How to Obtain and Interpret Periodontal

Radiographs in Dogs
Anson J. Tsugawa, VMD and
FrankJ. M. Verstraete, DrMedVet, BVSc, MMedVet, Dipl AVDC, Dipl ECVS
Oral r adi ogr aphy pl ays an i mport ant role in t he di agnosi s of
per i odont al di sease. The di agnost i c yi el d of r adi ogr aphs is high,
and t hey shoul d be obt ai ned in all cases pr esent i ng f or per i odon-
tal treatment and t o assess t he l ong-t erm success of t herapy.
Di agnost i c- qual i t y r adi ogr aphs f or eval uat i ng t he per i odont i um
are best obt ai ned wi t h a dent al x- r ay uni t and wi t h t he pat i ent
under general anesthesi a. The st andar d f ul l - mout h r adi ogr aphi c
sur vey cont ai ns a mi ni mum of 6 vi ews, and wi t h pract i ce, can be
obt ai ned wi t h mi ni mal ef f ort and ti me. I nt erpret at i on of dental
radi ographs, however, requi res a keen under st andi ng of t he
normal r adi ogr aphi c anat omy of a t oot h and its suppor t i ng st r uc-
tures. The r adi ogr aphi c di agnosi s of peri odont al di sease is char -
act eri zed by roundi ng of t he al veol ar cr est wi t h l oss in cont i nui t y
of t he lamina dura, wi deni ng of t he per i odont al l i gament space,
and l oss of al veol ar cr est hei ght.
Copyr i ght 2000 by W.B. Saunder s Company
A radiograph is a 2-dimensional representation of a 3-dimen-
sional object, and will provide assessment of alveolar bone
height and periodontal ligament exclusively at the apical, distal,
and mesial aspects of a tooth. Because of a lack of visualization
of the bone level on the buccal and palatal/lingual sides of a
tooth, there is often an underest i mat i on of bone loss and an
inability to detect the differences between 1-, 2- or 3-walled
infrabony defects. ~,5 The assessment of furcation involvement
is also impaired unt i l bone loss has progressed apical to the
furcation. In human dentistry, the advent of standardized, dig-
ital subtraction radiography has overcome the poor sensitivity
i nherent wi t h conventional films, and has raised the detection
accuracy of osseous changes to greater t han 90%. 6 Subtraction
imaging is a validated modal i t y in human dentistry, but re-
quires standardized films, specialized software, and equi pment
that is not readily available for veterinary use.
p
eriodontal disease is the most common dental disease in
dogs. The accurate staging of periodontal disease is there-
fore of great importance. Conventional radiography and peri-
odontal probing are the common met hods of periodontal diag-
nosis in human and veterinary dentistry. The clinical signs of
gingivitis, gingival recession, and increased probing depths are
inadequate in revealing the true extent of disease. It has re-
cently been reported that in 26.2% of dogs presented for peri-
odontal treatment, radiographs showed the extent of periodon-
tal disease and bone loss as greater t han clinically expect ed)
Radiographs enable the clinician to assess bone levels, patterns
of bone loss, and combined periodontal-endodontic lesions not
appreciable clinically. 2 Conventional radiography is the stan-
dard in clinical practice for identifying the osseous changes
associated wi t h periodontitis, and is a noninvasive met hod of
assessing bone levels wi t hout direct surgical visualization. Con-
ventional radiography is, however, nonstandardized and insen-
sitive. The radiographic projection artifacts of image foreshort-
ening and elongation often preclude the accurate assessment of
bone loss and disease progression. It is commonl y accepted that
conventional radiography will not register alveolar bone loss
until 30% to 50% of bone mineral has been resorbed. 3
From the Veterinary Medical Teaching HospRal. and the Department of
Surgical and Radiological Sciences, School of Veterinary Medicine, Uni-
versity of California, Davis.
Address reprint requests to Frank J. M. Verstraete, DrMedVet, BVSc,
MMedVet, Dipl AVDC, Dipl ECVS, Department of Surgical and Radiolog-
ical Sciences, School of Veterinary Medicine, University of California,
Davis, CA 95616.
