21 Caries and Periodontal Disease










237
21
Caries and Periodontal Disease
EDUCATIONAL OBJECTIVES
Upon completing this chapter, the student will be able to:
1. Dene the key terms listed at the beginning of the chapter.
2. Discuss the following related to caries:
• Understandtheeectofcariesandperiodontaldisease
on the radiographic appearance of teeth and alveolar
bone.
• Recognizecariesonradiographs,correlateclinical
ndingswithradiographicndings,dierentiatecaries
fromanatomicfeaturesandrestorativematerials,aswell
as evaluate the extent of the carious lesion.
• Discussthelimitationsofradiographsincariesdetection.
• Listanddiscusstheconditionsthatresemblecarieson
dental radiographs.
3. Discuss the following related to periodontal disease:
• Identifythesignsofperiodontaldiseaseonradiographs.
• Recognizetheextentofbonelossandidentifythe
associated predisposing factors.
• Discussandlisttheclassicationsofperiodontaldisease.
KEY TERMS
abrasion
advanced caries
attrition
buccal caries
calculus
caries
cementoenamel junction (CEJ)
cervical burnout
composite
crown–root ratio
enamel hypoplasia
erosion
furcation
horizontal bone loss
incipient caries
infrabony pocket
interproximal caries
lingual caries
occlusal caries
open contact
periodontal abscess
periodontal disease
periodontal ligament space
triangulation
vertical bone loss
Detection of caries is probably the most common reason
for taking dental radiographs. Caries are seen on radio-
graphs as a radiolucency in the crowns and roots of teeth.
e caries process is one of demineralization of the hard
tooth structure with subsequent destruction. is decrease
in density allows greater penetration of the x-rays in the
carious area and resultant radiolucency on the dental image.
e degree of radiolucency on a given image is determined
by the extent of the caries in the buccolingual plane in
relation to the density of the overlying tooth structure.
Radiographic interpretation of caries can be misleading in
regard to relative depth and position in the tooth, as well
as dierentiation from other radiolucencies. For this reason,
technique factors (such as, proper vertical and horizontal
angulation) and all of the other factors discussed in Chapter
9 are very important. Caries always are advanced further
clinically than the radiographs indicate, because the bacte-
rial penetration of the dentinal tubules and early demin-
eralization do not produce signicant changes in density
to aect the penetration pattern. As a result, radiographs
Introduction
One of the most signicant reasons for attaining dental
images of a patient’s oral cavity is for caries detection. e
dental professional should be skilled in identifying caries
radiographically. e intention of this chapter is to describe
the evidence of caries on radiographs and to discuss dental
conditions that can resemble caries on radiographs. is
chapter also discusses the importance of dental radiographs
in the assessment of periodontal disease, the associated
predisposing factors, and the stages of periodontal disease
as seen radiographically.
Caries
Before beginning this discussion of caries interpretation, it
is imperative to stress that all areas interpreted as caries must
be conrmed by clinical examination. Many conditions can
resemble caries; simple errors in diagnostic judgment can be
prevented by clinical conrmation.

238 CHAPTER 21 Caries and Periodontal Disease
bitewing radiographs (Fig. 21.3). If the paralleling tech-
nique is used, caries also appear clearly and undistorted
on well-taken periapical projections (Fig. 21.4). In the
bisecting-angle technique, the vertical angulation may
distort or even mask interproximal caries. is is especially
true of recurrent decay under old restorations. Bitewing
radiographs are also useful in detecting poor contact, t,
contour, overhangs, and broken restorations (Fig. 21.5; see
Fig. 21.3). To repeat, all of these ndings may be obscured
because of incorrect horizontal angulation, which results in
an overlapped image that does not show the interproximal
tend to minimize the actual extent of the carious lesions
observed. e depth of the caries in relation to the pulp
also can be misleading. Because the radiograph portrays a
three-dimensional object in two planes, what may seem to
be an obvious pulpal exposure radiographically may be the
result of superimposition of images or improper horizontal
angulation.
Incipient Caries
Caries that have only penetrated halfway through the enamel
are called incipient caries (Fig. 21.1). is type of caries
may be dicult to detect radiographically, because the size
and density of the tooth structure have not undergone
enough of a change to be radiographically evident. In fact,
some clinicians, because of the possibility of remineraliza-
tion, may elect not to restore these areas and just observe
them for further changes.
