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Diagnosis and Treatment of Oral Diseases-- Lectures #13 and 14 [Normal
Structures and Common Pathologic Findings on Periapical and Pan
Radiographs by Dr. Stabulas

[1] [Introduction to Normal and Common Pathological Radiographic Findings]
[Dr. Stabulas] Good afternoon, everyone. So this is part of the pathology
component of the DOD course. And what were going to be talking about today is
normal and common pathologies, radiographically.

So I know youre all involved in the radiology 101 course at the moment. You
havent gotten to this point but this is a good introduction in to reading radiographs,
interpretations of radiographs. You have gotten a little bit in first year about
anatomic landmarks and areas in the oral cavity that are actually in the skull but
look completely different radiographically. So were going to be reviewing those and
between now and the time you graduate, you will have a review of those many many
times because based on my experience, it never gets old. Its just so much easier if
someone gives you directions to their home by the use of landmarks, you know what
that means, instead of giving them and I live on Long Island where its nice and
dark at night and you cant see any of the street signs and so we often give
landmarks when we give directions and the anatomic landmarks are really no
different. Because if you see a maxillary sinus well you know youre looking at the
maxillary arch. If you see a genial tubercle well you know youre looking at the
midline on the mandible. So knowing where you are in the mouth is heavily
dependent on knowing the anatomical landmarks, where they are, what they look
like in the normal state, whatever that might be. So were going to do a review of
that.

[2] [Radiographic Interpretation]
[Dr. Stabulas] Firstly, I want to start with some descriptive terminology. And these
terms only apply to looking at radiographs. So you cant look at some tangible item
like this desk or this stage and call it radiopaque or radiolucent because these terms
only apply to radiographs. So basically as Dr. Freidman has taught you and I am part
of the radiology department, by the way, so youre going to have to listen to me
twice next week, once this week and twice next week. And for those of you who
were in lab, more than that. So, heres the point. When youre looking at a
radiograph and Dr. Friendman will someone say to students, and you know hes a
joker, when you come back next time, make sure you take this picture in color. Well
you know, a radiograph will never be in color. Its always going to be shades of gray
or from a dark shade of gray to a light shade of gray. And thats where the
terminology radiopaque and radiolucent comes into play. And it has everything to
do with the density of the actual object. So if you have something that appears on a
radiograph as being very light or white, then you would call that radiopaque and
what that means is that the actual object that is appearing white or light has high
density. So you have enamel, you have cementum, you have bone, you have bony
projections like tuberosities. You have anything with a lot of density certainly
restorations, especially those that are metallic are going to appear radiopaque. And
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if youre looking at a radiograph with diagnostic contrast, with good diagnostic
contrast, youll see that those objects or structures that are radiopaque go from
different gradations of radiopacity. So the more dense something is, the more
radiopaque its going to look. So in other words, if you have an amalgam restoration
in a tooth, in the crown of a tooth, the crown of a tooth is made of enamel and
enamel would appear how? Radiopaque or radiolucent? Radiopaque because its
dense. But its not as dense as the metallic component of an amalgam restoration. So
the amalgam restoration is going to be more radiopaque. Therefore, you will be able
to distinguish between that restoration and the enamel that its sitting in.
understood? So there isnt one gradation of radiopacity and there is not one
gradation of radiolucency. So the radiolucent areas are the darker grade areas, the
darker areas and those are areas that are of object structures that have little or no
density. And there is also something to take into consideration about the radiation
penetration through those objects. If something doesnt have a lot of density, the
radiation will stop. It will have a tougher time going through it and reacts less with
the film on the other side with the emulsion or if youre doing digital radiography
with the sensor on the other side. So it maintains that white color. However, if you
have something with little or no density, the radiation is going to sail through. It
wont have a problem getting through the object and when it hits the film or the
sensor on the other side it can react to a great extent with the film or the sensor and
then turns the already white portion dark, you understand what Im saying? So,
radiopaque, as defined on the slide here: the white areas on a radiograph where
there is little or no radiation penetration and is of dense objects. On the other hand,
the radiolucencies or the radiolucent areas are the black areas where there is
greater radiation penetration and little or no density to that object or structure.
Okay? So all structures on a radiograph are either radiolucent or radiopaque. But
the category includes gradations as I just explained to you, according to the density
of the structure. So its important to know and obviously its important to know the
descriptive terminology because thats the way we describe, thats the beginning of
interpreting radiographs. Okay?

[3] [Normal Radiographic Anatomy]
[Dr. Stabulas] So when you look at normal radiograph anatomy, I could basically
split that into two categories. Those teeth parts, the parts of the tooth, the parts of
the surrounding area, the immediate surrounding area, as opposed to the anatomic
landmarks that are in the broader sense. So, when you consider identifying oral
lesions radiographically, the first thing you have to do is differentiate it from the
norm. So, in actuality, you need to know what things look like in the norm in order
to be able to tell that there is something different about it. Okay? So, that not only
goes for the anatomic landmarks, where they are and what they look like, but also
the structures of a tooth. If you didnt know that the enamel of a tooth should be
radiopaque in normalcy,, then how would you know when it turns radiolucent that
theres a carious lesion there? You understand? So thats a step away from what it
would look like under normal circumstances. When youre looking at a radiograph
you need to first rule out the normal structures when formulating the differential
diagnosis. So the differential diagnosis is like a shopping list, thats what I like to
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equate it to. So I look at a radiograph and I look at where the structure is, where its
located. I describe it. And then I make a shopping list of all the things that it could be.
For example, if I see something that is radiopaque, well is it condensing osteoitis? Is
it hypercementosis? And I know I'm throwing things out right now but were going
to talk about them later. So it could be a whole list of different things. And then you
take even more specific characteristics of what youre looking at to narrow it down
to a specific diagnosis, okay? So you have the differential which is then narrowed
down and in a little while well talk about the questions that you need to ask
yourself when youre looking at something on a radiograph to narrow that list down
and only come home with five things instead of twenty when you go to the store.
Okay? Now the landmarks are not always on radiographs. Some of them you can
depend on being there in most circumstances like the nasal cavity and that region,
the maxillary sinus and that region. On the mandible its a little difficult but a lot of
times youll see the mandibular canal. Often youll see the external and internal
oblique ridges but you need to know that because its not there on the radiograph
doesnt mean its not inside the patients mouth. So youre not going to see all of
them or even a majority of them sometimes and it all depends on how the
radiographs were taken, what type of radiograph youre taking. If its a periapical
radiograph or if its a bitewing radiograph, if its a panoramic radiograph. And you
can see a lot more on an extraoral radiograph like the panoramic radiograph than
you can see on the intraoral radiographs like periapicals and bitewing radiographs.

[4] [Radiographic Tooth Anatomy]
[Dr. Stabulas] So were first going to talk about what the tooth structure and the
immediate surrounding area of the tooth will look like radiographically. So, were
going to do that two ways.

First, were going to visualize where these different structures are and describe
them with words. And then were going to look at a radiograph and locate them on
the radiograph, even though theyre already labeled, to see that they look the way
that theyre described.

So the enamel is radiopaque and capital R and O is the it sort of looks like an
acronym because its a capital R and a capital O but its the abbreviation of
radiopaque because radiopaque is one word and not two.

