(Systemic Disease): Dental Panoramic Radiography

Journal of Oral Health and Dental Care

Review Article Open Access

zone corresponds to a three-dimensional area in which the structures are Multiple Radiographic Analysis fairly focused or well defined. Thus, the patient should be positioned at (Systemic Disease): Dental the X-ray device should be such that the dental arches are positioned strictly within this cutting area, resulting in a sharp image of the Panoramic Radiography teeth. Thus, each extra oral X-ray panoramic apparatus manufacturer recommends different layers of cutting, because, of course, dental arches are very different around the world. Plauto Christopher Aranha Watanabe*, Vanessa Faria and Angela Jordão Camargo The best and most modern equipment allows reaching the most Department of Stomatology, Public Health and Forensic Dentistry, School of different types of dental arches, always with maximum detail. Dentistry of Ribeirão Preto, São Paulo University, Brazil The Focal Layer is Determinative *Corresponding author: Plauto C. A. Watanabe, Email: [email protected] • From distance of the center of rotation to the central plane of the Received: 16 November 2016; Accepted: 20 January 2017; Published: 27 January 2017 image layer. • For the wide long distance slot, narrow (the narrower the beam, the Abstract highest the layer of the image). The purposes of this report, “Multiple Radiographic Analysis • Changes in film speed changes the position of the image layer. (Systemic Disease), dental panoramic radiography” will be interpreted • Increased film speed = the farthest image rotation center. conditions which are spread out within the body rather than localized strictly to the tissues of the oral cavity. Our main goal is discussing • Decreased film speed = image closer to the center of rotation. different possibilities for analysis and research, highlighting a few So, it is like the image layer is formatted to match the different types different publications in this theme of study, using initial panoramic / shapes of the dental arches. As a rule, the anterior region of the shear radiographic findings which have suggested widespread diseases of layer is narrower. Depending on the manufacturer, the number and significance enough to affect the patient’s longevity and quality of life. position of rotating centers differ. Keywords: Panoramic Radiography; Systemic Disease; Radiographic Analysis Advantages of Panoramic Radiograph • It has a unique dental examination by a panoramic representation Introduction of the stomatognathic system, including temporomandibular joint Panoramic radiography as a radiographic technique that produces (TMJ), styloid processes and maxillary sinuses; an image that includes both maxillary and mandibular dental arches • It allows the detection of functional and pathological relationship and the surrounding structures as the maxillary sinus, nasal fossa, and its effects on the stomatognathic system; temporomandibular joints, styloid processes, and hyoid bone [1]. Although dentists might only concentrate on teeth and their supporting • Provides a document to the treatment and preservation plan; tissues when the examining panoramic radiographs, they should also be able to identify all other structures that appear in the image [2-4]. • Reduces radiation exposure by means of a rotational strategic Panoramic imaging (also called ortopantomography) is a technique system covering a large area (Figure 1). for producing a single image of the facial structures that includes Disadvantages of Panoramic Radiograph both maxillary and the mandibular dental arch and their supporting structures. Paatero and Numata were the first to describe the principles • Patients with extreme dental relations class II and III make it of panoramic radiography [5]. impossible to obtain of great pictures of the segments of anterior teeth; During performance of this technique patient remains motionless • The ratio for the focus-object object-film distance is not the same while the x-ray source and the radiographic sensors move in opposite in all cases, resulting in a factor of constant expansion; direction at one or more centers of rotation. These pivot points can • Precise measurements are questioned; be internal or external focal layers. Focal layer tomography or “focal plane” or “image layer” is the plan which is not blurred in the • Structures that reside outside the focus layer can be superimposed radiographic image. The panoramic radiography or pantomography on normal structures of the jaw and simulate pathology; is produced using tomography curved surface and it is performed by • Technical errors. rotating a narrow radiation beam in a horizontal plane around a point / virtual axis (called rotation center) positioned within the oral cavity. Prior Indications Film / sensor head move in the opposite direction around the patient, who remains static. The blurring is determined by: The Panoramic Radiograph is indicated mainly in the first visit of patients who refer to the dentist for a routine visit and / or specific ● Tube distance; needs such as pain, aesthetics, etc. In addition to this main indication, ● Focal plane distance; panoramic radiographs are usually indicated in situations where there is: ● Film distance; • A real suspicion, based on a clinical examination, extensive and / or active pathology outside the alveolar bone; ● Tube rotation orientation. • Problems with third molars symptomatic in which the likely The rotation center changes as the film / sensor and rotate head, treatment will be followed; allowing the image layer to adapt to the elliptical shape of dental arches. Horizontal and vertical dimensions are correlated only when the object is within a particular zone or cutting plane representing the Copyright © 2017 The Authors. Published by Scientific Open Access Journals LLC. image layer, which is better interpreted as the focal layer. In fact, this Watanabe et al. Volume 1, Issue 1 J Oral Health Dent Care 2017; 1:007

