Dental Radiography Transcript PDF

SPEAKER 0 Today we're going to do patio and we're going to do Karis. We're going to talk a little bit about how to diagnose. And what are we looking for? So the period don't come as a structure. It serves like a supporting structure for the tooth. Um, it helps in the occlusal relationship of the tee...

SPEAKER 0 Today we're going to do patio and we're going to do Karis. We're going to talk a little bit about how to diagnose. And what are we looking for? So the period don't come as a structure. It serves like a supporting structure for the tooth. Um, it helps in the occlusal relationship of the teeth and it consists of the alveolar mucosa, the gingiva, the symptom, the PDL space, the periodontal ligament and the alveolar bone. The normal radiographic appearance. The first thing we care about is the lamina dura. The lamina dura is like a thin white line that surrounds the root of the tooth. It's dense, is radio, opaque, and is in contact with the PDL space, the PDL ligament. The periodontal ligament of the tooth, which is in contact with the root of the tooth. The alveolar crest. Usually. Typically what you want to see is you want it to have a distance of half a millimeter to two millimeters from the level of the CG of the root of the tooth. 0.5mm to two millimeters is considered normal, even sometimes a little bit more like two and a half or even three. I've seen in some cases is that this thing fracture between the posterior and the anterior teeth. So this is what we want to see. This is the normal appearance. We want to see a nice thin white line that surrounds the bone. We don't want to see any fuzziness. We don't want to see any interruptions of the cortical outlines. And if you draw a line that connects the CJS to the line that defines the alveolar bone, this line should be between 0.5 and 2mm height. This is what normal looks like. Clinical, uh, absence of radiographic features. If you don't have any features, it's either because you have a technique error. Meaning especially in the cases of the posterior teeth of the mandible. If you place it inside the patient's mouth, the instrument I'm talking about, the wind instrument. When we take radiographs, if you don't have the proper technique sometimes it goes down. If you don't push it all the way to the floor of the mouth, that means you're causing foreshortening. Does everybody know what foreshortening is? For those of you who don't know or afraid to say it, foreshortening means that you're having an object that is this big. And when you look at it from a different angle, you make it seem even smaller. Even shorter. This is what foreshortening means. If you create foreshortening in an image, what happens to the alveolar bone is it projects higher. And sometimes when you have a foreshortened image, you can even see the alveolar crest extending even beyond the level of the CG, which is anatomically impossible. It's a projection geometry error. This is what happens here as well. See where the level of the alveolar crest extends. This is your CX. SPEAKER 1 There. SPEAKER 0 It extends almost to the level of the CJ and even beyond. And as we said, we want to have half a millimeter to two millimeters distance between the CG and the alveolar crest. Over exposure. If you increase the dose too much, you increase the optical density of the film, the sensor, or the PSP plate. If you increase the optical density, you make everything look darker. If you make everything look darker, it means you burn out all the fine details. So something like this. If that was proper exposure, that would be considered mild periodontal bone loss. It's this fuzziness that we're looking for when we're describing mild periodontal bone loss. However this image is overexposed. So that means this fine detail is being burned out. From the radiation we use in a variation of normal. If everything is all good clinical manifestations, we have the soft tissue part and the hard tissue part. We have the gingivitis with which comes with swelling, edema, erythema. And then you have the periodontitis where you have pocket formation, involvement of the bifurcation, bleeding, purulent edema, bone loss, tooth mobility. And at the end of course you have tooth loss. In radiology. We classify periodontitis as mild, moderate or severe based on how much. Loss of bone. You have up to 15% of the root length, or between 2 and 3mm. It is considered mild or slight. If it's 16 to 30% of the length of the route, or between 3 and 5mm, you consider it moderate. And if it's beyond that, you consider it severe. So how does radiology help in the diagnosis? It shows us how much bone we have left and how much bone we have lost. It shows the condition of the alveolar crest. It shows involvement of the vacation areas of the old eroded teeth, premolars, and molars. Width of the periodontal ligament space. Sometimes when you have some kind of infection or something is wrong with the tooth, like occlusal trauma, for example, there is widening of the PDL space. The way this widening affects the PDL space, it translates to different diagnosis. For example, if you have occlusal trauma and you see occlusal trauma on one side, it means that this side is getting more. It gets all the pressure just on one side. So this side is going to have a widened periodontal uh PDL space. On the other hand, if you see a nice uniform widening of the PDL space for example, it can be associated with systemic diseases for example. Anybody. Yes, or. Scleroderma. Nice. Local irritating factors. Everybody has seen the calculus, how it looks on our BYD wings. Everybody has seen the overhang from adjacent restorations. People do all kinds of weird things on teeth, and they have. Made monstrosities on