So its a radiopaque band that covers the crown up to the CEJ, the cemento enamel
junction. The dentin is inside the enamel, its also radiopaque and so you can see
where the gradations of radiopacity can come in handy. Because if they werent
differentiated, you wouldnt know where the enamel would start and end or the
dentin for that matter. Okay?

So the dentin is a major part of the tooth structure. Its in crown and in the root and
it borders with the enamel at the dentinoenamel junction. Cementum is only on the
root but its also radiopaque. Its less radiopaque than enamel and similar in
radiopacity to the dentin. So its harder to tell the cementum form the dentin in the
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root of the tooth than it is the enamel from the dentin in the crown of the tooth.
Okay?

The pulp chamber can distinguish itself easily and how do you think thats true?
How do you distinguish the pulp from the dentin and enamel and cementum?
Because its radiolucent. Exactly.

So what is the pulp? The pulp is sort of a tissue, right? It has really no density or
little or no density and thats why it appears radiolucent. Where is the pulp? Is it in
the crown? Its not in the crown? The pulp is not in the crown? Dont feel special, I
get every class on this question. The pulp is in the crown and the root. The pulp
chamber is in the crown and the pulp canal is in the root. The entire apparatus, so to
speak, is known as the pulp but its in the crown and the root and its the innermost
part of the root. It stems from the crown to the root.

The periodontal ligament space is also radiolucent because theres really no density
to the periodontal ligament space. Its composed of a space with ligaments that
attach the tooth to what? To the bone. So its what we like to consider inside the
tooth socket, right? The tooth socket of bone that the tooth fits into. And it has little
or not density and so therefore is known as a radiolucency. And it surrounds only
the root of the tooth.

The lamina dura is a very thick, cortical part of the alveolar process and that is really
what we call the socket. So its a very radiopaque line that again is continuous
around the entire root, okay? Not around the crown.

The alveolar bone is the bone that surrounds the teeth and I like to look at it as a tic-
tac-toe board. Does everybody know what a tic-tac-toe game is? I dont take that for
granted anymore. Its a little game that you play with xs and os and its got lines
going down and lines going across and you choose the o or the x and I choose the
one that you didnt choose and we play on this board. And so if you visualize that
pattern you can get a feel for what alveolar bone looks like. The actual lines that
make the board are known as trabeculae and trabeculae are radiopaque. Just like
they are on the tic-tac-toe board. And then your spaces, in between the trabecular
pattern, we call them medullary spaces. And knowing what the trabecular pattern
and what the medullary spaces look like in normalcy and I keep doing this because
what is really normal? But we have a description of what normal should be. If you
see those spaces are quite large, larger than what you normally see, that could mean
the patient has a systemic illness like an anemia. Or if the medullary spaces are
punched out that could mean multiple myeloma. So its very important for you to
know what the trabecular pattern should look like. So the medullary spaces are the
spaces in between the trabeculae, okay? And the trabeculae remind me of a tic-tac-
toe board.

Cortical bone is a thicker bone and it comprises the buccal lingual plates, the inferior
border of the mandible, which is a really useful landmark because the inferior
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border of the mandible goes from the angle of the mandible to angle of the
mandible. So it can be visualized, and its important for you to note this, on any
periapical film. So you can have a periapical film by the way, do you know the
difference between periapicals and bitewings? I know those of you who have lab
already would know the difference because we already talked about that. Just
briefly, a periapical film shows the entire tooth from the apex of the tooth to the
incisal edge of an anterior tooth and from the apex to the occlusal surface if its
posterior. So if you want to see the tooth and the surrounding area because
preapical films should show at least 2 to 3 mm of the bone around the apex of the
tooth, that should be included. So if theres [unintelligible] whatevers going on in
the tooth, youll also see that in the surrounding bone, okay?

On the other hand, a bitewing radiograph will show both the upper and lower
arches in occlusion but not for occlusal purposes. Not to look at the occlusion of a
patient. If you want to classify occlusion, you do that clinically. What youre looking
at when you look at a bitewing, because of the way that its taken, its pretty much
completely parallel to the teeth in the vertical and horizontal planes, it should be
placed that way so that it is the extreme of a 90 degree angle when compared to the
central ray. So it looks more like the teeth should look if you look at them clinically.
And because of that perception or that perspective that youre looking at that
bitewing, theyre generally used for looking at interproximal lesions.

So if youre looking for interproximal caries, bone height, you can say bone loss lack
thereof bone, ha ha, anything having to do with the interproximal bone,
interproximal calculus accumulation. Calculus is a more formal term for the laymen
term tartar. Okay? It is calcified deposits of plaque. So interproximal calculus can tell
you a lot of different things about the area and the patient. So, the bitewings are
used for anything interproximal, overhang, malfitting restorations, sometimes
recurrent decay, decay thats already under fillings that already exist. So for
bitewing radiographs, you would really focus on the interproximal regions because
you dont see the apices at all. Pretty much you see the coronal region and a little bit
on the root but not much, okay?

[1] [Normal Radiographic Tooth Anatomy Anterior Teeth]
[Dr. Stabulas]-- So this is a periapical radiograph that were looking at here. The
periapical radiograph in this film is actually concentrating mostly on the canine
tooth and one thing that you should know is that a question back there?

[Student]-- You said the medullary space is radiolucent?

[Dr. Stabulas]-- Yes, its a space. Its an open space so its radiolucent. If you think
about when you look at a radiograph, and were going to talk about this in a little
while, things that you look for usually the first thing I notice about what I'm
looking at is is it radiopaque or radiolucent? And then I look at the location. Location
is very important. And then I fit in the other classifications. But you first want to
determine whether its radiolucent or radiopaque because that tells you something
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about the density of the area and vis a versa. If I told you that, if I asked you what a
sinus would look like on a radiograph well how would you describe the density of
a sinus? Not very. So more likely its going to show up radiolucent than radiopaque,
correct? But you have to be careful with that because theres walls and floors of the
sinus and theyre always radiopaque. So the sinus itself is radiolucent but the walls
and the floors and the septa in between are radiopaque. So, does that answer your
question?

So one of the things I wanted to tell you because were going to be looking at a
couple of radiographs today, is that you should give up your right and left. Dont
ever talk about your right and left again when it comes to looking at radiographs
because we look at radiographs the way we look at a patient if were facing the
patient. So, the far side of this radiograph or lets say the far side of this entire slide
would be your right or your left? Your left. So its opposite from me right now. Im
not looking at the radiograph. So that would be your left and that would be your
right. Okay? So if I'm looking at the patient, Im going to talk about the patients right
and left or else youre going to get it confused and you probably already did because
I asked you about you first. So if you look at the radiograph, youre looking at the
patients right this way and the patients left this way. So we look at this radiograph,
it is obviously going from the lateral to the canine to the premolar. So its going more
posteriorly toward the patients right so so that would be a patient's mandibular
right canine, yes? Okay.

