2. CONTENTS
Introduction
History of X-ray in dentistry
Guidelines for prescribing radiographs
in children
Behavioural consideration and
management techniques
Radiographic techniques
Newer digital radiographic techniques
Radiation safety and protection
Technical errors
References
3. Introduction
Definition- radiology
Plays a vital role in the diagnosis and treatment planning .
Plays a significant role in the assessment of growth and
development.
At the simplest level, help in the detection of dental caries
and at the most complex level, in the diagnosis of cysts,
tumors or any other major craniofacial disorders.
6. Dr Kells used impression
compound to stabilized the film
during exposure
7. Clinical situation for which
radiographs are indicated
Positive Historical Findings
a. History of pain
b. history of trauma
c. Familial history of dental anomalies
d. Postoperative evaluation of healing
e. Previous periodontal or endodontic treatment
f. Unexplained tooth mobility
8. Positive Clinical Signs/Symptoms
Deep carious lesions
Swelling
Evidence of dental/facial trauma
Mobility of teeth
Sinus tract (“fistula”)
Clinically suspected sinus pathology
Growth abnormalities
Oral involvement in known or suspected systemic disease
Clinical evidence of periodontal disease
Large or deep restorations
9. • Evidence of foreign objects
• Pain and/or dysfunction of the temporomandibular joint
• Facial asymmetry
• Abutment teeth for fixed or removable partial
prosthesis
• Unexplained bleeding
• Unexplained sensitivity of teeth
• Unusual eruption, spacing or migration of teeth
• Unusual tooth morphology, calcification or color
• Unexplained absence of teeth
• Clinical erosion
10. Radiographic Examination
Four film series: This series consists of a
maxillary and mandibular occlusal radiographs and
two posterior bitewing radiographs.
11. Eight film survey:
This survey includes a maxillary and mandibular anterior
occlusal radiographs. Four molar periapical radiographs.
Two posterior bitewings
12. Twelve film survey:
This survey include maxillary and mandibular
permanent incisor periapical radiographs.
Four primary canine periapical radiographs.
Four molar periapical radiographs.
Two posterior bitewing radiographs
13.
14. Sixteen film survey: This examination consists of
the twelve-film survey and the addition of four
permanent molar radiographs.
16. Age Consideration Radiograph
3-5 No apparent abnormalities (open
contacts)
No apparent abnormalities (closed
contacts)
Extensive caries
Deep caries
None
2 posterior bite
wings, size 0 film
4-film survey
Selected periapical
radiographs in
addition to 4-film
survey
17. Age Consideration Radiograph
6-7 No apparent abnormalities
Extensive or deep caries
8-film survey
(available by 7 years
of age)
Selected periapical
radiographs in
addition to 8-film
survey
8-9
10-
12
No apparent abnormalities or
extensive or deep caries
No apparent abnormalities or
extensive or deep caries
12-film survey
12 or 16 film survey
depending upon size
24. SPECIAL
CONSIDERATIONS IN
YOUNG CHILD
Introduce him to the “camera”
Tell-show-do
Careful words to describe the procedure
Easiest region first
Topical L.A. in case of exaggerated gag reflex
Patience for repeated attempts
Voice control, firmness & TLC
Special handling for alternatively abled children
25. If the child, less than three years of age it may be
necessary for the child to sit in the parent’s lap while the
radiograph is exposed.
26. Adequately protect the parent and child with
lead aprons to reduce radiation exposure.
If the child is uncooperative, then additional
restraint by a second adult may be necessary.
27. A second adult stabilizes the child’s head with one hand
while the other hand positions the x-ray holder in the
patient’s mouth.
If a second adult is not available, it may be necessary to
place the child in a mechanical restraining device (Papoose
Board) to adequately restrain the child.
If the child is still too uncooperative, it may be necessary to
manage the child pharmacologically with inhalation, oral, or
parental sedatives.
28. Older children may also be uncooperative for a variety of reasons.
These can range from the jaw being too small to adequately
accommodate the radiograph, fear of swallowing the radiograph,
fear of the procedure itself, or the patient exhibits a severe gag
reflex.
For the child with the small mouth, use the smallest size film
available (size 0 film). Roll the film (do not place sharp bends) to
allow the film to accommodate the shape of the jaw and not impinge
on the soft tissues.
29. Positioning the Radiograph
vertical radiograph
By biting on the large positioning device and watching in
a mirror they are assured they will not swallow the
radiograph
30. A self sticking sponge tab may also reduce
impingement of the radiograph on the intraoral
soft tissue.
32. Another example of desensitization is the “Lollipop Radiograph
Technique.” The child is given a lollipop to lick (preferably
sugarless).
After a few licks, the lollipop is taken from the child and a
radiograph is attached to the lollipop using an orthodontic
rubber band. The lollipop with the attached film is returned
to the child, who is told to lick the lollipop again.
After a few licks, the child is told to hold the lollipop in his
mouth while we take a tooth picture. The exposure is made.
33. Procuring Posterior Radiographs
Procuring posterior radiographs can be made more pleasant
by associating it with a pleasurable taste….bubble gum.
Before placing the radiograph in the patient’s mouth apply
bubble gum flavored toothpaste to the film. The child will be
more accepting of the radiograph.
34. Managing gag patients
The easiest is through diversion and positive suggestion.
The operator suggests to the patient the gag reflex can be
reduced by concentrating on something other than the
procedure.
