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DENTAL SCIENCE - ORIGINAL ARTICLE
Year : 2012  |  Volume : 4  |  Issue : 6  |  Page : 369-372  

Ultrasound imaging in the diagnosis of periapical lesions


1 Department of Oral Medicine and Radiology, JKK Nattaraja Dental College and Hospital, Komarapalayam, Tamil Nadu, India
2 Department of Oral and maxillofacial Surgery, JKK Nattaraja Dental College and Hospital, Komarapalayam, Tamil Nadu, India
3 Department of Oral Medicine and Radiology, College of Dental Sciences and Hospital, Davangere, Karnataka, India

Date of Submission01-Dec-2011
Date of Decision02-Jan-2012
Date of Acceptance26-Jan-2012
Date of Web Publication28-Aug-2012

Correspondence Address:
Christo Naveen Prince
Department of Oral Medicine and Radiology, JKK Nattaraja Dental College and Hospital, Komarapalayam, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7406.100275

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   Abstract 

Background and Objectives: To assess the diagnostic capability of real-time ultrasound imaging, together with the application of color power Doppler in the identification and differential diagnosis of the periapical lesions. Materials and Methods: Fifteen patients with periapical lesions of pulpal origin, diagnosed with clinical and conventional radiographic examination, were examined further using ultrasonography. The results from the biopsies of the lesions were compared and statistically analyzed. Results: The differential diagnosis between periapical granulomas and cystic lesions, which were based on the ultrasonographic findings, were confirmed by the results of the histopathologic examination in 13 (86.7%) of 15 cases, one being granuloma and 14 being cystic lesion. Interpretation and Conclusion: Ultrasound real-time imaging is a technique that may help make a differential diagnosis between cysts and granulomas by revealing the nature of the content of a bony lesion. This technique may have further applications in the study of other lesions of the jaws.

Keywords: Color power doppler, diagnosis, echography, periapical lesions


How to cite this article:
Prince CN, Annapurna CS, Sivaraj S, Ali I M. Ultrasound imaging in the diagnosis of periapical lesions. J Pharm Bioall Sci 2012;4, Suppl S2:369-72

How to cite this URL:
Prince CN, Annapurna CS, Sivaraj S, Ali I M. Ultrasound imaging in the diagnosis of periapical lesions. J Pharm Bioall Sci [serial online] 2012 [cited 2020 Nov 26];4, Suppl S2:369-72. Available from: https://www.jpbsonline.org/text.asp?2012/4/6/369/100275

Diagnostic ultrasonography, a safe, rapid, accurate, noninvasive, and easily reproducible dynamic modality providing "live" images, could be used to differentiate among solid, cystic, mixed, and dense cystic lesions. [1],[2] Real-time imaging is used to study the moving parts of the body and to obtain a three-dimensional information by rapidly changing the sections of anatomy. [2],[3] Using color power Doppler ultrasound, it is possible to evaluate and determine the presence and direction of blood flow within the ultrasonographic image of the tissue, together with information concerning flow, velocity, and perfusion of the area. [1]

The versatility of t method has proved its marked efficiency in the field of medicine, whereas it posses less exploration with little work in the field of dentistry. Ultrasonography, with its resourcefulness can fetch the differentiation among periapical lesions.


   Materials and Methods Top


The study group comprised 15 patients of both sexes, with age ranging from 13 to 65 years, attending the outpatient department. Only those periapical lesions which appeared as radiolucent on the radiographs were included in the study group. Those periapical lesions which appeared as radiopaque on the radiographs were eliminated from the study group.

Ultrasonographic examination

All the subjects underwent ultrasonographic examination using GE Logic 400 MR3 color Doppler machine having multifrequency linear transducer using 7-11 MHz frequency at Sheethal Diagnostics, Davangere, India.

The patients were examined with multifrequency linear transducer. All the examinations including real-time and Color Doppler imaging were performed in the periapical area extraorally.

The ultrasonographic images were analyzed based on the following principles:

  1. Cystic lesion: A hypoechoic well-contoured cavity surrounded by reinforced bone walls, filled with fluid, and with no evidence of internal vascularization on color Doppler examination.
  2. Granuloma: A poorly defined hypoechoic area, showing rich vascular supply on color Doppler examination.
  3. Mixed lesion: Predominantly hypoechoic area with focal anechoic area, showing vascularity in some areas on color Doppler examination.
The results of ultrasound were correlated with radiographic and histological findings and were statistically analyzed.


   Results Top


Correlation of histologic features with ultrasonographic findings

Out of the 15 subjects, 12 (80%) were diagnosed as periapical cyst ultrasonographically, whereas 14 (93.3%) were diagnosed as periapical cyst histopathologically and the correlation between ultrasonographic and histopathologic diagnoses was found to be in 12 (85.7%) subjects [Table 1] and [Graph 1].
Table 1: Correlation of histologic features with ultrasonographic findings

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Out of the 15 subjects, 2 (13.3%) were diagnosed as periapical granuloma ultrasonographically, whereas 1 (6.7%) was diagnosed as periapical granuloma histopathologically and the correlation between ultrasonographic and histopathologic diagnoses was found to be in 1 (50%) subject.

Out of the 15 subjects, 1 (6.7%) was diagnosed as periapical abscess ultrasonographically, whereas no subjects were diagnosed as periapical abscess histopathologically and there was no correlation between ultrasonographic and histopathologic diagnoses in this subject.

The correlation between histopathologic and ultrasonographic diagnoses was found to be in 13 (86.7%) subjects.

