Paresthesia of the left lower lip as a first manifestation of multiple myeloma —A case report

We experienced a case of multiple myeloma in a 62-year-old woman who visited our hospital with a chief complaint of paresthesia in the left lower lip, which was described as numb chin syndrome, as her initial symptom. The radiographic findings showed a large area of osteolytic destruction in the left mandible and multiple punched-out appearances in the skull plate. The MRI demonstrated lesions showing low signal intensity on T1WI, and medium intensity on T2WI. The scintigram of the whole-body revealed a positive image in the left mandible and multiple ribs. On clinical laboratory examination, the data revealed higher total protein, γ-globulin, IgG, CRP, and SAA, and lower albumin than normal. Pathologic findings revealed a neoplastic mass showing diffuse proliferation of atypical plasmacytoid cells with little stroma. Serum immunoelectrophoresis disclosed M-protein, indicating abnormal immunogloblin synthesized by tumor cells. The final diagnosis was multiple myeloma. Although the initial manifestation of multiple myeloma rarely appears in the oral/jaw area, this disease should be borne in mind as a differential diagnosis when considering a patient whose chief complaint is paresthesia, so-called numb chin syndrome (NCS), and careful examination of the disease including radiographic imagings should be undertaken.     

Triage screening for osteoporosis in dental clinics using panoramic radiographs

Oral Diseases (2010) 16 , 316–327 Many patients with osteoporosis go undiagnosed because typically no symptoms are present before a fracture. Triage screening to refer patients to appropriate medical professionals for further investigation would be useful to address the increase in the incidence of osteoporotic fractures. Dental clinics may offer a new triage screening pathway because dentists frequently take radiographs of bones in the course of dental treatment. A major premise for such triage screening in dental clinics is that dentists can readily use a screening tool in their dental practice. For example, cortical width and shape of the mandible detected on panoramic radiographs may be appropriate indices for triaging individuals with osteoporosis. To date, several investigators have demonstrated significant associations between cortical indices on panoramic radiographs and bone mineral density of the skeleton generally, such as the spine and femur, biochemical markers of bone turnover and risk of osteoporotic fractures. Further, in two recent Japanese clinical trials, approximately 95% of women who were identified by trained dentists in their clinics using cortical shape findings did have osteopenia or osteoporosis. These findings support the possibility that dental clinics may offer a new triage platform to identify individuals with otherwise undetected osteoporosis.     

Dentists’ use of digital radiographic techniques: Part II – extraoral radiography: a questionnaire study of Swedish dentists

Objective: The present study aims to gain knowledge about the dentist’s use and choice of digital extraoral imaging methods, panoramic radiography and cone beam computed tomography (CBCT).

Materials and Methods: A questionnaire sent to 2481 dentists within the Swedish Dental Society contained questions about the panoramic technique and CBCT technique used, education, clinic size and type of service. The response rate was 53%.

Results: The study showed that 61% of the Swedish dentists had access to panoramic techniques and that 84% used a direct digital sensor, while 6% used storage phosphor plate techniques. Around 8% of the Swedish dentists had access to CBCT. It was also observed that group practices had two times higher odds of having panoramic equipment compared with solo practices. Approximately 40% of the dentists had undergone postgraduate education in oral radiology during the last 5 years. Dental nurses and dental hygienists exposed 92% of the panoramic radiographs and 75% of the CBCTs. Thirty per cent of those clinics with access to a panoramic unit exposed >30 panoramic radiographs per month and 56% of the clinics having access to CBCT did more than 75 examinations per year.

Conclusions: Today 61% of Swedish dentists have access to panoramic radiography and 8% have access to CBCT. There is a greater likelihood of having access if the dentist works in the public dental health service or in a group practice and if the dentist has undergone any postgraduate course in oral radiology.     

