Section I

Topic-Wise Solved Questions

of Previous Years

Part I
Oral Medicine

Topic 1
Ulcerative, Vesicular and Bullous Lesions
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. Define vesicle. Write the pathogenesis, clinical features, investigations and management of primary herpetic
infection.
2. Classify vesiculobullous lesions. Write briefly about aetiology, clinical features and treatment of erythema
multiforme.
3. Classify the ulcerative and vesiculobullous lesions of oral cavity. Describe in detail recurrent aphthous stomatitis.
4. What are the bullous lesions of oral mucosa? Describe clinical features, differential diagnosis and treatment of
pemphigus vulgaris (PV).
5. List the common viral infections that may involve the oral cavity. Discuss in detail the differential diagnosis of
herpes simplex. [Same as LE Q.1]
6. Discuss in detail the aetiology, clinical features and management of erythema multiforme. [Same as LE Q.2]
7. Enumerate various vesiculobullous lesions of oral cavity and describe erythema multiforme in detail.
[Same as LE Q.2]
8. Classify vesiculobullous lesions. Write briefly about aetiology, clinical features and treatment of erythema
multiforme. [Same as LE Q.2]
9. Classify oral ulcerations with a suitable example of each condition. Describe the clinical features and
management of recurrent aphthous ulcers. [Same as LE Q.3]
10. Classify ulcerative and vesiculobullous lesions of oral cavity. Describe the aetiology, clinical features and
treatment plan for recurrent aphthous stomatitis. [Same as LE Q.3]
11. Classify oral ulcerations with a suitable example of each condition. Describe clinical features and management
of recurrent aphthous ulcer. [Same as LE Q.3]

247
248 Quick Review Series for BDS 4th Year, Vol 2

12. Classify ulcerative and vesiculobullous lesion of oral cavity. Describe the aetiology, clinical features and
treatment plan for recurrent aphthous stomatitis. [Same as LE Q.3]
13. Enumerate the various bullous lesions and describe aetiology, clinical features differential diagnosis and
management of pemphigus. [Same as LE Q.4]
14. Classify vesiculobullous lesions. Discuss in detail aetiopathogenesis, clinical features and management of PV.
[Same as LE Q.4]
15. What are the bullous lesions of oral mucosa? Describe clinical features, differential diagnosis and treatment of
PV. [Same as LE Q.4]
16. Define an autoimmune disease and enumerate autoimmune disease that has indirect and direct effect on the
oral cavity. Give the clinical features and investigations of PV. [Same as LE Q.4]

SHORT ESSAYS:
1. Classification and treatment of recurrent aphthous stomatitis. [Ref LE Q.3]
2. Describe clinical features of acute necrotizing ulcerative gingivitis (ANUG).
3. Give treatment plan for ANUG.
4. Give treatment plan for pemphigus vulgaris (PV). [Ref LE Q.4]
5. Describe clinical features of Stevens–Johnson Syndrome (SJS).
6. Investigations and management of primary herpetic gingivostomatitis. [Ref LE Q.1]
7. Classify vesiculobullous lesions of oral cavity. [Ref LE Q.2]
8. Clinical features of erythema multiforme. [Ref LE Q.2]
9. Herpes zoster.
10. Enumerate four differences between pemphigus vulgaris and benign mucous membrane pemphigoid (BMMP).
11. Write a note on the management of oral mucous membrane pemphigoid.
12. Aphthous ulcer. [Same as SE Q.1]
13. Recurrent aphthous stomatitis. [Same as SE Q.1]
14. Describe briefly about erythema multiforme. [Same as SE Q.8]

SHORT NOTES:
1. ANUG.
2. Patch test.
3. Tzank test.
4. Name two clinical features of discoid lupus erythematosus.
5. Nikolsky sign.
6. Target lesions.
7. Lipschutz bodies.
8. LE cells.
9. Define macule, papule and vesicle. Also give two examples of each.
10. Define postherpetic neuralgia.
11. Smoker’s palate.
12. Tzank smear. [Same as SN Q.3]

SOLVED ANSWERS

LONG ESSAYS: Vesicles

Primary herpetic infection
Q.1. Define vesicle. Write the pathogenesis, clinical
l Elevated blisters containing clear fluid that are
features, investigations and management of primary
under 1 cm in diameter are called vesicles. ‘Her-
herpetic infection.
pes’ is a Greek word which literally means creep,
Ans. it tells its nature of spreading.
Section | I Topic-Wise Solved Questions of Previous Years 249

l Although 80 herpes viruses are noted in humans, lHSV lesions can be scraped and smeared for
herpes 1–8 are mainly infectious. Among them cytologic studies and Giemsa, Wright and Pa-
herpes I and II are called herpes simplex. panicolaou, H&E staining is done, which may
Pathogenesis identify viral particles and multinucleated epi-
l Primary herpetic gingivostomatitis is caused by thelial cells.
herpes simplex virus (HSV) I infection. l The murine monoclonal antibody immunohis-

l The herpes simplex virus gains access to the tochemistry can also identify the presence of
patient via: intracellular HSV.
a. Direct or airborne (humans are only natural Treatment
reservoirs) l The two drugs most effective against HSV are

b. Water-droplet transmission from an infected systemic acyclovir and ganciclovir.

individual l Primary herpetic gingivostomatitis is self-limiting

Clinical presentation and should require only supportive care consisting

l Common incubation period is 5–7 days; first pro- of hydration, antipyretics, nutrition and possibly
dromal symptoms will appear for 2 days before antibiotics if secondary bacterial infections arise.
appearance of oral lesions. l In immunocompromised patients, topical 5% acy-

l Primary herpetic gingivostomatitis develops clovir is used.

mostly in children and young adults. l Immunocompromised patients may also require

l The mucous membrane lesions represent direct intravenous therapy, usually in divided dosages
viral infection at the site of inoculation. for a total of 30 mg/kg per day.
l Painful vesicular lesions develop on all mucosal l In acyclovir-resistant strains, foscarnet (Foscavir)

surfaces; because of their thin nature they rupture is used as a substitute to acyclovir or as an addition
to produce foul-smelling ulcers. to it at dose of 40–60 mg/kg, i.v. thrice a day.}
l The patient is usually febrile, drools, has significant
Q.2. Classify vesiculobullous lesions. Write briefly about
malaise, feels miserable and will have tender cervi-
aetiology, clinical features and treatment of erythema
cal lymphadenopathy especially submandibular.
multiforme.
l It will appear as generalized acute marginal

gingivitis. Ans.
l The lesions and acute illness last about 10 days
[SE Q.7]
and resolve with scar formation.
Differential diagnosis {Classification of vesiculobullous lesions
l The painful vesicular ulcerative lesions of acute I. Acute and chronic vesiculobullous
herpetic gingivostomatitis may resemble necrotiz- A. Acute vesiculobullous lesions
ing ulcerative periodontitis, pemphigus vulgaris i. Herpesvirus infections
(PV); these lesions will have systemic signs and a. Primary herpes simplex virus infection
symptoms. ii. Coxsackievirus infections
l Erythema multiforme mainly occurs on lips, the a. Herpangina
oral lesions by themselves might be suggestive of b. Acute lymphonodular pharyngitis
erythema multiforme, but without concomitant c. Hand, foot and mouth disease
skin lesions true erythema multiforme is not iii. Varicella zoster virus infection
likely. iv. Erythema multiforme
l Aphthous ulcers and focal atrophic candida v. Contact allergic stomatitis
lesions are other prime considerations. vi. Oral ulcers secondary to cancer chemotherapy
l Early herpes zoster is also possible. vii. Acute necrotizing ulcerative gingivitis (ANUG)
B. Chronic vesiculobullous lesions
[SE Q.6]
i. Pemphigus vulgaris
{Investigations ii. Pemphigus vegetans
a. Cytology iii. Subepithelial bullous dermatoses
b. Virus isolation iv. Bullous pemphigoid
c. Antibody titres v. Cicatricial pemphigoid
l In children with suspected primary herpetic vi. Erosive lichen planus
gingivostomatitis, circulating HSV antibodies II. Based on the clinical presentation
are used for investigation; however, it is not A. Predominantly vesicular
reliable in recurrent lesions. i. HSV infection
250 Quick Review Series for BDS 4th Year, Vol 2

ii. Varicella infection immune complexes in the superficial micro-

iii. Hand, foot and mouth disease vasculature of skin and mucosa or cell medi-
iv. Herpangina ated immunity.
v. Dermatitis herpetiformis Types
B. Predominantly bullous a. EM minor or erythema multiforme minor: It rep-
i. Pemphigus vulgaris resents the localized eruptions of skin with mild
ii. Bullous pemphigoid or no mucosal involvement.}
iii. Benign mucous membrane pemphigoid b. EM major or erythema multiforme major or
iv. Bullous lichen planus Stevens–Johnson syndrome (SJS): It is more se-
v. Erythema multiforme vere mucosal and skin disease and is potentially
vi. Stevens–Johnson syndrome life-threatening disorder.
vii. Epidermolysis bullosa Clinical manifestations
III. Histopathological classification
General features
Intraepithelial vesiculobullous lesions
i. HSV infection
[SE Q.8]
ii. Varicella infection
iii. Herpangina l {Occurs chiefly in children and young adults be-
iv. Hand, foot and mouth disease tween the ages of 15 and 40 years and males are
v. Pemphigus more commonly affected than females.
vi. Familial benign chronic pemphigus l Characterized by the occurrence of asymptomatic
vii. Epidermolysis bullosa vividly erythematous discrete macules, papules or
viii. Erythema multiforme (mucosal) occasionally vesicles and bullae that appear sym-
Subepithelial vesiculobullous lesions metrically distributed over hands and arms, legs and
i. Bullous pemphigoid feet, face and neck.
ii. Cicatricial pemphigoid l It is a self-limiting form of disease.
iii. Epidermolysis bullosa l The classical dermal lesions of erythema multiforme,
iv. Dermatitis herpetiformis which often appear on extremities are concentric ring
IV. Based on whether the lesions are infectious or non- like resulting from varying shades of erythema giv-
infectious ing rise to terms ‘target’, ‘iris’ or ‘bull’s eye’ lesions.
Infectious vesiculobullous lesions l The palms of the hands will show target-like lesions
i. Herpes simplex infections more than any other skin surface.
ii. Varicella infections l The vesicles of mucosal surface develop rapidly and
iii. Herpangina are short lived and become eroded or ulcerated and
iv. Hand, foot and mouth disease bleed profusely.
Noninfectious vesiculobullous lesions l Recurrence is common; patient also develops tra-
i. Pemphigus cheobronchial ulceration and pneumonia.}
ii. Bullous pemphigoid l Erythema multiforme major or SJS is a variant of ery-
iii. Cicatricial pemphigoid thema multiforme that represents a life-threatening
iv. Erythema multiforme and debilitating hypersensitivity.
v. Dermatitis herpetiformis} l Patients presented with ‘ocular-genital lesions’. Skin
lesions involve necrosis of scrotal skin, penile skin or
[SE Q.8]
vulval and labial surfaces.
{Erythema multiforme l The ocular component is epithelial necrosis of the cor-
Erythema multiforme is an acute self-limiting, inflamma- nea and conjunctiva, which develop prominent ulcer-
tory dermatological disorder that involves skin, mucus ation and necrosis, often leading to blindness directly
membrane and sometimes, internal organs. or to visual loss caused by secondary infection.
Aetiology l Oral lesions are severely painful large, haemor-
i. Infectious agents: Mycoplasma pneumonia, rhagic, crusting ulcers, especially of the lips and
herpes simplex, etc. labial mucosa.
ii. Drug hypersensitivity: Oxicam NSAIDs, anticon- l The pain prevents oral intake of fluids or solids.
vulsants like carbamazepine, phenobarbital, etc., l The oral lesions will secondarily produce drooling,
sulpha drugs, salicylates, allopurinol and penicillin. resulting in excess fluid and electrolyte loss and
iii. Hyperimmune reaction: It is an immune- leads to secondary infection, ultimately resulting in
mediated disease initiated by the deposition of cervical lymphadenitis.
Section | I Topic-Wise Solved Questions of Previous Years 251

l The progression from the initial emergence of lesions l The necrosed skin is treated as a burn with topical
to a full debilitating clinical picture with skin and antimicrobial creams (1% silver sulphadiazine;
mucous membrane necrosis often occurs within 24 h. Silvadene, Aventis), and the eyes are irrigated and
Oral findings patched.
l Oral lesions tend to be haemorrhagic ulcers that crust l Erythema multiforme major (SJS), however, requires
and may be seen on any portion of the oral mucosa, systemic corticosteroids.
with predilection for lip vermilion. l Topical steroid therapy coupled with antibiotics may
l Oral lesions will occur in only 50% of cases with be considered whereas systemic steroid therapy is
skin lesions and will emerge concurrently. controversial.}
l Oral lesions suggestive of erythema multiforme with- l Once the intensity of the disease resolves and no
out concomitant skin lesions probably do not repre- new skin lesions are developing, corticosteroids are
sent true erythema multiforme; they often represent a discontinued.
lichenoid drug eruption or an immune-based disease.
Q.3. Classify the ulcerative and vesiculobullous lesions
[SE Q.8] of oral cavity. Describe in detail recurrent aphthous
stomatitis.
{Histopathology
l The microscopic appearance of erythema multiforme Ans.
is not diagnostic as it depends in part on the stage of
the lesion and the area of the biopsy. Classification of vesiculobullous lesions
l It usually consists of changes such as intercellular or I. Acute and chronic vesiculobullous
intracellular oedema and necrosis of epithelium. A. Acute vesiculobullous lesions
l Necrosis of prickle cells is a significant finding. Epi- i. Herpesvirus infections
thelial necrosis is also very prominent within the a. Primary herpes simplex virus infection
centre of ‘iris’ lesions. ii. Coxsackievirus infections
l Vesicles may form within epithelium or at epithelial– a. Herpangina
connective tissue junction. b. Acute lymphonodular pharyngitis
l Subepithelial connective tissue shows oedema and c. Hand, foot and mouth disease
perivascular infiltration of lymphocytes and macro- iii. Varicella zoster virus infection
phages.} iv. Erythema multiforme
Diagnosis v. Contact allergic stomatitis
l Both types of erythema multiforme are clinical vi. Oral ulcers secondary to cancer chemotherapy
diagnoses. vii. Acute necrotizing ulcerative gingivitis (ANUG)
l A mucosa or skin biopsy is recommended to rule out B. Chronic vesiculobullous lesions
identifiable immune-based and viral diseases. i. Pemphigus vulgaris
Differential diagnosis ii. Pemphigus vegetans
l The main differential lesion is toxic epidermal iii. Subepithelial bullous dermatoses
necrolysis. iv. Bullous pemphigoid
l Severe cases of pemphigus or cutaneous pemphigoid v. Cicatricial pemphigoid
may also mimic erythema multiforme major, but the vi. Erosive lichen planus
progression of signs and symptoms is not nearly as II. Based on the clinical presentation
rapid. A. Predominantly vesicular
i. HSV infection
[SE Q.8]
ii. Varicella infection
{Treatment iii. Hand, foot and mouth disease
l Cause should be identified and withdrawn. iv. Herpangina
l Erythema multiforme minor usually requires no treat- v. Dermatitis herpetiformis
ment. It is self-limiting, will improve after 5–8 days, B. Predominantly bullous
and will completely resolve within 2–4 weeks. i. Pemphigus vulgaris
l In some cases, antibiotics are required to treat sec- ii. Bullous pemphigoid
ondary skin or oral infections appropriately. iii. Benign mucous membrane pemphigoid
l For all the forms of erythema multiforme, symptom- iv. Bullous lichen planus
atic treatment including oral antihistamines, analge- v. Erythema multiforme
sics, local skin care and soothing mouthwashes is of vi. SJS
great importance. vii. Epidermolysis bullosa
252 Quick Review Series for BDS 4th Year, Vol 2

III. Histopathological classification l The third or ulcerative stage: The classic ulcer
Intraepithelial vesiculobullous lesions appears, measuring between 3 and 10 mm and
i. HSV infection may last 7–14 days.
ii. Varicella infection l The fourth stage: It is the healing stage in
iii. Herpangina which granulation tissue followed by epithelial
iv. Hand, foot and mouth disease migration incurs healing without scar.
v. Pemphigus b. Recurrent aphthous major
vi. Familial benign chronic pemphigus l The major ulcers are over 1 cm in diameter and
vii. Epidermolysis bullosa take longer to heal with often scars.
viii. Erythema multiforme (mucosal) l Most individuals with major aphthous ulcers har-
Subepithelial vesiculobullous lesions bour at least one or two lesions at all times.
i. Bullous pemphigoid l Major aphthous ulcers are identical to minor aph-
ii. Cicatricial pemphigoid thous ulcers in their developmental stages and
iii. Epidermolysis bullosa their general appearance except that they are
iv. Dermatitis herpetiformis larger (.10 mm), deeper and long-lasting almost
IV. Based on whether the lesions are infectious or up to 6 weeks.}
noninfectious Pathogenesis
Infectious vesiculobullous lesions l The pathogenesis of aphthous stomatitis is unknown.
i. Herpes simplex infections l The current concept is that Recurrent Apthous Stomati-
ii. Varicella infections tis (RAS) is a clinical syndrome with several possible
iii. Herpangina causes: the major factors identified are heredity, haema-
iv. Hand, foot and mouth disease tologic deficiencies, immunologic abnormalities and
Noninfectious vesiculobullous lesions nutritional deficiencies.
i. Pemphigus l Other factors include trauma, psychological stress, anx-
ii. Bullous pemphigoid iety and allergy to foods such as milk, cheese, wheat-
iii. Cicatricial pemphigoid flour and detergent, i.e. sodium lauryl sulphate (SLS),
iv. Erythema multiforme present in toothpaste.
v. Dermatitis herpetiformis Histopathology
Clinical presentation l Histologic examination is not usually indicated for aph-
thous ulcers, although it is sometimes helpful for diffi-
[SE Q.1] cult clinical cases. The findings are rather nonspecific.
l {Aphthous ulcers are also commonly known as ‘canker Diagnosis
sores’. l No specific diagnosis is required. It is a clinical-recognition
l According to their clinical characteristics, aphthous diagnosis.
ulcers are divided into two types: Differential diagnosis
a. Recurrent aphthous minor l Minor aphthae will often be confused with recurrent
b. Recurrent aphthous major herpes lesions.
a. Recurrent aphthous minor l The lesions of Behcet syndrome will look very much
l Minor ulcers comprise over 80% of cases and are like those of major aphthous stomatitis.
less than 1 cm in diameter. l The oral lesions of hand, foot and mouth disease will
l They appear as single discrete ulcers or in groups also resemble aphthae.
of two or more and they heal without scar.
[SE Q.1]
l They are characteristically found on the free

movable oral mucosa rather than the attached {Treatment

mucosa. l As there is no known single effective treatment for aph-
l The formed ulcers are discrete with a white yel- thous stomatitis, there is a plethora of published and un-
low base, which is a fibrinous slough, and a dis- published treatment schedules and drugs. They include
tinct irregular border with a red halo. antibiotics; vitamins; zinc; levamisole as an immune
l The lesions emerge in four stages: stimulant; and either topical, intralesional or systemic
l The first or prodromal stage: The individual corticosteroids. In addition, chlorhexidine gluconate 0.12%
will experience a tingling or burning pain in a and iron therapy.
clinically normal-appearing site. l Minor aphthous ulcers are few and of short duration,
l The second or preulcerative stage: Red oval hence no specific therapy is required. It is reasonable to
papules appear and the pain intensifies. simply reassure the patient.
Section | I Topic-Wise Solved Questions of Previous Years 253

l Pain relief of minor lesions can be obtained by using Aetiology

topical anaesthetic agent or topical diclofenac. l PV is an autoimmune disorder that is characterized

l Single or small groups of ulcers that are uncomfortable by the appearance of intraepithelial bullae on unin-
may be directly cauterized with silver nitrate (AgNO3) flammed skin surface or mucous membranes.
or phenol, thereby avoiding systemic side effects. Mechanism of bullae formation
l In more severe cases, the use of a high-potency topical l PV is a B cell–mediated autoimmune disease in

steroid preparation, such as fluocinonide, betametha- which autoantibodies develop to antigens within the
sone or clobetasol, placed directly on the lesion shortens desmosome–tonofilament junction of the intercellu-
healing time and reduces the size of the ulcers. lar bridges. Such autoantibodies fix complement and
l For aphthous ulcers that are numerous, frequent enough initiate inflammation, which causes a suprabasilar
to debilitate patients, the three most effective antibiotic split as the primary pathogenesis causing an intraep-
regimens are ithelial blister to form.
l Erythromycin, 250 mg by mouth four times daily. Clinical features
l Tetracycline 250 mg by mouth four times daily. l PV is commonly seen in people of 50–60 years age

l A mixture often called ‘tetranydril elixir’, which group.

consists of 250 mg tetracycline and 12.5 mg diphen- l It is insidious in its onset and can often be fatal.

hydramine hydrochloride (Benadryl) per 5 mL of l Men and women are equally affected. Jewish people

kaopectate. The patient is instructed to use 1 tsp at a are more commonly affected.
time and swish, hold the solution in their mouth as l PV usually presents with painful skin and/or oral

long as possible, and swallow, three times daily. ulcers. The lesions actually begin as short-lived ves-
l The above regimens have been variably useful in con- icles that rapidly rupture because of their suprabasi-
trolling the number, frequency and duration of lesions. lar position.
l If these antibiotic regimens fail, systemic corticoste- l The characteristic feature of PV is rapidly appearing

roids are the treatment of choice.} multiple vesicles and bullae which vary in diameter
Prognosis from a few millimetres to several centimetres.
l Aphthous stomatitis is most active in young adulthood. l The lesions (bullae) appear on a perfectly normal ap-

With time and advancing age, the condition becomes pearing mucosa, although a large area of the skin
less intense and usually remits altogether. surface may be affected, the eye is not involved. The
bullae could be rubbed with fingers.
Q.4. What are the bullous lesions of oral mucosa? l PV can be fatal in several cases as the appearance of

Describe clinical features, differential diagnosis and large bullae all over the skin surface can lead to rapid
treatment of pemphigus vulgaris (PV). fluid loss just like a case of severe burns.
l The bullae are flaccid, fragile, regular and nonin-
Ans.
flammatory. They contain a thin watery fluid initially,
The various types of vesiculobullous lesions that affect the which may soon become purulent or sanguineous.
oral cavity have been categorized as follows: l Intraorally, the bullae, if seen sufficiently early, ap-
A. Viral diseases pear as vesicles on the palate, oropharynx or inside
l Herpes gingivostomatitis of the cheeks.
l Primary varicella zoster l When the affected epithelium ruptures, it leads to the

l Secondary varicella zoster formation of shallow painful ulcers that are covered
l Herpes labialis with a whitish ‘skin’, which is the original roof of the
l Measles bulla. These oral lesions may persist for months be-
B. Immunologic conditions fore the skin becomes involved.
l Pemphigus vulgaris l The oral mucosa may be affected 2–3 months before

l Bullous form of lichen planus the skin. Cheeks and vermilion border of the lips are
C. Hereditary conditions the common sites for the bullae.
l Epidermolysis bullosa l Nikolsky sign is positive, that is the loss of epithe-

l Familial benign pemphigus (Hailey–Hailey disease) lium occasioned by rubbing apparently unaffected
l Keratosis follicularis (Darier disease) skin is termed as Nikolsky sign.
D. Miscellaneous Histological features
l Impetigo l The pemphigus is characterized microscopically by

Pemphigus vulgaris the formation of a vesicle or bulla entirely intraepi-

l Pemphigus vulgaris (PV) is the most common form thelially just above the basal layer producing a dis-
of pemphigus, accounting for over 80% of cases. tinctive suprabasilar ‘split’.
254 Quick Review Series for BDS 4th Year, Vol 2

l The suprabasal separation of epithelium (i.e. float- lesions, and if the individual is older than 50 years,
ing epithelium) is the most important diagnostic pemphigoid becomes a realistic consideration.
feature of PV. l Bullous-erosive lichen planus: It is another pos-
l Disappearance of intercellular bridges results in loss sibility, but they are rare and more pruritic than
of cohesiveness or acantholysis because of which painful. They are also violet-red, not the pale grey
clumps of epithelial cells are found lying free within vesicles seen in PV.
the vesicular space; these cells are called ‘Tzanck Q.5. List the common viral infections that may involve
cells’. Tzank cells have large nuclei and hyper chro- the oral cavity. Discuss in detail the differential diagno-
matic staining. sis of herpes simplex.
l Bulla is filled with acantholytic multinucleated
epithelial cells known as ‘Tzank cells’, which are Ans.
diagnostic feature of this condition. [Same as LE Q.1]
l Immunofluorescent testing is considered to be of
great importance in establishing the diagnosis of PV, Q.6. Discuss in detail the aetiology, clinical features and
especially when the clinical or microscopic findings management of erythema multiforme.
are inconclusive. Ans.
[Same as LE Q.2]
[SE Q.4]
Q.7. Enumerate various vesiculobullous lesions of oral
{Treatment cavity and describe erythema multiforme in detail.
lThe mainstay of treatment remains high doses of
Ans.
systemic corticosteroid, usually given in dosages of
1–2 mg/kg/day. [Same as LE Q.2]
l Taking into account the pre-existing and coexisting
Q.8. Classify vesiculobullous lesions. Write briefly about
conditions, therapy may be tailored for each patient. aetiology, clinical features and treatment of erythema
l Various other therapies that have been reported as
multiforme.
beneficial are parenteral gold therapy, dapsone, tetra-
cycline and plasmapheresis and administration of Ans.
8-methoxypsoralen. [Same as LE Q.2]
l Patient may continue to experience mild disease

activity while under optimal treatment. Q.9. Classify oral ulcerations with a suitable example of
l When steroids must be used for long periods of time, each condition. Describe the clinical features and man-
adjuvants such as azathioprine or cyclophosphamide agement of recurrent aphthous ulcers.
are added to the regimen to reduce the complications Ans.
of long-term corticosteroid therapy.
[Same as LE Q.3]
l One new immunosuppressive drug, mycophenolate,
has been effective when managing patients resistant Q.10. Classify ulcerative and vesiculobullous lesions of
to other adjuvants.} oral cavity. Describe the aetiology, clinical features and
Differential diagnosis treatment plan for recurrent aphthous stomatitis.
The oral-only pemphigus presentation will include a Ans.
subset of diseases as follows:
[Same as LE Q.3]
l Erosive lichen planus: Has similar presentation;

however, lichen planus targets the dorsum of the Q.11. Classify oral ulcerations with a suitable example
tongue, buccal mucosa and attached gingiva. of each condition. Describe clinical features and man-
l Pemphigoid: Mild forms of PV may closely re- agement of recurrent aphthous ulcer.
semble but it does not usually produce a conjunc- Ans.
tivitis, which is frequently present in pemphigoid
cases. [Same as LE Q.3]
The PV that expresses vesicular skin lesions in addition Q.12. Classify ulcerative and vesiculobullous lesion of
to painful oral lesions includes a subset of following oral cavity. Describe the aetiology, clinical features and
diseases: treatment plan for recurrent aphthous stomatitis.
l Erythema multiforme.
Ans.
l Bullous pemphigoid: If the oral lesions are not es-

pecially painful and more prominent than the skin [Same as LE Q.3]
Section | I Topic-Wise Solved Questions of Previous Years 255

Q.13. Enumerate the various bullous lesions and de- subsequently involving marginal gingival and
scribe aetiology, clinical features differential diagnosis rarely attached gingival.
and management of pemphigus. l Craters are covered by greyish pseudo-membranous

slough with a marked demarcation of linear ery-

Ans.
thema from the normal mucosa.
[Same as LE Q.4] l Spontaneous bleeding from gingival tissue, fetid

odour and increased salivation.

Q.14. Classify vesiculobullous lesions. Discuss in detail ae- Symptoms
tiopathogenesis, clinical features and management of PV. l Extremely tender with radiating pain on eating

Ans. hot and spicy foods.

l Metallic foul taste.
[Same as LE Q.4] Extraoral and systemic signs and symptoms
Q.15. What are the bullous lesions of oral mucosa? Mild-to-moderate stages:
l Local lymphadenopathy
Describe clinical features, differential diagnosis and
l Slight elevation of temperature
treatment of PV.
Severe cases:
Ans. l High fever with increased pulse rate

l Loss of appetite and general lassitude

[Same as LE Q.4]
Systemic reactions
Q.16. Define an autoimmune disease and enumerate l They are severe in children.
autoimmune disease that has indirect and direct effect l Rarely gangrenous stomatitis, fusospirochetal men-
on the oral cavity. Give the clinical features and investi- ingitis, peritonitis, toxemia and fatal brain abscess
gations of PV. may occur.
Ans. Q.3. Give treatment plan for ANUG.
[Same as LE Q.4] Ans.
l Treatment of ANUG generally consists of local debride-
ment and irrigation coupled with oral antibiotics.
SHORT ESSAYS: l The conservative treatment is superficial cleaning of
oral cavity and irrigation with a solution of 3% hydro-
Q.1. Classification and treatment of recurrent aphthous gen peroxide mixed 1:1 with saline or chlorhexidine or
stomatitis. warm salt water.
Ans. l Initially, the teeth should undergo a light scaling to
remove superficial plaque and calculus under local or
[Ref LE Q.3] topical anaesthesia.
Q.2. Describe clinical features of ANUG. l In addition, home plaque control instructions should be
provided, and oral rinses with either the same hydrogen
Ans. peroxide solution or 0.12% chlorhexidine should be
used.
l It is an inflammatory and destructive endogenous
l Oral antibiotics are effective, and penicillin remains the
oral infection, which is characterized by the necrosis of
drug of choice.
gingival tissue.
l In the nonpenicillin allergic patient, oral phenoxy-
l It is also known as trench mouth, Vincent infection,
acute ulceromembranous gingivitis and acute ulcerative methyl penicillin 500 mg four times daily for 7–10 days
gingivitis. is recommended.
l For the penicillin allergic patient, erythromycin ethyl
Clinical features
succinate, 400 mg twice a day for 7–10 days, and
l It is identified as an acute disease characterized by sud-
ordoxycycline, 100 mg once daily for 7–10 days, are
den onset, sometimes followed by an episode of de-
good second choices.
bilitating diseases or acute respiratory tract infections.
l Nutritional supplements like vitamins B and C.
l It is seen commonly in age group 16–30 years.

Oral signs and symptoms Q.4. Give treatment plan for pemphigus vulgaris (PV).
Signs
Ans.
l Characterized by punched out, crater-like de-

pressions at the crest of the interdental papillae, [Ref LE Q.4]

256 Quick Review Series for BDS 4th Year, Vol 2

Q.5. Describe clinical features of Stevens–Johnson Q.7. Classify vesiculobullous lesions of oral cavity.
syndrome (SJS).
Ans.
Ans.
[Ref LE Q.2]
i. SJS is a very severe bullous form of erythema multi-
Q.8. Clinical features of erythema multiforme.
forme with widespread involvement typically includ-
ing skin, oral cavity, eyes and genitalia. It manifests as Ans.
generalized vesicles and bullae involving the skin,
[Ref LE Q.2]
mouth, eyes and genitals.
ii. It is characterized by the abrupt appearance of symp- Q.9. Herpes zoster.
toms such as fever, photophobia, malaise and erup-
Ans.
tions over the oral mucosa, skin and the genitalia.
iii. Widespread involvement of different regions like the l Varicella zoster virus (VZV) is responsible for two ma-
skin and the eyes are also noted which are commonly jor clinical infections of humans: chickenpox (varicella)
haemorrhagic and are often vesicular or bullous. and shingles (herpes zoster, HZ).
iv. The oral mucosal lesions are extremely painful and l Chickenpox is a generalized primary infection, analo-
mastication is usually impossible. In many cases, the gous to the acute herpetic gingivostomatitis of herpes
oral lesions may be the chief complaint. simplex virus. After the primary disease is healed, Vari-
v. The lips may exhibit ulceration with bloody crusting cella zoster virus (VZV) becomes latent in the dorsal
and are painful. root ganglia of spinal nerves or extramedullary ganglia
vi. Genital lesions include nonspecific urethritis, balanitis of cranial nerves. VZV becomes reactivated, causing
and vaginal ulcers. lesions of localized HZ.
vii. Some of the other complications may include tracheo- l The incidence of HZ increases with age or immunosup-
bronchial ulcerations and pneumonia patients usually pression and these lesions may be deepseated and dis-
recover unless they are secondarily infected. seminated, causing pneumonia, meningoencephalitis
viii. Treatment and hepatitis.
l Cause should be identified and withdrawn and in- l HZ commonly has a prodromal period of 2–4 days, when
fections should be appropriately treated. shooting pain, paraesthesia, burning and tenderness ap-
l Symptomatic treatment including oral antihista- pear along the course of the affected nerve. Unilateral
mines, analgesics, local skin care and soothing vesicles on an erythematous base then appear in clusters,
mouthwashes is of great importance. chiefly along the course of the nerve, giving the charac-
l Topical steroid therapy coupled with antibiotics teristic clinical picture of single dermatome involvement.
may be considered, whereas systemic steroid ther- Some lesions spread by viraemia outside the dermatome.
apy is controversial. l The vesicles turn to scabs in 1 week, and healing takes
l Mild cases of oral EM may be treated only with place in 2–3 weeks.
supportive measures, including topical anaes- l The nerves most commonly affected with HZ are C3,
thetic mouthwashes. Adults treated with short- T5, L11, L2 and the first division of the trigeminal
term systemic steroids, patients with severe cases nerve.
of recurrent EM have been treated with dapsone, l HZ may also occasionally affect motor nerves. HZ of
azathioprine, levamisole or thalidomide. the sacral region may cause paralysis of the bladder. The
l The most severe form of the disease is TEN (toxic extremities and diaphragm have also been paralysed
epidermal necrolysis or Lyell disease), which is during episodes of HZ.
usually secondary to a drug reaction and results in l The most common complication of HZ is postherpetic
sloughing of skin and mucosa in large sheets. Pa- neuralgia (PHN), which is defined as pain remaining for
tients with this form of the disease are most suc- over a month after the mucocutaneous lesions have
cessfully managed in burn centres, where necrotic healed.
skin is removed under general anaesthesia and heal- l Involves one of the branch of trigeminal nerve generally
ing takes place under sheets of porcine xenografts. but ophthalmic branch is most commonly involved.
l HZ has been associated with dental anomalies and severe
Q.6. Investigations and management of primary her- scarring of the facial skin when trigeminal HZ occurs
petic gingivostomatitis. during tooth formation. Pulpal necrosis and internal root
resorption have also been related to HZ.
Ans.
l Although the histopathology is not specific, two major
[Ref LE Q.1] histologic patterns have been described: an epidermal
Section | I Topic-Wise Solved Questions of Previous Years 257

pattern characterized by lichenoid vasculitis and intraepi- day for 6 months with slow tapering, may be helpful in
dermal vesicles, and a dermal pattern characterized by controlling the disease.
lymphocytic vasculitis and subepidermal vesiculation.
Q.12. Aphthous ulcer.
l The most accurate method of diagnosis is viral isolation
in tissue culture. [Same as SE Q.1]
l Acyclovir or famcyclovir accelerate healing and reduce
Q.13. Recurrent aphthous stomatitis.
acute pain, but they do not reduce the incidence of PHN.
The use of systemic corticosteroids to prevent PHN in [Same as SE Q.1]
patients over 50 years of age is controversial.
Q.14. Describe briefly about erythema multiforme.
l Effective therapy for PHN includes application of cap-
saicin tricyclic antidepressant, or gabapentin can also [Same as SE Q.8]
be used.
Q.10. Enumerate four differences between pemphigus SHORT NOTES:
vulgaris and benign mucous membrane pemphigoid
(BMMP). Q.1. ANUG.
Ans. Ans.
l The classical lesion of pemphigus is a thin-walled bulla l Acute necrotizing ulcerative gingivitis (ANUG) became
arising on otherwise normal skin or mucosa. The bulla known popular as ‘trench mouth’ during World War I
rapidly breaks but continues to extend peripherally, because of its prevalence in the combat trenches.
eventually leaving large areas denuded of skin. In BMMP Aetiology
lesions appear as blisters, which turn out into ulcer. l The fusiform bacillus and spirochetes.

l In BMMP, subepithelial blisters remain intact for a lon- Clinical features

ger time period compared to PV, due to a thicker blister l Sudden in onset with pain, tenderness, profuse saliva-

wall. tion, a peculiar metallic taste and spontaneous bleed-

l Routine histopathology shows subbasilar cleavage and ing from the gingival tissues, loss of the sense of taste.
no acantholysis, whereas acantholysis is commonly l The typical lesions of ANUG consist of necrotic

seen in PV. punched-out ulcerations, developing most commonly

l In PV, Tzanck cells (clumps of epithelial cells often on the interdental papillae and the marginal gingiva.
found lying free within the vesicular space, have swol- Treatment
len nuclei and hyperchromatic staining) are common l Local debridement.

histologic feature. l Complete gingival curettage and root planning.

l The conjunctiva is the second most common site of in- l Antibiotics are required in patients with extensive

volvement in BMMP. gingival involvement, lymphadenopathy or other

systemic signs. Metronidazole and penicillin are the
Q.11. Write a note on the management of oral mucous
drugs of choice.
membrane pemphigoid.
Q.2. Patch test.
Ans.
Ans.
Management of oral mucous membrane pemphigoid
l There is no single treatment for mucous membrane l Patch test is the only test used to distinguish contact
pemphigoid it differs according to patient condition. allergy from other lesions. It is also used in diagnosis
l If extensive lesions involving the oral cavity are present, of lichenoid reactions.
systemic prednisone may be indicated. l The technique is that, suspected allergen is placed on
l Normally, a short course of prednisone is prescribed normal nonhairy skin, usually upper portion of the back,
(40 mg per day for 7 days without tapering). it is covered and allowed to remain in contact with the
l Topical steroids may be prescribed either alone or in skin for 48 h the patch is removed and the area is exam-
addition to systemic steroids, as ointments or oral rinse ined for persistent erythema 2–4 h later.
solutions. l The patch testing directly on oral mucosa has been at-
l If lesions are extensive, immunosuppressive medica- tempted by incorporating the test substance in orabase,
tions such as azathioprine, mycophenolate and cyclo- by use of prosthetic appliance to hold the substance in
phosphamide may be necessary to manage. place or by use of a rubber cup attached to the teeth.
l Also, a combination of tetracycline and niacinamide l The patch testing of the skin may not be reliable in di-
(niacin flush free), 500 mg taken three or four times a agnosis of hypersensitive reactions of oral mucosa.
258 Quick Review Series for BDS 4th Year, Vol 2

Q.3. Tzank test. l The size of the iris lesion varies from a few mm to about
2 cm in diameter. These lesions usually resolve in about
Ans.
3–5 weeks.
l In pemphigus, on histological examination, disappear-
Q.7. Lipschutz bodies.
ance of intercellular bridges results in acantholysis be-
cause of which clumps of epithelial cells are found lying Ans.
free within the vesicular space, these cells are called
l The Lipschutz bodies are characteristic findings of her-
‘Tzanck cells’.
pes infection.
l Cytology smears taken from freshly opened vesicles are
l The presence of multinucleated giant cells and intranu-
usually preferred as ‘Tzanck cells’ can be seen. These
clear viral inclusion bodies such as Lipschutz bodies or
are characterized particularly by degenerative changes,
Cowdry Type A (ovoid, amorphous and eosinophilic
which include swelling of the nuclei and hyperchro-
bodies that exhibit peri-inclusion halo that is caused by
matic staining. This is also referred to as Tzanck test.
the peripheral displacement of the nucleolus and the
Q.4. Name two clinical features of discoid lupus erythe- nuclear chromatin). The cells exhibit ballooning degen-
matosus. eration of the nucleus.
Ans. Q.8. LE cells.
l Discoid lupus erythematosus (DLE) is a relatively com- Ans.
mon disease and occurs predominantly in females in the
l Lupus erythematous cells (LE cells) are characteristi-
third or fourth decade of life.
cally found in patients suffering from acute systemic
l It can present in both localized and disseminated forms
form of lupus erythematosus.
and is confined to the skin and oral mucous membranes
l The cells consist of rosette of neutrophils surrounding a
and has a better prognosis than SLE.
pale nuclear mass derived from lymphocytes.
l Typical cutaneous lesions appear as red and somewhat
scaly patches that favour sun-exposed areas such as the Q.9. Define macule, papule and vesicle. Also give two
face, chest, back and extremities. The oral mucosal le- examples of each.
sions of DLE frequently resemble reticular or erosive
Ans.
lichen planus.
Macules
Q.5. Nikolsky sign.
Well-circumscribed, flat lesions that are noticeable
Ans. because of their change from normal skin colour. They
may be red due to the presence of vascular lesions or
l Gentle retraction of unaffected mucosa or application of
inflammation, or pigmented due to the presence of
minimal pressure over unaffected skin or mucosa results
melanin, haemosiderin and drugs.
in blisters, producing a classical clinical sign known as
Papules
Nikolsky sign (named after Pyotr Vasilyewich Nikolsky
Solid lesions raised above the skin surface that are
who described it in 1896).
smaller than 1 cm in diameter. Papules may be seen
l The Nikolsky sign is positive if slight pressure or
in a wide variety of diseases including erythema mul-
rubbing of the skin produces lateral movement of the
tiforme simplex, rubella, lupus erythematosus and
upper layers of the epidermis.
sarcoidosis.
l Nikolsky sign is generally positive in PV and benign
Vesicles
oral mucous membrane pemphigoid.
Elevated blisters containing clear fluid that are under
Q.6. Target lesions. 1 cm in diameter.
Q.10. Define postherpetic neuralgia.
Ans.
Ans.
l The typical dermal lesions of EM are target, iris or
bull’s eye lesion. Spontaneous pain, pain provoked by trivial stimuli and al-
l These are asymptomatic, discrete, and erythematous tered sensation accompany herpes zoster which may con-
macules or papules set in a concentric ring pattern usu- tinue long after its characteristic rash has healed is known
ally comprising a central bulla. The iris lesion has three as postherpetic neuralgia.
concentric zones: a central dusky or darker red area
Q.11. Smoker’s palate.
(central bulla or area of necrosis), a paler pink or oede-
matous zone and a peripheral erythematous zone. Ans.
Section | I Topic-Wise Solved Questions of Previous Years 259

l Smoker’s palate or nicotine stomatitis or stomatitis papules with punctate red centres that represent in-
nicotina palati, refers to a specific white lesion that de- flamed and metaplastically altered minor salivary gland
velops on the hard and soft palate in heavy cigarette, ducts are noted.
pipe and cigar smokers. l Nicotine stomatitis is completely reversible once the
l The lesions are restricted to areas that are exposed to a rela- habit is discontinued.
tively concentrated amount of hot smoke during inhalation. l The lesions usually resolve within 2 weeks of cessation
l Nicotine stomatitis also develops in individuals with a of smoking.
long history of drinking extremely hot beverages. This
suggests that heat, rather than toxic chemicals in to- Q.12. Tzank smear.
bacco smoke, is the primary cause. Ans.
l Due to the chronic insult, the palatal mucosa becomes
diffusely grey or white. Numerous slightly elevated [Same as SN Q.3]

Topic 2
Red and White Lesions
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. Describe the clinical features and differential diagnosis of oral lichen planus (OLP).
2. Classify white lesions of the oral cavity. Describe the aetiology, clinical features and management of leukoplakia.
3. Enumerate oral precancerous lesions and conditions. Describe clinical features and management of oral
submucous fibrosis (OSMF).
4. Write an essay on oral candidiasis.
5. Describe briefly and give the differential diagnosis of psoriasis.
6. Discuss in detail clinical features, differential diagnosis and treatment of erythroplakia.
7. Describe the aetiology, clinical features, differential diagnosis and treatment of oral lichen planus (OLP).
[Same as LE Q.1]
8. Name some of the white lesions of oral mucosa. Describe the clinical features, differential diagnosis and treat-
ment of leukoplakia of hard palate. [Same as LE Q.2]
9. What are the keratinizing lesions of the oral cavity? Write about oral leukoplakia. [Same as LE Q.2]
10. Define leukoplakia. Discuss the aetiopathogenesis, clinical features and treatment of oral leukoplakia.
[Same as LE Q.2]
11. Enumerate the ‘white lesions’ of the oral cavity. Describe leukoplakia in detail, giving differential diagnosis.
[Same as LE Q.2]
12. What conditions may produce trismus? Describe in detail the predisposing factors, clinical features, treatment
of oral submucous fibrosis. [Same as LE Q.3]
13. Write the clinical features, differential diagnosis and management of oral submucous fibrosis. [Same as LE Q.3]
14. Describe in detail aetiology, clinical features and management of oral submucous fibrosis. [Same as LE Q.3]
15. Describe in detail the aetiology, clinical features, treatment plan and prognosis of submucous fibrosis.
[Same as LE Q.3]
16. Classify oral mucosal candidiasis. Write the aetiopathogenesis, clinical features, investigations and manage-
ment of chronic atrophic candidiasis. [Same as LE Q.4]
17. Enumerate the various white lesions that can be scrapped. Describe the clinical features, differential diagnosis
and treatment of candidiasis. [Same as LE Q.4]
18. Enumerate predisposing factors of candidiasis. Mention the various types and discuss in detail the treatment
plan. [Same as LE Q.4]
19. Classify candidiasis. Write in detail about the aetiology, clinical features and management of oral thrush.
[Same as LE Q.4]
260 Quick Review Series for BDS 4th Year, Vol 2

20. Classify candidiasis and give clinical features, laboratory diagnosis tests and treatment of oral candidal infec-
tion. [Same as LE Q.4]
21. Treatment of acute pseudomembranous moniliasis. [Same as LE Q.4]

SHORT ESSAYS:
1. Predisposing factors and smear examination for Candida albicans.
2. Aetiology and management of oral leukoplakia. [Ref LE Q.2]
3. Aetiology and management of oral submucous fibrosis (OSMF). [Ref LE Q.3]
4. Lichenoid reactions.
5. Lupus erythematosus.
6. Management of oral lichen planus (OLP).
7. Erythroplakia – clinical features and management. [Ref LE Q.6]
8. White spongy nevus.
9. Oral hairy leukoplakia.
10. Mention any four predisposing factors of candidiasis. [Same as SE Q.1]
11. Predisposing factors of moniliasis. [Same as SE Q.1]
12. Leukoplakia. [Same as SE Q.2]
13. Mention the treatment plan for submucous fibrosis. [Same as SE Q.3]
14. Systemic lupus erythematosus. [Same as SE Q.5]
15. Write briefly clinical and histologic features of discoid lupus erythematosus. [Same as SE Q.5]

SHORT NOTES:
1. Define vesicle and papule. Give two examples of each.
2. Behcet syndrome.
3. Candidiasis – aetiology.
4. Auspitz sign.
5. White spongy nevus.
6. Mention various types of lichen planus.
7. Grinspan syndrome.
8. Civatte bodies.
9. Oral manifestations of ectodermal dysplasia.
10. Systemic lupus erythematosus. [Ref SE Q.5]
11. Stevens–Johnson syndrome.
12. Target lesions.
13. Moniliasis. [Same as SN Q.3]

SOLVED ANSWERS

LONG ESSAYS: l Such cases are common following severe psychological

Q.1. Describe the clinical features and differential diag- stress such as death of a close friend or relative, marital
nosis of oral lichen planus (OLP). or sexual problems, failure in a career, loss of job and
security or exam tensions.
Ans.
Clinical features
l Lichen planus is a common chronic, dermatologic dis- l Lichen planus commonly occurs among the middle aged
ease of the skin and mucous membranes. and elderly people with slight predilection for females.
Aetiology l Oral lichen planus can involve several areas of oral cav-
l Lichen planus is primarily an immune-related disorder, ity including the buccal mucosa, vestibule, tongue, lips,
which may also be caused due to other factors. floor of mouth, palate and gingiva.
l One of the major factors that can cause exacerbations or l Patients may often report with burning sensation of oral
remission of the condition is emotional trauma. mucosa.
Section | I Topic-Wise Solved Questions of Previous Years 261

l The oral lesion is generally characterized by radiating include glandular enlargement and Treponema pallidum
white and grey velvety thread-like papules in linear, found in oral lesions.
angular or retiform arrangement. Tiny white elevated iv. Candidiasis (thrush)
dots are usually present at the intersection of these white The white patches of candidiasis can be easily scraped
lines and are known as ‘Wickham striae’. off and microscopically spores and mycelia can be
l Types or patterns of lichen planus in the oral cavity: seen from the collected specimens.
i. Linear pattern v. Recurrent aphthae (ulcer)
ii. Papular pattern They are usually associated with trauma.
iii. Reticular vi. Pemphigus
iv. Annular pattern, i.e. circular Is characterized by bullous lesions resulting on a nor-
v. Vesicular or bullous mal looking mucosa and histologically presence of
vi. Erosive or atrophic acantholytic cells is diagnostic.
vii. Hypertrophic vii. Lupus erythematosus
Is characterized by the area of atrophy and scarring
Histopathology
remains stationary over many months or years and is
The following histopathological changes may be noted
firm on palpation.
that are suggestive of lichen planus:
viii. Erythema multiforme
l The overlying surface epithelium exhibits hyperortho-
Can be differentiated by history and biopsy, its acute
keratosis or parakeratosis.
nature and severe involvement of labial mucosa.
l Thickening of granular cell layer.
Treatment
l Acanthosis of spinous cell layer and ‘saw-tooth’ appear-
l There is no known cure for OLP. Hence, the manage-
ance of rete pegs.
ment of symptoms guides therapeutic approaches.
l There is presence of necrosis or liquefaction degenera-
l Corticosteroids have been the most predictable and suc-
tion of basal cell layer of epithelium.
cessful medications for controlling signs and symptoms.
l Band-like subepithelial mononuclear infiltrate consist-
Topical and/or systemic corticosteroids are prescribed
ing of T cells and histiocytes.
electively for each patient.
l Chronic inflammatory cell infiltration is present in
l Topical medications include high-potency corticoste-
juxta-epithelial region.
roids, the most commonly used are as follows:
l Degenerating basal keratinocytes form rounded or
l 0.05% fluocinonide (Lidex), 0.05% clobetasol
ovoid, amorphous eosinophilic bodies known as ‘civatte,
(Temovate) and triamcinolone acetonide 0.1 % in
hyaline, cytoid’ bodies.
orabase, oral suspension of triamcinolone, high-
l Degeneration of basal keratinocytes and disruption of
potency steroid mouthwashes like betamethasone
anchoring elements of epithelial basement membrane
valerate 0.1%, fluocinolone acetonide 0.1% and clo-
weakens the epithelial connective tissue interface re-
betasol propionate 0.05% have been used effectively.
sulting in histological clefts known as Max–Joseph
l The topical forms are applied daily to meet each pa-
spaces.
tient’s needs. Topical corticosteroids reduce pain and
Differential diagnosis inflammation.
Lichen planus must be differentiated from the lesions, l In addition, extensive erosive lesions of OLP on the gin-
which may present a similar clinical appearance, they are as giva (desquamative gingivitis) may be treated effectively
follows: by using occlusive splints as carriers for the topical steroid.
i. Lichenoid reactions l Candida overgrowth with clinical thrush may develop,
Some of the varieties of medications may induce lesions requiring concomitant topical or systemic antifungal
that appear clinically very similar to lichen planus. therapy. It has been shown that the use of an antibacte-
ii. Leukoplakia rial rinse such as chlorhexidine before steroid applica-
Some of the distinguishing features of leukoplakia tion helps prevent fungal overgrowth.
from lichen planus are that it is more common in men, l Systemic steroids are rarely indicated for brief treat-
found in slightly younger age group, may have a fam- ment of severe exacerbations or for short periods of
ily history, has no history of remission and recurrence, treatment of recalcitrant cases that fail to respond to
usually involves commissures of the mouth, surround- topical steroids.
ing mucosa is normal in appearance and symptom like l Systemic administration of prednisone tablets may be
soreness is felt. done with dosages varying between 40 and 80 mg daily
iii. Mucous patches of secondary syphilis for less than 10 days without tapering. The time and
They are distinguished from lichen planus by the ten- dosage regimens are determined individually, based on
dency for the papules to ulcerate in the centre, favour the patient’s medical status, severity of disease and pre-
commissure of lips and tonsils. Other manifestations vious treatment responses.
262 Quick Review Series for BDS 4th Year, Vol 2

l Consultation with the patient’s primary care physician is ii. Acute atrophic candidiasis (antibiotic sore mouth)
important when underlying medical problems are present. iii. Chronic atrophic candidiasis (denture sore mouth
l Retinoids are also useful, usually in conjunction with and angular cheilitis)
topical corticosteroids as adjunctive therapy for OLP. iv. Median rhomboid glossitis
l Systemic and topically administered b all-trans retinoic v. Chronic hyperplastic candidiasis
acid, vitamin A acid, systemic etretinate and systemic IV. Keratotic white lesions with no increased potential for
and topical isotretinoin are all effective, and topical the development of oral cancer
application of a retinoid cream or gel will eliminate i. Stomatitis nicotina
reticular and plaque-like lesions in many patients. ii. Traumatic keratosis
However, following withdrawal of the medication, the iii. Intraoral skin grafts
majority of lesions recur. iv. Focal epithelial hyperplasia
l Topical retinoids are usually favoured over systemic v. Psoriasiform lesions (psoriasis, Reiter syndrome
retinoids since the latter may be associated with ad- and geographic tongue ‘ectopic geographic tongue’)
verse effects such as liver dysfunction, cheilitis and V. Red and white lesions with defined or uncertain pre-
teratogenicity. cancerous potential
l A new systemically administered retinoid, temarotene, i. Leukoplakia (homogenous, nodular or speckled
is reported to be an effective therapy for OLP and to be and verrucous)
free of side effects other than a slight increase in liver ii. Erythroplakia
enzymes. iii. Oral lesions are with use of tobacco and alcohol
l Other topical and systemic therapies reported to be use- (cigarette, cigar and pipe smoking, snuff clipping
ful, such as dapsone, doxycycline and antimalarials, tobacco and betel nut chewing and reverse smoking)
require additional research. iv. Carcinoma in situ
l Topical application of cyclosporine appears to be help- v. Bowen disease
ful in managing recalcitrant extensive and otherwise vi. Oral submucous fibrosis (OSMF)
intractable oral lesions of OLP. vii. Actinic keratosis
l When lesions have been confined to the mucosa just viii. Discoid lupus erythematosus
opposite amalgam restorations and when patients have ix. Dyskeratosis congenita
been positive for patch tests to mercury or other metals, x. Lichen planus
complete removal of the amalgam restorations has been xi. Oral lichenoid reactions (erythema multiforme,
curative in most patients. lupus erythematosus, dermatomyositis, drug-induced
l Surgical excision is indicated for the treatment of OLP lichenoid reactions, secondary syphilis and graft
only in cases where concomitant dysplasia has been vs. host reactions)
identified. This grouping provides a practical scheme for the clini-
cian faced with for making decisions about particular lesions.
Q.2. Classify white lesions of the oral cavity. Describe
the aetiology, clinical features and management of [SE Q.2]
leukoplakia.
{Leukoplakia
Ans. l Leukoplakia is defined as ‘a white patch or plaque that
cannot be characterized clinically or pathologically as
Classification of white lesions
any other disease’.
I. Variations in structure and appearance of the normal
l Leukoplakia is a keratotic plaque occurring on mucous
oral mucosa
membranes and is considered as a premalignant lesion.
i. Leukoedema
ii. Fordyce granules Aetiologic factors
iii. Linea alba and other areas of frictional cornifica- i. Tobacco products
tion ii. Ethanol
II. Nonkeratotic white lesions iii. Hot, cold, spicy and acidic foods and beverages
i. Habitual cheek biting iv. Alcoholic mouth rinse
ii. Burns (thermal, aspirin, dental medicaments, ra- v. Occlusal trauma
diation mucositis and uraemic stomatitis) vi. Sharp edges of prostheses or teeth
iii. Caused by specific infectious agents (Koplik spots, vii. Actinic radiation
and syphilitic patches) viii. Syphilis
III. Candidiasis ix. Presence of Candida albicans
i. Acute pseudomembranous candidiasis (oral thrush) x. Presence of viruses}
Section | I Topic-Wise Solved Questions of Previous Years 263

Classification v. The typical homogenous leukoplakia is characterized

Clinical types of leukoplakia are as follows: as white, well-demarcated plaque with an identical
a. Homogenous type reaction pattern throughout the lesion.
b. Speckled type vi. The surface texture can vary from smooth thin surface
c. White and red patches to leathery appearance with surface fissures referred to
d. Verrucous type as ‘cracked mud’.
a. Homogenous leukoplakia vii. The nonhomogeneous type of oral leukoplakia also
Homogenous white plaques have no red component but known as erythroleukoplakia or speckled leukoplakia
have a fine, white, grainy texture or a more mottled, may have white patches or plaque intermixed red tis-
rough appearance. sue elements.
b. Speckled leukoplakia viii. Verrucous or verruciform leukoplakias are the lesions
Composed of fine or coarse variety of white and red in which white component is dominated by papillary
flecks. projections similar to oral papillomas.
c. Combination of white and red patches This variety of leukoplakia with more aggressive
Basically erythroleukoplakic lesions demonstrating seg- proliferation pattern and recurrent rate are designated
regation of red and white components. as proliferative verrucous leukoplakia (PVL). This is
d. Verrucous leukoplakia more common in older women and lower gingiva is
Has red and white components of which the white com- the predilection site.
ponents are much thicker and protrude above the sur- ix. Malignant potential: Those lesions situated in the
face mucosa. high-risk areas, such as floor of the mouth, ventral
surface of tongue, margins of the tongue and retro
Histological types
molar regions, have high risk for malignant trans-
Leukoplakia is mainly categorized into two types:
formation.
i. Those that show no atypia (dysplasia).
ii. Those that show different degrees of atypia: Differential diagnosis
l A leukoplakia lesion may show severe atypia with i. Lichen planus
malignant change throughout the depth of epithelial ii. Leukoedema
layer, but its basement membrane may still be intact, iii. Cheek-biting lesions
such lesion is referred to as carcinoma in situ or in- iv. Smokeless tobacco lesion
traepithelial carcinoma. When intraepithelial carci- v. Lupus erythematosis
noma breaks through the basement membrane, it vi. Hyperplastic or hypertrophic candidiasis
becomes an invasive SCC. vii. Verrucous or squamous cell carcinoma
viii. Verruca vulgaris
Leukoplakia is also divided into two types according to ix. White sponge nevus (WSN)
its spontaneous disappearance following removal of chronic
irritant as follows: [SE Q.2]
i. Reversible leukoplakia: Lesions of leukoplakia are
reversible after removal of chronic irritants.
{Management
I. Elimination of aetiological factors
ii. Irreversible leukoplakia: Persistent lesions, even after
l No appropriate treatment has been established for
removal of irritants.
Sanguinaria-induced leukoplakia. So, complete
Clinical features discontinuation of Sanguinaria containing products
i. Asymptomatic, discovered during routine oral exami- is mandatory and cessation of any other harmful
nation. habits like alcohol and smoking by the patients
ii. More common in older age group .35 years (40–70 which are well established risk factors.
years) of age range, more common in men. II. Conservative treatment
iii. Frequent sites are lips, vermilion border, buccal l Vitamin therapy especially vitamin A and vitamin

mucosa, mandibular gingiva, tongue, oral floor, E, B complex, 13-cis-retinoic acid and antioxidant
hard palate, maxillary gingiva, lip mucosa and soft therapy.
palate. The floor of the mouth and lateral border l Nystatin therapy (in candidal leukoplakia).

of tongue are high risk sites for malignant transfor- III. Surgical therapy
mation. l Cold knife surgical excision.

iv. Lesions may greatly vary in size, shape and distribu- l Laser surgery.

tion; the borders may be distinct or indistinct smoothly l Cryosurgery (liquid nitrogen or CO2 snow is used).

contoured or ragged. l Fulguration (electro-cautery or electro-surgery).

264 Quick Review Series for BDS 4th Year, Vol 2

l Laser (light amplification by especially CO2 lasers Aetiology and pathogenesis

stimulated fusion of radiation). i. Chronic irritation
l However, in the absence of evidence-based treat-
a. Betel nut, i.e. areca nuts (alkaloids)
ment, strategies for oral leukoplakias, surgery will
b. Chillies capsaicin (active ingredient
remain the treatment of choice for leukoplakia and causing irritation)
erythroplakia. c. Tobacco Local irritants
l A general recommendation may be to re-examine d. Lime
the site every 3 months for first 1 year irrespective
of surgical excision. l Areca nut, quid chewing habit and development
l Follow up every 6 months to see whether there is of OSMF is dose dependant and the mechanism is
any change in reaction pattern and relapse. described below:
l Self-examination is reasonable approach if there is Areca nuts contain alkaloids like
no relapse for 5 years.
l However, an initial biopsy is mandatory. If a histo- g
pathologic diagnosis of dysplasia is rendered, the Arecoline (primary aetiologic factor)
condition should be treated in a fashion similar to
the treatment of other potentially premalignant g
processes. Modulates matrix metalloproteinases, lysyl oxidases and
collagenases
All patients should be given careful clinical follow-up, g all affect
with a biopsy of any recurrent or worsening lesion(s).}
Metabolism of collagen
Q.3. Enumerate oral precancerous lesions and condi- gleading to
tions. Describe clinical features and management of oral
submucous fibrosis. Increased fibrosis

Ans. ii. Genetic predisposition

l Genetic predisposition is an important aetiologic
l The premalignant lesions are defined as morphologically factor behind OSMF.
altered tissue in which cancer is more likely to occur l Familial occurrence of OSMF has been reported.
than in its apparently normal counterpart. For example, iii. Nutritional deficiency
l Leukoplakia
l Vitamin B complex deficiency.
l Erythroplakia
l Deficiency is precipitated by the defective nutri-
l Nicotiana palati
tion due to impaired food intake.
l Stomatitis
iv. Bacterial infections
l Dyskeratosis congenitis
For example, streptococcal toxicity.
l The premalignant condition is defined as generalized l Klebsiella rhinoscleromatis may be causative
state of body, which is associated with significantly in- factors in OSMF.
creased risk of cancer. v. Collagen disorders
For example, oral submucous fibrosis, syphilis, lichen l OSMF is thought to be localized collagen dis-
planus, white sponge nevus and so on. ease of oral cavity.
The following are the conditions that produce trismus: l It is linked to scleroderma and rheumatoid arthritis.
i. Odontogenic infections l Scleroderma and OSMF have similar histologi-
ii. Traumatic fractures cal features.
iii. Neoplastic conditions vi. Immunological disorders
iv. Neurotoxic agents l hESR and globulin levels indicate immunodefi-
v. Psychogenic factors ciency disorder. Serum immunoglobulin levels of
vi. Pharmacological substances IgA, IgG and IgM are h significantly found in
OSMF, which suggest an antigenic stimulus in
[SE Q.3]
the absence of any infection.}
{Oral submucous fibrosis l Circulating auto antibodies are present in some cases of
l It is a chronic disease that affects the oral mucosa OSMF.
as well as the pharynx and upper two-thirds of the Clinical features
oesophagus. i. Age and sex: Equally affects both the sexes, and
l It is a high-risk precancerous condition. patients are between second and fourth decade.
Section | I Topic-Wise Solved Questions of Previous Years 265

ii. Site: Most frequent locations are buccal mucosa Early lesions have a good prognosis as they may
(98%) and retromolar areas. Commonly involved regress.
sites are soft palate, (49%) palatal fauces, uvula, ii. Supportive treatment
tongue and labial mucosa. l Vitamin rich diet.

iii. Prodromal symptoms: Onset of OSMF is insidi- l Iodine, B-complex preparations (e.g. injection

ous and is often 2- to 5-year duration. Most com- ranodine), injection of arrsenotyphoid and iodine
mon initial symptom is burning sensation of oral (arrsenotyphoid is a fibrin dissolving agent).
mucosa, aggravated by spicy food followed by iii. Steroids
either hypersalivation or dryness of mouth.
iv. The first sign is erythematous lesions, some- Both Topical – e.g. hydrocortisone injection along with
times in association with petechiae, pigmenta- procaine HCl intralesionally every fortnight.
tions and vesicles. Systemic – e.g. cortisone, hydrocortisone 25 mg
v. Initial lesions are followed by paler mucosa, tab in doses of 100 mg/day. Triamcinolone or 90
which comprise white marbling. mg dexamethasone.
vi. In the later course of the disease, the most
prominent clinical features appear, i.e. fibrotic l Increased vascularity at the affected site attributed
bands located beneath an atrophic epithelium. to fibrolytic, antiallergic and anti-inflammatory ac-
vii. hfibrosis leads to loss of resilience, which causes tion of corticosteroid.
interference with speech, tongue mobility and a l The fibrosis is prevented by decreasing fibroblastic

decreased ability to open the mouth. production and deposition of collagen.

viii. The atrophic epithelium may cause a smarting iv. Placental extract
sensation and inability to eat hot and spicy food. l It is an essential biogenic stimulator. Only the

ix. Diagnosis of OSMF is based on clinical features aqueous extract of placenta acts as biogenic stimu-
and patients report of a habit of betel quid chewing. lator. It accelerates cellular metabolism, stimulated
An international consensus has been reached where regenerative process, aids in absorption of exu-
at least one of the following characteristics should be dates, increases physiologic function of organs and
present to diagnose OSMF, they are as follows: significant enhancement of wound healing and it
i. Palpable fibrous bands. has notable anti-inflammatory effect. Dose: Intral-
ii. Mucosal texture feels tough and leathery. esionally 2 mL of solution is deposited in five di-
iii. Blanching of mucosa together with histo- vided regions of the lesions at intervals of 3 days or
pathologic features consistent with OSMF about 15 days. If required the course is repeated
(i.e. atrophic epithelium with loss of rete after a month.
ridges and juxta-epithelial hyalinization of v. Hyaluronidase: It acts by breaking down the hyal-
lamina propria). uronic acid, i.e. the ground substance of connective
Pathology tissues.
Early histopathological characteristics of OSMF are vi. Surgical procedures: When there is marked limitation
l Fine fibrils of collagen, oedema, hypertrophic fi- of opening, the surgery is the treatment method of
broblasts, dilated and congested blood vessels and choice.
infiltration of neutrophilic and eosinophilic granu- a. Excision of fibrous bands followed by use of
locytes. tongue flap as a graft or bilateral full thickness
gfollowed by nasolabial flap.
l Downregulation of fibroblasts, epithelial atrophy b. New technique of bilateral palatal flaps to cover
and loss of rete pegs and early signs of hyalinization exposed area in combination with the bilateral tem-
in concert with an infiltration of inflammatory cells. poralis myotomy and coronoidectomy.
g c. LASER – with CO2 laser under GA incise the buc-
l Epithelial dysplasia (7%–26%) of cases. cal mucosa and vaporize the submucosal connec-
Malignant transformation of OSMF has been esti- tive tissue to the level of buccinator muscle.
mated in the range of 7%–13% and incidence over d. Cryosurgery – local destruction of tissue by freez-
10-year period is 8%. ing it in sites.
vii. Oral physiotherapy: oral exercises are advised in early
[SE Q.3]
and moderately advanced cases.
{Management viii. Diathermy: Microwave diathermy is useful in early
i. Stopping of chewing habits, especially areca nut as and moderate lesions like mouth opening and balloon-
it is carcinogenic. If this is successfully implemented. ing of mouth.}
266 Quick Review Series for BDS 4th Year, Vol 2

Q.4. Write an essay on oral candidiasis. VII. Others

l Radiation therapy
Ans.
l Sjögren syndrome
Oral candidiasis is the most prevalent opportunistic infec- l Pregnancy
tion affecting oral mucosa. l Old age
Most candida infections only affect mucosal linings, l Infancy
but the rare systemic manifestations may have fatal l Denture use
course.
Predisposing factors
Aetiology and pathogenesis
l C. albicans, C. tropicalis and C. glabrata. Local Systemic or general
l C. albicans constitute 80% of species isolated from Denture wearing Immunosuppressive diseases
human candidiasis. Smoking Impaired health status
l Candida is a common, harmless, dimorphic yeast.
Atopic constitution Immunosuppressive drugs
Predisposing factors to oral candidiasis Inhalation steroids Chemotherapy
I. Drugs and medications
Broad-spectrum antibiotics (e.g. tetracycline) Topical steroids Endocrine disorders
Multiple antibiotic regimens Hyperkeratosis Hematinic deficiencies
Corticosteroids Imbalance of oral microflora
Cytotoxic agents
Quality and quantity of salvia
Immunosuppressive agents
Anticholinergics (xerostomia producing)
II. Endocrinopathies Classification of oral candidiasis according to Sicher:
l Diabetes mellitus

l Hypoadrenalism
Acute Chronic
l Hypothyroidism i. Acute pseudo- i. Chronic hyperplastic oral candidiasis
l Hypoparathyroidism membranous ii. Chronic atrophic oral candidiasis
oral candidiasis iii. Chronic mucocutaneous candidiasis
l Polyendocrinopathy
(thrush) a. Chronic familial mucocutaneous
III. Haematologic disorders ii. Acute atrophic candidiasis
l Aplastic anaemia oral candidiasis b. Chronic localized mucocutaneous
l Agranulocytosis candidiasis
l Lymphoma c. Chronic diffuse mucocutaneous
candidiasis
l Leukaemia
d. Candidiasis endocrinopathy
IV. Immune deficiency syndrome
l HIV disease

l Thymic alymphoplasia (Nezelof syndrome) Classification of oral candidiasis according to Boucher:

l Thymic hypoplasia (DiGeorge syndrome) A. Primary oral candidiasis
l Severe combined immunodeficiency syndrome l Acute – pseudomembranous and erythematous

(Swiss type) l Chronic – pseudomembranous

l Chronic mucocutaneous candidiasis (CMC) l Erythematous

V. Leukocyte disorders l Plaque-like

l Myeloperoxidase deficiency l Nodular

l Agranulocytosis/leukopenia/neutropenia l Candida-associated lesions – denture stomatitis

VI. Malignancy l Angular cheilitis

l Leukaemia l Median rhomboid glossitis

l Lymphoma B. Secondary oral candidiasis

l Advanced cancer l Familial chronic mucocutaneous candidiasis

l Nutritional deficiencies l Diffuse chronic mucocutaneous candidiasis

l Iron deficiency l Candidiasis endocrinopathy syndrome

l Folic acid deficiency l Familial mucocutaneous candidiasis

l Vitamin B deficiency l Severe combined immune deficiency

l Vitamin C deficiency l DiGeorge syndrome

l Malnutrition l Chronic granulomatous disease

l Malabsorption l AIDS
Section | I Topic-Wise Solved Questions of Previous Years 267

C. Extraoral candidiasis cultured and counted and counter as in previous

l Oral candidiasis are with extraoral lesions (candidal methods.
vulvovaginitis and intertriginous candidiasis) l Advantage: Simple method.
l Gastrointestinal candidiasis l Better results if CFU .50/cm2.
l Candida hypersensitivity syndrome l Disadvantage: Simple method recommended for sur-
D. Systemic candidiasis veillance cultures in the absence of focal lesions,
l Mainly affects eye, kidney and skin cannot identify site of infection.
Clinical features
Treatment of oral candidiasis
Various types of clinical lesions are as follows:
l Several appropriate medications are available for treat-
l Pseudomembranous – white necrotic (loosely adherent)
ment of oropharyngeal candidiasis (topical 1 systemic
l Erythematous – red
drug agents) drug treatment should be continued for at
l Atrophic – red
least 1 week after signs and symptoms have disappeared
l Hyperplastic – white and red raised
without any tendency to recur.
l Mixed – red/white keratotic/white necrotic
I. Topical therapy
l Mucocutaneous – lip and angle
Generally indicated for milder superficial cases where
l Pseudomembranous type is most acute followed by
patients resistance is relatively good and there is im-
erythematous
mune competency.
l Atrophic and hyper plastic types are chronic
i. Nystatin
l 50% patients complain, oral burning and infections
ii. Clotrimazole
(more acute types will be more painful) and hyperplas-
iii. Chlorhexidine mouth rinse 0.1%–0.2%
tic types painless
iv. Gentian violet
l Age: 40 years with female predilection
Nystatin
Lab diagnosis l The majority of acute oral candida infections

i. Smear from infected area – scraping and smearing respond rapidly to topical nystatin.
directly on to slide l Action – This polyene drug destroys cell mem-

l Advantage: Simple and quick brane by binding to ergosterol in them.

l Disadvantage: Low sensitivity l Side effect – Unusual, it is not absorbed through

ii. Swab GIT.

iii. Imprint culture l Available forms – Oral suspension ointment/

l Sterile plastic foam pads dipped into sabouraud creams vaginal troches powder tablets.
broth, placed on lesion for 60 s, pad pressed on sab- l Pastilles (most widely used form) – 200,000 units/

ouraud agar plate and incubated, colony counter each pastille, 1–2 dissolved in mouth 4–5 times/day.
used. Clotrimazole
l Advantage: Sensitive and reliable, can differentiate l An imidazole derivative (clotrimazole) is avail-

between infected and carrier states. able for topical use.

iv. Impression culture l Action – This is an azole; it changes candida’s

l Maxillary and mandibular impressions with alginate membrane permeability by blocking the produc-
and casting in agar fortified with sabouraud broth tion of ergosterol.
and incubation. l Clotrimazole troches can also be used for treat-

l Advantage: Useful to determine relative distributions ment of oral lesions.

of yeasts on oral surfaces. l Available as 10 mg oral troche (Mycelex) dis-

l Disadvantage: Used as research tool. solved slowly in mouth, 5 times/day. Continue for
v. Salivary culture 2–4 weeks or at least week after manifestations
l 2 mL saliva is expectorated by patient into sterile have disappeared.
container. Vibrate and culture on sabouraud agar by Chlorhexidine (mouth rinse 0.1%–0.2%)
a spiral plating and counting. l It is active against candida and some bacteria and

l Advantage: Sensitive and reliable. causes increased cell membrane permeability.

l Disadvantage: More chair side time not useful in l It interferes with candidal adhesion to oral mucosa.

xerostomics. Gentian violet

vi. Oral rinse l Deep violet alcohol solution directly painted on

l Subject rinses for 60 s with PBS that is phosphate- lesions.

buffered saline at pH 7.2, 0.1 M and returns it to the l Advantage is that it is economical and quickly

original container concentrated by centrifugation, applied by clinician.

268 Quick Review Series for BDS 4th Year, Vol 2

lThe consumption of yogurt two to three times per l It occurs in all ages with equal predilection for both sexes.
week and improved oral hygiene can also help, l Severity of the disease increases in winter.
especially if underlying predisposing factors can- l Clinically it is characterized by small dry papules cov-
not be eliminated. ered by silvery scales. On removal of the scales, they
II. Systemic therapy leave tiny bleeding spots (Auspitz sign).
l Systemic therapy includes the use of anyone of these l The common extraoral sites include elbows, knees,
three: ketoconazole, itraconazole and fluconazole. scalp and lumbosacral skin and nails.
l Systemically administered drugs are chosen in l These patients also have arthritis. Temporomandibular
chronic deep-seated infections and superficial cases joint may be involved in such cases.
refractory to topical agents. l Intraoral lesions are rare and if involved the lesions
Ketoconazole occur on tongue and palate.
l Very effective and is still used. l There will be white scaly or raised erythematous patches
l Action: Affects permeability of fungal cell mem- with annular or irregular borders.
brane. l One of the special features of psoriasis is the capacity to
l Nizoral available as 200 mg tablets and as i.v. reproduce the skin lesion at the site of local injury. It is
preparation. called Koebner phenomenon or the isomorphic effect.
l 1–2 tabs/day with food for at least 2 weeks and
Considerations in the differential diagnosis of psoriasis
continue for 1–2 weeks after symptoms disappears.
l Reiter syndrome
l i.v. administration – Used for refractory infections
l Seborrhoeic dermatitis
in AIDS patients.
l Geographic tongue
l Caution
l Atopic eczema
l Liver toxicity (less when compared to other azoles).
l Lichen planus
l Liver profile tests done if chronic administra-
l Darier disease
tion is considered.
Fluconazole Treatment
l Fluconazole is more effective than ketoconazole, l Psoriasis can be treated using topical corticosteroids
but its frequent use can lead to the development of and keratinolytics. Methotrexate has also shown to be
resistance to the drug. effective.
l Available as diflucan 50 mg tablets. Dose: 50 mg/
Q.6. Discuss in detail clinical features, differential diag-
day as single dose in difficult cases 400 mg/day
nosis and treatment of erythroplakia.
can be used.
l It is very useful drug in AIDS patients for prophy- Ans.
laxis and treatment. It is still the mainstay of
[SE Q.7]
therapy for HIV-associated candidiasis.
l Fluconazole and amphotericin B may be used l {Erythroplakia has been defined as a ‘bright red vel-
intravenously for the treatment of the resistant vety plaque or patch which cannot be characterized
lesions of Chronic mucocutaneous candidiasis clinically or pathologically as being due to any other
(CMC) and systemic candidiasis. condition’.
l Fluconazole interacts with a number of other l The word is an adaptation of the French term ‘erythro-
medications and must be prescribed with care for plasie de Queyrat’, which describes a similar-appearing
patients who are using anticoagulants, phenytoin, lesion of the glans penis with a comparable premalig-
cyclosporine and oral hypoglycaemic agents. nant tendency.
Amphotericin B l Erythroplakia is far less common than leukoplakia in
l Its major role is as i.v. administered agent in most histopathologic series.
serious cases of systemic distribution which are l A number of studies have shown that the majority of
resistant to other antifungals. erythroplakias (particularly those located under the
l Disadvantage is significant toxicity to several tongue, on the floor of the mouth and on the soft palate
organ systems especially kidneys. and anterior tonsillar pillars) exhibit a high frequency of
Q.5. Describe briefly and give the differential diagnosis premalignant and malignant changes.
of psoriasis. l Although the aetiology of erythroplakia is uncertain,
most cases of erythroplakia are associated with heavy
Ans. smoking, with or without concomitant alcohol abuse.
l Psoriasis is a chronic, recurrent, scaly and erythematous l Shear described clinical variants of erythroplakia as:
disease of skin. i. Homogeneous erythroplakia
Section | I Topic-Wise Solved Questions of Previous Years 269

ii. Erythroplakia interspersed with patches of leuko- l Most asymptomatic malignant erythroplakic lesions are
plakia small; 84% are 2 cm in diameter, and 42% are 1 cm.
iii. Granular or speckled erythroplakia However, since recurrence and multifocal involvement
is common, long-term follow-up is mandatory.}
Clinical features
l Many of these lesions are irregular in outline, and some
contain islands of normal mucosa within areas of eryth- SHORT ESSAYS:
roplakia, a phenomenon that has been attributed to the
coalescence of a number of precancerous foci. Q.1. Predisposing factors and smear examination for
l Erythroplakia occurs predominantly in older men, in the Candida albicans.
sixth and seventh decades of life.
Ans.
l Erythroplakias are more commonly seen on the floor of
the mouth, the ventral tongue, the soft palate and the The following predisposing factors for oral candidiasis
tonsillar fauces, all prime areas for the development of have been identified on clinical observation:
carcinoma. i. Marked changes in oral microbial flora due to the use
l Multiple lesions may be present. These lesions are com- of antibiotics (especially broad spectrum antibiotics),
monly described as erythematous plaques with a soft vel- excessive use of antibacterial mouth rinses or xero-
vety texture. Almost all of the lesions are asymptomatic.} stomia.
ii. Chronic local irritants (dentures and orthodontic appli-
Histopathologic feature
ances).
l Severe epithelial dysplasia, carcinoma in situ or inva-
iii. Administration of corticosteroids (aerosolized inhalant
sive carcinoma.
and topical agents are more likely to cause candidiasis
Differential diagnosis than systemic administration).
l Clinically similar lesions may include erythematous iv. Poor oral hygiene.
candidiasis, areas of mechanical irritation, denture sto- v. Pregnancy.
matitis, vascular lesions and a variety of nonspecific vi. Immunologic deficiency.
inflammatory lesions. vii. Malabsorption and malnutrition.
l Differentiation of erythroplakia from benign inflamma-
Predisposing factors may be grouped as follows:
tory lesions of the oral mucosa can be enhanced by the
use of a 1% solution of toluidine blue, applied topically Local Systemic or general
with a swab or as an oral rinse. Although this technique
Denture wearing Immunosuppressive diseases
was previously found to have limited usefulness in the
evaluation of keratotic lesions, prospective studies of Smoking Impaired health status
the specificity of toluidine blue staining of areas of early Atopic constitution Immunosuppressive drugs
carcinoma contained in erythroplakic and mixed leuko-
Inhalation steroids Chemotherapy
plakic–erythroplakic lesions reported excellent results,
with false-negative (under diagnosis) and false-positive Topical steroids Endocrine disorders
(over diagnosis) rates of well below 10%. Hyperkeratosis Hematinic deficiencies
Imbalance of oral microflora
[SE Q.7]
Quality and quantity of salvia
{Treatment and prognosis
l The treatment of erythroplakia should follow the same Q.2. Aetiology and management of oral leukoplakia.
principles outlined for that of leukoplakia.
l Observation for 1–2 weeks following the elimination of Ans.
suspected irritants is acceptable, but prompt biopsy at [Ref LE Q.2]
that time is mandatory for lesions that persist.
l The toluidine blue vital staining procedure may be re- Q.3. Aetiology and management of oral submucous
done following the period of elimination of suspected fibrosis.
irritants. Lesions that stain on this second application Ans.
frequently show extensive dysplasia or early carcinoma.
Epithelial dysplasia or carcinoma in situ warrants com- [Ref LE Q.3]
plete removal of the lesion. Q.4. Lichenoid reactions.
l Actual invasive carcinoma must be treated promptly
according to guidelines for the treatment of cancer. Ans.
270 Quick Review Series for BDS 4th Year, Vol 2

l Lichenoid reactions and lichen planus exhibit similar

l These lesions frequently appear lichenoid, although
histopathologic features. Lichenoid reactions were dif-
they may be nonspecific and resemble leukoplakia,
ferentiated from lichen planus on the basis of
vesiculobullous disease or even a granulomatous
i. their association with the administration of a drug,
lesion.
contact with a metal, the use of a food flavouring or
l They typically respond well to topical or systemic
systemic disease
steroids. Clobetasol (a potent topical steroid) placed
ii. their resolution when the drug or other factor was
under an occlusive tray is very effective for tempo-
eliminated or when the disease was treated
rary relief of these lesions. Long-term remission of
l Clinically, lichenoid lesions may exhibit the classic ap-
these lesions obviously depends on treatment of the
pearance of lichen planus, but atypical presentations are
underlying systemic disease.
seen, and some of the dermatologic lesions included in
this category show little clinical lichenification.
l List of some of the disorders that are currently proposed
Discoid lupus erythematosus (DLE)
as lichenoid reactions:
l It is a relatively common disease and occurs predomi-
i. Drug-induced lichenoid reactions.
nantly in females in the third or fourth decade of life.
ii. Drug-induced lichenoid eruptions include those le-
l DLE can present in both localized and disseminated
sions (i.e. oral mucosal lesions that have the clinical
forms and is also called chronic cutaneous lupus erythe-
and histopathologic characteristics of lichen planus)
matosus (CCL).
that are associated with the administration of a drug,
l DLE is confined to the skin and oral mucous mem-
and that resolve following the withdrawal of the drug.
branes and has a better prognosis than SLE. Typical
l A drug history can be one of the most important aspects
cutaneous lesions appear as red and somewhat scaly
of the assessment of a patient with an oral or oral-and-
patches that favour sun-exposed areas such as the face,
skin lichenoid reaction. However, lichenoid lesions that
chest, back and extremities.
include the lip and are symmetric in distribution and that
l These lesions characteristically expand by peripheral
also involve the skin are more likely to be drug related.
extension and are usually disc-shaped.
l However, many lesions take months to clear, in the case
l The oral lesions can occur in the absence of skin le-
of a reaction to gold salts, 1 or 2 years may be required
sions, but there is a strong association between the two.
before complete resolution.
As the lesions expand peripherally, there is central atro-
l Gold therapy, nonsteroidal anti-inflammatory drugs
phy, scar formation and occasional loss of surface pig-
(NSAIDs), diuretics, other antihypertensives and oral
mentation. Lesions often heal in one area only to occur
hypoglycaemic agents of the sulphonylurea type are all
in a different area later.
important causes of lichenoid reactions.
l The oral mucosal lesions of DLE frequently resemble
Q.5. Lupus erythematosus. reticular or erosive lichen planus.
l The primary locations for these lesions include the buccal
Ans.
mucosa, palate, tongue and vermilion border of the lips.
l Unlike lichen planus, the distribution of DLE lesions is
usually asymmetric, and the peripheral striae are much
more subtle.
{SN Q.10}
l The lesions may be atrophic, erythematous and/or ulcer-
Systemic lupus erythematosus (SLE) ated and are often painful. Hyperkeratotic lichen pla-
l Systemic lupus erythematosus (SLE) is a prototypi- nus-like plaques are probably twice as common in pa-
cal example of an immunologically mediated inflam- tients with CCL as compared to patients with SLE.
matory condition that causes multiorgan damage. l The oral lesions of DLE are markedly variable and can
l The oral lesions of systemic lupus are generally also simulate leukoplakia.
similar to those of discoid lupus and are most preva- l The diagnosis must be based not only on the clinical
lent on the buccal mucosa, followed by the gingival appearance of the lesions but also on the coexistence of
tissues, the vermilion border of the lip and the palate, skin lesions and on the results of both histologic exami-
in decreasing order of frequency. nation and direct immunofluorescence testing.
l The lesions are frequently symptomatic, especially if
Histopathologic features
the patient ingests hot or spicy foods, and often con-
l The histopathologic changes of oral lupus consist of
sist of one or more of the following components:
hyperorthokeratosis with keratotic plugs, atrophy of the
erythema, surface ulceration, keratotic plaques and
rete ridges and liquefactive degeneration of the basal
white striae or papules.
cell layer.
Section | I Topic-Wise Solved Questions of Previous Years 271

l Oedema of the superficial lamina propria is also quite dosage regimens are determined individually, based on
prominent. Most of the time, lupus patients lack the the patient’s medical status, severity of disease and pre-
band-like leukocytic inflammatory infiltrate seen in vious treatment responses. Consultation with the pa-
patients with lichen planus. tient’s primary care physician is important when under-
l Immediately subjacent to the surface epithelium is a lying medical problems are present.
band of PAS-positive material, and frequently there is a l Retinoids are also useful, usually in conjunction with
pronounced vasculitis in both superficial and deep con- topical corticosteroids as adjunctive therapy for OLP.
nective tissues. l Systemic and topically administered beta all-trans reti-
l Another important finding in lupus is that direct immu- noic acid, vitamin A acid, systemic etretinate and sys-
nofluorescence testing of lesional tissue shows the de- temic and topical isotretinoin are all effective, and
position of various immunoglobulins and C3 in a granu- topical application of a retinoid cream or gel will
lar band involving the basement membrane zone. eliminate reticular and plaque-like lesions in many pa-
l Importantly, direct immunofluorescent testing of unin- tients. However, following withdrawal of the medica-
volved skin in a case of SLE will show a similar deposi- tion, the majority of lesions recur.
tion of immunoglobulins and/or complement. This is l Topical retinoids are usually favoured over systemic
called the positive lupus band test, and discoid lesions retinoids since the latter may be associated with ad-
will not show this result. verse effects such as liver dysfunction, cheilitis and
teratogenicity.
Q.6. Management of oral lichen planus (OLP). l A new systemically administered retinoid, temarotene,
is reported to be an effective therapy for OLP and to be
Ans.
free of side effects other than a slight increase in liver
Management of oral lichen planus (OLP) enzymes.
l There is no known cure for OLP; hence the manage- l Other topical and systemic therapies reported to be
ment of symptoms guides therapeutic approaches. useful, such as dapsone, doxycycline and antimalari-
l Corticosteroids have been the most predictable and suc- als, require additional research.
cessful medications for controlling signs and symp- l Topical application of cyclosporine appears to be help-
toms. Topical and/or systemic corticosteroids are pre- ful in managing recalcitrant extensive and otherwise
scribed electively for each patient. intractable oral lesions of OLP.
l Topical medications include high-potency corticoste- l When lesions have been confined to the mucosa just
roids, the most commonly used are: opposite amalgam restorations and when patients have
l 0.05% fluocinonide (Lidex), 0.05% clobetasol (Temo- been positive for patch tests to mercury or other metals,
vate) and Triamcinolone acetonide 0.1 % in orabase, complete removal of the amalgam restorations has been
oral suspension of triamcinolone, high potency steroid curative in most patients.
mouthwashes like betamethasone valerate 0.1 %, fluo- l Surgical excision is indicated for the treatment of OLP
cinolone acetonide 0.1 % and clobetasol propionate only in cases where concomitant dysplasia has been
0.05% have been used effectively. The topical forms are identified.
applied daily to meet each patient’s needs. Topical cor-
Q.7. Erythroplakia – clinical features and management.
ticosteroids reduce pain and inflammation.
l In addition, extensive erosive lesions of OLP on the Ans.
gingiva (desquamative gingivitis) may be treated effec-
[Ref LE Q.6]
tively by using occlusive splints as carriers for the topi-
cal steroid. Q.8. White spongy naevus.
l Candida overgrowth with clinical thrush may develop,
Ans.
requiring concomitant topical or systemic antifungal
therapy. It has been shown that the use of an antibacte- l White sponge nevus is a rare autosomal dominant disor-
rial rinse such as chlorhexidine before steroid applica- der with a high degree of penetrance and variable ex-
tion helps prevent fungal overgrowth. pressivity; it predominantly affects noncornified strati-
l Systemic steroids are rarely indicated for brief treat- fied squamous epithelium.
ment of severe exacerbations or for short periods of l The disease usually involves the oral mucosa and less
treatment of recalcitrant cases that fail to respond to frequently the mucous membranes of the nose, oesopha-
topical steroids. gus, genitalia and rectum.
l Systemic administration of prednisone tablets may be l The lesions of white sponge nevus may be present at
done with dosages varying between 40 and 80 mg daily birth or may first manifest or become more intense at
for less than 10 days without tapering. The time and puberty.
272 Quick Review Series for BDS 4th Year, Vol 2

l Genetic analyses of families with white sponge nevus l Lesions on the tongue are usually corrugated and may
have identified a missense mutation in one allele of have a shaggy or frayed appearance, mimicking lesions
keratin 13 that leads to proline substitution for leucine caused by tongue chewing.
within the keratin gene cluster on chromosome 17. l Oral hairy leukoplakia may also present as a plaque-like
lesion and is often bilateral.
Clinical and histopathologic features
l White sponge nevus presents as bilateral symmetric Histopathology
white, soft, ‘spongy’ or velvety thick plaques of the buc- l Histopathologic examination of the epithelium reveals
cal mucosa. However, other sites in the oral cavity may severe hyperparakeratosis with an irregular surface,
be involved, including the ventral tongue, floor of the acanthosis with superficial oedema and numerous
mouth, labial mucosa, soft palate and alveolar mucosa. koilocytic cells (virally affected ‘balloon’ cells) in the
l The condition is usually asymptomatic and does not spinous layer.
exhibit tendencies towards malignant change. l The characteristic microscopic feature is the presence of
homogeneous viral nuclear inclusions with a residual
Characteristic histopathologic features
rim of normal chromatin.
l Epithelial thickening, parakeratosis, a peculiar perinu-
l The definitive diagnosis can be established by demon-
clear condensation of the cytoplasm and vacuolization
strating the presence of EBV through in situ hybridiza-
of the supra-basal layer of keratinocytes.
tion, electron microscopy or polymerase chain reaction
l Electron microscopy of exfoliated cells shows numer-
(PCR).
ous cellular granules composed of disordered aggre-
gates of tonofilaments. Differential diagnosis
l It is important to differentiate this lesion from other
Treatment
clinically similar entities such as hyperplastic candidia-
l No treatment is indicated for this benign and asymp-
sis, idiopathic leukoplakia, leukoplakia induced by
tomatic condition.
tongue chewing, tobacco-associated leukoplakia, lichen
l Patients may require palliative treatment if the condition
planus, lupus erythematosus, White sponge nevus (WSN)
is symptomatic.
and verrucous leukoplakia.
Q.9. Oral hairy leukoplakia. l Since oral hairy leukoplakia is considered to be highly
predictive of the development of AIDS, differentiation
Ans. from other lesions is critical.
l Oral hairy leukoplakia is a corrugated white lesion that Treatment and prognosis
usually occurs on the lateral or ventral surfaces of the l No treatment is indicated. The condition usually disap-
tongue in patients with severe immunodeficiency. pears when antiviral medications such as zidovudine,
l The most common disease associated with oral hairy acyclovir or ganciclovir are used in the treatment of the
leukoplakia is HIV infection. Oral hairy leukoplakia is HIV infection and its complicating viral infections.
reported in about 25% of adults with HIV infection but l Topical application of podophyllin resin or tretinoin has
is not as common in HIV infected children. led to short-term resolution of the lesions, but relapse is
l Its prevalence reaches as high as 80% in patients with often seen.
acquired immunodeficiency syndrome (AIDS).
l Epstein–Barr virus (EBV) is implicated as the causative
agent in oral hairy leukoplakia. A positive correlation SHORT NOTES:
with decreasing cluster designation 4 (CD4) cell counts
has been established in HIV-positive patients. Q.1. Define vesicle and papule. Give two examples of
l The presence of this lesion has been associated with the each.
subsequent development of AIDS in a large percentage Ans.
of HIV positive patients.
l Hairy leukoplakia has also occasionally been reported Vesicles
in patients with other immunosuppressive conditions. Elevated blisters containing clear fluid that are under
For example, patients undergoing organ transplantation 1 cm in diameter. For example, herpes simplex virus infec-
and those who are on prolonged steroid therapy. tion.
Papules
Typical features Solid lesions raised above the skin surface that are
l Oral hairy leukoplakia most commonly involves the smaller than 1 cm in diameter. Papules may be seen in a
lateral border of the tongue but may extend to the ven- wide variety of diseases including erythema multiforme
tral or dorsal surfaces. simplex, rubella, lupus erythematosus and sarcoidosis.
Section | I Topic-Wise Solved Questions of Previous Years 273

Q.2. Behcet syndrome. l Lichen planus is a common chronic, dermatologic dis-

ease of the skin and mucous membranes.
Ans.
Various clinical types of lichen planus in the oral cavity
i. Behcet syndrome is a disease of uncertain aetiology. are as follows:
ii. Possible causes of the syndrome: PPLO virus/autoimmune. i. Linear
iii. Clinical features: ii. Papular
l It is more common in young adults between 25 and iii. Confluent
40 years of age. iv. Reticular
l Men are affected 5–10 times more as compared to v. Annular or circular
women. vi. Pigmented
l It is characterized chiefly by triad: recurrent oral vii. Vesicular or bullous
and genital ulcers; ocular inflammation and skill viii. Erosive or atrophic
lesions. ix. Hypertrophic
iv. There is no specific treatment for the disease.
Q.7. Grinspan syndrome.
Q.3. Candidiasis – aetiology.
Ans.
Ans.
l Grinspan syndrome refers to the triad of lichen planus,
l Oral candidiasis is the most prevalent opportunistic diabetes mellitus and vascular hypertension.
infection affecting oral mucosa. l This association of OLP and systemic diseases may be
l Most candida infections only affect mucosal linings, coincidental as the lichen planus commonly occurs in
but the rare systemic manifestations may have fatal older adults.
course.
Q.8. Civatte bodies.
Aetiology and C. albicans Constitute 80% of species iso-
pathogenesis C. tropicalis lated from human candidiasis
Ans.
C. glabrata l Civatte bodies are histological structures seen in lichen
planus.
Candida is a common, harmless, dimorphic yeast. l On histopathological examination of lichen planus,
chronic inflammatory cell infiltration is present in juxta-
Q.4. Auspitz sign. epithelial region.
Ans. l There is presence of necrosis or liquefaction degenera-
tion of basal cell layer of epithelium.
Auspitz sign is a characteristic sign of psoriasis. l Degenerating basal keratinocytes form rounded or
l Psoriasis is characterized by the appearance of small ovoid, amorphous eosinophilic bodies known as ‘civatte,
dry papules covered by silvery scales, removal of deep hyaline, cytoid’ bodies.
scales reveal one or more, tiny bleeding points, this is
known as Auspitz sign. Q.9. Oral manifestations of ectodermal dysplasia.
Q.5. White spongy nevus. Ans.
Ans. l Ectodermal dysplasia is also known as hereditary ecto-
dermal dysplasia.
l White sponge nevus is also called Cannon disease or
l It is a large heterogeneous group of inherited disorders
oral epithelial nevus or congenital leukokeratosis.
primarily involving ectodermal structures involving
l A congenital mucosal abnormality, in some cases may
skin, hair, nails, eccrine glands and teeth.
not appear till adolescence.
Several oral manifestations of particular interest in
l Oral lesions involve palate, cheeks, gingiva, floor of the
ectodermal dysplasia are
mouth and tongue.
l Patients invariably manifest anodontia or oligodontia
l Mucosa appears thickened, folded or corrugated and has
that is complete or partial absence of teeth.
a soft or spongy texture with a white opalescent hue.
l Abnormal morphogenesis of teeth like, truncated or
l The condition is benign and there is no treatment and is
cone shaped teeth.
not associated with any clinical complications.
l Dry and cracked protuberant lips with pseudorhagades
Q.6. Mention various types of lichen planus. formation.
l Dry mouth due to the hypoplasia of salivary glands.
Ans. l High palatal arch, cleft lip and cleft palate.
274 Quick Review Series for BDS 4th Year, Vol 2

Q.10. Systemic lupus erythematosus. l Constitutional disturbance.

l Cutaneous lesions are similar to those of erythema mul-
Ans. tiforme they are commonly haemorrhagic and are often
[Ref SE Q.5] vesicular or bullous.
l Oral mucous membrane lesions may be extremely severe
Q.11. Stevens–Johnson syndrome. and so painful that mastication is impossible.

Ans. Q.12. Target lesions.

l Stevens–Johnson syndrome is simply a severe bullous Ans.
form of erythema multiforme with widespread involve-
ment of skin, oral cavity, eyes and genitalia. l The ‘target’ lesions are characteristic in patients suffer-
ing from erythema multiforme.
It commences with abrupt occurrence of following features: l The classical dermal lesions of erythema multiforme,
l Fever. which often appear on extremities are concentric ring-
l Malaise. like resulting from varying shades of erythema giving
l Photophobia. rise to terms ‘target’, ‘iris’ or ‘bull’s eye’ lesions.
l Erythematous eruptions of oral mucosa, genitalia and l The concentric erythematous lesions may be purpuric or
skin. paler in the centre and has variety of appearances hence
l Purulent conjunctivitis (eye). the name multiforme.

Topic 3
Pigmentation of the Oral Tissues
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. General and oral manifestations of bismuthism.
2. Discuss the conditions that cause pigmentations of the oral mucosa.
3. Enumerate the various factors that cause exogenous pigmentation of the oral tissues. Describe in detail the oral
manifestations of lead and mercury intoxication.
4. Discuss the differential diagnosis of oral mucosal pigmentation. [Same as LE Q.2]
5. What are the causes of pigmentation of oral mucosa? [Same as LE Q.2]
6. ‘Pigmentation in oral structure’ diagnostic clue to diagnose systemic diseases. Discuss. [Same as LE Q.2]
7. Discuss in detail the diseases causing oral pigmentation. [Same as LE Q.2]

SHORT ESSAYS:
1. Classification of pigmentation and clinical significance of endogenous pigmentation.
2. Exogenous pigmentation of oral cavity.
3. Differential diagnosis of argyria.
4. Malignant melanoma.
5. Von Recklinghausen disease.

SHORT NOTES:
1. Endogenous pigmentation. [Ref LE Q.2]
2. Oral manifestations of bismuthism. [Ref LE Q.1]
3. Von Recklinghausen disease. [Ref SE Q.5]
4. Addison disease.
Section | I Topic-Wise Solved Questions of Previous Years 275

5. Café-au-lait spots.
6. Mention the causes of extrinsic discolouration of teeth.
7. Peutz–Jeghers syndrome.
8. Endocrinopathic pigmentation. [Same as SN Q.4]
9. Pigmented lesions of oro-facial region. [Same as SN Q.5]

SOLVED ANSWERS
LONG ESSAYS: l Usually pigment is collected in intercellular tissue but
may also be present in endothelial cells or mononuclear
Q.1. General and oral manifestations of bismuthism. phagocytes.
l Paper test: Pigmentation persists when small piece of
Ans. white paper is inserted in the gingival sulcus.
Bismuthism mainly is caused due to bismuth poisoning Treatment
through: l Stoppage of use of bismuth
a. Medicinal use of bismuth-containing drugs. l Establishing and maintaining oral hygiene
b. Bismuth-containing pastes and proprietary drugs contain- l Topical application of lignocaine hydrochloride
ing bismuth salt also result in pigmentation of bismuth. Q.2. Discuss the conditions that cause pigmentations of
Mechanism of action the oral mucosa.
Its mechanism of action in producing pigmentation is as Ans.
follows:
Bacterial degradation of organic material of food n
Bismuth compound 1 Hydrogen sulphide
{SN Q.1}
Bacterial degradation of organic material of food n Pigmentation is the deposition of colouring material.
Bismuth compound 1 Hydrogen sulphide n Pigmenta- l Oral pigmentations are mainly of two types:
tion due to bismuth sulphide granules (blue-black colour) a. Endogenous pigmentations
Clinical features b. Exogenous pigmentations
l General feature: Nausea l Endogenous pigmentations:
l Vague features: Gastrointestinal (GI) disturbances, It is the type of pigmentation in which pigments
jaundice and bloody diarrhoea. originate with in the body.
l ‘Bismuth line’ in long bones: Characteristic white bands l Exogenous pigmentations:
of increased density appear in ends of the diaphyses im- In this, pigments are deposited as such or are formed
mediately adjacent to epiphyseal lines in the long bones. as reaction of chemicals of exogenous origin.
Endogenous pigmentations of oral mucosa:
{SN Q.2}
Colour Signifies the following
Oral manifestations Pigment imparted disease process
l Metallic taste and burning sensation in oral cavity. Haemoglobin Blue, red Varix, haemangioma, Kaposi
l Ulcerative gingiva-stomatitis with discrete blue-black and purple sarcoma, angiosarcoma and
pigmentation of interdental and marginal gingiva. hereditary haemorrhagic
l Enlarged and sore tongue. telangiectasia
l Extremely painful shallow ulcerations in buccal Haemosiderin Brown Ecchymosis, petechiae,
mucosa. thrombosed vein, haemor-
l Regional lymphadenopathy. rhagic mucocoele and hae-
mochromatosis
l ‘Blue-black’ bismuth line appears on the gingiva.
Melanin Brown, Melanotic macule, nevus,
Histopathologic features black or melanoma and basilar mela-
grey nosis with incontinence
l Bismuth sulphide granules are seen as black irregular
collection of pigment in tissue section and even in peri- Bilirubin Yellow Jaundice or liver disorders
vascular location.
276 Quick Review Series for BDS 4th Year, Vol 2

Exogenous pigmentations of oral mucosa: Giving

clue to
Source Colour Disease process indicated
Oral pigmentation systemic
Silver amalgam Grey, black Tattoo, iatrogenic implanta- Pigmentation presentation disease
tion, trauma
Grey/black Solitary or focal pigmentation Amalgam
Graphite Grey, black Tattoo, trauma pigmentation lesions are macular and bluish tattoo
Lead, mercury, Grey Ingestion of paints or medi- Macular, focal grey or black Graphite
bismuth cines or poisoning traumatic implantation tattoo
from lead Heavy
Chromogenic Black, Superficial colonization Pigmentation in free marginal metal inges-
bacteria brown, green tion gingiva
grey to
black
Various pigments, their presentation in oral cavity signifies
the following systemic conditions: Q.3. Enumerate the various factors that cause exogenous
pigmentation of the oral tissues. Describe in detail the
Giving oral manifestations of lead and mercury intoxication.
clue to Ans.
Oral pigmentation systemic
Pigmentation presentation disease Various factors that cause exogenous pigmentations of
Blue, purple l Present as tumour-like ham- Haemangi-
oral mucosa are as follows:
vascular artoma, most are raised and oma
lesions nodular and some are flat, Angiosar- Disease process
macular or diffused coma Source Colour indicated
l Tongue: multinodular and Kaposi
i. Silver amalgam Grey and black Tattoo, iatrogenic im-
bluish red sarcoma
ii. Graphite Grey and black plantation and trauma
l Lip mucosa: localized, blue
iii. Lead, mercury, Grey Tattoo, trauma
and raised
bismuth Black and Ingestion of paints or
l Red, blue or purple nodular
iv. Chromogenic brown, green medicines or poisoning
tumour
bacteria Superficial colonization
l Oral tumours of red, blue or
purple on hard palate
Brown mela- l Melanomas in oral mucosa Malignant
Lead (plumbism)
notic lesions occur on anterior aspects of melanoma l Lead poisoning is known as plumbism.
hard palate Smoker’s
l Brown, black plaques with melanosis
Aetiology
an irregular outline Addison l Lead in paints, glazes, cooking vessels, batteries,
l Diffuse macular melanosis disease ointment and containers.
of buccal mucosa, lateral HIV oral l Acute lead poisoning due to moonshine an illicit
tongue, palate and floor of lesions alcoholic beverage distilled in car radiators.
mouth
l Bronzing of skin and patchy
l Tetraethyl lead antiknock compound from gasoline –
melanosis of the oral new source of lead.
mucosa l Lead from automobile exhaust dust and dust from house
Hyperpigmentation of skin, nails paint.
and mucus membrane l Acute exposure can occur in foundries, smelters battery
● Diffuse multifocal macular
brown pigmentation of buc-
plants munitions and garages.
cal mucosa, gingiva, palate Clinical features
and tongue may be involved
l Petechiae in soft palate
Nervous system
l Pb (lead) has high affinity for cells of central nervous
Brown haem- Bright red macule or as a Viral
l
system and peripheral nervous system.
associated swelling if a haematoma allergic
lesions forms. Lesions will assume pharyngitis l Acute poisoning – demyelination and axon degenera-
brown colouration but if Haemor- tion occurs.
multiple brown macular or rhagic l Patients may have lead encephalitis, peripheral neuritis
swellings are observed diathesis characterized by wrist or foot drop.
Traumatic
l Gastrointestinal symptoms like nausea, vomiting, con-
ecchymosis
stipation and colic.
Section | I Topic-Wise Solved Questions of Previous Years 277

l Lab findings: Patients may have hypochromic anaemia Q.5. What are the causes of pigmentation of oral mucosa?
with basophilic stippling of RBC.
Ans.
Oral findings
[Same as LE Q.2]
l Metallic taste, excessive salivation and dysphasia.
l Burtonian line – grey black line along gingival margin, Q.6. ‘Pigmentation in oral structure’ diagnostic clue to
lead line is more diffuse than bismuth line. diagnose systemic diseases. Discuss.
Treatment Ans.
l Treatment using chelating agents calcium edetate
[Same as LE Q.2]
(EDTA) and penicillamine.
Q.7. Discuss in detail the diseases causing oral pigmen-
Mercurialism
tation.
l Mercurialism is also known as Pink disease, Swift dis-
ease, dermato-polyneuritis and acrodynia. Ans.
Aetiology [Same as LE Q.2]
l Unknown mercury toxicity.
Idiosyncratic reaction to large doses of amalgam.
l

l Occupational contact, drug overdose, paints like phenyl

SHORT ESSAYS:
mercuric propionate, prolonged administration of mer-
Q.1. Classification of pigmentation and clinical signifi-
curial diuretics and improper use of dental amalgam
cance of endogenous pigmentation.
alloy.
Ans.
Clinical features
l Seen in children ,2 years up to 5–6 years. Pigmentation is classified as follows:
l GIT – Intestinal colic and diarrhoea, nausea, abnormal
pain. Endogenous pigmentation Exogenous pigmentation
l Nervous symptoms – headache, insomnia, tremors of Pigments originate with in the Pigments are deposited as such
fingers, lips and extremities and mental depression. body. or formed as a reaction of
l Hair and nails – premature loss of teeth, nails and alo- For example: Haemoglobin – chemical of exogenous origin
red and blue For example: Accidental
pecia, i.e. tear of hair in patches, raw beef appearance of
Haemosiderin – brown pigmentation and iatrogenic
skin of hands, feet, nose, ears and cheeks. Melanin – black pigmentation
Pigmentation due to drugs and
Oral finding
metals localized pigmentation
l Ptyalism that is profuse salivation as mercury is
excreted in saliva.
Endogenous pigmentation of oral cavity signifies:
l Glossodynia that is enlarged and painful tongue.
Blue/purple vascular lesion indicates:
l Oral ulceration, hyperaemia and swelling of gingiva.
i. Haemangioma
l Diffuse grey pigmentation of alveolar mucosa and gums
ii. Angiosarcoma
exhibit a deeper hue.
iii. Kaposi sarcoma
l Loosening and premature shedding of teeth.
Brown melanotic lesion:
Radiographic findings
i. Melanoma
Jaw changes similar to osteomyelitis irregular area of
ii. Melanoplakia
bone destruction.
iii. Addison disease
Treatment iv. HIV oral melanosis
l Bed rest and discontinuation of mercury exposure. v. Drugs in ductal melanosis
l Administration of British anti-Lewisite (BAL) dietary
Brown haem-associated lesion:
regimen to adjust renal damage.
i. Jaundice
l Atropine and belladona – to salivary flow.
ii. Haematoma
Q.4. Discuss the differential diagnosis of oral mucosal iii. Haemochromatosis
pigmentation. iv. Ecchymosis and petechiae

Ans. Q.2. Exogenous pigmentation of oral cavity.

[Same as LE Q.2] Ans.

278 Quick Review Series for BDS 4th Year, Vol 2

Exogenous pigmentation arises due to introduction of met-

als or drugs into the body via mucous membrane, intestinal
tract and skin.
Classification of exogenous pigmentation:

Accidental pigmentation (foreign Pigmentation due to Localized

substances embedded) due to Iatrogenic pigmentation drugs and metals pigmentation
Accidental during childhood Aetiology: i. Bismuthism i. Chlorhexidine stains
l Articles of road surface l During routine amalgam restorative ii. Plumbism (yellowish brown to
embedded in gingiva work removal of old fillings broken iii. Mercurialism brown colour)
l Charcoal containing tooth powder pieces embedded during extraction iv. Argyria ii. Hairy tongue (green
l Graphite tattoos. of teeth, retrograde amalgam filling v. Arsenism to brown or black)
l For example: pencil points during root canal preparation vi. Auric stomatitis iii. Tobacco stains (dark
Clinical findings: vii. Copper, chromium, brown or black
Gingiva and alveolar mucosa region, zinc and cadmium stain coal tar)
.12 years, females . male, blue-black pigmentation
flat macule or slight raised lesion

Radiographic findings:
l Presence of metal
Histological findings:
l Present as fine discrete dark growth
and irregular solid fragments dark
granules arranged along collagen
bundles, blood vessels and nerve
sheaths or interacellularly in macro-
phage multinucleated giant cell and
fibro blasts
Treatment:
l Not needed and excision if required

Q.3. Differential diagnosis of argyria. l Histologic identification of silver particles fixed to pro-
tein complexes in the dermis is diagnostic for the disease.
Ans.
Management
Argyria (silver pigmentation)
l The only special precaution to take during oral treatment
l Argyria is caused due to chronic exposure to silver
is to consider the patient’s disturbance in equilibrium.
nitrate as an occupational hazard.
l It results in pigmentation of both skin and mucous Q.4. Malignant melanoma.
membrane.
Ans.
l Whites who have silver pigmentation develop a striking,
bluish-grey (slate-coloured) skin, especially in the ex- l Malignant melanoma is a malignant neoplasm arising
posed areas. The bluish-grey discolouration also occurs from the melanocytes of the skin or mucous membrane.
in the oral mucosa. l They are biologically the most unpredictable tumours and
l Silver deposition often causes accompanying neuro- are recognized as the most aggressive as well as deadly
logic and hearing damage, which in turn affects the among the malignant tumours occurring in humans.
equilibrium. l Various types of malignant melanomas are as follows:
l It also stimulates melanocyte activity in the skin, caus- i. Superficial spreading melanoma
ing a more intense colour in exposed areas. ii. Nodular melanoma
iii. Lentigo malignant melanoma
Differential diagnosis
l The bluish-grey colour is usually easily distinguished Clinical features
from the more brownish Addisonian colour. l It occurs between the age of 20 and 90 years; however,
l Haemochromatosis also produces a browner colour. maximum of cases develop in 5th to 7th decades of life.
l Exposed areas of the skin that are not more discoloured l Both sexes are affected but there is slight male predilection.
than the covered areas differentiate cyanotic states from l Oral melanomas are most common on the hard palate,
argyria. maxillary alveolar ridge or gingiva.
Section | I Topic-Wise Solved Questions of Previous Years 279

Clinical presentation
l Tumours are of plexiform variety and thus are soft,
l Oral melanomas initiate as macular-pigmented focal
smooth, fluctuant, flesh coloured and nodular or
lesion.
pedenculated.
l The pigmented lesions are often dark-brown or bluish-
l Cafe-au-lait spots are the characteristic cutaneous
black or simply black in colour.
lesions present in this disease.
l The initial macular lesion grows very rapidly and often
results in a large, painful and diffuse mass. Oral manifestations
l Surface ulceration is very common and besides this, l Areas of melanin pigmentation are seen on oral mu-
haemorrhage, paraesthesia and superficial fungal infec- cosa with lips being the common site of occurrence.
tions are often present. l Neurofibromas may also occur as central jaw lesions
l As the tumour continuous to grow, small satellite in relation to the mandible or maxilla and in such
lesions can develop at the margin of the primary cases often produce a slow-growing, painless, expan-
tumour. sible and swelling of bone.
l Oral melanomas often cause rapid invasion and exten-
Radiographic features
sive destruction of bone, often resulting in loosening
l Neurofibromas of the jawbone usually produce rela-
and exfoliation of the regional teeth.
tively well-demarcated, unilocular or multilocular
l Widespread dissemination of the tumour cells occurs
radiolucent area, with expansion of the cortical plates
frequently in the lymph nodes as well as in the distant
and divergence of roots of the adjacent teeth.
sites such as lungs, liver and brain.
l Survival rates for oral melanomas are extremely Management
low and only less than 5% patients remain alive for l Solitary neurofibromas are treated by surgical exci-
5 years. sion, whereas neurofibromatosis is not treated since
surgical intervention may trigger the malignant
Radiographic features
potential of the individual lesions.
l Some melanomas in the jaws may present radiographic
picture, which is indistinguishable from osteomyelitis.
SHORT NOTES:
Treatment
l Early diagnosis is the key to successful treatment of Q.1. Endogenous pigmentation.
malignant melanoma, as long as the lesion remains in Ans.
the radial growth phases.
l It is treated by surgical irradiation, immunotherapy and [Ref LE Q.2]
by chemotherapy or by combination of these methods. Q.2. Oral manifestations of bismuthism.
l Radical surgery with prophylactic neck dissection is
often advised. Ans.
l Survival rate is very poor and are worse with metastasis. [Ref LE Q.1]
Q.5. Von Recklinghausen disease. Q.3. Von Recklinghausen disease.
Ans. Ans.
[Ref SE Q.5]
{SN Q.3}
Q.4. Addison disease.
l Von Recklinghausen disease is an autosomal domi-
nant hereditary disorder characterized by wide spread Ans.
overgrowth of nerve sheaths with formation of mul- l Addison disease is a primary disease of the adrenal
tiple neurofibromas on the skin and mucosa, along glands, where they are unable to elaborate sufficient
with brown pigmentation of the skin. quantities of hormones. Chronic insufficiency of adre-
l Triad of this disease consists of pigmentation, tumours nal cortex results in Addison disease.
of nerves and a sessile or pedenculated tumours of
skin and mucous membrane. Aetiology
l It usually develops following autoimmune destruction
Clinical features of adrenal glands or infections (TB, HIV).
l Neurofibromas may occur at any age; however, most
Clinical features
lesions are detected in adult life.
l Early manifestations include lethargy, fatigue and mus-
l Both sexes are equally affected.
cular weakness.
280 Quick Review Series for BDS 4th Year, Vol 2

l Other features include weight loss, hypotension, salt Causes for extrinsic discolouration
craving, abdominal pain, diarrhoea and vitiligo. l Oral drugs
l Increased levels of ACTH stimulate MSH and results in l Poor oral hygiene
skin and mucosal pigmentation that is bronzing of skin. l Chromogenic bacteria
l Oral pigmentation may be the first sign of Addison l Habits – tobacco and catechu
disease. l Chlorhexidine mouthwash
l In the oral mucous membrane pale brown to deep
Q.7. Peutz–Jeghers syndrome.
chocolate pigmentation, spreading over buccal mucosa
from angles of mouth and developing on gingiva, Ans.
tongue and lips, may be the first evidence of the disease.
l Peutz–Jeghers syndrome is also called hereditary intes-
Treatment tinal polyposis syndrome.
l Hormone replacement therapy with hydrocortisone and l It consists of familial generalized intestinal polyposis
fludrocortisone. and pigmented spots on the face, oral cavity and some-
times on hand and feet.
Q.5. Café-au-lait spots.
Clinical features
Ans.
l It is equally distributed in males and females.
l Cafe-au-lait pigmentations manifest as bronze or tan l There are bluish-black macules (1.5 cm) on skin. The
diffused multifocal macular pigmentations that appear skin pigmentation often fades away in life.
on the skin as well as the oral mucosa. Because of the l Frequent episodes of abdominal pain and signs of minor
pale brown colour these lesions are called cafe-au-lait obstruction, often terminate in intussusception.
spots.
Oral manifestations
l These pale brown macules vary considerably in size and
l Intraorally it appears on buccal mucosa, gingiva, tongue
have widespread distribution occurring on the face,
and hard palate in decreasing orders.
neck or the oral cavity.
l The melanin pigmentation of the lips and oral mucosa is
l It is usually associated with neurofibromatosis (Von
usually present from birth and appears as small brown
Recklinghausen syndrome), Albright syndrome (poly-
macules. There are multiple melanotic and brownish
ostotic fibrous dysplasia) and Peutz–Jeghers syndrome.
macules concentrated around the lip.
l These pigmented melanotic spots do not require any
treatment and are not associated with any risk for malig- Treatment
nant transformation. l Genetic counselling is indicated and no treatment is
required for oral lesions.
Q.6. Mention the causes of extrinsic discolouration of
l Surgical intervention is required for intussusception.
teeth.
Q.8. Endocrinopathic pigmentation.
Ans.
Ans.
l Discolouration of teeth is classified into:
a. Extrinsic discolouration [Same as SN Q.4]
b. Intrinsic discolouration
Q.9. Pigmented lesions of oro-facial region.
Extrinsic discolouration
Ans.
l Extrinsic discolouration is found on the outer surface of
teeth and is usually of local origin such as tobacco stain. [Same as SN Q.5]
Section | I Topic-Wise Solved Questions of Previous Years 281

Topic 4
Benign Tumours of the Oral Cavity
Including Gingival Enlargements
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. Enumerate the benign tumours of the jaws and describe in detail about ameloblastoma.
2. Write briefly histopathology of
a. Adenomatoid odontogenic tumour
b. Pleomorphic adenoma
3. Classify the cysts of the jaws and discuss in detail the odontogenic keratocyst.
4. Enumerate the odontogenic cysts of the jaws. Describe the clinical and radiographic features of three ‘dental
cysts’.
5. What are the oral causes of halitosis? How are you going to treat a case of ANUG?
6. Describe the aetiology, clinical features, radiological and histological features of ameloblastoma. [Same as LE Q.1]
7. Write in detail about the aetiopathogenesis, clinical features, investigations, management and prognosis of
ameloblastoma. [Same as LE Q.1]

SHORT ESSAYS:
1. Primodial cyst.
2. Enumerate the benign tumours of the oral cavity; describe the clinical features, radiographic appearance and
differential diagnosis of ameloblastoma. [Ref LE Q.1]
3. Enumerate the fibro-osseous lesions that involve the jaws. Discuss the aetiology, pathogenesis and clinical fea-
tures of Paget disease. Add a note on its complications.
4. Give the differential diagnosis of conditions that cause gingival enlargement.
5. Describe briefly about:
a. Fibrous dysplasia
b. Paget disease
c. Periapical cementifying dysplasia
6. Discuss the differential diagnosis of gingival enlargement. [Same as SE Q.4]
7. Enumerate the various causes of gingival enlargement. Discuss differential diagnosis of inflammatory and
noninflammatory gingival enlargement. [Same as SE Q.4]
8. Classify gingival enlargements and discuss in detail the inflammatory gingival enlargement of systemic
background. [Same as SE Q.4]

SHORT NOTES:
1. Treatment of dilantin gingival enlargement.
2. Name four drugs causing gingival enlargement.
3. Cementoma.
4. Nasopalatine cyst.
5. Name two multilocular cysts.
6. Periapical cemental dysplasia. [Ref SE Q.5]
7. Café-au-lait spots.
8. Torus mandibularis.
9. Ameloblastoma in mandible.
10. Biochemical investigations of Paget disease.
282 Quick Review Series for BDS 4th Year, Vol 2

11. Pregnancy tumour and gingivitis.

12. Cherubism.
13. Describe the radiographic features of fibrous dysplasia.
14. Condensing osteitis.
15. Describe radiographic appearance of dentigerous cyst.
16. Radiographic appearance of odontogenic keratocyst.
17. Pleomorphic adenoma of palate.
18. Describe the clinical features of ossifying fibroma.
19. Describe the radiographic features of Myxoma.
20. Albright syndrome.
21. Giant cell granuloma.
22. Epulis.
23. Fissural cysts.
24. Periapical granuloma.
25. Median mandibular cyst.
26. Fibromatosis gingivae.
27. Adenomatoid odontogenic tumour.
28. Von Recklinghausen disease.
29. Lipoma.
30. Pyogenic granuloma.
31. Odontomes.
32. Fibrotic gingival enlargement.
33. List out differential diagnoses for a swelling in the palate.
34. Pseudocysts.
35. Pathergy test.
36. What is Gorlin sign?
37. Residual cyst.
38. Papilloma.
39. Treatment of dilantin gingival hyperplasia. [Same as SN Q.1]
40. Name the drugs causing gingival enlargement. [Same as SN Q.2]
41. Name few nonodontogenic cysts of the jaws. [Same as SN Q.23]
42. Complex composite odontome. [Same as SN Q.31]
43. Compound odontome. [Same as SN Q.31]
44. Stafne bone cyst. [Same as SN Q.34]

SOLVED ANSWERS

LONG ESSAYS:
B. Odontogenic epithelium with odontogenic ectomes-
Q.1. Enumerate the benign tumours of the jaws and
enchyme, with or without hard tissue formation
describe in detail about ameloblastoma.
i. Ameloblastic fibroma
Ans. ii. Ameloblastic fibrodentinoma
iii. Ameloblastic fibro-odontoma
[SE Q.2]
iv. Odontoma (odontome)
{Benign odontogenic tumours v. Odontoameloblastoma
A. Odontogenic epithelium with mature, fibrous stroma vi. Calcifying cystic odontogenic tumour
without odontogenic ectomesenchyme vii. Dentinogenic ghost cell tumour
i. Ameloblastoma C. Mesenchyme and/or odontogenic ectomesenchyme
ii. Squamous odontogenic tumour with or without odontogenic epithelium
iii. Calcifying epithelial odontogenic tumour i. Odontogenic fibroma
iv. Adenomatoid odontogenic tumour ii. Odontogenic myxoma/myxofibroma
v. Keratocystic odontogenic tumour (KCOT) iii. Cementoblastoma}
Section | I Topic-Wise Solved Questions of Previous Years 283

Malignant odontogenic tumours l In the mandible, the molar-angle-ramus area is involved

A. Odontogenic carcinomas three times more commonly than premolar and anterior
i. Metastasizing (malignant) ameloblastoma regions combined.
ii. Ameloblastic carcinoma l Clinically ameloblastoma presents slow enlarging, pain-
iii. Primary intraosseous squamous cell carcinoma less, ovoid and fusiform bony hard swelling of the jaw.
iv. Clear cell odontogenic carcinoma l Pain, paraesthesia and mobility of regional teeth is pres-
v. Ghost cell odontogenic carcinoma ent in some cases.
B. Odontogenic sarcomas l Pathological fractures may occur in many affected bones.
i. Ameloblastic fibrosarcoma
Radiographic features
ii. Ameloblastic fibrodentino- and fibro-odontosarcoma
l Classical radiographic appearance is multilocular cyst-
Ameloblastoma like lesion in the jaw.
It is also known by other terms like: l The multilocular can be either of honeycomb type or
l Adamantoblastoma soap-bubble type.
l Adamantinoma – coined by Malassez in 1885 l In radiograph, the lesion typically exhibits an irregular
l Ameloblastoma – coined by Churchill in 1934 and scalloped margin.
l Epithelial odontoma l The lesion can cause resorption of roots of the teeth.
Definition as given by Robinson l It occurs in maxilla and produces a monocystic lesion.
Ameloblastoma is a tumour of odontogenic origin usu- l Sometimes even in mandible the lesion can occur as
ally unicentric, nonfunctional intermittent in growth ana- unilocular lesion.
tomically benign and clinically persistent. Treatment and prognosis
Definition according to WHO l No single standard type of therapy can be advocated for
Polymorphic neoplasm consisting of proliferating odon- patients with ameloblastoma. Rather, each case should
togenic epithelium usually occurring in two main forms in be judged on its own merits.
the follicular types of the growth. The tumour consists of l Of prime considerations are whether the lesion is solid,
enamel organ-like islands of epithelium cells, while in the cystic, extraosseous or malignant, and location.
plexiform type it forms continuous anastomosing islands. l The solid lesions require at least surgical excision, be-
cause recurrence follows curettage in 50%–90% of cases.
[SE Q.2] l Block excision or resection is generally reserved for
larger lesions.
{Pathogenesis l Cystic ameloblastomas may be treated less aggres-
l This neoplasm originates within the mandible or maxilla
sively, but with the knowledge that recurrences are often
from epithelium that is involved in the formation of
associated with simple curettage.
teeth. Potential epithelial sources include the enamel
l Peripheral ameloblastomas should be treated in a con-
organ, odontogenic rests (rests of Malassez and rests of
servative fashion. Malignant lesions should be managed
Serres), reduced enamel epithelium and the epithelial
as carcinomas.
lining of odontogenic cysts, especially dentigerous cysts.
l Patients with all forms of central ameloblastoma should
l The trigger or stimulus for neoplastic transformation of
be followed indefinitely, since recurrences may be seen
these epithelial residues is totally unknown mechanisms
as long as 10–20 years after primary therapy.}
by which ameloblastomas gain growth and invasion ad-
l Ameloblastomas of the maxilla are generally more diffi-
vantage include overexpression of antiapoptotic proteins
cult to manage than those of the mandible due to anatomic
(Bcl-2, Bcl-xL) and interface proteins (fibroblast growth
relationships and due to the high content of cancellous
factor [FGF] and matrix metalloproteinases [MMPs]).
bone in the maxilla.
l Ameloblastomas, however, have a low proliferation rate,
l Thus, intraosseous maxillary ameloblastomas are often
as shown by staining for the cell cycle – related protein,
excised with a wider normal margin than mandibular
Ki-67. Mutations of the p53 gene do not appear to play
tumours.
a role in the development or growth of ameloblastoma.
Clinical features Q.2. Write briefly histopathology of
l The ameloblastoma is a benign, aggressive tumour that a. Adenomatoid odontogenic tumour
is invasive and persistent. b. Pleomorphic adenoma
l It occurs in wide age range from 10 years to 90 years. Ans.
l The average age of occurrence is 33–39 years.
l The males are affected more commonly than females. Adenomatoid odontogenic tumour
l Ameloblastoma occurs in all the areas of the jaws but l Adenomatoid odontogenic tumour is also known as ad-
mandible is most commonly affected. enoameloblastoma or ameloblastic adenomatoid tumour.
284 Quick Review Series for BDS 4th Year, Vol 2

l The adenomatoid odontogenic tumour is uncommon, epithelial cells that have nuclei frequently polarized
well-circumscribed, and odontogenic neoplasm charac- away from the lumen. These rosette-like or microcyst
terized by the formation of multiple duct-like structures lumina frequently are lined by an eosinophilic material.
by neoplastic epithelial cells.
Pleomorphic adenoma
Macroscopic features l The pleomorphic patterns and the variable ratio of
l Central AOTs macroscopically appears as a soft, roughly ductal to myoepithelial cells are responsible for the
spherical mass with a distinct capsule. synonym pleomorphic adenoma.
l Upon gross sectioning, the tumour may exhibit solid to l A capsule of varying thickness surrounds mesenchymal
crumbly tissue or one or more cystic spaces of varying and stromal components.
sizes with yellowish brown fluid or semisolid material, l Approximately one-third of mixed tumours show an
fine, hard ‘gritty’ granular material and one to many almost equal ratio of epithelial and mesenchymal ele-
larger calcified masses. ments (believed to be derived from myoepithelial-
l Additionally, intact specimens demonstrate the crown differentiated cells).
of an embedded tooth in the solid mass or projecting l The epithelial component may appear as ducts, tubules,
into a cystic cavity. ribbons and solid sheets, and the mesenchymal compo-
Microscopic features nent may appear as myxoid, hyalinized connective tissue.
l The AOT exhibits diverse histopathologic features: l Infrequently, fat, cartilage and/or bone may be seen.
l An intracystic epithelial proliferation is composed of
Myoepithelial cells may appear as plasmacytoid cells or
polyhedral to spindle cells. spindled cells with an immunoprofile showing coex-
l The pattern is typically lobular, although some areas
pression of cytokeratin markers, vimentin, variable pos-
may show a syncytial arrangement of cells. itivity for S-100 protein, calponin, a-smooth muscle
l Rosettes and duct-like structures of columnar epithe-
actin and muscle-specific actin.
lial cells give the lesion its characteristic microscopic l The plasmacytoid cells, when seen, are highly charac-
features. teristic of mixed tumours and are almost never found in
l Foci of PAS-positive material are scattered through-
other salivary gland tumours.
out the lesion. l The ductal cell components are positive for several
l The tumour is made up of a multiple proliferations of
cytokeratins.
spindle, cuboidal and columnar cells, variety of pat- l The pseudocapsule surrounding mixed tumours may dem-
terns comprising of scattered duct-like structures, onstrate islands of tissue within it or extending through it.
eosinophilic material and calcifications in several l These islands represent outgrowths or pseudopods con-
cases, delimited by a fibrous capsule of variable tinuous with the main tumour mass, and likely contrib-
thickness. ute to recurrences, particularly in the parotid gland.
l Although not present in all tumours, the most distin-
Q.3. Classify the cysts of the jaws and discuss in detail
guishing microscopic feature of AOT is varying num- the odontogenic keratocyst.
bers of spindle-shaped structures with lumina of vary-
ing size lined by a layer of cuboidal to columnar Ans.

