bone loss radiographic techniques

1. D R G A U R I K A P I L A
M D S S T U D E N T
D E P A R T M E N T O F P E R I O D O N T O L O G Y A N D
O R A L I M P L A N T O L O G Y
Correlation of the interdental and the
interradicular bone loss:
A radiovisuographic analysis
Vishakha Grover, Ranjan Malhotra, Anoop Kapoor,
Chahat Singh Mankotia, Rupika Bither
Journal of Indian Society of Periodontology,
July-August, 2014;18:482-7

2. INTRODUCTION
 Periodontal disease
 If left untreated:
Progressive
bone
destruction
Tooth
mobility
Tooth loss
• “Furcation involvement”
-invasion of the bifurcation and trifurcation areas of multi-
rooted teeth
Main clinical finding
Diagnosis of advanced periodontitis
Less favorable prognosis for affected tooth

3. Contributing factors to the etiology and
compromised prognosis:
 Furcation entrance width
 Root trunk length
 Presence of root concavities
 Cervical enamel projections
 Bifurcation ridges
 Distal location in the arch
 Diagnosis of furcation involvements- enigma, with different
incidence estimates
 Drawbacks further limit the sensitivity and reliability of
furcation diagnosis

4. Diagnosing furcations
 Clinical probing
-Probing force –Angulation –Reference
 Radiographs
-Over or underestimate the amount of bone loss due to
projection errors and lack of three-dimensional
information
-Recognition of a large clearly defined radiolucency in the
furcation area presents no problem, but less clearly defined
radiographic changes produced by initial or early lesions
are often overlooked

5.  Transgingival probing or sounding-
-extent and configuration of the furcation defects
-it must be remembered that the information is still blind,
even though it is better than probing alone
Ross and Thompson (1980)
 Detection of furcation involvement by clinical examination
3% -maxillary, 9% -mandibular molars
 By combination of radiographic & clinical examinations
65% -maxillary, 23% -mandibular molars

6.  Recent techniques
Computed tomography (CT) and Cone-beam
computed tomography (CBCT)
-offer high resolution and are equivalent to macroscopic
evaluation of furcations
-high exposure of radiation to high-risk organs in the skull as
well as the technical difficulties and the costs involved are
still a concern for the routine clinical diagnosis

7.  A simple, less-elaborate, time and cost efficient diagnostic
tool or guide to screen and select such patients and sites
that need careful comprehensive examination, diagnosis
and timely intervention of furcation lesions at their earliest,
so that the best clinic outcomes can be reached out

8. AIM
To correlate the interdental and interradicular bone
loss in chronic periodontitis patients so as to explore
the potential of interdental bone loss as a rough
approximate screening tool for early furcation
diagnosis

9. MATERIALS AND METHODS
SUBJECTS
 50 patients- chronic generalized moderate (4-6mm) to
advanced periodontitis (≥6mm)
 Parameters measured- PPD, CAL and BOP
STUDY PROTOCOL
 Complete history -followed by a detailed clinical
examination
 Purpose and procedure of the study was explained to
patients and an informed consent was obtained

10. INCLUSION CRITERIA
 Moderate to advanced periodontitis patients
 Well-aligned mandibular molars with no spacing, no
crowding, no rotation and no intrusion or extrusion
 Age group of 20-75 years
 Willing to consent for the study

11. EXCLUSION CRITERIA
 Gingivitis
 Medication known to cause a risk for gingival hyperplasia
 Any systemic condition that can cause gingival enlargement
 Surgery in the last 6 months
 Molars with fused roots
 Open contacts or crowding in mandibular molars
 Limited mouth opening
 Orthodontic wire, extensive restorative work, shallow
palatal vault, excessive calculus, no identifiable
cementoenamel junction (CEJ)
 Pregnant women

12.  Mandibular molars with furcation involvement were
included in this study
 The patient was seated in an upright position in the
dental chair and shielded with a lead apron, with
proper adherence to radiation safety standards
 Under aseptic conditions, radiographic assessment
was carried out with the help of radiosvisiography
(RVG) on the mandibular first molars
 Radiovisuographs were taken by the paralleling
technique using holders

13.  Sensor covered with a disposable plastic sheet was
placed into the patient's mouth using a plastic
holding device with an attached ring that projects
out of the mouth
 Patient was asked to bite firmly on to the film-
holding device to keep the film positioned properly
and ensure that it remains stable
 Once the sensor was positioned, the cone of the X-
ray unit was directed toward the sensor using the
ring holder to help guide its position

