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| Year : 2014 | Volume
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| Issue : 1 | Page : 54-57 |
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| Ultrasound imaging versus conventional histopathology in diagnosis of periapical lesions of endodontic origin: A comparative evaluation |
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V Parvathy1, Ramesh Kumar2, Elizabeth Prabha James2, Sheila George1
1 Department of Conservative Dentistry and Endodontics, Noorul Islam College of Dental Sciences, Aralumoodu, Thiruvananthapuram, Kerala, India
2 Department of Conservative Dentistry and Endodontics, Government Dental College, Kozhikode, Kerala, India
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| Date of Submission | 21-Sep-2012 |
| Date of Decision | 18-Oct-2012 |
| Date of Acceptance | 01-Feb-2013 |
| Date of Web Publication | 21-Apr-2014 |
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 Abstract | | |
Context: Accurate assessment of periapical status is critical in diagnosis, treatment planning, and evaluation of healing. Novel imaging modalities like sonography offer promising results with reduced radiation risks.
Aims: To evaluate the potential of ultrasound imaging technique together with the application of color Doppler to differentiate between periapical lesions of endodontic origin.
Materials and Methods: Twenty patients with periapical lesions of endodontic origin who were already scheduled for undergoing endodontic surgery were examined further using sonography. Color Doppler was performed to assess blood flow. Information on the size of the lesion, its content, and vascular supply was gained and recorded by means of ultrasound images. The sonographic images were analyzed and discussed with an expert sonologist, and a tentative diagnosis between a periapical cyst and periapical granuloma was made. Endodontic surgery and histopathological examination was done for each case and the results were compared.
Results: The sonograms revealed the lesions within the bone in three dimensions and their contents, that is, fluids or tissues or blood vessels. Measurements of the periapical lesions in three dimensions were also obtained. Of the twenty cases studied, ultrasound could detect periapical granulomas in all 9 cases and radicular cysts in all 11 cases.
Conclusion: Ultrasound imaging had the potential to be used for the evaluation of periapical lesions of endodontic origin. However, further studies are required to establish a definite correlation. Keywords: Color Doppler, diagnosis, histopathology, periapical, ultrasound
Key Messages: Ultrasound imaging is a useful tool for evaluation of periapical lesions of endodontic origin. Sonography has definite advantages over other imaging modalities as it is noninvasive, lacks radiation hazards, availability of images in digital form, and achievement of maximum patient compliance. Further, research should be undertaken to unleash the vast avenues of sonography in study of periapical lesions.
How to cite this article:
Parvathy V, Kumar R, James EP, George S. Ultrasound imaging versus conventional histopathology in diagnosis of periapical lesions of endodontic origin: A comparative evaluation. Indian J Dent Res 2014;25:54-7 |
How to cite this URL:
Parvathy V, Kumar R, James EP, George S. Ultrasound imaging versus conventional histopathology in diagnosis of periapical lesions of endodontic origin: A comparative evaluation. Indian J Dent Res [serial online] 2014 [cited 2023 Mar 21];25:54-7. Available from: https://www.ijdr.in/text.asp?2014/25/1/54/131124 |
Endodontic treatment aims primarily at protecting (or healing) the periapical tissues from inflammation to re-establish normal tooth form and function. Accurate assessment of periapical status is critical in diagnosis, treatment planning, and evaluation of healing. [1],[2]
Conventional radiographs play an important role in the detection, treatment, and follow-up of periapical lesions. [2] However, routine radiographs cannot be relied upon due to the diffuse and infiltrative nature of the inflammatory process in bone, the inability of radiographic techniques to demonstrate noncortical radiolucencies, the effect of interrater and intrarater reliability measures, and radiation risk factors. [3],[4]
Digital radiography has been regarded as a viable alternative to film-based imaging. [4] However, recent studies have demonstrated that digital radiography even when used with image processing and color coding is no better than conventional radiography in the detection and measurement of periapical lesions. [5]
Computed tomography (CT) has been used to make a differential diagnosis between periapical granulomas and periapical cysts and for the follow-up management of extensive periapical lesions. [6],[7] However, routine use of CT even with the aid of dose reduction methods is associated with high dosage of radiation. [8]
Magnetic resonance imaging (MRI) has been suggested as an alternative to X-ray-based imaging modalities for the visualization of periapical lesions. [9] However, bone is better imaged by using conventional X-ray and CT than by using MRI. Also, MRI is claustrophobic, affects metallic implants, and expensive. [10]
The use of ultrasound imaging (also known as sonography or echography) for the diagnosis of periapical lesions of endodontic origin has been recently reported. [11],[12],[13] Ultrasound examination is a noninvasive technique that offers advantages like ease of availability and portability, provision of real-time dynamic functional studies, speed of investigation, patient acceptability, cost-effectiveness, availability of images in digital form that are easy to read, store, and reproduce, and freedom from radiation hazards. [14]
The purpose of this study was to evaluate the use of ultrasound imaging in an Indian population for the differential diagnosis between extensive periapical lesions of endodontic origin using histopathology as the gold standard.