Most advanced caries involving dentin in either the
crown or the root of the tooth appear on properly exposed
radiographs. However, small, deep occlusal, buccal, or
lingual carious lesions may not be seen, because the decrease
in density caused by the caries is small compared with the
total buccolingual density of the tooth (Fig. 21.2).
Interproximal Caries
It is in the diagnosis of interproximal decay that radiographs
are most important. Interproximal caries are best seen on
Figure 21.1 Bitewing radiograph showing incipient caries on the
distal of the maxillary rst premolar and the mesial of the maxillary
second premolar. Note the temporary lling and excess on the distal
of the mandibular rst molar.
Figure 21.2 Buccal and lingual caries and relative effects on object
thickness and the penetration of the x-rays when compared with
interproximal caries.
Figure 21.3 A, Interproximal caries on bitewing radiograph. A,
Recurrent; B, incipient; C, advanced; D, open contact. B, Caries seen
on periapical projection of maxillary incisors (arrows).
Figure 21.4 Periapical radiograph showing caries, mesial second
molar.

You're Reading a Preview

Become a DentistryKey membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Was this article helpful?

23721 Caries and Periodontal DiseaseEDUCATIONAL OBJECTIVESUpon completing this chapter, the student will be able to:1. Dene the key terms listed at the beginning of the chapter.2. Discuss the following related to caries:• Understandtheeectofcariesandperiodontaldiseaseon the radiographic appearance of teeth and alveolar bone.• Recognizecariesonradiographs,correlateclinicalndingswithradiographicndings,dierentiatecariesfromanatomicfeaturesandrestorativematerials,aswellas evaluate the extent of the carious lesion.• Discussthelimitationsofradiographsincariesdetection.• Listanddiscusstheconditionsthatresemblecariesondental radiographs.3. Discuss the following related to periodontal disease:• Identifythesignsofperiodontaldiseaseonradiographs.• Recognizetheextentofbonelossandidentifytheassociated predisposing factors.• Discussandlisttheclassicationsofperiodontaldisease.KEY TERMSabrasionadvanced cariesattritionbuccal cariescalculuscariescementoenamel junction (CEJ)cervical burnoutcompositecrown–root ratioenamel hypoplasiaerosionfurcationhorizontal bone lossincipient cariesinfrabony pocketinterproximal carieslingual cariesocclusal cariesopen contactperiodontal abscessperiodontal diseaseperiodontal ligament spacetriangulationvertical bone lossDetection of caries is probably the most common reason for taking dental radiographs. Caries are seen on radio-graphs as a radiolucency in the crowns and roots of teeth. e caries process is one of demineralization of the hard tooth structure with subsequent destruction. is decrease in density allows greater penetration of the x-rays in the carious area and resultant radiolucency on the dental image. e degree of radiolucency on a given image is determined by the extent of the caries in the buccolingual plane in relation to the density of the overlying tooth structure. Radiographic interpretation of caries can be misleading in regard to relative depth and position in the tooth, as well as dierentiation from other radiolucencies. For this reason, technique factors (such as, proper vertical and horizontal angulation) and all of the other factors discussed in Chapter 9 are very important. Caries always are advanced further clinically than the radiographs indicate, because the bacte-rial penetration of the dentinal tubules and early demin-eralization do not produce signicant changes in density to aect the penetration pattern. As a result, radiographs IntroductionOne of the most signicant reasons for attaining dental images of a patient’s oral cavity is for caries detection. e dental professional should be skilled in identifying caries radiographically. e intention of this chapter is to describe the evidence of caries on radiographs and to discuss dental conditions that can resemble caries on radiographs. is chapter also discusses the importance of dental radiographs in the assessment of periodontal disease, the associated predisposing factors, and the stages of periodontal disease as seen radiographically.CariesBefore beginning this discussion of caries interpretation, it is imperative to stress that all areas interpreted as caries must be conrmed by clinical examination. Many conditions can resemble caries; simple errors in diagnostic judgment can be prevented by clinical conrmation. 