The patient’s palate can be sprayed with a topical anesthetic
to reduce the sensation of the radiograph on the palate and
tongue.
An alternative is the use of nitrous oxide analgesia.
35. Bent film radiographic
technique
Used in young children who can not tolerate placement
of film inside their mouth
Pt bite on the film that has a sharp right angle bend at
the top, bent part serves as a self contained bite tab
to hold the film in the place.
Instruct the child to softly bite down to avoid cusp
marks and distortion on the film
Stick on foam tabs are also available for use
1 to 2 size films are used
Straighten the film for processing
36. Another alternative is to place the radiograph in such a
manner to not come in contact with the palate or tongue.
This is accomplished by either extraoral placement of the
film or placing the film between the cheek and the tooth and
exposing the film from the opposite jaw.
The film side of the packet (the solid color side) is facing the
buccal surface of the tooth.
37. The x-ray head is placed at the opposing side, and the cone is
positioned under the angle of the ramus on the opposite side.
As the x-ray beam is traveling a longer distance to the film
than in the typical positioning, it is necessary to double the
exposure time.
It is imperative that after mounting radiographs are
reversed.
Incorrect mounting and labeling of the reverse radiograph
can result in misdiagnosis and treatment of the wrong tooth.
38. It is difficult to take intraoral radiographs in patients who are
intolerable to place films in their mouth. For these patients ,
Newman and Friedman recommended a new technique of
extraoral film placement.
Extraoral periapical radiography : an alternative approach to
intraoral periapical radiography: Rahul Kumar, Neha Khambete;
Imaging Science in Dentistry; 2011;41 :161-5
42. Difference
Bisecting angle technique Parallel technique
Image shape distortion Slight image size distortion
Superimposition of zygomatic
process
Control of shadow of zygomatic
process
Anatomical relationship altered Correct anatomical relationship
Crown- root ratio is not preserved Crown-root ratio is preserved
Poor image standardization and
reproducibiliy
High image standardization and
reproducibility
43. Paralleling technique has geometric advantage over
the bisecting angle technique It has comparatively
less distortion. Errors are more likely to occur in
bisecting angle technique and leads to more
patient exposure due to frequent retakes.
However , bisecting angle technique is more
appropriate when it comes to patients comfort and
more recommended in pediatric population
Comparison of paralleling and bisecting angle technique in
endodontic working length radiography;M Fahim Ibrahim,Malik
Salman Azif; Pakistan oral & dental Journal;2013; vol 33 ;160-164
44. Localization Technique
Is a method to locate the position of a tooth or object
in the jaws.
Purpose: to depict the B-L relationship or depth of
an object.
Two methods
1. Buccal object rule
2. Right angle technique
45. Buccal object rule
Described by clark in 1910 and refined and
amplified by richards in 1952 and 1980.
According to this rule, when a radiograph is
performed at a certain angle, the object closer to
the radiographic source – the buccal object – is
displaced in the radiograph in the same direction
as the x-ray beam
Stated more simply as INGLES RULE(MBD)-
always shoot from mesial and buccal root will be to
the distal..
46. With an orthoradial projection
(A) the two objects appear
superimposed.
With an oblique projection
(B,C) the two objects cease to
be superimposed and easily
become recognizable when the
angulation of the X-ray
machine is known
The buccal object(the one
closest to the radiographic
source) is displaced in the
same direction as the x-ray
source
47.
48. Right angle technique
Given by Miller
The periapical radiograph
shows impacted canine lying
apical to roots of lateral incisor and first premolar
The vertex occlusal view shows that the canine
lies palatal to the roots of the lateral incisor an
premlar
A labially positioned mesiodens: A case report ; Robert J Henry,
A Charles Post; Pediatric Dentistry ;March 1989- vol 11:59-62
50. Intraoral
Periapical
Radiograph
Indications:
To evaluate the development of the root end and to
study the periapical tissue
To detect alterations in the integrity of the periodontal
membrane
To evaluate the prognosis of the pulp treatment by
observing the health of the periapical tissues
To identify the stage of development of unerupted teeth
To detect developmental abnormalities like
supernumerary, missing or malformed teeth
52. Bitewing Radiograph
Indications :
Early detection of incipient interproximal caries
To understand the configuration of the pulp chamber
Record the width of spaces created by premature loss of
deciduous teeth
Determine the presence or absence of premolar teeth
To determine the relation of a tooth to the occlusal plane
for possibility of tooth Ankylosis
Detect levels of periodontal bone at the interdental area
Detect secondary caries
55. The baseline examinations and intervals to the next
bitewing examination in children.
Baseline bitewing
examination
Interval to next bitewing examination
At age: Low caries risk High caries risk
5 years 3 years 1 year
8 or 9 years 3-4 years 1 year
12 to 16 years 2 years 1 year
16 years 3 years 1 year
56. Occlusal radiograph
The occlusal technique is used to examine large
areas of the upper or lower jaw.
In the occlusal technique, size-4 intraoral film is
used. The film is so named because the patient
bites, or “occludes,” on the entire film.
In adults, size-4 film is used in the occlusal
examination.
In children, size-2 film can be used.
57. Indications
1.Determine the presence, shape and position of
supernumerary teeth
2.Determine impaction of canines
3.Assess the extent of trauma to teeth and anterior
segments of the arches
4.In case of trismus and trauma, where the patient cannot
open the mouth completely
5.Determine the medial and lateral extent of cysts and
tumors.
