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Radiology and the oral surgeon
Radiology and the oral surgeon Merrill
I. Peldman,
BOSTON
UNIVERSITY
M.D., D.N.D.,’ SCHOOL
Boston, Mass.
OF GRADUATE
DENTISTRY
T
he increasing involvement of the oral surgeon in the hospital environment establishes a need for more than a passing acquaintance with some of the medical specialties involved in hospital practice. Among these is the application of radiology to the clinical needs of oral surgery. Despite some contact with a hospital department of radiology during an internship, the oral surgeon in training today has little opportunity to obtain the formal education in the radiography of the head and neck which serves to widen his intellectual horizon, make him a more useful consultant, and expand his role beyond that of exodontist in both the medical and dental communities. There is varying emphasis on ra,diology in the curricula of the dental schools, both undergraduate and graduate. As Dr. Arthur Wuehrmann has indicated,l limitation in the establishment of a separate specialty in radiology by current dental society policy has, in turn, limited the availability of expert teachers, investigators, and practitioners in this dental health area. Consequently, many of our dental schools today do not have separate departments of radiology, and their students receive either no courses in the basic physics of radiation, radiobiology, radiation safety, and intraoral and extraoral radiographic diagnosis, or they get only a smattering of the same. Yet it is common for the young dentist or oral surgeon beginning his practice to purchase an x-ray unit of some type and to embark upon its use without any real background or professional capability. He may even attempt radiographic studies of areas beyond the dental and periapical capabilities of the equipment, such as studies of the temporomandibular joints, paranasal sinuses, skull and jaws. Since the films have been produced at low milliamperage and long exposures, they result in poor diagnostic detail and definition, as well as high radian tion exposure to the patient. Conversely, the resident in medical radiology today receives little or no formal training in dental radiography and extends this to his practice by divorcing *Associate
22
Professor
of Oral
Radiology
and
Head
of the
Department.
Volume
Radiology and oral surgeon 23
26
Number 1
his clinical responsibilities in this area to the dental practitioner. Dr. Hugh Wilson, Professor Emeritus of Radiology, Washington University School of Medicine,2 states : our teaching job has not been well done at either the undergraduate or graduate level (in oral radiology). Patients suffering from tumors of the jaws may presentthemselves to any dental and oral surgeons or to of several surgical specialties including otolaryngologists, The total number of cases is small and physicians engaged in general medical practice. no one individual in any of these disciplines develops a very large experience. Physicians (particularly radiologists) frequently sidestep a realistic approach to problems of dental origin, and since early recognition may depend very largely on radiographic experience, radiologists should accept a larger measure of responsibility for teaching in this field.
Dr. H. M. Worth also emphasizes this in the introductory textbook, in which he states:
chapter of his
Most professional radiologists fail to show any interest in the study of teeth and jaws. While there are some abnormalities occurring in these areas which are not found elsewhere, it is true that a far greater number of pathologic conditions occur in other parts of the skeleton. However, the diagnostic principles which apply in one area are equally valid in others. Failure of radiologists to become proficient in dental matters means that most of them are of little if any assistance to the dentist in interpreting radiographs. It has, therefore, become incumbent on dentists to undertake their own radiographic work and to make their own interpretations. This is not entirely beneficial to the dentists or to their patients. In diagnosing common dental abnormalities, it is possible for a dentist to attain a high degree of skill, but in regard to the less common lesions, their lack of training and experience is likely to become apparent, all too frequently with serious consequences to the patient. It would be a good thing if all radiographs could be interpreted by those who are competent to deal with all parts of the body, but dentists cannot be expected to spend the necessary time to become proficient in so wide a field-they have too much to learn as it is during their student years. Quite naturally a compromise, not entirely satisfactory, has developed, made possible by the necessity for dentists to acquire skill in using x-ray apparatus to carry out their every-day procedures such as root canal t,herapy, identification of caries and buried roots, and many other investigations which cannot easily be undertaken away from the dental chair. That many abnormalities are overlooked while still small, or even while curable, is the unfortunate price resulting from the present situation. Only by dentists becoming aware of the abnormal conditions and the radiographic appearances can this weakness be mitigated. Better teaching facilities while the student is in training will go far to improve the situation.*
The specialist in thoracic surgery, neurosurgery, vascular surgery, otoloryngology, and urology is extensively trained and examined in the radiologic asp&s of his specialty interest. It would, therefore, not be out of keeping with modern professional standards to expect that the well-trained oral surgeon be proficient in the radiology of the head and neck without restriction to the teeth and jaws. This should, nevertheless, supplement direction and responsibility by a properly trained medical radiologist who has been exposed to the problems of dentistry by rotation through the dental service, where he has received formal training in oral pathology and oral radiology. This centralization of responsibility and diagnostic capability has been fur*From prh&les right @ 1963, Year Publishers.
