64
DENTINO
JURNAL KEDOKTERAN GIGI
Vol IV. No 1. Maret 2019
THE VARIANCE OF RADIOPAQUE IMAGES COMMONLY FOUND IN
PERIAPICAL LESION USING PERIAPICAL RADIOGRAPHIC TECHNIQUE
(Review article)
Indra G1, Ria F2, Lusi E, Azhari2
1
Residence at Oral and Maxillofacial Radiology Specialist Programme, Faculty of Dentistry, Padjadjaran
University, Bandung, Indonesia
2
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Padjadjaran University
Bandung, Indonesia
ABSTRACT
Background: Two pathological views are presented in radiographic imaging: radiolucency and radiopacity. In
radiographic examination, radiopaque lesions are reported as the most common manifestation to be found.
Opaque lesions are displayed into various depictions thus more specific examination is required to distinguish
respective lesions. Objectives: Investigate radiopacity aspect of periapical lesions using literature review to aid
dental practitioners obtain final diagnosis, differential diagnosis, and identification of each periapical opaque
lesion. Discussion: Assessing respective matter about lucent and opaque lesion images in periapical tissue, this
review resulted in the identification of elusive characterization in each opaque lesion. Conclucion:
Radiographically, each diagnosis possesses particular characteristic which differ each periapical opaque lesion
from another.
Keyword: Opaque lesion characteristic, periapical opaque lesion, periapical radiograph
Correspondence: Indra Gunawan, c/o: Residence of Oral and Maxillofacial Radiology Specialist Programme,
Faculty of Dentistry, Padjadjaran University, JL Sekeloa Selatan 1 Bandung, Indonesia. e-mail:
[email protected]
INTRODUCTION For many radiologists, radiopaque lesion of
jaw bone is known as terra incognita, the Latin term
Inflammatory lesion in periapical region is a for "unknown land". Jaw lesions mostly depict
local response of bone surrounding dental apex to radiolucent appearance, such as periapical (radicular)
periapical tissue destruction which induced by the cyst, folicular (dentigerous) cyst, ceratocyst
expansion of periodontal disease. Infectious agents odontogenic tumor (previously known as
from necrotized pulp spread via root apex to promote odontogenic keratocyst), and ameloblastoma; which
inflammatory reaction in surrounding bone. 1 This are well-explained in radiological literatures. Yet
frequently affects alveolar bone in periapical region radiopaque presentations of jaw lesion are
or surrounding teeth.2 This periapical lesion is continuously gained less attention. Radiological
identified as an abnormality around root apex, diagnosis of periapical and jaw lesions are obtained
periodontal membrane and alveolar bone. 2,3,4 through several imaging aspects such as attenuation,
Commonly began with inflammation or necrosis of margination (narrow or wide transition zone) and the
the pulp, this condition then progressively circulate interrelation with adjacent teeth.6
inflammatory mediators through apical foramen to
initiate the development of periapical lesion.2,5 Causing resorption in periapical bone
Traditionally, periapical radiograph has been structure, progressive phase of inflammatory
clinically used to diagnose periapical pathology. 18 condition can be identified by radiolucent lesion in
Indra G: The Variance Of Radiopaque Images Commonly 65
radiographic examination.19 Radiopaque lesion may osseus dysplasia usually progresses in the anterior of
also be identified near dental apices and should be mandibula and merely includes one or several teeth.
discerned, as it is possibly progressed from Other restricted manifestation occured in posterior
endodontic and non-endodontic problem.20 region of the jaw, commonly affects molar tooth, is
entitled as focal cemento-osseus dysplasia. Cemento-
The purpose of this review is to discuss about osseus dysplasia itself typically involves two or
radiopacity aspect of periapical lesion through more jaw quadrants.