Copyright 2000 by W.B. Saunders Company
1096-2867/00/1504-0003535.00/0
doi:10.1053/svms.2000.21042
Indi cat i ons
Ideally, ful l -mout h radiographs shoul d be obtained when the
patient is first presented for dental treatment. The diagnostic
yield of this practice is high and its routine use in the dog and
cat is medically justified.1 This may be cost-prohibitive, and an
alternative approach is to radiograph those areas where one
expects to find lesions based on the visual oral examination and
periodontal probing. Dental radiography is also indicated to
assess the long-term success of periodontal therapy. Because
dental radiographs in animals must be obtained under general
anesthesia, dental radiography may be contraindicated in cer-
tain high-risk patients. 7 Wi t h practice, however, a complete set
of radiographs can be obtained wi t h minimal effort and time. 1.7
Radiographic Equi pment and Film
Skull, extraoral, and intraoral radiographic techniques have
been described to image the periodontium. Standard and dental
x-ray units may be used to obtain these images. The relatively
immobile tube head of the standard radiographic uni t often
limits its use in obtaining many of the necessary views in a
ful l -mout h radiographic series. Anatomic superposition and
poor detail of skull films often obscures their interpretation.
Therefore, the dental x-ray uni t is essential in obtaining radio-
graphic images of optimal quality for evaluating the periodon-
tium.
Dental radiographic film is nonscreen, direct-exposure film
that is particularly sensitive to x-rays and does not require an
intensifying screen to convert x radiation into visible light to
produce a latent image. 15 Dental radiographic films are avail-
able in 2 film speeds, groups D and E. Group E films are the
204 Clinical Techniques in Small Animal Practice, Vol 15, No 4 (November), 2000: pp 204-210
TABLE 1. Film Sizes Commonly Used
in Veterinary Dentistry
Size Dimensions Possible Use
#0 22 x 3.5 mm Mandibular P3-M1 in very small dogs
#2 31 x 41 mm Standard size
#4 57 77 mm Occlusal views, large dogs
faster of the two, and result in decreased patient exposure to
radiation by up to 50%. as The trade-off for increased speed is a
radiographic image of comparably less contrast and detail. The
2 groups of film are available in 5 sizes, and of these 5, sizes 0,
2, and 4 are the most commonly used in veterinary dentistry
(Table 1). At the corner of each dental film and its wrapper is an
embossed bubble (dimple or dot) that is used to designate
proper positioning of the film with the incoming x-ray beam.
The convex surface of the bubble is by convention the surface of
the film facing the x-ray tube. The bubble is also a useful
positioning aid for properly orienting dental films on the radio-
graph viewing box. Film processing can be performed manually
with a chairside developer, or automatically, with a processor
specifically designed for dental film.
Radiographic Technique
Two techniques are commonly used to obtain radiographic
reproductions of dental structures (Fig 1). The simplest of
these techniques is the paralleling technique (Fig 2). The prin-
ciple of parallelism, as its name suggests, is implemented by
inserting the film parallel to the long axis of the tooth. The
primary x-ray beam is then positioned perpendicular to the
plane of the film and the long axis of the tooth; this technique is
used to obtain radiographs of the mandibular premolars and
molars. ~,7 The bisecting angle technique is used to image all
maxillary teeth and the mandibular incisors and canines (Fig
3). This technique is implemented by placing the film within
the oral cavity as close to parallel to the long axis of the tooth as
possible without bending or distorting the film. The x-ray beam
is then directed perpendicular to the line that bisects the angle
formed by the film and the long axis of the tooth. In doing so the
image obtained is neither elongated nor foreshortened. 7
Fig 2. Obtaining a radiograph of the caudal mandible using
the paralleling technique. (Reprinted with permission from
Verstraete FJM (ed): 1999 Self-Assessment Colour Review of
Veterinary Dentistry. Manson Publishing, London & Iowa
State University Press, Ames.)
Standard Views
A complete set of intraoral radiographs can range anywhere
from 6 to 12 views, or up to 16 views if additional projections of
the canine teeth are obtained. Table 2 summarizes the recom-
mended views, positions, and techniques.
