Stephens Radiology Final Review
Content
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 1 of 17
Extraoral Plain projections -Why get extraoral plain: -spatial relation for previously identified problem -at least one additional film, PERPENDICULAR to the original film 5 Extraoral Plain Projections: (all source to film dist 36”-40”, exc Lat Ceph has 60” source film dist) 1.) Water’s View 2.) Posteroanterior view 3.) Lateral projection a.) Lateral Cephalometric 4.) Submentovertex projection 5.) Reverse Towne’s projection Important reference for Extraoral plain films =Canthomeatal line – central point of ext auditory meatus to the outer canthus of the eye (The canthus is the notch at each edge of the eye, where the two eyelids meet. The inner, or medial, canthus is called the nasal canthus, because of its proximity to the nasal structures. The outer, or lateral, canthus is called the temporal canthus because of its proximity to the temporal region of the skull. The nasal canthus features the fleshy, pink lachrymal caruncle and the canaliculi which lead into the lachrymal sac. http://www.probertencyclopaedia.com/cgi-bin/res.pl?keyword=Canthus&offset=0) 1.) Water’s View -ONLY VIEW that shows ethmoid air cells separately -USE if suspect Max Sinus Lesion -good view of orbit b/c no petrous ridge superimposed over wall of the orbit -Central Ray position: Through midsagittal at level of the maxillary sinus -Canthomeatal= positioned 37 deg above horizontal
2.) Posteroanterior View -BEST demos posterior and midline facial structures -BEST FOR: a.) detecting mediolateral changes in the skull (asymmetry) b.) evaluate nasal fracture c.) visualize lamina papryacea (separate ethmoid air cells from or bits) -NOT GOOD FOR: Lower maxillary sinus b/c petrous ridge superimposed -Central Ray Position: Through Midsagittal at level bridge of nose -Canthomeatal = parallel to floor
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 2 of 17
3.)Lateral Projection -shows anterior posterior walls of max sinus, frontal sinus, sphenoid sinus, ethmoid sinus -BEST FOR: a.) evaluate fluid level of Max Sinus b.) eval trauma to or obstructive lesion of sinuses c.) show relationship b/w sphenoid to sella turcica and the nasopharyngeal soft tissue to the airway -Pt positioned: left side of face to cassette, midsagittal parallel to film -Central Ray: at ext aud meatus and perpendicular to film, perpendicular to midsagittal plain -Canthomeatal: parallel to the floor -NOTE DIFFERENCE W/ LATERAL CEPHALOMETRIC: -increased source film dist = 60” -wedge filter placed at anterior of beam to decrease the radiation (decrease the intensity) to reveal the pt’s soft tissue profile
4.) Submentovertex(SMV) -Shows: base of skull, position and orientation of condyles, curve of mandible, lateral wall maxillary sinus, pterygoid plates -BEST TO VIEW: FRACTURES OF ZYGOMATIC ARCH (jug handle/bucket handle view) -Only Projection that shows Left and Right sphenoid sinuses separately (RE: Water’s view is the only view that shows the ethmoid sinuses separately) -Pt Position: head backwards w/ vertex at center of cassette, midsagittal perpendicular to floor -Central Ray: from below mandible up toward vertex of skull to pass ~ 2 cm in front of line connecting Left and Right Condyles -Canthomeatal line: 10 deg past vertical -To visualize Zygomatic arches decrease the exposure time to 1/3 that used to visualize the entire skull
5.)Reverse Towne’s -most important film to assess SUBCONDYLAR FRACTURES -only plain film that optimally demonstrates the angulation or displacement that occurs because of fractures -also used for eval of: petrous ridge, mastoid air cells, posterolateral wall of maxillary antrum -pt pos: head front of cassette, mouth fully open to better visualize condyles -Central Ray: twd film through Occipital Bone -Canthomeatal Line= 25 deg-30deg downward -collimate beam to areas of interest to decrease pt exposure and decrease film fog
Stephens MK For Reference:
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 3 of 17
Note: Horizontal plane = Transverse plane= Axial plane (comes into play with Computed Tomography[CT])
http://www.google.com/imgres?q=anatomic+planes&hl=en&safe=strict&biw=1280&bih=507&tbm=isch&tbnid=Uv0C-jz8I75ORM:&imgrefurl=http://medicaldictionary.thefreedictionary.com/plane&docid=4w_EUEZl04yztM&imgurl=http://img.tfd.com/dorland/thumbs/plane.jpg&w=250&h=360&ei=WWfaTtr2C8Pu0gHG75GMDg&zoom=1&iact=hc&vpx=1004&vpy=116&dur=47&hovh=270&hovw=187&tx=181&ty=142&si g=116215483726398996774&page=1&tbnh=143&tbnw=97&start=0&ndsp=16&ved=1t:429,r:7,s:0
http://www.google.com/imgres?q=bones+of+the+skull&hl=en&safe=strict&biw=1280&bih=507&tbm=isch&tbnid=RPRGvFB20f-CwM:&imgrefurl=http://howtobecomeaparamedic.com/2010/11/how-to-become-a-paramedic-facialfeatures/&docid=ffJ3rcVE1tUYzM&imgurl=http://howtobecomeaparamedic.com/wp-content/uploads/2010/11/skull1.jpg&w=414&h=324&ei=iWfaTv2nLTW0QGW_9HWDQ&zoom=1&iact=hc&vpx=701&vpy=154&dur=223&hovh=199&hovw=254&tx=112&ty=112&sig=116215483726398996774&page=2&tbnh=128&tbnw=164&start=10&ndsp=12&ved=1t:429,r:9,s:10
http://www.google.com/imgres?q=sinuses&start=36&num=10&hl=en&safe=strict&biw=1280&bih=507&tbm=isch&tbnid=Ge7vwLiO217VM:&imgrefurl=http://www.billcasselman.com/unpublished_works/sinus_origin.htm&docid=WtnQIXgL3PMvAM&imgurl=http://www.billcasselman.com/paranasal_sinuses_ethmoid_eye_sockets_sphenoid_maxillary.jpg&w=468&h=242&ei=yGfaTrvZB 6Lh0QHs18zaDQ&zoom=1&iact=hc&vpx=681&vpy=201&dur=3160&hovh=161&hovw=312&tx=149&ty=112&sig=116215483726398996774&sqi=2&page=4&tbnh=86&tbnw=167&ndsp=12&ved=1t:429,r:3,s:36
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 4 of 17
Advanced Imaging I & II 2 types non-ionizing radiation = MRI and Ultrasound 6 Types Advanced Imaging 1.) Sialography 2.) Computed Tomography 3.) Magnetic Resonance Imaging (MRI) 4.) Nuclear Medicine 5.) Diagnostic Ultrasonography (Ultrasound) 6.) Cone Beam CT 1.) Sialography -def = retrograde injection of iodinated contrast media into duct system of salivary glands -2 types of contrast media : a.) Fat Soluble (Ethiodol) (+) = not diluted by saliva (+) = not absorbed across gland mucosa (-)=causes foreign body granulomata if duct rupture and extravasate the Ethiodol b.) Water Soluble (Sinografin) (-)=diluted by saliva (-)=passes rapidly across gland mucosa Therefore, poorly visualize peripheral ducts (+)=does not incite inflammatory reaction of extravasated -Sialography is best eval for obstructive inflammatory lesions of major salivary glands -Procedure=dilate and cannulate duct, inject 0.5-0.75 ml contrast until patient signals discomfort -2 phases of Sialography : a.) Ductal b.) Acinar -4 Standard Visualizations for Sialography: 1.) AP 2.) AP puffed Cheek 3.) Lateral 4.) Lateral Oblique -Sialoliths in Sialogram appearance = radiolucent filling voids -Sialodochitis = alternating areas of fusiform dilation and structuring of the primary duct (STRING OF SAUSAGES) -Swelling Common in Alcoholics = Parotid Gland -Sjogren’s Syndrome look in Sialography= Punctate and Globular FRUIT LADEN BRANCHLESS TREE 2.) Computed Tomography -axial cross-section of head using narrow collimated moving beam, remnant radiation detected in xenon filled ionizing chamberanalog signal passed to computer where analyzed and digitized by math algorithm into axial tomographic image -RE: only view CT takes is Axial=Horizontal=Transverse plane [top to bottom] -CT Accuracy vs Thickness vs Exposure: -the thinner the slice the more accurate -therefore must increase does for increase accuracy by getting thinner slice’s -CT Good for: -diagnose of lesion and staging of malignant disease [staging = document extent of] -assess lymph node metastases -eval effects of treatment with follow up CT’s -CT NOT Good for: soft tissue eval -however can be used to show extent of soft tissue lesion proliferation out of or within bone -CT Selection Criteria: -max or mand lesion, especially if sinuses involved
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 5 of 17
-suspect malignancy -soft tissue mass salivary gland (CT saliography) -osseous lesions in TMJ -developmental disorders involving max and mand -asses maxillofacial trauma 2.) Computed Tomography (cont’d) -CT image orientation = axial crossectional view as if looking at the patient from the floor pu -Neutral Density in CT = 0, based on the density of water -if tissue more dense than water it is a( + )number (e.g. muscle, skin) -if tissue is less dense than water it is a (-) number (e.g. fat) -Hounsfield Unit (H.U.) = correlates normal tissue density to the density of water and uses that to measure against HU of pathologic tissue -ex Hounsfield Unit (HU) use in tumor: -normal marrow is high in fat, so it’s normal H.U. = -20 to -40 H.U. -tumor in marrow replaces that fat marrow with other tissue (e.g. skin, muscle) and the tumor H.U. is a positive number -Cyst Hounsfield Unit = 0 -b/c cyst fluid attenuates radiation about the same amount as water -CT Terminology vs Radiographic Terminology: -Radiopaque = Hyperdense -Radiolucent = Hypodense -Scout Image in CT -Synonymn = scannogram -taken at the beginning of the study to give number and position of the slices obtained -aides in spatial orientation of individual slices 3.) Magnetic Resonance Imaging (MRI) -measures change in low freq radio signals in a magnetic field -used for soft Tissue exam -2 positives of MRI: a.) measure soft tissue better than CT b.) does not use ionizing radiation -NOT USED FOR: bony lesions (due to lack of signal generate by bone) -signal strength to be ready by MRI depends on: Hydrogen content of tissue -Fat = high Hydrogen content -Cortical bone = low Hydrogen content -2 most common MRI freqs and how they look: 1.) T1 -T1 freq Fat looks bright = hyperintense -T1 freq Cystic fluid looks dark = hypointense 2.) T2 -T2 freq Fat look dark = hypointense -T2 freq Cystic Fluid looks bright = hyperintense -MRI terms vs Radiology terms: -radiopaque = hyperintense -radiolucent = hypointense -ABSOLUTE MRI CONTRAINDICATION: implanted ferromagnetic devices (pacemaker, aneurysm clip, prosthetic joint, heart valves, hearing aids, IUD, etc) -Amalgam and titanium will not be pulled out by magnet b/c they do not contain iron -MRI Selection Criteria -eval internal derangement TMJ