18F-NaF uptake in dentomaxillofacial bones as a result of oral alterations: a positron emission tomography/computerized tomography scanning study

Objectives

¹⁸F-NaF is a bone scanning radiotracer that reflects changes in bone metabolism, and it is applied in oncology to scan bone tumors or metastasis. Dentomaxillofacial alterations can lead to ¹⁸F-NaF uptake and could lead to false-positive results in PET/CT examinations. Hence, the objective of this research was to verify if the uptake of ¹⁸F-NaF in the mandible or maxilla is correlated to the presence of odontogenic alterations, which could lead to false-positive results in positron emission tomography/computerized tomography (PET/CT) examinations.

Methods

42 patients who underwent ¹⁸F-NaF PET/CT examinations and panoramic radiographs to detect bone metastasis and to assess oral conditions before oncologic treatment were included. Edentulous patients and patients with neoplasms in the maxillofacial area, and those whose imaging examinations had technical failures were excluded from the study.

Results

A total of 252 areas from panoramic radiographs and PET/CT examinations were assessed. It was observed that the presence of periodontal bone loss resulted in a higher number of cases with false negatives. Accuracy, sensitivity, and specificity of ¹⁸F-NaF uptake—regardless of the type of odontogenic origin alteration—were 76.2%, 53.3%, and 89.4%, respectively.

Conclusion

¹⁸F-NaF uptake in the maxilla or mandible could be influenced by oral alterations in the alveolar bones. The alterations in the oral cavity that lead to ¹⁸F-NaF accumulation should be recognized by medical radiologists to prevent false-positive results in PET/CT examinations using the tracer ¹⁸F-NaF.

     

Cortical Integrity of the Inferior Alveolar Canal as a Predictor of Paresthesia After Third-Molar Extraction

BackgroundParesthesia is a well-known complication of extraction of mandibular third molars (MTMs). The authors evaluated the relationship between paresthesia after MTM extraction and the cortical integrity of the inferior alveolar canal (IAC) by using computed tomography (CT).MethodsThe authors designed a retrospective cohort study involving participants considered, on the basis of panoramic imaging, to be at high risk of experiencing injury of the inferior alveolar nerve who subsequently underwent CT imaging and extraction of the MTMs. The primary predictor variable was the contact relationship between the IAC and the MTM as viewed on a CT image, classified into three groups: group 1, no contact; group 2, contact between the MTM and the intact IAC cortex; group 3, contact between the MTM and the interrupted IAC cortex. The secondary predictor variable was the number of CT image slices showing the cortical interruption around the MTM. The outcome variable was the presence or absence of postoperative paresthesia after MTM extraction.ResultsThe study sample comprised 179 participants who underwent MTM extraction (a total of 259 MTMs). Their mean age was 23.6 years, and 85 (47.5 percent) were male. The overall prevalence of paresthesia was 4.2 percent (11 of 259 teeth). The prevalence of paresthesia in group 3 (involving an interrupted IAC cortex) was 11.8 percent (10 of 85 cases), while for group 2 (involving an intact IAC cortex) and group 1 (involving no contact) it was 1.0 percent (1 of 98 cases) and 0.0 percent (no cases), respectively. The frequency of nerve damage increased with the number of CT image slices showing loss of cortical integrity (P = .043).ConclusionsThe results of this study indicate that loss of IAC cortical integrity is associated with an increased risk of experiencing paresthesia after MTM extraction.     

The role of panoramic radiographs in the medical surveillance of a patient at risk for stroke: case report

Positive carotid calcifications on a panoramic radiograph were found to be in agreement with significant carotid stenosis as determined by duplex ultrasound examination. As dentists are expected to be aware of systemic health conditions that they identify while providing dental care and to refer patients for follow-up medical care, this case report may help dentists to detect incidental carotid artery calcifications on panoramic radiographs.     

Is linear distance measured by panoramic radiography reliable?

Objectives  

To re-examine the reliability of distance measurements on clinical panoramic radiographs by comparing them with computed tomography (CT) images, from which the most accurate distance measurement is possible.     

