What Else Could This Be? Exploring Diagnostic
QuandariesDavid Landwehr D.D.S., M.S.
Capital EndodonticsMadison, WI
Metabolic
Infectious
Neoplastic
Developmental
Differential Overview
NervesVeins
Glandular elements
Arteries
Bone
Odontogenic epithelium
Smooth Muscle
Radiology limitations
One piece of Subjective diagnostic information
Who is Reading the Radiograph ?
Goldman M, Pearson A, Darzenta N. Reliability of radiographic interpretations. Oral
Surg 1974; 38(2):340.
Who is Reading the Radiograph ?
Goldman M, Pearson A, Darzenta N. Reliability of radiographic interpretations. Oral
Surg 1974; 38(2):340.
Interexaminer agreement ~ 50%Intraexaminer agreement ~ 75 - 80 %
Who is Reading the Digital Radiograph ?
100% agreement < 25%5 agree ~ 50%
Intraobserver reliability range 41 % - 85 % Average 68 %
Tewary S, Luzzo J, Hartwell G. Endodontic radiography: who is reading the digital radiograph? J Endod. 2011 Jul;37(7):
919-21.
Radiology limitations
Sensitivity 0.65Specificity 0.78
Overall accuracy 70.2%Bohay RN. The sensitivity, specificity, and reliability of radiographic
periapical diagnosis of posterior teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000 May;89(5):639-42.
Bone loss will not be detected if the lesion is only in cancellous
bone
PA lesion when bone loss extends to the junction of the cortical and
cancellous bone
Radiology limitations
Bender IB, Seltzer S: Roentgenographic and direct observation of experimental lesions in bone. Part I. J Am Dent
Assoc 1961; 62:152.
Radiology limitations
Certain teeth are more prone to exhibit
radiographic changes than others, depending
on their anatomic location
Bender IB, Seltzer S: Roentgenographic and direct observation of experimental lesions in bone. Part II. J
Am Dent Assoc 1961; 62:708.
Radiology limitations
Lesions were always larger than the radiographic image, especially in the molar region
Shoha RR, Dowson J, Richards AG. Radiographic interpretation of experimentally produced bony lesions. Oral Surg Oral Med
Oral Pathol. 1974;38(2):294-303.
Lesions were evident on the radiograph before junctional bone or cortical plate was involved
Radiology limitations
7.1% mineral bone loss to produce a radiolucency
Lesions 1-7 mm didn’t produce a lesion in cancellous bone
Bender IB. Factors influencing the radiographic appearance of bony lesions. J Endod 1982 Apr;8(4):161-70.
Cone-Beam Computed
Tomography (CBCT)
Recommendation 2:
Limited FOV CBCT should be considered the imaging modality of choice for diagnosis in patients who present with contradictory or
nonspecific clinical signs and symptoms associated with
untreated or previously endodontically treated teeth
CBCTCBCT is accurate in detecting apical
periodontitis
Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic
and periapical radiography for detection of apical periodontitis.vJ Endod 2008 Mar;34(3):273-9.
De Paula-Silva FW, Wu MK, Leonardo MR, da Silva LA, Wesselink PR. Accuracy of periapical radiography and cone-
beam computed tomography scans in diagnosing apical periodontitis using histopathological findings as a gold
standard. J Endod 2009 Jul;35(7):1009-12.
CBCTCBCT devices demonstrated poor accuracy in detecting simulated lesions smaller than
0.8 mm in diameter
fair to good accuracy when simulated lesion diameter was between 0.8–1.4 mm
excellent accuracy when simulated lesions were larger than 1.4 mm in diameter
Tsai P, Torabinejad M, Rice D, Azevedo B. Accuracy of cone-beam computed tomography and periapical radiography in detecting small periapical lesions.
J Endod 2012 Jul;38(7):965-70.
Edwards R, Altalibi M, Flores-Mir C. The frequency and nature of incidental findings in cone-beam computed tomographic scans of
the head and neck region: a systematic review. J Am Dent Assoc 2013 Feb;144(2):161-70.