6. To localize foreign bodies in jaws and stones in ducts of
salivary glands.
7. To obtain information about the location, nature extent
and displacement of fractures of maxilla and mandible
58. Extraoral technique
RADIOGRAPHY OF PARANASAL SINUSES
1. Standard Occipitomental Projection
2. Modified method (30 degree OM)
3. Bregma Menton
4. PA Water’s
RADIOGRAPHY OF MANDIBLE
1. PA Mandible
2. Rotated PA Mandible
3. Oblique lateral radiography
I. True laterals
II. Oblique laterals
III. Bimolars (two oblique laterals on one film).
59. RADIOGRAPHY OF BASE OF SKULL
Submento-vertex projection
RADIOGRAPHY OF ZYGOMATIC ARCHES
Jughandle view (A modification of submentovertex view)
RADIOGRAPHY OF TEMPOROMANDIBULAR JOINT
1. Transcranial Projection
2. Transpharyngeal projection
3. Transorbital projection
60. RADIOGRAPHY OF THE SKULL
1.Lateral Cephalogram
2.True lateral (Lateral Skull)
3.PA Cephalogram
4.PA Skull
5.Towne’s projection
6.Reverse Towne’s projection
61. Panaromic Radiograph
Most common.
It is a technique for producing a single tomographic
image of facial structures that includes both
maxillary and mandibular arches and their supporting
structures.
This is curvilinear variant of conventional tomography
and is also used on the principle of the reciprocal
movement of an x-ray source and an image receptor
around a central point or plane called the image layer
in which the object of interest is located
62. Indications
Diagnose missing and supernumerary teeth,
Detect gross pathoses,
Asses development of the dentition,
Estimate the dental age of the patient,
Detect bone fractures, traumatic cysts,
Detect anomalies,
In some patients with disabilities (if the patient can sit in a
chair and hold head in position).
63.
64. Periapical radiograph allowed the assessment of
periapical status of 87% of teeth whereas only
57.6% and 34% of teeth could be appraised using
digital panaromic images displayed on monitor and
glossy paper respectively.
Teeth are best viewed on periapical radiographs
except maxillary second and third molar which are
better viewed on OPG
Radiological assessment of periapical status using the periapical index:
Comparison of periapical radiography and digital radiography; william
et. Al,International Endodontic journal 2007;Vol 40; 6: 433-440.
65. Interpretation
Raised dot toward your eye
(identification dot on tube side)
Imagine the x-ray in your mouth by
keeping the identification dot
bucally and decide the side.
First mention the area of oral cavity
visible on radiograph.
Followed by area of interest .
Identify normal anatomic landmarks
Knowledge of normal v/s abnormal
Attention to all regions on the film
systematically
One anatomic structure at a time
66. Teeth present
-Stage of development
-Position
Condition of crowns
-caries
- restorations
Condition of root
-length
-resorption
-crown:root ratio
The apical tissue
- integrity of lamina dura
-any radiolucency or radiopacity associated with apical area
Periodontal tissue
- width
-level of quality of crestal bone
-vertical and horizontal bone loss
-furcation involvement
Bone – density, trabecular pattern
67. Describing the lesion
1. size
2. shape
3. location
4. density
5.internal architechture
6.effect on adjacent structure
68. Measurements were carried out at 52 X-ray units for all types of
intraoral examinations performed in clinical routine. Not all X-ray units
have pre-set child exposure settings with reduced exposure time or in
some cases lower tube voltage. Child examinations are carried out using
adult exposure settings at these units, which increases the exposure
values by up to 50%. For example, values for periapical examination
ranges from 14.4 to 40.9 mGy cm2
for child settings and 20.6 to 48.8
mGy cm2
when the adult settings are included..
Radiation exposure to children in intraoral dental radiology
H. K. Looe,A. Pfaffenberger,N. Chofor ; Radiation protection
Dosimetry, vol 121, issue 4,461-465
69. All the three methods of working length determination used
in this study were found to be reliable and accurate for use
in deciduous molars.
Overall the three techniques show a greater reliability in
mandibular molars. Since all techniques are comparable it
may be concluded that weighing the advantages and
disadvantages of each technique and based on operator’s
preference any of the methods can be used for determining
the working length in deciduous molars..
Comparison of Root ZX, RVG and Conventional Radiography to
determine working length in roots of primary molars : Archana A
Thomas, Dr Shobha Tandon
70. Total of 320 premolars were examined. Of these, 218
(68%) were maxillary premolars and 102 teeth (32%) were
mandibular premolars. All the premolars in the sample had no
obvious caries, occlusal malformations, or any restorations.
1.Diagnodent gave similar sensitivity values but lower specificity
compared to visual-tactile examination in diagnosing occult dentinal
caries.
2. There were no significant differences between conventional or
digital radiography in diagnosis of occult dentin caries.
3. Although the diagnosis of occult dentinal caries may be further
enhanced by the Diagnodent, a combination of visual-tactile
examination and either conventional or digital radiography should
suffice in most cases.
Visual-tactile Examination Compared With Conventional Radiography,
Digital Radiography, and Diagnodent in the Diagnosis of OcclusalOccult
Caries in Extracted Premolars. Michael J. Chong, BDSc, MDSc, W. Kim
Seow, BDSc, MDSc,pediatric dentistry 2003, 25-29
73. DIGITAL RADIOGRAPHY
It is a method of capturing a radiographic image using
sensor, breaking it into electronic pieces and presenting and
storing the image using a sensor.