teeth, creating overhangs and causing severe periodontal bone loss in specific areas. It gives us the root length when we don't want to do endo, or it gives us the morphology, and also it gives us the ground to root ratio. If we want to do some kind of restoration in the teeth for our friends in process. Opening the proximal contacts where you have food impaction. And also always keep in mind that we can use it for anatomical considerations like position of the maxillary sinus compared to a period bone loss, missing teeth, supernumerary teeth, impacted tip twisted. Anything you can think of. Pathologic considerations obviously carries pediatric lesions and root resorption. The biggest limitation of intraoral imaging is the fact that we're trying to project something that is 3D onto a 2D image. We lose that third dimension. This is why you have artifacts like cervical burnout. The other problem is that you have bony defects overlapping. By higher bony walls and may be hidden. I'm going to explain this a little bit further down when I show you pictures. So it's better understandable when you have teeth overlapping, when you have close contacts, as we say in betweens, and you cannot tell if that is carries and the entire proximal bone, or even the proximal surfaces of the teeth cannot be seen. Decrease in the density of the roots, uh, structure that can indicate bone loss on the buckle or the lingual side of the tooth. Also, another big issue is the fact that. Bone destruction on radiographs is less severe than actually present. It underestimates our lesions. The other problem is that we cannot see soft tissue on radiographs. This is partially a problem because if you play with the contrast in on my packs, when you open my packs and you open a radiograph, it gives you a small option down right to start playing with the contrast and the brightness of the picture. If you adjust this properly, sometimes you might be able to see even the gum line, which will help you when you're trying to diagnose carries. And you're thinking to yourself, is this cervical burnout or is this carries? Um, also, it doesn't provide any, uh, information about how deep our pockets are in periodontitis, and. Also keep in mind that don't level is often measured from the cej, which is a reference point that is not very valid, especially when you have over Irruption when you have attrition, or even if you have technique errors. As we mentioned before, when you cause foreshortening and the alveolar crest projects higher even on the level of the kg. The technique we use in the clinic, obviously, is the parallel technique since we use the ring instruments. The point of using the parallel technique is that we try to minimize the distortion. We try to have the tooth looting as much as it actually looks like in real life. However, as we mentioned in the posterior teeth, especially in the mandible, it's very hard to do it all in the maxilla. Sometimes when you guys place it inside the patient's mouth, we have this. This byte block that the sensor and sticks, it might lose the glue it. Sometimes when you peel it off, you take the glue with you. So it's very hard sometimes to have an actual parallel technique. We try to minimize the distortion to make it look exactly as it should look like. And, um, today the new rotation started and they asked me the first thing everybody asks me is, is there a specific order you want things done when you're doing the FMS? And what I usually say is the best way to start is by doing the posterior Bayes first. And then keep going, either with the interior or the bat wings, I don't mind. The reason I say start with the posterior pace first is because if you have, let's say you have a significant period until bone loss in the middle of number three and you start with a bite means you start with a horizontal bite. Bring. You see a huge bone loss. And because you're horizontally placed, you don't capture the whole extent of the bone loss. That means this is a retake. You have to go again and do another one vertically. So start with a par, the posterior par and see if there is anything crude. If you can find anything that can can be solved with a vertical bite. And then when you get to the bottom you can decide either horizontal or vertical. And, um. Other imaging modalities. We have the subtractive radiography. I don't know if anybody has heard about this. Subtractive radiography is when you take two pictures and put them pixel by pixel on top of each other, and you subtract the gray values of one from the other. Whatever is left, whatever is left different, it means it's different before and after everything else is going to amount to zero. Does it make sense? I see somebody nodding your head like this. Let's say you have an image that that shows the Eiffel Tower. And then another image 50 years afterwards that shows the Eiffel Tower with a bird. Right. The Eiffel Tower is exactly the same. It never changed. If you take the one image from the other, everything that is going to be left is going to be the bird. Does it make more sense now? Yes. This is what I was going to talk about next. It's very hard to do subtractive radiography. Usually what they do, or at least what I did when I was in my undergrad years, you used. You can take an impression of the teeth and make a slot for your film, PSP or sensor and place your sensors somewhere that you can stabilize the process and make it repeatable. Otherwise, it doesn't make sense. If you start subtracting everything from everything, you'll get something that doesn't make sense. You're not getting an actual result. You're right. Panoramic. It's a very nice way to see the whole mouth in one go. It's a very crude. Oops. It's a very crude way to depict the teeth. The