advances in radiodiagnosis for periodontics.the latest advances

1. Advanced diagnostic aids
in
periodontology
Radiographs & imaging

3. Introduction
A better understanding of the
periodontal disease process
challenged usefulness of traditional
clinical and radiographic methods for
diagnosis and prompted revision of
outdated diagnostic aids.

4. DIAGNOSIS
The act or process of identifying or determining
the nature and cause of a disease or an injury
Evaluation of
patient history
Physical
examination
Laboratory
investigations

5. PRINCIPLES OF DIAGNOSIS
Diagnostic test are assessed in terms of their
sensitivity and specificity
Specificity – is the ability of test to clearly
differentiate one disease from other
True negative
Percentage of subjects with truly absent
disease who have a negative test

6. SENSITIVITY - the ability of a test to detect the disease
whenever it is present
Percentage of subjects with truly present disease who have
positive test
PREDICTIVE VALUE –Probablity that the test result agress
with disease status
Positive predictive
value-Probablity of
disease in a subject with
positive test results
Negative predictive
value
Probabllity of health
in presence of
negative test results

7. RADIOGRAPHS

8. It is the traditional method to asses the destruction of
alveolar bone associated with periodontitis.
CONVENTIONAL RADIOGRAPH CAN BE USED TO
EVALUATE
 Bone levels
 Bone loss – even or angular patterns
 Intra(infra) – bony defects
 Root morphologies ⁄ topographies
 Furcation radiolucencies
 Endodontic lesions
 Endodontic mishaps
 Developmental anomalies
 Root length and shape(s) remaining in bone

9. RADIOGRAPHS
INTRA ORAL
IOPA,BITEWINGS
&OCCLUSAL
EXTRA ORAL
OPGS
CONVENTIONAL
AND
DIGITAL

10. CONVENTIONAL RADIOGRAPHS
INTRA ORAL RADIOGRAPHS

11. Intra oral periapical radiographs
Paralleling technique
Also called as “right angle” or “long cone technique”.
X-ray film is placed parallel to long axis of tooth and
central ray of x-ray beam is directed at right angle to teeth
& film.
Preferable technique for periodontal use.

12. Central ray is directed at right angles to a plane
bisecting the angle between long axis of teeth &
film.
Bisecting angle technique
Projection Maxilla Mandible
Incisors +40 degrees -15 degrees
Canine +45 degrees -20 degrees
Premolar +30 degrees -10 degrees
Molar +20 degrees 2-5 degrees

13. Extraoral Periapical Radiograph
(Newman And Friedman 2003)
Limitations with intraoral periapical radiographic imaging:
Advancing age
Anatomical difficulties like large tongue, shallow palate,
restricted mouth opening,
Neurological difficulties, and size of radiographic sensor
Chen et al in 2007 developed a
sensor beam alignment aiming
device for performing
radiographs using this technique

14. aiming device with placement of the sensor

15. BITEWING RADIOGRAPHS
Records the coronal part of upper & lower dentition along
with periodontium.
USES
1)To study height & contour of interdental alveolar bone.
(2)To detect interproximal calculus.
(3)To detect periodontal changes
Horizontal bitewing radiographs
 useful for proximal caries
detection
 limited use in periodontal
treatment and treatment planning if
bone loss is advanced

16. Vertical bitewing radiographs
film is placed with its long axis at 90º to the placement
for horizontal bitewing radiography,
can be helpful in evaluating periodontium
POSITIONING DEVICES FOR BITEWING
Hawe Paro-Bite Centering Device
a positioning aid is advised to reduce the need for repeat
radiographs and hence the unnecessary x-ray exposure is
reduced

17. Occlusal Radiographs – Intraoral occlusal
radiographs enable viewing of a relatively
large segment of dental arch.
They are useful in patients who are unable to
open mouth wide enough for periapical
radiographs

18. LIMITATIONS OF RADIOGRAPHS
Conventional radiographs are specific but lack sensitivity
 More than 30% of bone mass at alveolar crest must be
lost to be recognized on radiographs
 Radiographs provide a 2-dimensional view of a 3-
dimensional situation,
 provides only information about inter proximal bone
level.
 Radiographs do not demonstrate soft tissue - to - hard
tissue relationship hence no information about depth
of soft tissue pocket