Cysts associated with Cysts of soft tissue of the mouth,

Epithelial cysts Nonepithelial cysts maxillary antrum face and neck
A. Odontogenic cysts l Simple bone cyst l Benign mucosal cyst of l Dermoid and epidermoid cysts
Developmental cysts l Aneurysmal bone maxillary antrum l Branchial cleft cyst
l Dentigerous cyst cyst l Surgical ciliated cyst of l Thyroglossal duct cyst
l Eruption cyst maxilla l Anterior medial lingual cyst
l Primodial cyst l Oral cyst with gastric or intestinal
l Gingival cyst of adults epithelium
l Calcifying odontogenic cyst l Cystic hygroma
Inflammatory cysts l Cysts of salivary glands
l Radicular cyst l Parasitic cyst
l Residual cyst l Hydatid cyst
l Inflammatory cyst l Cysticerus cellulosae
l Paradental cyst
B. Nonodontogenic cysts
l Nasopalatine cyst
l Median palatine cyst
l Globulomaxillary cyst
l Nasolabial cyst
Section | I Topic-Wise Solved Questions of Previous Years 285

Odontogenic keratocyst l Small single cysts with regular spherical outline, should
Incidence be enucleated from an intraoral approach, provided, the
l Primordial cysts comprise approximately about 5%– access is good.
10% of odontogenic cysts of the jaws. l Larger or less accessible cysts with regular spherical
l Seen predominantly in the second, third and fourth de- border should be enucleated from an extraoral ap-
cades of life, although they can occur in any age group. proach, as an intraoral access would be inadequate. Care
l They have a slight predilection for the males than females. should be taken to ensure fragments of the extremely
thin lining are removed.
Site
l Unilocular lesions with scalloped or loculated periph-
l Most commonly seen in the mandible than the maxilla,
ery, small multilocular lesions should be treated by
about one half of the former are seen to involve the
marginal excision that is resection of the containing
angle of the mandible.
block of bone while maintaining the continuity of the
l They can occur anywhere in the jaws, including the
posterior inferior borders as in the ascending ramus,
midline, although majority of the cysts are seen poste-
angle, body of the mandible, if there is difficulty of ac-
rior to the first bicuspids.
cess, extraoral exposure is necessary.
Clinical features l If the cystic lining is too adherent and in contiguity to
l The physical signs and symptoms of a jaw cyst depend the overlying mucosa or muscle then it should be ex-
on the dimensions of the lesion. cised along with marginal excision. The defect is closed
l A small cyst is unlikely to be diagnosed on routine primarily and can be left to heal by secondary intention
examination of the mouth, and is generally detected or can be filled with hydroxyapatite crystals, autoge-
accidentally on a radiographic examination. nous bone graft, corticocancellous chips or allogenous
l Asymptomatic until the cysts have reached a large size at bone powder, chips or block.
times involving the entire ascending ramus. This is because l Large multilocular lesions with or without cortical per-
the primordial cyst initially extends in the medullary cavity foration may require resection of the involved bone
and clinically observable expansion of the bone occurs late. followed by primary or secondary reconstruction with a
l The enlarging cyst may lead to displacement of the choice of reconstruction plates of stainless steel, vital-
teeth, percussion of the teeth overlying the cyst may lium, titanium, use of titanium or stainless steel mesh
produce a dull or hollow sound. and bone grafting procedures with iliac crest graft, cos-
l A single missing tooth from the normal series should tochondral graft or allogenous bone grafts.
invite suspicion of the existence of an odontogenic kera- l Carnoy’s solution
tocyst of the primordial type. A more conservative approach to large keratocysts,
l The teeth adjoining the cyst will have vital pulps unless treatment is done with enucleation, excision of the over-
there is coincidental disease of the teeth. lying mucosa and/or muscle, if attachment existed to
l Buccal expansion of the bone is commonly seen; lingual eliminate epithelial rests and/or microcysts and careful
and palatal expansion is rare. cauterization of the bony defect with Carnoy’s solution.
l Large mandibular cysts, invariably deflect the neurovas-
Q.4. Enumerate the odontogenic cysts of the jaws. De-
cular bundle into an abnormal position.
scribe the clinical and radiographic features of three
l If acute infection sets in, with accumulation of pus
‘dental cysts’.
within the sac, neuropraxia of the nerve results with the
onset of labial paraesthesia or anaesthesia. Ans.
l When tension is relieved, with spontaneous discharge
The various odontogenic cysts of the jaws are as follows:
of pus via a sinus tract or surgical drainage, sensation
returns to normal. Developmental cysts
l Dentigerous cyst
Radiologic features
l Eruption cyst
l The keratocyst can be unilocular or multilocular.
l Primodial cyst
l Majority of the unilocular radiolucencies have a smooth
l Gingival cyst of adults
periphery, some may have scalloped margins, which
l Calcifying odontogenic cyst
suggest an unequal growth activity.
l Multilocular cysts can have various radiographic ap- Inflammatory cysts
pearances, e.g. one large cyst and some smaller daugh- l Radicular cyst
ter cysts giving the polycystic appearance. l Residual cyst
l Inflammatory cyst
Treatment
l Paradental cyst
l Treatment should always be based on clinical assess-
ment, accurate diagnosis and appropriate tests of the Dentigerous cyst
cystic aspirate. l It is also called follicular cyst or pericoronal cyst.
286 Quick Review Series for BDS 4th Year, Vol 2

l It is most common type of odontogenic cyst, which l Enucleation is the treatment of choice in case of adults.
encloses the crown of the unerupted tooth by expansion
Odontogenic keratocyst
of its follicle and is attached to neck.
l Odontogenic keratocyst was first described by Philpsen
Clinical features in 1956 and recently WHO has designated OKC as a
l Second most common odontogenic cyst after periapical keratocystic odontogenic tumour.
cyst.
Clinical features
l Third molars and canine teeth most commonly affected.
l The physical signs and symptoms of a jaw cyst depend
l Age: second and third decade of life
on the dimensions of the lesion.
l Site: mandibular third molar and maxillary canine
l A small cyst is unlikely to be diagnosed on routine ex-
regions.
amination of the mouth, and is generally detected acci-
l Sex: Equally affects males and females.
dentally on a radiographic examination.
Symptoms l The patients are remarkably free of symptoms until the
l Generally, it is painless but may be painful if it gets cysts have reached a large size at times involving the en-
infected. tire ascending ramus. This is because the primordial cyst
l When dentigerous cyst expands rapidly to compress initially extends in the medullary cavity and clinically
sensory nerve it produces pain, which may be referred observable expansion of the bone occurs at later stages.
to other sites and described as headache. l The enlarging cyst may lead to displacement of the
teeth, percussion of the teeth overlying the cyst may
Signs produce a dull or hollow sound.
l It has a potential to become an aggressive lesion with l A single missing tooth from the normal series should
expansion of bone and subsequent facial asymmetry. invite suspicion of the existence of an odontogenic kera-
l In some cases pathological fracture can occur. tocyst of the primordial type.
Radiographic features l The teeth adjoining the cyst will have vital pulps unless
l Unilocular radiolucency associated with crowns of un- there is coincidental disease of the teeth.
erupted impacted teeth; at times a multilocular effect l Buccal expansion of the bone is commonly seen, lingual
can be seen when the cyst is ovular shape due to bony and palatal expansion is rare.
trabeculations. l Large mandibular cysts, invariably deflect the neurovas-
l Cysts have a defined sclerotic margin. cular bundle into an abnormal position.
l With the pressure of an enlarging cyst, the unerupted l If acute infection prevails, with accumulation of pus
tooth can be pushed away from its direction of eruption, within the sac, neuropraxia of the nerve results with the
e.g. the lower molar may be pushed to the inferior bor- onset of labial paraesthesia or anaesthesia.
der, or into ascending ramus, whereas the maxillary Once the tension is relieved, with spontaneous discharge of
cuspid tooth may be pushed up into the maxillary sinus pus via a sinus tract or surgical drainage, sensation returns
or floor of nose. to normal.
l As compared to the other jaw cysts, dentigerous cysts
have a higher tendency to cause root resorption of adja- Radiological features
cent teeth. l The keratocyst can be unilocular or multilocular.
l Radiologically, the dental follicle expands around the l Majority of the unilocular radiolucencies have a smooth
unerupted or impacted tooth in variations, like (a) cir- periphery, some may have scalloped margins, which
cumferential, (b) lateral and (c) coronal. suggest an unequal growth activity.
l Multilocular cysts can have various radiographic ap-
Histopathology pearances, e.g. one large cyst and some smaller daugh-
l Lined by nonkeratinized stratified squamous epithelium ter cysts giving the polycystic appearance.
l Proliferation of reduced enamel epithelium
l Retepegs seen Treatment
l Enucleation, i.e. surgical excision is the treatment of
Common complications choice.
l Extensive bone destruction with growth
l Resorption of adjacent tooth roots Radicular cyst
l Displacement of teeth l It is the most common inflammatory odontogenic cyst.

Treatment Clinical features

l Marsupialization in case of children if there is possibil- l The cyst itself is symptomless and may be discovered,
ity of eruption of impacted tooth. when periapical radiographs are taken.
Section | I Topic-Wise Solved Questions of Previous Years 287

l It is associated with nonvital teeth. l Prevotella intermedia

l Slowly enlarging swellings are often complained of l Fusobacterium nucleatum
radicular cysts that at times attain a large size. l Bacteroides for synthesis

l Pain may be a significant chief complaint, in the pres- l Treponema denticola

ence of suppuration. iii. Oral infection (primary and secondary)

l Initially, the enlargement is bony hard, as the cyst in- l Candidiasis

creases in size, the covering bone becomes thin and l Pericoronitis

exhibits springiness due to fluctuation. l Postextraction alveolitis

l In the maxilla, buccal and palatal or only palatal expan- iv. Oral ulcerative and erosive diseases
sion due to the lateral incisor or a palatal root will be v. Xerostomia
noted. In the mandible, lingual expansion is very rare.
Treatment of ANUG
l The mucosa overlying the cystic expansion, as with the
l Involved areas are isolated with cotton rolls and dried.
other cysts, is at first of normal colour; then it may be-
l A topical anaesthetic is applied and after 2–3 min, and
come conspicuous because of the presence of dilated
the areas are gently swabbed with a cotton pellet to re-
blood vessels and finally it will take on a profound dark
move the pseud membrane and nonattached surface.
bluish tinge, in case of large cysts.
After the area is cleansed with warm water, the superfi-
l An intraoral sinus tract may be identified with discharging
cial calculus is removed.
pus or brownish fluid, when the cyst is infected. The in-
l The patient is asked to rinse the mouth every 2 h with
volved tooth/teeth will be found to be nonvital, discoloured,
a glassful of an equal mixture of warm water and 3%
fractured or with heavy restorations or a failed root canal.
hydrogen peroxide. Twice daily rinse with 0.12%
l They may be sensitive to percussion or hypermobile, or
chlorhexidine are also effective.
displaced.
l Patients with severe ANUG and lymphadenopathy are
l It may involve deciduous or the permanent dentition.
treated with antibiotics penicillin V 250 or 500 mg,
l Temporary paraesthesia or anaesthesia of the regional
6 hourly with metronidazole 400 mg, 8 hourly, for
nerve distribution may be evident as with other cysts
7 days are the drug of choice.
when infection is present.
l Scaling is performed, if sensitivity permits, after the
l Pathologic fracture may be the form of presentation in
disease process is diminished, complete gingival curet-
the mandible, as with other large cysts.
tage and root planning is done.
Radiological features l Supportive treatment consists of copious fluid consump-
l The common description of radicular cysts is a round, tion and administration of nutritional supplements.
pear or ovoid shaped radiolucency. Q.6. Describe the aetiology, clinical features, radiologi-
l Outlined by a narrow radiopaque margin that extends cal and histological features of ameloblastoma.
from the lamina dura of the involved tooth/teeth.
l In case of very large cysts or infected cysts, this periph- Ans.
eral white line is occasionally absent. [Same as LE Q.1]
l Root resorption is rare, but may be seen.
l A lateral radicular cyst may be seen in association with Q.7. Write in detail about the aetiopathogenesis, clinical
an accessory root canal or lateral perforation during root features, investigations, management and prognosis of
canal therapy. ameloblastoma.
Treatment Ans.
Surgical removal of cyst combined with either root [Same as LE Q.1]
canal treatment or extraction of involved tooth.

Q.5. What are the oral causes of halitosis? How are you
going to treat a case of ANUG?
SHORT ESSAYS:
Q.1. Primodial cyst.
Ans.
Ans.
Oral causes of halitosis
 i. Oral cavity l Primordial cyst is relatively quite uncommon.
l Poor oral hygiene/prosthesis hygiene l It originates due to cystic degeneration and liquefaction of
l Posterior dorsal surface of tongue stellate reticulum in an enamel organ before calcification.
ii. Periodontal pathogens Sometimes it occurs in the place of supernumerary teeth.
l Porphyromonas gingivalis l Primordial cysts account for 5%210% of all jaw cysts.
288 Quick Review Series for BDS 4th Year, Vol 2

Clinical features Clinical features

l It has equal sex predilection occurring often in early l Occurs mainly in males over 55 years of age.
adulthood. l There is a strong genetic component. Genes involved
l Site: Mandibular third molar and ramus region, premo- include the sequestosome1 gene (SQSTM1).
lar region and maxillary incisor region. l In PDB, bone remodelling is disrupted, and an anarchic
l Size of the cyst varies considerably. alternation of bone resorption and apposition results
l It causes expansion of the bone and displacement of in mosaic-like ‘reversal lines’, often associated with
adjacent teeth. severe bone pain.
l Presents as two histological types: l In early lesions, bone destruction predominates (osteolytic
A. Nonkeratinizing type (less common) stage) and there is bowing of the long bones, especially
B. Keratinizing type (more common) the tibia, pathological fractures, broadening/flattening of
l Some investigators consider primordial cyst as odonto- the chest and spinal deformity.
genic keratocyst (OKC). l The increased bone vascularity can lead to high output
cardiac failure.
Radiographic features
l Later, as disease activity declines, bone apposition in-
l It appears as radiolucency with a sclerotic border or
creases (osteosclerotic stage) and bones enlarge, with
reactive border, which is usually scalloped.
progressive thickening (between these phases is a mixed
l The lesion can be present as a unilocular or multilocular
phase). PDB is typically polyostotic and may affect
lesion.
skull, skull base, sphenoid, orbital and frontal bones.
l The cyst can occur below the teeth, between the teeth or
l The maxilla often enlarges, particularly in the molar
near the crest of the ridge.
region, with widening of the alveolar ridge.
Treatment l In early lesions, large irregular areas of relative radiolu-
l Surgical removal with thorough curettage of the bone. cency (osteoporosis circumscripta) are seen, but later
l Recurrence rate is high if it represents OKC; otherwise, there is an increased radiopacity, with appearance of
recurrence rate is quite low. ‘cotton wool’ pattern.
l Constriction of skull foramen may cause cranial neu-
Q.2. Enumerate the benign tumours of the oral cavity;
ropathies.
describe the clinical features, radiographic appearance
l The dense bone and hypercementosis make tooth extrac-
and differential diagnosis of ameloblastoma.
tion difficult, and there is also a liability to haemorrhage
Ans. and infection.
[Ref LE Q.1] Management
l Diagnosis is supported by imaging, biochemistry and
Q.3. Enumerate the fibro-osseous lesions that involve
histopathology.
the jaws. Discuss the aetiology, pathogenesis and
l Bone scintiscanning shows localized areas of high
clinical features of Paget disease. Add a note on its
uptake.
complications.
l Plasma alkaline phosphatase and urine hydroxyproline
Ans. levels increase with little or no changes in serum cal-
cium or phosphate levels.
Fibro-osseous lesions
l Bisphosphonates are the treatment but calcitonin may
l Cemento-osseous dysplasia (osseous dysplasia)
also help.
l Cherubism
l Fibrous dysplasia Q.4. Give the differential diagnosis of conditions that
l Hypercementosis cause gingival enlargement.
l Ossifying fibroma
Ans.
l Paget disease of bone
Classification of gingival enlargements based on
Paget disease of bone (PDB) aetiology
l It is a progressive fibro-osseous disease affecting bone  i. Local inflammatory and traumatic factors
and cementum, characterized by disorganization of os- a. Poor oral hygiene, calculus deposits
teoclastogenesis (osteoclast formation), a process depen- b. Malposed teeth, improper contacts
dent on two cytokines – macrophage colony stimulating c. Irritation from ill-fitting crowns, clasps, prosthetic or
factor (M-CSF) and receptor activator of NF-kB ligand orthodontic appliances, overhanging restorations
(RANKL), which induce gene expression changes, pre- d. Mouth breathing, smoking
sumably by inducing transcription factors. e. Occlusal interferences
Section | I Topic-Wise Solved Questions of Previous Years 289

ii. Systemic predisposing factors l Histopathology shows woven bone directly forming
A. Endocrine (hormonal) from a fibrocellular background, fusing to adjacent
a. Puberty cortical lamellar bone.
b. Menstruation, pregnancy and oral contracep- l Typically no treatment is needed. Bisphosphonates
tive medication can help and surgery may be indicated if there is major
c. Hypothyroidism and pituitary dysfunction deformity or pressure on nerves.
d. Diabetes mellitus l McCune–Albright syndrome is FD bone lesions with
B. Nutritional skin pigmentation and endocrinopathy (precocious
a. Scurvy puberty in females and hyperthyroidism in males).
b. Nutritional deficiencies of mixed type, includ-
ing vitamin B complex Paget disease
iii. Blood dyscrasias l Paget disease of bone (PDB) is a progressive fibro-osseous
a. Leukaemia disease affecting bone and cementum, characterized by
b. Polycythemia vera disorganization of osteoclastogenesis (osteoclast forma-
iv. Drug induced tion), a process dependent on 2 cytokines – macrophage
a. Phenytoin sodium colony-stimulating factor (M-CSF) and receptor activator
b. Nifedipine of NF-kB ligand (RANKL).
c. Cyclosporine Clinical features
d. Barbiturates l It is seen mainly in males over 55 years of age.
v. Idiopathic l In PDB, bone remodelling is disrupted, and an anarchic
vi. Familial alternation of bone resorption and apposition results
vii. Miscellaneous conditions in mosaic-like ‘reversal lines’, often associated with
viii. Systemic conditions can affect the periodontium in severe bone pain.
two mechanisms. l In early lesions, bone destruction predominates (osteolytic
a. Magnification of an existing inflammation initiated stage) and there is bowing of the long bones, especially
by dental plaque, e.g. pregnancy and puberty the tibia, pathological fractures, broadening/flattening of
b. Manifestation of the systemic disease indepen- the chest and spinal deformity.
dently of the inflammatory status of the gingiva, l The increased bone vascularity can lead to high output
e.g. neoplastic enlargement cardiac failure.
c. Conditioned enlargement l Later, as disease activity declines, bone apposition in-
d. Pregnancy gingival enlargement creases (osteosclerotic stage) and bones enlarges, with
e. Pregnancy tumour progressive thickening (between these phases is a mixed
Q.5. Describe briefly about phase). PDB is typically polyostotic and may affect
a. Fibrous dysplasia skull, skull base, sphenoid, orbital and frontal bones.
b. Paget disease l The maxilla often enlarges, particularly in the molar
c. Periapical cementifying dysplasia region, with widening of the alveolar ridge.
Ans. l In early lesions, large irregular areas of relative radiolu-
cency (osteoporosis circumscripta) are seen, but later
Fibrous dysplasia there is increased radiopacity, with appearance of ‘cot-
l Fibrous dysplasia (FD) is a self-limiting fibro-osseous ton wool’ pattern.
lesion caused by mutation in the gene encoding G pro- l Constriction of skull foramen may cause cranial neu-
tein (GNAS1). ropathies.
l It usually affects only one bone (monostotic, about 70%) l The dense bone and hypercementosis make tooth ex-
but occasionally several (polyostotic). Maxillofacial FD traction difficult, and there is also a liability to haemor-
may occur anywhere in the jaws, but is essentially mono- rhage and infection.
stotic and typically affects the maxilla in young people;
although it sometimes affects adjacent bones (craniofa- Management
cial fibrous dysplasia), it rarely crosses the midline. l Diagnosis is supported by imaging, biochemistry and
l Although bone enlarges, its morphology is preserved, histopathology.
distinguishing FD from a neoplasm. l Plasma alkaline phosphatase and urine hydroxyproline
l CT can best assess the extent in the facial skeleton. levels increase with little or no changes in serum cal-
l FD lesions vary from radiolucent to radiopaque (often a cium or phosphate levels.
‘ground-glass appearance’) with ill-defined margins – a l Bisphosphonates are the treatment but calcitonin may
feature helpful to distinguish it from other lesions. also help.
290 Quick Review Series for BDS 4th Year, Vol 2

l There are, however, a variety of new-generation anti-

{SN Q.6}
convulsants, immunosuppressants and antihypertensive
Periapical cemental dysplasia available today. For example, tacrolimus is a new im-
l It is also called fibrocementoma, sclerosing cementum, munosuppressant that has been shown to be an effective
periapical osteofibrosis and periapical fibrosarcoma. replacement for cyclosporine and does not cause gingi-
l It is a reactive fibro-osseous lesion derived from the val enlargement.
odontogenic cells in the periodontal ligament. l Nonsurgical treatments such as professional gingival
l It is located at the apex of the teeth. debridement and topical or systemic antimicrobials may
l Seen in middle age group at an average age of ameliorate gingival enlargement.
39 years. l Surgical management is reserved for severe cases and
l Male-to-female ratio is 1:9 and is three times more usually does not provide long-term efficacy.
common in blacks than in whites. l Conventional gingivectomy is the most commonly em-
l It is usually discovered as an incidental finding dur- ployed, although periodontal flap surgery may be indi-
ing routine radiographic surveys. cated when osseous recontouring is needed, if there are
l Mandibular anterior region is commonly affected. mucogingival considerations.
l Involved teeth are vital with no history of pain or l Laser ablation gingivectomy may offer an advantage over
sensitivity. conventional surgery since procedures are faster and
l Occasional lesions localize near the mental foramen there is improved haemostasis and more rapid healing.
and impinge on the mental nerve and produce pain, l Prevention through optimal oral hygiene is essential to
paraesthesia or even anaesthesia. minimize the severity of enlargement.
l Signs: Hypercementosis is usually associated with it.
Q.2. Name four drugs causing gingival enlargement.
It rarely enlarges.
l No treatment is required. Ans.
The drugs causing gingival enlargement are as follows:
l Phenytoin
l Valproic acid
Q.6. Discuss the differential diagnosis of gingival
l Phenobarbital
enlargement.
l Vigabatrin
Ans. l Nifedipine
l Diltiazem
[Same as SE Q.4]
Q.3. Cementoma.
Q.7. Enumerate the various causes of gingival enlarge-
ment. Discuss differential diagnosis of inflammatory Ans.
and noninflammatory gingival enlargement.
l Cementoma or benign cementoblastoma is a true neoplasm
Ans. of functional cementoblasts, which form a large mass of
cementum or cementum-like tissue on the tooth root.
[Same as SE Q.4]
Clinical features
Q.8. Classify gingival enlargements and discuss in detail
l Age: Under 25 years.
the inflammatory gingival enlargement of systemic
l Sex: Male predilection.
background.
l Site: Mandible three times more common than maxilla.
Ans. Mandibular first molar is the most commonly affected
tooth.
[Same as SE Q.4]
l The lesion is slow growing and may cause expansion
of cortical plates of the bone, but is otherwise asymp-
SHORT NOTES: tomatic.
Q.1. Treatment of dilantin gingival enlargement. Treatment
l Extraction of the tooth, as there are chances of expan-
Ans.
sion of the cortical plates.
l There are several treatment options for drug-induced
Q.4. Nasopalatine cyst.
gingival enlargement. The most predictable treatment is
either the withdrawal or change of medication. Ans.
Section | I Topic-Wise Solved Questions of Previous Years 291

l Nasopalatine cyst is a most common nonodontogenic l Middle-aged adults are affected.

cyst, which is developmental, nonneoplastic in nature. l It may occur singly, multiply and unilaterally, but is
l Arises from remnants of the vestigial paired palatine usually bilateral in premolar region.
ducts. l Symptoms: There is growth on the lingual surface of the
l It affects midline anterior maxilla. mandible, above the mylohyoid line, usually opposite to
l Aetiology is unknown, but possible pathogenic factors the bicuspid teeth.
are trauma, infection and mucous retention within as- l Size: Their size is variable ranging from an outgrowth
sociated salivary gland ducts. that is just palpable to one that contacts a torus on the
opposite side.
Clinical features
l Radiographically, they appear as sharply demarcated
l Male predilection within 40–60 years.
radiopaque oval-shaped shadow superimposed over the
l Small cysts are asymptomatic in early stages. In large
roots of premolars and molars and occasionally, on the
cyst, variety of symptoms can be seen including swell-
incisors and canine.
ing, discharge and pain.
l Treated by surgical excision.
l Tooth displacement is a common finding.
Q.9. Ameloblastoma in mandible.
Radiographic features
l A nasopalatine canal cyst is purely radiolucent, with Ans.
sharply defined margins. The anterior nasal spine often
l Ameloblastoma is a benign, aggressive tumour that is
is centrally superimposed on the lucent defect, produc-
invasive and persistent.
ing a heart shape.
l Adults are most commonly affected.
Treatment l Broad age range; mean age, 30 years.
l Enucleation l Mandibular molar-ramus is the most commonly affected
site.
Q.5. Name two multilocular cysts. l Classical radiographic appearance is multilocular cyst-
Ans. Two multilocular cysts are odontogenic keratocysts like lesion in the jaw. The multilocular can be either of
and aneurismal bone cyst. honeycomb type or soap-bubble type.
Q.6. Periapical cemental dysplasia. l No single standard type of therapy can be advocated
for patients with ameloblastoma. Each case should be
Ans. judged on its own merits.
[Ref SE Q.5] l Block excision or resection is generally reserved for
larger lesions.
Q.7. Café-au-lait spots. l Cystic ameloblastomas may be treated less aggres-
Ans. sively, but with the knowledge that recurrences are often
associated with simple curettage.
l As the term implies, asymmetric areas of cutaneous l Patients with all forms of central ameloblastoma should
pigmentation, often described as café-au-lait spots have be followed indefinitely, since recurrences may be seen
the colour of coffee with cream and vary from small as long as 10–20 years after primary therapy.
ephelis-like macules to broad diffuse lesions.
l They tend to appear in late childhood and can be mul- Q.10. Biochemical investigations of Paget disease.
tiple. Ans.
l Importantly patient will manifest cutaneous signs as the
predominant feature of the disease. For example, neuro- l The biochemical investigations can provide important
fibroma, polyostotic fibrous dysplasia, Peutz–Jeghers information about the diagnosis of Paget disease.
syndrome, hypothyroidism, etc. l Serum calcium and serum phosphate levels are normal
in the presence of markedly elevated alkaline phospha-
Q.8. Torus mandibularis. tase levels.
l The intense osteoblastic activity in this metabolically
Ans.
active bone is believed to be responsible for the elevated
l Torus mandibularis is also called mandibular torus. It is alkaline phosphatase levels.
an exocytosis or outgrowth of bone found on the lingual l The amount of bone resorption may be correlated with
surface of the mandible. increases in urinary calcium and hydroxyproline levels.
l It primarily consists of the compact bone.
Q.11. Pregnancy tumour and gingivitis.
l Cause: Genetic and environmental factors are respon-
sible for its formation. Ans.
292 Quick Review Series for BDS 4th Year, Vol 2

l Pregnancy tumour occurs due to hormonal changes dur- Q.15. Describe radiographic appearance of dentigerous
ing pregnancy, which lead to an altered response of cyst.
gingival tissues to local irritants towards the end of first
Ans.
trimester.
l Clinically the lesion appears as a deep red or purple l Dentigerous cyst is also called follicular cyst or peri-
mass, pedunculated or sessile. coronal cyst.
l A traumatized lesion may resemble pyogenic granu- l It usually occurs in association with the crowns of
loma. unerupted teeth.
l It is better not to treat the lesion until parturition. l The teeth involved are mandibular third molars, maxil-
l The lesion has to be excised if it is too big and is con- lary canines and the premolars. It can also occur in
stantly traumatized due to mastication. relation with the supernumerary teeth.
l Well-defined radiolucency with sclerotic or hyperostotic
Q.12. Cherubism. border in association with the crown of an unerupted
Ans. tooth.
l Usually cyst is unilocular, rarely exhibits a multilocular
l Cherubism is also known as familial dysplasia of the pattern.
jaws.
l Males are affected mostly compared to females. Q.16. Radiographic appearance of odontogenic kera-
l Characteristic chubby facial appearance of affected tocyst.
children with bilateral enlargement of the mandible.
Ans.
l ‘Eye raised to heaven’ appearance.
l Difficulty in speech, mastication, deglutition and jaw l Odontogenic keratocyst appears as multilocular radiolu-
movements. cency with undulating borders and cloudy interior.
l Alveolar process is wide, fibrous replacement of bone l The borders are hyperostotic.
may happen. l There will be displacement of the teeth.
l Radiologically expansion of buccal and lingual cortical l The maxillary lesions are usually smaller and unilocular.
plates is seen and in mandible inferior alveolar canal
may be displaced. Q.17. Pleomorphic adenoma of palate.
l Deciduous teeth shed prematurely. Ans.
Q.13. Describe the radiographic features of fibrous l In the parotid gland, these neoplasms are slow growing
dysplasia. and usually occur in the posterior inferior aspect of the
Ans. superficial lobe.
l Intraorally, pleomorphic adenomas most often occur
The radiographic features of fibrous dysplasia depend on on the palate, followed by the upper lip and buccal
the stage of the lesion and are as follows: mucosa.
a. Lesions with osseous tissue have mottled appearance. l Pleomorphic adenomas can vary in size, depending on
b. Lesions with excessive osseous tissue appear radiopaque. the gland in which they are located.
c. The typical radiographic appearance is termed as ground l One case series reported an infrequent yet clinically
glass appearance. significant malignant transformation to carcinoma of
8.5%. In the parotid gland, the tumours are usually sev-
Q.14. Condensing osteitis.
eral centimetres in diameter but can reach much larger
Ans. sizes if left untreated.
l Condensing osteitis is also called focal sclerosing osteo- Q.18. Describe the clinical features of ossifying fibroma.
myelitis.
Ans.
l It is a localized low-grade chronic inflammation of the
bone marrow and is associated with bone formation and l Ossifying fibroma is a usually benign, slow-growing,
not bone destruction. painless bone neoplasm, typically monostotic.
l It is seen in the periapical region of a tooth with deep l Seen in the third and fourth decades in the posterior
carious lesion. mandible as a radiolucent, radiopaque, or mixed opacity
l Mandibular molar area is the frequent site of occurrence. which has a fibro-osseous microscopic appearance.
l Asymptomatic. l Ossifying fibroma is an aggressive variant with a rapid
l Radiographically: radiopacity in the periapical region of growth pattern seen mainly in boys aged less than
the involved tooth. 15 years.
Section | I Topic-Wise Solved Questions of Previous Years 293

l Traditionally, the initial treatment has been surgical l Epulis fissuratum seen in edentulous patients, arising
enucleation. More definitive resection has been reserved from mucosal tissue of the alveolar ridge.
for recurrent disease. l Represents extensive inflammatory hyperplasia due to
chronic local irritation, especially ill-fitting denture.
Q.19. Describe the radiographic features of myxoma.
l Lesion should be surgically excised to avoid recurrence.
Ans.
Q.23. Fissural cysts.
l Characteristically, myxoma appears radiographically as
Ans.
a unilocular or multilocular lesion.
l It is clinically and radiographically indistinguishable Nonodontogenic cysts of the jaws are as follows:
from other lesions that present with a similar radio- l Nasopalatine duct cyst
graphic appearance. l Median palatine cyst
l Globulomaxillary cyst
Q.20. Albright syndrome.
l Nasolabial cyst
Ans.
Q.24. Periapical granuloma.
l Albright syndrome is also known as McCune–Albright
Ans.
syndrome.
l Albright syndrome includes: precocious puberty 1 poly- l Periapical granuloma refers to the formation of granulo-
ostotic fibrous dysplasia 1 café-au-lait pigmentation. matous tissue at the apex of tooth with necrosed pulp.
l Severe polyostotic fibrous dysplasia involving nearly all l The diffusion of toxic products of bacteria and infected
bones of the skeleton. material due to a low-grade infection leads to the forma-
l Pigmented lesions of the skin, i.e. café-au-lait spots tion of the granulation tissue as reparative mechanism
seen. of the body.
l Endocrine disturbances occur due to hyperfunction of l It consists of the central portion of loose connective
one or more endocrine glands, they include preco- tissue and blood vessels with presence of lymphocytes,
cious puberty, goitre, hyperthyroidism and hyperpara- plasma cells, mononuclear and polymorphonuclear
thyroidism. leukocytes. Peripheral to this central portion there is a
fibrous capsule.
Q.21. Giant cell granuloma.
l It is asymptomatic.
Ans. l Well-defined radiolucency with sclerotic border.
l The giant cell granuloma is of two types: Q.25. Median mandibular cyst.
i. Central giant cell granuloma
Ans.
ii. Peripheral giant cell granuloma
l Peripheral giant cell granulomas arise interdentally or l Median mandibular cyst is a rare lesion, occurring in the
from marginal gingiva, seen on labial surface. midline of the mandible.
l Colour varies from pink to purplish blue. l It is a developmental cyst.
l Smooth to irregularly shaped, sessile or pedunculated l Asymptomatic.
multilobulated protuberances with surface indentations, l It produces obvious expansion of the cortical plate of
ulceration of the margin occasionally seen. the bone.
l Painless, vary in size and cover several teeth. l Treatment: Surgically remove the cyst by preserving the
l Central giant cell granulomas, arise within the jaws and associated teeth.
produce central cavitation, occasionally create defor-
Q.26. Fibromatosis gingivae.
mity of the jaw.
l Radiographically, soap-bubble appearance. Ans.
l Treatment: Local curettage.
l Fibromatosis gingivae, also called elephantiasis gingi-
Q.22. Epulis. vae, appear as diffuse overgrowth of gingival tissue.
l Autosomal dominant.
Ans.
l It is manifested as dense smooth, diffuse or nodular
l Giant cell epulis occurs on the gingiva. overgrowth of gingival tissue of one or both the arches
l Aetiology: Local irritation or trauma. that usually occurs at the time of eruption teeth.
l Clinically appears as a pedunculated or sessile mass; l Characteristic pebbled surface, dense gingival swelling
surface is smooth and shiny. results in spacing between the teeth and change in pro-
l It causes pressure to the adjacent teeth. file and facial appearance.
294 Quick Review Series for BDS 4th Year, Vol 2

l Management: Surgical removal of excessive tissue with l The overlying epithelium is intact, and superficial blood
exposure of teeth is necessary. vessels are usually evident over the tumour.
l All types have adipocytes of various degrees of maturity.
Q.27. Adenomatoid odontogenic tumour.
l The usual simple lipoma consists of a well-circum-
Ans. scribed, lobulated mass of mature fat.
l Numerous microscopic subtypes have been described,
l Adenomatoid odontogenic tumour (AOT) is a tumour
but they are primarily of academic interest.
of odontogenic epithelium that exhibits behaviour very
different from the ameloblastoma. Q.30. Pyogenic granuloma.
l This tumour is characterized histologically by a very Ans.
distinct capsule surrounding the tumour and structures
resembling ducts (adenomatoid) within the epithelium. Aetiology
l Approximately, 70% of AOTs occur in females younger l Initiated by trauma or irritation
than 20 years of age and 70% involve the anterior jaw. l Modified by hormones, drugs
This lesion rarely recurs even with conservative curettage. Location
Q.28. Von Recklinghausen disease. l Predominantly gingiva, but any traumatized soft tissue
Histopathology
Ans.
l Hyperplastic granulation tissue
l Von Recklinghausen disease is also known as neurofi-
Treatment
bromatosis (neurofibroma and fibroma molluscum).
l Excision to periosteum or periodontal membrane
l It is a benign tumour of nerve tissue origin, derived
from the nerve sheath. Recurrence
l Neurofibroma is either solitary lesion or as part of the l Some recurrence
generalized syndrome of neurofibromatosis.
Q.31. Odontomes.
Clinical features
Ans.
Oral manifestation
l Odontome is the most common odontogenic tumour,
l Discrete, nonulcerated nodular, which tends to be of
regarded as a hamartoma rather than a neoplasm.
the same colour as the normal mucosa, but can occur
l Commonly seen in children.
on buccal mucosa, palate, alveolar ridge, vestibule and
l Asymptomatic.
tongue.
l Discovered on routing radiographic examination or
l Occasionally, neurofibroma located centrally within the
when it blocks eruption of a tooth.
jaw are seen.
l Compound type is composed of multiple miniature
l These are generally in mandibular nerve, and radio-
teeth. Most commonly found in anterior maxilla.
graphically shows a fusiform enlargement of mandibu-
l Complex type is a conglomerate mass of enamel and
lar canal.
dentine, most commonly found in the posterior jaws.
l Involvement of trigeminal nerve can cause facial pain or
l Treated by enucleation, does not recur.
paraesthesia.
l Skin lesions: Café-au-lait spots. Q.32. Fibrotic gingival enlargement.
l Malignancy: Malignant neurolemmoma.
Ans.
l Neurological: CNS tumour, mental retardation.
l Fibrotic gingival enlargement is of two types:
Treatment
i. Drug induced
l Solitary oral neurofibromas are usually treated by surgi-
ii. Idiopathic
cal excision, depending on the extent and the site.
l It is the ‘painless enlargement of gingiva at interproxi-
Q.29. Lipoma. mal aspect’.
Ans. Aetiology
Drugs:
l Lipomas are uncommon neoplasms that may occur in
l Phenytoin
any region of the oral cavity.
l Cyclosporine
l The buccal mucosa, tongue and floor of the mouth are
l Nifedipine
among the more common locations.
l Lesions typically present clinically as asymptomatic, Clinical features
yellowish submucosal masses. l Buccal and anterior segment are more affected.
Section | I Topic-Wise Solved Questions of Previous Years 295

l Gingiva appears pink and firm and unless infected. l Ehlers–Danlos syndrome (EDS) is a group of inher-
l Formation of psuedopockets. ited disorders characterized by excessive looseness
(laxity) of the joints, hyperelastic skin that is fragile
Treatment
and bruises easily and/or easily damaged blood
l Adequate oral hygiene maintenance and change of
vessels.
drugs or dosage and surgical excision.
Q.33. List out differential diagnoses for a swelling in the Signs
palate. l Excessive joint laxity and hypermobility.
l Soft, thin or hyperextensible skin.
Ans. l The tongue is very supple. Approximately, 50% of those
Various differential diagnoses for a swelling in the palate with the syndrome can touch the end of their nose with
are as follows: their tongue (Gorlin sign) and the palate is commonly
vaulted.
Traumatic
l Fracture of maxilla Q.37. Residual cyst.
l Hematoma
l Epulis Ans.
l Denture hyperplasia
l Residual cyst is retained periapical cyst from teeth that
Inflammatory have been removed.
l Tuberculosis l It can be found in maxilla or mandible.
l Syphilis l Histology of lining is a nondescriptive stratified squa-
l Actinomycosis mous epithelium.
l Infected cyst l Morphologically, the cyst may present as a well-defined
l Toxoplasmosis radiolucency that can vary in size from few millimetres
Necrosis to several centimetres.
l Osteoradionecrosis l Clinically, these cyst are found on routine radiographic
l Noma examination.
l Usually, residual cyst do not expand bone.
Nonodontogenic cysts l Treatment: Surgical curettage.
l Nasopalatine
l Globulomaxillary Q.38. Papilloma.
Developmental conditions Ans.
l Torus palatines
l Hyperplasia of palatal gland l Papilloma is a common benign neoplasm of the oral
cavity, arising from the epithelial tissue.
Q.34. Pseudocysts. l Papilloma is caused by human papilloma virus.
Ans.
Clinical features
l Stafne bone cyst is a developmental defect, located l Most commonly seen in third, fourth and fifth decades
below the mandibular canal. of life and is equally affected in both sexes.
l Salivary gland or adipose tissue is seen in defect. l Sites: Tongue, lips, buccal mucosa, gingival, hard and
l No symptoms. soft palate, etc.
l Discrete corticated margin. l Papilloma appears as a slow-growing, exophytic, soft,
l Diagnostic on panoramic film. usually pedunculated, painless and nodular growth with
l No treatment required. typical cauliflower-like appearance.
Q.35. Pathergy test. l It is characterized by numerous figure like projection
on their surface, which can be either blunt or pointed.
Ans.
Because of these projections, it appears as an ovoid
l Pathergy test, done for Behcet disease. swelling with a rough, corrugated surface.
l Cutaneous hypertrophy to intracutaneous injection or l The size of the lesion is usually small and that varies
needle sticks with the finding of pustule forming 24 h from few millimetre to centimetre in diameter.
after needle puncture.
Treatment
Q.36. What is Gorlin sign? l Conservative surgical excision of the lesion including
Ans. the base. Recurrence is common.
296 Quick Review Series for BDS 4th Year, Vol 2

Q.39. Treatment of dilantin gingival hyperplasia. Q.42. Complex composite odontome.

Ans. Ans.
[Same as SN Q.1] [Same as SN Q.31]
Q.40. Name the drugs causing gingival enlargement. Q.43. Compound odontome.
Ans. Ans.
[Same as SN Q.2] [Same as SN Q.31]
Q.41. Name few nonodontogenic cysts of the jaws. Q.44. Stafne bone cyst.
Ans. Ans.
[Same as SN Q.23] [Same as SN Q.34]

Topic 5
Oral Cancer

COMMONLY ASKED QUESTIONS

LONG ESSAYS:
1. Enumerate premalignant lesions and premalignant conditions. Describe the aetiology, clinical features and
treatment of oral submucous fibrosis.
2. Describe clinical features of carcinoma of tongue.
3. Pathogenesis and management of osteoradionecrosis.
4. Describe the differential diagnosis of oral precancerous lesions and conditions. [Same as LE Q.1]
5. Enumerate premalignant conditions and premalignant lesions of oral mucosa. Describe in detail any two of
them. [Same as LE Q.1]
6. Describe the clinical features and management of oral submucous fibrosis. Discuss the aetiological factors of this
condition. [Same as LE Q.1]

SHORT ESSAYS:
1. Rodent ulcer.
2. Squamous cell carcinoma.
3. Clinical features and radiographic appearance of osteosarcoma.
4. Mention the treatment plan for submucous fibrosis. [Ref LE Q.1]
5. Malignant melanoma.
6. Kaposi sarcoma.
7. Investigations of oral cancer.
8. TNM staging of oral cancer.
9. Radiotherapy.
10. Treatment of postirradiation mucositis.
11. Basal cell carcinoma. [Same as SE Q.1]
12. Treatment of squamous cell carcinoma. [Same as SE Q.2]
13. Osteogenic sarcoma. [Same as SE Q.3]
14. Treatment plan for oral submucous fibrosis. [Same as SE Q.4]
Section | I Topic-Wise Solved Questions of Previous Years 297

SHORT NOTES:
1. Brachytherapy.
2. Verrucous carcinoma.
3. Aids in diagnosis of oral malignancies.
4. Oral precancerous lesions.
5. Carcinoma in situ.
6. Clinical features of erosive lichen planus.
7. Give the treatment plan for erosive lichen planus.
8. Kaposi sarcoma. [Ref SE Q.6]
9. Oral cancer – predisposing factors.
10. Management of submucous fibrosis. [Ref LE Q.1]
11. TNM staging. [Ref SE Q.8]
12. Define a premalignant lesion and a condition.
13. Oncogenes.
14. Chemopreventive agents.
15. Osteoradionecrosis.
16. Radiographic appearance of osteogenic sarcoma.
17. Epithelial dysplasia.
18. Toluidine blue test.

SOLVED ANSWERS
LONG ESSAYS:
l It is a high-risk precancerous condition.}
Q.1. Enumerate premalignant lesions and premalignant
conditions. Describe the aetiology, clinical features and Aetiology and pathogenesis
treatment of oral submucous fibrosis. l Chronic irritation, e.g. betel nut, i.e. areca nut, chillies,
tobacco, lime, etc.
Ans. l Genetic predisposition
Oral premalignant lesions are defined as morphologically l Nutritional deficiency
altered tissues in which malignancy is more likely to occur than l Bacterial infections
in its apparently normal counterparts. The alterations include l Collagen disorders
genetic changes, epigenetic changes and surface alterations. l Immunological disorders
The sum total of these physical and morphologic altera- Clinical features
tions are of diagnostic and prognostic relevance and are l It affects both the sexes equally, and patients are
known as ‘precancerous’ changes. between second and fourth decades.
Premalignant lesions l Most common locations are buccal mucosa and retro-
l Leukoplakia molar areas.
l Leukoedema l Initial symptoms commonly seen are burning sensation
l Erythroplakia of oral mucosa aggravated by spicy food followed by
l Smoker’s palate either hypersalivation or dryness of mouth.
l The first sign is erythematous lesion sometimes associ-
Premalignant conditions ated with petechiae, pigmentations and vesicles.
l Oral submucous fibrosis l Initial lesions are followed by paler mucosa, which
l Lichen planus comprise marbling.
l Intraepithelial carcinoma l Fibrous bands located beneath an atrophic epithelium
are the most prominent clinical feature.
[SE Q.4]
l Increased fibrosis leads to loss of resilience, which
{Oral submucous fibrosis causes interference with speech, tongue mobility and a
l It is a chronic scarring disease that affects the oral tis- decreased ability to open the mouth.
sues as well as the pharynx and upper two-thirds of the l The atrophic epithelium may cause a smarting sensation
oesophagus. and inability to eat hot and spicy food.
298 Quick Review Series for BDS 4th Year, Vol 2

l Diagnosis of oral submucous fibrosis (OSMF) is based l Squamous cell carcinoma of the tongue may arise in
on clinical features and patients report of habit of betel apparently normal epithelium, in areas of leukoplakia,
quid chewing. or in an area of chronic glossitis.
l These lesions are usually larger than 2 cm at presenta-
(SE Q.4 and SN Q.10) tion, with the lateral border being the most common
{(Management subsite of origin. At this point, the patient may develop
l Restriction of the habits speech and swallowing dysfunction. Pain occurs when
It is safe to restrict betel nut chewing and to avoid spicy the tumour involves the lingual nerve, and this pain may
food. also be referred to the ear.
l Nutritional support l Carcinomas of the tongue base are clinically silent until
Vitamin B complex and iron therapy and long-term they deeply infiltrate the tongue musculature.
therapy of antioxidants gives good results. l They are usually less differentiated. Because of the dif-
l Intralesional injections of steroids ficulties with direct visualization, they may extend into
Corticosteroids are injected intralesionally with the aim the oral tongue or have lymph node metastases before
of antifibrinolytic and anti-inflammatory action. the diagnosis is established.
Intralesional injection of 1 mL suspension containing Q.3. Pathogenesis and management of osteoradionecrosis.
hydrocortisone along with 1 mL of lignocaine hydro-
chloride once a week or may be increased to twice a Ans.
week depending on the severity of the disease. l Osteoradionecrosis is necrotic tissue and bone that fails
l Medications to heal spontaneously and does not respond to local care
Antioxidants like retinoid and b-carotene and vitamin E over a period of 6 months following radiotherapy.
prevent the formation of toxic substances and enhance l Radiotherapy causes endarteritis obliterans resulting in
the indigenous concentration of vitamin A the func- obliteration of fine vasculature, progressive fibrosis, loss
tional and structural ingredients of epithelial cells. of normal cellular elements, fibrous and fatty degenera-
l Surgery tion of the bone marrow. These factors predispose to the
Skin grafts give better results in small lesions. Coverage development of osteoradionecrosis if exposed or injured
of the small area with full thickness flaps like nasola- and also increased vulnerability to trauma and infection.
bial, tongue and palatal flaps has provided better long- l The pathophysiologic characteristic is a nonhealing
term relief. LASER is used to reduce scar formation hypoxic wound in the bone.
further.)} l It develops most commonly after local trauma such as
dental extractions, biopsies, related cancer surgery and
Q.2. Describe clinical features of carcinoma of tongue.
periodontal procedures.
Ans. l Radiation induces tissue hypoxia in normal cells result-
ing in an imbalance where cell death and collagen lyses
l In most countries, the tongue is the most common site
exceed the homeostatic mechanism of cell replacement
of intraoral carcinoma.
and collagen synthesis, resulting in a wound that will
l Of all potential aetiologic factors, use of tobacco prod-
not heal, in which the metabolic demands exceed the
ucts is correlated as the closest cause to the carcinoma
oxygen and vascular therapy.
of the tongue.
l Squamous cell carcinoma is the most common malig- Clinical features
nancy of the tongue, typically having three gross mor- l Clinical manifestations include pain, foul taste, paraes-
phologic growth patterns: exophytic, ulcerative and thesia or anaesthesia, orocutaneous fistula’s, exposed
infiltrative. necrotic bone, pathological fracture and suppuration.
l The infiltrative and ulcerative types are most common l It is more common in mandible than in maxilla due to
on the tongue. Lateral margins and ventral surface of the decreased vascularity and density of the mandible.
tongue are more frequently affected sites. l On physical examination, missing hair follicles,
l The most common finding is an indurated, ulcerated change in surface texture of skin and colour are impor-
area of the tongue. The induration may extend deep into tant findings that assist the clinicians in finding the
the tongue musculature and root of the tongue. area of radiation injuries.
l Before causing symptoms, malignancies of the tongue l Irradiated mandible, periosteum and overlying soft tis-
may grow to significant size. Because of the relative laxity sue undergo hyperaemia, inflammation, endarteritis,
of the tissue planes separating the intrinsic tongue muscu- periarteritis, hyalinization, fibrosis and thrombosis of
lature, the cancer may spread easily and become symp- the vessels. These conditions ultimately lead to cellular
tomatic only when its size interferes with movement. death and progressive hypovascularity. The result is
Section | I Topic-Wise Solved Questions of Previous Years 299

aseptic necrosis of the portion of the bone directly in the Q.5. Enumerate premalignant conditions and premalig-
beam of radiation. nant lesions of oral mucosa. Describe in detail any two
l There is minimal localization of the infection, and there of them.
may be necrosis of considerable amount of bone, peri-
Ans.
osteum and overlying mucosa. Finally sequestration
occurs. [Same as LE Q.1]
Prophylactic therapy Q.6. Describe the clinical features and management of
l Prior to beginning of radiotherapy, all patients should oral submucous fibrosis. Discuss the aetiological factors
undergo a thorough dental evaluation including full of this condition.
mouth radiographs, dental and periodontal diagnosis
Ans.
and prognosis for each tooth.
l Patient education regarding the need for meticulous oral [Same as LE Q.1]
hygiene and frequent follow-up must be stressed. The
dentist should perform periodontal scaling, caries con-
trol and fabrication of fluoride trays. SHORT ESSAYS:
l Teeth that are infected/nonvital and cannot be salvaged Q.1. Rodent ulcer.
with conservative endodontic therapy should be ex-
tracted. Ideally, extraction should be done 3 weeks prior Ans.
to radiation therapy. l Basal cell carcinoma is also known as rodent ulcer. It is
l Prophylactic antibiotic therapy (penicillin) should be given the most common cutaneous malignancy, which typi-
in patients who are undergoing any extraction of teeth. cally affects the sun-exposed surfaces of the skin.
l To prevent radiation caries, patient should be begin daily l It arises from the basal cells of the surface epidermis or
fluoride treatment with 1% neutral sodium fluoride gel in external root sheath of the hair follicle.
prefabricated trays for 5 min each day, for life time. l These are slow-growing tumours. On long standing they
Postradiation dental care can cause local destruction of tissues.
l Dentures should be avoided in the irradiated arch for l Metastasis is seldom encountered. It is estimated that
1 year after therapy. less than 0.1% of tumours metastasize. The most com-
l A saliva substitute should be used to lubricate the mouth mon sites of metastasis are the lymph nodes, bones and
to replace diminished flow from irradiated mucous and lungs.
salivary glands. Clinical features
l If postirradiation pulpitis develops and involved tooth is l Basal cell carcinoma is usually seen in individuals over
restorable, endodontic therapy should be undertaken. the fourth decade of life.
l There should be an interval of at least 3–9 months be- l Men are affected twice as commonly as women and
fore undertaking extraction or osseous surgery, unless the fair complexioned individuals are relatively more
indicated. prone to develop basal cell carcinoma compared to dark
l Necessary extractions should be limited to 1–2 teeth per complexioned individuals.
appointment. Removal of teeth should be performed as l Basal cell carcinoma can have various clinical appear-
atraumatically as possible. ances. Some of the relatively common varieties are as
Management follows:
l Medical therapy in the treatment of osteoradionecrosis a. Noduloulcerative type (most common variety)
is primarily supportive involving nutritional support b. Superficial spreading type
along with superficial debridement and oral saline irri- c. Pigmented
gation for local wounds. d. Morphea-form (sclerosing)
l Antibiotics are indicated only for definitive secondary e. The cystic type
infection as well as of use of hyperbaric oxygen therapy. Ulceronodular type
l Minimal resection or in some cases mandibulectomy l In the initial stages, it appears as a large nontender papule
may be required for management of sequestrated bone. which slowly enlarges and exhibits a central depression,
Q.4. Describe the differential diagnosis of oral precan- which over a period of time reveals ulceration associated
cerous lesions and conditions. with some bleeding and crusting.
l The pathognomonic feature of basal cell carcinoma is a
Ans. waxy, translucent or pearly appearing ulcer with a
[Same as LE Q.1] raised pale border. Telangiectasias are common.
300 Quick Review Series for BDS 4th Year, Vol 2

Pigmented form l Diagnosis is based on clinical examination of head

l It resembles melanomas and appear as bluish-black or and neck followed by a fibreoptic examination of the
brown coloured macules. laryngopharynx and then a TNM staging and inci-
sional biopsy for confirmation.
Cystic variety
l This form of basal cell carcinoma is rare and appears as Treatment
a bluish-to-grey-coloured, mucin filled cyst-like lesions. l The tumour can be treated through surgery and radiation.
l Generally, the primary tumour is excised with 1.5 cm
Sclerosing type
margins for T1N0M0 lesions and for T2N0M0 and
l This form of basal cell carcinoma is uncommon and
more advanced stages, treating the neck prophylacti-
typical lesion mimics a scar.
cally with either an incontinuity functional neck dissec-
l It appears as a white or yellow waxy sclerotic plaque.
tion or radiotherapy in a dose of 5000–6500 cGy is
l The tumour cells initiate the proliferation of fibroblasts
recommended if the incisional biopsy shows greater
within the dermis and an increased collagen deposition,
than 3-mm depth of invasion.
i.e. sclerosis.
l For nodal invasion disease of N1, functional neck dis-
Superficial type section is recommended for nodal disease of N2 or
l It is seen as an erythematous, well-circumscribed patch N3-modified radical neck dissection is preferred by
or plaque. postoperative radiotherapy from 5000 to 6500 cGy.
l The lesion may be associated with the formation of a
Q.3. Clinical features and radiographic appearance of
white coloured scales mimicking lesions of psoriasis.
osteosarcoma.
l Surgical excision for basal cell carcinoma is still the
most popular modality of treatment. Mohs micrographic Ans.
surgery offers high cure rates for basal cell carcinoma.
l Osteosarcomas are primary malignant bone tumours in
Q.2. Squamous cell carcinoma. which mesenchymal cells produce osteoid.
Ans. Predisposing factors
l The exact pathogenesis for the tumour is unknown.
l Squamous cell carcinoma is defined as ‘a malignant
l Various predisposing factors proposed are trauma, virus,
epithelial neoplasm exhibiting squamous differentiation
genetic mutations, pre-existing bone cyst, osteogenesis
as characterized by the formation of keratin and/or the
imperfecta, Paget disease, fibrous dysplasia and previous
presence of intercellular bridges’.
history of radiation.
l The epidermoid carcinoma is the most common malig-
nant neoplasm of the oral cavity. Clinical features
l Osteosarcomas of the jaw bones are usually seen in the
Aetiology
third and fourth decades of life.
l Tobacco
l Males are slightly more commonly affected than females.
l HIV infected as well as immunosuppressed individuals
l The mandible and maxilla are equally affected.
l Low consumption of vitamins A and C
l The common sites affected are the symphysis, ramus
l Prolonged exposure to UV light
and posterior parts of the body of the mandible. In the
l History of syphilis and chronic irritation/trauma
maxilla, the alveolar ridge, antrum and the palate are
l Leukoplakia
frequently affected.
l Poor oral hygiene
l The common symptoms of this lesion in jaws are swelling
Clinical features and pain, paraesthesia/anaesthesia, loose teeth and trismus.
l Presents as painless mass or ulcer. l When the tumour extends to involve the nasal cavity,
l The tumour may begin as a superficially indurated ulcer maxillary sinus and orbit, clinical signs and symptoms
with slightly raised borders and may proceed either to such as epistaxis, nasal obstruction, haemorrhage, ex-
develop a fungating, exophytic mass or to infiltrate the ophthalmos and blindness may be apparent.
deep layers of the tongue, producing fixation and indu- l The earliest radiographic changes consists of a symmetric
ration without much surface changes. widening of the periodontal ligament space around a tooth
l Typical lesion develops on the lateral border or ventral or several teeth as a result of tumour infiltration along the
surface of the tongue. ligament space. This radiographic feature is referred to as
l The lesion is red white in colour. Garrington sign. Occasionally lamina dura may be lost.
l It can appear as leukoplakia, exophytic or ulcerated, l The irregular widening of the mandibular canal, with
some lesions will be indurated firm on palpation, in- areas of narrowing and loss of fine parallel cortical mar-
dicative of tumour cells infiltrating muscle fibres of gins of the walls of the mandible. In some individuals
the tongue. spiking resorption of the teeth are seen.
Section | I Topic-Wise Solved Questions of Previous Years 301

l Other radiographic findings include ill-defined ‘moth- l Usually the treatment is wide resection of the surgical
eaten’ destruction of bone, honey comb-like appearance, margins followed by radiotherapy and chemotherapy.
granular appearance, sunray appearance, Codman’s tri-
Q.6. Kaposi sarcoma.
angle and onion peel appearance.
l The typical features seen on radiograph are as follows: Ans.
i. Radiolucent with absence of bone formation within
l The Kaposi sarcoma is caused by human herpes virus-8.
the tumour.
ii. Mottled with small areas of amorphous ossification. Clinical features
iii. ‘Lamellar’ ossification with bony plates radiating l Classic Kaposi sarcoma usually occurs in adult males.
from a focus like a sunburst. l Almost all individuals suffering from the classic form
will tend to have an associated malignant lymphoma.
Management
l It has rarely any intraoral findings, the palate may be
l The choice of treatment for osteosarcoma is radical
involved in some cases.
surgery along with adjuvant chemotherapy.
l Kaposi sarcoma has four distinct variants:
l As most of the osteosarcoma metastasizes by haematog-
a. Classic or Mediterranean
enous route, there is a rationale for addition of adjuvant
b. Endemic or African
chemotherapy.
c. Epidemic or AIDS associated
l Literature reveals metastasis free survival rate of 8 years
d. Post-transplant or iatrogenic immunosuppression
is 60%–70%.
associated Kaposi sarcoma
l The factors contributing to poor prognosis include neu-
l The classic variety may affect any part of the body but,
ral sensory alteration, increasing age of patients and
lower extremities are commonly affected than the trunk,
surgical margins less than 5 mm.
arms and hands. The skin of the extremities may reveal
Q.4. Mention the treatment plan for submucous fibrosis. blue to purple macules which over a period of time may
turn into painless nodules.
Ans.
l Endemic Kaposi sarcoma is also known as African
[Ref LE Q.1] Kaposi sarcoma. It can present as benign nodular, infil-
trative, florid and lymphadenopathic type.
Q.5. Malignant melanoma. l The association of AIDS with Kaposi sarcoma was first
described in the early part of 1980s. It is estimated to
Ans.
appear in up to 40% of AIDS patients.
l Due to genetic alterations resulting from solar radiation, l It accounts for up to 90% of all cancers found in the
malignant transformation of melanocytes occurs. The AIDS population.
junctional melanocytes exhibit the earliest changes. l The iatrogenically induced variety is seen a few months
l If there is junctional proliferation of melanocytes along and years following organ transplants in post-transplant
with nuclear atypia, it is referred to as atypical melano- patients due to the effects of the immunosuppressive drugs.
cytic hyperplasia. When cytologic atypia becomes more
advanced, the lesions are called as superficial spreading
melanomas. {SN Q.8}
l Subsequently they invade into the connective tissues
Robert A. Schwartz and co-workers in 1984, proposed the
and infiltrate in adjacent tissues causing nodular growths
following classification system for Kaposi sarcoma (KS):
and swellings.
l Stage I
l Malignant melanoma of the oral mucosa usually occurs
Localized nodular KS, with more than 15 cutaneous
after 40 years of age. Most of the lesions about 70%–80%
lesions or involvement restricted to one bilateral ana-
occur on the palate, upper gingiva and alveolar mucosa.
tomic site, and few, if any, gut nodules.
l Clinically, melanoma usually begins as a solitary small
l Stage II
asymptomatic brown or black macule which later un-
Includes both exophytic destructive lesions and locally
dergoes proliferation.
infiltrative cutaneous lesions as locally aggressive KS.
l It starts as an asymptomatic, slow-growing brown or
l Stage III (generalized lymphadenopathic KS)
black macule having asymmetric and irregular borders
Wide-spread lymph node involvement, with or with-
or it may appear as a rapidly growing mass associated
out skin lesions, but with no visceral involvement.
with ulceration, bleeding, pain and bone destruction.
l Stage IV (disseminated visceral KS)
l Rarely, some amelanotic variants of oral melanomas
This variety has widespread KS, usually progressing
may not show usual bluish-black discolouration.
from stage II or stage III, with involvement of mul-
l As compared to the cutaneous melanomas, oral melano-
tiple visceral organs.
mas are more fatal.
302 Quick Review Series for BDS 4th Year, Vol 2

Histopathology Q.8. TNM staging of oral cancer.

The histopathological and immunohistochemical fea-
Ans.
tures of all forms of Kaposi sarcoma are similar.
TNM staging of oral cancer is as follows:

{SN Q.8}
Management {SN Q.11}
l Surgical excision:
Individual solitary lesions are surgically excised. Clinical and histopathological T classification of
l Electron beam radiotherapy: cancer of the oral cavity
It can be used effectively. Tl – Tumour 2 cm or less in greatest dimension.
l Chemotherapy: T2 – Tumour more than 2 cm but not more than 4 cm in
Occasionally intralesional or systemic chemothera- greatest dimension.
peutic agents are used. T3 – Tumour more than 4 cm in greatest dimension.
For example, vinblastine (most commonly used anti- T4 – Tumour invades adjacent structures.
neoplastic agent). Clinical and histopathological N classification of
cancer of the oral cavity
NX – Regional lymph nodes cannot be assessed.
Q.7. Investigations of oral cancer. N0 – No regional lymph metastasis.
Nl – Ipsilateral single node less than 3 cm.
Ans.
N2a – Single ipsilateral lymph node, greater than 3 cm
Various diagnostic tests can be employed to detect but less than 6 cm.
potentially malignant and malignant lesions. N2b – Multiple ipsilateral nodes up to 6 cm.
l In routine practice following diagnostic tests are used: N2c – Bilateral or contralateral lymph nodes up to 6 cm.
l Vital staining N3 – Metastasis in lymph nodes greater than 6 cm.
l Brush biopsy Clinical and histopathological M classification of
l Exfoliative cytology cancer of the oral cavity
l Tissue biopsy MX – Distant metastasis cannot be assessed.
l Various imaging techniques, for example plain radio- Ml – No distant metastasis.
graphs, CT, MRI, ultrasonography, etc. M2 – Distant metastasis.
l In the early diagnosis of oral malignancies, newer di-
agnostic tools such as VELscope and ViziLite Plus,
Raman spectroscopy and high-performance laser spec-
Q.9. Radiotherapy.
troscopy–laser-induced fluorescence (HPLC-LIF) also
play a significant role. Ans.
l The VELscope is based on the direct visualization of
l Radiation prevents the cells from multiplying by inter-
tissue fluorescence. Its hand piece emits a safe blue light
fering with their nuclear material.
into the oral cavity, causing tissue fluorescence from the
l Tumour cells in stages of active growth are more sus-
surface of the epithelium through to the basal membrane
ceptible to ionizing radiation than adult tissues. The
where premalignant changes typically start.
faster the cells are multiplying or the more undifferenti-
l By utilizing special optical filters in the VELscope hand
ated tumour cells, the more likely that radiation will be
piece, the clinician is able to immediately view the differ-
effective.
ent fluorescence signatures in the oral tissue to help dif-
ferentiate between normal and abnormal cellular activity. Principal methods employed
l Another popular screening tool for detection of oral i. X-ray therapy
cancers is ViziLite Plus. As it is passed over oral tissue (a) Superficial X-ray therapy 45–100 kV
that has been treated with the rinse solution, normal (b) Kilovoltage X-ray therapy 300 kV
healthy tissue will absorb the light and appear dark, ii. Electron therapy
abnormal tissue will appear white. iii. Surface applicator (radium mould)
l Recently in 2003, a high-performance laser spectroscopy– iv. Interstitial implantation – radium source
laser-induced fluorescence (HPLC-LIF) technique was l Most common radiation is delivered externally by
developed to detect and record simultaneously spectra the use of large X-ray generators.
and chromatograph of physiological samples. This sys- l The normal amount of tolerable radiation for a per-
tem enables the detection of multiple ‘markers’ in a son should not be exceeded and adjacent uninvolved
single physiological sample in a short time. areas are spared by the protective shielding.
Section | I Topic-Wise Solved Questions of Previous Years 303

l The patient’s host tissues are protected from radia- oral cavity, for boosted doses of radiation to a specific
tion by two mechanism of delivery: (i) fractionation site or for treatment following recurrence.
and (ii) multiple ports. l The isotopes used include caesium, iridium and gold.
l Directly implanted sources may be used to deliver ra-
Q.10. Treatment of postirradiation mucositis.
diation, or an after loading technique may be used in
Ans. which the radiation source is placed by using previously
inserted guide tubes.
l In patients receiving irradiation for head and neck can-
cers, radiotherapy-related mucositis is the most frequent Q.2. Verrucous carcinoma.
complication.
Ans.
l Chronic oral sensitivity frequently continues after treat-
ment, due to mucosal atrophy. l Verrucous carcinoma is also known as snuff dipper’s
l Management of severe oropharyngeal mucositis often cancer and Ackerman’s tumour.
requires the use of systemic opioids. Systemic analgesics l It has a predilection for mucous membranes of the head
should be prescribed by following the World Health Or- and neck and is most commonly found in the oral cavity
ganization (WHO) analgesic ‘ladder’, which suggests the followed by the larynx.
use of nonopioid analgesics, alone or in combination with l It has been suggested that opportunistic viruses such as
opioids and adjunctive medications, for increasing pain. HPV-6 and -16 act in them with frank carcinogenesis to
l Analgesics should be provided on a time contingent promote development of verrucous carcinomas lesions
basis, with provision for breakthrough pain. at sites of chronic irritation and inflammation.
l Systemic prednisone provided to patients with head and Q.3. Aids in diagnosis of oral malignancies.
neck cancer in a double-blind protocol resulted in a
trend to reduced severity and duration of mucositis. Ans.
l However, the use of steroids may result in increased risk of l To detect potentially malignant and malignant lesions,
infection. Systemic b-carotene administered during a com- various diagnostic tests can be employed.
bined course of chemotherapy and radiotherapy for pa- l In routine practice, vital staining, brush biopsy, exfolia-
tients with advanced head and neck squamous carcinoma tive cytology, tissue biopsy and various imaging tech-
has been reported to reduce the severity of mucositis. niques like plain radiographs, CT, MRI, ultrasonogra-
Q.11. Basal cell carcinoma. phy, etc. can be used effectively.
l Newer diagnostic tools such as VELscope and ViziLite
Ans. Plus, Raman spectroscopy and high-performance laser
[Same as SE Q.1] spectroscopy–laser-induced fluorescence (HPLC-LIF)
also play a significant role in the early diagnosis of oral
Q.12. Treatment of squamous cell carcinoma. malignancies.
Ans. Q.4. Oral precancerous lesions.
[Same as SE Q.2] Ans.
Q.13. Osteogenic sarcoma. l A morphologically altered tissues in which cancer is
more likely to occur than in its apparently normal coun-
Ans.
terparts are known as oral precancerous lesions, e.g.
[Same as SE Q.3] leukoplakia.
l These alterations may include genetic changes, epi-
Q.14. Treatment plan for oral submucous fibrosis.
genetic changes and surface alterations in intercellular
Ans. interactions.
l The sum total of these physical and morphological al-
[Same as SE Q.4]
terations are of diagnostic and prognostic relevance and
are designated as ‘precancerous’ changes.
The diagnosis of precancerous lesions is primarily
SHORT NOTES: l

based on morphology and its grading on histology (dys-

Q.1. Brachytherapy. plasia).
l It is widely practiced method to assess the risk of malig-
Ans.
nant potential of such lesions, despite the fact that this
l Brachytherapy may be the primary treatment modality estimation is subjective and carries a low prognostic
for localized tumours in the anterior two-thirds of the value.
304 Quick Review Series for BDS 4th Year, Vol 2

Q.5. Carcinoma in situ. Q.9. Oral cancer – predisposing factors.

Ans. Ans.
l Carcinoma in situ is also known as intraepithelial carci- Oral cancer predisposing factors are as follows:
noma. i. Genetic susceptibility
l It is a condition that arises frequently on the skin but ii. Immune status
occurs also on mucous membranes including those of iii. Environmental factors and nutrition
the oral cavity. iv. Habits like tobacco consumption in smokeless form or
l The term carcinoma in situ is used for lesions in smoke form and alcohol
which epithelial changes occur throughout their entire v. Ionizing radiation
thickness, but without violation of the basement mem- vi. Oral hygiene and other dental factors
brane. vii. Cellular genetics and molecular abnormalities, etc.
Q.6. Clinical features of erosive lichen planus.
Q.10. Management of submucous fibrosis.
Ans.
Ans.
l Erosive lichen planus is a T cell–mediated autoimmune
interface in which the basal cell layer of mucosa or skin [Ref LE Q.1]
is attacked.
Q.11. TNM staging.
Clinical features
l It presents in one of the three clinical forms, i.e. reticu- Ans.
lar, plaque or erosive form. [Ref SE Q.8]
l All forms are seen in patients older than 40 years.
l Occurs equally in men and women. Q.12. Define a premalignant lesion and a condition.
l Predilection for buccal mucosa, the tongue and the
attached gingiva is more. Ans.
l Erosive form is characterized by intense pain and l Premalignant condition is a generalized state, associated
erythematous mucosal inflammation. with a significantly increased risk of cancer. These
l When it involves buccal mucosa or tongue, it will alterations include genetic changes, epigenetic changes
produce fibrinous-based ulcers against a background and surface alterations in intercellular interactions, e.g.
of erythema and sometimes hyperkeratotic foci. oral submucous fibrosis.
Q.7. Give the treatment plan for erosive lichen planus. l A premalignant lesion is defined as a morphologically
altered tissue in which cancer is more likely to occur
Ans. than in its apparently normal counterparts. These al-
terations include genetic changes, epigenetic changes
Management of erosive lichen planus
and surface alterations in intercellular interactions, e.g.
l The mild cases of erosive lichen planus often can be man-
leukoplakia.
aged with topical corticosteroids, usually 0.05% fluocinonide
gel four times daily, or combined with antifungal agent gris- Q.13. Oncogenes.
eofulvin, 250 mg of the micronized form twice daily.
l Intralesional triamcinolone may also be used for focal Ans.
symptomatic lesions.
l Oncogenes are abnormal forms of normal genes (proto-
l Most erosive lichen planus requires systemic corticoste-
oncogenes) that regulate cell growth.
roid regimen I or II and only rarely III A or III B.
l Mutation of these genes may result in direct and con-
l Griseofulvin or topical fluocinonide or topical fluoci-
tinuous stimulation of the molecular biologic pathways
nonide can be added to either regimen to reduce the
(e.g. intracellular signal transduction pathways, tran-
prednisone requirements or help maintain a remission.
scription factors, secreted growth factors) that control
l Topical retinoids, vitamin A analogue may also be used
cellular growth and division.
in reticular lichen planus.
l Oncogenes typically result from acquired somatic cell
Q.8. Kaposi sarcoma. mutations secondary to point mutations (e.g. from
chemical carcinogens), gene amplification (e.g. increase
Ans.
in the number of copies of a normal gene) or from inser-
[Ref SE Q.6] tion of viral genetic elements into host DNA.
Section | I Topic-Wise Solved Questions of Previous Years 305

Q.14. Chemopreventive agents. radiographic feature is referred to as Garrington sign.

Occasionally lamina dura may be lost.
Ans.
l The irregular widening of the mandibular canal, with
l Chemotherapeutic agents affect the rapidly dividing areas of narrowing and loss of fine parallel cortical
cells of the target tumour and the lining epithelium, the margins of the walls of the mandible.
oral ecology. l In some individuals, spiking resorption of the teeth are
l The vascular, inflammatory reaction may result in mu- seen.
cositis and ulceration of the oral mucosa. l Other radiographic findings include ill-defined ‘moth-
l Chemotherapeutic agents also target the hematopoietic eaten’ destruction of bone, honey comb-like appearance,
cells of the bone marrow, resulting in anaemia, throm- granular appearance, sunray appearance, Codman’s tri-
bocytopenia and leukopenia. angle and onion-peel appearance are the typical features.
Q.15. Osteoradionecrosis. Q.17. Epithelial dysplasia.
Ans. Ans.
l Osteoradionecrosis is bone death caused by radiation Epithelial dysplasia includes following features:
injury. l Increased abnormal mitosis
l As previously been thought it is not an infection of com- l Individual cell keratinization
promised bone, but an avascular necrosis of bone caused l Epithelial pearls within spinous layer
by the three H tissue effects (hypovascular, hypocellar l Alteration in nuclear cytoplasmic ratio
and hypoxic) of radiotherapy. l Loss of polarity and disorientation of cells
l Infections associated with osteoradionecrosis are sec- l Hyperchromatism of cells
ondary infections due to the exposure of bone and deep l Large, prominent nucleoli
tissue plans. l Dyskaryosis or nucleus atypism
l The three types of osteoradionecrosis are early l Poikilokaryosis or division of nuclei without division of
trauma-induced osteoradionecrosis, spontaneous os- cytoplasm
teoradionecrosis and late trauma-induced osteoradio- l Basilar hyperplasia
necrosis.
Q.18. Toluidine blue test.
Q.16. Radiographic appearance of osteogenic sarcoma.
Ans.
Ans.
l In the method of toluidine blue staining, 1% aqueous
l The earliest radiographic changes of osteogenic sar- solution of the dye that is decolourized with 1% acetic
coma is symmetric widening of the periodontal liga- acid is used.
ment space around a tooth or several teeth as a result l The dye has tendency to bind with dysplastic and malig-
of tumour infiltration along the ligament space. This nant epithelial cells with a high degree of accuracy.

Topic 6
Diseases of the Tongue and Lips

COMMONLY ASKED QUESTIONS

LONG ESSAYS:
1. Discuss tongue lesions in various nutritional deficiency states and give differential diagnosis of bald tongue.
2. Describe the appearance of tongue in geographic tongue.
3. Describe the appearance of tongue in:
a. Amyloidosis
b. Hunter glossitis
306 Quick Review Series for BDS 4th Year, Vol 2

4. How the clinical examination of the tongue can be carried out? Describe glossodynia and mention the treatment
plan in brief.
5. Describe briefly about benign migratory glossitis. [Same as LE Q.2]

SHORT ESSAYS:
1. Pernicious anaemia – tongue lesions. [Ref LE Q.3]
2. Angular cheilitis.
3. Glossopyrosis and glossodynia. [Ref LE Q.4]
4. Fissured tongue.
5. Migratory glossitis.
6. Angioneurotic oedema.
7. Tuberculosis ulcers on the tongue.
8. Mention the causes of macroglossia.
9. Ankyloglossia.
10. Black hairy tongue.
11. Glossitis. [Same as SE Q.1]
12. Burning mouth syndrome. [Same as SE Q.3]
13. Geographic tongue. [Same as SE Q.5]

SHORT NOTES:
1. Benign migratory glossitis.
2. Treatment of atrophic glossitis.
3. Mention the causes of ‘bald tongue’.
4. Aetiology of angular cheilitis.
5. Hairy tongue.
6. Glossopyrosis.
7. Dysgeusia.
8. Management of a patient suffering from glossodynia. [Ref LE Q.4]
9. Ankyloglossia.
10. Differential diagnosis of bald tongue. [Same as SN Q.3]
11. Bald tongue. [Same as SN Q.3]

SOLVED ANSWERS
LONG ESSAYS: Features
Q.1. Discuss tongue lesions in various nutritional defi- l Symptoms vary from a tender to burning tongue to
ciency states and give differential diagnosis of bald tongue. extreme glossodynia.
l In the beginning, the tongue may be intensely red and
Ans. then becomes smooth as the filiform and other types of
Tongue lesions in various deficiency states papillae atrophy. In some instances, normal papillation
l It has been recognized for years that certain deficiency returns when the patient’s basic problem is successfully
states can produce a glossitis of a completely bald or a treated.
patchy bald type. l The deficiency states reported to produce the type of
l Diagnosticians of gone years prided themselves in their glossitis are discussed as follows:
ability to diagnose the specific deficiency by recogniz-
ing minute differences in appearance.
l Now it is generally agreed that the glossal changes in- Nutrient Deficiency symptoms
duced by specific deficiencies are so similar that a de- Vitamin A None
finitive diagnosis based on their differentiation is at least
Thiamin (B1) Painful or burning tongue; loss of taste acuity
unlikely, if not impossible.
Section | I Topic-Wise Solved Questions of Previous Years 307

Nutrient Deficiency symptoms l Its dominant characteristic is a constantly changing pat-

tern of serpiginous white lines surrounding areas of
Riboflavin Inflammation, fissures and ulcers at the corner of
(B2) the lips (angular cheilitis); dry, scaly lips; red to
smooth, depapillated mucosa.
purple colour tongue; atrophy and inflammation l The changing appearance with depapillated areas has
of tongue papillae; enlarged fungiform papillae reminded of continental outlines on globe, hence popu-
giving the tongue surface a pebbly appearance lar with the term geographic tongue.
Niacin Atrophy of tongue papillae resulting in a fiery,
red, smooth, shiny surface; oedematous or en- Clinical presentation and pathogenesis
larged tongue; ulcerations of tongue on central l Benign migratory glossitis is usually noted as an inci-
surface; angular cheilitis; loss of appetite dental examination finding or by patient recognition.
Pyridoxine Inflamed and atrophic tongue with a red, Although all surfaces of the tongue may be involved, the
(B6) smooth appearance; angular cheilitis dorsum is the most common.
Vitamin B12 Atrophy and inflammation of tongue; bright red,
l Adults are affected more than children, and women
painful, oedematous tongue with glossy appear- slightly more than men.
ance; altered taste sensations and decreased l The tongue will show alternating areas of normal tex-
appetite ture and a whitish colour due to filiform papillae and
Folic acid Smooth, bright red tongue; patchy surface of surface keratinization, contrasted with smooth red areas
tongue as papillae atrophy; ulcerations along where the filiform papillae have flattened and a dekera-
edges of tongue; angular cheilitis tinization of the surface has occurred.
Zinc Impaired taste; thickening and parakeratotic l The confluent borders of these two areas are usually el-
tongue with underlying muscle atrophy evated, rolled and more intensely white. The pattern and
Protein Red, smooth, oedematous tongue; angular chei- areas of involvement will change over a period of days.
litis; fissures on lower lip; depigmentation along l At times the tongue will revert to a normal texture and
buccal border of lips appearance, and at times it will exhibit almost a bald
denudation. Usually the appearance will be somewhere
Differential diagnosis in between.
If the tongue is completely bald, the only other condi- l The lesions are innocuous and asymptomatic except on
tion that needs to be considered is xerostomia. occasions when spicy foods or acidic citrus products are
Xerostomia can usually be recognized by noting the consumed.
absence of a salivary pool in the floor of the mouth or by l A small percentage of benign migratory glossitis cases
sticking a tongue blade to the oral mucosa during the oral will be accompanied by constant burning pain, known
examination. as the glossopyrosis.
If the tongue shows partial or patchy baldness, all the l These cases are usually related to invasive candidiasis
conditions previously mentioned should be considered; and occasionally to erosive lichen planus. In fact, can-
these include Migratory glossitis (MG), psoriasis, Reiter dida colonization rather than true invasive infection may
syndrome, pityriasis rubra pilaris, changes caused by the be the stimulus for benign migratory glossitis.
use of mouthrinse, atrophic lichen planus and median l Although the disease is often referred to as ‘geographic
rhomboid glossitis (MRG). The differential diagnosis of tongue’, it does occasionally appear in the floor of the
these entities may be reviewed under the differential diag- mouth or buccal mucosa as a benign migratory stomatitis.
nosis section of MG. A thorough discussion of the differen-
Histologically
tial aspects of all the deficiency states that may produce a
l Biopsy should be taken from a prominent serpiginous
glossitis is well beyond the intended scope of this text.
lines at the periphery of a depapillated patch.
Management l A thickened layer of keratin is infiltrated with neutro-
Once the deficiency state or states have been identified, phils; these inflammatory cells often produces small
specific measures may be undertaken for their correction, if microabscesses, called Monro abscess, in keratin and
such are available. spinous layers.
l Chronic inflammatory cells can be seen in variable
Q.2. Describe the appearance of tongue in geographic
numbers within the stroma.
tongue.
l Silver and PAS staining will demonstrate candida hy-
Ans. phae or spores in the superficial layers of the epithelium.
l Geographic tongue is a psoriasiform mucositis of the Differential diagnosis
dorsum of the tongue. It is also known as benign migra- l Surface tongue lesions that are generally asymptomatic
tory glossitis. include candidiasis, lichen planus and perhaps lesions
308 Quick Review Series for BDS 4th Year, Vol 2

related to both systemic lupus erythematosus and discoid l Amyloidosis may or may not be apparent on macro-
lupus erythematosus. In addition, the clinician must be scopic examination, but when the suspected organ is
aware of the possibility of premalignant dysplasia. painted with iodine and sulphuric acid, a peculiar
mahogany brown staining of amyloid deposits is
Diagnostic work-up
revealed.
l Benign migratory glossitis is a diagnosis of clinical
l If large amount of amyloid is accumulated, the affected
recognition. If clinical doubt exists or a burning tongue
organ is frequently enlarged and the tissue appears grey
sensation accompanies the lesion, a biopsy is indicated
with a waxy firm consistency.
to rule out the other entities on the differential list.
l Histologically, the deposition always begins between
l A PAS stain is recommended to rule out Candida
the cells and eventually surrounds and destroy the
organisms.
trapped native cells.
Treatment l The diagnosis of amyloidosis is established by demon-
l No specific treatment is indicated in asymptomatic stration of the characteristic emerald-green birefrin-
cases. gence of tissue specimens stained with Congo red and
l Symptomatic lesions can be treated with topical examined by polarizing microscopy.
prednisolone and a topical or systemic antifungal l There is no specific therapy for primary amyloidosis.
medication can be tried if infected secondary with
candidiasis. [SE Q.1]
Symptomatic cases respond well to nystatin oral sus-
l

pension, 100,000 U/mL given as 5 mL (1 teaspoon) oral

{Hunter glossitis
l Pernicious anaemia is rare before the age of 30 years
swish and expectorate 4 times daily, alone or combined
and increases in frequency with advancing age.
with clotrimazole troches (Mycelex, Alza) and 10 mg as
l The disease is often characterized by the presence of a
a lozenge three times daily. Response to such therapy
triad of symptoms: generalized weakness, a sore, pain-
suggests the presence of Candida organisms.
ful tongue and numbness or tingling of the extremities.
l Emphasis on the innocuous nature of the condition and
l Glossitis is one of the more common symptoms of per-
the fact that it is not malignant or premalignant is rec-
nicious anaemia.
ommended.
l The patients complain of painful and burning lingual
Q.3. Describe the appearance of tongue in: sensations.
a. Amyloidosis l The tongue is generally inflamed, often described as
b. Hunter glossitis ‘beefy red’ in colour, either in entirety or in patches
scattered over the dorsum and lateral borders.
Ans. l In some cases, small and shallow ulcers – resembling
aphthous ulcers – occur on the tongue.
Amyloidosis
l Characteristically, with the glossitis, glossodynia and
l Amyloidosis is fundamentally a disorder of protein mis-
glossopyrosis, there is gradual atrophy of the papillae of
folding.
l It is a condition associated with a number of inherited the tongue that eventuates in a smooth or bald tongue,
which is often referred to as Hunter glossitis or Moeller
and inflammatory disorders in which extracellular de-
glossitis.
posits of fibrillar proteins are responsible for tissue
l Loss or distortion of taste is sometimes reported accom-
damage and functional compromise.
panying these changes.
l This abnormal proteinaceous substance that is deposited
l The fiery red appearance of the tongue may undergo
between cells and organs of the body in a variety of
periods of remission, but recurrent attacks are common.
clinical disorders is referred to as an amyloid.
l On occasion, the inflammation and burning sensation
l Of the more than 20 biochemically distinct forms of
extend to involve the entire oral mucosa but, more fre-
proteins, three are most common. They are
quently, the rest of the oral mucosa exhibits only the
i. Amyloid light chain (AL)
pale yellowish tinge noted on the skin.
ii. Amyloid associated (AA)
l Commonly, the oral mucous membranes in patients
iii. ab-amyloid
with this disease become intolerant to dentures.
l Any organ can be involved but the most commonly
affected organs are kidneys, heart, gastrointestinal tract, Treatment
liver and spleen. l Regardless of the aetiology of vitamin B12 deficiency,
l Amyloidosis is generally irreversible condition. high-dose oral supplementation (l000–2000 mcg daily
l Amyloid deposition in tongue results in macroglossia, for 2 weeks), followed by 1000 mcg daily for mainte-
and gingiva is also commonly affected. nance, is currently recommended.
Section | I Topic-Wise Solved Questions of Previous Years 309

l Historically pernicious anaemia was treated with intra- allergic disorders, salivary gland hypofunction, chronic
muscular vitamin B12 supplementation. low-grade trauma and psychiatric abnormalities.
l Management for folic acid deficiency consists of l In addition to burning sensation, patient also experience
administration of oral folic acid (5 mg/day), which is mucosal pain often described as ‘rawness’ (stomato-
given for a period of 4 months. The differentiation of dynia and glossodynia).
B12 deficiency and folic acid deficiency is crucial as l The so-called scalded mouth syndrome is an apparently
folic acid supplements may correct the anaemia but will unrelated immune response to certain medications, espe-
not stop the neurological manifestations.} cially angiotensin-converting enzyme (ACE) inhibitors.
l Burning mouth syndrome affect postmenopausal women.
Q.4. How the clinical examination of the tongue can Women experience symptoms of BMS seven times more
be carried out? Describe glossodynia and mention the frequently than men.
treatment plan in brief. l Mean age is 40 years for men.
l It has typical abrupt onset, although may be gradual.
Ans.
l Dorsum of tongue develops a burning sensation, usually
Clinical examination of tongue in the anterior third of the tongue.
l Inspect the dorsum of the tongue while it is at rest for l Mucosal changes are seldom visible, if dorsum of tongue
any swelling, ulcers, coating or variation in size, colour is significantly erythematous and smooth, an underlying
and texture. systemic or local infectious process, such as anaemia or
l Observe the margins of the tongue and note the distribu- erythematous candidiasis, should be suspected.
tion of filiform and fungiform papillae, crenations and l Other oral sites affected are hard palate and the lips.
fasciculations, depapillated areas, fissures, ulcers and l Salivary levels of various proteins, immunoglobulins
keratotic areas. and phosphates may be elevated, and there may be a
l Note the frenal attachment and any deviations as the decreased salivary pH or buffering capacity.
patient pushes out the tongue and attempts to move it to l There will be mild discomfort on awakening with in-
the right and left. creasing intensity throughout the day. Contact with hot
l Wrap a piece of gauze (4 cm 3 4 cm) around the tip of food or liquid often intensifies the symptoms.
the protruding tongue to steady it, and lightly press a l Chronically affected patients demonstrates psychological
warm mirror against the uvula to observe the base of the dysfunction, usually depression, anxiety or irritability.
tongue and vallate papillae, note any ulcers or signifi- l The discomfortness reduces as the painful condition
cant swellings. reduces or disappears.
Treatment}
l Holding the tongue with the gauze, gently guide the
tongue to the right and retract the left cheek to observe
the foliate papillae and the entire lateral border of the (SE Q.3 and SN Q.8)

l
tongue for ulcers, keratotic areas and red patches.
Repeat for the opposite side, and then have the patient
l {(Underlying local or systemic causes should be identi-
fied and eliminated.
touch the tip of the tongue to the palate to display the l Counselling and reassurance may be adequate manage-
ventral surface of the tongue and floor of the mouth. ment for individuals with mild burning sensations, but
Note any varicosities, tight frenal attachments, stones in patients with symptoms that are more severe often re-
Wharton ducts, ulcers, swellings and red or white quire drug therapy.
patches. Gently palpate the muscles of the tongue for l The drug therapies that have been found to be the most
nodules and tumours, extending the finger onto the base helpful are low doses of TCAs, such as amitriptyline and
of the tongue and pressing forward if this has been doxepin, or clonazepam (a benzodiazepine derivative).
poorly visualized or if any ulcers or masses are l Mood altering drugs such as chlordiazepoxide. Addi-
suspected. tional therapies used are clonazepam alpha lipoic acid,
l Note tongue thrust on swallowing. amitriptyline, transcutaneous electric nerve stimulation,
analgesics, antibiotics, antifungals, vitamin B complex
[SE Q.3] and placebo-controlled trial.
{Burning mouth syndrome (glossodynia) l Burning of the tongue that results from parafunctional
oral habits may be relieved with the use of a splint cov-
Burning mouth syndrome is a common dysaesthesia
ering the teeth and/or the palate.)}
l

(i.e. distortion of a sense) typically described by the

patient as a burning sensation of the oral mucosa in the Q.5. Describe briefly about benign migratory glossitis.
absence of any clinically apparent alterations.
Ans.
l The cause of BMS remains unknown, but a number of
factors have been suspected, including hormonal and [Same as LE Q.2]
310 Quick Review Series for BDS 4th Year, Vol 2

SHORT ESSAYS: l Numerous fissures covers the entire dorsum surface and
divides the tongue papillae into multiple separate ‘islands’.
Q.1. Pernicious anaemia – tongue lesions. l Sometimes fissures can be seen located dorsolaterally
Ans. over tongue.
l It is usually asymptomatic, but some patients may have
[Ref LE Q.3] mild burning or soreness. This condition can be seen in
Q.2. Angular cheilitis. children or adults but it increases with age.
l Fissured tongue may be a component of Melkersson–
Ans. Rosenthal syndrome.
l Angular cheilitis is one of the clinical types of oral can- l Histopathologically, there is hyperplasia of rete ridges
didiasis. and loss of keratin on the surface of filiform papillae,
l Associated factors are idiopathic, immunosuppression, which are separated by deep grooves.
loss of vertical dimension, iron deficiency and vitamin
Treatment
B12 deficiency.
l Fissured tongue is a benign condition and no specific
l Infection with Candida albicans and in some cases with
treatment is indicated.
a mixture of other microorganisms such as Staphylococ-
l Patient should be encouraged to brush the tongue with
cus aureus seems to represent a major cause.
soft bristled toothbrush, because food or debris that may
l Angular cheilitis is usually a reddish ulcerative or
be entrapped in the grooves may act as an irritation.
proliferative condition marked by one or a number of
deep fissures spreading from the corners of the mouth. Q.5. Migratory glossitis.
l The lesions are most often bilateral, usually do not bleed,
Ans.
and are restricted to the vermilion and skin surface.
l Resolution is relatively easily obtained if angular l Geographic tongue is a psoriasiform mucositis of the
cheilitis is an isolated finding. dorsum of the tongue. It is also known as benign migra-
l If it is part of a generalized oral/systemic candidal in- tory glossitis.
fection, it may be very deep seated and resistant to l It is also known as erythema migrans, glossitis areata
eradication. These lesions usually persist even though migrans, glossitis areata exfoliativa, wandering rash of
the predisposing factors have been eliminated, unless the tongue and annulus migrans.
they are treated with an antifungal ointment such as
Aetiology
nystatin in conjunction with an S. aureus agent or met-
l Although the cause is unknown, emotional stress may
ronidazole.
be one of several factors involved in the onset or exac-
l The major priority of treatment must be directed to the
erbation of this lesion.
main reservoir of infection in the body.
l Its dominant characteristic is a constantly changing
Q.3. Glossopyrosis and glossodynia. pattern of serpiginous white lines surrounding areas
of smooth, depapillated mucosa.
Ans.
l The changing appearance with depapillated areas have
[Ref LE Q.4] reminded of continental outlines on globe, hence popu-
larly known as geographic tongue.
Q.4. Fissured tongue.
Clinical features
Ans.
l The lesions are usually asymptomatic and are discovered
l Fissured tongue has also been referred to as scrotal as an incidental finding during a routine examination.
tongue or lingua plicata. l The patient may complain of a burning sensation made
l Fissured tongue is a relatively common condition char- worse by spicy foods or citrus fruits.
acterized by the presence of numerous grooves, or fis- l MG occurs most commonly in young or middle-aged
sures, on the dorsal surface of the tongue. adults but has been seen in patients ranging in age from
l Cause is uncertain, but ageing and local environmental 5 to 84 years.
factors may contribute to the development of fissured l There is a reported predilection for female patients.
tongue. l The lesions are found more frequently on fissured
l Heredity, chronic trauma and vitamin deficiency have tongues.
been proposed as some more causes for this condition. l Lesions may be single or multiple. Frequently the
l Patient exhibits multiple grooves, or furrows, on the lesions are confined to the dorsal surface and lateral
surface of the tongue, ranging from 2 to 6 mm in borders of the tongue, but they may extend to the ventral
depth. surface.
Section | I Topic-Wise Solved Questions of Previous Years 311

l Initially, MG appears as irregular, circinate and nonin- Treatment

durated atrophic areas that gradually widen, change Antihistamine and sympathomimetic agents such as
shape and migrate over the tongue. adrenalin provide symptomatic relief and are sometimes
l An increased incidence of MG has been reported in ju- lifesaving.
venile diabetes and in those people with several regions Recurrent episodes are sometimes controlled by consis-
of cutaneous psoriasis. tent daily administration of antihistamines (e.g. 50–75 mg
Histologically diphenhydramine hydrochloride daily).
l Biopsy should be taken from a prominent serpiginous Q.7. Tuberculosis ulcers on the tongue.
lines at the periphery of a depapillated patch.
Ans.
l A thickened layer of keratin is infiltrated with neutro-
phils, these inflammatory cells often produces small l Tuberculosis is a specific infectious granulomatous dis-
microabscesses, called Monro abscesses, in keratin and ease caused by mycobacterium tuberculosis.
spinous layers. l Lesions of secondary tuberculosis may occur at any site
l Chronic inflammatory cells can be seen in variable on the oral mucous membrane, but tongue is the most
numbers within the stroma. commonly affected followed by palate, lips, buccal mu-
l Silver and PAS staining will demonstrate candida hy- cosa, gingiva and frenula.
phae or spores in the superficial layers of the epithelium. l Lesion presents as an irregular, superficial or deep,
Treatment painful ulcers that tend to increase slowly in size.
l No treatment is usually necessary for benign migratory l It is frequently found in the area of trauma and may be
glossitis and stomatitis. mistaken as a simple traumatic ulcer or even carcinoma.
l Symptomatic lesions can be treated with topical pred- l Oral lesions of tuberculosis (TB) will present as painful,
nisolone and a topical or systemic antifungal medica- ragged ulcers, mostly on the posterior aspect of the oral
tion can be tried if infected secondary with candidiasis. tongue, pharyngeal tongue or palate.

Q.6. Angioneurotic oedema. Differential diagnosis

l Oral TB will closely mimic squamous cell carcinoma
Ans. and also in addition, the cancers of primary syphilis and
l Angioneurotic oedema is one form of acute anaphylac- the oral lesions of pulmonary fungal diseases such as
tic reaction representing an immediate hypersensitivity histoplasmosis, coccidioidomycosis and blastomycosis,
response allied to urticaria, allergic rhinitis and asthma. all of which have a similar appearance.
l The clinical response is well demarcated, localized oe- l If there is a history of trauma, it is important to remem-
dema involving the deeper layers of the skin and subcu- ber that trauma remains as the leading cause of oral ul-
taneous tissues. cers and should be included in the differential diagnosis.
l When this reaction is localized to the mucosa of the Histopathology
tongue, oropharynx and larynx, considerable swelling l Tuberculosis is a disease that epitomizes the formation
of the tongue, glottis and laryngeal structures occurs of so-called epithelioid granulomas.
with rapid occlusion of the airway. l The typical histology of tuberculosis then is effacement
l In milder forms of the disorder, crenation of the tongue of the normal architecture by numerous granulomas,
margins, a sensation of recurrent swelling of the tongue, which are often confluent.
and associated rhinitis and sinusitis may be the extent of l The granulomas consist of macrophages, epithelioid
the findings. cells and multinucleated giant cells with peripheral lym-
l It may also occur on a hereditary basis, when it is as- phocytes, plasma cells and fibroblasts. The centre of the
sociated with deficiency in the function of an inhibitor granuloma may show caseous necrosis. This is not usu-
of the first component of complement. ally seen in intraoral lesions but may be an important
l Both acute and chronic forms of the disorder exist, re- component in lymph node involvement and in the lung.
current episodes that become self-limited after 6 weeks
Treatment
are called acute while attacks persisting beyond this
l Oral TB lesions are treated with the same drug regimens
period are referred to as chronic.
used to treat pulmonary TB, except that treatment lasts
l A variety of antigenic stimuli may be involved: seasonal
for a duration of 9 months rather than 6 months because
respiratory allergens, animal danders, bacterial antigens,
the lesions are considered extrapulmonary foci.
foods such as shellfish, chocolate, nuts, various drugs
and occasionally cold and physical trauma to the tongue. Prognosis
l Other evidences of predisposition to the immediate type l A responding patient will have a reduction in pain as-
of hypersensitivity reactions may or may not be present. sociated with the oral lesion and evidence of healing.
312 Quick Review Series for BDS 4th Year, Vol 2

Q.8. Mention the causes of macroglossia. Autoimmune disorders

l Sarcoidosis
Ans. l Giant cell arteritis
l Macroglossia is an abnormally enlarged tongue that Miscellaneous
protrudes beyond the teeth or alveolar ridge in the rest l Angioneurotic oedema.
position.
Q.9. Ankyloglossia.
It is of two types:
i. True macroglossia Ans.
ii. Pseudo macroglossia l Ankyloglossia is also known as tongue-tie.
Various causes of true macroglossia are as follows:
Aetiology
Congenital causes
l It is the result of a short, tight and thick, lingual frenu-
l Muscular hypertrophy
lum causing tethering of the tongue tip. According to
l Vascular malformations (haemangioma and lymphan-
A.H. Messner, the incidence of ankyloglossia ranged
gioma)
from 0.02% to 4.8% in newborns.
l Congenital hypothyroidism
l Down syndrome Classification
l Trisomy 22 Based on anatomical appearance
l Beckwith–Wiedemann syndrome Type 1: Frenulum attaches to tip of tongue in front of
l Behmel syndrome alveolar ridge in low lip sulcus.
l Tollner syndrome Type 2: Attaches 2–4 mm behind tongue tip and attaches
l Laband syndrome on alveolar ridge.
l Mucopolysaccharidoses I and II Type 3: Attaches to mid-tongue and middle of floor of the
l Transient neonatal diabetes mellitus mouth, usually tighter and less elastic. The tip of the tongue
l Ganglioside storage disease type I may appear ‘heart-shaped’.
l Lipoid proteinosis Type 4: Attaches against base of tongue, is shiny, and is
Acquired causes very inelastic.
l Endocrinal disturbances Hazelbaker assessment tool for lingual frenulum func-
l Acquired hypothyroidism tion (1998 version)
l Acromegaly l This assessment tool was designed to evaluate ankylo-
l Pituitary gigantism glossia in infants.
l Myxoedema l The assessment tool takes into consideration the ‘appear-
Infections ance’ and ‘function’ parameters.
l Tuberculosis
Appearance parameters
l Actinomycosis
Appearance of tongue when lifted:
Traumatic injuries
Score 2: Round or square
l Self-inflicted (self-harm, injury during epileptic
Score 1: Slight cleft in tip of tongue
seizure)
Score 0: Heart-shaped
l Presurgical (intubation)/surgical trauma/postsurgical
(anaesthesia/haemorrhage) Elasticity of frenulum:
Neoplasms Score 2: Very elastic (excellent elasticity)
l Lymphangioma Score 1: Moderately elastic
l Haemangioma Score 0: Minimal or no elasticity
l Carcinoma Length of lingual frenulum when tongue lifted:
l Sarcoma Score 2: More than 1 cm or embedded in tongue
l Solitary plasmacytoma Score 1: 1 cm length
l Neurofibroma Score 0: Less than 1 cm length
l Granular cell tumour
Nutritional and metabolic disorders Attachment of lingual frenulum to tongue:
l Amyloidosis Score 2: Posterior to tip of tongue
l Scurvy Score 1: At tip
l Pellagra Score 0: Notched tip of tongue
Section | I Topic-Wise Solved Questions of Previous Years 313

Attachment of lingual frenulum to inferior alveolar ridge: Class III (severe) 4–8 mm
Score 2: Attached to floor of mouth well below the ridge
Class IV (complete) 0–4 mm
Score 1: Attached just below ridge
Score 0: Attached at ridge below
Clinical significance
Functional parameters l Majority of the cases of ankyloglossia resolve spontane-
Lateral movement of tongue: ously or are asymptomatic.
Score 2: Complete lateral movement l It may cause feeding problems in infants as well as articu-
Score 1: Body of tongue but not tongue tip lation problems, gingival recession, open bite and abnor-
Score 0: None mal facial development.
Ability to lift the tongue: l In some children, tongue tie may also cause speech
Score 2: Tip to mid-mouth defects, especially articulation of the sounds such as
Score 1: Only edges to mid-mouth l, r, t, d, n, th, sh and z.
Score 0: Tip stays at alveolar ridge or rises to mid-mouth l Tongue tie may also contribute to dental problems
only with jaw closure such as causing a persistent gap between the mandibu-
lar incisors.
Extension of tongue: l Intraoral radiography may be difficult in some patients
Score 2: Tip over lower lip owing to the limited space available to position the film.
Score 1: Tip over lower gum only
Score 0: Neither of the above, or anterior or mid-tongue humps Treatment
l Frenectomy is recommended.
Spread of anterior tongue:
l Frenotomy and frenuloplasty also have been effective
Score 2: Complete
treatments for ankyloglossia.
Score 1: Moderate or partial
Score 0: Little or none Q.10. Black hairy tongue.
Cupping: Ans.
Score 2: Entire edge, firm cup l Black hairy tongue is also known as lingua nigra, lingua
Score 1: Side edges only, moderate cup villosa, lingua villosa nigra and hairy tongue.
Score 0: Poor or no cup l It is a commonly observed condition of defective filiform
Peristalsis: papillae that results from a variety of precipitating factors.
Score 2: Complete, anterior to posterior originating at the tip
This condition is most commonly referred to as black hairy
Score 1: Partial, originating posterior to tip
tongue, but hairy tongue may also appear as brown, white,
Score 0: None or reverse peristalsis
green, pink or variety of hues depending on the specific
Snapback: aetiology and secondary factors.
Score 2: None
Aetiology
Score 1: Periodic
l The hypertrophy of the filiform papillae on the dorsal
Score 0: Frequent or with each suck
surface of the tongue.
Interpretation of the score: l Poor oral hygiene.
Total score of 14: Perfect score (regardless of appearance l Other contributory factors are use of tobacco and coffee
parameter score) and tea drinking.
Total score or 11: Acceptable if appearance parameter score
Clinical features
is 10
l Most commonly seen in males and patients infected
Score less than 11: Function impaired
with HIV.
Frenotomy is necessary if appearance parameter score
l As its name implies, black hairy tongue will present as
is less than 8.
a black area, along with some small red and white areas,
Classification of ankyloglossia based on distance of the on the dorsum of the tongue.
insertion of the lingual frenum to the tip of the tongue l Black hairy tongue actually represents a superficial bac-
This classification was suggested by Kotlow (2004). terial infection of the tongue by pigment-producing
microorganisms often called chromogenic bacteria. It is
Normal 16 mm therefore a type of glossitis that may exist in isolation or
as part of a pharyngitis or tonsillitis.
Class I (mild) 12–16 mm
l Rarely symptomatic, when secondarily infected with C.
Class II (moderate) 8–12 mm albicans, the patient may complain of pain or a burning
314 Quick Review Series for BDS 4th Year, Vol 2

sensation on the tongue and also of pain on swallowing Q.13. Geographic tongue.
or a generalized pharyngitis.
Ans.
l Normal filiform papillae are approximately 1 mm in
length but in hairy tongue, it becomes more than 15 mm [Same as SE Q.5]
in length.
l In addition to the elongated filiform papillae and the
colonies of microorganisms formed upon an inflamed SHORT NOTES:
base, which gives rise to the hairy appearance of the Q.1. Benign migratory glossitis.
tongue, there may be a submandibular or cervical
lymphadenopathy. Ans.
l Patient complains of tickling sensation in the soft palate l Benign migratory glossitis or geographic tongue is a
and oro-pharynx during swallowing. psoriasiform mucositis of the dorsum of the tongue.
l In more severe cases, patient may actually complain of l It is also known as erythema migrans, glossitis areata
gagging sensation. migrans, glossitis areata exfoliativa, wandering rash of
l Retention of oral debris between the elongated papillae the tongue and annulus migrans.
may result in halitosis. l Aetiology is usually unknown.
l The tongue has a thick coating in the middle, with great
accentuation towards the back. Clinical features
l Rarely patient may give history of altered taste l The lesions are usually asymptomatic.
sensation. l The patient may complain of a burning sensation made
worse by spicy foods or citrus fruits.
Differential diagnosis l It occurs most commonly in young or middle-aged
l Candidiasis, leukoplakia, oral lichen planus and hairy adults.
leukoplakia. l Lesions may be single or multiple. Frequently the
lesions are confined to the dorsal surface and lateral
Treatment borders of the tongue.
The treatment is variable. l Initially, MG appears as irregular, circinate and nonin-
l Removing of the aetiologic factors. durated atrophic areas that gradually widen, change
l Black hairy tongue is treated with oral antibiotics for shape and migrate over the tongue.
10–14 days and physical tongue brushing. The antibi- l Histologically a thickened layer of keratin is infiltrated
otic of choice remains phenoxymethyl penicillin 500 with neutrophils, these inflammatory cells often pro-
mg four times per day. In the penicillin-allergic patient, duces small microabscesses, called Monro abscesses, in
erythromycin ethyl succinate (EES, Abbott), 400 mg keratin and spinous layers.
three times per day, is effective. l No treatment is usually necessary for benign migratory
l The tongue brushing can be accomplished with tooth- glossitis and stomatitis.
paste or with 0.12% chlorhexidine (Peridex) or with the
bare brush alone. Q.2. Treatment of atrophic glossitis.
l Brushing the tongue with brushes or the commercially
Ans.
available tongue scrapers is sufficient to remove elon-
gated filiform papillae and retard the growth. l Atropic glossitis is seen in iron deficiency anaemia.
l Surgical removal of the papillae by using electrodesic- l It is diffuse or patchy atrophy of papillae on the dorsal
cation, carbon dioxide laser or even scissor is the treat- surface of the tongue.
ment of the last resort. l This is often accompanied by tenderness or burning
l Prognosis is excellent. sensation.
l Treatment: dietary iron supplementations by means of
Q.11. Glossitis.
oral ferrous sulphate.
Ans. l Patient with malabsorption problems, parental iron may
be given periodically.
[Same as SE Q.1]
l The underlying causes of anaemia should be identified
Q.12. Burning mouth syndrome. and eliminated.

Ans. Q.3. Mention the causes of ‘bald tongue’.

[Same as SE Q.4] Ans.

Section | I Topic-Wise Solved Questions of Previous Years 315

l If the tongue is completely bald, the only other condi- patient as a burning sensation of the oral mucosa in the
tion that needs to be considered is xerostomia. absence of any clinically apparent alterations.
If the tongue shows partial or patchy baldness, the l Burning mouth syndrome affects postmenopausal
following conditions should be considered: women.
l Migratory glossitis l Mean age is 40 years and it has typical abrupt onset,
l Psoriasis although may be gradual.
l Reiter syndrome l Contact with hot food or liquid often intensifies the
l Pityriasis rubra pilaris symptoms.
l Changes caused by the use of mouthrinse l Chronically affected patients demonstrates psychological
l Atrophic lichen planus dysfunction, usually depression, anxiety or irritability.
l Median rhomboid glossitis
Treatment
Q.4. Aetiology of angular cheilitis. l Underlying local or systemic causes should be identi-
fied and eliminated.
Ans. l Some relief from symptoms is also usually obtained
Aetiologic factors of angular cheilitis are as follows: from the use of topical analgesics.
l Idiopathic Q.7. Dysgeusia.
l Nutritional deficiency
l Denture irritation Ans.
l Infections like C. albicans l Disordered taste (dysgeusia) constitutes the bulk of
chronic oral sensory abnormalities for which patients
Q.5. Hairy tongue.
overtly seek medical and dental care.
Ans. l Loss of olfactory stimulation by way of the first cranial
nerve (as often occurs with a cold or other nasal ob-
l Hairy tongue is also known as lingua nigra, lingua struction preventing access of volatile components of
villosa, lingua villosa nigra and hairy tongue. food to the olfactory receptors in the upper part of the
Aetiology nasal cavity) alters the ‘taste of food’ greatly because
l Irritation to filiform papillae caused by smoking, alco- oral chemoreception then becomes the main sensation
hol, hydrogen peroxide and antacids associated with eating.
l Damage to the maxillary branch of the trigeminal nerve
Clinical features may also produce diminished taste sensation in the
l Brownish to black appearance on the dorsal surface of same way, since nonspecific stimulation of receptors of
the tongue the 5th nerve throughout the nasal mucosa, by heat and
Histologic characteristics pungent volatile components, also contributes to the
l Elongation of filiform papillae; characteristic inflamma- ‘taste of food’.
tory cells l Evaluation of dysgeusia, therefore, must always include
an examination of cranial nerves I and V, as well as VII
Treatment/prognosis and IX nerve functions.
l Brushing or scraping of the tongue
Q.8. Management of a patient suffering from gloss-
Prognosis odynia.
l Good and totally reversible
Ans.
Q.6. Glossopyrosis.
[Ref LE Q.4]
Ans.
Q.9. Ankyloglossia.
l Glossopyrosis is a burning tongue whereas glossodynia
Ans.
is a painful tongue.
l Dorsum of tongue develops a burning sensation, usually l Ankyloglossia is also known as tongue-tie.
in the anterior third of the tongue. Mucosal changes are l It occurs due to the attachment of inferior frenulum to
seldom visible. Other oral sites affected are hard palate the bottom of the tongue, which subsequently restricts
and the lips. the free movement of the tongue.
l Burning mouth syndrome is a common dysaesthesia l Ankyloglossia occurs in approximately in 1.7% of all
(i.e. distortion of a sense) typically described by the neonates.
316 Quick Review Series for BDS 4th Year, Vol 2

l Tongue tie can cause feeding problems in infants. Q.10. Differential diagnosis of bald tongue.
l In some children may also cause speech defects, espe-
Ans.
cially articulation of the sounds such as l, r, t, d, n, th, sh
and z. [Same as SN Q.3]
l Tongue tie may also contribute to dental problems
Q.11. Bald tongue.
such as causing a persistent gap between the mandibu-
lar incisors. Ans.
l Frenulectomy is the recommended treatment.
[Same as SN Q.3]

Topic 7
Salivary Glands Diseases

COMMONLY ASKED QUESTIONS

LONG ESSAYS:
1. Enumerate the causes for xerostomia. Describe the clinical features, investigations and management of Sjögren
syndrome.
2. Describe in detail sialography and its significance in various diseases of salivary glands.
3. Clinical features, differential diagnosis and management of functional disturbance of salivary glands.
4. Name the various diseases of salivary glands. Discuss clinical features, diagnosis, differential diagnosis and
treatment of parotitis.
5. Classify salivary gland diseases. Describe the various causes, clinical features and the management of
sialadenitis.
6. Classify functional disorders of the salivary glands. Describe the aetiology, clinical features, diagnosis and
management of Sjögren syndrome. [Same as LE Q.1]
7. Describe sialography in detail and write briefly on its significance in various salivary gland disorders.
[Same as LE Q.2]
8. Describe the procedure for sialography of parotid gland. [Same as LE Q.2]
9. Describe the indications and contraindications of sialography. Describe the technique briefly. [Same as LE Q.2]
10. Enumerate the clinical and radiological features of functional disturbances of salivary glands. [Same as LE Q.3]

SHORT ESSAYS:
1. Liths in orofacial region.
2. Indications of sialography. [Ref LE Q.2]
3. Treatment of xerostomia. [Ref LE Q.3]
4. Clinical features and investigations of submandibular sialolithiasis.
5. Bacterial sialadinitis. [Ref LE Q.5]
6. Sialadenosis.
7. Sjögren syndrome.
8. Pleomorphic adenoma.
9. Parotitis. [Ref LE Q.4]
10. Sialolithiasis. [Same as SE Q.1]
11. Indications and contraindications of sialography. [Same as SE Q.2]
Section | I Topic-Wise Solved Questions of Previous Years 317

SHORT NOTES:
1. Mucocele.
2. Mumps.
3. Xerostomia.
4. Schirmer test.
5. Treatment of ptyalism.
6. Sialolithiasis.
7. Sialography.
8. Sialometaplasia.
9. Sjögren syndrome. [Ref LE Q.1]
10. What are the functions of saliva?
11. Sialosis.
12. Ptyalism.
13. Ranula.
14. Why sialolithiasis is more common in submandibular gland?
15. Necrotizing sialometaplasia. [Same as SN Q.8]
16. Sialadenosis. [Same as SN Q.11]
17. Sialorrhoea. [Ref LE Q.3]

SOLVED ANSWERS

LONG ESSAYS: {SN Q.9}

Q.1. Enumerate the causes for xerostomia. Describe the Sjögren syndrome
clinical features, investigations and management of l Sjögren syndrome is a chronic inflammatory dis-
Sjögren syndrome. ease that affects salivary, lacrimal and other exo-
Ans. crine glands.
Or
Xerostomia is defined as dryness of mouth, which is a l Sjögren syndrome is the expression of an autoim-
clinical manifestation of salivary gland dysfunction. mune process that results principally in dry eyes
Causes of xerostomia are as follows: (keratoconjunctivitis sicca) and dry mouth (xerosto-
mia) owing to lymphocyte-mediated destruction of
Autoimmune or Other
lacrimal and salivary gland parenchyma.
Medications systemic diseases conditions
l Analgesics l Sjögren syn- l Local radia- Types
l Opioids drome tion therapy l Primary Sjögren syndrome (sicca complex): only dry
l Anticholinergic l Primary l Type 1 or eyes and dry mouth.
drugs l Secondary 2 diabetes l Secondary Sjögren syndrome: primary Sjögren 1
l Antihistamines l Primary biliary l Radioactive
l Antidepressants cirrhosis iodine
systemic lupus erythematosus, polyarteritis nodosa,
l Selective sero- l Wegener’s treatment polymyositis, scleroderma or rheumatoid arthritis.
tonin reuptake granulomatosis l Human
inhibitors (SSRIs) l Sarcoidosis immunodefi-
l Tricyclic and l Scleroderma ciency virus Aetiology
heterocyclic an- (HIV)/ l The specific cause of this syndrome is unknown, numer-
tidepressants acquired ous immunologic alterations indicate a disease of great
Atypical antide- immunodefi-
l
complexity.
pressants ciency
l Antihypertensive syndrome l This syndrome appears to be of autoimmune origin that
agents (AIDS) may be limited to exocrine glands, or it may extend to
l Diuretics l Anxiety/ include systemic connective tissue disorders.
l Muscle relaxants depression l Viruses, particularly retroviruses and Epstein–Barr
Sedatives/
l
virus, have been implicated in the aetiology of Sjögren
anxiolytics
syndrome, but none are proven causes.
318 Quick Review Series for BDS 4th Year, Vol 2

Clinical features precipitating antinuclear antibodies such as anti-Sjögren

l Sjögren syndrome occurs in all ethnic and racial groups. syndrome-A (SS-A) and anti-Sjögren syndrome-B
The peak age of onset is 50 years, and 90% of cases (SS-B) in association with both primary and secondary
occur in women. Sjögren syndrome.
l Typical features are dryness of mouth and eyes as a re- l Patients who have SS-B antibodies are more likely to
sult of hypofunction of the salivary glands and lacrimal develop extra-glandular disease.
glands. l HLA-DR4 antigen is often identified in patients with
l Painful, burning sensation of the oral mucosa. secondary Sjögren syndrome; antigens found in patients
l Other secretory glands involved in dryness are of the with the primary form are often HLA-B8 and HIA-DR3
nose, larynx, pharynx, tracheobronchial tree and the types.
vagina.
Histological features
l The chief oral complaint in Sjögren syndrome is xero-
l Three types of histological patterns are seen in the
stomia, which may be the source of eating and speaking
major salivary glands:
difficulties.
a. Intense lymphocytic infiltration of the gland replac-
l These patients are also at greater risk for dental caries,
ing all the acinar structures.
periodontal disease and oral candidiasis because of dry
b. Proliferation of the ductal epithelium and myoepi-
mouth.
thelium to form ‘epimyoepithelial islands’.
l Parotid gland enlargement, which is often recurrent and
c. Atrophy of the glands following the lymphocytic
symmetric, occurs in approximately 50% of patients.
infiltration.
l A significant percentage of these patients also present
l Similar changes were seen in the accessory salivary
with complaints of arthralgia, myalgia and fatigue.
glands in the lips.
l There is an increased risk of lymphoreticular malig-
nancy developing in the primary form, the relative risk Treatment
is estimated to be approximately 44 times that in the l Sjögren syndrome and the complication of the sicca
general population. An interesting associated sign is a component are best managed symptomatically.
decrease in serum immunoglobulin levels accompany- l Artificial saliva and artificial tears are available for this
ing or preceding the malignant change. purpose.
l In the sicca complex, there is parotid gland enlargement l Preventive oral measures are extremely important relative
that is usually absent in secondary Sjögren syndrome. to xerostomia. Scrupulous oral hygiene, dietary modifica-
tion, topical fluoride therapy and remineralizing solutions
Investigations are important in maintaining oral and dental tissues.
l The salivary component of Sjögren syndrome may be l Use of sialogogues, such as pilocarpine and cevimeline,
assessed by sialochemical studies, nuclear imaging of remains of limited value, especially in long-standing
the glands (scintigraphy), contrast sialography, flow rate Sjögren syndrome.
analysis and a minor salivary gland biopsy.
Prognosis
l Sialochemistry studies have shown increased levels of
l The prognosis of Sjögren syndrome is complicated by
IgA, potassium and sodium in the saliva.
an association with malignant transformation to lym-
l The most commonly used and most reliable method of
phoma. This may occur in approximately 6%–7% of
assessing salivary alteration in this syndrome currently
cases, it is more common in those with only the sicca
is a labial salivary gland biopsy.
component of the syndrome.
l Nuclear medicine techniques using a technetium
pertechnetate isotope and subsequent scintiscanning can Q.2. Describe in detail sialography and its significance
yield functional information relative to the uptake of the in various diseases of salivary glands.
isotope by salivary gland tissue. Ans.
l Contrast sialography aids in detecting filling defects
within the gland being examined.
[SE Q.2]
l A punctate sialectasia is characteristic in individuals
with Sjögren syndrome. This finding reflects significant l {Sialography is a technique in which ducts and ductules
ductal and acinar damage. of the salivary glands are demonstrated radiographically
l Other laboratory findings commonly found in primary after a radiopaque liquid has been injected along them.
and secondary Sjögren syndrome include mild anaemia, l First performed in 1902, sialography is a radiographic
leukopenia, eosinophilia, an elevated ESR and diffuse technique wherein a radiopaque contrast agent is in-
elevation of serum immunoglobulin levels. fused into the ductal system of a salivary gland before
l In addition, numerous autoantibodies may be found, imaging with plain films, fluoroscopy, panoramic radi-
including rheumatoid factor, antinuclear antibodies and ography, conventional tomography or CT.
Section | I Topic-Wise Solved Questions of Previous Years 319

l Sialography remains the most detailed way to image the Q.3. Clinical features, differential diagnosis and man-
ductal system. The parotid and submandibular glands agement of functional disturbance of salivary glands.
are more readily studied with this technique.
Ans.
Indications The two types of functional disorders of salivary glands
l To demonstrate – calculi, strictures, recurrent paroti- are as follows:
tis, tumours, etc. a. Sialorrhoea
l Salivary fistula. b. Xerostomia
l Relationship of salivary glands and ducts to sur-

rounding structures.
l Autoimmune or radiation-induced sialadenitis. {SN Q.18}
Contraindications
Sialorrhoea
l Active or recent infection of the gland.
l Sialorrhoea describes increased salivary flow.
l Allergy to contrast media.}
Causes
Technique
l Painful lesions or foreign bodies in the mouth.
l A surveyor ‘scout’ film is usually made before the in-
l Drugs, e.g. anticholinesterases, insecticides
fusion of the contrast solution into the ductal system
and nerve agents; antipsychotics and cholin-
as an aid in verifying the optimal exposure factors and
ergic agonists used to treat dementia and
patient positioning parameters and for detecting radi-
myasthenia gravis).
opaque sialoliths or extra glandular pathosis.
l Toxins (e.g. mercury and thallium); and rarely
l A lacrimal or periodontal probe is used to dilate the
other causes, e.g. rabies may be implicated.
sphincter at the ductal orifice before the passage of a
l Sialorrhoea is an uncommon subjective com-
cannula (blunt needle or catheter) connected by ex-
plaint but objective evidence is even less com-
tension tubing to a syringe containing contrast agent.
mon, and the problem is sometimes perceived
l Lipid-soluble (e.g. ethiodol) or nonlipid-soluble
rather than real.
(e.g. Sinografin) contrast solution is then slowly in-
l Drooling is the overflowing of saliva from the
fused until the patient feels discomfort (usually be-
mouth not usually associated with increased
tween 0.2 and 1.5 mL, depending on the gland being
saliva production.
studied).
l Drooling is normal in healthy infants, but usu-
l These iodine-containing agents render the ductal
ally stops by about 18 months and is consid-
system radiopaque.
ered abnormal if it persists beyond the age of
l The filling phase can be monitored by fluoroscopy or
4 years.
with static films.
l Saliva soils clothing and patients may have
l The intention is to opacify the ductal system all the way
perioral skin breakdown and infections, dis-
to the acini. The image of the ductal system appears as
turbed speech and eating and can occasionally
‘tree limbs’, with no area of the gland devoid of ducts.
develop aspiration related and pulmonary com-
l With acinar filling, the ‘tree’ comes into ‘bloom’,
plications.
which is the typical appearance of the parenchymal
opacification phase.
l The gland is allowed to empty for 5 min without Diagnosis
stimulation. l Absolute quantification of saliva spill or intraoral

l If postevacuation images suggest contrast retention, pooling by volumetric measurement can help guide
a sialogogue such as lemon juice or 2% citric acid treatment. A subjective estimate can be made by
may be administered to augment evacuation by stim- counting the bibs or items of clothing soiled each day.
ulating secretion.
l Nonlipid-soluble contrast agents are preferred because {SN Q.18}
of reports of inflammatory reactions subsequent to
inadvertent extravasation of lipid-soluble agents. Management
l Management options range from conservative

[SE Q.2] therapy to medication, radiation or surgery, and

often a combination is needed.
{Advantage l Pharmacological treatment (anticholinergic drugs,
l Visualizes ductal anatomy/blockage.
e.g. atropinics such as hyoscine or ipratropium or
Disadvantage
adrenergic stimulators, e.g. clonidine) decreases
l Invasive; requires iodine-containing dye; no quantifi-
salivation.
cation.}
320 Quick Review Series for BDS 4th Year, Vol 2

factors are considered, along with analysis of all pre-

l Botulinum toxin serotype A injections may have a
scription and over-the-counter medications and diet.
positive outcome.
l Direct interventional strategies include the use of
l Persistent drooling is managed by redirecting the
topical agents such as oral polymer-based sprays, so-
submandibular duct flow to the back of the mouth;
called saliva substitutes, sipping of small amounts of
or duct ligation (mainly parotid) or gland removal
water during the day.
or neurectomy
Palliation
l Gustatory salivary stimulation
Xerostomia l Drug modification when possible
l Xerostomia means dryness of mouth. l Elimination of caffeine-containing products
Causes l Chewing of sugarless candies and sugar-free gum
l Various drugs capable of causing xerostomia are as l Moist sugar-free or complex carbohydrate foods
follows: l Elimination of alcohol-containing mouth rinses
i. Analgesics l Scrupulous oral hygiene
ii. Opioids l Topical fluoride application
iii. Anticholinergic drugs l Careful dental follow-up are required to help prevent
iv. Antihistamines or control dental caries
v. Antidepressants l Oral lubricants, e.g. carboxymethylcellulose- or hy-
vi. Selective serotonin reuptake inhibitors (SSRIs) droxymethyl cellulose-based products
vii. Tricyclic and heterocyclic antidepressants l In some cases, prescription strategies include cholin-
viii. Atypical antidepressants ergic agonists like pilocarpine and cevimeline may
ix. Antihypertensive agents be helpful, as may the use of acupuncture}
l Diuretics
Q.4. Name the various diseases of salivary glands. Dis-
l Muscle relaxants
cuss clinical features, diagnosis, differential diagnosis
l Sedatives/anxiolytics
and treatment of parotitis.
l Autoimmune or systemic diseases:

l Sjögren syndrome: both primary and secondary Ans.

l Primary biliary cirrhosis Diseases of salivary glands
l Wegener’s granulomatosis Reactive lesions
l Sarcoidosis l Mucus extravasation phenomenon
l Scleroderma l Mucus retention cyst (obstructive sialadenitis)
l Other conditions: l Maxillary sinus retention cyst/pseudocyst
l Local radiation therapy l Necrotizing sialometaplasia
l Diabetes: both type 1 and 2 l Adenomatoid hyperplasia
l Radioactive iodine treatment Infectious sialadenitis
l Human immunodeficiency virus (HIV)/acquired l Mumps
immunodeficiency syndrome (AIDS) l Cytomegaloviral sialadenitis
l Anxiety/depression l Bacterial sialadenitis
Clinical features l Sarcoidosis
l Increased thirst and hence increased uptake of fluids Metabolic conditions
especially l Sjögren syndrome
l Burning and tingling sensation in the mouth l Salivary lymphoepithelial lesion
l Difficulty in swallowing l Scleroderma
l Painful salivary gland enlargement l Xerostomia
l Swelling of salivary glands l Taste disturbances
l Increased incidence of dental caries l Halitosis
l Angular cheilitis Benign neoplasms
l Oral infections l Mixed tumour (pleomorphic adenoma)

l Basal cell adenoma

[SE Q.3]
l Canalicular adenoma

{Management l Myoepithelioma

l Management of the patient with xerostomia is gener- l Oncocytic tumours

ally directed towards palliation and requires a careful l Sebaceous adenoma

multifactorial approach, wherein local and systemic l Ductal papilloma

Section | I Topic-Wise Solved Questions of Previous Years 321

Malignant neoplasms Prognosis

l Mucoepidermoid carcinoma l Often remits around puberty.}
l Polymorphous low-grade adenocarcinoma
Q.5. Classify salivary gland diseases. Describe the vari-
l Adenoid cystic carcinoma
ous causes, clinical features and the management of
l Clear cell carcinoma
sialadenitis.
l Acinic cell carcinoma

l Adenocarcinoma not otherwise specified Ans.

