Oral Radiograph Interpretation

Re: Oral Radiograph Interpretation

Evelyn Barbour-Hill — Fri, 17 May 2013 13:10:13 GMT

[quote user="Iain McAllister"] x-ray machine (The Curie One - a fine model in it's day) [/quote]

I have seen this, in the Madame Curie museum. I'd recommend it, if you find you have a couple of hours spare in Paris.

Re: Oral Radiograph Interpretation

Iain McAllister — Fri, 17 May 2013 11:00:33 GMT

Wow - you don't log in for a week and all hell breaks loose!

[quote user="Evelyn Barbour-Hill"]His radiographs are not very good but clearly they are the best he can obtain (he's a locum, remember?)[/quote]

Yes I am "only" a locum (smiley to indicate that I am not taking this too seriously....) working with a medieval x-ray machine (The Curie One - a fine model in it's day) and no non-screen film - so had to force the smallest plate in the practice deep into the dogs's mouth - probably causing TM joint damage in the process - but that's another story - then I had to photograph the radiograph with a Box Brownie while it was stuck to their decrepit viewer -in the circumstances I thought the radiographs were not too bad - I have taken much worse believe me!

PS thanks to EBH for being my spokesperson in my absence - I would remunerate you but you patently earn far too much already - let's hope HMRC don't monitor these forums...

Re: Oral Radiograph Interpretation

Malcolm Ness — Fri, 17 May 2013 10:33:03 GMT

What is the difference between God and a dentist?

God doesn't think that she is a dentist.

Re: Oral Radiograph Interpretation

Bob Russell — Fri, 17 May 2013 09:40:28 GMT

Not sure why the antagonism. Evelyn has made sensible comments and opinions based on the radiographs. There is clear pathology, the X-rays do not give a conclusive diagnosis (rarely do!).

Treatment options outlined by Evelyn are sensible, affordable and include biopsy to try to rule out neoplasia.

This is a veterinary forum, money and facilities to investigate are often limited therefore human dental 'rules' do not always apply.

A more helpful attitude, less condescending would be very much appreciated as veterinary dentistry, whilst having moved forward massively in the last decade has a lot to learn! It might lead to fewer red stars as well!

All my opinion of course!

Re: Oral Radiograph Interpretation

Evelyn Barbour-Hill — Thu, 16 May 2013 22:35:10 GMT

[quote user="Pynadath George"] In terms of attacking you; the world doesn't revolve around you.[/quote]

Yes it does.

I am the absolute fount of all knowledge, so naturally any post that queries my utterly infallible answers, even by implication, must be severely condemned.

Further, I make absolute pots of money by maintaining my reputation as the absolute fount of all knowledge so any detraction, even inadvertent, must be viciously dealt with.

Above all, I have a quite enormous ego which I cannot allow to be traumatised, it is far too important to me.

Seriously chum, just lighten up a bit. Think a little about what you write and how it might appear to others, bearing in mind that a written post gives no indication of tone of voice, facial expression or body language.

And yes, if I have criticised you unfairly, or disregarded my own strictures just mentioned, I apologise.

Otherwise my friends will wait upon you. Pistols, please.

Re: Oral Radiograph Interpretation

Pynadath George — Thu, 16 May 2013 20:27:16 GMT

Who said the op asked for a lecture or tutorial?? You're the only one who keeps mentioning this. If you assumed he gave all the info, well the bully for you. It doesn't mean I can't ask further questions does it? That's the whole point of this forum. To discuss cases. If the op feels a certain way then I'm pretty sure he is an adult and can speak for themselves. Why do you feel to be his spokesperson in this?? It's not just your opinion that matters here. I'm posting to ask questions to discuss a case. You don't need to tell me what's fine to post or what to post on here. In terms of attacking you; the world doesn't revolve around you. You aren't a focus in my life. I'm sorry if this disappoints you as you obviously seem to think otherwise. If you actually look back at the posts, I asked genuine questions only to be pounced by you. Not that I'm particularly bothered. But I find it amusing you feel I'm attacking you. If you want to discuss this further I'm sure you can contact me privately instead of on this thread as there is no relevance to it.