In looking at the canine, the letter A is pointing to a radiopaque band on the outside
of the crown. So what do you think that is? I should cover that up somehow, huh? So
thats enamel. If you look at, I like to go to D right away, its pointing at the center of
the tooth but only in the crown so that area actually goes from crown to root and its
radiolucent and thats the pulp. If you look at B, B is coming somewhat inside the
root and that could also go up to the crown because thats pointing at dentin, okay?
And then the letter C is actually indicating the outside of the root, which would
basically be cementum. And the E is actually pointing to the radiolucent line around
the tooth which is the periodontal ligament. The F is looking at, well actually they
did it backwards because they said C is the periodontal membrane and E is the
cementum and its hard to tell when the arrows not right on top of it. I promise you,
I wont put this on an exam, not this one. So F is the lamina dura, which is this socket,
and G is just randomly laying in the middle of the alveolar bone. Okay?

[6] [Normal Radiographic Anatomy Posterior Teeth]
[Dr. Stabulas] Now if you look at a posterior film so who wants to name what
film this is for me? What is this a projection of, what area of mouth? So start with the
patient, is it the patients left or right? Its the patients left. Is it mandibular or
maxilary? Its mandibular. How do you know that? Because its two roots pointing
down, right. And you can see a nice trabecular pattern here, by the way. You see this
looking like a tic-tac-toe board? Okay. And so, you know it doesnt change from
anterior to posterior. A is still the enamel, B is still the dentin, C is the periodontal
ligament space D is the pulp and now theyre pointing to the pulp on the crown, E
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is the cementum on the inside of the periodontal ligament space. The lamina dura is
F and G is the alveolar bone. And so ,with that being said, what do you think this and
this is? It is, actually. Theyre actually this one on the first molar, what number
tooth is that? Patients first molar, lower left? So thats 19. if you look at 19, how
would you describe that carious lesion? Its recurrent because its under an already
existing restoration. And this one back here, what do you think of that? Is that
recurrent or new? Its new and its pretty far in. so yea, knowing that it should be
what is radiopaque, radiolucent really helps to go forward and know what is not
within normal limits.

[7] [Anatomic Landmarks Maxillary Incisor Area]
[Dr. Stabulas]-- Now when we talk about yes?
[Student] [unintelligible]
[Dr. Stabulas] or not recurrent? Recurrent, incipient or new? Well first of all, that
lesion that was on number 18 is not so new. Its just not recurrent unless it invaded
the tooth really quickly, its pretty far in. But a recurrent carious lesion is always
associated with a pre-existing restoration. Doesnt matter what the restoration is.
Caries that is not recurrent is in a part of the tooth that hasnt been restored before.
So this one is the lower restoration, this one isnt Okay?
Alright so anatomic landmarks you know, I was driving somewhere the other day
with a friend, wouldnt it be nice if the GPS systems would tell you and there
might be one out there but I dont have it like a landmark instead of telling you
at the last very second, make a right, make a right, ding ding ding. If they said youre
coming up to BJs, make a right right after BJs, it would be nice, wouldnt it? If you go
on Mapquest, they give you landmarks. I look at the landmarks in the oral cavity,
and I look at them all the time, as being road signs. Signs that tell you where you are
in somebodys mouth and after you take radiographs youre going to be asked pretty
much with conventional radiography and not so much with digital, thats a whole
other scene, what well talk about next week when I give you the lecture on digital
radiography, but you need to put we call this mounting when you put the
radiographs youve taken in the order they appear in the mouth. Its important to
know where those landmarks are and what they look like radiographically because
what Ive done here in making these slides is to give you what the landmark looks
like when youre looking at it on a skull, you can see that up top, and then what it
looks like when you look at it on a radiograph and it looks very different because
probably what Im about to tell you youre going to hear repeated so many times
that youll get sick of hearing it. But, basically I'm going to give you the
rationalization behind this and it is that when you look at a skull, youre looking at
three dimensions, correct? ... Okay, take a break.
Im back, that was a very short break. Everybody wake up, okay. So what I was
saying is that when you look at the landmarks in a skull, that you can see from front
to back. So if youre looking .. and here youre looking at the underside of the
maxillary arch So you see the nasopalatine foramen, you see the zygomatic process
coming out of the maxilla and you can see it in depth. But when you look at a
radiograph, on the other hand, there is no depth because everything that youre
seeing on the skull actually has 3 dimensions, right? It has width, it has length and it
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has depth. When you look at a radiograph, youre only seeing 2 of those dimensions.
Which two dimensions are you seeing? Width, which we call mesial distal, right? Or
length, which we call incisal to apical. But we dont see depth. So when youre
specifically looking at the maxillary anterior region, its like taking that skull that
youre seeing up there and smushing it like this. So what you see is from the incisal
to the apical but everything above that really comes from forward to back but
appears like its inferior to superior, you get that? So it doesnt change the fact that
those landmarks are there, it just changes the way that they look, okay? So you, I
would say that, and Im not going to go through every single landmark in every
single area, are you responsible for it? For sure. Otherwise you wouldnt know
where you were when you were trying to describe things on a radiograph. Being
responsible for it doesnt necessarily mean its going to be on an exam but not
everything that isnt on an exam doesnt say that youre not responsible for it
because youre responsible for knowing it for every day practice. So those more
common would be the nasopalatine foramen that you see here. You see the nasal
spine. This is the nasal septum. On both sides of the nasal cavity are the nasal fossae.
If you see the radiopacities inside the nasal fossae, theyre called conchae, like as in
shell. Theyre little bones inside and there are actually 3 conchae. You never see the
medial or the superior conchae on a radiograph. Usually the conchae that you do see
when you see it if its not a panoramic radiograph, which gives you a much bigger
view, are the inferior conchae, here and here, okay? You will also see the medium
palatine suture. Again, heres the nasal spine. And I want to talk about foramen for a
second. When you see the foramen, theyre mostly what, radiolucent or radiopaque?
You see that egg? I like to call it egg-shaped or the oval radiolucency between the
maxillary central incisors. So, is it radiopaque or radiolucent? Radiolucent. But if you
look at this you can actually see trabeculae beyond the radiolucency, cant you? Its
not completely radiolucent. You can see trabecular patters beyond it and the reason
is because its superimposed. Its that smushed, elongated look. So, if you see
trabecular pattern in a radiolucency, thats more than likely a foramen. So thats one
of the ways that we distinguish periapical radiolucencies that could be pathology
from a formanen. The other way to distinguish that is location. Okay? This is located
right where the nasopalatine foramen should be located, which is between the two
central incisors. Whats the other name for that foramen, does anybody remember?
Incisive, yeah. So thats the same foramen, its not a different foramen. Its the only
foramen in that area. Okay?