Patterns of radiograph use in a population of commercially insured children

BackgroundThe objective of this study was to evaluate differences in number and type of radiographs used among 3 age groups (0-5, 6-12, 13-18 years) by general dentists, pediatric dentists, and other specialists, and to determine the association between number and type of radiographs and clinical need.MethodsA retrospective analysis of insurance claims by age group and oral health care provider type included children aged 0 through 8 years in 2005 who had a minimum of 10 years of continuous eligibility. Indicator claim variables were calculated to identify high-risk, high-need patients.ResultsA total of 6,712,155 records from 105,010 patients and 34,406 providers were analyzed. There was a significant effect (P < .001) of age on the number of radiographs obtained per visit. The estimated rates of radiographs per visit for ages 0 through 5, 6 through 12, and 13 through 18 were 0.373, 0.492, and 0.393, respectively. There was a significant interaction effect between age and provider type. For patients younger than 13 years, general dentists had lower rates of obtaining radiographs than did pediatric dentists, with no significant difference between providers for the 13- through 18-year age group. Treatments received, except for extractions and prosthodontics, were significantly associated with rate of radiographs per visit, with “number of restorations” as an indicator of increased risk, need, or both showing an inverse association with radiograph use.ConclusionsChild age and provider type had an effect on number of radiographs obtained per visit. Lack of caries diagnostic codes and uncommon use of risk codes hindered interpretation of whether use, frequency, or both is associated with need.Practical ImplicationsRadiograph use should follow existing guidelines or recommendations based on clinical need.     

A comparison of the diagnostic advantages of panoramic radiography and computed tomography scanning for placement of root form dental implants

This study evaluated the advantages of computed tomography (CT) in comparison to routine panoramic radiography for dental implant treatment planning. An in vitro validation study was performed to assess the accuracy of CT and panoramic radiography film images for measurement of anatomic structures and distances between anatomic structures. After correcting by a standard 25% magnification on the panoramic images, a significant difference in measurements was found between the CT and panoramic radiography images. Ten subjects requiring implants in compromised ridges were treatment planned with either CT and panoramic radiographs or panoramic radiographs alone. The ideal implant length was determined at surgery with direct digital radiography. The dentists were significantly more confident using CT and panoramic images than panoramic radiographs alone. Implant length treatment planned with panoramic radiography alone underestimated length significantly compared with the implant length determined to be ideal during surgery.whereas treatment planning with CT and panoramic radiography demonstrated no significant difference. The data indicate the CT may be of value in treatment planning for dental implants, especially when gaining maximum length is of critical importance.     

Aspects of panoramic radiography in general dental practice.

OBJECTIVES: To gather information on the types of panoramic x-ray equipment used in NHS dental practice and whether dentists satisfy the legal requirements for safety, to determine which practice personnel take panoramic radiographs and to assess the prevalence of the practice of 'routine' panoramic radiography among NHS dentists. DESIGN: Postal questionnaire survey of general dental practitioners carried out during 1997 in selected FHSAs in England and Wales. RESULTS: 542 dentists returned the questionnaire, a 73.3% response. Panoramic x-ray equipment ranged in age from 27 years old to new, with 42.2% exceeding 10 years in age. The overwhelming majority of GDPs satisfied the requirement for regular maintenance and surveying of equipment. Almost all dentists (95.9%) performed a history and clinical examination prior to panoramic radiography but 42% practised 'routine screening' of new adult patients. A substantial proportion (36.7%) of dentists used unqualified personnel to take panoramic radiographs. CONCLUSIONS: While some aspects of this study give reassurance about the prevalence of good practice, widespread panoramic screening and using unqualified staff to take radiographs causes concern. These findings have implications for educators and for those involved in maintaining clinical standards.     

Lowe syndrome: literature review and case report

Abstract

This paper is the first to describe dental findings and orthodontic characteristics of a young adult patient with Lowe syndrome. This syndrome is a rare genetic disorder inherited by a sex-linked pattern, involving primarily the kidneys, eyes and nervous system, which also present oral manifestations. This paper also present the results of careful extra and intra-oral evaluations and the findings of panoramic and cephalometric radiographs of an 18-year-old male with Lowe syndrome.     