Maxillary Incisors and Canines
To radiograph the maxillary incisors and canines, the patient is
positioned in sternal recumbency. A size 2 or 4 dental film is
placed into the mouth, paralleling the hard palate, and with the
convex surface of the embossed bubble of the film facing up and
outside of the mouth. Both canine cusps should be in contact
with the film. A tongue depressor can be placed underneath the
film to prevent distortion of the film from the underlying endo-
tracheal tube. When viewed from the side, the plane of the film
should parallel the table surface. The bisecting angle technique
~
long axis
_ _ _ of tooth
mandibul
1st molar " ~
~, , , - - , ,
8y uR~~ / / .. dental x-r / /
~ , / / l ong axis
~. ~ / ~I I ~ / of root
-qik~. / X ray
/
/ / S / ~ ~ angle
maxillary ~ / ~ "
J hard palate
/.
/
Fig 1. Line drawings representing both the paralleling technique (left) and bisecting angle technique (right) for obtaining dental
radiographs. (Illustration by John Doval, University of California, Davis.)
PERIODONTAL RADIOGRAPHS IN DOGS 205
Fig 3, Obtaining a radiograph of the caudal maxilla using the
bisecting angle technique. Disposable wooden sticks are
used to facilitate determination of the bisecting angle. (Re-
printed with permission from Verstraete FJM (ed): 1999 Self-
Assessment Colour Review of Veterinary Dentistry. Manson
Publishing, London & Iowa State University Press, Ames.)
is used to obtain this view, bisecting the angle between the
plane of the film and the plane of the root of the canine tooth,
when viewed from the side. The cone of the tube head is then
positioned so that the central x-ray beam is directed perpendic-
ular to the plane of the bisecting angle.
Caudal Maxillary Premolars and Molars
The caudal maxilla view is obtained with the patient positioned
in lateral recumbency. A size 2 or 4 film is inserted into the
mouth with the convex surface of the embossed bubble facing
toward the incoming x-ray beam, and with the bubble pointing
away from the teeth being imaged. The film is inserted toward
the midline of the hard palate, and as close to parallel with the
long axis of the teeth as anatomically feasible. The coronal edge
of the film should be positioned close to the cusp tips of the
maxillary teeth without causing undue bending of the film. The
alveolar jugum of the mesiobuccal root of the maxillary fourth
premolar is palpated, and is used as an anatomic landmark to
approximate the long axis of the fourth premolar. The angle to
be bisected is located between the long axis of mesiobuccal root
of the fourth premolar and the plane of the film. The cone head
of the tube is then positioned to direct the primary beam per-
pendicu]ar to the bisecting plane. The edge of the cone should
also line up with the edge of the film.
RostraI Maxillary Premolars
The rostral maxilla view is also obtained with the patient posi-
tioned in lateral recumbency. A size 0 or 2 film is inserted
toward midline, and the bisecting angle is determined using the
TABLE 2. Standard Radiographic Views Used in Dogs
Vi ew Position Techni que
Maxi l l ary I and C Intraoral (occlusal) Bisecting angl e
Caudal maxilla: P4 - M2 Intraoral Bi secti ng angl e
Rostral maxilla: P1 - P3 Intraoral Bi secti ng angl e
Mandi bul ar I and C Intraoral (occlusal) Bi secti ng angl e
Caudal mandi bl e: P4 - M3 Intraoral Parallel
Rostral mandi bl e: P1 - P4 Intraoral Parallel
same anatomic landmarks as described for the caudal maxilla.
Often, by maintaining the same tube angle from the caudal
maxillary view, the tube head can be shifted mesially and posi-
tioned for the rostral maxilla view with minimal adjustment.
Mandibular Incisors and Canines
The bisecting angle technique is used to radiograph the man-
dibular incisors and canines, and the patient is positioned in
dorsal recumbency. A size 2 or 4 dental film is inserted dorsal to
the tongue by applying gentle pressure against the lingual
frenulum. The embossed bubble of the film should be directed
up and outside of the mouth. The placement of gauze squares
underneath the film is helpful in retaining the film in the de-
sired position and to overcome the tendency of the lingual
frenulum to expel the film. The patient's head should be ad-
justed so that the plane of the film rests parallel to the surface of
the table. The angle to be bisected is that between the plane of
the film and the plane of the canine tooth root.
Caudal Mandibular Premolars and Molars
The patient is positioned into either side lateral recumbency,
and depending on the size of the dog, either a size 0, 2, or 4 film
is used. Using the principle of the paralleling technique, the
film is inserted lingual and parallel to the long axis of the caudal
mandibular teeth, and with the embossed bubble directed up
and caudal. The cone of the tube is then positioned so that the
central x-ray beam is directed perpendicular to the film.