CBCT Sensitivity
1.3 - 2.9 incidental findings per CBCT
24 - 93 % of scans had incidental findings
1029 scans looked at by 3 observers for changes in maxillary
sinus
prevalence of pathology was 56.3 %
CBCT Sensitivity
Ritter L, Lutz J, Neugebauer J, Scheer M, Dreiseidler T, Zinser MJ, Rothamel D, Mischkowski RA. Prevalence of pathologic findings in the maxillary sinus in cone-
beam computerized tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011 May;111(5):634-40.
Clinicians’ experience level appears to be correlated with their
ability to correctly diagnose periapical disease in CBCT
volumes
CBCT Limitations
Parker JM, Mol A, Rivera EM, Tawil PZ. Cone-beam Computed Tomography Uses in Clinical Endodontics: Observer Variability in
Detecting Periapical Lesions. J Endod 2017 Feb;43(2):184-187.
Remember
• Common things occur more often *** • Same lesion can have different presentations • Similar clinical presentations can have different
treatments and potential outcomes• Patient can have more than a single pathology
Remember
• 90% ≠ 100%
• Smaller lesions- unilocular• Larger lesions- multilocular
• These lists have crossover and omissions
Systematic Differential Diagnosis
of Periapical Pathology
Unilocular
Multilocular
MULTILOCULAR RADIOLUCENCIES
Odontogenic keratocyst***Ameloblastoma***
Central giant cell granuloma**
MULTILOCULAR RADIOLUCENCIES
Keratocystic Odontogenic Tumor***Ameloblastoma***
Central giant cell granuloma**
Keratocystic Odontogenic Tumor
• 3-11% of all cysts• Infancy to old age (rare before 10)• Mn in 60-80%• Posterior body and ramus
Keratocystic Odontogenic Tumor
• Usually asymptomatic- pain, drainage, swelling with larger lesions
• Grow in AP direction• 25-40% will have impacted tooth • Recurrence
Ameloblastoma
• Tumor of Odontogenic epithelium• Incidence • Expansion is frequent• Resorption of roots common• Slow growing
Ameloblastoma• Locally invasive • Usually benign• Wide age range (rare before 10)• Equal prevalence 3rd-7th decade• M=F• 80% Mn (usually posterior)
Ameloblastoma
• Often asymptomatic• Painless swelling or
expansion• Can grow to large size• Pain/ paresthesia
MULTILOCULAR RADIOLUCENCIES*
Ameloblastic fibromaOdontogenic myxoma
Central odontogenic fibromaCalcifying epithelial odontogenic tumor
Orthokeratinized odontogenic cystLateral periodontal cyst (botryoid type)
Calcifying odontogenic cyst
MULTILOCULAR RADIOLUCENCIES*
Ameloblastic fibromaOdontogenic myxoma
Central odontogenic fibromaCalcifying epithelial odontogenic tumor
Orthokeratinized odontogenic cystLateral periodontal cyst (botryoid type)
Calcifying odontogenic tumor
MULTILOCULAR RADIOLUCENCIES*
Central hemangioma/arteriovenous malformationAneurysmal bone cyst
CherubismHyperparathyroidism (brown tumor)
Intraosseous mucoepidermoid carcinoma
Isolated
Multifocal
Multifocal
Cemento-osseous dysplasia***
Nevoid basal cell carcinoma syndrome**Multiple myeloma**
Cherubism*Hyperparathyroidism*
Langerhans cell histiocytosis*
Periapical Cemento-osseous Dysplasia
• Early lesions will be radiolucent but with time this will change
• Anterior Mn• More common multiple, solitary
possible
Periapical Cemento-osseous Dysplasia
• Female (10:1)• 70% African American• Initial Dx between 30-50 years of
age (almost never before 20)• Vital pulps• Asymptomatic
Radiolucent
MixedRadiopaque
Torus or exostosisRetained root tip
Condensing osteitisIdiopathic osteosclerosis
RADIOPACITIES: WELL-DEMARCATED BORDERS***
Well Defined
Poorly Defined
RADIOLUCENCIES: ILL DEFINED
Periapical granuloma or cyst***Focal osteoporotic marrow defect***
Osteomyelitis**Bisphosphonate-associated osteonecrosis**
Drug Related Osteonecrosis of the Jaw?