problem that I have with pano is that it's a very, very sensitive technique. If you ask anybody that comes into radiology for the first time and you ask them, which one do you think is going to be easier to do, is it going to be the FM or is it going to be the panel? Everybody says the panel. The problem with the panel is that it is very, very sensitive. Whatever you do to the head of the patient, it's going to show up on the picture, for example. If the patient is tilted down, you have a very big smile. That means that the teeth of the patient are going to be outside of the focal trough. Do we know what the focal trough is? Okay. If the patient doesn't place the tongue in the palate, you have the palate of colossal airspace. If the patient's head is rotated in one way, then you have a very wide ramus and one side and a very narrow on the other side side, meaning that the patient was tilted like this. Look how big. The hyoid bone is on this side, and how huge it looks on that side and distorted because the patient was rotated. It's very, very technique sensitive. Cone beam is going to be very questionable. If you want to see involvement of the bifurcation, if you want to see something like this, or loss of one of the buckle or the lingual cortical plates, it's nice to use it. It's very, very limited due to the artifact, especially if you have a restoration in the area. It's going to look all wrong because of the metal hardening, the hardening artifact. And it doesn't have the same spatial resolution, spatial resolution that you would have with a PA. Especially for implants. When I was in my residency in Texas, there were some people that insisted on sending small field of view scans to look for very mild implant bone loss, and we kept sending the same sentence back in our reports over and over and over again. It cannot be evaluated due to severe metal artifact. If you have seen the CBC ever, you have the implant and right next to the implant is going to be a very dark line from the beam hardening artifact. You won't be able to see anything adjacent to it, so it doesn't really make sense to use it. If you want to see mild periodontal bone loss, it's better to take a PA much more useful. Emerging features. What are we trying to look for? We're trying to look for. For change in morphology of the bone. Loss of crustal bone is this white line. We're trying to see if it's interrupted in any way and changes in the internal aspect of the bone. If you have lesions, for example, a periodontal abscess, you're going to have a low density lesion, especially if it's acute. And if you have a more chronic lesions, chronic lesions tend to be a little bit more sclerotic. These are the lines that we use to assess. Periodontal bone loss. You draw a line that extends from CG to CG. Then you draw a line that defines the alveolar crest. If these two lines are completely parallel to each other and are between 0.5 and 2mm far away, that means you have a normal periodontal bone and you see this white line defining the alveolar crest. If these two lines are parallel and at the same time, it's more than 2 or 3mm. So instead of this line being here it's there. This is a horizontal periodontal bone loss. If these two lines are not parallel at all then you have a vertical bone loss. Does it make sense? I didn't hear either yes or no? SPEAKER 1 Yes. SPEAKER 0 Changes in morphology. Please tell me you can see that. SPEAKER 1 Barely. SPEAKER 0 This is what we're looking for. See how you have this nice white outline defining the alveolar crest. And then all of a sudden you have something that looks like a fuzzy. You have an erosion of the bone of the cortical outline. This is mild periodontal bone loss, very mild blunting or slight loss of alveolar crest. Horizontal bone loss. If you draw a line from C.J. to C.J. and a line that defines the alveolar crest, these lines are going to be parallel and more than 2 to 3mm away from each other. It is way more evident here in the interior. Line from C.J. to C.J. line that defines the alveolar crest. Way more than two millimeters and still parallel. Those lines are still parallel. Vertical bone loss. If you draw the line, this line goes up like this. This line goes like that. They're not parallel. You have vertical periodontal bone loss. Then you have inter dental craters and buckle and lingual cortical plate loss. So what happened here is you see this white line and then something a little bit more dense with. If you have loss of one of the cortical plates, either buccal or lingual, we can never tell because there is superimposition. Everything is smudged. This is what you see. You can tell there is some bone left somewhere, but it looks a little bit less opaque compared to the adjacent part that has both cortices, both the buckle and the lingual. This is missing one of them, so it looks a little bit more radio loosened. Osseous deformities and vacations. When you have involvement of the vacations, you can see it clinically, you have mild and then you have even the whole tool can go through. And you can tell by this widening. In between the roots, you have vertical periodontal bone loss extending towards the formation of the roots. Like you can see it here and you can see a big one there. Then we have things like periodontal abscess. When you have a thin black line communicating the oral cavity and a low density lesion that is not located in the periodical area of the root. It looks like this. It's an acute lesion. It's going to be more reduced compared to a sclerotic lesion. That would be more chronic. And you have aggressive periodontitis, usually younger individuals affecting specific teeth with vertical or horizontal periodontal bone loss. And here we see a case of affected first molars. Permanent molars. Dental conditions. As we mentioned, occlusal trauma. Usually in occlusal trauma, what we see is we can see some mobility and we can see some widening of the PDL space that it's going to be specific to one of the sides of the tooth, depending on how the tooth is receiving the forces from the antagonist, you can have tooth mobility, open contacts. That is dangerous for food impaction, and we have local irritating factors like overhang from adjacent restorations or calculus. Let's play a game. Patient comes in in your office. 