Diagnostic validity of ultrasonography

Comparing the results of ultrasonography with the histopathologic features, the sensitivity, specificity, positive predictive value, and negative predictive value of ultrasonography to diagnose periapical lesions were calculated. In our study, tp denotes true positive = 12 subjects, tn denotes true negative = 1 subject, fp refers to false positive = 2 subjects, fn is false negative = 0 subjects, and N is total number of patients = 15 subjects [Table 2] and [Graph 2].
Table 2: Diagnostic validity of ultrasonography

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   Discussion Top


Correlation of histologic features with ultrasonographic findings

Out of the 15 subjects in the present study, ultrasonographic examination showed 12 (80%) periapical cysts whereas histopathologic diagnosis revealed 14 (93.3%) periapical cysts. One of the periapical cysts (2 nd subject) was misdiagnosed ultrasonographically as periapical granuloma. This misinterpretation was because of the content of the lesion which showed high density equivalent to a solid lesion, even though with lack of vascular supply on color Doppler examination. Hence, it was diagnosed as periapical granuloma.

One of the periapical cysts (11 th subject) was misdiagnosed ultrasonographically as periapical abscess [Figure 1]. This lesion showed both hypoechoic and anechoic regions, i.e., mixed echogenic patterns with numerous scattered internal echoes and varying density values within the lesion suggestive of periapical abscess. Similar to our observations, Dib et al.[4] in their study of 72 intraosseous lesions of the jaw could identify accurately only in 17 (73.9%) out of 23 cystic lesions. The reason for this could be due to the presence of thick cortical bone covering the lesion, the occurrence of infected cysts and solid areas within the cystic lesion. The cystic lesions on the ultrasound imaging appeared as anechoic lesion in six cases, turbid fluid in one case, scattered internal echoes in one case, and posterior enhancement in three cases [Figure 2] and [Figure 3].
Figure 1: Ultrasonograph showing well-defined hypoechoic lesion with vascularity

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Figure 2: Ultrasonograph showing well-defined anechoic lesion

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Figure 3: Ultrasonograph showing well-defined anechoic lesion

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The internal echoes present in infected cysts and odontogenic keratocyst could be due to dense particles (cholesterol clefts in the infected cysts) in the cystic fluid and keratin in odontogenic keratocyst. The density values varied within the lesion in case of infected cysts and odontogenic keratocyst, indicative of difference in the contents within the lesion, which reflects the disease process.

Out of the 15 subjects in the present study, ultrasonographic examination showed 2 (13.3%) periapical granuloma among which 1 (50%) was diagnosed histopathologically as periapical granuloma and the other as periapical cyst. This observation is similar to the observations made by Cotti et al. [5],[6] and Gundappa et al, [3] where they had accurately diagnosed all the periapical granulomas (100%) ultrasonographically.

Thus, the observations from the present study infer that the diagnostic validity of ultrasonography is similar to that made by Dib et al, [4] where they have reported 92.8% accuracy and less compared to that made by Cotti et al, [5],[6] and Gundappa et al. [3] where they have reported 100% accuracy.

Comparison of ultrasonography with conventional radiography

In all the subjects, conventional radiography provided the preliminary information about the lesion [Figure 4]. It pictorially represents the anatomic location of the periapical lesion in relation to the particular involved tooth and it provides size of the lesion [Figure 5] and [Figure 6], whereas ultrasound was able to accurately identify the underlying disease process reasonably accurately and the size measurements in three dimensions using the ultrasound software.
Figure 4: Panoramic radiograph showing unilocular radiolucent lesion

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Figure 5: Occlusal radiograph showing unilocular radiolucent lesion

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Figure 6: Intraoral periapical radiograph showing radiolucent lesion

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A major concern over the performance of ultrasonography was the difficulty in attributing the lesions to a specific area of the maxillary bone because the dental landmarks (i.e. roots) were not specifically visualized. This made it difficult to orient the lesion in the different regions of the mouth without using a reference radiograph.


   Conclusion Top


With its potential usefulness to differentiate the periapical lesions, ultrasonography can be considered as a better imaging modality with improved efficacy when compared to conventional radiography. In comparision to histopathologic diagnosis, ultrasonography showed less accuracy and thus can be considered to be a supplementary tool in the differential diagnosis of periapical lesions. Further research can be directed in larger samples and in different types of periapical lesions to assess the diagnostic validity of ultrasonography.

 
   References Top

1.Yoshida H, Akizuki H, Michi K. Intraoral Ultrasonic scanning as a diagnostic aid. J Craniomaxillofac Surg 1987;15:306-11.  Back to cited text no. 1
    
2.Zhao Y, Ariji Y, Gotoh M, Kurita K, Natsume N, Ma X, et al. Color Doppler Sonography of the facial artery in the anterior face. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:195-201.  Back to cited text no. 2
    
3.Gundappa M, Ng SY, Whaites EJ. Comparison of ultrasound, digital and conventional radiography in differentiating periapical lesions. Dentomaxillofac Radiol 2006;35:326-33.  Back to cited text no. 3
    
4.Dib LL, Curi MM, Chammas MC, Pinto DS, Torloni H, Paulo S. Ultrasonography evaluation of bone lesions of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:351-7.  Back to cited text no. 4
    
5.Cotti E, Campisi G, Garau V, Puddu G. A new technique for the study of periapical bone lesions: Ultrasound real time imaging. Int Endod J 2002;35:148-52.  Back to cited text no. 5
    
6.Cotti E, Campisi G, Ambu R, Dettori C. Ultrasound real time imaging in the differential diagnosis of periapical lesions. Int Endod J 2003;36:556-63.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]


This article has been cited by
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Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2016;
[Pubmed] | [DOI]
2 Effect of Cortical Bone Thickness on Detection of Intraosseous Lesions by Ultrasonography
Sadaf Adibi,Alireza Shakibafard,Zohreh Karimi Sarvestani,Najmeh Saadat,Leila Khojastepour
Radiology Research and Practice. 2015; 2015: 1
[Pubmed] | [DOI]



 

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