10/23/2014. features to image interpretation what to look for and what it means. interpretation vs. diagnosis. science or art? image investigation

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1 features to image interpretation what to look for and what it means interpretation vs. diagnosis ERNEST LAM, DMD, MSc, PhD, FRCD(C) PROFESSOR AND THE DR. LLOYD & MRS. KAY CHAPMAN CHAIR IN CLINICAL SCIENCES GRADUATE PROGRAM DIRECTOR AND HEAD, DISCIPLINE OF ORAL & MAXILLOFACIAL RADIOLOGY science or art? vision cognition radiologic interpretation vision image investigation radiologic interpretation 1

2 a systematic approach is it normal or is it abnormal? this is the most elementary step in radiographic interpretation; identifying what is normal, a normal variant or within the range of normal. systematic approach turgeon, 2014 DDS IV student another DDS IV student turgeon, 2014 turgeon,

3 cervical spine DDS IV students turgeon, 2014 turgeon, 2014? normal developmental abnormal acquired oral and maxillofacial radiologists inflammation cyst benign neoplasia malignant neoplasia metabolic disease vascular anomaly trauma turgeon, 2014 feature identification the osseous dysplasias are a group of non-neoplastic processes usually confined to the tooth-bearing areas of the jaws or edentulous alveolar processes. 3

4 the osseous dysplasias have been known in the past as the cemental dysplasias (e.g. periapical cemental dysplasia) and the cemento-osseous dysplasias (e.g. periapical cementoosseous dysplasia). three stages have been described in the life of an osseous dysplasia: an early stage, in which the lesions are primarily radiolucent, mimicking lesions of rarefying osteitis. a mixed stage where a radiopaque focus may be seen at or near the centre of a larger radiolucent area. a mature stage, where the lesion is primarily radiopaque, although with a thin peripheral radiolucent rim. 4

5 over the years, a large number of published case reports or small case series suggests that this is not well-understood by clinicians, and as a result, there can be mismanagement. what radiologic features support a correct interpretation of osseous dysplasia? reviewer groups 3 general dentists 3 oral radiologists alsufyani & lam, dmfr

6 37 osseous dysplasia cases and 13 additional image sets consisting of other similarly-appearing entities: cementoblastoma ossifying fibroma complex odontoma dense bone island fibrous dysplasia interpretation general dentists oral radiologists correct 38.7% 79.3% incorrect 61.3% 20.7% P a <0.001 a chi-square value = df = 1 alsufyani & lam, dmfr 2011 alsufyani & lam, dmfr 2011 logistic regression model for oral and maxillofacial radiologists radiographic feature logistic regression model for general dentists adjusted OR 95.0% CI for exp (β) p lower upper no root resorption ant. & post. teeth constant radiographic feature adjusted OR 95.0% CI for exp (β ) p lower upper well-defined periphery bilateral mixed radiolucent/radiopaque no cortical expansion anterior & posterior teeth internal radiolucent periphery <0.001 constant alsufyani & lam, dmfr 2011 alsufyani & lam, dmfr 2011 while the identification of key radiologic features may be important in image interpretation, is there anything else that may be important? cognition radiologic interpretation 6

7 bone resorption inflammatory response (lymphocytes, PMNs, interleukins, TNF, prostaglandins). inflammatory response (lymphocytes, PMNs, interleukins, TNF, prostaglandins). 7

8 it s an osteoclast. inflammatory mediators percolate throughout the haversian system and volkmann canals to reach the bone surface and periosteum. the periosteum is lifted by the pressure, off the surface of the bone. pluripotential stem cells adjacent to the periosteum are stimulated and differentiate into osteoblasts, which lay down new reactive bone. 8