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 6 of 17
-salivary gland disease -assess soft tissue invasion by malignant disease -MRI Selection Criteria (cont’d) -brain tumors -neural involve w/ HIV -MS plaque and white matter disorders -extent and mechanism of stroke 4.) Nuclear Medicine -how:inject radiopharmaceutical (Technetium), wait 2 hrs for uptake in to target tissue and start of radioactive decay, measure amount taken up by measuring amount gamma radiation given off -gamma radiation given off converted to green light in the collimater and digitized -show up as Cold Spots and Hot Spots -Cold Spot = metabolically inactive bone, decreased osteogenesis, lack of vascular activity -Hot Spot = metabolically active areas, increased osteogenesis (areas of inflammation or tumor growth) -Nuke Med Sensitivity versus Specificity = Highly Sensitive but Low Specificity -Advantage of Nuke Med = Bone changes seen early -Plain film radiography req 60% bone demin to see radiographically -Nuke Med req 5-15% bone demin to see -Nuclear Medicine Selection Criteria: -detect metastatic tumor for tumor staging -locate margin for treatment plan -salivary gland disorder, esp MASS LESION -eval bio status and extent osteomyelitis -Salivary glands and radiopharmaceuticals (Technetium): -DO NOT CONCENTRATE radiopharmaceuticals salivary glands will be cold spots -EXCEPT: WARTHIN TUMOR of Parotid will concentrate radiopharmaceuticals (will be a Hot Spot) 5.) Diagnostic Ultrasonography (Ultrasound) -how: sound waves in 7-15 MHz range to target tissue, and reflected waves transduced into an image -NO IONIZING RADIATION (other is MRI) -Best suited for: providing info on body cavities -Selection Criteria: -assess sinus disease -assess extracranial carotid vasculature -assess salivary gland and thyroid masses 6.) Cone Beam CT (CBCT) -cone of rays vs fan of rays in a MDCT -provides a DATA SET, not a single image or stack of images -Data Set size based on field of view req: S, M, L -Quick Scan~20 sec (Pan is 16 sec) -CONEBEAM CT is specified for certain body parts don’t order a CBCT, must specify H&N CBCT (+) CBCT = lighter, smaller, room does not req cooling, LOWER radiation dose (-)=less resolution that MDCT -CBCT Craniofacial Selection Criteria: -infection, trauma, developmental deformities -presurgical implant analysis -presurgical anatomic landmark assessment -TMJ eval -Sinus disease -Airway space analysis (for OSA) -Orthodontics
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 7 of 17
6.)Cone Beam CT(cont’d) -not justified for every patient -Aide in implant simulations -Height and Width, esp Width, of bone is key to implant success, this can be measured on the CBCT before moving forward with the surgery -software allows disarticulation of articulated structures -can define Area of Interest on the scan (AOI) -can superimpose soft tissue profile -BEAM HARDENING = artifact from high amnts metal restoration, looks like spoking -can still get motion artifacts if pt moves Radiographic Patterns of Disease -describe lesion on image so someone who has not seen the image could draw it -2 most critical patterns : -radiographic density -borders of the lesion -Pattern Descriptors: 1.) Size 2.)Numerical distribution 3.)Borders 4.) Geometry 5.) Location 6.)Architecture 7.)Texture 8.) Density 9.) Effect on adjacent teeth 10.) Effect on adjacent bone 1.) Size-measure 2 greatest dimension and recorded in mm in chart -guides treatment planning -helps evaluate dynamic changes over time 2.) Numerical Distribution – how many you see a.)Solitary/ Focal = only 1 lesion -solitary lesions are usually small b.)Diffuse = multiple lesions which have spread throughout a significant portion of jawbone c.)Generalized = found in at least 3 quadrants of the jaw, involve both mand and max d.) Symmetrical = lesions in same location in the right and left side of jaw -Frequently indicates a variant of normal or an inherited condition 3.) Borders = the most important pattern is the borders of the lesion -gives info about the active portion of lesion , how growing , and host reaction a.)Well defined/Distinct = if can draw a line confidently around the edges of the lesion -small portions may be ill-defined due to shape and direction of beam b.) Punched Out = very sharp boundary w/ no apparent rxn of host bone to lesion -looks like someone used a hole punch -Punched out most commonly seen in: i.) multiple myeloma ii.) Langerhan’s cell histiocytosis c.) Peripheral Radiolucent Rim Around a Radiopaque Lesion = indicates that the lesion has a soft tissue capsul and that it will likely shell out easily at surgery
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 8 of 17
3.) Borders (cont’d) d.) Ill-defined, Poorly Marginated = indistinct, could not draw a line around -due to a zone of transition from the clearly normal to the clearly abnormal bone -clinician has a general but not exact idea where the lesion starts and stops e.) Ragged, Moth-eaten= indicates the presence of severe inflammatory disease or malignant neoplasia. Indicates Aggressive disease -most aggressive, rapidly destructive pattern =cortical involvement in the setting of permative lesion 4.) Geometry a.) Round/ Ovoid = good because round is slow growing in all directions -Radiopaque Round lesion = not fluid filled -Radiolucent Round lesion = fluid filled cyst called a Hydraulic patter n b.) Scalloped = lesion undulates up and down along the roots of teeth in a series of contiguous arcs -the arcs may indicate mechanism of growth -ONLY OCCURS IN RADIOLUCENT LESIONS -Common in: simple Bone cysts and Odontogenic Keratocytes c.) Irregular = no regular geometric shape, more extensive in some areas and less extensive in others -indicates certain parts of lesion are growing faster than others -indicates a degree of aggressiveness 5.) Location -can give idea of lesion’s developmental origin or indicate what tissue it may contain -e.g. tissue if in IAN, lesion could have neural, vascular or smooth m. elements If in condyle, lesion could have cartilage a.) Epicenter = site of origin -aides in differential diagnosis -if epicenter is superior to IAN and especially if coronal to tooth = ODONTOGENIC ORIGIN -if epicenter is below IAN = NONODONTOGENIC Lesion b.)Central – arise in the cancellous bone of the jaw, have cortex on either side and alveolar bone superiorly -do not use if lesion arises at the alveolar bone or in the cortex c.) Peripheral – arise at the alveolar crest -can have saucerization w/ a wide zone of transition b/w the normal and abnormal bone -can indicate a soft tissue lesion that has subsequently invaded down into the bone (as in carcinoma) d.) Periosteal – arise in the periosteal compartment of bone -seen earliest on occlusal radiographs e.) Associated w/ teeth: Circumcoronal - around the crown of an impacted tooth -could be dentigerous cyst(from reduced enamel epithelium) or infiltration of the space by another cyst such as an Odontogenic Keratocyst f.)Associated w/ teeth: Periapical – develop around the apex of a tooth -usually rep osteolysis resulting from products of inflammation exuding from a devitalized tooth -if have lesion, then NSRCT the tooth, must follow it: if the periapical lesion does not resolve w/ root canal therapy, biopsy is req. g.) Associated w/ teeth: Interradicular – arise between tooth roots, can be the roots of the same tooth or between the roots of 2 adjacent teeth -between 2 teeth common place for: lateral radicular cysts and Lateral periodontal cysts 6.) Architecture= means how many rooms the structure has. Define the architecture of radiolucent lesions only a.) Unilocular = lesion has only one compartment = 1 locule b.)Multilocular = lesion has multiple compartments separated by bony septations -usually have a higher recurrence rate than uniloculars of the same histo type i.) Soap Bubble Multilocular = multiple overlapping compartments
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 9 of 17
6.) Architecture (cont’d) b.) Multilocular (cont’d) ii.) Honeycomb Multilocular = small, uniformly sized compartments -usually indicates presence of Ameloblastoma -may also indicate intraosseous hemangioma iii.) Spider Web Multilocular = septae radiate from a central body iv.) Tennis Racket Multilocular = septae are aligned at right angles to each other -pathoneumonic for Odontogenic Myxoma 7.) Texture – used to describe radiopacities exclusively (therefore do not talk architecture) a.) Homogenous = uniform radiopacity b.)Multilobulated = consists of conglomerations of multiple lobules that can be separate or clustered c.) Ground glass = look like frosted end of a glass microscope slide -Fibrous Dysplasia has ground glass texture d.) Orange Peel/ Peau D’Orange = trabeculations are fine but dense -Late Stage Fibrous Dysplasia has Orange Peel texture e.) Cotton Wool = dense patches of sclerotic bone forming in response to local or widespread inflammatory stimulus -e.g Local inflammatory stimulus causing cotton wool radiopacity = condensing osteitis -e.g. Widespread inflammatory stimulus causing cotton wool radiopacity = chronic diffuse sclerosing osteomyelitis -cotton wool radiopacity also occur in later stage fibro-osseous disorders: -florid cement-osseous dysplasia -Paget’s disease 8.) Density = other most critical radiographic pattern to identify besides Border a.) Radiolucent = black, due to lack of structure allowing all radiation to pass through and overexpose film in that area -lack of structure due to osteolysis -large lesion w/ cortical destruction will be completely dark -small lesion w/ no cortical destruction can have residual B/L trabeculae superimposed b.) Radiopaque = White -the larger the radiopaque lesion, the less residual trabeculation B/L superimposed c.) Radiolucent w/ Radiopaque Flecks (Foci) = a radiolucent lesion which has some radiopaque particles (less than 50% of lesion is radiopaque) d.) Mixed Radiolucent/Radiopaque = a lesion that is approx 50% radiolucent and 50% radiopaque 9.) Effect of Lesion on Adjacent Teeth a.) Root Divergence = displacement of adjacent tooth roots away from each other -generally caused by slow growing benign cyst or neoplasm -will cause contact point at crowns to be different than previous b.) Floating in Air Tooth = malignant or aggressive lesions that resorb bone so quickly that only soft tissue holds tooth in and appears to float in air on radiograph c.)Root Resorption by Blunt Pressure = sheer mechanical pressure of cysts and benign neoplasms can cause resorption of adjacent tooth rooths from the apex coronally. d.) Circumferential Root Resorption = root have very tapered or spiked appearance -caused by malignant neoplasms or very aggressive lesions surrounding tooth and causing resorption 10.) Effect of Lesion on Adjacent Bone a.) Cortical Expansion = caused by benign lesions whose slow growth allows periosteum to lay down new bone peripherally so that perforation does not occur the expansion of the lesion remains contained in bone, so the bone expands
