Dental And Breast Pattern

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO

CRT04211 · Image Pattern Recognition

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DENTAL AND BREAST RADIOGRAPHY

Apply image pattern recognition steps in identifying abnormalities in dental radiographs

Dental And Breast Pattern

Radiographic imaging plays a vital role in the early detection, diagnosis, and monitoring of diseases affecting both the oral cavity and the breast.

Dental radiographs are essential for identifying pathologies such as dental caries, periodontal disease, cysts, and jaw fractures, while breast radiographs (mammograms) are crucial for the detection of abnormalities like breast masses, calcifications, and early signs of breast cancer.

Learning objectives

Describe breast and dental anatomical structures
Outline indications for breast and dental radiography
Explain preparation procedures for breast and dental radiography

Describe normal dental radiographic findings Describe abnormal dental radiographic findings (dental carries, trauma, neoplasm, salivary ducts calcifications) Correlate patient clinical history with findings of dental radiography

BREAST ANATOMICAL STRUCTURES

The breast is a glandular organ located on the anterior chest wall.

The breast is an apocrine gland found in both males and females. However, in females, it has a specific function – the production of milk for neonatal nutrition and immune function.

The breast has an inhomogeneous structure that is predominantly composed of adipose tissue and glandular tissue. In addition, there are also suspensory Cooper's ligaments and connective tissue such as collagen and elastin.

An apocrine gland is a type of exocrine gland that releases its secretions by "decapitation," where part of the cell membrane pinches off along with the secreted product

Dental And Breast Pattern

The adult breast has nearly 14-18 lactiferous lobes. Each lobe is made up of several lobules, and each lobule is made up of several acini. Each acinus drains into a branching duct that converges into a single lactiferous duct in each lobe, which subsequently drains at the nipple-areola complex.

The breast parenchyma comprises glandular structures, namely acini and ductal tissue. Meanwhile, the breast stroma consists of fat and fibrous tissue.

Dental And Breast Pattern

The glandular parenchyma is estrogen-dependent. During adolescence, the growing breast becomes increasingly glandular. During pregnancy and lactation, the number of acini increases.

When lactation stops, the gland becomes even less glandular when compared to before pregnancy. Thus, the breast of a parous woman is less glandular when compared to a nulliparous woman of the same age.

Breast parenchyma starts to atrophy in adulthood and accelerated in menopause with an increasing amount of fat.

Key Anatomical Structures:

Lobes: Each breast contains 14-20 lobes, arranged like the petals of a daisy. These lobes are the major milk-producing glands.

Lobules: Smaller sacs within the lobes, these are where milk is produced.

Ducts: Tubes that carry milk from the lobules to the nipple.

Nipple: The central projection of the breast, containing muscle fibres that allow it to become erect.

The nipple is the small, raised part at the centre of the breast. It has 10–20 tiny openings for milk ducts, allowing milk to exit during breastfeeding.

It contains smooth muscle, which makes it erect when stimulated.

Areola: The circular area of pigmented skin surrounding the nipple.

or The areola is the circular, darker skin surrounding the nipple. It contains small glands (Montgomery’s glands) that keep the area moist and protected.

The areola helps guide the baby to the nipple during breastfeeding.

Ligaments: Connective tissue bands that support the breast and attach it to the chest wall.

Fatty and Connective Tissue: Surrounds and fills the spaces between the lobes and ducts, providing structure and volume to the breast.

Blood Vessels: Supply the breast with oxygen and nutrients, as well as remove waste products.

Adipose Tissue

Fat that surrounds and cushions the breast.

Connective Tissue

Provides structure and support to the glandular tissue

Nerve Supply

The nipple is richly supplied with nerves, making it sensitive to touch.

Muscle:

There are no muscles within the breast tissue itself, but muscles like the pectoralis major and pectoralis minor lie underneath the breast.

Lymphatic Drainage:

Lymph vessels from the breast tissue drain into lymph nodes, primarily in the axillary (armpit) region, but also in the parasternal (along the breastbone) and supraclavicular (above the collarbone) areas.

The lymphatic drainage is significant for clinical reasons, particularly in cancer metastasis.