Rare tumour
l Carcinoma ex-mixed tumour [SE Q.5]
l Metastasizing mixed tumour

l Epimyoepithelial carcinoma
{Aetiology and pathogenesis
l Salivary duct carcinoma
l Bacterial infections of salivary glands generally are
l Basal cell adenocarcinoma
due to microbial overgrowth in association with a
l Squamous cell carcinoma
reduction in salivary flow.
l Submandibular gland sialadenitis is far less com-
mon than its parotid counterpart, in part because of
[SE Q.10] the stated higher degree of bactericidal quality and
{Parotitis the greater viscosity of submandibular saliva versus
l Bacterial parotitis occurs both in a childhood form the serous and lower viscosity quality of parotid
and in an adult form; in either form, the gland fluid.
becomes swollen and painful. l Other possible causes include trauma to the duct
l Repeated parotitis and sialectasis in a child, associ- system and hematogenous spread of infection from
ated with a sialographic pattern of sialectasis. other areas.
l Prevalence (approximate): uncommon. l Traditionally, bacterial sialadenitis has been a com-
Age mainly affected: Usually begins in preschool mon postoperative complication of surgery related to
inadequate hydration.}
l

children.
l Gender mainly affected: Male. l The most commonly isolated organisms in parotitis
l Aetiopathogenesis: Congenital or autoimmune duct are penicillin-resistant Staphylococcus aureus, Strep-
defects. tococcus viridans, Streptococcus pneumoniae, Esch-
erichia coli and Haemophilus influenzae.
Clinical features and diagnostic features l Anaerobic organisms may be cultured from acute
Oral signs cases and include Porphyromonas gingivalis.
l Little pain l It is of interest to note the marked reduction in the
l Parotid swelling overall incidence of acute parotitis after antibiotic
l Intermittent, unilateral parotid swelling which lasts preparations are introduced. As resistant strains of
,3 weeks with spontaneous regression bacteria have appeared, the prevalence of acute par-
l It may occur simultaneously or alternately contralaterally otitis has increased.
Extraoral signs
l Occasional fever [SE Q.5]
Differential diagnosis
l Sjögren syndrome
{Clinical features
Clinical features of acute parotitis are as follows:
Diagnosis
l The sudden onset of painful lateral facial swell-
l It is mainly based on clinical grounds but serum anti-
ing, low-grade fever, malaise and headache.
SS-A and SS-B antibodies are indicated to exclude
l Laboratory studies disclose an elevated erythro-
Sjögren syndrome.
cyte sedimentation rate (ESR) and leukocytosis,
l Imaging with ultrasonography and CT scan or sialogra-
often with a characteristic shift to the left, where
phy showing sialectasis is confirmatory.
neutrophil counts are elevated, indicating acute
Management infection.
l Medical: Episodes are managed with sialogogues, glan- l The involved gland is extremely tender, and the

dular massage and duct probing to promote ductal patient often demonstrates guarding during exami-
lavage. nation.
l No specific treatment is available. l Trismus is often noted, and purulence at the duct

l Antibiotics and corticosteroids are limited in value. orifice may be produced by gentle pressure on the
l Surgery is unnecessary. involved gland or duct.
322 Quick Review Series for BDS 4th Year, Vol 2

If the infection is not eliminated early, suppura-

l Q.10. Enumerate the clinical and radiological features
tion may extend beyond the limiting capsule of of functional disturbances of salivary glands.
the parotid gland.
Ans.
l Extension into surrounding tissues along fascial

planes in the neck or extension posteriorly into [Same as LE Q.3]

the external auditory canal may follow.
Treatment and prognosis
Management of bacterial sialadenitis is as follows: SHORT ESSAYS:
l Elimination of the causative organism combined
Q.1. Liths in orofacial region.
with rehydration of the patient and drainage of
purulence, if present. Ans.
l Culture and sensitivity testing of the exudate at
l Sialoliths are calcified organic matter that forms within
the orifice of the duct is the first step in antibiotic the secretory system of the major salivary glands.
management. l The round, ovoid calcified structure present in the sali-
l After a culture is obtained, all patients should
vary duct or gland is called a ‘sialolith’.
empirically be placed on a regimen of a penicil- l It is formed by the deposition of calcium salts around a
linase-resistant antibiotic such as semisynthetic
central nidus.
penicillin.
l Along with rehydration and attempts at establish- Aetiology
ing and encouraging salivary flow, moist warm l Still unknown, yet several factors that cause pooling of
compresses, analgesics and rest are in order. saliva within the duct are known to contribute to stone
l Medications containing parasympathomimetic formation:
agents, which reduce salivary flow, should be re- l Inflammation

duced or eliminated. l Irregularities in the duct system

l In cases of chronic recurrent parotitis with consid- l Local irritants

erable destructive glandular changes, painful recur- l Anticholinergic medications

rent enlargement and xerostomia, sialadenectomy, l Fifty per cent of parotid gland sialoliths and 20% of
particularly in cases of submandibular gland in- submandibular gland sialoliths are poorly calcified. This
volvement may be considered, although duct liga- is clinically significant as these sialoliths will not be
tion and parotidectomy remain treatment options.} detected radiographically.
Location
Q.6. Classify functional disorders of the salivary glands. l They are by far most common in the submandibular
Describe the aetiology, clinical features, diagnosis and glands (80%–90%), followed by the parotid (5%–15%)
management of Sjögren syndrome. and then sublingual (2%–5%) glands.
Ans. l The higher rate of sialoliths formation in the subman-
dibular gland is due to:
[Same as LE Q.1] i. The torturous course of Wharton duct
Q.7. Describe sialography in detail and write briefly on ii. Higher calcium and phosphate levels
its significance in various salivary gland disorders. iii. The dependent position of the submandibular
glands, which leaves them prone to stasis
Ans.
Clinical features
[Same as LE Q.2] l Common in adults.
l Swelling and pain which is related to meal time.
Q.8. Describe the procedure for sialography of parotid
l Stones may be palpable.
gland.
l Occurs more frequently in submandibular duct and glands.
Ans. l The degree of symptoms is dependent on the extent of
salivary duct obstruction and the presence of secondary
[Same as LE Q.2]
infection.
Q.9. Describe the indications and contraindications of l The stone totally or partially blocks the flow of saliva,
sialography. Describe the technique briefly. causing salivary pooling within the gland ductal system.
l Salivary glands with obstructive sialoliths are frequently
Ans.
enlarged and tender. Stasis of the saliva may lead to in-
[Same as LE Q.2] fection, fibrosis and gland atrophy.
Section | I Topic-Wise Solved Questions of Previous Years 323

l Fistulae, a sinus tract or ulceration may occur over the l The degree of symptoms is dependent on the extent of
stone in chronic cases. salivary duct obstruction and the presence of secondary
l An examination of the soft tissue surrounding the duct infection.
may show oedema and inflammation. l Typically, eating will initiate the salivary gland swelling.
l Bidigital palpation along the pathway of the duct may l The stone totally or partially blocks the flow of sa-
confirm the presence of a stone. liva, causing salivary pooling within the gland ductal
l Supportive or nonsupportive retrograde bacterial infections system.
can occur, particularly when the obstruction is chronic. l Salivary glands with obstructive sialoliths are frequently
l Other complications from sialoliths include acute enlarged and tender. Stasis of the saliva may lead to in-
sialadenitis, ductal stricture and ductal dilatation. fection, fibrosis and gland atrophy.
l Fistulae, a sinus tract or ulceration may occur over the
Diagnosis
stone in chronic cases.
l Radiographs are helpful to visualize sialoliths; however,
l An examination of the soft tissue surrounding the duct
poorly calcified stones may not be readily identifiable.
may show oedema and inflammation.
l An occlusal radiograph is recommended for subman-
l Bidigital palpation along the pathway of the duct may
dibular glands.
confirm the presence of a stone.
l Stones in the parotid gland can be more difficult to visu-
l Complications from sialoliths include acute sialadenitis,
alize due to the superimposition of other anatomic struc-
ductal stricture and ductal dilatation.
tures. An AP view of the face is useful for visualization
l Supportive or nonsupportive retrograde bacterial infec-
of a parotid stone.
tions can occur, particularly when the obstruction is
l CT images maybe used for the detection of sialoliths
chronic.
and have a 10-fold greater sensitivity of plain-film radi-
ography for detecting calcifications. Treatment
Treatment l During the acute phase, therapy is primarily supportive.
l During the acute phase, therapy is primarily supportive. Standard care includes analgesics, hydration, antibiotics
l Standard care includes analgesics, hydration, antibiotics and antipyretics, as necessary.
and antipyretics, as necessary. l In pronounced exacerbations, surgical intervention for
l In pronounced exacerbations, surgical intervention for drainage or removal of the stone may be required.
drainage or removal of the stone maybe required. l Stones at or near the orifice of the duct can often be re-
l Stones at or near the orifice of the duct can often be moved transorally by milking the gland, but deeper
removed transorally by milking the gland, but deeper stones require removal with surgery or sialoendoscopy.
stones require removal with surgery or sialoendoscopy. l Lithotripsy and sialoendoscopy can be helpful as nonin-
l Lithotripsy and sialoendoscopy can be helpful as nonin- vasive or minimally invasive treatments for sialoliths.
vasive or minimally invasive treatments for sialoliths. l Ultrasonography will detect stones with diameter .2 mm
l Ultrasonography will detect stones (diameter .2 mm) and extra corporeal lithotripsy will fragment the stone,
and extracorporeal lithotripsy will fragment the stone, although repeat lithotripsy procedures may be needed.
although repeat lithotripsy procedures may be needed. Q.5. Bacterial sialadinitis.
Q.2. Indications of sialography. Ans.
Ans.
[Ref LE Q.5]
[Ref LE Q.2]
Q.6. Sialadenosis.
Q.3. Treatment of xerostomia.
Ans.
Ans.
l Sialadenosis is characterized by neoplastic noninflam-
[Ref LE Q.3] matory enlargement of the salivary gland.
Q.4. Clinical features and investigations of submandibu- l Enlargement is usually bilateral.
lar sialolithiasis. l May present as a course of recurrent painless enlarge-
ment of gland.
Ans. l The parotid gland is more frequently affected and more
Clinical presentation commonly affects the females.
l Patients with sialoliths most commonly present with a l Swelling of the preauricular portion of the parotid gland
history of acute, painful and intermittent swelling of the is the most common symptom, but retromandibular por-
submandibular salivary gland. tion of the gland may also be affected.
324 Quick Review Series for BDS 4th Year, Vol 2

l The condition is found in association with systemic Clinical presentation

diseases especially cirrhosis, diabetes, ovarian and thy- l Pleomorphic adenomas may occur at any age, but the
roid insufficiency, alcoholism and malnutrition. highest incidence is in the fourth to sixth decades of life.
l A characteristic alteration in the chemical constituents l These tumours appear as painless, firm and mobile
of saliva is a distinguishing feature of sialosis. Signifi- masses that rarely ulcerate the overlying skin or mucosa.
cant elevation of salivary potassium and concomitant l In the parotid gland, these neoplasms are slow growing
decrease in salivary sodium is observed. and usually occur in the posterior inferior aspect of the
superficial lobe.
Q.7. Sjögren syndrome. l In the submandibular glands, they present as well-
Ans. defined palpable masses.
l It is difficult to distinguish these tumours from malig-
l Sjögren syndrome is characterized by a triad of symp- nant neoplasms and indurated lymph nodes.
toms consisting of keratoconjunctivitis sicca, xerosto- l Intraorally, pleomorphic adenomas most often occur
mia and rheumatoid arthritis. on the palate, followed by the upper lip and buccal
l Primary Sjögren syndrome (sicca complex) – only dry mucosa.
eyes and dry mouth. l Pleomorphic adenomas can vary in size, depending on
l Secondary Sjögren syndrome – primary Sjögren 1 sys- the gland in which they are located.
temic lupus erythematosus, polyarteritis nodosa, poly- l When observed in situ, the tumours are encased in a
myositis, scleroderma or rheumatoid arthritis pseudocapsule and exhibit a lobulated appearance.
Clinical features Pathology
l Female predilection and age of occurrence is over l The gross appearance of pleomorphic adenoma is that
40 years. of a firm smooth mass within a pseudocapsule. The
l Typical features are dryness of mouth and eyes as a re- lesion demonstrates both epithelial and mesenchymal
sult of hypofunction of the salivary glands and lacrimal elements.
glands. l The epithelial cells make up a trabecular pattern that is
l Painful, burning sensation of the oral mucosa. contained within a stroma. The stroma may be chondroid,
l Other secretory glands involved in dryness are of the nose, myxoid, osteoid or fibroid. The presence of these differ-
larynx, pharynx, tracheobronchial tree and the vagina. ent elements accounts for the name pleomorphic tumour
l Sialochemistry studies have shown increased levels of or mixed tumour. Myoepithelial cells are also present in
IgA, potassium and sodium in the saliva. this tumour and add to its histopathologic complexity.
l In the sicca complex, there is parotid gland enlargement
that is usually absent in secondary Sjögren syndrome. Treatment
l Lymphadenopathy is twice common in the primary l Surgical removal with adequate margins is the principal
form of the disease. treatment.
l Because of its microscopic projections, this tumour
Treatment requires a wide resection to avoid recurrence.
l Symptomatic treatment. l A superficial parotidectomy is sufficient for the major-
l Keratoconjunctivitis is treated with ocular lubricants ity of these lesions.
such as artificial tears containing methylcellulose. l Lesions that occur in the submandibular gland are
l Xerostomia is treated by saliva substitutes. treated by the removal of the entire gland.
l Oral hygiene and fluoride application to prevent and treat
problems associated with dry mouth like dental caries. Q.9. Parotitis.
Ans.
Q.8. Pleomorphic adenoma.
[Ref LE Q.4]
Ans.
Q.10. Sialolithiasis.
l The pleomorphic adenoma is the most common tumour
of the salivary glands; overall, it accounts for about 60% Ans.
of all salivary gland tumours. [Same as SE Q.1]
l It is often called a mixed tumour because it consists of
both epithelial and mesenchymal elements. Q.11. Indications and contraindications of sialography.
l The majority of these tumours are found in the parotid
Ans.
glands, with less than 10% in the submandibular, sub-
lingual and minor salivary glands. [Same as SE Q.2]
Section | I Topic-Wise Solved Questions of Previous Years 325

SHORT NOTES: l Patients with xerostomia must be advised to frequently

sip water so as to prevent dryness and also to facilitate
Q.1. Mucocele. cleansing action.
Ans. l In some patients, use of artificial saliva substitutes play
a useful role.
i. Retention of mucous material due to trauma, involving
salivary glands and their ducts is known as mucocele. Q.4. Schirmer test.
ii. Clinical features: Ans.
l Occurs most frequently on the lower lip, can also occur

on the palate, cheek, tongue and floor of the mouth. l Schirmer test is done in patients with Sjögren syndrome
l The lesion may lie superficial or deep in the tissue. to assess the amount of secretions in eyes, by keeping a
iii. Histological features: filter paper in the lower conjunctival sac and finding out
l The cavity is not lined by epithelium and is therefore the extent of wetting.
not a true cyst. l Normal patients wet 15 mm of filter paper in 5 min,
l The wall is made of compressed fibrous connective whereas patients with Sjögren syndrome wet less than
tissue and fibroblasts. 5 mm.
iv. Treatment: Q.5. Treatment of ptyalism.
l Excision.
Ans.
Q.2. Mumps.
l Ptyalism is also called as sialorrhoea.
Ans.
Management of ptyalism
l Mumps is an acute contagious viral infection usually l In children less than 4 years no treatment recom-
seen in children, characterized by unilateral or bilateral mended.
parotid swelling. l In adults following treatment is advised:
l Incubation period of 2–3 weeks. i. Oral motor training and Biofeedback.
l It is transmitted through droplet infection. ii. Removal of local factors that is dental diseases and
nasal airway obstruction.
Clinical features
iii. Anticholinergic drugs can also be used.
l Disease preceded by headaches, chills, moderate fever,
iv. Surgery is a primary recommendation in individuals
vomiting and pain below the ear.
with cognitive delay and profuse drooling and sec-
l After this firm, rubbery or elastic swelling of the sali-
ondarily in those that have failed to nonsurgical
vary glands elevating the ear which lasts for 1 week.
therapy for a minimum of 6 months.
l Produces pain on mastication.
l The swelling reaches its maximum in 3 days and then Q.6. Sialolithiasis.
gradually subsides.
Ans.
l The papilla of the opening of the parotid duct is often
puffy and reddened. l The round, ovoid calcified structure present in the sali-
vary duct or gland is called a ‘sialolith’.
Treatment
l It often occurs due to inflammation, local irritants or
l Conservative.
drugs causing decreased saliva flow resulting in stasis
l Maintaining hydration.
and obstruction.
l Prevention is by means of vaccination.
l Calcareous deposits form around a central nidus in a
Q.3. Xerostomia. concentric manner.
l Structurally, it is hydroxyapatite crystals and octacal-
Ans.
cium phosphate.
l Xerostomia refers to dry mouth, where there is de- l Submandibular gland is more prone to get sialolithiasis
creased salivary flow. due to following reasons:
l In patients with xerostomia, an important complaint i. Long and tortuous course of submandibular salivary
may be halitosis. duct
l If the saliva flow is decreased the normal cleansing ii. Secretion against gravity
action of mouth does not take place. iii. Viscous secretion
l This results in accumulation of food debris and iv. More mineral content of saliva
plaque. l Symptoms associated are:
l Halitosis. i. Pain or swelling in the gland area
326 Quick Review Series for BDS 4th Year, Vol 2

ii. Long-term effects of like stasis of saliva can result in Treatment

infection, fibrosis and atrophy of the salivary gland. l Incisional biopsy to establish diagnosis.

l Larger and well-mineralized calcareous deposits are l Observation, because lesion is self-limiting and heals

visible in the radiograph as localized and well-defined spontaneously in 6–10 weeks.

radiopacity.
Q.9. Sjögren syndrome.
l The best radiograph for the visualization of sialolithia-
sis involving the submandibular salivary gland duct in Ans.
mandibular occlusal radiograph.
[Ref LE Q.1]
l Sialography demonstrates filling defect distal to the site
of obstruction. Q.10. What are the functions of saliva?
l Treatment:
i. Small calculi can be removed by manipulation or by Ans.
increasing the salivation by sucking a lemon, lead- Functions of saliva are as follows:
ing to expulsion of the stone. l Participates in digestion by providing fluid environment
ii. The larger stones need to be removed by surgical for solubilization of food and taste substance.
exposure. l Lubrication: keeps food moist.
Q.7. Sialography. l Protects teeth from dental caries.
l Dilutes hot or irritant substance and thus prevents
Ans. injury to mucus membrane.
i. Sialography is a technique in which ducts and ductules l Maintenance of neutral pH of oral cavity.
of the salivary glands are demonstrated radiographically l Helps in wound healing.
after a radiopaque liquid has been injected along them. l Immunoglobulins of saliva have antibacterial properties.
ii. Indications: Q.11. Sialosis.
l To demonstrate – calculi, strictures, recurrent paroti-

tis, tumours, etc. Ans.

l Salivary fistula
l Sialadenosis or sialosis refers to the noninflammatory,
l Relationship of salivary glands and ducts to sur-
nonneoplastic enlargement of salivary glands.
rounding structures
l It is usually a bilateral and painless enlargement.
iii. Contraindication:
l Prevalent in women.
l Active or recent infection of the gland
l Parotid glands are mostly affected.
iv. Advantage:
l Responsible factors:
l Visualizes ductal anatomy/blockage
i. Drug induced sialosis – caused by iodine containing
v. Disadvantage:
drugs, phenylbutazone, etc.
l Invasive; requires iodine-containing dye; no quantifi-
ii. Hormonal factors
cation
iii. Malnutrition
Q.8. Sialometaplasia. iv. Alcoholism
v. Dehydration
Ans.
Q.12. Ptyalism.
Necrotising sialometaplasia is a non-neoplastic inflam-
matory condition of the salivary glands. Ans.
Aetiology
l Ptyalism is also called as hyper salivation.
l In most cases, it occurs spontaneously.
l Causes of ptyalism are as follows:
l Other causes may be: trauma, radiation therapy,
i. Various forms of stomatitis.
surgery, tobacco use or vascular ischaemia.
ii. Effects of drugs that stimulate the parasympathetic
Clinical appearance
nervous system resulting increase in salivary flow.
l Usually involves the minor salivary glands, particu-
iii. Malignancy of the oral cavity.
larly the ones in the palate
l Junction of hard and soft palates Q.13. Ranula.
l Unilateral or bilateral
Ans.
l Swelling, erythema, tenderness, followed by ulcer-

ation Ranula means swollen abdomen of frog.

Clinical differential diagnosis i. This is a type of retention cyst involving submandibular
Squamous cell carcinoma, salivary gland tumour, and sublingual glands and occurring in the floor of the
chronic infection and traumatic ulcer. mouth (more often sublingual gland).
Section | I Topic-Wise Solved Questions of Previous Years 327

ii. Aetiology – trauma ii. Secretion against gravity

iii. Clinical findings: iii. Viscous secretion
l Slow-growing, painless swelling on one side in the iv. More mineral content of saliva
floor of the mouth.
Q.15. Necrotizing sialometaplasia.
l Tongue is pushed up.

iv. Treatment: Ans.

l Complete surgical excision along with the whole of
[Same as SN Q.8]
the sublingual salivary gland.
Q.16. Sialadenosis.
Q.14. Why sialolithiasis is more common in subman-
dibular gland? Ans.
Ans. [Same as SN Q.11]
l Submandibular gland is more prone to get sialolithiasis Q.17. Sialorrhoea.
due to following reasons:
Ans.
i. Long and tortuous course of submandibular salivary
duct [Ref LE Q.3]

Topic 8
Disorders of TMJ and MPDS

COMMONLY ASKED QUESTIONS

LONG ESSAYS:
1. Describe TMJ disorders in detail.
2. Describe in detail MPDS.
3. What conditions may produce trismus?
4. Describe in detail TMJ ankylosis.
5. Describe radiographic techniques to diagnose temporomandibular joint diseases and disorders.
6. Articular disc disorders of temporomandibular joint.
7. Classify temporomandibular disorders. Discuss the management of TMJ arthritis. [Same as LE Q.1]
8. Write clinical features and management of MPDS. [Same as LE Q.2]
9. Management of MPDS. [Same as LE Q.2]
10. Enumerate the causes of trismus. Discuss in detail. [Same as LE Q.3]

SHORT ESSAYS:
1. Subluxation of TMJ.
2. Myofacial pain dysfunction syndrome (MPDS). [Ref LE Q.2]
3. Clinical features and management of degenerative arthritis of TMJ.
4. Internal derangement of temporomandibular joint.
5. Bruxism.
6. Clinical features of TMJ subluxation. [Same as SE Q.1]
7. Treatment plan for MPDS. [Same as SE Q.2]
8. Aetiology of MPDS. [Same as SE Q.2]
328 Quick Review Series for BDS 4th Year, Vol 2

SHORT NOTES:
1. Four causes of trismus.
2. Subluxation of TMJ – aetiology. [Ref SE Q.1]
3. Myositis ossificans.
4. Temporomandibular joint ankylosis.
5. How will you differentiate true ankyloses from pseudoankylosis of temporomandibular joint? [Ref LE Q.4]
6. Mention the staging of internal derangement of temporomandibular joint. [Ref SE Q.4]
7. Define myofunctional pain dysfunction syndrome.
8. Enumerate the temporomandibular joint views.
9. Drugs to relieve muscular spasm.
10. Define trismus. [Same as SN Q.1]

SOLVED ANSWERS
LONG ESSAYS: lCondylar hypoplasia
lAplasia
Q.1. Describe TMJ disorders in detail. Acquired disorders
Ans. l Neoplasms

l Fractures
Classification of temporomandibular disorders is as Diagnostic classification of temporomandibular
follows: disorders
I. Disorders of the Temporomandibular joint (TMJ)
Deviation in form
l Articular surface defects Diagnostic category Diagnoses
l Disc thinning and perforation Cranial bones (includ- Congenital and developmental disor-
l Adherence and adhesions ing the mandible) ders like hemifacial microsomia
l Disc displacement Temporomandibular Arthritides-like osteoarthritis ankylo-
l Disc displacement with reduction joint disorders sis can be fibrous or bony
l Disc displacement without reduction
Masticatory-muscle Myofascial pain dysfunction syndrome
Displacement of disc–condyle complex disorders Myositis
l Hypermobility

l Dislocation

Inflammatory conditions Degenerative joint disease (osteoarthritis)

l Capsulitis and synovitis l It is also known as osteoarthrosis, osteoarthritis

l Retrodiscitis and degenerative arthritis.

Degenerative diseases Aetiology
l Osteoarthrosis l It is primarily a disorder of articular cartilage

l Osteoarthritis and subchondral bone, with secondary inflam-

l Juvenile idiopathic arthritis mation of the synovial membrane.
l Polyarthritides l The process starts in loaded articular cartilage,

Ankylosis later it thins and clefts (fibrillation) and then

II. Masticatory muscle disorders breaks away during joint activity leading to
Acute conditions sclerosis of underlying bone, subcondylar cysts
l Reflex muscle splinting and osteophyte formation. It is essentially a re-
l Myositis sponse of the joint to chronic microtrauma or
l Muscle spasm pressure.
Chronic conditions l The microtrauma could be due to continuous

l Myofacial pain abrasion of the articular surfaces as in natural

l Hypertrophy wear associated with age or as a result of in-
l Fibromyalgia creased loading forces possibly related to chronic
III. Congenital, developmental and acquired disorders parafunctional activity.
of condylar process l However, the fibrous tissue covering is preserved

Congenital and developmental disorders due to remodelling and the recovery process in
l Condylar hyperplasia osteoarthrosis and osteoarthritis.
Section | I Topic-Wise Solved Questions of Previous Years 329

l Degenerative joint disease can be either primary infiltrate and subsequent formation of granula-
or secondary even though they may present tion tissue.
similar histopathologic pattern. l The cellular infiltrate spreads from the articular

l Primary degenerative joint disease is usually of surfaces eventually to cause an erosion of the
unknown origin, but sometimes genetic factors underlying bone.
play an important role. Clinical manifestations
l Trauma, congenital dysplasia or metabolic dis- l The rheumatoid arthritis (RA) usually involves

ease may be the cause for secondary degenera- the TMJ bilaterally.
tive disease. l The most common symptoms are mandibular

Clinical manifestations opening and joint pain. Pain may be due to the
l It is most commonly seen in people above the early acute phases of the disease. Other symp-
age of 50 years. toms include morning stiffness, joint sounds and
l Patients will have unilateral pain directly over tenderness and swelling over the joint area.
the affected condyle, limitation of mandibular l The symptoms are usually transient in nature

opening, crepitus and a feeling of stiffness after only in some cases there will be disability.
a period of inactivity. l Common findings are pain on palpation of the

l Tenderness and crepitus on intra-auricular and joints and limitation of opening. Crepitus also
pretragus palpation with deviation of the mandi- may be evident.
ble to the painful side is detected on examination. l Micrognathia and an anterior open bite are com-

l It is detected accidentally on radiographic ex- monly seen in patients with juvenile RA.
amination and may not be responsible for facial l Radiographic changes in the TMJ associated

pain symptoms or TMJ dysfunction. with RA may include a narrow joint space,
l When the defects are confined to articular soft destructive lesions of the condyle and limited
tissue, the symptoms may not be diagnosed by condylar movement.
conventional radiography. MRI helps to detect l There is little evidence of marginal proliferation

soft tissue changes better. or other reparative activity in RA in contrast

l Radiographic findings may include narrowing to the radiographic changes often observed in
of the joint space, irregular joint space, flattening degenerative joint disease.
of the articular surfaces, osteophytic formation, l High-resolution CT of TMJ in an RA patient

anterior lipping of the condyle and the presence will show erosions of the condyle and glenoid
of Ely cysts. fossae that cannot be seen by conventional radi-
l These can be seen best on tomograms or CT ography.
scans and MRI images. Treatment
Treatment l It is treated by anti-inflammatory drugs.

l Conservative treatment is a treatment of choice l The patient should be placed on a soft diet dur-

and should be considered for 6 months to 1 year ing acute exacerbation of the disease process,
before considering surgery, unless severe pain or but intermaxillary fixation is to be avoided be-
dysfunction persists after an adequate trial of cause of the risk of fibrous ankylosis.
nonsurgical therapy. l Use of a flat plane occlusal appliance may be

l Conservative therapy involves nonsteroidal anti- helpful, particularly if parafunctional habits are
inflammatory medications, heat application, soft exacerbating the symptoms.
diet, rest and occlusal splints that allow free l An exercise programme should be started after

movement of the mandible. the acute symptoms subside to help in the man-
l When TMJ pain or significant loss of function dibular movements.
persists and when distinct radiographic evidence l When patients have severe symptoms, the use of

of degenerative joint changes exists, surgery is intra-articular steroids should be considered.

indicated. Prostheses appear to decrease symptoms in fully
l An arthroplasty, which limits surgery to the or partially edentulous patients.
removal of osteophytes and erosive areas, is l Surgical treatment of the joints, including place-

commonly performed. Patients with advanced ment of prosthetic joints, is indicated in patients
degenerative changes of the TMJ are treated who have severe functional impairment or intracta-
with artificial TMJs. ble pain not successfully managed by other means.
Rheumatoid arthritis Psoriatic arthritis
l The disease process starts as a vasculitis of the l Psoriatic arthritis (PA) is an erosive polyarthritis

synovial membrane progressing to chronic in- occurring in patients with a negative rheumatoid
flammation marked by an intense round cell factor who have psoriatic skin lesions.
330 Quick Review Series for BDS 4th Year, Vol 2

l The skin lesions start few years before the joint l Diagnosis is made by detection of bacteria on
lesions. grams stain and culture of aspirated joint fluid.
l The cutaneous and joint manifestations of the l Serious sequelae include osteomyelitis of the

disease may be traced to the same immunologic temporal bone, brain abscess and ankylosis.
abnormality. l Facial asymmetry may accompany septic arthri-

l TMJ involvement is more common. tis of the TMJ, especially in children. The pri-
Clinical manifestations mary sources of these infections were the mid-
l The signs and symptoms are likely to be unilat- dle ear, teeth and the hematologic spread of
eral and they are more likely that of RA. gonorrhoea.
l Limitation of mandibular movement, deviation l Evaluation of patients with suspected septic ar-

to the side of the pain and tenderness directly thritis must include a review of signs and symp-
over the joint may be observed on examination. toms of gonorrhoea, such as purulent urethral
l Erosion of the condyle and glenoid fossae rather discharge or dysuria.
than proliferation is detected radiographically. Treatment
l Coronal CT is particularly useful in showing l Treatment of septic arthritis of the TMJ involves

TMJ changes of PA. surgical drainage, joint irrigation and 4–6 weeks
Treatment of antibiotics.
l The management of PA gives emphasis on phys- Gout and pseudogout
ical therapy and NSAIDS that control both pain l Gouty arthritis is caused by long-term elevated

and inflammation in many cases. serum urate levels, which results in the deposi-
l For patients who do not respond to conservative tion of crystals in a joint, triggering an acute
treatment of immunosuppressive drugs, particu- inflammatory response.
larly methotrexates, are used. l Acute pain in a single joint, i.e. monoarticular

l Only when there is intractable TMJ pain or arthritis, is the characteristic clinical manifesta-
disabling limitation of mandibular movement, tion of gouty arthritis.
surgery is indicated. l Gouty arthritis appears to be very rare; an attack

l Arthroplasty or condylectomy with placement of gouty arthritis is most accurately diagnosed

of costochondral grafts has been performed by examination of aspirated synovial fluid from
successfully. the involved joint by polarized light microscopy.
l Surgery may be complicated by psoriasis form- l The detection of monosodium urate crystals

ing in the surgical scar (Koebner effect). confirms the diagnosis of gout.
Septic arthritis l An acute attack of gout can be treated with col-

l Septic arthritis of the TMJ occurs in patients with chicine, NSAIDs or the intra-articular injection
previously existing joint disease such as RA. of corticosteroids.
l Septic arthritis is also seen patients receiving l The deposition of other crystals, such as calcium

immunosuppressive drugs or long-term cortico- pyrophosphate dihydrate (CPPD) or calcium

steroids. hydroxyapatite, may cause a syndrome that
l The infection of the TMJ may result from blood- resembles gout and that has been referred to as
borne bacterial infection or through infection pseudogout.
from adjacent sites such as the middle ear, max- l This disorder most frequently affects elderly

illary molars and parotid gland. individuals, with the involvement of the TMJ.
l Gonococci are the primary blood=borne agents l Colchicine or arthrocentesis is used for success-

causing septic arthritis in a previously normal TMJ. ful treatment of pseudogout of TMJ.
Clinical symptoms
l Symptoms include trismus, deviation of the
Q.2. Describe in detail MPDS.
mandible to the affected side, severe pain on Ans.
movement and an inability to occlude the teeth,
owing to the presence of inflammation in the
[SE Q.2]
joint space.
l Examination reveals redness and swelling in the l {When muscle spasm develops in one or more mastica-
region of the involved joint. tory muscles, dysfunction as well as pain occurs and the
l Septic arthritis can be differentiated from more condition usually is designated as MPDS.
common types of TMJ disorders by large tender l The muscles of mastication, the tongue muscles and
cervical lymph nodes on the side of the infection. the strap muscle of the neck function as a unit and that
Section | I Topic-Wise Solved Questions of Previous Years 331

dysfunction in one group of muscles is frequently as- Cardinal signs and symptoms outlined by Laskin
sociated with altered tonus and symptoms of ‘tension’ in Positive characteristics emphasized by Laskin
the other related groups. l Unilateral, dull pain in the ear or preauricular region
that is commonly worse on awakening.
Aetiology
l Tenderness of one or more muscles of mastication in
Occlusal status
palpation.
l Periodontal point of view: It is a self-protecting and
l Clicking or popping noise in the TMJ.
modifications occur in the pathway of closure to avoid
l Limitation or deviation of the mandible on opening.
and potentially damaging or painful contacts.
l Tooth muscle theory: In coordination and spasm of Negative characteristics emphasized by Laskin
some muscles of mastication is caused due to occlusal l Absence of clinical, radiographic or biochemical evi-
interferences and altered proprioceptive feedback. dence in TMJ.
l Prosthetic reasons: Decreased vertical dimension due l Lack of tenderness in TMJ area on palpation through
to overclosure caused by bilateral loss of molar teeth or external auditory meatus.
increased VD in partial and complete dentures lead to
TMJ dysfunction. Signs
l Orthodontic conditions: Malocclusion and discrepancies l Restriction of opening and protrusion by deflection of
in occlusion or MPDS can lead to TMJ dysfunction. mandibular incisal path.

Psycho-physiologic theory Symptoms

The following are the reasons for spasm due to over l Masticatory pain.
extension of muscles: l Difficulty in chewing.
l Faulty dental restorations or FPD/RPD encroaching l Restricted mandibular excursion.
intra maxillary space l Mandibular movements are with noise on rubbing,
l Bilateral loss of posterior teeth grinding, clicking and with popping snapping sounds.
l Parafunctional habits clenching and grinding, bruxism} l Soreness of muscles (myofacial trigger zones).
l Parafunctional habits, e.g. bruxism.
Pathogenesis l Acute malocclusion with abnormal teeth relationship.
Energy released during muscle contraction Treatment of MPDS
g l Treatment of MPDS should include the treatment of
emotional as well as physical components of the disorder.
Formation and accumulation of lactic acid l In acute stages, conservative noninvasive treatment is
g usually successful in alleviating the pain and dysfunction.
l Treatment of MPDS should begin with strong doctor–
Changes in osmolality with decreased p H patient relationship by showing concern and empathy
g when reviewing the history of patient problems.
l Patient should be told that they are not suffering from
Muscle receptors prone to impulse excitation more serious, life-threatening disorder like malignancy.
with impairment of their critical firing levels
Conservative treatment and recommendations
g
Conservative treatment and recommendations at the
Decreased p H and lactic acid causes infusion initial visit should include the following:
and effusion of histamine, bradykinin and serotonin l Limitation of parafunctional habits: Patient should attempt
and other acines into area to limit parafunctional habits by becoming more aware of
clenching and grinding of the teeth during the day.
g
l Hot moist packs: Warm to hot, moist compresses should
Pathologic muscular derangement ‘trigger zones’ be applied over the involved muscles for 15–20 min
carry the hypersensitive from where impulses can three times a day.
bombard CNS giving rise to referred pain l Soft diet: A relatively soft diet should be advised and
limit wide opening of mouth while eating.
Joint status l Pharmacotherapy or drugs to be prescribed: Aspirin or
l Hypermobility. NSAID should be recommended for analgesic and anti-
l Sleep angulation of articular eminence. inflammatory actions.
l Degenerative changes secondary to parafunctional l Breaking up stress–pain–stress cycle with LA injections
habits. without epinephrine: Injecting the trigger points of
332 Quick Review Series for BDS 4th Year, Vol 2

muscles that are in spasm with a local anaesthetic not l The release of endorphins may be involved in the
containing epinephrine is often beneficial in breaking pain relief as with acupuncture.
up the spasm and in disrupting the stress pain stress ii. Hypnosis:
cycle. l Used as an adjunct to other treatments.

l Ethylchloride spray on the skin: The skin overlying the iii. Psychological counselling and antidepressant drugs:
affected muscles can be sprayed with ethylchloride or l They are indicated in the treatment of MPDS if

fluoromethane or ultrasound can be used in an attempt anxiety or neurotic behaviour appears to be signifi-
to relieve muscle spasms. The effectiveness of local cant component of facial pain.
anaesthetic injections, ethylchloride refrigerant spray
and ultrasound in allowing patients to open wide with- [SE Q.2]
out pain may be noted immediately following treatment. {Treatment of MPDS is summarized as follows:
l Jaw exercises: Isometric exercises are often beneficial,
for example, placing the tip of the tongue in the back of
the palate and then opening and closing may help in Treatment
retraining spastic muscles. component Description
l Diazepam: Diazepam 2 mg/3 times daily and 5 mg at bed
Education The diagnosis and treatment should be
time during a 2-week trial period is commonly advocated explained to the patient
for its anxiety reducing and muscle relaxing properties. Encourage the patient to take self-care with
reassurance about the good prognosis
Occlusal splints
l They should be fabricated if pain and dysfunction per- Self-care Educate the patient towards elimination of
oral habits (e.g. tooth clenching and chew-
sist without improvement following the treatment and
ing gum)
recommendations of the initial visit.
l Splints most often used are Physical therapy Education regarding biomechanics of jaw,
neck and head posture
 i. Maxillary night guard Passive modalities and posture therapy
ii. A Hawley appliance with an anterior platform with general stretching and exercise is
l Benefits derived from occlusal splints have most com- advised
monly attributed to greater freedom in mandibular Intraoral appli- Cover all the teeth in the arch with appli-
movement and to an increase in muscle balance. ance therapy ance placed on them
Simultaneous contact against opposing teeth
Biofeedback should be achieved
l It is helpful when the primary reason for the failure in Adjust to comfortable position avoiding
initial treatment appears to be the inability to control continuous use
stress and anxiety. Pharmacotherapy NSAIDs, acetaminophen, muscle relaxants,
l Biofeedback is a valuable therapeutic aid that permits antianxiety agents, tricyclic antidepressants
patients to treat themselves while decreasing their de- and clonazepam
pendence on therapists as it provides them with infor- Behavioural/ Relaxation therapy such as hypnosis is
mation concerning bodily functions that are usually not relaxation preferred}
discernible or controllable. techniques

Nerve stimulation
l Transcutaneous electrical nerve stimulation (TENS)
treatment appears to be more effective in alleviating Q.3. What conditions may produce trismus?
chronic pain than acute pain.
Ans.
l The mode of action of TENS in reducing pain is uncer-
tain but it is attributed to neurologic, physiologic, phar- The word trismus is derived from the Greek word ‘trismus’
macologic and psychologic effects. meaning gnashing and is defined as a prolonged, tetanic
l The pharmacologic action of TENS may involve the spasm of the jaw muscles by which normal opening of the
stimulated release of endorphins, which are endogenous mouth is restricted (locked jaw).
morphine like substances.
Aetiology
l TENS also has a placebo effect in relieving pain.
i. Congenital
Other treatments l Trismus-pseudocamptodactyly syndrome

i. Acupuncture: l Craniocarpotarsal dysplasia

l Used in treatment of chronic MPDS here brief in- l Hemifacial microsomia

tense stimulation is applied designated points using l Fibrodysplasia ossificans progressiva

needles with or without electrical current. l Birth injury

Section | I Topic-Wise Solved Questions of Previous Years 333

ii. Traumatic (acute) l Physiotherapy

l Fractures of mandible, zygomatic or temporal bones l Heat application
l Haematomas in the joint or muscle of mastication l Warm saline gargles
l Injury due to local anaesthetic injection l Forceful mouth opening with gag
l Anterior dislocated meniscus
Q.4. Describe in detail TMJ ankylosis.
l Postsurgical (e.g. third molar removal and TMJ

surgery) Ans.
iii. Neoplastic (benign)
l Mesenchymal tumours of the TMJ and surrounding {SN Q.5}
structures (e.g. osteochondroma)
l Enlargement of the coronoid process of the mandible
l TMJ ankylosis is an intra-articular condition where
iv. Neoplastic (malignant) there is a fusion between the bony surfaces of the
l Chondrosarcoma
joint, the condyle and the glenoid fossa. The term
l Osteosarcoma
‘ankylosis’ is derived from the Greek word that means
l Tumours of the oropharynx (Trotter syndrome)
stiffening of a joint as a result of a disease process.
l Metastatic disease of the mandible and infratempo-
l Ankylosis of the mandible with immobility of the
ral fossa joint may be of an osseous, fibro-osseous or carti-
v. Neuromuscular disorders laginous variety.
l Parkinson disease
l Ankylosis must be distinguished from its counterpart
vi. Reactive (acute) pseudoankylosis.
l Septic arthritis
l In pseudoankylosis, hypomobility of the joint occurs
l Tetanus
due to coronoid hyperplasia or due to fibrous adhesions
l Osteomyelitis of the mandible and temporal bone
between the coronoid and tuberosity of the maxilla or
l Abscesses of the submasseteric, lateral pharyngeal,
zygoma as in ‘V-shaped’ fracture of the zygomatic arch
pterygomandibular, submandibular and temporal impinging on coronoid leading to fibrous or bony
spaces union are also examples of pseudoankylosis.
l Tonsillitis and peritonsillar abscess
l In pseudoankylosis, even though jaw movement is
l Parotid abscess
restricted as in bony ankylosis, the pathology is extra-
l Mumps
articular in these cases.
l Cancrum oris

vii. Reactive (chronic) Aetiopathology

l TMJ ankylosis (fibrous and bony) I. Tauma
l Degenerative joint disease l Most cases of ankylosis result from condylar injuries

l Rheumatoid arthritis sustained before 10 years of age.

l Systemic sclerosis l A unique pattern of condylar fractures is seen in

l Submucous fibrosis children. Condylar cortical bone in children is thin

l Radiation therapy with a broad condylar neck and rich subarticular
l Myofascial pain dysfunction (MPDS) interconnecting vascular plexus. An intracapsular
l Ankylosing spondylitis fracture leads to combination and haemarthrosis of
l Myositis ossificans traumatica the condylar head. This sort of intracapsular burst
viii. Psychogenic fracture is called ‘mushroom fracture’.
l Hysterical trismus l It results in the organization of a fibro-osseous mass

l Hyperventilation syndrome in a highly osteogenic environment. Moreover, im-

ix. Drug induced mobility leads to ossification and consolidation of
l Extrapyramidal reaction (facial dyskinesia) the mass, resulting in ankylosis.
l Strychnine poisoning l Ankylosis may also occur in trauma sustained during

forceps delivery.
Clinical examination Laskin (1978) had outlined various factors that may be
l Decreased interincisal distance usually normal is 3–4 cm. implicated in the aetiology of ankylosis following
l Extrusive and protrusive movements (normal .6 cm). trauma, they are as follows:
l Facial swelling or asymmetry. a. Age of the patient
Treatment l Younger patients have significantly higher osteo-

l Treatment of underlying cause genic potential and rapidity of repair. Moreover,

l Anti-inflammatory drugs the articular capsule is not as well developed in
l Muscle relaxants younger patients, thus permitting easier condylar
334 Quick Review Series for BDS 4th Year, Vol 2

displacement out of the fossa and thereby damage in disc followed by repair leading to ankylosis. De-
to the disc ultimately, there is a greater tendency struction of the disc leads to bony contact between the
for prolonged self-imposed immobilization of the condyle and glenoid fossa.
mandible post-traumatically in children.
b. Type of fracture Classification of ankylosis
l The condyle in children has a thinner cortex along Classification of ankylosis according to tissues involved
with a thick neck, which predisposes them to a and extent:
higher proportion of intracapsular comminuted l True ankylosis or pseudoankylosis
fractures. In contrast, adults have a thinner condy- l Extra-articular or intra-articular
lar neck which usually fractures at the neck, thus l Fibrous, bony or fibro-osseous
sparing the head of the condyle within the capsule. l Unilateral or bilateral
c. Damage to articular disc l Partial or complete
l The direct contact between a comminuted con-
Classification of ankylosis by Topazian (1966):
dyle and the glenoid fossa either from a displaced l Type I: Fibrous adhesions in or around the joint with
or torn meniscus is the key factor in the develop- restricted condylar gliding.
ment of ankylosis. l Type II: Formation of a bony bridge between the
d. Period of immobilization condyle and glenoid fossa.
l Prolonged mechanical immobilization or muscle
l Type III: Condylar neck is ankylosed to the fossa
splinting can promote osteogenesis and consolida- completely.
tion to set in an injured condyle. Total immobility
between articular surfaces after condylar injury Grading of TMJ ankylosis
leads to a bony type of fusion, whereas some Sawhney (1986) graded TMJ ankylosis into four
movement leads to a fibrous type of union. types:
II. Local infections l Type I: Flattening or deformity of condyle with little
l The source of infection is contiguous, from adja- joint space on radiograph. There is minimal bony fu-
cent structures. sion, but extensive fibrous adhesions around joint. Some
l For example, otitis media, mastoiditis, osteomyeli- movement is possible.
tis of temporal bone, parotid abscess, infratemporal l Type II: Bony fusion on the outer edge of articular
or submasseteric space or parapharyngeal infec- surface, but no fusion on the deeper aspect of the joint.
tions, furuncle and actinomycosis. l Type III: A bridge of bone exists between the ramus
III. Systemic conditions and zygomatic arch. The upper articular surface and the
l In systemic conditions like tuberculosis, meningitis, articular disc on the deeper aspect are still intact. Medi-
pharyngitis, tonsillitis, rubella, varicella, scarlet fe- ally, a displaced atrophic condyle still exists and which
ver, gonococcal arthritis and ankylosing spondylitis, is functional. Type III ankylosis results from a fracture-
the route of spread of infection is haematogenous. displaced condyle, compared to the crushing types of
l The local and systemic infections may pass along as condylar injuries as in types I and II.
septic arthritis, which may not always cause ankylo- l Type IV: Total TMJ obliteration between ramus and
sis. Staphylococcus species, Streptococcus species, skull by large bony mass. It is the most common type.
Haemophilus influenza and Neisseria gonorrhoea Clinical features
are the most likely causes of septic arthritis. The The clinical features of ankylosis depend on:
infection may take either the haematogenous, con- i. Type of ankylosis
tiguous or by direct inoculation. The synovium with a. Unilateral vs. bilateral
its high vascularity and lack of a limiting basement b. Bony vs. fibrous
membrane is vulnerable to infection. ii. Extent of joint involvement
IV. Arthritis/inflammatory conditions iii. Age of onset and duration of ankylosis: The deformity
l About 50% cases in juvenile rheumatoid arthritis will be severe if it occurs before the age of 5 years.
(Still disease) also have TMJ involvement along
with polyarthritis. Osteoarthritis may also lead to Unilateral ankylosis
ankylosis. Clinical features of unilateral ankylosis are as follows:
V. Neoplasms Facial features
l Sarcoma, osteoma and chondroma may also result in i. Obvious facial asymmetry.
ankylosed joint. The pathogenesis of ankylosis is ii. Receded chin with hypoplastic mandible on affected
generally the same in all the nontraumatic conditions: side, resulting in deviation of chin and mandible to-
degenerative, destructive and inflammatory changes wards affected side.
Section | I Topic-Wise Solved Questions of Previous Years 335

iii. Unilateral vertical deficiency on the affected side. l Other features include deepening of the antegonial
iv. Roundness/fullness on affected side; foreshortened notch and compensatory elongation of the coronoid
mandible, flatness and elongation on normal side as it process on the affected side.
grows towards the affected side.
Management
v. Loss of the normal bilateral symmetrical divergence
l The goals of management should include restoration of
from the mental region towards the angle.
mouth opening and joint function, facilitation of condy-
vi. The lower border of the mandible on the affected side
lar growth, correction of facial profile and to relieve
has a concavity that ends in a well-defined antegonial
upper airway obstruction.
notch.
l Surgical correction of ankylosis is best achieved by
vii. Markedly elongated coronoid process.
condylectomy, gap arthroplasty, coronoidectomy, in-
Intraoral features terpositional arthroplasty with autogenous or allo-
i. Occlusal cant with deviation of maxillary and man- plastic grafts and secondary procedures such as
dibular midlines towards affected side. orthognathic surgery and distraction osteogenesis.
ii. Angle’s class II malocclusion present on the Surgical correction should be followed by active
affected side with unilateral cross bite on the opposite physiotherapy.
side. l When ankylosis is left untreated it may result in abnormal
iii. The mouth opening is restricted; amount of opening facial growth and development, speech defects, nutri-
depends upon degree of ankylosis. tional impairment, respiratory distress syndrome, con-
ditions related to poor oral hygiene and psychological
Bilateral ankylosis
impact on the patient.
Clinical features of bilateral ankylosis are as follows:
Facial features Q.5. Describe radiographic techniques to diagnose tem-
i. Symmetrical defect. poromandibular joint diseases and disorders.
ii. Retrognathia mandible with a short ramus and a small
Ans.
body.
iii. Often microgenia, small chin. l The purpose of an imaging assessment of the TMJ is to
iv. ‘Bird-face deformity’ or ‘Andy Gump’ facies. depict clinically suspected disorders of the joint.
v. Convex profile. l The objective of TMJ imaging is to visualize both the
vi. Relatively short hyomental distance with tight supra- hard and soft tissue structures of the TMJ.
hyoid musculature. Common imaging modalities to study hard and soft
vii. Cervicomental angle may be reduced or completely tissues of TMJ are as follows:
absent.
viii. Obstructive sleep apnoea may be present due to
oropharyngeal airway narrowing in cephalocaudal, Hard tissue imaging Soft tissue imaging
anteroposterior and transverse directions. i. Orthopantomograph i. Arthrography
ii. Plain film TMJ views ii. Magnetic resonance
Intraoral features l Transcranial projection imaging
i. Mouth opening would be less than 5 mm or may be nil l Transpharyngeal projection
at times. l Transorbital projection
ii. Generally a class II malocclusion, although class I l Submentovertex view
iii. Conventional
occlusion may also be seen.
iv. Computed tomography (CT)
iii. Incompetent lips and proclined lower anteriors. v. Radionuclide imaging
iv. Open bite with protrusion of both upper and lower
anteriors resulting from the protrusive action of tongue
because of decreased tongue space. l For decades plain film radiography, mainly a transcra-
v. Severe crowding, multiple impacted teeth with oral nial projection, was the most commonly used imaging
health maintenance problems, leading to caries and technique.
periodontal problems.
Hard tissue imaging
Radiographic features Orthopantomography
l In fibrous ankylosis, joint may appear normal or the l Panoramic radiography has been advocated by many
articulating surfaces may be irregular. The joint space is authors as a good imaging modality and is routinely
markedly decreased. used to image the hard tissues of the maxillofacial re-
l In bony ankylosis, the joint space may be obliterated, gion and is a modality readily accessible to the majority
completely or partly by an osseous bridge. of oral healthcare specialists.
336 Quick Review Series for BDS 4th Year, Vol 2

l In most dental settings, a panoramic radiograph can be a perpendicular relationship with the surface of the cas-
obtained and interpreted within minutes at the time of sette as determined from the condylar angulation seen
clinical examination. on a submentovertex projection.
l Orthopantomography is used as a screening projection l The lack of visualization of the soft tissues of the joint
and it is the imaging of choice when it comes to viewing is one of the major disadvantages.
the teeth and the adjacent structures. l Conventional tomography has been used extensively to
l Changes in the bony structures of the TMJ can be inter- evaluate the osseous components of the TMJ as well as
preted only on the lateral slope and central parts of the a greater number of structural changes as compared
condyle because of the oblique orientation of the beam with the oblique trans cranial projection
with respect to the long axis of the condyle. There is l Tomography represents the anatomic structures better
superimposition by the base of the skull and zygomatic than transcranial radiography; it also provides accu-
arch. rate condylar position within the fossa than transcra-
l Only obvious erosions, sclerosis and osteophytes of the nial radiography; however, it cannot predict proper
condyle can be seen. disc position.
l Special TMJ techniques provided by some TMJ tech- l Tomography has little effect on the diagnosis or treat-
niques permit placement of opened and closed views of ment plan of patients with TMJ disorders when it comes
both condyles on a single film. to diagnosis of osseous pathosis.
l Recent panoramic machines have specific TMJ pro-
Computed tomography
grammes but are of limited usefulness due to its disadvan-
l In computed tomography (CT), thin sections of the
tages. Furthermore, changes in the body of the cortical
structures of interest can be made in several planes and
bone may be difficult to visualize in the panoramic view
viewed under varying conditions that highlight either
as the buccal and lingual cortical plates may mask any
hard or soft tissues.
internal changes.
l This technique overcomes the distortion or superimposi-
Plain film radiography tion of plain film radiography and the blurring of struc-
l Plain films are made with a stationary X-ray source and tures outside the image layer of conventional tomogra-
film. phy, but suffers from volume averaging artefacts that are
l Plain films of the TMJ depict only the mineralized parts most likely on small curved cortical bone surfaces.
of the joint but do not reveal nonmineralized cartilage l CT can also provide three-dimensional reconstructed
and soft tissues. images from the original data.
l Superimposition of adjacent anatomic structures is one l CT examinations are used for the diagnosis of bony
of the major disadvantages and although imaging abnormalities including fractures, dislocations, arthritis,
the joint from multiple angles helps overcome this ankylosis and neoplasia.
limitation. l They are also useful in the evaluation of the effects
l The projections taken are oblique transcranial, the trans- of polytetrafluoroethylene (PTFE) and silicon sheet
orbital and the submentovertex views. implants.
l Each of these is projected approximately 90° to the l Cadaver and clinical studies have indicated that CT ex-
other two. The transpharyngeal view is sometimes used aminations produce excellent images for the evaluation
as an alternative to the transcranial projection. of osseous morphology.
l Disc position cannot be determined from any of these
Soft tissue imaging
techniques.
Arthrography
Conventional tomography l Arthrography involves injection of a radiopaque con-
l In tomography, the images of structures outside a prede- trast material into the joint spaces. The space occupied
termined anatomic layer containing the pertinent struc- by the disc can then be visualized lying between the
tures are blurred as the X-ray source and the film are layers of contrast material.
continuously moving.
Types of arthrography
l The major advantage of tomography is the ability to
 i. Single contrast arthrography
provide multiple thin sections through the region of
ii. Double contrast arthrography
interest without superimposition.
l Various tomographic angles and motions, such as lin-  i. Single contrast arthrography:
ear, circular, spiral and hypocycloidal affect the image l One of the more commonly used approaches in-

quality. volves injection of contrast material into the lower

l Distortion is minimized due to individualized head joint spaces, referred to as lower joint space or single
positioning by placing the long axis of the condyle into contrast arthrography.
Section | I Topic-Wise Solved Questions of Previous Years 337

l Perforations of the disc or posterior attachment are l Spot radiographs are obtained during the fluoroscopic
demonstrated by contrast material simultaneously procedure.
flowing into the upper joint space as the lower space
Advantages
is injected.
l Arthrography provides information regarding the soft
ii. Double contrast arthrography:
tissue components, specifically the shape and position
l This technique involves injecting contrast material
of the articular disc. It has been demonstrated that with
into both the spaces and viewing the more central
the addition of tomography, the diagnosis of abnormali-
portions of the joint with tomography. Because con-
ties in the position and shape of the disc is accurate.
trast material is in both the joint spaces, the outline
l Fluoroscopic observation of the injection may reveal the
of the disc is profiled, showing its configuration and
presence of adhesions, perforations and discontinuities
position.
in the capsule and provides a dynamic study of disc
l The outline of the disc can often be enhanced by using
movements, also any abnormal accumulation of joint
double-contrast arthrography. This technique involves
fluid may be evident.
injecting a small amount of air along with a small
l Synovial fluid sampling (arthrocentesis) and lavage of
amount of contrast material into both joint spaces,
the joint can accompany the procedure of arthrography.
producing a thin coat around the periphery of both
l An arthrograph can clearly distinguish the synovial
joint spaces that highlights the disc and the joint
changes of an inflammatory arthritis from an internal
spaces.
derangement resulting from meniscal dysfunction.
Procedure Limitations and complications
l The patient is placed on the fluoroscopic table in a lat- l Direct medial or lateral displacements are difficult to
eral recumbent position with the head tilted on the table interpret with arthrography cannot be used when the
top. This allows the joint to project over the skull above disc is severely deformed.
the facial bones in a manner similar to a transcranial l The rare serious complications associated with arthrog-
radiograph. raphy include joint sepsis, allergic reaction to the iodin-
l Under fluoroscopic guide, the posterosuperior aspect of ated contrast medium and haemarthrosis.
the mandibular condyle is identified with a metal l Pain during and after the procedure, extravasation of the
marker. This area is marked with an indelible pen and contrast medium, disc perforation and transient facial
local anaesthetic lidocaine is infiltrated into the superfi- paralysis are less serious complications of arthrography.
cial skin. l The radiation exposure to the patient can be significant,
l A 0.75 or 1 inch scalp vein needle and the attached tub- depending on the duration of fluoroscopy and the num-
ing are filled with contrast material and care is taken to ber of tomographic exposures made.
eliminate air bubbles. Air bubbles may simulate bodies l The most frequent complication of the technique is the
within the joint space. extravasation of contrast medium into the capsule and
l In a direction perpendicular to the skin and X-ray beam, soft tissues around the joint, causing pain. Nonionic
the 23 gauge needle is introduced in a predetermined contrast media will be the agents of choice to minimize
region of the condyle with the jaw in the closed posi- this discomfort.
tion. Advancement of the needle is done under fluoro- l Parotitis has been reported following arthrography with
scopic observation to ensure proper positioning. large needles and cannulas.
l When the condyle is encountered, the patient is in- l Some patients experience a vagal reaction, as a result of
structed to open the jaw very slightly, and the needle is increased anxiety during the procedure; this can be
guided by feel of the posterior slope of the bony con- managed by administering 0.6 mg of atropine intrave-
dylar margin. On fluoroscopic observation the needle nously.
will appear contiguous with the posterior condylar l Intravasation of contrast material infrequently occurs.
outline. Epinephrine in a dose of 0.03 mL (1:1000 per 3 mL) of
l Approximately, 0.4–0.5 mL of contrast material is in- contrast material is recommended because there is a risk
jected into the lower joint compartment under fluoro- of an acute hypotensive episode with intravasation of
scopic examination. If the contrast is successfully higher doses.
placed into the lower joint space, the opaque material l Transient facial paralysis may result from too vigorous
will be seen flowing freely anterior to the condyle in the infiltration of lidocaine. Some patients experience a mod-
anterior recess of the lower joint compartment. erate degree of pain as the needle is placed on the perios-
l The needle is then withdrawn and fluoroscopic video- teum of the condyle and as the joint is distended with
tape images are recorded during opening and closing contrast material. This discomfort is transient in majority
manoeuvres of the jaws. of the cases. If persistent joint pain occurs following the
338 Quick Review Series for BDS 4th Year, Vol 2

procedure, aspirin or acetaminophen and cold compress useful for determining deviation in the form of the
application to the affected side is recommended. joint, disc displacement, dislocation or ankylosis.
Interpretations ii. Thermography
l Thermography has been used experimentally to
l The location, shape and movement of the disc can be
interpreted by observing the shape of the contrast ma- evaluate patients with facial pain and may have a
terial on either side of the disc and its flow within its role in detecting joint inflammation.
own compartment as the patient opens and closes the iii. Ultrasound
l It is not considered to be sensitive or specific for any
mouth.
l Sideways and rotational displacements of the disc can- TMJ abnormality.
not reliably be determined from orthopantomography. Imaging protocol
l Perforation of the disc or disc attachment can be deter- Decision to be made considering the:
mined by flow of contrast medium into one space after i. Clinical situation
injection of the other; capsular tears and disc adhesions ii. Cost
can also be shown by this technique. iii. Radiation dose
Magnetic resonance imaging Plain films, panoramic radiographs, conventional and CT
l Magnetic resonance imaging (MRI) is a noninvasive tech- can be reserved for evaluation of:
nique that uses a magnetic field and radiofrequency pulses i. Foreign body giant cell reaction to implants
instead of ionizing radiation to produce the images. ii. Suspected tumours
l MRI gives information including the location of the disc iii. Ankylosis
in both open and closed mouth positions at multiple iv. Complex facial fractures
levels through the joint.
l Mediolateral and rotational displacements can be de- MRI
tected, as well as the straight anterior displacements. l MRI is indicated for soft tissues, including disc position
l Information on bony contours and cortical outline is and contour.
available with MRI. l MRI when contraindicated, arthrography is recom-
l Abnormalities within the bone marrow of the condyle mended.
and within the muscles and surrounding soft tissues can
Q.6. Articular disc disorders of temporomandibular
be detected.
joint.
l Other information includes the presence of soft tissue
ingrowths, fibrosis and joint effusion. Ans.
l MRI is also used to detect avascular necrosis of the con-
Articular disc disorders
dylar head and myxoid degeneration of the disc, although
Disc thinning and perforation
the significance of these findings is controversial.
l It is believed that the disc wears out over a period of
l In inflammatory arthritis, MRI has been shown to dem-
time. Hence, elderly individuals may generally present
onstrate disc destruction.
with thinning of the disc which may ultimately perforate.
Contraindications l The other causes include excessive occlusal loads from
MRI is contraindicated in certain patients, such as those parafunctional habits such as bruxism, clenching and
with: trauma.
l Pacemakers l The thinnest intermediate portion of the disc may show
l Intracranial vascular clips a circular hole with irregular or fragmented border.
l Any metallic prosthesis in the body l A perforated disc will expose the articular surface of the
Relative contraindications include patient with: joint leading to degenerative changes.
l Obesity Clinical features
l Claustrophobia l On auscultation of the TMJ, crepitus or grating noises
l Inability to remain motionless for the examination may be heard.
Other imaging techniques l In the early phases of the process, pain may be a present-
i. Single-photon emission CT (SPECT) ing complaint. Once the disc is perforated occlusion may
l Single-photon emission CT (SPECT), other nuclear be altered when teeth are in maximum intercuspation.
medicine procedures like ultrasound and thermogra- l Disc changes are readily evident on MRI and arthrogra-
phy have occasionally been used to evaluate the TMJ. phy. Degenerative changes can be appreciated on tradi-
l Nuclear medicine and SPECT are particularly sensi- tional imaging modalities and CT.
tive for inflammatory disorders and arthritis are not l Most joints with disc perforations were osteoarthrotic.
Section | I Topic-Wise Solved Questions of Previous Years 339

Adherence and adhesions l In normal conditions, when the teeth are in occlusion,
l Adherence refers to a transient phase in which the con- the posterior band of the disc ends at the apex of the
dylar head and the articular disc (inferior joint space) or condyle. In anterior disc displacement, the posterior
the articular disc and the glenoid fossa (superior joint band of the articular disc terminates ahead of the condy-
space) may adhere together. lar apex.
l However, prolonged periods of adhesion may result in a A. Disc displacement with reduction
permanent state of adhesion (true adhesions). l It is characterized by an anterior or anteromedial

l The causes for adhesion are long periods of static load- displacement of the disc upon mouth opening. How-
ing of the joint (e.g. jaw clenching during sleep) and ever, on closing the mouth, the disc returns to a more
haemarthrosis caused, by macrotrauma or surgery. normal position relative to the condyle on opening.
l Normally, when the joint is loaded, weeping lubrication Clinical features
is exhausted and boundary lubrication takes over to l Clicking sound may be heard during mandibular

prevent adhesions. But when the jaw is subjected to opening and closing. The opening click may be
long periods of static loading, the boundary lubrication heard during any phase of the translatory cycle
is not sufficient to compensate for the exhaustion of and the closing click may be felt as the disc again
weeping lubrication, resulting in adherence of the disc becomes displaced. Mandible may be deviated to
either with the upper or lower joint compartment. the affected side.
l Muscle splinting may result in joint tenderness
Clinical features
and limitation of mouth opening.
l Patients may complain of a stiff jaw, dull aching pain
B. Disc displacement without reduction
and limited mouth opening, especially if they habitually
l In this condition, the condylar head is unable to pass
clench their teeth.
under the displaced disc.
l However, the limitation in mouth opening characteristi-
l The reasons for the condyle to be trapped include
cally corrects following a single click when the patient
thickening of posterior band, change in shape of disc
makes attempts to open the mouth.
from biconcave to biconvex and decrease in tension
l True adhesions may cause elongation of the collateral
in the posterior attachment.
disc ligaments and anterior capsular ligaments.
l Such a trapping, the disc in front of the condyle,
l During translatory movements, the condyle is ahead of
limiting the condylar translation in the affected joint
the articular disc thereby appearing that the disc is pos-
results in a ‘closed lock’.
teriorly dislocated. It is thus hypothesized that posterior
Clinical features
disc displacements may result from disc adhesions.
l It is generally a painful condition as the articular
l Clinically, restriction of the condylar movements to
capsule, disc ligaments and posterior attachment
rotation alone, is typical of adhesions between disc and
are inflamed.
superior joint space (mouth opening may be restricted
l Patient may present with pain and severe limita-
to about 25 mm).
tion in mouth opening (maximum of 25–30 mm).
l However, when the adhesion occurs between the disc
l Mandible is deflected to the ipsilateral side on
and the inferior joint compartment, rotational move-
mouth opening.
ment is inhibited and the translatory cycle is normal
l There is limitation in protrusive movements.
(patient can open the mouth to a normal inter-incisal
l Chronic cases may present with joint crepitus.
distance but experience a jerk or limitation when at-
Lateral excursions are limited.
tempting to open the mouth to its full extent).
Disc displacement Displacement of disc–condyle complex (hypermobility
l Disc displacements are also termed as internal de- and dislocation)
rangement. l Occasionally during the terminal phases of the transla-
l The commonest causes for internal derangement in- tory cycle, as the condyle moves past the articular emi-
clude trauma, clenching and biting on hard substances. nence it may suddenly move forward to facilitate a wide
l The internal derangements could include: mouth opening referred to as subluxation (hypermobil-
A. Disc displacement with reduction ity, partial dislocation).
B. Disc displacement without reduction l Hypermobility may occur due to joint laxity seen as a
l Anterior disc displacement is common and it usually oc- genetic predisposition (Ehlers–Danlos syndrome), fol-
curs when there is elongation of the disc attachment and lowing dental procedures that require prolonged mouth
deformation or thinning of the posterior border of the disc, opening (endodontic procedures, third-molar extrac-
which in turn permits the articular disc to get displaced in tion), excessive yawning and during endotracheal incu-
an anterior direction on the surface of the condyle. bation for general anaesthesia.
340 Quick Review Series for BDS 4th Year, Vol 2

Clinical features usual position. It is usually associated with a fracture

l Many patients describe the sudden forward movement of base of skull or the anterior wall of bony meatus.
as a feeling of a ‘thud’ sound. iii. Lateral dislocation
l This condition is usually painless unless it becomes l Lateral dislocation has been described by Allen and

chronic. Young, in 1969, in two subgroups:

l Patients may exhibit a tapered/elongated face. a. Type I is the late subluxation and
l Hypermobility may be distinguished from anterior disc b. Type II is a complete dislocation where condyle
displacements in that the click is associated only with is forced laterally and superiorly to the tempo
wide opening and absence of closing click. fossa. It is accompanied by the fracture of body
of mandible at symphysis.
Dislocation (open lock)
iv. Superior dislocation
l Dislocation of the condyle is a common condition that
l Superior dislocation as described by Zecha in 1977,
may occur in an acute or chronic form. It is character-
the dislocation of condyle in to the middle cranial
ized by inability to close the mouth with or without
fossa and associated with fracture of glenoid fossa.
pain.
l It is said most probably due to the small rounded
l Dislocation has to be differentiated from subluxation
shape of the condyle which fails to impinge in the
which is a self-reducible condition. When the mouth is
margins strongly than the central area.
opened, the head of the condyle should not pass beyond
the apex of articular eminence. Managing temporomandibular disorder patients re-
l In case of laxity of capsular structures, a wide open quiring dental procedures
position allows the condyle to move pass the articular l Hot compresses to masseter and temporalis areas for
eminence which cannot be reduced by the patient. about 10–20 min two to three times daily for 2 days.
l Dislocation can occur in any direction with anterior l Use a minor tranquillizer or skeletal-muscle relaxant
dislocation being the commonest one. (e.g. lorazepam, 1 mg; cyclobenzaprine, 10 mg) on the
l Various predisposing factors have been associated with night and day of the procedure.
dislocation like muscle fatigue and spasm, the defect in l On the day of the procedure, before starting of the pro-
the bony surface like shallow articular eminence and cedure give an NSAID.
laxity of the capsular ligament. l During surgical procedure, to support the patient’s comfort-
l People with defect in collagen synthesis like Ehlers– able opening, use a child-sized surgical rubber mouth prop.
Danlos syndrome and Marfan syndrome are said to be l Intravenous sedation and/or inhalation analgesia, during
genetically predisposed to this condition. procedure.
l Provide frequent rest periods to avoid prolonged open-
Clinical features ing and apply moist heat to masticatory muscles during
l The condition is characterized by inability to close the rest period and gently massage them.
mouth after wide opening. Bilateral dislocation is more l Perform the procedure in the morning, when reserve is
common than unilateral dislocation. likely to be greatest.
l However, when the dislocation is unilateral, the chin is l Use of muscle relaxant and NSAID medication if neces-
deviated to the contralateral side. Palpation in the preau- sary, after procedure.
ricular region reveals an empty fossa and may reveal the l Apply cold compresses to the TMJ and muscle areas
condyle anterior to the joint. during and 24 h after the procedure.
l The inability to close the mouth is due to the spasm of
masticatory muscles. Q.7. Classify temporomandibular disorders. Discuss the
l A typical facial expression (elongated face) is due to management of TMJ arthritis.
anxiety related to the thought of not being able to close Ans.
the mouth.
[Same as LE Q.1]
Types of dislocation
Depending upon the position the condyle occupies: Q.8. Write clinical features and management of MPDS.
i. Anterior dislocation
Ans.
l Heslop, in 1956, described the anterior dislocation in

which the condyle moves anterior to the articulating [Same as LE Q.2]

eminence. It is one of the most common type of
dislocation. Q.9. Management of MPDS.
ii. Posterior dislocation
Ans.
l Helmy, in 1957, described the posterior variant in

which the head of condyle is displaced posterior to its [Same as LE Q.2]

Section | I Topic-Wise Solved Questions of Previous Years 341

Q.10. Enumerate the causes of trismus. Discuss in Surgical treatment

detail. l Insertion of bone graft.
l Capsulorraphy – joint is exposed and vertical incision is
Ans.
made and edges of capsule are overlapped and sutured
[Same as LE Q.3] to tighten the capsule in anteroposterior plane.
l Intermaxillary Fixation (IMF) for 7 days relieves sublux-
ation and clicking of joint.
SHORT ESSAYS: l Shortening of temporalis tendon.
Q.1. Subluxation of TMJ. Q.2. Myofacial pain dysfunction syndrome (MPDS).
Ans. Ans.
[Ref LE Q.2]
{SN Q.2}
Q.3. Clinical features and management of degenerative
l Self-reducing incomplete dislocation or habitual dis- arthritis of TMJ.
location of TMJ is known as subluxation.
Ans.
l It may be unilateral or bilateral, generally due to
stretching of the capsule and ligaments. l Other names of degenerative arthritis are: osteoarthrosis
or osteoarthritis.
Aetiology
l It is a disorder of articular cartilage and subchondral bone,
l Long continuous mouth opening, e.g. biting on a big
with secondary inflammation of the synovial membrane.
apple or burger, long yawning.
l It is a localized joint disease without systemic manifes-
l Excessive movement during oral surgical procedures.
tations.
l Chronic degenerative changes, e.g. osteoarthritis.
l Genetic factors play an important role. It is asymptomatic
l Underlying psychiatric problems.
in patients above age of 50 years, but sometimes early
l Use of phenothiazine group of drugs.
arthritic changes can be seen in younger individuals.
l Secondary degenerative joint disease results from a
Clinical feature known underlying cause, such as trauma, congenital
l It may be unilateral or bilateral. dysplasia or metabolic disease.
Symptom Clinical manifestations
l Cracking noise, temporary locking of condyle, immobili- l Patients with symptomatic DJD of the TMJ presents
zation of jaw, pain in last few millimetre of mouth opening. with unilateral pain directly on the condyle, limiting
mandibular opening, crepitus and a feeling of stiffness
Signs
after a period of inactivity.
l Condyle gets locked when mouth is opened widely, and
l Degenerative changes of the TMJ detected on radio-
upon closing it will return with jumping motion.
graphic examination could be incidental.
l On palpation click on opening and sliding of condyle
l Sometimes degenerative changes may be undiagnosed
over articular eminence.
by conventional radiography as the defects are confined
Histopathology to the articular soft tissue.
l Long-standing opening causes stretching of ligament l MRI visualizes soft-tissue changes better.
and capsule due to absence of elastic fibres the ligament l On tomograms and CT scans radiographic findings in
stretched beyond its capacity will not come back to degenerative joint disease may show narrowing of the
normal length. joint space, irregular joint space, flattening of the articu-
l Laxity of capsule and over stretched ligament causes lar surfaces, osteophytic formation, anterior lipping of
subluxation. the condyle and the presence of Ely cysts.
l The presence of joint effusion is most accurately de-
Treatment
tected in T2-weighted MRI images.
Conservative method
l Shrinkage of capsule leading to fibrosis – by use of Treatment
sclerosing agents like 5% sodium psylliate or 5% in- l This disease is managed by conservative treatment.
tracaine in oil base. Mixture of equal parts of 0.5% l Improvement is noted in many patients after 9 months,
eucupine in oil 15% aqueous solution of sodium as well as a ‘burning out’ of many cases occurs after
psylliate. 1 year is seen.
l Repeat the injections every 2–3 weeks till fibrosis of the l Conservative therapy includes nonsteroidal anti-
capsule occurs. inflammatory drugs, heat application, soft diet, rest
342 Quick Review Series for BDS 4th Year, Vol 2

and occlusal splints that allow free movement of the Aetiology

mandible. Trauma, either macrotrauma or microtrauma.
l Surgery is indicated when TMJ pain or significant loss
Macrotrauma
of function persists and when distinct radiographic evi-
It can be direct or indirect.
dence of degenerative joint changes exists.
Direct trauma
Q.4. Internal derangement of temporomandibular joint.
l Trauma to mandible in open mouth position.
Ans. l Can also be iatrogenic.
l Intubation procedures.
{SN Q.6} l Third molar extractions.
l Long dental appointments.
l Internal derangement of TMJ was first described by l Over-extension of jaw causes elongation of the liga-
Hey and Davies (1814) as a localized mechanical ments each time.
fault interfering with smooth action of a joint.
l Internal derangement is defined as a disturbance in Indirect trauma
the normal anatomical relationship between the disc l Cervical flexion-extension injury.
and condyle that interferes with smooth movement Microtrauma
of joint and cause momentary catching, clicking, l Bruxism or clenching
popping/locking, etc. l Mandible orthopaedic instability
Clinical and diagnostic features
Pathogenesis
l History of severe pain on yawning
l Internal derangement is a progressive anterior and
l History of direct trauma to the joint years earlier
medial subluxation of meniscus from its normal posi-
l Opening click and reciprocal click
tion at rest.
l Joint tenderness, especially with function
l Previous trauma may lead to stretching of lower lamina
l Deviation to affected side till clicking occurs
of bilaminar zone, allowing posterior band to sublux
l Deviation on opening
forward in relation to condylar head in centric relation.
l Crepitus
The first abnormality seen is a click on opening.
l Trismus – with 20–25 mm interincisal distance
l The open click represents the posterior band relocating
l Continuous pain on side of face and head exacerbated
posteriorly over the condyle from its subluxed position.
by moving the jaw
l Pain at this stage represents the meniscus beginning to
l Elimination of pain following local anaesthesia of the
lose its insertion into lateral pole.
affected joint
l Following further trauma (acute or chronic), the menis-
cus subluxes progressively forwards and medially, so Management
that it cannot regain its position over condylar head on Conservative management
wide opening. l Reassure the patient.
l Inflammation associated with damage to meniscal at- l Use of tricyclic antidepressant drugs in patient with history
tachments and joint surface by incorrect positioning of of bruxing, clenching and tenderness of muscles of masti-
meniscus leads to formation of exudates and eventual cation. They act to reduce jaw movements during sleep.
adhesions and fibrosis. This fibrosis maintains meniscus l Mild sedative may be prescribed to overcome anxiety
in subluxed position, and the joint becomes locked. and tension.
There will be painful restriction of opening. l Occlusal splints – anterior positioning splint.
l NSAIDs in cases of acute episodes of pain.
l Intra-articular injection of steroid for acute pain and
{SN Q.6} tenderness in the joint.
l 1 mL hydrocortisone along with 1 mL of local anaes-
Staging of internal derangement – Wilkes
thetic is injected into the joint.
Stage I Early reducing disc of displacement
Stage II Late reducing disc displacement Surgical management
Stage III Nonreducing disc displacement – acute/subacute When all the conservative measures fail and in some
cases of irreducible, medially displaced meniscus, surgery
Stage IV Nonreducing disc displacement – chronic
is the last resort.
Stage V Nonreducing disc displacement with osteoarthroses Various surgical procedures indicated are as follows:
l Arthrocentesis and lavage
Section | I Topic-Wise Solved Questions of Previous Years 343

l Arthroscopy spasm of the jaw muscles by which normal opening of the

l Disc repositioning mouth is restricted (locked jaw).
l Disc removal and autologous graft disc replacement Aetiology of trismus
l Autologous flap reconstruction Congenital
l Alloplastic disc replacement l Birth injury
l Condylotomy l Hemifacial macrosomia, etc.
l Condylectomy
Traumatic (acute)
Q.5. Bruxism. l Fractures of mandible, zygomatic or temporal bones
Ans. l Hematomas in the joint or muscle of mastication
l Injury from local anaesthetic injection
l Night grinding of the teeth unintentionally is known as l Postsurgical (e.g. third molar removal and TMJ surgery)
bruxism.
l The aetiology is not understood, but several factors are Neoplastic (benign)
thought to be responsible for this such as emotional l Mesenchymal tumours of the TMJ and surrounding
stress, etc. structures (e.g. osteochondroma)
l Occlusal appliances such as splint should be worn dur- Neoplastic (malignant)
ing night, but does not decrease the activity of bruxism. l Chondrosarcoma, osteosarcoma, tumours of the oro-
Treatment pharynx (Trotter syndrome), etc.
l Symptoms decrease when buspirone was added. Reactive (acute)
l Buspirone has a postsynaptic dopaminergic effect and l Septic arthritis
may act to partially restore suppressed dopamine levels l Tetanus
associated with the use of SSRIs. l Abscesses of the submasseteric, lateral pharyngeal,
l Severe bruxers injected in the masseter muscles with pterygomandibular, submandibular and temporal
botulinum toxin in an open-label prospective trial and spaces
reported significant improvement in symptoms and l Tonsillitis and peritonsillar abscess
minimal adverse effects. l Parotid abscess
l The treatment effect lasted approximately 5 months and l Mumps
had to be repeated.
l Botulinum toxin exerts a paralytic effect on the muscle Reactive (chronic)
by inhibiting the release of acetylcholine at the neuro- l TMJ ankylosis (fibrous and bony)
muscular junction. l Degenerative joint disease
l Rheumatoid arthritis
Q.6. Clinical features of TMJ subluxation. l Myofascial pain dysfunction (MPD), etc.
Ans. Psychogenic
[Same as SE Q.1] l Hysterical trismus
Q.7. Treatment plan for MPDS. Drug induced
l Strychnine poisoning
Ans.
Q.2. Subluxation of TMJ – aetiology.
[Same as SE Q.2]
Ans.
Q.8. Aetiology of MPDS.
[Ref SE Q.1]
Ans.
Q.3. Myositis ossificans.
[Same as SE Q.2]
Ans.
Myositis ossificans is a rare disturbance characterized
SHORT NOTES: l

by the formation of bone in the interstitial tissue of

Q.1. Four causes of trismus. muscle.
l It has also been observed in the superficial tissues away
Ans.
from muscle, even in the skin.
The word ‘trismus’ is derived from the Greek trismus l When muscles of the face are involved, the masseter
meaning gnashing and is defined as a prolonged, tetanic muscle is most frequently affected.
344 Quick Review Series for BDS 4th Year, Vol 2

l It results in a restriction of mandibular movements, Q.8. Enumerate the temporomandibular joint views.
which should alert the clinician to the possibility of
Ans.
myositis ossificans.
Various TMJ views are as follows:
Q.4. Temporomandibular joint ankylosis. i. Transcranial view
l Provides a sagittal view of the lateral aspects of the
Ans.
condyle and temporal component of the joint.
l Ankylosis of TMJ can be true ankylosis or false ankylosis. ii. Transorbital view
l The most common cause of TMJ ankylosis is trauma to l The mediolateral dimension of the articular emi-
the chin although infections also may be involved. nence, condylar head and condylar neck is visible,
l Children are more prone to ankylosis because of greater which makes this view particularly useful for visu-
osteogenic potential and an incompletely formed disc. alizing condylar neck fractures.
l Ankylosis results from prolonged immobilization iii. Transpharyngeal view
following condylar fracture. l Sagittal view of the medial pole of the condyle and
l Limited mandibular movement, deviation of the man- medial aspect of the condyle are seen.
dible to the affected side on opening, and facial asym- iv. Submentovertex view
metry may be observed in TMJ ankylosis. l Shows the base of the skull, condyles bilaterally.
l Osseous deposition may be seen on radiographs. v. Reverse Townes’ view
l Treatment: It can be treated by surgical procedures like l Useful to view condylar neck and medially dis-
condylectomy, gap arthroplasty or interpositional gap placed condyle.
arthroplasty. vi. PA mandible
l Gap arthroplasty using interpositional materials be- l Bilateral condylar fractures.
tween the cut segments is the technique most commonly vii. Lateral skull view
performed. l Unilateral condyle

Q.5. How will you differentiate true ankyloses from viii. Lateral obligue (ramus)
l Unilateral coronoid and condyle and also the ramus
pseudoankylosis of temporomandibular joint?
of mandible are seen.
Ans.
Q.9. Drugs to relieve muscular spasm.
[Ref LE Q.4]
Ans.
Q.6. Mention the staging of internal derangement of
temporomandibular joint. Various drugs used to relieve muscular spasm are as
follows:
Ans. l NSAIDs, acetaminophen, muscle relaxants, antianxiety
[Ref SE Q.4] agents and clonazepam.
l Tricyclic antidepressants have been used up to a toler-
Q.7. Define myofunctional pain dysfunction syndrome. ated level for its central acting muscle relaxant analge-
Ans. sic affect.
l Aspirin or NSAID should be recommended for analge-
l The muscles of mastication, the tongue muscles and the sic and anti-inflammatory actions.
strap muscle of the neck function as a unit and that dys-
function in one group of muscles is frequently associ- Q.10. Define trismus.
ated with altered tonus and symptoms of ‘tension’ in the Ans.
other related groups.
l When muscle spasm develops in one or more mastica- [Same as SN Q.1]
tory muscles, dysfunction as well as pain occurs and the
condition usually is designated as MPDS.
Section | I Topic-Wise Solved Questions of Previous Years 345

Topic 9
Ionizing Radiation and Regressive Alterations
of the Oral Cavity
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. Describe radiation complications of the jaws.

SHORT ESSAYS:
1. Classify regressive alterations of teeth.

SHORT NOTES:
1. Pink disease.
2. Mention causes of resorption of roots.
3. Abfraction.
4. Osteoradionecrosis.
5. Attrition.

SOLVED ANSWERS

LONG ESSAYS: l Reassurance that this condition and accompanying

pain will subside is welcomed by patients.
Q.1. Describe radiation complications of the jaws. II. Radiation-induced xerostomia
l Radiation-induced xerostomia is caused by the di-
Ans.
rect damaging effects of radiation on both major
Complications of radiation and their management and minor salivary glands located in the path of
I. Radiation mucositis radiation.
l Radiation mucositis is the response of oral mucosa l Glandular tissue in general is very sensitive to radia-
to acute radiation injury. tion. Following radiation therapy, the mouth becomes
l It presents as a diffuse erythema with pain or muco- dry as a result of the loss of salivary gland acini.
sal ulcerations and a fibrinous exudate. l The skin becomes dry as well because of loss of
l It is a self-limiting condition, may develop in the sweat and sebaceous glands.
last 3 weeks of radiotherapy and may extend for l A histopathologic study of irradiated glands will
about 1 month after radiotherapy. show the three-H tissue replacement of the acini but
l During this acute painful phase, topical viscous 2% preservation of the ducts. Ductal epithelium is
xylocaine gel as well as systemic analgesics may be somewhat radiation resistant.
needed to control pain. Antibiotics are not required l As most radiation ports leave some areas of mucosa
unless there is an associated lymphadenitis or sys- untouched, there is an opportunity to stimulate
temic toxicity. the remaining glands to overproduce. Although it
l Patients will benefit from chlorhexidine gluconate improves mouth moisture in only about 70% of
rinses, if tolerated, to reduce bacterial colonization irradiated patients.
of the ulcers. l Pilocarpine (Salagen, MGI Pharma), 5 mg by
l Nutritional support may be needed in some cases. mouth three times daily, often improves eating,
l In severe cases, it is reasonable to provide intrave- speaking, and swallowing functions.
nous fluid therapy and nasogastric tube feeding for l It should be taken regularly to gain and maintain
a short time. an improvement, and it must be given with caution
346 Quick Review Series for BDS 4th Year, Vol 2

to individuals with heart diseases associated with l Improving mouth moisture and increasing the liq-
bradycardia, heart block, or other medications that uid content of the diet helps indirectly.
may slow heart rate or conduction. l Oesophageal dilations do not improve this condi-

l Additionally, sports water bottles are used by many tion unless the oesophagus itself was included in
individuals, and Evian atomized water spray has the radiation ports.
been found to be beneficial to many. V. Radiation effects on jaw growth and developing teeth
III. Radiation caries l Radiation therapy during the growth and develop-

l Those teeth in the direct path of 6000 cGy or ment years will create a dose-related hypoplasia of
greater radiation are most at risk of developing the mandible as well as partial or complete agenesis
radiation caries. of teeth within the portals of radiotherapy.
l It results from xerostomia, which permits cario- l These effects are primarily manifested as an antero-

genic bacteria to proliferate unopposed by the usual posterior deficiency of the mandible that is retrogna-
lysosomes and IgA immunoglobulins in saliva and thia and a general reduction in the size of the ramus
causes the loss of the saliva’s natural buffering and body of the mandible, creating a severe chin
capacity. Although this mechanism contributes to deficiency appearance.
radiation caries, it is not its only or most significant l The teeth within the radiated bone will generally be

cause. smaller and will usually exhibit arrested root devel-

l Radiation caries is hard and black and occurs at the opment. Since the crowns will be affected to a
gingival margin, cusp tips and incisal surfaces. lesser degree, many teeth will appear radiographi-
l Radiation caries is either present only in the irradi- cally to have a normal crown size with no roots,
ated field or is more severe in the irradiated field, mimicking an exfoliating primary tooth. Some teeth
whereas the entire mouth is affected by xerostomia. will fail to form altogether, that is, agenesis.
l Radiation caries is mainly due to pulpal necrosis l The teeth may be replaced with removable partial

and odontoblast death, which causes deterioration dentures or with implant-supported fixed dental ap-
of both the dentine and the dentinoenamel junction. pliances, provided that all remaining growth has been
l The enamel is subsequently lost from the dentine completed and the patient has undergone the 20/10
because of dentinal dehydration and dentinoenamel hyperbaric oxygen (HBO) protocol (20 sessions at
junction deterioration similar to dentinogenesis 2.4 ATA for 90 min on 100% oxygen prior to surgery
imperfecta. The exposed dentine becomes black or and 10 sessions after surgery).
brown and hard and deteriorates further. l In cases of significant anteroposterior deficiency

l Pulp testing teeth with radiation caries mayor may and provided that the patient has completed the
not produce a response. Yet when the pulp is exam- 20/10 HBO protocol osteotomies advancing the jaw
ined, it is avascular. The tooth with radiation caries using bone grafting can be accomplished.
may have a responsive pulp but is actually nonvital As an alternative, distraction osteogenesis can also
due to avascular necrosis of the vascular pulpal tis- be successfully provided usually in a young patient
sues, including the odontoblasts. who has undergone the 20/10 HBO protocol.
l Even the best oral hygiene, dental care and fluoride VI. Radiation-induced trismus
carriers will not prevent all radiation caries. Once l Radiation-induced trismus is a condition that fre-

developed, radiation caries should be treated quently accompanies osteoradionecrosis in the pos-
promptly using restorative techniques appropriate terior body and ramus region of the mandible and is
for the degree of lost and involved tooth substance. usually improved with the successful treatment of
IV. Radiation dysphagia the osteoradionecrosis.
l It is one of the most troubling and least treatable l The trismus is not a consequence of the effects
later complications of radiotherapy. of radiation on the temporomandibular joint but
l Many patients will report difficulty in ‘swallowing’ instead is due either to radiation fibrosis within the
food, ‘getting stuck’ in the hypopharynx and will masseter and medial pterygoid muscles or due to
aspirate on swallowing after radiotherapy. restrictive fibrosis in the mucosa of the anterior
l This condition is caused by radiation fibrosis within tonsillar pillar and retromolar areas.
the pharyngeal constrictors, which makes these se- l If the trismus is due to tight and unresilient mucosal

ries of three muscle pairs stiff and unable to con- restrictions in the tonsillar and/or retromolar areas,
tract in the coordinated fashion that is necessary to a significant increase in opening may be achieved
propel food into the oesophagus. by excising this tissue and replacing it with a viable
l There is only a little that can be done directly to cor- skin paddle from either a myocutaneous or a free
rect this. Occasionally, swallowing therapy helps. microvascular flap.
Section | I Topic-Wise Solved Questions of Previous Years 347

l If the trismus is the result of radiation fibrosis in the Resorption of teeth

pterygomasseteric sling, the prognosis is much a. External resorption
worse. Such fibrosis cannot be effectively excised l It occurs due to periapical granuloma or by pressure

without risking the blood supply to the ramus and of cysts most common by apical periodontal cyst and
thus precipitating an osteoradionecrosis. tumours by heavy orthodontic forces.
l Modest gains can be achieved with bilateral coro- b. Internal resorption
noidectomies or partial excisions of the fibrosis in l It is also known as odontoclastoma or pink tooth of

the masseter or medial pterygoid muscles. mummery. It is due to inflammatory hyperplasia of

l These also must be followed with intensive jaw- the pulp.
opening exercises using a device such as the thera-
bite, by tongue blade exercises or by the chewing of Changes in dentine
soft, sugarless gum. a. Dental sclerosis/transparent dentine/reparative
dentine
l Calcification of dentinal tubules due to trauma, car-
SHORT ESSAYS: ies, etc.
b. Secondary dentine/irregular dentine
Q.1. Classify regressive alterations of teeth.
l It is also known as adventitious dentine, deposited
Ans. after the completion of primary dentine and is associ-
Regressive alterations affecting teeth ated with normal ageing process, also known as irri-
tation dentine as it is also stimulated by trauma,
l Tooth wear
caries, attrition, etc.
a. Attrition
l Tertiary dentine localized exclusively adjacent to the
b. Abrasion
irritated zone, tubules are less in number, very irregular.
c. Erosion (corrosion)
c. Dead tracts
d. Abfraction
l Are not calcified and are permeable to penetration of
l Resorption of teeth
dyes.
a. External
b. Internal Changes in pulp
l Changes in dentine a. Reticular atrophy of pulp
a. Reparative dentine l There is an atrophy of pulp tissue and decrease in the
b. Secondary dentine size of pulp chamber due to increase age.
c. Dead tracts b. Pulp calcifications
l Changes in pulp
There are various types of denticles as follows:
a. Reticular atrophy of pulp
i. True denticles resemble dentine due to their tubular
b. Pulp calcifications
structure; resemble secondary dentine as tubules are
l Changes in cementum
less and irregular and more common in pulp chambers.
a. Cementicles
ii. False denticles are localized masses of the calcified tis-
b. Hypercementosis
sue and do not contain dentinal tubules. They are made
These are all described as follows: of concentric layers of dentine. Are more common in
Tooth wear pulp chamber and are larger than true denticles.
a. Attrition iii. Free denticles are not attached to dentinal wall, but ly-
l Physiologic wearing away of the tooth material as- ing entirely in pulp tissues.
sociated with the ageing process iv. Attached denticles are continuous with dentinal wall; it
b. Abrasion is more common than free denticles.
l Pathological wearing of tooth substance usually v. Diffuse calcifications are most common in root canals;
occurs at exposed root surface of the tooth seen as a as calcific degenerates.
wedge-shaped ditch near CEJ. Changes in cementum
c. Erosion a. Cementicles
l Chemical loss of tooth material without involving These are foci of calcified tissue that lie free in peri-
bacterial action; smooth, highly polished and scooped odontal ligament. They develop by calcification of nests
out depression on enamel adjacent to CEJ. of epithelial cell rests in Periodontal Ligament (PDL).
d. Abfraction b. Hypercementosis/cementum hyperplasia
l Refers to loss of tooth structure from repeated tooth Deposition of secondary cementum (cellular), on the
flexure caused by occlusal stresses. root surface. Increased incidence in nonfunctional teeth.
348 Quick Review Series for BDS 4th Year, Vol 2

SHORT NOTES: Q.3. Abfraction.

Q.1. Pink disease. Ans.
Ans. l Abfraction refers to the loss of tooth structure from
repeated tooth flexure caused by occlusal stresses.
l Pink disease is also known as acrodynia or Swift disease.
l It is due to mercurial toxicity. Q.4. Osteoradionecrosis.
l It is most common in young infants of less than 2 years Ans.
of age.
l Skin resembles raw-beef, skin peeling, severe pruritis l Osteoradionecrosis implies infection of bone rendering
and children tear their hair out in patches. necrosis by ionizing radiation.
l Treatment: BAL, i.e. British anti-lewisite. l Occurs due to radiation in massive doses, partial necro-
sis of bone and trauma which causes infection.
Q.2. Mention causes of resorption of roots. l Cure of malignancy of tongue, floor of oral cavity, salivary
Ans. glands, sinuses and neoplasm causes necrosis of maxillary
and mandibular bones, and ulceration of soft tissues.
a. External resorption may occur due to: l Osteoradionecrosis is best managed with topical antibi-
l Periapical inflammation
otic (tetracycline) or antiseptic (chlorhexidine) rinses.
l Tumours and cysts
l Hyperbaric oxygen (HBO) therapy increases the oxy-
l Reimplantation
genation of tissue, increases angiogenesis and promotes
l Excessive mechanical or occlusal forces (e.g. orth-
osteoblast and fibroblast function.
odontic treatment) especially in hypothyroidism
l Impacted teeth Q.5. Attrition.
l Idiopathic (maxillary premolars – maximum; man-

dibular incisors and molars – least) Ans.

l Trauma
l Physiological wearing away of the tooth material is
l Hormonal imbalances
known as attrition.
b. Internal resorption l Usually associated with ageing.
l Pink tooth of mummery/odontoclastoma/internal
l Polished facets on occlusal surfaces.
granuloma l Arch length decreases due to proximal attrition.
l Idiopathic
l Advanced attrition seen in amelogenesis imperfecta and
l Due to inflammatory hyperplasia of pulp
dentinogenesis imperfecta.

Topic 10
Odontologic Diseases

COMMONLY ASKED QUESTIONS

LONG ESSAYS:
1. Write briefly about the clinical features of
a. Amelogenesis imperfecta
b. Dentinogenesis imperfecta.
2. Describe in detail developmental anomalies of shape of teeth.

SHORT ESSAYS:
1. Internal resorption.
2. Dens invaginatus.
3. Anodontia.
Section | I Topic-Wise Solved Questions of Previous Years 349

SHORT NOTES:
1. Enamel hypoplasia.
2. Talon cusp.
3. Dilaceration.
4. Dens in dente.
5. Turner tooth.
6. Clinical features of regional odontodysplasia.
7. Dentinogenesis imperfecta.
8. Pink tooth of mummery.
9. Hutchinson triad.
10. Fordyce granules.
11. Anodontia.
12. Concrescence.
13. Supernumerary teeth.
14. Taurodontism.
15. Describe briefly the causes for early loss of teeth.
16. Median rhomboid glossitis.
17. Geographic tongue.
18. Benign migratory glossitis.
19. Macroglossia.
20. Dentine dysplasia.
21. Black hairy tongue.
22. Natal teeth.
23. Peutz–Jeghers syndrome.
24. Globulomaxillary cyst.
25. Gingival cysts of infants.
26. What is fusion.
27. Oligodontia.
28. Gardner syndrome.
29. Mesiodens.
30. Turner hypoplasia. [Same as SN Q.5]

SOLVED ANSWERS

Clinical features
LONG ESSAYS:
l Hypoplastic type: Enamel thickness is not complete.
Q.1. Write briefly about the clinical features of l Hypocalcification type: Enamel is soft and can be re-
a. Amelogenesis imperfecta moved by prophylactic instrument.
b. Dentinogenesis imperfecta. l Hypomaturative type: Enamel can be pierced with
explorer point and chipped off.
Ans.
l Teeth are brownish in colour. Vertical lines or grooves
Amelogenesis imperfecta may be present on surface.
l It is a group of hereditary defects of enamel associ- l Enamel is chalky and it can be chipped off with expo-
ated with other generalized defects, dentine is usually sure of underlying dentine.
normal. l Contact points are abraded.
l It may be of three types:
Treatment
a. Hypoplastic type: It is the defect of enamel organic
l There is no treatment except for improvement of cos-
matrix formation.
metic appearance by veneering or capping of teeth.
b. Hypocalcification type: It is the defect of mineraliza-
tion of enamel. Dentinogenesis imperfecta
c. Hypomaturation type: It is the defect of enamel crys- l Dentinogenesis imperfecta is an autosomal dominant
tal maturation. condition.
350 Quick Review Series for BDS 4th Year, Vol 2

l It is defect of collagen formation hence only dentine is Treatment for both type I and type II dentinogenesis
affected rather than enamel. imperfecta
l Treatment of these patients is directed towards prevent-
Dentinogenesis imperfecta revised classification ing the loss of enamel and subsequent loss of dentine
l Dentinogenesis imperfecta I through attrition.
Dentinogenesis imperfecta without osteogenesis imper- l Crown capping may be done on teeth to avoid attrition.
fecta (opalescent dentine), this corresponds to dentino- Cast metal crowns on posterior teeth and jacket crowns
genesis imperfecta type II of Shields classification. on anterior teeth have been used with considerable
l Dentinogenesis imperfecta II (brandywine type dentino- success.
genesis imperfecta)
This corresponds to dentinogenesis imperfecta type III Q.2. Describe in detail developmental anomalies of
of Shields classification. shape of teeth.
There is no substitute for the category designated as Ans.
dentinogenesis imperfecta type I of the previous classi-
fication (Shields). Developmental disturbances affecting shape of teeth
i. Gemination, fusion and concrescence
Dentinogenesis imperfecta I ii. Accessory cusps
Clinical features l Cusp of Carabelli
l Enamel may be thinner than normal, with amber-like l Talon cusp
translucency and teeth have variety of colours blue-grey l Dens invaginatous
or amber brown and are opalescent. l Dens evaginatous

Radiographic features iii. Ectopic enamel

l Enamel pearls
l In both primary/permanent teeth, radiographs show
l Cervical enamel extensions
bulbous crowns with a cervical constriction.
l Short slender roots and obliterated pulp canals and iv. Taurodontism
chambers in type I dentinogenesis imperfecta. v. Dilaceration
vi. Supernumerary roots
Histological features
l Enamel is normal, while in dentine irregular tubules are I. a. Gemination
l Gemination is a developmental anomaly that re-
seen with large areas of uncalcified matrix.
l Pulp chamber is obliterated by continuous deposition fers to division of single tooth germ into incom-
of dentine with entrapped ‘odontoblasts’. plete or complete formation of two teeth.
l Crowns may be partially or totally separated from
l Dentinoenamel junction is without scalloping, so oc-
clusal surface is lost due to attrition. each other.
l Roots are fused and single root canal is present
Dentinogenesis imperfecta II (Brandywine type dentin- within the root.
ogenesis imperfecta) l The structure is usually one with two completely
l This disorder was found in Brandywine triracial isolate or incompletely separated crowns that have a sin-
in southern Maryland. This corresponds to dentinogen- gle root and a root canal.
esis imperfecta type III of Shields classification. l The condition is seen in both deciduous and

Clinical features permanent dentition, with a higher frequency in

l The crowns of the deciduous and permanent teeth wear the anterior and maxillary region.
rapidly after eruption and multiple pulp exposures are I. b. Fusion
seen in primary teeth. l Fusion is defined as single enlarged tooth or joined

l Colour of teeth has unusual translucent/opalescent hue. tooth in which the tooth count reveals a missing
l Enamel lost earlier due to fracture; defective tooth when the anomalous tooth is counted as one.
l One of the most important criteria for fusion is the
Dentino Enamel Junction (DEJ) and dentine is worn off.
fused tooth must exhibit confluent dentine.
Radiographic features l Both permanent and deciduous dentition are af-
l Deciduous dentition shows ‘shell teeth’ appearance due fected in case of fusion, although it is more com-
to enlarged pulp chambers and root canals. mon in deciduous teeth.
l The permanent teeth have pulpal spaces that are either l Fusion can be complete or incomplete and its ex-
smaller than normal or completely obliterated. tent will depend on stage of odontogenesis at
Histological features which fusion takes place.
l The incisor teeth are more frequently affected in
l Histopathology of teeth in shields type III has not been
adequately documented. both the dentitions.
Section | I Topic-Wise Solved Questions of Previous Years 351

I. c . Concrescence Dens evaginatous (occlusal tuberculated premolar,

l Concrescence is defined as union of two adjacent Leong’s premolar, evaginated odontome)
teeth by cementum only without confluence of the l Dens evaginatus is a developmental condition ap-

underlying dentine. pearing as an accessory cusp or globule of enamel

l It is the type of fusion, which is limited only to the on occlusal surface between buccal and lingual
roots of teeth and it occurs after the root formation cusps of premolars unilaterally or bilaterally.
of involved teeth is completed. l This is opposite of invagination. That means there

l Aetiology: Concrescence may be developmental or occurs extrusion of the dental papilla outwards
postinflammatory or due to traumatic injury. into the enamel organ.
l Common between maxillary second molar and l Clinical findings:

unerupted third molar. l This condition is more common in people of

II. Accessory cusps Chinese race.

a. Cusp of Carabelli l More common in maxillary first premolars

b. Talon cusp but also occurs rarely on molars, cuspids and

c. Dens invaginatous (dens in dente) incisors.
d. Dens evaginatous l Presents a tubercle of enamel with a core of

Cusp of Carabelli dentine with a narrow pulp chamber.

l Present on mesiopalatal cusp of maxillary first l When the tooth erupts, this bit of enamel is

molars. higher than the cusps, and covers the underly-

l An analogous accessory cusp is seen occasionally ing mass of dentine.
on the mesiobuccal cusp of a mandibular perma- l If present in deciduous teeth, it causes diffi-

nent or deciduous molar known as protostylid. culty in feeding.

Talon cusp l When the thin surface enamel of the tubercle

l Talon cusp is an anomalous projection resembling breaks down, infection of the tooth takes place
eagle’s talon projects lingually from cingulum resulting in death of the pulp and abscess for-
area of permanent incisors. mation.
l A developmental groove is present at the site, l Treatment consists of extraction of the tooth.

where this projection meets with the lingual sur- III. Ectopic enamel
face of tooth. l Enamel pearls

l This groove is prone to caries, so it should be l Cervical enamel extensions

removed. If pulp exposure is present then end- l Ectopic enamel or enamel pearls or enameloma

odontic therapy is done. or enamel drop usually occurs in furcation area

l Found in association with ‘Rubinstein–Taybi syn- below the crest of gingiva.
drome’. l Cervical enamel extension also occurs along the

Dens in dente or dens invaginatous surface of dental roots.

l Dens in dente is a developmental variation, which l Maxillary and mandibular molars are most com-
arises as a result of enamel epithelial invagination monly affected.
of the crown surface before calcification. l Predisposes to development of buccal bifurcation

l Several causes of this condition are: focal growth cysts.

proliferation and focal growth retardation that IV. Taurodontism (bull-like teeth)
take place in certain areas of tooth bud, increased l Taurodontism is a dental anomaly in which the

localized external pressure. body of the tooth is enlarged at the expense of roots.
l After calcification it appears as accentuation of Aetiology
lingual pit. l Specialized or retrograde character.

l Teeth most frequently involved are maxillary lat- l Primitive pattern.

eral and maxillary central incisors. l Atavistic feature.

l Radiographic features l Mendelian recessive trait.

Appearance of tooth within tooth due to deep l Mutation.

pear-shaped invagination from lingual pits, ap- l Associated with Klinefelter syndrome.

proximating to pulp. l It is due to failure of Hertwig epithelial root

l Treatment sheath to invaginate at proper horizontal level.

This anomaly makes teeth prone to caries so Clinical findings
endodontic therapy should be done. Restoratory l It may affect both deciduous and permanent

procedures are unsuccessful because of this deep dentition, but more common in permanent
invagination, which generally approximates pulp. dentition.
352 Quick Review Series for BDS 4th Year, Vol 2

l Molars are commonly affected. l Once perforation has occurred, extraction of tooth is
l Tooth morphology is normal. the treatment.
Radiographic features
Q.2. Dens invaginatus.
l Enlarged and rectangular pulp chamber is present.

l No constriction of pulp at cervical area. Ans.

l Roots are very short.
l Dens invaginatus is otherwise known as dens in dente or
l Furcation is present just above root apex.
gestant odontoma.
Treatment
l It is a developmental variation that arises as a result
l No treatment is required.
of enamel epithelial invagination of the crown surface
V. Dilaceration
before calcification.
l Dilaceration refers to angulation or curve in root or
l It is an enamel lined surface invagination of crown or
crown of tooth.
root.
l Angulation is caused due to trauma to the tooth dur-

ing formative stage of tooth. Causes

l Curve is present at apical, middle or at cervical por- l It is because of focal growth proliferation and focal
tion depending on the portion which is forming at growth retardation that takes place in certain areas of
the time of trauma. tooth bud due to increased localized external pressure.
l Occlusal trauma in deciduous tooth may also cause l Coronal form is formed by the infolding of enamel or-
dilaceration of permanent tooth. gan in to dental papilla, while radicular form is pro-
l More common in the maxillary anterior region. duced due to invagination of Hertwig root sheath.
l Significance: Tooth with bent root is difficult to
Clinical features
extract.
l Teeth most frequently involved are maxillary lateral and
VI. Supernumerary roots
maxillary central incisors.
l One or more extra roots may be present in tooth.
l After calcification of teeth, it appears as accentuation of
l Usually single rooted teeth such as mandibular cus-
lingual pit.
pids and bicuspids are involved.
l Oehlers classified coronal dens invaginatus into three
l Third molars of both jaws also present one or more
types based on depth of invagination:
extra roots.
Type I: Invagination ends in a blind sac, limited to den-
tal crown.
SHORT ESSAYS: Type II: Invagination extends in to CEJ, also ending in
a blind sac.
Q.1. Internal resorption.
Type III: Invagination extends to the interior of the
Ans. root, providing an opening to periodontium, some-
times presenting another foramen in apical region of
l Internal resorption is also known as chronic perforating
the root.
hyperplasia of pulp, odontoclastoma or pink tooth of
mummery. Radiographic features
l It is an unusual form of resorption that begins centrally l Appearance of tooth within tooth due to deep pear-
within the pulp, apparently initiated by a peculiar in- shaped invagination from lingual pits, approximating to
flammatory hyperplasia of the pulp. pulp.
Aetiology l In severe forms, crown is malformed and an open apex
l Idiopathic is present.
Clinical features
Treatment
l No early clinical signs and symptoms.
l This anomaly makes teeth prone to caries so endodontic
l Tooth may show pink spot (pink tooth) when more of
therapy should be done.
dentine is resorbed from one area of the crown, leav-
l Restorative procedures are unsuccessful because of this
ing a covering of translucent enamel.
deep invagination, which generally approximates pulp.
l It appears as a pink area due to vascular pulp visible

through the translucent enamel. Q.3. Anodontia.

Radiographic appearance
Ans.
l Pink spot appears as round or ovoid area of radiolu-

cency in the central portion of the tooth. l Anodontia is defined as the condition in which there is
Treatment congenital absence of teeth in oral cavity.
l If condition is discovered before perforation of l Anodontia is rare and most cases occur in the presence
crown, root canal therapy may be carried out. of ectodermal dysplasia.
Section | I Topic-Wise Solved Questions of Previous Years 353

Aetiology l Enamel of the affected teeth fails to develop to its nor-

The causes of anodontia are as follows: mal thickness.
i. Hereditary factor l Yellowish brown colour of the teeth.
ii. Environmental factor l Enamel may be pitted, rough, smooth and glossy.
iii. Familial factor l Open contacts and anterior open bite may occur.
iv. Syndrome associated
Q.2. Talon cusp.
v. Radiation injury to the developing tooth germ
Ans.
Types
l Anodontia can also be divided into following types: l Talon cusp is an anomalous structure resembling an
a. True anodontia: It occurs due to failure of develop- eagle’s talon, projects lingually from the cingulum areas
ment or formation of tooth in jaw bone. of a maxillary or mandibular permanent incisor.
b. Pseudo anodontia: It refers to the condition in which l It consists of deep developmental groove where the cusp
teeth are present within the jaw bone but are not blends with the sloping lingual tooth surface.
clinically visible in the mouth, as they have not l It is composed of normal enamel and dentine and con-
erupted, e.g. impacted teeth. tains a horn of pulp tissue.
c. Induced or false anodontia: It is the condition in l It may be associated with Rubinstein–Taybi syndrome.
which teeth are missing in the oral cavity because of
Q.3. Dilaceration.
their previous extractions.
Ans.
True anodontia
True anodontia is of two types: l Dilaceration refers to an angulation, or a sharp bend or
a. Complete anodontia: There is congenital absence of all curve, in the root or crown of a formed tooth.
the teeth. l This condition is caused due to trauma during the period
b. Partial anodontia: Congenital absence of one or few in which the tooth is forming.
teeth. l Dilacerated teeth frequently present difficult problems
at the time of extraction.
Complete anodontia
l It is the condition in which there is neither any decidu- Q.4. Dens in dente.
ous tooth nor any permanent tooth present in the oral Ans.
cavity.
l A complete anodontia is a common feature of heredi- l Dens in dente is also known as dens invaginatus/dilated
tary ectodermal dysplasia; however, in many cases cus- composite odontome or gestant odontome.
pids are present in this disease. l It is a developmental variation that arises as a result of
l Complete anodontia occurs among children those who an invagination in the surface of the tooth crown before
have received high doses of radiation to the jaws as calcification has occurred.
infants for therapeutic reasons. l Causes: increased localized external pressure, facial
growth retardation.
Partial anodontia l Permanent maxillary lateral incisors are commonly in-
l It is a common phenomenon and is characterized by volved followed by maxillary central incisors.
congenital absence of one or few teeth. l Condition is usually bilateral.
l In partial anodontia any tooth can be congenitally
missing. Q.5. Turner tooth.
For example, the third molars are most frequently ob- Ans.
served congenitally missing teeth.
The mandibular first molars and the mandibular lateral l Turner first described this localized type of hypoplasia.
incisors are least likely to be missing. l He noted defects in the enamel of two premolars and
traced the defects to apical infection of the nearest pri-
mary molar.
SHORT NOTES: l Enamel hypoplasia resulting from local infection is
Q.1. Enamel hypoplasia. called Turner tooth.
Q.6. Clinical features of regional odontodysplasia.
Ans.
Ans.
l Enamel hypoplasia occurs as a result of some defect in
ameloblasts due to nutritional deficiencies, exanthema- l One or several teeth in a localized area are affected.
tous diseases, congenital syphilis, ingestion of fluoride, l Anterior teeth are affected mostly.
local infection or idiopathic. l Maxillary arch is more commonly involved.
354 Quick Review Series for BDS 4th Year, Vol 2

Clinical features l They appear as small yellow spots, either discretely

l Delayed or no eruption of teeth may be seen. separated or large plaques, often projecting slightly
l Defective mineralization causes irregular shape of teeth. above the surface of tissue.
l They are found most frequently in a bilaterally sym-
Radiographic feature
metrical pattern on the mucosa of cheeks opposite to
l Ghost-like appearance of tooth with large pulp, thin
molar teeth, inner surface of the lips, retromolar region
enamel and dentine.
and occasionally tongue, gingiva, frenum and palate.
Histological features
Q.11. Anodontia.
l Enamel is hypoplastic and hypomineralized.
l Dentine has thickened predentin layer. Ans.
Q.7. Dentinogenesis imperfecta. l Anodontia is defined as the condition in which there is
Ans. congenital absence of teeth in oral cavity.
l Absence of teeth in the oral cavity causes growth re-
l Dentinogenesis imperfecta is a developmental distur- striction of alveolar process. This is more common in
bance in the structure of the teeth. the permanent dentition.
l This is an autosomal condition affecting both deciduous l Anodontia may be total (complete) or partial (incom-
and permanent teeth. plete) and true or pseudo.
l Affected teeth are grey to yellowish brown and have
broad crowns with a constriction area of the cervical True anodontia
area resulting in a tulip-shape. l Congenital absence of teeth is termed as true anodontia.
l Types: l Total absence of teeth is found in case of hereditary
l Dentinogenesis imperfecta type I (opalescent dentine)
ectodermal dysplasia.
l Dentinogenesis imperfecta type II (brandy wine type).
l Partial absence of teeth is termed as true partial anodon-
tia and affects third molars, lateral incisors and premo-
Treatment for both type I and type II dentinogenesis im- lars usually.
perfecta
l Crown capping may be done on teeth to avoid attrition. False or pseudoanodontia
Cast metal crowns on posterior teeth and jacket crowns It results from noneruption of multiple teeth.
on anterior teeth have been used with considerable Q.12. Concrescence.
success.
Ans.
Q.8. Pink tooth of mummery.
l Concrescence is a developmental anomaly where the
Ans. fusion of teeth occurs along the cementum only.
l Internal resorption (pink tooth of mummery) odonto- l It occurs after the root formation is completed.
clastoma/internal granuloma/chronic perforating hyper- l This may be due to trauma, crowding of teeth with
plasia of pulp) resorption of interdental bone.
l Idiopathic Q.13. Supernumerary teeth.
l Due to inflammatory hyperplasia of pulp
Ans.
Q.9. Hutchinson triad.
l Supernumerary teeth are a developmental disturbance in
Ans. the number of teeth.
l Hutchinson triad is a pathognomonic feature of con- l A supernumerary tooth is an additional entity to the
genital syphilis. normal series and is seen in all quadrants of the jaw
l The Hutchinson triad includes hypoplasia of the inci- l Morphological types of supernumerary teeth:
l Conical
sors and molar teeth, eighth nerve deafness and intesti-
l Tuberculate
nal keratitis.
l Supplemental
Q.10. Fordyce granules. l Odontome

l Supplemental supernumerary teeth are teeth that resem-

Ans.
ble the typical anatomy of posterior and anterior teeth.
l Fordyce granules are a developmental anomaly charac- l Rudimentary supernumerary teeth these are conical in
terized by heterotopic collection of sebaceous glands at shape. Usually they are found in syndromes like cleido-
various sites in the oral cavity. cranial dysplasia, and orofacial digital syndrome.
Section | I Topic-Wise Solved Questions of Previous Years 355

l Multiple supernumerary teeth can occur in association l Geographic tongue is often detected during routine den-
with the conditions like Gardener syndrome and cleido- tal examination of paediatric patients who are unaware
cranial dysplasia. of the condition.
l Red, smooth areas devoid of filiform papillae appear on
Q.14. Taurodontism.
the dorsum of the tongue. The margins of the lesions are
Ans. well developed and slightly raised.
l Taurodontism is a dental anomaly in which the body of l The involved areas enlarge and migrate by extension of
the tooth is enlarged at the expense of the roots. the desquamation of the papillae at one margin of the
l The term taurodontism refers to ‘bull-like teeth’. lesion and regeneration at the other.
l Cause: Failure of Hertwig epithelial sheath to invaginate l Every few days a change can be noted in the pattern of
at the proper horizontal level. the lesions.
l Most commonly involves permanent dentition followed l The condition is self-limited, hence no treatment is nec-
by deciduous dentition, molars are be commonly essary.
involved. Q.19. Macroglossia.
l Condition may be unilateral or bilateral.
l Involved teeth are rectangular in shape. Ans.

Q.15. Describe briefly the causes for early loss of teeth. i. Macroglossia is a developmental disturbance of tongue.
ii. It is also called as tongue hypertrophy or enlarged
Ans. tongue.
l Along with hypophosphatasia, prepubertal periodontitis iii. Types are
appears to be the most common cause of premature ex- a. True macroglossia
foliation of the primary teeth, especially in girls. b. Psuedomacroglossia
l The early exfoliation of primary teeth resulting from iv. Clinical features
l Severe retrognathia, unusually small maxilla or man-
periodontitis has been observed occasionally in young
children. dibular size.
l It may be associated with Down syndrome and Beck-
Q.16. Median rhomboid glossitis. with–Wiedemann syndrome.
Ans. v. Treatment
Surgical intervention
l Median rhomboid glossitis is a developmental distur-
bance of tongue. Q.20. Dentine dysplasia.