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 10 of 17
10.) Effect of Lesion on Adjacent Bone(Cont’d) b.)Cortical Perforation = malignant neoplasm or fast growing benign neoplasm outgrows the capacity of the surrounding periosteum and perforates the bone and extends into the surrounding soft tissue c.) Periosteal Reactions: Onion Skinning = some inflammatory conditions and neoplasms so irritate the periosteum that it lays down multiple layers of new periosteal bone -appears as tree layers, or onion skinning -eg. Inflammatory conditions causing onion skinning= proliferative periostitis -eg. Neoplasm causing onion skinning=Ewing’s sarcoma d.) Periosteal Reactions: Sunburst Spiculation = malignant tumor grows so rapidly that it perforates the bone cortex and drags the striae of bone from the periosteum out with it into the adjacent tissue e.) Periosteal Reactions: Hair on End = conditions can cause fine short striae of bone to project upward perpendicular to surface of skull -2 conditions causing Hair on End Reactions: i.) Sickle Cell Anemia ii.) Thalassemia Differential Diagnosis of Soft Tissue Calcifications 2 Mechs of Calcification: 1.) Dystrophic: Pt body is Normocalcemic, but dead, dying ,diseased, damaged, degenerated tissue causes calcification causes and aread of increased local alkalinity - Increase in local alkalinity: alkalinity in area of damage will pull out minerals in the passing acidic blood to precipitate out into that tissue 3.) Metastatic: Pt entire body Hypercalcemic, so mineral can precipitate out into normal tissue -Implications of Tissue Calcification = no worry to fatal Types of Soft Tissue Calcifications: 1.) Calcified Lymph Node 2.)Sialoliths 3.)Tonsilloliths 4.)Rhinoliths 5.)Antroliths 6.)Phleboliths 7.)Arterial Calcifications 8.)Calcified Stylohyoid ligament 9.) Laryngeal Cartilage Calcifications 10.)Intraoral Osseous Choristoma 11.)Miliary Osteomas 12.)Myositis Ossifcans 13.)Cysticercosis Cellulosae 14.) Calcifications in Autoimmune Disorders 15.) Calcifications in Metastases 16.) Meniscal Replacements 1.) Calcified Lymph Node -result of prior infection or inflammation can be from granulomatous disorder, deep fungal infection, lymphoma -IRREGULAR, CAULIFLOWER SHAPED (Multilobulated radiopacity) -solitary or chains -from dystrophic mechanism (local alkalinity) -eg of granulomatous disorder – Tb or CAT SCRATCH FEVER -fungal normally due to agriculture work
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 11 of 17
1.) Calcified Lymph Node (Cont’d) -lymphoma pt: node in area of radiation calcified -chaining calcified lymph node most likely seen in person w/ Tb -must treat underlying cause 2.) Sialoliths -Etiology = sluggish mucous cells or epithelial cells causing mineralize precip -grow by ACCRETION = organic nidus causes minerals to precip out -Loc = majority in submand, due to tortuous route and more mucous secretion, some in parotid -Wharton’s duct is longer than Stenson’s duct, parotid has more serous (watery) secretion -Submand most likely one sialolith, parotid could have multiple -Presentation = no probs, but when duct obstructed can get: -Obstructive Sialodenitis = anytime salivate, they have pain -ones in the duct normally cause pain -Re: SMOOTH, SOLITARY, SUBMANDIBULAR -Note: long genial tubercles if seen on radiograph may indicate tongue thrusting -Treatment: milk it out, send it for review, only remove gland if sialolith is in gland 3.) Tonsilloliths- hard yellow/white objects sticking out of tonsillar crypts -in Tonsilar Crypts after swelling from infection traps junk, then when infection resolves, swelling disappears and crypt opening closes trapping junk inside -Dietrich’s Plug = only organic Crude in Tonsilar Crypt -if other stuff précis out so as to be radiographically evident = Tonsillolith -symptoms, pain, no pain, feeling of something stuck in throat, bad breath even with good oral hygiene -Treatment = if pt can’t flick out = Tonsillectomy -Note: pt w/ swallowing problem (Parkinson’s or Post-Stroke) = the tonsillolith could be nidus for aspiration pneumonia -radiographically found inferior to Submandibular canal (inferior toIAN) & in oropharyngeal airspace below ramus of mandible 4.) Rhinoliths – nose 2 sources: 1.) Endogenous = retained root tip = most common cause in adults 2.) Exogenous = foreign object causing mineralization = most common in kids -either origin, the mineralization will cause necrosis 5.) Antroliths = Rhinoliths in Maxillary Antrum (go through the hole that goes from nose to Max Antrum) -have a long asymptomatic period, but will require eventual removal 6.) Phleboliths = calcified thrombi in veins -could be fatal -Phleboliths in head and neck are associated w/ HEMANGIOMAS (not that way in other parts of body) -DO NOT PROCEED WITH FURTHER TREATMENT UNTIL FIND OUT WHAT’s GOING ON W/ HEMANGIOMA -Cavernous Hemangioma = common in High to low shunt (large artery to large vein) -These have a BRUIT (whoosh) when auscultated, but if don’t hear bruit, doesn’t mean it’s not there -Capillary Hemangioma = won’t be able to hear -Have BULLSEYE/TARGETOID APPEARANCE -round b/c they are veins in cross section
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 12 of 17
7.) Arterial Calcification -2 types: a.) Monckeberg’s Medial Calcinosis b.) Calcified Atherosclerotic Plaque a.) Monckeberg’s Medial Calcinosis -arteriosclerosis caused by deposition of calcium around fragmented elastic fibers in medial coat -FREQUENT IN HYPERPARATHYROIDISM AND CHRONIC RENAL FAILURE -radiographically looks like Pipestem/ Tram-track calcifications -track treatment w/ serial radiographs to see decrease in number of calcifications b.) Calcified Atherosclerotic Plaques -occurs in a mature plaque -first and worst at vessel Bifurcations – due to turbulence in the area -Site = Common Carotid, approx C3-C4 vertebrae or below Hyoid Bone -will be irregular verticolinear radiopacities 8.) Calcified Stylohyoid Ligament -most pt’s asymptomatic -Stylohyoid has 4 embryologic stages and each one can calcify separately -4 grades of stylohyoid complex: 1.) Normal 2.) Elongated 3.) Segmented 4.) Pseudoarticulated -2 assoc syndromes: a.)Classic Styloid Syndrom/Eagle’s Syndrome post-tonsillectomy -throat pain, dysphagia, foreign body sensation, pain on yawning b.) Carotid Artery Syndrome no tonsillectomy -pain on turning head, vertigo, otitis media = ECA -turning head causes syncope = ICA 9.) Laryngeal Cartilage Calcifications -of the Triticeous Cartilage bilateral on the Thyroid cartilage -Look like a grain of wheat -innocous, no treatment, and the Triticeous cartilage is prone to calcify 10.) Intraoral Osseous Choristoma -bone producing neoplasm most common on posterior Dorsal Tonge -firm, asymptomatic sessile mass -Radiographically = nodule w/ cortical rim and internal cancellous bone -Treat= surgical excision 11.) Miliary Osteoma -superficial on skin but show up radiographically as multiple, round radiopacities w/ radiolucent centers -pt might have history of cystic acne 12.)Myositis Ossificans -Bone forming in muscle -2 types: a.) Systemic = fatal b/c cardiac m. and diaphragm calcify (rare) b.) Traumatic = hemorrhage calcifies -treat = serial radiographs, once ossificans stop growing means osteoblastic phase is complete and can excise
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 13 of 17
13.) Cysticerosis Cellulosae -tapeworm xmt by food grown where animals defecate -tapeworm settles into any tissue, but prefer Skeletal m. -WILL NOT SHOW UP UNTIL LARVAE HAS DIED (NONVIABLE LARVAE) -treat w/ Proziquonto 14.) Calcifications in Autoimmune disorders -3 main calcifying AI disorders: a.) dermatomyositis – calcinosis of muscle and subcutaneous tissue b.) Scleroderma-part of CREST syndrome, w/ ulcerating, calcinotic masses c.) Raynaud’s disease-poor circulation to extremities when even think of cold (excessive vasoconstriction -seen at tips of fingers, flexon surfaces of tendon sheats, and feet 15.) Calcifications in Metastases -soft tissue calcifications caused by extraosseous or periosteal metastases -PROSTATE MOST COMMON -Osteoblastic tumors tend to calcify = prostate>lung>thyroid>breast 16.) Calcifications related to Meniscal Replacements -calcifications around the now unused Silastic and Proplast TMJ meniscus replacements -device becomes brittle, fragments and causes foreign body response leading to a dystrophic calcification Systemic Disease Associated w/ Heightened Periodontal Pathosis and Premature Tooth Loss 1.)Chediak-Higashi Syndrome 2.)Hypophosphotasia 3.)Papillon-Lefevre Syndrome 4.)Ehlers-Danlos Syndrome 5.)Agranulocytosis 6.)Cyclic Neutropenia 7.)Leukemia 8.)Acrodynia 9.)Argyria 10.)Lead Poisoning 11.) Bismuth Poisoning 12.) Diabetes Mellitus 13.) HIV Assoc Perio disease 14.) Langerhan’s Cell Disease 15.) Scurvy 1.) Chediak-Higashi Syndrome: childhood autosomal recessive disorder w/ albinism -diagnosed by Giant Lysozomes in Neutrophils (pathoneumonic) -Have ulcers, hypertrophic gingival and severe alveolar destruction caused by repeated infections -leads to poor response to perio treatment and tooth exfoliation due to alveolar bone loss 2.)Hypophosphotasia: metabolic autosomal recessive disorder -defect in gene for tissue non-specific alkaline phosphotase required to make Hydroxyapatite crystals -diagnose via low serum alkaline phosphotase and increased urinary phosphoethanolamine -results in hypomineralized bone 4 types: a.) perinatal (always fatal) b.) infantile c.) juvenile