Lymph fluid drains into axillary nodes (75%), parasternal nodes (20%), and posterior intercostal nodes (5%). This drainage system plays a critical role in immune response and cancer spread.

Nerve Supply:

The breast receives sensory and autonomic nerve fibers from the anterior and lateral cutaneous branches of the 4th through 6th intercostal nerves.

Innervation
Thoracic intercostal nerve T3-T5

Supraclavicular nerve from the cervical plexus

Relations

The breasts overlie the pectoralis major muscles and extend from the level of the 2nd to 6th ribs:

Superior: clavicle
Lateral: midaxillary line
Medial: sternum

There is often an extension of breast tissue into the axilla called the axillary tail.

Arterial supply

Internal thoracic artery perforators (2nd to 5th)
Thoracoacromial artery
Vessels to serratus anterior
Lateral thoracic artery

terminal branches of 3rd to 8th intercostal perforators Blood supply comes from branches of the internal thoracic, lateral thoracic, and thoracodorsal arteries

Venous drainage

Axillary vein
Internal thoracic vein

Posterior intercostal vein

INDICATIONS FOR BREAST (MAMMOGRAPHY) RADIOGRAPHY

Breast radiography indications includes:
Breast lump or mass
Routine breast cancer screening (especially in women aged 40+)
Nipple discharge

Breast pain (mastalgia)

Follow-up of previous breast surgery or biopsy

Detection of microcalcifications

Implant Evaluation

Axillary lymphadenopathy

Mammography (Breast X-Ray) Preparation

Mammography is a specialized X-ray technique used to detect early signs of breast cancer. Proper preparation can enhance the clarity of the images and your comfort during the procedure.

Preparation Steps:

Schedule: During menstruation, aim to schedule your mammogram for the week after your period, when breasts are less tender.

Avoid Certain Products: On the day of the exam, the patient should not apply deodorant, perfume, lotion, or body powder under their arms or on their breasts, as these can appear as white spots on the X-ray

Clothing Choice: Wear a two-piece outfit so you only need to remove your top during the exam.

Previous Records: If you've had mammograms at other facilities, bring those images or reports for comparison.

Medication: If you experience discomfort during mammograms, consider taking an over-the-counter pain reliever about an hour before the exam, after consulting with your doctor.

DENTAL RADIOGRAPHY

TOOTH TYPES

Humans have four types of teeth: incisors, canines, premolars, and molars. Each type has a specific shape and function in the process of chewing and biting.

Adults typically have 32 permanent teeth: 8 incisors, 4 canines, 8 premolars, and 12 molars.

Incisors: Located at the front of the mouth, incisors are used for cutting and biting food. There are 4 incisors in the upper jaw and 4 in the lower jaw (8 total).

Canines: These are the sharp, pointed teeth next to the incisors, used for tearing food. There are 2 canines in the upper jaw and 2 in the lower jaw (4 total).

Dental And Breast Pattern

Premolars: These teeth, located behind the canines, have a broader surface area and are used for crushing and grinding food. There are 4 premolars in the upper jaw and 4 in the lower jaw (8 total).

Molars: Found at the back of the mouth, molars have a large, flat surface area and are primarily used for grinding and chewing food. There are 6 molars in the upper jaw and 6 in the lower jaw (12 total).

Dental Anatomical Structures

The teeth and oral cavity play a crucial role in digestion and communication, encompasses various structures that contribute to oral health and function

Enamel

The hardest substance in the body, covering the tooth’s crown.
Dentin
Lies beneath enamel, providing support and structure.
Pulp

The innermost layer contains nerves and blood vessels.

Gingiva (Gums)

Soft tissue surrounding the teeth, protecting underlying bone.

Periodontal Ligament

Connects the tooth to the alveolar bone, aiding stability.

Alveolar Bone

The part of the jawbone that supports the teeth.

Cementum

This calcified substance covers the roots of teeth and helps anchor them within the jawbone via periodontal ligaments.