[8] [Maxillary Canine Area]
[Dr. Stabulas] Going on to the canine region and there is not a distinction or a wall
set up when you leave the anterior region meaning the central and lateral incisors to
the canine. So, in other words, theres a lot of overlapping. I mean, weve chosen a
very small area to make our lives work in. The oral cavity is not a big place. So
theres going to be overlapping from the incisal region, the central-lateral region to
the canine region. So in this case you may still see the nasal cavity, you still see may
see the nasal cavity, nasal fossae, you still may see the nasal septum. Youll probably
see the nasal spine and the conchae you can see halfway through. But the most
common radiographic landmark that distinguishes central-lateral region from the
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canine region is what we call the antral-Y. Now, the antral-Y is actually where the
anterior segment of the maxillary sinus, notice how here were getting toward the
posterior? So this is the wall and floor of the maxillary sinus, can you see that?
Which meets the floor of the nasal cavity. Now, if you turn that upside down, this
would be the stem of the Y and these are the arms of the Y and thats why we call it
the antral-Y. So it indicates in the canine region, the distinction between the anterior
extent of the maxillary sinus and the floor of the nasal cavity. Okay? No? Nobodys
answering. Okay, you dont see it there? Is that what that look of confusion is? So
lets go here, is this a better one for you? This is the floor of the nasal cavity and this
is the anterior extent, you see that? of the maxillary sinus and this is also the floor
so this is the floor of the nasal cavity and the anterior extent of the maxillary sinus.
So this is an arm, this is an arm and then thats the leg of a Y. Antral means upside
down. They also call it the inverted Y. Anyway, thats the most common landmark in
the canine region.

[9] [Maxillary Premolar Area]
[Dr. Stabulas] Now in the premolar region, again, you can see the antral-Y there
and keep on continuing back. You start seeing the maxillary sinus. Now, the
maxillary sinus is radiolucent but before I mention that the walls and the floor of the
maxillary sinus are radiopaque. Theres also septa in the maxillary sinus that you
can see. And anything that separates, wall, floor, septa, usually is radiopaque
because thats one of its functions to separate different parts of a structure. Okay?

[10] [Maxillary Molar Area]
[Dr. Stabulas] As you go back further youre getting more into the area where
youre going to see not only the maxillary sinus but the zygoma and the zygomatic
arch. Now, depending on what book you read, there are different ways to describe
the zygomatic apparatus. As far as Im concerned, there are two parts to it. One part
belongs to the maxilla and looks like a very dense bone and its a U-shaped bone,
you see here the letter C? Thats the zygoma and the part of the zygomatic process
that belongs to the maxilla. What other bone has a part in producing the zygomatic
arch? The entire zygomatic process, what other bone is involved there? Its the
temporal bone. So, the process, the zygomatic process, which is more drawn out is
usually and belongs to the temporal bone is the zygomatic arch and that belongs
to the temporal bone. So you have the zygomatic process of the maxilla and the
zygomatic arch. Okay? Yes? Okay.

So, also, and I would have to say that this landmark is one of the landmarks that can
confuse you. Thank goodness, its not on a GPS system. Because this little finger-like
projection in the inferior border of the maxillary molar film, is actually part of the
mandible. And its the coronoid process of the mandible. Because when the patient
closes, the anterior segment of that process, which is made up of the coronoid
process and the condylar process, the coronoid process is in the anterior and it
shoots into the maxillary posterior periapical radiograph. Okay? So this is part of the
mandible, in fact its the coronoid process.

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[11] [Posterior Part of Maxillary Molar Region]
[Dr. Stabulas] If you go back further and you would really never see this area on a
periapical film unless you removed the cheek. This is actually the maxillary
tuberosity and if you go distal to that, thats known as the hamular notch and you
can see that its a notch in the bone. And then this little I think that youre
probably too young to what Im going to compare this to but its a shoe-horn, do
you know what a shoe-horn is? They used to use them to help you get your foot
inside a shoe and its shaped like a shoe-horn and thats known as the hamular
process. But its way far back and you would more likely see it on an extraoral film
than an intraoral film.

[12] [Maxillary Anterior and Posterior Projections of Tori]
[Dr. Stabulas] These are not considered to be anatomical landmarks but they are
variations of the norm and theyre known as tori. And you can see tori, maxillary tori
and mandibular tori, on a radiograph. Tori is just extra bone deposited in the areas
where the arches are fused. So the maxillary arch, in utero, is formed from two
processes so when theres deposition of more bone along the suture point, you get a
tori right down the middle of the palate. On the mandible, the mandible is formed
from 3 different processes so there are two suture lines and that would be exactly
where you would see the mandibular tori, okay? Right at those processes or sutures
in the processes.

[13] [Mandibular Incisor Area]
[Dr. Stabulas] So this is the mandible. This would be looking at the mandible from
the outside, and this would be looking at the mandible from the inside. So what you
see outside is not what you see inside. However, when you see it on a radiograph,
its all superimposed on top of each other because you dont see depth. And you
would never be able to tell what is lingual and what is buccal. So what is usually
seen and, again, Im mentioning the more common that you will always see and
thats very often seen inferior border of the mandible. You could see the mental
ridges and again, the ridges are on the inside, if youre looking at the inside of the
mandible and not on the outside. You can see them a little bit but more often on the
inside. And the genial tubercles are little tubercles of bone that stick out form the
center of where the incisive foramen is. So you see the incisive foramen here? And
then you see these little tubercles of bone? Thats known as a genial tubercle and
thats where the muscle from the mandible to the tongue is attached. So that area
usually indicates, if you see it, the midline of the mandible. Now the lifesaver, you
know what a lifesaver is, the candy? The lifesaver shaped bone, the radiopacity, is
known as the genial tubercle. The radiolucency in the middle of it is actually the
lingual foramen. Okay? So theres a distinction between the two, the genial tubercle
and the lingual foramen. Also, you see these black vertical lines coming down here?
Its not that these nutrient canals are only in the mandibular anterior region, its that
you see them more often in that region than you do anywhere in the mouth and
whats the reason for that? Why do you think? Nutrient canals, you know that
nutrient canals bring nutrients to the teeth so obviously theyre going to be all over
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the oral cavity but most of the time you see them, or when you see them, you see
them in the mandibular not only, but most of the time in the mandibular anterior
region. And why do you think thats true? Well if you look at the mandible you see
how its kind of scooped out right in the center here? And where its scooped out is
actually very thin bone, so when the bone is thinner, you can see the nutrient canals
more clearly on the radiograph. Thats the reason for that. And they love that
structure on the board exam. When youre looking at radiographs because that
could look like a pathological condition unless you know that its nutrient canals in
the lower anterior region. Okay?

[14] [Mandibular Canine Area]
[Dr. Stabulas] As you get towards the canine region, again, you see the same things
but now you might see the internal oblique ridge coming in. Again, you see the
border of the mandible. These are the mental ridges.

[15] [Mandibular Premolar Area]
[Dr. Stabulas] As you go back further, the mental foramen is generally seen more
clearly in the premolar region than anywhere else. And the mental foramen is the
foramen that is most likely confused with the periapical radiolucency. Why?
Location, first of all. Its usually between the roots of the two premolars. And
secondly, the shape. Its more rounded and more of the size that you can confuse
with periapical pathology, PAP, or periapical radiolucency, than you could with the
nasopalatine foramen or with the lingual foramen. So the mental foramen is round
and radiolucent and it usually falls in the area between two premolars. The exterior
and internal oblique ridges are hard to tell the difference but the way that I usually
remember it is that the external and the word external makes me think that its
more outside but I like to think of it as being the higher ridge. So the external ridge
is higher and shorter than the internal oblique ridge which is longer and lower. Do
you know what another name for the internal oblique ridge is? The mylohyoid
ridge? And mylo, the L in mylo and the fact that it says low, mylo, is longer and
lower. Thats how I remember it. The internal oblique ridge is longer and lower than
the external oblique ridge.