19. STANDARDIZATION OF RADIOGRAPHS
• Constant film position – film holders, stents
• Constant tube geometry - Positioning
devices , Cephalostat
• Using paralleling techniques
• Using vertical bitewings
• Using superimposed mm grid

20. Extraoral radiographs
Extraoral radiographs are taken
when large areas of the skull or jaw must be examined
or
 when patients are unable to open their mouths for film
placement.
Useful for evaluating large areas of the skull and jaws but
are not adequate for detection of subtle changes such as
the early stages of dental caries or periodontal disease.

21. Conventional panoramic
imaging/Pantamography

23. LIMITATIONS OF OPG
 Image distortion
 Lingual structures would be projected higher than buccal
surfaces
 Use of screen film combination results in less details than
intral oral images
 Production of ghost images
It can be used as a alternative for intra oral full mouth series when
combined with bite wing radiographs

24. Tugnait et al. 2000,2005
 The periodontal structures of interest noted on periapical
radiographs are also noted on panoramic radiographs.
 The radiographic features of interest on a panoramic radiograph
supplemented when necessary by a small number of intra-oral
views, is sufficient for the management of periodontal diseases.
Pepallasi EA et al 2000
Panoramic radiographs may not reveal alveolar bony defects as
accurately as periapical radiographs.
But question is whether there is any additional therapeutic yeild
from greater accuracy from IOPAs

25. Vazquez et al 2007
 Determined the efficacy of panoramic radiographs in
the preoperative planning of posterior mandibular
implants
 mental nerve parasthesia following implant
placement in 1527 patients with 2584 implants with
only OPGs as preoperative imaging technique
 No permanent sensory disturbances of the inferior
alveolar nerve
 Only 2 cases 0.08 %reported paresthesia
 Panoramic examination safe preoperative
evaluation tool

26. Digital radiography
Digital radiography is a superior alternative for film based imaging
Digital in digital radiography means numeric format of image content as
well as its discreteness
Images are numeric and discrete in two ways –
• Spatial distribution of picture elements (pixels)
and
• In terms of different shades of gray of each of pixels
•
Collections of individual pixels
organized in a matrix of rows and columns
Digital image

27. DIGITAL RADIOGRAPHY
Direct Method
 Uses a Charge Couple Device
(CCD) or CMOS sensor linked
with fiberoptic or other wires to
computer system
 CCD receptor is placed
intraorally as traditional films ,
images appear on a computer
screen which can be printed or
stored
Indirect Method
 This method uses a phosphor
luminescence plate, which is a
flexible film like sensor placed
intraorally & exposed to
conventional x-ray tube.
 A laser scanner reads the
exposed plates & reveals
digital image data.

28. Direct Digital Imaging
Components
• X-ray source
• an electronic sensor,
• A digital interface card,
• a computer with an analog to-
digital converter (ADC),
• a screen monitor, software, and a
printer.
Direct digital sensors- charge-coupled device (CCD) or complementary
metal oxide semiconductor active pixel
sensor (CMOS-APS).
array of X-ray or light sensitive pixels
on a pure silicon chip.

29. Indirect imaging
Photostimulable phosphor radiographic
systems
PSP is scanned with a helium-neon laser
beam. The emitted light is captured and intensifi ed
by a photomultiplier tube and then converted into
digital data.

30. ADVANTAGES
 image can be instantly viewed by patient & dentist.
Reduction in radiation received by patient by as much
50% to 80%
 Images can be altered to achieve task specific image
characteristics for eg. density & contrast can be lowered
for evaluation of marginal bone and increased for
evaluation of implant components.
 enables the dental team to conduct remote
consultations.
Computerized images can be stored, manipulated &
corrected for under & overexposure

31. DISADVANTAGES
 Familarity with digital nature of images and understanding of
principles of image manipulation is required
 Lack of infection control.

Patient discomfort during placement.