9 sinus mucosa 96 undergraduate dentistry and dental hygiene students, randomly divided into 3 learning conditions. feature list (unstructured algorithm) structured algorithm basic science periosteum bone baghdady et al, j dent ed 2009 feature list a a: periapical osseous dysplasia b: complex odontome c: dense bone island d: sclerosing osteitis b c d Odontomas are the most common odontogenic tumors in the jaws. They often interfere with the eruption of permanent teeth. The lesion has no gender predilection, and most begin forming while the normal dentition is developing. Most odontomas occur in the second decade of life and are found during investigation of delayed eruption of adjacent teeth. 70% of complex odontomas occur in the first and second mandibular molar area. Radiographically, they appear as well-defined corticated lesions with a fibrous capsule internally. The content of these lesions are mixed radiolucent and radiopaque but are largely radiopaque. Complex odontomas contain an irregular mass of calcified tissue. The degree of radiopacity is equivalent to adjacent tooth structure. Odontomas interfere with normal eruption of teeth. 70% of odontomas are associated with abnormalities such as impaction, malpositioning of adjacent teeth, diastema, and devitalization of adjacent teeth. baghdady et al, j dent ed 2009 baghdady et al, j dent ed 2009 structured algorithm basic science Complex Odontomas are the most common odontogenic tumours in the jaws. Location: 70% of complex odontomas occur in the mandibular first and second molar region. Periphery: Odontomas are well defined and have a corticated boarder. Immediately inside and adjacent to the cortical border is a soft tissue capsule appearing as a smooth radiolucent space. Internal Structure: Complex odontomas contain an irregular mass of calcified tissue. The degree of radiopacity is equivalent to adjacent tooth structure. Effect on surrounding structures: Odontomas interfere with normal eruption of teeth. 70% of odontomas are associated with abnormalities such as impaction, malpositioning of adjacent teeth, diastema, and devitalization of adjacent teeth. Odontomas are benign tumours that originate from remnants of the dental lamina in the jaws. The histological appearance is characterized by the production of mature enamel, dentin, cementum, and pulp tissue. In complex odontomas the tumor forms nondescript masses of dental tissue. This is manifested radiographically as an irregular radiopaque mass. The degree of radiopacity is equivalent to adjacent tooth structure. Radiographically, odontomas are well defined with a corticated border, which represents reactive bone. Corticated borders are typically seen in slow growing lesions (i.e. cysts and benign slow growing tumours). Immediately inside and adjacent to the cortical border there is a smooth uniform radiolucent space, which represents the soft tissue fibrous capsule, surrounding the tumor. Odontomas develop and mature while the related teeth are forming and cease development when the associated teeth complete development. Because of the slow and space-occupying nature of the growth of this tumour, frequently it displaces nearby teeth and obstructs the normal eruption of adjacent teeth. baghdady et al, j dent ed 2009 baghdady et al, j dent ed

10 51undergraduate dentistry students, randomly divided into 2 learning conditions. baghdady et al, j dent ed 2009 baghdady et al, j dent ed 2013 Score percentage baghdady et al, j dent ed 2013 baghdady et al, j dent ed 2013 acquired number location borders density a systematic approach associations with teeth internal structure effects on adjacent structures 10

11 acquired i number i location i borders i density does the interpretation make sense in light of the other information I may have? i associations with teeth i internal structure effects on adjacent structures i acquired number location how many abnormalities do you see? the presence of multiple abnormalities may suggest borders density underlying systemic involvement. associations with teeth internal structure effects on adjacent structures cleidocranial dysplasia this is an autosomal-dominantly acquired disorder characterized by a mutation in the CBFA1/RUNX2 family of transcription factors. this gene that is essential for osteoblast differentiation and bone development. multiple supernumerary teeth in cleidocranial dysplasia. 11

12 multiple cyst-like lesions in nevoid basal cell carcinoma syndrome (2002). keratocystic odontogenic tumour/odontogenic keratocyst recently, the odontogenic keratocyst was reclassified by the WHO as an odontogenic tumour because of its aggressive nature, its propensity to undergo budding of the basal epithelial cell layer and the identification of the putative tumour suppressor gene, PTCH * * * the more obvious ones the less obvious one. 12

13 total number r = 0.78 p< age at first occurence lam et al, dmfr 2009 lam et al, dmfr 2009 multiple well-defined, punched out radiolucent areas in multiple myeloma (subtle). multiple well-defined, punched out radiolucent areas in multiple myeloma (not so much). a relatively new complication associated with the treatment of multiple myeloma (and other osteolytic malignancies) is bisphosphonaterelated osteonecrosis. 13

14 acquired number location where do you see it (or them)? associations with teeth borders density internal structure in some instances, pin-pointing a lesion s growth centre may enable you to determine its biological origin; whether it is odontogenic or non-odontogenic. effects on adjacent structures this ameloblastic fibro-odontome arising coronal to the teeth is of odontogenic origin. ameloblastic fibroma/fibro-odontome it remains controversial whether the ameloblastic fibroma and fibro-odontome are true tumours or hamartomas. some authors hypothesize that they represent immature odontomes. the area of rarefying osteitis located at the apex of 1.2 is also of odontogenic origin. 14

15 in the context of pulpal necrosis, rarefying osteitis is an umbrella term for the following 3 histopathologic entities: (peri) radicular abscess, (peri) radicular granuloma and radicular cyst. radiographically, it is not possible to distinguish between the three. 57 year old female with a persistent radiolucency, following endodontic treatment. this STAFNE defect is also not odontogenic in origin. the STAFNE defect, or latent bone cavity, is an invagination of the lingual cortex of bone in the posterior mandible inferior to the mandibular canal. the defect is developmental (NOT congenital) in origin, arising in adulthood, although enlargement is finite. 15