based on the principle of radioprotection ALARA, or either, we must always use the lesser possible amount of radiation for the attainment of diagnostic information of our patients [8]. In addition, panoramic examinations may have the advantage of reduced radiation dose, cost and imaging of a larger area instead of periapical radiographs which have higher resolution in the image, particularly in the search for detail, for example, an accessory root canal. Panoramic radiography is effective in dental diagnosis and treatment planning [1]. Specifically, the status of dental development can be assessed using panoramic radiography. Third molars also should be evaluated in this age group for their presence, position, and stage

Figure 1: Simulation of the beam in fan-shaped collimated output hillock in the X-ray equipment. • Symptomatic problems with third molars with a likelihood that the treatment will be followed; • Assessment for placement of dental implants; • Trauma involving more than one tooth or suspicion of underlying bone damage; • Participation periodontal involving “exchange” widespread with more than 5 mm, in which the equivalent diagnostic information needs more than 3 intraoral radiographs; • Multiple extractions, in which the equivalent diagnostic Figure 2: Areas of interest in the panoramic radiograph for information needs more than 3 intraoral radiographs; radiographic interpretation. • Evaluation of the growth and development of the maxillo- mandibular complex for orthodontics / orthopedic and orthognathic A C surgery. In the context of panoramic radiographic image, there are several areas of interest for analysis / interpretation of extra oral radiographic technique (Figure 2), and the great view of the teeth, that is able to provide rich details in several other regions.

With the arrival of digital images and their image manipulation tools the radiographic Interpretation became more precise, and even increased this capability of diagnosis and radiographic analysis, for B example, enabling the visualization of small carious lesions, excess / lack of material restorers, caries recurrence, etc. (Figure 3). “The Selection of Patients for X-Ray Examination”, US Food and Drug Administration Center for Devices and Radiological Health (FDA/CDRH) guidelines were first published in 1987 spurred by concern about the US population’s total exposure to radiation from all sources. These referential guidelines were updated in 2004 following work by a joint panel of the American Dental Association and FDA [6]. The updated guidelines expanded the use of panoramic examination as an alternate baseline dental radiographic examination, recognizing that

panoramic technology has improved. The latest version is the Dental Radiographic Examinations: Recommendations for Patient Selection Figure 3: Digital panoramic images demonstrating some image and Limiting Radiation Exposure (revised 2012) [7]. The authors manipulation tools such as zoom (A and C), and Smart sharpening highlight that the panoramic x-ray is used in the routine of all the application filter (B) that allows you to analyze details such as types of patients. Its use also has endorsement of “Ordinance 453 of decay, lack / excess restorative materials, and bone quality (cortical the Health Department – ANVISA – Brazil”, in the recommendation and trabecular).

Citation: Watanabe PCA, Faria V, Camargo AJ. Multiple Radiographic Analysis (Systemic Disease): Dental Panoramic Radiography. J Oral Health Dent Care 2017; 1:007. Watanabe et al. Volume 1, Issue 1 J Oral Health Dent Care 2017; 1:007 of development. Taking posterior bitewing radiographs of new adult osteoporosis since they are correlated with systemic bone mineral patients was found to be reducing the number of radiological findings density (BMD) values measured with dual-energy x-ray absorptiometry and the diagnostic yield of panoramic radiography. In addition, the (DXA). Another factor to study is the Fractal Dimension, trabecular following clinical indicators for panoramic radiography were identified area per total area (TrA/TA), and connectivity on PR. Moreover, as the best predictors for useful diagnostic yield: suspicion of teeth with fractal dimension (FD) of trabecular bone has been associated with periapical pathologic conditions, presence of partially erupted teeth, bone strength [15,16]. However, little is known on the difference in caries lesions, swelling, and suspected unerupted teeth and agree with diagnostic performance among the above-mentioned methods. Thus, the Guidelines when it cites that from 30 to 50 percent of edentulous patients have exhibited abnormalities in panoramic radiographs [7]. The main disadvantage of panoramic radiology was that the image does not display the fine anatomic detail available on intraoral periapical radiographs. However, with the implementation of modern digital systems, many of these limitations are now in the past [9]. Dental Anomalies Fusion and gemination is not an uncommon finding and has affected most primary dentition and permanent maxillary incisors, and the authors reported an unique case in literature involving a posterior molar, first seen on a routine panoramic radiograph (Figure 4)and confirm by axial CBCT (Figure 5), assuming being a fusion ofthe second and third molars or gemination/twinning of a second molar [9]. In case of endodontic involvement several articles report technicians of successful non-surgical endodontic treatment [10,11]. The authors concluded that the alteration, although it is common in other regions, did not have any case in the literature involving “second and third” molar. Highlighting those patients also has numerous anomalies, agenesis of 35 tooth and forth molar presence. In this case, the radiology does not close diagnosis, but brings an important discussion about possible dental findings and shows the importance of a great clinical judgment and evaluation. Radiomorphometrics Indices Panoramic radiomorphometric indices can be correlated and compare precision, sensitivity and specificity by analyses of fractal dimension (FD) for screening low bone mineral density (BMD) [12]. The authors highlighted the panoramic radiography in this context because it is commonly used as an initial dental examination. Furthermore, it is fast and low-cost and uses low-dose X-radiation. Figure 4: Initial panoramic radiography of patient. Observe PR are useful to diagnose systemic [13] and alveolar bone quality the mandibular right side. Below, periapical and Cone Beam by assessing the width and shape of the inferior mandibular cortex tomography of the same region show details about the Double [14]. These measurements have been described as indices to predict Tooth.