| Materials and Methods | |  |
Twenty patients with periapical lesions of endodontic origin in either the maxillary or mandibular anterior teeth (diagnosed with conventional clinical and radiographic examination), who were already scheduled for undergoing periapical surgery in the Department of Conservative dentistry and Endodontics, Government Dental College, Kozhikode were examined further using sonography. Patients who agreed to take part in the study were requested to sign an informed consent form. Endodontic surgery and histopathological examination was done for each case. The histopathology report was then compared with the description obtained from the ultrasound images. The study was conducted after obtaining approval from the Human Ethics Committee, Government Medical College, Kozhikode.
Ultrasound examination
The equipment used in this study was an ultrasound machine Logiq 500 MD MRS, Wipro-GE , Bangalore, India (USG with Doppler facility) with a high definition regular size linear array transducer probe having a frequency of 8-11 MHz.
The patient was seated in the supine position and the operator seated in a rotating stool beside the bed of the patient. The area to be examined was covered with a layer of ultrasound transmission gel (Technomed). The ultrasonic probe was covered with a thin disposable latex film and positioned either inside the mouth on the buccal sulcus of the bone corresponding to the apical area of the tooth or outside the mouth against the skin at the corresponding external area, depending on which technique gave better results. The position of the probe was changed slightly in order to obtain an adequate number of transverse and longitudinal scans.
Color Doppler was performed to assess blood flow. Information on the size of the lesion, its content and vascular supply was gained and recorded by means of ultrasound images. The sonographic images were analyzed and discussed with an expert sonologist. The reports were recorded on a chart and a tentative diagnosis between a periapical cyst and periapical granuloma was made based on the principles of sonography.
| Results | | |
The patients experienced no discomfort during the sonographic examination. Sonographic images of the periapical lesions were obtained in all the 20 cases. Measurements of the periapical lesions in three dimensions were also obtained.
The sonographic examination revealed the presence of 11 lesions with well-defined contours and hypoechoic/anechoic content. Acoustic enhancement was also seen. The lesions showed no evidence of internal vascularization with color Doppler. These lesions were diagnosed as periapical cysts [Figure 1], [Figure 2], and [Figure 3]. Histopathology examination demonstrated the presence of a cavity lined by stratified squamous epithelium, either in a regular or in an arcading pattern. The lumen of the cavity was filled with fluids and cellular debris. Cholesterol clefts were occasionally present. These lesions were diagnosed as periapical cysts from a histopathological stand point [Figure 4]. | Figure 1: Intraoral periapical X ray showing a well-defi ned radiolucency (arrow) in relation to 11,12
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 | Figure 2: Ultrasound image showing a transonic lesion (arrow) with well-defi ned and reinforced contours suggestive of a periapical cyst
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 | Figure 3: No evidence of internal vascularization on color Doppler examination
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 | Figure 4: Photomicrograph of the lesion showing a cystic cavity lined by epithelium in an arcading pattern, diagnosed histopathologically as periapical cyst
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Nine lesions revealed hyperechoic or mixed content (showing both hyperechoic and hypoechoic areas) with poorly defined borders. The lesions showed evidence of rich internal vascularization on color Doppler examination. All these cases were diagnosed as periapical granulomas [Figure 5], [Figure 6], and [Figure 7]. Histopathologic examination demonstrated inflamed granulamatous tissue intermingled with neutrophils, plasma cells, and histiocytes. Cholesterol clefts with areas of red blood cell extravasation with hemosiderin pigmentation were observed in some cases. These lesions were diagnosed as periapical granulomas from a histopathological stand point [Figure 8]. | Figure 5: Intraoral periapical X ray showing a well-defi ned radiolucency (arrow) in relation to 11
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 | Figure 6: Ultrasound image showing a hyperechoic lesion (arrow) with poorly defi ned contours suggestive of a periapical granuloma
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 | Figure 7: Evidence of internal vascularization on color Doppler examination
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 | Figure 8: Photomicrograph of the lesion showing connective tissue with widespread areas of infl ammatory cells and newly formed blood vessels, diagnosed histopathologically as periapical granuloma
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| Discussion | | |
Ultrasound imaging has been found to be useful in imaging various structures of oral and maxillofacial region. As there is a paucity of data regarding the use of ultrasound for diagnosis of periapical lesions of endodontic origin, a need was felt to conduct a study to evaluate the diagnostic validity of this imaging modality.