literature review and assist dental practitioner obtain
final diagnosis, differential diagnosis, and In radiographic presentation, initial lesion
identification of each periapical opaque lesion. manifests as a lucent area which developed into a
combination of lucent and opaque lesion and
This article elucidates four common lesions frequently with central calcified area. Initial lesion
frequently found in dental practice, comprised of: (lucent) may be confounded by periapical
cementoblastoma, cemento-osseus dysplasia, inflammatory lesions like cyst, granuloma, and
condensing osteitis/periapical sclerosing osteitis and abscess. Differ from other inflammatory lesions,
hypercementosis. These lesions are reported as the cemento-osseus dysplasia/cementoma is usually
most common lesion to be found in periapical associated with unrestored vital teeth, intact
region.6 periodontal ligament and lamina dura, and visible
calcified epicenter.8
Cementoblastoma
Cementoblastoma frequently occurs among
adolescent and children under age 20 (50%) and
under 30 (75%). The incident varies from less than
1% to 6.2% among other odontogenic tumors. More
than 75% cementoblastomas are developed in
mandibula where 90% progressed in mandibular first
molar or second premolar area. Radiographically,
cementoblastoma appeared as sclerotic periapical Figure 2. Progression of cemento-osseus dysplasia
lesion with clear and sharp border surrounded by (left to right)
round radiolucency which attached closely to dental
root.6 Lesion progression is comprised of three
phases, where initial phase presented as
radiolucency, followed by radiolucent image with
patchy opacity inside radiolucent structure. The last
stage is depicted by compact radiopaque lesion
surrounded by thin radiolucent line.9
Cemento-osseus dysplasia possesses a strong
tendency in race and sexes, where most lesions occur
among Black and Asian females in fourth or five
decade of life. Only focal variant frequently reported
Figure 1. Round sclerosing and opaque lesion in in White female. Cemento-osseus dysplasia often
dental periapical region with clear and sharp border manifests with no noticeable symptoms yet it
surrounded by round radiolucent area. manifests with blunt pain. This lesion can also be
mystified by osteomyelitis and drainage of necrotic
Cemento-osseus dysplasia bone debris in oral cavity or skin surface through
osteocutan sinus.6
Cemento-osseus dysplasia is hamartomatosed
process which frequently related with dental apex.
Presented in many clinical variations, respective
terminology becomes quite confusing. Cemento-
66 Dentino (Jur. Ked. Gigi), Vol IV. No 1. Maret 2019 : 64-68
Condensing osteitis/periapical condensing osteitis Condensing osteitis/periapical sclerosing
osteitis occurs in child and adolescent, frequently in
Condensing osteitis (CO), known as focal mandibular premolar and molar. This is a localized
sclerosing osteomyelitis, is a persistent, form of osteitis and reactive sclerosis which
asymptomatic, pathological change in bone structure surrounds dental apex persisted with pulpitis or pulp
which considered as a response upon long-term necrosis. Adjacent tooth commonly present the
inflammatory stimulus and low-grade stage of widening in periodontal ligament or the presence of
inflamed or necrotized pulp.10 periapical inflammatory lesion (like granuloma, cyst
or abscess). In radiographic image, condensing
osteitis/periapical sclerosing osteitis appears as non-
expansive, uni or multifocal periapical sclerotic
lesion, with ill-defined margin related to dental
caries.6
Biopsy is not required to diagnose CO. It is
assessed based on clinical manifestations and
radiographic image where root canal treatment is
considered as selected treatment.11
Hypercementosis
Hypercementosis is an excessive non-
neoplastic cementum deposition blend with normal
root cementum.12 In most cases, etiologic factor
remains unknown. The lesion progressed in supra-
erupted teeth as the consequence of antagonist tooth
loss. Another cause of hypercementosis is
inflammation, which commonly induced by
scleroting ostetitis. This lesion is sometimes
Figure 3. Condensing osteitis (CO): CBCT exposed associated with hyper-occlusion or tooth fracture .1
a diffuse radiopaque lesion in the apex of mandibular
molar (arrow) (D), adjacent to inflammatory Hypercementosis generally requires no
periapical lesion (arrow) (E). treatment. Any dental intervention therapy, be it
tooth extraction, endodontic or orthodontic therapy,
will demand adequate preventive measure to avoid
further complication generated from this condition.21
Figure 4. Presentation of ill-defined border with
progressive transition from condensed (short arrow)
to normal trabecula near alveolar crest (long arrow)
Indra G: The Variance Of Radiopaque Images Commonly 67
varied in size, 2-3 mm in diameter. Internal structure
presents radiopaque image surrounded by thin
radiolucent. It is located in the apical of mandibular
first permanent molar and sometimes in the
premolar. Large attachment in dental root may cause
localized extension of cortical plate. The incident
occurs between age 8 and 44 with average age of 20.