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 14 of 17
4 types hypophosphatasia (cont’d) d.) adult -tip off for juvenile = child losing deciduous teeth at early age w/o trauma or poor oral hygiene, everything else in mouth looks healthy -caused by little to no cementum 3.) Papillon-Lefevre Syndrome: autosomal recessive, noted at 2 yrs old w/ palmar-plantar hyperkeratosis -at same time gingivo-perio inflammation begins, alveolar bone resorbs and teeth lost in order they erupted -all primary teeth lost by age 5 -the gingival will revert to health once deciduous teeth lost, but the process of inflammation and bone destruction begins again when permanent teeth erupt -AA bacteria involved (Actinomyces actinomycetemcomitans) required for condition -also neutrophil chemotaxis is depressed 4.) Ehlers-Danlos Syndrome: autosomal Dominant CT disorder spectrum (abnormal collagen) -hypermobile joints, hyperelastic skin -50% have ability to touch nose -Ehlers-Danlos IV and VIII have early onset perio and tooth loss -perio prob begins at puberty w/ tooth loss by 30 y.o. -also repeated luxations of TMJ -Type IV most fatal w/ early death from dissecting hematoma -Dental Management = short visits, care during IAN blocks, lighter ortho forces 5.) Agranulocytosis: NO NEUTROPHILS-can be either caused by decreased production, increased destruction, or sequestration of neutrophils -most cases caused by Drug Exposure(sulfonamides, thiazides, chloramphenicol, chemotherapeutics -usually resolves in 10-14 days for non-chemotherapeutics -chemotherapeutics can take several weeks -Systemic Lupus and Felty’s Syndrome can cause neutrophil sequestrations in spleen -Spleenectomy resolves the sequestration -decreased production due to low levels of G-CSF – granulocyte colony stimulating factor -now can inject the G-CSF, only side effect is bone pain as neutrophils grow and expand the volume of the bone marrow -usually give the neutrophil booster w/ chemo -Oral lesion is common as NECROTIZING DEEPLY PUNCHED OUT ULCERS LACKING SURROUNDING INFLAMMATION -ulcers w/ a lack of host response -if freq and long angranulocytosis, then can have bad perio w/ loss of alveolar bone and tooth loss -if agranulocytosis due to chemotherapeutics have oral hygiene visit and prescribe chlorhexidine rinse 6.) Cyclic Neutropenia: 1/3 autosomal dominant, 2/3 spontaneous or idiopathic, all cause periodic decrease in neutrophil population -periods of infection lasting 3-6 days correspond to decreased neutrophil -21 Day Cycle -oral problems caused by even slightest truamhave a peripheral eythmatous halo (this shows a decreased host response, where Agranulocytosis has no host response) -can have severe perio and tooth loss if poor oral hygein -routine dental tx should be done when neutrophil count is >2,000/ml3
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 15 of 17
7.) Leukemia: malignancies of hematopoietic stem cell derivation, can be caused by radiation exposure >1Gy -get oral manifestations w/ platelet count drop below 20,000/ ml3 -get hypertrophich gingival and bruise easily (hematomas on lips), spontaneous gingival hemorrhage -ulcers deep, punched out w/ gray, white necrotic base (like Agranulocytosis) 8.) Acrodynia = Mercury poisoning -problem caused when we ingest methylmercury -can be ingested, inhaled, absorbed through skin -Mercuric oxide still used to treat eyelid mites -need to warn construction workers as they can inhale during demolition as it is a useful industrial material -oral character = metallic taste, excessive saliva, ulcerative gingivo-stomatitis -enlarged salivary glands, tongue -gingiva could have blue black line at gingival margin(but can be caused by any heavy metal) -causes alveolar bone destruction because oral bacteria convert mercury into mercuric sulfide which eats the bone and causes tooth exfoliation -Pink disease: acrodynia in kids w/ bright pink color, hyperirritablity w/ tearing of hair , bruxism, photophobia 9.) Argyria = Silver poisoning -excessive ingestion of silver w/ sequestration and pt turns gray/blue 10.) Lead poisoning -destructive to periodontium as oral bacteria convert metal to lead sulfide NOTE: Any heavy metal sulfide leaves a tell-tale blue-black line, generically called a “Lead Line” at the Free Gingival Margin -in children, lead poisoning from ingestion -in adults, lead poisoning from industrial exposure 11.) Bismuth Poisoning -same method of periodontal breakdown -cause is bismuth used in past as an Antisyphilitic 12.) Diabetes Mellitus -oral manifestations only in Type I (Insulin dependent ) Diabetes mellitus -diffuse, nodular, striking erythmatous , fiery red inflammation of gingival in uncontrolled type I -has decreased immune response to periodontitis as well as more bacteria (gram neg rods) in the pocket, also affects healing after surgery along w/ an increased risk of infection 13.) HIV Associated Periodontal Disease 4 types:a.) gingivitis HIV gingivitis characterized by Linear marginal gingivitis w/ skip areas -caused by Candidiasis, so controlled w/ Fluconazole, not oral hygeine b.) periodontitis very painful w/ quick attachment loss but lack Deep Pockets due to decreased gingival height c.) necrotizing stomatitis of periodontal origin massively destructive bone sequestration and soft tissue loss accompanying HIV periodontitis d.) acute necrotizing ulcerative gingivitis (ANUG) punched out interdental papilla caused by 2 bacteria: i.) Prevotella intermedia ii.) PROS (pathogen related oral spirochete) -do not respond to normal perio therapy -must continually debride, then give povidone-iodine irrigation, chlorhexidine rinses and systemic Ab -normally can’t eat, so nutrition decreases, and disease progresses -HIV can also manifest orally w/ Oral Hairy Leukoplakia and Kaposi Sarcoma
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 16 of 17
14.) Langerhan’s Cell Disease: spectrum of disorders that all have proliferation of Langerhan’s Cell histiocytes w/ eosinophils, lymphocytes, plasma cells, and multinucleated giant cells -Histo Diagnosis = Tennis Racket Shape -Most commonly affects Posterior Mandible, w/ bone loss around posterior teeth -Radiographically = sharply punched out bone lesions in jaw cause alveolar bone resorp w/ accompanying tooth loss -TEETH FLOATING IN AIR appearance -pt will also have gingivitis and soft tissue necrosis 15.) Scurvy : due to chronic insufficient intake of Vit C -Humans and guinea pigs only animals that don’t make own Vit C -Vit C importance = req for hydroxylation of Proline in Collagen synthesis -Corkscrew hair growth and subungual (under fingernails) hematomas -Oral manifestations in dentulous = mucosal pallor (pale) w/ hypertrophic and hemorrhagic gingivae -perio attachment loss gives mobility, leads to alveolar resorption and tooth exfoliation -seen in: alcoholics, isolated individuals, psychotics, those w/ extremely limited food preferences Case Reviews 1.) Osteochondroma = is a radiopacity, that in radiograph or CT would show a continuity between the lesion and the condyle -AAOS website says osteochondroma (bone tumor) is a developmental abnormality where the growth plate forms and outgrowth on the bone surface Osteochondromatosis = AAOS website calls it synovial chondromatosis, and involves the tissue and lining of the synovial joint which grows abnormally and produces cartilage nodules -our slides say there is NO CONTINUITY b/w the lesion and the condyle 2.) Aneurysmal bone cyst -pt had swelling after trauma for 3 months -don’t aspirate a cyst until check for pinkness and warmth, which indicate active blood, in which case don’t want to aspirate -multiloculated radiolucency whose dark locules indicate cortical perforation -lesion caused external root resorption and shift of teeth -border scalloped 3.)Osteoblastic Metastatic Prostate Carcinoma -pathoneumonic for prostate carcinoma is that it grows along the bone surface -does not have a detectable epicenter -OSTEOSARCOMA would have a detectable epicenter -pt had asymmetric swelling of mandible (also in his late 80’s when prostate cancer more common) -swelling caused parastesia -abnormal cortical border showed a lytic/blastic process Weird Descriptors and Food Terms -Jug Handle/ Bucket Handle = Zygoma Visualization on Submentovertex Extraoral Plain Skull Films -String of Sausages = Sialodochitis in Sialography -Fruit laden Branchless Tree = Sjogren’s Syndrome in Sialography -Cauliflower Shaped = Calcified Lymph Node -Bullseye/ Targetoid = Phleboliths
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 17 of 17
Weird Descriptors and Food Terms(cont’d) -Grain of Wheat = Laryngeal Cartilage Calcifications (calcified Triticeous Cartilage) -Tennis Racket = Langerhan’s Cell Disease histology -Tooth Floating in Air = Langerhan’s Cell Disease radiographically -Corkscrew hair growth = Scurvy