am& Praohice Book Medical
of Oral Publishers,
Radiologic Interpretaticm Inc. Used by permission
by H. M. Worth. Copyof Year Book Medical
24
Feldman
023,
O.M. & 02’. July, 1968
ther emphasized by H. H. Jacobsen” in his review of the sepa,ratio’n of dental radiology from medical radiology in the Scandinavian countries shortly after the discovery of the roentgen ra,y in the late nineteeth century. The present-day practice in his native country of Denmark is for the general radiologist. to be thoroughly indoctrinated and trained in odontology so that he is able to serve as a consultant for the radiogra,phic examination of not only the teeth and ja,wws but the entire skeletal system and the body as a whole. A combined teaching program for radiologists whereby the resident in radiology is rotated through all of the medical specialties, including dentistry, has been evolved and has served to bridge the long-standing educat.ion gap between these two health disciplines. With this basic philosophy, therefore, a curriculum in radiology has been established for the didactic period of the oral surgery residency at the Boston University School of Graduate Dent,istry. The curriculum is presented here in outline form to illustrate the comprehensiveness considered important for the training of the oral surgeon of today. Course
outline
1. Radiologic physics and radiographic technique. This deals with the basic physics of the roentgen ray and its production. The differences between the standard medical a,nd dental x-ra,y equipment are illustrated, particularly with reference to devices used for obta,ining detail, contrast, and density. The theory and application of special radiographic equipment used in most hospital departments, such as the laminagram, the image-intensification fluoroscope, cineradiography, and angiography, are reviewed, with emphasis on their application to the clinical needs of the oral surgeon. 2. The normal and abnormaNlskull. The standard positions, technique, and anatomy of a complete radiographic examination of the skull are presented, with film and slide reviews. Emphasis is placed on how the maxilla and mandible are projected to great advantage on several of the standard skull projections. The normal anatomy is defined in each projection. The abnormal skull is presented to illustrate the wide range of pathosis demonstrated by this examination. 3. The paranasal sinu-ses. The routine projections of a complete examination of the sinuses are illustrated and anatomically defined. Radiographic findings associated with sinusitis, tumors, and other pathologic conditions are presented in film and slide reviews. The application of the orthopantomogram to maxillofacial diagnosis is reviewed, and the distorted anatomy is identified. 4. The mastoid. The normal development and anatomy of the temporal bone, with pa,rticular reference to the mastoid area, are illustrated. Emphasis is placed on the frequency with which the oral surgeon will view this area during the routine examination of the temporomandibular joint and on the need for viewing the entire radiographic film rather than concentrating on a single entity. 5. The temporomandibular joint. The multiple projections and their characteristics are demonstrated in the examination of this area. More sophisticated radiographic techniques, such as laminagraphy, arthrography, and cineradiography, are reviewed with respect to their individual value in the diagnosis of
Volume 26 Number 1
Radiology and oral surgeon 25
the temporomandibular joint dysfunction or pain syndrome. The pitfalls associated with radiographic distortion, poor radiographic detail, and improper interpretation are emphasized and illustrated. 6. The salivary glands and sialography. The standard intraoral and extraoral examinations of the salivary glands for the projection of calculi are demonstrated. Intraoral and extraoral techniques are described. The technical and diagnostic approach to sialography is discussed, with a review of the many techniques and contrast agents in use today. The value of image-intensification fluoroscopy for the examination is described. 7. Bone tumors. Emphasis is placed on making observations and deductions based on multiple projections. Abnormal cha,nges in the jaws are characterized by descriptive terms relative to the pathologic process taking place. Tumors of the entire skeletal system are shown, differentiating inflammatory, benign, and malignant neoplastic characteristics. The common primary sites of metastatic malignant bone diseaseare defined, and their radiographic studies are illustrated. Radiologic-pathologic conferences are conducted, with the student discussing the differential diagnosis of case presentations from the ra,diographic viewpoint. 8. Metabolic bone disease. The material encompassesa wide range of pathologic conditions involving the various forms of osteoporosis and osteosclerosis. Dental and general skeletal findings are demonstrated. 9. Fractures and trauma. Maxillofacial fractures are stressed, with the projections required for demonstrating zygomatic, maxillary, and orbital fractures. The secondary changes of trauma, such as hemosinus, interstitial air, blowout orbital fractures, and foreign bodies, are shown in film presentations. 