[17] [Mandibular Molar Area]
[Dr. Stabulas] And you can see them both much more so in the posterior region. So
this is the external, higher and shorter. And the internal, longer and lower. Okay?
You also have the submandibular fossa where the submandibular gland sits. And the
mandibular canal and the walls of the mandibular canal, which would be
radiopaque, the canal itself radiolucent. Okay?

[18] [Radiographic Anatomy For Panoramic Radiographs]
[Dr. Stabulas] Now, when you look at and these are known as panoramic
radiographs. Panoramic radiographs are considered extraoral radiographs. And
what that means is that the receptor and source of radiation are outside the mouth.
In intraoral radiography, the receptor is inside the mouth, the source of radiation is
outside the mouth. So extraoral. And the panoramic radiograph is not the only
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extraoral radiograph that can be taken. There are others as well. What you need to
know on a panoramic radiograph are there are anatomic landmarks that can be seen
on panoramic radiographs that you would never see on intraoral radiographs. And if
you look at the list below here, those that can be seen on intraoral radiographs, I will
not mention. But those that are specific basically only to the panoramic I will
mention. Like the mandibular foramen. The mandibular foramen is way in the back
of the mandibular canal. So the mental foramen is the most anterior portion of the
mandibular canal. The mandibular foramen, I dont know if youve ever had a or
ever seen a block, a mandibular block anesthetic being given block, thats where its
given, right into the mandibular foramen, which lies in the retromolar region on the
mandible. Okay? The pharyngeal air space just means that theres that black line in
between, so its just the air space in the back of the mouth but makes it look like
theres a space in between the teeth. It sometimes can present a problem and well
talk about that later on. Styloid process cannot be seen on intraoral radiographs.
Sometimes the styloid process is calcified to a degree where you can even see it
better. But in this case, it would be here. And if its calcified, it can also indicate that
the patient has a syndrome known as Eagles syndrome where the neck does not
move freely and thats the styloid process. Maxillary sinus you could see and
intraoral coronoid process. The articular eminence is here where the TMJ is, glenoid
fossa in front oft that. The hard palate just appears as a radiopaque line across the
sinus. So this is the hard palate here. And note that not only with panoramic
radiographs but with intraoral radiographs as well, the landmarks dont always look
the same. It depends on the patient and how the radiographs are taken. So not every
mental foramen is going to look alike. Or the glenoid fossa or the articular eminence.
So what you need to know is if its radiolcuent or radiopaque and where it basically
exists in order to be able to identify it. Okay?

[19] [Radiographic Anatomy for Maxillary Occlusal Radiographs]
[Dr. Stabulas] This is an occlusal radiograph and an occlusal radiograph is a
radiograph, again, not taking an image of the occlusal surfaces. Its taking an image
so that you can see the dimension that is missing from an periapical or panoramic or
bitewing radiograph. We already said that you can only see width and length. Here
is your depth. So this is looking at the maxilla as youre looking from a birds eye
view. So this is the front of the maxilla and this is the back of the maxilla. Okay?
Same thing with the mandible.

[20] [Radiographic Anatomy for Mandibular Occlusal Radiographs]
[Dr. Stabulas] So what an occlusal radiograph gives you is the buccal lingual
perspective. And its the same anatomic landmarks but they just appear a little bit
differently and here you have the genial tubercle hanging down which doesnt look
like that when you take a periapical radiograph nor does the inferior border of the
mandible. So its the same landmarks, they just look differently from a different
perspective.

[21] [Principles of Radiographic Interpretation]
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[Dr. Stabulas] So, keeping that in mind, when you try to interpret radiographs,
there should be several steps in formulating a diagnosis. First thing you should do is
identify the area that questionable. After youve identified that, and that information
that allows you to identify that is that its not within normal limits. You know that
this radiolucency is not an anatomic landmark. Its not within normal limits. Once
youve identified the area that is questionable, you interpret what has been
identified and that includes saying whether its radiopaque/radiolucent, whether its
unilateral/bilateral, whether its or where its located, I should say. And the
diagnosis is usually based upon the interpretation. So a diagnosis is the end result of
an interpretation. So if your interpretation of the radiograph is not correct in
formulating a differential diagnosis, it will affect the ultimate diagnosis or the
definitive diagnosis, which comes after the differential.

[22] [Diagnostic Questions]
[Dr. Stabulas] So here are some question you need to ask. First of all when a
patient comes to you in trying to come up with a diagnosis, you need to be
interested in what the patients chief complaint is. And that is often your first step in
acquiring a diagnosis. The patient will point you in the right direction. So, whats
your chief complaint? I have a dull pain in my upper anterior region. You know to
take a radiograph in the upper anterior region. You know some of the things that
could affect the upper anterior. So first thing you want to do is ask the patient what
the chief complaint is. Then you want to ask the patient or have the patients records
stating what the clinical findings were. So was there a clinical examination done and
what did the clinical findings what was the result of the clinical findings. Was
there a vitality test done? Did we test whether the tooth was vital or not? And what
was the end result of that vitality test?

[23] [Diagnostic Questions]
[Dr. Stabulas] Depending on what youre looking at, what radiographic projections
are available to look at and what additional films need to be taken. So lets say that
we took a panoramic. This is a panoramic radiograph on the patient and were still
not able to zone in on whatever it is that the patient is complaining about and what
were seeing. Well maybe we need a periapical radiograph of the area to give it more
detail and definition. Panoramic radiograph, because of the field size, doesnt have
enough detail and definition to see periodontal disease or incipient periapical
pathology, or incipient caries, new caries. So, sometimes the general rule is to go
bigger if you dont see the whole lesion on a radiograph, you go bigger. Sometimes
you need to go smaller in order to get more detail and definition.

[24] [Diagnostic Questions]
[Dr. Stabulas] Is the lesion radiopaque, radiolucent and the other option that I
havent mentioned before is mixed. So there are some lesions that have both
radiolucent and radiopaque components. So while were looking at the radiograph
we need to distinguish that. Is it radiolucent? Is it radiopaque? Or is it mixed? Okay?
This lesion here would be a radiolucent lesion, right, on the mesial root.

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[25] [Radiopaque Lesion]
[Dr. Stabulas] This lesion would be a radiopaque lesion. Okay?

[26] [Mixed Lesion]
[Dr. Stabulas] And this lesion is a mixed lesion. Does anybody know what this is?
What does it look like? If you had to describe it, first of all, tell me, is it radiopaque or
radiolucent? Its both. So you have dont confuse with who knows what this is?
Does anyone want to take a stab at that? What tooth does it look like? Its a canine.
Whats wrong with the canine? Well its on a transverse angle, yeah. And thats
because its impacted. And the reason why its impacted is because this little guy is
there. So this is really what were looking at and not the impacted canine. Okay?
Now, this has both radiopaque and radiolucent components. Okay? Who wants to
take a stab at what this might be? No, you have a first premolar here. You have a
lateral incisor here. So this is actually the primary canine. The reason why the
primary canine is there is why? Because the secondary canine is impacted. And why
is the secondary canine impacted? Because this little thing is sitting in the way. This
little thing is called an odontoma. And an odontoma is a mixture of tooth
components that form a tumor-like structure. Theres a compound odontoma and a
complex. Complex odontoma does not look like this. If you see closely now, do you
see little tooth parts in there? Little parts of a tooth? And you can see the pulp and
you can see radiopacities? So thats a compound, thats taking pieces of a tooth and
putting them together. A complex odontoma is more diffuse. You cant see the actual
tooth parts but it does have radiopaque and radiolucent components. So knowing
how to describe a lesion sometimes tells you what that lesion can be.