Figure 5: Axial view; the sequence showed initially three separate roots (IMG: 23 and 24), the next slice begins “fusion” of the mesial root with the “median” root. Slices IMG: 26 and IMG: 27, the pulp chamber is shared (the junction of the pulp chamber or the pulp portion of these roots), and finally showed the union, the mesial and median root are covered by dentin and is seen the distal root canal.

Citation: Watanabe PCA, Faria V, Camargo AJ. Multiple Radiographic Analysis (Systemic Disease): Dental Panoramic Radiography. J Oral Health Dent Care 2017; 1:007. Watanabe et al. Volume 1, Issue 1 J Oral Health Dent Care 2017; 1:007 the aim of this study was to assess the diagnostic performance of • The ratio of the thickness of the mandibular cortex (measured panoramic radiomorphometric indices and parameters in detecting low along a line perpendicular to the mandible base at the level of the center bone density. The authors concluded that the analyzed test, FD offers of the mental foramen) to the distance between the inferior margin of a significant and relatively high sensitivity, for screening low systemic the base of the mandible and its maximum limit bone density. Furthermore, the diagnostic performance results and • Normal cortex for thickness greater than or equal to 3 mm and significant correlations found in this study suggest that it is possible to abnormal cortical density for thickness lower than 3 mm. obtain evidences of the trabecular bone pattern by assessing panoramic radiographic images. For qualitative analysis, the same set of radiographs was also classi fied according to the mandibular cortical index (MCI) of Klemetti [19], Alonso et al. [17] studied validation of cone-beam computed which qualitatively evaluates the endosteal border of the mandibular tomography as a predictor of osteoporosis using the Klemetti cortex, classifying it as C1 (normal) when smooth and homogeneous, classification. The authors have concluded that individuals with C2 (low density) when exhibiting half-moon defects, and as C3 (osteo osteoporosis are also more likely to show erosions; thus, individuals porosis) when porous with tapered and thinned cortical width. could be classified into three distinct groups: C1 – the margin of the In order to determine the QQPI index (qualitative and quantitative cortex is clear and sharp on both sides; C2 – endosteal surface defects panoramic index), the two analyses are combined for the same are semi lunar; C3 – the cortical layer is extremely porous (Figure 6) panoramic radiograph, yielding the following classifications: Q1 = [17]. A systematic review evaluated the accuracy (relative to DXA) mandibular cortex classified as C1, according to MCI, and PMI ≥ 3 of the different panoramic morphometric indices, and, based on the mm; Q2 = mandibular cortex classified a s C 2, according to MCI, and findings, it suggested future studies to examine ways of controlling PMI < 3 mm; Q3 = mandibular cortex classified as C3, according to the limitation of the magnification/distortion of PAN in order to attain MCI, and PMI < 3 mm. more reliable conclusions precisely [18]. Seeking to address this limitation, the present study aims at evaluating the validity of CBCT The index applied in the present study (QQPI) proposes the use in assessing mandibular bone quality using the Klemetti classification of both methodologies suggested by the mentioned authors [19,21], of inferior mandible morphology for the diagnosis of mandibular combining quantitative and qualitative analyses of the mandible and bone quality. To this end, the classification obtained from CBCT observing both the thickness and aspect of the mandibular cortex in images was compared to that derived from panoramic images. It was determining density, with three possible diagnostic outcomes: normal concluded that The Klemetti index [19] should not be used to assess (Q1), low density (Q2) and osteoporosis (Q3). In conclusion, the osteoporosis on CBCT cross-sectional slices; on the other hand, this authors rated that the results of this study allowed confirmation of digital imaging modality has great potential for performing osteoporosis panoramic radiography as a useful method for detecting morphologic age-related changes in the mandible and creation of a single quantitative analysis, because the inferior mandible cortex is given visibility in its and qualitative panoramic index (QQPI) to aid in the diagnosis of extension by dynamic evaluation. mandibular low density /osteoporosis. Haddad et al. [20] has devised a qualitatively and quantitatively Camargo et al. [22] has conducted a study comparing two reliable index for screening changes in mandibular bone density based radiological methods evaluation of bone density in postmenopausal on digital panoramic radiographs [20]. The quantitative analysis was women. based on the panoramic mandibular index8 (PMI) proposed by Benson et al. in 1991, which defines [21]: They selected panoramic radiography images and carpal radiography, corresponding to 68 female patients, aged between 49 and 80 years old. For the evaluation of radiological images obtained by the carpal radiography (Figure 7) it was applied the method of the radiogrammetry. According to the results of this study it is possible to conclude that there is correlation between the presences of a mandibular bone density low level observed in the radiograph panoramic patients in the sample, with the low bone density presented in the carpal radiography [22].