Rostral Mandibular Premolars
The rostral mandible is also obtained using a paralleling tech-
nique and a size 0 or 2 film. The caudal border of the mandib-
ular symphysis often prevents the mesial edge of the film from
being positioned to include the apices of the first premolar. The
film must therefore be positioned into a near-parallel position,
with the mesial edge of the film angled slightly lingually and
abutting against the rostral aspect of the lingual frenulum. The
rim of the cone is positioned parallel to plane of the film, with
the central x-ray beam directed perpendicular to the film.
Special Views
The lateral projections of the mandibular and maxillary canines
are helpful in assessing the periapical region, the mesial and
distal aspects of the alveolar crest, and overcomes the overlap of
the canine tooth and the third incisor on the occlusal view.
Using a bisecting angle technique, and with the patient posi-
tioned in either dorsal or sternal recumbency, the angle be-
tween the long axis of the canine and the plane of the film, as
viewed from the front of the patient, is bisected (Fig 4). These
views can be collected with little additional effort while obtain-
ing the mandibular and maxillary occlusal views.
Film Orientation
Films should be arranged on the view box identical to their
orientation on the dental chart, and placed with the convex side
of their embossed bubble facing up (Fig 5). The right side of the
patient should be represented on the left side of the view box,
and vice versa. The films including the maxillary teeth should
be arranged with their crowns pointing down, and those in-
206 TSUGAWA AND VERSTFIAETE
Fig 4. The use of the bisecting angle radiographic technique
to obtain the lateral view of the left mandibular canine (A).
The lateral view of the left mandibular canine (B).
Radiographic Anatomy
A keen understanding of the supporting structures of a tooth is
essential to the radiographic interpretation of periodontal dis-
ease. The support structure of a tooth includes the lamina dura,
alveolar crest, periodontal ligament (PDL) and cancellous bone
(Fig 6). The lamina dura (hard layer) is the radiographically
visible thin layer of compact bone that lines the alveolus seen as
a thin, solid white line, which may vary significantly in its
appearance. 8 Its varied appearance is both an artifact of the
angulation/attenuation of the incoming x-ray beam and sec-
ondary to the age of the patient. 9 The lamina dura is dense and
uniform in the young dog, but less dense and ill-defined in the
aged dog. 9 Disruption of the continuity of the lamina dura may
be seen in early periodontitis, but is an inconsistent finding, and
must be interpreted in combination with other more consistent
indicators of disease. The alveolar crest is the cortical border of
the alveolar process. The level of this crest in relation to the
cementoenamel junction (CEJ) is important in the assessment
of a patient's periodontal status, and is considered normal if
within 2 to 3 mm. ~2 The PDL, which is composed primarily of
collagen, is imaged as a radiolucent space between the lamina
dura and the tooth root. Although its width may vary from
patient to patient, the PDL will also appear widened secondary
to attachment loss with periodontitis. Cancellous bone is
present between the cortical plates of both jaws, and is depicted
radiographically by an extremely variable pattern of plates and
rods (trabecula) and radiolucent pockets, s The absence of tra-
beculae may be an indicator of disease, but should be inter-
preted with respect to intrapatient and interpatient variation
and in comparison with previous radiographs where available, a
Periodontal Disease Interpretation
The radiographic signs consistent with the diagnosis of peri-
odontal disease are rounding of the alveolar crest with loss in
cluding the mandibular teeth oriented with their crowns point-
ing up. The last molar should be on the periphery of the view
box, and the first incisor should be just off the midline. Stan-
dardizing film orientation facilitates radiologic interpretation,
and allows for a seamless correlation with clinical findings on
the dental chart.
L
v
: 2
Fig 5. Standard full-mouth intraoral radiographic series with
right (R) and left (L) markers designating the patient's right
and left side, respectively.
Fig 6. Radiograph of a left mandibular first molar with la-
beled anatomic landmarks: lamina dura (A); cementoenamel
junction (B); alveolar crest (C); periodontal ligament space
(D); normal variation in the trabecular pattern of cancellous
bone (D).