DIRECT DIGITAL IMAGING- a digital sensor used
CCD
CMOS
INDIRECT DIGITAL IMAGING-Uses film like photo
phsphor plates that are activated using X-rays, then scanned
in special devices that read the images from the plate.
74. Advantages of digital
radiography over
conventional radiography
Working time reduced.
Chemical processing is avoided.
Exposure to radiation is reduced.
Cephalometric meaurements and analyses can be
more easily performed with the aid of task
dependent software.
Storage and communication are electronic
75. Radiovisiography
Introduced by Mouyen et al in 1989.
Radio part sensor- Exchangeable
scintillation
screens
- A fibre optic
miniature CCD
device
Visio part- stores and converts
point by point into one of 256 gray
scales.
Graphy Part
76. This system is capable of rapidly displaying a
digital radiographic image on a monitor with a 80%
radiation dose reduction when compared with
conventional radiography
The major components of the RVG system include
an X-ray head with an advanced timer, a
radiographic sensor connected to a charged
coupling device (CCD), a monitor for image display,
and a computer with the appropriate software for
image storage and manipulation. One of the
software’s features allows the operator to vary
the contrast.
77. Merits
The image processing time is very short being
about 5 seconds.
Sensors can be easily moved from operatory to
operatory , allowing the operators to work with a
minimum number of sensor and within a computer
network enviornment.
The problems that can be caused through
processing faults are eliminated.
It gives opportunity to enhance the images for
more precise viewing.
78. Demerits
They are thicker than films and cables running off
the sensor which some patients don’t tolerate well.
The high cost of sensor
Difficulty in placing sensor due to its rigidity.
79. The periapical areas of 16 teeth from 6 human mandibular jaw
specimens were randomly examined by 3 observers using
conventional radiography with Kodak E-speed film and
radiovisiography (with variable contrast and with fixed contrast).
results showed that conventional radiography and
radiovisiography (variable contrast) have opposite strengths.
Conventional radiography tended to be more accurate in the no
lesion condition, whereas radiovisiography using variable contrast
was somewhat more accurate in the smallest lesion condition. The
accuracy of radiovisiography with fixed contrast was not
significantly different from the other two methods..
RadioVisiography in the Detection of Periapical Lesions ,John E.
Sullivan, Jr., DDS, MS, Peter M. Di Fiore, Journal of
endodontics,2000 , vol 26:65-69
80. Xeroradiography
Records images without film
Consist of images receptor plates- selenium
particles
Latent image is converted to a positive image-
process called develpment in processing unit.
Advantages
Reduced radiation dose
Image can be produced in 20 seconds
Edge enhancement effect.
Ability to have both positive and negative prints
81. Improves visualization of files and canals.
Two times more sensitive than conventional D-
speed films.
Disadvantage
Exposure time varies according to the thickness
of plate
Xeroradiography and its application to dentistry
Thomas Katsanulas, 'Theodor Lambrianidis
Department of Dental Pathology and Therapeutics, Greece:March 22, 1989.
82. Digital subtaraction
radiography
This is a method by which structured noise is
reduced in order to increase the detectability in
the radiographic pattern.
“Image – enhancement method” – area under focus
displayed aaginst a neutral background
83. Standard radiographs are produced with identical
exposure geometry.
Reference/baseline images
Follow up image for comparison.
If there is change in the radiographic attenuation
between the baseline and follow up examination, this
change shows up as a brighter- if there is gain
And as a darker area , when change represents Loss
The strength of digital substraction radiograph is
that it cancels out the complex anatomical
background against which this change occurs.
84.
85. Application
Useful in detecting progress of remineralization
and demineralization, pattern of dentinal caries,
diagnostic of incipient caries.
Assess success of root canal treatment detecting
periapical lesion.
90% accurate in detecting as little as 5% mineral
loss as compared to conventional radiograph (30-
60% loss)
86. Computed tomography
CT has evolved into an
indispensable imaging
method in clinical routine.
Non –invasively acquires
images
Not biased by
superimposition of
anatomical structures
CT yields images of much
higher contrast compared
with conventional.
87.
88. Tomographic views used to examine various facial
structures:
Tomography of sinuses:
- more precise evaluation of sinus
pathologies
-sphenoidal and ethmoidal sinuses are
more clearly visualized
Tomography of facial bones, to study facial
fractures, extent of orbital blow out fracture
Tomography of mandible
Tomography of temporomandibular joint
89. Advatages
Eliminates the super-imposition of images of
structures outside the area of interest.
Because of the inherent high-contrast resolution
of CT differences between tissues that differ in
physical density by less than 1% can be
distinguished.
Very small amount difference in the X-ray
absorption can be detected
90. Excellent differentiation between different types
of tissues both normal and diseased
Images can be manipulated
Changes in the linear and volumetric measures can
be determined by sequential scans
Images can be enhanced by the use of IV contrast
media providing additional information
91. Disadvantages
Since the pixels that form the image represents discrete
subdivisions of space, the effect of blurring is much greater
than in conventional radiographs
Tissue non-specificity i.e. Have ability to highlight any
particular organ/tissue.
Cost concerns..
Metallic objects , such as restoration may produce streak or
star artefacts across the CT image.
Need for contrast media for enhanced soft tissue contrast.