238 CHAPTER 21 Caries and Periodontal Diseasebitewing radiographs (Fig. 21.3). If the paralleling tech-nique is used, caries also appear clearly and undistorted on well-taken periapical projections (Fig. 21.4). In the bisecting-angle technique, the vertical angulation may distort or even mask interproximal caries. is is especially true of recurrent decay under old restorations. Bitewing radiographs are also useful in detecting poor contact, t, contour, overhangs, and broken restorations (Fig. 21.5; see Fig. 21.3). To repeat, all of these ndings may be obscured because of incorrect horizontal angulation, which results in an overlapped image that does not show the interproximal tend to minimize the actual extent of the carious lesions observed. e depth of the caries in relation to the pulp also can be misleading. Because the radiograph portrays a three-dimensional object in two planes, what may seem to be an obvious pulpal exposure radiographically may be the result of superimposition of images or improper horizontal angulation.Incipient CariesCaries that have only penetrated halfway through the enamel are called incipient caries (Fig. 21.1). is type of caries may be dicult to detect radiographically, because the size and density of the tooth structure have not undergone enough of a change to be radiographically evident. In fact, some clinicians, because of the possibility of remineraliza-tion, may elect not to restore these areas and just observe them for further changes.Most advanced caries involving dentin in either the crown or the root of the tooth appear on properly exposed radiographs. However, small, deep occlusal, buccal, or lingual carious lesions may not be seen, because the decrease in density caused by the caries is small compared with the total buccolingual density of the tooth (Fig. 21.2).Interproximal CariesIt is in the diagnosis of interproximal decay that radiographs are most important. Interproximal caries are best seen on • Figure 21.1 Bitewing radiograph showing incipient caries on the distal of the maxillary rst premolar and the mesial of the maxillary second premolar. Note the temporary lling and excess on the distal of the mandibular rst molar. • Figure 21.2 Buccal and lingual caries and relative effects on object thickness and the penetration of the x-rays when compared with interproximal caries. • Figure 21.3 A, Interproximal caries on bitewing radiograph. A, Recurrent; B, incipient; C, advanced; D, open contact. B, Caries seen on periapical projection of maxillary incisors (arrows). • Figure 21.4 Periapical radiograph showing caries, mesial second molar. 239CHAPTER 21 Caries and Periodontal Diseasehorizontal radiolucent line. As the decay progresses into the dentin, it appears as a diuse radiolucent area with poorly dened borders. is appearance dierentiates it from advanced buccal or lingual decay, which has more dened borders. is radiographic dierentiation is always conrmed clinically (Fig. 21.9).Very often, radiographs of teeth with deep or broad occlusal pits and ssures show radiolucencies that resemble caries. ese normal variants can be dierentiated by clini-cal examination.Buccal and Lingual CariesEarly lesions on buccal and lingual surfaces may be very dicult, if not impossible, to detect radiographically • Figure 21.5 Caries seen on a periapical radiograph. Note the faulty contour on restorations and periapical radiolucency. • Figure 21.6 Bitewing radiographs showing horizontal overlapping. • Figure 21.7 Interproximal caries (arrows). • Figure 21.8 The effect of contact point on caries interpretation. surfaces clearly and therefore does not have diagnostic value (Fig. 21.6).e rst radiographic sign of interproximal caries is a notching of the enamel, usually just below the contact point. As the caries progress inward, they assume a shape that resembles a triangle lying on its side with the apex of the triangle toward the dentoenamel junction. As it invades the dentin, the caries spread along the dentoenamel junc-tion and proceed toward the pulp in a roughly triangular pattern (Fig. 21.7).e radiographic appearance of interproximal caries is aected by the size and shape of the contact of the tooth involved. A tooth with a broad contact point does not show the caries as well as one with a narrow contact point, because of the greater density of the tooth structure sur-rounding the caries (Fig. 21.8).Occlusal CariesA careful clinical examination will detect occlusal caries earlier than radiographic interpretation. e absence of radiographic ndings is a result of the superimposition of the dense buccal and lingual cusps on the relatively small carious area in the occlusal pits and ssures. Occlusal caries are not seen radiographically until they have reached the dentoenamel junction, at which point it appears as a 240 CHAPTER 21 Caries and Periodontal Diseasethe radiographic contrast. It is seen most often in the mandibular incisor and molar areas (Fig. 21.11).Abrasion, Attrition, Erosion, and Enamel HypoplasiaRadiographically, cervical abrasion may resemble caries, because it causes a wearing away of root structure and results in a decrease in density in the aected area. e radiolu-cency produced by the abrasion is usually a well-dened horizontal defect seen at the CEJ. Evidence of secondary dentin formation and pulp recession in response to the irritant also may be seen radiographically.Attrition, which is dened as occlusal wear on teeth, is easily visualized clinically and radiographically by