Re: Oral Radiograph Interpretation

Evelyn Barbour-Hill — Tue, 14 May 2013 00:46:42 GMT

[quote user="Pynadath George"]Thank you for that. I'm not too sure what the head banging in the wall is about. My whole point was you gave just 2 things for a differential diagnosis from very little clinical signs and symptoms and from just 1 radiograph of one view. Obviously you can't diagnose from a radiograph. I couldn't understand why you would give just 2 possible causes from such little info. Yet you are the one who feels like banging their head on a wall???

[/quote]

Jeez.

The OP didn't ask for a lecture, tutorial or seminar. He wanted to know on what lines he should be thinking and what he should do (or not do) next. I assumed he gave us all the information he could because that's what you do on this forum. His radiographs are not very good but clearly they are the best he can obtain (he's a locum, remember?) Anyway I offered what comments i could based on his information. I didn't "give just two things for a differential diagnosis". I don't know where you got that idea but I can't say I care too much. If you are posting to give some help to the OP, that's fine, but I suggest you couch it in terms that are more tactful and less critical of the OP. If you are posting in order to open a general discussion, that's fine too but again remember to be tactful and not critical. If you are posting in order to attack me, that's also fine so by all means carry on.

Re: Oral Radiograph Interpretation

Pynadath George — Mon, 13 May 2013 18:15:48 GMT

Thank you for that. I'm not too sure what the head banging in the wall is about. My whole point was you gave just 2 things for a differential diagnosis from very little clinical signs and symptoms and from just 1 radiograph of one view. Obviously you can't diagnose from a radiograph. I couldn't understand why you would give just 2 possible causes from such little info. Yet you are the one who feels like banging their head on a wall???

Re: Oral Radiograph Interpretation

Evelyn Barbour-Hill — Sun, 12 May 2013 22:52:27 GMT

Sigh.

One thing that irritates the hell out of me is people posting in capital letters. However I'll accept your apology.

If you want to quote and then reply, what you do is select the words you wish to quote and then hit "Quote this post"

[quote user="Pynadath George"] I can't put links to the databases I belong to[/quote]

Like that.

Another thing that irritates the hell out of me is being lectured. Especially by people who know less than I do about what I'm discussing..

[quote user="Pynadath George"]why not think of ameloblastoma, bony haemangioma, dentigerous cyst , osteosarcoma[/quote]

It isn't a dentigerous cyst. The signalment's wrong, the gross appearance is wrong, the radiographic appearance is wrong.

Ameloblastoma, bony haemangioma, osteosarcoma.............. come under the heading of neoplasia in my book.

[quote user="Pynadath George"]

Not so much likely as certain. But the point is that the OP must not jump to the conclusion that that is the whole story and the cause of the whole condition we see here. Maybe it is, and that would be great because it would mean that extractions would be curative. Or maybe it isn't..........

IF YOU THINK IT'S PERIAPICAL PATHOLOGY FOR CERTAIN WHY EVEN JUMP TO NEOPLASM?? THAT IS WHAT IM GETTING AT.[/quote]

Sigh again.

There is certainly periapical pathology of endodontic origin on 404.. What we don't know for certain is that this is the whole cause of the whole condition of this jaw. There might even be two, or even three, separate diseases going on. Biopsies would be highly advisable. ( Did i mention that?) Biopsy would of course pick up the rare as well as the common.

[quote user="Pynadath George"]

I was assuming that the OP had given all the information he could, so the answers to most of those questions would be "normal" or "no". However perhaps he will answer your questions himself.HENCE WHY THE QUESTION IS DIRECTED TO HIM. HE MAY HAVE FURTHER DETAILS WHICH HAVEN'T BEEN PUT DOWN.WHY NOT LET HIM RESPOND?

[/quote]

He may indeed wish to. But at the moment thee and me are online and he is not.

[quote user="Pynadath George"]YES AND THIS IS A OPEN FORUM FOR DISCUSSION.NOT JUST FOR ONE PERSON TO STATE SOMETHING AND FOR IT TO BE TAKEN AS GOSPEL. [/quote]

I could not agree more. I absolutely agree.

And when someone posts for practical advice and help, that's what they want. If you think we have misled the OP, I and probably all of us are ready to stand corrected.

[quote user="Pynadath George"]

[quote user="Pynadath George"] Neoplasia generally causes root resorption., which isn't present.[/quote]

Not always so at all.HENCE WHY I SAID GENERALLY.