72 years old shows up with this. What would you do? What? Louder. And ideas. SPEAKER 1 Why? SPEAKER 0 Why would you take a seat? SPEAKER 3 The level of destruction of the world. SPEAKER 0 What do you expect to see in the city? SPEAKER 3 See the extension of it. SPEAKER 0 I'm trying to figure out what is your way of thinking so I can. SPEAKER 3 Well, there is not enough local evidence of that level of extraction. So you have. SPEAKER 0 Parietal. SPEAKER 3 Pathology or something like that. SPEAKER 1 Okay. SPEAKER 0 It happens. SPEAKER 3 Right? SPEAKER 0 Kind of. Yes. If you don't see any local irritants, I mean, you have some calculus, to be honest, right? Not to justify something like that, and especially not to justify something like this. You. Look how bubbly this looks. Bone doesn't usually, like, look like this. It shouldn't have those small bubbles inside. There is no reason to have something like this. What about this one? Any ideas? SPEAKER 1 What works for you. SPEAKER 0 The first thing that if. What if I told you this is a 20 year old. SPEAKER 1 Some. SPEAKER 0 Fibro dysplasia would look a bit more granular, would look a bit more ground glass when you see something like that. Like this. I'm not worried only about how the bone looks, which looks a little bit. The tribulation is sparse. That means you have something affecting the whole thing without having any severe bone loss as well. The other thing you see is the what? Loss of lamina dura, generalized loss of lamina dura in all of the involved teeth, and even have some root resorption. Root resorption like this. It's never good. SPEAKER 1 Yeah. SPEAKER 0 I don't think so. That's malignancy. And if I had to bet, if I had to guess what kind of malignancy, I think we would be talking about some kind of hematopoietic malignancy like lymphoma, leukemia. If it's more generalized, especially if the patient is young. We had a patient in Greece. He was 15 years old. He went to the patio and he was diagnosed with aggressive periodontitis. They did, uh, root scaling for two months before they took a biopsy. And the patient has leukemia. If it doesn't heal super fast, it means something is wrong. If you have polio after scaling, you should be seeing at least some improvement, not complete gain of the periodontal bone loss that you lost. But you should be seeing something. Langerhans. If you see something like this, like a scooped out lesion, when there is no reason to have a scooped out lesion, especially if it's bilaterally. You should be thinking of something like Langerhans cells used to psychosis. There are many things that affect affect the condition of the period of time it's going to be practically. It shows how healthy your patient is if the patient is diabetic, if the patient has any immunodeficiency syndromes, or if the patient has undergone radiation therapy, you can tell everything by looking inside the patient's mouth. Even if the patient is pregnant, you're going to have changes in the gums and the gum. SPEAKER 1 Health. SPEAKER 0 Any questions for perio? How we diagnose? What are we looking for? Are we clear on that? Yes. SPEAKER 1 Does also affect the space. SPEAKER 0 What is my friend from ortho that judged me last time that I said about the protocols? I plead the fifth. How about that? Do I answer your question? It depends. It depends if you have if you have proper treatment. Technically, you you could cause some widening of the PDL space or even some mild reformatting of the route. But it shouldn't be too much if you start dragging the tooth like a dead dog around. SPEAKER 1 Guess what? Yeah. SPEAKER 0 We've seen I've seen cases that there is no route left because of extreme forces, but it's not. Technically, it means something went wrong in the process of moving the teeth. It shouldn't be like that. Unless the patient is super sensitive and everything that you do to the patient, you cause root resorption. But it's very unlikely. Are we clear on the diagnosis of perio with the lines drawing the lines. Vertical bone loss. Horizontal bone loss. Good. SPEAKER 4 Okay. SPEAKER 0 Okay. Charisse doesn't want to work, so take a break for ten minutes. When we get back, we're going to do the attendance and start with Carrie so I can resolve the issue with presentation. Is everybody back? SPEAKER 5 Do we have everybody back? SPEAKER 4 Okay. SPEAKER 0 Let's do attendance. What was that? SPEAKER 1 I don't. Know. Did I? Put it. On. SPEAKER 0 Everybody done. SPEAKER 1 I. Coming. SPEAKER 0 I see one person in the back, two people in the back. Done. I heard a faint. No. Somewhere there. I'm going to assume everybody's done. SPEAKER 1 That's better. SPEAKER 0 Okay, we talked about paleo. Now we talk. The other bane of our existence carries calories is going to be way more hard to detect, especially if we're talking about incipient calories. And I firmly believe that even if you ask ten radiologists about calories, they're going to tell you ten different things. We're going to talk about the disease mechanism. Not so much the role of radiology in diagnosing and all the locations of the carriers. And we're going to talk about. Each one of them specifically. And what are the diagnostic confounders we have