As image can be easily manipulated, it can be misused in legal
proceedings
 Grossly overexposed or underexposed images cannot be corrected

32. Radiovisiography (RVG)
Duret F et al (1988)
Based on use of CCD
Radio – X-ray generator connected to sensor
Visio – storage of incoming signals during exposure and
convertion to gray levels
Graphy – digital mass storage unit – connected to various
video printout devices
latest version
Trophy has released a wireless version
of their RVG intraoral sensor named
the RVG 6500.

33. Mechanism of image display
Radiographic digital
detector
Conventional radiographic
source used to expose sensor
Detector converts X-rays to
visible image
Image display on monitor

34. Mouyen F et al (1989):
The RVG system when compared with conventional
uses considerably reduced levels of radiation to
produce an image immediately after exposure..
Adosh L in 1997 in a comparative study for
marginal bone between RVG and after surgical
exploration presented that Majority showed
difference of less than 0.5 mm between two
techniques

35.  The radiographic measurements overestimated
interproximal bone loss as compared to the
intrasurgical measurements:
A.R. Talaiepour et al in 2005
 evaluated the accuracy of RadioVisioGraphy (RVG) in
the linear measurement of interproximal bone loss in
intrabony defects.
 Comparison between RVG measures and
intrasurgical estimates were performed in 56 teeth
with intrabony defects

36. Diagnostic efficacy of digital imaging
with regard to periodontal lesions
Nair et al. 2000 investigated the accuracy of alveolar crestal bone
detection utilizing Ektaspeed Plus film, Sidexis
direct digital images, and brightness-enhanced
digital images. No significant differences were found
Wallace et al 2004 Demonstrated that E film displayed the
highest sensitivity and specificity followed
by PSP and CCD images when observers
were able to adjust digital image contrast
and brightness enhancements.

37. Specialized techniques
Introduction of digital radiography applications with meaningful
in dentistry diagnostic utility
Early detection
Quantitative assessment
3 D imaging

38. Digital subtraction radiography
Zeidses des Plantes (1935) : 1st demonstrated use of
subtraction imaging
 Depends up on conversion of serial radiographs
into digital images.
 The serially obtained digital images are
superimposed & image intensities of corresponding
pixels are subtracted
If change has occurred
The brighter area represents gain
Darker area represents loss

39. This technique facilitates both qualitative &
quantitative visualization of even minor density
changes in bone by removing the unchanged anatomic
structures from image
Base line after one year bone gain

40. Ortmann (1994)- 5% of bone loss can be
detected.
Diagnostic subtraction radiography (DSR) can
be used for enhanced detection of crestal or
periapical bone density changes and to
evaluate caries progression

41. STANDARDIZATION
 Baseline projection geometry and image density
should be reproduced
 bite blocks must be made and attached to the film
holders and the film holder must be reproducibly
aligned to the x-ray beam collimating device

42. Several image processing techniques are also developed
to reduce the error in DSR
 Semiautomated registration Byrd V et al 1998
 Automated registration algoritham .Ettinger et al
samarabandhu et al 1994
 Computer corrected of distorted projections webber1984

43. Overall contrast is
improved
Trabecular marrow
spaces are visualized
Enhancement of low
and high density
images
no objective description
High standardization of x
rays
No reduction in exposure
ADVANTAGES DISADVANTAGES

44. COMPUTER ASISTED DENSITROMETRIC
IMAGE ANALYSIS SYSTEM
Introduced by Urs Brägger et al 1988
 A video camera mesaures the light transmitted through
the a radiograph
 Signal are converted to grey scale images
 Camera is interfaced with computer and image
processor for storage and mathematic manipulation of
image
 Offers an objective method for studying alveolar bone
changes quantitatively
 High degree of sensitivity ,accuracy and reproducablity

45. Urs Brägger et al in 1988
 CADIA was more sensitive than subtraction radiography
 CADIA was capable of assessing differences in
remodeling activity over 4–6 weeks after periodontal
surgery
 Objective method to quantify alveolar bone density
Deas et al 1991
on monitoring the relationship of CALs and CADIA, found
that prevelance of progressive lesions as detected by
radiograph is higher than previous accepted data
CADIA is still used in research purposes for detecting
quantitatively the alveolar bone density