In another similar study also use panoramic radiography [23] has aimed to analyze the importance of panoramic and carpal radiographs for evaluation of edentulous individuals in different ages, demonstrating the contribution of different dental radiographic techniques in detecting patients with signs of osteoporosis. The panoramic radiographs were performed to measure the thickness of the mandibular cortical index

(mental index—MI and gonial index—GI; Figure 8), and evaluation of the morphology of the mandibular cortical shape (Klemetti classification). The authors concluded that there was positive correlation between age and indices of quantitative assessment (IM, IG, BMI) and qualitative (analysis Klemetti) on panoramic and carpal radiographs. Age is a risk factor for the onset of osteoporosis. Dental Diagnosis Camargo et al. [24], has reported a case of the undifferentiated osteosarcoma of the mandible oblique line first seen on panoramic

radiographs for patient who had their appointments in private radiology Figure 6: Drawing and panoramic radiograph cuts to exemplify dental clinics for implants planning [24]. According to World Health the Rating or Index of Klemetti. Organization (WHO), osteosarcoma (OS) is the most common primary

documentation for placement of implants. During anamnesis reported difficulty to open the mouth. In the clinical evaluation, it was detected a discrete area of fibrous consistency, asymptomatic, with no changes in color and volume in the oral mucosa, located in the right retromolar triangle. Panoramic radiographic examination showed radiopaque area with a sun-ray appearance located above the external oblique line on the right side (Figure 9). The important point in this case report is the fact that the lesion was a radiographic finding. Despite the patient had reported difficulty to open the mouth, she showed no symptomatology described previously. Another point was the sex and age of the patient. The lesion found in the panoramic radiograph can generate other diagnostic hypotheses. The fibrous dysplasia involving the jaws, the disease tends to appear in the early stages in life. The classic radiographic appearance is a “groundless” or “orange peel” effect, a mixed pattern of radiolucent, showing irregular and heavy radiopaque foci; this has been described Figure 7: Measurement of Metacarpal Index using Radioimp as a “smoke” pattern [28]. Osteomyelitis of the jaws of a chronic nature software. has findings consistent with swelling, pain, purulence, intraoral or extra oral draining fistulae; positive radiographic finding is lesion with diffuse sclerosing [29]. Osteoma is a benign osteogenic lesion characterized by the proliferation of compact or trabecular bones, clinically, the peripheral osteoma is usually asymptomatic but can cause swelling and asymmetry, radiographically the lesion appears as a well-circumscribed radiopacity [30]. The final diagnosis is made by biopsy and histopathological analysis. In this reported case, it was performed an m-resection of the mandible. Resection with surgical margins is the most important factor for prognosis and provides a 5 years survival rate of 80% [31].