for the disease mechanism? As we know, it's the mineralization process of the tooth structure. And it's a dynamic process and it's being considered in infectious disease. As for the disease mechanism, you're going to have contributing factors and you're going to have preventing factors. Contributing factors are going to be the bacteria, the plaque or the biofilm and streptococcus mutants, which is the most important one. The diet. When you have a lot of sugar intakes, fermentable carbohydrates. And that's preventative factors. Obviously, the hygiene of the patient we see very often in kids that never brush their teeth, they come in with rampant carries. So removing or interrupting the bacterial plaque is a preventive factor for developing carries and fluoride with remaining minerals uses the structure of the tooth and makes it more resistant. It always starts as in SIP and carries, affecting the enamel. Usually it starts in the occlusal surfaces or the proximal surfaces. It pierces through the enamel, it eats it away, destroys us demeanor, analyzes it, and then it passes on to the dentin. And it's it's snowballs. If it snowballs, then it gets to the pulp at some point, like you see on the second image. When you get to the pulp, you have infection of the pulp and you end up having very apical lesions in radiology. The three apical lesions that define most of the pathologies we see in our everyday life, which is going to be granuloma, apical cyst and abscess. Usually we put them in an umbrella term that is called apical rarefied osteoarthritis, meaning something that causes verification of the apex of the tooth. Care is detection. The first and biggest thing is patient history and clinical examination. Never skip the patient history and clinical examination. Upstairs on the fourth floor. It happens like 2 to 3 times a week. No, not 2 to 3 times. Maybe like once or twice a week. They send us a patient. We start doing the FMS. We take a couple of X-rays and then the patient like halfway through the FMS, the patient remembers, oh, I had an FM like a week ago. And I'm like, nobody asks you about this. Nobody asks you about your history of X-rays if you've taken anything before or recently. So be careful with that. Ask the patient if they had many, many of them have. Done fmqs previously. And also the clinical examination is very important because sometimes you don't have to take x rays to see the the surfaces of the teeth. A couple of weeks back in the clinic. One of the students from the disease sends in a patient. We start doing the PhD on the patient. Do we take our PA? We take our BYD wings. We take an interior piece, and just before we're done, the student comes in and says, could we please do a retake on the right premolar right wing? And I'm like, why would you do that? Why would you need a retake on this one? And he said, oh, we're missing the medial aspect of the first molar of the mandible. And I'm like, did you check clinically? And he says, no. Why? The tooth was rotated almost 90 degrees. The medial aspect was facing Berkeley and had the caris lesion as big as the patient's head. What kind of pa do you want me to do there? What kind of Batwing do you want there? You can see it clinically. It's evident. It's like half of the tooth is missing. So check the patient clinically before you ask. Either retakes or ask for a full mouth. Check. Visually check. Tactile cartridge detection. Dye and trans illumination. Radiographic examination. The best tool we have currently to diagnose character is going to be the bite wing. It's going to have the best results technique wise, because it's as parallel as it can be because the patient is biting on the thin bite block. Then you have the pixels that have issues like foreshortening that we discussed before, or sometimes you have the sensor on sticking because you had you don't have enough glue on your bite block. Panoramic radiographs is going to be a very crude tool. If you want to evaluate something in one go and cone beam CT doesn't have the same resolution. And as we mentioned before, it is significantly limited by metal artifact, especially so especially in the implants when you're trying to see if there is per implant. Titus CT is going to be the worst tool to use. The location. Usually, as we said, the location is going to be either in between the teeth, the inter proximal surfaces or the occlusal surfaces. You have proximal, you have occlusal, you have rampant carries that affect multiple teeth and multiple surfaces of the same tooth. You have buccal and lingual surfaces and root surfaces. For the inter proximal. The Kari's susceptible zone is going to be from the point where the two teeth almost touch all the way to the level of the gum line. This is what I was talking about when I was. I think I told you guys about the filters on my packs, like the, the preset filters that about the brightness and contrast. Before you use them, try to play around with the brightness and the contrast and see if you if you can trace the soft tissue of the gums. Sometimes if you're very, very careful with your brightness and your contrast, you can even see the soft tissues. So if you're thinking about cervical burnout or caries, you're way more able to diagnose it in. CPM carries the most mild form of caries, only affecting the enamel doesn't extend beyond to the level of the dentin. It's going to happen in the susceptible zone in between the point of contact and the soft tissues. It doesn't extend into the dental enamel junction and therefore into the dentin. And it's a triangle with its broad side facing the outer surface of the tooth. Can we see any here? Where? Best of the premolar. Good. It shows. SPEAKER 1 Nice. SPEAKER 0 They are very, very small. Usually