A chance finding of a well defined multilocular lucency in the region of missing #32. There is no expansion of the mandible but small locules can be seen in the buccal cortical plate.
A biopsy is needed as this could be one of a number of possible conditions including an ameloblastoma.
- Dr Douglas K Benn
Maxillofacial Radiologist
Www.ReadCTs.com
Female 32 years chance finding of two asymptomatic dome shaped well defined opacities attached to the floor and outer wall of the right maxillary sinus.
Although I have presented once before a patient with a pseudocyst, these two are such good examples that it is worth while seeing them.
Just to remind you, a pseudocyst is a fluid filled sac of mucosa which is not epithelial lined (definition of a true cyst). It is believed they are caused by a blockage of the duct from a mucous gland in the mucosa and the pressure of the fluid causes a dissection of the mucosa allowing a spherical ball to form.
These are usually asymptomatic and spontaneously burst so no treatment is required.
An 80-year-old lady presented incidental findings of unusual calcifications of the right TMJ. The red arrow shows a triangular opaque “beak” on the anterior surface of the condyle and two circular and one faint curvilinear opacity anterior to the condyle (3 orange arrows).
The latter are probably calcifications of the joint ligament capsule and/or possibly calcifications of the lateral pterygoid muscle. MRI would show better what tissues were involved. However, as the lady is asymptomatic no further investigation or treatment is required.
A 55-year-old female presents with an asymptomatic well defined unilocular lucency 13 mm in diameter. It is partly corticated and there are no signs of an ill defined or “moth eaten” periphery typical of malignancy.
The lucency extends from below the inferior alveolar nerve canal indicating it is not of dental origin.
This is likely a benign Stafe Bone cyst. The name is misleading as this is not a true cyst but most likely a region of salivary gland tissue.
Sometimes it can contain vascular tissue and fat.
A follow-up panoramic in 12 months can be made to confirm lack of change and no further treatment is needed.
It has been suspected for over 100 years that oral sepsis is associated and probably causes many systemic diseases (Hunter 1900). In recent years there have been many papers describing strong associations between chronic periodontal disease and cardiovascular disease (REVIEW: Hayashi et al 2010).
The dental profession is becoming aware of the importance of preventing and treating chronic periodontal diseases. However, less well known is the association between chronic apical periodontitis and cardiovascular disease (CVD). In 2012 Pasqualini D et. al. published an important paper showing an association between apical periodontitis and CVD which makes perfect sense since many of the same organisms found in periodontal diseases are found in apical disease.
For many years, as a radiologist, I have seen and reported on the presence of apical radiolucent areas as “probably apical granuloma and possibly a radicular cyst” as shown in the images below of two lesions seen in the same patient.
Fig 1 #30 mesial apex with 5 mm lucency.
Fig 2 #30 mesial apex with thin panoramic slice to reveal the true extent of the lucency.
Fig 3 Same patient as figs 1 and 2 #3 mesiobuccal apical lucency 6 mm in diameter with associated mucosal thickening of the floor of the right maxillary sinus
Recently I have decided that the research literature is showing such high association between oral infections and other systemic diseases that I would be failing in my reports just to state that oral sepsis is present. When I see a large cyst or possible malignant tumor I always add a recommendation such as “a biopsy and/or consultation with an oral surgeon is advised.” Carotid artery calcifications I recommend “the patient and their MD should be informed” so that they can decide if an ultrasound examination is needed. Apart from providing the best care for the patient it also ensures that you avoid the possible legal situation of failing to diagnose and appropriately deal with a serious medical condition. With regard to apical lucencies I now write “There is an association between chronic apical periodontitis and coronary heart disease (Pasqualini D et. al. Association among Oral Health, Apical Periodontitis, CD14 Polymorphisms, and Coronary Heart Disease in Middle-aged Adults. Journal of Endodontics 2012 38 (12) 1570-1577).”
“The times they are achangin” (Bob Dylan 1964)…….
Hunter W (1900). Oral sepsis as a cause of disease. Br Med J 2: 215.
Hayashi C et. al. (2010). Pathogen-induced inflammation at sites distant from oral infection. Molecular Oral Biology 25 305-316.
Pasqualini D et. al. (2012) Association among Oral Health, Apical Periodontitis, CD14 Polymorphisms, and Coronary Heart Disease in Middle-aged Adults. Journal of Endodontics 38 (12) 1570-1577.
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Dr. Douglas K Benn
Tonsiliths are calcifications of tonsilar lymphoid tissue which are normally seen in the superficial layers of the lateral pharyngeal walls.
Usually they are less than 2 mm in size.
Prevalence is reported as only 4% in pans.
