• Users Online: 406
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 5  |  Issue : 2  |  Page : 74-78

Unusual incidental findings on intra- and extra-oral radiographs in North Indian Population: A radiographic study


Department of Oral Medicine and Radiology, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab, India

Date of Web Publication25-Oct-2016

Correspondence Address:
Gaurav Goyal
Department of Oral Medicine and Radiology, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-4696.192974

Rights and Permissions
  Abstract 

Aims and Objectives: To detect the prevalence of unusual incidental findings on intra- and extra-oral radiographs in North Indian Population: A radiographic study. Methods: All the intra- and extra-oral conventional dental radiographs were analyzed for the period of 2 year along with the radiographic findings related to patient's chief complaint. Results: A total of 6780 conventional intra- and extra-oral dental radiographs were screened and 90 radiographs showed incidental findings. A total of 10 varieties and 95 numbers of incidental findings were noted, 50 (55.55%) affected mandible, and 24 (44.44%) affected maxilla. Out of 90, 44 (48.88%) were bony findings and 46 (51.11%) were dental findings. Most common type of incidental pathology was idiopathic osteosclerosis. The most uncommon type of incidental pathology was regional odontodysplasia with 35 (38.88%), 25 (27.77) cases of cysts, 16 cases of supernumerary teeth (17.77%), 9 (10%) cases of sinus abnormality, 4 (5.40%) of each findings were of odontome, dense in dente, internal resorption, and calcifications. About 1 (1.11%) of each findings were regional odontodysplasia, focal cemental dysplasia. Conclusions: Conventional radiography is still most commonly used tool to primarily investigate lesions quickly with low cost to patient and then further diagnostic and advanced radiological or other examinations can be performed for comparison, periodic follow up, management, and research purposes.

Keywords: Conventional radiography, incidental findings, North Indian population


How to cite this article:
Goyal G, Padda S, Kaur B. Unusual incidental findings on intra- and extra-oral radiographs in North Indian Population: A radiographic study. J Dent Allied Sci 2016;5:74-8

How to cite this URL:
Goyal G, Padda S, Kaur B. Unusual incidental findings on intra- and extra-oral radiographs in North Indian Population: A radiographic study. J Dent Allied Sci [serial online] 2016 [cited 2021 Jun 18];5:74-8. Available from: https://www.jdas.in/text.asp?2016/5/2/74/192974


  Introduction Top


Radiographic incidental findings of abnormality refers to the occult or hidden abnormality that exhibits no clinical signs and symptoms but is present as an incidental finding when the radiograph is taken to detect some pathology related to the patients chief complaint. Commonly, the radiographs are prescribed when the dentist thinks that they are likely to offer useful diagnostic information that will influence the treatment plan. Often some clinical sign or symptom or finding from the patient's history indicates the need for a radiologic examination. The information obtained from the clinical examination is used first to select the appropriate radiograph and later to aid in their interpretation.[1] Radiographic incidental findings in the jaws include a combination of dental and/or introsseous findings. The consequences of some these incidental findings may be quite serious.[2] Therefore, one should avoid limiting attention to one particular region of the film; rather, all aspects of each image should be examined systematically. If the presence of any abnormalities detected in advance, the prognosis is improved; moreover, it may reduce the mortality and morbidity rate to some extent.

There are only limited studies that have analyzed the prevalence of abnormal findings in radiographs ordered primarily for chief complaint related findings. Most of these studies described as an isolated case reports on dentigerous cysts, keratocystic odontogenic tumor (KOT), Gorlin Goltz syndrome, and maxillary sinus or Temporomandibular Joint pathologies. Only two studies handled this topic in patients with pretreatment orthodontic panoramic radiographs (orthopantomogram [OPG]), whereas in the present study, patients from all age groups were included. Thus, the aim of the present study was to evaluate the prevalence of incidental findings of abnormalities on conventional dental radiographs.

Aims and objectives

To detect the prevalence of unusual incidental findings on intra- and extra-oral radiographs in North Indian population: A radiographic study.


  Materials and Methods Top


This prospective study was conducted in the Department of Oral Medicine and Radiology, Genesis Institute of Dental Sciences and Research, after getting the approval from Ethical Committee.

To evaluate the prevalence of incidental findings of abnormalities, all the intra- and extra-oral conventional dental radiographs were screened along with the radiographic findings related to patient's chief complaint. Radiographs were not prescribed as a screening tool. All radiographic examinations performed during January 2013–January 2015 at the Department of Oral Medicine and Radiology were included in the study. Intra- and inter-examiner accuracy and reproducibility for each of the radiograph was done to increase the authenticity of the study.