[/quote]

I'd dispute even the "generally" in this context.

[quote user="Pynadath George"]YET YOU HAVEN'T DESCRIBED WHAT IN THE RADIOGRAPH MAKES YOU THINK IT'S A NEOPLASM BUT NOT ANY OTHER TYPE OF GROWTH?

[quote user="Pynadath George"]What makes you think radio graphically it looks neoplastic? [/quote]

Because it does.AGAIN NOT REALLY BACKED UP WITH ANYTHING BUT YOU SAYING "BECAUSE"

[/quote]

OK, let's be more scientific. There are three separate areas of bone loss or rarefaction (which may or may not be interconnected). Of the one in the vicinity of the apex of 404 I have already pointed out the features, so if you'll let me I'll leave that one. In the incisor region is a large rounded area of apparent complete bone loss (it may not be complete, this may be the effect of the radiographic exposure chosen) which does not have very defined edges but shades off into more straggly demineralisation. Around the apex of 304 is a vague and ill-defined area which just does not look normal, with some demineralisation or vague bone loss, and possibly a couple of small linear dense flecks, while the adjacent cortex appears to bulge a little; some of this may be artefact of exposure or positioning, but the bone loss is probably genuine, considering the clinical findings on probing 305 by the OP.

The differential diagnoses of each of these lesions would include neoplasia (of many kinds, but the appearance suggests a neoplastic disease which is destructive and invasive rather than expansile), obscure rare and poorly-understood tumours which are not neoplastic, abscess, osteomyelitis and probably a few other things.

Just as you cannot tell by looking at it with the naked eye exactly what species a tumour is, you cannot tell by looking at the radiographic appearance here for sure what is going on.

Re: Oral Radiograph Interpretation

Pynadath George — Sun, 12 May 2013 20:02:25 GMT

I wasn't trying to be patronising. I was genuinely stating that I can't put links to the databases I belong to!

Re: Oral Radiograph Interpretation

James Laidlaw — Sun, 12 May 2013 19:40:33 GMT

You can always tone down a little on the patronising if you like.

Re: Oral Radiograph Interpretation

Pynadath George — Sun, 12 May 2013 19:31:10 GMT

The links I put up quickly. You can actually see peer reviewed stuff if you do a search. Unfortunately I can't put links to peer reviewed stuff as you won't have membership to the databases I belong to.

Re: Oral Radiograph Interpretation

Pynadath George — Sun, 12 May 2013 19:20:23 GMT

Hi James Differential diagnoses include rare and common stuff. Not just common stuff. Provisional diagnosis can be made with more clinical signs and symptoms and special tests. Definitive diagnosis can only be made with biopsy.

Re: Oral Radiograph Interpretation

James Laidlaw — Sun, 12 May 2013 18:56:41 GMT

I'm not sure about all the links - one looks a bit "www" to me rather than scientific/peer review. Dentigerous cyst isn't really possible as all the teeth look to be present and not in an abnormal position, and the OP didn't note any missing teeth. The other link is a human case in a single patient. Others would know better than me how common or uncommon these things are, but I'd expect "not very" at best.

Re: Oral Radiograph Interpretation

Pynadath George — Sun, 12 May 2013 18:43:35 GMT

Totally agree, but these differentials do happen in dogs. Hence the links added.

Re: Oral Radiograph Interpretation

James Laidlaw — Sun, 12 May 2013 18:40:57 GMT

I don't think human dentistry extrapolates directly to veterinary dentistry. Hence Evelyn's "tone". Common things happen commonly, but common in one species can be completely different from another.

Re: Oral Radiograph Interpretation

Pynadath George — Sun, 12 May 2013 18:17:12 GMT

On another note my apologies in using capital letters. I'm not sure how to reply to posts properly with quotes. To carry on ... If you were thinking along vascular and neoplasia and cysts for differential diagnosis lines then why not think of ameloblastoma, bony haemangioma, dentigerous cyst , osteosarcoma etc etc http://www.sciencedirect.com/science/article/pii/S0099239905608977 http://veterinarymedicine.dvm360.com/vetmed/article/articleDetail.jsp?id=160624&sk=&date=&pageID=2 http://www.vetxray.com/anitem.cfm?AnnID=1467 Evelyn I'm not sure why your posts have the tone they have. But it says more about you than me.