Bony margins for resection should at least be 2 cm from the clinical radiographic edge or the nearest suture in the mid face. Soft tissue margins around an osteosarcoma resection should be 2 cm or more assessed with frozen section. Adjuvant chemotherapy or radiotherapy seems to be efficacious [32]. The treatment of osteosarcoma of the jaws should be approached in two ways. Radical surgery is the primary treatment for (OS) of long bones as well as jaws, although it cannot be contemplated as the sole treatment. The additional use of radiotherapy was left to the discretion of the treating physician but was generally encouraged in cases of incomplete resection [33]. The clinical importance of this case report is that the lesion was a radiographic finding, since the patient had no symptoms, and the Figure 8: Mental index—MI and gonial index. diagnosis was made due the indication for placement of implants. The diagnostic is obtained through the x-ray examinations (panoramic, malignant tumor of bone, accounting for approximately 35 percent periapical, occlusal), CT and pathologic analyses should be the earliest of cases, followed by chondrosarcoma (25%), and Ewing sarcoma possible. Prognostic is associated with several variables, such as tumor (16%), and occurs predominantly in patients younger than age of location, initial size, existence or absence of metastasis, gender, age, twenty, and in this group 80% occur in long bones of the extremities cytogenetic chances and responds to chemotherapy pre-surgery. [25]. Osteosarcoma of the jaw (JOS) is a rare, aggressive malignancy constituting 5% to 13% of all cases of skeletal OS [26]. The signs and While panoramic radiograph should not be prescribed primarily for symptoms of JOS include pain, parestesia, regional swelling and the patients can report loose teeth, changes of teeth position or changes in prosthesis adaptation [27]. The diagnostic is obtained through the X-ray examinations, Computed Tomography (CT) and pathologic analyses. Panoramic radiography remains the primary way of diagnosis, in which the image “sun ray” shows pathognomonic signal, although CT images provide high quality and excellent anatomic resolution, providing visualization of tumor calcification and cortical bone involvement, being of great importance in the diagnostic and treatment planning. The emergence of this disease at the trigonoretromolar region (oblique line) is the novelty of this clinical case. In the most cases the growth of the lesion is low. Figure 9: Panoramic radiograph showing the radiopaque lesion The case report presented a Caucasian patient, female, 82 years old, with a sun-ray appearance located above the external oblique line who consulted a private dental radiology clinic to perform radiographic on the right side.