Clinical features Ans.

l It presents as oval-shaped reddish patch or plaque in the l Dentine dysplasia is also known as ‘rootless teeth’ and
posterior midline of the dorsum of the tongue, just anterior is a developmental disturbance in the structure of
to the V-shaped grouping of the circumvallate papillae. teeth.
l It appears in the childhood and is of 3:1 male predilection. l It is a rare disturbance of dentine formation character-
l Lesion with atrophic candidiasis appears erythematous. ized by normal enamel but atypical dentine formation
l Infected lesions show midline soft palate erythema in with abnormal pulpal morphology.
the area of routine contact with tongue involvement l Shields and colleagues categorized it into two types:
referred as a ‘kissing lesion’. i. Radicular dentine dysplasia (type I)
l They may be caused due to localized chronic fungal ii. Coronal dentine dysplasia
infection specially candida. l Both primary and secondary dentitions are affected in
Q.17. Geographic tongue. dentine dysplasia type I, which is inherited as an auto-
somal dominant trait.
And l Radiographically, the roots are short and may be more
Q.18. Benign migratory glossitis. pointed than normal.
l Usually, the root canals and pulp chambers are absent
Ans.
except for a chevron-shaped remnant in the crown.
l Benign migratory glossitis is also known as geographic l The colour and general morphology of the crowns of the
tongue/wandering rash of tongue/glossitis areata exfo- teeth are usually normal, although they may be slightly
liativa/erythema migrans. opalescent and blue or brown.
l It is a wandering type of lesion and probably the most l Periapical radiolucencies may be present at the apices
common tongue anomaly. of affected teeth.
356 Quick Review Series for BDS 4th Year, Vol 2

l Dentine dysplasia type II is inherited as an autosomal l Histopathologically, there is increased melanin produc-
dominant trait in which the primary dentition appears tion without melanocytic hyperplasia.
opalescent and on radiographs has obliterated pulp
chambers, similar to the appearance in dentinogenesis Q.24. Globulomaxillary cyst.
imperfecta. Ans.
l In dentine dysplasia type II, the permanent dentition has
normal colour and radiographically exhibits a thistle l Globulomaxillary cyst is described as a fissural cyst
tube pulp configuration with pulp stones. found within the bone between the maxillary lateral in-
cisor and canine teeth.
Q.21. Black hairy tongue. l Clinical features: Asymptomatic, only if cysts become
Ans. infected, patient may complain of local discomfort or
pain in the area.
l Hairy tongue is also known as lingua nigra, lingua vil-
l Radiologically, it is a well-defined inverted pear-shaped
losa and black hairy tongue.
radiolucency, which frequently causes the roots of the
l It is a condition of defective desquamation of filiform
adjacent teeth to diverge.
papillae that results from a variety of precipitating
l Treatment: Cyst should be surgically removed.
factors.
l Hairy tongue may appear as brown, green, pink or any Q.25. Gingival cysts of infants.
of a variety of hues depending on specific aetiology and
secondary factors. Ans.
l Filiform papillae in hairy tongue measures more than l Gingival cyst of infants or newborn is an odontogenic
15 mm in length. cyst, which is developmental in nature.
l Over growth of Candida albicans may result in glosso- l These cysts are seen in infants. These cysts are seldom
pyrosis (burning tongue). seen after 3 months of age.
Q.22. Natal teeth.
Origin
Ans. l They arise from the epithelial remnants of dental lamina
l Teeth present at birth are known as natal teeth. In these called cell rests of Serres.
teeth there is almost no root present. Clinical features
l Teeth that erupt within 30 days after birth are called l The cyst is seen on the crest of the maxillary and man-
neonatal teeth. dibular dental ridges and appears creamish-white in
l Preferably natal or neonatal tooth should not be ex- colour.
tracted for normal growth and uncomplicated eruption l These cysts are usually minute in size and rarely exceed
of the adjacent teeth. But in case it is hyper mobile and 3 mm in diameter and commonly occur on the maxillary
there is a danger of its avulsion and swallowing by the alveolar ridge.
child, it should be extracted.
l The mother may have some problem in breastfeeding Histopathology
the child with natal or neonatal teeth. If the mother can- l Histopathological evaluation reveals a keratin filled cyst
not bear this discomfort, she can use the breast pump. lined by parakeratinized epithelium.
Q.23. Peutz–Jeghers syndrome. Treatment
l Gingival cysts in infants need no treatment as they tend
Ans.
to undergo involution and disappear. Most cysts tend to
l This syndrome consists of familial generalized intesti- rupture spontaneously.
nal polyposis and pigmented spots on the face, oral
cavity and sometimes hands and feet. Q.26. What is fusion.
l The syndrome is due to a mutation of gene LKB 1, Ans.
which has an autosomal dominant inheritance.
l Brown macules of varying number and size (usually l Fusion is a development disturbance in the shape of the
1–5 mm) are seen in buccal mucosa, gingiva and hard tooth.
palate. l Fused teeth arise through union of two normally sepa-
l Facial pigmentation tends to fade later in life, mucosal rated tooth germs.
pigmentation persists. l Fusion is defined as single enlarged tooth or joined
l Intestinal polyposis of colon may undergo malignant tooth in which the tooth count reveals a missing tooth
change. when the anomalous tooth is counted as one.
Section | I Topic-Wise Solved Questions of Previous Years 357

l Both permanent and deciduous dentitions are affected in Q.28. Gardner syndrome.
case of fusion, although it is more common in decidu-
Ans.
ous teeth.
l The incisor teeth are more frequently affected in both l It is autosomal dominant pattern of inheritance.
the dentitions.
Clinical features
Q.27. Oligodontia. l Multiple impacted supernumerary and permanent
teeth.
Ans.
l Multiple polyposis of large intestine that are prema-
l Oligodontia refers to lack of development of six or more lignant.
teeth. l Osteomas of bones.
l Damage to dental lamina before tooth formation can l Multiple epidermal sebaceous cysts.
result in hypodontia. l Desmoid tumours.
l May be caused by genetic factors, trauma, endocrine
Q.29. Mesiodens.
disturbances, infection, radiation and chemotherapeutic
medications. Ans.
l It may also occur in hereditary syndromes such as Crou-
l Mesiodens (maxillary) is the most common supernu-
zon syndrome, Down syndrome, ectodermal dysplasia,
merary teeth.
Hurler syndrome and Turner syndrome.
l Autosomal dominant-type of inheritance.
l It usually affects permanent third molars, second pre-
l 90% occur in maxilla.
molars and lateral incisors in that order. Associated mi-
l Develops from third tooth bud or splitting of permanent
crodontia may be observed.
tooth bud.
l Oligodontia and hypodontia may cause abnormal spac-
l More common in males compared to females.
ing of teeth, delayed tooth formation, delayed decidu-
l Occurrence is very less in deciduous teeth (Maxillary B .
ous tooth exfoliation and late permanent tooth eruption.
Maxillary C and D).
l Treatment: Prosthetic replacement of teeth may be
needed.

Topic 11
Orofacial Pain

COMMONLY ASKED QUESTIONS

LONG ESSAYS:
1. Write about the aetiology, diagnosis, clinical features and management of trigeminal neuralgia.
2. Define pain. Classify facial pain. Describe the aetiopathogenesis, clinical features and management of atypical
facial pain.
3. Describe in detail aetiology, clinical features, differential diagnosis and management of periodic migrainous
neuralgia.
4. Discuss neuralgias affecting maxillofacial region. How would you treat trigeminal neuralgia? [Same as LE Q.1]
5. Describe aetiopathogenesis clinical features and management of trigeminal neuralgia. [Same as LE Q.1]
6. Describe in detail aetiology, clinical features and management of trigeminal neuralgia. [Same as LE Q.1]
7. What is neuralgia? Describe the different types of neuralgias of orofacial origin. And add a note on management
of orofacial neuralgia. [Same as LE Q.1]
8. Give the differential diagnosis of pain in and around the tooth. [Same as LE Q.2]
9. Describe the ‘pain in and around the tooth’. Mention the treatment. [Same as LE Q.2]
358 Quick Review Series for BDS 4th Year, Vol 2

SHORT ESSAYS:
1. Aetiology, signs and symptoms of Bell palsy.
2. Pain in migraine and periodic migrainous neuralgia. [Ref LE Q.3]
3. Aetiology, signs and symptoms of trigeminal neuralgia.
4. Treatment of myofascial pain dysfunction syndrome.
5. List the differences between pain characteristics of trigeminal neuralgia and acute pulpitis.
6. Transelectric nerve stimulation.
7. Trismus.
8. Burning mouth syndrome (glossodynia).
9. Postherpetic neuralgia.
10. Bell palsy. [Same as SE Q.1]
11. Trigeminal neuralgia. [Same as SE Q.3]

SHORT NOTES:
1. Bell sign.
2. Burning mouth syndrome.
3. Clinical features of Bell palsy.
4. Name the neuralgias of orofacial origin.
5. Define atypical facial pain. [Ref LE Q.2]
6. Gamma knife stereotactic radio surgery in management of the tic douloureux.
7. Enumerate the two important differences between the paroxysmal neuralgias and atypical neuralgias.
8. PHN: mention two clinical manifestations.
9. Glossopharyngeal neuralgia.
10. Trismus. [Ref SE Q.7]
11. ‘TENS’ therapy. [Ref SE Q.6]
12. Types of migraine.
13. Alarm clock headache.
14. Trigger zones.
15. Classifications of headaches. [Ref LE Q.2]
16. Glossodynia. [Same as SN Q.2]
17. Atypical odontalgia. [Same as SN Q.5]

SOLVED ANSWERS
LONG ESSAYS: l Nicholaus Andre coined the term tic douloureux.
Q.1. Write about the aetiology, diagnosis, clinical fea- l John Fothergill in 1773 published detailed descrip-
tures and management of trigeminal neuralgia. tion of trigeminal neuralgia, hence it is known as
Fothergill disease.
Ans.
Different types of neuralgias
l Neuralgia is a clinical condition involving pain of a
l Paroxysmal neuralgia (trigeminal, glossopharyngeal,
severe intensity, with a throbbing or stabbing character
nervous intermedius and superior laryngeal)
in the course or distribution of a specific nerve.
l Occipital neuralgia, postherpetic neuralgia (PHN) and
l Trigeminal neuralgia is defined as sudden, usually uni-
post-traumatic neuropathic pain
lateral severe, brief, lancinating, recurring pain in the
distribution of one or more branches of 5th cranial Aetiology
nerve. l Unknown
l Trigeminal neuralgia is also called as tic douloureux. l Two categories:
l John Locke has given first full description with its a. Idiopathic
treatment. b. Secondary multiple origins
Section | I Topic-Wise Solved Questions of Previous Years 359

Probable aetiological factors are listed below: xi. Different stimuli can trigger pain – ‘trigger zones’.
l Vascular factors l Touching or applying heat/cold to cheek/gums, etc.

l Mechanical factors l Wind blowing on face.

l Anomaly of superior cerebellar artery l Gustatory stimuli and vibration.

i. Intracranial vascular abnormalities:

Diagnosis
l Pontine infarcts – compression/distortion at root
i. Well-taken history.
entry zone of 5th nerve at pons by arterial loop
ii. Clinical tests
l Arteriovenous malformation in the vicinity (ve-
l Blink reflex study
nous compression)
l Diagnostic nerve blocks with L.A. infiltration
l Compression of intracranial retrogasserian por-
(2% xylocaine)
tion of 5th nerve by a displaced vein/artery
l Response to treatment with tablet carbamazepine
l Aneurysm of the internal carotid artery
iii. Imaging techniques
ii. Intracranial tumours
l MRI – Imaging modality of choice, it reviews mul-
l May impinge on nerve, e.g. epidermoid tumours
tiple sclerosis plaques and pontine gliomas.
such as meningiomas of cerebellopontine region
l CT (pool resolution in posterior fossa) vascular com-
and Meckel’s cave
pressions.
l Trigeminal neuromas of middle cranial fossa
l Conventional angiogram (only if vascular malforma-
and posterior cranial fossa
tion is suspected)
iii. Inflammatory
l Multiple sclerosis, sarcoidosis – sclerotic plaque Treatment
located at root entry zone of trigeminal nerve, etc. Please refer the text given in the following box:
iv. Infections
l Granulomatous/nongranulomatous involving
5th cranial nerve Medical Surgical
v. Viral aetiology i. Carbamazepine Interruption of Intracranially
l Postherptic neuralgia, history of previous infec- (tegretol, carba- pain pathways be- i. Alcohol
tion by varicella zoster virus trol) – standard- tween centre and blockade
ized criteria for periphery a. Gasserian
l Viral lesions of the ganglion may be the aetio-
treatment of tri- Extracranially ganglion
logical factors geminal neuralgia i. Alcohol block ii. RFTC at
vi. Post-traumatic neuralgia (dose starts with in peripheral gasserian
vii. Dental aetiology 100 mg t.i.d. up nerve. ganglion
viii. Ratner’s jawbone cavities to large doses like ii. Nerve section iii. Retrogasse-
1000–1500 mg/ and avulsion, rian rhizot-
ix. Petrous bridge or basilar compression
day). i.e. peripheral omy
ii. Phenytoin (dilan- neurectomy iv. Medullary
Clinical features tin) 100 mg t.i.d. l Supraor- tractotomy
i. Incidence – Rare affliction 4 in 100,000 persons. iii. Oxcarbazepine – bital v. Midbrain
ii. Age – Late middle age/later in life (5th or 6th decade). 1200 mg/day l Infraorbital tractotomy
iii. Sex – more prediction in females. iv. Valproic acid – l Lingual vi. Intracranial
600 mg/day Inferior nerve de-
iv. Prediction for right side in 60% of the cases.
l

v. Clonazepam alveolar compression

v. Division of 5th nerve involved – V3 is more common, (Klonopin) not (Ginwalla’s Janetta’s and
V1 is rarely involved (5% of cases). recommended in technique) Dandy’s
vi. Trigeminal neuralgia manifest as – Sudden, unilateral, case of sedation iii. Electrosurgery approach
intermittent, paroxysmal, sharp, shooting, lancinating, and dependence iv. Cryosurgery
vi. Amitriptyline (cryoprobe at
shock-like pain. (Elavil): success temperature
vii. Pain is of short duration and lasts for few seconds. A rate is low. colder than
refractory period can be as short as a couple of seconds. Other least toxic 260°C causes
viii. Pain is unilateral and does not shift sides, although agents: Wallerian
very rare bilateral cases have been described. l Baclofen (Liore- degeneration)
sal) 10 mg t.d.s. v. Selective
ix. Pain is usually confined to one part or one division of l Gabapentin radiofrequency
5th nerve mandible or maxilla but may occasionally (Neurontin) thermo-
spread to adjacent division or rarely involve all three l Lamotrigine coagulation
divisions. l Felbamate
x. The characteristic of this disorder is that attacks do not l Topiramate
l Vigabatrin
occur during sleep.
360 Quick Review Series for BDS 4th Year, Vol 2

New technique for trigeminal neuralgia Neurologic disorders

Gamma knife stereotactic radiosurgery l Paroxysmal neuralgias
l New minimally invasive technique for treatment of l Trigeminal neuralgia
trigeminal neuralgia. l Glossopharyngeal neuralgia
l It uses beams of radiation usually in doses of 70–90 Gy l Continuous neuralgias
units, converging in three dimensions to focus precisely l Atypical odontalgia
on a small volume. l Traumatic neuroma
l This method relies on precise MRI sequencing that helps l Neuritis
localization of the beam and allows a higher dose of ra- l PHN
diation to be given with more sparing of nerve tissue.
W.E. Bell (1989) has classified orofacial pain as follows:
l Advantage of this technique is that it is particularly
Axis I (physical conditions)
helpful for elderly patients with a high surgical risk.
Somatic pain
Q.2. Define pain. Classify facial pain. Describe the aetio- l Superficial somatic pain (cutaneous, mucogingival)
pathogenesis, clinical features and management of atyp- l Deep somatic pain
ical facial pain. l Musculoskeletal pain (muscle, TMJ, osseous and

periosteal, soft connective tissue and periodontal)

Ans.
l Visceral pain (pulpal, vascular, neurovascular,
Pain is defined as an unpleasant sensory and emotional ex- visceral mucosal, glandular, ocular and auricular)
perience associated with actual or potential tissue damage, Neuropathic pain
or described in terms of such damage. l Episodic (trigeminal, glossopharyngeal, genicu-

late, nervous intermedius neuralgias and neuro-

Classification of orofacial pain
vascular pains)
The American Academy of Orofacial Pain has classi-
l Continuous (neuritis, deafferentation pain and
fied orofacial pain as follows:
sympathetically maintained pain)
Intracranial structures
Axis II (psychologic conditions)
l Neoplasm
i. Mood disorders
l Aneurysm
ii. Anxiety disorders
l Haematoma
iii. Somatoform disorders
l Haemorrhage
iv. Other conditions
l Abscess

l Oedema
Differential Diagnosis of Orofacial Pain
Extracranial structures
Intracranial pain Neoplasms, aneurysms, abscess, haemor-
l Teeth
disorders rhage, haematoma, oedema
l Ears
Primary head- Migraine, migraine variants, cluster head-
l Eyes
ache disorders ache, cranial arteritis, carotidynia, tension-
l Nose
(neurovascular type headache
l Throat disorders)
l Sinuses
Neurogenic pain Paroxysmal neuralgias (trigeminal, glossopha-
l Tongue
disorders ryngeal, nervus intermedius, superior laryn-
l Glands geal), continuous pain disorders (neuritis, PHN,
Musculoskeletal disorders post-traumatic and postsurgical neuralgia)
l Temporo mandibular Joint (TMJ) disorders Intraoral pain Sympathetically maintained pain: dental
l Masticatory muscle disorders disorders pulp, periodontium, mucogingival tissues,
l Fibromyalgia tongue
l Cervical disorders Temporoman- Masticatory muscle, temporomandibular
l Generalized polyarthritides dibular disorders joint – associated structures
Neurovascular disorders Associated Ears, eyes, nose, paranasal sinuses, throat.
structures lymph nodes, salivary glands, neck
{SN Q.15}
l Migraine headaches {SN Q.5}
l Cluster headaches
l Tension-type headaches Atypical odontalgia (atypical facial pain)
l The term ‘atypical odontalgia’ is used when the pain
is confined to the teeth or gingivae, whereas the term
l Cranial arteritis
Section | I Topic-Wise Solved Questions of Previous Years 361

l Symptoms may remain unilateral, cross the midline in

‘atypical facial pain’ is used when other parts of the
some cases, or involve both the maxilla and mandible.
face are involved.
l Feinmann characterized AFP as a nonmuscular or Diagnosis
joint pain that has no detectable neurologic cause. l A thorough history and examination including evalua-
l Atypical facial pain was described by Truelove and tion of the cranial nerves, oropharynx and teeth must be
colleagues as a condition characterized by the absence performed to rule out dental, neurologic or nasopharyn-
of other diagnoses and causing continuous, variable- geal disease.
intensity, migrating, nagging, deep and diffuse pain. l Examination of the masticatory muscles should also be
l Recent advances in the understanding of chronic performed to eliminate pain secondary to undetected
pain suggest that at least a portion of patients who muscle dysfunction.
have been diagnosed with AFP may be experiencing l Laboratory tests should be carried out when indicated
neuropathic pain. by the history and examination. Patients with AFP have
completely normal radiographic and clinical laboratory
studies.
Aetiology and pathogenesis
Management
l There are several theories regarding the aetiology of
l Once the diagnosis is confirmed, it is important that the
Atypical odontalgia (AO) & Atypical facial pain (AFP).
symptoms are taken seriously and are not dismissed as
One theory considers AO and AFP to be a form of deaf-
imaginary.
ferentation or phantom tooth pain.
l Patients should be counselled regarding the nature of
l This theory is supported by the high percentage of patients
AFP and reassured that they do not have an undetected
with these disorders who report that the symptoms began
life-threatening disease and that they can be helped
after a dental procedure such as endodontic therapy or an
without invasive procedures.
extraction.
l When indicated, consultation with other specialists such
l Others have theorized that AO is a form of vascular,
as otolaryngologists, neurologists or psychiatrists may
neuropathic or sympathetically maintained pain.
be helpful.
l Other studies support the concept that at least some of
l Tricyclic antidepressants such as amitriptyline, nortrip-
the patients in this category have a strong psychogenic
tyline and doxepin, given in low to moderate doses, are
component to their symptoms and that depressive, so-
often effective in reducing or in some cases eliminating
matization and conversion disorders have been de-
the pain.
scribed as major factors in some patients. It is frequently
l Other recommended drugs include gabapentin and clon-
difficult to accurately study the psychological aspects of
azepam. Some clinicians report benefit from topical
a chronic pain.
desensitization with capsaicin, topical anaesthetics or
Clinical manifestations topical doxepin.
l The major clinical manifestation of AFP is a constant
Q.3. Describe in detail aetiology, clinical features, differ-
dull aching pain without an apparent cause that can be
ential diagnosis and management of periodic migrainous
detected by examination or laboratory studies.
neuralgia.
l It occurs most frequently in women in the fourth and
fifth decades of life, and women make up more than Ans.
80% of the patients.
l The pain is described as a constant dull ache. There are [SE Q.2]
no trigger zones, and lancinating pains are rare.
l The patient frequently reports that the onset of pain
l {Migraine is the most common of the vascular head-
aches, which may occasionally also cause pain of the
coincided with a dental procedure such as oral surgery
face and jaws. It may be triggered by foods such as nuts,
or an endodontic or restorative procedure.
chocolate and red wine; stress; sleep deprivation; or
l Patients also report seeking multiple dental procedures
hunger.
to treat the pain; these procedures may result in tempo-
rary relief, but the pain characteristically returns in days Aetiology and pathogenesis
or weeks. l The classic theory is that migraine is caused by vaso-
l Other patients will give a history of sinus procedures or constriction of intracranial vessels, which causes the
of receiving trials of multiple medications, including neurologic symptoms, followed by vasodilation which
antibiotics, corticosteroids, decongestants or anticon- results in pounding headache.
vulsant drugs. l Newer research techniques suggest a series of factors,
l The pain may remain in one area or may migrate, either including the triggering of neurons in the midbrain
spontaneously or after a surgical procedure. that activate the trigeminal nerve system in the medulla,
362 Quick Review Series for BDS 4th Year, Vol 2

resulting in the release of neuropeptides such as sub- Treatment

stance P. l Patients with migraine should be carefully assessed to
l These neurotransmitters activate receptors on the ce- determine common food triggers. Attempts to mini-
rebral vessel walls, causing vasodilation and vasocon- mize reactions to the stress of everyday living by us-
striction. ing relaxation techniques may also be helpful to some
patients.
Types of migraine
l Drug therapy may be used either prophylactically to
There are several major types of migraine:
prevent attacks in patients who experience frequent
l Classic
headaches or acutely at the first sign of an attack.
l Common
l Drugs that are useful in aborting migraine include
l Basilar
ergotamine and sumatriptan, which can be given orally,
l Facial migraine (also referred to as carotidynia)
nasally, rectally or parenterally. These drugs must be
Clinical manifestations used cautiously since they may cause hypertension and
l Migraine is more common in women. other cardiovascular complications.
l Classic migraine starts with a prodromal aura that is l Drugs that are used to prevent migraine include pro-
usually visual but that may also be sensory or motor. pranolol, verapamil and TCAs. Methysergide or mono-
l The visual aura that commonly precedes classic mi- amine oxidase inhibitors such as phenelzine can be
graine includes flashing lights or a localized area of used to manage difficult cases that do not respond to
depressed vision (scotoma). safer drugs.}
l Sensitivity to light, haemianaesthesia, aphasia or other
Q.4. Discuss neuralgias affecting maxillofacial region.
neurologic symptoms may also be part of the aura,
How would you treat trigeminal neuralgia?
which commonly lasts from 20 to 30 min.
l The aura is followed by an increasingly severe unilateral Ans.
throbbing headache that is frequently accompanied by
[Same as LE Q.1]
nausea and vomiting.
l The patient characteristically lies down in a dark room Q.5. Describe aetiopathogenesis clinical features and
and tries to fall asleep. management of trigeminal neuralgia.
l Headaches characteristically last for hours up to 2 or [Same as LE Q.1]
3 days.
Q.6. Describe in detail aetiology, clinical features and
l Common migraine is not preceded by an aura, but pa-
management of trigeminal neuralgia.
tients may experience irritability or other mood changes.
[Same as LE Q.1]
l The pain of common migraine resembles the pain of
classic migraine and is usually unilateral, pounding and Q.7. What is neuralgia? Describe the different types of
associated with sensitivity to light and noise. Nausea neuralgias of orofacial origin. And add a note on man-
and vomiting are also common. agement of orofacial neuralgia.
l Basilar migraine is most common in young women. The
Ans.
symptoms are primarily neurologic and include aphasia,
temporary blindness, vertigo, confusion and ataxia. [Same as LE Q.1]
These symptoms may be accompanied by an occipital Q.8. Give the differential diagnosis of pain in and
headache. around the tooth.
l Facial migraine (carotidynia) causes a throbbing and/or
sticking pain in the neck or jaw. The pain is associated Ans.
with involvement of branches of the carotid artery rather [Same as LE Q.2]
than the cerebral vessels.
l The symptoms of facial migraine usually begin in indi- Q.9. Describe the ‘pain in and around the tooth’.
viduals who are 30–50 years of age. Mention the treatment.
l Patients often seek dental consultation, but unlike Ans.
toothache, facial migraine pain is not continuous but
lasts minutes to hours and recurs several times per [Same as LE Q.2]
week. Examination of the neck will reveal tenderness of
the carotid artery. SHORT ESSAYS:
l Face and jaw pain may be the only manifestation of
Q.1. Aetiology, signs and symptoms of Bell palsy.
migraine, or it may be an occasional pain in patients
who usually experience classic or common migraine. Ans.
Section | I Topic-Wise Solved Questions of Previous Years 363

i. Bell palsy is an abrupt, isolated and unilateral periph- l Circulatory insufficiency or reflex vasoconstriction of
eral facial nerve paralysis. Gasserian ganglion.
ii. Aetiology: l An area of demyelination as found in patients with mul-
l May be idiopathic or due to viral infections (HSV) tiple sclerosis may be the precipitant.
or ischaemia of the nerve near the stylomastoid
Clinical features
foramen.
l More common in older adults compared to young
iii. Clinical features:
persons.
l Paralysis of the facial musculature, usually unilater-
l Pain is confined to area of distribution of trigeminal
ally causing mask-like expressionless face.
nerve.
l Middle-aged women are more commonly affected.
l Right side of the face is affected in more patients com-
l Drooping of corners of mouth, epiphora, drooling
pared to left side.
of saliva, inability to close or wink the eye, loss
l The pain is usually searing, stabbing or lancinating
of wrinkling of forehead, ‘mask-like expressionless
type, which lasts only for few seconds or minutes and is
face’.
unilateral, seldom crosses the midline.
l Taste sensation is lost.
l The term tic douloureux is applied only when the pa-
iv. Treatment:
tient suffers from spasmodic contractions of the facial
l There is no universally preferred treatment for Bell
muscles.
palsy.
l ‘Trigger zone’ is characteristic feature of the trigeminal
l The only medical treatment that may influence the
neuralgia. The ‘trigger zones’, which precipitate an
outcome is the administration of systemic cortico-
attack when touched are usually common on the vermil-
steroids within the first few days after the onset of
ion border of the lips, ala of nose and around eyes.
paralysis, but this therapy should be avoided if Lyme
l Stimulation of trigger zone due to touching, laughing or
disease is suspected. Combining steroids with anti-
eating precipitate an attack of pain. In some cases, even
herpetic drugs such as acyclovir may decrease the
exposure to strong breeze or simply the act of eating or
severity and length of paralysis.
smiling has been known to precipitate the pain.
l It is also helpful to protect the eye with lubricating

drops or ointment and a patch if eye closure is not Treatment

possible. The treatment of trigeminal neuralgia is extremely var-
l When paralysis-induced eye opening is permanent, ied over the years. The various treatment modalities are as
intrapalpebral gold weights are inserted, thus closing follows:
the upper eyelid. i. Medical management
l Surgical decompression of the infratemporal facial Commonly used drugs are as follows:
nerve. l Carbamazepine (up to a dose of 600–1200 mg/

l Facial plastic surgery and the creation of an anasto- day): This drug is frequently used as therapeutic
mosis between the facial and hypoglossal nerves can challenge to the diagnosis of trigeminal neuralgia.
occasionally restore partial function and improve l Phenytoin (dilantin 100 mg t.d.s.): Use of this
appearance of patients with permanent damage. drug has been found be efficacious in some
cases.
Q.2. Pain in migraine and periodic migrainous neuralgia. l Anticonvulsants.

l Baclofen (50–60 mg/day).

Ans.
ii. Injection of alcohol or boiling water in to peripheral
[Ref LE Q.3] nerve area or centrally in to the Gasserian ganglion has
Q.3. Aetiology, signs and symptoms of trigeminal neu- been reported to be beneficial in causing respite from
pain.
ralgia.
iii. Surgical treatment
Ans. l Peripheral neurectomy.

l Is one of the earliest forms of the treatment for tri-

l Trigeminal neuralgia is a disease of trigeminal nerve or
geminal neuralgia, which includes sectioning of
fifth cranial nerve. It is otherwise known as tic doulou-
nerve at mental foramen, or at supraorbital or infra-
reux or Fothergill disease or trifacial neuralgia.
orbital foramen.
Aetiology l Microsurgical decompression of trigeminal nerve

l Most cases are idiopathic. root is one of the newest procedures for the manage-
l Sometimes it occurs due to pressure over trigeminal ment of trigeminal neuralgia. It has been reported to
nerve, e.g. by tumours or vascular anomalies, etc. produce good results.
364 Quick Review Series for BDS 4th Year, Vol 2

Q.4. Treatment of myofascial pain dysfunction syn- Diazepam

drome. Diazepam 2 mg 3 times daily and 5 mg at bed time dur-
ing a 2-week trial period is commonly advocated for its
Ans.
anxiety reducing and muscle relaxing properties.
l Treatment of MPDS should include the treatment Occlusal splints
of emotional as well as physical components of the Should be fabricated if pain and dysfunction persist
disorder. without improvement, following the treatment and rec-
l In acute stages, conservative noninvasive treatment ommendations of the initial visit.
is usually successful in alleviating the pain and dys- Splints most often used:
function. l Maxillary night guard
l Treatment of MPDS should begin by showing concern l A Hawley appliance with an anterior platform
and strong doctor–patient relationship empathy when Benefits derived from occlusal splints have most com-
reviewing the history of patient problems. monly attributed to greater freedom in mandibular
l Patient should be told that they are not suffering movement and to an increase in muscle balance.
from more serious, life-threatening disorder like ma- Biofeedback
lignancy. l It is helpful when the primary reason for the failure

in initial treatment appears to be the inability to con-

Conservative treatment and recommendations at the trol stress and anxiety.
initial visit should include following: l Biofeedback is a valuable therapeutic aid that per-

Limitation of parafunctional habits mits patients to treat themselves while decreasing

l Patient should attempt to limit parafunctional habits their dependence on therapists as it provides them
by becoming more aware of clenching and grinding with information concerning bodily functions that
of the teeth during the day. are usually not discernible or controllable.
Hot moist packs Nerve stimulation
l Warm to hot, moist compresses should be applied l Transcutaneous electrical nerve stimulation (TENS)

over the involved muscles for 15–20 min three times treatment appears to be more effective in alleviating
a day. chronic pain than acute pain.
Soft diet l The mode of action of TENS in reducing pain is

l A relatively soft diet should be advised and limit uncertain but it is attributed to neurologic, physio-
wide opening of mouth while eating. logic, pharmacologic and psychologic effects.
Pharmacotherapy or drugs to be prescribed l The pharmacologic action of TENS may involve the

l Aspirin or NSAID should be recommended for anal- stimulated release of endorphins, which are endoge-
gesic and anti-inflammatory actions. nous morphine like substance.
l Breaking up stress–pain–stress cycle with L.A. injec- l TENS also has a placebo effect in relieving pain.

tions without epinephrine: Other treatments

l Injecting the trigger points of muscles that are in Acupuncture
spasm with a local anaesthetic not containing This procedure is used in treatment of chronic
epinephrine is often beneficial in breaking up MPDS. Here brief intense stimulation is applied to
the spasm and in disrupting the stress pain stress designated points using needles with or without elec-
cycle. trical current.
Ethyl chloride spray on the skin The release of endorphins may be involved in the
The skin overlying the affected muscles can be sprayed pain relief area with acupuncture.
with ethyl chloride or fluoromethane or ultrasound can Hypnosis
be used in an attempt to relieve muscle spasms. Used as an adjunct to other treatments.
The effectiveness of local anaesthetic injections, ethyl Psychological counselling and antidepressant
chloride refrigerant spray and ultrasound in allowing drugs
patients to open wide without pain may be noted im- They are indicated in the treatment of MPDS if
mediately following treatment. anxiety or neurotic behaviour appears to be signifi-
Jaw exercise cant component of facial pain.
Isometric exercises are often beneficial, e.g. placing
Q.5. List the differences between pain characteristics of
the tip of the tongue is the back of the palate and then
trigeminal neuralgia and acute pulpitis.
opening and closing may help in retraining spastic
muscles. Ans.
Section | I Topic-Wise Solved Questions of Previous Years 365

Trigeminal neuralgia Acute pulpitis l TENS has been proven to be useful in controlling mas-
ticatory muscle and neurogenic pains.
l Trigeminal neuralgia is l Caused due to noxious
defined as sudden, usually stimulation of the nerve Q.7. Trismus.
unilateral severe, brief, endings
lancinating, recurring pain l May be intermittent or con- Ans.
in the distribution of one tinuous, depending upon
or more branches of 5th the stage of pathology
{SN Q.10}
cranial nerve l May manifest at any age,
l Aetiology unknown may from youngsters to elderly Trismus is defined as the prolonged spasm of the masti-
be idiopathic Not associated with any
l
catory muscles, which leads to limited mouth opening.
l Probable aetiological particular habits
factors are vascular fac- l May or may not respond
tors, mechanical factors or to cold test
anomaly of superior cere-
Aetiology
bellar artery i. Congenital – Birth injury
ii. Traumatic – Injury to masticatory muscles
Q.6. Transelectric nerve stimulation. Jaw fractures – Condylar fracture, depressed zygo-
matic arch fracture
Ans. iii. Neoplastic – Benign – Osteoma and chondroma of
condyle
Malignant – Osteosarcoma and chondrosarcoma of
{SN Q.11}
condyle
l TENS treatment appears to be more effective in iv. Neuromuscular disorders – Parkinson disease
alleviating chronic pain than acute pain. v. Reactive disorders
l The mode of action of TENS in reducing pain is
uncertain but it is attributed to neurologic, physio- Acute Chronic
logic, pharmacologic and psychologic effects.
l Septic arthritis l Rheumatoid arthritis
l The pharmacologic action of TENS may involve the l Masticatory compartment l Ankylosing spondylitis
stimulated release of endorphins, which are endoge- infections l Osteoarthritis
nous morphine-like substances. l Tetanus l TMJ ankylosis
l TENS also has a placebo effect in relieving pain. l Tonsillitis l Radiation therapy
l Peritonsillar abscess l Oral Submucous Fibrosis
l Mumps (OSMF)
l Meningitis l MPDS
l TENS is often used to start physical therapy, reduce l Osteomyelitis
pain and allow the patient to perform jaw exercises that
promote recovery. vi. Psychogenic, e.g. hysterical trismus
l TENS uses a low-voltage biphasic current of varied vii. Drugs, e.g. strychnine poisoning.
frequency and is designed for sensory counter stimula-
tion for the control of pain. Clinical examination
l It is thought to increase the action of the modulation that l Difficulty in opening mouth
occurs in pain processing at the dorsal horn of the spinal l Decreased inter-incisal distance (normal 3 cm)
cord and in the case of the face, the trigeminal nucleus l Extrusive and protrusive movements (normal .6 cm)
of the brainstem. l Facial swelling or asymmetry
l TENS temporarily activates afferent nerves, thereby
modulating pain.
l The electrical impulses are produced in a hand-held {SN Q.10}
battery-operated device.
Treatment
l The impulses generated have a duration of 2 min with
l Treatment of underlying cause
an interval of 0.5–1.5 s. The operating voltage is about
l Anti-inflammatory drugs
4 V.
l Muscle relaxants
l TENS is believed to have physiological (rhythmic con-
l Physiotherapy
tractions of muscles increases blood supply), neurologi-
l Heat application
cal (electrical stimulation inhibits pain conduction),
l Warm saline gargles
pharmacological (releases endorphins) and psychologi-
l Forceful mouth opening with gag
cal (placebo effects).
366 Quick Review Series for BDS 4th Year, Vol 2

Q.8. Burning mouth syndrome (glossodynia). l It should be stressed to the patient that these drugs are
being used not to manage psychiatric illness, but for
Ans.
their well-documented analgesic effect. Clinicians pre-
The term burning mouth syndrome is reserved for describ- scribing these drugs should be familiar with potential
ing oral burning that has no detectable cause. The burning serious and annoying side effects.
symptoms in patients with BMS do not follow anatomic l Burning of the tongue that results from parafunctional
pathways, there are no mucosal lesions or known neuro- oral habits may be relieved with the use of a splint cov-
logic disorders to explain the symptoms, and there are no ering the teeth and/or the palate.
characteristic laboratory abnormalities.
Q.9. Postherpetic neuralgia.
Aetiology and pathogenesis
l The cause of BMS remains unknown, but a number of Ans.
factors have been suspected, including hormonal and l Herpes zoster (shingles) is caused by the reactivation
allergic disorders, salivary gland hypofunction, chronic of latent varicella zoster virus infection that results in
low-grade trauma and psychiatric abnormalities. both pain and vesicular lesions along the course of the
l It is likely that some cases of BMS have a strong psy- affected nerve.
chological component, but other factors, such as chronic l Herpes zoster of the maxillary and mandibular divisions
low-grade trauma resulting from parafunctional oral of trigeminal nerve is a cause of facial and oral pain as
habits (e.g. rubbing the tongue across the teeth or press- well as of lesions.
ing it on the palate), are also likely to play a role. l In a majority of cases, the pain of herpes zoster re-
solves within a month after the lesions heal. Pain that
Clinical manifestations
persists longer than a month is classified as PHN,
l Women experience symptoms of BMS seven times
although some authors do not make the diagnosis of
more frequently than men.
PHN until the pain has persisted for longer than 3 or
l The tongue is the most common site of involvement, but
even 6 months.
the lips and palate are also frequently involved.
l PHN may occur at any age, but the major risk factor is
l The burning can be either intermittent or constant, but
increasing age. Few individuals younger than 30 years
eating, drinking or placing candy or chewing gum in the
of age experience PHN whereas more than 25% of indi-
mouth characteristically relieves the symptoms.
viduals older than 55 years of age and two-thirds of
l Patients presenting with BMS are often apprehensive
patients older than over 70 years of age will suffer from
and admit to being generally anxious or ‘high-strung’.
PHN after an episode of herpes zoster.
They may also have symptoms that suggest depression,
l Elderly patients also have an increased risk of experi-
such as decreased appetite, insomnia and a loss of inter-
encing severe pain for an extended period of time. The
est in daily activities.
pain and numbness of PHN results from a combination
l Patients complaining of a combination of xerostomia
of both central and peripheral mechanisms. This combi-
and burning should be evaluated for the possibility of a
nation of peripheral and central injury results in the
salivary gland disorder, particularly if the mucosa ap-
spontaneous discharge of neurons and an exaggerated
pears to be dry and the patient has difficulty swallowing
painful response to nonpainful stimuli.
dry foods without sipping liquids.
l When indicated, laboratory tests should be carried out Clinical manifestations
to detect undiagnosed diabetic neuropathy, anaemia or l Patients with PHN experience persistent pain, paraes-
deficiencies of iron, folate or vitamin B12. thesia, hyperaesthesia and allodynia months to years
after the zoster lesions have healed.
Treatment
l The pain is often accompanied by a sensory deficit, and
l Once the diagnosis of BMS has been made by eliminat-
there is a correlation between the degree of sensory
ing the possibility of detectable lesions or underlying
deficit and the severity of pain.
medical disorders, the patient should be reassured of the
benign nature of the symptoms. Management
l Counselling and reassurance may be adequate manage- l Many treatment options are available for the manage-
ment for individuals with mild burning sensations, but ment of PHN. Treatment includes topical and systemic
patients with symptoms that are more severe often re- drug therapy and surgery.
quire drug therapy. l Topical therapy includes the use of topical anaesthetic
l The drug therapies that have been found to be the most agents, such as lidocaine or analgesics, particularly cap-
helpful are low doses of TCAs, such as amitriptyline saicin. Lidocaine used either topically or injected gives
and doxepin, or clonazepam. short-term relief from severe pain.
Section | I Topic-Wise Solved Questions of Previous Years 367

l Combinations of topical anaesthetics such as EMLA l Women experience symptoms of BMS seven times
Cream (AstraZeneca) have also been reported as helpful. more frequently than men.
l Capsaicin, an extract of hot chili peppers that depletes l The tongue is the most common site of involvement, but
the neurotransmitter substance P when used topically, the lips and palate are also frequently involved.
has been shown to be helpful in reducing the pain of l Once the diagnosis of BMS has been made, the pa-
PHN, but the side effect of a burning sensation at the site tient should be reassured of the benign nature of the
of application limits its usefulness for many patients. symptoms.
l The use of tricyclic antidepressants such as amitripty- l The drug therapies that have been found to be the
line, nortriptyline, doxepin and desipramine is a well- most helpful are low doses of TCAs, such as amitrip-
established method of reducing the chronic burning pain tyline and doxepin or clonazepam (a benzodiazepine
that is characteristic of PHN. derivative).
l Because a significant number of elderly patients cannot l Burning of the tongue that results from parafunctional
tolerate the sedative or cardiovascular side effects as- oral habits may be relieved with the use of a splint cov-
sociated with tricyclic antidepressants, the use of other ering the teeth and/or the palate.
drugs, particularly gabapentin, has been advocated.
Q.3. Clinical features of Bell palsy.
l When medical therapy has been ineffective in managing
intractable pain, nerve blocks or surgery at the level of Ans.
the peripheral nerve or dorsal root have been effective
Clinical manifestations
for some patients.
l Bell palsy begins with slight pain around one ear, fol-
l The best therapy for PHN is prevention. There is evi-
lowed by an abrupt paralysis of the muscles on that side
dence that the use of antiviral drugs, particularly Famci-
of the face.
clovir, along with a short course of systemic corticoste-
l The eye on the affected side stays open, the corner of
roids during the acute phase of the disease may decrease
the mouth drops and there is drooling.
the incidence and severity of PHN.
l As a result of masseter weakness, food is retained
Q.10. Bell palsy. in both the upper and lower buccal and labial folds.
The facial expression changes remarkably, and the
Ans.
creases of the forehead are flattened. Due to im-
[Same as SE Q.1] paired blinking, corneal ulcerations from foreign
bodies can occur. Involvement of the chorda tym-
Q.11. Trigeminal neuralgia.
pani nerve leads to loss of taste perception on the
Ans. anterior two-thirds of the tongue and reduced sali-
vary secretion.
[Same as SE Q.3]
Q.4. Name the neuralgias of orofacial origin.
Ans.
SHORT NOTES:
Q.1. Bell sign. Various neuralgias of orofacial region are as follows:
l Paroxysmal neuralgias such as trigeminal, glossopha-
Ans. ryngeal, nervus intermedius and superior laryngeal
l Occipital neuralgia
l Bell sign is one of the diagnostic features of Bell palsy.
l PHN
l When a patient is asked to close the eyes, the patient is
l Post-traumatic neuropathic pain, etc.
unable to do so and the eye ball goes upwards in the
attempt, it is known as Bell sign. Q.5. Define atypical facial pain.
Q.2. Burning mouth syndrome. Ans.
Ans. [Ref LE Q.2]
l The term burning mouth syndrome (glossodynia) is re- Q.6. Gamma knife stereotactic radio surgery in man-
served for describing oral burning sensation that has no agement of the tic douloureux.
detectable cause. The burning symptoms in patients
Ans.
with BMS do not follow anatomic pathways, there are
no mucosal lesions or known neurologic disorders to l Gamma knife stereotactic radio surgery is a new tech-
explain the symptoms, and there are no characteristic nique for treatment of tic douloureux.
laboratory abnormalities. l Masseter.
368 Quick Review Series for BDS 4th Year, Vol 2

l It uses beams of radiation usually in doses of 70–90 Gy l The age of onset varies from 15 to 85 years but the aver-
units, converging in three dimensions to focus precisely age age is 50 years.
on a small volume. l No sex predilection and rarely there is bilateral
l This method relies on precise MRI sequencing that involvement.
helps localization of the beam and allows a higher l Sharp shooting pain in ear, pharynx, nasopharynx, ton-
dose of radiation to be given with more sparing of sil and posterior portion of tongue, i.e. at base of tongue
nerve tissue. and fauces on one side.
l Advantage of this technique is that it is particularly l Trigger zone is present in posterior oropharynx or ton-
helpful for elderly patients with a high surgical risk. sillar fossa. It is stimulated during swallowing, talking,
coughing or yawning.
Q.7. Enumerate the two important differences between
l May be associated with vagal symptoms such as syn-
the paroxysmal neuralgias and atypical neuralgias.
cope, hypotension and arrhythmias or cardiac arrest
Ans. may accompany the paroxysmal pain as may coughing
or excessive salivation.
Paroxysmal neuralgias Atypical neuralgias Treatment
l Paroxysmal neuralgias (tri- l AFP is a condition charac- l Approximately 80% of patients experience immediate
geminal, glossopharyn- terized by the absence pain relief when topical anaesthetic agent is applied
geal, nervus intermedius, of other diagnoses and to tonsil and pharynx on the side of pain. It is used as
superior laryngeal). causing continuous, vari-
diagnostic tool and can aid in distinguishing it from the
l Neuralgia is a clinical able intensity, migrating,
condition involving a pain nagging, deep and diffuse pain of other neuralgias.
of a severe intensity, with pain. l No therapy is considered to be uniformly effective or
a throbbing or stabbing l In the TMD classification even adequate.
character in the course or of the AAOP, AFP it is l Glossopharyngeal neuralgia is considerably less respon-
distribution of a specific defined as ‘a continuous
sive than trigeminal neuralgia to treatment with anticon-
nerve. unilateral deep aching
pain sometimes with a vulsant medications.
burning component’. l If the patient fails drug therapy, then surgical options
should be considered.
l The preferred neurosurgical treatments are microvascular
Q.8. PHN: mention two clinical manifestations.
decompression or surgical sectioning of the glossopharyn-
Ans. geal nerve and the upper two rootlets of the vagus nerve.
l Herpes zoster (shingles) is caused by the reactivation of Q.10. Trismus
latent varicella zoster virus infection.
l In a majority of cases, the pain of herpes zoster resolves Ans.
within a month after the lesions heal. Pain that persists [Ref SE Q.7]
longer than a month is classified as PHN, although some
authors do not make the diagnosis of PHN until the pain Q.11. ‘TENS’ therapy.
has persisted for longer than 3 or even 6 months. Ans.
Clinical manifestations [Ref SE Q.6]
l Patients with PHN experience persistent pain, paraes-
thesia, hyperaesthesia and allodynia months to years Q.12. Types of migraine.
after the zoster lesions have healed. Ans.
l The pain is often accompanied by a sensory deficit, and
there is a correlation between the degree of sensory There are several major types of migraine:
deficit and the severity of pain. l Classic
l Common
Q.9. Glossopharyngeal neuralgia. l Basilar
Ans. l Facial migraine (also referred to as carotidynia)

l Glossopharyngeal neuralgia is the disease of ninth cra- Q.13. Alarm clock headache.
nial nerve, i.e. glossopharyngeal nerve.
Ans.
l It is a rare condition that is associated with paroxysmal
pain, which is similar to, though less intense than, the Alarm clock headache is a pain syndrome referable to
pain of trigeminal neuralgia. the nasal ganglion. It may be caused either due to irritation
Section | I Topic-Wise Solved Questions of Previous Years 369

of nasal (sphenopalatine) ganglion or irritation to vidian l For example:

nerve. l Touching or applying heat/cold to cheek/gums, etc.

l Wind blowing on face

Clinical features
l Gustatory stimuli and vibration
l Unilateral paroxysm of severe pain at or near eyes, max-
illa, ear, mastoid and nose base. Q.15. Classifications of headaches.
l No trigger zone is present.
Ans.
l Usually pain occurs at least once in a day. Interestingly,
in some patients the onset of the paroxysm occurs ex- [Ref LE Q.2]
actly at the same time of day and for this reason, the
Q.16. Glossodynia.
disease has been referred to as ‘alarm clock headache’.
l Sneezing and watering from eyes are other complaints. Ans.
Treatment [Same as SN Q.2]
l Alcohol injection of sphenopalatine ganglion.
Q.17. Atypical odontalgia.
l Ergotamine or methysergide often provides complete
relief of symptoms. Ans.
Q.14. Trigger zones. [Same as SN Q.5]
Ans.
l In case of trigeminal neuralgia, different stimuli can
trigger pain; they are known as ‘trigger zones’.

Topic 12
Bacterial, Viral and Infectious Diseases
of the Oral Cavity Including AIDS
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. Describe the aetiology, clinical features, radiographic features and histological features of periapical granuloma
and mention its sequelae.
2. What are the aetiological factors of osteomyelitis of mandible.
3. Enumerate viral lesions occurring in the oral cavity and discuss in detail about acute herpetic gingivostomatitis.
4. What are the predisposing factors of acute necrotizing ulcerative gingivostomatitis? How will you diagnose and
treat a patient suffering from this disease?
5. Describe the clinical features and treatment of actinomycosis of the jaw.
6. Ludwig angina.
7. Classify osteomyelitis. Write in detail about the aetiology, clinical features, radiographic features and manage-
ment of chronic suppurative osteomyelitis. [Same as LE Q.2]
8. What are the viral infections in the oral cavity? Write about the aetiology, clinical features, diagnosis and dif-
ferential diagnosis of acute herpetic gingivostomatitis. [Same as LE Q.3]

SHORT ESSAYS:
1. Pyogenic granuloma.
2. Classify types of osteomyelitis. [Ref LE Q.2]
3. Secondary stage of syphilis.
4. Oral manifestations of HIV infection.
370 Quick Review Series for BDS 4th Year, Vol 2

5. Cellulitis.
6. Chancre.
7. Herpes zoster infection.
8. Clinical appearance of actinomycosis.
9. Chancre. [Same as SE Q.3]
10. Oral manifestations of syphilis. [Same as SE Q.3]
11. Clinical features of gumma in palate. [Same as SE Q.3]

SHORT NOTES:
1. Oral manifestations of HIV infection. [Ref SE Q.4]
2. Clinical features of gumma in palate.
3. Pyogenic granuloma.
4. Focal infection.
5. Lipschutz bodies.
6. Hutchinson triad.
7. Treponema pallidium.
8. Mucous patches.
9. Koplik spots.
10. Garre osteomyelitis.
11. Herpangina.
12. Scrofula.
13. Oral hairy leukoplakia.
14. Enumerate periapical lesions.
15. Treatment of candidiasis.
16. Treatment plan of herpes zoster.
17. Behcet syndrome.

SOLVED ANSWERS
LONG ESSAYS: Clinical features
● The involved tooth is usually nonvital and may be
Q.1. Describe the aetiology, clinical features, radio-
slightly tender to percussion.
graphic features and histological features of periapical
● Percussion may produce dull sound instead of normal
granuloma and mention its sequelae.
metallic sound because of the presence of granulation
Ans. tissue around the root apex.
● The involved tooth feels slightly elongated from the
● Periapical granuloma or chronic apical periodontitis or
socket.
dental granuloma is a localized mass of chronic granu-
● Patients may complain of pain on biting or chewing
lation tissue formed in response to infection around the
solid food.
root apex of nonvital tooth.
● The sensitivity is due to hyperaemia, oedema and in-
● It is a low-grade infection and one of the most com-
flammation of the apical periodontal ligament.
mon of all sequelae of pulpitis, i.e. acute periapical
● The early or even the severe chronic periapical granu-
periodontitis.
loma rarely presents with any severe clinical features.
Aetiology ● Most of the cases are asymptomatic. If pus has formed,
● Extension of pulpal inflammation. a small reddish swelling may be found on the buccal
● Acute trauma due to blows on the tooth. gum or a sinus may be present.
● Spread of periodontal infection into the tooth. ● If the lesion undergoes an acute exacerbation then there
● Perforation of root apex in endodontic therapy. will be perforation of the overlying bone and oral mu-
● Orthodontic tooth movements with excessive uncon- cosa with the formation of a fistulous tract.
trolled force. ● Granuloma remains attached to the extracted tooth.
Section | I Topic-Wise Solved Questions of Previous Years 371

● Enlargement and tenderness of regional lymph nodes. [SE Q.2]

Fever and malaise occurs.
●
● {Osteomyelitis is defined as an inflammatory condition
Radiographic features of the bone that begins as an infection of medullary
● The earliest changes in the periodontal ligament appear cavity and the Haversian system and extends to involve
as thickening of the periodontal ligament at the root the periosteum of the affected area.
apex and loss of lamina dura.
Classification of osteomyelitis
● It appears as a radiolucent area of variable size usually
Based on location
less than 1.5 cm in diameter attached to root apex.
● Intramedullary
● In some cases, radiolucency is well-circumscribed, defi-
● Subperiosteal
nitely demarcated from surrounding bone.
● Periosteal
● In some instances it appears as a diffuse blending of
the radiolucent area with the surrounding bone. Some Based on duration and severity
degree of root resorption is also seen. ● Acute
● Chronic
Histologic features
● Periapical granuloma consists of inflamed granula- Based on presence or absence of suppuration
tion tissue surrounded by a fibrous connective tissue a. Suppurative
wall. ● Acute suppurative osteomyelitis

● The granulation tissue demonstrates a variably dense ● Chronic suppurative osteomyelitis:

lymphocytic infiltrate that is intermixed with neutro-  i. Primary

phils, plasma cells, and eosinophils. ii. Secondary
● When numerous plasma cells are present, scattered eo- ● Infantile osteomyelitis

sinophilic globules of g globulin (Russell bodies) may b. Nonsuppurative

be seen. ● Chronic nonsuppurative

● There is presence of epithelial islands, cholesterol clefts,  i. Focal sclerosing

foam cells, plasma cells and T lymphocytes in the ii. Diffuse sclerosing
lesion. ● Radiation osteomyelitis

● The epithelial cell rests of Malassez proliferate in re- ● Garre sclerosing osteomyelitis

sponse to chronic inflammation and these proliferating ● Osteomyelitis due to specific infection like actino-

cells undergo liquefaction. mycosis, tuberculosis, syphilis, etc.}

● In addition, cluster of lightly basophilic particles (pyro- Chronic suppurative osteomyelitis
nine bodies) may also be seen with the plasmacytic in- ● Chronic osteomyelitis is the persistent abscess of

filtrate. the bone characterized by the complex inflamma-

● Collection of cholesterol clefts, with associated multi- tory process including necrosis of mineralized
nucleated giant cells and areas of red blood cell extrava- and marrow tissues, suppuration, resorption, scle-
sation with haemosiderin pigmentation, may be seen. rosis and hyperplasia.
● Small foci of acute inflammation with focal abscess ● Chronic suppurative osteomyelitis exists when the

formation may be seen. defensive response leads to the production of granu-

lation tissue, which subsequently forms dense scar
Treatment and prognosis tissue in an attempt to wall of the infected areas.
● Successful treatment depends on the reduction and con- ● The encircled dead space acts as a reservoir for
trol of the offending organisms. If tooth can be main- the bacteria and antibiotic medication will have
tained then root canal therapy with apical curettage difficulty in reaching the site.
should be performed. ● The disease may be acute, subacute or chronic
● Nonrestorable teeth must be extracted, followed by and presents with a different clinical course, de-
curettage of all apical soft tissue. pending on its nature.
● In symptomatic cases, NSAIDs are beneficial. Predisposing factors
● Use of antibiotic is not recommended, unless systemic ● Fractures due to trauma and road traffic accidents,
symptoms or swelling is not visible. gunshot wounds, radiation damage, Paget disease
Q.2. What are the aetiological factors of osteomyelitis of and osteoporosis.
● Systemic conditions like malnutrition, acute leu-
mandible.
kaemia, uncontrolled diabetes mellitus, sickle cell
Ans. anaemia and chronic alcoholism.
372 Quick Review Series for BDS 4th Year, Vol 2

Pathogenesis can demonstrate significant osteogenic periosteal

hyperplasia.
Infection of bone marrow from infected pulp
● The main radiographic feature of suppurative os-
g
teomyelitis is an expanding radiolucent osteolytic
Extension of infection into cancellous bone changes instead of the potential for peripheral
g sclerosis.
Thrombus formation in nutrient vessels of the living bone Treatment and prognosis
● Chronic osteomyelitis is difficult to manage med-
g
ically, presumably because pockets of the dead
Death of cancellous bony trabeculae with formation bone and organisms are protected from antibiotic
of sequestrum drugs by the surrounding walls of the fibrous con-
g nective tissue.
● Surgical intervention is mandatory.
Spread of infection via Volkmann’s canal in cortical plates
● The most frequently used antibiotics are penicil-
g
lin, clindamycin, cephalexin, cefotaxime, tobra-
Periostitis mycin and gentamicin, but these antibiotics
g should be used intravenously and in high doses.
● The extent of the surgical intervention depends
Multiple sinus tract formation
on the spread of the process; removal of all the
g
infected material down to good bleeding bone is
Necrosis of cortical bone mandatory in all cases.
g ● For small lesions, curettage, removal of necrotic

Discharge of the pus from involucrum through sinuses bone and saucerization are sufficient.
● In patient with more extensive osteomyelitis, de-
known as ‘cloacae’
cortication or saucerization is combined with
Clinical features transplantation of cancellous bone chips.
● If the acute osteomyelitis is not resolved expedi- ● In case of persisting osteomyelitis, resection of
tiously, the entrenchment of chronic osteomyelitis the diseased bone followed by immediate recon-
occurs, or the process may arise primarily without struction with an autologous graft is required.
a previous acute episode. ● Weakened jaw bones must be immobilized.
● Swelling, pain, sinus formation, purulent dis- ● The goal of the surgery is removal of all infected
charge, sequestrum formation, tooth loss or patho- tissue.
logic fractures may occur. ● Persistence of chronic osteomyelitis is typically
● Patients may experience acute exacerbations or the result of diseased tissue.
periods of decreased pain associated with chronic
smoldering progression. Q.3. Enumerate viral lesions occurring in the oral cav-
● The molar area of mandible is more frequently ity and discuss in detail about acute herpetic gingivo-
affected. stomatitis.
● Pain is usually mild and insidious and is not re-
Ans.
lated to the severity of the disease.
● Jaw swelling is common feature but mobility of The viral infections of oral cavity are classified depending
teeth and sinus tract formation are rare. on the presence of the major viruses as follows:
● Regional lymphadenopathy is common.

● There is thickened, woodened feeling of bone and RNA viruses

slow increase in jaw size. a. Orthomyxovirus
Radiographic features ● Influenza
● Radiography reveals a patchy, ragged and ill- b. Paramyxovirus
defined radiolucency that often contains a central ● Measles (rubeola)
radiopaque sequestra. ● Mumps
● On CT scan, the osteolytic changes are continu- c. Rhabdovirus
ous and may exhibit spread to the periosteum by ● Rabies
direct extension. d. Arena virus
● Occasionally, the surrounding bone may exhibit ● Lassa fever
increased radiodensity, and the cortical surface ● Lymphocytic choriomeningitis
Section | I Topic-Wise Solved Questions of Previous Years 373

e. Calicivirus Herpetic gingivostomatitis

f. Corona virus Clinical features
● Upper respiratory tract infection ● Herpetic gingivostomatitis is a common oral dis-

g. Bunya virus ease transmitted by droplet spread or contact with

h. Picornavirus the lesions.
i. Reovirus ● This infection occurs in the persons who are not

j. Toga virus infected previously with herpes virus or they do

k. Retro virus not have circulatory antibodies against virus.
DNA viruses ● It affects children and young adults.

a. Herpes virus ● Disease occurring in children is frequently the

● Herpes simplex virus 1 and 2 primary attack and is characterized by the devel-
● Varicella zoster virus opment of fever, irritability, headache, pain up on
● Cytomegalovirus swallowing and regional lymphadenopathy.
● Epstein–Barr virus ● Within a few days mouth becomes painful, and

● Human herpes virus 6–8 the gingiva becomes intensely inflamed and ap-
b. Poxvirus pears erythematous and oedematous.
● Smallpox ● Lips, tongue, buccal mucosa, palate and tonsils

● Molluscum contagiosum may be involved. Shortly, yellowish fluid filled

c. Adeno virus vesicles develop in oral cavity.
● Pharyngoconjunctival fever ● These vesicles rupture to form painful ulcers cov-

d. Parvovirus ered by grey membrane and surrounded by ery-

e. Iridovirus thematous halo.
f. Papovavirus ● Healing occurs in 7–14 days and leave no scar.

● Human warts or papillomas ● Herpetic whitlows in hands of hospital staff and

Herpes simplex virus disseminated infection of new born are examples

● Herpes simplex is a DNA virus, which causes the of primary herpetic infections.
disease in the man. Histological features
● The tissues preferentially involved by herpes simplex ● Intraepithelial fluid-filled vesicles.

virus are often referred to as herpes virus hominis and ● Ballooning degeneration.

are derived from ectoderm principally the skin, mu- ● Intranuclear inclusions known as Lipschutz bod-

cous membranes, eyes and central nervous system. ies are present, these are eosinophilic, ovoid ho-
● Two types of infections occur with herpes simplex virus: mogeneous structures within the nucleus.
A. Primary infection ● Perinuclear halo in nucleus produced by displace-

B. Secondary or ‘recurrent’ infection ment of chromatin peripherally by Lipschutz bodies.

Primary infection occurs in persons who do not have ● Cytoplasm of infected cells forms giant cells and

circulating antibodies whereas secondary or ‘recur- subjacent connective tissue is usually infiltrated
rent’ infection occurs in persons who have circulat- by inflammatory cells.
ing antibodies. Diagnosis
● Primary herpetic infections may manifest clinically ● It can be diagnosed by both clinical and labora-

as primary gingivostomatitis, primary vulvovaginitis, tory procedures.

inoculation herpes simplex, varicelliform eruption, ● HSV can be demonstrated in laboratory by isola-

meningoencephalitis and disseminated herpes sim- tion of virus in tissue culture or by DNA in the
plex. Subclinical primary infection is common in scrapings from the lesion.
99% of cases; the primary infection is subclinical ● Most sensitive and accurate method for diagnosis

with no visible clinical disease. is PCR technique.

● Recurrent herpetic manifestations include fever Treatment
blister, genital herpes simplex and dendritic corneal ● Antiviral drugs: If diagnosed early, the antiviral

ulcers. drugs have significant impact on the course of the

● HSV2 is associated with carcinoma of uterine cervix; disease.
HSV does not remain latent at site of original infec- ● Antibiotics: They help in the prevention of sec-

tion; reaches regional ganglia along the nerve path; ondary infection.
HSV1 seen in trigeminal and HSV2 in lumbosacral ● NSAIDs and topical anaesthetic gel: May relieve

ganglions. the discomfort considerably.

374 Quick Review Series for BDS 4th Year, Vol 2

Differential diagnosis subsequently involving marginal gingival and

● Herpes zoster rarely attached gingiva.
● Impetigo ● Craters are covered by greyish pseudomembra-

● Epidermolysis bullosa nous slough with a marked demarcation of linear

● Erythema multiforme erythema from the normal mucosa.
● Smallpox ● Spontaneous bleeding from gingival tissue

● Pemphigus ● Fetid odour and increased salivation.

● Food or drug allergies Symptoms

● Drug or chemical burns ● Extremely tender with radiating pain on eating

hot and spicy foods

Q.4. What are the predisposing factors of acute necro- ● Metallic foul taste
tizing ulcerative gingivostomatitis? How will you diag- ● Pasty saliva
nose and treat a patient suffering from this disease? Extraoral and systemic signs and symptoms
Mild-to-moderate stages
Ans.
● Local lymphadenopathy

● Acute necrotizing ulcerative gingivitis (ANUG) is an ● Slight elevation of temperature

inflammatory and destructive endogenous oral infection Severe cases

which is characterized by the necrosis of gingival tissue. ● High fever with increased pulse rate

● It is also known as trench mouth, Vincent infection, ● Loss of appetite and general lassitude

acute ulceromembranous gingivitis and acute ulcerative Systemic reactions

gingivitis. ● They are severe in children.

Aetiology ● Rarely noma, gangrenous stomatitis, fusospiro-

Role of bacteria chetal meningitis, peritonitis, toxaemia and fatal

● It is caused mainly by specific bacteria: Fusiform brain abscess may occur.
bacillus and spirochaetes. Histopathology
● The constant flora is composed of Prevotella in- ● It involves both stratified squamous epithelium and

termedia, in addition to Fusobacterium, Trepo- underlying connective tissue.

nema and Selenomonas species. ● The surface epithelium is destroyed and is replaced

Local predisposing factors by pseudomembranous meshwork of fibrin, necrotic

● Poor oral hygiene, pre-existing marginal gingivi- epithelial cells, polymorphonuclear neutrophils and
tis and faulty dental restoration. various microorganism that appears as a surface
● Area of gingiva traumatized by opposing in mal- pseudomembrane.
occluded teeth such as the palatal surface behind ● The underlying connective tissue is hyperaemic with

maxillary incisors and labial gingival surface of numerous engorged capillaries and dense infiltration
mandibular incisors. of polymorphonuclear neutrophils, which appears as
● Smoking – due to direct toxic effect of nicotine. a linear erythema.
● Emotional stress. ● Numerous plasma cells may appear in periphery of

Systemic predisposing factors infiltrate.

● Nutritional deficiency - vitamins A, C and B2. Treatment
● Marked malnutrition ● The conservative treatment is superficial cleaning of

● Chronic diseases – syphilis and cancer oral cavity by chlorhexidine, diluted hydrogen per-
● Gastrointestinal diseases – ulcerative colitis oxide or warm salt water. This is followed by scaling
● Blood dyscrasias – leukaemia, aplastic anaemia and polishing under topical anaesthesia.
and AIDS ● Use of antibiotics is coupled with local treatment in

Clinical features patients with toxic systemic complications.

● It is identified as an acute disease characterized by ● Nutritional supplements like vitamin B and vitamin C.

sudden onset, sometimes followed by an episode

of debilitating diseases or acute respiratory tract Q.5. Describe the clinical features and treatment of ac-
infections. tinomycosis of the jaw.
● It is seen commonly in age group 16–30 years.
Ans.
Oral signs and symptoms
Signs ● Actinomycosis is subacute to chronic, suppurative gran-
● Characterized by punched out, crater-like de- ulomatous disease that tends to produce draining sinus
pressions at the crest of the interdental papillae, tracts.
Section | I Topic-Wise Solved Questions of Previous Years 375

● It is caused by anaerobic Gram-positive, nonacid-fast ● A diagnosis is usually made by identifying the typical
bacilli. actinomycotic colonies in a surgical specimen.
● Occasionally, the periapical actinomycotic lesion may
Clinical features appear radiopaque mimicking condensing osteitis.
● Actinomycosis is mostly found in young adults. Women
Management
are less frequently affected than men.
● The sinus tracts have to surgically excised and abscess
● Based on the site of involvement, actinomycosis can be
drainage should be facilitated.
grouped into the cervicofacial, pulmonary, abdominal
● Long-term antibiotic therapy with penicillin or tetracy-
and pelvic and cutaneous and genitourinary actinomy-
cline is recommended.
cosis.
● Cutaneous actinomycosis is extremely rare and these Q.6. Ludwig angina.
are said to arise from wounds contaminated with saliva Ans.
or as a consequence of haematogenous dissemination
following a dental procedure. ● Ludwig angina is a form of firm, acute, toxic and severe
● However, primary cutaneous actinomycosis have also diffuse cellulitis causing board like swelling of subman-
been reported. dibular, sublingual and submental spaces bilaterally.
● The genitourinary form has been reported in patients ● It is a potentially life-threatening, rapidly expanding,
using intrauterine contraceptive devices. diffuse inflammation of the submandibular and sublin-
● The presenting symptoms of pulmonary actinomycosis gual spaces that occurs most often in young adults with
are fever, cough thoracic pain and dyspnoea. dental infections.
● The sputum is mucopurulent or even sanguineous. With ● It is a disease primarily of dental origin following infec-
the appearance of fistulae, the disease spreads to the tion of second and third mandibular molars.
mediastinum, the pericardium and finally to the skin of Aetiology
the chest. ● Odontogenic infections – Common teeth involved are
● Actinomycosis is believed to be acquired by endoge- mandibular second and third molars
nous implantation into deep tissues where anaerobic ● Vincent angina
conditions prevail. ● Periodontal disease
● Actinomyces israelii is an anaerobic normal inhabitant ● Acute tonsillitis
of the mouth, especially in the teeth and tonsils. ● Peritonsillar abscess (Quinsy)
● In the cervicofacial region, puncture wounds, dental ● Pericoronitis
extractions or compound fractures are some of the ● Fracture of the mandible
routes of infection. ● Erysipelas
● The cervicofacial variant is characterized by the appear- ● Submandibular and sublingual sialadenitis
ance of solid sub- or supramandibular nodules or swell-
ings and the overlying skin becoming purple to violet. Predisposing factors
● Clinical presentation of cervicofacial actinomycosis is ● Lowered resistance and poor oral hygiene
characterized by the presence of suppurative or ‘wooden’ Clinical findings
indurated mass with discharging sinuses. ● Ludwig angina begins as a mild infection and can rap-
● Pus from the discharging sinuses contains tiny yellow idly progress to brawny induration of the floor of the
sulphur granules. mouth and upper neck.
● Common initial symptoms of infection including ● Elevation of tongue and enlarged painful lymph nodes.
pain, fever, erythema, oedema and suppuration may Difficulty in swallowing and opening the mouth.
be absent. ● Headache, malaise and other signs of toxaemia.
● Actinomycosis often involves lymphatic nodes but by ● High fever, rapid pulse and fast breathing.
the direct extension of a primary lesion. ● Oedema of glottis causing respiratory obstruction. Stri-
● Occasionally, the masticatory muscles and tongue may dor suggests an impending airway crisis.
be involved resulting in trismus and dysphagia. ● Anxiety, cyanosis and sitting posture are late signs of
● Radiographs reveal ill-defined radiolucencies with a impending airway obstructions and indicates the need
radiopaque periphery. for an immediate artificial airway.
● Periapical actinomycosis is believed to be a nonresolv- ● Infection may spread to pharyngeal spaces, to carotid
ing periapical lesion associated with actinomycotic in- sheath or to pterygopalatine fossa.
fection and has been suggested as a contributing factor ● Complications such as descending necrotizing medias-
in the perpetuation of periapical radiolucencies after tinitis usually occurs through the retropharyngeal space
root canal treatment. and carotid sheath.
376 Quick Review Series for BDS 4th Year, Vol 2

● Cavernous sinus thrombosis with subsequent meningitis ● The pyogenic granuloma is a distinctive clinical entity
is sequel to this type of spread of infection. originating as a response of the tissue to a nonspecific
infection.
Microbiology
● It is a tumour-like growth that is considered as an exag-
● Causative bacteria include many Gram-negative and
gerated, conditioned response to minor trauma.
anaerobic organisms, streptococci and staphylococci.
● Alpha haemolytic streptococci, staphylococci and bac- Aetiology
teroides are commonly reported. ● It arises as a result of minor trauma to the tissues, which
● Other anaerobes such as peptostreptococci, peptococci, provides pathway for the invasion of nonspecific types
Fusobacterium nucleatum, Veillonella species and spi- of microorganisms.
rochaetes are also seen.
Clinical features
Treatment ● Pyogenic granuloma occurs more frequently on gingiva.
● The treatment plan for each patient should be individu- It may also occur on lips, tongue and buccal mucosa and
alized and based on a number of factors. occasionally on the other areas.
● Treatment includes assessment and protection of air- ● It is common in maxillary anterior region and on the
way, use of intravenous antibiotics, surgical evaluations facial aspect than the lingual or palatal aspect.
and if necessary, operative decompression. ● Lesion may vary in size from few millimetres to centi-
● Incision and drainage of pus. metres or more in diameter.
● The lesion is usually elevated, pedunculated or sessile
Antibiotic therapy
vascular mass with a smooth, lobulated or even a warty
● Recommended initial antibiotics are high doses peni-
surface, which commonly is ulcerated and shows a ten-
cillin G, sometimes used in combination with metroni-
dency for haemorrhage either spontaneously or upon
dazole.
slight trauma.
● In penicillin allergic patient, clindamycin hydrochloride
● It is deep red or reddish purple, depending upon its vas-
is the drug of choice.
cularity, painless and rather soft consistency.
● Alternative choices are ceftizoxime sodium or combina-
● The lesion develops rapidly, reaches full size and then
tion drugs such as ticarcillin–clavulanate, piperacillin–
remains static for an indefinite period.
tazobactum or amoxicillin–clavulanate (Augmentin).
● Intravenous dexamethasone sodium phosphate given for Histologic features
48 h reduces oedema, which helps maintain airway in- ● It is similar to granuloma except that it is exuberant and
tegrity and enhances antibiotic penetration. is usually well localized.
● Mouth washes. ● The overlying epithelium if present may be thin or atro-
● Liquid diet. phic, but may be hyperplastic also.
● Emergency tracheostomy for establishment of a defini- ● If lesion is ulcerated it shows a fibrinous exudate of
tive airway, if symptoms of asphyxia are present. varying thickness over the surface.
● Vast number of endothelium-lined vascular spaces and
Q.7. Classify osteomyelitis. Write in detail about the
the extreme proliferation of fibroblast and budding en-
aetiology, clinical features, radiographic features and
dothelial cells are seen.
management of chronic suppurative osteomyelitis.
● In addition, there is usually a moderately intense infil-
Ans. tration of polymorphonuclear leukocytes, lymphocytes
and plasma cells, but this finding varies, depending
[Same as LE Q.2]
upon the presences or absence of ulcerations.
Q.8. What are the viral infections in the oral cavity? ● Both clinically and microscopically, an old lesion may
Write about the aetiology, clinical features, diagnosis and resemble a fibro-epithelial polyp or even a typical
differential diagnosis of acute herpetic gingivostomatitis. fibroma.
Ans. Treatment
● Treated by surgical excision.
[Same as LE Q.3]
● Recurrence is common because the lesion is not encap-
sulated.
SHORT ESSAYS: Q.2. Classify types of osteomyelitis.

Q.1. Pyogenic granuloma. Ans.

Ans. [Ref LE Q.2]
Section | I Topic-Wise Solved Questions of Previous Years 377

Q.3. Secondary stage of syphilis. ● Palatal perforation by ulcer after vigorous antibiotic
use, known as Herxheimer reaction.
Ans.
● Atrophic/interstitial glossitis is most characteristic
● Syphilis is caused by Treponema pallidum, a spirochaete/ lesion and has malignant potential to squamous cell
demonstrated best by dark field microscopy in silver carcinoma.
impregnation.
Q.4. Oral manifestations of HIV infection.
● Syphilis may be classified as:
a. Acquired Ans.
b. Congenital
[SE Q.1]
Acquired syphilis
It has three stages: {Lesions strongly associated with HIV infection
i. Primary ● Candidiasis – erythematous and pseudomembranous
ii. Secondary ● Hairy leukoplakia
iii. Tertiary ● Kaposi sarcoma

● Primary and secondary stages are infectious and ● Non-Hodgkin lymphoma

painless. ● Periodontal diseases: For example, linear gingival

erythema, necrotising ulcerative gingivitis and nec-

Primary stage (chancre)
rotizing ulcerative periodontitis}
● Chancre develops at the site of inoculation approxi-
Lesions seen in HIV infection
mately 3–90 days after contact with the infection.
Bacterial infections
● Chancre is usually solitary but may be multiple at
● Actinomyces israelii
times. It occurs mainly on genitalia, may occur on
● Escherichia coli
oral mucosa and fresh extraction wound, as painful
● Klebsiella pneumoniae
ulcers.
● Cat-scratch disease
● Highly infectious, and exhibits positive serologic
● Epithelioid (bacillary) angiomatosis
reaction despite the presence of spirochaete.
Fungal infections other than candidiasis
● Unilateral lymphadenopathy, nontender and rubbery
● Cryptococcus neoformans
nodes.
● Geotrichum candidum
● The chancre appears microscopically as a superficial
● Histoplasmosis capsulatum
ulcer showing intense inflammatory infiltrate espe-
● Mucormycosis
cially plasma cells.
● Aspergillus flavus
● Chancre heals spontaneously in 3 weeks to 2 months’
Neurologic disturbances
time.
● Facial palsy
Secondary or metastatic stage (mucous patches)
● Trigeminal neuralgia
● Usually commences 6 weeks after primary lesions.
Viral infections
● The lesions are typically multiple and occur on skin as
● Recurrent aphthous stomatitis
painless macules or papules. The oral lesions are called
● Cytomegalo virus (CMV), etc.
‘mucous patches’ and are usually painless, multiple,
greyish white plaques overlying an ulcerated surface. Q.5. Cellulitis.
● The mucous patches occur more frequently on
Ans.
tongue, gingiva or buccal mucosa or as a split papule
on lips and are highly infectious. ● Cellulitis is an inflammation and infection of cellular
● Serologic reaction is always positive. tissue especially of loose subcutaneous tissue.
● Secondary syphilis can present as explosive and wide ● The soft tissue filling the facial planes and spaces is
spread form known as ‘lues maligna’. the common site. It occurs in the facial spaces or
Tertiary or late syphilis muscular spaces or takes the form of deep-seated
● Tertiary or late syphilis is noninfectious and occurs phlegmons.
several years later. ● It occurs due to spread of dental infection, i.e. from api-
● Diffuse form may involve cardiovascular and central cal abscess, osteomyelitis, pericoronal infection, peri-
nervous system that is cardiosyphilis and neuro- odontal infection, after extraction of tooth, fracture of
syphilis. the jaw followed by secondary infection.
● Gumma is classic of tertiary or late syphilis, it is a ● The condition may progress rapidly, leading to serious
granuloma with central necrosis occurring most complications, which are surgical emergencies, requir-
commonly on tongue or palate. ing incision and drainage.
378 Quick Review Series for BDS 4th Year, Vol 2

● Infection may be localized to one space or may spread ● To avoid the further spread of infection or solidification
along the various facial planes at the same time. of abscess, the patients should be advised not to mas-
● This type of reaction occurs as a result of infection by sage the affected area with any medication.
microorganisms that produces significant amounts of ● Although this condition is extremely serious, the resolu-
streptokinase, hyaluronidase and fibrinolysins, which tion is usually prompt with adequate treatment, and
act to breakdown or dissolve hyaluronic acid, the inter- untoward sequelae are uncommon.
cellular cement substance and fibrin.
Q.6. Chancre.
Aetiopathogenesis Ans.
● Streptococci are particularly potent producers of hyal-
uronidase and are therefore a common causative organ- ● Primary syphilis is characterized by the chancre that
ism in cases of cellulitis. develops at the site of inoculation.
● The anaerobes such as Prevotella and Porphyromonas ● This becomes clinically evident 3–90 days after the
spp. destroy collagen. initial exposure.
● Cellulitis of face and neck are common from dental ● The majority of chancres are solitary, although multiple
infection, either as a sequalae of an apical abscess or lesions may be seen occasionally.
osteomyelitis. ● The external genitalia and anus are the most common
sites.
Clinical features ● The affected area begins as a papular lesion, which de-
● Patient will be moderately ill and has elevated tempera- velops a central ulceration.
ture and leukocytosis. ● Less than 2% of chancre occurs in other locations, but
● Patient will have painful swelling of the soft tissue in- the oral cavity is the most common extragenital site.
volved that are firm and brawny. ● Oral lesions are seen most commonly on the lips, but
● Most of the swelling is due to inflammatory oedema. other sites included are tongue, palate, gingiva and
● If superficial spaces are involved, the skin is inflamed, tonsils.
has an orange peel appearance and is even more pur- ● The upper lip is affected more in males, whereas lower
plish sometimes. lips involvement is more in females.
● In cases of inflammatory spread of infection along the ● The oral lesions appear as a painless, clean-based ulcer-
deeper planes of cleavage, the overlying skin may be of ation or, rarely, as a vascular proliferation resembling a
normal colour. pyogenic granuloma.
● In addition, regional lymphadenitis is usually present. ● Regional lymphadenopathy, which may be bilateral, is
● Infection when arises from maxilla perforates the outer seen in most of the patients.
cortical layer of the bone above the buccinator attach- ● At this time, the organism is spreading systemically
ment and causes swelling, initially of the upper half of through the lymphatic channels, setting the stage for
the face. future progression.
● The diffuse spread soon involves the entire facial area. ● If untreated, then the initial lesion heals within 3–8
● Extension towards the eyes is a potentially serious com- weeks.
plication because of the cavernous sinus thrombosis
through the veins of the inner canthus of the eye. Q.7. Herpes zoster infection.
● When infection in the mandible perforates the outer Ans.
cortical plate below the buccinators attachment, there is
a diffuse swelling of the lower half of the face, which is ● Herpes zoster is also known as shingles or Zona.
then seen as superior as well as cervical spread. ● It is an acute infectious viral disease of an extremely
● Spread to cervical tissue can cause respiratory discomfort. painful and incapacitating nature.
● As the infection persists. The facial cellulitis tends to ● The viral infection affects sensory nerves with trigemi-
become localized, and a facial abscess may form. When nal nerve most frequently involved and other sensory
this happens, the suppurative material present seeks to nerves involved are C3, T5, Ll and L2.
point or discharge upon a free surface. Aetiology
● If early treatment is instituted, resolution usually occurs ● Virus causing infection is ‘varicella zoster’ virus.
without drainage through a break in the skin.
Clinical features
Treatment ● Clinical features can be grouped into three phases:
● Cellulitis is treated by administration of proper antibiot- i. Prodrome
ics including antimicrobials and also the removal of the ii. Acute
cause of infection. iii. Chronic
Section | I Topic-Wise Solved Questions of Previous Years 379

● The disease is most common in adult life and affects accelerate healing of the cutaneous and mucosal
both the sexes equally. lesions, reduce the induration of acute pain and
● Initially adult patient exhibits fever, a general malaise, decrease the duration of the postherpetic neuralgia.
pain and tenderness along the course of involved sensory ● For the treatment of postherpetic neuralgia.
nerves, usually unilaterally. Often the trunk is affected. ● Intralesional corticosteroids.
● Within few days, the patient has a linear papular or ve- ● Topical application of capsaicin.
sicular eruption of the skin or mucosa supplied by the ● The newer antiviral drugs are under intensive clinical
affected nerves. It is typically unilateral and derma- testing for potential effectiveness in treatment of
tomic in distribution. herpes zoster.
● The acute phase begins as the involved skin develops
Q.8. Clinical appearance of actinomycosis.
clusters of vesicles set on an erythematous base.
● Within 3–4 days the vesicle becomes pustular and ulcer- Ans.
ate, with crust developing after 7–10 days.
● Actinomycosis is a chronic granulomatous suppurative
● The lesions tend to follow the path of the affected nerve
and fibrosing disease.
and terminate at the midline.
● Endogenous, opportunistic infection.
● The dorsal root ganglion is also inflamed with vesicular
● Actinomycosis is mostly found in young adults. Men
eruptions unilaterally along the sensory nerve path, over
are more frequently affected than women.
the skin or mucosa.
● Chronic phase of herpes zoster is characterized by pain Aetiology
that persists longer than 3 months after the initial pre- ● It is caused most commonly by Actinomyces israelii, al-
sentation of the acute rash. though A. naeslundii, A. viscosus, A. odontolyticus and A.
● The pain is described as burning, throbbing, aching, itch- propionica have been shown to cause the human disease.
ing or stabbing, often with flares caused by light stroking ● This bacterium is anaerobic Gram-positive, fungus-like
of the area or from contact with adjacent clothing. filamentous and branched and normally present in
● Triggering factors for infections are malignancy, trauma crypts of tonsils and cavities over teeth.
and radiations, etc.
a. Clinical featuresa. Actinomycosis is classified ana-
tomically into three forms according to location of le-
Oral manifestations
sion as cervicofacial (most common)
● Lesions of oral mucosa are fairly common, and ex-
b. Abdominal
tremely painful vesicles may be found on the buccal
c. Pulmonary
mucosa, tongue, uvula, pharynx and larynx. They gen-
● Cervicofacial actinomycosis is characterized by
erally rupture to leave the areas of erosion.
‘lumpy jaw’ and swelling of the soft tissue with for-
● One of the characteristic clinical features of the disease
mation extraoral draining sinuses over skin or muco-
involving the face or oral cavity is the unilaterality of
sal surface.
the lesions. Typically when large, the lesions will extend
● Pus collected from sinus shows typical ‘sulphur
up to midline and stop abruptly.
granules’ or tiny yellow grains which are colonies of
James Ramsay Hunt syndrome
organism.
● A special form of zoster infection of the geniculate
● The skin over the sinus is scarred. No lymphade-
ganglion with the involvement of external ear and
nopathy is present.
oral mucosa, has been termed as James Ramsay Hunt
● The infection of soft tissues may extend to involve
syndrome.
the mandible or maxilla resulting in osteomyelitis if
● The clinical manifestations include facial paralysis,
not treated.
pain in external auditory meatus and pinna of the ear.
● Abdominal actinomycosis is an extremely serious
In addition, vesicles occur in the oral cavity and oro-
form of the disease and carries high mortality rate.
pharynx with hoarseness, tinnitus, vertigo and other
● Radiographs reveal ill-defined radiolucencies with a
disturbances.
radiopaque periphery. Occasionally, the periapical
Diagnosis
actinomycotic lesion may appear radiopaque mim-
● Characteristic distribution of lesions
icking condensing osteitis.
● Cytological smears
● A diagnosis is usually made by identifying the typi-
● Fluorescent antibody staining techniques
cal actinomycotic colonies in a surgical specimen.
● Viral culture and serologic diagnosis

Treatment Treatment
● Appropriate antiviral medications such as acyclo- ● Treatment of this disease is difficult and has not been
vir, valacyclovir and famciclovir have been found to uniformly successful.
380 Quick Review Series for BDS 4th Year, Vol 2

● Long-standing fibrosis cases are treated by draining ● Intravenous pyogenic granuloma occurs on neck and
the abscess, excising the sinus tract with high doses of upper extremities.
antibiotics. ● It is deep red or reddish-purple, painless and soft in
● Antibiotics such as penicillins and tetracyclines have consistency.
been most frequently used. ● Pregnancy tumour is a lesion histologically similar to
pyogenic granuloma, occurs in pregnancy.
Q.9. Chancre.
Treatment
Ans.
● Surgical excision.
[Same as SE Q.3] Q.4. Focal infection.
Q.10. Oral manifestations of syphilis. Ans.
Ans. ● A focal infection is a localized or generalized infection
[Same as SE Q.3] caused by the dissemination of microorganisms or toxic
products from a focus of infection.
Q.11. Clinical features of gumma in palate. ● Two mechanisms of focal infection: by either haema-
Ans. togenous or lymphogenous spread.
● Metastasis of microorganisms from infected focus.
[Same as SE Q.3] ● Toxins are carried from focus to distant site.
Q.5. Lipschutz bodies.
SHORT NOTES: Ans.
Q.1. Oral manifestations of HIV infection. ● Lipschutz bodies are characteristic histological feature
Ans. of primary herpetic gingivostomatitis.
● Intranuclear inclusions known as Lipschutz bodies are
[Ref SE Q.4] present; these are eosinophilic, ovoid homogeneous
Q.2. Clinical features of gumma in palate. structures with in the nucleus.
● Perinuclear halo in nucleus produced by displacement
Ans. of chromatin peripherally by Lipschutz bodies.
● Gumma is classic lesion of tertiary or late syphilis. Q.6. Hutchinson triad.
● It is a granuloma with central necrosis occurring most
commonly on tongue or palate. Ans.
● Palatal perforation by ulcer after vigorous antibiotic ● Pathognomonic of the congenital syphilis is the occur-
use, known as Herxheimer reaction. rence of Hutchinson triad, which includes:
● Atrophic/interstitial glossitis is most characteristic i. Hypoplasia of incisors and molars (screw driver-
lesion and has malignant potential to squamous cell shaped incisors, mulberry molars/Moon’s/Fournier’s
carcinoma. molar)
● The palatal lesions shows ulcerations frequently perfo- ii. Eighth nerve deafness
rating through to the nasal cavity. iii. Interstitial keratitis
Q.3. Pyogenic granuloma. Q.7. Treponema pallidum.
Ans. Ans.
● Pyogenic granuloma or Granuloma pyogenicum origi- ● Treponema pallidum is the causative agent of syphilis.
nates as a response to nonspecific infection. ‘Trepo’ means to turn, ‘nema’ means thread and ‘palli-
dum’ refers to its pale staining.
Aetiology
● It is a thin delicate spirochaete with tapering ends. It has
● Infection either by staphylococci or streptococci.
about 10 regular spirals, which are sharp and angular, at
● Sulphhydryl radical is most essential stimulating agent.
regular intervals of about 1 micron.
Clinical features ● It can be seen by dark ground microscope or negative
● Arises more frequently on gingiva, may also occur on staining. It can be stained by silver impregnation meth-
lips, tongue and buccal mucosa. ods. It stains light rose red with Giemsa stain.
● Overzealous proliferation of a vascular type of connec- ● Pathogencity: Natural infection with T. pallidum occurs
tive tissue. only in human beings.
Section | I Topic-Wise Solved Questions of Previous Years 381

Q.8. Mucous patches. ● Herpangina is a specific viral infection caused by cox-

sackie group A virus.
Ans.
Clinical features
● A superficial greyish area of mucosal necrosis is seen in
● In herpangina or aphthous pharyngitis, the clinical fea-
secondary syphilis. This lesion is termed a mucous
tures are mild and are of short duration (1 week).
patch.
● It is commonly seen in young children.
● Secondary syphilis usually develops within 6 weeks
● The incubation period is probably 2–10 days.
after the primary lesion and is characterized by diffuse
● It begins with sore throat, cough, rhinorrhoea, low-
maculopapular eruptions of the skin and mucous mem-
grade fever, headache, sometimes vomiting, prostration
branes.
and abdominal pain.
● On the skin, these lesions may present as macules or
● Small vesicles that rupture to form crops of ulcers are
papules.
more common on pharynx and posterior oral mucosa and
● In the oral cavity, the lesions are usually multiple pain-
are less frequent on tongue, buccal mucosa and palate.
less greyish-white plaques overlying an ulcerated ne-
● The ulcers do not tend to be extremely painful although
crotic surface.
the patients will have dysphagia.
● The lesion occur on the tongue, gingiva, palate and
● A permanent immunity develops to the infecting strains
symptoms (including fever, sore throat, general malaise
rapidly and antibodies are found.
and headache) may also be present.
● The mucous patches of the secondary stage of syphilis Laboratory findings
resolve within a few weeks but are highly infective be- ● The coxsackie virus can be isolated in suckling mice or
cause they contain large numbers of spirochaetes. hamsters by inoculation of scrapings from throat lesions
or stool specimens.
Q.9. Koplik spots.
Treatment
Ans.
● No treatment is necessary as the disease appears to be
● Measles is a disease with a prodromal phase that is self-limiting.
characterized by symptoms of upper respiratory infec-
Q.12. Scrofula.
tion, tonsillopharyngitis and small white lesions with
erythematous bases on the buccal mucosa and inner Ans.
aspect of the lower lip (Koplik spots).
● These lesions are pathognomonic of early measles ● Tuberculosis is a specific infectious granulomatous
infection. disease.
● In India, tuberculosis is the most common opportunistic
Q.10. Garre osteomyelitis. infection caused by mycobacterium tuberculosis, an
Ans. acid-fast bacillus.
● General clinical signs and symptoms are remarkably
● Garre osteomyelitis is also known as chronic osteomy- inconspicuous. The patient may suffer from episodic
elitis with proliferative periostitis or periostitis ossificans fever and chills, but easy fatigability and malaise are
or Garre chronic nonsuppurative sclerosing osteitis. often the chief early features of the disease.
● It represents a reactive periosteal osteogenesis in re- ● Tuberculous lymphadenitis of submaxillary and cervi-
sponse to low-grade infection or trauma. cal lymph nodes is known as scrofula.
● It is common in young children and adults in the poste-
rior region of mandible. Q.13. Oral hairy leukoplakia.
● The involved jaw bone has a carious nonvital tooth.
Ans.
● Lymphadenopathy, slight pyrexia and leukocytosis may
be present but ESR is normal. ● The most common (Epstein-Barr virus) EBV-related
● Radiologically, it exhibits characteristic onion-skin ap- lesions in patient with AIDS is oral hairy leukoplakia.
pearance. ● This lesion clinically presents as a white mucosal
● Treatment consists of elimination of causative agent plaque that does not rub off and is characterized histo-
and extraction of carious infected tooth and antibiotic pathologically by a distinctive pattern of hyper keratosis
therapy. and epithelial hyperplasia.
● Prognosis is good. ● Most cases occurs on lateral border of the tongue and
ranges in appearance from faint white vertical streaks to
Q.11. Herpangina.
thickened and furrowed areas of leukoplakia, exhibiting
Ans. a shaggy keratotic surface.
382 Quick Review Series for BDS 4th Year, Vol 2

● The lesion may become extensive and cover the entire Q.16. Treatment plan of herpes zoster.
dorsal surface of the tongue.
Ans.
● Histopathologically, OHL exhibits thickened para-
keratin that demonstrates surface corrugations or thin ● In healthy patients, if diagnosis occurs within 72 h of
projections. initiation of the disease, a course of acyclovir or valaci-
● The epithelium is acanthotic and exhibits a band-like clovir can be administered.
zone of lightly stained cells with abundant cytoplasm in ● If patient is seen later during the course of the disease,
the upper spinous layer. symptomatic relief in the form of magic mouthwash can
● Treatment is usually not needed, although slight dis- be prescribed.
comfort or aesthetic concerns may necessitate therapy. ● In immunosuppressed patients, a prescription of acyclo-
● Surgical excision or cryotherapy has been used sometimes. vir or valaciclovir can be administered.
● It is belief that prescription of antiviral and corticoste-
Q.14. Enumerate periapical lesions.
roids therapy prevents postherpetic neuralgia.
Ans.
Q.17. Behcet syndrome.
Acute periradicular diseases
Ans.
● Acute alveolar abscess
● Acute apical periodontitis ● The lesions in Behcet are similar to aphthous ulcer-
ations occurring in otherwise healthy individual.
Chronic periradicular diseases with areas of rarefaction
● The Behcet syndrome includes triad of clinical features:
● Chronic alveolar abscess
recurrent oral and genital ulcers, ocular inflammation
● Granuloma
and skin lesions.
● Cyst
● Cause: PPLO virus; autoimmune.
● Condensing osteitis
● Oral involvement is an important component of Behcet
Q.15. Treatment of candidiasis. syndrome. Lesions commonly involve soft palate and
oropharynx.
Ans.
● Genital lesions appear on the vulva, vagina, glans penis,
The treatment of candidiasis is as follows: scrotum and perianal area.
● Rectify the underlying cause. ● Common cutaneous lesions include erythematous pap-
Topical agents used are as follows: ules, vesicles, pustules, folliculitis, acneiform eruptions
● Clotrimazole 1% cream 5 times/day for 2 weeks. and erythema nodosum-like lesions.
● Clotrimazole 2% gel 5 times/day for 2 weeks. ● Ocular involvement is seen in 70%–85% cases.
● Clotrimazole 1% solution 5 times/day for 2 weeks. ● The most common secondary ocular complications are
● Nystatin 5 lakh units tablets (mycostatin) 4 times/day cataracts, glaucoma and neovascularization of the iris
for 14 days – crush and mix with water and use as and retina.
mouth rinse and swallow.
Treatment
● Fluconazole dispersible tablets (Nuforce) with water –
● The oral and genital ulcers respond well to potent
use mouth rinse 3 times/day for 14 days.
topical or intralesional corticosteroids or topical tacro-
Parenteral route
limus.
● Amphotericin B i.v. infusion 0.3 mg/kg can be
● In most severe cases, this therapy can be combined with
infused over 4–8 h.
oral colchicine or dapsone.
Oral route
● Severe ocular or systemic lesions often needs systemic
● Fluconazole 150 mg b.i.d. for 14 days/fluconazole
immunomodulatory and immunosuppressive drugs, e.g.
200 mg b.i.d. for 14 days.
corticosteroids, cyclosporine, azathioprine, interferon-
● Ketoconazole 200 mg OD for 1–4 weeks.
a2a and cyclophosphamide.
● Itraconazole 100 mg OD for 14 days.
Section | I Topic-Wise Solved Questions of Previous Years 383

Topic 13
Diseases of the Endocrine and Respiratory
System: CVS and GIT
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. Hyperparathyroidism.
2. Oral manifestations of diabetes mellitus.
3. Describe general, oral and dental manifestations of various endocrine disorders.
4. Discuss the role of oral diagnosis in diagnosing endocrinal disorders.
5. Acromegaly.

SHORT ESSAYS:
1. Hyperthyroidism.
2. Management of cardiac patient in dental extraction.

SHORT NOTES:
1. Hyperparathyroidism.
2. Oral manifestations of diabetes mellitus. [Ref LE Q.3]
3. Addison disease – aetiology.
4. Acromegaly. [Ref LE Q.5]
5. Radiographic appearance of hyperparathyroidism.
6. Dental considerations for a patient with a history of gastritis.
7. Koplik spots.
8. Grinspan syndrome.

SOLVED ANSWERS

LONG ESSAYS: stimulate thyroid hormone production and goitre

formation.
Q.1. Hyperparathyroidism. ● Graves disease is characterized by diffuse enlargement
of the thyroid gland, infiltrative ophthalmopathy (ex-
Ans.
ophthalmos) and pretibial myxoedema (dermopathy).
● A state of excessive thyroid hormone due to hyper func- ● Important manifestations of hyperthyroidism are
tion of the thyroid gland is called hyperthyroidism or weight loss with increased appetite, heat intolerance,
thyrotoxicosis. sweating, palpitation, tremors and nervousness.
● The signs are tachycardia, atrial fibrillation, fine fin-
Clinical features ger tremors, moist warm skin, lid retraction, wide
● The most common cause of thyrotoxicosis is palpebral fissure, lid lag and exophthalmos.
Graves disease (Basedow disease) in 60%–80% of ● Ophthalmopathy is present in 20%–50% patients of
people. Graves disease. It may precede the development of
● Graves disease is an autoimmune disorder with thyrotoxicosis or may develop after successful treat-
genetic predisposition. The antibodies (TSH-R an- ment of hyperthyroidism of Graves disease. It usually
tibodies) bind Thyroid Stimulating Harmone consists of chemosis, scleral injection, periorbital
(TSH) receptors on thyroid follicular cells and oedema and proptosis.
384 Quick Review Series for BDS 4th Year, Vol 2

●Proptosis may cause corneal drying and damage. In ● Serum total and unbound (free) T3 and T4 are in-
severe cases, exophthalmos, diplopia and optic nerve creased.
compression may occur. ● The uptake of radioactive iodine by thyroid is high in

● Dermopathy occurs in about 5% of patient with Graves disease and toxic nodular goitre whereas it is
Graves disease. Purple or pink patches over anterior low in subacute thyroiditis.
and lateral aspect of the leg (pretibial myxoedema) ● Ultrasonography of thyroid gland reveals diffuse

are commonly seen. enlargement of thyroid gland, which helps us to dif-

● Thyroid acropathy is unusual feature of Graves dis- ferentiate Graves disease from nodular goitre.
ease and manifests as digital clubbing and swelling Treatment
of fingers and toes. ● Hyperthyroidism or Graves disease is treated by an-

Symptoms tithyroid drugs, radioactive iodine (131I) or subtotal

● Excitability, hyperactivity, irritability and dysphoria. thyroidectomy.
● Heat intolerance and swelling ● The choice of treatment depends on the cause and

● Hyper reflexia, muscle wasting and proximal myopa- severity of hyperthyroidism, the age of the patient
thy without fasciculation and clinical situation.
● Profuse sweating, fatigue and weakness I. Symptomatic
● Weight loss with increased appetite ● b-blockers (e.g. propranolol) can be used to in-

● Diarrhoea and polyuria hibit the sympathetic nervous system symptoms

● Oligomenorrhoea and loss of libido like tachycardia until antithyroid treatments
● Goitre/enlarged thyroid gland start to take effect.
Signs II. Antithyroid drugs
● Tachycardia. ● Antithyroid medication is recommended to

● Systolic hypertension. be given for 6 months to 2 years. Upon cessa-

● Hot moist palms. tion of the drugs, the hyperthyroid state may
● Presence of fine tremors, i.e. involuntary movement recur.
of body parts is present. ● The main antithyroid drugs are carbimazole,

● Cardiac arrhythmias, i.e. atrial fibrillation and atrial methimazole and propylthiouracil (PTU).
tachycardia develop. ● These drugs block the binding of iodine and

● Diaphoresis is present, i.e. excessive sweating is coupling of iodotyrosines. The most dangerous
present. side effect is agranulocytosis. Other potential
● There is presence of powerful wide pulse pressure side effects include granulocytopenia and aplas-
and good bounding pulse is present. tic anaemia. The most common side effects are
● Exaggerated deep tendon reflexes are seen. rash and peripheral neuritis.
● Ophthalmopathy. ● If treatment with antithyroid drugs fails to induce

● Pretibial myxoedema: thickening of skin due to mu- remission, radioactive iodine (131I) or surgery
cin deposition on tibia. must be considered.
Eye signs include III. Radioiodine
131
● Exophthalmos with staring look. ● Radioiodine (radioactive iodine – I, abbrevi-
● Lid lag/Von Graefe’s sign: Lagging of upper eyelids. ated as RAI) is suitable for most patients, al-
● Lid retraction. though some prefer to use it mainly for older
● Moebius sign: Absence of convergence of eyeballs. patients.
● Joffroy’s sign: Absence of wrinkling of forehead ● Indications for RAI include failed medical ther-

when patient is asked to look upward. apy or surgery, or when medical or surgical
● Stellwag’s sign: Staring look of patient. therapies are contraindicated.
● Ophthalmoplegia: Paralysis of ocular muscles. ● Contraindications to RAI are pregnancy (abso-

Diagnosis lute), ophthalmopathy (relative; it can aggra-

● TFT: Elevation of T3, T4 and decrease in TSH vate thyroid eye disease) and solitary thyroid
levels. nodules.
● Thyroid scan: Radioisotope scan using 131 Iodine or ● The radio-iodine treatment acts slowly (over

99Tc. months to years) to partially or completely de-

● Ultrasound: For search of cyst or STN. stroys the thyroid gland.
Investigations ● Patients must therefore be monitored regularly

● Serum TSH level is suppressed and is the initial with thyroid blood tests to ensure that they do
diagnostic test. not evolve to hypothyroidism.
Section | I Topic-Wise Solved Questions of Previous Years 385

IV. Surgery before the age of 40 years and results in ketoaci-

● This modality is suitable for young patients and dosis when patients are without insulin therapy.
pregnant patients. ● This account for 10% of cases of DM. Type 1 DM

● Indications for surgery are a large goitre, suspi- is caused by b islet cell failure, which is of multi-
cious nodules or suspected cancer and patients factorial causes such as genetic predisposition,
with ophthalmopathy. viral and autoimmune attacks on the b islet cells.
● Preoperative administration of Lugol’s iodine ● The abrupt onset of symptoms, with polyuria,

solution, decreases intraoperative blood loss polydypsia, polyphagia and weight loss develop-
during thyroidectomy in patients with Graves ing over days or weeks.
disease. ● Some cases may present as ketoacidosis during an

● Choice can be made between partial or total re- intercurrent illness or following surgery.
moval of the thyroid gland (subtotal thyroidec- ● Occasionally, an initial episode of ketoacidosis is

tomy vs. total thyroidectomy). A total removal followed by a symptom-free interval known as
excludes the difficulty in determining how much ‘honeymoon period’ during, which no treatment is
thyroid tissue must be removed. required.
V. Thyroid hormones ● Characteristically, the plasma insulin is low or

● Many Graves disease patients will become life- unmeasurable.

long thyroid patients, due to the surgical removal ● Glucagon levels are elevated but suppressible

or radioactive destruction of their thyroid. with insulin.

● In effect, they are then hypothyroid patients, Type 2 DM
requiring perpetual intake of artificial thyroid ● Type 2 DM formerly known as noninsulin-depen-

hormones. dent DM usually begins after the age of 40 years

● Given the 1-week plasma half-life of levothy- and 60% of the patients are obese. However, type
roxine (T4), it takes about 5–6 weeks (half- 2 DM is being increasingly seen in the teenage
lives) before a steady state is attained after the years.
dosage is initiated or changed. ● Type 2 DM occurs with intact b islet cell function

● After the optimal thyroxine dose has been de- but there is peripheral tissue resistance to insulin.
fined, long-term monitoring of patients with an ● There may be some decrease in insulin production

annual clinical evaluation and serum TSH mea- or a hyperinsulin state. These patients are not ke-
surement is appropriate. tosis prone but may develop it under conditions of
stress.
Q.2. Oral manifestations of diabetes mellitus.
● The symptoms begin gradually, over a period of

Ans. months to years. Frequently, hyperglycaemia is

detected in an asymptomatic person on a routine
● Diabetes mellitus (DM) is hyperglycaemia secondary to
examination.
decreased insulin production or peripheral tissue resis-
● These patients usually do not develop ketoacido-
tance to insulin.
sis. In the decompensated state, they are suscep-
● Classification and aetiology is based on 1997 Report of
tible to the syndrome of hyperosmolar hypergly-
the Expert Committee on the diagnosis and classifica-
caemic state, i.e. hyperosmolar nonketotic coma.
tion of diabetes mellitus.
● The plasma insulin levels are normal to high. Glu-
● Comprises a group of disorders that share a common
cagon levels are elevated, but resistant to insulin.
phenotype of hyperglycaemia.
● Symptoms of complications – burning feet, noctu-

Classification ria and diminished vision.

i. Type 1 DM Gestational onset DM (GODM)
ii. Type 2 DM ● Gestational onset DM occurs when diabetes onset

iii. Gestational diabetes is during pregnancy and resolves with delivery.

iv. Other causes – Cushing syndrome, hypothyroidism, ● These patients are at a higher risk for developing

genetic causes and viral infections of the pancreas DM at a later date.

Clinical features Other specific types of DM
l The clinical features of type 1 and type 2 DM are They include diseases of the exocrine pancreas,
distinctive. various endocrinopathies (Cushing syndrome, pheo-
Type 1 DM chromocytoma), drug or chemical-induced DM
● Type 1 DM/insulin-dependent DM usually occurs (b-blockers, oral contraceptives) or genetic syn-
in childhood or early adulthood that is usually dromes (lipodystrophies) associated with diabetes.
386 Quick Review Series for BDS 4th Year, Vol 2

Complications ●Food habits

● Neuropathy ●Containing more of complex carbohydrates
● Retinopathy ● Exercise

● Nephropathy Dietary regimen for a diabetic patient

● Coronary artery disease The preparation of a dietary regimen for a diabetic can
● Peripheral artery disease be considered under three steps:
Diagnosis First step
History ● This involves the estimation of the total daily ca-

● Clinical presentations of DM may include poly- loric requirement of the individual patient based
uria, polydypsia and polyphagia associated with on a number of variable factors like age, sex,
weight loss, blurred vision, recurrent candidal weight, activity and occupation of the patient. An
vaginitis, soft-tissue infections or dehydration. approximate total daily caloric requirement can
Many cases will be asymptomatic and picked up be calculated as:
on routine screening. ● Sedentary individuals 30 kcal/kg/day

Diagnosis of diabetes mellitus based on various test ● Moderately active individual 35 kcal/kg/day

results is as follows: ● Heavily active individuals 40 kcal/kg/day

a. Random plasma glucose of .200 mg/dL along Second step

with symptoms of diabetes are present. ● This involves allocation of the calories in a proper

b. Two readings of fasting plasma glucose of proportion to carbohydrate, protein and fat.
.126 mg/dL. ● The recommended proportion of calories to be

c. The 2-h postprandial plasma glucose 200 mg/ derived from each of them is given as:
dL during oral glucose tolerance test, after a
glucose load of 75 g. Carbohydrate 50%–60%
d. Elevated HbA1c. However, the HbA1c is not
Protein 10%–20%
an adequate screening tool for DM because it
may be normal in those with impaired glucose Fats 10%–20%
tolerance.
e. The patient is said to have impaired glucose However, a few more important factors need be con-
tolerance if the fasting plasma glucose is .110 sidered at this stage are
and ,126 mg/dL. ● The minimal protein requirement for a good
f. Impaired glucose tolerance: 2-h plasma glu- nutritious diet is about 0.9 g/kg/day.
cose values between 140 and 200 mg/dL. ● The carbohydrates should be taken in the form
Differentiating type 1 and type 2 DM of starches and other complex sugars.
● Occasionally, it may be difficult to differenti- ● Rapidly absorbed simple sugars like glucose
ate between type 1 and type 2 DM based on the should generally be avoided. Use of caloric
clinical situation. The diagnosis can be clari- sweeteners including sucrose is acceptable in
fied by the use of the C-peptide, a product of many patients.
the cleavage of proinsulin to insulin. This will ● Fish oils containing omega-3 fatty acids have
be present in those with type 2 DM and low or been reported to be beneficial, as antiathero-
absent in those with type 1 DM. genic.
● If the C-peptide is border line, checking it after ● A high-fibre diet is beneficial as it has an anti-
a glucose load may help. In those with type 2 atherogenic effect mediated through lowering
DM, it will increase significantly after glucose of blood lipids.
load, this response will be absent in those with Third step
type 1 DM. ● This involves distribution of the calories through-
Treatment out the day. This is particularly important in insu-
● Oral antidiabetics lin-requiring diabetics, to avoid hypoglycaemia.
● Glibenclamide ● Different distributions may be required for differ-
● Glimiperide ent lifestyles, a typical pattern of distribution of
● Metformin calories is:
● Acarbose ● 20% of the total calories for breakfast
● Insulin ● 35% of the total calories for lunch
● Short/intermediate/long-acting insulin ● 30% of the total calories for dinner
● Modification of life style ● 15% of the total calories for late-evening feed
Section | I Topic-Wise Solved Questions of Previous Years 387

Q.3. Describe general, oral and dental manifestations of ● Thyroid acropathy is unusual feature of Graves dis-
various endocrine disorders. ease and manifests as digital clubbing and swelling
of fingers and toes.
Ans.
Hyperparathyroidism
Oral and dental manifestations of various endocrine disor- ● Diaphoresis is present, i.e. excessive sweating is

ders are as follows: present.

● There is presence of powerful wide pulse pressure

and good bounding pulse.

{SN Q.2}
● Exaggerated deep tendon reflexes are seen.
Diabetes mellitus ● Opthalmopathy.
● Gingivitis ● Pretibial myxoedema: Thickening of skin due to
● Polyuria mucin deposition on tibia.
● Polydypsia Hypothyroidism
● Polyphagia ● Enlargement of the thyroid gland.
● Periodontitis ● General manifestations: Weakness, tiredness, cold
● Bones loss intolerance, dry coarse skin pallor, hair loss, puffy
● Compromised healing face, hand and feet, myxoedema, weight gain, poor
● More accumulation of plaque appetite, hypothermia, goitre and hoarse voice.
● Gastrointestinal: Decreased appetite, constipation

Acromegaly and ascites.

● Face becomes enlarged and mandible is prominent ● Cardiorespiratory: Angina, bradycardia, hyperten-

with teeth widely spaced. sion, cardiac failure, pericardial effusion and pleural
● Coarse facial features. effusion.
● Temporal headaches, photophobia and reduction in ● Neuromuscular: Aches and pains, muscle stiffness,

vision. delayed relaxation of tendon reflexes, carpal tunnel

● Lips are thick and voice is coarse and husky. syndrome, deafness, depression, psychosis, cerebel-
● There is brownish pigmentation of face. lar ataxia and myotonia.
● General features like fatigue and weight gain are ● Dermatological: Myxoedema (nonpitting oedema of

present. the skin of hands, feet and eyelids), dry flaky skin and
● Cardiac effects: Coronary artery disease, hyperten- hair, alopecia, vitiligo, purplish lips and malar flush,
sion and left ventricular hypertrophy are present. carotenaemia, erythema abigne and xanthelasmas.
● Metabolic effects: Intolerance or clinical diabetes ● Reproductive: Menorrhagia, infertility, galactorrhoea

mellitus. and impotence.

● Soft tissue changes like thickening of skin, increased ● Haematological: Macrocytosis and anaemia.

skin tags, acanthosis nigricans, increased sweat and ● Miscellaneous: Tiredness, somnolence, cold intoler-

sebum resulting in moist and oily skin, enlargement ance, hoarseness of voice, low-pitched voice and
of lips, nose and tongue (macroglossia), increased slurred speech.
heel pad thickness, visceral enlargement (viscero- ● Myxoedema coma is a rare complication of hypothy-

megaly), e.g. thyroid, heart (cardiomegaly) and liver, roidism, seen usually in elderly patients.
carpal tunnel syndrome, myopathy and sleep apnoea. Dental considerations
Hyperthyroidism ● Impaired ability of small vessels to contract when

● Important manifestations of hyperthyroidism are cut due to deposition of subcutaneous mucopoly-

weight loss with increased appetite, heat intolerance, saccharides in hypothyroidism may result in ex-
sweating, palpitation, tremors and nervousness. cessive bleeding. Hence, local pressure is required
● The signs are tachycardia, atrial fibrillation, fine fin- for longer period to control bleeding.
ger tremors, moist warm skin, lid retraction, wide ● Due to poor healing in hypothyroidism there is

palpebral fissure, lid lag and exophthalmos. a delayed wound healing and increased risk of
● Proptosis may cause corneal drying and damage. In infection.
severe case, exophthalmos, diplopia and optic nerve ● In patients with hypothyroidism use of sedatives,

compression may occur. opioid analgesics and tranquillizers may precipi-

● Dermopathy occurs in about 5% of patient with tate myxoedema coma.
Graves disease. Purple or pink patches over anterior ● Well-controlled hyperthyroidism and hypothy-

and lateral aspect of the leg (pretibial myxoedema) roidism do not pose any additional risk for dental
are commonly seen. procedures.
388 Quick Review Series for BDS 4th Year, Vol 2

Addison disease ● More likely to have candida and fungal infections, pos-
● Clinical features of Addison disease result from glu- sibly due to abnormal flora on the skin and mucosa.
cocorticoid deficiency, mineralocorticoid deficiency, ● There can also be osteoporosis.

androgen deficiency and ACTH excess. Hyperpituitarism

● The cardinal features of Addison disease are hypo- Acromegaly
tension, pigmentation and previous history of acute Mandibular prognathism and thickening of cortical
adrenal crisis following stress, or slow recovery from plates.
illness. ● Connective tissue proliferation and oedema of

● Glucocorticoid deficiency results in malaise, weakness, the face. Lips and nose are enlarged.
weight loss, anorexia, nausea, vomiting, diarrhoea or ● Flaring of teeth due to increased jaw development.

constipation, postural hypotension and hypoglycaemia. ● Macroglossia or enlarged tongue.

● Mineralocorticoid deficiency manifests as hypo- Gigantism

tension. ● Maxilla and mandible are enlarged with marked

● ACTH excess results in pigmentation of exposed ar- increase in vertical dimension.

eas, pressure areas like elbows, knees and knuckles, ● There may be accelerated dental development and

palmar creases, mucous membranes, conjunctivae eruption of teeth.

and recently acquired scars. ● Other features may be macroglossia, hyperce-

● Androgen deficiency results in diminution of body mentosis and macrodontia.

hair, especially in females. Hyperthyroidism
● Increased susceptibility to caries and periodontal
Q.4. Discuss the role of oral diagnosis in diagnosing en-
docrinal disorders. disease
● Enlargement of extraglandular thyroid tissue
Ans. (mainly in the lateral posterior tongue)
Diabetes mellitus ● Maxillary or mandibular osteoporosis

● Periodontal disease is the most consistent finding in ● Accelerated dental eruption(s)

patients with poorly controlled diabetes mellitus. Ap- ● Burning mouth syndrome

proximately, 75% of these patients have periodontal Hypothyroidism

disease, with increased alveolar bone resorption and Childhood hypothyroidism (CRETINISM)
inflammatory gingival changes. Common oral findings in hypothyroidism are
● Diabetics whose disease is under good control also ● Thick lips.

have a higher incidence and greater severity of peri- ● Macroglossia.

odontal disease. ● Long-term effects include impaction of man-

● Diabetics may demonstrate xerostomia and recurrent dibular second molars.

abscesses. ● Dysgeusia.

● Enamel hypoplasia and hypocalcification can result ● Macroglossia.

in an increased frequency of caries. ● Delayed eruption.

● The oral flora is often altered by colonization with ● Poor periodontal health.

Candida albicans, haemolytic streptococci and ● Altered tooth morphology.

staphylococci. ● Delayed wound healing.

● Abnormal eruption patterns may be noted in children ● Glossitis.

with diabetes. Advanced eruption may be seen before ● Mouth breathing.

the age of 10, whereas delayed eruption occurs after ● Anterior open bite.

the age of 10. ● Salivary gland enlargement.

Cushing syndrome Hyperparathyroidism (Brown tumour)

● Results from excess of adrenocorticoid hormone ● Results in poorly mineralized bone with giant cell

production. tumour or cystic lesions in the jaw.

● Characterized by adiposity of upper portion of the ● There is usually osteoporosis and drifting and

body, buffalo hump, muscular weakness, vascular spacing of teeth.

hypertension, glycosuria and albuminuria. ● Bone resorption.

● Patients with Cushing syndrome tend to bleed and Hypoparathyroidism

bruise easily. ● It usually occurs following surgical removal of

● Wound healing is also impaired, and scar formation the thyroid gland.
is less timely and less vigorous than in the normal ● Deficiency of parathyroid secretion can cause

subject. aplasia or hypoplasia of teeth.

Section | I Topic-Wise Solved Questions of Previous Years 389

Q.5. Acromegaly. b. Radiotherapy

● Irradiation is advised when initial attempts at surgery
Ans.
do not reduce growth hormone levels to 5 MU/L.
● Implantation of radioactive isotope yttrium 90
{SN Q.4} causes major reduction in growth hormone levels.
Acromegaly occurs due to excess secretion of Growth c. Medical therapy
Harmone (GH) later In the life after epiphyseal closure. ● Somatostatin analogues:

● Bromocriptine 20–30 mg/day orally in divided

doses is given.
Causes ● Octreotide 0.05–0.1 mg subcutaneously is given.
● Pituitary adenomas – In 95% of cases.

● Pancreatic islet cell tumours – Excessive growth hor-

mone secreting pancreatic islet cell tumours. SHORT ESSAYS:

● Hypothalamic tumours. Q.1. Hyperthyroidism.
● Bronchial carcinoid.

● Small cell carcinoma of lung.

Ans.
Clinical features ● A state of excessive thyroid hormone due to hyperfunc-
tion of the thyroid gland is called hyperthyroidism or
thyrotoxicosis.
{SN Q.4}
Clinical features
Acromegaly is characterized by: ● The most common cause of thyrotoxicosis is Graves

● Increased hand and foot size and enlargement of disease (Basedow disease) 60%–80%.
terminal phalanges of limbs. ● Graves disease is an autoimmune disorder with

● The ribs also increase in size. genetic predisposition. The antibodies (TSH-R an-
● Face becomes enlarged and mandible is prominent tibodies) bind TSH receptors on thyroid follicular
with teeth widely spaced. cells and stimulate thyroid hormone production
● Coarse facial features. and goitre formation.
● Temporal headaches, photophobia and reduction ● Graves disease is characterized by diffuse enlargement

in vision. of the thyroid gland, infiltrative ophthalmopathy (ex-

● Lips are thick and voice is coarse and husky. ophthalmos) and pretibial myxoedema (dermopathy).
● There is brownish pigmentation of face. ● Important manifestations of hyperthyroidism are

● General features like fatigue and weight gain are weight loss with increased appetite, heat intolerance,
present. sweating, palpitation, tremors and nervousness.
● Cardiac effects: Coronary artery disease, hyperten- ● The signs are tachycardia, atrial fibrillation, fine fin-

sion and left ventricular hypertrophy are present. ger tremors, moist warm skin, lid retraction, wide
palpebral fissure, lid lag and exophthalmos.
● Ophthalmopathy is present in 20%–50% patients of
● Metabolic effects: Intolerance or clinical diabetes Graves disease. It may precede the development of
mellitus. thyrotoxicosis or may develop after successful treat-
● Soft tissue changes like thickening of skin, increased ment of hyperthyroidism of Graves disease.
skin tags, acanthosis nigricans, increased sweat and ● Proptosis may cause corneal drying and damage. In
sebum resulting in moist and oily skin, enlargement severe case, exophthalmos, diplopia and optic nerve
of lips, nose and tongue (macroglossia), increased compression may occur.
heel pad thickness, visceral enlargement (viscero- ● Dermopathy occurs in about 5% of patient with
megaly), e.g. thyroid, heart (cardiomegaly) and liver, Graves disease. Purple or pink patches over anterior
carpal tunnel syndrome, myopathy and sleep apnoea. and lateral aspect of the leg (pretibial myxoedema)
Investigations are commonly seen.
● IGF-1 (insulin-like growth factor-1) is elevated. ● Thyroid acropathy is unusual feature of Graves dis-
● GH is elevated. ease and manifests as digital clubbing and swelling
Treatment of fingers and toes.
a. Surgical Investigations
● Surgery is the treatment of choice. Surgical resec- ● Serum TSH level is suppressed and is the initial
tion of the adenoma is done by trans-sphenoidal diagnostic test.
route followed by radiotherapy. ● Serum total and unbound (free) T3 and T4 are increased.
390 Quick Review Series for BDS 4th Year, Vol 2

●The uptake of radioactive iodine by thyroid is high ● Patient on long-term anticoagulant therapy should
in Graves disease and toxic nodular goitre whereas discontinue the anticoagulant at least 4–5 days, prior
it is low in subacute thyroiditis. to surgery with physician’s concern.
● Ultrasonography thyroid gland reveals diffuse en- ● If discontinuation of oral anticoagulant therapy is not

largement of thyroid gland. advisable, the patient should be shifted to intrave-

Treatment nous anticoagulants like heparin.
● Hyperthyroidism or Graves disease is treated by: ● The patient’s bleeding time and clotting time is

a. Antithyroid drugs checked on the day of the surgery after omission of

b. Radioactive iodine (131I) the anticoagulant.
c. Subtotal thyroidectomy Intra- and postoperative care
● The choice of treatment depends on the cause and ● All the patients should be monitored intra- and post-

severity of hyperthyroidism, the age of the patient operatively by means of an ECG, pulse oximetre and
and clinical situation. arterial line.
Antithyroid drugs ● A central venous pressure (CVP) cut down may be

● The commonly used drugs are carbimazole, me- performed if necessary.

thimazole and propylthiouracil. ● The patient should be maintained on intravenous

● The drugs are given for prolonged periods of about cardiac drugs till oral feeds are given.
1–2 years. After stopping treatment, relapse occurs in ● Fluids overload should be avoided, especially in

about 50% of patients. cases of congestive cardiac failure.

● Rash, fever and arthralgia are common side effects, ● The fluid volume can be judged by CVP.

whereas agranulocytosis is a serious side effect.

Radioactive iodine (131I)
● Iodine (
131
I) causes progressive destruction of thy-
SHORT NOTES:
roid cells. It can be used as initial treatment after Q.1. Hyperparathyroidism.
antithyroid drugs or surgery.
Ans.
Thyroid surgery (subtotal thyroidectomy)
● In cases of relapse after antithyroid drugs and in ● Primary hyperparathyroidism is caused by hypersecre-
young males with large goitre or severe hyperthy- tion of Parathormone (PTH). In majority of cases, this
roidism surgery is indicated. This is also preferred in is due to autonomous hypersecretion of PTH.
pregnant women. ● Primary hyperparathyroidism (adenoma or hyperplasia)
may be familial and part of multiple endocrine neopla-
Q.2. Management of cardiac patient in dental extrac- sia (MEN types I, 2a).
tion. ● Secondary hyperparathyroidism is characterized by
the hypersecretion of PTH due to stimulation by hy-
Ans.
pocalcaemia. There is hyperplasia of parathyroid
Preoperative investigations glands.
● Routine chest radiograph – Posteroanterior view. ● In tertiary hyperparathyroidism, hyperplastic parathy-
● Electrocardiogram. roid glands may result in adenoma formation autono-
● Echocardiogram. mous PTH secretion.
● Stress test. ● Majority of patients may be asymptomatic. However,
● Blood investigations like rapid profile and bleeding symptoms are generally due to hyperkalaemia. Bone
time, clotting time and prothrombin time. resorption occurs due to ‘brown tumours’ or cysts of
● PTH activity may lead to demineralized pathological the jaw.
fractures and generalized cystic lesions (osteitis and
Q.2. Oral manifestations of diabetes mellitus.
fibrosa cystica).
Preoperative medication Ans.
● If the patient is a case of rheumatic heart disease or
[Ref LE Q.3]
has undergone valve replacement, ‘PTH activity. This
may lead to demineralized pathological fractures and Q.3. Addison disease – aetiology.
generalized cystic, ions (osteitis fibrosa cystica)’ a
Ans.
suitable antibiotic prophylaxis must be given.
● If the patient is on injection penidure every 3 weeks, Addison disease is a primary disease of the adrenal
the surgery should be scheduled after the scheduled glands, which is unable to elaborate sufficient quantity of
doses to reduce the risk of infective endocarditis. hormones.
Section | I Topic-Wise Solved Questions of Previous Years 391

Aetiology ● Since stress can accentuate stomach acid production, a

● Idiopathic stress reduction protocol should be employed. Wherever
● Infections possible, lengthy procedures should be spread over sev-
● Haemorrhage eral appointments.
● Autoimmune adrenalitis and tuberculous adrenalitis ● Adjunctive sedation techniques should be considered
● Bilateral adrenalectomy when appropriate for minimization of stress. Sedation
● Adrenal haemorrhage or infarction techniques might include the use of nitrous oxide/
● Drugs (e.g. ketoconazole) oxygen inhalation, oral antianxiety medications
● Amyloidosis, etc. such as Diazepam (valium) or intravenous sedation
techniques.
Q.4. Acromegaly.
● Antacid therapy is commonly utilized. It should be
Ans. borne in mind that the efficacy of a number of antibiot-
ics prescribed by the dentist is compromised if given
[Ref LE Q.5]
together with antacids.
Q.5. Radiographic appearance of hyperparathyroidism. ● Antibiotics such as tetracycline, ciprofloxacin and other
quinolones, and metronidazole (flagyl) should not be
Ans.
given together with antacids.
● The bones of the affected persons show a general radio-
Q.7. Koplik spots.
lucency as compared with those of normal people.
● Later, sharply defined round or oval radiolucent areas Ans.
develop, which may be lobulated.
● Koplik spots are seen in measles. These lesions are
● Small cystic areas may be seen in the calvarium, and
pathognomonic of the early measles infection.
large or small sharply defined radiolucencies may
● Measles is a disease with a prodromal phase that is
present the maxilla or mandible. These lesions must dif-
characterized by symptoms of upper respiratory tract
ferentiated from the lesions of multiple myeloma and
infection, tonsillopharyngitis and small white lesions
eosinophilic granuloma.
with erythematous bases on the buccal mucosa and in-
● Ground-glass appearance can be seen in the jaw radio-
ner aspect of the lower lip (Koplik spot).
graph.
● The lamina dura may be partially lost. Q.8. Grinspan syndrome.
Q.6. Dental considerations for a patient with a history of Ans.
gastritis.
● This syndrome is associated with oral lichen planus.
Ans. ● Association of lichen planus, diabetes mellitus and
vascular hypertension described by Grinspan, the
● Drugs that cause gastrointestinal irritation should be
triad being described as Grinspan syndrome by
avoided. This includes aspirin, NSAIDs, corticosteroids
Grupper.
and erythromycin.