Inherent risks associated with IV contrast agents
92. Cone –Beam Computed Tomography
CBCT is an X-ray imaging approach that provides
high resolution 3-dimensional images of the jaws
and teeth
CBCT shoots out a cone shaped X-ray beam and
captures a large volume of area requiring minimal
amounts of generated x-rays.
Within 10 seconds, the machine rotates around
the head and captures 288 static images.
93. Advantages
Precise identification and detection of periapical
lesions
Detection of mandibular canal
Complete 3-D reconstruction and display from any
angle.
Patient radiation dose 5 times lower than normal
CT
Excellent resolution
Require only a single scan to capture the entire
object with reduced exposure time.
Less expensive than CT
94. Phantom, armed with lithium fluoride thermoluminescent
dosemeters (TLDs) was exposed using a set of four
conventional radiographs (orbital view, modified Waters
view, orthopantomography, skull posterior–anterior), two
different cone beam computed tomography (CBCT) , and
multislice computed tomography (CT) modalities
Results: Multislice CT showed the highest exposure values.
Exposure levels of the CBCT systems lay between CT and
conventional radiography. Dose measurement for the 16-slice
CT revealed nearly the same radiation exposure as the 4-
slice system when adapted examination protocols were used..
Radiation exposure during midfacial imaging using 4- and 16-slice
computed tomography, cone beam computed tomography systems and
conventional radiography; D Schulze, M Heiland, H Thurmann,
Dentomaxillofacial Radiology (2004) 33, 83–86
95. Tuned Aperture Computed
Tomography (TACT)
Improve accuracy in caries diagnosis because of
its 3-D or pseudo 3-D capabilities.
Principle of TACT
TACT slices can be produced from an arbitary
number of X-ray projections, each exposed from a
different angle.
Using TACT , it is possible to use one X-ray source
and move it through several points in space or use
several fixed sources to collect multiple X-ray
projections which in turn can be processed to
produce TACT slices
97. TACT useful in
Detection of caries and recurrent caries
Periodontal bone loss
Periapical lesion localization
TMJbone change
98. Magnetic Resonance
Imaging
Principles
Magnetism is a dynamic
invisible phenomenon
consisting of discrete fields
of forces.
Magnetic fields are caused
by moving electrical charges
or rotating electric charges.
Images are generated from
protons of the hydrogen
nuclei.
Essentially imaging of the
water in the tissue
99. When images are displayed ; intense signals show
as white and weak ones as black nd intermediate
shades of gray.
Cortical bone and teeth with low presence of
hydrogen are poorly imaged and appear black.
Role of Magnetic Resonance Imaging in dentistry : C
D nayak, S S Pagare, scientific Journal 2009 vol3 :67-
69
100. Application
Inflammatory and neoplastic lesion of the
nasopharynx, salivary glands, paranasal sinuses.
Diagnosis of internal derangement of TMJ due to
its ability to define cartilaginous disk.
Can differentiate between solid and cystic lesions
Perineural spread of a tumour by branches of
trigeminal and facial nerve.
101. Advatages
It offers the best resolution of tissues of low
inherent contrast.
No ionizing radiation is involved with MRI.
Direct multiplanar image is possible without
reorienting the patient.
Disadvantages
Long imaging time
Potential hazards imposed by the presence of
ferromagnetic metals in the vicinity of the imaging
magnet.
102. Ultra Sound Scanning
Ultra high frequency sound waves are used.
The reflected sound waves are converted to an
electrical signal that is amplified , processed and
ultimately displayed on a monitor.
US waves are generated by a quartz or synthetic
ceramic crystal when it is exposed to an altering
current of 3-10 Mhz as a result of the
piezoelectric effect, the crystals distributes US
waves oscillating at the same frequency
103. US image produced – automatic movement of the
crystals over the tissue of interest.
As each movement gives one images of this tissue
(depending on its plane) and there is a frequency
of 30-50 images per seconds, they appear in a
screen as moving images.
Useful adjunct to conventional radiography in the
management of extensive periapical lesions , as it
provides specific information on the size of the
lesion
106. Source of the radiation in
dental radiology department
Primary beam- radiation originating from focal
spot
Secondary radiation-originating from irradiated
tissue of patient.
Leakage or stray radiation-radiation from X-ray
tube hea positioning
Scattered radiation – from filters and cones,
coming from objects other than patient such as
walls and furnitures that the primary beam may
strike
107. Means of protection can be divided into:
1. Protection for operator
2. Protection for patient
108. Protection for the operator
Effort must be made so that operator can leave
the room or can take a suitable position behind a
barrier
If there is no barrier operator should use lead
aprons
The film should never be held by the operator .
Ideally film holding devices should be used . If
correct retention or placement is still not possible
a parent must hold the film in the position.
There should be no use of fluroscent mirrors in
the oral cavity
109. Operator Location
The operator of the dental unit must stand at
least six feet from the useful beam or behind
a protective barrier. [Stand at an angle of from
90 to 135 degrees from the central ray. Do
NOT stand in the path of the primary x-ray
beam.]
If a protective barrier is
used, it must have a viewing
window to allow the operator
to see the patient.
110.
111. Personnel Radiation Badges
Use of film badge/ TLD badge / pocket dosimeter ,
for personnel radiation monitoring to avoid
accumulate over exposure.
112. Protection of others
No one but the patient should be in the exam room
during x-ray exposures. If a person’s presence is
necessary for the performance of the examination,
that person must be behind a shield or wearing a
lead apron.
He/she must not be in line with the primary
beam, and should stand at least six feet from the
x-ray tube if feasible. He/she must also be at least
18 years of age and not be pregnant.