Re: Oral Radiograph Interpretation

Pynadath George — Sun, 12 May 2013 18:06:43 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Pynadath George"]Why have you ruled out rct now but it would've been ok 10 yes ago?[/quote]

It should have been done ten years ago. NOT REALLY A ANSWER WITH A DECENT REASON. Now, with this horror of a jaw, yes (assuming everything here arises originally from endodontic disease in the one broken tooth - big assumption) it might possibly cure the whole disease condition given sufficient time and sufficient owner resolve but we don't have either of those. Practicalities.

[quote user="Pynadath George"]Why give only differential diagnoses of neoplasm or periapical infection? How about other cysts and tumours?[/quote]

Because we are sticking to the likely stuff.And the signalment. And it doesn't have the appearance of any cysts of the dog that I know of. (If there is some obscure lesion of the dog that I haven't heard of that has an appearance exactly like this, I'm always ready to stand corrected.)

YET YOU HAVEN'T DESCRIBED WHAT IN THE RADIOGRAPH MAKES YOU THINK IT'S A NEOPLASM BUT NOT ANY OTHER TYPE OF GROWTH?

[quote user="Pynadath George"]What makes you think radio graphically it looks neoplastic? [/quote]

Because it does.AGAIN NOT REALLY BACKED UP WITH ANYTHING BUT YOU SAYING "BECAUSE"

[quote user="Pynadath George"] Neoplasia generally causes root resorption., which isn't present.[/quote]

Not always so at all.HENCE WHY I SAID GENERALLY.

[quote user="Pynadath George"] Why section a mandible without taking a simple biopsy[/quote]

I quite agree, but I guess the poster was just thinking aloud, as it were.

[quote user="Pynadath George"]Why would you think this is chronic periodontitis in a apical region of a tooth?[/quote]

You wouldn't. THIS WAS DIRECTED TO THE PERSON WHO MENTIONED IT.

[quote user="Pynadath George"] I personally think this looks like just a periapical association with a tooth with a very large pulp and pulp horn close to the incisal tip.[/quote]

Sure. The tooth was injured ten years ago and the pulp has been dead ever since! And unquestionably periapical pathology has been creeping up ever since.

[quote user="Pynadath George"] (Look at the same tooth the other side with a very sclerosed canal in comparison)[/quote]

That's a normal eleven year old tooth. As I think the OP appreciated.

[quote user="Pynadath George"]Likely pulpal necrosis and associated apical pathology.[/quote]

IF YOU THINK IT'S PERIAPICAL PATHOLOGY FOR CERTAIN WHY EVEN JUMP TO NEOPLASM?? THAT IS WHAT IM GETTING AT.

[quote user="Pynadath George"]Any more intra oral signs? Expansion of jaw? How's the mobility of the teeth? What are the pocket depths of the teeth? Is there bleeding on pocket probing? How much bleeding? Is it delayed bleeding or profuse? What colour is the overlying mucosa? Any fistula/ sinus? If not a periapical infection could drain periodontally through the gums. Could you place a radio opaque thin instrument into the pocket and then take an X-ray to see where it is going to? Are there any other radiological views you could take?[/quote]

He wanted help and practical advice as to what to do next. I hope he got it.YES AND THIS IS A OPEN FORUM FOR DISCUSSION.NOT JUST FOR ONE PERSON TO STATE SOMETHING AND FOR IT TO BE TAKEN AS GOSPEL. This isn't a tutorial. I can do those elsewhere.I DON'T THINK ANYONE HAS ASKED YOU FOR A TUTORIAL SO I DON'T UNDERTSAND YOUR COMMENT? I'VE ASKED YOU SOME QUESTIONS TO JUSTIFY YOUR THOUGHT PROCESS.WHICH HAS BEEN ANSWERED WITH "BECAUSE".

[/quote]

Re: Oral Radiograph Interpretation

Evelyn Barbour-Hill — Sun, 12 May 2013 17:41:35 GMT

[quote user="Pynadath George"]Why have you ruled out rct now but it would've been ok 10 yes ago?[/quote]

It should have been done ten years ago. Now, with this horror of a jaw, yes (assuming everything here arises originally from endodontic disease in the one broken tooth - big assumption) it might possibly cure the whole disease condition given sufficient time and sufficient owner resolve but we don't have either of those. Practicalities.