SunitinibSunitinib inhibits cellular signaling by
targeting multiple receptor tyrosine kinases (RTKs)
These include all receptors for platelet-derived growth factor (PDGF-Rs) and
vascular endothelial growth factor receptors (VEGFRs)
DenosumabHuman monoclonal antibody for the
treatment of osteoporosis, bone metastases, rheumatoid arthritis, multiple
myeloma, and giant cell tumor of bone
Targets RANKL (RANK ligand), a protein that acts as the primary signal for bone
removal
Bevacizumab
Recombinant IV humanized mAb binds to VEGF
Block angiogenesis through inhibition of cell proliferation and
vessel sprouting
RADIOLUCENCIES: ILL DEFINED*
Metastatic tumorsOsteoradionecrosisMultiple myeloma
Primary intraosseous carcinomas odontogenic or salivary
RADIOLUCENCIES: ILL DEFINED*
OsteosarcomaChondrosarcomaEwing's sarcoma
Other primary bone malignancies: fibrosarcoma, lymphoma
Desmoplastic fibroma of boneMassive osteolysis
NICO (neuralgia-inducing cavitational osteonecrosis)
Unilocular Well Defined
Isolated Radiolucencies
UNILOCULAR RADIOLUCENCIES:
PERIAPICAL
Periapical granuloma***Periapical cyst***
Periapical cemento-osseous dysplasia (early)**
Periapical scar*Dentin dysplasia type I *
UNILOCULAR RADIOLUCENCIES:OTHER LOCATIONS
Developing tooth bud***
Lateral radicular cyst**Nasopalatine duct cyst**Lateral periodontal cyst**
Residual (periapical) cyst**Odontogenic keratocyst**
Central giant cell granuloma**Stafne bone defect**
THICKENED PERIODONTAL LIGAMENT
Periapical abscess***Current orthodontic therapy***
Increased occlusal function**Systemic sclerosis (scleroderma)Sarcoma or carcinoma infiltration
Radiology Limitations
“interpreting the lamina dura continuity, shape and density, and the periodontal ligament width and shape
proved to be the best radiographic features”
Kaffe I, Gratt BM. Variations in the radiographic interpretation of the periapical dental region. J Endod 1988 Jul;14(7):330-5.
Can have PA radiolucency or PDL changes and
inflamed tissue in root canal
Yamasaki M1, Kumazawa M, Kohsaka T, Nakamura H, Kameyama Y. Pulpal and periapical tissue reactions after experimental pulpal exposure in rats. J
Endod 1994 Jan;20(1):13-7.
Radiology limitations
CBCT Limitations
PDL spaces of a healthy teeth demonstrated significant
variation when examined by CBCT
Pope O, Sathorn C, Parashos P. A comparative investigation of cone-beam computed tomography and periapical radiography in the diagnosis of a healthy periapex. J Endod 2014 Mar;40(3):360-5.
Diagnosis: Necrotic Pulp, Symptomatic Apical Periodontitis
45 year old male
No significant medical history
“ I can’t sleep and have had extreme sensitivity to heat, cold
and pressure for 10 days”
Pulp contents necrotic
Root canal treatment completed in a single session
without complication
Patient reported immediate improvement - follow up
phone call11 month recall
11 month recall
THICKENED PERIODONTAL LIGAMENT
Periapical abscess***Current orthodontic therapy***
Increased occlusal function**Systemic sclerosis (scleroderma)Sarcoma or carcinoma infiltration
SYSTEMIC SCLEROSIS
Probably immunologically mediatedRare (19/million/year)
Dense collagen depostition in large amounts F>M (3-5 times more likely)
AdultsInsidious onset… Raynaud’s Phenomenon
SYSTEMIC SCLEROSIS
Organ involvement subtle at first
Fibrosis of lungs, heart, kidneys, GI tract leads to organ failure
(usually within 3 years of Dx)
Nerves Veins
Glandular elements
ArteriesBone
Odontogenic epithelium
Smooth MuscleMINDPerfection is not attainable, but if we chase
perfection we can catch excellence
???