Exclusion criteria

Radiopaque lesions associated with dental caries, deep restorations, or tooth extraction regions were not diagnosed as idiopathic osteosclerosis, since they could be the result of condensing osteitis or residual condensing osteitis, when located in a tooth extraction region. Lesions located in tooth extraction regions could also be the result of alveolar sclerosis. Exostoses of the torus type were excluded by evaluating the intraoral photographs.


  Results Top


The patients in this study were advised radiographs as a part of routine investigative procedures for their chief complaints such as panoramic radiographs (OPG) for orthodontic and periodontics work up, intraoral periapical (IOPA) radiographs for evaluating periapical region, lateral oblique for third molar and so on. A total of 6780 conventional intraoral and extraoral dental radiographs were screened and ninety radiographs showed incidental findings. A total of 10 varieties and 95 numbers of incidental findings were noted. Out of 8962 radiographs, 4546 were of males and 2234 were of females. Out of 6780 radiographs, 90 (0.013%) radiographs showed incidental findings. Out of these 95 incidental findings, 51 (53.68%) affected males and 44 (46.31%) affected females. Out of 90, 44 (48.88%) were bony findings and 46 (51.11%) were dental findings. Most common type of incidental pathology was idiopathic osteosclerosis with 35 cases (38.88%) [Figure 1] and [Figure 2], 25 (27.77%) cases of cysts [Figure 3], 16 cases of supernumerary teeth (17.77%), 9 (10%) cases of sinus abnormality, 4 (4.40%) of each findings were of odontome, dense in dente, internal resorption and calcifications, 1 (1.11%) of each findings were regional odontodysplasia, focal cemental dysplasia.
Figure 1: Intraoral X-ray film showing idiopathic osteoscelrosis

Click here to view
Figure 2: Panoramic radiograph showing idiopathic osteoscelrosis

Click here to view
Figure 3: Panoramic radiograph showing Stafne bone cyst

Click here to view


The most common type of incidental pathology was idiopathic osteosclerosis (38.88%). The most uncommon type of incidental pathology found was regional odontodysplasia. The second most common type of incidental pathology that was encountered was 25 (27.77%) cases of cysts, out of which 15 were KOT; 4 were dentegerous cysts; 3 were Stafne cysts [Figure 3]; and 3 were radicular cysts. The third type of incidental pathology was 16 (17.77%) cases of supernumerary teeth. Out of these 16 supernumerary teeth, 10 were in maxillary anterior region and remaining 6 were in mandibular premolar-molar region. The fourth type of incidental pathology was sinus abnormality 9 (10%) cases.


  Discussion Top


Detection of incidental finding is not a deliberate procedure to find out one. However, its presence is appreciated during radiographic evaluation of the patient for the purpose which is not related to the incidental finding of abnormality. Hence, these are found on routine radiographic evaluations. Most common abnormalities usually found in bone are radiolucent, mixed, or radiopaque lesions associated with the teeth and introsseously in the jaws and may present as an incidental findings on radiographs apart from the chief symptom of a patient.

Idiopathic osteosclerosis is an asymptomatic, nonexpansive, and localized increase of bone radiopacity caused by an increase in the width of the bone trabeculae at the expense of medullary space. It is usually located in the mandibular premolar region. The lesion has benign characteristics and seems not to increase over time. As described by DS MacDonald-Jankowski in 1999,[3] the radiographic appearance of idiopathic osteosclerosis is a localized, well-defined nonexpansile radiopacity, generally round or ovoid in shape; but sometimes irregular. The results were in consistence to our study, as all cases we had encountered of idopathic osteosclersosis had well demarked borders. On occasion, osteoscelrosis may be very large sometimes occupying almost the whole height of the body of the mandible. The cause of idiopathic osteosclerosis is obscure. It is asymptomatic, uniformly radiopaque foci of dense bone, usually with distinct outlines, that are apparently not the sequelae of infection or systemic disease. It has also been claimed that many radiopacities described as idiopathic osteosclerosis may be developmental variations of normal bony architecture, unrelated to local stimuli, which can arise at any age and at any location in the jaws.[4] When the lesion is present in the alveolous between first and second premolar, its occurrence is generally described as a sequela of retained roots. These retained roots are resorbed and replaced by sclerotic bone or fragments of the roots are surrounded and obliterated by the condensed bone.[5] Bondemark et al.[6] found 22 cases of idiopathic osteosclerosis. Idiopathic osteosclerosis does not require any treatment. Diagnosing idiopathic osteosclerosis accurately is a difficult task, since this lesion may be radiographically mistaken for exostosis, including torus mandibularis and palatinus, residual condensing osteitis, alveolar calcification after exodontia (whether complicated or not), bone architectural change in response to occlusal trauma on an inclined tooth, particularly on mandibular second molars, when the first molars are missing. The lesion may even be mistaken for a radiographic projection over bone of a soft tissue calcification. The mere presence of teeth, their carious lesions, occlusal traumas and infectious processes, as well as the primary teeth shedding process, may also cause bone tissue architectural changes, adding to the abovementioned enostoses and dense bone islands.