Panoramic radiographs: determination of mandibular steepness

The aim of this study was to evaluate the potential of panoramic radiographs to measure mandibular inclination and steepness. Standardized panoramic and lateral cephalometric radiographs were taken for 95 subjects (46 females, mean age 12.4 +/- 1.2 years; 49 males, mean age 12.1 +/- 1.3 years). Mandibular inclination from panoramic radiograph was measured using gonial angle formed by the tangents of the lower border of the mandible and the distal border of the ascending ramus and the condyle. A correlation test was performed to check for similarity between the measurements. The mean values for the gonial angle were 127.3 +/- 6.2 and 125.7 +/- 6.5 degrees measured from the panoramic and cephalometric radiographs respectively. A high correlation between the measurements taken from both radiographs was found (r = 0.83, P < 0.001). Panoramic radiographs are a useful tool for the measurement of gonial angle, which is an indicator of manibular steepness and subsequently mandibular growth direction. The ability to determine growth direction from the orthopantomogram will be useful because majority of dentists request an OPG for patients during routine dental examination. This will enable the dental professional to spot vertical growth problems using a readily available tool.     

Management of patients with trigeminal nerve injuries after mandibular implant placement

BACKGROUND: Placement of mandibular endosseous implants can result in damage to the lingual nerve, the inferior alveolar nerve or both nerves. All dentists who place mandibular implants should be aware of the appropriate early management of these injuries, as well as the appropriate time to refer patients with these injuries to a microneurosurgeon. OVERVIEW: The lingual nerve is less likely to undergo spontaneous regeneration than is the inferior alveolar nerve, which is protected within the inferior alveolar canal. Since the inferior alveolar canal can be seen on most panoramic radiographs and on all high-quality computed tomographic scans, it is easier to avoid damage to the inferior nerve than to the lingual nerve, which is not visualized on radiographs and whose relationship to the posterior portion of the mandible varies from person to person. RESULTS: The authors reviewed one study that showed that lingual nerve repair helped 90 percent of patients. A second study found that patients who underwent lingual nerve repair reported a mean score of 7 on a scale from 0 to 10 in regard to the postoperative return of nerve function. Several other studies reported favorable patient responses to inferior alveolar nerve repair. CONCLUSIONS AND CLINICAL IMPLICATIONS: These results reinforce the need for early referral and intervention when inferior alveolar nerve injuries occur. Failure to refer patients with trigeminal nerve injury before distal nerve degeneration develops prevents minimization of the injury through microneurosurgical repair.     

The subjective image quality of conventional and digital panoramic radiography among 6 to 10 year old children

OBJECTIVES: To compare the diagnostic quality of orthopantomographs made with the conventional unit Orthophos Siemens and the direct digital unit Planmeca 2000 cc Proline among children 6-10 years old and to investigate possible diferences on image interpretation between oral radiologists and pediatric dentists. METHODS: Study material included two independent groups of panoramic images (50 in each group) made with different panoramic modalities (digital conventional). Eight observers (four pediatric dentists and four oral radiologists) evaluated all images for diagnostic quality in 12 pre-determined areas using a 4-point rating scale. RESULTS: Digital and conventional panoramic radiography performed almost similarly as far as it concerns the specific diagnostic tasks rated with the exception of the interproximal contacts of mandibular molars where digital panoramic radiography was scored significantly higher and the periapical region of anterior mandible and anterior mandibular tooth germs where conventional panoramic radiography was found to be significantly better. Both oral radiologists and pediatric dentists graded similarly digital and conventional radiographs for a variety of diagnostic tasks. CONCLUSIONS: It can be concluded that diagnostic image quality obtained with the digital orthopantomograph unit Planmeca 2000 cc Proline was generally equal to image quality obtained with the conventional orthopantomograph unit Orthophos Plus CD. Image interpretation between oral radiologists and pediatric dentists was not substantially different     

A study to determine the added value of 740 screening panoramic radiographs compared to intraoral radiography in the management of adult (>18 years) dentate patients in a primary care setting

Objectives

To measure the added value of panoramic radiography in new dentate patients attending for routine treatment.