114. Required Distances
If the dental unit can operate above 50 kVp,
the source to skin distance must be at least
18 cm [7 inches].
Use of long source to film distance of 40 cm (16
inches), rather than short distance of 20 cm,
decreases exposure by 10 to 25 percent, distances
between 20 cm to 40 cm are appropriate, but the
longer distance are optimal.
115. Filtration Requirements
The amount of filtration required varies with the
operating range of the x-ray unit. For example:
For 51 to 70 kVp units* 1.5 mm Al [HVL]
Units above 70 kVp 2.1 or more
Al
*Note: Settings below 65 kVp are not recommended
because of higher patient exposure.
116. Collimators
Collimators limit the size and shape of the
useful beam which reaches the patient.
The x-ray field must be limited to a circle
having a diameter of no more than 7 cm [~3 in].
Rectangular collimators are recommended for
periapical radiographs as their use significantly
reduces the area of the patient’s body that
is exposed to radiationis exposed to radiation
117. Cones
The ADA discourages the use of short, closed,
pointed cones because of the increased
scatter radiation close to the face and adjacent
areas of the patient’s body.
119. Thyroid
The thyroid gland, especially in children, is
among the most radiosensitive organs.
Even with optimum techniques, the primary
dental beam may pass near or occasionally
through the gland. A thyroid shield may
reduce the dose to the gland without
interfering with obtaining a diagnostic image.
120. Lead aprons and shields
Even though the dose from digital
radiography is less than
convention radiography,
patients should be shielded
with lead aprons and thyroid
shields.
These shields should have at least
0.5 mm of lead
equivalent.
Do not fold or bend aprons. Hang
aprons to prevent damage and
loss of protective qualities..
121. The dentist should use every means to reduce
unnecessary exposure to their patients and
themselves. This philosophy of radiation exposure
is often referred to as principle ALARA- AAss LLowow
AAss RReasonablyeasonably AAchievablechievable
The exposure to ionizing radiation should be kept
as low as reasonable achievable by considering all
economic and social factors
122. ReferencesReferences
McDonald RE, Avery DR, Dean JA. Dentistry for th child
and adolescent, 8th
edn. Mosby, 2004 :117-28
Tandon S. Textbook of pedodontics, 1st
edn. Paras
Publishing, 2001 :19-28
Koch G. Pediatric dentistry, 1st
edn. Munksgaard, 2001 :
99-11
Mathewson RJ, Primosch RE. Fundamentals of pediatric
dentistry 3rd edn. Quintessence Publishing Co. Inc
1995: 35-55
Damle SG. Textbook of pediatric dentistry, 1st
edn. Arya
Publishing House, 2000 : 167-71
123. Oral Radiology- Principles and Interpretataion
- White and Pharoah
Textbook of Dental and Maxillofacial Radiology
- Freny R Karjodkar
Essentials of Dental Radiography and Radiology
- Eric Whaites
Bramanet CM, Berbert A. A critical evaluation of some
methods of determining tooth length. Oral Surg 1974; 37:
463.
Forsberg J. Radiographic reproduction of endodontic
“working length” comparing the paralleling and the bisecting-
angle techniques.Oral Surg Oral Med Oral Pathol 1987; 64(3):
353-60.
124. • Langland OF, Langlais RP, Preece JW. Principles of dental
imaging. In: Langland OF, Langlais RP, Preece JW.
Intraoral radiographic techniques. 2nd ed. Philadelphia:
Lippincott Williams & Wilkins, 2002: 91-97.
•
•Jhon PR. Essentials of Dental Radiology. In: Jhon PR.
Intraoral radiographic techniques and indications of
intraoral radiographs.1st ed. New Delhi: Jaypee Brothers,
1999: 75-81.
RADIOLOGY - Radiology is a branch of medical science that deals with the study of radiation and its use , radioactive substances and other forms of radiant energy in the diagnosis and treatment of diseases .
On November 8th, 1895, Wilhelm Conrad Roentgen was working in his laboratory in Wurzburg, Germany, using Crooke’s tubes.
In the darkened laboratory, he noticed that a sheet of cardboard, placed several feet away, was glowing in the shape of the letter
A that a student had painted in liquid barium platinocyanide.
It is thought that the first dental radiograph made in the United States was by Dr. Edmund Kells of New
Orleans, Louisiana.Dr C Edmund Kells has been known as the Father of Dental Radiology as he was the first to install a dental x ray machine and practised recording of x rays using the paralleling technique in his dental clinic.
This radiograph was made on February 1st,1896 by Dr. Walter Konig of Germany
When a new pt is seen at the dental office and no previous radiographs are available it may b necessary to obtain a base line series of radiograph
When fast moving electrons slam into a metal target, x-rays are produced.
Kinetic energy of electrons is converted to x-ray photons.
The components of dental x ray machine are:
Control panel
Extension arm
Tube head
--CONTROL PANEL
It has the on/switch and indicator light
Exposure button and indicator light
Control device to regulate X ray beam
It is plugged into electrical out
--EXTENSION ARM
Suspends X ray tube head, houses electrical wires, allows movement and positioning of Tube head.
--TUBE HEAD
Tightly sealed, heavy metal housing contains X ray tube that produces dental x rays.