PERIODONTAL RADIOGRAPHS IN DOGS 207
Fig 7. Early periodontitis: Scalloping of the alveolar crests.
continuity of the lamina dura, widening of the periodontal
ligament space, and loss of alveolar crest height. 1 Clinically,
however, periodontal disease begins with inflammation of the
gingiva: gingivitis, which progresses apically to involve the
underlying alveolar bone if left untreated, at which time the
disease becomes radiographically apparent. It is important to
remember, however, that the radiographic documentation of
bone loss is not always a direct correlate to the current state of
disease, and that periodontal disease is an episodic, cyclical
disease process.
The earliest radiographic sign that disease has spread beyond
the gingiva is rounding of the alveolar crest and loss of conti-
nuity of the lamina dura at the level of the alveolar crest. 11 This
early change may also manifest as "scalloping" of the alveolar
crest (Fig 7). As the inflammatory process proceeds apically, a
wedge-shaped widening (Fig 8) of the periodontal space at the
level of the crest is often identified, followed by loss of alveolar
crest height (ACH). Two types of bone loss describe this reduc-
tion in ACH: horizontal and vertical (or angular) bone loss.
Horizontal bone loss is defined as bone loss parallel to the
occlusal plane or perpendicular to the long axis of the tooth,
and may be localized or generalized (Figs 9 and 10). Vertical
bone loss describes the resorption that occurs at an oblique
angle to the occlusal plane, or perpendicular to the CEJ, at 1 or
between 2 teeth. The presentation of vertical bone loss is varied,
and is perhaps better described as osseous (infrabony) defects.
Infrabony defects are classified by the number of osseous walls
they contain, and may have 1, 2, or 3 walls (Fig 11). The "cup"
lesion is a combined lesion where the osseous defect surrounds
the tooth (Fig 11). Clinically demonstrable osseous defects are
often classifiable radiographically, but because the radio-
Fig 9. Mild to moderate horizontal bone loss with furcation
involvement of a premolar,
graphic image is a 2-dimensional representation of a 3-dimen-
sional defect, radiographic findings are only suggestive, and
cannot stand alone without clinical verification (Figs 12
and 13).
To quantitatively record the amount of bone loss, the level of
the alveolar crest is routinely measured in relation to a fixed,
easily identifiable position on the tooth, the CEJ; by doing so, it
allows for reproducibility in measurement and assessment of
disease progression. The authors have found the use of a
semidisposable plastic periodontal probe (PerioWise, Premier
Dental Products Co, King of Prussia, PA) useful for this pur-
pose, with the soft, flexible tip preventing marring of the sur-
face of the film. In health, the level of the alveolar crest should
measure approximately 2 to 3 mm apical to the level of the
CEJ. j2 Unfortunately, because of the large variation in size of
our canine patients, this quantitative measurement of bone loss
is of little value unless it is qualified by the breed or size of the
patient. Furthermore, the true bone level of the alveolar crest at
the mandibular incisors is also extremely variable, and it is
common to identify alveolar crest levels of greater than 2 to 3
mm apical to the CEJ in patients with a healthy periodontium.
Therefore, it is indicated to measure the alveolar crest at the
mandibular incisors, but to interpret the measurement in com-
bination with clinical findings. The measurement of crown-
root ratio and percentage of root length may overcome some of
Fig 8. Early periodontitis: Wedge-shaped widening of the
proximal periodontal ligament space, Fig 10. Severe horizontal bone loss with furcation exposure.
208 TSUGAWA AND VERSTRAETE
A B C D
0 (3
(3 0
Fig 11. Classification of osseous defects: 1-walled (A);
2-walled (B); 3-walled (C); cup lesion (D). (Illustration by John
Doval, University of California, Davis.)
these shortcomings, and may be more applicable to veterinary
dentistry, but are not of value as a direct correlate to probing
depths. The crown-root ratio of a particular tooth is obtained by
dividing the measured distance between the tip of the crown
and the alveolar crest by the distance between the alveolar crest
and the root apex. ~ Percentage of root length is derived by
dividing the measured distance between the CEJ and the alve-
olar crest by the distance between the CEJ and the root apex. ~
A larger ratio and larger percentage is consistent with periodon-
tal attachment loss of increasing severity.