Citation: Watanabe PCA, Faria V, Camargo AJ. Multiple Radiographic Analysis (Systemic Disease): Dental Panoramic Radiography. J Oral Health Dent Care 2017; 1:007. Watanabe et al. Volume 1, Issue 1 J Oral Health Dent Care 2017; 1:007 detection of non-maxillofacial conditions, it is incumbent upon the restorations. Currently these rehabilitations are made with the help of health practitioner to be cognizant of panoramic image features that dental implants, and the panoramic radiograph becomes the preferred are indicative of systemic health. method for analyzing the structural condition of these bones and their relationship with important surrounding structures. It should be Systemic Disease emphasized that the phase in which this type of rehabilitation treatment Hypoparathyroidism becomes necessary, in general, coincides with the decline phase of bone mass, having as main target women in post - menopausal. Mendonça et al. [34], has studied the impact of PhPT on bone mineral density (BMD), on the frequency of subclinical vertebral fracture and For many years, the relationship of the jawbone with PHPT was on mandible morphometry [34]. The bone mineral density (BMD) restricted to manifestation of the disease at this site, the brown tumor of lumbar spine, total hip and 1/3 radius, radiographic evaluation of [40,41]. So, other aspects that could be present on radiographs ended vertebral morphometry, panoramic radiography of the mandible, and up being less valued and not interpreted as early signs of the disease. biochemical evaluation of mineral metabolism and bone remodeling With the advancement in knowledge of bone metabolic changes were evaluated in both groups. In the panoramic radiography were during the evolution of primary hyperparathyroidism, the radiographic projected areas of interest that are used for the determination of the examination of the facial bones became a tool with great potential to Mental Index and Goniac Index, as previously described [35,36]. The evaluate the association of these changes and their impact on the bones results show that panoramic radiography of the mandible is a useful of the face. tool for the recognition of bone disorders in PhPT. Furthermore, Several studies initiated the evaluation of mandibular bone and jaw the panoramic radiography of the mandible was especially useful to in patients with PHPT by periodontal changes that these individuals capture the reduction in cortical thickness in another bone site. These began to develop, generating an impairment of the stomatognathic results suggest that PhPT has a great impact on bone structure which system and the evolution of the disease [42]. The authors was not meant is not necessarily detected by BMD density. Subclinical vertebral to evaluate the periodontal status of patients with PHPT, however fracture was identified in more than 60% of PhPT patients, including those exhibiting high BMD. Panoramic radiography of the mandible we found that during the six months while repeating the panoramic should be thoroughly scrutinized to determine its place in the diagnosis radiograph, some patients had tooth loss. A recent study evaluated the or screening of osteoporosis. This site was useful to reveal cortical thickness of the mandibular cortical bone, the presence of the hard layer, changes in PhPT. Panoramic radiography has the additional advantage the occurrence of brown tumor and the presence of the mandibular torus of relying on a dentist for the screening of osteoporotic patients. The in patients with HPTP. These authors found that the cortical levels were study encourages further investigation to determine the role of PTH decreased in patients with PHPT compared to the control group [43]. as hormone replacement therapy in postsurgical hypoparathyroidism. Similar to the study RAI, the data from this study show that patients with HPTP present in cortical thickness values mental foramen region; Hyperparathyroidism and the angle region gonial smaller than a reference population that Mendonça et al. [37] has also studied the Skeletal and metabolic corresponds to 3 mm and 1 mm, respectively. However, there was no characterization in primary hyperparathyroidism (HPTP) before and significant difference between PHPT and control groups in this study. after the surgical cure to assess quantitatively the evolution of bone The authors also draw attention to the evaluation of this cortical bone marrow adiposity and its relationship with the maintenance of bone site that has not shown significant gain after parathyroidectomy. Thus, mass and the changes in mandibular bone in patients with HPTH this result may be more of a foothold in the confirmation that the cortical submitted to parathyroidectomy, as well as the influence of insulin impairment in PHPT does not present the same pattern of recovery after resistance status in HPTP and its effect on bone metabolism [37]. curing the trabecular bone. There was a negative correlation between BMD at all sites and bone In addition to the mandibular cortical thickness, assessed in marrow adiposity during the preoperative period, a fact that was not panoramic radiographs the morphology of the mandibular cortex observed for mandibular cortical thickness. Quantitative evaluation according to the classification proposed by Klemetti (1994). It was of the mandible revealed a significant difference in extracellular possible to verify that individuals with PHPT showed no index Klemetti matrix mineralization on the right side between the preoperative and C-1, that is none showed normal Klemetti index. Meanwhile, 60% of postoperative determinations in the HPTP group (p=0.04). Conclusion: patients have had index Klemetti 2 and 40% were compatible with During the cure of HPTP there is an increase in BMD at predominantly, standard 3, resulting in greater loss of bone quality. To compare, in 12% trabecular bone sites, whereas bone gain is impaired in the forearm. of the control group subjects had Klemetti index 1 and none had standard Bone marrow adiposity may be one of the causes of impaired bone 3 Klemetti. Surgical cure of primary hyperparathyroidism had a positive resistance in HPTP. The behavior of mandibular bone may differ from impact among patients with lower Klemetti index (Figure 10). Thus, the that to other cortical areas such as the forearm. authors were able to conclude that the quantitative and qualitative study A study of panoramic and periapical radiographs of 42 patients of mandibular bone in PHPT provided data that encourage the use of on haemodialysis and having renal osteodystrophy, demonstrated panoramic radiography face as an examination aid in the diagnosis of a progressive increase in periodontal disease, loss of lamina dura, bone metabolic diseases, since the mandibular cortical thickness showed deviation in the trabecular pattern, brown tumor “pseudocyst” behavior similar to region of 1/3 of the forearm, except ECMMd. Even formation and pulp calcifications [38]. with Klemetti technique it was observed that morphological changes of Bandeira et al. [39] tells the Brazilian experience of the severe and soft primary hiperparatireoidismo in Pernanbuco-Brazil. The authors had cited that in severe disease pathological fractures are frequently seen, especially in long bones of the lower extremities, and also loss of lamina dura of the teeth and salt-and-pepper appearance of the skull. At authors institution, including outpatients and inpatients, the prevalence in postmenopausal women is 1.3%.

The jawbones are bones that require great attention of the dentist, Figure 10: Panoramic radiograph showing the inferior mandibular since in these areas, the teeth often inserted need to receive dental cortical, male patient, Klemetti Class III.