Topic 14
Metabolic Disorders
COMMONLY ASKED QUESTIONS
SHORT ESSAYS:
1. Dental management of rheumatic fever patient.
2. What are the oral manifestations of hypovitaminosis?
3. Describe in detail about rickets.
4. Scurvy.
5. Dental considerations in asthmatic patients.
6. Discuss the oral manifestations of avitaminosis. [Same as SE Q.2]
392 Quick Review Series for BDS 4th Year, Vol 2

SHORT NOTES:
1. Dental management of rheumatic patient. [Ref SE Q.1]
2. Paul–Bunnell test.
3. Multiple myeloma.
4. Avitaminosis A.
5. Oral manifestations of vitamin D deficiency. [Ref SE Q.3]
6. Infective endocarditis.
7. Bronchial asthma.
8. Dental considerations in pregnancy.
9. Scorbutic gingivitis.
10. Riboflavin deficiency.
11. Hypervitaminosis A.
12. Bence–Jones proteinuria.
13. Dental significance of hypertension.
14. Oral manifestations of vitamin A deficiency. [Same as SN Q.4]

SOLVED ANSWERS
SHORT ESSAYS: ● All dental surgical procedures should be carried out
Q.1. Dental management of rheumatic fever patient. under antibiotic chemoprophylaxis to prevent infec-
tive endocarditis in patient with history of congenital
Ans.
or valvular defects, prosthetic heart valves, previous
● Rheumatic fever is primarily a disease of childhood and history of infective endocarditis, etc.
adolescence.
● It is assumed that it is an infection caused by group A The following is the standard regimen of antibiotic
beta hemolytic streptococci. prophylaxis to be employed:
● One or two weeks before the appearance of the disease,
Oral medications
the individual manifests tonsillitis and pharyngitis.
● Adults: Amoxicillin 2 g orally 1 h before procedure
● Rheumatic fever is characterized by arthritis and/or
● Children: 50 mg/kg amoxicillin 1 h before procedure
carditis and involvement of central nervous system.
Clinical features In patients with allergic to penicillin
● Pain, swelling and stiffness in one or more joints, tachy- ● Adults:
cardia, fatigue and weight loss. ● 600 mg clindamycin 1 h before procedure or

● The typical feature of rheumatic fever is migrating poly- ● 2.0 g cephalexin 1 h before

arthritis. ● Children:
● Patient may manifest retrosternal pain due to pericarditis. ● 20 mg/kg clindamycin orally 1 h before proce-

● Small painless, subcutaneous nodules may be palpable dure or

over bony prominences such as elbow, knees, etc. ● 50 mg/kg cephalexin or cephadroxil 1 h before

● Another feature is pink patches on the trunk. procedure or

● Sydenham chorea is yet another clinical feature. ● 15 mg/kg azithromycin or clarithromycin 1 h

● ESR may be raised in these patients. before procedure

Treatment
● Bed rest, NSAIDs such as prednisolone (60–80 or 3 mg/kg
in children) Q.2. What are the oral manifestations of hypovitaminosis?

Ans.
{SN Q.1}
● Vitamins are essential for growth and normal body
Dental consideration
functions and deficiency of vitamins causes various
● A patient with recent history of rheumatic fever or
clinical manifestations as follows:
rheumatic heart disease requires antibiotic chemopro-
i. Thiamine
phylaxis prior to dental procedures. Precautions to be
● Cardiac beriberi – High output cardiac failure
taken in these patients during dental treatment
● Dry beriberi – Polyneuropathy
Section | I Topic-Wise Solved Questions of Previous Years 393

● Wernicke encephalopathy – Confusion, nystagmus,

● The wrist and ankles are swollen and the changes in
ophthalmoplegia, ataxia and polyneuropathy
bone are found in epiphyseal plates, metaphysis and
● Korsakoff psychosis – Amnesia with confabulation
shaft.
ii. Riboflavin
● Localized area of thinning are sometime present in
● Angular stomatitis, glossitis and cheilosis
skull so that a finger can produce indentation. This
● Seborrhoeic dermatitis
condition is called as craniotabes.
● Photophobia, lacrimation and visual fatigue
● Pigeon breast.
iii. Niacin (Pellagra)
● Developmental abnormalities of dentine, hypoplasia
● Dermatitis
of enamel and delayed eruption.
● Diarrhoea
● Higher caries index.
● Dementia
● Malocclusion of teeth is present.
iv. Pyridoxine
● Angular stomatitis, glossitis and cheilosis Treatment
● Convulsions, peripheral neuropathy ● Dietary enrichment of vitamin D in form of milk.
● Hypochromic, microcytic anaemia ● If tetany is present, give i.v. calcium gluconate. Daily
v. Pantothenic acid dose is 1000–2000 IU of vitamin D combined with
● Apathy, depression, paraesthesia, muscle weak- 500–1000 mg of calcium.
ness, burning feet and personality changes
vi. Biotin
● Periorofacial dermatitis, conjunctivitis, alopecia,

ataxia, deafness, optic atrophy ● Curative treatment includes 2000–4000 IU of calcium

vii. Cyanocobalamin daily for 6–12 weeks followed by daily maintenance
● Megaloblastic anaemia, peripheral neuropathy,
dose of 2000–4000 IU for long period.
subacute degeneration of spinal cord and megalo-
blastic madness Q.4. Scurvy.
viii. Folic acid Ans.
● Megaloblastic anaemia

● Psychosis and neural tube defects i. Scurvy is caused due to deficiency of vitamin C, which
ix. Ascorbic acid (scurvy) results in defective collagen formation in connective
● Bleeding gums, petechiae, ecchymosis, purpura, tissue.
arthralgia and joint effusions ii. It is of two types:
● Depression, hysteria and postural hypotension a. Adult scurvy
x. Vitamin A b. Infantile scurvy
● Night blindness, Bitot spots, corneal ulceration, iii. In adult scurvy:
blindness and follicular keratosis ● Swollen spongy gums – scurvy buds

● Recurrent respiratory tract infections ● Scorbutic gingivitis

xi. Vitamin D ● Perifollicular haemorrhages

● Rickets and osteomalacia ● Petechial haemorrhages, ecchymoses, epistaxis and

xii. Vitamin E Gastro intestinal (GI) bleeding

● Haemolytic anaemia, macrocytic anaemia, spinocere- ● Nail beds: Splinter haemorrhages

bellar syndrome, myopathy and peripheral neuropathy ● Haemorrhages into muscles and joints

xiii. Vitamin K ● Poor wound healing

● Ecchymosis, mucosal bleeding and internal haem- iv. Infantile scurvy:

orrhage ● Scorbic child usually assumes a frog-like position

and this may reflect as subperiosteal haemorrhage in

Q.3. Describe in detail about rickets.
to shafts of long bone
Ans. ● Scorbutic rosary – i.e. enlargement of costochondral

joints
{SN Q.5} ● Lassitude and anorexia

● Painful limbs giving rise to pseudoparalysis

Vitamin D deficiency – Rickets occurs generally in
growing children. v. Management:
● Consumption of citrus fruits and vegetables
Clinical features ● Vitamin C 500 mg daily initially
● In first 6 months of life, tetany and convulsions are
common; these manifestations are due to hypocal- Q.5. Dental considerations in asthmatic patients.
caemia. Ans.
394 Quick Review Series for BDS 4th Year, Vol 2

● The major goal for the dentist in the management of the Q.3. Multiple myeloma.
patient with asthma is to minimize the likelihood of the
Ans.
precipitating an asthmatic attack.
● A detailed history of the severity of the asthma, precipi- ● Multiple myeloma is a malignant neoplasm, which is
tating factors and the medications used is very helpful characterized by the production of pathogenic M pro-
in the management of these patients. teins, bone lesions, kidney diseases, hyperviscosity and
● Patients with asthma can occasionally have an exacer- hypercalcaemia.
bation under stress, and efforts should be made to iden- ● Skeletal pain is the most common presenting symptom.
tify patients whose bronchospasm is precipitated by ● These plasma cells produce abnormal M proteins that
emotional stress. are useful in the diagnosis of the disease due to their
● Minimize stress: wherever possible, lengthy procedures characterized electrophoretic pattern but useless in
should be spread over several appointments. functioning as normal antibodies.
● Adjunctive sedation technique should be considered ● The most common radiographic abnormality is the pres-
when appropriate for minimization of stress. ence of ‘punched-out’, radiolucent lesions, but general-
● Sedation technique might include the use of N2O/O2 ized osteoporosis may occur in the absence of these
inhalation, diazepam or other oral antianxiety medi- discrete punched-out lesions.
cation.
Oral manifestation
● Avoid antihistaminic drugs such as promethazine or di-
● Patient may experience pain, swelling, numbness of
phenhydramine.
the jaw, epulis formations or unexplained mobility of
● Minimize epinephrine use.
the teeth.
● Avoid erythromycins and clarithromycin: These drugs
● Skull lesions are very common than jaw lesions.
should be avoided in patient on methylxanthines prepa-
● Mandible is more frequently involved because of its
rations, e.g. theophyllines in order to minimize the
greater content of marrow.
likelihood of the arrhythmias.
● Extraoral lesions also occurs in a significant number of
● Local symptomatic lesions are treated with radiotherapy.
patients, although a majority of them are asymptomatic.
Q.6. Discuss the oral manifestations of avitaminosis.
Treatment
Ans. ● The alkylating agents, such as melphalan or cyclophos
phamide, are the treatment of choice for patients with
[Same as SE Q.2]
extensive bone lesions or rising level of M proteins.
● Local symptomatic lesions are treated with radiotherapy.
SHORT NOTES:
Q.4. Avitaminosis A.
Q.1. Dental management of rheumatic patient.
Ans.
Ans.
● Deficiency of vitamin A causes interference with
[Ref SE Q.1]
growth, reduced resistance to infections and interfer-
Q.2. Paul–Bunnell test. ence with nutrition of cornea, conjunctiva, trachea, hair
follicle and renal pelvis.
Ans.
● Vitamin A deficiency interferes with ability of eyes to
● Paul–Bunnell test is the diagnostic test for infectious adapt to darkness and impairs visual affinity.
mononucleosis. ● Children with vitamin A deficiency will experience im-
● The patient exhibits atypical lymphocytes in the circu- paired growth and development.
lating blood, as well as antibodies to EB virus and an
Aetiology
increased heterophil antibody titre.
● Poor intake
● The increased heterophils are present only in small
● Malabsorption
minority of children with the disease.
● Disease of liver and intestine
● The normal titre of agglutinins and haemolysins in
human blood against sheep red blood cells does not Clinical features
exceeds 1:8. ● Earliest sign of deficiency of vitamin A is difficulty in
● In infectious mononucleosis, the titre may rise to reading or sewing at night times or finding anything in
1:4096. darkness.
● This is referred to as positive Paul–Bunnell test and is ● Conjunctiva becomes dry and small greyish white raised
both characteristic and pathognomonic of the disease. spots known as Bitot spots appear.
Section | I Topic-Wise Solved Questions of Previous Years 395

● Cornea subsequently becomes lustreless and if there is ● It is characterized by recurrent and reversible airflow
lack of treatment the changes are irreversible. limitation due to underlying inflammatory process.
● Keratomalacia involving the cornea leading to the ulcer-
Aetiology
ation and blindness may result.
l Unknown, but allergic sensitivity is seen in most of the
● The children with vitamin A deficiency not only have
patients.
retarded growth but also increased tendency to chest
infection. Clinical features
● Microcytic anaemia. ● Clinical feature of asthma is due to the underlying
● Skin becomes dry and rough. chronic inflammatory process.
● Imperfect enamel formation of teeth. ● Hallmark clinical feature of asthma are recurrent revers-
ible airflow limitation and airways hyper responsiveness.
Treatment
● These factors lead to the development of the signs and
● Vitamin A deficiency can be prevented by giving good
symptoms of asthma, which includes intermittent
nutrition, intake of fresh leafy green vegetables and ad-
wheezing, coughing, dyspnoea and chest tightness.
dition of vitamin A to food stuffs.
● Symptoms of asthma tends to worsen at night and in
● Vitamin A may be administered orally as retinol 30 mg
early morning hours.
daily for 3 days.
● In advanced cases where absorption is effected vitamin Management
A in dose of 50,000 IU parenterally for 3 days. ● Pharmacotherapy is based on the severity of the disease.
Q.5. Oral manifestations of vitamin D deficiency. Q.8. Dental considerations in pregnancy.
Ans. Ans.
[Ref SE Q.3] The dentist must be aware of and cautious about the
following:
Q.6. Infective endocarditis.
● Treatment strategies and limitations
Ans. ● Limitation on radiographic examination
● The safest trimester for the dental treatment
● Infective endocarditis is a serious infection of the heart
● Limitations on the drug therapy prescribed by the dentist
valve or the endothelial surfaces of the heart.
● Potential increased risk to fetus in the presence of peri-
Dental considerations odontal diseases during pregnancy
● The risk of endocarditis primarily depends upon the
Q.9. Scorbutic gingivitis.
pre-exisiting underlying cardiac condition.
● The dental health and hygiene of the patient also con- Ans.
tributes to the relative risk.
● It chiefly affects the gingival and periodontal structures.
● Patient with active periodontal disease and active peri-
● The interdental and marginal gingival becomes bright
apical infection are more likely to have transient bacte-
red, swollen, smooth, shiny producing appearance known
raemia.
as scurvy bud.
● The likelihood of transient bacteraemia from the oral
● There is a typical fetid breath of a patient with fusospi-
cavity is related directly to the degree of the oral inflam-
rochetal stomatitis.
mation and infection.
● The greater the soft tissue trauma, the greater the risk of Q.10. Riboflavin deficiency.
bacteraemia.
Ans.
Prevention
● Riboflavin (vitamin B2) is part of the oxidation chain in
● All dental surgical procedure should be carried out un-
the mitochondria, acting as a coenzyme in oxidation
der antibiotic chemoprophylaxis to prevent infective
reduction reactions.
endocarditis in patient with history of congenital or
● It is widely distributed in animal and vegetable foods,
valvular defects, prosthetic heart valves, previous his-
the richest supply coming from milk and its nonfat
tory of infective endocarditis, etc.
products.
Q.7. Bronchial asthma. ● Levels of the vitamin are low in staple cereals but ger-
mination increases its content.
Ans.
● Clinical deficiency is rare in developed countries. It
● Asthma is a chronic disease that affects the lower mainly affects the tongue and lips and manifests as glos-
airways. sitis, angular stomatitis and cheilosis.
396 Quick Review Series for BDS 4th Year, Vol 2

● The genitals may be affected, as well as the skin areas Q.13. Dental significance of hypertension.
rich in sebaceous glands, causing nasolabial or facial
Ans.
dyssebaceous.
● Rapid recovery occurs with oral intake of 10 mg ● In the dental clinic to determine the blood pressure in
daily. suspected cases and to check whether the blood pres-
sure is under control prior to any dental procedures in
Q.11. Hypervitaminosis A.
patient undergoing any hypertensive therapy, a blood
Ans. pressure apparatus or sphygmomanometer must be
readily available.
i. Acute toxicity has been reported after excess consump-
● A patient with moderate or severe hypertension requires
tion or intake of more than 150 mg vitamin A.
evaluation and treatment by physicians.
ii. Clinical presentation of acute toxicity includes in-
● Uncontrolled hypertension is a contraindication for oral
creased intracranial pressure, vertigo, diplopia, seizures
surgical procedures as there can be excessive bleeding.
and exfoliative dermatitis.
● Diuretics, a-adrenergic and ganglionic channel blockers
iii. Chronic toxicity (ingestion of 15 mg/day for several
can cause orthostatic hypotension or a fall in the blood
months) manifests as dry skin, cheilosis, glossitis, alo-
pressure due to the sudden change of the posture from a
pecia, bone pain, hypercalcaemia and increased intra-
supine position as on a dental chair to an upright posi-
cranial pressure.
tion, which leads to fainting.
iv. High dose of carotenoids may cause yellowing of skin
● Therapy with methyldopa can lead to oral ulcerations.
but not the sclera.
● Some of the antihypertensive drugs can cause lichenoid
Q.12. Bence–Jones proteinuria. reactions in the oral cavity.
● Calcium channel blockers such as nifedipine can cause
Ans.
gingival enlargement.
● Bence–Jones proteinuria is a diagnostic test for multiple
Q.14. Oral manifestations of vitamin A deficiency.
myeloma.
● Bence–Jones proteins are monoclonal immunoglobulin Ans.
light chains detected in 24 h urine specimens of multiple
[Same as SN Q.4]
myeloma patients.

Topic 15
Haematologic Diseases
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. Define purpura. Discuss in detail the clinical features and investigations of purpura.
2. Describe the laboratory investigations for bleeding and clotting disorders.
3. What are the aetiological factors for the spontaneous bleeding from gingiva? Describe the oral manifestations
of myelogenous leukaemia.
4. Classify anaemias. Discuss in detail the oral manifestations, diagnosis and management of pernicious anaemia.
5. Enumerate various causes of bleeding in oral cavity. How would you manage a case of haemophilia?
6. How do you manage a case of myeloid leukaemia patient visiting dental hospital. [Same as LE Q.3]
7. Define and classify anaemias. Discuss in detail about iron deficiency anaemia. [Same as LE Q.4]
8. Classify anaemias. Describe clinical features and laboratory diagnosis of iron deficiency anaemia. [Same as LE Q.4]

SHORT ESSAYS:
1. Causes of bleeding in the oral cavity. [Ref LE Q.5]
2. Agranulocytosis.
Section | I Topic-Wise Solved Questions of Previous Years 397

3. Infectious mononucleosis.
4. Pernicious anaemia. [Ref LE Q.4]
5. Iron deficiency anaemia.
6. Cooley anaemia.
7. Oral manifestation of acute leukaemia.
8. Thrombocytopenic purpura. [Ref LE Q.1]
9. Haemophilia A.
10. Thalassaemia major. [Same as SE Q.6]

SHORT NOTES:
1. Bleeding time.
2. Mention causes of eosinophilia.
3. Oral manifestations of haemophilia.
4. Four oral manifestations of aplastic anaemia.
5. Oral manifestations of leukaemia.
6. Cyclic neutropenia.
7. Schilling test.
8. Plummer–Vinson syndrome.
9. Polycythaemia rubra vera.

SOLVED ANSWERS
LONG ESSAYS: Treatment
● For mild cases, no treatment is required.
Q.1. Define purpura. Discuss in detail the clinical fea- ● Severe cases need transfusion of platelets, steroid treat-
tures and investigations of purpura. ment and splenectomy.}
Ans.
Q.2. Describe the laboratory investigations for bleeding
[SE Q.8] and clotting disorders.
● {Purpura is defined as purplish discolouration of skin Ans.
and mucus membrane due to subcutaneous and submu-
cus extravasation of blood. Various laboratory diagnostic tests for bleeding and clotting
● In thrombocytopenic purpura due to thrombocytopenia, disorders are as follows:
purpuric spots of focal haemorrhages may occur in skin
and mucous membranes. Investigation of disordered vascular haemostasis
● This is of two types: Disorders of vascular haemostasis may be due to vascu-
i. Idiopathic/primary thrombocytopenic purpura lar permeability, reduced capillary strength and failure to
ii. Secondary (due to various other causes) contact after injury.
Bleeding time
Clinical features ● This simplest test is based on the principle of hae-
● Petechiae in skin, mucous membrane occurs. mostatic plug formation following standard incision
● Epistaxis (bleeding from nose). on volar surface of forearm and the time the incision
● Bleeding from Gastrointestinal tract (GIT) (melena, takes to stop bleeding is measured; the test is depen-
haematemesis). dent upon capillary function as well as on platelet
● Intracranial haemorrhages. number and ability of platelets to adhere to form
● Gingival bleeding and palatal petechiae. aggregates.
Investigations ● Normal range is 3–8 min

● Platelet count is below 150,000/mm3 (usually below ● A prolonged bleeding time may be seen due to

50,000/mm3). ● Thrombocytopenia

● Bleeding Time (BT) prolonged, Clotting Time (CT) normal. ● Disorder of platelet function, for example von

● Increased megakaryocytes in bone marrow. Willebrand disease

398 Quick Review Series for BDS 4th Year, Vol 2

● Vascular abnormalities, for example Ehlers– ●Congenital hamartomas – Haemangioma, hereditary

Danlos syndrome haemorrhagic telangiectasia
● Severe deficiency of factor V and II ● Arteriovenous malformation

Hess capillary resistance test (tourniquet test) Haemorrhage due to platelet disorders
● This test is done by placing sphygmomanometer cuff ● Thrombocytopenia

to the upper arm and raising the pressure in it be- ● Thrombocytosis

tween diastolic and systolic for 5 min. ● Thrombasthenia

● After deflation, the number of petechia appearing in ● Glanzmann disease

the next 5 min in 3 cm area over the cubital fossa is ● Aldrich syndrome

counted. Haemorrhage due to coagulation diseases

● Presence of more than 20 petechiae is considered a ● Haemophilia

positive test. The test is positive in increased capil- ● Christmas disease

lary fragility as well as in thrombocytopenia. ● von Willebrand disease

● Deficiency of Stuart factor

Investigation of platelet and platelet function
● Multiple myeloma
● Haemostatic disorder is most commonly due to abnor-
● Systemic lupus erythematosus
malities in platelet number, morphology or function.
● Diffuse intravascular coagulation
● Screening tests carried out for assessing peripheral
● Macroglobulinaemia
blood platelet count is bleeding time.
Haemorrhage due to systemic diseases
● Examination of fresh blood film to see the morphologic
● Scurvy
abnormalities of platelets.
● Diabetes mellitus
Special tests
● Septic embolism in bacterial endocarditis
● If these screening tests suggest a disorder of platelet
● Meningococcemia
function, the following platelet function tests may be
● Systemic viral infection
carried out.
● Anticoagulant therapy
i. Platelet adhesion test: Retention in a glass bead
● Graft versus host reaction
column, and other sophisticated techniques.
● Sturge–Weber syndrome
ii. Aggregation test: Turbidimetric techniques using
ADP, collagen or ristocetin.
Leukaemia
iii. Granular content of platelets and their release
Leukaemia is a disease characterized by the progressive
can be assessed by electron microscopy.
over production of white blood cells, which usually appear
Tests for coagulative defect in the circulating blood in an immature form.
● Clotting time Classification
● Thrombin time ● Depending on the onset and the course of the leukae-

● Prothrombin time mia it is classified as:

● Thromboplastin generation time a. Acute leukaemia
● Partial thromboplastin time b. Chronic leukaemia
● Depending on the type of cell of origin leukaemia is
Q.3. What are the aetiological factors for the spontane- also classified into:
ous bleeding from gingiva? Describe the oral manifesta- a. Myeloid (myelogenous) leukaemia
tions of myelogenous leukaemia. b. Lymphoid (lymphoblastic, lymphocytic) leukaemia
Acute and chronic leukaemias are broadly classified as:
Ans.
i. Acute lymphoblastic leukaemia (ALL)
The various causes of bleeding in the oral cavity are as ii. Acute myeloblastic leukaemia (AML)
follows: iii. Chronic lymphocytic leukaemia (CLL)
Local causes iv. Chronic myelocytic leukaemia (CML)
● Postextraction, postsurgical, posttraumatic Aetiology
● Infections – Viral, bacterial fungal, parasitic and ● Unknown.

spirochete ● However, some are associated with ionizing radia-

● Oral ulcerative lesions – Stomatitis, glossitis, etc. tion, cytotoxic drugs, chemical carcinogens and in-
● Oral exophytic soft tissue lesions – Pyogenic granu- fectious origin of unknown organism.
loma, pregnancy tumour ● Other predisposing factors may be chromosomal

● Local irritants leading to gingivitis and periodontitis abnormalities, genetics, age, hormones, immune
● Rupture of blood containing bulla competence and stress.
Section | I Topic-Wise Solved Questions of Previous Years 399

Clinical features Treatment

Acute leukaemia ● The management of acute leukaemia consists of sup-

● Acute lymphoblastic leukaemia is common in portive and specific treatment.

children while acute myeloid leukaemia is com- Supportive treatment
mon in adults. ● Anaemia is managed with infusion of red cell

● Sudden onset. concentrate. Platelet transfusion is needed to treat

● Characterized by weakness, fever, headache, pete- bleeding manifestations and to maintain platelet
chial or ecchymotic haemorrhages in the skin and count above 10,000–20,000/mm3.
mucous membranes. Specific treatment
● Lymphadenopathy is often the first sign of the ● The objective of specific treatment is to eliminate

disease. leukaemic cells without affecting the normal

● Gingival bleeding, epistaxis, haemorrhage may cells. However, the therapy may be associated
occur due to thrombocytopenia. with high morbidity and mortality. Hence, the
● Bleeding may occur due to disseminated intravas- decision to administer a specific therapy to a par-
cular coagulation (DIC), which is mainly in pa- ticular patient is based on the age, type of leukae-
tients with acute promyelocytic leukaemia. mia and the presence of other associated illnesses.
● Hepatomegaly, splenomegaly, gum hyperplasia, Chemotherapy
stomatitis, sternal tenderness, enlargement and ● In chemotherapy, a combination of various cyto-

infiltration of skin may be seen. toxic drugs is given under a standard protocol.
Chronic leukaemia The first step is to achieve remission (normal
● Disease is present before the symptoms are seen. blood counts, normal bone marrow and normal
● Patient may appear with excellent health or ex- clinical status). The initial induction phase is fol-
hibit emaciation suggestive of a chronic debilitat- lowed by the consolidation phase and the mainte-
ing disease. nance phase.
● Lymph node enlargement common in CLL but Radiotherapy
uncommon in CML. ● Cranial irradiation along with intrathecal meth-

● Splenomegaly and hepatomegaly are fully devel- otrexate is given in ALL patients for CNS pro-
oped due to protracted course of the disease. phylaxis.
● Enlargement of salivary glands and tonsils lead- Bone marrow transplantation
ing to leukaemic infiltration and xerostomia. ● If a patient relapses after chemotherapy, remission

● Petechiae, ecchymosis of skin. Papules, pustules, is difficult to induce, then bone marrow transplan-
bullae, areas of pigmentation, herpes zoster, itch- tation is advised in such cases.
ing and burning sensations are also seen.
Oral manifestations Q.4. Classify anaemias. Discuss in detail the oral mani-
● Oral lesions occur in both acute and chronic
festations, diagnosis and management of pernicious
forms. anaemia.
● Gingivitis, gingival hyperplasia, haemorrhage,
Ans.
petechiae and ulceration of the mucosa.
● Rapid loosening of the teeth due to necrosis Anaemia is defined as an abnormal reduction in the number
of PDL. of circulating red blood cells, the quantity of haemoglobin
● Alterations in the developing tooth crypts. and the volume of packed red cells in a given unit of blood.
● Osseous changes in jaws. The normal haemoglobin level varies from 14 to 16 g/dL in
Diagnosis the adult male and 12 to 14 g/dL in the female.
a. Peripheral blood examination reveals the presence of
Classification
blast cells with high, low or normal total leukocyte
Anaemia has been traditionally classified into:
count.
● Dyshematopoietic
b. There is also the evidence of anaemia and thrombo-
● Haemorrhagic
cytopenia.
● Haemolytic anaemia
c. The bone marrow examination shows hypercellular-
ity along with the presence of .20% leukaemic blast According to the morphology (MCV, MCH and MCHC)
cells. into the following types:
d. Cytochemical staining, cytogenetics and immune ● Normocytic
phenotyping of the cells help in differentiating dif- ● Microcytic
ferent types of leukaemia. ● Macrocytic
400 Quick Review Series for BDS 4th Year, Vol 2

● Normochromic ● The four major cardinal features of pernicious

● Hypochromic anaemia are as follows:
a. Abnormally large RBCs
However, the recent classification is based on reticulocyte
b. Hypochlorhydria
index, which is a measure of RBC production:
c. Neurologic and gastrointestinal symptoms
● The reticulocyte index is increased (.2.5) due to in-
d. A fatal outcome unless the patient receives
crease in erythropoiesis in haemolytic and haemor-
life-long injections of vitamin B12
rhagic anaemias.
● Generalized weakness, fatigue, headache, palpita-
● A low reticulocyte index ,2% shows decreased
tion, nausea, vomiting, anorexia and diarrhoea.
marrow production or maturation defects during
● Shortness of breath, dyspnoea, loss of weight,
erythropoiesis.
pallor and abdominal pain.
Aetiologic classification of the anaemias ● Patients have smooth, dry and yellow skin.

I. Blood loss ● Neurological manifestations include tingling sen-

● Acute posthaemorrhagic blood loss sation in hands and feet, paraesthesia of extremi-
● Chronic posthaemorrhagic blood loss ties due to peripheral nerve degeneration.
II. Deficiency of haemopoietic factors Oral manifestations
● Iron deficiency ● Glossitis, glossodynia (painful tongue) and glos-

● Folate and vitamin B12 deficiency sopyrosis (itching and burning tongue).
● Protein deficiency, i.e. diarrhoea, malabsorption ● Tongue appears beefy red in colour.

III. Bone marrow aplasia ● Sometimes loss of papilla produces a bald appear-

● Aplastic anaemia ance of tongue which is referred to as Hunter

● Pure red cell aplasia glossitis or Moeller glossitis.
IV. Anaemia due to systemic infections or systemic ● Sometimes hyperpigmentation occurs in mucosa.

disorders Histopathology
● Anaemia due to chronic infection ● Oral epithelial cells in pernicious anaemia reveal

● Anaemia due to chronic renal disease enlarged and hyperchromatic nuclei with promi-
● Anaemia due to chronic liver disease nent nucleoli and serrated nuclear membrane.
● Disseminated malignancy ● There is atrophy of epithelium with intra- or sub-

● Endocrinal diseases epithelial chronic inflammatory cell infiltration.

V. Anaemia due to bone marrow infiltration ● Cellular atypia is sometimes present.

● Leukaemias Laboratory findings

● Lymphomas i. Blood
● Myelofibrosis/myelosclerosis ● RBC count is seriously decreased to 1,000,000

● Congenital sideroblastic anaemia or less per mm3.

VI. Anaemia due to increased red cell destruction (hae- ● Macrocytosis, haemoglobin content of RBCs

molytic anaemia) is increased proportional to their size.

● Intracorpuscular defect (hereditary or acquired) ● Great many red blood cell abnormalities have

● Extracorpuscular defect (acquired) been described in advanced cases of anaemia-

Pernicious anaemia like polychromatophilic cells, stippled cells,
(Vitamin B12 deficiency, Addisonian anaemia) nucleated cells, Howell–Jolley bodies and
Cabot rings punctuate basophilia.
[SE Q.4] ● Mild-to-moderate thrombocytopenia.

{Pernicious anaemia is a type of a chronic progressive, ● Iron deficiency.

megaloblastic anaemia of adults and is caused by defi- ii. Serum

ciency of intrinsic factors in stomach. ● The indirect bilirubin may be elevated.

● It is probably an autoimmune disorder with a ge- ● Serum lactic dehydrogenase usually is mark-

netic predisposition and the disease is associated edly increased.

with human leukocyte antigen (HLA) types A2, ● The serum potassium, cholesterol and skeletal

A3, B7 and A blood group. alkaline phosphatase are often decreased.

Clinical features ● Serum antibodies for Intrinsic Factor (IF) are

● Occurs rarely before 30 years of age and increases highly specific.

in frequency with advancing age. iii. Gastric secretions
● No racial predilection; in all countries, except the ● Total gastric secretions are decreased to 10%

USA, females are more commonly affected. of reference range.

Section | I Topic-Wise Solved Questions of Previous Years 401

● Achlorhydria. Aetiology
● IF is either absent or markedly decreased. Haemophilia types
iv. Bone marrow i. Haemophilia A – Due to deficiency of factor
● Bone marrow biopsy and aspirate are hyper- VIII known as antihaemophilic globulin (AHG)
cellular and show trilineage differentiation. which is a clot promoting factor.
● Erythroid precursors are large and oval, their ii. Haemophilia B or Christmas disease – Due to
nucleus is large and contains coarse motley deficiency of factor IX known as Christmas factor.
chromatin clumps, providing a checker board iii. Haemophilia C – Due to deficiency of factor XI
appearance. and plasma thromboplastin antecedent.
Treatment Clinical features
● Administration of folic acid and vitamin B12. ● It occurs only in males, while females are only the

● Early recognition and treatment of pernicious anae- carriers.

mia provides a normal uncomplicated life span. ● Haemorrhagic tendency even in infancy.

● Delayed treatment permits progression of the ● Ecchymoses even from minor trauma.

anaemia and neurological complications.} ● Persistent oozing of blood and sudden bleeding into

the muscles and joints (knee).

Q.5. Enumerate various causes of bleeding in oral cav-
● Joint becomes swollen and painful.
ity. How would you manage a case of haemophilia?
● Symptoms of anaemia.

Ans. ● Blood test shows prolonged clotting time and normal

bleeding time.
[SE Q.1] ● Haemophilia is classified according to the clinical

{Various causes of bleeding in the oral cavity are as severity as mild moderate and severe.
Oral manifestations
follows:
● Gingival haemorrhage
A. Local causes
● Eruption and exfoliation of teeth associated with
● Postextraction, postsurgical, posttraumatic
severe haemorrhage
● Infections – Viral, bacterial, fungal
● Mandibular pseudotumour
● Oral ulcerative lesions – stomatitis, glossitis, etc.
Treatment and prognosis
● Oral exophytic soft tissue lesions – Pyogenic granu-
● There is no known cure for haemophilia. The affected
loma, pregnancy tumour
persons should be protected from traumatic injuries.
● Local irritants leading to gingivitis and periodontitis
● Replacement of clotting factors.
B. Haemorrhage due to platelet disorders
● Thrombocytopenia Q.6. How do you manage a case of myeloid leukaemia
● Thrombocytosis patient visiting dental hospital.
● Thrombasthenia
Ans.
C. Haemorrhage due to coagulation diseases
● Haemophilia [Same as LE Q.3]
● von Willebrand disease
Q.7. Define and classify anaemias. Discuss in detail
● Multiple myeloma
about iron deficiency anaemia.
● Systemic lupus erythematosus

● Diffuse intravascular coagulation Ans.

D. Haemorrhage due to systemic disease
[Same as LE Q.4]
● Scurvy
● Diabetes mellitus Q.8. Classify anaemias. Describe clinical features and
● Anticoagulant therapy, etc.} laboratory diagnosis of iron deficiency anaemia.
Haemophilia Ans.
● Haemophilia is also known as bleeder’s disease, the
disease of kings. [Same as LE Q.4]
It is a blood disease characterized by a prolonged co-
SHORT ESSAYS:
l

agulation time and haemorrhagic tendencies.

● The disease is hereditary, the defect being carried by Q.1. Causes of bleeding in the oral cavity.
the X chromosome, and is transmitted as a gender-
Ans.
linked Mendelian recessive trait, thus it occurs only in
males. [Ref LE Q.5]
402 Quick Review Series for BDS 4th Year, Vol 2

Q.2. Agranulocytosis. Aetiology

● It is caused by EBV.
Ans:
Clinical findings
● Agranulocytosis is also known as granulocytopenia. It is
● Chiefly occurs in children and young adults.
a serious disease involving white blood cells.
● Oral lesions include stomatitis, acute gingivitis, appear-
● It is characterized by decreased number of circulating
ance of a white or grey membrane in various areas,
granulocytes, especially neutrophils.
palatal petechiae and occasional ulcers.
Classification
Laboratory findings
 i. Primary agranulocytosis
● Increased neutrophil antibody titre (1:4096), that is
ii. Secondary agranulocytosis
positive Paul–Bunnell test
Aetiology ● Thrombocytopenia
● Ingestion of drugs (antithyroid, macrolides, procain-
Treatment
amide, sulphonamide, dipyrone, digitalis, corticoste-
● Bed rest.
roids, salicylates and others)
● Adequate diet and short-term steroid therapy is the
● Infections
usual form of therapy.
Clinical features
Q.4. Pernicious anaemia.
● It occurs at any age but common in adults particularly in
women. Ans.
● It frequently affects workers in the health professions
[Ref LE Q.4]
and in hospitals.
● Commences with high fever, chills and sore throat, mal- Q.5. Iron deficiency anaemia.
aise, weakness and prostration.
Ans.
● Skin appears pale anaemic and sometime jaundiced.
● Presence of infection in oral cavity, entire GIT, respira- Iron deficiency anaemia is the most common form of anae-
tory tract and skin. mia worldwide.
● Regional lymphadenitis.
Aetiology
Oral manifestations Causes of iron deficiency anaemia are as follows:
● Necrotizing ulcers on oral mucosa, tonsils and i. Blood loss:
pharynx a. Acute blood loss: accident and surgery
● No purulent discharge noticed b. Chronic blood loss: gastritis, peptic ulcer, hook-
● Tooth extraction is contraindicated worm infestation, haemorrhoids and menstrual loss
ii. Increased demand, e.g. during infancy, adolescence
Laboratory findings
and pregnancy
● WBC count is below 2000 cells/mm3 with an almost
iii. Malabsorption conditions, e.g. postgastrectomy,
absence of polymorphonuclear cells.
sprue, and Crohn disease
● RBC and platelet count is normal.
iv. Inadequate diet
● Bone marrow is relatively normal except absence of
granulocytes, metamyelocytes and myelocytes. Clinical features
● Promyelocytes and myeloblasts are near normal ● It occurs at any age, presenting general symptoms of
numbers. anaemia.
● Pagophagia, i.e. craving for ice, cheilosis and spoon-
Treatment
shaped nails (koilonychia).
● Not specific
● Dysphagia due to formation of cricoid web (Plummer–
● Removal of the cause
Vinson or Patterson–Kelly syndrome).
● Administration of broad spectrum antibiotics for oral
● Angular cheilitis, pallor of the skin, smooth red painful
ulcers should be prescribed
tongue with atrophy of filiform and fungiform papillae.
Q.3. Infectious mononucleosis. ● Postcricoid web is a premalignant lesion.
● Splenomegaly is uncommon.
Ans.
Laboratory findings
● Infectious mononucleosis is also known as glandular ● The general blood picture is microcytic hypochromic.
fever or kissing disease. ● Serum iron and ferritin are low while total iron-binding
capacity (TIBC) is increased.
Section | I Topic-Wise Solved Questions of Previous Years 403

● Transferrin saturation is below 16%. ● Increased serum bilirubin.

● Bone marrow stains for iron reveal decreased or absent ● Cellular hyperplasia of bone marrow.
iron stores.
Radiographic features
● Stool examination for parasites and occult blood is
● Extreme thickening of diploe producing ‘crew-cut’ or
useful.
‘hair-on-end’ appearance of surface of skull.
Treatment ● Osteoporosis of skull and long bones.
i. Oral iron therapy ● Intraoral radiographs show ‘salt and pepper appearance’.
● The drug of choice is ferrous sulphate 200 mg thrice
Treatment
a day (elemental iron 60 mg thrice a day) orally
● Blood transfusion
taken in between meals.
● Desferrioxamine is given for iron overload
● The treatment with oral iron is usually given for a

long duration and is sustained for 6–12 months even Q.7. Oral manifestation of acute leukaemia.
after normalization of haemoglobin.
Ans.
ii. Parenteral iron therapy
● Intravenous iron therapy is indicated when the pa- ● Acute leukaemia is a disorder in which there is failure
tient is unable to tolerate oral iron, or when his needs of maturation of leukocytes. As a result there is an ac-
are relatively acute. cumulation of immature cells with in bone marrow and
● Previously used iron compound, iron dextran has later in blood.
been associated with the risk of anaphylaxis which is ● Acute lymphoblastic leukaemia is common in children
almost never seen with newer preparations like so- while acute myeloid leukaemia is common in adults.
dium ferric gluconate and iron sucrose. ● Sudden onset.
● Red blood cell transfusion: It is indicated in patients ● Characterized by weakness, fever, headache, petechial
with severe anaemia where cardiorespiratory condi- or ecchymotic haemorrhages in the skin and mucous
tions warrant immediate intervention or when there membranes.
is continued and excessive blood loss. ● Lymphadenopathy is often the first sign of the disease.
Q.6. Cooley anaemia. Oral manifestations of acute leukaemia
Ans. Site
l Submental, cervical and pre- and postauricular
Thalassaemia is also called Cooley anaemia. lymph nodes may be enlarged and tender.
Clinical features Symptoms
● Paraesthesia of lower lip and chin. There may be
● Congenital disorder that is characterized by deficient
synthesis of haemoglobin, either a- or b-chain. toothache due to leukaemic cell infiltration dental
● Types: pulp.
(a) Heterozygous or thalassaemia minor or thalassae- Signs
● Oral mucous membrane shows pallor, ulceration
mia trait
(b) Homozygous or b-thalassaemia or thalassaemia major with necrosis, petechiae, ecchymosis and bleeding
● Two forms of a-thalassaemia: tendency.
● There may be massive necrosis of lingual mucosa
(a) Hb-H disease (mild)
(b) Hb Bart’s disease with hydrops fetalis with sloughing gingiva shows hypertrophy and cya-
● Mongoloid features, flaring of maxillary anteriors de- notic discolouration.
● The hypertrophy may be due to leukaemic cell infil-
pressed bridge of nose, unusual prominence of premax-
illa, poor spacing of teeth, a marked open bite, promi- tration within gingiva or due to local irritants.
● Rapid loosening of the teeth due to necrosis of PDL.
nent malar bone.
● Alterations in the developing tooth crypts.
● Ashen grey skin due to combination of pallor, jaundice
● Osseous changes in jaws.
and haemosiderosis.
● Oral infections (candida, viral and bacterial) are seri-
Laboratory findings ous and potentially fatal complication in leukaemic
● Hypochromic microcytic anaemia. patients.
● WBC count elevated.
● Presence of nucleated RBCs, ‘safety-pin’ cells and Q.8. Thrombocytopenic purpura.
‘target cells’.
Ans.
● Heinz bodies are formed by the precipitation of
a-chains. [Ref LE Q.1]
404 Quick Review Series for BDS 4th Year, Vol 2

Q.9. Haemophilia A. Interpretation

● An abnormal B.T. is usually the result of abnormalities
Ans.
in the structure or ability of capillary blood vessels to
● Haemophilia is a potentially fatal inherited bleeding contract.
disorder characterized by the profuse haemorrhage due ● Abnormalities in the number or functional integrity of
to deficiency of clotting factors. the platelets.
● Haemophilia A or classic haemophilia is a condition
Q.2. Mention causes of eosinophilia.
where factor VIII (AHG) deficiency is present.
Ans.
Clinical features of haemophilia A
● Mild cases are asymptomatic with prolonged bleeding ● Eosinophilia is an absolute eosinophil count exceeding
after tooth extraction and any major surgery. The levels 500/mL3.
of factor ‘VIII’ lie between 7% and 50% (normal level
The common causes of eosinophilia are as follows:
is 50%–150%).
● Helminthic infestations
● In moderate cases, haematoma formation occurs after
● Loeffler syndrome
minor trauma or surgery (level 1%–7 %).
● Tropical eosinophilia
● In severe case level of factor ‘VIII’ is less than 1%. This
● Allergic conditions such as hay fever, asthma, serum
causes spontaneous bleeding in muscles (haematomas)
sickness, etc.
and weight bearing joints (haemarthroses).
● Drugs, e.g. sulphonamides, aspirin, penicillins, cephalo-
Oral findings sporins, etc.
● Haemorrhage from many sites in oral cavity ● Collagen vascular diseases, e.g. rheumatoid arthritis,
● Tumour-like outgrowth in mandible (due to sub perios- Churg–Strauss syndrome
teal bleeding and subsequent new bone formation) ● Malignancies, e.g. Hodgkin disease, chronic myeloid
● TMJ – Haemarthroses leukaemia, etc.
● Idiopathic hypereosinophilic syndrome
Treatment
● Factor ‘VIII’ concentrate Q.3. Oral manifestations of haemophilia.
● Fresh frozen plasma (FFP) Ans.
● Cryoprecipitate
● Desmopressin acetate (in mild cases) Oral manifestations of haemophilia
● Haemorrhage from many sites in oral cavity
Q.10. Thalassaemia major. ● Gingival haemorrhage
Ans. ● Eruption and exfoliated with severe haemorrhage
● Mandibular pseudotumours
[Same as SE Q.6] ● Tumour-like outgrowth in mandible (due to subperios-
teal bleeding and subsequent new bone formation)
SHORT NOTES: ● TMJ – Haemarthroses
Q.1. Bleeding time. Q.4. Four oral manifestations of aplastic anaemia.

Ans. Ans.

● Bleeding time (B.T.) is defined as the time lapse be- Four oral manifestations of aplastic anaemia are as
tween skin puncture and the arrest of bleeding. follows:
● B.T. is the time from the onset of bleeding to the stop- ● Oral mucosa – Mucosa shows pallor
page of bleeding. Bleeding stops due to the formation of ● Symptoms – Spontaneous gingival bleeding, related to
a temporary haemostatic plug. blood platelet deficiency
Signs
Indications ● Petechiae, purpuric spots or frank haematomas of oral
● It is a useful screening test in patients with a history of mucosa.
prolonged bleeding. ● Large ragged ulcers covered by black necrotic mem-
● In patients with bleeding disorders before any surgical brane may be present, which are result of generalized
procedures. lack of resistance to infection and trauma.
Section | I Topic-Wise Solved Questions of Previous Years 405

Q.5. Oral manifestations of leukaemia. ● The flushing dose is the essence of Schilling test, which
allows vitamin B12 absorption measurement to be made
Ans.
with acceptable doses of radioactivity.
The oral manifestations of leukaemia in both acute and ● Patients with pernicious anaemia excrete less than 5%
chronic forms are as follows: of orally administered dose in comparison with excre-
● Gingivitis, gingival hyperplasia, haemorrhage, pete- tion of 8%–25% by normal individuals.
chiae and ulceration of the oral mucosa
Q.8. Plummer–Vinson syndrome.
● Rapid loosening of the teeth due to necrosis of PDL
● Alterations in the developing tooth crypts Ans.
● Osseous changes in jaws
● Plummer–Vinson syndrome is one of the manifestations
● Petechiae, bullae and burning sensation
of the iron deficiency anaemia.
Q.6. Cyclic neutropenia. ● It is also called as ‘Paterson–Brown–Kelly’ syndrome.
● Occurs at any age chiefly in women in the 4th or 5th
Ans. decades of life.
● Cyclic neutropenia is also known as periodic neutrope- ● Presents general symptoms of anaemia.
nia or periodic agranulocytosis. ● Cracks or fissures at the corner of mouth (angular
● It is characterized by a periodic or cyclic diminution in cheilitis) and spoon-shaped nails (koilonychia).
circulating polymorphonuclear neutrophilic leukocytes ● Dysphagia due to oesophageal webs and atrophy of
as a result of bone marrow maturation arrest. filiform papillae.
● Treatment consists of oral and parenteral iron therapy.
Clinical features
● It occurs at any age commonly seen in infants and Q.9. Polycythaemia rubra vera.
young children. Ans.
● Patients manifest fever, malaise, sore throat, stomatitis,
and regional lymphadenopathy. ● Polycythaemia vera is a chronic stem cell disorder with
● Headache, arthritis, cutaneous infection and conjunc- an insidious onset characterized as a panhyperplastic,
tivitis. malignant and neoplastic marrow disorder.
● Oral manifestations include severe gingivitis, stomatitis ● Prominent feature is an absolute increase in the total
with ulcerations. number of circulating red blood cells and in the total
blood volume because of uncontrolled red blood cell
Radiographic features production.
Loss of alveolar bone may be seen on radiograph. ● Bone marrow of this patient shows normal and abnor-
Treatment mal stem cells.
No specific treatment is present. Oral manifestation
● Oral mucosa appears deep purplish red, gingiva and
Q.7. Schilling test.
tongue are most commonly affected of them.
Ans. ● Cyanosis can be seen due to presence of reduced hae-
moglobin in amount exceeding 5 g/dL.
● Shilling test is a measure of patient’s ability to absorb
● Gingiva engorged and swollen and bleeds upon slight
orally administered radioactive vitamin B12 labelled
provocation.
with 60Co.
● Submucosal petechiae, ecchymosis and haematomas are
● Following oral administration of radioactive vitamin
commonly seen and intercurrent infection may be seen.
B12, unlabelled vitamin is given intramuscularly, as a
flushing dose to induce urinary excretion of labelled Treatment
vitamin, which is measured in a 24 h urine specimen. ● No specific treatment is required.
406 Quick Review Series for BDS 4th Year, Vol 2

Topic 16
Diagnostic Laboratory Procedures
COMMONLY ASKED QUESTIONS
SHORT ESSAYS:
1. Enumerate the importance of intravital staining.
2. What are the indications of following investigations in dentistry: (a) biopsy, (b) sialography and (c) exfoliative
cytology?
3. ESR.
4. Discuss: (a) Toluidine blue vital staining, (b) peripheral blood picture in oral medicine and (c) role of immuno-
globulin in oral medicine. [Same as SE Q.1]

SHORT NOTES:
1. Brush biopsy.
2. Schirmer test.
3. Paul–Bunnell test.
4. Oral exfoliative cytology.
5. State purpose of Toluidine blue staining. [Ref SE Q.1]
6. How do direct and indirect immunofluorescence differ from each other?
7. Vitality tests.
8. Age in examination.
9. Patch test.
10. Paget test.
11. Rose–Waaler test.
12. Describe the role of peripheral blood smear in oral medicine. [Ref SE Q.1]
13. ESR. [Ref SE Q.3]
14. Tzanck test.
15. Indications of Tzanck smear.
16. Nikolsky sign.
17. Acid phosphatase.
18. Alkaline phosphatase.
19. Antinuclear antibody (ANA) test.
20. Postprandial blood glucose technique.
21. Diagnostic tests of bleeding disorders.
22. Diagnostic test for HIV.
23. Biopsy. Types and indications of biopsy in oral medicine.
24. Lab investigations for anaemias.
25. Fine needle aspiration cytology.
26. Significance of haemogram.
27. Bence Jones proteins.
28. Schilling test.
29. Bleeding time.
30. Write in brief about toluidine blue test. [Same as SN Q.5]
31. Role of intravital staining in oral medicine. [Same as SN Q.5]
32. Two differences between direct and indirect immunofluorescence. [Same as SN Q.6]
33. Age estimation methods. [Same as SN Q.8]
34. Elevation of serum calcium. [Same as SN Q.17]
35. Serum alkaline phosphatase. [Same as SN Q.18]
36. Name two conditions that show elevated serum alkaline phosphatase levels. [Same as SN Q.18]
37. Western blot test. [Same as SN Q.22]
38. Aspiration biopsy. [Same as SN Q.25]
Section | I Topic-Wise Solved Questions of Previous Years 407

SOLVED ANSWERS
SHORT ESSAYS:
Q.1. Enumerate the importance of intravital staining.
Ans.
II. Peripheral blood picture in oral medicine
I. Toluidine blue vital staining

{SN Q.12}
{SN Q.5}
● Examination of a Wright’s stained smear of blood is
● Toluidine blue is a basophilic vital nuclear dye,
a long-established component of the complete blood
which can guide biopsy by localizing small foci of
count that provides information about morphologic
tumour cells within the larger area of inflammation
abnormalities of RBCs and platelets in addition to
in the evaluation of early asymptomatic oral cancers.
the differential WBC count.
● For evaluation of early asymptomatic oral cancers,
● The differential WBC count actually is the morpho-
areas of redness that persist beyond the observation
logic description of abnormal cells that constitutes
period must be biopsied.
the important diagnostic information that can be ob-
tained from the stained blood smear. It has little di-
● Obtaining multiple random samples from the entire agnostic validity unless the figure lies well outside
area is not a reliable diagnostic procedure because the normal range.
small foci of tumour cells can still be missed. ● The stained blood smear is usually examined only if
Toluidine blue vital staining procedure abnormalities are detected in the total RBC, total
● Topical application of the staining medium to the WBC or differential WBC counts. Automated optical
oral mucosa is followed by a rinse of 1.0% acetic scanning techniques provide information on abnor-
acid in order to remove dye retained by debris or mal RBCs and a platelet estimate, in addition to a
within irregularities of the mucosal surface. WBC differential, but abnormal smears detected in
● The dye, retained predominantly in the abnormal this way are also usually examined manually.
nuclei of tumour cells, produces areas of uptake ● The stained blood smear provides a variety of infor-
seen as discretely blue-stained tissue. mation about the RBC: size (macrocytes and micro-
● Positive areas of uptake do not represent ulcer- cytes), shape (anisocytosis, poikilocytosis and sphe-
ation or disruption of the mucosa; they represent rocytosis) and haemoglobin content (hyperchromia
retention of dye by the increased nuclear DNA and hypochromia).
content of tumour cells in the intact mucosa. ● Immature RBC, WBC and other abnormal cells that
● Biopsy of dye retention areas is most likely to appear in the bloodstream in some disease states may
demonstrate foci of invasive cancer on micros- also be observed and are recorded on the report of
copy. the stained smear. For example, patients with leukae-
● Routine use of this technique without due consid- mia, a leukaemoid reaction or severe anaemia.
eration of all other factors essential to diagnosis
should be discouraged.
III. Role of immunoglobulin in oral medicine
● The function of the immune system is to distinguish
{SN Q.5} self from nonself and eliminate potentially destruc-
tive foreign substances from the body. This function
● Casual overreliance on an apparently effective, yet
has direct clinical application in the fields of infec-
simple, screening modality encourages the examiner
tious and neoplastic diseases and in transplant im-
to become complacent regarding the comprehensive
munology.
integration of history and clinical examination, which
● Current concepts of human immunology support
are essential to the reliable detection of early cancer.
the theory that the cells responsible for the immune
● Toluidine blue staining is remarkably reliable. False-
response are derived from an undifferentiated stem
negative and false-positive rates are low. Although
cell precursor that originates in the bone marrow.
highly suggestive of malignancy, a positive toluidine
● These stem cells differentiate into two distinct
blue reaction is not conclusive in establishing the
populations of lymphocytes that form the two com-
diagnosis of cancer. Biopsy and histologic evaluation
ponents of the immune system.
are required for a definitive diagnosis.
● One population of lymphoid stem cells contacts
● Toluidine blue could be used as a general intraoral
the thymus and forms the thymus-dependent or the
rinse for gross screening purposes.
T-cell system.
408 Quick Review Series for BDS 4th Year, Vol 2

● Other cells contact the human equivalent of the bursa basement membrane and to search for nests of inva-
of Fabricius of birds, possibly the intestinal lym- sive tumour cells.
phoid tissue of Peyer’s patches or the appendix, to ● Most pathologists request that the specimen include a
differentiate into the bursa or B-cell system. zone of adjacent, clinically normal tissue in order to
● The T-cell system is responsible for cell-mediated recognize malignant changes; however, when ulcer-
immunity, which serves as the body’s primary de- ation is present, specimens obtained from the ulcer-
fence against viruses and fungi. ated areas may reveal only nondiagnostic necrosis.
● The T-cell system is also responsible for delayed ● Inclusion of some clinically uninvolved tissue in the
hypersensitivity reactions and graft rejection and specimen when ulceration is present, usually en-
helps to regulate the B-cell system. sures a representative sample of active non-necrotic
● T-lymphocytes perform many of their functions by tumour.
releasing mediators: cytotoxic mediators destroy ● Intentional excisional biopsy that is total removal of
grafts and tumour cells, while migration inhibition all abnormal tissue for diagnostic purposes has abso-
factor (MIF) attracts phagocytic macrophages to the lutely no role in the diagnosis of oral cancer.
site of bacterial infection. ● Planned excisional biopsy of a lesion clinically sus-
● T-cells populate the paracortical areas of lymph pected to be malignant cannot be justified by any
nodes and the white pulp of the spleen, and consti- rationale and should be condemned.
tute 60%–80% of lymphocytes in the peripheral ● Adequate excision of a malignant lesion usually re-
blood. quires at least a 1.5 cm margin of clinically unin-
● The B-cells populate the follicles around germinal volved tissue along each periphery; if the diagnosis
centres of lymph nodes, spleen and tonsils. is benign, it is impossible to justify removal of such
● B-lymphocytes have immunoglobulin receptors on a large block of tissue.
their surface. When these receptors combine with ● If the diagnosis is malignant, any specimen with less
antigen, they differentiate into plasma cells and pro- than 1.5 cm of clinically normal tissue along each
duce antibody. margin is inadequate, and retreatment of the lesion
● Antibodies are the body’s primary defence against would be mandated.
bacterial infection. ● Excision of a lesion for diagnosis is justifiable only
Five major classes of antibodies or immunoglobulins when the lesion is almost certainly benign or when
(lg) are now recognized: IgM, IgG, IgA, IgD and IgE. Each the lesion is so minute that total removal is required
of these immunoglobulins has different chemical as well as to ensure an adequate volume of tissue for micro-
distinct biological properties. scopic evaluation.
● In most cases, every reasonable attempt should be
Q.2. What are the indications of following investigations
made to obtain an incisional specimen that is re-
in dentistry: (a) biopsy, (b) sialography and (c) exfolia-
moval of small representative portion of the lesion.
tive cytology?
Sialography
Ans.
● Sialography is a specialized radiographic view taken by
Biopsy introduction of the radiopaque dye into the ductal sys-
● Biopsy is the removal of tissue from living individual tem of the major salivary glands, mainly parotid and
for microscopic examination and precise diagnosis of submandibular.
the lesion. ● This technique is used to examine the ductal and acinar
systems of the major salivary glands.
Various types of biopsy are as follows:
● Sialography will aid in the diagnosis in cases where the
i. Excisional biopsy
radiographs are negative and will demonstrate a filling
ii. Incisional biopsy
defects, narrowing of ducts at the site of the stone, and
iii. Aspiration biopsy
dilation of the duct proximal to the stone.
iv. Punch biopsy
● This technique is no longer considered as desirable,
v. Frozen section biopsy, etc.
since there is some danger of glandular damage by the
● Biopsy in diagnosis of malignant lesions is an abso-
injected dye, and in patients with severe Sjögren the dye
lute requirement before ablative cancer therapy can
will remain in the gland interfering with future tests.
be initiated.
● The biopsy specimen obtained should be representa- Exfoliative cytology
tive of the lesion under investigation. Adequate ● Intraoral exfoliative cytologic study, although eliminat-
depth that is through the epithelium into connective ing many of the disadvantages of the biopsy, by no
tissue is necessary to determine the integrity of the means supplants the usual biopsy study.
Section | I Topic-Wise Solved Questions of Previous Years 409

● Over the last 25 years, considerable experience has been ● In general, the preparation of the smear is similar to that
gained with the exfoliative cytologic techniques in oral used to obtain oral smears for other purposes with the
diagnosis that were originally developed by Silverman exception that firm pressure with a wooden or steel
and Sandler. scraper must be used to ensure that adequate numbers of
● A variety of oral diseases have been studied with this cells are obtained, and the smear must be fixed immedi-
technique, but the procedure is of most value in the ately. For this purpose, an aerosol fixative such as
evaluation of suspected malignancies, especially when Spraycyte or 95% alcohol may be used.
these present as ulcerated or red nonkeratinized lesions. ● Oral exfoliative cytology has been used for the study of
● Oral cytology should never be relied on for diagnosis of other nonmalignant changes in the oral cavity, for ex-
an oral lesion simply because it may be easier to obtain ample, studies of buccal mucosa in various anaemias
than a biopsy. and of the maturation of the buccal mucosa with the
● Once a lesion is suspected to have a slightest chance of menstrual cycle.
being malignant, the lesion should be biopsied ade- ● Oral cytology is generally most helpful in evaluation of
quately at the earliest opportunity. nonkeratinized ‘red patches’ or ulcerative lesions of the
● With these considerations in mind, Papanicolaou- oral mucosa. Specimens obtained from heavily keratin-
stained smears of oral mucosal lesions are indicated in ized ‘white patches’ are composed mainly of superficial
the following circumstances in clinical dentistry: squames, and the more immature basal cells are not
i. For rapid laboratory evaluation of an oral lesion represented on the smear.
on clinical grounds is thought to be malignant. For
The standard classification used in oral cytology reports is
example, in the case of advanced malignancies
as follows:
where delay or preliminary incision of the lesion is
● Class I, normal cells.
not warranted, laboratory confirmation of the clini-
● Class II, some atypical cells, but no evidence of malig-
cal impression often can be obtained by a Papanico-
nancy.
laou-stained smear in 1–2 days.
● Class III, changes in nuclear pattern of indeterminate
ii. For laboratory evaluation of an oral lesion that on
nature; no definite evidence of malignancy, but clearly
clinical grounds is thought to be premalignant and
aberrant cells are present.
for which the dentist is unable to obtain permission
● Class IV, suggestive of malignancy.
for a biopsy.
● Class V, obvious malignant changes.
iii. In patients with multiple premalignant lesions, bi-
A report of class III, IV or V changes should always be
opsy of multiple lesions or entire removal of exten-
followed by a biopsy of the lesion.
sive lesions may not be feasible, and cytology may
be a very practical adjunct to biopsy. Q.3. ESR.
iv. For sequential laboratory evaluation of an area of
Ans.
mucosa that has previously been treated by excision
or radiation to remove a malignancy. Successive
biopsies are often not possible, and cytology pro-
{SN Q.13}
vides something better than simple clinical observa-
tion, especially where previous treatment has led to ● The erythrocyte sedimentation rate (ESR) measures
scarring or other tissue change. the rate at which RBCs sediment in a tube of plasma.
v. For evaluation of vesicular lesions (herpes simplex, ● The rate is accelerated when changes in plasma pro-
pemphigus and pemphigoid) where facilities for teins cause the RBCs to aggregate or when there are
rapid evaluation of a Tzanck smear are not available changes in the physicochemical properties of plasma
or where more detailed cytology is required. or the red cell surface.
● The test is helpful in following the progress of some
Procedure chronic infections (tuberculosis and osteomyelitis)
● The clinical value of exfoliative cytology is directly re- as well as diseases characterized by altered globulins
lated to the skill of the cytologist and his experience such as the collagen diseases, nephritis, rheumatic
with oral smears. fever and the dysproteinaemias.
● A dentist who proposes to use this laboratory procedure ● It is claimed to be more sensitive than temperature,
should first determine, which laboratories are available WBC count, weight and subjective symptoms as an
to him to routinely handle oral smears. indication of progress of some diseases.
● The laboratory will frequently provide a kit (slides, cy- ● Marked elevations usually indicate the presence of dis-
toscraper and mailing tube) with instructions for obtain- ease, the exact nature of which should be investigated.
ing, fixing and transporting the specimen.
410 Quick Review Series for BDS 4th Year, Vol 2

Q.3. Paul–Bunnell test.

● In the Westergren method, a graduated sedimentation
tube is filled with oxalated blood and placed in an Ans.
absolutely vertical position.
● Patients with infectious mononucleosis develop an in-
● The erythrocyte level is read at 10 min intervals and
creased serum titre of an antibody that cross-reacts with
at the end of the hour.
red blood cells from other species (heterophil or Forss-
The generally accepted normal sedimentation rates in man antibody).
60 min for this method are males, 0–15 mm, and females, ● Whenever a patient is suspected of having infectious
0–20 mm. mononucleosis because of symptoms, examination find-
● The sedimentation rate may be increased in women ings, or haematologic abnormalities, ‘the titre of hetero-
with intrauterine contraceptive devices (IUDs) and phil antibody’ is used to confirm the diagnosis.
women taking an ovulatory steroids (oral contra- ● The traditional test for heterophil antibody is based on
ceptives). agglutination of sheep red cells and is known as the
Paul–Bunnell test.
● The (Davidsohn) differential test is a modification of
● This test is also of considerable importance in the diag- the Paul–Bunnell test, in which the serum titre of sheep
nosis of giant cell arteritis (temporal arteritis) and a agglutinins is measured before and after absorption of
closely related disease, polymyalgia rheumatica, which the patient’s serum with beef or guinea pig red cells to
are uncommon but clearly defined causes of recurrent make the test more specific for detecting infectious
facial pain. mononucleosis.
Q.4 . Discuss: (a) Toluidine blue vital staining, (b) periph- Q.4. Oral exfoliative cytology.
eral blood picture in oral medicine and (c) role of immu-
Ans.
noglobulin in oral medicine.
● Intraoral exfoliative cytology, originally developed by
Ans.
Silverman and Sandler, although eliminates many of the
[Same as SE Q.1] disadvantages of the biopsy, by no means supplants the
usual biopsy study.
A variety of oral diseases have been studied with this
SHORT NOTES: ●

technique, but the procedure is of most value in the

Q.1. Brush biopsy. evaluation of suspected malignancies, especially
when these present as ulcerated or red nonkeratinized
Ans.
lesions.
i. Brush biopsy technique is only a screening tool, which ● The clinical value of exfoliative cytology is directly re-
enables a transepithelial capture of cells. lated to the skill of the cytologist and his experience
ii. In this technique, a brush is rotated against the tissue with oral smears.
until slight bleeding is observed, indicating that the ● The laboratory will frequently provide a kit (slides, cy-
brush has reached the basement membrane. toscraper and mailing tube) with instructions for obtain-
iii. The cellular aggregate on the brush is transferred to ing, fixing and transporting the specimen.
a glass slide, fixed and then analysed by computer ● Oral cytology is generally most helpful in evaluation of
scans and pathologists trained specifically in oral brush nonkeratinized ‘red patches’ or ulcerative lesions of the
biopsy interpretation. oral mucosa.
iv. The technique can be applied to a wider segment of the ● Specimens obtained from heavily keratinized ‘white
population. patches’ are composed mainly of superficial squames,
and the more immature basal cells are not represented
Q.2. Schirmer test.
on the smear.
Ans.
Q.5. State purpose of Toluidine blue staining.
i. Schirmer test is one of the tests to evaluate lacrimal
Ans.
gland function in suspected Sjögren patients.
ii. The Schirmer test consists of placing a strip of filter [Ref SE Q.1]
paper in the lower conjunctival sac.
Q.6. How do direct and indirect immunofluorescence
iii. Normal patients will wet 15 mm of filter paper in 5 min.
differ from each other?
Patients with Sjögren syndrome will wet less than
5 mm of filter paper. Ans.
Section | I Topic-Wise Solved Questions of Previous Years 411

Fluorescent antibody procedures are carried out in one of Q.8. Age in examination.
three ways:
Ans.
i. Direct immunofluorescence
ii. Indirect immunofluorescence Age is one of the important parameter in estimation of
iii. The sandwich technique diseased.
There are various methods for the estimation of growth:
Direct immunofluorescence
i. Clinical methods of age estimation.
● Fluorescent-labelled antiserum directed against a
ii. Radiographic methods of age estimation.
particular tissue component is applied directly to a
iii. Estimating age in children and adolescents.
thin, unfixed smear or tissue section mounted on
● Moorrees’ method
slide, and the slide is incubated at 37°C to allow the
● Demirjian’s method
antigen and labelled antibody to react.
● Open apices method
● Nonspecific reactions are common with this tech-
iv. Third molars in age estimation.
nique, which requires a separate labelled antibody
v. A combined clinical and radiographic method.
preparation for each component to be located. It has
vi. Estimating age in adults, using Kvaal’s radiographic
largely been superseded by either the indirect or
method.
sandwich techniques.
Indirect immunofluorescence Q.9. Patch test.
● Unlabelled specific antiserum directed against a
Ans.
particular tissue component is applied directly to the
smear or tissue section, allowed to react and fol- ● The patch test is the only test that can be used to distin-
lowed by an FITC-conjugated antiglobulin antise- guish contact allergy from other lesions.
rum. Following incubation and washing to remove ● In this test, the suspected allergen is placed on normal
unreacted reagents, the slide is examined in the ul- nonhairy skin. The best test site is the upper portion of
traviolet microscope. the back.
● Similar staining reactions to those observed with the ● The test substance is covered in most instances and
direct technique are obtained, but the technique has allowed to remain in contact with the skin for 48 h. The
several advantages. patch is removed, and 2–4 h later the area examined
● In general, the fluorescence is brighter because sev- for persistent erythema.
eral fluorescent antiglobulin molecules bind onto ● Patch testing of the skin may not be reliable in diagno-
each of the antibody molecules in the specific antise- sis of hypersensitivity reactions confined to the oral
rum. Because the process of conjugation is lengthy, mucosa.
there is considerable cost saving and versatility to the ● Patch testing directly on the oral mucosa has been at-
indirect technique, which requires only one labelled tempted by incorporating the test substance in Orabase,
antiserum (antiglobulin antiserum). by use of a prosthetic appliance to hold the substance in
● Staining of more than one tissue component per slide place, or by use of a rubber cup attached to the teeth.
can also be accomplished, but usually with some loss
of specificity. Q.10. Paget test.
● A variation of this technique uses complement as an
Ans.
additional reagent that binds the specific antigen–
antibody complex and an FITC-labelled anticomple- ● Paget test is used to determine whether a mass is a solid
ment antiserum to locate the complex. tumour or a cyst.
● When a swelling is smaller than 2 cm in size, Paget test
Q.7. Vitality tests. is done.
Ans. ● Cystic swellings feel soft in the centre and firm at the
periphery.
● The tooth is said to be vital when it is capable of re- ● Solid swellings feel firm at the centre than periphery.
sponding to stimuli.
● To check the vitality of teeth, there are three basic Q.11. Rose–Waaler test.
stimuli in the form of thermal, electrical or mechanical.
Ans.
● Thermal: Heat/cold application.
● Electric pulp testing: Direct electric stimulation of sen- ● A special type of passive haemagglutination test is the
sory nerves in the pulp. Rose2Waaler test.
● Mechanical stimulation: Blowing air to the exposed ● In rheumatoid arthritis, an autoantibody (RA factor) ap-
dentine and test cavity preparation. pears in the serum, which acts as an antibody to g-globulin.
412 Quick Review Series for BDS 4th Year, Vol 2

● The RA factor is able to agglutinate red cells coated Q.17. Acid phosphatase.
with globulins.
Ans.
● The antigen used for the test is a suspension of sheep
erythrocytes sensitized with a subagglutinating dose of ● Acid phosphatase occurs in large quantities in the pros-
rabbit antisheep erythrocyte antibody. tate and erythrocytes.
● Elevated serum levels are found in about three-fourths
Q.12. Describe the role of peripheral blood smear in
of patients with metastatic prostatic carcinoma and in
oral medicine.
about one fourth of these before metastasis occurs.
Ans. ● The serum level also rises as a result of prostatic mas-
sage or biopsy and may also be increased in metastatic
[Ref SE Q.1]
breast carcinoma as a result of production of this en-
Q.13. ESR. zyme by the neoplastic tissue.
Ans. Q.18. Alkaline phosphatase.
[Ref SE Q.3] Ans.
Q.14. Tzanck test. ● The causes of raised serum alkaline phosphatase are as
follows:
Ans. i. Rickets
● Tzanck test is considered as a rapid supplemental test ii. Osteomalacia
for pemphigus. iii. Hyperparathyroidism
● It involves taking of cytological smears from freshly iv. Paget disease
opened vesicles. These smears characteristically display ● In the presence of increased serum alkaline phospha-
Tzanck cells that are diagnostic of pemphigus. tase, determination of serum 5-nucleotidase, which is
● Tzanck cells are clumps of large hyperchromatic epithe- elevated in obstructive biliary disease but not in bone
lial cells lying free within the vesicular fluid. These cells disease, can be helpful in identifying the site of origin
are also characterized by swollen nucleus and hyper- of the alkaline phosphatase.
chromatic staining. Q.19. Antinuclear antibody (ANA) test.
Q.15. Indications of Tzanck smear. Ans.
Ans. ● Antinuclear antibody test (ANA): Four types of antinu-
clear antibodies that produce characteristic patterns of
Indications of Tzanck smear
immunofluorescence can be identified by this technique.
● These smears are used for identification of the giant
● Both the titre of the serum (or joint fluid) and the mag-
cells that accompany vesicular virus infections (herpes
nitude of fluorescence are taken into consideration in
simplex, varicella and herpes zoster) and are commonly
reporting positive results.
known as viral giant cells.
● Tests that are scored as only 11 or 21 (on a 11 to 41 scale)
● For identification of acantholysis, a characteristic tissue
on undiluted serum are usually not reported as positive.
change occurring in pemphigus.
● The four patterns of nuclear fluorescence detected by
● In both diseases, the smear is made from the cells mak-
this technique are caused by differences in the distribu-
ing up the floor of the lesion. The technique of obtaining
tion of antigens in the cell nucleus as follows:
a smear from this location and staining it is known as
i. Diffuse:
the Tzanck smear.
Homogenous distribution of specific fluorescence
Q.16. Nikolsky sign. throughout the nucleus. It is not only characteristic
of Systemic lupous Erythematosis (SLE) but also
Ans.
seen in rheumatoid arthritis, Sjögren syndrome and
● The Nikolsky sign is most frequently associated with scleroderma.
pemphigus, but may also occur in epidermolysis bullosa ii. Shaggy:
and Ritter disease. Peripheral distribution of fluorescence, usually seen
● The characteristic sign of these diseases is that pressure only in SLE, especially with active nephritis.
to an apparently normal area will result in formation iii. Speckled:
of a new lesion. This phenomenon, is called as the Discrete particulate staining of the nucleus. Seen
Nikolsky sign, it results from the upper layer of the skin most commonly in rheumatoid arthritis, liver disease,
pulling away from the basal layer. ulcerative colitis, Sjögren syndrome and scleroderma.
Section | I Topic-Wise Solved Questions of Previous Years 413

iv. Nucleolar: ● Indirect immunofluorescence test

A relatively rare pattern seen most often in sclero- ● RIA
derma and Sjögren syndrome. Confirmatory tests
● Western blot test
Q.20. Postprandial blood glucose technique.
Western blot test
Ans. The most widely used confirmatory test for HIV is
Western blot test.
● Two-hour postprandial blood glucose can be done with
● In this test, HIV proteins are separated according to
Dextrostix, Visidex or Chemstrip bG techniques.
their electrophoretic mobility and molecular weight
● The 2 h blood glucose test should ideally be pro-
by polyacrylamide gel electrophoresis.
grammed for a particular appointment and the patient
● These separated proteins are bloated on the strips of
prepared with an explanation of the test and the diet
nitrocellulose paper. These strips are reacted with
instructions.
test sera and then with enzyme conjugated antihu-
● However, the test can be performed immediately, if pa-
man globulin.
tient has ingested approximately 75 g of carbohydrate.
● Antibodies to HIV proteins present in test serum
● A sample of urine should also be collected and checked
combine with all or any fragment of HIV. The strips
for glucose whenever the test is performed.
are washed and treated with enzyme conjugated
Indications antihuman g-globulin. Then a suitable substrate is
i. For evaluation of a patient suspected of having diabetes added that produces colour bands.
mellitus. ● The position of the band on the strip indicates the an-

ii. As a screening test for diabetes mellitus. tigen with which the antibody has reacted. In a posi-
iii. As a measure of the degree of control of the disease in tive serum, bands will be seen with multiple proteins
a patient who is known to be a diabetic, but who is not typically with p24, p31 and gp41, gp120 or gp160.
under regular medical care and is unwilling to accept
Q.23. Biopsy. Types and indications of biopsy in oral
referral to a physician for re-evaluation of this disease.
medicine.
Q.21. Diagnostic tests of bleeding disorders.
Ans.
Ans.
● Biopsy is a surgical procedure to obtain tissue from
● In most cases of bleeding and clotting disorders, first a living organism for its microscopic examination, usu-
consultation would include a medical history and physi- ally to perform a diagnosis.
cal examination. Types of biopsy
● The following is the laboratory work-up for bleeding i. Aspiration or Fine Needle Aspiration (FNA) biopsy
abnormalities: ii. Cone biopsy
i. Complete blood count iii. Core needle biopsy
ii. Measurement of bleeding time iv. Suction-assisted core biopsy
iii. Prothrombin time and partial thromboplastin time v. Endoscopic biopsy
iv. A platelet count vi. Punch biopsy
● With the exception of the haematocrit and bleeding vii. Surface biopsy
time, these procedures require specialized equipment viii. Surgical biopsy or excisional biopsy, etc.
and a trained technician. Indications of biopsy
● When blood tests are performed outside the office, the i. For the assessment of any unexplained oral muco-
bleeding time and capillary fragility test must be per- sal abnormality that persists despite of treatment or
formed as office/chairside procedures by the clinician the removal of local irritants.
unless the patient goes in person to the laboratory to ii. Malignancy is suspected when persistent oral mu-
have blood drawn. cosal lesions are ulcerated, indurated or fixed to
deeper tissues.
Q.22. Diagnostic test for HIV.
iii. Persistent lesions that bleed easily or grow rapidly
Ans. with possibility to transform into malignancy.
There are two types of serological tests for Anti-HIV Q.24. Lab investigations for anaemias.
antibodies:
Ans.
Screening tests
● Enzyme linked immunosorbent assay (ELISA) ● Anaemia is defined as a decrease in the amount of oxygen-
● Karpas test carrying substance per unit volume of blood and may
414 Quick Review Series for BDS 4th Year, Vol 2

result from a reduction in the number of red cells per Q.27. Bence Jones proteins.
cubic millimetre of blood, a reduction in haemoglobin Ans.
concentration or both.
● Anaemia may, therefore, be detected by several labora- ● Bence Jones proteins can be demonstrated in the urine
tory procedures: of patients who have multiple myeloma and is an excre-
i. Total red cell count tory product of the abnormal serum globulins.
ii. Haemoglobin concentration ● 60%285% of myeloma patients exhibit Bence Jones
iii. Haematocrit proteins in the urine.
● Of these procedures, only the haematocrit can be per- ● This is an unusual protein that coagulates when urine is
formed accurately without special training and with heated to 40260°C and disappears when urine is boiled.
simple equipment. It reappears as urine is cooled.
● When performed on capillary blood obtained from a ● Occasionally, Bence Jones proteins are found in urine of
finger prick, this procedure is known as the microhae- patients with other diseases such as leukaemia and poly-
matocrit and measures the percentage volume occupied cythaemia.
by the red cells in relation to the total volume of blood Q.28. Schilling test.
in a centrifuged capillary tube.
● The microhaematocrit is a rapid and accurate means of Ans.
detecting anaemia in the office or clinic setting when ● Of fundamental importance in the differentiation of
the services of a diagnostic laboratory are not readily megaloblastic macrocytic anaemias is the Schilling test,
available. a measure of the patient’s ability to absorb orally admin-
istered radioactive vitamin B12 labelled with Co.
Q.25. Fine needle aspiration cytology.
● Following oral administration of the radioactive vitamin
Ans. B12 unlabelled vitamin is given intramuscularly as a
flushing dose to induce urinary excretion of the labelled
● Fine needle aspiration cytology is performed with a fine vitamin, which is measured in a 24 h urine specimen.
needle attached to a syringe. Aspiration biopsy is often ● The flushing dose is the essence of the Schilling test,
referred to as fine needle aspiration. It is a percutaneous which allows vitamin B12 absorption measurements to
biopsy. be made with acceptable doses of radioactivity.
● FNA is typically accomplished with a fine gauge needle ● Patients with pernicious anaemia (who are unable to
(22 or 25 gauge). absorb orally administered vitamin B12) excrete less
Advantages than 5% of the orally administered dose in comparison
i. Excellent patient complaint with excretion of 8%225% by normal individuals.
ii. Can be readily repeated ● In patients with pernicious anaemia, repetition of the test
iii. Minimum/no complication such as pain or bleeding 3 days later together with administration of gastric intrin-
Disadvantages sic factor will result in normal levels of urinary excretion
i. Inadequate sample with little or no cells of the orally administered radioactive vitamin B12.
ii. False positive or negative results
Q.29. Bleeding time.
Q.26. Significance of haemogram. Ans.
Ans. ● The time taken for the arrest of bleeding is known
● Haemogram is used in the measurement of haemoglo- as bleeding time. The arrest of bleeding is due to the
bin concentration. formation of platelet plug.
● The haemoglobin concentration, expressed as grams of ● Bleeding time normally ranges from 2 to 5 min.
haemoglobin per decilitre of blood, is commonly mea- ● This can be determined by pricking the ear lobe or the
sured to obtain information about circulating RBCs fingertip.
and the amount of oxygen-carrying substance they ● Bleeding time is prolonged in purpura due to platelet
contain. deficiency.
● The haemoglobin concentration is also used for the cal- ● The bleeding time is a useful screening test in a patient
culation of MCHC and MCH, which are used in deter- with a history of prolonged bleeding following previous
mining the nature of a patient’s anaemia. surgery.
● The most satisfactory techniques for which stable stan- Q.30. Write in brief about toluidine blue test.
dards are commercially available. For example, the
Drabkin technique, Sahli’s method and oxyhaemoglo- Ans.
bin method. [Same as SN Q.5]
Section | I Topic-Wise Solved Questions of Previous Years 415

Q.31. Role of intravital staining in oral medicine. Q.35. Serum alkaline phosphatase.
Ans. Ans.
[Same as SN Q.5] [Same as SN Q.18]
Q.32. Two differences between direct and indirect Q.36. Name two conditions that show elevated serum
immunofluorescence. alkaline phosphatase levels.
Ans. Ans.
[Same as SN Q.6] [Same as SN Q.18]
Q.33. Age estimation methods. Q.37. Western blot test.
Ans. Ans.
[Same as SN Q.8] [Same as SN Q.22]
Q.34. Elevation of serum calcium. Q.38. Aspiration biopsy.
Ans. Ans.
[Same as SN Q.17] [Same as SN Q.25]

Topic 17
Miscellaneous
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. What are the oral causes of halitosis? How are you going to treat a case of ANUG?
2. Corticosteroids in dentistry.
3. Define halitosis. What are the various causes leading to halitosis? Discuss any two of them in detail. [Same as LE Q.1]

SHORT ESSAYS:
1. Metronidazole.
2. Oral penicillin.
3. Indications and contraindications of corticosteroid therapy in dentistry.
4. Anaphylactic shock.
5. Serum sickness.
6. Antifungal drugs in oral medicine.
7. Broad-spectrum antibiotics – side effects.
8. Classification and uses of oral penicillin. [Same as SE Q.2]
9. Uses and side effects of oral penicillin. [Same as SE Q.2]
10. Mention two oral conditions in which corticosteroids are drugs of choice and two oral conditions in which they
are contraindications. [Same as SE Q.3]
11. How will you manage a case of anaphylactic shock due to local anaesthesia? [Same as SE Q.4]
12. Anaphylaxis. [Same as SE Q.4]

SHORT NOTES:
1. Lipschutz bodies.
2. Melkersson–Rosenthal syndrome.
416 Quick Review Series for BDS 4th Year, Vol 2

3. Ascher syndrome.
4. Albright syndrome.
5. Papillon–Lefevre syndrome.
6. Eagle syndrome.
7. Ramsay Hunt syndrome.
8. Ethics in dental profession.
9. Fixed drug eruption.
10. Halitosis – physiologic causes. [Ref LE Q.1]
11. Diazepam.
12. Classify antiviral drugs.
13. Classify nonsteroidal anti-inflammatory drugs?
14. Jarisch2Herxheimer reaction.
15. Lip prints.
16. Bite Marks.
17. Battered baby syndrome.
18. Bite marks analysis. [Same as SN Q.16]

SOLVED ANSWERS
LONG ESSAYS: ● As the periodontal pocket depth increases, it is
Q.1. What are the oral causes of halitosis? How are you seen that the concentration of the malodorous
going to treat a case of ANUG? chemicals increases. Deep pockets also cause
the formation of putrescine and cadaverine.
Ans. II. Tongue coating that harbours microorganisms
● The dorsum of the tongue is considered to be
● Halitosis means oral malodour or bad breath.
● Volatile sulphur compounds are the main cause of breath the primary aetiologic factor for oral malodour.
● Dorsum of the tongue is irregular and accom-
malodour. These mainly include hydrogen sulphide,
methyl mercaptan and dimethyl sulphide. Various other modates microorganisms and food debris.
● Desquamated cells and food remnants remain
compounds have also been implicated in the aetiology
such as putrescine, indole, skatole, butyric acid or propi- entrapped on the surface and are consequently
onic acid. decomposed and contribute to oral malodour.
● There are several causes for halitosis, unpleasant breath III. Stomatitis, xerostomia
● Dry mouth can cause the volatile sulphur
can be due to intraoral or extraoral causes. They are as
follows: compounds to escape.
● The number of microorganisms that produce

volatile sulphur compounds are increased in

{SN Q.10} absence of saliva.
Physiologic causes IV. Faulty restorations retaining food and bacteria
a. Mouth breathing V. Unclean dentures
b. Medications VI. Oral pathologic lesions
c. Ageing and poor dental hygiene ● Carious cavities, infected extraction wounds,

d. Fasting/starvation dental abscesses and purulent discharge all can

e. Tobacco contribute to oral malodour.
f. Foods (onion, garlic, etc.) and alcohol VII. Aphthous ulcers
● Certain conditions such as pericoronitis,
ANUG and oral ulcers can also contribute to
Pathologic causes oral malodour.
Intraoral and other contributing factors such as: VIII. Crowding of teeth
I. Periodontal infections/periodontal pathology ● The crowded teeth cause accumulation of
● Actinobacillus actinomycetemcomitans, Porphy- food debris, which can result in halitosis.
romonas gingalis, Campylobacter rectus and Systemic and extraoral factors include:
Tannerella forsythia are responsible for patho- I. Nasal infections
genesis of periodontitis and production of vola- ● For example, rhinitis, sinusitis, postnasal drip,
tile sulphur compounds. tumours and foreign bodies.
Section | I Topic-Wise Solved Questions of Previous Years 417

II. Diseases of gastrointestinal tract (GIT) ● Halita 1M is a new solution containing 0.05%

● For example, various conditions that contrib- chlorhexidine, 0.05% cetyl pyridium chloride (CPC)
ute to oral malodour are Zenker diverticu- and 0.14% zinc lactate with no alcohol has been
lum, hiatus hernia, carcinomas, gastroesoph- more efficient than 0.2% chlorhexidine formulation
ageal reflux disorder (GERD) and intestinal in reducing the VSC levels.
gas production.
Q.2. Corticosteroids in dentistry.
III. Pulmonary infections
● For example, chronic bronchitis, pneumonia, Ans.
tuberculosis and carcinomas are also extra-
Corticosteroids are the hormones produced by the cortex of
oral causes of oral malodour.
the adrenal gland. They are as follows:
IV. Hormonal changes
● Glucocorticoids–cortisol.
● Certain hormonal changes that occur during
● Mineralocorticoids–aldosterone.
ovulation, menstruation, pregnancy and
● A small amount of androgens.
menopause.
V. Systemic diseases The secretion of adrenal cortex is under the control of
● Other extraoral causes that contribute to ACTH secreted by the anterior pituitary, which in turn is
halitosis are liver insufficiency, kidney in- regulated by corticotropin releasing factor (CRF). This is
sufficiency, diabetes mellitus, renal failure, termed as hypothalamic–pituitary–adrenal axis.
blood dyscrasias, rheumatologic diseases, Classification of corticosteroids
dehydration and fever and cirrhosis of liver. A. Short acting (8212 h)
Treatment aspects of oral malodour i. Hydrocortisone
Tongue cleaning ii. Cortisone
● In patients with thick coatings on their tongue, B. Intermediate acting (18236 h)
cleansing of tongue has been recommended. i. Prednisolone
Toothpastes ii. Methylprednisolone
● Cleaning the dentition and the tongue with a den- iii. Triamcinolone
tifrice has shown to reduce the levels of volatile C. Long acting (36254 h)
sulphur compounds. i. Paramethasone
Mouth rinses ii. Dexamethasone
● In addition to above procedures, the use of different iii. Betamethasone
mouth rinses containing cetylpyridinium chloride, Mechanism of action
triclosan, chlorhexidine, essential oils, chlorine diox- Corticosteroids bind to specific receptors in the cyto-
ide, metal ions, etc. has been shown to be effective in plasm, the drug–receptor complex is transported into the
controlling oral malodour. nucleus where it binds to specific sites on DNA and regu-
● Chemical reduction of oral microbial load in- lates the synthesis of new proteins that bring about the
cludes rinsing or gargling with an effective mouth- hormone effects.
wash.
Chewing gum Steroid hormone enters the cells of target organ
● Chewing gum containing metal salts such as fluo-
g
rides or chlorhexidine helps in reducing the bacte-
rial load and the levels of malodorous chemicals In the cytoplasm it binds to specific receptors
from the oral cavity. g
● Drinking water at frequent intervals and chewing
of gum can keep the volatile sulphur compounds Steroid receptor complex becomes activated
in solution and prevent them from producing oral g
malodour.
Oral malodour associated with periodontitis Enters the nucleus
● One way to treat oral malodour associated with peri-
g
odontitis is to combine regular periodontal treatment
and a chlorhexidine mouth rinse. Binds to specific site on the DNA
● Another treatment strategy for oral malodour is
g
conversion of volatile sulphur compounds by using
various metal ions. Zinc (Zn21) is an ion, which Protein synthesis regulation
bonds to the twice negatively charged sulphur radi- g
cals to reduce the expression of volatile sulphur
compounds. Shows response
418 Quick Review Series for BDS 4th Year, Vol 2

● Synthetic corticosteroids are more selective corti- and the relative potency of additional miner-
costeroids. They do not have mineralocorticoid alocorticoid effects.
action. i. Cushing syndrome: Abnormal fat distri-
● They are more potent than the natural corticoids. bution causes moon face, buffalo hump,
They generally have intermediate to long duration of truncal obesity, muscle wasting, thin-
action. ning of limbs and skin, easy brushing,
● Synthetic glucocorticoids include: purple striae and acne.
I. Prednisolone ii. Hyperglycaemia: Precipitation of dia-
● It is more selective glucocorticoid and is four betes mellitus or aggravation of pre-
times more potent than hydrocortisone. existing diabetes.
● Used for allergic, inflammatory, autoimmune iii. Susceptibility of infection: Long-term
diseases and in malignancies. therapy with steroids leads to immuno-
● For example, available as DELTACORTRIL, suppression, which makes the patient
HOSTACORTIN-H, 5, 10 mg tab, 20 mg/mL more vulnerable to various opportunis-
for i.m., intra-articular injection, WYSO- tic infections like fungal, viral and bac-
LONE, NUCORT, 5, 10 and 20 mg tab. terial, etc.
II. Methylprednisolone iv. Osteoporosis: Especially of the verte-
● Slightly more potent and more selective than brae is more common in the elderly.
prednisolone; 4232 mg/day oral. v. Avascular necrosis: Avascular necrosis
● For example, available as SOLU-MEDROL of the bone due to restriction of blood
methylprednisolone (as sodium succinate) flow through bone capillaries may cause
0.5 g (8 mL) and 1.0 g (16 mL) injection for pain and restriction of movement.
i.m., slow i.v. injection. Growth in children may be suppressed.
III. Triamcinolone vi. Peptic ulceration: This may sometimes
● Slightly more potent but highly selective occur on prolonged therapy especially
glucocorticoid than prednisolone: 4232 mg/ when other ulcerogenic drugs are (e.g.
day oral, 5240 mg i.m., intra-articular injec- NSAIDs) used concurrently.
tion. Also used topically. vii. Mental disturbance: Include euphoria,
● For example, available as KENACORT, TRI- psychosis and depression.
CORT 1, 4 and 8 mg tab., 10 mg/mL, 40 mg/mL viii. Eye: Cataract and glaucoma may occur
(as acetonide) for i.m., intra-articular injec- on prolonged therapy.
tion LEDERCORT 4 mg tab. ix. Delayed wound healing.
IV. Dexamethasone x. Other effects: Raised intracranial pres-
● Very potent and highly selective glucocorti- sure, convulsions, hypercoagulability of
coid than prednisolone. It is used for inflam- the blood and menstrual disorders.
matory and allergic conditions in a dose of xi. Mineralocorticoid effects: This includes
0.5–5 mg/day oral. In shock, cerebral oe- salt and water retention, oedema, hypo-
dema, etc. 4220 mg/day i.v., i.m., injection. kalaemia and hypertension are rare with
Also used topically. selective glucocorticoids.
● For example, available as DECADRON, xii. Thinning of muscles: Steroid treatment
DEXONA 0.5 mg tab, 4 mg/mL (as sodium can cause hypokalaemia leading to
phosphate) for i.v., i.m., injection, 0.5 mL muscle weakness and fatigability. Long-
oral drops, etc. term steroid therapy leads to steroid
V. Betamethasone myopathy.
● Same as that of dexamethasone: 0.5–5 mg/ xiii. HPA axis suppression: The most unde-
day oral, 4220 mg/day i.v., i.m., injection or sirable and dangerous outcome of long-
infusion, also topical. term steroid therapy leads HPA axis
● For example, available as BETNESOL, BE- suppression.
TACORTRIL and CELESTONE 0.5 mg, 1 mg
tab and 4 mg/mL (as sodium phosphate) for Q.3. Define halitosis. What are the various causes lead-
i.v., i.m., injection, 0.5 mL oral drops, etc. ing to halitosis? Discuss any two of them in detail.
● Most of the adverse effects of glucocorticoids
Ans.
are extension pharmacological actions and
are dependent on dose, duration of therapy [Same as LE Q.1]
Section | I Topic-Wise Solved Questions of Previous Years 419

SHORT ESSAYS: ● Metronidazole also inhibits warfarin metabolism.

Patients undergoing anticoagulant therapy should
Q.1. Metronidazole. avoid metronidazole because it prolongs prothrom-
Ans. bin time.
● It also should be avoided in patients who are taking
● Metronidazole is a potential agent for local antimicro- lithium.
bial therapy due to its selective antimicrobial features
against the obligate anaerobes. Q.2. Oral penicillin.
● The most extensively tested and used device for metro- Ans.
nidazole application is a gel consisting of a semisolid
suspension of 25% metronidazole benzoate in a mixture ● Antibiotic is a chemical substance produced by a micro-
of glyceryl monooleate and sesame oil (Elyzol Dental organism, which has the capacity to inhibit the growth
Gel, Dumex, Copenhagen, Denmark). Applied with a or kill other organism in dilute solution.
syringe inserted into the pocket, the gel increases in ● Penicillin is the most important and the first antibiotic to
viscosity after placement. be used, obtained from a fungus of penicillium notatum,
● Metronidazole is a nitroimidazole compound used to but the yield was very low. The present source of peni-
treat protozoal infections. It is bactericidal to anaerobic cillin is the high-yielding P. chrysogenum.
organisms. Classification
Clinical uses Natural penicillin
● Although metronidazole is not the drug of choice for ● Benzyl penicillin (penicillin G)

treating A. actinomycetemcomitans infections, it may Semisynthetic penicillin

be effective at therapeutic levels because of its hy- i. Acid-resistant penicillin
droxy metabolite. When used in combination with ● Phenoxymethyl penicillin (penicillin V)

other antibiotics metronidazole is effective against ii. Penicillinase-resistant penicillin

A. actinomycetemcomitans. ● Methicillin

● Metronidazole is also effective against anaerobes ● Oxacillin

such as Porphyromonas gingivalis and Prevotella ● Cloxacillin

intermedia. ● Dicloxacillin

● Metronidazole has been used clinically to treat gingi- iii. Extended-spectrum penicillin
vitis, acute necrotizing ulcerative gingivitis (ANUG), ● Aminopenicillins

chronic periodontitis and aggressive periodontitis. ● Ampicillin

● A single dose of metronidazole (250 mg orally) ap- ● Bacampicillin

pears in both serum and GCF in sufficient quantities ● Amoxicillin

to inhibit a wide range of suspected periodontal iv. Carboxypenicillins

pathogens. ● Carbenicillin

● Administered systemically (75021000 mg/day for ● Carbenicillin indanyl

2 weeks), metronidazole reduces the growth of an- ● Carbenicillin phenyl (carfecillin)

aerobic flora, including spirochetes, and decreases the ● Ticarcillin

clinical and histopathologic signs of periodontitis. v. Ureidopenicillins

● The most common regimen is 250 mg three times ● Piperacillin

daily (t.i.d.) for 7 days. ● Mezlocillin

Subgingival metronidazole ● Mecillinam (Amdinocillin)

● A topical medication containing an oil-based metro- vi. b-lactamase inhibitors

nidazole 25% dental gel (glyceryl monooleate and ● Clavulanic acid

sesame oil) has been tested in a number of studies. ● Sulbactam

● As a precursor, the preparation contains metronida- Therapeutic uses

zole-benzoate, which is converted into the active i. Penicillin G or benzyl penicillin is the drug of choice
substance by esterases in GCF. for infection caused by bacteria susceptible to it that
Side effects is streptococci, pneumococci, Bacillus anthracis,
● Metronidazole has an antiabuse effect when alcohol Corynebacterium diphtheriae, Clostridia, Listeria,
is ingested, resulting in severe cramps, nausea and spirochaetes and Neisseria species.
vomiting. Hence, products containing alcohol should a. Streptococcal infections:
be avoided during therapy and for at least 1 day after i. Pharyngitis, otitis media, scarlet fever, rheumatic
therapy is discontinued. fever. 0.525 MU i.v. 8 hourly for 7210 days.
420 Quick Review Series for BDS 4th Year, Vol 2

ii. Subacute bacterial endocarditic caused by ● The most convenient regimen of benzathine pen-
S. viridans or faecalis. 10220 MU i.v. daily icillin is 1.2 MU every 4 weeks till 18 years of
with streptomycin 0.5 g 1M BD for 226 weeks. age or 5 years after an attack whichever is more.
b. Pneumococcal infections: ii. Gonorrhoea and syphilis:
Though not recommended but can be given if or- ● 2.4 MU single dose of procaine penicillin or

ganisms are sensitive. 3–6 MU i.v. every 6 hourly. benzathine penicillin before or within 12 h of
c. Meningococcal infections: contact provides protection for both these sexu-
Respond well to high dose of penicillin. ally transmitted diseases.
d. Gonorrhoea: iii. Bacterial endocarditis:
i. Penicillin has been taken over by fluoroquino- ● Penicillin is used before dental extraction, endos-

lones/ceftriaxones as the first-line drugs. How- copies, catheterization and other surgical proce-
ever, it can be used in NPPG infection as 4.8 dures to prevent bacteraemia in patients with
MU i.m. single dose divided and given in both valvular heart disease.
buttocks or procaine penicillin with Ig proben- iv. Agranulocytosis:
ecid orally. ● Penicillin alone or in combination with an ami-

ii. For ophthalmia neonatorum due to sensitive noglycoside.

N. gonorrhoeae. v. Surgical infection:
● Saline irrigation 1 1 drop containing ● 1 MU of procaine penicillin 1 an aminoglyco-

10,000220,000 U/mL of sodium penicillin side injected i.m. 1 h before and 8212 h after
G in each eye every 122 h for 1 week. surgery can reduce wound infection.
● In severe cases, give 50,000 U i.m. BD in

addition. Q.3. Indications and contraindications of corticosteroid

e. Syphilis: therapy in dentistry.
Penicillin G is the drug of choice for syphilis.
Ans.
i. Early and latent syphilis
1.2 MU of procaine penicillin daily for 10 days ● Corticosteroids are the hormones produced by the
(or) 2.4 MU of benzathine penicillin weekly cortex of the adrenal gland. They are
for 123 weeks. i. Glucocorticoids – cortisol
ii. Late syphilis ii. Mineralocorticoids – aldosterone
2.4 MU of benzathine penicillin weekly for iii. A small amount of androgens
4 weeks Classification of corticosteroids
or A. Short acting (8–12 h)
5 MU i.m. of sodium penicillin G 6 hourly for i. Hydrocortisone
2 weeks ii. Cortisone
f. Diphtheria: B. Intermediate acting (18–36 h)
Penicillin treatment is of adjuvant value to anti- i. Prednisolone
toxin therapy and prevents carrier state. ii. Methylprednisolone
122 MU of procaine penicillin daily for 10 days. iii. Triamcinolone
g. Tetanus and gas gangrene: C. Long acting (36–54 h)
Penicillin is used to kill the organism and has i. Paramethasone
adjuvant value to antitoxin. 6212 MU of penicil- ii. Dexamethasone
lin G daily. iii. Betamethasone
h. Actinomycosis: Indications of corticosteroids
224 MU i.v. of penicillin G 6 h for 4 weeks Lesions that usually respond well:
i. Trench mouth: i. Atopic eczema
Along with metronidazole, low doses of penicillin ii. Allergic contact
G for 7 days are effective. iii. Dermatitis
j. Penicillin G is the drug of choice for rare infec- iv. Seborrhoeic dermatitis
tions like anthrax, actinomycosis, rat bite fever v. Psoriasis of face, flexures
and those caused by Listeria monocytogenes and vi. Varicose eczema
Pasteurella multocida. Lesions requiring potent steroids, respond slowly:
Prophylactic uses i. Cystic acne
i. Rheumatic fever: ii. Alopecia areata
● Low concentration of penicillin prevents coloni- iii. Discoid LE
zation by streptococci responsible for rheumatic iv. Hypertrophied scars, keloids
fever. v. Lichen planus
Section | I Topic-Wise Solved Questions of Previous Years 421

vi. Nail disorders ● History of asthma.

vii. Psoriasis of palm, sole, elbow and knee ● Family history of allergy.
Contraindications of corticosteroids ● Parenteral administration of the drug.
i. Peptic ulcer ● Administration of high-risk allergens such as peni-
ii. Diabetes mellitus cillin.
iii. Hypertension ● Anaphylactic reactions may occur within seconds of
iv. Viral and fungal infections drug administration or may occur 30240 min later,
v. Tuberculosis and other infections complicating the diagnosis.
vi. Osteoporosis ● The symptoms of generalized anaphylaxis should be
vii. Herpes simplex keratitis known so that prompt treatment may be initiated.
viii. Psychosis ● The generalized anaphylactic reaction may involve
ix. Epilepsy the skin, the cardiovascular system, the intestines
x. Congestive Heart Failure (CHF) and the respiratory system.
xi. Renal failure ● The first signs often occur on the skin and are similar
to those seen in localized anaphylaxis (e.g. urticaria,
Q.4. Anaphylactic shock.
angioedema, erythema and pruritus). Pulmonary symp-
Ans. toms include dyspnoea, wheezing and asthma. GI tract
disease (e.g. vomiting, cramps and diarrhoea) often
● Anaphylactic shock after the administration of xylo-
follows skin symptoms. If these are untreated, symp-
caine is one of the uncommon systemic causes for acute
toms of hypotension appear as the result of the loss of
circulatory insufficiency.
intravascular fluid; if untreated, this leads to shock.
● But, when it occurs, it is accompanied by severe circula-
● Patients with generalized anaphylactic reactions may
tory and respiratory collapse, urticaria, laryngeal oe-
die from respiratory failure, hypotensive shock or
dema, steep fall in BP, weak pulse, bronchospasm and
laryngeal oedema.
loss of consciousness.
● The most important therapy for generalized anaphy-
Treatment of anaphylactic shock laxis is the administration of epinephrine. All clinicians
Immediate emergency treatment includes the following: who administer drugs should have a vial of aqueous
● The patient is kept in reclining position, adminis- epinephrine (at a 1:1000 dilution) and a sterile syringe
ter oxygen at high flow rate and perform cardio- easily accessible. For adults, 0.5 mL of epinephrine
pulmonary resuscitation if required. should be administered intramuscularly or subcutane-
● Resuscitation methods like cardiac massage, ously; smaller doses of from 0.1 to 0.3 mL should be
mouth to mouth breathing, if necessary. Without used for children, depending on their size. If the aller-
any delay, immediate medical consultation and gen was administered in an extremity, a tourniquet
hospitalization must be arranged to save the life of should be placed above the injection site to minimize
the patient. further absorption into the blood. The absorption can
● Inject adrenaline 0.320.5 mg (0.320.5 mL of 1 be further reduced by injecting 0.3 mL of epinephrine
in 1000 solution) i.m. and repeat every 5210 min (1:1000) directly into the injection site. The tourniquet
if patient does not improve. It is the only life- should be removed every 10 min.
saving measure. ● Epinephrine will usually reverse all severe signs of
● Maintenance of ventilation with oxygen under generalized anaphylaxis. If improvement is not ob-
pressure. If severe bronchospasm develops, served in 10 min, readminister epinephrine.
2502500 mg of aminophylline intravenously. ● If the patient continues to deteriorate, several
● Administer (H1 antihistaminic) diphenhydramine steps can be taken, depending on whether the pa-
502100 mg i.m. or slow i.v. inject hydrocortisone tient is experiencing bronchospasm or oedema.
sodium succinate 1002200 mg i.v. For bronchospasm, slowly inject 250 mg of ami-
Generalized anaphylaxis nophylline intravenously, over a period of 10 min.
● Generalized anaphylaxis is an allergic emergency. Too rapid an administration can lead to fatal car-
● The mechanism of generalized anaphylaxis is the diac arrhythmias.
reaction of IgE antibodies to an allergen that causes ● Do not give aminophylline if hypotensive shock is a
the release of histamine, bradykinin and SRS-A. part of the clinical picture.
These chemical mediators cause the contraction of ● Inhalation sympathomimetics may also be used to
smooth muscles of the respiratory and intestinal treat bronchospasm, and oxygen should be given to
tracts, as well as increased vascular permeability. prevent or manage hypoxia.
The following factors increase the patient’s risk for ana- ● For the patient’s with laryngeal oedema, establish an
phylaxis: airway. This may necessitate endotracheal intubation;
● History of allergy to other drugs or food. in some cases, a cricothyroidotomy may be necessary.
422 Quick Review Series for BDS 4th Year, Vol 2

Q.5. Serum sickness. ii. Triazoles (systemic) – Fluconazole and itra-

conazole
Ans.
D. Allylamine
● Serum sickness is named for its frequent occurrence ● Terbinafine

after the administration of foreign serum, which was E. Other topical agents
given for the treatment of infectious diseases before the ● Tolnaftate, undecylenic acid, benzoic acid,

advent of antibiotics. salicylic acid, selenium sulphide, ciclopirox

● The reaction is presently less common but still occurs as olamine and sodium thiosulphate
a result of the susceptible patient’s being given tetanus Uses
antitoxin, rabies antiserum or drugs that combine with ● Broad-spectrum antifungal drugs are used against

body proteins to form allergens. a large variety of fungi and yeasts like Candida
● Penicillin, a drug commonly prescribed by dentists, oc- albicans, Histoplasma capsulatum, Cryptococcus
casionally causes serum sickness. The pathogenesis of neoformans, Blastomyces dermatitidis, Coccidi-
serum sickness differs from that of anaphylaxis. oides immitis, Torulopsis, Rhodotorula, Aspergil-
● Antibodies form immunocomplexes in blood vessels lus, Sporothrix, Deep mycoses, Epidermophyton,
with administered antigens. The complexes fix comple- Trichophyton and Microsporum.
ment, which attracts leukocytes to the area, causing di-
rect tissue injury. Q.10. Broad-spectrum antibiotics – side effects.
● Serum sickness and vasculitis usually begin 7210 days
after the administration of the allergen, but this period
Ans.
can vary from 3 days to as long as 1 month. Unlike other
allergic diseases, serum sickness may occur during the Classification of antibiotics
initial administration of the drug. Antibiotics are classified in the following way ac-
● Major symptoms consist of fever, swelling, lymphade- cording to type of action:
nopathy, joint and muscle pains and rash. Less common i. Bacteriostatic:
manifestations include peripheral neuritis, kidney dis- For example, tetracyclines, sulphonamides,
ease and myocardial ischaemia. erythromycin, etc.
● Serum sickness is usually self-limiting, with spontane- ii. Bactericidal:
ous recovery in 123 weeks. For example, penicillin, cephalosporins, etc.
● Treatment is symptomatic. Aspirin is given for arthral- ● The broad-spectrum antibiotics are tetracy-

gia and antihistamines are given for the skin rash. clines and chloramphenicol. They are so
● Severe cases should be treated with a short course of termed as they are used against number of
systemic corticosteroids, which significantly shortens Gram-negative and Gram-positive infections.
the course of the disease. Although this reaction is rare, Adverse effects of broad-spectrum antibiotics
the dentist who is prescribing penicillin should be aware A. Irritative effects
of the possibility of serum sickness occurring weeks ● Epigastric pain, nausea, vomiting and diarrhoea.
after use of the drug. ● Pain at intramuscular (i.m.) injected site, throm-

bophlebitis of injected vein on repeated use.

Q.6. Antifungal drugs in oral medicine. B. Dose-related toxicity
i. Liver damage – Fatty infiltration of liver and
Ans.
jaundice.
● Fungal infections may be systemic or superficial. An- ii. Kidney damage – Prominent only in presence of
tifungal drugs are used in the treatment of fungal existing kidney disease.
infections. iii. Phototoxicity – Sunburn like or other severe skin
Classification of antifungal drugs reactions on exposed body parts especially with
A. Antifungal antibiotics demeclocyclines and doxycyclines.
i. Polyenes: Amphotericin-B, Nystatin, Hamy- iv. Teeth and bones – Tetracyclines have chelating
cin and Natamycin (Pimaricin) property and calcium tetracycline chelate get
ii. Heterocyclic benzofuran: Griseofulvin deposited in developing bone and teeth. Brown
B. Antimetabolites discolouration of ill-formed teeth.
● Flucytosine (5-FC) v. Antianabolic effect – Reduced protein synthesis
C. Azoles and overall catabolic effect.
i. Imidazoles (topical) – Ketoconazole, micon- vi. Increased intracranial pressure – Noted in some
azole, clotrimazole and econazole infants.
Section | I Topic-Wise Solved Questions of Previous Years 423

vii. Diabetes insipidus – Demeclocyclines antago- General features of Ascher syndrome

nizes Antidiuretic harmone (ADH) action and ● Blepharochalasis that is dropping of the tissue be-

reduces urine concentrating ability of kidney. tween the eyebrow and the edge of upper eyelid so
viii. Vestibular toxicity – Minocyclines produce that it hangs loosely over the margin of the lid
ataxia, vertigo and nystagmus which subsides on ● Nontoxic thyroid enlargement

discontinuation of drug. Oral manifestations

ix. Hypersensitivity reactions – Skin rashes, urti- ● Double lip.

caria, glossitis, pruritus and even exfoliative der-

Q.4. Albright syndrome.
matitis occurs but not common.
x. Superinfections – Tetracyclines are most com- Ans.
mon antibiotics responsible for superinfections
● Albright syndrome is also called as ‘McCune–Albright
by causing marked suppression of the resident
syndrome’.
flora.
● It includes:
xi. Adverse effects especially associated with chlor-
● Polyostotic fibrous dysplasia involving nearly all
amphenicol are bone marrow depression, agranu-
bones of the skeleton
locytosis, grey baby syndrome, aplastic anaemia
● Pigmented lesions of skin (café-au-lait spots)
and hypersensitivity reactions.
● Precocious sexual development
Q.11. How will you manage a case of anaphylactic shock ● Hyperfunction of one or more endocrine glands
due to local anaesthesia?
Q.5. Papillon–Lefevre syndrome.
Ans.
Ans.
[Same as SE Q.4]
General features of Papillon–Lefevre syndrome
Q.12. Anaphylaxis. ● Keratotic lesion of palmar plantar surface; general-

Ans. ized hyperhydrosis; very fine body hairs, calcifica-

tion of falx cerebri or dura, contralateral Jacksonian
[Same as SE Q.4] epilepsy, mental retardation, ocular and aural
changes
SHORT NOTES: Oral manifestation
● Severe destruction of alveolar bone involving both
Q.1. Lipschutz bodies. the dentitions; leading to premature exfoliation of
Ans. teeth; inflammatory gingival enlargement, gingival
ulceration and formation of deep pockets; hemifacial
● The herpetic vesicle is an intraepithelial blister filled atrophy and trigeminal neuralgia
with fluid. The infected cells are swollen and have pale
eosinophilic cytoplasm and large vesicular nuclei, de- Q.6. Eagle syndrome.
scribed as ballooning degeneration, whereas others Ans.
characteristically contain intranuclear inclusions known
as Lipschutz bodies. Eagle syndrome is characterized by:
● Lipschutz bodies are eosinophilic, ovoid, homogenous ● Elongation of styloid process or ossification of the

structures within the nucleus, which tend to displace the stylohyoid ligament causing dysphasia, sore throat,
nucleus and nuclear chromatin peripherally. otalgia, glossodynia, headache and vague orofacial
● The displacement of chromatin often produces a peri- pain
inclusion halo. ● Pain along the distribution of the internal and exter-

nal carotid arteries

Q.2. Melkersson–Rosenthal syndrome. ● Pharyngeal pain

Ans. ● Calcification of sternocleidomastoid muscle, etc

Melkersson–Rosenthal syndrome is a triad of: Q.7. Ramsay Hunt syndrome.

● Cheilitis granulomatosa. Ans.
● Facial paralysis.
● Fissured tongue. ● Ramsay Hunt syndrome is a zoster infection of genicu-
late ganglion with involvement of external ear and oral
Q.3. Ascher syndrome.
mucosa, Bell palsy and unilateral vesicles of the exter-
Ans. nal ear and vesicles of the oral mucosa.
424 Quick Review Series for BDS 4th Year, Vol 2

Q.8. Ethics in dental profession ● Antiviral drugs interfere with the steps of viral repro-
duction cycle with in host cell.
Ans.
Classification of antiviral agents
● Ethics is defined as the part of philosophy that deals
 i. Drugs used against herpetic infection (antiherpes
with moral conduct and judgement.
agents) – Acyclovir, valacyclovir, ganciclovir, idoxu-
Major principles are:
ridine, vidarabine and foscarnet
i. Do no harm (nonmaleficence).
ii. Drugs used against HIV infection (antiretroviral
ii. Do good (beneficence).
agents):
iii. Autonomy.
a. Nucleoside reverse transcriptase inhibitors – Zid-
iv. Justice.
ovudine, didanosine, zalcitabine, stavudine and
v. Truthfulness.
lamivudine
vi. Confidentiality.
b. Nonnucleoside reverse transcriptase inhibitors –
Q.9. Fixed drug eruption. Nevirapine, delaviridine and efavirenz
c. Protease inhibitors – Saquinovir indinavir, ritona-
Ans.
vir and lopinavir
● Intraoral fixed drug eruptions may occur in patients who d. Fusion inhibitor – Enfuvirtide
are administered on repeated occasions a drug to which e. Anti-influenza virus agents – Amantadine, riman-
they are sensitive. tadine and oseltamivir
● This fixed eruption is characterized in the appearance of l Other antiviral agents – Ribavirin and interferons

a skin reaction at the same sites each time and is appar-

Q.13. Classify nonsteroidal anti-inflammatory drugs?
ently due to local sensitization of the tissues.
● Drugs commonly implicated in such allergic reactions Ans.
include barbiturates, salicylates, phenazone derivatives,
● Analgesics are the drugs that are prescribed to relieve
sulphonamides and tetracycline.
patient from pain. Analgesics are basically two types:
● The oral lesions appear as localized areas of erythema
i. Narcotic analgesics (opioids)
and oedema, commonly seen on the labial mucosa and
ii. Nonsteroidal anti-inflammatory drugs (NSAIDs;
can later develop into vesiculoulcerative lesions.
nonopioids)
Q.10. Halitosis – physiologic causes. Classification of NSAIDs
Nonselective COX inhibitors:
Ans.
i. Aspirin
[Ref LE Q.1] ii. Piroxicam
iii. Ketorolac
Q.11. Diazepam.
iv. Ibuprofen
Ans. v. Diclofenac
vi. Indomethacin
● Diazepam is a popular anticonvulsant drug. It is rela-
vii. Phenylbutazone
tively safe if given intramuscularly or intravenously for
viii. Mephenamic acid
conscious or deep sedation.
Preferential COX inhibitors
● Of the many available agents, it is found that diazepam
i. Nimesulide
with or without nitrous oxide and xylocaine meet the
Selective COX inhibitors
requirements for a safe, effective, versatile technique of
ii. Rofecoxib
conscious sedation.
Analgesics – Antipyretics with poor anti-inflammatory
● Diazepam when given orally is one of the readily ac-
action
ceptable tranquillizing drugs.
i. Nefopam
● It provides muscle relaxation and a degree of amnesia.
ii. Metamizol
● Minimum dosage: for normal adults, 10 mg; for children
iii. Paracetamol
5–7.5 mg depending on the age group.
● Rapid injection of diazepam may cause apnoea and fall Q.14. Jarisch–Herxheimer reaction.
in BP.
Ans.
Q.12. Classify antiviral drugs.
● Jarisch2Herxheimer reaction is an acute exacerbation
Ans.
of signs and symptoms of syphilis during penicillin
● Viruses are intracellular parasites and depend on host therapy.
cells for food, growth and multiplication. ● It is due to release of endotoxins from the dead organisms.
Section | I Topic-Wise Solved Questions of Previous Years 425

● The manifestations are fever, chills, myalgia, hypoten- followed by the analysis of life-sized or enlarged photo-
sion, circulatory collapse, etc. graphs.
● It is treated with aspirin and corticosteroids. ● A separate qualitative and quantitative analysis of the
models and occlusal registrations of the suspect’s denti-
Q.15. Lip prints.
tion can be performed at this stage.
Ans. ● Rather than relying on the number of teeth depicted in
the mark, analyse uncommon characteristics such as
● The study of lip print is called cheiloscopy. It is impor-
presence or absence of a particular tooth, mesiodistal
tant in crime investigation.
dimension of the teeth and dental arch, rotation, fracture
● According to Ehara and Marumo (1998), lipstick smears
and diastema.
are frequently encountered in forensic investigations as
● According to Sweet (1995), the protocol for bite mark
an important form of transfer evidence.
comparison is made up of two broad categories:
● Snyder (1950) is believed to have first pointed out that
i. Metric analysis
the lines and fissures on the lips have individual varia-
ii. Pattern association
tions like fingerprints.
● These researchers and a few others studied lip prints Q.17. Battered baby syndrome.
using similar classification, a composite of which are:
i. Vertical grooves Ans.
ii. Branched grooves
● Battered child syndrome refers to injuries sustained by
iii. Bifurcated grooves
a child as a result of physical abuse, usually inflicted by
iv. Intersected grooves
an adult caregiver.
v. Reticular grooves
● It is also known as shaken baby syndrome, child abuse
vi. Other grooves (comma, ellipse, triangle, horizontal,
and nonaccidental trauma (NAT).
etc.)
● Internal injuries, cuts, burns, bruises and broken or frac-
Q.16. Bite marks. tured bones are all possible signs of battered child syn-
drome.
Ans.
● Emotional damage to a child is also often the byproduct
Analysing and comparing bite mark evidence: of child abuse, which can result in serious behavioural
● Ideally, bite mark analysis should begin with a qualita- problems such as substance abuse or the physical abuse
tive and quantitative analysis in situ. This should be of others.
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 Section I

Topic-Wise Solved Questions

of Previous Years

PART II: ORAL RADIOLOGY

Topic 1 Radiation Physics  429
Topic 2 Radiation Biology, Hazards of Radiation
and Radiation Protection  441
Topic 3 X-Ray Films and Accessories  455
Topic 4 Processing of X-Ray Films  463
Topic 5 Image Principles: X-Rays Quality Control  472
Topic 6 Intraoral Radiographic Techniques  483
Topic 7 Extraoral Radiographic Techniques  492
Topic 8 Specialized Imaging Techniques  507
Topic 9 Radiographic Interpretations  516
This page intentionally left blank
 Section I

Topic-Wise Solved Questions

of Previous Years
Part II
Oral Radiology

Topic 1
Radiation Physics
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. With a neatly labelled diagram explain the principle, construction and working of an X-ray tube, with the
significance of each component.
2. Define ideal radiograph and discuss the factors affecting the X-ray beam.
3. Describe the parts of an X-ray tube and add a note on the properties of X-rays.
4. What are the parts of an X-ray tube? Describe the working of an X-ray tube and add a note on Bremsstrahlung
radiation. [Same as LE Q.1]
5. Describe the construction and working of the X-ray tube. Also describe the production of X-rays. [Same as LE Q.1]
6. Describe with a neat and labelled diagram on the production of X-rays. [Same as LE Q.1]
7. Describe in detail the factors controlling X-ray beam. [Same as LE Q.2]
8. Write an essay on the properties of X-rays. [Same as LE Q.3]

SHORT ESSAYS:
1. Production of X-rays. [Ref LE Q.1]
2. Electromagnetic spectrum.
3. What are the properties of X-rays? [Ref LE Q.3]
4. Collimation and filtration. [Ref LE Q.2]
5. Ideal requirements of target material.