When the loss of ACH proceeds apical to the furcation, the
defect may be described as either a furcation exposure, absence
of both cortical plates within the furcation; or furcation in-
volvement, when at least 1 or a portion of a cortical plate
remains (Figs 9, 10, and 12). If the loss of ACH is severe enough
to reach either a lateral/accessory canal or the apical delta, a
retrograde infection of the pulp and pulpitis may occur, and
this type of combined periodontal and endodontic lesion is
identified as a class II perio-endo lesion (Fig 14). 16-18 Radio-
graphically, a vertical osseous defect is seen contiguous with a
periapical radiolucency. Although less common in our com-
panion animals, primary endodontic disease, for example in the
case of a fractured tooth, may progress beyond the confines of
the endodontic system, through the delta or a lateral/accessory
4;' ~
Fig 13. Severe supragingival calculus on the crown of the
right maxillary first molar (A). Note the vertical osseous
defects at the mesial aspect of the right first molar (B) and
right maxillary fourth premolar (C). The former is particularly
noteworthy because bone loss in this area is often obscured
by the close proximity of the adjacent teeth.
canal, and result in secondary periodontal disease, which is
known as a class I perio-endo lesion? 6,a8 These lesions have a
typical J-shaped appearance on radiographs. ~BWhen the incit-
ing source of inflammation in a combined lesion cannot be
discerned, for example in a tooth with both severe periodontal
disease and a complicated crown fracture, the lesion is labeled a
class III perio-endo or true combined periodontal-endodontic
lesion. 16,18
Incidental Findings
An important finding with respect to the etiology of periodon-
titis, but an incidental radiographic finding is supragingival
and subgingival calculus, identified at the coronal and root
surfaces of affected teeth, respectively (Fig 13). Hypercemen-
. . . . . ,&:(5 <
Fig 12. Radiograph of the caudal left mandibular premolars
and molars depicting combined horizontal and vertical bone
loss with furcation exposure at interradicular left mandibular
first molar.
Fig 14. Radiograph of the caudal right mandible with com-
bined horizontal and vertical bone loss and class II perio-
endo lesions at the right mandibular first and second molars.
The well-defined periapical lucency at the mesial root of the
first molar suggests extension of the inflammatory process
from the distal root through the endodontic system.
PERIODONTAL RADIOGRAPHS IN DOGS 209
B
',', ,,,,i , ~. ~.i ,,,
Fig 15. Progression of bone loss apical to the furcation:
Involvement (A) and exposure (B). The typical club-shaped
appearance of a root with hypercementosis (C).
tosis is the excessive deposition of cementum (Fig 15). z3 The
additional cementum often accumulates at the apical third of
the root, but may involve the entire root surface. 13 The etiology
of hypercementosis is considered to be a response to chronic
inflammation and abnormal occlusal forces. 14 Radiographi-
cally, hypercementosis is identified as a bulbous or club-shaped
thickening localized at the apical third of a root. The periodon-
tal ligament space is preserved with hypercementosis. Another
incidental finding is root ankylosis, which is the obliteration of
the periodontal ligament by fusion of root cementum with
bone. t4 Eventually, root resorption occurs as root cementum
and dentin are replaced by bone. TM The etiology of ankylosis is
similar to that of hypercementosis. The clinical implications of
a tooth affected with hypercementosis or ankylosis are most
relevant when considering extraction because it often enhances
the difficulty of the procedure. Replacement root resorption is
another common incidental periodontal radiographic finding,
and is a form of external root resorption in which the periodon-
tal ligament is preserved. Radiographically, the periodontal lig-
ament space is observed to follow the resorbing root, and the
affected root adopts a characteristic apple-core appearance. Re-
placement root resorption is an idiopathic process of unknown
significance.
Sui nl na r y
The routine use of dental radiography to evaluate the periodon-
tium is the standard of practice in human dentistry and is
rapidly becoming a standard in veterinary medicine. Dental
radiographs obtained on a dental x-ray unit produce images of
great detail and are a valuable addition to the clinical examina-
tion. In this article we have described a technique for obtaining
intraoral dental radiographs in the dog, and summarized the
important radiographic findings essential to the diagnosis of
periodontitis. Compared with many of the atlases devoted to
veterinary dental radiography, this article will serve only as an
introduction to the topic~ but hopefully will stimulate the in-
terest of the reader. As with any technique, practice will enable
increased efficiency in obtaining diagnostic quality radiographs
and proficiency in interpretation.
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