10. Radiation. therapy. Modern methods and concepts in the use of ionizing radiation in the treatment of head and neck cancer are discussed. The techniques of interstitial gamma source intraoral implantations are presented, with case demonstrations of ca,rcinomas located buccally, lingually, and in the floor of the mouth. The technical aspects in the use of supervoltage radiation therapy equipment, its advantages and disadvantages, are also reviewed. The role of preoperative, postoperative, and primary radiation therapy in the treatment and cure of cancer, with a critical review of statistics and results in the several areas of the oral cavity, is reviewed, as well as current concepts in the care of patients receiving radiation therapy for oral cavity and pharyngeal lesions to prevent osteoradionecrosis and other dental complications. 11. Dysplasius and dysostoses. The dynamic classification and theory of skeletal dysplasia aad dysosto’siswith its application to the many mandibulofacial dysostoses is presented in film discussions, with the total skeletal deformity illustrated. SUMMARY
The need for more comprehensive training in the special application of radiology to the practice of oral surgery has been outlined. One approach to the application of this concept has been presented in outline form to serve as a guide and stimulus in this direction.
26
Feldman
The structive education
author wishes to thank Drs. Henry M. Goldman and Kurt H. Thoma review of this manuscript. and their continued encouragement in this as well as Mrs. Carol Dullea for her diligent typing offorts.
O.S., O.M. & 0.1’. July, 1968 for their con. area. of dental
REFERENCES
1. Wuehrmann, A. J.: Dental Radiology-Pact or FantasyB ORAL SURL, ORAL MF~. & ORAL PATH. 21: 465472, 1966. 2. Glenn, J. C., Taylor, A., and Reeves, R. J.: Tumor of the Jaw, Southern M. J. 44: 481487. 1951. 3. Worth, H. M.: Principles and Practice of Oral Radiologic Interpretation, Chicago, 1963, Year Book Medical Publishers, Inc. 4. Jacobsen, H. H. Year of Crisis in Radiology, Tandlaegebladet 70: 267-273, 1966.
I. Peldman,
BOSTON
UNIVERSITY
M.D., D.N.D.,’ SCHOOL
Boston, Mass.
OF GRADUATE
DENTISTRY
T
he increasing involvement of the oral surgeon in the hospital environment establishes a need for more than a passing acquaintance with some of the medical specialties involved in hospital practice. Among these is the application of radiology to the clinical needs of oral surgery. Despite some contact with a hospital department of radiology during an internship, the oral surgeon in training today has little opportunity to obtain the formal education in the radiography of the head and neck which serves to widen his intellectual horizon, make him a more useful consultant, and expand his role beyond that of exodontist in both the medical and dental communities. There is varying emphasis on ra,diology in the curricula of the dental schools, both undergraduate and graduate. As Dr. Arthur Wuehrmann has indicated,l limitation in the establishment of a separate specialty in radiology by current dental society policy has, in turn, limited the availability of expert teachers, investigators, and practitioners in this dental health area. Consequently, many of our dental schools today do not have separate departments of radiology, and their students receive either no courses in the basic physics of radiation, radiobiology, radiation safety, and intraoral and extraoral radiographic diagnosis, or they get only a smattering of the same. Yet it is common for the young dentist or oral surgeon beginning his practice to purchase an x-ray unit of some type and to embark upon its use without any real background or professional capability. He may even attempt radiographic studies of areas beyond the dental and periapical capabilities of the equipment, such as studies of the temporomandibular joints, paranasal sinuses, skull and jaws. Since the films have been produced at low milliamperage and long exposures, they result in poor diagnostic detail and definition, as well as high radian tion exposure to the patient. Conversely, the resident in medical radiology today receives little or no formal training in dental radiography and extends this to his practice by divorcing *Associate
22
Professor
of Oral
Radiology
and
Head
of the
Department.
Volume
Radiology and oral surgeon 23
26
Number 1
his clinical responsibilities in this area to the dental practitioner. Dr. Hugh Wilson, Professor Emeritus of Radiology, Washington University School of Medicine,2 states : our teaching job has not been well done at either the undergraduate or graduate level (in oral radiology). Patients suffering from tumors of the jaws may presentthemselves to any dental and oral surgeons or to of several surgical specialties including otolaryngologists, The total number of cases is small and physicians engaged in general medical practice. no one individual in any of these disciplines develops a very large experience. Physicians (particularly radiologists) frequently sidestep a realistic approach to problems of dental origin, and since early recognition may depend very largely on radiographic experience, radiologists should accept a larger measure of responsibility for teaching in this field.