[27] [Diagnostic Questions]
[Dr. Stabulas] Have periapical and bitewing radiographs been taken recently? In
other words, if you want to tell a story about an area or a tooth, having baseline
radiographs come in really handy. So if I see a radiolucency below this restoration
here and I can say maybe it is recurrent decay but if I saw that lesion going back on
previous radiographs, I actually can get the idea that its been placed there. It
actually is very well-formed. It doesnt look like caries doesnt care about how it
eats away at a tooth. It doesnt usually have defined borders. But this one looks a
little bit more purposely placed. And it actually was pulp capping. It was something
placed on top of the carious lesion to promote the growth of secondary dentin.

[28] [Diagnostic Questions]
[Dr. Stabulas] So sometimes its important to know the history of an area.

[29] [Diagnostic Questions]
[Dr. Stabulas] Where is the lesion located? And just like when you go looking for an
apartment, in Manhattan, its all about the location. Location is very important
because again, if you see and what area am I looking at here? What is this? What
part of the patients mouth? Maxillary anterior region, correct? Okay. So I see a
whole blob thing going on in here that doesnt look too nice. Doesnt look like how it
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should look. However, I'm going to tell you there are two lesions here. One is normal
and one is not normal. Okay? So, what anatomic landmark do I know that occurs in
the midline of the palate between the roots of the maxillary central incisors? The
nasopalatine foramen, right? Or the incisive foramen, I heard somebody say incisive.
Okay. So which one of these two do you think might be the foramen? And the other
you may already know is a nasopalatine cyst. But which one do you think is the
foramen? This one or this one? Its the first one I mentioned [right side]. Why?
Because you can see bone. I can see superimposition of the alveolar process. Here,
its pretty much all eaten away. And that is a nasopalatine cyst. So you need to know
how to differentiate. Know where something exists and what its supposed to look
like in normalcy as compared to what it would look like if there was something,
some disease process.

[30] [Diagnostic Questions]
[Dr. Stabulas] Im going to tell you and go down as saying that most pathologic
lesions are not bilateral. Usually when they occur, they occur by themselves. One of
the ways that we can distinguish anatomic landmarks is that theyre bilateral, right?
You have two mental foramen Unless it exists straight down the midline like the
genial tubercle and the septum, the nasal spine, the nasopalatine foramen
anything down the midline is usually unilateral. Anything outside of the midline, the
inverted Y formation, the nasal fossae, the maxillary sinus (is usually bilateral), the
internal/external oblique ridge, the mandibular canal theyre all if its off the
midline, its bilateral. However, this is the exception to the rule. This is actually a
bilateral lesion. So what would be my first clue in knowing that thats a lesion and
its not part of the normal anatomy. So we said several things:
radiolucent/radiopaque, we talked about location. So what about he location here
on either side of the midline of the mandible? Well theres symmetry theres a
little asymmetry actually. This is actually a lesion; its not an anatomic landmark. So
youre saying that its asymmetrical, yes. That would be part of it. But its also not in
an area where you have a bilateral radiolucent anatomic landmark. We dont have
an anatomic landmark that appears in the canine region on both sides of the
mandible. Further back, yeah, submandibular fossa but thats much lower. So thats
why you need to know how anatomic landmarks appear and how you would
differentiate if it wasnt within normal limits.

[31] [Diagnostic Questions]
[Dr. Stabulas] You want to know the size and shape of lesions. Are the borders of
the lesion well-defined? If you have well-defined borders on a lesion, that usually
means that following a biopsy, that lesion probably wouldnt be considered
malignant. Because malignant lesions usually have irregular border, correct? So if
you see a lesion with regular borders, with borders that are well defined and its
usually and I say after a biopsy because you cannot describe a lesion as being
malignant or benign without a biopsy. You just cant. because those two, just like
radiolucent and radiopaque only apply to radiographs, benign and malignant only
apply to biopsy results, to cellular inspection of the area. You cant say that based on
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anything else. You can think it, it could be part of your differential but without a
biopsy you cant say that and be 100% sure.

[32] [Diagnostic Questions]
[Dr. Stabulas] This is a lesion thats considered to be multilocular. Now, just
looking at this lesion, what do you think multilocular means? That there are what?
Multilocular. So multiple locations? There are actually multiple areas within one
location. So it has different compartments. You see all the compartments? Thats
what multilocular means. That there are different compartments. There are certain
lesions that usually, not always, but usually occur multilocular. One of them is
known as an ameloblastoma. But not always. Ameloblastomas can be unilocular,
they can only have one compartment but sometimes they are multilocular. And the
amelobalastoma is actually what we consider a localized malignancy but it doesnt
not a metastatic lesion. So, in other words, it can grow through the entire mandible.
Its usually on the mandible and it starts towards the angle of the mandible but it
could take over the entire mandible. But wont metastasize to a different area. And it
is usually multilocular but not always.

[33] [Diagnostic Questions]
[Dr. Stabulas] Is the teeth in the affected area or I should say that are the teeth in
the area affected? So, in this case, what do you find odd about the teeth in this area?
Whats wrong with these teeth? And now, when you have a root, whether its short
or not and its formed properly, what does the apex of the root look like? Its kind of
sharp and pointy, right? Now, how would you describe the apex of this root? Its
blunted, rounded and blunted. So, we actually call this root resorption. And
sometimes in the case of a lesion, you might find root resorption due to the lesion in
the region. So you want to look at the teeth and see if the teeth have been affected.
Have they been pushed out of the way? Have they been flared out? Have the roots
been resorbed? Okay? And that also gives you some hints about where to go with
the differential diagnosis. All right?

[34] [Diagnostic Questions]
[Dr. Stabulas] So theres a lot to look at. One of the most basic building blocks in
using an interpretation to lead to a diagnosis is that you have to see all the borders
of a lesion. Now this lesion itself I cannot see the borders. I dont know how far that
lesions going to go. I dont know if theres a hyperstatic border, meaning a
radiopaque border around the entire lesion. I dont know if its well defined on the
area that I cant see. So first rule of thumb is if you dont see the whole lesion, go
bigger or go home. So if you have a PA, you may want to go for a PAN, depending on
where it is. Or if you suspect that this lesion is gong to be seen better, based on the
way that it presents itself, on an occlusal radiograph, where you can get more of a
look at the buccal lingual, then you would take an occlusal radiograph. But you
never settle for a film that doesnt show you all of the borders. Okay? What if its a
panoramic and it doesnt show all of the borders? Well maybe you need a CT scan. A
CB CT, cone beam. Okay?

