulp pathology
• PDL – cross-hatch pattern
o May be branched to accommodate tooth root
• Lined by compact bone, filled w trabecular bone
▪ Furcation area – point where roots join together
• Often bone loss in periodontitis
▪ Roots
• Distal, buccal, palatal in 3-rooted teeth (PM4 to M3)
▪ Crown
• Cusps
o Coronal pulp horns – branch off and come up into crown
o Breaking off can cause pulp necrosis due to exposure
▪ Cervical burn out – point where dentine and enamel become narrower on a
normal tooth - radiolucent
o Alveolar bone – supports root of tooth
▪ Allows PDL to attach to cementum
▪ Lateral canals can also be present
o Vomer/nasal septum – separation between L and R nasal cavity
▪ Mid-palatal suture
o Alveolar process of maxilla - where horizontal maxilla meets vertical maxilla
▪ Floor of nose
▪ Radiodense on RG
o Conchal crest – attachment point for ventral turbinates
o Infraorbital foramen – exit of infraorbital n., a. from infraorbital canal
o Zygomatic arch
Completed: 17/3/19

o Irregular trabecular pattern of bone

• Mandible
o Middle mental foramen – level with mesial root of LPM2 – radiolucent
o Mandibular canal – split into
▪ Part that runs into middle mental foramen
▪ Incisive n. that runs to incisors and canines
o Ventral cortex of mandible – need to assess if intact before performing root extractions
o Ventral + dorsal cortical plate of mandibular canal – line mandibular canal containing
mandibular n.
o Caudal mental foramen between LPM3 roots
o Ladder-like trabecular pattern of bone
o Radicular groove –
▪ Groove on inside of distal root of M1 – shows up as double line (in addition to
PDL line)
▪ Groove on mesial root of M1 – double radiolucent line

->LPM1 in dogs has no precursor

Normal cat anatomy:

• Maxilla – similar, but more porous (radiolucencies) rostral to palatine fissure

o Turbinates – often lost due to neoplasia
• Mandible

Detecting pathologies:

• Labial film mounting

• Point maxillary roots facing upwards, mandibular downwards
• R side teeth viewed with rostral teeth pointing to the R
• Use triadan numbering system
• Record missing/extra teeth
• Combine with
o Oral exam
o Periodontal probe
• RG all mouth to understand what is normal
• If in doubt, radiograph contralateral tooth
• If borders of lesion well-demarcted: radicular cyst
o Diffuse: apical periodontitis
o Widening/loss of PDL -> pulpal dz
o Widened pulp chamber -> pulp necrosis
• V. wide pulp chamber -> pulp necrosis at young age (<10mo?)
• Fracture of tooth root can cause periodontal disease
• Bony islands in mandible considered normal’

Bone resorption types:

• Type 1 – cervical resorption (loss of enamel/dentine)

• Type 2 – loss of PDL
o Loss of density of tooth root
• Type 3 – one root type 1, one root type 2
Completed: 17/3/19

Stages of tooth resorption :

1. D
2. D
3. D
4. D
5. Breaking off at tooth crown

Performing periodontal health examination:

• Look at crestal bone between teeth, in furcation areas

o Loss of crest = periodontitis
o Loss of sharp angle between lamina dura/crest
o Blunting of crestal bone
• Angular/horizontal bone loss = periodontitis
o Angular bone loss = deeper probing depth
o Horizontal bone loss = gingival recession

Common signs:

Cutaneous swelling ventral to eye Pulp necrosis PM4, UPM3

V. wide pulp chamber Pulp necrosis at young age
Wide pulp chamber + periapical bone loss Pulp necrosis
Loss of crestal bone/furcation bone Periodontitis
Loss of angle between lamina dura and crest + Early periodontitis
widening of PDL near crest
Angular bone loss
Horizontal bone loss Due to gingival recession
Localised periodontitis Wedged FB
Inflammatory granulation tissue on teeth External crown/root resorption
Sea of teeth floating in fibrous tissue 2ary hyperthyroidism

Procedure:

1. Intubate patient in sternal recumbency

2. RGs of maxilla
a. Rostral view
b. 2-4 lateral views with BAT technique
3. Roll into dorsal recumbency
a. Rostral view (all BAT)
b. 2 lateral views (PMs, Ms)
c. Aiming x-ray tube 15 degrees vertically

Common diseases:

• Pulpal dz
o Widening or loss of apical PDL
o Widened pulp chamber
Completed: 17/3/19

o Ipsilateral facial swelling

o Often associated with apical bone lysis and external inflammatory root resorption
o Check tube head horizontal angulation is the same
o Different types according to borders of lesion
▪ Radicular cyst
▪ Apical periodontitis
o Periodontal probing essential
• Periodontal dz
o Loss of bony crest between teeth, in furcation areas
o Loss of knife edge and blunting of crestal bone – early
periodontitis
o Loss of sharp angle between lamina dura and crest – early “
o Widening of periodontal ligament space near crest – early “
o Angular bone loss + deeper probing depths
o Horizontal bone loss + gingival recession

Grades of periodontal disease:

PD grade 1 2 3 4 5
Signs Bone loss Local stomatitis
between Extreme
teeth, calculus curvature
deposits, bone (dilaceration) of
island, Caudal root apices
mental
foramen,
chevron effect
mesial root
Completed: 17/3/19

Complications from tooth extractions:

• Creating oronasal fistula

Tooth resorption:

• Most common in cats

• Diagnosis
o Tactile probing + intraoral RGs
o Use inverted grayscale image to help diagnose
abnormal teeth spaces

Other tooth conditions:

• Cutaneous draining sinus due to infected fractured tooth

root
• Dental caries – bacterial erosion of crown (enamel,
dentine)
o Enter pulp and cause infections
• Apical bone lysis
• 2ary hyperparathyroidism (2ary to KD)
• Enamel hypoplasia
• Persistent deciduous canine
• Missing permanent teeth
• Dentinal dysplasia – e.g. due to distemper
o Short roots
o Impacted teeth
• Radicular cyst
• Fusion of 2 teeth
• Gemination – doubling of crown – like fusion but still same no. of teeth
• Dens invaginatus/concrescence of the roots
o Infolding of enamel and dentine onto itself
o Bacteria caught in fold
o Leads to pulp necrosis -> apical lucency
• Bilateral dentigerous cysts
o Fluid-filled swelling of gingiva due to retained permanent teeth
o Can eventually cause jaw fracture
• Supernumerary teeth
• Migrating retained roots – can travel through bone, tissue
o Need to drill through bone to retrieve them if in mandibular canal

Tooth and jaw fractures:

• 2ary to periodontitis (pathological)

• Crown fracture
• If permanent teeth fractured while unerupted will never erupt
• Often accompanied by
o External root resorption
o Apical lysis
Completed: 17/3/19

Oral tumours:

• Peripheral odontogenic fibroma (fibrous epulis)

• Odontoma
• Melanoma
o Bone lysis
o Pathological fractures
o Pulpitis – irregular root canal width
o Invades bone
• Canine acanthomatous ameloblastoma (CAA) – invades bone
o Cutting out 1cm margin
• Calcinosis circumscripta
• Intraosseous ameloblastoma

Distinguish oral inflammatory/neoplastic lesions:

• Inflammatory lesions grow rapidly

o Resorb tooth and bone structures instead of displacing structures
o Malignant tumours may also have this growth pattern
• Slow-growing lesions tend to create their own space by displacing other structures (teeth,
cortical plate)
Completed: 17/3/19
Completed: 17/3/19