the absence or thinning of the occlusal enamel and dentin. is loss of tooth material is seen as a radiolucent area (Fig. 21.12).Erosion of the teeth results from a chemical action not involving bacteria on the tooth surface. Areas of erosion appear as radiolucent defects on the tooth, particularly on the crown of the tooth. e erosive margins may be either well dened or diuse. A clinical examination usually resolves any questionable lesions when distinguishing them from carious lesions. Enamel hypoplasia can also be confused with a carious lesion on radiographs. Enamel hypoplasia is a defect associated with a reduced thickness of enamel that • Figure 21.9 A, Occlusal caries in mandibular rst molar. B, Ad-vanced occlusal caries in maxillary second molar and pulpal exposure in mandibular second molar. List the other carious lesions shown on this image. • Figure 21.10 Buccal caries, as indicated by arrows. List the other carious lesions on these images. because of the superimposition of the densities of normal tooth structures. As the caries progresses, the radiolucency is characterized by its well-dened borders. e dierentiation is identied more easily with a thorough clinical examina-tion. It is impossible to judge the relationship of buccal or lingual caries to the pulp on radiographs, because the depth of the caries lies in a geometric plane that is not recorded radiographically (Fig. 21.10).Conditions Resembling Cariesere are various radiolucencies seen on dental radiographs that may be mistaken for caries. e nal diagnosis of caries is always made by corroborating the clinical examination with the radiographic ndings.Cervical BurnoutCervical burnout appears as a radiolucent band or notches at the neck of the tooth in the area of the cementoenamel junction (CEJ). It is contrasted because the part of the tooth apical to it is covered by bone and hence is more radiopaque, whereas the area of the tooth occlusal to it is covered by enamel and is also radiopaque. In addition to these dierences in densities caused by enamel and bone, the concave root contours below the CEJ appear as radio-lucencies. Cervical burnout is what some might consider to be an “optical illusion” and is most often observed when there has been no loss of the alveolar bone that provides 241CHAPTER 21 Caries and Periodontal Diseasebase (Fig. 21.15). However, all base and pulp-capping formulations that have a metallic component (e.g., zinc oxyphosphate, zinc oxide, calcium hydroxide) appear radi-opaque (Fig. 21.16).Periodontal Diseasee proper diagnosis and evaluation of periodontal diseases can be made only with a combination of radiographic is formed during the developing stages of the enamel. Clinical examination can aid in distinguishing between this enamel defect and caries.Indirect Pulp CappingA radiolucent shadow under a metallic restoration may not always indicate recurrent decay but may indicate a previous indirect pulp capping. To avoid a carious pulp exposure in this technique, the last remaining portion of decayed tooth is not excavated. A sedative base and permanent restoration are placed with the hope that secondary dentin will be laid down to protect the pulp and, because of the seal and anaerobic conditions, caries will not progress any further. Radiographically, the indirect pulp-capping procedure shows the radiolucent band of the unexcavated decay near the pulp chamber with a sedative base and permanent restoration (Fig. 21.13).Restorative MaterialsRestorative materials (such as, silicates, acrylics, and some composites) may resemble caries radiographically (Fig. 21.14). Contemporary brands of composite lling material have had radiopaque materials added to their formulation. One can dierentiate between caries and the radiolucent lling on the basis of the regular geometric outline of a cavity preparation and the presence of a radiopaque cement • Figure 21.12 A, Attrition. B, Abrasion. • Figure 21.13 Indirect pulp capping. Note radiolucent area under restoration in maxillary second molar. • Figure 21.11 Cervical burnout (arrows). A, Anterior teeth. B, Pos-terior teeth. 242 CHAPTER 21 Caries and Periodontal Diseaseand clinical examinations. Periodontal disease has both soft tissue and bony components. ere are radiographic limitations in both aspects of the disease process. Soft tissue (gingival) changes (such as, inammation, hypertrophy, and recession) do not appear on radiographs, because all soft tissue is radiolucent. Bone loss in some areas may not be seen because of superimpositions of buccal and lingual alveolar bone. Dental professionals should remember that the radiograph portrays a three-dimensional disease process in two planes. Radiographic images of bone changes almost always show less bone loss than there is.Despite these limitations, a proper periodontal diagnosis cannot be made without the appropriate radiographic prescription. Radiographs serve to (1) identify the risk factors, (2) detect early to moderate bone changes for which treatment