Dental radiography indications include

Detection of dental caries(tooth decay)
Assessment of gum disease(periodontal disease)
Evaluation of tooth root structure and development
Detection of impacted teeth (e.g., wisdom teeth)
Diagnose cysts or tumours

INDICATIONS FOR DENTAL RADIOGRAPHY

Trauma to teeth or jaws

Pre-surgical planning for oral procedures

Dental Radiography (Dental X-Ray) Preparation

Dental X-rays help dentists diagnose issues not visible during a regular dental exam, such as cavities between teeth or bone infections.

Maintain Oral Hygiene: Brush and floss your teeth before the appointment to ensure a clean oral environment, which can help produce clearer images.

Remove Metal Objects: Take off any jewellery, glasses, or removable dental appliances like dentures before the X-ray, as metal can interfere with the imaging process.

Inform About Pregnancy: If you're pregnant or suspect you might be, inform your dentist. While dental X-rays are generally safe, precautions may be taken to minimize exposure

NORMAL DENTAL RADIOGRAPHIC FINDINGS

Refer to the typical, healthy appearance of teeth, supporting structures, and surrounding oral tissues as observed during clinical dental examinations and on dental radiographs.

Purpose: To identify and describe normal anatomical structures visible in dental radiographs.

Importance: Differentiating normal anatomy from pathological findings is crucial for accurate diagnosis and treatment planning.

Terminologies

Radiopaque: Structures that appear white or light on radiographs due to their density (e.g., enamel, bone).

Radiolucent: Structures that appear dark on radiographs because they are less dense (e.g., pulp chamber, periodontal ligament space) The following are the normal radiographic findings of dental radiography.

Tooth Structures

Well-defined tooth Structures and Proper tooth Alignment, with no pathology
Teeth should appear evenly spaced without crowding or gaps.

No evidence of caries, fractures, or abnormal lesions should be present.

Enamel: Highly mineralized outer layer; appears as the most radiopaque (white) outer layer, indicating a healthy tooth

Dentin: Less mineralized than enamel; appears slightly less radiopaque. (slightly less radiopaque than enamel, forming the bulk of the tooth).

Pulp Chamber & Canals: Contain nerves and blood vessels; appear radiolucent (dark).

Cementum: Covers the root; a thin layer that may not be distinctly visible on radiographs.

Periodontal Structures

Lamina Dura: Thin, radiopaque line surrounding the tooth root; represents the dense bone lining the tooth socket.

Periodontal Ligament (PDL) Space: Radiolucent line between the root and lamina dura; indicates healthy attachment.

Alveolar Crest: Radiopaque area between teeth; typically 1-2 mm below the cementoenamel junction (CEJ).

Intact Alveolar Bone and Periodontal Structures

The alveolar crest should be sharp and continuous, without bone loss.

The periodontal ligament space appears as a uniform radiolucent line, indicating healthy tooth attachment.

Maxillary Anatomical Landmarks

Nasal Septum: Vertical radiopaque line in the midline above the maxillary incisors.
Anterior Nasal Spine: V-shaped radiopaque structure at the base of the nasal cavity.

Incisive Foramen: Radiolucent area between the roots of the maxillary central incisors.

Median Palatine Suture: Thin radiolucent line extending posteriorly from the incisive foramen.

Maxillary Sinus: Large radiolucent area above the posterior teeth; bordered by a thin radiopaque line.

Normal anatomical landmarks of the maxilla and surrounding structures.

Mastoid process, 2. Styloid process, 3. External Auditory meatus, 4. Glenoid fossa, 5. Articular eminence, 6. Lateral pterygoid plate, 7. Pterygo-maxillary fissure, 8. Maxillary tuberosity, 9. Infraorbital foramen, 10. Orbit, 11. Incisive canal, 12. Incisive foramen, 13. Anterior nasal spine, 14. Nasal cavity and conchae, 15. Nasal septum, 16. Hard palate, 17. Maxillary sinus, 18. Floor of the maxillary sinus, 19. Zygomatic process of maxilla, 20. Zygomatic arch, 21. Zygoma, 22. Hamulus, 23. Dentition.