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[35] [Introduction to Normal and Common Pathological Radiographic Findings]
[Dr. Stabulas] Having previous films is always helpful because you can see the rate
of growth. What does a growing lesion mean in comparison to a non-growing, static
lesion? What do you think about a growing lesion? Theres more cause for concern
there, right? Because if a lesion grows or changes in size or shape, then theres more
of a concern for that lesion than there would be if it was just a stagnant lesion. Okay?

[36] [Common Pathologic Radiographic Findings]
[Dr. Stabulas] So now were just going to look at some common pathologies that
you might see. We used to use the term periapical pathology. Now thats not specific
at all, is it? Its just saying that we see a radiolucency at the apex that we look and
interpret as being a pathology. However, we no longer use that term. It has outdated
itself. Now we describe it as periapical radiolucency. Why do you think we dont say
periapical pathology anymore without investigating it further? Because if were
describing it, its round, its radiolucent. Its at the apex. Its a periapical
radiolucency. How do I know that its a pathology? I dont. It could be scar tissue
from before a root canal therapy was done, right? I dont really know what it is but I
know that theres something there that shouldnt be there and its at the periapical
and it lends itself for further investigation.

[37] [Periapical Granuloma]
[Dr. Stabulas] You really cant tell radiographically the difference between a
periapical cyst and a periapical granuloma. How do you think you make that
distinction? Theyre calling this a granuloma

[38] [Periapical Cyst]
[Dr. Stabulas] and this a cyst. So by looking at a radiograph do I really know the
difference between a granuloma and a cyst? No. what would you need to do? Biopsy.
Right? Take a look at the tissue microscopically.

[39] [Periapical Condensing Osteitis]
[Dr. Stabulas] Condensing osteitis. Now, the first thing is, Im going to look at this
molar. Okay? What tooth number is that? Its 30 and 31. At least I can say that I dont
see that this tooth is a premolar but based on what I can see it looks like a premolar,
so that would be 29, 30 and 31, right? Now, Im looking at 30 right now. What do I
see besides these radiopacities at the apex of the tooth? You see anything? What
about this? What is this? So , this is the pulp and this is a bit higher than where the
pulp should be but its radiolucent and you can see it coming outside the enamel so
what do you think it is? Now, the caries is pretty close to the pulp, isnt it? These
radiopaque lesions here are known as periapical condensing osteitis. And it usually
indicates a build-up of bone at the tips of the root either due to trauma to the tooth,
occlusal trauma, and in this case its from the carious lesion. Okay? So with
condensing osteitis, it is connected to the tooth itself but it doesnt change the shape
of the root. And I say that to distinguish it from some other differentials of
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radiopacities at the apex. So the apex of the root of the tooth is still the same but you
see a build-up of bone at the edge, at the end of the root. Okay?

[40] [Residual Cysts]
[Dr. Stabulas] A residual cyst, and it can be any size of shape, but it usually occurs
in an area where there was a tooth extracted, which is why its called a residual cyst.
Its left its a cyst thats left after the tooth is extracted, okay? So what would be
one of the things you would look at if you were including a residual cyst in your
shopping list of differentials? Is it an extraction site? Is it an edentulous site? If you
saw a cyst in an area where there was a tooth, would a residual cyst be included in
your differential diagnosis? No. Okay? Then you would look at the other cysts that
would be possible. So why am I calling it a cyst? What identifying characteristic does
this have that makes me call it a cyst? Because its radiolucent, right and not
radiopaque. Okay?

[41] [Root Resorption]
[Dr. Stabulas] Youll get to know it as time moves on. Now whats wrong with these
teeth? It already says it up here so just read it. So its root resorption. Now, root
resorption, again, can be as a result of trauma to the tooth. Whether its trauma due
to caries or trauma due to a lesion or in this case, trauma due to orthodontic
therapy. Now this is a very common area for root resorption due to orthodontic
movements. If the teeth are moved too quickly, too fast and too much, sometimes
the root jerks back. It says, oh wait a minute, I cant move that fast, Ive been here for
a long time. And now youre trying to take me out of my position and the root starts
to pull back. So this is root resorption due to orthodontic treatment.

[42] [Internal Root Resorption]
[Dr. Stabulas] And one of the ways I can find out if there was orthodontic
treatment in that area is to do what? Ask the patient. Okay. Internal resorption the
etiology can be questionable, were not really sure but it can be due to trauma. And
internal means that it starts from the inside and makes its way to the outside. Okay?
External resorption starts from the outside and makes its way to the inside.

[43] [External Root Resorption]
[Dr. Stabulas] And this is external resorption here. Okay?

[44] [Periapical Cemental Osseous Dysplasia]
[Dr. Stabulas] Usually you can see that clinically as well and clinical identification
I dont think that radiographic identification and clinical identification should ever
be separated. Theyre very reliant on each other. I mean there are certain things
that you cannot see clinically and certain things that you cannot see
radiographically. Like occlusal caries, for one, is not well-identified on radiographs.
Its much easier identified on clinical identification. And then there are bone loss,
for instance, you cant be see that clinically, you can use a perio probe and see if
theres been any detachment or attachment loss but you cant see the bone, right?
But that you can see on radiographs. So the two are really dependent on each other.
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Now, this is another situation that can happen in the mouth and this is actually what
we consider to be a mixed lesion but its a 3-stage lesion. Its called periapical
cemental osseous dysplasia. It is within normal limits. Theyre not sure about the
cause but it usually has familial tendencies. We actually in 1A, once had a
grandmother, her daughter and her daughter so the grandmother to the
granddaughter all had periapical cemental osseous dysplasia. And we had all three
of them in the clinic at once. So its really interesting to look at. Now periapical
cemental osseous dysplasia is not a pathologic process. It comes in 3 stages. The
first stage is actually to see radiolucencies at the apices anywhere from the canine to
the canine in the mandibular anterior region. Now, the way in In the first stage, if
theres already radiolucencies at the apices in those teeth, what would be your first
thought? Something wrong with those teeth, right? So how would I tell if there was
something wrong with those teeth? To distinguish it from what we know to be
periapical cemental osseous dysplasia and has nothing to do with the teeth? What
would be your first guess? What can I do in the clinical setting? Pulp vitality test.
Thats the first thing you do. You see multiple radiolucencies in the mandibular
anterior region, you do a pulp test. So what happens in the pulp test if the teeth do
not let me put it the first way first If they do respond, what does that mean? If
the teeth respond to the pulp tester? In other words, they feel when you use the
pulp tester. What does that mean? That the tooth is responding to it so the tooth is
dying, pretty much, right? If it doesnt respond no, its the other way around. If its
alive, itll respond, if its dead, it doesnt respond. So, lets say these teeth respond to
the pulp testing. So what can we assume that I could be? Periapical cemental
osseous dysplasia because theres nothing wrong with the tooth. Now if we go a
little further on in the second stage of the disease process, which is not really
anything to worry about and you dont do anything about it, it starts to get a mixed
appearance where you see some radiolucency and some radiopacity. And thats the
second stage. Now, mind you, this means nothing to the teeth, it means nothing to
the bone. Its just an anomaly. Its not .. Has to pathology whatsoever and nothing
needs to be done. But it exists in 3 stages and in the first stage, it could be confused
with periapical pathology. The second stage, not so much because you see it as a
mixed lesion. And the third stage, it can look like condensing osteitis or something
else that is completely radiopaque at the apex. So one of the things that helps is
vitality testing. The other thing that helps is that its in a certain region between
canine to canine on the mandible, okay?