can preserve the dentition, (3) approximate the amount of bone loss and its location, (4) help in evaluating the prognosis of aected teeth and the restorative needs of these teeth, and (5) serve as baseline data and as a means of evaluating posttreatment results.Normal Periodontal StructuresTo recognize disease, one must know the radiographic appearance of the “normal” anatomy. Periodontal anatomic structures identiable on radiographs include supporting structures, such as the lamina dura, alveolar bone, periodon-tal ligament space, and cementum (see Fig. 19.6).e normal crest of interproximal bone runs parallel to a line drawn between the CEJs on adjoining teeth at a level 1 to 1.5 mm apical to the CEJ (Fig. 21.17). e shape of the alveolar crest is primarily determined by the contact area of adjacent teeth and the shape of the CEJ. e alveolar crest is atter in the posterior areas and more convex and pointed in the anterior regions. e interdental bone septum can be narrow in cases of close root proximity. In some patients, the roots of adjacent teeth are so close that there may be little to no cancellous bone present.e lamina dura is seen radiographically as a thin radi-opaque line surrounding the entire root and is continuous with the alveolar crest. e lamina dura represents the • Figure 21.15 Synthetic restorations with radiopaque bases (arrow). • Figure 21.16 Radiopaque base and pulpotomy under metallic restoration. • Figure 21.17 Ideal level of interseptal bone. • Figure 21.14 Radiolucent restorations in central incisors. The mesial and distal surfaces of the lateral incisor have synthetic restora-tions with radiopaque material added. 243CHAPTER 21 Caries and Periodontal Diseasealveolar bone that lines the tooth socket. It may not be visible in all radiographs.e periodontal ligament bers traverse from the cemen-tum to the alveolar bone. Because these bers are soft tissue, they are not seen on radiographs, but the space that the bers occupy is seen and referred to as the periodontal ligament space. Evaluating the width of the periodontal ligament space is an important part of a periodontal radiographic examination. e normal ligament space is about 0.5 mm. For example, in situations of occlusal trauma, an increase in the size of the periodontal ligament space is often seen.Techniquese paralleling technique with an appropriate target-receptor (focal-lm) distance is the best method for evaluat-ing periodontal disease. A full periapical survey taken in this manner and augmented by posterior, anterior, or vertical bitewings is the technique of choice. Vertical bitewings are especially useful for detecting bone loss of 5 mm or more radiographically.e use of the bisecting technique with its inherent dimensional distortion provides a distorted representation of the level of bone present (see Fig. 10.11) and is not recommended for periodontal radiographic examinations.Panoramic images are of some value in the diagnosis of periodontal disease, especially in the most advanced cases. However, panoramic projections should only be used if intraoral projections cannot be taken, because panoramic images do not have the detail and denition to evaluate periodontal disease, especially in the early stages of the disease.Risk Factors in Periodontal Diseasee detection of local risk factors is one of the most important roles of radiography in periodontal disease. e management or prevention of early periodontal disease is much easier and has a higher success rate than eorts made once the disease has progressed. e detection and elimination of local irritants are essential steps in prevention or actual periodontal therapy. Reducing local risk factors increases the host response to disease.CalculusBoth subgingival and supragingival calculi are the most common of all local irritants. Early deposits, small and not fully calcied, are not seen radiographically. Even when calcied, supragingival calculus, which is seen most often on the lingual surface of lower anterior teeth and the buccal surface of upper molars, is not seen clearly in its early stage because of superimposition of tooth structure (Fig. 21.18). Subgingival calculus on the proximal surfaces is detected more easily than supragingival calculus, although both are not easily observed in the early calcied stages. e calculus appears as an irregularly pointed radiopaque projection from the proximal tooth surfaces (Fig. 21.19). Horizontal • Figure 21.18 Supragingival calculus on lingual surfaces of lower incisors. • Figure 21.19 Subgingival calculus. Note bone loss. NOTEThe dental professional should be aware of the radiographic limitations of characterizing subgingival and/or supragingival calculus by radiographs alone, because the gingival components are not visible on radiographs. For example, if a patient has advanced gingival recession clinically, calculus on the proximal root surface may appear to be subgingival on radiographic images but upon clinical examination can be found to actually be supragingival calculus deposits.bitewing radiographs are most helpful in discerning inter-proximal calculus in the posterior areas or vertical bitewings in the anterior or posterior areas.RestorationsRadiographic examination reveals restorations with open contacts, poor contours, overhanging and decient margins, and caries, all of which are signicant risk factors in periodontal disease (Figs. 21.20 to 21.22). 