46. Computer-Based Thermal Imaging
 Compare the rewarming rates of normal and
inflamed human gingiva
 gingival temperature measurement Valuable
objective method for the diagnosis of periodontal
diseases
 Infra-red thermography provides a non-invasive
method

47. Probeye Thermal Imaging Systems
The camera's lOx lens provides a
spatial resolution of 0.1 mm at a
distance of approximately 15 cm from
the gingiva.
composed of indium antimonide
which detects wave lengths from 2000
nm to 5600 nm
Technique is no more in use

48. Extra oral digital imaging

49. Conventional tomography
 Designed to image a slice or plane of tissue
 Accomplished by blurring the images lying outside
the plane of interest
 It consists of an x ray tube and radiographic film
rigidly connected which moves about a fixed axis
and fulcrum
 As exposure begins tube and film move in opposite
direction simultaneously .
 Objects located with in the fulcrum remain in fixed
positions and are viewed clearly

50. Used less frequently with the
introduction of:
MRI , CT and Cone beam imaging
OPG is a variant of conventional
Tomography

51. Computed tomography
Godfrey Hounsfield and Allan MacLeod Cormack (1979) shared Nobel
prize
 Consists of a x ray tube emitting
finely collimated x ray beam
directed through the patient to a
series of scintillating detectors or
ionizing chambers
 Detectors form a continuous ring
and x-ray tube moves in a circle
with in the ring
 Patients lie stationary and x ray
tube rotates one turn .Then the
table will move 1 to 5 mm to next
scan

52. HELICAL CT
Introduced in 1989
The gantry containing x ray tube and detectors continuously
revolve around the patient ,where as patients table advances
through the gantry.
Result is acquisition of a continuous helix of data.
DETECTORS
Gas filled ion chambers xenon
Solid state detectors cadmium tungstate

53. CT Image construction
Computer algorithms use photon counts to construct
digital CS images
Images are displayed in individual blocks -----
VOXELS
Each square of the image is matrix----PIXELS
Each pixel is assigned a CT number representing
tissue density
CT number HOUNSFIELD units
Range -1000 to 1000

54. ADVANTAGES
 Eliminates superimposition of images of
structures outside area of interest
 High contrast resolution – differences between
tissues that differ in density < 1% - can be
distinguished
 Images can be viewed in axial coronal and
sagittal planes

55. Naito T et al. 1998, Pistorius A et al. 2001.
Used Computed tomography (CT) in studies in
relation to periodontal defects.
CT does not offer any favourable cost benefit, dose
exposure or therapeutic yield advantage in periodontal
practice and is unlikely to find a routine

56. CONE BEAM COMPUTED TOMOGRPHY
 Developed in 1982 for angiography
 Utilizes cone shaped source of ionizing
radiation & 2D area detector fixed on a rotating
gantry .
 Multiple sequential images are produced in one
scan
• Rotates 360° around the head
• Scan time typically < 1 minute

57. • Image acquisition involves a Rotational
scan of a x ray source and reciprocating
area detector moving synchronously
around patients head
• Many exposures are made at fixed
intervals to form basic images.
• Software programs are used to reconstruct
3D images

58. Image reconstruction

59. INTERFACE CONE-BEAM CT MANAGEMENT SOFTWARE

60. INDICATIONS
Evaluation of the jaw bones
Implant placement and evaluation
 evaluation TMJ
 Bony & Soft tissue lesions
Periodontal assessment
Endodontic assessment
Alveolar ridge resorption
 Orthodontic evaluation
Airway assessment
Need for 3D reconstructions

61. panoramic cbct

62. CT V/S CBCT
 Conventional CT scanners
make use of a fan-beam and
Provides a set of consecutive
slices of image
 Conventional CT makes use
of a lie-down machine with a
large gantry.
 Greater contrast resolution &
More discrimination between
different tissue types (i.e. bone,
teeth, and soft tissue
 Utilize a cone beam, which radiates
from the x-ray source in a cone
shape, encompassing a large
volume with a single rotation.
 a sitting-up machine of smaller
dimensions
 Commonly used for hard tissue
 Ease of operation
 Dedicated to dental
 Both jaws can be imaged at the
same time
 Lower radiation burden