The second most common incidental findings in our study came out to be cyst, i.e., 27.77%. Out of various cyst KOT had highest incidental radiographic findings because of its propensity to grow along the internal aspect of the jaws, causing minimal expansion.[6] The relatively slight expansion common with these cysts probably contributes to their either late or incidental detection. As considerable numbers of KCOTs are asymptomatic and their clinical signs often fail to appear, these lesions are mostly detected in the late stage, which occasionally allow them to reach a large size. The radiographic appearance of KCOT may resemble that of many other odontogenic lesions. If it is associated with a crown of an unerupted tooth, it may be indistinguishable radiographically from dentigerous cyst.[7]

Dentigerous cysts are the second most common cysts occurring in the jaws. A dentigerous cyst is formed as a result of fluid accumulation in the reduced enamel epithelium surrounding an unerupted tooth. These cysts typically present as well-defined pericoronal radiolucencies either superior or lateral to the unerupted tooth. Dentigerous cysts involving the posterior maxillary teeth tend to grow into and fill the maxillary sinus and hence are discovered late. Posterior mandibular dentigerous cysts commonly extend well into the ramus. There are often no clinical symptoms, with the exception of swelling once the cyst reaches a considerable size.[8],[9] Ramesh and Pabla [10],[11] found dentigerous cyst and Stafne bone defect as an incidental findings on a dental radiograph. Cysts definitely require histopathologic confirmation and enucleation which was carried out in these cases.

The supernumerary teeth are more commonly encountered clinically as well as radiographically. The impacted supernumerary tooth requires disimpaction to avoid cyst formation or development of malocclusion.[12]

The maxillary sinuses are of particular importance to dentist because of their proximity to dental structures. Part or all of the paranasal sinuses may appear on radiographs made for dental purposes, including maxillary periapical, panoramic and lateral or posteroanterior cephalometric skull radiographs. Antral polyp rarely causes any signs or symptoms and is often noticed as an incidental finding on radiographs made for other purposes. It usually requires no treatment because they customarily resolve spontaneously without any residual effect on the antral mucosa and periodic follow up may be required. One case of thickening of mucosal lining was seen in peripheral nervous system which is frequently regarded as nonpathologic; even if in some cases, it can be associated with symptoms. One case of antrolith was found in IOPA, antroliths usually occur within the maxillary sinus and thus are positioned above the floor of maxillary antrum in periapical, occlusal or panoramic radiographs.[13],[14]

Most odontomas (70%) are associated with abonormalities such a impaction, malpositioning, diastema, aplasia, malformation, and devitalization of adjacent teeth and should be removed as early as possible.[15],[16] Early identification of internal resorption is vital, it may be transient and self-limiting or progressive, if endodontic treatment is started early or in time it halts the resorption. Most cases of dense in dente are discovered fortuitously and can be identified even before tooth erupts. Failure of early identification may result in premature tooth loss or they require root canal treatment.[16]

Thus, the data acquired from the findings of this study put forward that radiologist should not only interpret characteristic findings of the pathological conditions related to the chief complaint of the patient but also analyze coincidental findings. Moreover, this is not the one time activity but it is an ongoing process.