[quote user="Pynadath George"]Why give only differential diagnoses of neoplasm or periapical infection? How about other cysts and tumours?[/quote]

[quote user="Pynadath George"]What makes you think radio graphically it looks neoplastic? [/quote]

Because it does.

[quote user="Pynadath George"] Neoplasia generally causes root resorption., which isn't present.[/quote]

Not always so at all.

[quote user="Pynadath George"] Why section a mandible without taking a simple biopsy[/quote]

I quite agree, but I guess the poster was just thinking aloud, as it were.

[quote user="Pynadath George"]Why would you think this is chronic periodontitis in a apical region of a tooth?[/quote]

You wouldn't.

[quote user="Pynadath George"] I personally think this looks like just a periapical association with a tooth with a very large pulp and pulp horn close to the incisal tip.[/quote]

Sure. The tooth was injured ten years ago and the pulp has been dead ever since! And unquestionably periapical pathology has been creeping up ever since.

[quote user="Pynadath George"] (Look at the same tooth the other side with a very sclerosed canal in comparison)[/quote]

That's a normal eleven year old tooth. As I think the OP appreciated.

[quote user="Pynadath George"]Likely pulpal necrosis and associated apical pathology.[/quote]

I was assuming that the OP had given all the information he could, so the answers to most of those questions would be "normal" or "no". However perhaps he will answer your questions himself.

He wanted help and practical advice as to what to do next. I hope he got it. This isn't a tutorial. I can do those elsewhere.

Re: Oral Radiograph Interpretation

Pynadath George — Sun, 12 May 2013 10:54:45 GMT

Any more intra oral signs? Expansion of jaw? How's the mobility of the teeth? What are the pocket depths of the teeth? Is there bleeding on pocket probing? How much bleeding? Is it delayed bleeding or profuse? What colour is the overlying mucosa? Any fistula/ sinus? If not a periapical infection could drain periodontally through the gums. Could you place a radio opaque thin instrument into the pocket and then take an X-ray to see where it is going to? Are there any other radiological views you could take?

Re: Oral Radiograph Interpretation

Pynadath George — Sun, 12 May 2013 10:41:00 GMT

Just a few questions. Why have you ruled out rct now but it would've been ok 10 yes ago? Why give only differential diagnoses of neoplasm or periapical infection? How about other cysts and tumours? What makes you think radio graphically it looks neoplastic? Neoplasia generally causes root resorption., which isn't present. Why section a mandible without taking a simple biopsy? Why would you think this is chronic periodontitis in a apical region of a tooth? I personally think this looks like just a periapical association with a tooth with a very large pulp and pulp horn close to the incisal tip. (Look at the same tooth the other side with a very sclerosed canal in comparison).Likely pulpal necrosis and associated apical pathology.

Re: Oral Radiograph Interpretation

Bob Russell — Thu, 09 May 2013 17:01:41 GMT

But it isn't hurting therefore it must be OK!

Re: Oral Radiograph Interpretation

Evelyn Barbour-Hill — Thu, 09 May 2013 15:44:08 GMT

[quote user="Iain McAllister"]

...and they didn't show of course - phoned them and they are going to to see how it goes..." - badly I would imagine...

[/quote]

Sympathies. Very frustrating. B***** people.

Re: Oral Radiograph Interpretation

Iain McAllister — Thu, 09 May 2013 14:52:08 GMT

...and they didn't show of course - phoned them and they are going to to see how it goes..." - badly I would imagine...

Re: Oral Radiograph Interpretation

Evelyn Barbour-Hill — Wed, 08 May 2013 19:04:43 GMT

[quote user="Iain McAllister"]

Is there a case for going straight for rostral mandibulectomy at level of 306 406 - prob a shorter GA - no need for prolonged antibosis - will probably cure if we have a relatively non-invasive tumour...

[/quote]

I see what you are getting at but no, I would not have thought so. If it's a more invasive tumour that might not cure it. If it's not neoplastic mandibulectomy would be unnecessary.

I don't know if it would be a shorter GA, but I am unable to get excited about differences in GA time anyway.

Antibiotic administration might not be necessary at all, although I confess I would not try the experiment. A reasonably ordinary length of course would be enough, surely? And if it turns out to need prolonged antibiotic administration......... is that a big problem?