Dr. H. M. Worth also emphasizes this in the introductory textbook, in which he states:
chapter of his
Most professional radiologists fail to show any interest in the study of teeth and jaws. While there are some abnormalities occurring in these areas which are not found elsewhere, it is true that a far greater number of pathologic conditions occur in other parts of the skeleton. However, the diagnostic principles which apply in one area are equally valid in others. Failure of radiologists to become proficient in dental matters means that most of them are of little if any assistance to the dentist in interpreting radiographs. It has, therefore, become incumbent on dentists to undertake their own radiographic work and to make their own interpretations. This is not entirely beneficial to the dentists or to their patients. In diagnosing common dental abnormalities, it is possible for a dentist to attain a high degree of skill, but in regard to the less common lesions, their lack of training and experience is likely to become apparent, all too frequently with serious consequences to the patient. It would be a good thing if all radiographs could be interpreted by those who are competent to deal with all parts of the body, but dentists cannot be expected to spend the necessary time to become proficient in so wide a field-they have too much to learn as it is during their student years. Quite naturally a compromise, not entirely satisfactory, has developed, made possible by the necessity for dentists to acquire skill in using x-ray apparatus to carry out their every-day procedures such as root canal t,herapy, identification of caries and buried roots, and many other investigations which cannot easily be undertaken away from the dental chair. That many abnormalities are overlooked while still small, or even while curable, is the unfortunate price resulting from the present situation. Only by dentists becoming aware of the abnormal conditions and the radiographic appearances can this weakness be mitigated. Better teaching facilities while the student is in training will go far to improve the situation.*
The specialist in thoracic surgery, neurosurgery, vascular surgery, otoloryngology, and urology is extensively trained and examined in the radiologic asp&s of his specialty interest. It would, therefore, not be out of keeping with modern professional standards to expect that the well-trained oral surgeon be proficient in the radiology of the head and neck without restriction to the teeth and jaws. This should, nevertheless, supplement direction and responsibility by a properly trained medical radiologist who has been exposed to the problems of dentistry by rotation through the dental service, where he has received formal training in oral pathology and oral radiology. This centralization of responsibility and diagnostic capability has been fur*From prh&les right @ 1963, Year Publishers.
am& Praohice Book Medical
of Oral Publishers,
Radiologic Interpretaticm Inc. Used by permission
by H. M. Worth. Copyof Year Book Medical
24
Feldman
023,
O.M. & 02’. July, 1968
ther emphasized by H. H. Jacobsen” in his review of the sepa,ratio’n of dental radiology from medical radiology in the Scandinavian countries shortly after the discovery of the roentgen ra,y in the late nineteeth century. The present-day practice in his native country of Denmark is for the general radiologist. to be thoroughly indoctrinated and trained in odontology so that he is able to serve as a consultant for the radiogra,phic examination of not only the teeth and ja,wws but the entire skeletal system and the body as a whole. A combined teaching program for radiologists whereby the resident in radiology is rotated through all of the medical specialties, including dentistry, has been evolved and has served to bridge the long-standing educat.ion gap between these two health disciplines. With this basic philosophy, therefore, a curriculum in radiology has been established for the didactic period of the oral surgery residency at the Boston University School of Graduate Dent,istry. The curriculum is presented here in outline form to illustrate the comprehensiveness considered important for the training of the oral surgeon of today. Course
outline
1. Radiologic physics and radiographic technique. This deals with the basic physics of the roentgen ray and its production. The differences between the standard medical a,nd dental x-ra,y equipment are illustrated, particularly with reference to devices used for obta,ining detail, contrast, and density. The theory and application of special radiographic equipment used in most hospital departments, such as the laminagram, the image-intensification fluoroscope, cineradiography, and angiography, are reviewed, with emphasis on their application to the clinical needs of the oral surgeon. 2. The normal and abnormaNlskull. The standard positions, technique, and anatomy of a complete radiographic examination of the skull are presented, with film and slide reviews. Emphasis is placed on how the maxilla and mandible are projected to great advantage on several of the standard skull projections. The normal anatomy is defined in each projection. The abnormal skull is presented to illustrate the wide range of pathosis demonstrated by this examination. 