when I when we're in the clinic and people trying to do their grams and try to diagnose the fix they have done on the patients, I usually tell them, turn off the lights. You can see way more shades of gray your eyes are. More potent in dim lights. See how small they are? Only affecting the external surface. This is even considered to be a big one. If I had to guess, I would probably guess that even this one. It's starting to go into the dental enamel junction. This is too big. Interprofessional caries is going to be the next stage. It's going to be the evolution of an SAP and carries in the inter proximal surfaces. It spreads along the DJ, and it looks like a second triangle from the first, with its broad base in the dental enamel junction. And then it keeps spreading through the tubes and through the dentin, which is less calcified compared to the enamel. It has more room to grow. In some cases, the lesion may appear to not have penetrated the enamel. See how it looks. We have the base of the triangle facing outwards, and then you have a second triangle extending into the dentin, with the base of the second triangle facing the dental enamel junction. Primary dentition. We see it very often in kids very thin enamel. We have one triangle and then a second triangle extending, and this one almost reaches. The pulp. The horn of the pulp is super close. Everywhere. That's probably huge. If I had to guess, I would take. If I, if I had to guess and take a PA here, I would probably see some kind of widening of the PDL space or some kind of evidence of early findings of apical periodontitis or apical final status. What's wrong with this one? Technique wise. Can't see the distal of the canine. What do you mean by too low? SPEAKER 6 Yeah. SPEAKER 0 It's too low. And at the same time, it's not centered. There are two things going wrong. First of all, the patient is not biting. If the patient is not biting all the way, then you're missing the crown and you're missing the alveolar crest of the opposing side. I will tell you again when you come into the clinic, when you take bat wings, specifically bat wings, be very careful where the patient bites down, because sometimes they bite on the thick part of the bite block, or they bite on the cable of the sensor. And therefore you have something like this. You have an open bite and then you start missing things. That's a nice retake. Interior carries. Easily and digitally interruption of the enamel affecting the canteen extending beyond the DJ. And then we come to something like this. I don't know if you're familiar with it. I don't know how common it was in the States. I'm from Greece. In Greece it was way more common and we have seen it more and more, especially in older people. These are composites. So sometimes keep it in mind that for people that are older and it seems like they have that looks something that looks like this. This is a composite. Keep it in mind. Keep it as a differential. The difference between a composite and Carrey's usually composite is more well defined, is more round. It looks more manmade. It doesn't look like a natural process that extends by mineralization and extending in different pathways wherever it has the least resistance. Usually it's going to be very round like this. And also don't confuse this gap. This void in the restoration for carries. These are usually small air bubbles. When they did the composite they threw it like a three pointer. So they end up having bubbles. See looks like a heart or. Composites again compared to amalgams. This is a very interesting one, a composite. See how round this is compared to the carious lesion that is starting underneath as recurrent carries. See how ill defined this is and how much it extends in different pathways. And it doesn't have a specific shape that you would expect from a restoration. Occlusal caries, you have either very large ones or very small ones. If they are very large, they're very easily observed. Like this almost extends to the level of the horn of the pulp. This is missing half the crown. The appearance dark circles in the crowns. You can have pulp exposure, but it can. It cannot always be determined. And then you have the other side of the coin. You have very small occlusal caries. Even bat wings, which is our most sensitive and specific tool to detect carries. It's not going to be enough to detect and incipient carries you won't be. Don't expect to see occlusal carriers when it's only incipient, and it's only at the level of the enamel you would be able to see it when it starts extending. Beyond the DJ. Like this. Like this. See this? Round. Well-defined low density lesion. Directly underneath the DJ. This is occlusal carries. Don't expect to see it when it's at the level of the enamel. It's cup shaped radial line. Or it looks like a zone underneath the enamel. These are nice examples of occlusal caries. See how big they are? They're almost at the level of the pulp. This one? This one is smaller, but it still has pierced through the DJ. It's already big. This is missing practically the whole tooth. And this is recurrent, carries underneath a restoration. Rampant carries. Usually we see it in patients that have some kind of a disability and they are unable to brush the teeth. Like people with mental disorders or they have some kind of other disability. And also we see it in patients like this. This is a patient that has gone, uh, radiation. So in patients with radiation you can see that you have multiple multiple carries all over the mouth in many surfaces of the same tooth even. And also keep in mind that because we're a school and we have lower prices, we have a lot of people coming in that have a history of substance abuse like methamphetamine. So you can you probably