63. Artifacts arising from metal
restorations are more severe using
conventional CT.
artifacts that arise from metallic
restorations are less severe with the i-CAT

64. Kelly A. Misch et al . 2006
Compared radiographs with CBCT
Results: Three-dimensional capability of CBCT offers a significant
advantage in linear measurements for periodontal defect
All defects can be detected and quantified.
Mol A and Balasundaram 2008
Evaluated The NewTom 9000 CBCT scanner
Results: Better diagnostic and quantitative information on periodontal
bone levels in three dimensions than conventional radiography can be
obtained
B. BEZAK et al 2010
Assessed reliability and accuracy of Cone Beam Computed Tomography
(CBCT) against CAL
.
CBCT measurement protocol is reliable.
Accuracy of CBCT measurements correlates with CAL gold standard
measurements.

65. Brently A. et al 2009
 Compared the measurements from digital IR and
CBVT images to direct surgical measurements for the evaluation of
regenerative treatment outcomes.
 Compared to direct surgical measurements,
CBVT significantly more precise and accurate than IRs.
 CBVT may obviate surgical reentry as a technique
for assessing regenerative therapy outcomes
Walter C et al..2011-
Suggests that cone-beam CT may provide detailed
information about furcation involvements in
patients with chronic periodontitis and so may
influence treatment planning decisions

66. MICRO CT
The term micro the pixel sizes of the cross-sections are in the
micrometer range
.
Microtomography KNOW AS Industrial CT Scanning
uses X-rays to create cross-sections of a 3D-object
Used in animal studies
analysis of bone biopsies without destruction
of samples

67. Denta scan
DentaScan is a unique computer software program
provides computed tomographic (CT) imaging of the
mandible and maxilla in three planes of reference:
axial, panoramic, and oblique sagittal
.

68. Uses
♣ visualization of internal bone morphology in
three dimensions ; precise treatment
planning
♣ In cross sectional view, observation regarding
bone quality, density can be made
♣ pre-operative planning of endosseous
dental implants and subperiosteal implants
♣ to visualize the bony structures pre-
operatively

69.  Dentascan CT provides information of the
internal structures that cannot even be gained
by direct intra-operative visualization
 the precise location of the mandibular canal
 the location of the floor of the maxillary sinuses

70. Dr Urvashi shah, Dr Subraya bhat
Utilization of denta-scan for treatment planing in
patients with infra-bony defects
Infra-bony defects better visualized by denta-scan
compared to intra-oral radiographs

71. Computer program for assessing
oral implant site
Uses raw data from CT along with
advanced computer graphics
Advantages:
• assessment of bone volume,
bone height &quality
• proper length of implant can be
selected
• Clear visualization of inferior
alveolar canal
SIMPLANT

72. Digital tomosynthesis (DTS)
 Digital tomosynthesis (DTS) is a limited-angle tomographic
technique
 only small rotation angles (a few tens of degrees) with a small
number of discrete exposures are used.
 provides some of the tomographic benefits of computed tomography
(CT)
 at reduced dose and cost

73. K Ogawa et al 2010
Developed a new dental panoramic radiographic
system
based on a tomosynthesis method
This system allowed the extraction of an optimum-
quality panoramic image regardless of
irregularities in patient position
 the authors could freely reconstruct a fine image
of arbitrary planes

74. C Beda in 2010
proposed the Use of both DTS and CBCT
reconstruction methods as an integrated solution
for providing tomographic data in dental
application

76. OPTICAL COHERENCE TOMOGRAPHY
 Optical coherence tomography (OCT) is an
optical signal acquisition and processing method
 an interferometric technique, employing near-
infrared light.
Layperson's explanation
“a technique for obtaining
sub-surface images of
translucent or opaque
materials at a resolution
equivalent to a low-power
microscope.”