Methods

Thirty-seven general dental practitioners using panoramic radiographs routinely were recruited. Twenty dentate patients were identified prospectively by each participating dentist if they were new to the practice, attending for an examination and requesting any treatment deemed necessary. A panoramic radiograph was taken with appropriate intraoral radiographs in line with national guidelines. Each dentist completed a radiological report for the panoramic radiograph only and these 20 reports were forwarded to the researchers along with the 20 panoramic radiographs, their accompanying bitewing and periapical radiographs and twenty completed clinical assessment sheets.

Results

740 panoramic, 1418 bitewing and 325 periapical radiographs were assessed by the researchers. Only 32 panoramic films provided any additional diagnostic value when compared to intraoral films when guidelines had been observed resulting from the poor technical and processing quality of the accompanying intraoral films. Assessment of the number of caries and periapical lesions and the degree of periodontal bone loss from the intraoral films provided a greater diagnostic yield at the p < 0.001 level of significance. The research found that dentists underestimated the number of caries lesions present and level of periodontal bone loss when compared to the researchers but overestimated the presence of periapical pathology, at the level of significance at p < 0.001.

Conclusions

The study found that there was no support for the use of panoramic radiographs in routine screening as there was no net diagnostic benefit to the patient.     

Nervo alveolare inferiore bifido: revisione della letteratura e presentazione di un caso clinico

ObjectivesThe aim of this study is to describe a case of bifid Inferior Alveolar Nerve (IAN) identified using tomographic radiology.This finding motivated an extensive review of the literature to establish how frequently this anatomical variation occurs.Materials and methodsA case of a female patient is reported who was a candidate for implant rehabilitation and was subjected to a pre-surgical CT exam showing a duplication of the right inferior alveolar canal.ResultsFrequency studies of bifid IAN with panoramic radiographs report an incidence ranging from 0.08% to 8.3%. These results are discordant with those obtained by more recent studies conducted with the aid of three-dimensional radiology (CT and CBCT); in this case, frequency rates increase significantly (30%).ConclusionsThere is a large inter-individual variability in the course of bifid IAN and literature doesn’t provide reliable information about the frequency with which such anomaly occurs. This underlines the value of CT radiology as a routine examination for the planning of surgical procedures involving the posterior region of the mandible.     

Dental treatment need among 20 to 25‐year‐old Swedes: discrepancy between subjective and objective need

Abstract

Objective. This methodological study aimed to determine whether the mandibular trabecular bone assessment from panoramic radiographs, using a visual index, corresponds to the evaluation obtained from periapical radiographs. Material and methods. A panoramic radiograph and corresponding periapical radiographs of the region of the lower premolars and molars were collected from each of 32 patients (mean age 18.5 ± 5.5 years). Two calibrated observers assessed randomly the interdental sites between the first molar and second premolar and between the two premolars on all the radiographs using a visual index. Evaluations were repeated with an interval of 60 days. The results of the repeated evaluations were used to assess intra- and inter-observer agreements, employing Kappa statistics. Spearman's correlation was used to determine the association between assessments of panoramic and periapical radiographs. Results. In total, 79 interdental sites were evaluated on the panoramic and periapical radiographs. The visual analysis of periapical radiographs revealed intra-observer agreements of 0.88 for observer 1 and 0.93 for observer 2, and an inter-observer agreement of 0.82. The intra-observer agreement for panoramic radiographs was 0.79 and 0.83 for observers 1 and 2, respectively, and the inter-observer agreement was 0.79. A substantial correlation was found between periapical and panoramic radiographs (rho = 0.737, p = 0.001). Conclusions. Although panoramic radiographs are less reliable than periapical radiographs, they can be used for assessment of the trabecular bone pattern with the aid of a visual index. Training on the method is recommended to obtain results with a high reproducibility.