However, I see them much more frequently in CBCTs at about 15-20% of adult scans. They can be associated with halitosis. The main concern is not to confuse these with carotid artery calcifications which are approximately halfway between the pharynx and the facial surface at a level of cervical vertebra junction C3-C4.
In the images below, the tonsiliths are at the level of C2-C3 and just below pharyngeal airway surface.
Inline image 1
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Dr. Douglas K Benn
Communication of radiation risk to a patient is part of the process of
informed consent. In order to achieve this there are some fundamental
goals to achieve - the amount of radiation, the risk in terms of fatal
cancer and comparing those risks to everyday activities a patient
chooses to perform.
Risk versus benefit is the keystone to understanding when it is appropriate to expose a patient. This can be demonstrated by the case of when is it appropriate to expose a
pregnant woman? If a pregnant woman presents for dental examination and has no clinical signs or symptoms of disease then radiation exposure should be delayed until after the baby is born.
However, if a woman who is 10 weeks pregnant presents is complaining of a vague pain on the right side of the face and no clinical cause for the pain can be found, then is quite appropriate to take a panoramic radiograph to see if an unerupted third molar is present. If one is present and further palpation reveals a tender area from pericoronitis then prescribing an antibiotic, referral to an Oral Surgeon for a removal under local anesthetic when the acute infection has subsided, is the
management of choice.
Failure to diagnose the pericoronitis through avoiding an appropriate radiographic examination could have led to a delay in treating the acute infection which could have become severe with fever, swelling, abscess formation and its drainage under a
general anesthetic (GA). GAs are potentially more hazardous with a
risk of death 7 in 1,000,000 (1) to a woman and her fetus than a
panoramic radiograph with a 1 in 1,000,000 of causing fatal cancer
(2). In this situation there is a clear benefit to risk ratio for a
radiographic examination.
How much risk of fatal cancer is associated with dental radiographic
examinations?
Full mouth series (20 exposures) digital sensors or F speed film with
a rectangular collimator is 2 in 1,000,000. A collimator is a tube
that reduces the spread of x-rays reducing risk. A rectangular
collimator is better than a round one.
Full mouth series (20 exposures) digital sensors or F speed film with
a round collimator is 9 in 1,000,000.
* Full mouth series (20 exposures) D speed film with a round
collimator is 21 in 1,000,000.
Digital panoramic radiograph is 1 in 1,000,000.
Digital cephalometric radiograph 0.3 in 1,000,000.
These are all risks associated with a single examination and if you
have repeated examinations the odds increase proportionally.
How does this compare with a common activity such as driving? In your
lifetime there is a 1 in 113 chance you will die in a car crash (3).
As dentists we are obliged to keep the radiation risk as low as
reasonably achievable (ALARA) and on a population basis 160,000
dentists are likely to produce a few cancer-related deaths per year.
However, if X-rays are used cautiously where the clinical risks are
less than the benefits then X-ray examinations should be performed.
1. Lienhart A et al. Survey of Anesthesia-related Mortality in France.
Anesthesiology 2006; 105:1087–97
2. Ludlow JB et al Patient risk related to common dental radiographic
examinations. JADA 2008;139(9):1237-1243
3. National safety council.
https://www.nsc.org/learn/safety-knowledge/Pages/injury-facts-chart.aspx
(accessed 3/26/2016)
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Dr. Douglas K Benn
Degenerative joint disease is common in the Temporomandibular and other joints such as the cervical vertebrae. This 71-year-old gentleman has a chance finding of a well-defined opacity in the midline in close proximity to the anterior surface of the odontoid process of C2.
This is most likely an osteophyte or calcification of the anterior median ligament. It is of no clinical importance.
Degenerative joint disease is related to age and most people over the age of 50 years have visible signs of degenerative joint disease such as the Osteophyte labeled for C1.
- Dr. Douglas K Benn
Dear Colleagues,
Male, 78, chance finding of multilocular lucencies in edentulous #18
region which had tooth extractions 4 months ago with socket
preservation. Medical history nil relevant.
The CBCT slices below are reconstructed at 0.1 mm intervals so the total thickness of the region
displayed is 0.5 mm. Multiple small well defined locular lucencies can
be seen with some erosion of the internal surface of the buccal
cortical plate. A thorough examination of the rest of the mandible did
not reveal any similar trabecular appearance or cortical erosion.
A biopsy is planned and until the result is known the implant placements
will be delayed.
The differential diagnoses should include:
Odonotogenic keratocyst; Ameloblastoma, Central Odonotogenic Fibroma
and Intraosseous muco-epidermoid carcinoma.
Dr Douglas K Benn DDS PhD
Oral and Maxillofacial Radiologist