77. OCT is well-suited for periodontal diagnosis
pocket morphology, and attachment level are digitally
recorded
quantitative information of thickness and character of
the gingiva, root surface irregularities, and the
distribution of subgingival calculus
Otis L.L et. al. 2004
demonstrate the capacity of OCT to
determine gingival thickness and the shape and contour
of the alveolar crest.
Xiang et al. (2009)
OCT imaging can offer three-dimensional imaging of periodontal
soft tissues and bone at a very high resolution .
Identify active periodontitis before significant alveolar bone loss
occurs.
Reliable method for determining attachment level

78. TACT-tuned aperture CT
 Based on the principles of tomosynthesis
 Low cost,low dose ,3D Imaging stystem
 Series of radiographs taken from different
angles
 Soft ware (work bench) stacks the basic
images and reconstruct in to multi planar
images
 Caries detection
 Vertical root fracture
 Helps to detect osseous defects around implants
 Detection and localization of osseous changes in crestal
bone

79. Onanong Chai-U-Dom in 2002
 Compared the potentials of conventional and TACT DSR
detecting simulated bone-gain in periodontal defects, in
vitro
 TACT-DSR provide greater sensitivity and technique
flexibility in detecting periodontal bone-gain than standard
DSR.
Nair M K et al in 2002
 Compared the diagnostic efficacy of tuned-aperture
computed tomography (TACT) and conventional two-
dimensional direct digital radiography (DDR) in an in vitro
environment for detecting bone loss in mid-buccal and
lingual crests.
 TACT-IR performed significantly better than DDR

80. SMALL VOLUME CT
 Form of CBCT
 utilizes small field high resolution detector to
generate high resolution 3D volume
 Generally comparable to size of intraoral
radiographs
van Daatselaar 2003
based on comparison made between a full CT
geometry and a local CT geometry.
“local CT of dental structures appears to be a
promising diagnostic instrument.”

81. MRI Magnetic resonance imaging
 does not involve the use of ionizing radiation
 it involves the behaviour of protons in a
magnetic field.
 Hydrogen protons are used to create the MR
image.
 The image itself is another example of a
tomograph or
sectional image that at first glance resembles a
CT
 Used for imaging intracranial and soft tissue
lesions,

82.  The patient is placed within a very strong
magnetic field (usually between 0.5–1.5 Tesla)
 patient’s hydrogen protons, behaves like
magnets to produce the net magnetization
vector (NMV ) which aligns itself readily
with the longaxis of the magnetic field
 Radiowaves are pulsed into the patient by the
body coil transmitter at 90° to the magnetic
field
 Hydrogen atoms to resonate(store energy )
 When radio frequency is turned off ,the stored energy is released
from body and detected as a signal in a coil in scanner
 Reconstruction of image

83. USES IN HEAD AND NECK REGION
 Assessment of intracranial lesions involving particularly the posterior cranial
fossa, the pituitary and the spinal cord.
 Investigation of the salivary glands
 Tumour staging
 Investigation of the TMJ to show both the bony and soft tissue components
 Implant assessment
Schara et al 2009
In an invitro study evaluated the used the use of MRI to characterize
inflammation and healing process in periodontal tissues
It was concluded that MRI can characterize the type and healing process of
inflammation

84. BONE SCANNING or RADIONUCLIDE
IMAGING
IN contrast to X-ray, CT, MRI which require
structural or anatomic changes to be recorded,this
technique assesses biochemical alteration in body
It Is a nuclear scanning test that identifies new
areas of bone growth or breakdown.
It can be done to evaluate damage to the alveolar
bones,and monitor conditions that can affect the
periodontium (including infection and trauma)

85.  radioactive tracer eg. 99m technetium pertechnetate
substance is injected into a vein in the arm.
Areas that absorb little or no amount of tracer appear as
dark or "cold" spots, which may indicate a lack of blood
supply to the bone (bone infarction) or the presence of
certain types of cancer
Areas of rapid bone growth or repair absorb increased
amounts of the tracer and show up as bright or "hot"
spots in the pictures. Hot spots may indicate the presence
of a tumor, a fracture, or an infection.