Cemento-osseus dysplasia is presented as
round, small-sized unilocular lesion in vital teeth,
around 5-6 mm. Internal structure is divided into 3
stages: radiolucent, patchy opacity in radiolucent,
and radiopaque surrounded with radiolucent.
Common location is in the apical of vital lower
incisiv. It does not generate reposition of adjacent
tissue. The incidence commonly found in middle-
aged adult.
Scleroting/condensing osteitis occurs in
Figure 5. Enlarged root surrounded by radiolucent in
non-vital teeth (large caries) in irregular form.
PDL space and adjoining intact lamina dura. This
Internal structure expresses irregular and diffuse
enlargement may possibly progressed as
radiopaque, located commonly in mandibula
cementoblastoma
premolar and molar. It is typically found in adult in
DISCUSSION three to seven decade without any difference in sex
predilection.
Tooth-associated lesion can be found in
periapical (around dental apex), interapical (between Hypercementosis demonstrates an
apex of two adjacent teeth), or pericoronal (around enlargement image around affected root. The tooth
dental crown) area. Pericoronal lesions are may be vital or non-vital with different size and form
originated from ectoderm-derived component of adjusting the root shape. Internal structure presents
enamel organ (ameloblast). Periapical lesions radiopaque area with well-defined border located in
generally progress from endodontal or periodontal or affected root cementum. Hypercementosis are
ectodermal of dental papilla (odontoblast) or follicle mostly found in Indian population and usually
(cementoblast, fibroblast and osteoblast) of related with one or more local and systemic factors.
inflammatory disease area.6,13 The incident of hypercementosis based on race and
population are not yet able to determine. Mandibular
Inflammatory changes in periapical bone molar is the most frequent tooth to be affected,
structure are the consequence of root canal system followed by mandibular second premolar, upper first
infection and the result of osteoclastic or osteoblastic premolar and lower first premolar.22 Clinical aspect
activity. These changes are identified by like pulp sensibility and vitality test mostly assist the
radiographic examination in the presence of assessment of periapical change originated from
radiolucent or radiopaque image.14 Changes in bone inflammatory or non-inflammatory causes.23
structure may be presented in inflammatory,
neoplastic, displastic, and metabolic lesions. 15-17 There are several variances used to guide
Radiolucent area is frequently identified with root the assessment of clinical and radiological findings
canal infection yet radiopaque lesion may also be which is remarkably convenient in daily practice as a
induced by similar causation hence equal concern dentist. Cone-Beam Computed Tomography (CBCT)
should be given to prevent misdiagnosis. is also a significant tool for diagnosis in dentistry,24
which enable the detection of periapical lesion with
Cementoblastoma commonly resembles a high accuracy compared to periapical and panoramic
golf ball attached on the root of vital tooth which technique. CBCT characteristics and overall
68 Dentino (Jur. Ked. Gigi), Vol IV. No 1. Maret 2019 : 64-69
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multi-dimensional examination thus clarify accurate Acemoglu H. The frequency and
location of periapical lesion, bone resoprtion or bone characteristics of idiopathic osteosclerosis
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