Radiographic Density in Oral Medicine

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Radiolucent Lesions

• Radiolucent lesions appear darker on a radiograph
• Two types of radiolucent lesions:
  • Radiolucent lesions with well-defined borders
    • Indicate a slow proliferating benign process
    • Multilocular radiolucent lesions with well-defined borders indicate a benign yet aggressive process
  • Radiolucent lesions with ill-defined borders
    • Indicate aggressive, inflammatory, or neoplastic processes

Radiopaque Lesions

• Radiopaque lesions appear lighter on a radiograph
• Types of radiopaque lesions:
  • Radiopaque lesions with well-defined borders
    • Represent a benign or inflammatory process
  • Radiopaque lesions with ill-defined borders
    • Indicate a more aggressive or neoplastic process

Mixed Radiolucent-Radiopaque Lesions

• Can be due to:
  • Inflammatory conditions
  • Metabolic conditions
  • Fibro-osseous lesions
  • Malignant processes

Jaw Lesions

• Majority of jaw lesions are radiolucent (>80%)
• Jaw lesions can be described based on:
  • Density relative to adjacent bone
  • Borders (well-defined or ill-defined)
  • Number of loculi (unilocular or multilocular)
  • Aetiology (inflammatory, neoplastic, etc.)

Effect on Surrounding Structures

• Evaluating the effect of a lesion on surrounding structures helps in inferring the behaviour of the lesion
• Features to consider:
  • Displacement of teeth
  • Resorption of teeth
  • Cortical destruction or expansion

Radiographic Features of Periapical Lesions

• Radiographic features vary depending on the time course of the lesion
• Early stages:
  • Loss of bone density
  • Widening of the periodontal ligament space
  • No evidence of sclerotic bone reaction
• Later stages:
  • More extensive bone loss
  • Cortical destruction or expansion

Specific Lesions

• Odontogenic keratocyst:
  • Typically occurs in the mandible
  • Well-defined, radiolucent lesion
  • May displace teeth
  • May cause cortical expansion
• Ameloblastoma:
  • Typically occurs in the mandible
  • Multicystic, radiolucent lesion
  • May displace teeth
  • May cause cortical expansion
• Fibrous dysplasia:
  • Typically occurs in the maxilla
  • Radiolucent, ground-glass appearance
  • May cause cortical expansion
  • May displace teeth
• Cementoblastoma:
  • Typically occurs in the mandible
  • Periapical, sclerotic, sharply marginated lesion
  • Fuses directly to the tooth root
  • More common in children and young adults

Conditions Causing Generalized Loss of Lamina Dura

• Hyperparathyroidism
• Paget’s disease
• Fibrous dysplasia
• Osteomalacia
• Multiple myeloma
• Osteoporosis
• Pyle’s disease
• Hypophosphatasia
• Renal osteodystrophy
• Leukemia

Conditions Causing Thickening of Lamina Dura

• Local trauma from occlusion
• Malposition or served as abutments for fixed bridges
• Systemic hypoparathyroidism
• Bisphosphonate-related osteonecrosis of the jaw

Other Important Radiographic Features

• Alterations observed on panoramic radiographs that might compromise oral and general health
• Examples:
  • Calcified stylohyoid complex
  • Arterial calcifications
  • Sialolithiasis
  • Phleboliths
  • Tonsilloliths

Calcified Stylohyoid Complex

• Considered normal when it does not extend below the mandibular foramen
• Considered elongated when it extends below the mandibular foramen
• Causes:
  • Local chronic irritations
  • History of trauma
  • Endocrine disorders in female at menopause
  • Persistence of mesenchymal elements, bone tissue growth, and mechanical stress or trauma during stylohyoid ligament development

Arterial Calcifications

• Dystrophic calcification

• Deposited calcium salts in chronically inflamed or necrotic tissues

• Indicate a high risk of cardiovascular disease### Atherosclerotic Plaques

• Atherosclerotic plaques in the extracranial carotid vascular path are the primary cause of vasculocerebral embolism and obstructive diseases.

• Plaques develop when fatty substances, cholesterol, platelets, cellular waste products, and calcium are deposited in the artery lining.

• Risk factors for atherosclerosis include: diabetes mellitus, obesity, hypertension, smoking, inadequate diet, chronic kidney disease, and menopause.

Radiographic Features of Atherosclerotic Plaques

• Calcified carotid atheroma initially develops at the bifurcation of arteries, soft tissues of the neck, and adjacent to the greater horn of the hyoid bone and the cervical vertebrae C3 and C4 or the intervertebral space between them.
• Radiographically, calcified carotid atheroma appears radiopaque, usually multiple and irregularly shaped, with a vertical distribution and internally heterogeneous radiopacity.

Sialolithiasis

• Sialolithiasis is the most common disease of the salivary glands, characterized by obstruction of salivary secretion by a calculus, associated with swelling, pain, and infection of the affected gland.
• Imaging features of sialolithiasis may include a single sialolith in the right submandibular gland, calcification in the right parotid gland and its duct, calcifications in the right submandibular and parotid glands, and multiple microliths in the parotid gland on both sides.

Phleboliths

• Phleboliths are idiopathic calcifications that result from the deposition of calcium in normal tissue, despite normal serum levels of calcium and phosphate.
• Phleboliths are calcified thrombi found within vascular channels, often in the presence of hemangiomas or vascular malformations.
• Imaging features of phleboliths may include multiple phleboliths on the right side.

Tonsilloliths

• Tonsilloliths are calcifications within a tonsillar crypt, which involve primarily the palatine tonsil, caused by dystrophic calcification as a result of chronic inflammation.
• Imaging features of tonsilloliths may include multiple tonsilloliths in the lower one-third of the mandibular ramus on both sides.

Central Giant Cell Granuloma

• CGCG is a type of granuloma that affects the jawbones.