429
430 Quick Review Series for BDS 4th Year, Vol 2

6. Role of grid in diagnostic radiography.

7. Bremsstrahlung radiation. [Same as SE Q.1]
8. Name any four properties of X-rays. [Same as SE Q.3]
9. Types and uses of filtration. [Same as SE Q.4]

SHORT NOTES:
1. Basic principles of shadow casting.
2. Heel effect.
3. Position indicating device (PID).
4. Inverse square law. [Ref LE Q.2]
5. Filtration. [Ref LE Q.2]
6. Electromagnetic spectrum. [Ref SE Q.2]
7. Collimation. [Ref LE Q.2]
8. Anode in X-ray machine. [Ref LE Q.3]
9. Resolution.
10. Why is tungsten used as a target material in an X-ray tube?
11. Define frequency.
12. What represents the particulate radiations?
13. Compton effect.
14. What is line focus principle?
15. Gray.
16. Ionization.
17. Kilovoltage peak (kVp). [Ref LE Q.2]
18. Radiology and roentgenology.
19. Explain generation of X-rays.
20. Characteristic radiation.
21. Definition of roentgen.
22. Coolidge tube.
23. X-ray timer.
24. Uses of X-rays.
25. Factors controlling X-ray beam.
26. Filtration of X-ray beam. [Same as SN Q.5]
27. Collimation of X-ray beam. [Same as SN Q.7]
28. Tungsten application in an X-ray machine. [Same as SN Q.10]

SOLVED ANSWERS
LONG ESSAYS:
Q.1. With a neatly labelled diagram explain the princi- ● The component parts of the X-ray tube are
ple, construction and working of an X-ray tube, with the i. Leaded-glass housing
significance of each component. ii. Negatively charged cathode
iii. Positively charged anode
Ans.
Leaded-glass housing
Principle ● The leaded-glass housing is a leaded-glass vac-
The fundamental principle of X-ray production is that uum tube that prevents escape of X-rays in all
X-rays are produced by the sudden deceleration or directions.
stoppage of rapidly moving stream of electrons at a ● One central area of the leaded-glass tube has a
positively charged metal target in a high vacuum tube. ‘window’ that permits the X-ray beam to exit
Construction of X-ray tube the tube and directs it towards the aluminium
● The X-ray tube is like the heart of the X-ray generating discs, lead collimator and PID. It is also used for
system and is critical to the production of X-rays. earthing.
Section | I Topic-Wise Solved Questions of Previous Years 431

Negatively charged cathode ● Step-up transformer: It increases voltage from the

● The cathode, or negative electrode, consists of two incoming 110–220 line voltage to 65,000–100,000 V
components: as required by a high-voltage circuit.
a. Filament: Filament is a coiled wire made of tung- ● Autotransformer: It serves as a voltage compen-
sten, which produces electrons when heated. sator that corrects the minor fluctuations in the
b. Focusing cup: It is a cup-shaped holder made of current.
molybdenum and houses the filament. It focuses Timer
the electrons into a narrow beam and directs the A timer completes the circuit with the high-voltage
beam across the tube towards the tungsten target transformer and helps to control the time for which high
of the anode. voltage is applied to the tube.
● The purpose of the cathode is to supply the electrons Tube rating
necessary to generate X-rays. In the X-ray tube, the The maximum safe intervals (seconds) the tube
electrons produced in the negative cathode are acceler- may be energized at a given range of voltage (kVp)
ated towards the positive anode. and the tube current (mA) values is known as tube
Positively charged anode rating.
● Anodes are of two types: Duty cycle
a. Stationary/fixed Duty cycle is related to the frequency with which suc-
b. Rotating cessive exposures can be made.
The rotating anode helps to dissipate heat and is Working of X-ray tube and production of X-rays
mainly used in extraoral or cephalometric ma- A series of steps involved in the production of X-rays
chines. are as follows:
● The purpose of the anode is to convert electrons into ● When the X-ray machine is turned on, the electric

X-ray photons and it consists of: current enters the control panel from the wall out-
a. Tungsten target let and travels to the tube head through the electri-
i. It is a wafer thin tungsten plate embedded in cal wires in the extension arm.
a copper stem. It serves as a focal spot and ● In the tube head, the current is directed to the fila-

converts bombarding electrons into X-ray ment circuit and the step-down transformer, which
photons. reduces the 110 or 220 entering-line voltage to
ii. The target is inclined at an angle of 20° to the 3–5 volts.
central ray of electron to cause effective focal ● The filament circuit uses the 3–5 volts to heat

spot to be smaller in size (1 3 1 mm) in con- the tungsten filament in the cathode portion of the
trast to actual focal size (1 3 3 mm). This is X-ray tube.
known as ‘Line-Focus Principle’. a. When the tungsten filament in the cathode is
Sharpness of image increases by reducing the heated to incandescence or red hot, thermionic
effective focal spot size. emission occurs.
b. Copper stem: The copper stem dissipates the heat b. Thermionic emission is defined as the re-
away from the tungsten target through conduc- lease of electrons from the tungsten filament
tion. when the electrical current passes through it
Circuits used in the production of X-rays and heats the filament. The outer-shell elec-
● Filament circuit: Low voltage (3–5 V) trons of the tungsten atom acquire enough
a. Controlled by mA setting in control panel. energy to move away from the filament sur-
● Regulates flow of current to filament. face, and an electron cloud forms around the
● High-voltage circuit: Uses 65,000–100,000 V. filament.
a. Controlled by kVp setting in control panel. a. The electrons stay in an electron cloud until
b. Accelerates electrons. the high-voltage circuit is activated.
Transformers ● The high-voltage circuit is activated when the

Transformer is a device used to control voltage in the exposure button is pushed. The electrons pro-
electrical circuit. Various transformers used in the pro- duced at the cathode are accelerated across the
duction of X-rays are as follows: X-ray tube to the anode. The molybdenum cup in
● Step-down transformer: It has more turns in pri- the cathode directs the electrons to the tungsten
mary coil and reduces voltage from the incoming target in the anode.
110–220 line voltage to 3–4 V as required for fila- ● The electrons travel from the cathode towards the

ment circuit. anode. When the electrons strike the tungsten target,
432 Quick Review Series for BDS 4th Year, Vol 2

their kinetic energy is converted to X-ray energy ● It is defined as X-ray radiation produced when high-
and heat. speed electrons are suddenly stopped at the target. This
a. Less than 1% of energy of electrons is con- process of rapidly decelerating the high-speed electron
verted to X-rays at anode and other 99% is lost gives rise to Bremsstrahlung or braking radiation.
as heat. ● Bremsstrahlung radiation is produced by either:

b. The heat build-up at the anode is calculated as: a. The electron directly hitting the nucleus of an
Heat unit (HU) 5 kVp 3 mA 3 s (watts) atom of the target material or
● The heat produced during the production of b. Passage of the electron by the side or near the
X-rays is carried away from the copper stem nucleus due to which the electron will be de-
and absorbed by the insulating oil in the tube flected or decelerated.
head. i. Electron directly hitting the nucleus. When the
● The X-rays produced are emitted from the target electron directly hits the nucleus of the tung-
in all directions. The leaded-glass housing pre- sten atom in target material, the entire kinetic
vents the X-rays from escaping from the X-ray energy of it is transformed into a single X-ray
tube. A small number of X-rays are able to exit photon.
from the X-ray tube through the unleaded glass ii. Numerically the energy of the resultant photon
window portion of the tube. is equal to the energy of the electron, which
● The X-rays travel through the unleaded glass win- is in turn equal to the kVp applied across the
dow, the tubehead seal and the aluminium discs. X-ray tube.
The aluminium discs remove or filter the longer a. When the electron comes closer to the nucleus
wavelength X-rays from the beam. i. If the electron misses the hitting of nucleus and
● The size of the X-ray beam is restricted by passes by the side of it, then the negatively
the lead collimator. The X-ray beam then travels charged high-speed electron is attracted to-
down the lead-lined PID and exits the tube wards the positively charged nucleus and de-
head. celerates thereby losing some kinetic energy,
● The exposure time is the duration of time when which is converted into X-ray photon.
X-rays are produced; it is about 0.8–0.9 s. ii. The electron that misses the nucleus continues
● The X-ray tube does not emit a continuous to penetrate many such tungsten atoms before
stream of radiation, but a series of impulses of it imparts all its kinetic energy thus producing
radiation. The number of impulses depends on many low-energy X-ray photons. As a result
the number of cycles per second in the electric Bremsstrahlung radiation consists of X-rays of
current used. In a 60-s-cycle alternating cur- many different energies and wavelengths and
rent, there are 60 pulses of X-rays per second. hence it is also called continuous spectrum.
Each impulse lasts only l/120 s as no X-rays Characteristic radiation
are emitted in the negative half of the cycle ● When a high-speed electron dislodges the inner shell

when the polarity of the tube is reversed. A electron from the tungsten atom, it results in ioniza-
full-wave rectified X-ray machine produces tion of the atom. Once the electron is dislodged, the
120 bursts of X-ray photons per second. remaining orbiting electrons rearrange to fill the
vacancy; this produces a loss of energy that results in
X-ray photon, with energy equal to the difference
[SE Q.1]
in the two orbital energy states. The X-ray thus
{Production of X-rays is achieved by following two produced is called characteristic radiation.
processes that are described as follows: ● The radiation emitted constitutes the ‘Line Spectrum’.}

1. Bremsstrahlung radiation
2. Characteristic radiation Q.2. Define ideal radiograph and discuss the factors
The Bremsstrahlung radiation accounts for most of the affecting the X-ray beam.
X-rays produced in dental machines, while characteris- Ans.
tic radiation accounts for a very small part of X-rays
produced. According to HM Worth word’s, ‘An ideal radiograph is
Bremsstrahlung radiation one that has desired density and overall blackness and
● Bremsstrahlung is a German word for braking which shows the part completely without distortion with
radiation. It is also called general radiation, white maximum details and has the right amount of contrast to
radiation or Brems radiation or breaking radiation. make the details fully apparent’.
Section | I Topic-Wise Solved Questions of Previous Years 433

Factors controlling the X-ray beam Exposure time

The quality and quantity of the X-rays are controlled by ● Keeping mA and kVp constant, when the exposure

various factors as described below: time is doubled, the number of X-ray photons gener-
1. Tube current ated also doubles.
2. Tube voltage ● The changes in the exposure time influence the quan-

3. Exposure time tity of X-rays produced.

4. Filtration ● The effect of increasing or decreasing exposure time

5. Collimation will control the quantity of X-ray photons.

6. Inverse square law ● To compensate for the increased penetrating power

7. Quality of the X-ray beam of X-ray beam, when kVp is increased, an adjust-
8. Quantity of the X-ray beam ment in exposure time is necessary.
9. Half-value layer (HVL)
[SE Q.4]
Tube current {Filtration
● The number of X-ray photons generated is deter- ● An X-ray beam is composed of a spectrum of X-ray
mined by the tube current (mA). photons with different wavelengths and penetrating
● As the mA is increased, more number of electrons powers. Only those photons with sufficient energy
are generated at the cathode, which strikes the target and definite penetrating power contribute to image
to produce more number of X-ray photons. formation, whereas X-ray photons with less penetrat-
● The number of X-rays produced depends directly on ing power will be absorbed by the soft tissues and
the number of electrons that strikes the target. The cause unnecessary radiation exposure to the patient.}
number of electrons is directly proportional to the
tube current. (SE Q.4 and SN Q.5)
● Practically, the quantity of X-ray photons generated

depends on both the mA and the duration of time the ● {(Filtration is the process of removing X-ray pho-
X-ray machine is operated. tons of less penetrating power by placing a filter in
a. The quantity of radiation produced by an X-ray the path of the primary beam, which allows only X-
tube is directly related to the tube current and the ray photons with sufficient energy to pass through.
time the tube is operated. ● A filter is a device made up of an aluminium disc
b. There is a linear relationship between mA and placed in the path of the primary X-ray beam to ab-
tube output. Doubling the tube current should sorb X-ray photons of less penetrating power.
double the number of photons produced at each ● Filtration is of three types:
energy value. Inherent filtration:
Tube voltage a. Inherent filtration is produced by materials which
the X-ray beam encounters as it leaves from the
target, e.g. the glass wall of the X-ray tube, insu-
{SN Q.17} lating oil present around the tube and the barrier
● Voltage is a measurement of force that refers to the material, which prevents the oil from leaking out.
potential difference between two electric charges. In The inherent filtration usually provides 0.5–2.0
simple terms, voltage is a measurement of electrical mm aluminium equivalent of filtration.
force that causes electrons to move from negative b. Added filtration: Added filtration refers to any
cathode to positive anode. additional aluminium disc placed in the path of
● Tube voltage controls the energy of electrons. As the the primary beam.
kVp is increased, the energy of each electron striking c. Total filtration: Total filtration means the sum
the target increases resulting in increase in the of inherent and added filtration. The total filtra-
number of X-ray photons generated. tion should be equivalent to 1.5 mm of alu-
● As kVp increases, there is an increase in minium up to 70 kVp and 2.5 mm of alumin-
a. The number of photons generated ium above 70 kVp.)}
b. The mean energy of the photons
c. The maximum energy of the photons ● With the use of filters, the contrast and quality of film is
● As the kVp increases, the contrast of the resultant increased, while the density is affected; therefore, when
radiographic image decreases. filtration is increased, a slight increase in exposure time
is required.
434 Quick Review Series for BDS 4th Year, Vol 2

(SN Q.7 and SE Q.4) have less penetrating power and get absorbed by the
patient’s soft tissues.
{(Collimation ● The quality of an X-ray beam is governed by the

● Collimation is the process of restricting the size of kVp. When the kVp increases, it results in X-ray
the X-ray beam and thus the volume of the irradi- photons with high energy and better penetrating
ated tissue of the patient from which the scattered power.
photons originate. Quantity of the X-ray beam
● Quantity of the X-ray beam refers to the number of
● Collimator is a device that is used to shape or re-

strict the size of the X-ray beam striking the pa- X-ray photons produced.
● The amperage determines the electrons passing
tient’s tissues.
● The collimator is made up of a material, which is
through the filament. When mA is increased, more
capable of absorbing the radiation, e.g. lead. number of electrons are released in the cathode
● Various collimators used in dental radiography
and they strike the target to produce more number of
are the diaphragm, tubular and rectangular colli- X-ray photons.
● The quantity depends on the product of mA and ex-
mators. Among them, the rectangular collimators
help in defining the X-ray beam to a size slightly posure time in seconds (mAs).
larger than the size of the film. HVL
● HVL refers to the thickness of a specified material
Uses of collimation
● It decreases the size of the X-ray beam and the
such as aluminium required to reduce the intensity of
amount of scattered photons. an X-ray beam by one-half. Usually 2.0 mm filter is
● It decreases the volume of the irradiated tis-
required in dentistry.
● Quality of X-ray beam can be determined by deter-
sues, thereby decreasing the radiation exposure
to the patient. mining its HVL. HVL is the useful way to designate
● It minimizes the film fog and enhances the im-
the penetrating power of X-ray beam.
age quality.)} ● HVL is the thickness of an absorber, usually alu-

minium, required to reduce the number of X-ray

photons passing through it by one-half.
● Contrast and the quality of film are increased with
{SN Q.4}
the use of filters, while density is affected because
Inverse square law increased filtration may result in absorption of some
● Inverse square law states that the intensity of an of the useful penetrating X-rays.
X-ray beam at a given point is inversely propor- ● When filtration is increased, a slight increase in
tional to the square of the distance from the exposure time is required.
source of radiation.
● The mathematical formula used to calculate
Q.3. Describe the parts of an X-ray tube and add a note
inverse square law is given by on the properties of X-rays.
Ans.
Original intensity (I1 ) New distance 2 (D 2 ) 2

New intensity (I 2 ) Original distance 2 (D1 ) 2 The parts of the X-ray tube are
1. Leaded-glass housing
● The reason for this decrease in intensity of the 2. Negatively charged cathode
X-ray beam is due to the divergent nature of the 3. Positively charged anode
X-rays. If the distance from the source to the ob- Leaded-glass housing
ject is increased, the intensity of the X-ray beam ● The leaded-glass housing is a leaded-glass vacuum

decreases, thereby changing the image quality. tube that prevents escape of X-rays in all directions.
For example, if the distance from the source to the ● One central area of the leaded-glass tube has a ‘win-

film is doubled, say from 8 inches to 16 inches, it dow’ that permits the X-ray beam to exit the tube and
results in a beam that is one-fourth as intense. directs the X-ray beam towards the aluminium discs,
lead collimator and PID.
Quality of the X-ray beam Cathode
● The quality of the X-ray beam refers to its mean en- ● The cathode or negative electrode consists of two
ergy or penetrating ability. components:
● X-rays with shorter wavelengths have more penetrat- a. Filament: The filament is a coiled wire made of
ing power, whereas those with longer wavelengths tungsten, which produces electrons when heated.
Section | I Topic-Wise Solved Questions of Previous Years 435

b. Focusing cup: It is a cup-shaped holder made of ● X-rays affect photographic plate in the similar
molybdenum and houses the filament. It focuses manner as light. They can produce image on
the electrons into a narrow beam and directs the a photographic film.
beam across the tube towards the tungsten target ● X-rays can cause biological changes in living
of the anode. cells. The cells can either be damaged or killed
Anode due to X-ray exposure.
● Electrical and magnetic fields fluctuate perpen-
{SN Q.8} dicular to direction of X-rays and at right angles
to each other.
● Anodes are of two types: ● X-rays have selective attenuation.
a. Stationary/fixed and rotating anode. ● They produce different types of scattered and
b. Rotating anode helps to dissipate heat and is mainly secondary radiations. It is undesirable both for
used in extraoral or cephalometric machines. operator and the patient.
● The purpose of the anode is to convert electrons in to ● They cause the air through which they pass to
X-ray photons and consists of: become electrically conductive.}
a. Tungsten target: It is a wafer-thin tungsten plate ● They are not deviated by the influence of electric
embedded in a copper stem that serves as a focal or magnetic field.
spot and converts bombarding electrons into
X-ray photons. Q.4. What are the parts of an X-ray tube? Describe the
b. Copper stem: The copper stem dissipates the heat working of an X-ray tube and add a note on Brems-
away from the tungsten target through conduction. strahlung radiation.
Ans.

Properties of X-rays are as follows: [Same as LE Q.1]

[SE Q.3] Q.5. Describe the construction and working of the X-ray
tube. Also describe the production of X-rays.
● {X-rays are wave packets of energy of electro-
magnetic radiation that originate at the atomic Ans.
level. Each wave packet is equivalent to a quan-
[Same as LE Q.1]
tum of energy and is called a photon.
● X-rays are invisible and carry no charge and mass. Q.6. Describe with a neat and labelled diagram on the
● X-rays exhibit dualistic behaviour, i.e. wave and production of X-rays.
particle. They are electromagnetic waves.
● X-rays travel in straight line as waves and at the Ans.
same speed as that of light in free space. [Same as LE Q.1]
● No medium is required for its propagation.
● X-rays have penetrating power. Q.7. Describe in detail the factors controlling X-ray
● Wavelength of X-rays is 0.1–0.5 Angstrom. X-rays beam.
of shorter wavelength possess greater energy and Ans.
can therefore penetrate to a greater distance.
● X-rays have high frequency. Their frequency [Same as LE Q.2]
ranges from 2 3 1016 s–1 to 3 3 1019 s–1.
Q.8. Write an essay on the properties of X-rays.
● Intensity of X-ray beam obeys inverse square law.
● X-rays cannot be focused to a point as they di- Ans.
verge from the source.
● X-rays are absorbed by matter. [Same as LE Q.13]
● X-rays cause ionization of matter which they
penetrate. SHORT ESSAYS:
● X-rays cause certain substance to fluoresce or
emit radiation in longer wavelength. Q.1. Production of X-rays.
● X-rays produce phosphorescence, i.e. delayed Ans.
emission of light after exposure to radiation in
various inorganic salts. [Ref LE Q.1]
436 Quick Review Series for BDS 4th Year, Vol 2

Q.2. Electromagnetic spectrum. straight line carrying ‘energy’ or ‘electromagnetic

radiation’.
Ans.
Q.3. What are the properties of X-rays?
{SN Q.6} Ans.
● When the electromagnetic radiations are grouped [Ref LE Q.3]
according to their energies, it is called as electromag- Q.4. Collimation and filtration.
netic spectrum. Electromagnetic radiations are either
man-made or natural. Ans.
● The electromagnetic spectrum actually goes far [Ref LE Q.2]
below infrared and far above ultraviolet radiation.
● These radiations are cosmic rays, gamma rays, Q.5. Ideal requirements of target material.
X-rays, ultraviolet rays, visible light, infrared light, Ans.
radar waves and microwaves.
Properties of electromagnetic radiation Properties or ideal requisites of target metal
● They travel through space in a wave-like motion ● The target material should have higher atomic num-

along a straight line. ber. Higher the atomic number, denser is the metal.
● They do not carry mass, weight or electrical Sufficiently dense metal is required to stop the high-
charge. speed electrons.
● They travel at a speed of light, in a vacuum, i.e. ● It should have low vapour pressure at high tempera-

186,000/s. ture. Since electron beam is directed to a very small

● As they travel through space, they give off an area, some of the atoms may reach the vapour state,
electric field at right angle to the path of propaga- so water droplets may be found.
tion and a magnetic field at right angles to both. ● It should have high melting point. Since most of the

● They transfer energy from place to place in quanta energy is converted into heat, the melting point of the
(photons). target metal must be high, e.g. tungsten has MP of
● All electromagnetic radiations have measurable 3370°C, which is quite higher than others.
but different temperature, energy, frequency and ● It should have a high degree of thermal conductivity,

wave length. since most of the heat generated is passed to the ra-
● All electromagnetic radiations are invisible to the diator or other cooling device, e.g. as the thermal
naked eye, except those falling within the range of conductivity of tungsten is low, the tungsten target is
the visible spectrum. therefore fitted in a copper stem, which is a very
good thermal conductor.
Q.6. Role of grid in diagnostic radiography.
Theories of electromagnetic spectrum
Ans.
● Electromagnetic radiations move through spaces

as both a particle and a wave; hence, a dualistic ● A grid consists of a series of large number of long parallel
theory explains the characteristics of electromagnetic strips of radiopaque material, e.g. lead separated by radio-
radiation. lucent/transparent inter-space material such as plastic.
1. Wave theory – wave ● It was invented by Dr Gustave Bucky in 1913.
2. Quantum theory – particle ● It is the most effective way of removing scattered radia-
Wave theory tion from reaching the film. They are placed between
This theory states that all electromagnetic radia- the object and the film.
tions travel in the form of waves at the speed of ● Grids having 80 or more line pairs per inch do not show
light in vacuum (186,000 miles/s) and exhibit the grid lines in the image.
properties of velocity, wavelength, frequency and ● The scattered radiation usually travels obliquely. Hence,
amplitude. most of these scattered radiations get absorbed by the
Quantum theory lead strips of the grid, while some of the scattered pho-
According to this theory, particle concept character- tons travel in the same plane as the primary beam con-
izes electromagnetic radiations as discrete bundles of tributes to the formation of image.
energy called photons or quanta that travel as waves ● An ideal grid should be capable of removing 80%–90%
at the speed of light and move through space in a of the scattered radiation. The resultant image thus has
Section | I Topic-Wise Solved Questions of Previous Years 437

a better contrast. This improvement in the quality is Q.7. Bremsstrahlung radiation.

referred to as the ‘contrast improvement factor’ (K).
Ans.
X-ray contrast with grid
  [Same as SE Q.1]
X-ray contrass t without grid
Q.8. Name any four properties of X-rays.
An ideal grid should have a high K value, around 1.5–3.5.
Ans.
● Grid ratio is defined as the ratio between the height of the
lead strip and the distance between them. The lead strips [Same as SE Q.3]
are 0.05 mm thick. Inter spaces are much thicker than the
Q.9. Types and uses of filtration.
lead strips. Grid ratio usually ranges from 4.1 to 16.1.
Types of grid Ans.
● Stationary grid
[Same as SE Q.4]
● Moving grid

Stationary grid: Stationary grid is built in the tube side

of cassette. Its disadvantage is that there are grid lines SHORT NOTES:
in which absorption of primary beam occurs. There
are two basic patterns of grid – linear and crossed. Q.1. Basic principles of shadow casting.
Linear grid: In this grid, the lead strips are placed
Ans.
parallel to each other in longitudinal axis. This
grid allows the angle of the X-ray tube along the The basic principles of shadow casting are as follows:
length of the grid without loss of primary radia- ● The focal spot (source of radiation) should be as small
tion from grid cut-off. These grids can only be as possible.
used effectively with very small X-ray fields or ● The focal spot–object distance should be as long as
long target grid distance. possible.
Crossed grid: A crossed grid is made up of two ● The object–film distance should be as small as possible.
linear grids having same focusing distance superim- ● The long axis of the object and the film planes should
posed at right angle to each other. This minimizes be parallel to each other.
the scattered radiation traversing in the same line as ● The beam of X-ray should strike the object and the film
the primary beam. The disadvantage of crossed grid planes at right angles.
is that it cannot be used with oblique technique, ● There should be no movement of the tube, film or pa-
requiring angulation of the X-ray tube. tient during exposure.
Stationary grids are of two types:
Q.2. Heel effect.
a. Parallel grid: In this the secondary radiation is
absorbed by the parallelly placed radiopaque lead Ans.
strips.
The intensity of X-ray beam is not uniform throughout. The
b. Focused grid: Here, the lead strips are angled from
intensity of X-ray beam on anode side of the X-ray tube is
the centre to the edge and are directed towards the
significantly less than that of the cathode side. It is called
direction of the paths of the diverging secondary
heel effect.
radiation, thereby eliminating the absorption of
The reasons for this effect to occur are
more secondary radiation than parallel grid.
● Self-absorption: The X-ray photons that are emitted on
Moving grid: It was invented by Dr Hollis E. Potter
the anode side of the field passes through thickness of
in 1920 and is known as Potter-Bucky grid.
anode than those towards cathode side. As most of the
Grids are moved to blur out the shadow caused
photons are produced inside the surface of the target,
by the lead strips. Mostly they move 3–5 cm
they are absorbed by the target before they reach the
back and forth throughout the exposure. They
surface. It results in reduced intensity on the anode side.
start moving when the anode begins to rotate.
On cathode side there is short path within the target.
Advantage
The use of moving grid reduces/eliminates the grid, Q.3. Position indicating device.
i.e. white lead lines in the radiographic image. This is
Ans.
achieved by moving the grid sideways during exposure.
Disadvantages ● There are mainly three types of PIDs:
They are costly; they put a limit on the minimum expo- a. Rectangular PID
sure time because they move slowly, and increase the b. Cone PID
patient’s radiation dose. c. Round PID
438 Quick Review Series for BDS 4th Year, Vol 2

● Compared to round PID, the use of rectangular PID ● It has low vapour pressure at high temperature.
having an exit orifice of 3.58 3 40.4 cm will reduce the ● It does not have a high degree of thermal conductivity;
area of patient skin surface exposed by 60%. this problem can be overcome by embedding a small
● As PIDs are used, there is no specific head position or piece in a copper stem to form the anode.
vertical angulation for orienting the X-ray tube. ● The mechanical properties of tungsten are favourable
for moulding, machining and other processes involved
Q.4. Inverse square law.
in the manufacture of the target.
Ans.
Q.11. Define frequency.
[Ref LE Q.2]
Ans.
Q.5. Filtration.
● Frequency may be defined as the number of times wave
Ans. repeats itself each second, it is represented by ‘v’.
● Frequency and wavelength are inversely proportional to
[Ref LE Q.2]
each other.
Q.6. Electromagnetic spectrum. ● The unit of frequency is measured in Hertz, 1 Hertz 5
1 cycles/s.
Ans.
Q.12. What represents the particulate radiations?
[Ref SE Q.2]
Ans.
Q.7. Collimation.
● According to one of the theories of electromagnetic
Ans.
radiation, the transfer of energy is not in the form of
[Ref LE Q.2] waves but as a flux of quanta or photons.
● The quantum is small packet or bundle of energy with
Q.8. Anode in X-ray machine.
its size proportional to the frequency of radiation.
Ans. ● Every quantum is associated with a definite amount of
energy. Usually packet of energy is called quanta but in
[Ref LE Q.3]
case of electromagnetic radiation, it is called photons.
Q.9. Resolution. ● The unit of photon energy is electrons volt (eV), and the
photons and X-rays have energies greater than 1000 eV
Ans.
or 1 kiloelectron unit (1 keV).
● It is the measurement of a radiographic visualization to ● Energy of a quantum is directly proportional to the fre-
differentiate between different structures that are close quency of radiation and inversely proportional to the
together. wavelength. So, photons of shorter wavelength have
● According to photographic physics, resolution is measured higher energy. Photons used in dental radiography have
in terms of test pattern consisting of a series of black lines wavelength of 0.1–0.5 A.
on a white background, where width of lines is equal to the
Q.13. Compton effect.
width of spaces between them. Resolution is then expressed
in terms of the maximum number of lines per millimetre, Ans.
which the photographic material is capable of recording.
● Compton effect is also called inelastic scattering, modi-
● It is determined mainly by the type of film, speed and
fied scattering or incoherent scattering. It occurs when
silver halide crystal size, penumbra effect and contrast.
a photon interacts with a free or loosely bound outer
● Type of film: As compared to direct exposure, film
electron.
resolving power of intensifying screen is less.
● In dental X-ray beam, approximately 62% of the pho-
● Speed of film: It also affects the resolution of the
tons undergo Compton interaction.
film. High speed has less resolving power compared to
● It is accomplished by:
low-speed films.
a. Collision of incident photons
Q.10. Why is tungsten used as a target material in an b. Recoil electron
X-ray tube? c. Scattering
Influencing factors
Ans.
● Electron density: The probability of Compton inter-

Tungsten is used as target material due to the following action is directly proportional to the electron density.
reasons: The number of electron in bone is greater than in
● It has a high atomic number, i.e. 74. water, thus the probability of Compton interaction is
● It has high melting point, i.e. 3370°C. greater in bone than in tissues.
Section | I Topic-Wise Solved Questions of Previous Years 439

● Photon energy: The photon energy and Compton used in ionization chamber, proportional counters,
effect are inversely proportional to each other. When Geiger–Muller counters and semiconductor detectors.
compared to low-energy radiations, high-energy
Q.17. kVp.
radiations are less scattered.
● Unlike elastic scattering, Compton process results in Ans.
both scattering and absorption.
[Ref LE Q.2]
Q.14. What is line focus principle?
Q.18. Radiology and roentgenology.
Ans.
Ans.
● Line focus principle is also called as Benson line focus
The science or study of radiation as used in medicine; a
principle.
branch of medical science that deals with use of X-rays’
● The X-ray beam travels at approximately right angles to
radioactive substances and other forms of radiant energy in
the long axis of the X-ray tube. The sharpness of the
the diagnosis and treatment of disease is called Radiology
radiographic images increase as the size of the radiation
or roentgenology.
source, i.e. the focal spot size decreases.
The production of radiographs of teeth and adjacent
● Briefly, the line focus principle is the use of an anode
structures by the exposure of film to X-rays is known as
with the target material angulated such that effective
dental radiography.
focal spot is smaller than actual focal spot.
● The use of line focus principle allows the X-rays to be Q.19. Explain generation of X-rays.
generated over a large area on the target, thus less heat
Ans.
per unit area is produced. Therefore, greater number of
electrons can be used and great number of X-ray ● When the X-ray machine is turned on, the electric cur-
photons results. rent from wall outlet enters the control panel, and in the
● Effective focal spot size should be decreased to increase X-ray tube head, the current is then directed to the fila-
the sharpness of image. ment circuit.
● When the tungsten filament in the cathode is heated to
Q.15. Gray.
incandescence or red hot, thermionic emission occurs.
Ans. ● The electrons stay in an electron cloud until the high-
voltage circuit is activated, then electrons produced at
● If an ionizing radiation imparts 1 joules (J) of energy
the cathode are accelerated across the X-ray tube to the
per kg mass to a body, then absorbed dose is said to be
anode. The molybdenum cup in the cathode directs the
1 Gray.
electrons to the tungsten target in the anode.
● 1 Gy 5 100 rad.
● The electrons travel from the cathode towards the an-
● The term ‘Gray’ was coined after Dr L.H. Gray who
ode. When the electrons strike the tungsten target, their
made fundamental contribution to radiation dosimetry.
kinetic energy is converted to X-ray energy and heat.
● SI unit: Gray (Gy) measured in J/kg.
● Less than 1% of energy of electrons is converted to
● Subunit: Milligray (mGy).
X-rays at anode and other 99% is lost as heat.
Q.16. Ionization.
Q.20. Characteristic radiation.
Ans.
Ans.
● The ionization is a process of converting atom into
● When a high-speed electron dislodges inner shell electron
the ion.
from the tungsten atom, it results in ionization of the atom.
● An atom that is not electrically balanced is called ion.
Once electron is dislodged, the remaining orbiting elec-
When an atom loses the electron, it is called positive ion
trons rearrange to fill the vacancy. This produces a loss of
and when an atom gains the electron, it is called nega-
energy that results in X-ray photon, with energy equal to
tive ion.
the difference in the two orbital energy states. The X-ray
● Electrons can be removed from an atom by various
thus produced is called characteristic radiation.
means like heating or interaction with high-energy
● The radiation emitted constitutes the ‘line spectrum’.
X-rays or particles such as protons.
● In ionizing type of radiation, there are various products Q.21. Definition of roentgen.
like a-rays, b-rays, g rays or neutrons or X-rays.
Ans.
● In any ionization process, ion pairs are formed and this
is the process, which elicits chemical changes in matter. ● Roentgen is the traditional unit of exposure for X-rays. It
● These ion pairs can be collected by applying an electri- is defined as the quantity of X-radiation or gamma radia-
cal field, to give rise to current or pulses. This system is tion that produces an electrical charge of 2.58 3 1024
440 Quick Review Series for BDS 4th Year, Vol 2

Coulombs in a kilogram of air at standard temperature Uses of X-rays are as follows:

and pressure (STP). ● Diagnostic use in dentistry and medicine.
● It measures only the amount of energy that reaches the ● Radiotherapy–the treatment may be curative or palliative.
surface of an organism, but it does not describe the ● In industries to check uniformity of insulating materials,
amount of radiation absorbed. quality of oil paintings etc.
● For examination of gross engineering works.
Q.22. Coolidge tube.
● Spectroscopy.
Ans. ● Crystallography.
● Sterilization.
● Coolidge tube was invented by William Coolidge in
1913. Q.25. Factors controlling X-ray beam.
● It is the basis of all dental X-ray machines.
● The basic shape of original Coolidge tube consisted of Ans.
a spherical bulb with two cylindrical arms extending on
The factors controlling the quality and quantity of X-ray
opposite sides.
beam are as follows:
● Advantages of Coolidge tube are as follows:
i. Tube current: The quantity of radiation produced by
a. Quantity and hardness of X-ray beam could be inde-
an X-ray tube is directly related to the tube current and
pendently controlled.
the time the tube is operated.
b. Even voltage and tube current could be controlled
ii. Tube voltage: As kVp increases, there is an increase in
separately.
the number, mean energy and maximum energy of
c. Output of Coolidge tube was easily duplicated from
photons.
one time to another.
iii. Exposure time: Keeping mA and kVp constant, when
d. In Coolidge tube with only adjustment of voltage
the exposure time is doubled, the number of X-ray
and current, the X-ray beam could be hardened or
photons generated also doubles.
softened.
iv. Filtration: With the use of filters, the contrast and
Q.23. X-ray timer. the quality of film are increased while density is
affected.
Ans.
v. Collimation:
● An X-ray timer completes the circuit with the high- l It decreases the volume of the irradiated tissues and

voltage transformer and helps to control the time for radiation exposure to the patient.
which high voltage is applied to the tube. l It minimizes the film fog and enhances the image

● Exposure timers control the length of X-ray exposure. It quality.

is included in primary circuit of high-voltage supply. vi. Inverse square law
● Most of the timer machines automatically reset them- l Inverse square law states that the intensity of an

selves. X-ray beam at a given point is inversely propor-

● There are four types of exposure timers: tional to the square of the distance from the source
a. Mechanical timers of radiation.
b. Electronic timers vii. Quality of the X-ray beam
c. Photo timers l When the kVp increases, it results in X-ray photons

d. Pulse counting timers with high energy and better penetrating power.
viii. Quantity of the X-ray beam
Q.24. Uses of X-rays.
l The quantity of X-rays depends on the product of

Ans. mA and exposure time in seconds (mAs).

Section | I Topic-Wise Solved Questions of Previous Years 441

X-ray
tube

Stepup Leaded Stepdown

transformer glass transformer
housing Metal housing
Focal of X-ray
spot Vacuum
Tungsten Copper tubehead
filament stem

Cathode 
Anode Insulating oil

Focusing
cup
Tungsten
Electron target
stream Tube
window

Aluminium Lead collimator

discs PID (position
indicating device)
Tubehead seal
X-ray tube.

Q.26. Filtration of X-ray beam. Q.28. Tungsten application in an X-ray machine.

Ans. Ans.
[Same as SN Q.5] [Same as SN Q.10]
Q.27. Collimation of X-ray beam.
Ans.
[Same as SN Q.7]

Topic 2
Radiation Biology, Hazards of Radiation
and Radiation Protection
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. What are the effects of radiation in the oral cavity? Write in detail about osteoradionecrosis.
2. Describe radiation protection measures.
3. Discuss types of biologic effect of X-rays.
4. Write in detail about harmful effects of radiation on whole body.
5. Write an essay on the effects of ionizing radiation on the living cells and tissues.
6. What are the biologic effects of radiation in the oral cavity? [Same as LE Q.1]
7. Enumerate hazards of radiation or effects of radiation on oral tissues. [Same as LE Q.1]
8. Discuss radiation protection. [Same as LE Q.2]
9. Discuss the methods of radiation safety and protection of the operator, patient and public. [Same as LE Q.2]
10. Discuss the different methods of radiation protection of the patient and personnel (operator) in oral radiography.
[Same as LE Q.2]
442 Quick Review Series for BDS 4th Year, Vol 2

11. Mention radiation hazards affecting whole body. How would you protect patients from these while taking
intraoral radiographs? [Same as LE Q.4]
12. What are the hazards of radiation seen on skin and bone? Discuss briefly protection of patient from radiation.
[Same as LE Q.4]

SHORT ESSAYS:
1. Radiation dosimetry.
2. Osteoradionecrosis.
3. Biological effects of radiation in oral cavity.
4. X-ray monitoring devices.
5. Radiation protection from X-rays.
6. Write briefly about postirradiation mucositis.
7. Types of the radiation caries.
8. Write briefly on radiation hazards in dentistry. [Ref LE Q.1]
9. Dosimetry. [Same as SE Q.1]
10. Write in brief about osteoradionecrosis. [Same as SE Q.2]
11. Clinical features and management of osteoradionecrosis. [Same as SE Q.2]
12. Thermoluminescent dosimeter (TLD). [Same as SE Q.4]
13. TLD. [Same as SE Q.4]
14. Radiation protection for the operator. [Same as SE Q.5]
15. Radiation protection of patient. [Same as SE Q.5]
16. Enumerate the various means to reduce the exposure to the patient while taking radiograph for diagnosis.
[Same as SE Q.5]
17. Treatment of postirradiation mucositis. [Same as SE Q.6]
18. Write briefly on radiation caries. [Same as SE Q.7]
19. Describe radiation hazards in oral cavity. [Same as SE Q.8]

SHORT NOTES:
1. Radiation mucositis.
2. TLD.
3. Effects of radiation on developing tooth.
4. Dosimetry.
5. Enumerate four means to reduce the exposure to the patient while taking diagnostic radiographs.
6. Definition of erythema dose.
7. Film badge. [Ref SE Q.4]
8. Types of the radiation caries. [Ref SE Q.7]
9. Treatment of postirradiation mucositis. [Ref SE Q.6]
10. Write briefly on radiation hazards in dentistry/ oral cavity. [Ref LE Q.1]
11. Osteoradionecrosis.
12. Radiolysis of water.
13. Radiosensitive and radioprotective.
14. Definition of ‘roentgen’ and ‘erythema dose’.
15. ALARA principle.
16. Limitations of radiography.
17. Postirradiation mucositis. [Same as SN Q.1]
18. Measures to protect the patient from radiation hazards. [Same as SN Q.5]
19. Write briefly on radiation caries. [Same as SN Q.8]
20. Radiation hazards of jaws. [Same as SN Q.10]
21. Radiation hazards of teeth, oral mucosa and the jaws. [Same as SN Q.10]
22. Effects of radiation in the oral cavity. [Same as SN Q.10]
23. Clinical features and management of osteoradionecrosis. [Same as SN Q.11]
24. Radioresistant cells. [Same as SN Q.13]
25. ALARA. [Same as SN Q.15]
Section | I Topic-Wise Solved Questions of Previous Years 443

SOLVED ANSWERS
LONG ESSAYS:
Q.1. What are the effects of radiation in the oral cavity? ● Radiation caries: The decrease in the salivary flow,
Write in detail about osteoradionecrosis. its pH and buffering capacity coupled with increased
viscosity are the complications of radiation exposure
Ans.
which lead to rampant type of carious lesions.
[SE Q.8] Bone
The effects of radiation are more marked on man-
{The biological effects of radiation on oral cavity are
●

dible; the initial changes are seen in the vasculature.

mainly the result of radiotherapy for malignant lesions. The ● Marked decrease in vascularity of bone because
effects of radiation on various structures of oral cavity are of irradiation decreases the capacity of bone to
as follows:} resist infection.
(SE Q.8 and SN Q.10) ● The bone marrow becomes hypoxic and hypocellular.
● These atrophic changes within the bone lead to
i. {(Oral mucous membrane osteoradionecrosis.)}
● ‘Radiation mucositis’ is seen by the end of second
week of radiotherapy, as the oral mucous membrane [SE Q.8]
contains radiosensitive vegetative and differentiating {Osteoradionecrosis
intermitotic coils in the basal layer. The term osteoradionecrosis implies an infection in
● Radiation mucositis is exhibited as marked redness bone rendered necrotic by ionizing radiation.
and inflammation. An inflammatory condition of bone (osteomyelitis) that oc-
● One of the most common complications of radiation curs often after the bone has been exposed to therapeutic
mucositis is candidiasis, a secondary infection caused doses of radiation usually given for the treatment of malig-
by Candida albicans. nancy of head and neck region is called osteoradionecrosis.}
Taste buds Precipitating factors
● By the end of second or third week of radiotherapy, Factors leading to osteoradionecrosis are as follows:
the changes occurring in the taste buds are exten- i. Irradiation of inadequately healed surgical site.
sive degeneration of normal histologic pattern and ii. Surgery in the irradiated areas in close proximity
loss of taste sensation. to bone.
● When the posterior two-third of tongue is irradi- iii. A high dose of irradiation with or without proper
ated, it affects the bitter and acidic flavours. fractioning.
● Anterior one-third of tongue when irradiated iv. Use of a combination of external radiation and
affects the sweet and salty flavours. intraoral implants with poor oral hygiene.
Salivary glands v. Indiscriminate use of prosthetic appliances
● Salivary glands are exposed to radiation during following radiation therapy.
radiotherapy of head and neck region. vi. Failure to prevent trauma to irradiated bony areas.
● The parenchymal cells are more radiosensitive. vii. Presence of numerous physical and nutritional
There can be inflammatory response involving factors prior to surgery.
serous acini, increase in serum amylase and pro- Pathogenesis
gressive fibrosis, adiposis, loss of fine vasculature The main factors involved in pathogenesis of osteora-
and parenchymal degeneration. dionecrosis are radiation, trauma and infection.
● Salivary flow becomes more viscous when flow is Osteoradionecrosis results from either of the following
decreased. The pH of saliva also decreases. or in combination:
Teeth ● Radiation in massive doses
● When teeth are irradiated during their develop- ● Partial necrosis of bone
ment, their growth is retarded. ● Trauma which causes infection
● If the radiation precedes calcification, the tooth The primary risk factor in the development of post ra-
may be destroyed. After calcification is com- diation osteoradionecrosis is radiation therapy in which
pleted, if irradiation continues, malformation can dose, fraction and number of fractions results in bio-
result and the root development is retarded. logical effect.
● Fully developed teeth are usually very resistant to There is increase in risk when greater volumes of bone
the X-radiations. are included in the field of irradiation.
444 Quick Review Series for BDS 4th Year, Vol 2

Radiation induced damage to the vasculature be kept in mind when exposing dental films. This can be
g achieved by:
i. X-ray machines: Only use good machines by
Invasive doses destroy osteoblasts and to lesser extent
reputed manufacturing companies.
osteoclasts
ii. Only radiograph should be taken when required
g and avoid repeating the radiographic examination.
Subsequent irradiation to the tissues leads to partial iii. Film selection: Good quality, highly sensitive
necrosis of bone films like F and E-speed films should be used.
g In dental practice today only the type ‘E’ or the
Ektaspeed is recommended, since it reduces the
Hypovascular, hypotoxic and hypocellularity of the bone
exposure by at least 40% as compared to type D.
marrow
iv. Filtration: Filtration removes the low energy
g X-rays from the beam. These ‘soft’ X-rays are
Reduced mineralization of the bone absorbed by the patient and do not contribute to
g the image; removing them before they reach the
Brittleness or little alteration of the bone patient reduces the radiation exposure.
Units operating at 70 kVp or above should have
g filtration equivalent to 2.5 mm of aluminium
Bone death and those operating below 70 kVp should have
g the equivalent of 1.5 mm of aluminium.
Osteoradionecrosis v. X-ray collimation: Collimation should be used
to prevent scattering. The beam should be colli-
Clinical features mated so that it is no more than 7 cm in diameter
i. The posterior region of mandible is more commonly at the patient’s face. Rectangular collimators
affected than the maxilla due to the microanatomy and further reduce the amount of tissue irradiation.
reduced vasculature of the mandible. vi. Intensifying screens: Use of rare earth screens
ii. Intermittent swelling and drainage extraorally. reduces dosage for extraoral films like, lateral
iii. Intense pain may occur; pain is of severe, boring-type, cephalogram, Orthopantomogram (OPG) and
which may continue for weeks or months. lateral oblique, etc.
iv. Swelling of face results from secondary infection. vii. Grids: The use of grids reduces the fogginess of
v. Trismus, fetid odour and pyrexia can be noted. the film due to secondary radiation, thereby re-
vi. Soft-tissue abscesses. ducing the need for repeat films. Good consis-
vii. Persistently draining sinuses. tent processing technique also helps in prevent-
viii. Exposure of bone is the hallmark of osteoradionecrosis. ing unnecessary repetitions.
ix. The exposed bone becomes necrotic as a result of loss viii. Kilovoltage: X-ray units should be operated
of vascularity from periosteum and subsequently it using at least 60–90 kVp. Using an X-ray beam
sequestrates. with low kilovoltage results in higher patient
x. Pathological fractures of bone are common. doses, primarily to the skin.
xi. Osteoradionecrosis is treated by hyperbaric oxygen ix. Position-indicating devices (PIDs):
therapy. ● The cone-shaped devices should be replaced by

Q.2. Describe radiation protection measures. long, open-ended, lead-lined cylinders. Open-
ended, circular or rectangular lead-lined cylin-
Ans.
ders are preferred for directing the X-ray beam.
Various measures of radiation protection for patient, ● A long (12–16 inches) PID will reduce exposure
operator and associated personnel are as follows: to the patient better than a short (8 inch) PID,
Protective measures are employed for the operator of because there will be less divergence of the beam.
the X-ray equipment, patients and any associated personnel x. Lead aprons having lead content equivalent to
including individuals in adjacent office and occupants of 0.25 mm aluminium should be worn by the patient
doctor’s reception. while taking radiograph.
Protection of the patient xi. Use of thyroid collars will protect the thyroid
Mandatory steps during routine diagnostic radiographic gland from radiations.
examination are as follows: xii. Film-holding devices:
Despite the low risk to the patient from dental radiogra- ● Patient should not be asked to hold the film
phy, it is always best to keep exposure to ionizing radia- in the mouth to prevent additional exposure
tion to a minimum. Hence, the ALARA concept should of tissues.
Section | I Topic-Wise Solved Questions of Previous Years 445

● Film-holding devices usually result in a more Q.3. Discuss types of biologic effect of X-rays.
stable positioning of the film. In addition, the
Ans.
patient’s hands are not exposed to radiation.
xiii. Proper processing: Biological effects of radiation can be considered under
Well-designed darkroom will optimize the pro- the following headings:
cessing. Classification 1
xiv. Radiovisiography (RVG): A. Somatic: The effect of radiation, which occurs in ex-
● In the recent period, the use of RVG has posed individuals during their lifetime, is called somatic
further reduced the dose of the radiation re- effect.
quired in the Intra oral periapical radiograph Except reproductive cells, all the cells in the body are
(IOPA) with the Charged-coupled-device known as somatic cells.
sensors (CCD) sensors. a. Stochastic effect: It includes increase in probabil-
● Here the image appears directly on the com- ity of occurrence of biological effect with increas-
puter screen and can be saved as a picture ing absorbed dose rather than its severity. They
file on the hard disc. Printout on a regular occur as direct effect of dose.
paper is possible. b. Nonstochastic effects or deterministic effect: It is
Protection of the operator one in which severity increases with increase in
i. The operator should not: absorbed dose in affected individual.
● Hold the film in the patient’s mouth during exposure B. Genetic: The effect, which is manifested in the future
● Stabilize the X-ray machine during exposure generations of the exposed individuals, is known as ge-
● Stand near or directly in the path of the primary netic effect.
radiation The reproductive cells are termed genetic cells.
ii. The operator should: Classification 2
● Stand behind a lead barrier having 0.5 mm lead Acute or immediate effect: The effect appearing shortly
equivalent during exposure. after the exposure as a result of large dose.
● Stand 6 feet away from the primary X-ray beam Chronic or long-term effect: The changes become evi-
in an area called the zone of maximum safety, dent after long period of time.
which ranges from 90° to 135° with respect to Somatic effects
the primary X-ray beam. a. Somatic stochastic Effects
● Have radiation exposure periodically monitored by ● These are the effects in which probability of the

using personnel monitoring devices or film badges. occurrence of a change increases, rather than its
● Work on rotation of duties, so that continuous severity.
accidental exposure is avoided. ● These are effects that are likely to occur and are

iii. There are exposure limits for occupationally exposed dose dependent. There is as such no threshold
radiation workers. The maximum permissible dose dose for stochastic effect.
(MPD) is the dose of radiation to the whole body that ● When the body is exposed to any amount of radiation,
produces very little chance of somatic or genetic in- damaging effect may be induced. Lower the radiation
jury. The MPD for whole body exposure per year for dose, there is less possibility of cell damage.
occupationally exposed personnel is 0.05 Sv (5 rem). For example, radiation-induced cancer is a stochastic
Protection of other persons effect because greater exposure of a person or popu-
i. Only people whose presence is required should stay lation to radiation increases the probability of cancer
in the room. but not its severity.
ii. Plan and design maxillofacial radiology department. b. Somatic deterministic effects or nonstochastic effects
Conch shell design of the operatory area is recom- ● Effects that have increased probabilities of occur-

mended to protect people in surrounding areas from rence with increase in dose and have dose thresh-
radiation. old below which the response cannot be seen are
iii. An X-ray tube should be away from doorways to known as nonstochastic effects.
avoid accidental exposure. ● They result from specifically high doses of radia-

iv. Radiation exposure to the room and to adjacent tion, e.g. during radiotherapy.
office premises should be monitored. ● Ulceration and desquamation of skin resulting in

v. The walls of the room should be reinforced with reddening of skin, damage to connective tissue,
barium plaster or the thickness of the walls should blood vessels and glands, damage to alveolar
be increased by using an additional layer of bricks. bone and formation of cataract are all the exam-
vi. Caution or warning signs should be displayed. ples of this effect.
446 Quick Review Series for BDS 4th Year, Vol 2

Genetic effects Dryness, erythema, thickening, desquamation

Genetic effects are not seen in the person irradiated but and cracking of hands may also occur.
are transferred to future generation. ii. Finger nails: Fingernails may become brittle,
Generic cells are germ cells of the reproductive organs. develop longitudinal fissures and ridges, and
Reproductive cells are prone to damage with compara- finally crumbled.
tively much smaller dose than amount needed to produce iii. Hair: Radiation causes epilation. It is often seen
radiation effect in somatic cells of the body. in association with dermatitis. Hair loss can be
Radiations cause fragmentation of chromosomes and permanent.
mutation of genes of sex cells and these mutant genes iv. Blood-forming tissue: The bone marrow and
with altered characteristics pass on to next generation. lymph nodes are susceptible to excessive expo-
Mutations are the changes in the information carried by sure, and it can manifest itself as change in blood
the chromosomes within the germ cells, i.e. sperm and count. The usual blood picture is leukopaenia.
egg cells. It is indicative of change in the DNA of the cells. v. Eyes: Radiation dose can cause cataract and
It may result in congenital abnormality in the offspring of the larger doses can cause detached retina.
person irradiated. There may be retardation of growth rate. Chronic or long-term effects
Doubling dose: This is the dose that causes complete Chronic effects are mainly due to low level of irradia-
doubling of all gene mutations. tion for longer period, or chronic irradiation.
Damage can be caused to either dominant or recessive Effect that appears after years, decades or generation is
genes. The dominant variety effect is seen in next gen- known as long-term effect.
eration, whereas recessive variety effect may be seen It depends on the extent of damage to the fine vasculature.
after several generations. Pathogenesis of long-term effect
Genetic damage follows nonthreshold type of response, Irradiation of capillaries causes swelling, degeneration
i.e. small amount of radiation has the potential to and necrosis.
produce lesser number of mutations in chromosomes. It increases the capillary permeability and initiates a
Genetic damage is cumulative and it cannot be repaired. slow progressive fibrosis around the vessels.
Human embryo is said to be most sensitive especially Due to this, deposition of fibrous scar tissue increases
during 15–42 days of its life, so radiation is avoided around the vessels, leading to premature narrowing and
during pregnancy. eventual obliteration of vascular lumen.
Sterility in human beings has been reported on exposure This impairs the transportation of oxygen, nutrients and
to heavy doses. waste products, and results in death of all cells.
No genetic effect is seen in individuals beyond the age This leads to loss of function and reduced resistance to
of reproduction. infection and trauma.
Acute or short-term effects Pathologic effects
Acute somatic effects will be manifested within few The long-term effects are associated with small amount
hours to few days of acute irradiation and the severity of of radiation absorbed over long period of time. The
the effect will depend on dose and dose rate. abnormalities induced by repeated low levels of radia-
Following the latent period, effects are seen within min- tion exposure are as follows:
utes, days or weeks. Carcinoma: The cancer of skin is the earliest form of
Acute radiation effect is a short-term effect. It occurs radiation-induced malignant tumour.
when large dose of radiation given in short period of time Leukaemia: It is one of the late effects and can be due to
as in atomic bomb explosion and in nuclear accidents. primary and secondary radiation. A higher incidence of
Short-term effect is not applicable to the dentistry as leukaemia is observed in radiologists as compared to others.
dental diagnostic radiographs use less than 5 rads. Necrosis: Due to heavy radiations, destruction of tissue
Factors modifying the acute effect are as follows: can occur. Necrosis can be seen in extraction socket
Sensitivity: It is determined by the sensitivity of paren- after radiation exposure.
chymal cells. If continuously proliferating tissues are Retardation of growth: Irradiation of developing teeth
irradiated with a moderate dose, cells are lost primarily results in disorganization of the odontoblasts. With
by mitosis-linked death. larger doses, retardation of bone and tooth development
Proliferative rate: The extent of cell loss depends on the is more obvious.
damage to the stem cell pools, and the proliferative rate Effect on the taste buds: Taste buds are very sensitive to
of cell population. radiation and soon degenerative changes begin. Loss of
Immediate effects of radiation are as follows: taste is very common.
i. Skin: Excessive exposure causes dermatitis. Effect on the salivary glands: The parenchymal compo-
Repeated exposures have a cumulative effect. nent of salivary gland is more radiosensitive. Exposure
Section | I Topic-Wise Solved Questions of Previous Years 447

to radiation leads to injury of these parenchymal cells Signs and symptoms include ulceration following
leading to following conditions: haemorrhage of the intestine. All these changes lead
● Loss of salivary secretion to diarrhoea, dehydration and loss of weight.
● Xerostomia Bone marrow depression
● Difficulty in swallowing Endogenous intestinal bacteria readily invade the
● Decrease in pH of saliva denuded surface producing septicaemia. By this
● Reduced buffering capacity of saliva time, the developing damage to the gastrointestinal
● Increase in bacterial count and radiation caries system reaches a maximum, the effect of bone
marrow depression begins to manifest.
Q.4. Write in detail about harmful effects of radiation Lowering of body defence
on whole body. By the end of 24 hours, the number of circulating
Ans. lymphocytes falls to a very low level. This is followed
by the decrease in the number of granulocytes and
When the whole body is exposed to low or moderate platelets. This hampers body defence mechanism
dose of radiation, characteristic changes called acute against bacterial infection and decreases the effective-
radiation syndrome develop. ness of the clotting mechanism.
Acute radiation syndrome Death
Prodromal period The combined effect on these stem cells causes death
After exposure of 1.5 Gy within the first few minute within 2 weeks due to fluid and electrolyte loss,
to few hours, symptoms characteristic of gastrointes- infection and possible nutritional impairment.
tinal tract (GIT) disturbance occur, such as anorexia, Cardiovascular and central nervous system syndrome
nausea, vomiting, diarrhoea, weakness and fatigue. Exposure in excess of 50 Gy can cause death in
They are dose-dependent; higher the dose, the more 1–2 days. Human beings show collapse of the circu-
rapid onset and greater is the severity of symptoms. latory system with precipitous fall in blood pressure
Latent period in the hours preceding death.
After the prodromal period, latent period occurs, Victims may show intermittent stupor, incoordina-
during which no signs and symptoms are present. tion, disorientation and convulsion suggestive of
This latent period is also dose-related. It varies from extensive damage to the nervous system.
hours or days at supralethal exposure (.5 Gy) to few This syndrome is irreversible and clinical course
weeks at sublethal exposures (,2 Gy). may run from only few minutes to about 48 h before
Haematopoietic syndrome death commences.
Whole body exposure of 2–7 Gy causes injury to Management of acute radiation syndrome
the haematopoietic stem cells of the bone marrow Antibiotics: Antibiotics should be started when infec-
and spleen. It causes rapid and profound fall in the tion threatens life or the granulocyte count falls.
number of circulating granulocytes, platelets and Fluid supplements: It is necessary to replace fluid
erythrocytes. and electrolytes.
Common signs: Infection, haemorrhage and anae- Blood transfusion: Whole blood transfusion is given
mia. Death can result from this syndrome usually to treat anaemia.
10–30 days after irradiation. Platelet: Administration of platelet to arrest thrombo-
As periodontitis may be the likely source of entry of cytopaenia.
microorganism in the bloodstream, the role of dentist Bone marrow grafts: Bone marrow grafts are indi-
is very important. The removal of source of infection cated for identical twins because there is no risk of
by administration of antibiotics should be attempted graft-versus-host response.
at the earliest. Protection of the patient
Gastrointestinal syndrome Mandatory steps during routine diagnostic radio-
Exposure of whole body in the range of 7–15 Gy graphic examination are as follows:
causes extensive damage to the gastrointestinal i. Use of good machines by reputed manufactur-
system. ing companies.
It causes considerable injury to the rapidly proliferat- ii. Radiograph should be taken only when re-
ing basal epithelial cells of the intestinal villi and quired and avoid repeating the radiographic
leads to loss of the epithelial layer of the intestinal examination.
mucosa. Due to this denuded mucosal surface, plasma iii. Good quality, highly sensitive films should be
and electrolytes are lost, and efficient intestinal ab- used.
sorption is impaired. iv. Collimation should be used to prevent scattering.
448 Quick Review Series for BDS 4th Year, Vol 2

Q.5. Write an essay on the effects of ionizing radiation are required for the induction of deterministic
on the living cells and tissues. effects than when a rapidly dividing cell system
is involved.
Ans. b. Bystander effect
● Damaged cells release into immediate environ-
Radiation can induce structural and functional changes
in cellular organelles that culminate in cell death. ment certain molecules that kill nearby cells.
● This effect is demonstrated in both alpha particles
Radiation-induced changes in macromolecules results
in effects of radiation on intracellular structures. and X-rays. It causes chromosomal aberration,
Following are the effects of ionizing radiation on intra- cell killing, gene mutation and carcinogenesis.
cellular structures: c. Apoptosis or programmed cell death
● This occurs during normal embryogenesis.
i. Nucleus
● It is more radiosensitive than cytoplasma especially
Apoptosis is particularly common in haemato-
in dividing cells. poietic and lymphoid tissues.
● Cells round up, draw away from their neigh-
● The sensitive sight in the nucleus is DNA.

ii. Chromosome aberration: bours and condense nuclear chromatin.

● Chromosomes serve as a useful marker for radiation
This characteristic pattern can be induced by radia-
injury. tion in both normal tissues and tumours.
● Extent of chromosomal damage is related to cell
Recovery involves enzymatic repair of single-
survival. stranded breaks of DNA.
● Chromosomal aberrations are noted in irradiated
Radiosensitivity and cell type
cells at the time of mitosis when DNA condenses to Different cells of organs of the same individual may
form chromosome. respond to radiation differently. Radiosensitive cells
● The type of cell damage depends on stage of cell in
have the following characteristics:
cell cycle at the time of irradiation. i. High mitotic rate
● Radiation can cause breakage in the chromosomes. If
ii. Undergo many future mitosis
one arm of DNA is broken, it is called as chromatid iii. Are most primitive in differentiation
aberration. If both arms are broken, it is called as Mammalian cells may be divided into three broad cate-
chromosome aberration. gories of radiosensitivity as follows:
The frequency of aberration is generally proportional to a. High radiosensitivity, e.g. spermatogenic and eryth-
radiation dose received. roblastic stem cells, basal cells of oral mucosa.
Simple breaks can be repaired by biological process, b. Intermediate radiosensitivity, e.g. vascular endo-
but incorrect pair forming rings and dicentrics is le- thelial cells, fibroblasts, parenchymal cells of
thal as they cannot complete mitosis. liver, kidney and thyroid
Sometimes breakage occurs and union takes place at c. Low radiosensitivity, e.g. neurons and striated
different levels other than normal resulting in muta- muscles.
tions. Following are the deterministic effects of radiation on
Following are the effects on cell replication: the tissues:
l Short-term affects
Radiation is especially damaging to rapidly dividing
l Long-term effects
cell systems, e.g. skin and intestinal mucosa and
haematopoietic tissue are affected leading to de- Radiosensitivity of tissues or organ is measured by
crease in size of cell or cell death. its response to irradiations. If large number of cells
Reproductive death in a cell population is loss of the are affected, organisms display an observable result.
capacity for mitotic division. The severity of this change thus depends on dose
The three mechanisms of reproductive death are: amount of cell loss.
a. DNA damage Short-term effects
b. Bystander effect The effects seen in first days or weeks after exposure are
c. Apoptosis determined primarily by sensitivity of parenchymal
cells.
a. DNA damage When continuously proliferating tissues like bone mar-
● The chromosomal aberration due to DNA row and oral mucosa are irradiated with a moderate
damage causes cell to die in first few mitosis dose, loss of cells primarily occurs by reproductive
after irradiation. death, bystander effect and apoptosis. The extent of
● When population of slowly dividing cells is ir- cell loss depends on damage to the stem cell pools and
radiated, larger doses and longer time intervals proliferative rate of cell population.
Section | I Topic-Wise Solved Questions of Previous Years 449

The effects of irradiation on such tissues become appar- SHORT ESSAYS:

ent quickly as a reduction in the number of mature cell
Q.1. Radiation dosimetry.
in the series.
Tissues composed of cells that rarely or never divide, Ans.
e.g. neurons and muscles shows less or no hypoplasia.
Long-term effects The determination of the quantity of radiation exposure
These are seen after months or years of exposure, loss or dose is known as dosimetry.
of parenchymal cell and replacement of fibrous connec- Radiation dosimetry deals with the measurement of the
tive tissue caused by reproductive death of replicating absorbed dose or dose rate resulting from the interaction of
cell and by damage to fine vasculature. Damage to cap- ionizing radiation with matter and particularly in different
illaries leads to narrowing and eventually obliteration of tissues of the body.
vascular lumens. The various measures of dosimetry are as follows:
i. Absorbed dose
Q.6. What are the biologic effects of radiation in the oral ● The amount of radiation at a given point to the
cavity? amount of energy absorbed per unit mass at the site
Ans. of interest is known as dose.

[Same as LE Q.1] Or

Q.7. Enumerate hazards of radiation or effects of radia- Dose can be defined as the amount of energy absorbed
tion on oral tissues. by a tissue. The radiation absorbed dose or rad is the
traditional unit of dose.
Ans. ii. Erythema dose
[Same as LE Q.1] The dose which produces in one sitting a reversible
reddening of the skin (3–4 Gy) is known as erythema
Q.8. Discuss radiation protection. dose.
iii. Exposure
Ans.
● It is a measure of radiation quantity or the capacity
[Same as LE Q.2] of the radiation to ionize air.
● It is measured as the amount of charge per mass of
Q.9. Discuss the methods of radiation safety and protec-
air namely Coulombs/kg.
tion of the operator, patient and public.
iv. Equivalent dose(HT)
Ans. ● It is used to compare the biologic effects of different

types of radiation on a tissue or organ.

[Same as LE Q.2]
● It is the sum of absorbed dose and radiation weigh-
Q.10. Discuss the different methods of radiation protec- ing factor.
tion of the patient and personnel (operator) in oral ra- ● Effective dose.
diography. ● The dose used to estimate the risk in humans is

known as effective dose.

Ans.
● It is the sum of products of equivalent dose to each
[Same as LE Q.2] organ or tissue and the tissue weighing factor.
● The unit of effective dose is Sievert (Sv).
Q.11. Mention radiation hazards affecting whole body.
v. Radioactivity
How would you protect patients from these while taking
● The measurement of radioactivity (A) describes the
intraoral radiographs?
decay rate of a sample of a radioactive material.
Ans. vi. MPD:
It is the equivalent that a person or specified parts of
[Same as LE Q.4]
the person shall be allowed to receive in a stated period
Q.12. What are the hazards of radiation seen on skin of time.
and bone? Discuss briefly protection of patient from vii. Maximum accumulated dose:
radiation. It indicates that higher limits permitted for occupation-
ally exposed persons do not pertain to individual under
Ans.
the age of 18. They are limited to the same exposure as
[Same as LE Q.4] the general that is 0.005 Sv/year.
450 Quick Review Series for BDS 4th Year, Vol 2

Q.2. Osteoradionecrosis. ● Acute effects are divided into those affecting large
and small area of the body.
Ans.
● Chronic somatic effects are mainly due to low

i. An inflammatory condition of bone (osteomyelitis) that level of irradiation for longer period, or chronic
occurs often after the bone has been exposed to thera- irradiation.
peutic doses of radiation usually given for the treatment ● Chronic somatic effects are also of two types:

of malignancy of head and neck region is called osteo- those affecting large area of the body and those
radionecrosis. affecting small area of the body.
ii. Predisposing factors to osteoradionecrosis are as follows: ● Bombardment

● Irradiation of inadequately healed surgical site. ● Acute radiation affecting small area of the

● Surgery in the irradiated areas in close proximity to bone. body is seen in cases of treatment of malignant
● Improperly fractioned high dose of irradiation. tumours.
● Indiscriminate use of prosthetic appliances follow- ● Acute reactions do occur over skin and other

ing radiation therapy. parts resulting in skin erythema.

● Failure to prevent trauma to irradiated bony areas. Chronic radiation affecting large area of the body
iii. The main factors involved in pathogenesis of osteora- Usually seen in the workers (occupational hazard) or
dionecrosis are radiation, trauma and infection. exposure received by a group of population.
iv. Clinical features: Patients feel nervous, apprehensive and tired. Nausea,
● The posterior region of mandible is more commonly vomiting and other GIT disturbances are likely to follow.
affected than the maxilla. Chronic radiation affecting small area of the body
● Intense pain may occur along with intermittent It may result in radiation burns, dry skin, burning sensa-
swelling and drainage extraorally. tions on skin and mucous membrane, friable nails, loss
Pain is of severe, boring type which may continue for of hair (alopecia), cataract, radiation mucositis, loss of
weeks or months. taste, xerostomia and radiation caries.
Trismus, foetid odour and pyrexia can be noted. Marked decrease in vascularity of bones because of
Exposure of bone is the hallmark of osteoradionecrosis. irradiation results in osteoradionecrosis.
Pathological fracture of bone is common. Genetic effects
Radiations cause fragmentation of chromosomes and
Q.3. Biological effects of radiation in oral cavity.
mutation of genes of sex cells and these mutant genes
Ans. with altered characteristics pass on to next generation.
Human embryo is said to be the most sensitive, espe-
Acute radiation affecting large area of the body: cially during 15–42 days of its life, hence avoided in
These are rare in dentistry but are only possible in pregnancy.
nuclear accidents and atomic explosions. Sterility in human beings has been reported on exposure
I. Biological effects of radiation can be considered in two to heavy doses.
aspects:
A. Somatic: The effect which occurs in exposed indi- Q.4. X-ray monitoring devices.
viduals is called somatic effect. Ans.
B. Genetic: The effect which is manifested in the future
generation of the exposed individuals is known as
{SN Q.7}
genetic effect.
II. Biological effects can also be categorized into: X-ray monitoring devices are used for physical measure-
A. Stochastic effects: The effects for which the proba- ment of X-radiations. Commonly used devices are film
bility of an effect occurring rather than its severity badges and thermoluminescent badges.
is regarded as a function of the dose without thresh- A. Film badges.
old, e.g. leukaemia and carcinoma. B. Thermoluminescent badge or dosimeter (TLD).
B. Nonstochastic effects: For this type of nonstochastic
A. Film badges
effects, the severity of the effect varies with the dose
i. Film badges are worn on chest, and under nor-
for which a threshold may matter, e.g. cataract,
mal conditions they give whole body radiation.
shortening of life span and infertility.
ii. Wide range of doses from 10 mR to 1000 R of
Somatic effects
various types of radiations like X-rays, beta rays
Somatic effects can be classified into:
and gamma rays are measured with film badges.
a. Acute
iii. Advantages:
b. Chronic
● Permanent record can be kept.
● Acute somatic effects will be manifested within
● Differentiation of radiation is possible.
few hours to few days of acute irradiation.
Section | I Topic-Wise Solved Questions of Previous Years 451

Protection of the operator

iv. Disadvantages:
The operator should not:
● Not very accurate
l Hold the film in the patient’s mouth during
● Cannot read immediately and accidental
exposure.
exposures cannot be recorded.
l Stabilize the X-ray machine during exposure.

l Stand near or directly in the path of the primary

B. Thermoluminescent badge or dosimeter (TLD) radiation.
i. TLD is used for the measurement of the actual l Use personnel monitoring devices or film badges
dose received by the operator/patient as a result of for monitoring radiation and rotation of duties of
radiography or radiotherapy exposures. the operator so that continuous accidental expo-
ii. They are most common type of personnel monitor- sure is avoided.
ing devices used for personal monitoring of the The operator should preferably stand behind a lead
whole body and/or the extremities, as well as mea- barrier having 0.5 mm lead equivalent during expo-
suring the skin dose from particular investigations. sure or should stand 6 feet away from the primary
iii. Features X-ray beam.
● They contain materials, such as lithium fluoride, Protection of other persons
which absorb radiation and then release the en- i. Only people whose presence is required should stay
ergy in the form of light when heated. in room.
● TLD badge consists of a nickel plated aluminium ii. An X-ray tube should be away from doorways to
plate having three symmetrical holes, each of avoid accidental exposure.
diameter 12 mm, over which three identical iii. Radiation exposure to the room and to adjacent
CaSO4 Teflon discs are embedded. office premises should be monitored.
● Personal monitors consist of a yellow or orange
Q.6. Write briefly about postirradiation mucositis.
plastic holder, worn like the film badge for about
1–3 months. Ans.
iv. Uses:
● Radiotherapy
{SN Q.9}
● Radiodiagnosis

● Personal monitoring Postirradiation mucositis has an effect on oral mucous

v. Advantages: membrane following radiation therapy.
They are chemically inert, reusable and suitable for
a wide variety of dose measurements. As a part of the treatment of malignancy, patients, who re-
vi. Disadvantages: ceive radiotherapy to the head and neck, invariably develop
● Relatively expensive, only limited information is
widespread and painful oral mucosal erosion or ulceration
provided on the type and energy of the radiation. known as radiation mucositis.
● Read-out is destructive, giving no permanent
Once the irradiation is over, usually the mucous membrane
record; results cannot be checked or reassessed. heals rapidly, otherwise after few months, the mucous mem-
Q.5. Radiation protection from X-rays. brane will tend to become atrophic and relatively avascular.
Aetiology
Ans.
Protective measures are employed for the operator of the {SN Q.9}
X-ray equipment, patients and any associated personnel,
It is secondary to therapeutic radiation (doses in excess
including individuals in adjacent office and occupants of
of 3500–4000 rads).
doctor’s reception.
Protection of the patient
Mandatory steps during routine diagnostic radiographic Superinfection by Candida and staphylococci may also play
examination are as follows: a role in the development of radiation-induced mucositis.
i. Use of good machines by reputed manufacturing Clinical features
companies. The symptoms typically begin 1–2 weeks after the com-
ii. Radiograph should only be taken when required mencement of radiation therapy.
and avoid repeating the radiographic examination. The mucous membrane shows areas of redness and in-
iii. Good quality, highly sensitive films should be flammation known as mucositis.
used. With repeated exposures, pseudomembranes are formed
iv. Collimation should be used to prevent scattering. because of breakdown of the mucous membrane, and
452 Quick Review Series for BDS 4th Year, Vol 2

secondary infection by Candida albicans is a common

Treatment
complication.
i. Daily application of viscous topical 1% neutral so-
l Sloughing of the mucosa
dium fluoride gel in custom-made trays causes de-
l Oral ulcerations
lay in growth of Streptococcus mutans.
l Unable to tolerate prosthesis
ii. Avoid dietary sucrose and restricted intake of
l Fibrosis of connective tissue
cariogenic foods.
Diagnosis
iii. Restorative dental procedures and good oral hy-
giene maintenance.
{SN Q.9}
It is usually diagnosed by straightforward history of
radiotherapy that encompassed the orofacial tissues. Q.8. Write briefly on radiation hazards in dentistry.
Treatment
Maintaining good oral hygiene is the most important Ans.
aspect of management. [Ref LONG ESSAY Q.1]
Topical anaesthetics may be required at meal times.
A soothing mouth rinse such as an antihistaminic Q.9. Dosimetry.
with Kaopectate will offer pain relief. [Same as SE Q.1]
Q.10. Write in brief about osteoradionecrosis.
Q.7. Types of the radiation caries.
Ans. [Same as SE Q.2]
Q.11. Clinical features and management of osteoradio-
necrosis.
{SN Q.8}
Radiation caries is a rampant type of dental caries that [Same as SE Q.2]
occurs due to radiotherapy. Q.12. Thermoluminescent dosimeter (TLD).
Patients who have received therapeutic radiation to
the head and neck may suffer loss of salivary gland func- [Same as SE Q.4]
tion leading to xerostomia.
Q.13. TLD.
Radiation caries develops secondary to changes seen
in the salivary glands and saliva-like reduced flow rate, [Same as SE Q.4]
decrease in pH, lack of buffering capacity and increased
viscosity etc. Q.14. Radiation protection for the operator.
In postirradiation period, due to lack of normal [Same as SE Q.5]
cleansing action of saliva, accumulation of local irritants
results in increased incidence of dental caries. Q.15. Radiation protection of patient.
The destruction begins at the cervical region and may
aggressively encircle the entire tooth resulting in loss of [Same as SE Q.5]
the entire crown with only root fragments remaining in Q.16. Enumerate the various means to reduce the expo-
the jaws. sure to the patient while taking radiograph for diagnosis.
The radiographic appearance of radiation caries is
characteristic dark radiolucent shadows appearing at [Same as SE Q.5]
the neck of the teeth, most obvious on mesial and distal
Q.17. Treatment of postirradiation mucositis.
aspect.
Clinically there are three types of radiation caries: [Same as SE Q.6]
i. Widespread superficial lesion – it attacks buccal,
occlusal, incisal and palatal surfaces. Q.18. Write briefly on radiation caries.
ii. Circumferential caries – it usually occurs in cemen- [Same as SE Q.7]
tum and dentine in cervical region. It may result in
loss of irradiation of the crown. Q.19. Describe radiation hazards in oral cavity.
iii. Pigmentation of crown – it is usually dark in colour.
[Same as SE Q.8]
Section | I Topic-Wise Solved Questions of Previous Years 453

SHORT NOTES: Radiation dosimetry deals with the measurement of the

absorbed dose or dose rate resulting from the interaction of
Q.1. Radiation mucositis. ionizing radiation with matter and particularly in different
Ans. tissues of the body.
The various measures of dosimetry are as follows:
Postirradiation mucositis is an effect on oral mucous mem- i. Absorbed dose
brane following radiation therapy. ii. Erythema dose
The mucous membrane shows areas of redness and inflam- iii. Exposure dose
mation. iv. Equivalent dose
With repeated exposures, pseudomembranes are formed be- v. Effective dose
cause of breakdown of the mucous membrane, and secondary vi. Radioactivity
infection by Candida albicans is a common complication.
Once the irradiation is over, usually the mucous membrane Q.5. Enumerate four means to reduce the exposure to
heals rapidly, otherwise after few months, the mucous mem- the patient while taking diagnostic radiographs.
brane will tend to become atrophic and relatively avascular. Ans.
Q.2. Thermoluminescent dosimeter. Means of protection of the patient during routine diag-
Ans. nostic radiographic examination are as follows:
i. Use of good machines by reputed manufacturing
TLD is used for the measurements of the actual dose received companies.
by the operator/patient as a result of radiography or radio- ii. Radiograph should only be taken when required and
therapy exposures. avoid repeating the radiographic examination.
These are most common type of personnel monitoring de- iii. Good quality highly sensitive films should be used.
vices used for personal monitoring of the whole body or the iv. Collimation should be used to prevent scattering.
extremities. v. X-ray equipment is frequently tested.
These contain materials such as lithium fluoride, which vi. During X-ray exposure, use a thyroid collar and lead
absorbs radiation and then releases the energy in the form apron to protect body from X-ray radiation.
of light when heated.
TLD badge consists of a nickel-plated aluminium plate having Q.6. Definition of erythema dose.
three symmetrical holes, each of diameter 12 mm, over which Ans.
three identical CaSO4 Teflon discs are embedded.
These are chemically inert, reusable and suitable for a wide i. The dose that produces in one sitting a reversible
variety of dose measurements. reddening of the skin (3–4 Gy) is known as erythema
Relatively expensive, read-out is destructive, giving no per- dose.
manent record; results cannot be checked or reassessed. ii. In acute radiation affecting small area of the body, the
acute reactions resulting in skin erythema and even
Q.3. Effects of radiation on developing tooth. bone marrow depression are seen.
iii. However, skin reactions vary from individual to indi-
Ans.
vidual depending on the threshold.
i. Adult teeth are resistant to the effects of radiation. iv. Usually 250 roentgen is considered normal. In den-
ii. When the teeth are exposed to radiation in their devel- tistry, exposures are kept at 1/2 of the threshold dose
oping stage, their development may be retarded. (TED).
iii. Prior to calcification, the tooth buds gets destroyed, while
Q.7. Film badge.
after the initiation of calcification, there may be inhibition
of cellular differentiation causing malformation or arrest Ans.
of growth.
[Ref SE Q.4]
iv. Irradiation during developmental stages can result in
malformation of teeth. Q.8. Types of the radiation caries.
v. The pulp shows decreased vascularity, reduced cellularity
Ans.
and exhibits fibroatrophy.
[Ref SE Q.7]
Q.4. Dosimetry.
Q.9. Treatment of postirradiation mucositis.
Ans.
Ans.
The determination of the quantity of radiation exposure or
dose is known as dosimetry. [Ref SE Q.6]
454 Quick Review Series for BDS 4th Year, Vol 2

Q.10. Write briefly on radiation hazards in dentistry/ vii. They have a lifetime of about one microsecond and
oral cavity. attack most of the organic substances.
The free radicals can react with proteins, carbohy-
Ans.
drates, hormones and enzymes resulting in their
[Ref LE Q.1] breakdown.
Q.11. Osteoradionecrosis. Q.13. Radiosensitive and radioprotective.
Ans. Ans.
l Osteoradionecrosis implies infection of bone rendering i. Radio sensitivity of a tissue or organ is measured by its
necrosis by ionizing radiation. response to irradiation. (2500 R or less kills or seriously
l Occurs due to radiation in massive doses, partial necro- injures many cells, e.g.
sis of bone, trauma that causes infection. l Lymphocytes or lymphoblasts

l Cure of malignant conditions of tongue floor of oral l Bone marrow (myeloblastic and erythroblastic cells),

cavity, salivary glands, sinuses and neoplasms. epithelium of intestine or stomach

l Causes necrosis of maxillary and mandibular bones, l Germ cells (ovary and testis)

ulceration of soft tissues. ii. Radioprotective (over 5000 R necessary to kill or injure
l Strangulation of blood vessel. many cells, e.g. kidney, liver, thyroid, pancreas, pitu-
l Extractions are not indicated in such patients. itary adrenal and parathyroid glands, mature bone and
l Osteoporosis and atherosclerosis are there. cartilage, muscles, brain and other tissues).
l Poor oral hygiene, residual roots, periodontal diseases,
Q.14. Definition of ‘roentgen’ and ‘erythema dose’.
caries should be healed to prevent further osteoradione-
crosis. Ans.
Q.12. Radiolysis of water. i. The quantity of X-radiation or gamma radiation that
produces an electric charge of 2.58 3 1024 Coulombs
Ans.
in a kilogram of air at standard temperature and
i. Human tissues consist of 85% of water, on irradiation pressure is called roentgen.
most of the energy will initially get deposited in ii. The dose that produces in one sitting a reversible red-
water; only small proportion will be taken up by bone, dening of the skin (3–4 Gy) is known as erythema
skin, etc. dose.
ii. When water molecules are irradiated, ionization takes iii. In acute radiation affecting small area of the body, the
place as follows acute reactions resulting in skin erythema and even
H2O loses an electron and becomes H2O1 bone marrow depression are seen.
● Ionizing radiation
Q.15. ALARA principle.

H O → H O  e Ans.
2 2
i. The ALARA concept states that all exposure to radia-
iii. The electron can be captured by another H2O molecule tion must be kept to a minimum, or ‘as low as reason-
to give a negative molecule. ably achievable’ to provide protection for both patients
and operators.
H O  e → H O ii. It is one of the possible methods of reducing exposure
2 2 to radiation employed to minimize risk.
This completes the formation of an ion pair. iii. This principle can be used to minimize patient and
iv. The stability of molecule is maintained till now, and operator exposure, thus keeping radiation exposure ‘as
this comes under physical changes. low as reasonably achievable’.
v. The chemical change follows as shown: Q.16. Limitations of radiography.
Ans.
H O → H  OH
2
   The limitations of radiography are as follows:
H O → H  OH i. Initial bone changes may not be apparent in the radio-
2
graph.
vi. Free radicals have an odd electron (surplus or deficient), ii. Soft-tissue and hard-tissue relationship cannot be deter-
which are highly reactive entities. mined.
Section | I Topic-Wise Solved Questions of Previous Years 455

iii. Radiographically, it may not be possible to differen- Q.21. Radiation hazards of teeth, oral mucosa and the jaws.
tiate between a diseased state and successfully
Ans.
treated case.
iv. The actual extent of bone destruction may be more than [Same as SN Q.10]
what has been visualized in the radiograph.
Q.22. Effects of radiation in the oral cavity.
Q.17. Postirradiation mucositis.
Ans.
Ans.
[Same as SN Q.10]
[Same as SN Q.1]
Q.23. Clinical features and management of osteoradio-
Q.18. Measures to protect the patient from radiation necrosis.
hazards.
Ans.
Ans.
[Same as SN Q.11]
[Same as SN Q.5]
Q.24. Radioresistant cells.
Q.19. Write briefly on radiation caries.
Ans. Ans.

[Same as SN Q.8] [Same as SN Q.13]

Q.20. Radiation hazards of jaws. Q.25. ALARA.

Ans. Ans.
[Same as SN Q.10] [Same as SN Q.15]

Topic 3
X-Ray Films and Accessories
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. What is the composition of the radiographic film? Describe the mechanism of image formation. Add a note on
the constituents of developing and fixing solutions.
2. Packaging of intraoral periapical films.
3. Composition of intraoral periapical films. [Same as LE Q.1]

SHORT ESSAYS:
1. Radiographic film composition (or) dental X-ray film. [Ref LE Q.1]
2. Intensifying screens.
3. Grid functions and grids in radiography.
4. Composition, ideal requirements and uses of intensifying screen.
5. Speed of intraoral film.
6. Moving grid.
7. Enumerate various types of intraoral films.

SHORT NOTES:
1. Storage of X-ray films.
2. Composition of intensifying screen. [Ref SE Q.4]
456 Quick Review Series for BDS 4th Year, Vol 2

3. Advantages of bitewing radiographs. [Ref SE Q.7]

4. Intraoral X-ray film packet. [Ref LE Q.2]
5. Occlusal film. [Ref SE Q.7]
6. State the functions of lead foil in the X-ray film packet.
7. Intraoral periapical film.
8. Speed of intraoral film. [Ref SE Q.5]
9. Potter–Bucky diaphragm. [Ref SE Q.6]

SOLVED ANSWERS
LONG ESSAYS:
Q.1. What is the composition of the radiographic ● The emulsion is a homogenous mixture having two
film? Describe the mechanism of image formation. principal components:
Add a note on the constituents of developing and fix- a. Silver halide crystals
ing solutions. b. Gelatin matrix}
Ans. a. Silver halide crystals
● A halide is a chemical compound that is
[SE Q.1]
sensitive to radiation or light. The halides
{The dental X-ray film serves as a recording medium used in dental X-ray film are made up of the
or image receptor. A latent image is recorded in the X-ray element silver plus a halogen (bromine or
film when it is exposed to information carrying X-ray iodine).
photons. ● Silver bromide (AgBr) and silver iodide (AgI)
Composition of the radiographic film are two types of silver halide crystals found in
The X-ray film used in dentistry has four basic comp­onents: the film emulsion. The typical emulsion is
i. Film base 80%–99% silver bromide and 1%–10% silver
ii. Adhesive layer iodide.
iii. Film emulsion ● It is composed primarily of silver bromide and
iv. Protective layer to lesser extent silver iodide.
i. Film base The presence of silver iodide adds greatly to the
● The film base is a flexible piece of polyester plastic
sensitivity to the film emulsion, thereby reducing
(polyethylene terephthalate) 0.2 mm in thickness radiation dose required to produce an adequate
that is constructed to withstand heat, moisture and diagnostic image.
● The silver halide crystals absorb radiation dur-
chemical exposure.
● It is transparent and exhibits a slight blue tint that is
ing X-ray exposure and store energy from the
used to emphasize contrast and enhance image qual- radiation.
ity and also to provide optimal viewing conditions. b. Gelatin matrix
● The gelatin is derived from ‘cattle bone’.
● The primary purpose of the film base is to provide a
● It is used to support silver halide crystals sus-
stable support for the delicate emulsion. The base also
provides strength. pended in gelatin framework over the film base.
● During film processing, the gelatin absorbs the
ii. Adhesive layer
● The adhesive layer is a substratum or subcoating
processing solutions and allows the chemicals
consisting of a thin layer of adhesive material that to react with the silver halide crystals.
covers both sides of the film base. [SE Q.1]
● This layer is added to the film base before the emul-

sion is applied and it serves to attach the emulsion to iv. {Protective layer
the base. ● The protective layer is a thin, nonabrasive, transparent
iii. Film emulsion super coat placed over the emulsion.
● The film emulsion is a coating on both sides of the ● It serves to protect the emulsion surface from ma-
film base to give the film greater sensitivity to X-ray nipulation as well as mechanical and processing
radiation. damage.}
Section | I Topic-Wise Solved Questions of Previous Years 457

Image formation Ingredient Chemical Function

Latent image formation
iii. Activator Sodium or ● Activates developer
● Silver halide crystals absorb X-ray radiation dur-
potassium agents by providing
ing X-ray exposure and store the energy from the hydroxide, necessary alkaline en-
radiation. sodium vironment for develop-
● Depending on the density of the objects in the carbonate ing agents
area exposed, silver halide crystals contain vari- ● Softens gelatin of the
film emulsion so that
ous levels of stored energy. developing agents can
● The stored energy within the silver halide crystals diffuse more rapidly in
forms a pattern and creates an invisible image the emulsion
within the emulsion on the exposed film. This pat- iv. Restrainer Potassium ● Depresses the reduc-
tern of stored energy on the exposed film cannot bromide tion of unexposed
be seen and is referred to as a latent image. silver halide crystals
● When the X-ray photons hit the surface of the film ● Acts as antifog agent
emulsion, some silver bromide crystals are ex- and increases the
contrast
posed and energized, while other crystals are not
exposed. The silver bromide crystals exposed to
X-ray photons are ionized, and the silver and bro- Fixer solution
mine atoms are separated. The fixer solution contains four basic ingredients:
● Irregularities in the lattice structure of the exposed i. Fixing agent
crystal, known as sensitivity specks, attract the ii. Preservative
silver atoms. These aggregates of neutral silver iii. Hardening agent
atoms are known as latent image centres. iv. Acidifier
● Collectively, the crystals with aggregates of silver The functions of each ingredient in fixer solution are as
at the latent image centres become the latent im- follows:
age on the film.
● The latent image remains invisible within the Ingredient Chemical Function
emulsion until it undergoes chemical processing Clearing Sodium thio- Removes all unexposed
procedures. agent sulphate or undeveloped silver halide
Visible image formation ammonium grains from the emulsion
When the exposed film with latent image is pro- thiosulphate
(hypo)
cessed, a visible image results.
Developer solution Acidifier Acetic acid; Neutralizes or inactivates
The developer solution contains four basic ingredients: sulphuric acid any carryover developing
agents in film emulsion and
i. Developer stops further development
ii. Preservative
iii. Activator Preservative Sodium Prevents oxidation of the
sulphite thiosulphate clearing agent
iv. Restrainer
The functions of each ingredient in developer solution Hardener Aluminium Shrinks and hardens the
are as follows: sulphate or po- gelatin in the emulsion
tassium alum

Ingredient Chemical Function

i. Developer Hydroquinone ● Converts exposed sil- Q.2. Packaging of intraoral periapical films.
and Phenidone ver halide crystals to
and Elon metallic silver grains Ans.
● Quickly generates
the grey tones in the
image
{SN Q.4}
● Slowly generates the ● An intraoral film is a film that is placed inside the
black tones and con-
trast in the image
mouth during X-ray exposure and is used to examine
the teeth and supporting structures.
ii. Preserva- Sodium sulphite Prevents rapid oxida-
●
Intraoral film packaging
tive tion of the developing
● Each intraoral film is packaged to protect it from
agents
● Extends their useful life light and moisture.
458 Quick Review Series for BDS 4th Year, Vol 2

● The outer wrapper of the film packet has two sides:

● The film and its surrounding packaging are
a. Tube side
referred to as a film packet.
b. Label side
● Intraoral X-ray film packets have four basic
components: a. Tube side:
i. The X-ray film ● The tube side is solid white and has a raised

ii. Paper film wrapper bump in one corner that corresponds to the
iii. Lead foil sheet identification dot on the X-ray film.
iv. Outer film wrapping ● When placed in the mouth, the white colour

side of the film packet must face the teeth and

the tube head.
i. X-ray film
b. Label side:
● The intraoral X-ray film is a double-emulsion film.
● The label side of the film packet has a flap
Double-emulsion film is used instead of single-
used to open the film packet.
emulsion film because it requires less radiation ex-
● This side is colour-coded to identify films
posure to produce an image.
outside of the plastic packaging container.
● A film packet may contain one film (one-film packet)
Colour codes are used to distinguish between
or two films (two-film packet).
one-film and two-film packets and between
A two-film packet produces two identical radiographs
film speeds.
with the same amount of exposure necessary to produce
● When placed in the mouth, the colour-coded
a single radiograph. This is used when a duplicate re-
side (label side) of the packet must face the
cord of a radiograph is needed either for insurance
tongue.
claims or patient referrals.
● The following information is printed on the
● A small, raised dot known as the identification dot
label side of the film packet:
is located in one corner of the intraoral X-ray film.
● A circle or dot that corresponds with the
This raised dot is used to distinguish between the
raised identification dot on the film
left and right sides of the patient after the film is
● The statement ‘opposite side toward tube’
processed; hence, it is significant in film orienta-
● The manufacturer’s name
tion, mounting and interpretation.
● The film speed
ii. Paper film wrapper
● The number of films enclosed
● The paper film wrapper within the film packet is a
● In dentistry, the terms ‘film packet’ and ‘film’
protective sheet of black paper that covers the film.
are often used interchangeably. Intraoral film
● It also shields the film from light leak.
packets are typically available in quantities of
iii. Lead foil sheet
25, 100 or 150 films per container.
● The lead foil sheet is a single thin piece of lead foil
● Film packets are packaged in convenient plastic
within the film packet that is located behind the film
trays or cardboard boxes that can be recycled.
wrapped in black protective paper.
● Boxes of intraoral film are labelled with the
● The thin lead foil sheet is positioned behind the film;
type of film, film speed, film size, number of
it absorbs most of the X-rays that pass through the film
films per individual packet, total number of
and prevent them from reaching the tongue and other
films enclosed and the film expiry date.
oral tissues. It also shields the film from back scattered
or secondary radiation, which results in film fog. Q.3. Composition of intraoral periapical films.
● It also gives sufficient strength to the whole film
Ans.
packet.
● If the film packet is inadvertently positioned reverse [Same as LE Q.1]
in the mouth, then the shadow of the foil is seen on
radiograph as ‘tyre track’ marks or ‘Herring bone’
appearance, which is the embossed pattern placed on
SHORT ESSAYS:
the lead foil by the manufacturer. Q.1. Radiographic film composition (or) dental X-ray film.
iv. Outer package wrapping
Ans.
● The outer package wrapping is a soft-vinyl or a pa-

per wrapper that hermetically seals the film packet, [Ref LE Q.1]
protective black paper and lead foil sheet.
Q.2. Intensifying screens.
● This outer wrapper serves to protect the film from
exposure to light and saliva. Ans.
Section | I Topic-Wise Solved Questions of Previous Years 459

● An intensifying screen is a device that transfers X-ray They may also be classified as:
energy into visible light, which in turn exposes the C. Focused grids
screen film. D. Nonfocused grids
● As they intensify, the effect of X-rays on the film and
A. Stationary grids
the use of intensifying screens reduce the radiation re-
i. Linear grid
quired to expose a screen film, thereby reducing the
● In the linear grid, the strips of lead are placed
patient’s exposure to radiation.
parallel to each other.
● In extraoral radiography, a screen film is sandwiched
● While using the linear grid, cut-off of the beam
between two intensifying screens of matching size and
can occur as some of the primary beam may
is secured in a cassette.
get absorbed by the lead in the peripheral re-
● An intensifying screen is a smooth plastic sheet coated
gion. If the grid is not perpendicular to the
with minute fluorescent crystals known as phosphors.
central axis of the beam, this can also take
When exposed to X-rays, the phosphors fluoresce and
place in the centre of the film.
emit visible light in the blue or green spectrum; the
● For all practical purposes, the central beam
emitted light then exposes the film.
should be in plane parallel with grid lines.
● Conventional calcium tungstate screens have phosphors
ii. Focused grid:
that emit blue light. The newer rare earth screens have
● In the focused grid, the lead strips are angled
phosphors that are not commonly found in the earth and
from the centre to the edge so that the inter-
emit green light.
spaces are directed at the focal spot.
● Rare earth intensifying screens are more efficient than
● The disadvantage of using a linear grid can be
calcium tungstate intensifying screens at converting
greatly minimized by using a focused grid.
X-rays into light. As a result, rare earth screens require
iii. Pseudofocused grid:
less X-ray exposure than calcium tungstate screens and
● The extra reduction of primary radiation away
are considered to be faster.
from the centre of the beam can be minimized
● The use of rare earth screens means less exposure to
by using a pseudofocused grid.
X-ray radiation for the patient. Rare earth intensifying
● In this grid, the height of the lead strips is
screens (Kodak Lanex Regular and Medium screens)
progressively reduced from the centre to the
are designed for use with green-sensitive films (Kodak
periphery.
Ortho and T-Mat films); whereas, conventional screens
iv. Crossed grid:
(Kodak X-somatic Regular screens) are used with blue-
● Another effective way of limiting the scattered
sensitive films (Kodak X-Omat and Ektamat films).
radiation further is by using a crossed grid.
Q.3. Grid functions and grids in radiography. ● In crossed grid, two grids are placed on top of

each other and at right angles. This minimizes

Ans.
the scattered radiation traversing in the same
● Grid is a radiographic accessory, which helps in reduc- line as the primary beam.
ing the scattered radiation when placed between the B. Moving grids
patient and the film, as close as possible to the latter. ● They are moved sideways across the film during

● It helps to reduce the film fog and improves the contrast. exposure.
● The grid is made up of alternate layers of radiolucent, ● The use of moving grid reduces the white lead

i.e. plastics and radiopaque, such as lead, which are lines in the radiographic image.
aligned in the direction of the primary beam either par-
Q.4. Composition, ideal requirements and uses of inten-
allel to each other or at an angle/focused. In general,
sifying screen.
grid has 80 line pairs per inch.
● Grid ratio – the ratio of the thickness of the grid to the Ans.
distance between the spacer is termed as the grid ratio.
● The moving grid is normally used to get rid of the radi- ● An intensifying screen is a device that transfers X-ray
opaque fine lines that may appear on the radiograph. It energy into visible light, which in turn exposes the
is also termed as the Potter–Bucky diaphragm. screen film.
● Most of the extraoral radiographic projections of the skull- ● Intensifying screens make use of the principle of
like Paranasal sinus view (PNS), Caldwell view, submento- fluorescence.
vertex view are best visualized using grids with screen films. ● An intensifying screen and film combination makes the
Various types of grids are classified as follows: image receptor system 10–60 times more sensitive than
A. Stationary grids when the film is used alone. Hence, their use consider-
B. Moving grids ably reduces the radiation exposure to the patient.
460 Quick Review Series for BDS 4th Year, Vol 2

{SN Q.2} ● It is the surface layer of the intensifying screen which

protects phosphor layer from mechanical insult.
Composition of intensifying screens is as follows:
i. Base
ii. Reflecting layer ● This layer can be cleaned. The intensifying screen
iii. Phosphor layer should be kept clean without any debris, spots, or
iv. Coat scratches. Otherwise, these areas will result in underex-
posed or light areas in the image.
i. Base
The ideal requirements of a fluorescent material are:
● Base of an intensifying screen is usually made up
● The material should absorb a greater amount of X-rays,
of either stiff sheet of cardboard or polyester
i.e. it should have a high absorption coefficient.
plastic having a thickness of 0.25 mm.
● It should have moderately high atomic number (Z).

● It should emit a large amount of light of a suitable

● The base is the supporting component of the screen. energy and colour. There should not be any afterglow
which can adversely affect the image quality.
{SN Q.2} Q.5. Speed of intraoral film.
ii. Reflecting layer Ans.
● This layer is usually made of a white material

either magnesium oxide or titanium dioxide. {SN Q.8}

● It lies below the phosphor layer. It reflects the
● Film speed refers to the amount of radiation required
light emitted by the phosphor layer to the X-ray to produce a radiograph of standard density.
film. ● The speed of a film is clearly indicated on the label
iii. Phosphor layer side of the intraoral film packet as well as on the
This layer consists of a light sensitive phosphor outside of the film box or container.
crystal suspended in a plastic material. ● The factors determining film speed, or sensitivity, are
● The various phosphors used are as follows:
as follows:
● Calcium tungstate
i. Size of the silver halide crystals
● Zinc sulphide
ii. Thickness of the emulsion
● Zinc cadmium sulphide
iii. Presence of special radiosensitive dyes
● Barium lead sulphate
● Film speed determines how much radiation and how
● Terbium-activated gadolinium oxysulphide
much exposure time are necessary to produce an im-
(GdzOz:Tb). age on a film.
● For example, a fast film requires less radiation expo-
● Thallium-activated lanthanum oxybromide (LaOBr:Tm). sure because the film responds more quickly; a fast
● The last two phosphors in the list are rare earth materi- film responds more quickly because the silver halide
als. These phosphors are also called as ‘salts’; hence, crystals in the emulsion are larger. The larger the crys-
the intensifying screens are also called as salt screens. tals, the faster is the film speed.
● Calcium tungstate is the most commonly used phos- ● An alphabetical classification system is used to iden-
phor. When these crystals are struck by photons, they tify film speed:
fluoresce, i.e. emit visible light photons that expose the ● X-ray films are given speed ratings ranging from
X-ray film. A speed (the slowest) to F speed (the fastest). Only
● The rare earth intensifying screens are about four times D-speed film and F-speed film are used for intraoral
more efficient than calcium tungstate intensifying screens. radiography; E-speed film has been discontinued by
● Special X-ray films sensitive to green light are required Kodak.
while using rare earth intensifying screens. ● The American Dental Association (ADA) and the Amer-
ican Academy of Oral and Maxillofacial Radiology
(AAOMR) currently recommend the use of F-speed film.
{SN Q.2}
● F-speed film requires 60% of the exposure time of
iv. Coat D-speed film and has comparable image contrast and
● This acts as a protective coat and is made up of resolution.
plastic having a thickness of about 8 microns over ● The use of F-speed film results in less radiation ex-
the phosphor layer. posure for the patient. F-speed film is a faster film
Section | I Topic-Wise Solved Questions of Previous Years 461

than D-speed because of the larger crystals and the Disadvantages

increased amount of silver bromide in the emulsion. ● Costly

● Current F-speed films not only reduce radiation dose ● Subject to failure

to the patient but also provide stable contrast charac- ● Increases the minimum exposure time due to slow

teristics under various processing conditions. motion

● The Ekta speed films (E speed) have a marking EKT ● Increases patient dose

and only the E speed films must be used in the clinics

today since they allow good radiographic visualiza- Q.7. Enumerate various types of intraoral films.
tion with minimum radiation exposure.
Ans.

Q.6. Moving grid. ● Intraoral films are used inside the oral cavity. These
films are comparatively of smaller size. Intraoral films
Ans. are usually coated on both the sides, which allows fewer
radiations to make an image.
{SN Q.9} ● Single film packets or sometimes double film packets
are used. If two films are used, second film is used for
● Moving grid is also known as Potter–Bucky dia-
keeping the duplicating records.
phragm invented by Hollis E. Potter in 1920.
● Intraoral films are generally divided into three catego-
● Grid is a radiographic accessory, which helps in reduc-
ries. Categories are only on the basis of their clinical
ing the scattered radiation when placed between the
use. For sake of convenience, the intraoral films are
patient and the film, as close as possible to the latter.
designated by numbers, as periapical films (No. 1), bite
● Potter–Bucky grid is a moving type of a grid used in
wing films (No. 2) and occlusal films (No. 3).
radiography; it prevents scattered radiation from
A. Periapical films
reaching the film, thereby securing better contrast
● The periapical films are designated as No. 1. They
and definition.
are utilized where radiographs of crowns, roots
● The first models were built up from alternate strips of
and periapical areas are required. One such film is
lead and wood. The strips are built up on a radius
sufficient for three teeth.
which would have at its centre the X-ray tube anode.
● Periapical films are given number 1.0, 1.1, and so on.
● In this the grid is moved sideways across the film dur-
1.0 is periapical film for children (20 3 35 mm).
ing exposure. This leads to the blurring out of the shad-
This is also used in adults where the patient has the
ows of grid strips, thus they are not visible on the film.
problem of gagging. 1.1 is periapical film for routine
use and 1.2 is of little higher size.
● The image of the radiopaque grid lines on the film can ● The contrast and details are quite well with these

be deleted by mechanically moving the grid in a direc- films, whether the film may be single or double in
tion of 90° to the grid lines, during exposure. This re- one packet.
sults in blurring out the radiolucent lines and resulting B. Bitewing Films
in a more uniform exposure.
● When radiation encounters some form of matter, some {SN Q.3}
of the radiation is scattered in all directions and simply
● The bitewing films are designated as No. 2. Further
produces an overall fog level.
these are designated as 2.0, 2.1, and so on depending
● The Potter–Bucky diaphragm removes most of the scat-
upon the size. 2.3 is used in anterior teeth because
ter while allowing most of the primary radiation through.
the vertical height is greater than horizontal height.
● The lead slats would be expected to cast a shadow on
● These are available in three sizes suitable for anteri-
the image, but this is removed by moving the grid dur-
ors, premolars and molars.
ing the exposure.
● These films record the coronal portion of maxillary
● The modern version of the Potter–Bucky diaphragm is
and mandibular teeth in one image and are generally
flat instead of curved, but employs the same principle.
taken for periodic check-up to see early changes in
caries and periodontal tissues.
{SN Q.9}
● Bite wing films are used:
Advantages ● To detect early caries and periodontal lesions.

● It removes the scatter radiation effectively. ● To see the penetration of caries on the proximal

● Grid reduces the white lead lines effectively. side and extent of pulp chamber.
462 Quick Review Series for BDS 4th Year, Vol 2

Q.3. Advantages of bitewing radiographs.

● To see the permanent tooth bud in relation to the
deciduous tooth. Ans.
[Ref SE Q.7]
C. Occlusal films Q.4. Intraoral X-ray film packet.
Ans.
{SN Q.5}
[Ref LE Q.2]
● The occlusal films are designated as No. 3. The size
of the film is four times the routine periapical films Q.5. Occlusal film.
(60 3 75 mm). Ans.
● As the name derives, the occlusal film is held in posi-
tion by letting the patient bite lightly on the film to [Ref SE Q.7]
support it between the occlusal surface of each jaw. Q.6. State the functions of lead foil in the X-ray film packet.
● They are used:
● For gross examination of maxilla and mandible Ans.
and to have a broad view of deciduous teeth for ● The lead foil sheet is a single thin piece of lead foil
serial extractions. within the film packet that is located behind the film
● To view large areas with pathological involvement
wrapped in black protective paper.
and determine their buccolingual relationship. ● Functions of the lead foil sheet:
● To detect extent of fractures.
i. It absorbs most of the X-rays that pass through the
● To detect impacted or supernumerary teeth.
film and prevent them from reaching tongue and
● Localization of foreign bodies in glands.
other oral tissues.
ii. It also shields the film from backscattered or
secondary radiation, which results in film fog.
iii. It also gives sufficient strength to the whole film
SHORT NOTES: packet.
Q.1. Storage of X-ray films.
Q.7. Intraoral periapical film.
Ans.
Ans.
As the X-ray film is adversely affected by heat, humidity
● The term periapical is derived from the Greek word
and radiation, the following points should be considered
peri, meaning ‘around’, and the Latin word apex, mean-
while storing X-ray films:
ing the terminal end of a tooth root. This type of film
● To prevent film fog, unexposed, unprocessed film must
shows the tip of the tooth root and surrounding struc-
be kept in a cool, dry place.
tures as well as the crown.
● The optimum temperature for film storage ranges from
● The periapical film is used to examine the entire tooth
50° to 70° F, and the optimum relative humidity level
both crown and root and supporting bone.
ranges from 30% to 50%.
● Periapical films are available in three sizes:
● Film must be stored in areas that are adequately shielded
from sources of radiation and should not be stored in Size 0 Paediatric film – 22 3 35 mm
areas where patients are exposed to X-ray radiation.
Size 1 Adult anterior – 24 3 40 mm
● To prevent film fog, lead-lined or radiation-resistant
film dispensers and storage boxes are ideal. Size 2 Standard adult – 32 3 41 mm
● All dental X-ray films have a limited shelf life. They
must be used before the labelled expiration date. Q.8. Speed of intraoral film.
● The ‘first in, first out’ rule of thumb should be applied
Ans.
to film use; the oldest film in stock should always be
used before any new film. [Ref SE Q.5]
Q.2. Composition of intensifying screen. Q.9. Potter–Bucky diaphragm.
Ans. Ans.
[Ref SE Q.4] [Ref SE Q.6]
Section | I Topic-Wise Solved Questions of Previous Years 463

Topic 4
Processing of X-Ray Films
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. What is the composition of radiographic film? Describe the mechanism of image formation.
2. Describe the composition of developing and fixing solution and their functions.
3. Describe the processing of X-ray film.
4. Describe the darkroom chemistry.
5. Write in detail the composition and actions of developer and fixer used in dental radiography. [Same as LE Q.2]

SHORT ESSAYS:
1. Composition of developer solution. [Ref LE Q.2]
2. Fixing solution. [Ref LE Q.2]
3. Processing errors of radiographs.
4. Automatic film processing.
5. Processing of X-ray film.
6. Coin test.
7. Requirements of a darkroom. [Ref LE Q.4]
8. Composition and functions of developing solution. [Same as SE Q.1]
9. Composition and actions of developing solution. [Same as SE Q.1]
10. Composition and action of fixer solution. [Same as SE Q.2]
11. X-ray fixing solution. [Same as SE Q.2]
12. Types of X-ray film processing. [Same as SE Q.5]
13. Processing of an intraoral film. [Same as SE Q.5]

SHORT NOTES:
1. Composition of developer solution. [Ref LE Q.2]
2. Resolution.
3. Replenisher.
4. Fixing solution.
5. Actions of developing solutions.
6. Automatic film processing.
7. Storage of X-rays films.
8. Requirements of darkroom. [Ref LE Q.4]
9. Coin test. [Ref SE Q.6]

SOLVED ANSWERS
LONG ESSAYS:
Q.1. What is the composition of radiographic film? Composition of the radiographic film
Describe the mechanism of image formation. The X-ray film used in dentistry has four basic
components:
Ans.
i. Film base
The dental X-ray film serves as a recording medium or im- ii. Adhesive layer
age receptor. A latent image is recorded in the X-ray film iii. Film emulsion
when it is exposed to information carrying X-ray photons. iv. Protective layer
464 Quick Review Series for BDS 4th Year, Vol 2

The mechanism of image formation in detail is as site, it is neutralized, with the result that an atom of
follows: metallic silver is deposited at the site.
● On exposure of the X-ray film to the information ● This process occurs many times at a single site
carrying beam of photons coming out of an ob- within a crystal whenever photons and recoil elec-
ject, there is a chemical change in the photosensi- tron strike bromide ions.
tive silver halide crystals in the film emulsion that ● After exposure of a film to radiation, the aggregate of
interact with these photons. These chemically al- silver atoms at the latent image sites comprises the
tered crystals are said to constitute the latent or latent image.
invisible image on the film. ● It is the metallic silver at each latent image site that
● The concept of the latent image implies that catalyses the development of the halide crystal in
chemical changes produced by the X-ray increase which it is formed, i.e. renders the crystal sensitive to
the ability of the altered crystals to the chemical development and image formation.
action of the ‘developing’ process that converts ● The larger the aggregate of silver atoms, the
the latent image to visible image. more sensitive the crystal is to the effects of the
Formation of latent image developer.
● The film emulsion is a suspension of tiny photosensi- ● The primary actions of the processing solution are to
tive silver bromide and silver iodide crystals that convert the crystals with the latent images to black
have been precipitated in gelatin and layered to a thin metallic silver grains that can be visualized and to
sheet of transparent plastic base. remove the unexposed silver bromide crystals.
● These silver halide crystals are imperfect in many
Q.2. Describe the composition of developing and fixing
ways and they contain a few free silver ions in the solution and their functions.
spaces between the crystalline lattice positions,
which are referred to as interstitial silver ions. Ans.
● There are physical distortions in the regular rectan-
(SE Q.1 and SN Q.1)
gular arrangement of the silver and bromide ions in
the crystals due to the presence of the iodine atoms {(Developer and fixer are two special chemical
occupying some of the bromide sites. solutions that are necessary for film processing.
● The silver halide crystals are chemically sensitized Developer solution
by the presence of added sulphur compounds that The developer solution contains the following five basic
play a critical role in image formation. The physical chemicals and other ingredients as follows:
irregularities in the crystal produced by the iodide i. Developing agent
ions are called the latent image sites. ii. Preservative
● There are many such latent image sites in each crys- iii. Activator
tal; their function is to begin the process of image iv. Restrainer
formation by trapping the electrons generated when v. Hardener
the emulsion is irradiated. vi. Fungicide, buffers and solvent)}
● When the silver halide crystals are irradiated, X-ray Developing agent
photons interact primarily with the bromide ions by ● The developing agent is also known as the reducing

Compton and photoelectric interactions. These result agent, which contains the following chemicals:
in the removal of an electron from the bromide ions a. Hydroquinone (paradihydroxybenzene)
with the production of high-speed electrons and scat- b. Elon or Metol (monomethyl-para-amino phenol
tered photons. sulphate)
● Due to the loss of the electrons, the bromide ions are c. Metol/phenindione (1-phenyl-3-pyrazolidinone)
converted into bromine atoms that are absorbed by ● The purpose of the developing agent is to reduce the

the gelatin of the emulsion. exposed silver halide crystals chemically to black
● The recoil electrons move through the crystal, gener- metallic silver.
ating additional bromine atoms, secondary recoil ● Hydroquinone is a benzene derivative and acts at

electrons and scattered photons until a major portion slow rate but generates the black tones and the sharp
of their energy has been expended and they encoun- contrast of the radiographic image. Hydroquinone is
ter a latent image site. Here they become ‘trapped’ temperature sensitive; it is inactive below 60°F and
and thereby impart a negative charge to the site. very active above 80°F. Films are best developed at
● The positively charged free interstitial silver ions are 70°F for 5 min.
attracted to the negatively charged latent image site. ● Elon is the product of aniline dyes and acts quickly

When the silver ion reaches the charged latent image to produce a visible radiographic image. It helps to
Section | I Topic-Wise Solved Questions of Previous Years 465

develop shadow areas or shades of grey on the film Solution should not be used for more than 10–14 days
and brings detail. It is less sensitive to temperature irrespective of the number of films processed during
changes and generates grey tones in the image. that time.
● Metal phenindione: It is a by-product of aniline dyes,

works at faster rate but gives a low contrast. It is an [SE Q.1]

efficient activator for hydroquinone at a very low {Composition of developer in brief
concentration and works at lower alkalinity. It is
more commonly used in automatic processor. Ingredient Chemical Function
● The image produced will have shades of grey if only Developing i. Hydroquinone i. Converts exposed silver ha-
Elon is used; if only hydroquinone is used, the image agent ii. Elon lide crystals to black metal-
will be black and white and if a combination is used, lic silver. Slowly generates
the black tones and contrast
image will have all black, white, and grey shades. in the image
Preservative ii. Converts exposed silver ha-
● Sodium sulphite is used as preservative. As it has lide crystals to black metal-
great affinity for oxygen, it prevents oxidation of lic silver. Quickly generates
developer solution and forms sulphonates, when the grey tones in the image
combined with oxygen. Preservative Sodium sulphite Prevents rapid oxidation of the
Activator developing agents
● Sodium carbonate is used as an activator. It provides Accelerator Sodium Activates developer agents
alkaline medium usually above a pH of 11, which is carbonate Provides alkaline environment
required for hydroquinone to act, and it also softens for developing agents; softens
gelatin of the film emulsion
the gelatin of the emulsion.
● It causes the emulsion to swell, makes the penetra- Restrainer Potassium Prevents the developer from
tion of developing agent, and diffusion of the reac- bromide developing the unexposed
silver halide crystals
tion product out, easier. This component of developer
makes it soapy to touch. Hardener Glutaraldehyde Used in automatic processing,
● Other activators used are sodium hydroxide, sodium
to prevent emulsion from soft-
ening and sticking to the rollers
metaborate and sodium tetraborate.
● Excessive alkalinity causes rapid reduction even of Antibacterial Fungicide Prevents bacterial growth
the unexposed silver bromide crystals and produces Solvent Water Dissolves chemicals }
fog.
Restrainer
● Potassium bromide or benzothiazole is used as the Composition of fixer
restrainer. It prevents chemical fog, which is also The function of fixer is to remove the undeveloped sil-
called developmental fog. ver halide crystals from the emulsion and harden the
● The added bromide serves to depress the reduction in emulsion.
the unexposed crystals and hence acts as an antifog The fixer solution contains four basic ingredients:
agent and it restricts the action of the developing i. Fixing agent
agent only to those silver halide crystals that are ii. Preservative
irradiated. iii. Hardening agent
Hardener iv. Acidifier
● Glutaraldehyde is added as a hardener, particularly in
[SE Q.2]
automatic processing to prevent emulsion from soft-
ening and sticking to the rollers. {Fixing agent
Fungicide ● The fixing agent is also known as the clearing agent
● It is added to prevent bacterial growth. and is made up of sodium thiosulphate (hypo) or am-
Buffers monium thiosulphate.
● These are added to maintain the pH of developer. ● Its purpose is to remove or clear all unexposed and unde-
Solvent veloped silver halide crystals from the film emulsion al-
● Distilled water is used as the solvent and as a me- lowing light to pass through the film image and permit-
dium in which the chemicals can react with the silver ting viewing of the radiographic image on a view box.
bromide of the emulsion. ● This chemical ‘clears’ the film so that the black
The alkaline developer solution should be concentrated image produced by the developer becomes readily
as recommended by the manufacturer’s instructions. distinguished.}
466 Quick Review Series for BDS 4th Year, Vol 2

Preservative The purpose of processing is

● Sodium sulphite, the same preservative as in the de- ● Visible image formation
veloper solution, is also used in the fixer solution. ● Preservation of image permanently for later correspon-
● The purpose of the preservative is to prevent the dence
chemical deterioration of the fixing agent. Types of processing
● It also helps to clear the film by binding with any There are basically two types of processing methods. They are
oxidized developer, which is carried to the fixing i. Manual processing
solution. a. Visual method
Hardening agent b. Time–temperature method
● Potassium alum, aluminium chloride, etc. are used as ii. Automatic processing
the hardening agent in the fixer solution.
i. Manual processing
● It hardens and shrinks the gelatin in the film emul-
a. Visual method:
sion to prevent its oxidation and protects it against
● The visual method of manual processing is carried
the scratches.
out in a darkroom with safelighting conditions.
● It also shortens the drying time. It reduces the swell-
● In this method, an exposed X-ray film is im-
ing of the emulsion during the final wash resulting in
mersed in the developing solution and periodi-
less mechanical damage to the emulsion, hence lim-
cally viewed under the safelight for the emer-
iting water absorption.
gence of a clear image.
● It also neutralizes any contaminating alkali from the
● When the image appears, the film is washed
developer.
and immersed in the fixing solution.
Acidifier
b. Time–temperature method:
● The acidifier used in the fixer solution is acetic acid
● Time–temperature method is a type of manual
or sulphuric acid. Its purpose is to neutralize the al-
processing method in which effective stan-
kaline developer.
dardization may be achieved without any auto-
● It provides necessary acidic medium for diffusion of
matic aids.
thiosulphate into emulsion.
● It is a simple technique of immersing the film
● The acidifier also produces the necessary acidic en-
in the developer kept at a constant temperature
vironment required by the fixing agent.
for a fixed duration of time.
[SE Q.2] The time–temperature chart is as follows:

{Composition fixer Temperature Development Time

Ingredient Chemical Function 65°F 6 min
Fixing agent Sodium thiosul- Removes all unexposed 68°F 5 min
phate; ammonium undeveloped silver halide 70–72°F 4 min
thiosulphate crystals from the emulsion 76°F 3 min

Preservative Sodium sulphite Prevents deterioration of

fixing agent ● The advantage of manual processing is that the ac-
Hardening Potassium alum Shrinks and hardens the tion of development is under the direct control of the
agent gelatin in the emulsion operator.
● Disadvantages: Handling wet film, the requirement
Acidifier Acetic acid; Neutralizes the alkaline
sulphuric acid developer and stops further of a darkroom and time consuming.
development ii. Automatic processing
Solvent Water It dissolves chemicals} ● In automatic processing machines, the exposed

film is fed at one end and it passes successively

through the developer, fixer, water and drier.
● The roller system has a squeezing action; the de-

Q.3. Describe the processing of X-ray film. veloping solution absorbed by the gelatin of the
emulsion will be less as it is transported from the
Ans. developer to the fixer.
Processing is the term used to describe the sequence of ● The automatic processing machines make use of

events required to convert the invisible latent image con- roller system for the transport of film. The film
tained in the sensitized emulsion into the visible permanent comes out through the other end of the processor,
radiographic image. processed, dry and ready for viewing.
Section | I Topic-Wise Solved Questions of Previous Years 467

The steps involved in manual processing of X-ray film Darkroom equipment

consist of: ● The darkroom should contain the following infra-

i. Developing the film structure:

ii. Rinsing in water i. Safelights
iii. Fixing of film ii. Visible light source (tube lights)
iv. Washing film in running water iii. Working area to load extraoral cassettes
v. Drying and mounting of film iv. Processing tanks
v. Thermometer and stop clock
i. Developing the film vi. Dryer
● The exposed film is immersed in the developing
vii. Storage facility for unexposed films
solution until the image emerges. viii. Exhaust and appropriate ventilation
● Depending on the exposure time of film and
Requirements of a darkroom
concentration of the developing solution, the
time taken for development ranges from a few (SE Q.7 and SN Q.8)
seconds to a few minutes.
ii. Rinsing in water
● After developing the film, it is rinsed in water for
{(The darkroom must be properly designed and well
equipped. A well-planned darkroom makes processing
15–20 s before placing in the fixer. This slows down
easier. An ideal darkroom must have the following
the development process and removes any alkali of
characteristics:
the developing solution before placing in acidic fixer.
i. Convenient location
iii. Fixing of film
ii. Adequate size with ample working space
● Film is placed in the fixer for about 8–10 min.
iii. Correct lighting equipment
● The action of the fixing solution is to remove the
iv. Adequate storage
unexposed silver halide crystals and harden the
v. Temperature and humidity controlled
emulsion.
Other miscellaneous darkroom requirements include a
● Too long fixing time can cause film fog and loss
waste basket for the disposal of all film wrappings and
of proper contrast.
an X-ray view box.)}
iv. Washing of film
● The film should be washed thoroughly for suffi-

cient length of time in running water to remove [SE Q.7]

residual fixing solution.
● If the silver compounds are not removed, there i. {Convenient location
can be stains on the film. Discolouration of the ●The location of the darkroom must be convenient.
image can also result due to the presence of thio- Ideally, it should be located near the area where
sulphate and its products. X-ray units are installed.
v. Drying and mounting of film ii. Adequate size with ample working space
● The last step in the processing is drying the film ● The darkroom must be large enough to accommo-

and mounting for viewing. date film processing equipment and to allow ample
● The film should be dried in a relatively dust-free working space.
environment. ● The size of the darkroom is determined by the fol-

● Commercially, driers are available for drying the lowing factors:

film. a. Volume of radiographs processed
● Drying a film is very important as sometimes the b. Number of persons using the room
water marks can result in artefacts. The processed c. Type of processing equipment used
films should be properly identified, mounted and d. Space required for duplication of films and
then viewed under transillumination. storage
The dental darkrooms, since smaller developer and
Q.4. Describe the darkroom chemistry. fixer tanks can be utilized, may be of small sizes. The
Ans. average size required is 6 feet 3 8 feet. The ceiling
should not be less than 2.7 m high. The floor should
(SE Q.7 and SN Q.8) be made in such a way that it remains nonslippery
and resistant to staining. The ceiling and walls should
{(The main function of a darkroom is to provide a be well painted.
● For protection from the ionizing radiations, the walls
completely darkened environment where X-ray film can be
handled and processed to produce diagnostic radiographs should have 2.0 mm equivalency of lead. A 25-mm
in an efficient, precise and standardized procedure.)} thick barium plaster can also be used. The area where
films are stored should be covered well.
468 Quick Review Series for BDS 4th Year, Vol 2

iii. Correct lighting equipment ● A relative humidity level of between 50% and 70%
● The main requirement of the darkroom is that it should be maintained. When humidity levels are too
should be light tight (light proof). The door should high, the film emulsion does not dry. When humidity
be light tight and with proper lock to avoid acciden- levels are too low, static electricity becomes a prob-
tal opening. lem and causes film artefacts.}
Two types of lightings essential in a darkroom are as ● The darkroom plumbing must include both hot and
follows: cold running water along with mixing valves to ad-
a. Room lighting just the water temperature in the processing tanks. A
● Incandescent room lighting is required for proce- utility sink with running water is also useful in the
dures not associated with the act of processing films. darkroom.
● An overhead white light that provides adequate il-
Q.5. Write in detail the composition and actions of
lumination for the size of the room is necessary to
developer and fixer used in dental radiography.
perform tasks such as cleaning, stocking materials
and mixing chemicals. Ans.
b. Safelighting
● The special type of lighting used to provide illu- [Same as LE Q.2]
mination in the darkroom is termed as safe-
lighting. SHORT ESSAYS:
● A safelight typically consists of a lamp equipped

with a low-wattage (15 watts) bulb and a safe- Q.1. Composition of developer solution.
light filter. A safelight filter removes the short Ans.
wavelengths in the blue-green portion of the vis-
ible light spectrum that are responsible for ex- [Ref LE Q.2]
posing and damaging X-ray film. Q.2. Fixing solution.
● Under safelight conditions, it is necessary to

maintain an adequate safelight illumination dis- Ans.

tance minimum of 4 feet (1.2 m) and to keep [Ref LE Q.2]
film handling times to a minimum otherwise
they appear fogged, and unwrapped films must Q.3. Processing errors of radiographs.
be processed immediately under safelight con-
Ans.
ditions.
● A good universal safelight filter recommended Processing errors of radiographs
for use in a darkroom in which both extraoral ● Poor image in an X-ray film results in loss of diagnostic
screen films and intraoral films are processed in information. Many defects are commonly encountered
the GBX-2 safelight filter by Kodak. in manual processors, though automatic processors also
iv. Adequate storage produce certain faults.
● The darkroom storage space must include ample Following errors are mainly encountered with manual pro-
room for chemical processing solutions, film cessing:
cassettes and other miscellaneous radiographic a. Light radiographs
supplies. The radiographs appear lighter due to:
● Storage of unopened boxes of film in the darkroom ● Underexposure and also may be due to insuffi-

is not recommended; a reaction between the fumes cient mA, kVp or time.
from chemical processing solutions and the film ● Excessive film–source distance.

emulsion may occur that will result in film fog. ● Underdeveloped, may be due to insufficient time,

● Boxes of opened extraoral film must be stored depleted developer or excessive fixation.
in the darkroom. A light tight storage drawer is ● Total white film is usually because of placing re-

necessary to protect opened boxes of unexposed verse side of the film during exposure.
extraoral film. b. Dark radiographs
v. Temperature and humidity controlled Dark radiographs are predicted because of the
● The temperature and humidity level of the darkroom following reasons:
must be controlled to prevent film damage. A room ● Overexposure or may be due to excessive mA,

temperature of 70°F is recommended; if the room kVp or excessive exposure time.

temperature exceeds 90°F, film fog results. ● Insufficient film–source distance.
Section | I Topic-Wise Solved Questions of Previous Years 469

● Overdevelopment or inadequate fixation. ● Automatic processing cycle is the same as for manual
● Accidental exposure to light. processing except that the rollers squeeze off any excess
c. Film fog developing solution before passing the film on to the
Fog on the film is due to: fixer, eliminating the need for the washing with water
● Leaking light in darkrooms. between these two solutions.
● Safelights not proper and/or excessive watt- Advantages
age. ● Time saving – dry films are produced in about five

● Contaminated solutions. minutes.

● Deteriorated films or films stored at the higher ● There is no need for a darkroom.

temperature and even outdated films. ● Controlled, standardized processing conditions are

● Overdevelopment. easy to maintain and chemicals can be replenished

d. Dark spots automatically.
The dark spots on the film are due to: Disadvantages
● Finger prints on the radiographs before ● Strict maintenance and regular cleaning are essential;

development. dirty rollers produce faulty radiographs.

● Excessive bending before development. ● Equipment is expensive.

● Film in contact with other films during fixation.

Q.5. Processing of X-ray film.
● Forceps touching the film during development.

e. Light spots/water spots Ans.

● Film contaminated with fixer before the pro-
Processing is the term used to describe the sequence of
cessing.
events required to convert the invisible latent image con-
● Film in contact with other film during developing.
tained in the sensitized emulsion into the visible permanent
● Scratches over the film.
radiographic image.
f. Yellow/brown stains
Various methods of processing are as follows:
The film shows yellow/brown stains due to:
i. Manual methods:
● Contaminated solutions and depleted devel-
a. Visual method
oper or fixer.
b. Rapid processing method
● Not thorough rinsing after fixing.
c. Time–temperature method
g. Blurred radiographs
ii. Automatic method
● Movement of the patient or X-ray tube and insta-
iii. Monobath method
bility of film during exposure.
iv. Daylight method
h. White lines
v. Digitalized processing method
● Manufacturing defects produce such type of
vi. Self-developing films
lines.
Various faults in case of automatic processor are as i. Manual method/time–temperature method
follows: The following steps are involved in manual method:
a. Pressure marks: Too tight roller springs. a. Replenish solutions and developing the film
b. Stripping of the emulsions: It may be because b. Rinsing in water
of the defective rollers or defective chemical c. Fixing of film
nature of the films. d. Washing film in running water
c. Streaks and mottles: They may result due to e. Drying and mounting of film
faulty position of air driers, squeezers and even a. Replenish solutions
too high temperature of the drier. ● The first step is to replenish the developer and fixer.

● Eight ounces (0.0284 L) per gallon (4.546 L)

Q.4. Automatic film processing.
of fresh developer and fixer are added to main-
Ans. tain the proper strength of each solution.
● Ensure that the level of developer and fixer in
● When the processing is carried out automatically by a tanks should cover the films on the top.
machine, it is known as automatic processing. ● The solutions are stirred to mix the chemicals and
● Several automatic processors are available, which are equalize the temperature throughout the tanks.
designed to carry the film through the complete cycle ● This prevents cross-contamination.
usually by a system of rollers. b. Developing
● Most have a daylight loading facility, eliminating the ● The timer mechanism is set and the hanger and
need for a darkroom. films are immersed immediately in the developer.
470 Quick Review Series for BDS 4th Year, Vol 2

● The films are left in the developer for the pre- ● Results are not satisfactory as in conventional
determined time. processing.
The films are removed and the excess developer is
Q.6. Coin test
drained into the water bath. After developing, the
film hanger is placed in the running water bath for Ans.
30 s, agitating continuously to remove excess
developer and thus slow the development and {SN Q.9}
minimize contamination of the fixer.
c. Fixing ● Coin test is also known as Penny test.
● The hanger and film are then placed in the fixer ● The safelighting conditions in the darkroom can be
solution for a minute and agitated for 5 s every evaluated using a coin test.
30 s. The procedure of coin test is as follows:
d. Wash and dry i. Turn off all the lights in the darkroom, including
● After fixation of the films is complete, they are the safelight.
placed in running water for at least 10 min to ii. Unwrap the unexposed film. Place on a flat sur-
remove residual processing solutions. face at least 4 feet distance from the safelight.
● After the films have been washed, surface Place a coin on top of the film.
moisture is removed by gently shaking excess iii. Turn on the safelight. Allow the film and coin to
water from the films and hanger. be exposed to the safelight for 3–4 min and then
● The films are dried in circulating, moderately remove the coin and process the film.
warm air. The results of the safelighting test can be interpreted as
● After drying, the films are ready to mount. follows:
ii. Automatic method of processing ● If no visible image is seen on the processed radio-

This method uses equipment that automates all the graph, the safelighting is proper and proceed with
processing steps. film processing.
Types ● If the image of the coin and a fogged background

● Miniature roller-type that produces a dried film. appears on the processed radiograph, it indicates
● Automatic Dunking models that produces a washed improper safelighting and is not safe to use with
film that still has to be dried. processing of films.
Advantages
● Uniformity of results. Steps to avoid safelighting problems:
● Rapidity of the operation, the entire process may The dental radiographer must use the film manufactur-
take less than 4–7 min. er’s recommended safelight filters and bulb wattages. In
● Less floor space required and has daylight loading addition, the film must be unwrapped at least 4 feet away
capability. from the safelight. Safelighting problems must be corrected
● No reading of wet films. before proceeding with film processing.
Disadvantages Q.7. Requirements of a darkroom.
● High cost of the equipment and maintenance.