Metal housing: Metal body fitted with oil which
Protects X ray tube and grounds the high voltage component
Insulating oil: Surrounds the X Ray tube and transformer
Prevents over heating by absorbing heat created by production of x rays
Maintains insulation properties of glass envelope
Insulates tube from metal shield
Tube head seal: Aluminium or leaded glass of tube head
Permits exit of x rays from tube head
Seals oil in tube head
Filters the x ray beam
X RAY TUBE
All dental and medical x-ray tubes are called Coolidge tubes because they follow the original design of W. C. Coolidge introduced in 1913.
The basic apparatus for generating x rays, the x-ray tube, is composed of a cathode and an anode.
The cathode serves as the source of electrons that flow to the anode.
CATHODE
The cathode in an x-ray tube consists of a filament and a focusing cup.
The filament is the source of electrons within the x-ray tube.
It is a coil of tungsten wire about 2mm in diameter and 1cm or less in length.
It is mounted on two stiff wires that support it and carry the electric current. These two mounting wires lead through the glass envelope and connect to both the high- and low-voltage electrical sources.
The filament is heated to incandescence by the flow of current from the low-voltage source and emits electrons at a rate proportional to the temperature of the filament
The filament lies in a focusing, a negatively charged concave reflector made of molybdenum.
The focusing cup electrostatically focuses the electrons emitted by the incandescent filament into a narrow beam directed at a small rectangular area on the anode called the focal spot.
The electrons move in this direction because they are repelled by the negatively charged cathode and attracted to the positively charged anode.
The x-ray tube is evacuated to prevent collision of the moving electrons with gas molecules, which would significantly reduce their speed.
This also prevents oxidation and “burning out” of the filament
ANODE
The filament lies in a focusing, a negatively charged concave reflector made of molybdenum.
The focusing cup electrostatically focuses the electrons emitted by the incandescent filament into a narrow beam directed at a small rectangular area on the anode called the focal spot.
The electrons move in this direction because they are repelled by the negatively charged cathode and attracted to the positively charged anode.
The x-ray tube is evacuated to prevent collision of the moving electrons with gas molecules, which would significantly reduce their speed.
This also prevents oxidation and “burning out” of the filament
The focal spot is the area on the target to which the focusing cup directs the electrons from the filament.
The sharpness of the radiographic image increases as the size of the focal spot-the radiation source decreases
The projection of the focal spot perpendicular to the electron beam (the effective focal spot) is smaller than the actual size of the focal spot.
Typically, the target is inclined about 20 degrees to the central ray of the x-ray beam.
This causes the effective focal spot to be almost 1.x 1mm, as opposed to the actual focal spot, which is about 1 x 3mm.
The effect is a small apparent source of x rays and an increase in sharpness of the image with a larger actual focal spot for heat dissipation.
SPEED OF FILM
speed of the film refers to the amount of radiation required to produce an image of standard density. A fast film requires relatively low exposure . The fastest dental film currently available is film F
Behaviour modification technique are very important for successfully taking radiograph
Such positioning reduces the child’s anxiety, provides additional emotional security for the child, increases cooperation and also enables the parent to adequately restrain child and avoid any unexpected sudden movements.
Obtaining the least difficult radiograph first (such as an anterior occlusal) desensitizes the child to the procedure.
Correct settings are made on the apparatus and the x-ray head is properly positioned before placing the film in the child’s mouth.
A positioning device such as a Snap-A-Ray can be used to aid the parent in positioning and securing the film.
-Positioning the radiograph vertically in the mouth for both periapical and bitewing radiographs reduces the distal extension of the radiograph and may result in greater tolerance by patients, especially those with a mild gag reflex
-The vertical bitewing radiograph provides greater detail of the periapical area.
For patients frightened of the procedure itself, desensitization techniques may be necessary to gain the patient cooperation.
An example of this is introducing the patient to x-rays by initially taking an anterior radiograph which is easier to tolerate than a posterior radiograph.
Some patients, young and old, have an exaggerated gag reflex. The etiology of an exaggerated gag reflex had been attributed to psychological and physical factors.
Taking a radiograph for a child with exaggerated gag reflex can be challanging. Some of the measures which can be used are:
Psychological ---
Pant like a dog
Move the leg up and point a toe
Place a small amount of salt on the tip of the tongue (distraction procedure)
Pharmacological—
2% topical xylocain or topical anaesthetic rinses.
Bent film radiographic technique—
Used in young children who can not tolerate placement of film inside their mouth
Pt bite on the film that has a sharp right angle bend at the top, bent part serves as a self contained bite tsb to hold the film in the place.
Instruct the child to soflty bite down to avoid cusp marks and distortion on the film
Stick on foam tabs are alos available fo use
1 to 2 size films are used
Straighten the film for processing
Advantages
Position of the film is reasonably comfortable for the patient in all areas of the mouth
- positioning simple and quick
-if all angulations are assessed correctly. The image of the tooth will be the same length as the tooth itself
-decreased exposure time
Disadvantages
-many variable invoved in tech often result in the image being badly distorted
-incorrect verticla angualation result in foreshortening or elongation
-periodontal bone levels are poorly shown
Shadow of zygomatic buttress frequently overlies the roots of upper molar
Horizontal and vertical angulation have to be assessed for every patient and considerable skill is required
-not possible to obtain reproducible views
Cone cut may result if the central ray is not aimed at the center of the film
Incorrect horizontal angulation will result in overlapping of crown and roots
The crowns of the teeth are often distorted, thus preventing detection of proximal caries.