Principles of sonography
The vital ingredients of sonar imaging are transducer, ultrasound beam, and display method. [14],[15]
Transducer
The ultrasound transducer acts as both a transmitter and a receiver of sound. Application of voltage across the electrodes causes the plate to vibrate to produce ultrasounds.
Matching layer
Quarter wave matching using a mixture of aluminium powder and epoxy resin between the transducer and the patient's skin is an effective means of transmitting energy from the transducer to the patient and vice versa.
Ultrasound beam
Ultrasound is a coherent, mechanical vibration. It propagates as a sequence of compression and rarefaction waves which are transmitted by virtue of the elastic forces between adjacent tissue particles. At the interface between two tissues with different acoustic impedance, the ultrasound waves undergo refraction and reflection. The echo is the part of the ultrasound wave reflected back toward the crystal.
Display method
The ultrasonic image is an electronic representation of data generated from returning echoes and displayed on a TV monitor. Each returning echo generates one bit of data and many bits together form the electronic image. Moving the transducer probe by hand over the area of interest changes the sector plane and thus a real time three-dimensional impression of the space is obtained.
A qualitative comparison of the echo intensity with that of normal tissue aids in the interpretation of gray values on an image. An interface or area of tissue area with low echo intensity is termed ''hypoechoic'' or ''transonic''; an area where no reflection of echoes occurs is termed ''anechoic'' and an area which has high echo intensity is termed ''hyperechoic''. Nonhomogenous areas which have different types of tissues demonstrate a ''dishomogenous echo'', consisting of hyperechoic and hypoechoic signals. Bony surfaces demonstrate total reflection of echoes (hyperechoic/totally echogenic). Ultrasound imaging can be performed through windows in bone where the bone cortex has become thinned or perforated.
The application of color Doppler mode provides additional information regarding the presence, direction, and velocity of blood flow within the examined tissue.
In this study, it was possible to obtain sonographic images in all the 20 cases and to evaluate the content and measure the size of the lesion and its vascularization. This finding was in accordance with studies by Cotti et al., [11],[12] and Gundappa et al. [13]
Of the 20 cases studied, ultrasound could detect periapical granulomas in all 9 cases and radicular cysts in all 11 cases.
Sonography has definite advantages over other imaging modalities as it is noninvasive, less costly, lacks radiation hazards, availability of images in digital form and achievement of maximum patient compliance. Drawbacks of sonography include the need for expertise of the operator in interpreting the findings and interobserver variations. Also, the ultrasonic probe is cumbersome for endodontic use and the diagnostic validity of sonography is diminished in areas where there is thick overlying bone.
The results of this study demonstrated that ultrasound imaging had the potential to be used for the evaluation of periapical lesions of endodontic origin. However, further studies are required to establish a definite correlation.
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Correspondence Address:
V Parvathy
Department of Conservative Dentistry and Endodontics, Noorul Islam College of Dental Sciences, Aralumoodu, Thiruvananthapuram, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.131124
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8] |
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