16 acquired number location how does the border what is normal? borders density associations with teeth internal structure effects on adjacent structures 16

17 border definition well-defined moderately well-defined punched-out poorly-defined how easily can I draw a line around the periphery of the? incisive canal cyst clinically, a midline enlargement in the hard palate that arises from proliferation of the lining of the incisive canal. radiographically, an incisive foramen with a horizontal diameter >10 mm. there have been reports of cyst wall calcifications, and these may sometimes be appreciated radiographically. benign, slow-growing lesions, such as this incisive canal cyst typically display a well-defined border. dentigerous cyst. dentigerous cysts arise from the proliferation of the reduced enamel epithelium lining the tooth follicle, and by definition, they must be associated with the crown of an unerupted tooth. the same may be said of this dentigerous cyst border. 17

18 dentigerous cysts are well-defined, variablycorticated, hydraulic, radiopaque entities when they occur in the maxilla against the background of an air-filled maxillary sinus. it is important to be able to assess the association between the crown of the tooth and the cystic area as the cyst should arise from the CEJ area. if this association cannot be determined, the possibility of other types of cysts must be considered. some malignant lesions such as multiple myeloma may display moderately well-defined, or punched-out borders. 18

19 in general, malignant lesions have very poorly-defined borders. the poor definition of the border reflects the almost cell-by-cell, piece-meal infiltration of tumour cells into the bone, and consequent destruction of the bone by the advancing front of tumour cells. lesions that have become secondarily-infected may also have poorly-defined borders. border cortication corticated partially-corticated non-corticated 19

20 the presence or absence of a cortex may signal more indolent or more aggressive behaviour. the simple bone cyst has one of the finest, and most delicate cortices. the simple bone cyst has one of the finest, and most delicate cortices. simple (hemorrhagic/idiopathic/traumatic) bone cyst (cavity) radiographically, the cortex of the simple bone cyst is one of the most delicate. classically, it shows a scalloping border around the roots of the teeth, but this is not the case should the cavity develop away from the roots of teeth. lamina dura and tooth follicles are undisturbed. 20

21 note the inclination most benign odontogenic lesions like this buccal bifurcation cyst, display a thin, or etched cortex. abnormalities with thick cortices involve an external cortex of bone like this STAFNE defect. new bone formation at the bone border periosteal new bone formation the lamellar or onion skin effect may arise in response to inflammation. 21

22 and osteosarcoma. metastatic lesions from prostate or breast cancer. acquired number location borders density associations with teeth internal structure a more tightly-packed, hair-on-end appearance to be seen with blood dyscrasias. effects on adjacent structures 22

23 how light or dark is it inside? radiolucent radiopaque mixed radiolucent/radiopaque radiolucency and radiopacity are relative terms that describe the attenuation or absorption characteristics of tissues to radiation. radiolucent entities have not attenuated radiation to any significant degree, whereas radiopaque entities have. RADIOPAQUE metal (restorations, sutures, bullet fragments) radiopaque white restorations and cements enamel dentin cementum cortical bone trabecular bone calculus soft tissues (including normal cartilage) body fluids radiolucent white restorations and cements fat RADIOLUCENT air on the background of bone, this recurrent keratocystic odontogenic tumour appears radiolucent. but on a background of air, this maxillary sinus retention pseudocyst appears radiopaque. 23

24 retention pseudocyst although the etiology is still somewhat unclear, retention pseudocysts are believed to arise from either a blockage of seromucous secretory glands in the sinus mucosa resulting in submucosal serous accumulations, or cystic degeneration within an inflamed sinus lining. this dense bone island is also radiopaque. dense bone island an asymptomatic, non-inflammatory hamartoma that may or may not have an apparent association with teeth. if there is an association, the tooth pulp is vital. mixed radiolucent/radiopaque lesions are those that show multiple intra-lesional attenuation characteristics. cells within these lesions have the capacity to produce a mineralized matrix of immature bone, either peripherally or centrally. even after the lesions have matured, their appearances can still change over time. the radiopaque areas in florid osseous dysplasia have a globular appearance. 24

25 courtesy DR. C. POON-WOO courtesy DR. C. POON-WOO as the lesions mature, the amount of immature bone increases while the local blood supply decreases. as such, mature lesions may be susceptible to infection if exposed to oral pathogens as a result of pulpal necrosis, periodontal disease, or surgical manipulation. this is a bigger problem with larger lesions, as the dysplastic bone may act as sequestrae, and an osteomyelitis may ensue courtesy DR. C. POON-WOO mineralized osteoid matrix deposition in osteosarcoma. courtesy, DR. M. DAGENAIS courtesy, DR. M. DAGENAIS 25