3. The paranasal sinu-ses. The routine projections of a complete examination of the sinuses are illustrated and anatomically defined. Radiographic findings associated with sinusitis, tumors, and other pathologic conditions are presented in film and slide reviews. The application of the orthopantomogram to maxillofacial diagnosis is reviewed, and the distorted anatomy is identified. 4. The mastoid. The normal development and anatomy of the temporal bone, with pa,rticular reference to the mastoid area, are illustrated. Emphasis is placed on the frequency with which the oral surgeon will view this area during the routine examination of the temporomandibular joint and on the need for viewing the entire radiographic film rather than concentrating on a single entity. 5. The temporomandibular joint. The multiple projections and their characteristics are demonstrated in the examination of this area. More sophisticated radiographic techniques, such as laminagraphy, arthrography, and cineradiography, are reviewed with respect to their individual value in the diagnosis of
Volume 26 Number 1
Radiology and oral surgeon 25
the temporomandibular joint dysfunction or pain syndrome. The pitfalls associated with radiographic distortion, poor radiographic detail, and improper interpretation are emphasized and illustrated. 6. The salivary glands and sialography. The standard intraoral and extraoral examinations of the salivary glands for the projection of calculi are demonstrated. Intraoral and extraoral techniques are described. The technical and diagnostic approach to sialography is discussed, with a review of the many techniques and contrast agents in use today. The value of image-intensification fluoroscopy for the examination is described. 7. Bone tumors. Emphasis is placed on making observations and deductions based on multiple projections. Abnormal cha,nges in the jaws are characterized by descriptive terms relative to the pathologic process taking place. Tumors of the entire skeletal system are shown, differentiating inflammatory, benign, and malignant neoplastic characteristics. The common primary sites of metastatic malignant bone diseaseare defined, and their radiographic studies are illustrated. Radiologic-pathologic conferences are conducted, with the student discussing the differential diagnosis of case presentations from the ra,diographic viewpoint. 8. Metabolic bone disease. The material encompassesa wide range of pathologic conditions involving the various forms of osteoporosis and osteosclerosis. Dental and general skeletal findings are demonstrated. 9. Fractures and trauma. Maxillofacial fractures are stressed, with the projections required for demonstrating zygomatic, maxillary, and orbital fractures. The secondary changes of trauma, such as hemosinus, interstitial air, blowout orbital fractures, and foreign bodies, are shown in film presentations. 10. Radiation. therapy. Modern methods and concepts in the use of ionizing radiation in the treatment of head and neck cancer are discussed. The techniques of interstitial gamma source intraoral implantations are presented, with case demonstrations of ca,rcinomas located buccally, lingually, and in the floor of the mouth. The technical aspects in the use of supervoltage radiation therapy equipment, its advantages and disadvantages, are also reviewed. The role of preoperative, postoperative, and primary radiation therapy in the treatment and cure of cancer, with a critical review of statistics and results in the several areas of the oral cavity, is reviewed, as well as current concepts in the care of patients receiving radiation therapy for oral cavity and pharyngeal lesions to prevent osteoradionecrosis and other dental complications. 11. Dysplasius and dysostoses. The dynamic classification and theory of skeletal dysplasia aad dysosto’siswith its application to the many mandibulofacial dysostoses is presented in film discussions, with the total skeletal deformity illustrated. SUMMARY
The need for more comprehensive training in the special application of radiology to the practice of oral surgery has been outlined. One approach to the application of this concept has been presented in outline form to serve as a guide and stimulus in this direction.
26
Feldman
The structive education
author wishes to thank Drs. Henry M. Goldman and Kurt H. Thoma review of this manuscript. and their continued encouragement in this as well as Mrs. Carol Dullea for her diligent typing offorts.
O.S., O.M. & 0.1’. July, 1968 for their con. area. of dental
REFERENCES
1. Wuehrmann, A. J.: Dental Radiology-Pact or FantasyB ORAL SURL, ORAL MF~. & ORAL PATH. 21: 465472, 1966. 2. Glenn, J. C., Taylor, A., and Reeves, R. J.: Tumor of the Jaw, Southern M. J. 44: 481487. 1951. 3. Worth, H. M.: Principles and Practice of Oral Radiologic Interpretation, Chicago, 1963, Year Book Medical Publishers, Inc. 4. Jacobsen, H. H. Year of Crisis in Radiology, Tandlaegebladet 70: 267-273, 1966.