Citation: Watanabe PCA, Faria V, Camargo AJ. Multiple Radiographic Analysis (Systemic Disease): Dental Panoramic Radiography. J Oral Health Dent Care 2017; 1:007. Watanabe et al. Volume 1, Issue 1 J Oral Health Dent Care 2017; 1:007 the mandibular cortical can be found in patients with HPTP even for a six-month follow-up. Thus, these tools ensure that dental professionals have knowledge to recognize changes in the bones of the face to suggest osteometabolic changes as in PHPT. Osteoporosis Osteoporosis is defined by the World Health Organization (WHO), a disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to bone fragility and a consequent increase in the risk of fracture [44] is currently considered as a serious global public health problem, with high levels of morbidity and mortality and high prevalence in developed and developing countries. This is a systemic metabolic disorder characterized by slowly progressive decrease in bone mass, by compromising the integrity of the bone structure, reduction of its strength and the involvement of bone fractures, even in minimal efforts. The person has no signs and symptoms in the early stages of the disease; it is also known as a “silent Figure 11: Brazil life expectancy in relation to The USA and disease.” The signs and symptoms appear later, when bone density Mexico. decreases to cause bone fracture or collapse, which can lead to pain and bone deformity [45]. Recent research devoted primarily to investigate and detect diseases within a shorter period of time, aimed at early diagnosis and prevention of diseases. With the increasing life expectancy of the population and the importance in the quest for healthy aging, it becomes extremely important the clinical and social knowledge of chronic diseases that interfere significantly in one’s quality of life such as osteoporosis (Figure 11). In Brazil, the prevalence of osteoporosis is little known, but by Kowalski [46] that measured the use of resources and annual cost for Figure 12: Panoramic radiography shows the characteristics of the patients with osteoporosis, pos-menopausal in the clinic of osteoporosis mandibular canal, both sides and superior and inferior walls. of the UNIFESP, the annual average cost for patient was approximately $ 442,00/patient. However, Araujo et al. [47] has assessed the direct by osteopenia/ osteoporosis, checking for correlation between the cost during hospitalization for an osteoporotic hip fracture in Brazilian mandibular bone quality and systemic bone quality. private health care system, by health plan companies’ perspective, Camargo (2013) divided the sample into three groups according to so the authors concluded that this cost had assess in approximately $ DXA exam: Group N (n = 26) normal in three sites (forearm, hip and 6.900. The study “Osteoporosis - Brazil Year 2000”, developed by 300 spine), Group E (n = 18) with osteopenia at the three sites and Group medical specialists, estimated that less than a third of Brazilians with O (n = 8) with osteoporosis in the three sites. The DXA and panoramic osteoporosis are diagnosed, and that only 20 % of those known to be radiography were performed in the same period. All panoramic affected are treated [47,48]. radiographs had been done using a Veraviewepocs Digital unit (J. ® Triage better, and earlier, patients to perform DXA whole body, is a Morita Mfg. Corp., Kyoto, Japan) and DXA performed by HOLOGIC key strategy in the fight against this disease. The panoramic radiograph (Waltham, MA, USA). To study the pattern of the cortical bone of has been used in routine dental care worldwide, thanks mainly to the the mandibular canal, we use an adaptation of morphological analysis great technological development in recent decades, and as a clinical methodology proposed by White and Rudolph [56]. protocol has the backing of the International Guide Radiographic After selection of radiography was performed trimming of hemi- Prescription. arches on both sides (left / right) focusing on the region of the mandibular Panoramic radiography covers important anatomical structures canal using a computer software ADOBE ® PHOTOSHOP ® CS3 and has a low cost can be of great value to dentistry providing the v.10.0 (Adobe Systems Incorporated, San Jose, California, USA). From dentist the diagnosis of bone quality of the jaws. For these reasons this stage, it was performed a cutting of the regions of mandibular canal: and because of the panoramic radiograph can continue to be used for after the mental foramen (MF) angle region (A) and branch region(R) diagnosis of low bone mineral density in the cortex of the mandible selecting the canal, bilaterally, along its entire length (Figure 13). [49-52]. Evaluation the characterization of the cortical walls of the This division of the canal was necessary because of its slightly mandibular canal in patients with osteopenia/ osteoporosis, hoping curved anatomy, thereby was limited to the clipping only in mandibular to indicate whether there is the correlation between mandibular bone canal. Regions of interest (ROI) were defined from the anatomy of quality and systemic bone quality or not it’s an important question each patient. In each clipping of the mandibular canal was performed [53]. duplicating the original image (step 1) before performing the blurring Panoramic radiography has been used to screen patients with low of image using Gaussian filter (sigma = 35 pixels) (step 2) in Image bone mineral density (BMD) evaluating the thickness and shape of the J® 1.42q® (National Institutes of Health, USA) software. The resulting image is subtracted from the original image (step 1-step 2), and added mandibular cortical [49,5054,55]. 128 (half value of the grayscale contrast scale 256) (step 3). The image For these reasons and because panoramic radiograph is already binarization is performed on a threshold value of brightness of 128 used for diagnosis of low bone mineral density in the mandibular (step 4), transforming the image into black and white. The image taken cortex [49-52] Camargo 2013 has evaluated the characterization of is eroded (step 5) and dilated (step 6) for noise reduction. Lastly it is the mandibular canal walls (Figure 12) to evaluate changes caused performed to characterize the cortical on the canal with “skeletonization”