Dental And Breast Pattern

Normal anatomical landmarks of the maxilla and surrounding structures: 1. Mastoid process ( White arrow), 2. Styloid process ( black arrow), 3. External Auditory meatus, 4. Glenoid fossa, 5. Articular eminence, 6. Lateral pterygoid plate, 7. Pterygo-maxillary fissure, 8. Maxillary tuberosity, 9. Infraorbital foramen, 10. Orbit, 11. Incisive canal, 12. Incisive foramen, 13. Anterior nasal spine, 14. Nasal cavity and conchae, 15. Nasal septum, 16. Hard palate, 17. Maxillary sinus, Yellow arrow – cervical vertebra, 18. Floor of the maxillary sinus, 19. Zygomatic process of maxilla, 20. Zygomatic arch, 21. Zygoma, 22. Hamulus, 23. Dentition.

Mandibular Anatomical Landmarks

Mental Foramen: Round radiolucent area near the apices of the premolars; may be mistaken for pathology.

Mandibular Canal: Radiolucent band outlined by two thin radiopaque lines; carries the inferior alveolar nerve.

Genial Tubercles: Radiopaque ring-like structures below the central incisors.

Lingual Foramen: Small radiolucent dot in the midline below the central incisors

Normal anatomical landmarks of the mandible and surrounding structures.

Mandibular condyle, 2. Coronoid notch, 3. Coronoid process, 4. Mandibular foramen, 5. Ramus, 6.Lingula, mandibular canal, 7. Mental foramen, 8. Mandibular or Inferior alveolar canal, 9. Mental ridge, 10. Mental fossa, 11. Lingual foramen, 12. Genial tubercles, 13. Inferior border of mandible, 14. Mylohyoid ridge, 15. Internal oblique ridge, 16. External oblique ridge, 17. Angle of mandible, 18. Dentition, 19. Hyoid bone

Dental And Breast Pattern

The OPG depicts the anatomical landmarks. Arrows depict the anatomical landmarks in the maxillary region, which is in correlation with the pictorial diagram.

Mandibular condyle, 2. Coronoid notch, 3. Coronoid process, 4. Mandibular foramen, 5. Ramus, 6. Lingula, mandibular canal, 7. Mental foramen, 8. Mandibular or Inferior alveolar canal, 9. Mental ridge, 10. Mental fossa, 11. Lingual foramen, 12. Genial tubercles, 13. Inferior border of mandible, 14. Mylohyoid ridge, 15. Internal oblique ridge, 16. External oblique ridge, 17. Angle of mandible, 18. Dentition, 19. Hyoid bone.

Cancellous and Cortical Bone

Cancellous Bone: Appears as a network of radiopaque trabeculae with radiolucent marrow spaces; gives a "spongy" appearance.

Cortical Bone: Dense outer layer of bone; appears uniformly radiopaque.

ABNORMAL DENTAL RADIOGRAPHIC FINDINGS

Dental radiographs help identify various pathological conditions affecting the teeth, jawbone, and surrounding structures.

Below the are key abnormal findings:

Dental Caries (Tooth Decay)

Is a progressive demineralization of the tooth structure caused by acid-producing bacteria.

It leads to cavities, enamel erosion, and potential infection if untreated. Caries can affect the enamel, dentin, and pulp, leading to pain, sensitivity, and potential tooth loss.

Demineralization is the process of removing mineral components from a substance, like bone or teeth, often leading to a weakening of that substance.

Demineralization of teeth occurs when acids, produced by bacteria in the mouth, dissolve minerals like calcium and phosphate from the tooth enamel.

This process can lead to tooth decay (cavities) if not addressed.

Factors like sugary and acidic foods, poor oral hygiene (plaque buildup), and reduced saliva flow can contribute to tooth demineralization

Radiographic findings of dental caries

Radiolucent (Dark) Areas in Enamel and Dentin
Represents demineralization, appearing as dark spots on X-rays.
Early caries are confined to enamel, while advanced cases extend into dentin.
Types of dental caries and how they appear in x-ray:-

Interproximal Caries (Between Teeth)

Seen as triangular or notch-like radiolucencies at contact points.

Often detected in bitewing radiographs, indicating decay progression.

Interproximal caries, also known as interdental caries, are cavities that form in the spaces between teeth. They are a type of tooth decay that can be more dangerous than cavities on other tooth surfaces because they can progress more rapidly and may not be easily detected until they are advanced.