● Quality is not as high as that of a manually devel- Ans.

oped radiograph. [Ref LE Q.4]
iii. Monobath method
● In this method, the developer and fixer are combined
Q.8. Composition and functions of developing solution.
in one solution. Ans.
● This monobath is injected into special water proof-
[Same as SE Q.1]
ing film packet and the film is developed simply by
rubbing the film packet. Q.9. Composition and actions of developing solution.
Advantages Ans.
● There is no need of a darkroom.

● It is ideal and helpful in cases of quick spot diagno-

[Same as SE Q.1]
sis, e.g. RCT cases. Q.10. Composition and action of fixer solution.
Disadvantages
● The alkaline type of fixer very rapidly oxidizes
Ans.
under atmospheric conditions. [Same as SE Q.2]
Section | I Topic-Wise Solved Questions of Previous Years 471

Q.11. X-ray fixing solution. ● It removes the alkali activator, preventing neutraliza-
tion of the acid fixer.
Ans.
Q.4. Fixing solution.
[Same as SE Q.2]
Ans.
Q.12. Types of X-ray film processing.
Composition
Ans. ● Clearing agent–sodium thiosulphate

● Preservative–sodium sulphate
[Same as SE Q.5]
● Acidifier–acetic acid
Q.13. Processing of an intraoral film. ● Hardener–aluminium chloride

● Solvent–water
Ans.
Functions
[Same as SE Q.5] ● To help in removal of the undeveloped silver halide

grains from the emulsion.

● It also hardens the emulsion.
SHORT NOTES:
Q.5. Actions of developing solutions.
Q.1. Composition of developer solution.
Ans.
Ans.
Actions of developing solutions are as follows:
[Ref LE Q.2]
● When an exposed film is developed, initially the devel-
Q.2. Resolution. oper produces no visible effect, after which the density
increases very rapidly and then it slows down.
Ans.
● Eventually all the exposed crystals develop and become
● Sharpness of image is also known as detail, resolution reduced to black metallic silver. Slowly generates the
or definition. black tones and contrast in the image.
● Sharpness refers to how well the smallest details of an
Q.6. Automatic film processing.
object are reproduced on a dental radiograph.
● The sharpness of a film is influenced by the following Ans.
three factors:
This method uses equipment that automates all the pro-
a. Focal spot size
cessing steps.
b. Film composition
Types
c. Movement
i. Miniature roller-type
Q.3. Replenisher. ii. Automatic Dunking
Advantages
Ans. ● Uniformity of results
● Rapidity of the operation
Replenisher or developer replenisher
● Less floor space required and has daylight loading
● Developer becomes inactivated with use and by
capability
exposure to oxygen.
Disadvantages
● The developing solution of both manual and auto-
● High cost of the equipment and maintenance
matic developers should be replenished with fresh
solution each morning to prolong the life of the Q.7. Storage of X-rays films.
seasoned developer.
● The recommended amount to be added daily is
Ans.
8 ounces of replenisher per gallon of developing Storage of X-ray films
solution. Some of the used solution may need to be ● Film must be stored in areas that are adequately
removed to make room for the replenisher. shielded from sources of radiation.
Composition Optimum conditions
● The replenisher generally has the same composition ● To prevent film fog, unexposed, unprocessed film
as the developing solution, only thing is that it is must be kept in a cool, dry place.
more alkaline and does not contain restraining ● The optimum relative humidity level ranges from
bromide. 30% to 50%.
Uses ● The optimum temperature for film storage ranges

● Dilutes the developer. from 50°F to 70°F.

472 Quick Review Series for BDS 4th Year, Vol 2

Other parameters Q.8. Requirements of darkroom.

● To prevent film fog, lead-lined or radiation-resistant
Ans.
film dispensers and storage boxes are ideal.
● The ‘first in, first out’ rule of thumb should be ap- [Ref LE Q.4]
plied to film use; the oldest film in stock always used
before any new film. Q.9. Coin test.
● All dental X-ray film has a limited shelf life.
Ans.
● Each box or container of film is clearly labelled with

an expiry date. [Ref SE Q.6]

Topic 5
Image Principles: X-Rays Quality Control
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. Describe artefacts, blemishes and faults in dental radiography.
2. Discuss in detail factors responsible for obtaining an ideal radiograph.
3. Discuss ‘faulty intraoral (IO) radiographs’.
4. Discuss the causes of distortion and magnification of images in the radiographs.
5. Discuss the causes of faulty radiograph. How would you avoid it? [Same as LE Q.1]
6. Discuss in detail the faults in dental radiograph and prevention of these faults. [Same as LE Q.1]
7. Discuss in detail the various causes for faulty radiographs and measures to rectify them. [Same as LE Q.1]
8. What is an ideal radiograph? Enumerate the various factors influencing the quality of radiograph. [Same as LE Q.2]
9. Define an ideal radiograph. Describe basic principles to obtain an ideal radiograph. [Same as LE Q.2]

SHORT ESSAYS:
1. Artefacts on a radiograph.
2. Light radiograph.
3. Define an ideal radiograph. Enumerate the factors affecting the production of an ideal radiograph.
4. Dark radiograph.
5. Film fog.
6. Write note on image receptors.
7. Causes for dark radiographs. [Same as SE Q.4]

SHORT NOTES:
1. Cone-cut.
2. What are the causes of fog on radiograph?
3. Define faulty radiographs. [Ref LE Q.4]
4. Dark and light radiographs.
5. Artefacts. [Ref SE Q.1]
6. Define density and contrast in radiology.
7. Faulty X-rays. [Same as SN Q.3]
8. Four causes for dark radiographs. [Same as SN Q.4]
9. Radiographic density. [Same as SN Q.6]
Section | I Topic-Wise Solved Questions of Previous Years 473

SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe artefacts, blemishes and faults in dental x. Black lines and marks
radiography. ● Moisture contamination especially failure to

blot the film pocket results in black marks.

Ans.
● Writing lines are caused by writing on the film
Artefacts packet with a ball point pen or a lead pencil.
● Artefact is a structure or radiographic appearance that is xi. Yellow/brown stains
normally not present in the radiograph but produced by ● Depleted fixer
artificial means. ● Oxidized or exhausted developer
i. Blank radiograph ● Contaminated solutions
● Unexposed film. ● Insufficient washing/rinsing
● Exposed film dipped into the fixer solution be- Blemishes
fore it was placed into the developer solution. ● Blemishes are the defects or faults or errors on the ra-
ii. Partial image diographs.
● Only part of the film might have been immersed A wide variety of causes for the defective/faulty radio-
into the developer solution. graphs are grouped under the following headings:
iii. Blurring of image i. Errors in film storage and handling
● Exposure twice on the same film or movement ii. Errors in film placement and projection technique
of patient or tube head. iii. Errors in exposure parameters and processing technique
iv. Blisters on the film
i. Errors in film storage and handling
● Air-bubbles on film while developing.
a. Film fog
● Increased acidity of the developer solution.
● Outdated films.
● Films not agitated when first immersed in fixer.
● Films stored at high temperature or exposed to
v. Dark spot on the radiograph
radiation.
● Finger prints.
b. Emulsion peel
● Excessive bending of the film.
● Wet film in contact with finger nails.
● Film in contact with another film or tank walls
c. Dark spots or line
during the fixing procedure.
● Contamination with finger prints.
● Film contaminated with the developer solution
ii. Errors in film placement and projection technique
before the actual processing.
a. Type mark pattern
vi. Light spots on the radiograph
● Wrong side (opposite side) of the film exposed to
● Film contaminated with the fixer solution before
radiation.
the actual processing.
b. Cone-cut
● Film in contact with another film or tank walls
● Improper placement of the film and the position
during the developing procedure.
indicating device (PID).
vii. Foreign body image on the radiograph
c. Shortened image
● Radiopaque materials like ear rings, nose studs
● Increased vertical angulation used in bisecting
in the path of the X-ray beam.
angle technique.
● Placement of the finger between the X-ray tube
● Film not placed parallel to the long axis of the
and the film such as using the finger to stabilize
tooth in paralleling technique.
the film in the mouth.
d. Elongated image
viii. Static electricity artefact
● Decreased vertical angulation in bisecting angle
● Forceful unwrapping of the film from the pocket
technique.
or from the cassette.
● Film not placed parallel to the long axis of the
● Static electricity marks or smudge markings
tooth in paralleling technique.
may result from visible light produced by sparks
e. Overlapping of the teeth
caused by a relatively low potential electrical
● Incorrect horizontal angulation.
discharge in the air next to the film surface.
f. Blurred image
ix. Nail mark artefact
● Movement of the film or patient during the expo-
● Too much bending of the film.
sure causes totally blurred image.
474 Quick Review Series for BDS 4th Year, Vol 2

● Excessive bending of the film causes partially ● A visible photographic record on the X-ray film pro-
blurred image. duced by passage of X-rays through an object or body
g. Crown portion of the teeth or apical ends of the teeth is called radiograph.
not imaged ● Dental radiograph is a photographic image produced
● Improper placement of the film. on the film by the passage of X-rays through teeth and
● Insufficient vertical angulation. related structures.
h. Double images According to H.M. Worth, ‘An ideal radiograph is one
● Film exposed twice to radiation. which has desired density and overall blackness and which
i. Tyre track effect (Herring bone effect) shows the part completely without distortion with maxi-
● Opposite side of film placed towards tube. mum details and has the right amount of contrast to make
iii. Errors in exposure parameters and processing tech- the details fully apparent’.
nique The characteristics of an ideal radiograph are as follows:
a. Film fog A. Visual characteristics
● Improper wattage of the safelight. B. Geometric characteristics
● Prolonged exposure of the film to safelight. C. Anatomic accuracy of radiographic images
● Safelight not at a proper distance from the work- D. Adequate coverage of the anatomic region of interest
ing place. The image quality and the amount of detail shown on a
● Light leaks from cracked safelight filters or ven- radiographic film depend on several factors mentioned
tilators. above and described in detail below:
b. Dark radiographs Visual characteristics
1. Exposure errors i. Density
● Excessive milliamperage (mA), kilovoltage ii. Contrast
peak (kVp) and exposure time.
i. Density
● Insufficient film and X-ray source distance.
● Factors affecting the density of a radiograph are as
2. Processing errors
follows:
● Improper safe lighting and accidental expo-
First-degree factors:
sure to light.
a. mA
● Too high developer temperature and concen-
b. Exposure time
tration.
c. Operating kVp
● Film developed for a longer period.

● Longer developing time. a. mA

● Inadequate fixation. ● An increase in mA produces more X-rays that
c. Light radiographs expose the film and result in increased film den-
1. Exposure errors sity.
● Insufficient mA, kVp and exposure time. ● If mA increases, then film density increases. If mA
● Film packet placed with the wrong side facing decreases, then film density decreases. Thus, den-
the X-ray source. sity varies directly and proportional to the mA or
● SFD (source–film distance) too large. the tube current.
2. Processing errors b. Exposure time
● Excessive fixation. ● An increase in the exposure time increases the film
● Depleted and diluted or contaminated devel- density. If exposure time is increased, then film
oper solution. density is increased and if exposure time is de-
● Too low temperature of the developer solution. creased, then film density is decreased.
d. Low contrast radiographs ● Exposure time and mA are interchangeable and
● kVp too high. are thus considered as a single factor.
● Under exposure or under development. c. Operating kVp
A quality-controlled radiographic service can be ● An increased kVp increases the penetrating power
given to patients if the dental surgeon can identify of X-rays, thereby increasing the density.
the causes of these errors and develop his/her own ● If kVp increases, then film density increases. If
chart for trouble shooting. kVp decreases, then film density decreases. Thus,
density varies directly and in proportion to the
Q.2. Discuss in detail factors responsible for obtaining
square of the relative kVp.
an ideal radiograph.
D a (kVp)2
Ans.
Section | I Topic-Wise Solved Questions of Previous Years 475

d. SFD ● A graphical relationship between film density and expo-

● The intensity of an X-ray beam varies inversely sure is called a characteristic curve or hand D curve.
as the square of the SFD; density also varies in- ● This curve is typical of a screen–film combination, and
versely as the square of the SFD. reveals information about film contrast, speed and lati-
tude.
(kVp)2  mA  S
Hence, Density  ● It can be seen from the curve that as exposure is in-
[(S  F) dista n ce]2 creased, density also increases.
The film has greatest diagnostic value, at the relatively
Second-degree factors:
straight portion of the graph.
a. Subject thickness
ii. Contrast
b. Development conditions
● The difference in the degree of blackness (densities)
c. Type of film
between adjacent areas on a dental radiograph is
d. Screens
known as contrast.
e. Grids
● A radiograph is said to have a ‘high contrast’ if a
f. Amount of filtration used
dental radiograph has very dark areas and very light
g. Fog
areas, as the dark and the light areas are strikingly
a. Subject thickness: different.
● In a patient with an increased amount of soft tissue ● A radiograph that does not have very dark and very

or thick dense bones, fewer X-rays will reach the light areas, but instead has many shades of grey is
film and the radiograph will appear light and have said to have a ‘low contrast’.
less density. ● Radiographic contrast, i.e. the final visual difference

● If subject thickness increases, then density de- between the various black, white and grey shadows
creases. If subject thickness decreases, then den- depends on:
sity increases. a. Subject contrast
● Adjustments in the operating mA, kVp or expo- b. Film contrast
sure time can be made to compensate for varia- c. Fog and scatter
tions in size of the patient and subject thickness.
The next lower kVp and/or mA should be used, a. Subject contrast
if patient is thin and has a narrow facial bone ● The difference caused by different degrees of

structure. attenuation as the X-ray beam is transmitted

b. Development conditions: through different parts of the patient’s tissues is
Under or over development of the radiograph results known as subject contrast.
in a light or dark radiograph. ● It depends on:

c. Type of film: i. Differences in tissue thickness

● Film speed: High-speed films require less mA/s in ii. Differences in tissue density
order to obtain a density change. iii. Differences in tissue atomic number or
● Film latitude: It is measured as a range of expo- photoelectric absorption
sures that can be recorded as distinguishable den- b. Film contrast
sities on a film. ● This is an inherent property of the film itself. It

● Radiographic noise: It is the appearance of uneven determines how the film will respond to the dif-
density of a uniformly exposed radiographic film. ferent exposures it receives after the X-ray
It is seen on a small area of film as localized varia- beam has passed through the patient.
tions in density. ● Film contrast depends on four factors:

d. Screens: Use of screens requires less mAs in i. The characteristic curve of the film.
order to obtain a density change. ii. Optical density or degree of blackening of
e. Grids: The use of grids requires more mAs in the film.
order to obtain a density change. iii. Type of film – direct or indirect action.
f. Amount of filtration used: Reduction in the amount of iv. Processing.
added filtration used will increase the density. c. Fog and scatter
g. Fog: Film fog may result in an undesirable form of Radiographic contrast reduces as a result of stray
darkening of the film. radiation reaching the film either as a result of
Characteristic curve background fog, or owing to scatter from within
● Hurter and Driffield first described the relationship be- the patient, which produces unwanted film density
tween film density and exposure in 1890. or darkening.
476 Quick Review Series for BDS 4th Year, Vol 2

Geometric characteristics ● The image magnification on a dental radiograph is

i. Sharpness or detail influenced by the following:
ii. Resolution or definition a. Target–film distance
iii. Magnification b. Object–film distance
iv. Distortion
a. Target–film distance
i. Sharpness or detail ● The distance between the source of X-rays

● The ability of the X-ray film to define an edge is and the film is known as the target–film dis-
known as image sharpness. tance also known as the SFD.
ii. Resolution or definition ● When a longer PID is used, more parallel rays

● Resolution, or resolving power of the film, is a mea- from the middle of the X-ray beam strike the
sure of the film’s ability to differentiate between object rather than the diverging X-rays from
different structures and record separate images of the periphery of the beam. As a result, a lon-
small objects placed very close together and is mea- ger PID and target–film distance result in less
sured in line pairs per mm. image magnification, and a shorter PID and
The main causes of loss of edge definition include: target–film distance result in more image
A certain degree of unsharpness is present in all magnification.
dental radiographs. The fuzzy, unclear area that sur- b. Object–film distance
rounds a radiographic image is termed ‘penumbra’. ● The distance between the object being radio-

● Geometric unsharpness: This type of unsharp- graphed, i.e. the tooth and the dental X-ray
ness is due to criss-crossing of rays at the edges film is known as the object–film distance.
of the object, resulting in a fuzzy image border. ● A decrease in object–film distance results in a

Size of the focal spot and target object distance decrease in magnification, and an increase in
affect geometric unsharpness. object–film distance results in an increase in
● Size of the focal spot: Smaller the focal spot, image magnification.
sharper the image produced. When a ‘point iv. Distortion
source’ is used, the normal focal spot size is ● Dimensional distortion of a radiographic image is a

0.6 mm2 to 1 mm2 and nonsharpness is produced. variation in the true size and shape of the object be-
● Object–film distance: This should be as small as ing radiographed.
possible to get a sharper image. ● A distorted image results from the unequal magnifi-

● Target–object distance: Should be as large as cation of different parts of the same object. Distor-
possible, to get a sharper image. tion results from improper film alignment or beam
● Motion unsharpness: It is caused by the patient angulation.
moving during the exposure. The factors influencing dimensional distortion of a
● Absorption unsharpness: It is caused due to radiographic image are:
variation in object shape, e.g. cervical burn-out a. Object–film alignment
at the neck of a tooth. ● To minimize dimensional distortion, the ob-
● Screen unsharpness: It is caused by the diffusion ject and film must be parallel to each other.
and spread of the light emitted from intensifying ● A distorted image may appear too long or too

screens. short.
● Poor resolution: Resolution is determined mainly b. X-ray beam angulation
by characteristics of the film including: type, di- ● To minimize dimensional distortion, the X-ray

rect or indirect action, speed and silver halide beam must be directed perpendicular to the
emulsion crystal size. tooth and the film.
iii. Magnification ● If the vertical angulation is increased, there

● Image magnification refers to a radiographic image will be shortening of the image and if it is
that appears larger than the actual size of the object decreased, there will be elongation of the
it represents. image.
● Magnification or enlargement of a radiographic ● If the horizontal angulation is increased mesi-

image results from the divergent paths of the ally or distally, there will be overlapping of
X-ray beam. Because of this some degree of im- structures.
age magnification is present in every dental radio- ● The geometric accuracy of any image depends

graph. on the position of the X-ray beam, object and

Section | I Topic-Wise Solved Questions of Previous Years 477

image receptor satisfying certain basic geo- Faulty radiographs resulting from faulty radiographic
metrical requirements: technique
● The object and the film should be in contact or Foreshortening of the image
as close together as possible. ● Foreshortening refers to images of the teeth that

● The object and the film should be parallel to appear too short.
one another. ● Excessive vertical angulation results in foreshort-

● The X-ray tube head should be positioned so ening of images.

that the beam falls at right angles on the object Elongation of the image
and the film. ● Elongation refers to images of the teeth that ap-

Alterations in geometric characteristics are mainly pear too long.

due to: ● Decreased vertical angulation results in elonga-

● X-rays originate from a definite area rather than tion of image.

a point source. Elongation of a few teeth
● X-rays travel in diverging straight lines as they ● Elongation of a few teeth refers to a few teeth ap-

radiate from their source of origin. pearing longer than normal, whereas other teeth
● Dental radiographs are a two-dimensional repre- are of normal size.
sentation of three-dimensional structures. This re- ● Excessive bending of the film in an attempt to

sults in unequal magnification of different parts of place in the mouth results in elongation of a few
an object, because of the varying distances of these teeth in the bent portion of the film.
parts from the film. Overlapping of proximal surfaces
Anatomic accuracy of radiographic images ● Improper horizontal angulation results in overlap-

● Anatomical accuracy means when the anatomical ping of proximal surfaces, which makes the radio-
structures are reproduced on the film in exact rela- graphs of less diagnostic value, especially in the
tionship as they normally appear. detection of proximal caries.
● A radiograph with anatomical accuracy will have a Crown portion of the teeth or apical ends of the teeth
minimum of superimposition of images of adjacent not seen on the image
tissues. ● Improper placement of the film.

Adequate coverage of the anatomic region of interest: ● Insufficient vertical angulation.

● It is important that the area of interest is well covered Blurred or distorted image
in the radiograph. Adequate coverage of the area of ● An image which appears hazy and without any

interest depends on following factors: sharpness is known as blurred or distorted image.

i. Proper alignment of the film and the radiation ● Blurring or distortion of the image is due to either

beam to the area of interest. the movement of the patient, the film placed in the
ii. Proper selection of the film types and projection patient’s mouth or the X-ray tube during exposure.
techniques. Cone-cut appearance
● Cone-cut appearance refers to a clear, unexposed
Q.3. Discuss ‘faulty intraoral (IO) radiographs’. area in a dental radiograph while in the rest of the
area of the film the image is seen.
Ans.
● This fault results from the X-ray beam not centred

over the film, or in other words, if the central

X-ray is not perpendicular to the centre of the film.
{SN Q.3} Phalangioma
● The term phalangioma was used by Dr David F.
● A diagnostic radiograph is one that provides a
great deal of information; the images have proper Mitchell.
● It refers to the image of phalanx or phalanges
density and contrast, have sharp outlines and are
of the same size and shape as the object radio- appearing in the film.
● It occurs when the patient holds the film in the
graphed.
● Faulty radiographs are nondiagnostic radiographs in mouth in an incorrect way.
the sense that these radiographs are of no diagnostic Double exposure or double image
● Double exposure or double image appears due to
value as they do not provide adequate detail and
required information. repeated exposure of an already exposed film.
● Problems encountered in radiographic images Reversed film
● Reversed film refers to a film exposed from the
are due to faulty technique of radiography or
processing. opposite side, i.e. the film placed in the mouth
reversed and then exposed.
478 Quick Review Series for BDS 4th Year, Vol 2

● This results in light images with herringbone or Dark areas on the film
tyre-track or car-tyre appearance on the radio- ● Dark areas appear on film when overlap has

graph. occurred in the fixer solution.

Film creasing Straight white border
● Film creasing can result either in cracking of ● If the level of the developing solution is too low,

emulsion or a thin radiolucent line appearing in the film will not be fully immersed in the devel-
the radiograph. oper, resulting in a straight white border repre-
Crimp-marks senting the undeveloped portion of the film.
● Crimp-marks or nail-like curved dark lines result Straight black border
from sharp bending of the film. ● If the level of the fixer is too low, in the unfixed

Light image potion of the film, straight black border appears.

● A light image is devoid of proper contrast. A de- White marks on the film
crease in the exposure time, mA or kVp results in ● When air-bubbles are trapped on the film surface,

a light image. the processing solution does not come in contact

Dark image with the film. This results in white marks on the film.
● A dark image results from excessive exposure Nail marks
time, rnA or kVp. ● Nail mark artefacts are crescent-shaped when the

Faulty radiographs resulting from faulty processing emulsion is damaged by the finger nail due to
techniques rough handling of the film.
Light image Finger marks
● Less exposure time, mA and kVp, results in a ● Handling the film with wet fingers results in

light image. finger marks on the film.

● It can also result from inadequate development Scratched emulsion
time, inaccurate timer, low developer tempera- ● When the film comes in contact with sharp

ture and depleted or contaminated developing objects, the emulsion in that area is removed,
solution. causing scratched emulsion, as in these areas the
Dark image emulsion gets peeled off.
● A dark image is the result of excessive develop- Thin black branching lines or tree-like appearance
ment time, inaccurate timer, higher developer ● This appearance results from static electricity ex-

temperature and concentration. posing the film due to opening of the film packet
Cracked or reticulated image too quickly, humid conditions or rubbing of the
● When the film is subjected to a sudden tempera- film with the intensifying screen.
ture change between the developer and the water Fogging of the film
bath, it results in cracked or reticulated image. ● Fogged film refers to a film which appears grey

Dark spots on the film without image detail and contrast.

● The droplets of developing solution coming in ● It results from improper safe lighting conditions,
contact with an exposed film before it is devel- light leakage, improper storage conditions of the
oped results in dark spots or developer spots on film, expired or outdated film, contaminated process-
the film. ing solution or high temperature of the developer.
White spots on the film
● When droplets of fixing solution come in contact
Q.4. Discuss the causes of distortion and magnification
with an exposed film before it is developed results of images in the radiographs.
in white spots or fixer spots on the film. Ans.
Blank film
● Blank film refers to total absence of image. Distortion
● Immersing the exposed film in the fixing solution ● Dimensional distortion of a radiographic image is a

before it is immersed in the developing solution variation in the true size and shape of the object be-
results in blank film. ing radiographed.
● The film appears translucent as the entire emul- ● A distorted image does not have the same size and

sion is washed off. shape as the object being radiographed.

White area on the film ● A distorted image results from the unequal magnifi-

● During development when two films come in con- cation of different parts of the same object. Distor-
tact with each other, the overlapped portion ap- tion results from improper film alignment or beam
pears whiter. angulation.
Section | I Topic-Wise Solved Questions of Previous Years 479

The factors influencing dimensional distortion of a image magnification, and a shorter PID and
radiographic image are target–film distance result in more image
i. Object–film alignment magnification.
ii. X-ray beam angulation ii. Object–film distance
● The distance between the object being radio-
i. Object–film alignment
graphed, i.e. the tooth and the dental X-ray
● To minimize dimensional distortion, the object
film, is known as the object–film distance.
and film must be parallel to each other.
● The tooth and the X-ray film should always be
● If the object (tooth) and film are not parallel, an
placed as close together as possible. The closer
angular relationship results, which produces a
the tooth to the film, the less image enlarge-
variation of distances between the tooth and the
ment there will be on the film. A decrease in
film that results in a distorted image.
object–film distance results in a decrease in
● A distorted image may appear too long or too
magnification, and an increase in object–film
short.
distance results in an increase in image
ii. X-ray beam angulation
magnification.
● To minimize dimensional distortion, the X-ray

beam must be directed perpendicular to the Q.5. Discuss the causes of faulty radiograph. How would
tooth and the film. you avoid it?
● The central ray of the X-ray beam must be as
Ans.
nearly perpendicular to the tooth and film as
possible to record the adjacent structures in [Same as LE Q.1]
their true spatial relationships.
Q.6. Discuss in detail the faults in dental radiograph
● If the vertical angulation is increased, there
and prevention of these faults.
will be shortening of the image and if it is de-
creased, there will be elongation of the image. Ans.
● If the horizontal angulation is increased mesially
[Same as LE Q.1]
or distally, there will be overlapping of structures.
● The film should never be bent in the direction Q.7. Discuss in detail the various causes for faulty radio-
of long axis of tooth, and to prevent movement graphs and measures to rectify them.
during exposure, a film holder must be used.
Ans.
Magnification
● Image magnification refers to a radiographic image [Same as LE Q.1]
that appears larger than the actual size of the object
Q.8. What is an ideal radiograph? Enumerate the vari-
it represents.
ous factors influencing the quality of radiograph.
● Magnification, or enlargement of a radiographic im-

age, results from the divergent paths of the X-ray Ans.

beam. X-rays travel in diverging straight lines as they
[Same as LE Q.2]
radiate from the focal spot. Because of these diverg-
ing paths, some degree of image magnification is Q.9. Define an ideal radiograph. Describe basic princi-
present in every dental radiograph. ples to obtain an ideal radiograph.
● The image magnification on a dental radiograph is
Ans.
influenced by the following:
i. Target–film distance [Same as LE Q.2]
ii. Object–film distance
i. Target–film distance SHORT ESSAYS:
● The distance between the source of X-rays and
Q.1. Artefacts on a radiograph.
the film is known as the target–film distance,
also known as the SFD. Ans.
● The target–film distance is determined by the

length of the PID.

● When a longer PID is used, more parallel rays {SN Q.5}
from the middle of the X-ray beam strike the ● Artefact is a structure or radiographic appearance
object rather than the diverging X-rays from that is normally not present in the radiograph but
the periphery of the beam. As a result, a longer produced by artificial means.
PID and target–film distance result in less
480 Quick Review Series for BDS 4th Year, Vol 2

● Depleted developer solution.

● Various artefacts seen on the radiograph are:
● Diluted or contaminated developer.
i. Black lines and marks
● Excessive fixation.
● Moisture contamination especially failure to
D. Processing errors can be corrected by:
blot the film pocket results in black marks.
● Setting the darkroom timer correctly and replacing
Blot the film packet after removal from the
inaccurate thermometer.
patient mouth to avoid black lines or marks.
● Raising the temperature of developer to 70°F.
● Black lines on the radiograph are caused
● Replacing the depleted developer solution.
due to routine bending of the film to reduce
● Adding replenisher or replacing developer or adding
patient discomfort.
more developer solution.
● To correct this, avoid unnecessary bending of
● Regulating the fixing time as per time table.
the film.
ii. Writing lines on the radiograph Q.3. Define an ideal radiograph. Enumerate the factors
● These are caused by writing on the film affecting the production of an ideal radiograph.
packet with a ball point pen or a lead pencil.
Ans.
● To prevent these lines use a crayon type pencil

to mark on the film. According to H.M. Worth, ‘An ideal radiograph is one
iii. Nail mark artefact which has desired density and overall blackness and which
● Too much bending of the film. shows the part completely without distortion with maxi-
● Avoid unnecessary bending. mum details and has the right amount of contrast to make
iv. Static electricity artefact the details fully apparent’.
● Forceful unwrapping of the film from the Factors affecting the production of an ideal radiograph
pocket or from the cassette. may also be classified as:
● Static electricity marks or smudge markings I. Factors related to the radiation beam
may results from visible light. a. mA
v. Random artefacts on film b. kVp
● Caused by contaminants like paper felt and dust. c. Exposure time
● To prevent this, check the screens inside the d. SFD
cassettes for contaminants. e. Size of the focal spot
f. Collimation and filtration
II. Factors related to the absorbing media or object
Q.2. Light radiograph.
a. Density and thickness of the object
Ans. III. Factors related to the technique
a. Position of patient’s head
Low-density film or light radiograph results from:
b. Placement and position of the film
A. Exposure errors resulting in light radiographs are
c. Angulation of the X-ray beam
● Under exposure, i.e. too short an exposure time.
IV. Factors related to recording of the radiographic image
● Using too large SFD.
of the object
● Use of too low kVp and mA.
a. Film storage
● Drop in the line voltage.
b. Secondary radiation
● Film packet placed with the wrong side facing the
c. Intensifying screens
tooth.
d. Processing of film
● Insufficient size of the power line.

● Use of incorrect film screen combination. Q.4. Dark radiograph.

B. Exposure errors can be corrected by
Ans.
● Setting exposure time correctly, checking the SFD,

increasing kVp and the mA. The causes of high density or dark radiographic film are as
● Placing the pebbled side of the film facing the tooth follows:
and towards the cone. Exposure errors
● Using a separate circuit for X-units and increasing ● Exposure time too long.
size of the power line or transformer. ● Too high mA or kVp for the stipulated exposure
● Always using the right screen–film combination. time.
C. Processing errors resulting in light radiograph are ● Too short SFD.
● Underdevelopment due to too low temperature, time ● Inaccurate timer.
too short, use of inaccurate thermometer. ● Incorrect combination of screen–film.
Section | I Topic-Wise Solved Questions of Previous Years 481

Developmental errors vii. Use time–temperature method for developing

● Too long developing time. films.
● Developer temperature too high. viii. Store film in a cool and dry place (70°F and 50%
● Inaccurate thermometer. relative humidity).
● High concentration of developer. ix. Limit supply and use older films first.
Exposure errors and developmental errors can be
Q.6. Write note on image receptors.
corrected by:
i. Use time temperature method with a darkroom Ans.
timer.
In dentistry, various image receptors are used to detect
ii. Reduce kVp and mA and exposure time.
X-rays. They are as follows:
iii. Measure the SFD.
i. Radiographic film
iv. Replace inaccurate thermometer and lower the
● Direct-action or packet film
developer temperature to 70°F.
● Indirect-action film used in conjunction with intensi-
v. Check tank capacity and concentration of dev­
fying screens in a cassette
eloper.
ii. Digital receptors
vi. Set timer correctly and/or reduce exposure time.
● Solid-state sensors
vii. Too fast a film and/or screen for the kVp and/or
● Phosphor plates
mA setting should not be used. Make sure that
Radiographic film
appropriate screen–film combination be used.
● In dentistry, radiographic film has traditionally been

Q.5. Film fog. used as the image receptor and is still widely used.
There are two basic types:
Ans. a. Direct-action or nonscreen film:
● This type of film is sensitive primarily to X-ray
The causes of film fog are as follows:
photons.
A. The causes of fogging due to light are
b. Indirect-action or screen film:
i. Light leaks in the darkroom.
● It is so called because it is used in combination
ii. Improper safelight.
with intensifying screens in a cassette.
iii. Improper filters in safelight.
● It is sensitive primarily to light photons, which
iv. Turning overhead (white) light on too soon.
are emitted by the adjacent intensifying screens.
v. Prolonged exposure of films to safelight.
● They respond to shorter exposure of X-rays,
vi. Smoking in the darkroom.
enabling a lower dose of radiation to be given
B. The causes of fogging due to chemicals are
to the patient.
i. High concentration of developer.
Digital receptors
ii. Developer temperature too high.
Direct digital image receptors available are of two types as
iii. Prolonged development time.
follows:
iv. Contaminated developer solution.
a. Solid-state (CCD or CMOS)
C. Deterioration of the film due to:
b. Photostimulable phosphor storage plates
i. Too high temperature and humidity of storage area.
Uses
ii. Strong fumes (ammonia and paint).
● Both of the above sensors can be used for i.o. (periapi-
iii. Outdated film.
cal and bitewing radiograph) and extraoral radiography
iv. Improper screen–film combination.
including panoramic and skull radiography.
v. Films exposed to radiation.
● Only phosphor storage plates are available for occlu-
D. The fogging can be prevented by following measures:
sal and oblique lateral radiography as it is currently
i. Checking for light leaks, vents, doors and walls,
too expensive.
and even cracked safelight filter are to be corrected.
ii. Reducing the wattage of the bulb and keeping ade- Q.7. Causes for dark radiographs.
quate (4 feet) distance between safelight and work
Ans.
area.
iii. Reducing exposure time of films to safelight. [Same as SE Q.4]
iv. Fix films for 1–2 min before turning on the light.
v. Store unexposed films in lead receptacles and away
from source of radiation in a protective compart-
SHORT NOTES:
ment.
Q.1. Cone-cut.
vi. Reduce temperature of developer and cleaning de-
veloper tank periodically. Ans.
482 Quick Review Series for BDS 4th Year, Vol 2

● Cone-cut appearance refers to a clear, unexposed area in ● Film developed for a longer period.
a dental radiograph while in the rest of the area of the ● Developing time more.
film, image is seen. ● Inadequate fixation.

Causes Light radiographs

i. This occurs due to projection errors. This fault re- i. Exposure errors
sults from the X-ray beam not centred over the film, ● Insufficient mA, kVp and exposure time.

or in other words, if the central X-ray is not perpen- ● Film packet placed with the wrong side facing the

dicular to the centre of the film. X-ray source.

ii. PID not aligned properly with periapical film holder. ● SFD too large.

iii. Top of the film not completely immersed in devel- ii. Processing errors
oping solution. ● Excessive fixation.

● Correction. ● Depleted and diluted or contaminated developer

● Make sure that cone is properly centred over the solution.

area of interest and the film, both vertically and ● Too low temperature of the developer solution.

horizontally.
Q.5. Artefacts.
● PID and aiming ring should be properly aligned.

● Maintain the level of solution in the processing tanks. Ans.

Q.2. What are the causes of fog on radiograph? [Ref SE Q.1]
Ans. Q.6. Define density and contrast in radiology.
● Fogged film refers to a film that appears grey without Ans.
image detail and contrast.
i. Density: The overall blackness or darkness of a dental
● It results from:
radiograph is known as density.
i. Improper safelighting conditions
ii. Contrast:
ii. Light leakage in the darkroom
● The difference in the degrees of blackness (densities)
iii. Improper storage conditions of the film
between adjacent areas on a dental radiograph is
iv. Expired or outdated film
termed as contrast.
v. Contaminated processing solution
vi. High temperature of the developer Or
vii. Stray radiation reaching the film either as a result of
● Radiographic contrast may also be defined as the
background fog, or owing to scatter from within the
final visual difference between the various black,
patient, which produces unwanted film density or
white and grey shadows.
darkening
The image quality and the amount of detail shown on a
Q.3. Define faulty radiographs. radiographic film depend on several factors including
contrast.
Ans.
Q.7. Faulty X-rays.
[Ref LE Q.4]
Ans.
Q.4. Dark and light radiographs.
[Same as SN Q.3]
Ans.
Q.8. Four causes for dark radiographs.
Dark radiographs
Exposure errors Ans.
● Excessive mA, kVp and exposure time
[Same as SN Q.4]
● Insufficient film and X-ray source distance

Processing errors Q.9. Radiographic density.

● Improper safelighting and accidental exposure to
Ans.
light.
● Too high developer temperature and concentration. [Same as SN Q.6]
Section | I Topic-Wise Solved Questions of Previous Years 483

Topic 6
Intraoral Radiographic Techniques
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. Write the principles of imaging and discuss the bisecting angle technique.
2. Name intraoral radiographic techniques.
3. Compare paralleling and bisecting techniques.
4. Describe the indications/advantages, disadvantages and technique of bitewing radiographs.
5. Describe the procedure of localizing an impacted left maxillary canine. Enumerate intraoral radiographic
technique.
6. Describe the procedure of periapical radiograph of the mandibular central incisor using short cone technique.
7. Describe in detail the bisecting angle technique of intraoral periapical radiography. [Same as LE Q.1]
8. Describe in detail technique, advantages and limitations of bisecting angle technique of periapical radiography.
[Same as LE Q.1]
9. Discuss the bisecting angle technique and intraoral periapical radiography and advantages and limitations of
bisecting angle technique of periapical radiography. [Same as LE Q.1]
10. Describe the bisecting technique for intraoral periapical radiographs in detail with advantages and disadvan-
tages. [Same as LE Q.1]
11. What are the uses of occlusal X-ray? Describe the techniques of occlusal X-ray of maxillary palate. [Same as LE Q.2]
12. What are indications for occlusal radiographs? Describe the radiographic techniques in taking maxillary and
mandibular cross-sectional occlusal radiographs. [Same as LE Q.2]

SHORT ESSAYS:
1. Describe bisecting technique of lower third molar.
2. Define ideal radiograph. Enumerate the types of intraoral films.
3. Enumerate localization techniques, describe any one.
4. Occlusal radiograph. [Ref LE Q.2]
5. Clark’s technique.
6. Radiographic technique for maxillary standard occlusal view.
7. Give the indications of true occlusal radiograph. [Same as SE Q.4]

SHORT NOTES:
1. Indications of bitewing radiographs.
2. Mention four disadvantages of the bisecting angle technique. [Ref LE Q.1]
3. How will you manage the problem of gagging in a patient during the periapical technique?
4. Indications of transorbital view.

SOLVED ANSWERS
LONG ESSAYS:
Q.1. Write the principles of imaging and discuss the Basic principles of shadow casting
bisecting angle technique. i. Focal spot should be as small as possible.
ii. Focal spot–object distance should be as long as possible.
Ans.
484 Quick Review Series for BDS 4th Year, Vol 2

iii. Object–film distance should be as small as possible. point where the film is in contact with the
iv. The long axis of the object and the film placed teeth.
should be parallel. ● When the angle is bisected by an imaginary

v. X-ray beam should strike the object and film at right line, two congruent angles, with a common
angles. side (the imaginary bisector), are formed.
vi. There should be no movement of the tube, film or ● A line, representing the central ray of the

patient during exposure. X-ray beam will complete the third side of
● Smaller the focal spot, sharper the image. two triangles, when it is directed perpen-
● Larger the focal spot, greater the amount of pen- dicular to the bisecting line.
umbra and greater the unsharpness. ● Involves taking radiographs such that the long

● Longer the target–film distance, lesser is the axis of the rays is perpendicular to the bisector
magnification. between the long axis of the tooth and long
● Lesser the object–film distance, lesser is the axis of the film.
magnification. ● An 8-inch cone is normally used and kVp used

● If central ray is not perpendicular to tooth, short- is usually 55–65 kVp.

ening occurs. Advantages of bisecting technique
Intraoral periapical radiograph i. It can be used without a film holder when the anat-
● The intraoral periapical radiograph (IOPA) is the omy of the patient precludes the use of a film-
basic investigation that gives radiographic informa- holding device, e.g. shallow palate, bony growths
tion about the alveolar bone, periodontal areas and and sensitive mandibular premolars.
the hard tissues of the tooth. ii. Positioning is relatively easy, simple and quick.
● Two intraoral projection techniques may be used for iii. Positioning of the film packet is reasonably com-
periapical radiography: fortable for the patient.
a. Paralleling cone technique iv. A shorter exposure time is recommended, when a
b. Bisecting angle technique short (8 inch) PID is used with the bisecting technique.
v. If angulations are assessed properly, there will be no
a. Paralleling cone technique (long cone tech- changes in the dimensions of the tooth which is imaged.
nique/right angle technique)
● The rationale is that the central ray of X-ray
{SN Q.2}
beam is directed at right angles to the teeth and Disadvantages of bisecting technique
the film. i. Image distortion
● The X-ray film is kept parallel to the long axis
● Distortion occurs when a short PID is used,
of the teeth. because with a short PID there is an increased
● Special holders, which keep the film parallel to
divergence of X-rays, resulting in image mag-
the long axis of the tooth, may also be utilized, nification.
e.g. XCP® instruments (extension cone paral- ● Distortion also occurs when a tooth (three-
leling), the stab disposable film holder, and the dimensional structure) projected onto a film
Snap-A-Ray intraoral film holder. (two-dimensional structure) structure that is
● A long cone of 12 inches is used and the kVp
farther away from the film appears more elon-
used is usually 85–90 kVp. gated than those closer to the film.
● The X-rays are directed perpendicular to the film
ii. Angulation problems
and therefore there is minimum geometric dis- ● It is difficult for the dental radiographer to
tortion, less magnification and more definition. visualize the imaginary bisector and then de-
b. Bisecting angle technique termine the vertical angulation without the
● Bisecting angle technique is based on a simple
use of a film holder and aiming ring. Any er-
geometric theorem known as Cieszynski’s law ror in vertical angulation will result in image
of isometry, which states that two triangles are distortion either elongation or foreshortening.
said to be equal, when they share one complete iii. Unnecessary exposure
side and have two equal angles. ● When the patient stabilizes the film with a
● In dental radiography, this theorem is applied
finger, the patient’s hand is unnecessarily ex-
as follows: posed to the primary beam of X-ray radiation.
● The film is positioned as close as possible
iv. Incorrect horizontal angulation will result in over-
to the lingual surface of the teeth, resting lapping of the images, while incorrect vertical angu-
in the palate or in the floor of the mouth. lation will result in foreshortening or elongation of
● The plane of the film and the long axis of
the image.
the teeth form an angle with its apex at the
Section | I Topic-Wise Solved Questions of Previous Years 485

v. The periodontal bone levels are not well determined. ● To detect disease in the palate or floor of the mouth and
vi. The crowns of the teeth are often distorted and determine the medial and lateral extent of disease (cysts,
hence detection of proximal caries will be difficult. osteomyelitis, malignancies).
vii. The shadow of the zygomatic bone frequently over- ● To measure the changes in the size and shape of the
laps the periapical areas of maxillary molars. maxilla and mandible.
● To study the expansion of the palatal arch during the
Q.2. Name intraoral radiographic techniques.
orthodontic jaw expansion.}
Ans.
Maxillary occlusal projections
Classification of intraoral radiographic techniques is as There are three different maxillary occlusal projections:
follows: (i) topographic, (ii) lateral (right or left) and (iii) paediatric.
I. Intraoral radiographic techniques i. Topographic projection: The maxillary topographic
a. Bitewing radiography occlusal projection is used to examine the palate and
b. Periapical radiography: the anterior teeth of the maxilla.
i. Bisecting angle technique/short cone technique ii. Lateral (right or left) projection: The maxillary lat-
ii. Paralleling technique/long cone technique/right- eral occlusal projection is used to examine the palatal
angle technique roots of the molar teeth. It may also be used to locate
c. Occlusal radiography foreign bodies or lesions in the posterior maxilla.
i. Maxillary occlusal views iii. Paediatric projection: The maxillary paediatric oc-
ii. Mandibular occlusal views clusal projection is used to examine the anterior teeth
Maxillary and mandibular occlusal views are of the maxilla and is recommended for use in children
further divided into: 5 years old or younger.
i. Cross-sectional occlusal views Technique of maxillary topographic occlusal projection
ii. Topographic occlusal views – anterior/posterior ● Position the patient upright with the maxillary
iii. Paediatric occlusal views arch parallel to the floor, so that the sagittal plane
II. Intraoral localization radiographic techniques is perpendicular to the floor and occlusal plane is
a. Stereoscopy horizontal.
b. Buccal object rule ● Place a size-4 film with the white-side facing
c. Contrast radiography the maxilla and the long edge in a side-to-side
d. Tube shift technique/Clark’s rule direction.
e. Right angle technique/Miller’s technique ● Insert the film into the patient’s mouth, placing it
Occlusal radiography as far posteriorly as the patient’s anatomy permits
● Occlusal films are used to show larger areas of
usually till it contacts the anterior border of man-
the maxilla or mandible. The size of the film is dibular rami.
57 3 76 mm. ● Ask the patient to bite gently on the film, retaining

the position of the film in an end-to-end bite.

[SE Q.4]
● Position the PID so that the central ray is directed
{Indications of occlusal radiographs through the midline of the arch towards the centre
● To examine the area of cleft palate. of the film at a vertical angulation of 165° and a
● To precisely locate retained roots of extracted teeth, horizontal angulation of 0° towards the midline of
supernumerary teeth, unerupted and impacted teeth. the film. The top edge of the PID is placed be-
● This technique is especially useful for impacted ca- tween the eyebrows on the bridge of the nose. In
nines and third molars and also to localize foreign general, the central ray enters the patient’s face
bodies on the maxilla and mandible. through the bridge of the nose.
● To locate sialoliths in the ducts of sublingual and Maxillary lateral occlusal projection
submandibular glands. ● Position the maxillary arch parallel with the floor.
● To demonstrate and evaluate the integrity of the ● Position a size-4 film with the white side facing
anterior, medial and lateral outline of the maxillary the maxilla and the long edge in a front-to-back
sinus. direction. Insert the film into the patient’s mouth
● To aid in the examination of patients with trismus, who and place it as far posteriorly as the patient’s
can open their mouths only a few millimetres. anatomy permits. Shift the film to the side (right
● To obtain information about the location, nature, extent or left) of intended interest. The long edge of the
and displacement of fractures of the mandible and film should extend approximately ½ inch beyond
maxilla. the buccal surfaces of the posterior teeth.
486 Quick Review Series for BDS 4th Year, Vol 2

● Instruct the patient to bite gently on the film, retain- vi. There should be no movement of the tube, film or
ing the position of the film in an end-to-end bite. patient during exposure.
● Position the PID so that the central ray is directed ● Under given conditions, both procedures would use
through the contact areas of intended interest. the same source of radiation. Hence, factors affecting
● Position the PID so that the central ray is directed rule 1 would be the same in both techniques.
at 160° towards the centre of the film. The top ● The paralleling technique more adequately fulfils rule 2
edge of the PID is placed above the corner of the for shadow casting. It ordinarily uses a long or
eyebrow. extended cylinder, which at least doubles the target–
Maxillary paediatric occlusal projection object distance as compared to the short cone or
● Position the maxillary arch parallel with the floor. cylinder bisecting technique.
● Position a size-2 periapical film with the white ● The bisecting technique can be used advantageously
side facing the maxilla and the long edge in a with either the short or extended distance.
side-to-side direction. Insert the film into the ● The tooth–film distance is somewhat greater in the par-
child’s mouth. alleling technique, particularly in the coronal area of the
● Instruct the child to bite gently on the film, retain- tooth. This separation of the tooth and film is due to
ing the position of the film in an end-to-end bite. anatomic limitations such as palatal curvature and mus-
● Position the PID so that the central ray is directed cle attachments. Thus, the bisecting technique more
through the midline of the arch towards the centre closely satisfies rule 3 of shadow casting. This inade-
of the film. quacy of the paralleling technique is compensated for
● Position the PID so that the central ray is directed by the increased target–object distance.
at 160° towards the centre of the film. The top ● The paralleling technique again excels in fulfilling rules
edge of the PID is placed between the eyebrows 4 and 5. The paralleling technique is so named because
on the bridge of the nose. the tooth and film are parallel.
Technique in mandibular cross-sectional occlusal view ● In the bisecting procedure, the film contacts the tooth at
Image field the occlusal or incisal surface and then diverges away
● This projection shows soft tissues of the floor from the long axis of the tooth. If the tooth and film are
of the mouth and delineates the lingual and not parallel, it is impossible for the rays to strike both
buccal plates of the jaw and the teeth from object and recording surface at right angles.
second molar to second molar. ● When the bisecting technique is used, it is impossible to
Film placement superimpose labial or buccal anatomic entities on their
● The film is placed in the mouth with its long palatal or lingual counterparts; invariably, when viewed
axis perpendicular to tile sagittal plane and the on the radiograph, the labial or buccal counter part of a
pebbled side towards the mandible. similar joint on the palatal or lingual surface will lie
● The anterior border of the film should be approxi- closer to the occlusal or incisal edge. This situation is
mately ½ an inch anterior to the mandibular not necessarily bad, but the interpreter must view the
central incisors. resultant films with this phenomenon in mind.
Projection of the central ray
In brief the bisecting angle technique and paralleling
● The central ray is directed at right angles to the
techniques are compared as follows:
centre of the film.
● The point of entry is in the middle through the floor

of the mouth approximately 3 cm below the chin. Bisecting angle technique Parallel line angle technique
Distortion of image occurs Sharpness is more as compared
Q.3. Compare paralleling and bisecting techniques.
to bisecting technique
Ans. Elongation and shortening of It is less compared to bisecting
image is more technique
● The paralleling and bisecting techniques will be com-
Bending of film is common Bending of film is uncommon
pared from the standpoint of the basic principles (rules)
for shadow casting mentioned below: Shadow of alveolar bone Alveolar crest is seen in true
i. Focal spot should be as small as possible. tends to fill the interproximal relationship with teeth
spaces
ii. Focal spot–object distance should be as long as possible.
iii. Object–film distance should be as small as possible. Super imposition of Superimposition of zygomatic
zygomatic arch occurs on arch occurs on apices of molar
iv. The long axis of the object and the film placed
apices of molar teeth teeth
should be parallel.
v. X-ray beam should strike the object and film at right Easier and less space Need trained technician and
required more space
angles.
Section | I Topic-Wise Solved Questions of Previous Years 487

Bisecting angle technique Parallel line angle technique Technique of bitewing radiographs
● In this technique, the patient is asked to bite on the
Cone cut is common It is uncommon
tab or bite block provided by the special bitewing
Distortion of film occurs due As film holder is used bending film holders.
to bending by finger pressure does not occur ● The bite platform should be positioned on the middle

of the film packet and parallel to the upper and lower

edges of the film packet.
● The patient head is positioned with the head sup-
Q.4. Describe the indications/advantages, disadvantages ported and with the occlusal plane horizontal; in case
and technique of bitewing radiographs. a film holder is used, position the film holder and
Ans. align the tube head.
● If a tab is attached to the film packet then the opera-
● Bitewing radiography is an intraoral technique which tor holds the film packet between the thumb and
allows the clinicians to evaluate initial lesions by pass- forefingers and inserts the film packet into the lingual
ing the primary ray perpendicular to the long axis of the sulcus of the dental arch.
respective teeth. ● If the tab is placed on to the occlusal surfaces of the tooth,
● In this technique, the patient is asked to bite on the bite the patient is asked to occlude the teeth firmly on the tab.
block provided by the special bitewing film holders. ● To ensure that the film packet and the teeth are in con-
● The exposed film is designed to show the crowns of the tact, the operator pulls the tab firmly between the teeth,
teeth and the alveolar crystal bone. once the patient closes the teeth and then releases.
Indications of bitewing radiographs ● The X-ray beam is directed through the contact ar-
● Screening for incipient proximal carious lesions. eas, at right angles to the teeth and the film packet,
● To check the health of the interdental alveolar bone with an approximate 5° to 8° downward vertical an-
in normal and periodontal diseases and detect calcu- gulation and the film is exposed.
lus deposits in interdental areas. ● For assessment of dental caries and restorations, films
● Detection of secondary caries under the restorations should be well exposed and should show good contrast
and to determine if restoration is fractured. to differentiate between the enamel and dentine.
● To know relationship of deciduous to the permanent ● Radiograph should show enamel-dentine junction
teeth in children during mixed dentition period. while assessing the periodontal status and the film
● Routine annual evaluation of all patients who come should be under exposed to avoid the burn out of the
to check up without any complaint. thin alveolar crest.
Disadvantages of bitewing radiographs Q.5. Describe the procedure of localizing an impacted
● As many variables are involved in this technique, it left maxillary canine. Enumerate intraoral radiographic
often results in the image being badly distorted. technique.
● Incorrect vertical angulation may result in foreshort- Ans.
ening or elongation of the image.
● The periodontal bone levels are poorly shown. ● Localization technique is a method used to locate the
● The shadow of the zygomatic buttress frequently position of a tooth or any object in the jaws.
overlies the roots of the upper molars. Use
● Considerable skill is required as the horizontal and ● The dental radiograph is a two-dimensional picture of

vertical angles have to be assessed for every patient. a three-dimensional object. There are times when it is
● It is not possible to obtain reproducible views. necessary to establish the three-dimensional position
● Coning off or cone cutting may result if the central of a structure, such as a foreign object or impacted
ray is not aimed at the centre of the film, particularly tooth, within the jaws.
if using rectangular collimation. ● Localization techniques can be used to obtain this

● Incorrect horizontal angulation will result in overlap- three-dimensional information of foreign bodies, un-
ping of the crowns and roots. erupted or impacted teeth, retained roots, salivary
● The crowns of the teeth are often distorted, thus stones, jaw fractures, broken needles and instruments.
preventing the detection of proximal caries. Types of localization techniques
● The buccal roots of the maxillary premolars and i. Buccal object rule
molars are usually foreshortened. ii. Right-angle technique
488 Quick Review Series for BDS 4th Year, Vol 2

i. Buccal object rule This technique is primarily used for locating objects
● The buccal object rule governs the orientation of in the mandible.
structures portrayed in two radiographs exposed at
different angulations. Q.6. Describe the procedure of periapical radiograph of
● Using appropriate technique and angulation, one
the mandibular central incisor using short cone technique.
periapical or bitewing film is exposed. Ans.
● A second periapical or bitewing film is then exposed

after changing the direction of the X-ray beam using Bisecting technique principle (short cone technique)
a different horizontal or vertical angulation. ● Bisecting angle technique is based on a simple geomet-

● A different horizontal angulation is used when trying ric theorem known as Cieszynski’s law of isometry,
to locate vertically aligned images (e.g. root canals), which states that, two triangles are said to be equal when
whereas a different vertical angulation is used when they share one complete side and have two equal angles.
trying to locate a horizontally aligned image, such as ● In dental radiography, this theorem is applied as follows:

the mandibular canal. ● The film is positioned as close as possible to the

● After the two films have been exposed and pro- lingual surface of the teeth, resting in the palate or
cessed, compare the radiographs with each other. in the floor of the mouth.
● When the dental structure or object seen in the second ● The plane of the film and the long axis of the teeth

radiograph appears to have moved in the same direction form an angle with its apex at the point where the
as the shift of the PID, the structure or object in question film is in contact with the teeth.
is positioned to the lingual. For example, if the horizon- ● When the angle is bisected by an imaginary line,

tal angulation is changed by shifting the position indicat- two congruent angles, with a common side (the
ing device (PID) mesially, and the object in question imaginary bisector), are formed.
moves mesially on the dental radiograph, then the object ● A line, representing the central ray of the X-ray beam

lies to the lingual (i.e. same side means lingual). will complete the third side of two triangles, when it
● Conversely, when the dental structure or object seen is directed perpendicular to the bisecting line.
in the second radiograph appears to have moved in ● Involves taking radiographs such that the long axis

the direction opposite the shift of the PID, the struc- of the rays is perpendicular to the bisector between
ture or object in question is positioned to the buccal. the long axis of the tooth and long axis of the film.
For example, if the horizontal angulation is changed ● An 8-inch cone is normally used and kVp used is

by shifting the PID distally, and the object in ques- usually 55–65 kVp.
tion moves mesially on the dental radiograph, then Placement of the film
the object lies to the buccal (i.e. opposite 5 buccal). ● As the rays are directed perpendicular to the

● In other words, when the two radiographs are com- imaginary plane, bisecting the film and the tooth,
pared, the object that lies to the lingual appears to the film can be placed in close contact with the
have moved in the same direction as the PID, and the tooth structure and alveolar mucosa.
object that lies to the buccal appears to have moved Position of the patient
in the opposite direction as the PID. Position of the patient depends upon the following
● The mnemonic ‘SLOB’ can be used to remember two planes:
the buccal object rule, i.e. Same side means Lingual, (a) Occlusal plane
Opposite side means Buccal. ● The occlusal plane is formed by the tangent

ii. Right-angle technique (Miller’s technique) passing through the occlusal surface of the max-
● The right-angle technique or Miller’s technique is illary and mandibular teeth when the teeth are in
another rule for the orientation of structures seen in centric occlusion.
two radiographs. ● It should be parallel to the plane of floor.

● One periapical film is exposed using the proper 1) In maxillary teeth, an imaginary line drawn
technique and angulation to show the position of the from the ala of nose to tragus of ear is almost
object in the superior–inferior and anterior–posterior parallel to maxillary occlusal plane.
relationships. 2) In mandibular teeth, when the patient opens
● The second one, an occlusal film is exposed directing the mouth, the occlusal plane of lower teeth
the central ray at right angles, or perpendicular (90°), changes its position and, therefore, does not
to the film. The occlusal film shows the object in the remain parallel to the floor. So to place the
buccal lingual and anterior–posterior relationships. occlusal plane of mandibular teeth in proper
● After that the two radiographs are compared with relationship to the floor, it becomes necessary
each other to locate the object in three dimensions. to tilt the head backward.
Section | I Topic-Wise Solved Questions of Previous Years 489

(b) Median sagittal plane Q.8. Describe in detail technique, advantages and limita-
● The plane vertically passing through the centre tions of bisecting angle technique of periapical radiography.
of head is known as midsagittal plane. This
Ans.
plane should be perpendicular to the floor, no
matter whether the head is tilted or not. [Same as LE Q.1]
● Adjusting these two planes is the first step in the
Q.9. Discuss the bisecting angle technique and intraoral
production of the radiograph and the deviation
periapical radiography and advantages and limitations
of this will seriously affect the angulation.
of bisecting angle technique of periapical radiography.
● Once these two planes are adjusted, horizontal and

vertical movement of the tube is considered. Ans.

Horizontal movement states that the central ray
must be directed perpendicular to the mean antero- [Same as LE Q.1]
posterior tangent of the teeth under examination. Q.10. Describe the bisecting technique for intraoral
● Horizontal movement is around the median sag- periapical radiographs in detail with advantages and
ittal plane and vertical movement is around the disadvantages.
occlusal plane.
● Vertical angulation is either positive or negative Ans.
depending upon whether the tube head is facing [Same as LE Q.1]
towards the floor (positive) or when the tube
head is facing upwards (negative). Q.11. What are the uses of occlusal X-ray? Describe the
Rules guiding the placement of film in oral cavity techniques of occlusal X-ray of maxillary palate.
The operator is advised to follow certain rules while Ans.
placing the film in the oral cavity. The rules are as
follows: [Same as LE Q.2]
● Avoid misshaping the film. Films can be bent
Q.12. What are indications for occlusal radiographs?
if necessary, but without crease. Describe the radiographic techniques in taking maxillary
● Carry film into mouth by thumb and forefingers.
and mandibular cross-sectional occlusal radiographs.
● Teeth under examinations should be in the

centre of the film. Ans.

● Position the lower margin of the film in such a way
[Same as LE Q.2]
that 1/8th inch of periapical area is included.
● The index finger of the patient will rest against

the side of the face, other fingers extending in SHORT ESSAYS:

such a way that these should not come in be-
Q.1. Describe bisecting technique of lower third molar.
tween the path of X-ray radiations.
Placement of film, angulation of tube and direction of Ans.
rays for various teeth (maxillary central, mandibular
Mandibular molar exposure using bisecting technique
central and lateral incisors)
● Centre the film holder and film packet on the second
● The mandibular anterior films, especially using
molar, so that the front edge of the film should be
narrow films, are easily inserted. The lower border
aligned with the midline of the second premolar.
of the film is placed in the floor of the mouth under
● Position the upper edge of the film parallel to the
the tongue. The palm of the finger tips should rest
occlusal plane so that an inch of it extends above the
on the edges of the teeth and not the film.
occlusal edges of the teeth.
● The film should not be pressed along the lingual
● Instruct the patient to ‘slowly close’ on the bite-block
surface of the teeth.
or film-holding device.
● The remaining fingers are elevated in such a way, so
● Establish the correct vertical angulation (set the ver-
that they may not come in operator’s line of vision.
tical angulation at 110°) and direct the central ray
● Angulations are adjusted and the rays are passed
perpendicular to the imaginary bisector.
along the symphysis menti.
● Establish the correct horizontal angulation by direct-

Q.7. Describe in detail the bisecting angle technique of ing the central ray between the contacts of the molars.
intraoral periapical radiography. ● Position the PID using the correct vertical and hori-

zontal angulations and centre it over the film and make

Ans.
certain that the PID is positioned far enough forward
[Same as LE Q.1] to cover both the maxillary and the mandibular second
490 Quick Review Series for BDS 4th Year, Vol 2

premolars and is positioned evenly over the mandibu- III. Bitewing films
lar and maxillary arches to avoid a cone-cut. The ● Bitewing films are used to record the crowns of

middle of the PID should be directed at the level of the maxillary and mandibular teeth in one film.
occlusal plane. ● They help in detection of interproximal caries,

● After the vertical angulation, horizontal angulation, visualize the alveolar crest and assessment of
and PID position have been established, the film periodontal disease in easier way.
should be placed without moving the PID. Types of bitewing films
● Make certain that the patient’s occlusal plane is par- 1. Size 0 – For children – posterior (22 3 35 mm)
allel with the floor. If necessary, instruct the patient 2. Size 1 – For children – anterior (24 3 40 mm)
to lower the chin. 3. Size 2 – For adults – posterior (31 3 41 mm)
● Expose the film. 4. Size 3 – For adults – anterior (27 3 54 mm)
Uses
Q.2. Define ideal radiograph. Enumerate the types of
● They are particularly valuable for detecting inter-
intraoral films.
proximal caries in the early stages of development
Ans. before it becomes clinically apparent.
● In checking on the gingival margins of proximal
● Ideal radiograph is the one which has desired density and
fillings.
overall blackness, and which shows the part completely
● They are especially effective and useful for de-
without distortion with maximum details and has the
tecting calculus deposits in interproximal areas.
right amount of contrast to make details fully apparent.
● In determining the relationship of the permanent
● The intraoral radiograph is the image receptor used in
tooth buds to the deciduous teeth.
dental radiology, and is available in plastic film pockets.
● In periodic check-up of the teeth for detection of
They greatly help in diagnosis and treatment of the
new caries and early periodontal changes.
problems.
Types of intraoral radiographs based upon their use: Q.3. Enumerate localization techniques, describe any one.
I. Periapical films: These films are used to record crowns, Ans.
roots and periapical areas related to the tooth.
Types of periapical films ● A localization technique is used to locate the position of
a. No 0 – for children (22 3 35 mm) a tooth or objects in the jaws.
b. No 1 – for anterior adult projections (24 3 40 mm) ● The buccal object rule, a rule for the orientation of
c. No 2 – for posterior adult projections (31 3 41 mm) structures seen in two radiographs exposed at different
Uses angles, can be used as a localization technique.
● For assessment of periodontal status. ● The right-angle technique, another rule for the orientation of
● For detection of apical infection/inflammation. structures seen in two radiographs (one periapical and an-
● After trauma to assess the teeth and alveolar bone. other occlusal), can also be used as a localization technique.
● For assessment of position of unerupted teeth. Indications
● For detailed evaluation of apical cysts and other ● To locate foreign objects like salivary stones, broken

lesions within the alveolar bone. teeth, remnants of root stumps, filling materials,
● During endodontic therapy, preoperative assess- broken needles and other instruments.
ment and postoperative appraisal of apical surgery. ● To assess unerupted teeth, retained roots and root

II. Occlusal films positions in the jaws.

Occlusal films are used to show larger areas of the max- ● To assess mediolateral dimensions and relationships

illa or mandible. The size of the film is 57 3 76 mm. of impacted teeth to the adjacent structures.
Uses: ● To assess the relationship of the mandibular canal to

● To precisely locate supernumerary teeth, un- the apices of teeth.

erupted and impacted teeth as well as retained Types of localization radiographic techniques
roots of extracted teeth. ● Commonly used intraoral localization radiographic

● To locate stones in the ducts of sublingual and techniques are as follows:

submandibular glands. i. Buccal object rule
● To demonstrate and evaluate the integrity of the ante- ii. Tube-shift technique/Clark’s rule
rior, medial and lateral outline of the maxillary sinus. iii. Right angle technique/Miller’s technique
● For obtaining information about the location, Other techniques:
nature, extent and displacement of fractures of i. Stereoradiography
both the mandible and maxilla. ii. Contrast radiography
Section | I Topic-Wise Solved Questions of Previous Years 491

Buccal object rule Interpretations

● Buccal object rule is used to evaluate the relative ● When the dental structure or the object is seen in the

relationship of the root apices of the mandibular second radiograph, it appears to have moved in the
molars to the mandibular canal. same direction as the shift of the PID, the structure
● Buccal object rule states that the object will move or the object is said to be positioned lingually.
with a change in angulation of the PID (right or ● If the object appears to have moved in a direction

left/up or down). opposite to the shift of the PID, then the object in
Technique question is said to be positioned buccally.
● A conventional intraoral periapical radiograph of the ● It follows SLOB rule: Same Side Lingual and

mandibular third molar is taken. Opposite Side Buccal.

● A second radiograph is taken with a 220° vertical
Q.6. Radiographic technique for maxillary standard
angulation.
occlusal view.
Interpretation
● Both the radiographs are examined. If the mandibu- Ans.
lar canal in the second radiograph moves in direction
This projection shows the following:
superior to the apices of the mandibular molar, then
● The palate
the mandibular canal is said to be placed buccally in
● Nasal septum
relation to the apices of the mandibular third molar.
● Nasolacrimal canals
● If the canal appears to have moved in a direction in-
● The zygomatic process of the maxilla
ferior to the apices of third molar, the mandibular
● The anterior–inferior aspects of each antrum
canal is said to be placed lingually to the apices of
● The teeth from the right second molar to the left
third molar.
second molar
● If the canal in the second radiograph does not seem
Technique of maxillary occlusal view
to move as compared to the first radiograph, then the
Patient position
canal is assumed to be in the same plane as that of
● Seat the patient upright with the sagittal plane
the apices of the third molar.
perpendicular to the floor and occlusal plane
Q.4. Occlusal radiograph. horizontal.
Film placement
Ans.
● Place the film, with its long dimension perpendic-

[Ref LE Q.2] ular to the sagittal plane, cross-wise in the mouth.

● Gently push the film in backward until it contacts
Q.5. Clark’s technique.
the anterior border of mandibular rami.
Ans. ● The patient stabilizes the film by gently closing

the mouth.
Clark’s technique is also known as shift-cone technique.
Projection of the central ray
Principle
● The central ray is directed at a vertical angulation
The basic principle is that the relative position of the
of 165° and a horizontal angulation of 50° towards
radiographic images of two separate objects changes
the midline of the film.
when the projection angle at which the projection was
● In general, the central ray enters the patient’s face
made is changed.
through the bridge of the nose.
● A different horizontal angle is used when trying to

locate vertically aligned images, e.g. root canals. Q.7. Give the indications of true occlusal radiograph.
● A different vertical angulation is used when trying
Ans.
to locate horizontally aligned images, e.g. man-
dibular canal. [Same as SE Q.4]
Technique
● Two radiographs of the object are taken.

● First using the proper technique and angulations as

SHORT NOTES:
prescribed. Q.1. Indications of bitewing radiographs.
● Second radiograph is taken keeping all other param-
Ans.
eters constant and equivalent of those of the first
radiograph, only changing the direction of the cen- Indications of bitewing radiographs are as follows:
tral ray either with a different horizontal or vertical ● Diagnosis of interproximal canes and secondary caries.
angulation. ● To study the height of pulp chamber.
492 Quick Review Series for BDS 4th Year, Vol 2

● To study the height of alveolar bone or assessment of ● Perform the examination in morning as the gag reflex is
bone loss. worse when the patient is tired.
● To study occlusion of teeth. ● Tongue should be very relaxed and positioned well
● Checking on the gingival margins of proximal fillings during placement of film.
and detecting calculus deposits in interproximal areas. ● Ask the patient to breathe rapidly through the nose.
● Determining the relationship of the permanent tooth ● Asking the patient to hold their breath/keeping a foot or arm
buds to the deciduous teeth. suspended during film; placement can create a distraction.
● Useful in periodic check-up of the teeth for the detec- ● In extreme cases, topical anaesthetic agents in mouth-
tion of new caries and of early periodontal changes. washes or spray can be administered to produce tempo-
rary numbness of the tongue and palate.
Q.2. Mention four disadvantages of the bisecting angle
technique. Q.4. Indications of transorbital view.
Ans. Ans.
[Ref LE Q.4] Indications of transorbital view are as follows:
Q.3. How will you manage the problem of gagging in a ● To examine the anterior view of Temporo mandibular

patient during the periapical technique? Joint (TMJ).

● Mediolateral dimension of articular eminence.
Ans. ● Condylar head and condylar neck.

● First relax and reassure the patient. ● To view the morphology of convex surface of condylar

● Radiologist can describe and explain the procedure. head.

Topic 7
Extraoral Radiographic Techniques
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. Enumerate the radiographic techniques to study temporomandibular joint and describe any two in detail.
2. Write in brief the radiographic technique used for viewing the maxillary sinus.
3. Give the radiographic diagnosis of important pathological entities involving the antrum.
4. Describe the principle, procedure, indications and limitations of panoramic radiography.
5. How will you take lateral oblique view of mandible and give interpretations to that?
6. Discuss briefly about tomography.
7. Enumerate various skull radiographs and discuss in detail posteroanterior paranasal sinus and submentover-
tex view of skull.
8. Describe in detail the transcranial and transpharyngeal radiographic techniques of TMJ. [Same as LE Q.1]
9. Discuss the procedure, advantages and disadvantages of panoramic imaging. [Same as LE Q.4]
10. How will you take a lateral oblique radiograph of the mandible? Mention normal radiographic landmarks in
the same radiograph. [Same as LE Q.5]
11. Discuss briefly the theory of tomography. [Same as LE Q.6]

SHORT ESSAYS:
1. Technique for better visualization of paranasal air sinus.
2. Oblique lateral radiograph of mandible.
3. Posteroanterior view.
Section | I Topic-Wise Solved Questions of Previous Years 493

4. Panoramic radiography. [Ref LE Q.4]

5. Radiographs to study the following: (A) fractures of the angle of mandible, (B) fracture in symphysis region
and (C) fracture zygomatic arch.
6. Define focal trough and write any two principal advantages of panoramic radiograph.
7. Technique of transcranial view of TMJ. [Ref LE Q.1]
8. Write in brief the radiographic techniques used for viewing the maxillary sinus.
9. Waters’ projection. [Same as SE Q.1]
10. Advantages of OPG. [Same as SE Q.4]

SHORT NOTES:
1. Principle of panoramic radiography.
2. Advantages of panoramic radiography.
3. Transorbital view. [Ref LE Q.1]
4. Give uses of lateral skull projection.
5. Name two radiographic techniques to study TMJ.
6. Mention the uses of Waters’ view.
7. Submentovertex view.
8. Name few extraoral radiographs.
9. Indications for extraoral radiographs.
10. Indications of PA view skull.
11. Bregma–Menton view. [Ref LE Q.2]
12. Name any two techniques for TMJ radiography. [Same as SN Q.5]

SOLVED ANSWERS
LONG ESSAYS:
Q.1. Enumerate the radiographic techniques to study [SE Q.7]
temporomandibular joint and describe any two in detail.
{Transcranial technique
Ans. ● This technique is also known as Lindblom tech-
nique. It is most useful in detecting arthritic
Temporomandibular joint (TMJ) radiography changes on the articular surface and it also helps
● In distinguishing among the disorders that may affect the to evaluate the joints’ bony relationship.
TMJ, radiography is the most important diagnostic aid. ● This technique is not helpful in detecting changes
● TMJ imaging depends on the clinical problem and on the central and medial surfaces.
the involvement of the hard or soft tissues. ● The cassette is placed flat against the patient’s ear
● The various radiographic techniques used to study and centred over the TMJ of interest, against the
TMJ are as follows: facial skin parallel to the sagittal plane.
a. Plain film radiography ● Patient’s head is adjusted so that the ala tragus
i. Reverse Towne line is parallel to the floor.
ii. Cephalometrics ● The view is taken with the patient’s mouth in
iii. Transorbital–frontal projection three positions:
iv. Transcranial–lateral projection i. Open mouth
v. Transpharyngeal–lateral projection ii. Rest position
vi. Xeroradiography iii. Closed mouth
vii. Posterior-anterior (PA) Waters’ view ● The point of entry is different according to the
b. Conventional tomography technique.
i. Linear tomography A. Point auricular or Lindblom technique
ii. Orthopan tomography ● Point of entry of the central ray is ½" behind and 2"
iii. Corrected tomography above the auditory meatus.
c. Computed tomography (CT) ● According to Lindblom, the central ray should be
d. Arthroscopy directed from posteriorly so that it passes along
e. Arthrography the long axis of the condyle and the medial pole of
f. Magnetic resonance imaging (MRI) the condyle is more posterior to the lateral pole.
494 Quick Review Series for BDS 4th Year, Vol 2

B. Grewcock approach Uses

● The central ray enters through a point 2” above the ● This view is primarily intended to provide gross
external auditory meatus. visualization of the condyle.
C. Gill’s approach ● It is helpful in diagnosing fractures of the condyle

● The central ray enters through a point ½” anterior and neck and in detecting gross alterations in
and 2” above the external auditory meatus. condylar form.
● In all the three techniques, the central ray is ● Unobstructed view of the superior surface of the

directed caudally at an angle of 120° to 125°. The condyle.

point of exit is through the TMJ of interest. Transorbital technique
● The exposure parameters are kVp – 70, mA – 07,

seconds – 1.5.
Uses {SN Q.3}
● It is most useful in detecting articulating surfaces

changes caused by various forms of arthritis. ● This technique, also known as Zimmer projection/
● The relationship of the condyle to the articulating
transmaxillary projection, is the conventional frontal
surface of the joint is seen in this radiograph. TMJ projection, which is most successful in delin-
● It shows the lateral oblique view of the condylar
eating the joint with minimal super impositions,
head and articular fossa. It shows minute, subtle leading to the production of a relatively true ‘enface’
bony irregularities on the lateral bony surfaces.} projection.
Transpharyngeal technique
● This technique also known as Parma projection/

infracranial projection/MacQueen–Dell projec- ● The structures shown in this technique are the
tion is a lateral projection of the condylar head articular surface (convex) and the articular emi-
and neck, usually taken in the mouth open posi- nence (flat or convex).
tion, so that the joint is projected into the shadow ● The film is positioned behind the patient’s head at
of air containing spaces of the nasopharynx, an angle of 45° to the sagittal plane and the
which helps to increase the contrast of the various patient is positioned so that the sagittal plane is
parts of the joint. vertical. The canthomeatal line should be 10° to
● The cassette is placed flat against the patient’s ear the horizontal, with the head tipped downwards.
and is centred to a point 1⁄21/2 anterior to the exter- The mouth should be wide open.
nal auditory meatus, over the TMJ of interest, ● The tube head is placed in front of the patient’s
against the facial skin parallel to the sagittal plane. face and the central ray is directed to the joint of
● The patient is positioned so that the sagittal plane interest, at an angle of 120°, to strike the cassette
is vertical and parallel to the film, with the TMJ at right angles.
of interest adjacent to the film. ● The point of entry may be taken at:
● The film is centred to a point 1/2 anterior to the i. Pupil of the same eye, asking the patient to
external auditory meatus. The occlusal plane look straight.
should be parallel to the transverse axis of the ii. Medial can thus of the same eye.
film so that the soft parts of the nasopharynx are iii. Medial can thus of the opposite eye.
in one line with the TMJ. ● Exposure parameters are kVp – 70, mA – 07,
● The patient is instructed to slowly inhale through seconds – 0.5.
the nose during exposure, so as to ensure filling of Uses
the nasopharynx with air during the exposure. The ● This view is particularly useful for visualizing
patient should open his mouth so that the condyles condylar neck fractures.
move away from the base of the skull and the man- ● Morphology of the convex surface of the condylar

dibular notch of the opposite side is enlarged. head can be evaluated in the diagnosis of gross
● Radiograhphic tube head is directed from the op- degenerative changes or other anomalies.
posite side cranially, at an angle of –5° to –10° Advantages
posteriorly. It is directed through the mandibular ● The lack of serious super impositions over most

notch, which is a window between the coronoid, of the condylar process.

condyle and the zygomatic arch, of the side below ● Simplicity.

the base of the skull to the TMJ of interest. ● This view provides an anterior view of the TMJ

● Exposure parameters are kVp – 70, mA – 07, perpendicular to transcranial and transpharyngeal
seconds – 0.8. projections.
Section | I Topic-Wise Solved Questions of Previous Years 495

Limitations iii. PA Waters’ view

● In this view, only the condylar neck is visible be- ● This projection is primarily used to demonstrate the

cause the areas of the joint articulating surfaces maxillary sinus, frontal and ethmoidal sinuses. The
are obscured by superimposition of the temporal sphenoidal sinuses can be seen if the patient is asked
component on the condylar head. to open his mouth, where by the sphenoidal sinuses
are projected on the palate.
Q.2. Write in brief the radiographic technique used for
● The orbit, frontozygomatic suture, nasal cavity, cor-
viewing the maxillary sinus.
onoid process of the mandible and the zygomatic
Ans. arch are also seen.
● The cassette is placed perpendicular to the floor in a
The various radiographic techniques used for viewing the
cassette holding device. The long axis of the cassette
maxillary sinus are as follows:
is positioned vertically.
i. Standard occipitomental projection (0° OM)
● The patient is positioned such that the midsagittal
ii. Modified method (30ooccipitomental projection)
plane should be vertical and perpendicular to the
iii. PA Waters’ view
plane of the film and the patient’s head is extended so
iv. Bregma–Menton view
that only the chin touches the cassette. The cassette is
The various radiographic techniques used for viewing
centred around the acanthion (anterior nasal spine).
the maxillary sinus are described in detail below:
● The canthomeatal line should be at 37° to the plane
i. Standard occipitomental projection (0° OM)
of the film and the line from the external auditory
● This projection shows the facial skeleton and the
meatus to the mental protuberance should be per-
maxillary antra and avoids superimposition of the
pendicular to the film.
dense bones of the base of the skull. It is especially
● Waters (1915) specified that the tip of the nose
useful to detect middle third fractures (Le Fort I, II,
should be 0.5–1.5 mm away from the cassette.
III, zygomatic complex, nasoethmoidal complex,
Mahoney (1930) found that the petrosal shadows
orbital blowout) and coronoid fractures.
can be correctly placed by adjusting the orbitome-
● The cassette is placed perpendicular to the floor with
atal line at 37° to the horizontal.
its long axis of cassette positioned vertically.
● The patient’s head is extended as far as comfortable,
● The patient should be positioned such that the mid-
to make the lower border of the mandible as parallel
sagittal plane should be vertical and perpendicular.
to the cassette as possible. Only the chin touches
Only the nose and chin should touch the cassette.
the cassette. The canthomeatal line should also be
The head is tipped back so that the radiographic
approximately parallel to the plane of the film.
baseline is at 45° to the film.
● The central ray enters at the Bregma and exits at the
● The central ray is directed horizontally through the
Menton.
occiput.
● Exposure parameters are kVp – 65, mA – 10,
● Exposure parameters are kVp – 65, mA – 10,
seconds – 2–3.
seconds – 2–3.
ii. Modified method (30° occipitomental projection)
● This projection shows the facial skeleton, from a dif-
{SN Q.11}
ferent angle enabling certain bony displacements to iv. Bregma–Menton view
be detected. It is useful in detecting middle third ● This projection is primarily used to demonstrate
fractures (Le Fort I, II, III) and coronoid process the walls of the maxillary sinus (especially in the
fractures. posterior areas), the orbits, the zygomatic arches
● The cassette is placed perpendicular to the floor in a and the nasal septum. It also demonstrates medial
cassette holding device. The long axis of the cassette or lateral deviations of any of the mandible.
is positioned vertically. ● The cassette is placed perpendicular to the floor
● The patient is positioned such that the midsagittal in a cassette holding device. The long axis of the
plane is vertical and perpendicular to the cassette cassette is positioned vertically.
and the head is centred, so that the nasion is in the ● The patient is positioned such that the midsagittal
centre of the cassette. Only the nose and chin touch plane should be vertical and perpendicular to the
the cassette; the head is tipped back so that the radio- plane of the film.
graphic baseline is at 45° to the film.
● The central ray is directed 30° to the horizontal,
Q.3. Give the radiographic diagnosis of important path-
centred through the lower border of the orbit.
ological entities involving the antrum.
● Exposure parameters are kVp – 65, mA – 10,

seconds – 2–3. Ans.

496 Quick Review Series for BDS 4th Year, Vol 2

The various pathologies involving the antrum are as ● Increased thickness of the radiopaque lining of the
follows: sinus, i.e. thickness of boundary walls.
i. Inflammatory changes thickened mucosal sinusitis II. Trauma
a. Acute ● Fractures are commonly demonstrated by conven-

b. Chronic tional radiographic techniques but CT is often neces-

ii. Empyema–fluid levels sary to show the fracture lines.
iii. Polyps, mucosal retention cysts and mucocoele a. Nasal fracture
iv. Carcinoma ● Most injuries affect the paired nasal bones, which

v. Postoperative maxillary cysts are best seen in the lateral skull view.
vi. Foreign objects within maxillary sinus b. Orbital blowout fracture
vii. Soft-tissue calcification like lymph nodes and sialoliths ● In pure ‘blowout’ fractures, the orbital rim is in-

Antral diseases and their radiographic appearances are as tact with no injury to the globe.
follows: ● On plain films, the bone fragments are dis-

I. Inflammatory diseases placed into the superior aspect of the maxillary

a. Acute sinusitis sinus and/or one end of the single fragment may
Acute sinusitis can be caused by: be in contact with the remaining walls, the so-
● Upper respiratory tract infection, e.g. common called ‘trap door’ appearance, which is repre-
cold. sented by a linear radiopacity that extends into
● Trauma, e.g. oroantral communication or a tooth the superior aspect of the maxillary sinus. This
fragment being pushed into the sinus. ‘trap door’ is a hallmark feature of the orbital
● Periapical infection of posterior teeth. A single blowout fracture.
maxillary posterior tooth with chronic apical peri- ● Waters’ view best demonstrates the intact orbital

odontitis may produce a localized inflammatory rim together with herniation of soft-tissue con-
response. It is known as ‘periapical mucositis’. tents into the maxillary sinus.
The radiographic picture would be: ● Coronal CT scans are the most favoured imaging

● Periapical picture depicting antral halo because of modality for identifying blowout fracture and
resorption and remodelling of antral floor. evaluating involvement of adjacent tissues.
● A periapical lesion that has resulted in an inward c. Orbital rim fractures
bulging of the sinus floor is characterized by a ● The Waters’ or Caldwell’s views are usually ade-

periapical radiolucency surrounded by a thin quate to demonstrate the integrity of the orbital
opaque line of bone. The radiographic appearance rims.
has been called the ‘halo effect’. ● Coronal CT may also be used, though the former

● Opaque zone at the base of the sinus because of can also be used to see the frontal sinuses. Be-
fluid collected in it. sides, an axial CT may be used to evaluate the
● Total opacity of sinus is because of mucosal hy- integrity of the anterior cranial fossa.
pertrophy and fluid in sinus. d. Zygomatic arch fractures
● Evidence of foreign body when applicable. ● Zygomatic arch fractures may occur singly or

b. Chronic sinusitis may be associated with either a tripod fracture or

Chronic sinusitis can be caused by: a Le Fort III fracture.
● Persistent infection of the sinus. ● The plain film study of choice is the ‘soft tis-

● Continued presence of a foreign body or commu- sue’ or low kVp submentovertex or ‘jug han-
nication. dle’ view.
The radiographic changes would be: ● Axial CT may be of use particularly in complex
● Irregular thickening of the radiopaque lining on fractures.
the inner side of sinus because of mucosal hyper- ● Three-dimensional CT scans have proved helpful

trophy. in evaluating degrees of displacement.

● Shrinkage of the radiolucent cavity of the sinus. e. Tripod fractures or zygomatic maxillary complex
● Radiopacity at the base of the sinus cavity due to fracture
collection of the fluid. ● The fracture of suggestive bone usually results in

● Round dome-shaped radiopacity seen in the cavity radiopacity of maxillary antrum because of the
may be because of a mucosal polyp. presence of blood.
Appearance of multiple, smooth, rounded opaci- ● Type I or nondisplaced or minimally displaced

ties on the sinus walls and floor is common with fractures can be visualized in plain films or in
patients suffering from allergic sinusitis. Waters’ view.
Section | I Topic-Wise Solved Questions of Previous Years 497

● Type II or segmented zygomatic arch or orbital iii. Dentigerous cysts

rim fractures result in subtle rotation of the frag- ● The dentigerous cysts appear as well-

ment. The coronal CT is the radiographic tech- corticated pericoronal radiolucencies ex-
nique of choice. ceeding 3.0 mm.
● Type III or fractures with substantial rotation or ● The margins are well corticated, thin and

displacement of the fracture fragment are best smoothly curved. A tooth is an integral part
seen on a coronal CT scan. of the dentigerous cyst.
● Type IV or comminuted fracture with gross rota- iv. Calcifying odontogenic cyst (Gorlin cyst)
tion or displacement is best seen by coronal CT ● The most common radiologic appearance is

scan. Three-dimensional CT scans have proved of a cystic radiolucency, which may be uni-
to be helpful in evaluating degrees of displace- locular or multilocular. Expansion and per-
ment. foration can be well demarcated or irregular
f. Transfacial fracture (Le Fort fracture) with characteristic calcifications. The radi-
● Le Fort fractures are complex fractures, Le Fort I opaque foci often are clustered around the
and Le Fort II involve the maxillary sinus and Le occlusal or incisal surfaces of an impacted
Fort III is a craniofacial disjunction. For such tooth.
fractures, plain film radiograph is inadequate and ● CT and MRI complement conventional

scans are the modality of choice for evaluating radiographs and show that calcifying
all transfacial injuries. odontogenic cyst originates as unilocular
III. Benign lesions of the maxillary sinus (cysts and lesion that may become multilocular with
tumours) time as CT and MRI display incomplete
● Cysts and tumours of the maxilla and maxillary antrum bony system.
are space-occupying lesions which increase in size B. Tumours
gradually to encroach on the contiguous structures i. Ameloblastoma
such as walls of sinus or the ostium. ● Ninety per cent of the maxillary lesions in-

● The signs and symptoms then follow. Radiographic volve the premolar–molar region.
analysis provides an immense database to aid in the ● On plain films and CT, the lesion appears

diagnosis of the sinus lesions. as a multilocular (soap bubble) lytic lesion

● A panoramic radiograph is useful as a beginning without mineralized components. Some-
investigation. Maxillary occlusal radiographs and times the sinus wall may be destroyed.
periapical radiographs are also useful in addition to ii. Odontoma
the more sophisticated modalities such as CT and ● Two-thirds of odontomes are found in

MRI. the anterior and posterior aspects of the

A. Cysts maxilla.
Cysts that develop outside the sinus may expand to ● Radiographically, the compound composite

produce a bowing inward of the sinus wall. odontome resembles an accumulation of

i. Radicular cysts small, fully formed teeth, whereas the com-
● The radicular cysts are most common of all plex composite odontome appears as an
cystic lesions and are most prevalent in the amorphous radiopacity.
anterior maxilla and appear as a rounded or iii. Squamous odontogenic tumour (benign epi-
ovoid radiolucency at the root end of a thelial odontogenic tumour)
tooth, often demarcated by marginal bone ● This rare, benign odontogenic tumour occurs
sclerosis. more often in the maxillary lateral canine re-
ii. Odontogenic keratocyst gion presenting as a triangular or semicircu-
● The odontogenic keratocyst radiographically lar radiolucency within the alveolar bone be-
presents as well-circumscribed radiolucency tween the roots of several teeth. Additionally,
with smooth margins and then radiopaque there is displacement of one or both the adja-
borders. cent roots, destruction of crestal bone and a
● Most of the lesions are unilocular, but larger sclerotic rim at the margin of the lesion.
lesions may be multilocular. They produce iv. Cementoma or periapical cemental dys-
buccal expansion rather than palatal. Large plasia
maxillary lesions are destructive, may be ● These are benign lesions that arise from
expansile and usually involve the sinus. cementum that surrounds the tooth root.
498 Quick Review Series for BDS 4th Year, Vol 2

● Periapical cemental dysplasia begins as a ● In the OPG, the film is attached to a rotating system
radiolucent lesion but gradually calcifies to and moves in the same direction as the beam. The
appear as a radiopaque mass separated from film is given the correct speed by opposing this
tooth root by a radiolucent zone. movement with a contrary movement relative to the
● The ‘gigantiform cementoma’ appears as beam.
nodular, irregular-shaped radiopacities in Procedure
multiple locations. ● Explain the procedure to the patient.

v. Benign cementoblastoma or true ceme­ntoma ● Make the patient wear a lead apron without a thyroid

● Radiographically, benign cementoblastoma collar, and remove all objects from the head which
appears as well-defined radiopacity attached will interfere with film exposure. Also have the pa-
to the tooth root with loss of outline of the tient remove jacket or bulky sweater; this allows
affected root. more room between the bottom of the cassette holder
vi. Odontogenic myxoma and the patient’s shoulder.
● The radiographic appearance of myxoma is ● Load the panoramic film in the darkroom and

variable. The lesion may have a ‘mottled’ or a cover the bite block with a disposable plastic cover
‘honeycomb’ appearance, or it may present as slip.
an expanding radiolucency with an occasional ● Set the exposure factors and adjust the height of the

multilocular pattern. machine to accommodate the patient.

IV. Malignancy of maxillary sinus ● Instruct the patient to sit or stand with the back
Squamous cell carcinoma straight and erect, and ask him to bite on the plastic
● A sinus opacity and in most cases, antral wall de- bite block. The upper and the lower front teeth must
struction with adjacent bony involvement is patho- be placed in an end-to-end position in the groove of
gnomic of maxillary sinus carcinoma. the bite block.
● Besides the conventional views, 3–5 mm contigu- ● The midsagittal plane should be perpendicular to
ous section of CT scan permits accurate evaluation the floor and aligned with the vertical centre of the
of tumour extension. chin rest, and the Frankfort plane should be parallel
● The primary pathologic and imaging feature of to the floor, thus obtaining the correct position for
squamous cell carcinoma is the propensity to de- the occlusal plane. The patient’s head is tilted
stroy bone even in the presence of a relatively small downwards so that the tragus ala line is 5° down
mass. and forward.
V. Antroliths ● If the patient has a low palatal vault, increase the oc-
● An antrolith is a calcified mass in the maxillary si- clusal plane angulation slightly. If the patient has a
nus or antrum. high palatal vault, decrease the occlusal plane
Radiographic features slightly. The indicator lights in the machine help as a
● These are the small opaque bodies of varying guide and the patients head should be immobilized
sizes generally found in the bases of the sinus. by the head band.
● Generally, the antroliths are of homogeneous ● Centre the lower border of the mandible on the chin
density, and rarely, they may have a more radi- rest and equidistant from each side.
opaque area around. They usually have an irregu- ● Instruct the patient to position the tongue on the
lar border. palate and ask him to remain still while the machine
is rotating during exposure. Also explain that the
Q.4. Describe the principle, procedure, indications and cassette holder will not strike him, although it may
limitations of panoramic radiography. gently rub his ear and head at the limits as of the
Ans. excursion.
● After the exposure is complete the film is subjected
Panoramic radiography is a radiographic procedure that to routine processing.
produces a single tomographic image of the facial struc- Indications
tures including both maxillary and mandibular arches and ● As a substitute for full mouth intraoral periapical
their supporting structures. radiographs.
Principle ● For evaluation of developmental anomalies and tooth
● If the film moves at a speed that follows the moving development for children during the mixed dentition
projection of a certain point, this point will always be period as well as TMJ dysfunctions.
projected on the same spot on the film and will not ● To assess the patient for and during orthodontic
appear unsharp. treatment.
Section | I Topic-Wise Solved Questions of Previous Years 499

● To establish the site and size of lesions such as cysts ● Useful for mass screening.
and tumours in the body and ramus of the mandible. ● This view helps in localization of objects/pathology
● For progress of pathology and follow-up of treat- in conjunction with a topographic occlusal view or
ment, or postoperative bony healing. an intraoral periapical radiograph.
● Prior to any surgical procedures such as extraction of ● The radiation dose (effective dose equivalent) of app.

impacted teeth, enucleation of a cyst, etc. 0.08 mSv is about one-third of the dose from a full
● For detection of fractures of the middle third and the mouth intraoral film.}
mandible following trauma. Disadvantages or limitations
● In case of periodontal disease for an overall view of ● Areas of diagnostic interest outside the focal trough

the alveolar bone levels. may be poorly visualized, e.g. swelling on the palate
● Assessment for underlying bone disease before con- and floor of the mouth.
structing complete or partial dentures. ● Image quality: Comparatively this radiograph is of a

● Evaluation of the vertical height of the alveolar bone poor diagnostic quality, in terms of magnification,
before inserting osseointegrated implants. geometric distortion, poor definition and loss of
detail.
[SE Q.4]
● Tomograms inherently show magnification, geomet-

{Advantages ric distortion and poor definition. Because of poor

● OPG is an extraoral procedure, which is convenient definition, panoramic radiography is less effective in
for the patient and requires a minimal amount of detecting early interproximal or recurrent caries,
patient’s cooperation. disruptions in lamina dura, loss of crestal alveolar
● Useful in patients with trismus and gagging prob- bone and thickened periodontal membrane.
lems. Most units can be operated without radiation to ● In cases of pronounced inclination, the anterior teeth

demonstrate to the patient what the procedure will be are poorly registered.
like, before the actual exposure will be made. It vir- ● Number of radiopaque and radiolucent areas may be

tually eliminates problems with gaggers, patient with present due to the superimposition of real/double or
trismus, and fearful or uncooperative children. ghost images and because of soft-tissue shadows and
● Time required is minimal compared to a full mouth air spaces.
intraoral periapical radiographs. ● Due to prescribed rotation, patient with facial asym-

● Radiation dose to the patient is relatively low when metry or patients who do not conform to the rotation
compared with conventional full mouth intraoral curvature cannot be X-rayed with any degree of
radiography. ­satisfaction.
● Patient education: OPG films are a valuable aid in ● If the patient positioning is improper, the amount of

patient education and case presentation. vertical and horizontal distortion will vary from one
● Conditions such as impactions, eruption patterns of part of the film to another part of the film.
teeth, the need for replacement of missing teeth and ● The ease and convenience of obtaining an OPG may

fractures are more easily illustrated on panoramic views. encourage careless evaluation of a patient’s specific
● Size of the area radiographed: A broad anatomic re- radiographic needs.
gion is imaged. The OPG covers an area that includes ● Overlap: OPG units have a tendency to produce

the entire mandible from condyle to condyle and overlapping of teeth images, most particularly in the
maxillary region extending superiorly to the middle premolar area.
third of the orbits. Areas such as condyles, inferior ● Overuse: The ease and convenience in obtaining the

border, angle and ascending ramus of the mandible, OPG might lead to carelessness by substitution for
and entire maxillary sinus that are not visualized in other projection that might be adequate. This is one
intraoral surveys are seen routinely on OPG. of the prime concerns in regard to patient dosage.
● The anatomical structures are most identifiable and ● Cost: Because of its high cost, it is an extra invest-

the teeth are oriented in their correct relationship to ment for practitioners.
the adjacent structures and to each other. ● Artefacts are easily misinterpreted and are more

● It allows for the assessment of the presence and posi- commonly seen, e.g. nose ring as a periapical radi-
tion of unerupted teeth in orthodontic treatment. opaque lesion, earring as a calcification in the maxil-
● It demonstrates periodontal disease in a general way lary sinus.
manifesting a generalized bone loss.
Q.5. How will you take lateral oblique view of mandible
● All the parameters are standardized, and repetitive
and give interpretations to that?
images can be taken on recall visits for comparative
and research purposes. Ans.
500 Quick Review Series for BDS 4th Year, Vol 2

Lateral oblique view of mandible can be used for large le- and the head is rotated 10°–15° from the true lat-
sions. The size of the cassette used is 5 3 7 inches. The eral line. For the molar and ramus region, the head
types of lateral oblique view are as follows: should not be turned away from the tube as this
i. Body of the mandible view will place the ramus behind the vertebral column.
ii. Ramus view ● The central ray is directed from under the mandi-

ble opposite to the side of examination, from 2 cm

I. Body of the mandible
below the angle of the mandible. The beam is di-
a. Anterior body of the mandible
rected upwards (–10° to –15°) and centred on the
● It shows anterior body of the mandible and teeth
body of the mandible. The beam must be directed
in the same area, helps to evaluate impacted teeth,
perpendicular to the horizontal plane of the film.
fractures, pathologic lesions located in the infe-
● Exposure parameters are kVp – 65–70, mA –
rior border of the mandible.
7–10, seconds – 0.8.
● The cassette is placed flat against the patient’s
II. Ramus of mandible
cheek, centred over the body of the mandible,
● The purpose of this view is to evaluate impacted
overlying the teeth and it should be positioned
third molar, retromolar area, angle of the mandible,
parallel to the body of the mandible. The patient
condyle and fractures that extend into the ramus of
must hold the cassette position with the thumb
the mandible.
placed under the edge of the palm against the
● The film placement should be such that the central beam
outer surface of the cassette.
is directed towards the centre of the imaged ramus, from
● The patient’s head is so adjusted that the ala tragus
2 cm below the inferior border of the opposite side of the
line is parallel to the floor. The mandible is pro-
mandible at the area of the first molar.
truded slightly. The sagittal plane is tilted so that it
Position of patient
is 5° to the vertical and rotated 30° from the true
● The patient’s head is so adjusted that the ala tra-
lateral position. For the bicuspid and incisor region,
gus line is parallel to the floor.
the patient can be turned slightly away from the
● The mandible is protruded slightly. The cassette is
tube so that chin approximates the cassette.
placed over the patient’s cheek and centred over
● Central ray is directed from under the mandible
the area of interest usually over the ramus and far
opposite the side of examination, from 2 cm behind
enough posteriorly to include the condyle.
the angle of the mandible. The beam is directed
● The lower border of the cassette is parallel and at
upwards (–10° to –15°) and centred on the anterior
least 2 cm below the inferior border of the man-
body of the mandible. The beam must be directed
dible. The head is tilted towards the side being
perpendicular to the horizontal plane of the film.
examined so that the condyle of the area of inter-
● Exposure parameters are kVp – 65–70, mA –
est and the contralateral angle of the mandible
7–10, seconds – 0.8.
form a horizontal line.
b. Posterior body of the mandible
● Exposure parameters are kVp – 65–70, mA –
● It shows position of the teeth in the same area, ra-
7–10, seconds – 0.8.
mus of the mandible, angle of the mandible. Helps
to evaluate impacted teeth, fractures and lesions Q.6. Discuss briefly about tomography.
located in the inferior border of the mandible.
Ans.
● The cassette is placed flat against the patient’s

cheek and is centred over the body of the mandi- ● Tomography is a process by which an image layer of
ble. The cassette also should be positioned paral- the body is produced, while the images of the struc-
lel to the body of the mandible. The patient must tures above and below that layer are made invisible by
hold the cassette in position with the thumb blurring.
placed under the edge of the cassette and the palm ● In normal radiography, the character of the pattern on
against the outer surface of the cassette. the radiograph formed by the anatomical structures of
● The patient’s head is so adjusted that the ala tragus interest is very often partially or sometimes even com-
line is parallel to the floor. The mandible is pro- pletely obscured by the shadows cast by the overlying
truded slightly to separate it from the vertebral or underlying structures.
column. The cassette is placed over the patient’s Principle
cheek and centred over the area of interest. The ● If the film moves at a speed that follows the moving

inferior border of the cassette should be parallel to projection of a certain point, this point will always be
the lower border of the mandible and below it. The projected on the same spot on the film and will not
sagittal plane is tilted so that it is 5° to the vertical appear unsharp.
Section | I Topic-Wise Solved Questions of Previous Years 501

Tomography may be classified into three types: relative position of the fulcrum between the
a. Conventional tomography tube and the film.
b. CT ii. The second design
c. Emission tomography ● It is so made that the distance between the

Conventional tomography fulcrum and the tube and the fulcrum and the
● Tomography is a generic term, formed from the film remains constant.
Greek word tomo (slice) and graph (picture) that was ● In this case, the film and the X-ray tube pass

adopted in 1962 by the International Commission on in opposite directions through proportional

Radiographic Units and Measurements to describe all arcs. Here the object of interest is posi-
forms of body section radiography. tioned with reference to the focal plane, and
● Body section radiography is a special X-ray tech- all the images contain the same degree of
nique that enables visualization of a section of the magnification.
patient’s anatomy, blurring regions of the patient’s Tomographic views that are used to examine various facial
anatomy above and below the section of interest. structures are as follows:
● This is achieved by a synchronized movement of the i. Tomography of sinuses affords the following advan-
film and the tube in opposite directions, about a ful- tages:
crum (i.e. the plane of interest in the patient’s body). ● It gives a more precise evaluation of sinus pa-

● Objects closest to the film are seen most sharply and thologies, which are poorly visualized on routine
objects farthest away are completely blurred. radiography.
● The thickness of the image layer depends on the an- ● When a pathology is strongly suspected clini-

gle of rotation or the amount of movement of the cally, but plain films are negative.
tube; thus, if the path of the X-ray tube is short, and ● Sphenoid and ethmoidal sinuses are more clearly

the angle is small then the image layer is relatively visualized.

thick. Whereas when the angle of the movement in- ii. Tomography of facial bones, to study facial frac-
creases, the thickness of the image layer decreases. tures and extent of orbital blowout fractures
● Some degree of image degradation also occurs within iii. Tomography of the mandible
the image layer. The greatest amount of blurring is at iv. Tomography of the TMJ, especially when the pa-
the periphery of the image layer, and the sharpest tient is unable to open his mouth or in conjunction
image is at the centre. with arthrography
The principles of tomography can be mechanically imple- v. For dental implant patients
mented in a variety of ways: CT
● The tube and the film move synchronously in a straight ● CT is a digital and mathematical imaging tech-

line in opposite directions in parallel planes. nique that creates tomographic sections where the
● The tube and the film move synchronously in oppo- tomographic layer is not contaminated by blurred
site directions in parallel planes, but with motions structures from adjacent anatomy. It enables dif-
other than a straight line, i.e. circular, cross, spiral, ferentiation and quantification and soft tissues,
hypocycloidal, trispiral and other multidirectional and is a noninvasive procedure.
movements. ● The discovery and development of CT revolution-

● The X-ray tube may move in arcs rather than in flat ized medical imaging technology.
planes. ● CT scanners use X-rays to produce sectional im-

● The blurring of objects outside a focal plane is ac- ages, but the radiographic film is replaced by very
complished most effectively by compound move- sensitive crystal or gas detectors.
ments of the X-ray tube and least effective by simple ● The detectors measure the intensity of the X-ray
movements. beam emerging from the patient and convert this
● There are two basic design options used in most into digital data, which is stored and manipulated
units: by the computer.
i. Adjustable fulcrum system ● The numerical information is converted into grey

● The image layer or plane of focus is changed scale representing different tissue densities, al-
by adjusting the point of rotation called the lowing a visual image to be generated. This can
fulcrum. provide tomographic sections of the body.
● The disadvantage of this system is that the im- ● The CT sections are reconstructed from profile

ages that are produced will have different X-rays taken at different angles from the structure
amount of magnification, depending on the to be imaged.
502 Quick Review Series for BDS 4th Year, Vol 2

● It has the ability to detect minute differences in between the source and the detector, the atten-
tissue alteration. uation of the beam by the material in the object
● It gives highly accurate quantitative information being scanned.
about the tissues imaged. ● In its simplest form, a CT scanner consists of a
Indications of CT radiographic tube that emits a finely colli-
● Investigations of intracranial diseases includ- mated, fan-shaped X-ray beam directed to a
ing tumours, haemorrhage and infarcts series of scintillation detectors or ionization
● Investigations of suspected intracranial and chambers.
spinal cord damage following trauma to the ● Depending on the scanner’s mechanical geom-
head and neck etry, both the radiographic tube and detectors
● Assessment of fractures involving: The orbits may rotate synchronously about the patient.
and nasoethmoidal complex, the cranial base,
Or
cervical spine, etc.
● Tumour staging: Assessment of site, size and ● The detectors may form a continuous ring
extent of benign and malignant tumours affect- around the patient and the X-ray beam may
ing the maxillary antra, base of the skull, ptery- move in a circle within the detector ring (in-
goid region, the pharynx and larynx cremental scanners).
● Investigations of tumours and tumour-like
Or
discrete swellings intrinsic and extrinsic to
the salivary glands and also investigation of ● Spiral or helix scanners – here the gantry con-
the TMJ taining the X-ray tube and detectors revolves
● Preoperative assessment of maxillary alveolar around the patient, the table on which the pa-
bone height and thickness prior to inserting tient is lying continuously advances through
implants the gantry. This results in the acquisition of a
Equipment continuous spiral data, which provides multi-
● The X-ray gantry planar image reconstructions, reduced exami-
i. The X-ray tube: Stationary anode ener- nation time and a reduced radiation dose.
gized continuously and rotating anode op- ● The CT image is a digital image, reconstructed
erated in impulse mode by the computer, which mathematically ma-
ii. The radiation detector nipulates the mission data obtained from the
a. Scintillation detectors multiple projections. Penetration profile is
b. Gas counters stored in the computer, which calculates the
iii. The ancillary components: This embodies density or absorption at points on a grid formed
the mechanical system providing the mo- by the intersections of penetrating profiles.
tions required ● The image consists of a matrix of individual
Computer system points or pixels. The size of the pixel is deter-
● The data collected by the radiation detectors in mined by:
the X-ray gantry are utilized for the reconstruc- ● The geometry of the scan

tion of the tomographic section. ● The frequency and spacing of measurements

● The reconstructed section is displayed either in ● The number of penetration profiles

the analogue form as an image or as a numeri- ● The size of the X-ray source and detector

cal print out. ● Each number or pixel represents a calculation

● These functions are carried out by the com- of the actual attenuation of the X-ray beam by
puter system. A CT image is initiated by a materials. It represents the absorption charac-
process called scanning. teristics, or linear attenuation coefficient of
● Beams from one or several small X-ray sources that particular volume of tissue in the patient.
are passed through the body and intercepted by ● CT numbers, also known as Hounsfield units,
one or more radiation detectors. These detec- may range from –1000 to 11000, each consti-
tors produce electrical impulses that are pro- tuting a different level of optical density. The
portional to the intensity of the X-ray beam scale of relative densities is based on air
emerging from the body. (–1000), water (0) and dense bone (11000).
● That intensity is determined by various factors; ● The numbers may vary from one machine to
the energy of the X-ray source, the distance another depending upon various factors. For
Section | I Topic-Wise Solved Questions of Previous Years 503

any particular unit and energy, numbers de- Central ray

scribing the attenuation of biological materials ● Is directed to the midline of the skull so that

with densities lying between hair and bone can the X-ray beam passes through the canthome-
be described. Since the numbers represent at- atal plane perpendicular to the film plane.
tenuation or density, the computer constructs ● Exposure parameters are kVp – 65 mA – 10,

an image by printing the numbers or by assign- seconds – 3.

ing different degrees of greyness or different II. Waters’ projection/Caldwell projection
colours to each number. ● It is a variation of PA view.

● The CT image is recorded and displayed as a Synonyms

matrix of individual blocks called ‘voxels’ (vol- ● Occipitomental projection, paranasal sinus (PNS)

ume elements). Each square of the image ma- view of the skull or posteroanterior maxillary sinus
trix is a pixel. Whereas a pixel (about 0.1 mm) projection
is determined partly by the computer program Indications/uses
used to construct the image, the length of the ● It is particularly useful for evaluating the maxil-

voxel (about 1–2 mm) is determined by the lary sinuses.

width of X-ray beam, which in turn is con- ● It demonstrates the frontal and ethmoid sinuses,

trolled by the prepatient and postpatient colli- the orbit, the zygomaticofrontal suture and the
mators. Voxel length is analogous to the tomo- nasal cavity.
graphic layer in film tomography. ● It demonstrates the position of the coronoid pro-

cess of the mandible between the maxilla and the

Q.7. Enumerate various skull radiographs and discuss zygomatic arch.
in detail posteroanterior paranasal sinus and submento- ● In contrast to the horizontal film position, the left
vertex view of skull. or right position permits the detection of fluid
level in the maxillary sinuses.
Ans. Film placement
Posteroanterior projection/occipitofrontal projection ● The film may be placed in either a vertical or

i. Posteroanterior projection/Granger projection horizontal position.

ii. Modified posteroanterior projection/Caldwell pro- Patient position
jection ● The head is oriented in such a way that the sagittal

plane is perpendicular to the plane of the film and

I. Posteroanterior (granger) projection the chin is raised high to elevate the canthomeatal
● It is also known as the occipitofrontal projection of line to 37° above the horizontal plane.
the nasal sinuses. ● To avoid the superimposition of petrous portion of
● This view is excellent for evaluating the inner and the temporal bone over the maxillary sinus, the
middle ear because the petrous pyramid can be chin has to be elevated further.
viewed through the orbits. Frontal sinuses lying ● To investigate the sphenoid sinus, the projection
above the frontonasal suture, anterior ethmoidal cells needs to be taken with patient’s mouth open.
lying each on either side of the nasal fossa, sphenoi- Central ray projection
dal sinuses projected through the nasal fossa just ● The central ray should be perpendicular to the
below or between the shadows of the ethmoids. The film, through the midsagittal plane and at the level
upper part of the antrum is superimposed by dense of the maxillary sinus.
shadows of the petrosae. Exposure
Technique ● The exposure parameters vary based on the
Film placement type of X-ray machine and the distance from
● The cassette is placed perpendicular to the the source to the patient. Exposures recom-
floor in a cassette holding device. The long mended for film with intensifying screens are
axis of the cassette is positioned vertically. 70 kVp, 100 mA.
Position of patient Submentovertex projection
● The midsagittal plane should be vertical and ● A full axial view of the base of the cranium show-
perpendicular to the plane of the cassette. ing a symmetrical projection of the petrosae, the
● Only the forehead and nose should touch the mastoid process, foramen ovale, spinosum canals,
cassette. carotid canals, sphenoidal sinuses, mandible,
o
● The radiographic baseline is at 90 to the film. maxillary sinus, nasal septum, odontoid process
504 Quick Review Series for BDS 4th Year, Vol 2

of the atlas and the entire atlas, axial inclination of a Frankfort horizontal angulation of 37–40° to the
the mandibular condyles. detector.
● It helps to study destructive/expansile lesions ● Patient’s midsagittal plane is perpendicular to the
affecting the palate, pterygoid region or base of plane of the detector and the central ray is directed
the skull, sphenoidal sinus. perpendicular to the detector through the midsagittal
● The film is placed such that the cassette is placed plane at the level of the maxillary sinus.
perpendicular to the floor in a cassette holding ● The three variations of the Waters’ projection are as
device. The long axis of the cassette is placed follows:
horizontally. i. Modified Waters’ view (23°):
● The patient is positioned in such a way that the ● It has reduced caudal angle to provide better

head is centred on the cassette, with the patient’s visualization of the floor of the maxillary sinus.
head and neck tipped back as far as possible; the ii. Open mouth Waters’ view:
vertex (top) of the skull touches the cassette. ● It is performed at standard caudal angle but

● Both the midsagittal plane and the radiographic the patient’s mouth is opened wide to provide
baseline should be perpendicular to the plane of better view of the sphenoid sinuses.
the film. iii. 45o Occipitomental view:
● The central ray is directed from below the man- ● It is taken with a greater caudal angle to provide

dible upwards, towards the vertex of the skull and better visualization of the sphenoid sinuses.
positioned far enough anterior to pass about 2 cm
Q.2. Oblique lateral radiograph of mandible.
in front of line connecting right and left condylar
processes. Ans.
Exposure parameters
Lateral oblique view of mandible can be used for large
● The target object distance is 18 inches and the
lesions and the size of the cassette used is 5 3 7 inches.
exposure time is 12 impulses (0.2 s).
Types of lateral oblique view
● For viewing the zygomatic arches specifically,
i. Body of the mandible view
exposure time is reduced to one-third that is used
ii. Ramus view
to visualize the skull.
● Shorter exposure time is needed because the i. Mandibular body projection
zygomatic arches are thin bony structures. ● The image receptor is placed against the patient’s

Uses cheek on the side of interest and centred in the

● To demonstrate base of skull molar–premolar area.
● Position and orientation of condyles ● The lower border of the cassette is parallel and at

● Detection of curvature of mandible, the lateral least 2 cm below the inferior border of the mandible.
wall of maxillary sinus ● The head is tilted towards the side being examined,

● To view fracture of zygomatic arch the mandible is protruded.

● The central beam is directed towards the molar–
premolar region from a point 2 cm below the angle
SHORT ESSAYS: of the opposite side of the mandible.
Q.1. Technique for better visualization of paranasal air ● A clear image of the teeth, alveolar ridge and the

sinus. body of the mandible should be obtained.

● If significant distortion is present, the head was tilted
Ans.
excessively. If the contralateral side of the mandible
● Waters’ projection is also known as ‘sinus view’. It is is superimposed over the area of interest, the head
used to view the maxillary sinus, orbital ridges and was not tilted sufficiently.
floor, frontal and ethmoidal sinus and the nasal cavity. ii. Mandibular ramus projection
● It is indicated in: ● The image receptor is placed over the ramus and far

i. Trauma to middle third of face more posteriorly to include the condyle. The lower
ii. To asses fluid levels and soft tissues of lateral, infe- border of the cassette is parallel and at least 2 cm
rior and medial wall of maxillary sinus below the inferior border of the mandible.
iii. To inspect the odontoid process of second cervical ● The head is tilted towards the side being examined so

vertebrae, mandible and condyles during trauma that the condyle of the area of interest and the contra-
Technique lateral angle of the mandible form a horizontal line.
● Tilt back the head to prevent superimposition of the ● The central beam is directed towards the centre of

highly dense petrous bone over the maxillary sinus. imaged ramus, from 2 cm below the inferior border
● The chin should rest on the detector and the nose is of the opposite side of the mandible at the area of the
approximately 3 cm away from the film approximating first molar.
Section | I Topic-Wise Solved Questions of Previous Years 505

● A clear image of the third molar–retromolar area, Q.6. Define focal trough and write any two principal
angle of the mandible, ramus and condyle head advantages of panoramic radiograph.
should be obtained. Ans.
● If significant distortion is present, the head was tilted
excessively. If the contralateral side of the mandible ● Focal trough is defined as that zone which contains
is superimposed over the area of interest, the head those object’s points that are depicted with optimum
was not tilted sufficiently. resolution. In other words, it is a three-dimensional
curved zone in which structures are clearly demon-
Q.3. Posteroanterior view. strated on a panoramic radiograph.
Ans. ● The size and shape of the focal trough varies according
to the manufacturer. The closer the rotation centre to the
● The purpose of the posteroanterior projection is to teeth, narrower the focal trough. In most machines, the
evaluate facial growth and development, trauma and focal trough is narrow in the anterior region and wide in
disease and developmental abnormalities. This projec- the posterior region.
tion also demonstrates the frontal and ethmoid sinuses, Advantages
the orbits and the nasal cavity. Principal advantages of panoramic radiograph:
● The cassette is placed perpendicular to the floor in a ● Convenient for the patient requiring very little patient
cassette holding device. The longaxis of the device compliance.
cassette is positioned vertically. ● Useful in patients with trismus and gagging problems.
● The patient faces the cassette such that the forehead and ● Time required is minimal compared to a full mouth
the nose both touch the cassette. The midsagittal plane intraoral periapical radiographs.
is positioned perpendicular to the floor, and the Frank- ● The patient exposure dose is relatively low compared
fort plane is positioned parallel with the floor. The head to a full mouth intraoral periapical.
is centred over the cassette.
Q.7. Technique of transcranial view of TMJ.
● The central ray is directed through the centre of the head
and perpendicular to the cassette. Ans.
● The exposure factors for the posteroanterior projection vary [Ref LE Q.1]
with the film, intensifying screens and equipment used.
Q.8. Write in brief the radiographic techniques used for
Q.4. Panoramic radiography. viewing the maxillary sinus.
Ans. Ans.
[Ref LE Q.4] The various radiographic investigations to examine the
maxillary sinus for foreign body are as follows:
Q.5. Radiographs to study the following: (A) fractures
of the angle of mandible, (B) fracture in symphysis
Radiographic view Area of the antrum shown
region and (C) fracture zygomatic arch.
i. Intraoral Floor, base of the antral cavity, relation-
Ans. periapical ship with upper posterior teeth
radiograph
The radiographs to study the following fractures are as
ii. OPG Floor, posterior wall, base of the antral
follows:
cavity, relationship with the posterior
Fractures of the angle of mandible teeth, allows comparison with both sides
● Lateral oblique view is satisfactory technique of hav-
iii. Standard occip-
ing an extraoral view of the jaw; it is used to visual- itomental view
ize large lesions. It can show body of mandible from
canine to the angle of mandible, ramus of mandible, iv. Posterior Floor, lower half of the antral cavity,
topographic relationship with upper posterior teeth
body of maxilla, condyle and coronoid process. occlusal view
Fracture in symphysis region
v. True lateral Main antral cavity, posterior wall and
● Posteroanterior projection is used to visualize the
skull anterior wall (in this view the antral
facial symmetry, frontal and ethmoid sinus pathol- shadows superimpose each other)
ogy, the occipital and facial bones and the orbits.
vi. Linear tomogra- Main antral cavity, floor, anterior wall,
Fracture zygomatic arch
phy in coronal lateral wall, posterior wall, medial
● Submentovertex view allows the visualization of the
or sagittal plane wall, roof or upper border and allows
base of the cranium including the occipital bone, the comparison of both sides
sphenoid and ethmoids in uses, petrous ridge and
vii. CT Main antral cavity, floor, all walls roof
mastoid sinuses of the temporal bone. or upper border, surrounding structures
● Facial structures imaged include the hard palate, zy- allows comparison of both sides, images
gomatic arch and mandible including the condyles. hard and soft structures
506 Quick Review Series for BDS 4th Year, Vol 2

SHORT NOTES: useful for visualizing condylar neck fractures and gross
degenerative changes or other anomalies.
Q.1. Principle of panoramic radiography.
Q.6. Mention the uses of Waters’ view.
Ans.
Ans.
● If the film moves at a speed that follows the moving
projection of a certain point, this point will always The uses of Waters’ view are as follows:
be projected on the same spot on the film and will not ● To evaluate the maxillary sinus
appear unsharp. ● To demonstrate the frontal and ethmoidal sinus, the
● In the OPG, the film is attached to a rotating system and orbits and nasal cavity
moves in the same direction as the beam. The film is Q.7. Submentovertex view.
given the correct speed by opposing this movement with
a contrary movement relative to the beam. Ans.
Q.2. Advantages of panoramic radiography. ● The purpose of submentovertex position is to identify
the position of the condyles, demonstrate the base of the
Ans. skull and evaluate the fractures of the zygomatic arch.
Advantages of panoramic radiography ● It also demonstrates the sphenoid and ethmoid sinuses
i. Convenient for the patient and requires very little patient and the lateral wall of the maxillary sinus.
compliance. Q.8. Name few extraoral radiographs.
ii. Useful in patients with trismus and gagging problems.
iii. Time required is minimal compared to a full mouth Ans.
intraoral periapical radiographs. ● Extraoral radiograph is a large inspection of the skull or
iv. The patient exposure dose is relatively low compared jaws. It requires the use of extraoral film that is placed
to a full mouth intraoral periapical radiographs. outside the mouth.
Q.3. Transorbital view. ● Examples of extraoral radiographs are as follows:
i. Lateral skull projection
Ans. ii. Submentovertex projection
[Ref LE Q.1] iii. Waters’ projection
iv. Posteroanterior skull projection
Q.4. Give uses of lateral skull projection.
Q.9. Indications for extraoral radiographs.
Ans.
Ans.
● It is a method used to examine posterior region of the
mandible and is used in children, in patients with Extraoral radiography is indicated for:
limited jaw opening due to a fracture or swelling, and in ● Evaluation of trauma
patients who have difficulty in tolerating intraoral film ● Impacted third molars
placement. ● Extensive dental or osseous disease known or suspected
● It is used to evaluate the teeth, the alveolar ridge and large lesions
the body of the mandible, third molar-retromolar area, ● Tooth development and retained teeth or root tips
angle of the mandible, ramus and condyle head. ● Developmental anomalies
● Monitor growth and development as well as treatment. Q.10. Indications of PA view skull.
Q.5. Name two radiographic techniques to study TMJ. Ans.
Ans. ● The purpose of the posteroanterior projection is to
evaluate facial growth and development, trauma and
Two techniques used to study TMJ joint are as
disease and developmental abnormalities.
follows:
● This projection also demonstrates the frontal and
● Transcranial view: Transcranial technique is also
ethmoidal sinuses, the orbits and nasal cavity.
known as Lindblom technique. It is most useful in de-
tecting arthritic changes on the articular surface and it Q.11. Bregma–Menton view.
also helps to evaluate the joints’ bony relationship.
Ans.
● Transorbital view: Transorbital technique is also
known as Zimmer projection. This view is particularly [Ref LE Q.2]
Section | I Topic-Wise Solved Questions of Previous Years 507

Topic 8
Specialized Imaging Techniques
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1. Sialography: describe the indications and contraindications of sialography. Describe the technique briefly.
2. Define sialography and describe in detail the contrast media used in sialography.
3. Describe sialography in detail and write briefly on its significance in various salivary gland disorders. Add a note
on its interpretation in various diseases of salivary glands.
4. What is tomography and describe in detail computed tomography?
5. Define sialography. Give the ideal requirements of the contrast media used in sialography. [Same as LE Q.2]

SHORT ESSAYS:
1. Describe the procedure for sialography of parotid gland.
2. Digital radiography.
3. Applications of ultrasound in dentistry.
4. Salivary scintigraphy.
5. Radionuclide imaging – advantages and disadvantages.
6. Magnetic resonance image and its advantages.