86. Other radioactive isotopes used are – iodine(131 I), gallium(67 Ga) &
selenium(74Se)
γ scintillation camera is used to capture photons and then convereted
to light and to voltage signal
Signal is constructed to planar image that shows radionuclide in the
image

87. Advanced nuclear
imaging
• Single photon emission computed
tomography
• Positron emission tomography

88. Positive bone scans are detected in beagle
dogs with advanced experimental
periodontitis kaplan 1975 ,Jeffcoat et al
1985
Jeffcoat et al1985 –There exist a significant
association with high intake of 99mTC and
bone loss in moderate to severe periodontitis
Sensitivity of 83 % and specificty of 84 %
Reddy et al 1991 scintillation camera images
following radiopharmaceutical
administration is accurate in detecting bone
loss

89. IMPLANT IMAGING

90. In 2000, the American Academy of Oral and Maxillofacial Radiology
(AAOMR) recommended “some form of cross-sectional
imaging be used for implant cases “
conventional cross-sectional tomography be
the method
2012

91. PRINCIPLES OF IMAGING FOR
DENTAL-IMPLANT ASSESSMENT
Images should have appropriate diagnostic quality and not
contain artifacts that compromise anatomic-structure
assessments
Images should extend beyond the immediate area of interest
to include areas that could be affected by implant placements
Practitioners should have appropriate training in operating radiographic
equipment and competence in interpreting images from the modality
used

92. Initial examination
• PANORAMIC RADIOGRAPHY
SHOULD BE USED AS AN
IMAGING MODALITY
RECOMMENDATION 1
• USE IOPAs TO SUPPLEMENT
PANORAMIC RADIOGRAPHY
RECOMMENATION 2
• DO NOT USE CROSS SECTIONAL
IMAGING AS AN INITIAL
DIAGNOSTIC AID
RECOMMENDATION 3

93. Preoperative site specific imaging
•establish characteristics of residual
alveolar bone
•determining orientation of RAR
•identifying local conditions restricting
implant placement
• match imaging findings to the prosthetic
plan

94. RECOMENTATION 4
cross sectional imaging of any potential
implant site
RECOMENTATION 5
CBCT considerd as the imaging modality of
choice for imaging implant sites
RECOMMENDATION 6
CBCT should be considered if need for
augmentaion or other site development
procedure is present

95. Postoperative imaging
In the absence
of clinical signs
use IOPAS or
OPGs
Patient has
mobility or
altered
sensation use
cross sectional
imaging
/CBCT
Implant
retrieval
CBCT

96. DICOM Standard
The Digital Imaging and Communications in
Medicine
 facilitate communications between imaging
devices and systems.
By dictating specific data and interface
requirements, DICOM ensure that devices--
particularly devices made by different
suppliers--can communicate with one another.
:

97. Transmission and
persistence of
complete objects
Eg images,docs
Query and retrieval
of objects
Printing images on
film
Work flow
management
Quality and
consistency of image
apperance
DICOM address five primary areas of functionality:

99. RADIOGRAPHS IN PERIODONTAL
DISEASE DIAGNOSIS & MANAGEMENT
Features of periodontal
diagnostic interest are
apparent on radiographs
Relationship exists b/w
clinical attachment and
radiographic bone height
Radiographs can be used in
all stages of periodontal
care
Tugnait et al 2000
Considered a provoking review

101. Full-mouthsurveys of paralleling periapical radiographs have
been considered to be a ‘‘gold standard’’ for periodontal
diagnosis and treatment planning
or
a panoramic radiograph supplemented by selected intra-
oral radiographs , numbered less than four per patient
reach the ‘‘gold standard’

102. EXPOSURE FROM X RAYS

104. Radiography must not be a substitute for clinical
investigation
X-rays as a component of periodic examinations cannot be
condoned.
Radiographic examination in clinical periodontology is only
justified if changes in treatment plans from those treatment
plans developed on the basis of clinical examination
supplemented by any already available radiographs are
anticipated
TO CONCLUDE…….

105. Advanced imaging systems like CTs,CBCTs,
have enabled better visualization of periodontal structures
and pathologies in3D thus helping in better diagnosis and
treatment planning
The cost factor and other technical difficulties have limited
their cliniclal utility but their utility as a research tool is
unquestionable
FURTHER IMPROVEMENT S ARE WARRANTED IN
FIELD OF DIGITAL IMAGING
And in near future these imaging techniques will become
routine diagnostic tools