-buccal roots of max molars and premolars are often foreshortened
Also known as tube shift technique.
If the tube is shifted and directed at the reference object (e.g., the apex of a tooth) from a more mesial angulation and the object in question also moves mesially with respect to the reference object, the object lies lingual to the reference object
Position of an object on each radiograph is noted relative to the anatomic landmark
For example, if a radio-opacity is found near the apex of first molar on a periapical radiograph., an occlusal projection can be taken to identify its mediolateral position. The occlusal radiograph may reveal a calcification in the soft tissue located laterally or medially to the body of the mandible.
The technique is best for mandible , in maxilla superimposition of structure may obscure the area of interest
A bite-wing radiograph shows the crowns and interproximal areas of the maxillary and mandibular teeth and the areas of crestal bone on one film.
Bite-wing radiographs are used to detect interproximal caries and are particularly useful in detecting early carious lesions that are not clinically evident.
Bite-wing radiographs are also useful in examining the crestal bone levels between the teeth.
The film is placed in the mouth parallel to the crowns of both the upper and lower teeth.
The film is stabilized when the patient bites on the bite-wing tab or bite-wing film holder.
The central ray of the x-ray beam is directed through the contacts of the teeth, using a +10˚ vertical angulation.
A +10˚ vertical
angulation is used to
compensate for the slight
bend of the upper portion of
the film and the tilt of the
maxillary teeth.
Indications:
Determine the presence, shape and position of midline supernumerary teeth
Determine impaction of canines
Determine the presence or absence of incisors
Assess the extent of trauma to teeth and anterior segments of the arches
In case of trismus and trauma, where the patient cannot open the mouth completely
Determine the medial and lateral extent of cysts and tumors.
Periapical assessment of the upper anterior teeth in patients unable to tolerate periapical films
Detecting the presence of unerupted canines, supernumeraries and odontomes
As the midline view, when using the parallax method for determining the bucco/palatal position of unerupted canines
Evaluation of the size and extent of lesions such as cysts or tumors in the anterior maxilla
Assessment of fractures of the anterior teeth and alveolar bone, especially useful for children
Basic principle
The film is positioned with the white side facing the arch being exposed.
The film is placed in the mouth between the occlusal surfaces of the maxillary and mandibular teeth.
The film is stabilized when the patient gently bites on the surface of the film.
For maxillary occlusal film the patient’s head must be positioned so that the upper arch is parallel to the floor and the midsagittal plane is perpendicular to the floor
For mandibular occlusal films the patient’s head must be reclined and positioned so that the occlusal plane is perpendicular to the floor.
Presence or absence of permanent teeth and their Positions in relation to the primary teeth.
Evaluation of bony lesions and the TMJ
Bone loss
Estimate the age of the patient
-Working time from image exposure to image displayed is reduced.
-Chemical processing is avoided ,so there are fewer hazards to the enviornment and no image errors because of processing.
-Exposure to radiation is reduced. Greater dynamic range is available compared with film , over exposure are less apt to occur, contarst and density can be enhanced, size can be changes , and colors added
-Cephalometric measurements and analyses can be performed more easily
-storage and communication are electronic, so copies of an image can be sent to others without losing original.
The structured noises are the images which are not of diagnostic value and which interfere in routine interpretation of the radiographs, i.e required areas are enlarged against a background.
Comparing baseline to follow up images made at 3.6,12 months following endodontic therapy, column 3 indicates substracted of follow up images from baseline radiograph progressive remineralisation of distal root of first molar is seen
During 1970, this was an enormous step toward the advance of diagnostic possibilities in medicine.
Estimated dose to the center of the condyle with ct is 180mR
Radiation dosage– 1.536 rad for a single section
1.843 rad for multiple section
Very small amount difference in the X-ray absorption can be detected
Which enables:
-detailed imaging of intar cranial lesions
-imaging of hard and soft tissues.
Arbitary example of generalized TACT projection applied to a simple cylinrical object
The technique is based on the presence of specific magnetic properties found within atomic nuclei containing protons and neutrons,
Inherent property of rotating about their axis
Causes a small magnetic field to be generated around the electrically charged nuclei.
When dipoles exposed within a strong electric field.
Orientation in response to the field
Depending on density and spatial relation
Signal interpreted and image produced
X rays are carcinogenic.
Chest x-ray vs background radiation
Dental x-ray vs background radiation.
Patient’s age and radiation
The x-rays can cause damage by two mechanisms:
Direct damage.
Somatic: It happens when X-ray photon or a high-energy ejected electron cause breakage of weak bonds between nucleic acids in RNA or DNA. This can cause inability to pass information, abnormal replication, or cell death. Or it might be resolved and the damage is repaired.
Genetic : Radiation-induced congenital abnormalities.
Indirect damage.
Indirect damage occurs due to formation of free radicals inside the cells.
OPERATOR’S PROTECTION
Never hold the film for the patient during exposure
Never stabilize the x ray tube during exposure
Never stand in the path of primary radiation
Should stand behind the lead barrier having
0.5 mm lead equivalent or leave the room during exposure.
Should stand 6 feet away from the primary beam,
at an angle of 90 to 135 degree (position – distance rule)
Increase distance from the source
(inverse square law- as distance doubles , exposure reduces by a factor of 4)
Never allow other people in the controlled area
X ray rooms should be located in secluded area if possible; Lead walls
X ray beam to be directed towards the outside wall and not to corridors or occupied rooms
Hazard light and sign on the door