Occlusal Caries (Chewing Surface)

Appears as broad-based radiolucency in dentin beneath enamel.
May not be visible in early stages but becomes evident as decay deepens.

Root Caries (Cemental Caries)

Found on exposed root surfaces, appearing as irregular radiolucencies.

Common in older adults with gum recession.

Occlusal caries refers to tooth decay, or cavities, that develop on the chewing surfaces (occlusal surfaces) of teeth, particularly on the molars and premolars.

These surfaces are characterized by pits and fissures, which can trap food particles and bacteria, making them susceptible to decay

In summary, Radiographic Detection of Dental Caries

Caries manifests as radiolucent lesions (irregular) in enamel/dentin
Interproximal caries: wedge-shaped density loss between teeth
Occlusal caries: subtle radiolucency under pits/fissures
May progress to pulp involvement & periapical radiolucency

Clinical Correlation

Clinical History: Patient reports tooth sensitivity to cold/sweets, pain, and food trapping in specific areas(food impaction).

Under examination: cavities, discoloration, softened enamel will be noted
Radiograph confirms depth and pulp proximity

Radiographic Findings:

Radiolucent (dark) areas in enamel and dentin indicate demineralization.

Dental Trauma

Refers to injuries affecting the teeth, surrounding structures, and jawbone due to accidents, falls, sports injuries, or physical impact.

Radiographic findings of dental trauma

Tooth Fractures

Appears as radiolucent (dark) lines disrupting the normal tooth structure.

Tooth Displacement

Shows abnormal positioning of the tooth, with widening of the periodontal ligament space.

Tooth displacement

Alveolar Bone Fractures

Appears as radiolucent lines disrupting the continuity of the jawbone.

Often associated with multiple tooth injuries, requiring stabilization.

Summarized Radiographic Signs of dental trauma

Root fractures: radiolucent lines across the root
Luxation and avulsion: widened periodontal ligament or absent tooth
Periapical radiolucency: indicates pulpal necrosis

Alveolar fractures: displaced bone segments are seen

Clinical Correlation – Trauma

Clinical History: History of fall, accident, or facial impact, leading to broken or displaced teeth.

Clinical signs: mobility, displacement, occlusal changes
Imaging guides treatment: such as splinting, endodontics, extraction

Radiographic Findings:

Fractured enamel and dentin (discontinuity in tooth structure).

Neoplasms

Is an abnormal and excessive growth of tissue that can be benign (non-cancerous) or malignant (cancerous).

Ameloblastomas

Are benign but locally aggressive odontogenic tumors that arise from the epithelial cells involved in tooth development.

They most commonly affect the mandible, particularly in the molar region, and can cause jaw expansion, facial deformity, and tooth displacement if left untreated.

Odontogenic tumors are a group of rare growths that originate from the tissues involved in tooth formation

Odontogenic Neoplasms – Ameloblastoma & Odontoma

Ameloblastoma: multilocular (“soap bubble”) radiolucency, cortical thinning, root resorption Odontoma: mixed radiopaque/radiolucent with tooth-like or amorphous structures

Radiographic Findings of ameloblastoma

Multilocular Radiolucency ("Soap-Bubble" Appearance)

Seen as multiple radiolucent areas separated by thin bony septa.
Indicates expansile growth, often causing cortical thinning and jaw enlargement.

Tooth Displacement

Teeth near the lesion appear shifted or misaligned, reflecting aggressive growth.

Odontomas

Odontomas are benign (non-cancerous) tumors of the teeth, specifically hamartomas, meaning they are composed of normal dental tissues (enamel, dentin, cementum, and pulp) that have grown abnormally. They are the most common type of odontogenic tumor and are Commonly Asymptomatic Slow Growth: They grow slowly and are often discovered during a routine dental X-ray Radiographic Examination: They are usually diagnosed through routine dental X-rays (panoramic or periapical).

It's a benign but locally aggressive odontogenic tumor, meaning it originates from tooth-forming tissues. While generally slow-growing, it can cause significant bone destruction and displacement of teeth. Odontomas, also common, are considered hamartomas rather than true tumors,

Radiographic findings of odontomas:

Well-defined, radiopaque masses with a radiolucent border.
May be associated with impacted teeth.
May be associated with root resorption of adjacent teeth.
May cause displacement or delayed eruption of adjacent teeth.

