Radiology · patient case question
Which projection best demonstrates the extent of SEVERE bone loss?
Patient case: Films for a Patient Not Seen in Ten Years
Patient: 48-year-old male
Chief Complaint: “I want a full check-up. I know it's been a while.”
Background: Last dental visit approximately ten years ago. No current symptoms. Reports his gums bleed when he brushes.
Medications: None
Vital Signs: BP 128/80 mmHg · HR 76 bpm · RR 16 · T 98.4°F
Findings: Generalized 5–7 mm pockets with bleeding on probing and visible recession. Several teeth are slightly mobile. On imaging: a horizontally impacted #17 whose crown abuts the distal root of #18, which shows a concave defect at the contact point; a well-defined mixed radiolucent-radiopaque lesion at the apices of the mandibular anteriors, which all test VITAL; and a radiopaque structure superimposed over the mandible on both the panoramic and lateral cephalometric films.
Show answer and explanation
Correct answer: D. Vertical bitewings
- A. Horizontal bitewings are the standard for caries detection and for EARLY bone loss, but the limited vertical coverage is exactly the problem in advanced disease.
- B. A panoramic film shows generalized bone levels but with poor resolution, superimposition and magnification. It supplements but does not replace intraoral films for periodontal assessment.
- C. An occlusal film shows the arch in cross-section, useful for locating impacted teeth, sialoliths and expansion — not for crestal bone levels.
- D. CORRECT. VERTICAL BITEWINGS. The receptor is oriented with its long axis vertically, which captures far more crestal-to-apical bone height on a single film. With advanced bone loss, a horizontal bitewing simply cuts the image off before the base of the defect is reached — the vertical orientation is what allows the true depth of the defect to be seen along with the interproximal contacts.
Note: Vertical bitewings are the standard periodontal radiographic examination once probing depths exceed roughly 5–6 mm. Periapicals with a paralleling technique give the most accurate bone-level detail of all.