[45] [Hypercementosis]
[Dr. Stabulas] Hypercementosis is another radiopacity at the apex but this, as
opposed to condensing osteitis, changes the entire shape of the apex. How would
you describe this shape? Any of you ever watch Fred Flinstone? Or any other
caveman movie? What are they known to have in their hands? A club. And its not a
golf club, its another type of club. But when we see something that looks like a
clubbing of the apex, of the cementum, we call that hypercementosis. Again, etiology
could be unknown. It could result from trauma to the tooth or occlusal trauma as
well. And it also can be affiliated with certain systemic illnesses. One being Pagets
disease. Patients with Pagents disease, which is that cotton appearance to the bone,
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are more susceptible to hypercementosis. Also, people with Down Syndrome have a
tendency to have a hypercementosis. So sometimes that can give you a hint onto a
systemic illness also. Some things that appear in the oral cavity.

[46] [Dens Invaginatus]
[Dr. Stabulas] This is called, it used to be called dens in dente meaning a tooth
within a tooth but it really is an invagination of the cingulum. Okay? Of the enamel
organ. So you see how it almost forms a little tooth and this is the bigger tooth? It
also doesnt require, I mean, sometimes it might not look well-formed but it doesnt
require any treatment.

[47] [Fissural Cysts Nasopalatine, Globulomaxillary, and Median Palatine Cysts]
[Dr. Stabulas] These are what we call fissural cysts, you saw one thats called the
nasopalatine cyst we saw before. Fissural cysts mean they form in the same area
each and every time and its usually at a fissure, in the bone, at a fissure site. So you
have the nasopalatine cyst [lower right], this one is a lateral [left side], and this is a
globular maxillary [center] but theyre not so sure that a globular maxillary is a cyst
anymore. It depends on where youre reading the information.

[48] [Dentigerous Cysts]
[Dr. Stabulas] But they always appear in the same spot. A dentigerous cyst. Now
what does this cyst [left] have in common with this cyst [right]? What is the
common denominator? So I'm tracing this cyst, and it starts at the CEJ and it goes
around the tooth to the other side and ends at the CEJ. Yes? So this one [right side]
starts pretty much at the CEJ and goes around to the other side and stops pretty
much at the CEJ. So what do they have in common?

[Student] what are we looking at?

[Dr. Stabulas] Oh, I dont know. What do you mean by what? All right, first of all.
This is not a periapical or a panoramic or an occlusal or a bitewing radiograph. This
is called a lateral cephalometric radiograph so it shows the whole side of the face.
Okay? So you actually dont know whether youre looking at the right or the left. You
would have to know that when you took it. I cant tell by just looking at it. And what
about this [lower right]? What kind of radiograph is this? This is actually an occlusal
radiograph. So neither one of them are periapicals but what is the one thing that
they have in common, those two cysts? Whats wrong with the teeth? Yeah, so what
do you call a tooth thats embedded in bone? Impacted. Who said it? I heard it, I
swear. So a dentigerous cyst is strictly only around an impacted tooth. And it goes
from the CEJ around the tooth to the CEJ. Now, what a dentigerous cyst is, you know
that theres a follicle around every tooth that forms. When the tooth comes out in
the oral cavity, what happens to the follicle? It dissipates, right? The tooth breaks
right though the follicle and the follicle falls off. If the tooth never comes out to the
oral cavity, what happens to the follicle? In some cases it becomes cystic. And in that
case, its called a dentigerous cyst.

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[49] [Malignant Lesions]
[Dr. Stabulas] Again, this is a lateral radiograph as well, a lateral cephalometric
radiograph. But what Im looking at is this radiolucency here. And if I was to
describe it, what kind of borders would I describe this as having? Follow the black
arrow. Theyre well-defined:? No, theyre not well-defined. Theyre actually not well-
defined. Thats one of the signs that it could be a malignant and not a benign lesion.
This one I dont really love [right side] because it all looks black because most of it is
but you can see the areas that dont look black and here there actually is a scalloped
appearance to the base of this, which makes me think that its irregular borders. Its
not the greatest picture. Not up there. It looks better here.

[50] [Benign/Malignant Tumors on Occlusal Radiographs]
[Dr. Stabulas] Again, if a lesion has malignant borders. If it causes the bone
usually if it causes the bone to move, its benign. And why is that? Because its
pushing, right? If its malignant, it actually infiltrates the bone, so it doesnt push it.

[51] [Ameloblastoma]
[Dr. Stabulas] This is the ameloblastoma we were talking about before. And now, I
said that it can be unilocular or multilocular. If you look at it, you can actually see a
few lobes but its mostly radiolucent throughout. And it is in the area of an impacted
tooth but it has nothing to do with that. The location of it, being somewhere
between the premolar and the angel for the mandible is what? Is a usual spot for an
ameloblastoma.

[52] [Well-defined RO Tumor in the Left Maxillary Sinus]
[Dr. Stabulas] This is the tumor were talking about in the maxillary sinus. If you
took a panoramic on a patient as a dentist and you saw a radiopaque tumor in the
left maxillary sinus like this one, what would you do? What would be your
responsibility and role in identifying this lesion? And let me tell you that this is what
we call an incidental finding. Why? We werent looking for an tumor in the maxillary
sinus, right? Because what can we do with a tumor in a maxillary sinus? Make a
referral. So there are plenty of lesions that we might find that are incidental in
finding. In other words, not what were looking for. You can actually see carotid
artery calcifications on a panoramic radiograph and if you see them, I would say to
the patient, well I think you should go and see your cardiologist or your general
doctor because you may have some calcifications in your carotid arteries. And you
can see that on a panoramic but we dont take it for that reason. Okay? Sometimes
you may see changes in the inferior border of the mandible that can indicate that
that patient has a tendency towards osteoporosis, if its thinning out. Would you say
to the patient I think you have osteoporosis? No, you would say to the patient you
may want to go for some tests or go and see your doctor and tell your doctor what
we found. So its not something that youre going to treat directly but it is something
that you can make a very important referral for.


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[53] [Odontoma]
[Dr. Stabulas] We saw an odontoma before. Again, this is a compound odontoma
because you see the parts of it.

[54] [Pagets Disease]
[Dr. Stabulas] Pagets disease as we said is the cotton-roll appearance to the bone.

[55] [RL Lesion of Hyperparathyroidism]
[Dr. Stabulas] These are lesions that are associated with hyperparathyroidism.

[56] [Trabecular Pattern of Anemia]
[Dr. Stabulas] What did we say about anemia before and looking at the
trabeculation? What happens to the medullary spaces? With anemics? Theyre
actually larger. So if you look at some of these areas, mainly here, some up here,
these spaces are usually larger than you would see normally. So what would you do
about if you saw a patient that presents with these medullary spaces, what would
be your role? Referral. But a referral sometimes is as important as a diagnosis.
Okay?

[57] [The End!]
[Dr. Stabulas] Thank you and well see you soon! If you have any questions and
dont want to say it out loud, you can come up here and I can answer them as well.