will see something like this in the clinic. Route surface carries. It's practically cratering on the route of the involved teeth, affecting the symptom. In order for it to happen, you need to have some part of the route exposed. If the route of the tooth is not exposed, the bacteria cannot go underneath the gum line and start penetrating the gamblin. Go all the way down. You need to have some sort of exposed route, maybe some mild periodontal bone loss there. Sorta like reading fluency. It can happen back at lingual and inter proximal and sometimes it can be confused with cervical burnout. Keep in mind what I told you about brightness contrast. And if you can see the gum line. For example, this one. And. Oh, yeah, I forgot to tell you, always. Look, when we were looking for Karis, try to look for something locally, like a local factor that can justify what you're seeing. For example, here you have a huge restoration and underneath you have a scooped out a saucer like radius Lucy that affects the tooth and even extends almost to the level of the pulp. It has obliterated the pulp and it's. Nice. This is exactly what we needed. SPEAKER 1 My God. SPEAKER 0 Exposed roots, significant periodontal bone loss. You have exposed root underneath the level of the CG radio lucent lesion affecting the semantic and the dentin of the two. In between teeth where you have bone loss, you have exposed root. Can anybody tell me what this is? SPEAKER 1 Very. What? SPEAKER 3 Cervical. SPEAKER 0 Cervical burnout. Again, a lot of period bone loss exposed roots symptom is more it's less calcified. It's more soft. It's more. It's easily affected. Any ideas what this is? Is this Karis or not? What is it? SPEAKER 1 What? SPEAKER 0 No. SPEAKER 6 What? SPEAKER 1 No. SPEAKER 0 It's the bone level. This is your periodontal bone. Remember that you have half a millimeter to two millimeters from the level of the CG underneath. This is your bone level. What about this? Of what? Burnout is the shape of the tooth, the shape of the root of the tooth. What about this? Any ideas? That's Kerry's. SPEAKER 6 Gradient descent. But. SPEAKER 0 The burnout looks usually like a small triangle. And always keep in mind where it shows up if it shows up in multiple teeth. We're going to talk about it. You want to wait? Okay. Okay. So here it's very evident that cervical burnout. The way to think about cervical burnout is to think where it happens primarily. It's always going to be underneath the gum line and underneath the CG. If you don't have exposed roots, if you don't have periodontal bone loss, if you don't have any local factors to justify something like Carrie's. Try to think of cervical burnout. Cervical burnout happens because you have. A route that has a limp. It has a looks like a fossa. It looks like, um. SPEAKER 1 What? SPEAKER 0 Concavity. I can I can never remember the word. Thank you. There is, there is a concavity in the root of the tooth. And then you have superimposition from one side to the other. When the X-rays pass by this part that has the concavity because it's it's missing some material, it's going to look less opaque. That means it's going to look darker like this. It's going to look darker. It's going to look darker. Usually it happens below the CG. So keep it in mind and usually happens underneath the gum line. For the current carries. It happens at the margins of existing restorations. And it can either be very big or it can be very, very small, like this one that extends to the level of the pulp. And you see that the pulp has been obliterated, has been completely calcified, and even the root canals have been calcified. If I had to guess, if I would take a PA here, I would see some kind of apical pathology. And then you have things like this again, the pulp is being pacified completely. Even the root canal is starting to get smaller and smaller. Underneath the restoration, don't confuse these things as carries. These are voids. The restoration material when the restoration was taking place. What I usually tell people is, don't try to guess what kind of restoration we're talking about or what kind of material we're talking about. I told you, people do all kinds of weird things to teeth. They use flow composites, they use amalgam, they use radial Lucent composites. They do all kinds of weird things. Don't try to guess what kind of composite you're dealing with. You're dealing with restoration. Everything is classified under the term restoration. Don't try to guess the history of the patient and what happened to the patient and what was the process? People do weird things. Look at this overhang. Very small. And it's starting to have some period bone loss there. See how fuzzy this gets. And then you have some carriers, some carriers underneath. The tooth here is chopped halfway through. It's missing the whole cervical area of the tooth because of carries. What about this. SPEAKER 1 Black. SPEAKER 0 Lining or. Open margin. As I told you, people do all kinds of weird things. Don't try to guess. Here. Carries underneath restoration. Carries underneath restoration. Huge overhang everywhere. Huge restoration. What is this? SPEAKER 1 What's that? SPEAKER 0 Any ideas? Louder. Cervical burnout. This is a cervical burnout. This is Carrie's. Carries underneath. Restoration. Recurrent. What about this? What are those two? The preparation. Sometimes people prepare more and then it doesn't fit when they take the final impressions. This is going to end up having carries at the end of the day. Diagnostic confounders. Usually it starts in the pits and fissures. It's way more common. You have the cervical burnout, as we mentioned see underneath the level of the CG. If you were to play with a contrast and the brightness here, you would