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 1 of 17
Extraoral Plain projections -Why get extraoral plain: -spatial relation for previously identified problem -at least one additional film, PERPENDICULAR to the original film 5 Extraoral Plain Projections: (all source to film dist 36”-40”, exc Lat Ceph has 60” source film dist) 1.) Water’s View 2.) Posteroanterior view 3.) Lateral projection a.) Lateral Cephalometric 4.) Submentovertex projection 5.) Reverse Towne’s projection Important reference for Extraoral plain films =Canthomeatal line – central point of ext auditory meatus to the outer canthus of the eye (The canthus is the notch at each edge of the eye, where the two eyelids meet. The inner, or medial, canthus is called the nasal canthus, because of its proximity to the nasal structures. The outer, or lateral, canthus is called the temporal canthus because of its proximity to the temporal region of the skull. The nasal canthus features the fleshy, pink lachrymal caruncle and the canaliculi which lead into the lachrymal sac. http://www.probertencyclopaedia.com/cgi-bin/res.pl?keyword=Canthus&offset=0) 1.) Water’s View -ONLY VIEW that shows ethmoid air cells separately -USE if suspect Max Sinus Lesion -good view of orbit b/c no petrous ridge superimposed over wall of the orbit -Central Ray position: Through midsagittal at level of the maxillary sinus -Canthomeatal= positioned 37 deg above horizontal
2.) Posteroanterior View -BEST demos posterior and midline facial structures -BEST FOR: a.) detecting mediolateral changes in the skull (asymmetry) b.) evaluate nasal fracture c.) visualize lamina papryacea (separate ethmoid air cells from or bits) -NOT GOOD FOR: Lower maxillary sinus b/c petrous ridge superimposed -Central Ray Position: Through Midsagittal at level bridge of nose -Canthomeatal = parallel to floor
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 2 of 17
3.)Lateral Projection -shows anterior posterior walls of max sinus, frontal sinus, sphenoid sinus, ethmoid sinus -BEST FOR: a.) evaluate fluid level of Max Sinus b.) eval trauma to or obstructive lesion of sinuses c.) show relationship b/w sphenoid to sella turcica and the nasopharyngeal soft tissue to the airway -Pt positioned: left side of face to cassette, midsagittal parallel to film -Central Ray: at ext aud meatus and perpendicular to film, perpendicular to midsagittal plain -Canthomeatal: parallel to the floor -NOTE DIFFERENCE W/ LATERAL CEPHALOMETRIC: -increased source film dist = 60” -wedge filter placed at anterior of beam to decrease the radiation (decrease the intensity) to reveal the pt’s soft tissue profile
4.) Submentovertex(SMV) -Shows: base of skull, position and orientation of condyles, curve of mandible, lateral wall maxillary sinus, pterygoid plates -BEST TO VIEW: FRACTURES OF ZYGOMATIC ARCH (jug handle/bucket handle view) -Only Projection that shows Left and Right sphenoid sinuses separately (RE: Water’s view is the only view that shows the ethmoid sinuses separately) -Pt Position: head backwards w/ vertex at center of cassette, midsagittal perpendicular to floor -Central Ray: from below mandible up toward vertex of skull to pass ~ 2 cm in front of line connecting Left and Right Condyles -Canthomeatal line: 10 deg past vertical -To visualize Zygomatic arches decrease the exposure time to 1/3 that used to visualize the entire skull
5.)Reverse Towne’s -most important film to assess SUBCONDYLAR FRACTURES -only plain film that optimally demonstrates the angulation or displacement that occurs because of fractures -also used for eval of: petrous ridge, mastoid air cells, posterolateral wall of maxillary antrum -pt pos: head front of cassette, mouth fully open to better visualize condyles -Central Ray: twd film through Occipital Bone -Canthomeatal Line= 25 deg-30deg downward -collimate beam to areas of interest to decrease pt exposure and decrease film fog
Stephens MK For Reference:
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 3 of 17
Note: Horizontal plane = Transverse plane= Axial plane (comes into play with Computed Tomography[CT])
http://www.google.com/imgres?q=anatomic+planes&hl=en&safe=strict&biw=1280&bih=507&tbm=isch&tbnid=Uv0C-jz8I75ORM:&imgrefurl=http://medicaldictionary.thefreedictionary.com/plane&docid=4w_EUEZl04yztM&imgurl=http://img.tfd.com/dorland/thumbs/plane.jpg&w=250&h=360&ei=WWfaTtr2C8Pu0gHG75GMDg&zoom=1&iact=hc&vpx=1004&vpy=116&dur=47&hovh=270&hovw=187&tx=181&ty=142&si g=116215483726398996774&page=1&tbnh=143&tbnw=97&start=0&ndsp=16&ved=1t:429,r:7,s:0
http://www.google.com/imgres?q=bones+of+the+skull&hl=en&safe=strict&biw=1280&bih=507&tbm=isch&tbnid=RPRGvFB20f-CwM:&imgrefurl=http://howtobecomeaparamedic.com/2010/11/how-to-become-a-paramedic-facialfeatures/&docid=ffJ3rcVE1tUYzM&imgurl=http://howtobecomeaparamedic.com/wp-content/uploads/2010/11/skull1.jpg&w=414&h=324&ei=iWfaTv2nLTW0QGW_9HWDQ&zoom=1&iact=hc&vpx=701&vpy=154&dur=223&hovh=199&hovw=254&tx=112&ty=112&sig=116215483726398996774&page=2&tbnh=128&tbnw=164&start=10&ndsp=12&ved=1t:429,r:9,s:10
http://www.google.com/imgres?q=sinuses&start=36&num=10&hl=en&safe=strict&biw=1280&bih=507&tbm=isch&tbnid=Ge7vwLiO217VM:&imgrefurl=http://www.billcasselman.com/unpublished_works/sinus_origin.htm&docid=WtnQIXgL3PMvAM&imgurl=http://www.billcasselman.com/paranasal_sinuses_ethmoid_eye_sockets_sphenoid_maxillary.jpg&w=468&h=242&ei=yGfaTrvZB 6Lh0QHs18zaDQ&zoom=1&iact=hc&vpx=681&vpy=201&dur=3160&hovh=161&hovw=312&tx=149&ty=112&sig=116215483726398996774&sqi=2&page=4&tbnh=86&tbnw=167&ndsp=12&ved=1t:429,r:3,s:36
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 4 of 17
Advanced Imaging I & II 2 types non-ionizing radiation = MRI and Ultrasound 6 Types Advanced Imaging 1.) Sialography 2.) Computed Tomography 3.) Magnetic Resonance Imaging (MRI) 4.) Nuclear Medicine 5.) Diagnostic Ultrasonography (Ultrasound) 6.) Cone Beam CT 1.) Sialography -def = retrograde injection of iodinated contrast media into duct system of salivary glands -2 types of contrast media : a.) Fat Soluble (Ethiodol) (+) = not diluted by saliva (+) = not absorbed across gland mucosa (-)=causes foreign body granulomata if duct rupture and extravasate the Ethiodol b.) Water Soluble (Sinografin) (-)=diluted by saliva (-)=passes rapidly across gland mucosa Therefore, poorly visualize peripheral ducts (+)=does not incite inflammatory reaction of extravasated -Sialography is best eval for obstructive inflammatory lesions of major salivary glands -Procedure=dilate and cannulate duct, inject 0.5-0.75 ml contrast until patient signals discomfort -2 phases of Sialography : a.) Ductal b.) Acinar -4 Standard Visualizations for Sialography: 1.) AP 2.) AP puffed Cheek 3.) Lateral 4.) Lateral Oblique -Sialoliths in Sialogram appearance = radiolucent filling voids -Sialodochitis = alternating areas of fusiform dilation and structuring of the primary duct (STRING OF SAUSAGES) -Swelling Common in Alcoholics = Parotid Gland -Sjogren’s Syndrome look in Sialography= Punctate and Globular FRUIT LADEN BRANCHLESS TREE 2.) Computed Tomography -axial cross-section of head using narrow collimated moving beam, remnant radiation detected in xenon filled ionizing chamberanalog signal passed to computer where analyzed and digitized by math algorithm into axial tomographic image -RE: only view CT takes is Axial=Horizontal=Transverse plane [top to bottom] -CT Accuracy vs Thickness vs Exposure: -the thinner the slice the more accurate -therefore must increase does for increase accuracy by getting thinner slice’s -CT Good for: -diagnose of lesion and staging of malignant disease [staging = document extent of] -assess lymph node metastases -eval effects of treatment with follow up CT’s -CT NOT Good for: soft tissue eval -however can be used to show extent of soft tissue lesion proliferation out of or within bone -CT Selection Criteria: -max or mand lesion, especially if sinuses involved
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 5 of 17
-suspect malignancy -soft tissue mass salivary gland (CT saliography) -osseous lesions in TMJ -developmental disorders involving max and mand -asses maxillofacial trauma 2.) Computed Tomography (cont’d) -CT image orientation = axial crossectional view as if looking at the patient from the floor pu -Neutral Density in CT = 0, based on the density of water -if tissue more dense than water it is a( + )number (e.g. muscle, skin) -if tissue is less dense than water it is a (-) number (e.g. fat) -Hounsfield Unit (H.U.) = correlates normal tissue density to the density of water and uses that to measure against HU of pathologic tissue -ex Hounsfield Unit (HU) use in tumor: -normal marrow is high in fat, so it’s normal H.U. = -20 to -40 H.U. -tumor in marrow replaces that fat marrow with other tissue (e.g. skin, muscle) and the tumor H.U. is a positive number -Cyst Hounsfield Unit = 0 -b/c cyst fluid attenuates radiation about the same amount as water -CT Terminology vs Radiographic Terminology: -Radiopaque = Hyperdense -Radiolucent = Hypodense -Scout Image in CT -Synonymn = scannogram -taken at the beginning of the study to give number and position of the slices obtained -aides in spatial orientation of individual slices 3.) Magnetic Resonance Imaging (MRI) -measures change in low freq radio signals in a magnetic field -used for soft Tissue exam -2 positives of MRI: a.) measure soft tissue better than CT b.) does not use ionizing radiation -NOT USED FOR: bony lesions (due to lack of signal generate by bone) -signal strength to be ready by MRI depends on: Hydrogen content of tissue -Fat = high Hydrogen content -Cortical bone = low Hydrogen content -2 most common MRI freqs and how they look: 1.) T1 -T1 freq Fat looks bright = hyperintense -T1 freq Cystic fluid looks dark = hypointense 2.) T2 -T2 freq Fat look dark = hypointense -T2 freq Cystic Fluid looks bright = hyperintense -MRI terms vs Radiology terms: -radiopaque = hyperintense -radiolucent = hypointense -ABSOLUTE MRI CONTRAINDICATION: implanted ferromagnetic devices (pacemaker, aneurysm clip, prosthetic joint, heart valves, hearing aids, IUD, etc) -Amalgam and titanium will not be pulled out by magnet b/c they do not contain iron -MRI Selection Criteria -eval internal derangement TMJ