  Conclusions Top


Various incidental findings in radiographic images are to be expected. Dental findings were the encountered more common than bone findings. In the present study, we had incidentally reported maximum cases idopathic osteosclerosis followed to KOT. Idopathic osteosclerosis lesions can arise at any age, at any location, and usually requires no treatment other than diagnosis by recognition. As KOT shows relatively slight expansion common with cysts probably contributes to their either late or incidental detection. As considerable numbers of KOTs are asymptomatic and their clinical signs often fail to appear, these lesions are mostly detected in the late stage. Hence, the detailed and elaborate reports prepared by oral and maxillofacial radiologists may bring many important aspects, which can simply be overlooked, into clinicians' attention. Therefore, to detect more and more incidental finding, a thorough radiographic examination should be accomplished by applying a step by– step analytic process in a systematical order to enhance the scrutiny of all parts of images which can maximize the likelihood of detecting all abnormalities. A thorough review of all radiographic images will ensure early diagnosis and management of incidental pathologies while a good documentation of significant anatomical variations will provide important preoperative information.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
White SC, Pharoah MJ, editors. Principles of radiographic interpretation. In: Oral Radiology. Principles and Interpretation. 5th ed. St. Louis: Mosby; 2004. p. 281-96.  Back to cited text no. 1
    
2.
Brooks SL, Atchison KA. Guidelines for prescribing dental radiographs. In: White SC, Pharoah MJ, editors. Oral Radiology. Principles and Interpretation. 5th ed. St. Louis: Mosby; 2004. p. 265-77.  Back to cited text no. 2
    
3.
MacDonald-Jankowski DS. Idiopathic osteosclerosis in the jaws of Britons and of the Hong Kong Chinese: Radiology and systematic review. Dentomaxillofac Radiol 1999;28:357-63.  Back to cited text no. 3
    
4.
Geist JR, Katz JO. The frequency and distribution of idiopathic osteosclerosis. Oral Surg Oral Med Oral Pathol 1990;69:388-93.  Back to cited text no. 4
    
5.
Wood NK, Goaz PW. Solitary radiopacities not necessarily contacting teeth. In:Wood NK, Goaz PW. Oral and Maxillo-facial lesions. 5th ed. St luis: Mosby; 1996. p. 488-92.  Back to cited text no. 5
    
6.
Bondemark L, Jeppsson M, Lindh-Ingildsen L, Rangne K. Incidental findings of pathology and abnormality in pretreatment orthodontic panoramic radiographs. Angle Orthod 2006;76:98-102.  Back to cited text no. 6
    
7.
White SC, Pharoah MJ. Cysts of the jaws. In: White SC Pharoah MJ. Oral Radiology. Principles and interpretation. 5th ed. St Lous, Mosby; 2004. p. 394-6.  Back to cited text no. 7
    
8.
Farah CS, Savage NW. Pericoronal radiolucencies and the significance of early detection. Aust Dent J 2002;47:262-5.  Back to cited text no. 8
    
9.
Gonzalez SM, Spalding PM, Payne JB, Giannini PJ. A dentigerous cyst associated with bilaterally impacted mandibular canines in a girl: A case report. J Med Case Rep 2011;5:230.  Back to cited text no. 9
    
10.
Ramesh A, Pabla T. Incidental findings on dental radiographs: Dentigerous cyst. J Mass Dent Soc 2009;58:42.  Back to cited text no. 10
    
11.
Ramesh A, Pabla T. Incidental findings on dental radiographs: Stafne bone defect. J Mass Dent Soc 2009;58:42-3.  Back to cited text no. 11
    
12.
Rai HC, Shetty DC, Kumar A, Dua M. Incidental finding of jaw lesions- a case report and its review of literature. The Internet Journal of Pathology 2011;11:21-2.  Back to cited text no. 12
    
13.
Ruprecht A, Lam EW. Paranasal sinuses. In: White SC, Pharoah MJ, editors. Oral Radiology. Principles and Interpretation. 5th ed. St. Louis: Mosby; 2004. p. 576-84.  Back to cited text no. 13
    
14.
Petrikowski CG. Diagnostic imaging of temporomandibular joint. In: White SC Pharoah MJ, editors. Oral Radiology. Principles and Interpretation. 5th ed. St. Louis: Mosby; 2004. p. 552.  Back to cited text no. 14
    
15.
Blasberg B, Greenberg MS. Temporomandibular Disorders. In: Burkets Oral Medicine Diagnosis and treatment. 10th ed. Ontario: BC Decker; 2003. p. 271-306.  Back to cited text no. 15
    
16.
White SC, Pharoah MJ, editors. Benign tumors of the jaws. In: Oral Radiology. Principles and Interpretation. 5th ed. St. Louis: Mosby; 2004. p. 425-7.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusions
References
Article Figures

 Article Access Statistics
    Viewed3102    
    Printed54    
    Emailed0    
    PDF Downloaded319    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]