Compound Odontoma:

Multiple, small, tooth-like structures (denticles) that are radiopaque.
Surrounded by a radiolucent rim.
Often found in the anterior maxilla.

Complex Odontoma:

A disorganized, radiopaque mass of calcified dental tissues.
May show varying densities, ranging from enamel to dentin/cementum.
Also surrounded by a radiolucent rim.

Often found in the posterior mandible.

Non-Odontogenic & Malignant Neoplasms

Osteosarcoma

Sunburst periosteal reaction, Codman’s triangle, symmetrical Periodontal ligament(PDL) widening Other malignant signs: ill-defined margins, cortical destruction, mixed lucent/sclerotic patterns

Clinical Correlation – Neoplasms

Clinical History: slow vs rapid swelling, pain, nerve symptoms (e.g., paresthesia)

Physical exam: asymmetry, expansion, tooth displacement/resorption

Oral Cancer

Refers to malignant tumors that develop in the mouth, tongue, gums, or throat.

It is commonly associated with tobacco use, alcohol consumption and prolonged sun exposure (for lip cancer). Early detection is crucial for improving treatment outcomes.

Radiographic findings/features

Bone Loss and Radiolucent Areas
Appears as dark (radiolucent) regions where bone destruction has occurred.
Indicates tumor invasion into the jawbone, often seen in advanced cases.
Irregular Borders and Cortical Bone Erosion

Shows ill-defined, asymmetric lesions disrupting normal bone structure.

Dental Cysts

Is a fluid-filled sac that develops in the jawbone or soft tissues of the mouth, often associated with infected teeth.

These cysts can be odontogenic (arising from tooth structures) or non-odontogenic and may cause swelling, pain, or displacement of teeth if they grow large.

Radiographic findings of a dental cyst

Radiolucent (Dark) Well-Defined Lesion

Appears as a round or oval dark area on X-rays.
Indicates fluid accumulation, often surrounded by a thin radiopaque border.
Displacement of Adjacent Teeth
Large cysts may push nearby teeth out of alignment.

Seen as shifting or tilting of teeth on panoramic radiographs.

Expansion and Thinning of Cortical Bone

The jawbone may appear expanded or thinned due to cyst growth.

Salivary Duct Calcifications (Sialoliths)

Are calcifications that can occur in the salivary glands and ducts, commonly in the submandibular gland. Or Salivary duct calcifications, also known as sialoliths or salivary stones, are hardened mineral deposits that form within the salivary ducts or glands.

These stones can obstruct saliva flow, leading to pain, swelling, and potential infection of the salivary gland.

Calcification : the hardening of tissue or other material by the deposition of or conversion into calcium carbonate or some other insoluble calcium compounds

Radiographic Findings of Sialothis

Radiopaque (bright, white) structures, either round, oval, or cylindrical, within or near the salivary glands and their ducts (appear as bright, well-defined opacities along the course of the salivary duct) Obstruction with Ductal Dilation

The affected duct may appear enlarged or dilated due to salivary flow obstruction.

Panoramic radiographs: Useful for visualizing sialoliths in the submandibular and parotid glands.

Occlusal radiographs: Excellent for visualizing sialoliths in the submandibular duct and gland.

Periapical radiographs: Can be used to visualize sialoliths in the parotid duct by taking a periapical film of the buccal vestibule.

Clinical History of Sialothis:

Patient complains of intermittent pain and swelling near the salivary glands, worse during meals.

Palpable hard nodule in floor of mouth.

Differential – Soft Tissue Calcifications

Phleboliths: laminated radiopacities in vascular lesions

Tonsilloliths, lymph node calcifications also appear similar Phleboliths are small, calcified masses that form within veins. They are essentially blood clots that have become hardened due to calcium deposits.

Clinical Correlation – Sialolithiasis

Symptoms: recurrent swelling/pain during meals

Imaging confirms stone location; guides removal or lithotripsy

NOTE: Periodontal Disease

Clinical History: Patient experiences gum bleeding, swelling, and loose teeth.

Radiographic Findings:

Alveolar bone loss with irregular crests.