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 6 of 17
-salivary gland disease -assess soft tissue invasion by malignant disease -MRI Selection Criteria (cont’d) -brain tumors -neural involve w/ HIV -MS plaque and white matter disorders -extent and mechanism of stroke 4.) Nuclear Medicine -how:inject radiopharmaceutical (Technetium), wait 2 hrs for uptake in to target tissue and start of radioactive decay, measure amount taken up by measuring amount gamma radiation given off -gamma radiation given off converted to green light in the collimater and digitized -show up as Cold Spots and Hot Spots -Cold Spot = metabolically inactive bone, decreased osteogenesis, lack of vascular activity -Hot Spot = metabolically active areas, increased osteogenesis (areas of inflammation or tumor growth) -Nuke Med Sensitivity versus Specificity = Highly Sensitive but Low Specificity -Advantage of Nuke Med = Bone changes seen early -Plain film radiography req 60% bone demin to see radiographically -Nuke Med req 5-15% bone demin to see -Nuclear Medicine Selection Criteria: -detect metastatic tumor for tumor staging -locate margin for treatment plan -salivary gland disorder, esp MASS LESION -eval bio status and extent osteomyelitis -Salivary glands and radiopharmaceuticals (Technetium): -DO NOT CONCENTRATE radiopharmaceuticals salivary glands will be cold spots -EXCEPT: WARTHIN TUMOR of Parotid will concentrate radiopharmaceuticals (will be a Hot Spot) 5.) Diagnostic Ultrasonography (Ultrasound) -how: sound waves in 7-15 MHz range to target tissue, and reflected waves transduced into an image -NO IONIZING RADIATION (other is MRI) -Best suited for: providing info on body cavities -Selection Criteria: -assess sinus disease -assess extracranial carotid vasculature -assess salivary gland and thyroid masses 6.) Cone Beam CT (CBCT) -cone of rays vs fan of rays in a MDCT -provides a DATA SET, not a single image or stack of images -Data Set size based on field of view req: S, M, L -Quick Scan~20 sec (Pan is 16 sec) -CONEBEAM CT is specified for certain body parts don’t order a CBCT, must specify H&N CBCT (+) CBCT = lighter, smaller, room does not req cooling, LOWER radiation dose (-)=less resolution that MDCT -CBCT Craniofacial Selection Criteria: -infection, trauma, developmental deformities -presurgical implant analysis -presurgical anatomic landmark assessment -TMJ eval -Sinus disease -Airway space analysis (for OSA) -Orthodontics
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 7 of 17
6.)Cone Beam CT(cont’d) -not justified for every patient -Aide in implant simulations -Height and Width, esp Width, of bone is key to implant success, this can be measured on the CBCT before moving forward with the surgery -software allows disarticulation of articulated structures -can define Area of Interest on the scan (AOI) -can superimpose soft tissue profile -BEAM HARDENING = artifact from high amnts metal restoration, looks like spoking -can still get motion artifacts if pt moves Radiographic Patterns of Disease -describe lesion on image so someone who has not seen the image could draw it -2 most critical patterns : -radiographic density -borders of the lesion -Pattern Descriptors: 1.) Size 2.)Numerical distribution 3.)Borders 4.) Geometry 5.) Location 6.)Architecture 7.)Texture 8.) Density 9.) Effect on adjacent teeth 10.) Effect on adjacent bone 1.) Size-measure 2 greatest dimension and recorded in mm in chart -guides treatment planning -helps evaluate dynamic changes over time 2.) Numerical Distribution – how many you see a.)Solitary/ Focal = only 1 lesion -solitary lesions are usually small b.)Diffuse = multiple lesions which have spread throughout a significant portion of jawbone c.)Generalized = found in at least 3 quadrants of the jaw, involve both mand and max d.) Symmetrical = lesions in same location in the right and left side of jaw -Frequently indicates a variant of normal or an inherited condition 3.) Borders = the most important pattern is the borders of the lesion -gives info about the active portion of lesion , how growing , and host reaction a.)Well defined/Distinct = if can draw a line confidently around the edges of the lesion -small portions may be ill-defined due to shape and direction of beam b.) Punched Out = very sharp boundary w/ no apparent rxn of host bone to lesion -looks like someone used a hole punch -Punched out most commonly seen in: i.) multiple myeloma ii.) Langerhan’s cell histiocytosis c.) Peripheral Radiolucent Rim Around a Radiopaque Lesion = indicates that the lesion has a soft tissue capsul and that it will likely shell out easily at surgery
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 8 of 17
3.) Borders (cont’d) d.) Ill-defined, Poorly Marginated = indistinct, could not draw a line around -due to a zone of transition from the clearly normal to the clearly abnormal bone -clinician has a general but not exact idea where the lesion starts and stops e.) Ragged, Moth-eaten= indicates the presence of severe inflammatory disease or malignant neoplasia. Indicates Aggressive disease -most aggressive, rapidly destructive pattern =cortical involvement in the setting of permative lesion 4.) Geometry a.) Round/ Ovoid = good because round is slow growing in all directions -Radiopaque Round lesion = not fluid filled -Radiolucent Round lesion = fluid filled cyst called a Hydraulic patter n b.) Scalloped = lesion undulates up and down along the roots of teeth in a series of contiguous arcs -the arcs may indicate mechanism of growth -ONLY OCCURS IN RADIOLUCENT LESIONS -Common in: simple Bone cysts and Odontogenic Keratocytes c.) Irregular = no regular geometric shape, more extensive in some areas and less extensive in others -indicates certain parts of lesion are growing faster than others -indicates a degree of aggressiveness 5.) Location -can give idea of lesion’s developmental origin or indicate what tissue it may contain -e.g. tissue if in IAN, lesion could have neural, vascular or smooth m. elements If in condyle, lesion could have cartilage a.) Epicenter = site of origin -aides in differential diagnosis -if epicenter is superior to IAN and especially if coronal to tooth = ODONTOGENIC ORIGIN -if epicenter is below IAN = NONODONTOGENIC Lesion b.)Central – arise in the cancellous bone of the jaw, have cortex on either side and alveolar bone superiorly -do not use if lesion arises at the alveolar bone or in the cortex c.) Peripheral – arise at the alveolar crest -can have saucerization w/ a wide zone of transition b/w the normal and abnormal bone -can indicate a soft tissue lesion that has subsequently invaded down into the bone (as in carcinoma) d.) Periosteal – arise in the periosteal compartment of bone -seen earliest on occlusal radiographs e.) Associated w/ teeth: Circumcoronal - around the crown of an impacted tooth -could be dentigerous cyst(from reduced enamel epithelium) or infiltration of the space by another cyst such as an Odontogenic Keratocyst f.)Associated w/ teeth: Periapical – develop around the apex of a tooth -usually rep osteolysis resulting from products of inflammation exuding from a devitalized tooth -if have lesion, then NSRCT the tooth, must follow it: if the periapical lesion does not resolve w/ root canal therapy, biopsy is req. g.) Associated w/ teeth: Interradicular – arise between tooth roots, can be the roots of the same tooth or between the roots of 2 adjacent teeth -between 2 teeth common place for: lateral radicular cysts and Lateral periodontal cysts 6.) Architecture= means how many rooms the structure has. Define the architecture of radiolucent lesions only a.) Unilocular = lesion has only one compartment = 1 locule b.)Multilocular = lesion has multiple compartments separated by bony septations -usually have a higher recurrence rate than uniloculars of the same histo type i.) Soap Bubble Multilocular = multiple overlapping compartments
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 9 of 17
6.) Architecture (cont’d) b.) Multilocular (cont’d) ii.) Honeycomb Multilocular = small, uniformly sized compartments -usually indicates presence of Ameloblastoma -may also indicate intraosseous hemangioma iii.) Spider Web Multilocular = septae radiate from a central body iv.) Tennis Racket Multilocular = septae are aligned at right angles to each other -pathoneumonic for Odontogenic Myxoma 7.) Texture – used to describe radiopacities exclusively (therefore do not talk architecture) a.) Homogenous = uniform radiopacity b.)Multilobulated = consists of conglomerations of multiple lobules that can be separate or clustered c.) Ground glass = look like frosted end of a glass microscope slide -Fibrous Dysplasia has ground glass texture d.) Orange Peel/ Peau D’Orange = trabeculations are fine but dense -Late Stage Fibrous Dysplasia has Orange Peel texture e.) Cotton Wool = dense patches of sclerotic bone forming in response to local or widespread inflammatory stimulus -e.g Local inflammatory stimulus causing cotton wool radiopacity = condensing osteitis -e.g. Widespread inflammatory stimulus causing cotton wool radiopacity = chronic diffuse sclerosing osteomyelitis -cotton wool radiopacity also occur in later stage fibro-osseous disorders: -florid cement-osseous dysplasia -Paget’s disease 8.) Density = other most critical radiographic pattern to identify besides Border a.) Radiolucent = black, due to lack of structure allowing all radiation to pass through and overexpose film in that area -lack of structure due to osteolysis -large lesion w/ cortical destruction will be completely dark -small lesion w/ no cortical destruction can have residual B/L trabeculae superimposed b.) Radiopaque = White -the larger the radiopaque lesion, the less residual trabeculation B/L superimposed c.) Radiolucent w/ Radiopaque Flecks (Foci) = a radiolucent lesion which has some radiopaque particles (less than 50% of lesion is radiopaque) d.) Mixed Radiolucent/Radiopaque = a lesion that is approx 50% radiolucent and 50% radiopaque 9.) Effect of Lesion on Adjacent Teeth a.) Root Divergence = displacement of adjacent tooth roots away from each other -generally caused by slow growing benign cyst or neoplasm -will cause contact point at crowns to be different than previous b.) Floating in Air Tooth = malignant or aggressive lesions that resorb bone so quickly that only soft tissue holds tooth in and appears to float in air on radiograph c.)Root Resorption by Blunt Pressure = sheer mechanical pressure of cysts and benign neoplasms can cause resorption of adjacent tooth rooths from the apex coronally. d.) Circumferential Root Resorption = root have very tapered or spiked appearance -caused by malignant neoplasms or very aggressive lesions surrounding tooth and causing resorption 10.) Effect of Lesion on Adjacent Bone a.) Cortical Expansion = caused by benign lesions whose slow growth allows periosteum to lay down new bone peripherally so that perforation does not occur the expansion of the lesion remains contained in bone, so the bone expands