inexpensive technique and recommended by the International Statutory Period Radiographic Guide in many situations, especially for the first visit of patients seeking the dentist should always be interpreted considering early signs of potential systemic diseases, abnormalities, iatrogenic and others. This is an area in which the dentist may as well save a life, valuing their performance as a health professional, understanding the patient as a whole. References 1. Watanabe PCA, Farman A, Watanabe MGDC, Issa JPM. Radiographic signals detection of systemic disease. Orthopantomographic Radiography. Int J Morphol. 2008; 26:915-926. 2. White SC, Taguchi A, Kao D, Wu S, Susan KS, Yoon D, et al. Clinical and panoramic predictors of femur bone mineral density. International Osteoporosis Foundation; National Osteoporosis Foundation. 2004. 3. Farman AG, Nortje C J, Wood RE. Oral and Maxillofacial Diagnostic Imaging. Mosby -Year Book, St. Louis. 1993. Figure 13: Each channel of the mandible was divided into 3 ROI 4. Watanabe PCA, Arita ES, Monteiro SAC, Oliveira TM, Taguchi by side (right / left) totaling 6 ROI per patient. A. The relationship among three indicators of bone quality in the osteoporosis research on panoramic radiographic. Osteoporos Int. 2004; 15:S67-255. 5. Paeetero Yv. Pantomography And Orthopantomagraphy. Oral Surg Oral Med Oral Pathol. 1961; 14:947-953. 6. American Dental Association, U.S. Food & Drug Administration. The Selection Of Patients For Dental Radiograph Examinations. Guidelines for Prescribing Dental Radiographs. 2004. 7. American Dental Association, U.S. Food & Drug Administration. Figure 14: Skeletonized process characterization of cortical The Selection Of Patients For Dental Radiograph Examinations. mandibular canal. Guidelines for Prescribing Dental Radiographs. 2012. image of step 6 until they are reduced to a simple skeleton (step 7). 8. Secretaria De Vigilancia Sanitaria; Ministerio Da Saude After the process of skeletonization, it overlaps with skeletonized Brasil. Portaria 453 - “Diretrizes De Protecao Radiologica E image over the original image (step 8), to show the cortical (Figure Radiodiagnostico Medico E Odontologico” Brasilia (Brasil). 1998. 14). The histogram was used in skeletonized images for analysis of the number of black pixels representing the cortical canal using Image J® 9. Camargo AJ, Arita Es, Watanabe Pca. Fusion or Gemination? An 1.42q® software for each ROI. Unusual Mandibular Second Molar. Int J Surg Case Rep. 2016; 21: 73-77. Thus, in the normal group of the cortical of the mandible canal were more radiopaque and evident (contained more black pixels) 10. Ballal S, Sachdeva GS, Kandaswamy D. Endodontic management of than the group with osteoporosis. Therefore, the more radiopaque the a fusedmandibular second molar and paramolar with the aid of spiral cortical wall of the mandibular canal (MC), the structure is denser and computedtomography: a case report. J Endod. 2007; 33:1247-1251. healthier. 11. Beltes P, Huang G. Endodontic treatment of an unusual mandibular This significant difference between the groups in the region of secondmolar. Endod Dent Traumatol. 1997; 13:96–98. branch of MC may be related to the low number of teeth present in 12. Camargo AJ, Côrtes ARG, Aoki EM, Baladi MG, Arita ES, Watanabe women with osteoporosis as the mean found in group N was 18.730 PCA. Analysis of Bone Quality On Panoramic Radiograph In and the group O of 3.075. These findings were consistent with several Osteoporosis Research By Fractal Dimension. Applied Mathematics. studies [49,50,54,58,59]. 2016; 7:375-786. Visual analysis of the morphological characteristics of the 13. Oliveira ML, Pedrosa EFNC, Cruz AD, Haiter-Neto F, Paula FJA, mandibular canal performed by an experienced radiologist, it had a Watanabe PCA. Relationship Between Bone Mineral Density and high sensitivity value (70.4%) when correlated to systemic bone Trabecular Bone Pattern in Postmenopausal Osteoporotic Brazilian diagnosed by DXA. The resorption of the upper border of the CM Women. Clinical Oral Investigations. 2013; 17:1847-1853. is most commonly affected in women. These results suggest that the mandibular canal suffers action of osteoporosis and the analysis of 14. White SC, Cohen JM, Mourshed FA. X Digital Analysis of cortical mandibular canal through the number of black pixels can be a Trabecular Pattern in Jaws of Patients With Sickle Cell Anemia. useful tool in the evaluation of patients with osteoporosis [60]. Dentomaxillofacial Radiology. 2013; 29:119-124. Concluding Remarks 15. Shrout MK, Hildebolt CF, Potter BJ. 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Citation: Watanabe PCA, Faria V, Camargo AJ. Multiple Radiographic Analysis (Systemic Disease): Dental Panoramic Radiography. J Oral Health Dent Care 2017; 1:007.