see that it's also underneath the gum line, which would be impossible to have carries underneath the gum line. How did you get bacteria underneath? Soft tissue. And then we have the marbled effect. Does anybody know what the marble effect is? SPEAKER 3 If you keep looking at the animals. SPEAKER 7 I kind of worried. SPEAKER 0 If you put two things of very different densities next to each other, one amplifies the contrast to the other. If you have oops. If you have air and cortical bone and you put them next to each other, you would see a dark line separating the air on the side of the air, and a very thick white line on the side of the bone. One amplifies the contrast of the other. It's way more evident if you look at CBT. When you look at CBT and you look at the edge, uh, the inferior border cortical border of the mandible, if you start scrolling in the CBT, you will see a very dark line separating the cortical bone from everything else. And that also sometimes hinders us from diagnosing, because if I want to see a apical lesion in the in a tooth of a root that is in contact or very close to the cortical, uh, to the cortical border of the mandible, either buccal or lingual. If I start scrolling through, then I see this dark line from the defect, and I'm not able to tell if there is widening of the PDL space, for example, and I cannot tell if there is a culprit, don't I this in that tooth? Apparently delusions. We talked about cervical burnout. Remember below the level of the CK, even below sometimes the level of the soft tissue. No road carries unless there is alveolar bone loss. You need to have exposed root to have root carries the Marfan defect. It's more evident here. This is how it looks a little bit. I told you it's way more evident on CBC. If you actually see a slice of CBC, you would be able to see it more and more clearly. But this is how it looks when you have air and something dense next to each other. One amplifies the contrast of the other. Dental anomalies. You have hyperplastic pits way more common on seven and ten. Teeth seven and ten sometimes can be confused with. Uh, incipient carries. Make sure to know your anatomy before you start diagnosing. There is no point in trying to diagnose something if you don't know how normal looks, especially for the people that come up to the rotation. We try to give them a review of the anatomy of the anatomy and of the basic interpretation. I cannot tell you how many times people have sent me. Uh, consults on patients that had, uh, according to them, radio loosened lesion in the anterior jaw. And they were talking about the mental fossa or reducing the lesion in number 18, 19 and 20. Uniform, well-defined low density lesion. They even describe it. And is this submandibular gland fossa. So keep in mind that anatomy. You have to know the anatomy to justify the pathology. Con cavities produced by wear and tear. Like this. Make sure to know your anatomy, especially if you have sometimes, especially in the interior. If you have a lot of period bone loss and you have calculus, sometimes this calculus might look like an actual restoration from the from the thickness of it. This is a nice example of cervical burnout. The first molar, it has a concavity in between the medial buckle root and the palatal root. And that concavity depicts like this. Sometimes the roots have a wonky shape. They have all kinds of different shapes. Another one that I like a lot is the one that looks like a target. I don't know if you have seen it. It looks like a circle and then another circle in the middle. And this happens when the root goes like this. And then buckle or lingual. And what you see is the route and then a circle at the end. The extent of Carrie's. We cannot always know this looks incipient, but if you were to take a slice of it, you can see that it extends even further down. Sometimes. Most of the times we underestimate how big the lesion is with carries. We cannot see exactly how big it is and how much it has the mineralized, the enamel and the dentin. And if it gets to the point of the dentin, then it snowballs because of the less calcification and the tubes. Overlap. This is the main thing we care about, especially for the white wings. Make sure when when you're taking parts that you don't have any overlap, or at least you have this contact open somewhere. I don't mind if you don't have it open there, but it should be open somewhere because it happens. Sometimes you have lesions in the inter proximal surfaces. I mean, you can tell there is something wrong there, but you can you don't you cannot actually tell how big the lesion is. And then you take another one and you see that it almost extends to the level of the pulp. Projection angle means depending on how you take the x rays, you can see different things. For example, if you were to look at this. You would probably say some incipient carries. Or if you're very observant, you can see there is some mild extension into the dentin beyond the level of the JX. When you turn it distally. You see that it extends even more towards the dentin. So depending on how you take the X-ray you can see different things. You can see different extensions. So be careful with that. Any questions? Does everybody understand how cervical burnout works? Can you differentiate it from incipient carries and carries? I'm asking because that is going to be asked in the exam. Don't tell me I didn't tell you. Can we differentiate mild periodontitis? Okay. SPEAKER 1 Good luck. Hi. What's up? SPEAKER 6 I was able to take my assistant because there's a fire. The link are I can write my name or something, and then I can. SPEAKER 1 Come here. It's nice. SPEAKER 6 Is that why it crashed? SPEAKER 0 Give it a second. It's going to restart.