SHORT NOTES:
1. Two indications and contraindications of sialography. [Ref LE Q.1]
2. Digital radiography (radiovisiography). [Ref SE Q.2]
3. Mention few requirements of ideal contrast medium used for sialograph. [Ref LE Q.2]
4. Scanography.
5. Write notes on xeroradiography.
6. Indications of CT in oral and maxillofacial region. [Ref LE Q.4]
7. Contraindications of sialography. [Same as SN Q.1]
8. Indications of sialography. [Same as SN Q.1]

SOLVED ANSWERS
LONG ESSAYS:
Q.1. Sialography: describe the indications and contrain-
{SN Q.1}
dications of sialography. Describe the technique briefly.
Indications
Ans.
Sialography is used for:
Sialography is a specialized radiographic view taken by in- i. Detection of calculus or calculi or foreign bodies.
troduction of the radiopaque dye into the ductal system of the ii. Determination of the extent of destruction of the
major salivary glands, mainly parotid and submandibular. gland secondary to obstructing calculi or foreign
This technique is used to examine the ductal and acinar bodies. This will help in deciding treatment plan
systems of the major salivary glands. The sublingual and whether a total excision of the gland or a simple
the minor glands cannot be studied obviously because of lithotomy should be performed.
their small and numerous openings.
508 Quick Review Series for BDS 4th Year, Vol 2

iii. If the gland has some degree of function, a drop of

iii. Detection of fistulae, diverticula or strictures.
saliva can be expressed by applying gentle pres-
iv. Determination and diagnosis of recurrent swell-
sure to the skin over main parotid area, thus iden-
ings and inflammatory processes.
tifying the location of the orifice.
v. Demonstration of a tumour and the determina-
iv. The submandibular excretory duct orifice is situated on
tion of its location, size and origin.
the summit of the small papilla at the side of the lingual
vi. Determining outline of the plane of the facial nerve
frenum, but care should be taken to differentiate it from
as a guide in planning a biopsy or dissection.
the sublingual gland orifices in the same region.
vii. Detection of residual stone or stones, residual
v. The duct can be explored with the lacrimal probe,
tumour, fistula or stones retention cysts following
after the appropriate orifice has been identified.
surgical procedures.
● In case of the submandibular gland, the probe
viii. Sialography has also been employed as a thera-
should pass through the length of the floor of the
peutic procedure because:
mouth to the level of the posterior border of the
● The dilatation of the ductal system produced
mylohyoid muscle, a penetration of about 5 cm.
during the study may aid in the drainage of
● Due to the tortuous course of the parotid duct, the
the ductal debris.
cheek has to be turned outward before the probe is
● A therapeutic effect is produced by the
inserted into the duct. The aversion of the cheek
iodinated contrast media when injected into
will help reduce the possibility of penetrating the
the ductal system.
duct at one of the sharp angles in its course.
Contraindications
● In both the parotid and submandibular ducts,
i. Patient with a known sensitivity to iodine com-
the probe should slide easily back and forth and
pounds and those who have experienced severe
also rotate freely without dragging.
asthmatic attacks or anaphylaxis following use
vi. When the duct orifice has been adequately sized
of iodine compounds in a prior radiologic ex-
and enlarged, the sialographic cannula is inserted
amination should not be considered as subjects
into the duct so that the tissue stop presses firmly
for this technique.
into the orifice to prevent dye reflux.
ii. The use of sialography during the period of acute
vii. After insertion of the cannula, the radiopaque dye
inflammation of the salivary system is contrain-
is slowly introduced into the duct. The amount of
dicated. During this period, the ductal epithelium
dye to be injected into the gland for adequate fill-
may be disrupted, and escape of the contrast
ing varies from patient to patient and depends on
medium from the ductal system into the paren-
the condition of the gland.
chyma can produce severe foreign body reaction,
viii. The amount used is best determined by fluoroscopic
accompanied by severe pain.
observation; the patient should be instructed to inform
iii. The administration and retention of the iodinated
the operator when the gland area feels tight or full.
contrast material used in sialography may inter-
Appropriate volumes of dye required vary from
fere with subsequent thyroid function tests,
0.76 to 1.00 mL for the parotid glands, and 0.0 to
hence such functional studies if required should
0.75 mL for submandibular glands. The cardinal
be done prior to the sialography procedure.
rule is that the injection should be stopped when
the gland is full, if the dye is extravasated, or when
Procedure the patient experiences mild discomfort.
Armamentaria required: Radiographic projections
● Polyethylene tubing with a special blunt end me- ● The filming procedure is carried out with the patient

tallic tip in the supine position. Often several films are ob-
● 5 or 10 cc syringe tained during the injection in order to monitor the
● Lacrimal dilators filling phase and degree of filling.
● Contrast media ● The lateral oblique projection or mandibular occlusal

● Sialagogue-like five lemon slices or lemon extract view is used to delineate the submandibular gland.
or chewing gum ● In the lateral oblique view, the duct pattern is not dis-

i. The parotid orifice is located at the base of the pa- torted, while a sialoliths is well demarcated on the occlu-
pilla in the buccal mucosa adjacent to the first or sal view. The anteroposterior (AP) view of both glands
second molar. demonstrates the medial and lateral gland structures.
ii. The area over the mucosa where the duct orifice is ● In case of the parotid gland, the patient should

depicted to be located should be dried with a small be asked to keep the mouth open. The panoramic
sponge. projection may also be taken, which is helpful in
Section | I Topic-Wise Solved Questions of Previous Years 509

studying erosion of bone or destruction of the man-

iii. Absence of local or systemic toxicity.
dible, in case of salivary tumours.
iv. Pharmacologically inert.
The evacuation (fat-soluble medium) or the parenchy-
v. Satisfactory opacification.
mal phase (water-soluble medium):
vi. Low surface tension and low viscosity to allow easy
● After the final sialographic views have been made,
filling of fine components of the ductal system.
the cannula should be removed from the duct orifice.
vii. Easy elimination, but should be durable for suffi-
The patient is instructed to chew gum or the lemon
cient time so as to permit time for satisfactory
slice and then asked to rinse. This is done to stimu-
radiographs.
late the gland and cause excretion of the dye.
viii. Residual contrast media should be absorbed by
● Lateral jaw, lateral oblique or AP view radiographs
the salivary gland and detoxified by the liver or
should be made 5 min after removal of the cannula.
excreted by the kidney.
They provide the information about the excretory
function of the gland.
● Normal salivary gland will excrete 100% of the con-
Two types of contrast media available are explained in the
trast dye within 5 min after removal of the cannula.
table below:
Additional views required to be taken to study special
features are as follows:
● Reverse basilar view to demonstrate the deep portion Water-soluble media Fat-soluble media (oil-based)
of the parotid. a. These are principally a. There are two types of
● A film made with the cheek in the blow-out position in iodinated benzene or fat-soluble contrast media
the AP view to demonstrate the superficial portion of pyridone derivatives i. Iodized oil
ii. Water-insoluble organic
the course of the Stensen’s duct of the parotid gland.
iodine compounds
● Occlusal view for the demonstration of the distal

submandibular gland’s Wharton duct. b. They have a low b. These are more viscous,
viscosity, less surface have more surface tension and
● Filming of the filling phase with the mouth open
tension and are are less miscible with the sali-
will reduce superimposition of the mandible on the more miscible with vary secretions
parotid gland. the salivary secretions
● Stereoscopic studies are invaluable for the study of
c. Their physical character- c. These compounds require a
tube spatial relationships of the gland and the duct. istics permit filling of higher injection pressure
● Subtraction views are of great value in the delineation the finer ductal system than that of the water-soluble
of the finer ducts and of the sublingual ductal system. under lower pressure media, to visualize finer ducts.
● Plesioradiography is a technique in which a small X-ray
and facilitate prompt Oil-based media is poorly
drainage eliminated and causes ductal
tube is placed in contact with the facial soft tissues obstruction
contralateral to the gland being examined in an attempt
to eliminate the obscuring overlying bony structures. d. They cause less pain or d. Usually accompanied with
discomfort, with no pain and a lot of discomfort.
Q.2. Define sialography and describe in detail the granulomatous reaction, Extravasation of the fat-soluble
contrast media used in sialography. in the glands media can produce severe
foreign body reaction with
Ans. focal necrosis of the
parenchyma and stroma
Sialography is a specialized radiographic view taken by in-
e. Opacification of the e. The fat-soluble contrast media
troduction of the radiopaque dye into the ductal system of the water-based media is on the whole produces a satis-
major salivary glands, mainly parotid and submandibular. not as good as that of factory degree of opacifica-
This technique is used to examine the ductal and acinar oil media tion. They are an excellent
systems of the major salivary glands. The sublingual and media if the ductal systems
under examination are intact
the minor glands cannot be studied obviously because of
their small and numerous openings. f. The excretion of this f. The excretion of this type of
Contrast media type of contrast media is contrast media is slow and
very rapid gives adequate time to carry
out the various radiographic
{SN Q.3} procedures

An ideal sialographic contrast media should have the g. Examples of the g. Example of the available
available water-soluble fat-soluble contrast media is
following characteristics:
contrast media are Ethiodol
i. Physiological properties similar to that of saliva. hydropaque and
ii. Miscibility with saliva. Renografin
510 Quick Review Series for BDS 4th Year, Vol 2

Q.3. Describe sialography in detail and write briefly on ● Lacrimal dilators

its significance in various salivary gland disorders. Add ● Contrast media, e.g. Con ray 420
a note on its interpretation in various diseases of sali- ● Sialagogues-like five lemon slices or lemon extract

vary glands. or chewing gum

● Gauze sponge pads
Ans.
● Magnifying glasses

● Sialography is a specialized radiographic view taken by ● Good dental lighting

introduction of the radiopaque dye into the ductal sys- Procedure

tem of the major salivary glands, mainly parotid and ● The parotid gland and submandibular glands are

submandibular. more readily studied using sialography.

● This technique is used to examine the ductal and acinar ● Before the passage of cannula, a lacrimal or peri-

systems of the major salivary glands. The sublingual odontal probe is used to dilate the sphincter at the
and the minor glands cannot be studied obviously be- ductal orifice.
cause of their small and numerous openings. ● Cannula is connected by extension tubing to a sy-

Indications ringe containing contrast medium. Once the duct is

i. Detection of calculus or calculi or foreign bodies cannulated, the injection of contrast medium is made
and also ductal disorders of major salivary glands. with hand pressure. Patient may complain of mild
ii. Determination of the extent of destruction of the gland pain during injection. A slow constant injection tech-
secondary to obstructing calculi or foreign bodies. nique can accomplish complete ductal filling without
iii. To evaluate the extent of irreversible ductal dam- patient discomfort.
age caused by infection. This will help in deciding ● Patient sensation of glandular fullness is suggested

treatment plan whether a total excision of the by a sharp pain when the operator usually stops and
gland or a simple lithotomy should be performed. proceeds for radiography.
iv. Detection of fistulae, diverticula or strictures. ● Phases of sialography are as follows:

v. Determination and diagnosis of recurrent swell- i. Ductal phase

ings and inflammatory processes. ● This phase follows immediately after the in-

vi. Demonstration of a tumour and the determination jection of contrast medium.

of its location, size and origin. ● It allows visualization of major ducts.

vii. Determining outline of the plane of the facial ii. Acinar phase
nerve as a guide in planning a biopsy or dissection. ● This phase begins after the ductal system

viii. Detection of residual stone or stones, residual tu- becomes fully opacified.
mour, fistula or stone retention cysts following iii. Evacuation phase
surgical procedures. ● Evidence of retention of contrast medium.

ix. Sialography has also been employed as a therapeu- ● Retention of contrast medium beyond 5 min is

tic procedure because: normal.

● The dilatation of the ductal system produced Appearance
during the study may aid in the drainage of the i. Normal salivary glands
ductal debris. Normal salivary glands have a leafless-tree appear-
● A therapeutic effect is produced by the iodin- ance on sialograph.
ated contrast media when injected into the ii. Obstructive and inflammatory disorders
ductal system. a. Sialolithiasis: It has a cigar- or oval-shaped
● It may be used as a dilating procedure for mild radiopacity on sialogram.
ductal stenosis. For evaluation of diverticula, b. Bacterial sialadenitis: Ball-in-hand appearance.
strictures and fistula. c. Saccular dilatation of acini of the glands: Pro-
Contraindications duces focal narrowing of duct.
i. Acute infection of salivary gland, as it results in d. Autoimmune sialadenitis: Sialography is help-
foreign body reaction and severe pain. ful in diagnosis and staging of sialadenitis.
ii. Allergic reactions to any component of radiopaque (1) Early stage: Initiation of punctate and glob-
material to be used. ular spherical collection of contrast medium
iii. Thyroid disease due to iodine content of contrast evenly distributed
medium. (2) During progression of disease: Collection of
iv. Not indicated in minor salivary gland. contrast agent greater than 2 mm and irregu-
Armamentaria required lar in shape
● Polyethylene tubing with a special blunt-end metallic tip (3) At the end point: Complete destruction of
● 5 or 10 cc syringe the glands
Section | I Topic-Wise Solved Questions of Previous Years 511

e. Sicca syndrome: Gives snowstorm or cherry the exact location of the lesion is noted and its
blossom-like appearance size may even be precisely measured.
f. Sialectasis: Appearance of focal collection of ● Displacement of Stensen’s or Wharton duct by the
contrast medium presence of a tumour may also be detected sialo-
iii. Noninflammatory disorders graphically.
a. Sialodenosis: Enlargement of glands are seen. a. With forward displacement of the gland n
b. Cystic lesions: Cystic masses are visualized. buckling of the major duct is observed, with
c. Benign tumours: Sialography suggests a space oc- the posterior portion crowding upon its ante-
cupying mass or smoothly displaced mass around rior segment.
the lesion giving a ball-in-hand appearance. b. Posterior glandular displacement results in the
d. Sialodochitis: Sausage-link pattern. opposite effect n A distention and elongation
Interpretations of sialograph of the major duct.
● The sialographic appearance of the normal salivary c. Inferior or superior gland displacement inevi-
glands is that of a leafless tree. This radiograph tably causes n a disturbance in the course of
shows the main duct gradually going in secondary Stensen’s and Wharton ducts that may be visu-
branches and then into tertiary branches. alized sialographically.
● Various sialographic findings are described below:

● Sialography is an invaluable asset in the diagnosis

Q.4. What is tomography and describe in detail com-
of neoplastic diseases of salivary gland origin. puted tomography?
● Since the benign tumour develops at the expense
Ans.
of normal glandular structure, the sialogram will
often reflect its presence by revealing a filling ● Tomography is a process by which an image layer of the
defect, the latter being due to distortion and body is produced, while the images of the structures above
displacement of the normal duct system by the and below that layer are made invisible by blurring.
pressure of the expanding mass. ● In many cases, a distinction can be made by choosing
● A centrally located defect, devoid of ducts and appropriate orientation of the patient, or otherwise it is
surrounded by a whorl-like formation of ducts, is necessary to use a technique known as ‘body section
referred to as the ‘ball-in-hand’. radiography’ or tomography’.
● The tumour with no ductal structures in its midst Tomography may be classified into three types:
represents the ‘ball’ whereas the normal second- a. Conventional tomography
ary and tertiary ducts that have been pushed to the b. Computed tomography (CT)
periphery are supposedly the fingers and palm of c. Emission tomography
the ‘hand’. This pattern may be visualized on Conventional tomography
lateral and/or AP films. ● Tomography is a Greek word where tomo means

● The presence of localized puddling or widespread ‘slice’ and graph means ‘picture’, which was ad-
diffusion of the contrast medium throughout the opted in 1962 by the International Commission on
gland parenchyma suggests the diagnosis of a Radiographic Units and measurements to describe
malignant neoplastic disease. all forms of body section radiography.
● The invasive character of the malignant tumour ● Body section radiography is a special X-ray tech-

leads to partial destruction of ducts, and as the nique that enables visualization of a section of the
sialographic solution reaches these regions, it patient’s anatomy by blurring regions above and
escapes into the surrounding interstitial connec- below the section of interest.
tive tissue, either accumulating in localized pud- ● This is achieved by a synchronized movement of

dles or diffusing widely. the film and the tube in opposite directions, about
● Not all malignant tumours are portrayed in this a fulcrum.
manner. Occasionally, a malignant neoplasm ● Objects closest to the film are seen most sharply

gives the ‘ball-in-the hand’ pattern, since it, too, and objects farthest away are completely blurred.
may manifest a tendency to encapsulation in spite ● The thickness of the image layer depends on the

of its infiltrative character. angle of rotation or the amount of movement of

● When dealing with a parotid gland tumour, an AP the tube. Thus, if the path of the X-ray tube is
film may shed further light regarding its nature short and the angle is small, then the image layer
and more precise location. The parotid gland with is relatively thick. Hence, as the angle of the
its contained duct system may be displaced later- movement increases, the thickness of the image
ally away from the ramus of the mandible. Thus, layer decreases.
512 Quick Review Series for BDS 4th Year, Vol 2

● The greatest amount of blurring is at the periphery of

● It also enables differentiation and quantification of
the image layer, and the sharpest image is at the centre.
soft tissues and is a noninvasive procedure.
The principles of tomography can be mechanically
implemented in a variety of ways:
● The tube and the film move synchronously in a ● CT scanners use X-rays to produce sectional
straight line in opposite directions in parallel planes. images, but the radiographic film is replaced by
● The tube and the film move synchronously in op- very sensitive crystal or gas detectors.
posite directions in parallel planes, but with mo- ● The detectors measure the intensity of the X-ray
tions other than a straight line, i.e. circular, cross, beam emerging from the patient and convert this
spiral, hypocycloidal, trispiral and other multidi- into digital data, which is stored and manipulated
rectional movements. by the computer.
● The X-ray tube may move in arcs rather than in ● The numerical information is converted into
flat planes. grey scale representing different tissue densities,
● The blurring of objects outside a focal plane is allowing a visual image to be generated.
accomplished most effectively by compound ● It has the ability to detect minute differences in
movements of the X-ray tube and least effective tissue alteration. It gives highly accurate quantita-
by simple movements. tive information about the tissues imaged.
There are two basic design options used in most units:
i. Adjustable fulcrum system: The image layer or
plane of focus is changed by adjusting the point of {SN Q.6}
rotation called the fulcrum. The disadvantage of
Indications
this system is that the images that are produced
● Used in investigation of intracranial diseases like
will have different amount of magnification, de-
tumours, haemorrhage and infarcts
pending on the relative position of the fulcrum
● Assessment of fractures involving the cranial base,
between the tube and the film.
orbits, nasoethmoidal complex and the cervical spine
ii. The second design: It is so made that the distance
● Tumour staging – assessment of site, size and
between the fulcrum and the tube and the fulcrum
extent of tumours either benign or malignant in
and the film remains constant. In this case, the film
various parts of the body
and the X-ray tube pass in opposite directions through
● Investigations of tumours and tumour-like discrete
proportional arcs. Here, the object of interest is posi-
swellings intrinsic and extrinsic to the salivary
tioned with reference to the focal plane, and all the
glands
images contain the same degree of magnification.
● Investigation of the TMJ
Tomographic views are used to examine various facial
● In implant dentistry for preoperative assessment
structures as follows:
of maxillary alveolar bone height and thickness
i. Tomography of sinuses:
● It gives a more precise evaluation of sinus
pathologies. Equipment
● When a pathology is strongly suspected clini- ● The X-ray gantry consists of:

cally, but X-ray films are negative. i. The X-ray tube:

● Sphenoid and ethmoidal sinuses are more ● Stationary anode energized continuously

clearly visualized. ● Rotating anode operated in impulse mode

ii. Tomography of facial bones: ii. The radiation detector:

● To study facial fractures ● Scintillation detectors
● Extent of orbital blow-out fractures ● Gas counters
iii. Tomography of the mandible iii. The ancillary components
iv. Tomography of the temporomandibular joint (TMJ) The CT sections are reconstructed from profile
v. For dental implant patients X-rays taken at different angles from the struc-
Computed tomography ture to be imaged.
The computer system
● The tomographic section is reconstructed from the
{SN Q.6} data collected by the radiation detectors in the
● CT is a digital and mathematical imaging technique X-ray gantry and is displayed either in the ana-
that creates tomographic sections where the tomo- logue form as an image or as a numerical printout.
● These functions are carried out by the com-
graphic layer is not contaminated by blurred struc-
tures from adjacent anatomy. puter system. A CT image is initiated by a
process called scanning.
Section | I Topic-Wise Solved Questions of Previous Years 513

● Beams from one or several small X-ray SHORT ESSAYS:

sources are passed through the body and in-
Q.1. Describe the procedure for sialography of parotid
tercepted by one or more radiation detectors.
gland.
These detectors produce electrical impulses
that are proportional to the intensity of the Ans.
X-ray beam emerging from the body.
Procedure of sialography for parotid glands
● In its simplest form, a CT scanner consists of
● The parotid is the largest of the salivary glands, lying just
a radiographic tube that emits a finely colli-
below the zygomatic arch in front and below the ear and
mated, fan-shaped X-ray beam directed to a
on the masseter muscle over the ramus of the mandible.
series of scintillation detectors or ionization
● The duct from the parotid gland (Stensen’s duct) runs
chambers.
along the outer surface of the masseter to the buccal
● The CT image is a digital image, recon-
mucous membrane opposite the upper second molar.
structed by the computer, which mathemati-
● A cannula tip is inserted into the opening of the
cally manipulates the mission data obtained
Stensen’s duct opposite second maxillary molar.
from the multiple projections.
● Each gland is examined turn wise and small amount
● Penetration profile is stored in the computer,
of contrast medium is injected.
which calculates the density or absorption at
The projections for parotid gland:
points on a grid formed by the intersections of
● They are the same as that of the ramus of the mandible
penetrating profiles. The image consists of a
a. In lateral positioning, the head is in exactly lateral
matrix of individual points or pixels.
position with angle of the mandible over shadow-
● Each number or pixel represents a calculation
ing each other. Central rays of X-rays are passed
of the actual attenuation of the X-ray beam by
over the angle of the mandible.
materials with the body.
b. In lateral oblique view, the head is straight almost
● It represents the absorption characteristics, or
similar to lateral view. The only difference is cen-
linear attenuation coefficient, of that particu-
tral ray is projected below and behind the angle of
lar volume of tissue in the patient.
the jaw away from the film, 25° towards the head.
● CT numbers, also known as Hounsfield units,
c. In frontal position (AP), the median plane is kept at
may range from –1000 to 11000, each consti-
right angle to the film. The head is slightly raised
tuting a different level of optical density. The
and the chin lowered towards the chest. In these
scale of relative densities is based on air
cases, the main duct is well shown as it crosses to
(–1000), water (0) and dense bone (11000).
mandible, but the gland region is overexposed with
The numbers may vary from one machine to
intraglandular ducts largely obliterated.
another depending upon various factors.
● Since the numbers represent attenuation or Q.2. Digital radiography.
density, the computer constructs an image by
Ans.
printing the numbers or by assigning different
degrees of greyness or different colours to
each number.
{SN Q.2}
● The CT image is recorded and displayed as a
matrix of individual blocks called ‘voxels’ (vol- ● Digital radiography refers to a method of capturing a
ume elements). Each square of the image matrix radiographic image using a sensor, breaking it into
is a pixel. Whereas a pixel (about 0.1 mm) is electronic pieces and presenting and storing the image
determined partly by the computer program using a computer.
used to construct the image, the length of the ● Three methods to obtain a digital image are as follows:
voxel (about 1–2 mm) is determined by the i. Direct digital imaging
width of X-ray beam, which in turn is controlled ii. Indirect digital imaging
by the prepatient and postpatient collimators. iii. Storage phosphorous imaging
● Voxel length is analogous to the tomographic
i. Direct digital imaging: Here a sensor is placed in
layer in film tomography.
the mouth and exposed. The sensor captures the
Q.5. Define sialography. Give the ideal requirements of image and transmits to a computer monitor.
the contrast media used in sialography. ii. Indirect digital imaging: An X-ray film is digitized
using Charged coupled device (CCD) cameras that
Ans.
scans the image, digitizes and converts the image to
[Same as LE Q.2] display it on computer screen.
514 Quick Review Series for BDS 4th Year, Vol 2

iii. As a screening process to detect atheromatous

iii. Storage phosphor imaging: Wireless digital sys-
plaques in the carotid artery, tumours of carotid
tem. Here, a reusable imaging plate coated with
sheath and venous thrombosis.
phosphors is exposed and a high-speed scanner is
In dentistry
used to convert information to electronic files.
i. Used for ultrasound-guided fine-needle aspira-
Clinical applications
tion biopsy (FNA).
i. To evaluate growth and development
ii. For detection of fractures of the orbital wall.
ii. To confirm or classify suspected disease
iii. Examination of congenital and inflammatory
iii. Detection of lesions, diseases and conditions of
neoplasms.
the teeth and surrounding structures
iv. Examination of thyroid gland and parathyroid
iv. To illustrate changes secondary to caries, peri-
glands and the lymph nodes.
odontal diseases or trauma
v. Examination and detection of salivary gland
v. To provide the information during the dental
masses. It also helps to differentiate between
procedures like root canal instrumentation and
cystic and solid lesions and to locate calculus in
surgical placement of implants
the ducts or parenchyma of the gland.
Advantages
Advantages
i. Effective patient education tool
i. It is widely available and inexpensive.
ii. Reduced exposure to radiation
ii. Gives good differentiation between soft tissues.
iii. Lower equipment and film cost
Disadvantages
iv. Easy reproducibility
i. Ultrasound technique is operator dependent.
v. Superior grey-scale resolution
ii. It has limited application in head and neck region as
vi. Enhancement of diagnostic image
the sound waves are absorbed by bone.
vii. Increased efficiency and speed of image
iii. Images are difficult to interpret for inexperienced
viewing
operators as image resolution is often poor.
viii. Image processing, enlargement and recon-
struction for specific diagnostic purpose are Q.4. Salivary scintigraphy.
possible
Ans.
ix. Excellent quality image
Disadvantages ● Scintigraphy is a radionuclide diagnosis imaging tech-
i. Initial set-up is costly. nique used for the detection of salivary gland disorders
ii. Image quality is still a source of debate. and other disorders.
iii. Sensor size is thicker than intraoral films, ● For this, technetium 99m pertechnetate is injected to the
hence it is not patient compliant and also it artery and salivary glands, which if rapidly metabolized
has to be covered adequately in a disposable will preferentially bind to it.
plastic wrapper. Phases of salivary scintigraphy
iv. Over-exposure and overloading of CCD sen- ● The imaging is done under the following three phases:

sors creating the phenomenon of blooming. i. Dynamic phase:

v. Large pixels result in poor resolution and ● Spread of radioactive marker through the vascu-

structures may not be represented accurately. lar system occurs during this phase.
vi. Loss of image quality and resolution on hard ● A set of radiographs are taken in first 30–120 s.

copy printouts when using thermal, laser or ii. Static phase:

inkjet printers. ● Concentration in the gland

● Radiographs taken every 10 min for 30–45 min

iii. Secretory phase:
Q.3. Applications of ultrasound in dentistry. ● Secretion of the marker by the gland. Patient is given

sialagogue and the final sets of radiographs are taken.

Ans.
Advantages
● Diagnostic ultrasound is a noninvasive investigation that i. Scintigraphy is much more sensitive to early or small
uses a very high frequency (7.5–20 MHz) pulsed ultra- changes in salivary metabolism than other techniques.
sound beam, rather than ionizing radiation, to produce ii. It provides valuable information concerning the
high-resolution images of more superficial structures. functional capacity of the salivary glands, which
Clinical application have undergone radiotherapy.
In medical field iii. It has been successfully used to image a wide vari-
i. Assessment of blood flow in the carotids and ca- ety of salivary gland disorders including sarcoid-
rotid body tumours. osis, Sjogren syndrome, sialadenitis, salivary gland
ii. Assessment of ventricular systems in babies. tumours and postoperative healing.
Section | I Topic-Wise Solved Questions of Previous Years 515

Disadvantages of many atoms of the body, including hydrogen atoms to

i. It cannot resolve lesions smaller than l cm. align themselves with the magnetic field. After application
ii. Ductal obstruction can trap the radionuclide tracer of an RF signal, energy is released from the body, detected
and cause a distorted image. and used to construct the MR image by the computer.
iii. A single scan of technetium 99 m pertechnetate can ● Two types of images are produced:
result in full body radiation of 1 m Gy which is i. T1-weighted image:
equivalent to 33% of the annual radiation. ● T1-weighted images are called fat images, because

of the shortest T1 relaxation time, short repetition

Q.5. Radionuclide imaging – advantages and disadvantages.
time between RF pulses and a short signal recov-
Ans. ery time. Intense MR signal is obtained.
● T1 gives a good image contrast and T1-weighted
● Radionuclide imaging uses radioactive compounds that
images are helpful for depicting small anatomical
have affinity for particular tissues called target tissues.
lesions like TM joint.
● Here radioactive compounds are injected into the patient,
● In TI-weighted images, cerebrospinal fluid ap-
concentrated in the target tissue and their radiation emis-
pears black.
sions are detected and imaged using gamma camera.
● Used to visualize normal anatomical structures.
● It provides the only means of assessing physiologic
ii. T2-weighted images:
change. It allows the examination of function and struc-
● These images are called water images because
ture of the target tissues to be examined under static and
they have the longest T2 relaxation time and
dynamic conditions.
appear as bright image.
Indications
● These T2-weighted images are used to see inflam-
● Metastases: The assessment of the sites and extent of
matory or pathologic changes.
metastases in tumour staging.
Advantages
● Salivary gland function: Assessment of the salivary
● It is an ionizing radiation.
gland function.
● No biological effects due to exposure.
● Graft assessment: It is also useful in bone grafts
● Highly effective tissue contrast, even blood ves-
assessment.
sels are clearly seen.
● Growth pattern: It is used in assessing continued
● Excellent differentiation between soft tissues is
growth of condylar hyperplasia.
possible between normal and abnormal tissues.
● Thyroid examination: Investigation of the thyroid.
● The region of the body imaged in MRI is con-
● Brain: Brain scans and investigation for the break-
trolled electronically; direct multiplanar imaging
down of the blood–brain barrier.
is possible without reorienting the patient.
Advantages
● High-resolution images can be constructed in all
● Functional details: Functional details of the target
the three planes.
tissue are investigated.
● No need for using any contrast media with their
● More area coverage: All similar target tissues can be
associated risks to enhance image contrast.
examined during one investigation, e.g. the bone scan
images the whole skeleton.
● Computer analysis: Computer analysis and image SHORT NOTES:
enhancement are possible.
Q.1. Two indications and contraindications of sialography.
Disadvantages
● Poor resolution: Anatomical details of the target Ans.
tissue are not obtained due to a decreased resolution.
[Ref LE Q.1]
● High radiation dose: Radiation dose to the patient’s

whole body is high as compared to that in conven- Q.2. Digital radiography (radiovisiography).
tional radiography.
Ans.
● Less specific image: Image obtained is less specific.

[Ref SE Q.2]
Q.6. Magnetic resonance image and its advantages.
Q.3. Mention few requirements of ideal contrast me-
Ans.
dium used for sialograph.
● MRI works on nuclear magnetic resonance to produce
Ans.
signal that can be used to construct an image.
● Uses nonionizing radiations from the radio frequency [Ref LE Q.2]
band of the Electromagnetic spectrum (EMS).
Q.4. Scanography.
● The patient is placed inside a large magnet, which induces
a relatively strong external magnetic field that causes nuclei Ans.
516 Quick Review Series for BDS 4th Year, Vol 2

● The scanography technique uses a narrowly collimated, Uses

fan-shaped beam of radiation to scan the area of inter- ● Mammography
est, sequentially projecting image data relative to this ● Cephalometry
area onto a moving film. ● Sialography

● Produces images with a higher contrast and greater detail. ● TMJ tomography

● The commercially available X-ray unit capable of Indications

performing both rotational and linear scanography is ● Detailed assessment of periodontal and periapical

Soredex SCANORA®. bone lesions

● Scanography is useful for the assessment of periodontal ● To show fine duct structures on sialography

disease and detection of periapical lesions. ● To show required hard and soft tissue landmarks on

one cephalometric radiographic film

Q.5. Write notes on xeroradiography.
● Assessment of soft tissue shadows in pharynx and

Ans. larynx
● Xeroradiography is based on electrostatic process simi- Q.6. Indications of CT in oral and maxillofacial region.
lar to that used for xeroxing. It does not require films
Ans.
commonly used for conventional radiography.
● There are two systems in xeroradiography: [Ref LE Q.4]
i. The Medical 125 system
Q.7. Contraindications of sialography.
ii. The Dental 110 system
● Conventional X-ray source is used in the production of [Same as SN Q.1]
xeroradiographs.
Q.8. Indications of sialography.
● Xeroradiograph can be viewed in reflected or transmitted
light. [Same as SN Q.1]

Topic 9
Radiographic Interpretations
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1.
Describe the normal anatomical landmarks in intraoral radiographs.
2.
Describe the radiolucent and radiopaque anatomic landmarks seen on the IOPA radiographs of mandible.
3.
Radiographic features of fibro-osseous lesions of the jaws.
4.
Discuss the differential diagnosis of periapical radiolucencies.
5.
Describe various radiopaque lesions at the root of mandibular premolar.
6.
Describe the radiographic appearance of different types of osteomyelitis of jaws.
7.
Name the malignant tumours of the jaws. Describe the radiographic appearance of carcinomas and sarcomas
of the jaws.
8. Describe the radiographic appearance of different cysts of maxilla and mandible.
9. Describe in detail periapical radiolucent areas. [Same as LE Q.4]
10. Describe briefly the characteristics of the malignant tumours of the jaws. Describe the radiographic appear-
ance of the same. [Same as LE Q.7]

SHORT ESSAYS:
1. Describe various radiographic landmarks of the maxilla. Why is it important to know radiographic landmarks
of maxilla?
2. Multilocular radiolucencies.
3. Enumerate the various radiographic techniques for the diagnosis of fracture of mandible.
Section | I Topic-Wise Solved Questions of Previous Years 517

4. Cemento-ossifying fibroma.
5. Describe radiographic appearance of dentigerous cyst.
6. Describe in detail the radiographic appearance of various odontomas and give the differential diagnosis.
7. Enumerate the radiopaque lesions of the jaws.
8. Discuss the radiological features of cementoma.
9. Radiographic features of periodontal disease.
10. Radiographic appearance of adenomatoid odontogenic tumour.
11. Radiographic appearance of (A) multiple myeloma and (B) cherubism.
12. Radiographic appearance of osteosarcoma.
13. Radiographic appearance of Paget disease.
14. Describe the radiological appearance of fibrous dysplasia.
15. Discuss any three multilocular lesions of the mandible. [Same as SE Q.2]
16. Periapical radiopacities. [Same as SE Q.7]
17. Differential diagnosis of periapical radiopacities. [Same as SE Q.7]
18. Discuss: (A) adenoameloblastoma and (B) ameloblastoma. [Same as SE Q.10]
19. Describe the radiological appearance of jaws in osteogenic sarcoma. [Same as SE Q.12]

SHORT NOTES:
1. Cotton-wool appearance on radiograph.
2. Lamina dura.
3. Name the anatomical landmarks seen on upper posterior periapical film.
4. ‘Onion-peel’ appearances on a radiography.
5. Radiographic appearance of ameloblastoma.
6. Name four conditions showing soap-bubble appearance on skull radiograph.
7. Herring bone pattern.
8. Moth-eaten appearance.
9. Line of Ennis.
10. Radiographic appearance of compound composite odontomes. [Ref SE Q.7]
11. Radiopaque landmarks of maxilla. [Ref SE Q.1]
12. Radiographic appearance of dentigerous cyst.
13. Radiographic appearance of hyperparathyroidism.
14. Name a few periapical radiopacities.
15. Discuss the radiological appearance of chronic osteomyelitis.
16. Describe the radiographic appearance of myxoma.
17. Enumerate the landmarks seen on the intraoral periapical view of upper third molar region. [Same as SN Q.3]
18. Onion-skin appearance. [Same as SN Q.4]
19. Soap-bubble appearance. [Same as SN Q.6]
20. Tyre track appearance. [Same as SN Q.7]
21. Radiographic features of chronic osteomyelitis. [Same as SN Q.15]

SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe the normal anatomical landmarks in The normal bony landmarks that frequently appear in
intraoral radiographs. maxillary periapical radiographs are as follows:
i. Incisive foramen
Ans.
● The incisive foramen or nasopalatine foramen
Normal anatomic landmarks in intraoral radiographs are as is an opening or hole in bone through which
follows: nasopalatine nerve exits the maxilla located at
A. Bony landmarks of the maxilla the midline of the anterior portion of the hard
All the bones of the face articulate with the maxilla, palate directly posterior to the maxillary central
with the exception of the mandible. The maxilla forms incisors.
the floor of the orbit of the eyes, the sides and floor of ● On a maxillary periapical radiograph, the inci-
the nasal cavities and the hard palate. sive foramen appears as a small, ovoid or round
518 Quick Review Series for BDS 4th Year, Vol 2

radiolucent area located between the roots of the ● On an IOPA radiograph, the anterior nasal spine
maxillary central incisors. appears as a V-shaped radiopaque area located
ii. Superior foramina of incisive canal at the intersection of the floor of the nasal cavity
● The nasopalatine nerve enters the maxilla through and the nasal septum.
the superior foramina, travels through the incisive ix. Inferior nasal conchae
canal and exits at the incisive foramen. ● The inferior nasal conchae are wafer thin,

● On a maxillary periapical radiograph, the supe- curved plates of bone that extend from the lat-
rior foramina appear as two small, round radio- eral walls of the nasal cavity. They are seen in
lucencies located superior to the apices of the the lower lateral portions of the nasal cavity.
maxillary central incisors. ● On a maxillary IOPA radiograph, the inferior

iii. Median palatal suture nasal conchae appear as a diffuse radiopaque

● The median or midpalatal suture is the immov- mass or projection within the nasal cavity.
able joint between the two palatine processes of x. Maxillary sinus
the maxilla extending from the alveolar bone ● The maxillary sinuses are paired cavities or com-

between the maxillary central incisors to the partments of bone located within the maxilla.
posterior hard palate. ● On a maxillary periapical radiograph, the maxil-

● On a maxillary periapical radiograph, the me- lary sinus appears as a radiolucent area located
dian palatal suture appears as a thin radiolucent above the apices of the maxillary premolars and
line between the maxillary central incisors. molars. The floor of the maxillary sinus is com-
iv. Lateral fossa posed of dense cortical bone and appears as a
● The lateral fossa also known as the canine fossa radiopaque line.
is a smooth, depressed area of the maxilla lo- xi. Inverted ‘Y’ of Ennis
cated just inferior and medial to the infraorbital ● On a maxillary periapical radiograph, the inverted

foramen between the canine and lateral incisors. ‘Y’ appears as a radiopaque upside-down Y,
● On a maxillary periapical radiograph, the lat- formed by the intersection of the lateral wall of
eral fossa appears as a radiolucent area between the nasal fossa and the anterior border of the
the maxillary canine and lateral incisors. maxillary sinus.
In some periapical radiographs, the lateral fossa ● The lateral wall of the nasal cavity and the

may appear as a distinct radiolucency. anterior border of the maxillary sinus are
v. Nasal cavity composed of dense cortical bone and appear as
● The nasal cavity also known as the nasal fossa a radiopaque line or band. The inverted Y is
is a pear-shaped compartment of bone located located above the maxillary canine.
superior to the maxilla. xii. Maxillary tuberosity
● On a maxillary periapical radiograph, the nasal ● The maxillary tuberosity is a rounded promi-

cavity appears as a large, radiolucent area above nence of bone that extends posterior to the third
the maxillary incisors. molar region.
vi. Nasal septum ● On a maxillary periapical radiograph, the max-

● The nasal septum is a vertical bony wall or par- illary tuberosity appears as a radiopaque bulge
tition that divides the nasal cavity into the right distal to the third molar region.
and left nasal fossae. xiii. Hamulus
● On a maxillary periapical radiograph, the nasal ● The hamulus or the hamular process is a small,

septum appears as a vertical radiopaque partition hook-like projection of bone extending from
that divides the nasal cavity. The nasal septum may the medial pterygoid plate of the sphenoid
be superimposed over the median palatal suture. bone, and is located posterior to the maxillary
vii. Floor of nasal cavity tuberosity region.
● The floor of the nasal cavity is a bony wall ● On a maxillary periapical radiograph, the ham-

formed by the palatal processes of the maxilla ulus appears as a radiopaque hook-like projec-
and the horizontal portions of the palatine bones. tion posterior to the maxillary tuberosity area.
● On a maxillary periapical radiograph, the floor of The radiographic appearance of the hamulus
the nasal cavity appears as a dense radiopaque varies in length, shape and density.
band of bone above the maxillary incisors. xiv. Zygomatic process of maxilla
viii. Anterior nasal spine a) On a maxillary periapical radiograph, the zygo-
● The anterior nasal spine is a sharp projection of matic process of the maxilla appears as a
the maxilla located at the anterior and inferior J-shaped or U-shaped radiopacity located supe-
portion of the nasal cavity. rior to the maxillary first molar region.
Section | I Topic-Wise Solved Questions of Previous Years 519

xv. Zygoma ● On a mandibular periapical radiograph, the

● The zygoma or ‘cheekbone’ also known as the mental fossa appears as a radiolucent area
malar bone or zygomatic bone articulates with above the mental ridge.
the zygomatic process of the maxilla. The zy- vi. Mental foramen
goma is composed of dense cortical bone. ● The mental foramen is an opening or hole in

● On a maxillary periapical radiograph, the zy- bone located on the external surface of the man-
goma appears as a diffuse radiopaque band ex- dible in the premolar region. Blood vessels and
tending posteriorly from the zygomatic process nerves that supply the lower lip exit through the
of the maxilla. mental foramen.
B. Bony landmarks of the mandible ● On a mandibular periapical radiograph, the

The bony landmarks that frequently appear in mandibu- mental foramen appears as a small, ovoid or
lar periapical radiographs are as follows: round radiolucent area located in the apical
i. Genial tubercles region of the mandibular premolars.
● The genial tubercles are tiny bumps of bone that ● The mental foramen is frequently misdiagnosed

are located on the lingual aspect of the mandible. as a periapical lesion (periapical cyst, granu-
● On a mandibular periapical radiograph, the ge- loma or abscess) because of its apical location.
nial tubercles appear as a ring-shaped radiopac- vii. Mylohyoid ridge
ity below the apices of the mandibular incisors. ● The mylohyoid ridge is a linear prominence of

ii. Lingual foramen bone located on the internal surface of the man-
● The lingual foramen is a tiny opening or hole in dible extending from the molar region down-
bone located on the internal surface of the man- ward and forward towards the lower border of
dible near the midline and is surrounded by the the mandibular symphysis.
genial tubercles. ● On a mandibular IOPA radiograph, the mylohy-

● On a mandibular periapical radiograph, the lin- oid ridge appears as a dense radiopaque band
gual foramen appears as a small, radiolucent dot that extends downward and forward from the
located inferior to the apices of the mandibular molar region and may be superimposed over the
incisors. The lingual foramen is surrounded by roots of the mandibular teeth.
the genial tubercles, which appear as a radi- viii. Mandibular canal
opaque ring. ● The mandibular canal is a tube-like passageway

iii. Nutrient canals through bone that travels the length of the man-
● The nutrient canals are tube-like passageways dible. It extends from the mandibular foramen
through bone that contain nerves and blood ves- to the mental foramen and houses the inferior
sels that supply the teeth. alveolar nerve and blood vessels.
● On a mandibular periapical radiograph, nutri- ● On a mandibular periapical radiograph, the

ent canals appear as vertical radiolucent lines. mandibular canal appears as a radiolucent band
They are readily seen in areas of thin bone and below or superimposed over the apices of the
they may be more prominent in the edentulous mandibular molar teeth.
mandible. ● The mandibular canal is outlined by two thin

iv. Mental ridge radiopaque lines that represent the cortical

● The mental ridge is a linear prominence of corti- walls of the canal.
cal bone located on the external surface of the ix. Internal oblique ridge
anterior portion of the mandible and it extends i. The internal oblique ridge is a linear promi-
from the premolar region to the midline and nence of bone located on the internal surface of
slopes slightly upward. the mandible that extends downward and for-
● On a mandibular periapical radiograph, the men- ward from the ramus. It may end in the region
tal ridge appears as a thick radiopaque band that of the mandibular third molar or it may con-
extends from the premolar region to the incisor tinue as the mylohyoid ridge.
region and often appears superimposed over the ii. On a mandibular periapical radiograph, it ap-
mandibular anterior teeth. pears as a radiopaque band that extends down-
v. Mental fossa ward and forward from the ramus.
● The mental fossa is a scooped-out, depressed x. External oblique ridge
area of bone located on the external surface of ● The external oblique ridge is a linear promi-

the anterior mandible above the mental ridge in nence of bone located on the external surface of
the incisor region. the body of the mandible.
520 Quick Review Series for BDS 4th Year, Vol 2

● On a mandibular periapical radiograph, the ex- Lamina dura

ternal oblique ridge appears as a radiopaque ● The lamina dura is the wall of the tooth socket

band extending downward and forward from the that surrounds the root of a tooth and is made up
anterior border of the ramus of the mandible. of dense cortical bone.
xi. Submandibular fossa ● On a dental radiograph, the lamina dura appears

● The submandibular fossa or the mandibular fossa as a dense radiopaque line that surrounds the root
or submaxillary fossa is a scooped-out, depressed of a tooth.
area of bone located on the internal surface of the Alveolar crest
mandible inferior to the mylohyoid ridge. ● It is the most coronal portion of the alveolar bone

● On a mandibular periapical radiograph, the sub- found between the teeth. The alveolar crest is
mandibular fossa appears as a radiolucent area made up of dense cortical bone and is continuous
in the molar region below the mylohyoid ridge. with the lamina dura.
xii. Coronoid process ● On a dental radiograph, the alveolar crest appears

● The coronoid process is a marked prominence radiopaque and is typically located 1.5–2.0 mm
of bone on the anterior ramus of the mandible. below the junction of the crown and the root
● The coronoid process is not seen on a mandibu- surfaces (CEJ).
lar periapical radiograph but does appear on a PDL space
maxillary molar periapical film. It appears as a ● The PDL space is the space between the root of

triangular radiopacity superimposed over or in- the tooth and the lamina dura. It contains connec-
ferior to the maxillary tuberosity region. tive tissue fibres, blood vessels and lymphatics.
Normal tooth anatomy in both maxilla and mandible ● On a dental radiograph, the PDL space appears as

Tooth structures that can be viewed on IOPA radio- a thin radiolucent line of uniform thickness around
graphs are as follows: the root of a tooth.
i. Enamel
Q.2. Describe the radiolucent and radiopaque anatomic
ii. Dentine
landmarks seen on the IOPA radiographs of mandible.
iii. The dentinoenamel junction (DEJ)
iv. Pulp cavity Ans.
Normal anatomical landmarks seen on the mandibular peri-
i. Enamel
apical radiographs are classified as:
● Enamel is the densest structure found in the
A. Radiolucent
human body. It is the outermost radiopaque
B. Radiopaque
layer of the crown of a tooth.
ii. Dentine A. Radiolucent landmarks of mandible
● Dentine is found beneath the enamel layer of i. Mental foramen
a tooth surrounding the pulp cavity. It appears ● It is present below the roots of first and second
radiopaque and makes up most of the tooth premolars. Usually, it is corticated.
structure, but is not as radiopaque as enamel. ● The shape of the foramen may vary from round to
iii. DEJ oblong and the size may vary from 1 mm to 0.5 mm.
● The DEJ is the junction between the dentine ii. Mandibular foramen
and the enamel of a tooth. ● It is only visible in lateral jaw films as a small
● The DEJ appears as a demarcating line where rounded or funnel-shaped black shadow over the
the enamel meets the dentine. ramus of mandible.
iv. Pulp cavity iii. Mandibular canal
● The pulp cavity consists of a pulp chamber ● It commences from mandibular foramen in the
and pulp canals. It contains blood vessels, ascending ramus and appears as a radiolucent
nerves and lymphatics and appears relatively area covered superiorly and inferiorly by radi-
radiolucent on a dental radiograph. opaque margin.
● The pulp cavity is generally larger in children ● Position of canal varies; usually, it lies below the
than in adults due to the formation of second- roots of the molars and little distance below the
ary dentine. bicuspids. Sometimes, the apices of the molars
Supporting structures may appear to be superimposed over the canals.
The alveolar process, or alveolar bone, serves as the Anatomically, the canal lies buccal to the molars
supporting structure for the teeth of the jaws. and premolars.
The anatomic landmarks of the alveolar process in- iv. Mental fossa
clude the lamina dura, the alveolar crest and the ● The mental fossa is a depression found on the la-
periodontal ligament (PDL) space. bial aspect of the mandible on the anterior region.
Section | I Topic-Wise Solved Questions of Previous Years 521

v. Pharyngeal space the molar region towards ramus. Sometimes

● This is seen as a radiolucent area, only in lateral overlaps the molar apices.
jaw films, as a broad dark area extending verti- iv. External oblique ridge
cally on ramus. It is caused by patients swal- ● The external oblique ridge is a linear promi-

lowing when the film is being exposed. nence of bone located on the external surface of
vi. Submandibular fossa the body of the mandible.
● The submandibular fossa or the mandibular fossa ● White line on the anterior portion of ascending

or submaxillary fossa is a scooped-out, depressed ramus. Sometimes it overshadows the roots of

area of bone located on the internal surface of the the molars.
mandible inferior to the mylohyoid ridge. v. Internal oblique ridge
● On a mandibular periapical radiograph, the sub- ● The internal oblique ridge is a linear promi-

mandibular fossa appears as a radiolucent area nence of bone located on the internal surface of
in the molar region below the mylohyoid ridge. the mandible that extends downward and for-
vii. Nutrient canals or interdental canals ward from the ramus. It may end in the region
● The nutrient canals are often seen in mandibu- of the mandibular third molar or it may con-
lar periapical radiographs as tube-like passage tinue as the mylohyoid ridge.
ways that carry neurovascular bundle in the jaw ● On a mandibular periapical radiograph, it ap-

bones and supply the teeth and gingival tissues. pears as a radiopaque band that extends down-
● On a mandibular periapical radiograph, nutrient ward and forward from the ramus.
canals appear as vertical radiolucent lines. They vi. Inferior border of mandible
are readily seen in areas of thin bone and they may ● It appears as a heavy white line on the radio-

be more prominent in the edentulous mandible. graph. This is seen on IOPA whenever increased
● Width of nutrient canal may vary from 100 micron negative angulation is given in mandibular pos-
to 1 mm. Margins of the canal may reveal a thin terior radiography.
white cortical plate, which may be slightly irregular. vii. Enamel
viii. Pulp cavity ● Enamel is the densest structure found in the hu-

● The pulp cavity consists of a pulp chamber and man body. It is the outer most radiopaque layer
pulp canals. It contains blood vessels, nerves of the crown of a tooth.
and lymphatics, and appears relatively radiolu- viii. Dentine
cent on a dental radiograph. ● Dentine is found beneath the enamel layer

● The pulp cavity is generally larger in children of a tooth surrounding the pulp cavity. It
than in adults due to the formation of secondary appears radiopaque and makes up most of the
dentine. tooth structure, but is not as radiopaque as
ix. PDL space enamel.
● The PDL space is the space between the root of ix. Cementum
the tooth and the lamina dura. It contains connec- ● Cementum is found beneath the dentine layer
tive tissue fibres, blood vessels and lymphatics. of a root surrounding the pulp cavity. It appears
● On a dental radiograph, the PDL space appears radiopaque and makes up most of the root
as a thin radiolucent line of uniform thickness structure, but is not as radiopaque as dentine.
around the root of a tooth. x. Lamina dura
B. Radiopaque landmarks of mandible ● The lamina dura is the wall of the tooth socket

i. Genial tubercle that surrounds the root of a tooth and is made up

● They are usually seen in occlusal films and are of dense cortical bone.
four in number, two on either sides of the median ● On a dental radiograph, the lamina dura appears
line on internal surface of mandibular incisors. as a dense radiopaque line that surrounds the
● They appear as a white ring with a dark centre root of a tooth.
immediately beneath and between lower central xi. Alveolar crest
incisors. ● It is the most coronal portion of the alveolar

ii. Mental ridge bone found between the teeth. The alveolar
● A dark white ridge extending from symphysis to crest is made up of dense cortical bone and is
the bicuspid region. Sometimes superimposed by continuous with the lamina dura.
apices of lower anterior teeth. ● On a dental radiograph, the alveolar crest

iii. Mylohyoid ridge appears radiopaque and is typically located

● This appears as a white line starting from lower 1.5 –2.0 mm below the junction of the crown
border of symphysis and continuing upwards in and the root surfaces (CEJ).
522 Quick Review Series for BDS 4th Year, Vol 2

Q.3. Radiographic features of fibroosseous lesions of the Ossifying fibroma

jaws. ● Ossifying fibroma, a rare neoplasm, is also

called as fibro-osteoma.
Ans.
● It is an encapsulated lesion within which

● The fibro-osseous lesions are a diverse group of condi- the highly cellular fibrous tissue undergoes
tions. A common feature of all these lesions is that, calcification.
there is replacement of the normal bone by a tissue ● It usually affects young adults. Females have a

composed of collagen fibres and fibroblasts that contain slightly greater predilection. The lesion is slow
varying amounts of mineralized substances that may be growing and causes displacement of the teeth.
either osseous in nature, cementum-like or combination. Usually it involves the mandible.
● The radiographic appearance of these lesions is also ● Radiographic findings depend on the stage of

variable, either as diffuse, ground-glass appearance or development of the lesion. It may either appear
well-defined cystic areas that may be radiolucent or radiolucent or multiple radiopaque foci may be
containing varying amounts of calcified material. seen within the radiolucency.
● There is no acceptable classification for these lesions. ● Eventually these foci coalesce together. Borders

● A simple way of classifying the fibro-osseous lesions is of the lesion are well defined, often showing
to broadly divide these lesions into two groups based on radiolucent ring suggestive of fibrous capsule.
their site of origin. There may be displacement of the teeth.
A. The fibro-osseous lesions of PDL origin are as follows: Periapical cemental dysplasia
● Cementifying fibroma ● Periapical cemental dysplasia was earlier

● Ossifying fibroma called as cementoma.

● Cemento-ossifying fibroma l It is also variously named as fibrocementoma,

● Fibroma sclerosing cementoma, periapical osteofibrosis

B. The fibro-osseous lesions originating from the medul- or periapical fibro-osteosis.
lary bone are as follows: ● It is considered as a reactive fibro-osseous

● Fibrous dysplasia lesion.

● Fibro-osteoma ● The lesion usually occurs in the middle age

● Giant cell tumour and females are affected more than the males.
● Aneurysmal bone cyst ● The lesion usually occurs in the periapical re-

● Jaw lesions associated with hyperparathyroidism gion of the mandibular anterior teeth and the
● Cherubism lesions may be multiple.
● Paget disease ● The affected teeth are vital and it is an asymp-

Radiographic features of various fibro-osseous lesions tomatic lesion and most often is detected dur-
of the jaws are as follows: ing a routine radiographic examination.
Fibrous dysplasia ● Radiographic appearance of the lesion depends

● Fibrous dysplasia is a benign fibro-osseous lesion. on the stage of development of the lesion. Ac-
● Two types of fibrous dysplasia have been rec- cordingly, it may be radiolucent (fibrous),
ognized, the monostotic or the solitary form mixed radiolucent–radiopaque (fibrous and
and the polyostotic form. calcified elements) or radiopaque (calcified
● Fibrous dysplasia predominantly involves the stage). The margins of the lesion may be well
maxilla than the mandible and is unilateral. defined or ill-defined.
The tumour usually manifests between 10 and ● Usually no treatment is required for periapical

30 years of age. Often the posterior region of cemental dysplasia.

the jaw is involved. Florid cemento-osseous dysplasia
● The radiographic appearance varies with the ● Florid osseous dysplasia is also called as gigan-

degree of maturation and the stage of the lesion. tiform cementoma, chronic sclerosing osteo-
● In lesions with more fibrous tissue, it may be myelitis, sclerosing osteitis, multiple enostosis
radiolucency either unilocular or multilocular. and sclerotic cemental mass.
● Lesions with osseous tissue have a mottled ap- ● This lesion has a female predilection, usually

pearance. Lesions with excessive osseous tis- occurring in the middle age. Both the jaws are
sue appear radiopaque. usually involved simultaneously. Sometimes it
● The typical radiographic appearance is termed occurs only in the mandible.
as ‘ground-glass’ or ‘orange-peel’ appearance. ● Often the lesion does not cause any symptoms.

Usually the lesion is well circumscribed. Occasionally pain or swelling may be noted.
Section | I Topic-Wise Solved Questions of Previous Years 523

● Radiographically the lesion appears radiolu- can be drifting of the teeth and malocclusion.
cent with dense radiopaque masses within. It Edentulous patients often complain of ill-
has a similarity to ‘cotton-wool’ appearance of fitting dentures.
Paget disease. Individual lesions often exhibit ● Serum alkaline phosphatase level is increased
a cortical outline. in these patients.
Cementoblastoma ● Radiographic appearance of this lesion depends
● Cementoblastoma is a rare neoplasm originat- on the stage of formation. Accordingly, it may
ing in the PDL. be radiolucency of granular or ‘ground-glass’
● Males have a greater predilection and it usually appearance or dense radiopaque or the so-called
occurs before 25 years of age. ‘cotton-wool’ appearance. In the skull, the early
● Most common in the mandible and it appears lesions are lytic and appear as multiple radiolu-
as a solitary lesion. The involved tooth is vital. cencies called osteoporosis circumscripta.
● Radiographically it appears as a well-defined radi- ● The management of this lesion is done
opacity at the apex of a premolar or molar. Usually with calcitonin or sodium etidronate therapy.
the calcified mass shows radiolucent halo. Surgery is indicated for cosmetic purposes.
Cherubism
● Cherubism is characterized by bilateral benign,
Q.4. Discuss the differential diagnosis of periapical
firm, painless swellings in the mandible and radiolucencies.
usually in the angle region. Ans.
● The lesion usually develops in the infancy and

continues to grow causing greatest expansion ● A periapical lesion is a lesion that is located around the
in the first and second years after the onset. As apex of a tooth.
the age advances, the deformity becomes less ● Periapical lesions cannot be evaluated on a clinical basis
obvious. The lesion has a familial tendency. alone. On dental radiographs, periapical lesions may
● The lesion has derived the name as the affected appear either radiolucent or radiopaque.
children have characteristic chubby, cherubic Various periapical radiolucencies
facial appearance. ● Periapical granulomas, cysts and abscesses are

● Typically, the affected individuals have ‘eyes common periapical radiolucencies that can be seen
raised to the heaven’ appearance, if the lesion in- on dental radiographs.
volves the maxilla. The characteristic radiographic ● Because it is impossible to distinguish between these

appearance is multiple cyst-like radiolucencies three periapical lesions based on their radiographic
in the mandible. The lesions have multilocular appearance, hence they should be referred to simply
appearance and the borders are well defined. as ‘periapical radiolucencies’.
● Cortical plate expansion is seen in the occlusal Periapical granuloma
or PA views. Maxillary lesions project into the ● A periapical granuloma is a localized mass of

maxillary sinus. The developing tooth buds are chronically inflamed granulation tissue at the
usually displaced. There is usually premature apex of a nonvital tooth.
exfoliation of the deciduous teeth. ● The periapical granuloma results from pulpal

● As the lesion is self-limiting, no treatment is death and necrosis and is the most common
required. sequelae of pulpitis (inflammation of the pulp).
Paget disease (osteitis deformans) ● A periapical granuloma may give rise to a periapi-

● Paget disease was described as a clinical entity cal cyst or periapical abscess.
by Sir James Paget in 1877 and is character- ● A tooth with a periapical granuloma is typically

ized by abnormal bone destruction followed by asymptomatic but has a previous history of pro-
bone formation involving several bones. longed sensitivity to heat or cold.
● Though this disease mainly affects the skull, ● On a dental radiograph, a periapical granuloma is

the femur, the sacrum and the pelvis, jaw in- initially seen as a widened PDL space at the root apex.
volvement is rarely seen bilaterally. ● With time, the widened PDL space enlarges and

● The disease usually occurs above 50 years of appears as a round or ovoid radiolucency.
age. Males are affected more than the females. ● The lamina dura is not visible between the root

● Symptoms of the lesion are bone pain, in- apex and the apical lesion.
creased temperature, curvature of the spine, ● Treatment for a periapical granuloma may include

enlargement of the skull and facial bones and endodontic therapy or removal of the tooth with
bone deformity. In dentulous patients, there curettage of the apical region.
524 Quick Review Series for BDS 4th Year, Vol 2

Periapical cyst ● Odontomes: compound and complex

● A periapical cyst also known as a radicular cyst is ● Root remnants: hypercementosis
a lesion that develops over a prolonged period. B. Conditions of variable radiopacity affecting the bone
● Cystic degeneration takes place within a periapical ● Developmental exostoses including tori mandibular

granuloma and results in a periapical cyst. The peri- or palatal

apical cyst results from pulpal death and necrosis. ● Inflammatory low-grade infections, sclerosing osteitis

● Periapical cysts are the most common of all tooth- and osteomyelitis
related cysts and comprise 50%–70% of all cysts ● Tumours:

in the oral region. a. Odontogenic (late stages)

● Periapical cysts are typically asymptomatic. On ● Calcifying epithelial odontogenic tumour (CEOT)

a dental radiograph, the typical periapical cyst ● Adenomatoid odontogenic tumour

appears as a round or ovoid radiolucency. ● Calcifying odontogenic cyst

● Treatment may include endodontic therapy or b. Nonodontogenic

extraction of the tooth as well as curettage of the ● Benign: e.g. osteoma and chondroma.

apical region. ● Malignant: e.g. osteosarcoma and osteogenic

Periapical abscess secondary metastases.

● The periapical abscess is a localized collection of c. Fibro-osseous lesions (late stages)
pus in the periapical region of a tooth that results ● Fibrous dysplasia

from pulpal death. ● Ossifying fibroma

● Periapical abscesses may be acute or chronic. An ● Cementifying fibroma

acute periapical abscess has features of an acute pus- ● True cementoma (cementoblastoma)

producing process and inflammation. The periapical ● Periapical cemental dysplasia

abscess refers to a tooth with an infection in the pulp. d. Others

● An acute abscess may result from an acute inflam- ● Paget disease

mation of the pulp or an area of chronic infection, ● Osteopetrosis

such as a periapical granuloma. C. Superimposed soft-tissue calcifications

● A chronic periapical abscess has features of a ● Salivary calculi

long-standing, low-grade, pus-producing process. ● Calcified lymph nodes

● A chronic abscess may develop from an acute ● Calcified tonsils

abscess or a periapical granuloma. ● Phleboliths

● An acute periapical abscess is painful; the pain may ● Calcified acne scars

be intense, throbbing and constant. The tooth is non- D. Foreign bodies

vital and is sensitive to pressure, percussion and heat. ● Intrabony, within the soft tissues on or overlying the skin

● Chronic periapical abscesses are usually asymp- Periapical radiopacities

tomatic because the pus drains through bone or Condensing osteitis, sclerotic bone and hypercemen-
the PDL space. tosis are a few of the common periapical radiopacities
● With an acute periapical abscess, no radiographic that can be seen on dental radiographs.
change may be evident. Condensing osteitis
● Early radiographic changes include an increased ● Condensing osteitis is also known as chronic fo-

widening of the PDL space. cal sclerosing osteomyelitis and is a well-defined

● A chronic periapical abscess appears as a round or radiopacity that is seen below the apex of a nonvi-
ovoid apical radiolucency with poorly defined tal tooth with a history of long-standing pulpitis.
margins. ● It is the most common periapical radiopacity
● The lamina dura cannot be seen between the root observed in adults.
apex and the radiolucent lesion. ● The opacity represents a proliferation of periapi-

● Treatment of the periapical abscess includes cal bone that is a result of a low-grade inflamma-
drainage and endodontic therapy or extraction. tion or mild irritation.
● The inflammation that stimulates condensing
Q.5. Describe various radiopaque lesions at the root of osteitis occurs in response to pulpal necrosis.
mandibular premolar. ● The tooth most frequently involved is the man-

Ans. dibular first molar.

● It may vary in size and shape and does not appear
Commonly occurring radiopaque lesions to be attached to the tooth root.
A. Abnormalities of teeth ● Teeth associated with condensing osteitis are non-
● Unerupted and misplaced teeth including supernu- vital and typically have a large carious lesion or
meraries large restoration.
Section | I Topic-Wise Solved Questions of Previous Years 525

● No treatment is necessary, because condensing Pathology Radiographic appearance

osteitis is believed to represent a physiologic reac-
iv. Diffuse sclerosing Ill-defined osteolytic lesions with
tion of bone to inflammation. osteomyelitis (OPG/ osteosclerotic zones, which progres-
Sclerotic bone lateral oblique view) sively become more osteosclerotic
● Sclerotic bone also known as osteosclerosis or
v. Chronic subperios- Shortening of the roots, moth-eaten
idiopathic periapical osteosclerosis is a well- teal (OPG/lateral appearance, and cortical sequestra-
defined radiopacity that is seen below the apices oblique view) tion onion-skin appearance
of vital, noncarious teeth.
vi. Garre osteomyelitis Ragged, patchy ‘moth-eaten’
● The cause of sclerotic bone is unknown; however, it
(occlusal radiograph) appearance
is not believed to be associated with inflammation.
● The lesion is not attached to a tooth and varies in

size and shape. Q.7. Name the malignant tumours of the jaws. Describe
● The margins may appear smooth or irregular and the radiographic appearance of carcinomas and sarco-
diffuse. The borders are continuous with adjacent mas of the jaws.
normal bone, and no radiolucent outline is seen.
Ans.
● Sclerotic bone is asymptomatic and is usually dis-

covered during routine radiographic examination. Characteristics of malignant lesion

Hypercementosis ● As a result of change in the nature of the lesion, the

● Hypercementosis is the excess deposition of cemen- lesion grows and disrupts the normal anatomy there
tum on root surfaces. Hypercementosis results from by causing obvious changes in the anatomic and ra-
supraeruption, inflammation or trauma; sometimes diographic picture of the tissue and the surrounding
there is no obvious cause. structures.
● On dental radiographs, hypercementosis is visible ● The nature of the lesion, rate of its growth and sur-

as an excess amount of cementum along all or part rounding tissues are the factors, which ultimately
of a root surface. elicit a radiographic picture specific to some extent
● The apical area is most often affected and appears to a particular lesion.
enlarged and bulbous. ● The various features to be analysed and the reasons

● Root areas affected by hypercementosis are sepa- for those features being so specific have been dis-
rated from periapical bone by a normal-appearing cussed below in comparison to benign lesions.
PDL space, the surrounding lamina dura appears (a) Border of the lesion
normal as well. ● Benign lesions characteristically have well-

● No signs or symptoms are associated with hyper- defined borders, which is because of their inher-
cementosis; most cases are discovered during ent nature of being nonaggressive and slow
routine radiographic examination. growth.
● Teeth affected by hypercementosis are vital and ● They grow gradually and hence have a rounded

do not require treatment. or oval extent.

● On the other hand, malignant lesions are aggres-
Q.6. Describe the radiographic appearance of different
sively expanding outwards and cause virtual
types of osteomyelitis of jaws.
erosion of the surrounding tissues. As a result of
Ans. this the borders are irregular, ragged and ill-
defined. They have a mosaic form and blend
with the normal tissue; for this reason radio-
Pathology Radiographic appearance graphic extent of the lesion is difficult to define.
Osteomyelitis ● Fuzzy or blurred appearance of ● Acute infection causes bony destruction, hence
i. Acute the trabeculae, with small areas results in sclerosing osteitis and a conforming
ii. Acute subperiosteal ● Erosion of cortex, moth-eaten
(occlusal view) appearance. Evidence of new
radiographic picture of well-defined radiopaque
subperiosteal bone formation margin.
usually beyond the area of ● It is not only the radiograph or the clinical pic-
necrosis, particularly along the ture alone, which always is diagnostic of a pa-
lower border of the mandible thology, but both act as adjuncts to each other.
iii. Chronic suppurative ● Moth-eaten appearance, (b) Adjacent cortical bone
osteomyelitis (OPG/ sequestra is seen ● The benign lesions are slow growing and hence
lateral oblique view) ● Sclerosis of surrounding bone result in displacement of the surrounding struc-
● Involucrum formation
tures like the cortical bone.
526 Quick Review Series for BDS 4th Year, Vol 2

● With the elevation of the periosteum, there is a Carcinomas

stimulated formation of layers of reactive bone Squamous cell carcinoma
termed as onion-skin appearance as it appears ● It is a tumour of epithelial origin arising mostly in

like peels of onion on a radiograph. the oral mucosa.

● The growth pattern of malignant lesion is by de- ● It is the most common type of oral cancer spread-

struction and invasion of the adjacent structures. ing by invasion of the soft tissues, neurovascular
Hence, the expansion of the lesion causes destruc- tissue, and through the bone.
tion of the cortex and drags the bony material along ● Subsequent advancement brings them in contact

its path of expansion. It forms a trail of bone, hence, with bone resulting in bony involvement.
giving a typical picture of sunburst appearance. Aetiology
(c) Radiodensity There is no specific aetiology but many factors have
● Depending upon the tissue involved, the radioden- been accounted for:
sity of the lesion is variable, e.g. an osteoma is a ● Spirit and alcohol

radiopaque lesion while a central haemangioma is ● Spices

radiolucent; both are benign. ● Smoking

● Malignant lesions such as carcinomas are radio- ● Sharp margins

lucent except in case of metastatic lesion, e.g. Clinical features

carcinoma of the prostrate gland. ● Occurs predominantly in men over 50 years of age.

● There is simultaneous resorption and deposition ● The most predominant site is the posterolateral

of bone in case of sarcomas, a feature diagnostic border of the tongue and lower lip, less frequently
of sarcomas. floor of mouth, alveolar mucosa, palate and buc-
(d) Dental involvement cal mucosa.
● Teeth are more calcified than the bone. ● Size and bony involvement: Osseous involvement

● When the lesion is expanding, the response of is most frequently in third molar region of man-
the teeth is recorded in the following two ways: dible where it is closest to the bone. Small lesions
1. Displacement , 1.0 cm in diameter are generally asymptomatic.
● Usually the benign lesions are slow grow- It is only when the lesion enlarges that there is
ing and put slight persistent pressure on pain, anaesthesia or swelling. With the gradual
the teeth resulting in gradual displacement increase in size of the lesion, if lying close to the
of the teeth. tooth there occur loosening of the tooth with some
● In malignant lesion, the rate of expansion root resorption or at times leading to exfoliation.
of the lesion is reasonably high for the ● Further increase in size may lead to metastasis

teeth to respond to the pressure. through the lymphatic channels to submental and
● The roots are well within the border of the submandibular lymph nodes.
lesion; therefore, in malignant lesions there Radiographic features
is a typical picture of floating teeth, more ● It appears as a destructive lesion. There is gradual
so, the teeth lie in their actual position. erosion of the bone resulting in ill-defined margins
2. Resorption of roots all along the tumour or at some specific points.
● As far as resorption of roots is concerned, ● In the mandible, gradual growth of the lesion may

benign lesions cause resorption. lead to complete erosion of the bone resulting in a
● In a malignant lesion, the contact period is pathological fracture.
relatively less; hence, resorption is not a ● Usually a combination of posteroanterior view,

specific feature of a malignant lesion as in occlusal view and lateral oblique view are helpful
benign lesion. in understanding the extent of the lesion and in the
(e) Radiographic features demonstration of such fractures.
● Since radiograph is a two-dimensional image of ● Usually the lesion has an irregular border but at

the tissues, superimposition of various structures times the border of the tumour is lined by a radi-
occurs thereby making it difficult for the ob- opaque margin as in condensing osteitis.
server to analyse the extent of the features of the ● Also, sometimes specks of radiopaque materials

lesion. Radiographic exposure at two angula- signifying pieces of left over bone by the rapidly
tions can solve this problem to some extent. advancing tumour (especially in central squamous
● Computed tomographic (CT) scan or computer- cell carcinoma).
ized tomography is good answer to this problem. Management
● With CT scan, the invasion of the lesion into the (a) The management is by radiotherapy, surgery or
soft tissue can also be analysed. both.
Section | I Topic-Wise Solved Questions of Previous Years 527

Metastatic carcinoma ● First sign of the disease is swelling, occasionally

● It is the most common malignant tumour of the associated with pain having a fairly short history.
skeleton resulting from metastasis of primary car- ● Teeth may become loose and paraesthesia may

cinoma from a distant site to the bone. develop.

● The metastatic carcinoma of the jaws is relatively ● The rate of growth of lesion is very high; it dou-

rare, only 1% –8% of all malignant tumours of the bles in about a month.
oral region. Radiographic features
Clinical features ● The radiographic feature of an osteosarcoma is

● Mandible is more susceptible for metastatic quite variable.

carcinoma than the maxilla. ● Widening of PDL membrane or radiolucency

● The most common site is premolar and molar around teeth could be one of the earliest signs of
region. the lesion.
● Age varies from 40 to 60 years. Metastasis ● It may present itself in any of the three types as de-

may occur from breasts, lungs, kidneys, pros- scribed earlier, i.e. sclerosing, osteolytic or mixed.
trate glands, colon, testis and stomach. ● In the osteolytic type, there is only resorption

● Oral findings are usually the first indication of thereby giving a picture as that of a carcinoma.
the disease. ● In the sclerosing and mixed type, there may be

● The lesion is asymptomatic. obliteration of the trabecular pattern imparting it a

● Only when the mandibular nerve is involved dense granular or sclerotic appearance.
by the lesion, there is pain, paraesthesia or an- ● Further growth of the lesion results in the perfora-

aesthesia. tion of the cortical plate.

● The teeth may become loose or get exfoliated ● As a result of rapid advancement of the lesion, the

with occasional evidence of root resorption. sclerosing nature of the lesion is depicted by
● Prognosis for the patient with metastasis is traces of bone formation parallel to the direction
poor. of advancement of lesion, since the bone forma-
Radiographic features tion in this direction is suffering least resistance
● The features for metastatic carcinoma are sim- from the advancing lesion. This phenomenon re-
ilar to those of primary carcinoma having a sults in the formation of sun-ray pattern.
radiolucent picture with ill-defined margins. ● At times the sun-ray pattern may not be present

● The lesions may be single or multiple or of and bone formation may be perpendicular to the
variable size. advancing lesion and result in the formation of
Sarcomas onion-peel pattern.
Osteosarcoma Chondrosarcoma
● It is the most common malignant tumour of the ● This tumour is a malignant lesion of cartilaginous

bone, which arises from the undifferentiated bone- origin.

forming mesenchymal tissue. ● It may arise centrally in the bone, peripherally in
● Depending upon the nature of the lesion, sarcoma the periosteum or in the connective tissues con-
can be of three types: taining cartilage.
a. Sclerosing: This type forms neoplastic osteoid ● The origin is generally from the bone and can be:

and bone. ● Centrally or medullary: if arising from within

b. Osteolytic: This type does not form bone and the bone.
elicits a picture of only resorption of bone. The ● Peripheral: if arising from cartilaginous caps

rate of growth of this type is more. on the bone.

c. Mixed: It is one, which has both the compo- Clinical features
nents, i.e. resorption and formation of bone. ● The lesion is rare in the jaws, but when present it

Clinical features is mostly in the maxilla.

● The mean age of occurrence of an osteosarcoma ● The average age group is 30 years (20–60 years).

is around 50 years. ● Males are more prone to this lesion and are af-

● It involves the maxilla (antrum or alveolar ridge fected twice more than females.
excluding palate) or the mandible (body of man- ● First symptom is innocuous hard swelling result-

dible) equally and does not favour any sex. ing in facial asymmetry.
● Incidence of this lesion is more in bones that have ● The affected tooth may get loosened, resorbed or

been irradiated, subjected to trauma or affected by even exfoliated. Irradiation can be one of the pre-
Paget disease. cipitating factors.
528 Quick Review Series for BDS 4th Year, Vol 2

● The transition from a benign to malignant lesion Clinical features

is also common. ● Though the lesion may occur at any age, it is most

● The rate of growth of lesion is relatively less than common in the second decade of life, i.e. mostly
osteosarcoma and it seldom metastasizes. below 30 years.
● Recurrence of the lesion after surgery is common ● Males are affected twice more often than females.

and death results by local aggressive nature. ● It usually affects long bones and about 10% affect

Radiographic features the jaws.

● Like osteosarcoma, the radiographic picture of the ● By nature, it is a fast spreading and a highly inva-

lesion is highly variable. sive tumour.

● There is resorption of the bone, which may and ● The involved bone is painful, tender to palpation,

may not depict sclerosis. In addition, it may ap- swollen and there is a feeling of warmth in the area.
pear as a cystic lesion. ● Metastasis may occur to other bones, lymph nodes

● The lobules of cartilage may give a soap-bubble and lungs.

appearance. ● The teeth may become loose and there may be

● There may also be a sun-ray pattern (in one-fourth paraesthesia of the soft tissue.
of the cases) or a ground-glass appearance. Radiographic features
● With the passage of time, irregular small dense ● The radiograph shows osteolysis with ill-defined

calcification may appear in the outer region. irregular borders.

● The widening of PDL membrane may also be ● The picture is most likely to be confused with

evident as in osteosarcoma. osteomyelitis.

● As all these features are characteristics of a malig- ● Areas of sclerosis may develop at the border of

nant lesion, the radiographic picture cannot be the lesion.

pathognomonic but suggestive of a malignant lesion. ● There may be expansion of the cortical bone and

Fibrosarcoma subsequent formation of new bone subperioste-

● It is a primary malignant fibroblastic tumour, ally. Hence, it may give an onion-peel appearance
which fails to exhibit bone or osteoid formation occasionally.
and also does not metastasize. ● Sun-ray pattern may be seen in advanced cases.

● It arises either from periosteum or periodontal

Q.8. Describe the radiographic appearance of different
membrane or endosteal connective tissue.
cysts of maxilla and mandible.
Clinical features
● Mostly the lesion is centrally arising in the bone Ans.
but may also arise in the periosteal tissues.
Radiographic appearance of various cysts of maxilla and
● The usual age of occurrence is fifth decade, the
mandible are as follows:
range being 20–50 years.
● Clinical examination reveals hard painful swell-

ing with or without covering of oral mucosa. Type of cyst Radiographic appearance
● Paraesthesia is noted in one-third of the cases.
Odontogenic ● Associated with the tooth forming
Radiographic features cysts apparatus.
● There are no specific radiographic features of the le- ● Attached or in relation with a tooth or
sion, which helps to distinguish it from other lesions. in place of a tooth.
● The general features of a malignant lesion, namely
● May cause external root resorption or
displacement of the tooth.
osteolytic changes, ill-defined borders and dis-
placement of teeth with or without root resorption Radicular cyst ● Well-defined unilocular radiolucency at
the periphery of nonvital teeth with a
may also be noted.
distinct sclerotic margin, continuous
Management with lamina dura.
● The tumour is resistant to radiotherapy.
Dentigerous cyst Unilocular cystic cavity with a well-
● The recurrence after surgery is common especially
●

defined border associated with the

when removal of the lesion by surgical excision is crown of an unerupted tooth.
limited. ● Adjacent teeth may be displaced.
● Prognosis depends on analysis of extent of the ● Buccal or medial expansion, may be
lesion and well-planned surgery. extensive, with a large cyst causing
facial asymmetry and displacement of
Ewing sarcoma
the antrum.
a) It is a primary malignant tumour originating in the
bone marrow from the mesenchymal connective Residual cyst ● Round to ovoid radiolucency with a regu-
lar margin in relation to an empty socket
tissues.
Section | I Topic-Wise Solved Questions of Previous Years 529

Type of cyst Radiographic appearance Q.10. Describe briefly the characteristics of the malig-
nant tumours of the jaws. Describe the radiographic
Odontogenic ● Unilocular or multilocular, hazy radio-
keratocyst lucency due to the keratin-filled lumen,
appearance of the same.
with a thin sclerotic border, which may Ans.
be smooth or scalloped.
● Adjacent teeth may be distally displaced [Same as LE Q.7]
● Expansion and perforation of cortical
plate is rare.
Basal cell naevus ● Bifid ribs, multiple jaw cysts; usually
SHORT ESSAYS:
syndrome unilocular odontogenic keratocysts in Q.1. Describe various radiographic landmarks of the
the mandible.
● Multiple nevoid basal cell carcinoma
maxilla. Why is it important to know radiographic land-
with occasional malignant transforma- marks of maxilla?
tion with or without foci.
Ans.
Primordial cyst ● Radiolucent lesion with well-defined
hyperostotic border with no involve- Various radiographic landmarks of maxilla are as follows:
ment of unerupted teeth. Radiolucent areas
Lateral ● Well-defined, round or oval radiolucency i. Incisive foramen or incisal foramen or anterior
periodontal cyst with hyperostotic margins, usually gingi- palatine foramen
val cyst, less than 1 cm in diameter. ii. Intermaxillary suture
Nonodontogenic ● May be fissural, developmental or iii. Nasal fossae or nostrils
cysts traumatic. iv. Nasopalatine canals
● Located along lines of fusion, embry- v. Antrum of Highmore or maxillary sinus
onic processes or at the site of trauma. vi. Nasolacrimal duct
May cause divergence of roots with an
vii. Posterior palatine foramen
●

intact lamina dura.

viii. Median palatine suture
Globulomaxillary ● Well-defined unilocular pear-shaped
cyst radiolucency, causing divergence of
upper canine and lateral incisor
(displaced teeth are vital). {SN Q.11}
Median ● Circular, well-defined, unilocular radio- Radiopaque areas
mandibular lucent lesion with sclerotic border in i. Lamina dura
cyst the symphyseal region.
ii. Lower border of maxillary sinus
Nasopalatine cyst ● Well-defined heart-shaped radiolu- iii. Internasal septum
cency between the upper centrals, with
iv. Anterior nasal spine
a sclerotic border.
● There may be loss of definition of the v. Pterygoid plate
lateral wall of the incisive canal. vi. Inverted Y of Ennis.
Median palatine ● Well-defined radiolucency behind the
cyst (occlusal) incisive canal in the premolar–molar
area. Radiolucent landmarks of maxilla
Nasoalveolar cyst ● Soft-tissue cyst not visible on the 1. Incisive foramen or incisal foramen or anterior pala-
radiograph. tine foramen:
Postoperative ● Unilocular or multilocular radiolu- ● It is the oral termination of nasopalatine canal,

maxillary cyst cency, on the inferior extension of the transmitting nasopalatine nerves and vessels.
floor of the maxillary sinus. May cause Present palatally at the middle of central incisors.
pressure resorption of the maxillary ● It can be of various shapes such as mere slit,
alveolar bone.
rounded, oval, rhomboid and heart-shaped.
Static bone cavity ● Ovoid radiolucency with well-defined bor- 2. Intermaxillary suture:
ders found near the angle of the mandible ● Also known as median palatine suture. This ap-
below inferior alveolar canal or adjacent
to the inferior border of the mandible.
pears between two portions of the premaxilla as a
thin radiolucent line between the centre of roots
of incisors.
Q.9. Describe in detail periapical radiolucent areas. ● This is visible usually in young children. It ap-

pears as a dark line extending from central inci-

Ans.
sors to the posterior aspect of the palate. Width of
[Same as LE Q.4] the suture is almost uniform.
530 Quick Review Series for BDS 4th Year, Vol 2

● Only in very young patients, it may terminate as its open end directed superiorly. It is seen often in
funnel-shaped widening at the anterior end. the maxillary sinus radiolucency.
Margins are lined by cortical bone which appears ii. Zygoma or malar bone:
radiopaque. ● It appears as an irregular radiopaque shadow

3. Nasal fossae or nostrils: covering the third molar apices which may
● These appear as dark shadows over the lateral in- extend up to the apices of second molars.
cisors. The nasal cavities are air filled; therefore, ● In cases where palatal vault is low, this shadow

they appear as radiolucent areas in periapical ra- of malar bone may be misinterpreted as hyperce-
diographs of anterior teeth. Nasal septum, a dark mentosis or as ankylosis of second and third
radiopaque line, divides the two fossae. molars.
● The margins of the fossae are lined with compact iii. Hamular process or sphenoid bone:
bone. Therefore, in radiograph, the dark shadow ● This is seldom visible in intraoral films. In extra-

of the cavities is lined with narrow white lines. oral films, this appears as a thick radiopaque line
4. Nasopalatine canals: terminating just below the region of maxillary
● This is usually not seen in periapical film but can tuberosity.
be viewed in occlusal films. iv. Nasal septum:
● This canal originates at the floor of the nasal ● It is seen as a pear-shaped radiopaque area

cavity. The openings are on either side of the nasal extending backwards from the incisive foramen
septum. in between two central incisors.
5. Antrum of Highmore or maxillary sinus: v. Inverted ‘Y’ of Ennis:
● This appears as dark shadows over the posterior ● In an IOPA radiograph, in the periapical region

teeth usually from premolar to the tuberosity re- of the maxillary canine, the lateral wall of
gion. This appears quite dark because it contains the nasal fossa and the anterior border of the
air. Maxillary sinus is the largest of the paranasal maxillary sinus form an inverted Y, which is
sinuses. The two sinuses right and left can be of termed as inverted Y of Ennis after one of the
similar shape or different. senior researchers in oral radiology Dr Ennis.
● On the intraoral periapical radiograph, it appears vi. Coronoid process of mandible:
as either U-shaped or W-shaped with one septa or ● It is a triangular grey area of radiopacity seen on

rarely with two or more septae. In the IOPA, there the radiograph of maxillary molar region.
is always U-shaped radiopacity, which is the
shadow of the zygoma. It is also termed as malar Q.2. Multilocular radiolucencies.
process by some authors. Ans.
● Sometimes, the maxillary sinus exhibits uniform

shadows of nutrient canals. They can follow any ● Multilocular appearance is the radiographic appearance
directions; usually the course is convex towards of certain conditions.
the alveolar process. ● Septa represent residual bone that has been organized
6. Nasolacrimal duct: into long strands or walls. If these septa divide the inter-
● This is seen in occlusal films and very rarely in nal structure into at least two compartments, the term
periapical films. This is round or oval-shaped ra- multilocular is used.
diolucent area over the roots of the first molar. It ● Straight, thin septa in small number are seen in odonto-
can be slightly mesial or distal to it. This can be genic myxoma. Septa seen in giant cell granuloma are
superimposed over the apices of either second described as Wispy or Granular. Curved, coarse septa seen
bicuspid or first and second molar. in ameloblastoma give internal pattern a multilocular,
7. Posterior palatine foramen: soap-bubble appearance.
● This is seen only in occlusal films and very rarely ● Pathological conditions which shows multilocular
in periapical films. This is a round or oval-shaped appearance are as follows:
radiolucent area over the roots of the first molar. i. Ameloblastoma
8. Median palatine suture: ii. Cherubism
● Seen in occlusal films as a thin radiolucent line in iii. Odontogenic myxoma
the centre of the palate. iv. Aneurysmal bone cyst
Radiopaque landmarks of maxilla v. Ameloblastic fibroma
i. Zygomatic process and the bone: vi. Odontogenic keratocyst
● In the periapical radiograph, the zygomatic pro- vii. Central giant cell granuloma
cess appears as a U-shaped radiopaque line with viii. Brown tumour
Section | I Topic-Wise Solved Questions of Previous Years 531

Various multilocular radiolucencies seen in the mandi- iv. Aneurysmal bone cyst
ble are described in detail as follows: ● The aneurysmal bone cyst is characterized as a false

i. Ameloblastoma cyst because it does not have an epithelial lining.

● Ameloblastoma is usually locally invasive be- ● It is a slow-growing lesion that affects mandible

nign tumour; 88%–89% lesions occur in mandi- more commonly than maxilla.
ble where 61% of the total tumour involves the ● It occurs as a unilocular or multilocular radiolu-

third molar region and ascending ramus area. cency and, when it is large, frequently balloons
● It grows very slowly without any clinical signs in out of the cortex.
the early stages. In advanced stages, this neo- ● Grossly the lesion is soft and reddish-brown;

plasm may expand cortical plates but frequently because of its rich blood supply, it resembles a
erodes them and invades the soft tissue. sponge filled with blood.
● It can be unilocular or multilocular. Multilocular ● On microscopic examination, it contains giant

images may be of soap-bubble or honeycomb cells scattered through a fibrous stroma that
appearance. contains cavernous, thin-walled blood spaces.
● Radiographically, these multilocular lesions may Bone spicules and osteoid may be present.
appear in a soap-bubble, honeycomb or tennis-
racket appearance. Q.3. Enumerate the various radiographic techniques for
● Extraosseous ameloblastomas are rare lesions the diagnosis of fracture of mandible.
that occur mostly on the gingiva. They are found Ans.
in older individuals and follow a nonaggressive
course. ● For assessing mandibular fractures although the pan-
ii. Cherubism oramic image may be a good initial image to make, the
● It occurs in patients between 2 and 20 years. intraoral cross-sectional occlusal view of the mandible
● Cherubism is seen bilaterally in the rami of the may provide important information about body or al-
mandible and becomes apparent as painless veolar process fractures in the tooth-supporting areas.
swelling of the face. Sometimes whole mandible ● If a panoramic image is not available, lateral oblique
is involved. views of the mandible should be made.
● The lesion grows slowly, expanding but not per- ● The open mouth Townes view may be particularly useful
forating the cortex. At puberty, the lesion begins in cases of suspected trauma to the mandibular condylar
to regress. head and neck areas. These views are important to sup-
● Radiologically, cherubism occurs with two or plement lateral views of the TMJ, especially in cases of
more separate, multilocular appearing lesions. nondisplaced greenstick fractures of the condylar neck.
● Sometimes the interlocular bone becomes so in- ● For suspected multiple and complex fractures of the man-
distinct that the multilocular appearance is lost. dible, CT is the imaging modality of choice. Magnetic reso-
● Usually the bony architecture returns to normal nance imaging may be useful to assess soft-tissue injury to
by the age of 30, except for a few instances in the temporomandibular joint capsule or articular disc.
which the involved bone of the ramus retains in Radiographic features of mandibular body fractures
appearance that resembles ground glass on radio- ● The radiographic examination of a suspected man-

graphic examination. dibular fracture may include intraoral or occlusal

iii. Odontogenic myxoma views, a panoramic view, posteroanterior or submen-
● The odontogenic myxoma is an infiltrative be- tovertex plain radiographic views or CT.
nign tumour of the bone that occurs almost in the ● Intraoral images may, given their higher resolution,

jawbones. The approximate ratio of maxillary to reveal fractures that extraoral plane images may fail
mandibular occurrence is 3:4. to reveal.
● The main feature of the lesion is slowly enlarging ● The margins of fracture planes usually appear as

painless expansion of the jaw with the possible sharply defined radiolucent lines of separation that
spreading, loosening and migration of the teeth. are confined to the structure of the mandible. They
● Radiographically, lesion produces several pat- are best visualized when the X-ray beam is oriented
terns unicystic, multilocular, pericoronal and along the plane of the fracture.
radiolucent–radiopaque. ● Displacement of the fragments results in a cortical

● Fine intralesional trabeculation occurs in most of discontinuity or ‘step’ or an irregularity in the occlu-
the multilocular and in some of the unicystic sal plane. Occasionally, the margins of the fracture
types, as a soap-bubble, honeycomb or tennis- overlap each other, resulting in an area of increased
racket pattern. radiopacity at the fracture site.
532 Quick Review Series for BDS 4th Year, Vol 2

●Nondisplaced mandibular fractures may involve one ● Displacement of the teeth may be an early clinical fea-
or both buccal and lingual cortical plates. ture, although most lesions are discovered during rou-
● An incomplete fracture involving only one cortical tine dental examinations.
plate is often called a greenstick fracture; these usu- ● In cases of juvenile ossifying fibroma, rapid growth may
ally occur in children. occur in a young patient, resulting in deformity of the
● An oblique fracture that involves both cortical plates involved jaw.
may cause some diagnostic difficulties if the fracture Radiographic features
lines in the buccal and lingual plates are not superim- ● Cemento-ossifying fibroma (COF) appears almost

posed. In this case, two lines are seen that converge exclusively in the facial bones and most commonly
at the periphery, suggesting two distinct fractures in the mandible, typically inferior to the premolars
when in reality only one exists. A right-angle view and molars and superior to the inferior alveolar ca-
such as an occlusal view may be useful. nal. In the maxilla, it occurs most often in the canine
Radiographic features of mandibular condyle fractures fossa and zygomatic arch area.
● Nondisplaced fractures of the condylar process may be ● The borders of COF lesions usually are well defined. A

difficult to detect on plain radiographic or panoramic im- thin, radiolucent line, representing a fibrous capsule,
ages. CT is the imaging modality of choice because it will may separate it from surrounding bone. Sometimes,
enable the clinician to visualize the three-dimensional the bone next to the lesion develops a sclerotic border.
relationship of the displaced condylar head to the glenoid ● The internal structure of a COF lesion is a mixed

fossa and to adjacent anatomical structures in the skull radiolucent-radiopaque density with a pattern that
base and infratemporal fossa. depends on the amount and form of the manufac-
● Studies of remodelled previously fractured condyles tured calcified material.
show that young persons have much greater remodel- ● In some instances, the internal structure may appear al-

ling potential than do adults. The most common most totally radiolucent with just a hint of calcified mate-
deformities are medial inclination of the condyle, rial. In the type that contains mainly abnormal bone, the
abnormal shape of the condyle, shortening of the pattern may be similar to that seen in fibrous dysplasia,
neck, erosion and flattening. or a wispy (similar to stretched tufts of cotton) or floc-
● Early condylar fractures commonly result in hypo- culent pattern (similar to large, heavy snowflakes) may
plasia of the ipsilateral side of the mandible. be seen. Lesions that produce more cementum-like mate-
Radiographic features of fractures of the alveolar rial may contain solid, amorphous radiopacities (ce-
processes menticles) similar to those seen in cemental dysplasia.
● Periapical radiographs, if they can be made, will Effects on surrounding structures
often not reveal fractures of a single cortical wall of ● COF tends to grow concentrically within the medul-

the alveolar process, although evidence exists that lary part of the bone with outward expansion ap-
the teeth have been luxated. proximately equal in all directions. This can result in
● A fracture of the anterior labial cortical plate may be displacement of teeth or of the inferior alveolar canal
apparent on an occlusal radiograph or on a lateral and expansion of the outer cortical plates of bone.
extraoral image of the mandible if bone displacement ● The COF lesion can grow into and occupy the entire

has occurred maxillary sinus, expanding its walls outward; how-

● It may be difficult to differentiate a root fracture ever, a bony partition always exists between the in-
from an overlapping fracture line of the alveolar ternal aspect of the remaining sinus and the tumour.
bone. Several images produced with different projec- The lamina dura of involved teeth usually is missing,
tion angles may help with this differentiation. and resorption of teeth may occur.
● If the fracture plane is truly associated with the tooth,
Q.5. Describe radiographic appearance of dentigerous
the line should not shift relative to the tooth. Frac-
cyst.
tures of the posterior alveolar process may involve
the floor of the maxillary sinus and result in abnor- Ans.
mal thickening of the sinus mucosa or the accumula-
● Dentigerous cyst is also called as follicular cyst. It is the
tion of blood and sinus secretions, in which case an
most common type of odontogenic cyst, which encloses
air-fluid level may be appreciated.
the crown of the unerupted tooth.
Q.4. Cemento-ossifying fibroma. ● Radiographically it appears as well-defined radiolu-
cency usually associated with hyperostotic borders.
Ans.
● Usually it is unilocular but sometimes may appear
● Cemento-ossifying fibroma consists of highly cellular, multilocular, due to ridges in the bony wall.
fibrous tissue that contains varying amounts of abnor- ● It may envelop the crown symmetrically but may
mal bone or cementum-like tissue. expand laterally from the crown.
Section | I Topic-Wise Solved Questions of Previous Years 533

Radiological types of dentigerous cysts are as follows: the degree of radiopacity from one another, reflecting
According to Thoma variations in amount and type of hard tissue that has
i. Central type: When the cystic cavity envelops been formed.
the crown of the impacted tooth symmetrically ● A dilated odontoma has a single calcified structure

from all sides, it is called central type. with a more radiolucent central portion that has an
ii. Lateral type: In this type, the cystic cavity is overall form like a donut.
located on one side of involved crown. ● Odontomas can interfere with the normal eruption of

iii. Circumferential type: When cystic cavity appears teeth.

to enclose the entire tooth, it is called circumfer- ● Most odontomas are associated with abnormalities

ential type. such as impaction, malpositioning, diastema, aplasia,

According to Mourshed malformation and devitalization of the adjacent teeth.
i. Class I: Dentigerous cyst associated with com- Large complex odontomas may cause expansion of
pletely unerupted teeth. the jaw with maintenance of the cortical boundary.
ii. Class II: Dentigerous cyst associated with par- Differential diagnosis
tially erupted teeth. ● A tooth-like appearance of the radiopaque structures

Effects on surroundings structures within a well-defined lesion leads to easy recognition

i. Associated teeth may get displaced in any direction. of a compound odontoma.
ii. There may be resorption of roots of adjacent teeth. ● Complex odontomas differs from cement-ossifying

iii. In maxilla, third molar may get displaced into max- fibromas by their tendency to associate with un-
illary sinus or adjacent nasal fossa or floor of orbit. erupted molar teeth and because they usually are
more radiopaque than cemento-ossifying fibromas.
Q.6. Describe in detail the radiographic appearance of
● Odontomas can develop in a very younger age group
various odontomas and give the differential diagnosis.
patient than do the cemento-ossifying fibromas.
Ans. ● Periapical cemental dysplasia may resemble com-

plex odontomas but lesions are usually multiple and

● The term odontoma is used to identify a tumour that is
centred on the periapical region of teeth.
radiographically and histologically characterized by the
● If the cemental dysplastic lesion is solitary and lo-
production of mature enamel, dentine, cementum and
cated in an edentulous region of the jaws, the differ-
pulp tissue.
ential diagnosis may be more difficult.
Synonyms
● The periphery of the cemental dysplasia usually has
Compound composite odontome; complex odontoma;
a wider, uneven sclerotic border, whereas odontomas
complex composite odontoma, odontogenic hamartoma;
have a well-defined cortical border and usually the
calcified mixed odontomes, cystic odontoma.
soft-tissue capsule is more uniform and better de-
Radiographic features
fined with odontomas than in cemental dysplasia.
● Dense bone islands are radiopaque but do not have a

{SN Q.10} soft-tissue capsule, as is seen with odontomas.

● Compound odontome is mostly seen (62%) in the Q.7. Enumerate the radiopaque lesions of the jaws.
anterior maxilla in association with the crown of an
Ans.
unerupted canine.
● Seventy per cent of complex odontomes are found in Various periapical radiopacities are as follows:
the mandibular first and second molar areas. Superimposed periopaque shadows–normal
● The borders are well defined and may be smooth or ● Mylohyoid ridge

irregular. These lesions have a cortical border ● Body of the zygoma

and adjacent to that cortical border is a soft-tissue ● Area of sclerotic bone (dense bone islands)

capsule. Periapical radiopaque lesions–abnormal

● The contents of these lesions are largely radiopaque. True periapical radiopacities
● Compound odontomes have a number of tooth-like ● Hypercementosis

structures or denticles that look like deformed teeth. ● Rarefying osteitis

● Focal sclerosing osteitis

● Benign osteoblastoma
● Complex odontomes contain an irregular mass of ● Benign cementoblastoma
calcified tissue. ● Idiopathic osteosclerosis
● The degree of radiopacity is equivalent to or exceeds ● Periapical cemental dysplasia
that of the adjacent tooth structure and may vary in ● Central cementifying fibroma
534 Quick Review Series for BDS 4th Year, Vol 2

Rarities any tooth can be involved, and in rare cases the

● Calcifying odontogenic cyst maxillary teeth may be involved.
● Chondroma and chondrosarcoma ● In most cases, the lesion is multiple and bilateral,

● Focal or diffuse sclerosing osteomyelitis but occasionally a solitary lesion arises.

● Mature complex odontoma Periphery and shape
● Osteogenic sarcoma ● In most cases, the periphery of a PCD lesion is

● Paget disease – Intermediate and mature stages well defined. Often a radiolucent border of varying
False periapical radiopacities width is present, surrounded by a band of sclerotic
● Anatomic structures like impacted teeth, supernu- bone that also can vary in width.
merary teeth and compound odontomas, tori, exosto- ● The sclerotic bone represents a reaction of the

ses and peripheral osteomas. immediate surrounding bone. The lesion may be
● Retained root tips irregularly shaped or may have an overall round
● Foreign bodies or oval shape centred over the apex of the tooth.
Ectopic calcifications Internal structure
● Sialoliths The internal structure varies, depending on the maturity
● Rhinoliths and antroliths of the lesion:
● Calcified lymph nodes i. In the early stage:
● Phleboliths ● Normal bone is resorbed and replaced with

● Arterial calcifications fibrous tissue that usually is continuous with

Rarities the PDL causing loss of the lamina dura.
● Calcified acne lesion ● Radiographically, this appears as a radiolu-

● Calcified hematoma cency at the apex of the involved tooth.

● Calcinosis cutis ii. In the mixed stage:
● Hamartomas ● Radiopaque tissue appears in the radiolucent

● Mineralized tumours structure. This material usually is amorphous,

● Multiple osteomas of the skin has a round, oval or irregular shape and is
● Myositis ossificans composed of cementum or abnormal bone.
● Pathologic soft-tissue masses ● Sometimes the cementum-like material forms

● Tumoural calcinosis a swirling pattern. These structures some-

times are called cementi.
Q.8. Discuss the radiological features of cementoma. ● Internal structure may appear dramatically ra-

Ans. diolucent if cavities resembling simple bone

cysts form within the cemental lesions. In some
Synonyms: Periapical cemental dysplasia/cementoma cases, the simple bone cyst extends beyond the
Periapical cemental dysplasia/cementoma original margin of the cemental lesion.
● Periapical cemental dysplasia is a localized change iii. Mature stage:
in normal bone metabolism that results in the re- ● Internal aspect may be totally radiopaque
placement of the components of normal cancel- without any obvious pattern.
lous bone with fibrous tissue and cementum-like ● Thin radiolucent margin can be seen at the
material, abnormal bone or a mixture of the two. periphery, because this lesion matures from
● By definition, the lesion is located near the apex of the centre to outward.
a tooth. The involved teeth are vital, and the pa- Effects on surrounding structures
tient usually has no history of pain or sensitivity. ● The normal lamina dura of the teeth involved with
● The lesions usually are diagnosed as an incidental the lesion is lost, making the PDL space either
finding during a periapical or panoramic radio- less apparent or giving it a wider appearance.
graphic examination made for other purposes. ● The tooth structure usually is not affected, although
The lesions can become quite large, causing a in rare cases some root resorption may occur.
notable expansion of the alveolar process and may ● Also, occasionally hypercementosis occurs on the
continue to enlarge slowly. root of a tooth positioned within the lesion.
Radiographic features ● Larger lesions may cause expansion of the jaw, an
Location area that is always bordered by a thin, intact outer
● The PCD lesion usually lies at the apex of a tooth. cortex similar to that seen in fibrous dysplasia. The
● The condition has a predilection for the periapical expansion is usually undulating in shape. This le-
bone of the mandibular anterior teeth, although sion may elevate the floor of the maxillary antrum.
Section | I Topic-Wise Solved Questions of Previous Years 535

Q.9. Radiographic features of periodontal disease. c. Periodontal abscess

● It occurs when coronal portion of pocket becomes
Ans. occluded.
Depending on the radiographic features, periodontitis is Q.10. Radiographic appearance of adenomatoid odon-
classified into: togenic tumour.
i. Early periodontitis
ii. Moderate periodontitis Ans.
iii. Advanced periodontitis
Adenomatoid odontogenic tumour
i. Early periodontitis ● Adenomatoid odontogenic tumours are uncommon

● Areas of localized erosions of alveolar bone crest. nonaggressive tumours of odontogenic epithelium in
● In the anterior region, there will be blunting of al- variety of patterns mixed with mature connective
veolar bone. tissue stroma.
● In posterior region, alveolar bone appears round off Radiographic features
with irregular and diffuse borders. Location
ii. Moderate periodontitis ● At least 75% of adenomatoid odontogenic

a. Horizontal bone loss tumours occur in the maxilla. The incisor-

● It may be localized or generalized depending canine-premolar region, especially the cuspid
on the areas involved and it may be mild, se- region, is the usual area involved in both jaws.
vere and moderate depending on the amount of It occurs more commonly in the maxilla.
bone loss. ● This tumour may have a follicular relationship

● In horizontal bone loss, both buccal and lingual with an impacted tooth; however, often it does
bone plates and intervening interdental bone not attach at the cementoenamel junction but
resorbed. surrounds a greater part of the tooth, most
b. Osseous defects often a canine.
● Interproximal crater is a trough-like depression Periphery
that occurs in the crest of interproximal septal ● The usual radiographic appearance is a well-

bone between two adjacent teeth. Craters that are defined corticated or sclerotic border.
radiographically detected are about 1 mm or Internal structure
more in depth. ● Radiographically, radiopacities develop in about

● Proximal infrabony defect is a vertical defect two-thirds of cases. One tumour may be com-
within the bone. It extends apically, from the al- pletely radiolucent, another may contain faint
veolar crest and is surrounded by three walls of radiopaque foci and some may show dense clus-
the bone ters of ill-defined radiopacities. Occasionally,
● Hemisepta is the bone of interdental septum that the calcifications are small with well-defined
remains on the roots of uninvolved adjacent tooth borders, like a cluster of small pebbles.
after destruction of either distal or mesial portion ● Intraoral radiographs may be required to demon-

of interproximal bone septum. strate the calcifications within the lesion, which
● Interproximal hemisepta occurs in the anterior or may not be seen on panoramic radiographs.
posterior teeth and it is of U or V shaped. ● Microscopic studies have verified that the size,

● Bony pockets are the extensions of the proximal number and density of small radiopacities in the
bony defect. They are surrounded by roots of in- central radiolucency of the lesion vary from tu-
volved teeth and cortical bone. mour to tumour and seem to increase with age.
iii. Advanced periodontitis Effects on surrounding structures
a. Furcation involvement ● As the tumour enlarges, adjacent teeth are dis-

● The most common area for furcation involvement placed. Root resorption is rare. This lesion also
is maxillary first molar region from mesial side. may inhibit eruption of an involved tooth. Al-
Triangular-shaped radiolucency between mesio/ though some expansion of the jaw may occur, the
distobuccal roots and palatal roots. outer cortex is maintained.
b. Alveolar bone dehiscence Ameloblastoma
● It results when the marginal bone chips apically ● The ameloblastoma, a true neoplasm of odon-

and exposes lengths of root. On radiographs, it togenic epithelium, is a persistent and locally
will appear as a faint radiopaque line representing invasive tumour; it has aggressive but benign
its apical extension. growth characteristics.
536 Quick Review Series for BDS 4th Year, Vol 2

● Ameloblastomas grow slowly, and few, if any, ● An occlusal radiograph may demonstrate cyst-
symptoms occur in the early stages. like expansion and thinning of an adjacent
● The mucosa over the mass is normal, but teeth cortical plate leaving a thin ‘eggshell’ of bone.
in the involved region may be displaced and ● CT images often reveal regions of perforation

become mobile. of the expanded cortical plate as a result of the

● In most cases, patients with ameloblastomas inability of the production of periosteal new
do not have pain, paraesthesia, fistula, ulcer bone to keep up with the rate of growth of the
formation or tooth mobility. expanding ameloblastoma.
● As the tumour enlarges, palpation may elicit a Effects on surrounding structures
bony hard sensation or crepitus as the bone thins. ● There is a pronounced tendency for ameloblasto-

If the lesion destroys overlying bone, the swell- mas to cause extensive root resorption. Tooth
ing may feel firm or fluctuant. As it grows, this displacement is common. Because a common
tumour can cause bony expansion and sometimes point of origin is occlusal to a tooth, some teeth
erosion through the adjacent cortical plate with may be displaced apically.
subsequent invasion of the adjacent soft tissues.
● An untreated tumour may grow to great size
Q.11. Radiographic appearance of (A) multiple myeloma
and is more of a concern in the maxilla, where and (B) cherubism.
it can extend into vital structures and reach into Ans.
the cranial base. Tumours that develop in the
maxilla may extend into the paranasal sinuses, Multiple myeloma
orbit, nasopharynx or vital structures at the ● Multiple myeloma is a malignant neoplasm of plasma

base of the skull. cells. It is the most common malignancy of bone in

Radiographic features adults.
Location ● Single lesions are called plasmacytoma, and multiple

● Most ameloblastomas develop in the molar lesions are termed multiple myeloma.
ramus region of the mandible, but they may ● Multiple myeloma is a fatal systemic malignancy.

extend to the symphyseal area. The patient may complain of fatigue, weight loss,
● Most lesions that occur in the maxilla are in the fever, bone pain and anaemia, although the typical
third molar area and extend into the maxillary presenting feature is low back pain.
sinus and nasal floor. ● Characteristic Bence Jones protein is present in the

Periphery urine, which causes the urine to be foamy. The disease

● The ameloblastoma is usually well defined and is more common in men. When this clonal cellular
frequently delineated by a cortical border. The bor- proliferation occurs, these cells occupy first cancel-
der is often curved, and in small lesions the border lous and later cortical bone, replacing the normally
and shape may be indistinguishable from a cyst. radiopaque bone with areas of radiolucency.
● The periphery of lesions in the maxilla is usu- ● Orally, patients may complain of dental pain, swell-
ally more ill-defined. ing, haemorrhage, paraesthesia and dysaesthesia, or
Internal structure they may have no complaints.
● The internal structure varies from totally radio- Radiographic features
lucent to mixed with the presence of bony Location
septa creating internal compartments. ● Multiple myeloma is seen more frequently in

● These septa can be straight but are more com- the mandible than the maxilla but is uncom-
monly coarse and curved and originate from nor- mon in either.
mal bone that has been trapped within the tumour. ● The incidence of jaw involvement has been re-

● Because this tumour frequently has internal ported to vary from 2% to 78%. In the mandible,
cystic components, these septa are often re- the posterior body and ramus is favoured. Maxil-
modelled into curved shapes providing a hon- lary lesions usually appear in posterior sites.
eycomb or soap-bubble patterns. Generally, the ● The periphery of multiple myeloma lesions is

loculations are larger in the posterior mandible well defined but not corticated; it lacks any
and smaller in the anterior mandible. sign of bone reaction.
● In the desmoplastic variety, the internal struc- ● The lesions have been described as appearing

ture can be composed of very irregular sclerotic ‘punched out’. However, many appear ragged
bone resembling a bone dysplasia or bone- and even infiltrative. Some lesions have an oval
forming tumour. or cystic shape.
Section | I Topic-Wise Solved Questions of Previous Years 537

● Untreated or aggressive areas of destruction Q.12. Radiographic appearance of osteosarcoma.

may become confluent, giving the appearance
Ans.
of multilocularity.
● If the lesion is located in the periapical PDL ● Osteosarcoma or osteogenic sarcoma is the most
space, it may have a border similar to that seen common malignant tumour of bone. It is derived from
in inflammatory or infectious periapical disease. osteoblasts in which tumour cells contain high levels of
● Soft-tissue lesions have been reported in the alkaline phosphate.
jaws and nasopharynx. When visible on radio- Radiographic features are divided into three stages:
graphs, they appear as smooth-bordered soft- i. Frankly osteolytic stage
tissue masses, possibly with underlying bone ii. Frankly mixed stage
destruction. iii. Frankly osteoblastic stage
Internal structure Frankly osteolytic stage
● No internal structure is radiographically visi- ● There is moth-eaten appearance, margins of the

ble. Occasionally islands of residual bone, yet lesions are unicentric and borders are ill-defined.
unaffected by tumour, give the appearance of Adjacent lamina dura may be destroyed
the presence of new trabecular bone within the ● Perforation and expansion of cortical margins by

mass. Very rarely the lesions appear radiopaque extension into subperiosteal bone.
internally. ● As sarcoma extends more deeply into the bone,

Effects on surrounding structures pathological bone fracture occurs.

● If a good deal of bone mineral is lost, teeth may ● Mandibular lesion may destroy the cortex of neuro-

appear to be ‘too opaque’ and may stand out con- vascular bundles.
spicuously from their osteopenic background. Frankly mixed stage
● Lamina dura and follicles of impacted teeth may ● There is evidence of bone formation as well as

lose their typical corticated surrounding bone in a destruction.

manner analogous to that seen in hyperparathy- ● Sarcoma with small amount of new bone formation

roidism. usually present margins, which are not well defined.

Cherubism ● The bone within the radiolucent area of destruction

● Cherubism is a rare inherited autosomal dominant may take the forms of strands, which may be few and
disease that causes bilateral enlargement of the intersecting or may produce more or less honeycomb
jaws, giving the child a cherubic facial appearance. appearance
● As children’s faces are rather chubby, mild cases ● If the maxillary sinus or nasal fossa is involved, they

may go undetected until the second decade. are invaginated rather than infiltrated, since there is a
● Profound swelling of the maxilla may result in complete bony covering over the tumour.
stretching of the skin of the cheeks, which depresses Frankly osteoblastic stage
the lower eyelids, exposing a thin line of sclera and ● Mixed lesions has ragged, ill-defined borders and its

causing an ‘eyes raised to heaven’ appearance. radiographic pattern is result of excessive bone pro-
● The mandible is the most common location. duction intermingled with radiolucent foci of bone
Radiographic features destruction.
● The lesion grows in an anterior direction and in ● Granular appearance – The sclerotic portion of mixed

severe cases can extend almost to the midline. and opaque lesions may show vertical obliteration of
● The periphery usually is well defined and in some trabeculae pattern by new bone, impairing dense
instances corticated. granular or sclerotic appearance.
● The internal structure resembles that of Central ● Sun-ray appearance – If the tumour has invaded
giant cell granuloma (CGCG), with fine, granular the periosteum, many thin irregular spicules of
bone and wispy trabeculae forming a prominent new bone are directed outwards and perpendicular
multilocular pattern. to the surface of the lesion producing a sun-ray
● Expansion of the cortical boundaries of the max- appearance.
illa and mandible by cherubism can result in se- ● Codman’s triangle – Sometimes two triangular radi-

vere enlargement of the jaws. Maxillary lesions opacities project from the cortex and mark the lateral
enlarge into the maxillary sinuses. extremities of the lesion referred to as Codman’s
● As the epicentre is in the posterior aspect of the triangle.
jaws, the teeth are displaced in an anterior direc- ● Onion-peel appearance – On rare occasions, subperi-

tion. The degree of displacement can be severe, and osteal bone lay down in layers and it may take form
with some lesions the tooth buds are destroyed. of onion-peel lamination.
538 Quick Review Series for BDS 4th Year, Vol 2

Q.13. Radiographic appearance of Paget disease. ● The lamina dura may become less evident and hyper-
cementosis develops on a few or most of the teeth in
Ans.
the involved jaw. This hypercementosis may be exu-
● Paget disease is a skeletal disorder and essentially a berant and irregular, which is characteristic of Paget
disease involving osteoclasts, resulting in abnormal re- disease. The teeth may become spaced or displaced
sorption and apposition of osseous tissue in one or more in the enlarging jaw.
bones.
● The jaws also enlarge when affected. Separation and Q.14. Describe the radiological appearance of fibrous
movement of teeth may occur, causing malocclusion. dysplasia.
Dentures may be tight or may fit poorly in edentulous Ans.
patients.
● Bone pain is an inconsistent symptom, most often di- ● Fibrous dysplasia results from a localized change in nor-
rected towards the weight-bearing bones. mal bone metabolism that results in the replacement of all
● Paget disease occurs most often in the pelvis, femur, the components of cancellous bone by fibrous tissue con-
skull and vertebrae and infrequently in the jaws. It af- taining varying amounts of abnormal-appearing bone.
fects the maxilla about twice as often as the mandible. ● The most common sites are the ribs, femur, tibia, maxilla
● Whenever the jaws are involved, it is important to note and mandible. Patients with jaw involvement first may
that the entire mandible or maxilla is affected. Although complain of unilateral facial swelling or an enlarging
this disease is bilateral, occasionally it affects only one deformity of the alveolar process. Pain and pathologic
maxilla or the involvement may be significantly greater fractures are rare. If extensive craniofacial lesions have
on one side. impinged on nerve foramina, neurologic symptoms such
● Generally, the appearance of the internal structure de- as anosmia, deafness or blindness may develop.
pends on the developmental stage of the disease. Radiographic features
Radiographic features ● Fibrous dysplasia involves the maxilla almost twice

● Paget disease has three radiographic stages, although as often as the mandible and occurs more frequently
they often overlap in the clinical setting: in the posterior aspect.
i. An early radiolucent resorptive stage ● Lesions more commonly are unilateral except for

ii. A granular or ground-glass appearing second stage very rare extensive lesions of the maxillofacial region
iii. A denser, more radiopaque appositional late stage that are bilateral.
These stages are less apparent in the jaws. Radiographic types
● The trabeculae are altered in number and shape. ● Obisesan et al. classified the lesions of fibrous dysplasia

Most often they increase in number, but in the early radiographically into six types:
stage they may decrease. i. Peau d’orange or orange-peel type
● The trabeculae may be long and may align them- ii. Whorled plaque-like type
selves in a linear pattern, which is more common in iii. Diffuse sclerotic type
the mandible. They may also be short, with random iv. Cyst-like type
orientation, and may have a granular pattern similar v. Pagetoid type
to that of fibrous dysplasia. vi. Chalky type
● A third pattern occurs when the trabeculae may be ● The periphery of fibrous dysplasia lesions most com-

organized into rounded, radiopaque patches of ab- monly is ill-defined, with a gradual blending of normal
normal bone, creating a cotton-wool appearance. trabecular bone into an abnormal trabecular pattern.
● The overall density of the jaws may decrease or Later on, as the lesion matures, a classical ‘ground-
increase, depending on the number of trabeculae. glass’ or ‘orange-peel’ or ‘pebbled’ appearance of bone
Effects on surrounding structures is observed in the radiographs.
● Paget disease always enlarges an affected bone to ● The internal aspect of bone may be more radiolucent,

some extent, even in the early stage. Prominent more radiopaque or a mixture of these two variations
pagetoid skull bones may swell to three or four compared with normal bone.
times their normal thickness. In enlarged jaws, the ● The internal density is more radiopaque in the max-

outer cortex may be thinned but remains intact. The illa and the base of the skull. Early lesions may be
outer cortex may appear to be laminated in occlusal more radiolucent than are mature lesions and in rare
projections. cases may appear to have granular internal septa,
● When the maxilla is involved, the disease invariably giving the internal aspect a multilocular appearance.
involves the sinus floor. Cortical boundaries such as ● The abnormal trabeculae usually are shorter, thinner,

the sinus floor may be more granular and less apparent irregularly shaped and more numerous than normal
as sharp boundaries. trabeculae creating a radiopaque pattern.
Section | I Topic-Wise Solved Questions of Previous Years 539

● It may have a granular appearance or ‘ground-glass’ SHORT NOTES:

appearance, resembling the small fragments of a shat-
Q.1. Cotton-wool appearance on radiograph.
tered windshield, a pattern resembling the surface of
an orange, a wispy arrangement (cotton wool) or an Ans.
amorphous, dense pattern.
● A distinctive characteristic is the organization of the
● Cotton-wool appearance results from the haphazard
abnormal trabeculae into a swirling pattern similar to deposition of sclerotic bone in the radiolucent areas.
a fingerprint. ● Conditions showing cotton-wool appearance on the ra-
● Occasionally, radiolucent regions resembling cysts
diographs are as follows:
may occur in mature lesions of fibrous dysplasia. i. Paget disease
Effects on surrounding structures ii. Fibrous dysplasia
● The effects on the involved bone may include expan-
iii. Odontogenic fibroma
sion with maintenance of a thinned outer cortex. ● Cotton-wool appearance is the characteristic feature of
Fibrous dysplasia may expand into the antrum by Paget disease. In the mature stage of Paget disease, the
displacing its cortical boundary and subsequently osteoblastic activity predominates and produces a gener-
occupying part or most of the maxillary sinus. alized cotton-wool appearance.
● Often the bone surrounding the teeth is altered with-
Q.2. Lamina dura.
out affecting the dentition, and a distinct lamina dura
disappears because this bone also is changed into the Ans.
abnormal bone pattern. In rare cases, some root re-
● The radiograph of sound teeth in a normal dental arch,
sorption may occur. Involved teeth may have hyper-
which demonstrates that the tooth socket is bound by a
cementosis.
thin radiopaque layer of dense bone.
● If the fibrous dysplasia increases the bone density,
● Its thickness and density varies according to amount of
the PDL space may appear to be very narrow. Fi-
occlusal stress to which tooth is subjected.
brous dysplasia can displace teeth or interfere with
● It is wider and denser in cases of heavy occlusion while
normal eruption.
thinner and less dense in teeth that are not subjected to
● Fibrous dysplasia appears to be unique in its ability
occlusal forces.
to displace the inferior alveolar nerve canal in a su-
● Discontinuity in periapical region suggestive of inflam-
perior direction.
matory lesion.
Q.15. Discuss any three multilocular lesions of the ● PDL space can be identified and analysed with the help
mandible. of lamina dura.

Ans. Q.3. Name the anatomical landmarks seen on upper

posterior periapical film.
[Same as SE Q.2]
Ans.
Q.16. Periapical radiopacities.
Upper posterior periapical film shows following
Ans. landmarks:
[Same as SE Q.7] Radiolucent areas
i. Maxillary sinus
Q.17. Differential diagnosis of periapical radiopacities. ii. Nasolacrimal duct
iii. Posterior palatine foramen
Ans.
Radiopaque areas
[Same as SE Q.7] i. Zygomatic process
ii. Zygomatic bone
Q.18. Discuss: (A) adenoameloblastoma and (B) amelo-
iii. Malar bone
blastoma.
iv. Coronoid process of mandible
Ans. ● Maxillary sinus appears as a dark shadow over

the posterior teeth from premolar to the tuberosity

[Same as SE Q.10]
region.
Q.19. Describe the radiological appearance of jaws in ● Nasolacrimal duct is round or oval-shaped radio-

osteogenic sarcoma. lucency over the roots of first molar.

● Posterior palatine foramen is rarely seen on peri-
Ans.
apical films. It is round or oval-shaped radiolu-
[Same as SE Q.12] cency over the roots of first molar.
540 Quick Review Series for BDS 4th Year, Vol 2

● Zygomatic process appears as a U-shaped radi- ● Tyre track appearance or Herring bone effect is one of
opaque line with its open end directed superiorly. the errors in faulty radiograph that results from the pro-
● Malar bone appears as an irregular radiopaque jection error.
shadow covering the third molar apices, which ● It is caused when back side of the film with the lead foil
may extend up to the apices of second molars. is placed facing towards the cone.
● Coronoid process of mandible is a triangular ● It can be avoided by always taking care to place the
grey area of radiopacity seen on the radiograph pebbled or the front side of the film towards the cones.
of upper molars.
Q.8. Moth-eaten appearance.
Q.4. ‘Onion-peel’ appearances on a radiography.
Ans.
Ans.
Moth-eaten appearance is seen in the following conditions:
● Laminar periosteal new bone formation has been re- ● Squamous cell carcinoma
ported leading to onion-peel appearance on radiographs. ● Malignant lymphoma
● The conditions showing onion-peel/skin appearance on ● Chronic osteomyelitis
radiographs are as follows: ● Histiocytosis-X
i. Ewing sarcoma ● Degeneration of condyle
ii. Osteogenic sarcoma ● Eosinophilic granuloma
iii. Garre osteomyelitis
iv. Eosinophilic granuloma Q.9. Line of Ennis.

Q.5. Radiographic appearance of ameloblastoma. Ans.

Ans. ● Line of Ennis is the synonym of inverted Y of Ennis.

It is so called as it was reported by one of the senior
● Ameloblastoma is defined as benign tumour that is usu- researchers in oral radiology Dr Ennis.
ally unicystic, nonfunctional, intermittent in growth, ● In an IOPA radiograph of the periapical region of the
anatomically benign and clinically persistent. maxillary canine, the lateral wall of the nasal fossa
Radiographic features and the anterior border of the maxillary sinus form an
● In early stages, there is area of bone destruction which
inverted Y, which is termed as ‘inverted Y of Ennis’.
is well defined and is indicative of slow growth.
● Outline is smooth, scalloped, well defined and well Q.10. Radiographic appearance of compound composite
corrugated. odontomes.
● Usually it is multilocular but may be unilocular.
Ans.
Coarse or fine trabeculae may be present.
● There is presence of septa in the lesion and appears as [Ref SE Q.6]
honeycomb appearance or soap-bubble appearance.
Q.11. Radiopaque landmarks of maxilla.
Effect on surrounding structures
● Extensive root resorption, expansion of cortical Ans.
plates as well as perforation of bone are late features.
[Ref SE Q.1]
Q.6. Name four conditions showing soap-bubble appear-
ance on skull radiograph. Q.12. Radiographic appearance of dentigerous cyst.

Ans. Ans.
Soap-bubble appearance is seen in the following conditions: Radiographic appearance of dentigerous cyst
● Ameloblastoma ● Dentigerous cyst is also called as follicular cyst. It is

● Central haemangioma the most common type of odontogenic cyst, which

● Odontogenic myxoma encloses the crown of the unerupted tooth.
● Giant cell lesions ● Radiographically, it appears as well-defined radiolu-

● Odontogenic keratocyst cency usually associated with hyperostotic borders.

● Pindborg tumour ● Usually it is unilocular but sometimes may appear

● Aneurysmal bone cyst multilocular, due to ridges in the bony wall.

● It may envelop the crown symmetrically but may
Q.7. Herring bone pattern.
expand laterally from the crown.
Ans. There may be resorption of roots of adjacent teeth.
Section | I Topic-Wise Solved Questions of Previous Years 541

Radiological types of dentigerous cysts are as follows: Radiographically, chronic suppurative osteomyelitis
i. Central type: When the cystic cavity envelops the may present at least four different images:
crown of the impacted tooth symmetrically from a. A radiolucency in the bone with ragged borders.
all sides, it is called central type. b. A radiolucency with multiple radiopaque foci
ii. Lateral type: In this type, the cystic cavity is within it.
located on one side of the involved crown. c. A dense zone of radiopacity with faint radiolu-
iii. Circumferential type: When cystic cavity appears cency at the margin.
to enclose the entire tooth, it is called circumfer- d. A ‘salt and pepper’ radiographic effect in the bone.
ential type.
Q.16. Describe the radiographic appearance of myxoma.
Q.13. Radiographic appearance of hyperparathyroidism.
Ans.
Ans.
● The odontogenic myxoma is an infiltrative benign tumour
● Hyperparathyroidism is an endocrine disorder in which of bone that occurs almost exclusively in the jawbones.
there is an excess of circulating parathyroid hormone. ● Radiographically, the odontogenic myxoma may produce
Radiographic features several patterns: unicystic, multilocular, pericoronal (less
● Due to loss of central trabeculae and thinning of corti- often) and radiolucent–radiopaque.
cal tables, entire calvarium has granular appearance. ● Fine intralesional trabeculation occurs in most of the mul-
● Bone matrix contains less than normal amounts of cal- tilocular examples, as well as some of the unicystic types,
cium producing unusually radiolucent skeletal image. as a soap-bubble, honeycomb or tennis-racket pattern.
● Ground-glass appearance and moth-eaten appear- ● The unilocular variety tends to be small and is mostly
ance and pepper pot skull appearance. located in the anterior region and the multilocular type
● Teeth show loss of lamina dura; it may be complete in the posterior region.
or partial. ● Margins may be poorly or well defined, and border scle-
● Demineralization of inferior border of mandibular rosis has been observed in some cases. The tumour may
canal, thinning of outlines of the maxillary sinus. be scalloped between the roots of the teeth.
● The odontogenic myxoma expands the cortical plates,
Q.14. Name a few periapical radiopacities.
showing as a smooth enlargement of the alveolar and
Ans. basal bone. Sometimes, it perforates the cortical plate
and produces a bosselated surface
Various periapical radiopacities are as follows:
● Hypercementosis Q.17. Enumerate the landmarks seen on the intraoral
● Focal sclerosing osteitis periapical view of upper third molar region.
● Benign osteoblastoma
Ans.
● Benign cementoblastoma
● Idiopathic osteosclerosis [Same as SN Q.3]
● Periapical cemental dysplasia
Q.18. Onion-skin appearance.
Q.15. Discuss the radiological appearance of chronic
Ans.
osteomyelitis.
[Same as SN Q.4]
Ans.
Q.19. Soap-bubble appearance.
● Chronic osteomyelitis is a diffuse sclerosing osteomy-
elitis in which the balance in bone metabolism is tipped [Same as SN Q.6]
towards increased bone formation, producing a subse-
Q.20. Tyre track appearance.
quent sclerotic radiographic appearance.
Radiographic features of chronic suppurative osteomyelitis Ans.
● Radiographically, chronic suppurative osteomyelitis
[Same as SN Q.7]
presents a ‘moth-eaten’ radiolucent area in the bone
with poorly defined margins. Q.21. Radiographic features of chronic osteomyelitis.
● Within the radiolucent area, multiple radiopaque foci
Ans.
are evident which represent areas of sequestrations
formation. [Same as SN Q.15]