244 CHAPTER 21 Caries and Periodontal Diseasewith bulbous roots have more area for attachment than those with ne, tapered roots. In multirooted teeth, the space between the roots is important; teeth with widely spaced roots have a better periodontal prognosis. Adjacent teeth whose roots are close together have a poorer prognosis than those with adequate areas of interseptal bone.Stages of Periodontal Diseasee classication system for periodontal disease was last revised in 1999. is framework classies periodontal disease based on the amount of bone loss that can be identied radiographically as initially devised by the joint eorts of the American Dental Association (ADA) and the American Academy of Periodontology (AAP). e classications are as follows: gingivitis (type I), mild or slight periodontitis (type II), moderate periodontitis (type III), and advanced or severe periodontitis (type IV).Gingivitis (Type I)Because gingivitis is a soft tissue change, there are no radio-graphic ndings other than the presence of predisposing factors. Existing periodontal pockets, if there is no bone loss, will not be seen. Postoperative radiographs of extended surgery only show the new bone level and do not indicate healthy tissue and lack of pocket depth. Among the risk factors for gingivitis are medications that may cause gingival hyperplasia and inammation (e.g., phenytoin [Dilantin], antiepileptic or anticonvulsant drug).Mild or Slight Periodontitis (Type II)e early stage of periodontal change is characterized radio-graphically by changes in the crest of the interproximal bone septum and triangulation of the periodontal mem-brane. Triangulation is the widening of the periodontal membrane space at the crest of the interproximal septum that gives the appearance of a radiolucent triangle to what is normally a radiolucent band. As mentioned earlier, the normal crest of the interseptal bone runs parallel to a line drawn between CEJs on adjoining teeth at a level 1 to 1.5 mm below the CEJ. e crest of the septa normally has a distinct radiopaque border. Fading of the density of the crest with cup-shaped defects appears in the early • Figure 21.21 Restoration with open contact and overhang. Note the bony response. • Figure 21.22 Restoration with overhang. Note the heavy calculus formation in other areas. • Figure 21.23 Unfavorable crown–root ratio. Anatomic CongurationsOnly through radiographic examination can information about the size, shape, and position of the roots and the bone level of periodontally involved teeth be obtained. ese factors are important in evaluating the present condition and planning periodontal and restorative therapy.e crown–root ratio refers to the length of root surface embedded in bone compared with the length of the rest of the tooth. e greater the length of the tooth embedded in bone, the better the prognosis (Fig. 21.23). is becomes a critical factor when designing both xed and removable prostheses.Teeth that have an anatomically short root have a poorer prognosis periodontally than teeth with long roots. Teeth • Figure 21.20 Overcontoured crown on premolar and bone response. 245CHAPTER 21 Caries and Periodontal Diseaseloss, the resorption on one tooth root sharing the septum is greater than on the other tooth, the so-called infrabony pocket (Fig. 21.27). In this stage, the horizontal bone loss on the buccal or lingual surfaces may go undetected because of superimposition. Careful examination of the radiograph may reveal a dierence in density, indicating dierent levels of bone on the buccal and lingual surfaces (Fig. 21.28).Advanced or Severe Periodontitis (Type IV)e advanced stage of periodontal disease is easily identied radiographically by the advanced vertical and horizontal bone loss, furcation involvement, thickened periodontal membranes, and indications of changes in tooth position (Figs. 21.29 and 21.30).Periodontal Abscesse radiographic signs of a periodontal abscess vary greatly. is diagnosis is dictated by an acute clinical manifestation. A periodontal abscess is caused by the blockage of an exist-ing pocket; therefore, the radiograph of the acute episode may not dier greatly from previous images of the existing condition that produced the pocket. In other instances, there may be signs of rapid and extensive bone destruction (Fig. 21.31).stages of periodontal disease (Fig. 21.24) and is known as cupping.Moderate Periodontitis (Type III)In the moderate stages, bone loss shows up in both the horizontal and vertical planes. Radiolucencies appear in the furcations of multirooted teeth, indicating bone loss in these critical areas (Fig. 21.25). Horizontal bone loss is resorp-tion that occurs in a plane parallel to a line drawn between the CEJs on adjoining teeth (Fig. 21.26). In vertical bone • Figure 21.25 Moderate to advanced bone loss showing bifurcation involvement. • Figure 21.26 Horizontal bone loss. • Figure 21.27 Vertical and horizontal bone loss. Note the early bifurcation involvement on the second molar. • Figure 21.28 Different levels of buccal and lingual bone, as indi-cated by arrows. • Figure 21.24 Early periodontal bone loss. Note the fading of density of the alveolar crest, slight cupping, and triangulation. 