26 hard tissue sarcomas such as osteosarcoma and chondrosarcoma are exceptionally rare in the jaws. both these malignant tumours may undergo varying degrees of mineralization of their soft tissue components tumour. 26

27 small tooth-like masses may be seen in compound odontomes. acquired number location is there anything inside? borders density associations with teeth internal structure effects on adjacent structures septation cotton wool ground glass fallen snow these are radiopaque structures within radiolucent lesions that represent remnants of normal bone (septation), or mineralized tissue derived from the lesion itself (dystrophic mineralization). 27

28 septations represent displaced bone, the result of heterogeneous tumour growth, and some of these can be linear. central giant cell lesions these lesions have been thought to be reactive, yet their stimulus is unknown. radiographically, the lesions are radiolucent with a delicate network of straight septae that course through the radiolucency, but unlike myxomas, these lesions do produce considerable expansion of the bone. external resorption of teeth is a common feature with the larger lesions. and some can be curvilinear as in this ameloblastoma. 28

29 the prototypical odontogenic tumour, ameloblastoma is characterized by 3 important radiologic features as identified by WORTH (1963): the presence of septation within a larger cavity. when a septum produces partial loculation within a cavity. where there is loss of a bony margin, particularly the retromolar alveolar crest or anterior border of the ramus. PAGET s disease of bone a non-neoplastic process of bone that has recently been linked to mutations or gene polymorphisms of TNFRSF11A (RANK), TNFRSF11B (osteoprogerin), VCP (p97) and SQSTM1 (p62). these genes affect the RANK-NF B signaling pathway, and lead to abnormal osteoclast activation. three stages have been identified: increased osteoclastic resorption of bone. increased osteoblastic deposition of bone, and increased bone vascularity. continued bone deposition, and reduced cellularity and vascularity. the so-called cloud, or cotton wool appearance is a feature of PAGET s disease of bone. 29

30 the ground glass, or orange peel pattern may be seen in hyperparathyroidism (bilaterally), and here, in fibrous dysplasia, unilaterally. fibrous dysplasia a process of bone that can affect one or more bones, and is typically unilateral. monostotic, affecting a single bone. polyostotic, affecting multiple bones, and can be accompanied by: melanin pigmentation (JAFFE type). pigmentation and endocrine disturbances (McCUNE/ALBRIGHT type/syndrome). craniofacial. the etiology of fibrous dysplasia is controversial. there is recent evidence that at least the McCUNE/ALBRIGHT type may develop as a result of a mutation of the GNAS1 gene (20q13.3). the GNAS1 gene encodes a subunit of the G protein, a key factor in signal transduction. 30

31 acquired number location borders density associations with teeth internal structure dystrophic tumour calcifications that have the appearance of fallen snow may be associated with the adenomatoid odontogenic tumour. effects on adjacent structures is anything being pushed around? other effects of benign lesions when they arise in the maxillae, may include the displacement of adjacent normal anatomical structures, such as the maxillary sinus floor. tooth displacement by a keratocystic odontogenic tumour. extreme tooth displacement in cherubism. 31

32 acquired number location what s it doing to the teeth? borders density the association may indicate that the is of odontogenic origin or not. associations with teeth internal structure effects on adjacent structures the absence of a visible lamina dura at the root apices suggests that this lesion may be attached (and thus may be odontogenic). the presence of a visible lamina dura may suggest that this entity is not odontogenic in origin. asymmetric, focal periodontal ligament space widening in sarcomas (osteosarcoma). courtesy, DR. K.C. CHAN 32

33 p * t b g * courtesy, DR. K.C. CHAN courtesy, DR. K.C. CHAN acquired number location borders density disease interpretation associations with teeth internal structure effects on adjacent structures?? normal abnormal normal abnormal developmental acquired developmental acquired inflammation cyst benign neoplasia malignant neoplasia metabolic disease vascular anomaly trauma inflammation cyst benign neoplasia malignant neoplasia metabolic disease vascular anomaly trauma 33

34 ? normal developmental abnormal acquired inflammation cyst benign neoplasia malignant neoplasia metabolic disease vascular anomaly trauma one last word on the art acknowledgements NOURA ALSUFYANI, BDS, MSc, FRCD(C) MARIAM BAGHDADY, BDS, MSc, PhD, FRCD(C) NICOLE WOODS, PhD WILSON CENTRE FOR RESEARCH IN EDUCATION DANIEL TURGEON, DMD, MSc, FRCD(C) MEDICAL COUNCIL OF CANADA BERTHA ROSENSTADT FUND, FACULTY OF DENTISTRY 34

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