14.  Then, the sensor was exposed to radiation to obtain the
radiovisuograph RVG keeping the following guidelines in
mind:
1. Radiograph should show the tips of the molar cusps with
little or none of the occlusal surface
2. Enamel caps and pulp chambers should be distinct
3. Interproximal spaces should be open
4. Proximal contacts should not overlap unless teeth are
out of line anatomically
5. All RVGs were evaluated and radiographs that did not
fulfill the above criteria were repeated

15. The following measurements were recorded
Measured by a single examiner to avoid error due to interobserver variation
using the digital software, the “Kodak dental imaging software,” installed
within the RVG

16. STATISTICAL ANALYSIS
 The mean values calculated
Mesial interdental bone loss
Distal interdental bone loss
Interradicular bone loss
• Differences among means were compared- t test
• Correlations for the mesial and the distal interdental
bone loss to the interradicular bone loss were
analyzed- Pearson correlation coefficient which was
considered significant at the 0.01 level

17. RESULTS
Study population of total 50 patients, with a male: female ratio of 2.12:1
and age ranging 20-75 years
The mean values of mesial and distal interdental bone loss and
interradicular bone loss

18. The mean values of interdental and interradicular bone loss

19. Correlation between interdental and interradicular bone loss
was highly significant

20. Scatter Diagram showing correlation between mesial interdental and
interradicular bone loss

21. Scatter diagram showing the correlation between distal interdental and
interradicular bone loss

22. Correlation between interdental and interradicular bone loss based on age
and gender

23. DISCUSSION
 Prevalence –furcation involvement
maxillary -25% to 52%, mandibular -16% to 35%
 Teeth with furcation involvement are 2.5-times more likely
to lose attachment as compared with teeth without
furcation involvement
 Proper diagnosis of the furcation lesion and knowledge of
furcal anatomy are the cornerstones for optimal therapy,
for which the clinician has relied on data from clinical
examinations and radiographs

24. DISCUSSION
With regard to aim & methodology- digital radiography
(RVG) was used in the present study
 speed of image capture and display
 low X-ray exposure
 ability to manipulate the image and maximize diagnostic
efficacy
 use of digital tools (such as linear, angular and density
measurements)
 improved patient education
 ease of storage, transfer and copying and seamless
integration with, electronic patient record management or
other software

25. DISCUSSION
 Results- smallest amount of interradicular bone loss of
approximately 0.80 mm and above was observed only when
the bone loss at the interdental area was equal to or
exceeded 3.70 mm
 In the present study, it was seen that values ranging from
2.40 to 10.50 mm for the mesial and those ranging from
2.90 to 12.90 mm for the distal interdental bone loss were
associated with interradicular bone loss in the range of
0.80-9.70 mm, and both were significantly correlated with
each other (P < 0.001)

26. DISCUSSION
 Corelation –age
 Older people tend to have less bone support
 Corelation –gender
females - mesial
males - distal

27. DISCUSSION
 Assessment of the interdental bone loss can be used as a
screening tool to detect the disease in the earliest stage
 Treatment of furcation involvement in its advanced stage is
complex, expensive, time-consuming
 Correction in its infancy via exclusive periodontal
intervention appears quite promising to upgrade the total
periodontal treatment success

28. DISCUSSION
 With an interdental bone loss of 3-4 mm, a comprehensive
examination of the furcation areas is recommended
 This can be particularly of benefit in cases
-a large number of patients are to be examined, such as in
mass examinations, dental camps and community surveys
-in very busy and heavy clinical practices
-for general dentists so as to select patients for specialist's
referral
-in medically compromised patients, where our focus is to
minimally insult the tissue and reduce the incidence of
bacteremia

29. RELATED ARTICLES
 Popova C, Mlachkova A, Emilov D. Correlation of
interdental and interradicular bone loss-
radiographic assessment. J IMAB- Ann Proc
(Scientific Papers) 2008, book 2. p. 35-7
-the furcation bone loss with ranges of 1 mm and
above were in correlation with interdental bone loss
of above 4 mm

30. LIMITATIONS
 Effects such as root trunk length, root length, root form,
interradicular dimension, anatomy of furcation, cervical
enamel projections and presence of restorations could not
be addressed
 Further studies with larger samples should aim to confirm
these results and to identify the influencing factors

31. THANK YOU