246 CHAPTER 21 Caries and Periodontal Disease• Figure 21.31 Periodontal abscess. Patient had acute buccal swell-ing and facial edema. Chapter Summary• Dental radiographs have signicant diagnostic valuein the identication of dental caries and periodontal disease.• Radiographicevidenceofcariesshouldbeconrmedbyclinical examination. Both of these diagnostic processes are integral components of a denitive diagnosis and treatment plan.• Radiographic examinations have both limitations andvalue in the identication of dierent types of carious lesions, including incipient caries, interproximal caries, occlusal caries, and buccal/lingual caries.• Conditions that can resemble caries radiographicallyinclude cervical burnout, abrasion, attrition, erosion, enamel hypoplasia, synthetic restorations, and pulp capping.• eidenticationofperiodontaldiseaseisreliantonbothan equally eective radiographic and clinical examination. e limitations of a radiographic examination in the diagnosis of periodontal disease include a failure to view soft tissue structures involved in periodontal disease, the representation of only two dimensions of a three-dimensional structure or lesion, and the superimposition of the buccal and lingual alveolar bone.• eriskfactorsforperiodontaldiseasethatcanbeidenti-ed radiographically include the presence of calculus, ill-tting restorations, and various anatomic congura-tions of the roots of the periodontally involved areas in a patient’s oral cavity.• eclassicationofperiodontaldiseaseconsistsoffourcase types that include gingivitis, early bone loss, moder-ate bone loss, and advanced or severe bone loss.• Figure 21.29 Advanced periodontal bone loss. • Figure 21.30 Trifurcation bone loss, upper rst molar; bifurcation bone loss, lower rst and second molars. 247CHAPTER 21 Caries and Periodontal DiseaseChapter Review QuestionsMultiple Choice1. e interproximal radiolucent lesions that the arrows are pointing to on the accompanying bitewing radiograph are identied as: a. Buccal caries b. Interproximal caries c. Horizontal bone loss d. Interproximal calculus e. Lingual caries2. e bone loss between the roots of tooth #19 is speci-cally known as: a. Trifurcation involvement b. Horizontal bone loss c. Vertical bone loss d. Periapical bone loss e. Bifurcation involvement3. e radiopaque calcied deposit on the mesial of tooth #30 and tooth #31 is identied as: a. An enamel pearl b. A denticle c. An overhang d. Interproximal calculus e. Gutta percha4. e bone loss on the mesial of tooth #19 is classied as: a. Vertical bone loss b. Horizontal bone loss c. Medullary bone loss d. Trifurcation bone loss e. Cervical burnout5. e radiolucencies on the distal of tooth #8 and mesial of tooth #9 are: a. Base materials b. Synthetic restorations c. Interproximal caries d. Gold restorations e. Amalgam restorations6. As for periodontal prognosis, teeth that have tapered roots will: a. Be more resistant to caries b. Have a better prognosis c. Have a poorer prognosis d. Be less resistant to caries e. None of the above 248 CHAPTER 21 Caries and Periodontal DiseaseCritical Thinking Exercise1. A patient presents to the periodontal oce where you are currently employed. e patient was referred by her general dentist’s practice to receive a periodontal examination and consultation. e patient did not bring previously exposed radiographs with her. e patient has not had radiographs taken in more than 5 years. e patient presents with 6- to 8-mm pockets and appears to exhibit mobility on three of the posterior teeth. You are responsible for providing the sequence of care that is outlined for this patient. Be sure to include the follow-ing procedures and reasons for the procedures in your presentation: a. Clinical examination b. Radiographic prescription c. Radiographic evaluation d. Evaluation of the risk factors for periodontal disease that are present in the patient’s mouth e. e apparent stage of the patient’s periodontal diseaseBibliographyArmitage GC: Development of a classication system for periodontal diseases and conditions, Ann Periodontol 4(1):1–6, 1999.Iannucci JM, Howerton LJ: Dental radiography: Principles and tech-niques, ed 5, St Louis, MO, 2016, Elsevier Saunders.White SC, Pharoah MJ: Oral radiology: Principles and interpretation, ed 7, St Louis, MO, 2013, Mosby.

Related Articles

Leave A Comment?

You must be logged in to post a comment.