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 10 of 17
10.) Effect of Lesion on Adjacent Bone(Cont’d) b.)Cortical Perforation = malignant neoplasm or fast growing benign neoplasm outgrows the capacity of the surrounding periosteum and perforates the bone and extends into the surrounding soft tissue c.) Periosteal Reactions: Onion Skinning = some inflammatory conditions and neoplasms so irritate the periosteum that it lays down multiple layers of new periosteal bone -appears as tree layers, or onion skinning -eg. Inflammatory conditions causing onion skinning= proliferative periostitis -eg. Neoplasm causing onion skinning=Ewing’s sarcoma d.) Periosteal Reactions: Sunburst Spiculation = malignant tumor grows so rapidly that it perforates the bone cortex and drags the striae of bone from the periosteum out with it into the adjacent tissue e.) Periosteal Reactions: Hair on End = conditions can cause fine short striae of bone to project upward perpendicular to surface of skull -2 conditions causing Hair on End Reactions: i.) Sickle Cell Anemia ii.) Thalassemia Differential Diagnosis of Soft Tissue Calcifications 2 Mechs of Calcification: 1.) Dystrophic: Pt body is Normocalcemic, but dead, dying ,diseased, damaged, degenerated tissue causes calcification causes and aread of increased local alkalinity - Increase in local alkalinity: alkalinity in area of damage will pull out minerals in the passing acidic blood to precipitate out into that tissue 3.) Metastatic: Pt entire body Hypercalcemic, so mineral can precipitate out into normal tissue -Implications of Tissue Calcification = no worry to fatal Types of Soft Tissue Calcifications: 1.) Calcified Lymph Node 2.)Sialoliths 3.)Tonsilloliths 4.)Rhinoliths 5.)Antroliths 6.)Phleboliths 7.)Arterial Calcifications 8.)Calcified Stylohyoid ligament 9.) Laryngeal Cartilage Calcifications 10.)Intraoral Osseous Choristoma 11.)Miliary Osteomas 12.)Myositis Ossifcans 13.)Cysticercosis Cellulosae 14.) Calcifications in Autoimmune Disorders 15.) Calcifications in Metastases 16.) Meniscal Replacements 1.) Calcified Lymph Node -result of prior infection or inflammation can be from granulomatous disorder, deep fungal infection, lymphoma -IRREGULAR, CAULIFLOWER SHAPED (Multilobulated radiopacity) -solitary or chains -from dystrophic mechanism (local alkalinity) -eg of granulomatous disorder – Tb or CAT SCRATCH FEVER -fungal normally due to agriculture work
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 11 of 17
1.) Calcified Lymph Node (Cont’d) -lymphoma pt: node in area of radiation calcified -chaining calcified lymph node most likely seen in person w/ Tb -must treat underlying cause 2.) Sialoliths -Etiology = sluggish mucous cells or epithelial cells causing mineralize precip -grow by ACCRETION = organic nidus causes minerals to precip out -Loc = majority in submand, due to tortuous route and more mucous secretion, some in parotid -Wharton’s duct is longer than Stenson’s duct, parotid has more serous (watery) secretion -Submand most likely one sialolith, parotid could have multiple -Presentation = no probs, but when duct obstructed can get: -Obstructive Sialodenitis = anytime salivate, they have pain -ones in the duct normally cause pain -Re: SMOOTH, SOLITARY, SUBMANDIBULAR -Note: long genial tubercles if seen on radiograph may indicate tongue thrusting -Treatment: milk it out, send it for review, only remove gland if sialolith is in gland 3.) Tonsilloliths- hard yellow/white objects sticking out of tonsillar crypts -in Tonsilar Crypts after swelling from infection traps junk, then when infection resolves, swelling disappears and crypt opening closes trapping junk inside -Dietrich’s Plug = only organic Crude in Tonsilar Crypt -if other stuff précis out so as to be radiographically evident = Tonsillolith -symptoms, pain, no pain, feeling of something stuck in throat, bad breath even with good oral hygiene -Treatment = if pt can’t flick out = Tonsillectomy -Note: pt w/ swallowing problem (Parkinson’s or Post-Stroke) = the tonsillolith could be nidus for aspiration pneumonia -radiographically found inferior to Submandibular canal (inferior toIAN) & in oropharyngeal airspace below ramus of mandible 4.) Rhinoliths – nose 2 sources: 1.) Endogenous = retained root tip = most common cause in adults 2.) Exogenous = foreign object causing mineralization = most common in kids -either origin, the mineralization will cause necrosis 5.) Antroliths = Rhinoliths in Maxillary Antrum (go through the hole that goes from nose to Max Antrum) -have a long asymptomatic period, but will require eventual removal 6.) Phleboliths = calcified thrombi in veins -could be fatal -Phleboliths in head and neck are associated w/ HEMANGIOMAS (not that way in other parts of body) -DO NOT PROCEED WITH FURTHER TREATMENT UNTIL FIND OUT WHAT’s GOING ON W/ HEMANGIOMA -Cavernous Hemangioma = common in High to low shunt (large artery to large vein) -These have a BRUIT (whoosh) when auscultated, but if don’t hear bruit, doesn’t mean it’s not there -Capillary Hemangioma = won’t be able to hear -Have BULLSEYE/TARGETOID APPEARANCE -round b/c they are veins in cross section
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 12 of 17
7.) Arterial Calcification -2 types: a.) Monckeberg’s Medial Calcinosis b.) Calcified Atherosclerotic Plaque a.) Monckeberg’s Medial Calcinosis -arteriosclerosis caused by deposition of calcium around fragmented elastic fibers in medial coat -FREQUENT IN HYPERPARATHYROIDISM AND CHRONIC RENAL FAILURE -radiographically looks like Pipestem/ Tram-track calcifications -track treatment w/ serial radiographs to see decrease in number of calcifications b.) Calcified Atherosclerotic Plaques -occurs in a mature plaque -first and worst at vessel Bifurcations – due to turbulence in the area -Site = Common Carotid, approx C3-C4 vertebrae or below Hyoid Bone -will be irregular verticolinear radiopacities 8.) Calcified Stylohyoid Ligament -most pt’s asymptomatic -Stylohyoid has 4 embryologic stages and each one can calcify separately -4 grades of stylohyoid complex: 1.) Normal 2.) Elongated 3.) Segmented 4.) Pseudoarticulated -2 assoc syndromes: a.)Classic Styloid Syndrom/Eagle’s Syndrome post-tonsillectomy -throat pain, dysphagia, foreign body sensation, pain on yawning b.) Carotid Artery Syndrome no tonsillectomy -pain on turning head, vertigo, otitis media = ECA -turning head causes syncope = ICA 9.) Laryngeal Cartilage Calcifications -of the Triticeous Cartilage bilateral on the Thyroid cartilage -Look like a grain of wheat -innocous, no treatment, and the Triticeous cartilage is prone to calcify 10.) Intraoral Osseous Choristoma -bone producing neoplasm most common on posterior Dorsal Tonge -firm, asymptomatic sessile mass -Radiographically = nodule w/ cortical rim and internal cancellous bone -Treat= surgical excision 11.) Miliary Osteoma -superficial on skin but show up radiographically as multiple, round radiopacities w/ radiolucent centers -pt might have history of cystic acne 12.)Myositis Ossificans -Bone forming in muscle -2 types: a.) Systemic = fatal b/c cardiac m. and diaphragm calcify (rare) b.) Traumatic = hemorrhage calcifies -treat = serial radiographs, once ossificans stop growing means osteoblastic phase is complete and can excise
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 13 of 17
13.) Cysticerosis Cellulosae -tapeworm xmt by food grown where animals defecate -tapeworm settles into any tissue, but prefer Skeletal m. -WILL NOT SHOW UP UNTIL LARVAE HAS DIED (NONVIABLE LARVAE) -treat w/ Proziquonto 14.) Calcifications in Autoimmune disorders -3 main calcifying AI disorders: a.) dermatomyositis – calcinosis of muscle and subcutaneous tissue b.) Scleroderma-part of CREST syndrome, w/ ulcerating, calcinotic masses c.) Raynaud’s disease-poor circulation to extremities when even think of cold (excessive vasoconstriction -seen at tips of fingers, flexon surfaces of tendon sheats, and feet 15.) Calcifications in Metastases -soft tissue calcifications caused by extraosseous or periosteal metastases -PROSTATE MOST COMMON -Osteoblastic tumors tend to calcify = prostate>lung>thyroid>breast 16.) Calcifications related to Meniscal Replacements -calcifications around the now unused Silastic and Proplast TMJ meniscus replacements -device becomes brittle, fragments and causes foreign body response leading to a dystrophic calcification Systemic Disease Associated w/ Heightened Periodontal Pathosis and Premature Tooth Loss 1.)Chediak-Higashi Syndrome 2.)Hypophosphotasia 3.)Papillon-Lefevre Syndrome 4.)Ehlers-Danlos Syndrome 5.)Agranulocytosis 6.)Cyclic Neutropenia 7.)Leukemia 8.)Acrodynia 9.)Argyria 10.)Lead Poisoning 11.) Bismuth Poisoning 12.) Diabetes Mellitus 13.) HIV Assoc Perio disease 14.) Langerhan’s Cell Disease 15.) Scurvy 1.) Chediak-Higashi Syndrome: childhood autosomal recessive disorder w/ albinism -diagnosed by Giant Lysozomes in Neutrophils (pathoneumonic) -Have ulcers, hypertrophic gingival and severe alveolar destruction caused by repeated infections -leads to poor response to perio treatment and tooth exfoliation due to alveolar bone loss 2.)Hypophosphotasia: metabolic autosomal recessive disorder -defect in gene for tissue non-specific alkaline phosphotase required to make Hydroxyapatite crystals -diagnose via low serum alkaline phosphotase and increased urinary phosphoethanolamine -results in hypomineralized bone 4 types: a.) perinatal (always fatal) b.) infantile c.) juvenile
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 14 of 17
4 types hypophosphatasia (cont’d) d.) adult -tip off for juvenile = child losing deciduous teeth at early age w/o trauma or poor oral hygiene, everything else in mouth looks healthy -caused by little to no cementum 3.) Papillon-Lefevre Syndrome: autosomal recessive, noted at 2 yrs old w/ palmar-plantar hyperkeratosis -at same time gingivo-perio inflammation begins, alveolar bone resorbs and teeth lost in order they erupted -all primary teeth lost by age 5 -the gingival will revert to health once deciduous teeth lost, but the process of inflammation and bone destruction begins again when permanent teeth erupt -AA bacteria involved (Actinomyces actinomycetemcomitans) required for condition -also neutrophil chemotaxis is depressed 4.) Ehlers-Danlos Syndrome: autosomal Dominant CT disorder spectrum (abnormal collagen) -hypermobile joints, hyperelastic skin -50% have ability to touch nose -Ehlers-Danlos IV and VIII have early onset perio and tooth loss -perio prob begins at puberty w/ tooth loss by 30 y.o. -also repeated luxations of TMJ -Type IV most fatal w/ early death from dissecting hematoma -Dental Management = short visits, care during IAN blocks, lighter ortho forces 5.) Agranulocytosis: NO NEUTROPHILS-can be either caused by decreased production, increased destruction, or sequestration of neutrophils -most cases caused by Drug Exposure(sulfonamides, thiazides, chloramphenicol, chemotherapeutics -usually resolves in 10-14 days for non-chemotherapeutics -chemotherapeutics can take several weeks -Systemic Lupus and Felty’s Syndrome can cause neutrophil sequestrations in spleen -Spleenectomy resolves the sequestration -decreased production due to low levels of G-CSF – granulocyte colony stimulating factor -now can inject the G-CSF, only side effect is bone pain as neutrophils grow and expand the volume of the bone marrow -usually give the neutrophil booster w/ chemo -Oral lesion is common as NECROTIZING DEEPLY PUNCHED OUT ULCERS LACKING SURROUNDING INFLAMMATION -ulcers w/ a lack of host response -if freq and long angranulocytosis, then can have bad perio w/ loss of alveolar bone and tooth loss -if agranulocytosis due to chemotherapeutics have oral hygiene visit and prescribe chlorhexidine rinse 6.) Cyclic Neutropenia: 1/3 autosomal dominant, 2/3 spontaneous or idiopathic, all cause periodic decrease in neutrophil population -periods of infection lasting 3-6 days correspond to decreased neutrophil -21 Day Cycle -oral problems caused by even slightest truamhave a peripheral eythmatous halo (this shows a decreased host response, where Agranulocytosis has no host response) -can have severe perio and tooth loss if poor oral hygein -routine dental tx should be done when neutrophil count is >2,000/ml3
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 15 of 17
7.) Leukemia: malignancies of hematopoietic stem cell derivation, can be caused by radiation exposure >1Gy -get oral manifestations w/ platelet count drop below 20,000/ ml3 -get hypertrophich gingival and bruise easily (hematomas on lips), spontaneous gingival hemorrhage -ulcers deep, punched out w/ gray, white necrotic base (like Agranulocytosis) 8.) Acrodynia = Mercury poisoning -problem caused when we ingest methylmercury -can be ingested, inhaled, absorbed through skin -Mercuric oxide still used to treat eyelid mites -need to warn construction workers as they can inhale during demolition as it is a useful industrial material -oral character = metallic taste, excessive saliva, ulcerative gingivo-stomatitis -enlarged salivary glands, tongue -gingiva could have blue black line at gingival margin(but can be caused by any heavy metal) -causes alveolar bone destruction because oral bacteria convert mercury into mercuric sulfide which eats the bone and causes tooth exfoliation -Pink disease: acrodynia in kids w/ bright pink color, hyperirritablity w/ tearing of hair , bruxism, photophobia 9.) Argyria = Silver poisoning -excessive ingestion of silver w/ sequestration and pt turns gray/blue 10.) Lead poisoning -destructive to periodontium as oral bacteria convert metal to lead sulfide NOTE: Any heavy metal sulfide leaves a tell-tale blue-black line, generically called a “Lead Line” at the Free Gingival Margin -in children, lead poisoning from ingestion -in adults, lead poisoning from industrial exposure 11.) Bismuth Poisoning -same method of periodontal breakdown -cause is bismuth used in past as an Antisyphilitic 12.) Diabetes Mellitus -oral manifestations only in Type I (Insulin dependent ) Diabetes mellitus -diffuse, nodular, striking erythmatous , fiery red inflammation of gingival in uncontrolled type I -has decreased immune response to periodontitis as well as more bacteria (gram neg rods) in the pocket, also affects healing after surgery along w/ an increased risk of infection 13.) HIV Associated Periodontal Disease 4 types:a.) gingivitis HIV gingivitis characterized by Linear marginal gingivitis w/ skip areas -caused by Candidiasis, so controlled w/ Fluconazole, not oral hygeine b.) periodontitis very painful w/ quick attachment loss but lack Deep Pockets due to decreased gingival height c.) necrotizing stomatitis of periodontal origin massively destructive bone sequestration and soft tissue loss accompanying HIV periodontitis d.) acute necrotizing ulcerative gingivitis (ANUG) punched out interdental papilla caused by 2 bacteria: i.) Prevotella intermedia ii.) PROS (pathogen related oral spirochete) -do not respond to normal perio therapy -must continually debride, then give povidone-iodine irrigation, chlorhexidine rinses and systemic Ab -normally can’t eat, so nutrition decreases, and disease progresses -HIV can also manifest orally w/ Oral Hairy Leukoplakia and Kaposi Sarcoma
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 16 of 17
14.) Langerhan’s Cell Disease: spectrum of disorders that all have proliferation of Langerhan’s Cell histiocytes w/ eosinophils, lymphocytes, plasma cells, and multinucleated giant cells -Histo Diagnosis = Tennis Racket Shape -Most commonly affects Posterior Mandible, w/ bone loss around posterior teeth -Radiographically = sharply punched out bone lesions in jaw cause alveolar bone resorp w/ accompanying tooth loss -TEETH FLOATING IN AIR appearance -pt will also have gingivitis and soft tissue necrosis 15.) Scurvy : due to chronic insufficient intake of Vit C -Humans and guinea pigs only animals that don’t make own Vit C -Vit C importance = req for hydroxylation of Proline in Collagen synthesis -Corkscrew hair growth and subungual (under fingernails) hematomas -Oral manifestations in dentulous = mucosal pallor (pale) w/ hypertrophic and hemorrhagic gingivae -perio attachment loss gives mobility, leads to alveolar resorption and tooth exfoliation -seen in: alcoholics, isolated individuals, psychotics, those w/ extremely limited food preferences Case Reviews 1.) Osteochondroma = is a radiopacity, that in radiograph or CT would show a continuity between the lesion and the condyle -AAOS website says osteochondroma (bone tumor) is a developmental abnormality where the growth plate forms and outgrowth on the bone surface Osteochondromatosis = AAOS website calls it synovial chondromatosis, and involves the tissue and lining of the synovial joint which grows abnormally and produces cartilage nodules -our slides say there is NO CONTINUITY b/w the lesion and the condyle 2.) Aneurysmal bone cyst -pt had swelling after trauma for 3 months -don’t aspirate a cyst until check for pinkness and warmth, which indicate active blood, in which case don’t want to aspirate -multiloculated radiolucency whose dark locules indicate cortical perforation -lesion caused external root resorption and shift of teeth -border scalloped 3.)Osteoblastic Metastatic Prostate Carcinoma -pathoneumonic for prostate carcinoma is that it grows along the bone surface -does not have a detectable epicenter -OSTEOSARCOMA would have a detectable epicenter -pt had asymmetric swelling of mandible (also in his late 80’s when prostate cancer more common) -swelling caused parastesia -abnormal cortical border showed a lytic/blastic process Weird Descriptors and Food Terms -Jug Handle/ Bucket Handle = Zygoma Visualization on Submentovertex Extraoral Plain Skull Films -String of Sausages = Sialodochitis in Sialography -Fruit laden Branchless Tree = Sjogren’s Syndrome in Sialography -Cauliflower Shaped = Calcified Lymph Node -Bullseye/ Targetoid = Phleboliths
Stephens MK
Radiology Final Review (all info and pics directly from Dr. Carter’s slides unless noted otherewise)
Page 17 of 17
Weird Descriptors and Food Terms(cont’d) -Grain of Wheat = Laryngeal Cartilage Calcifications (calcified Triticeous Cartilage) -Tennis Racket = Langerhan’s Cell Disease histology -Tooth Floating in Air = Langerhan’s Cell Disease radiographically -Corkscrew hair growth = Scurvy
