Radiographic Techniques for the Pediatric Patient

1The Journal of Contemporary Dental Practice, Volume 1, No. 4, Fall Issue, 2000

Abstract

Obtaining quality radiographs on pediatric patients can be a challenge. Suggestions for communicatingwith patients about radiation safety and the need for radiographs can facilitate the process. Guidelinesfor radiographic exposure intervals for young patients are key elements in the reduction of exposure toionizing radiation and are presented in this paper. The child patient presents unique challenges for thedental professional and special techniques are presented in this article that may be helpful in theconducting radiographic examinations for this patient population.

Keywords : Radiographs, gagging, radiographic guidelines, child restraint

Radiographic Techniques for the Pediatric Patient

Volume 1 Number 4 Fall Issue, 2000

Steven Schwartz. DDS

http://www.thejcdp.com


During the first appointment, a dental professionalreduces a parent’s resistance to the use ofradiographs by informing the parents of thediagnostic need for radiographs and educatingthem about current radiation hygiene practicesand radiographic techniques. An explanationshould include the concept that withoutradiographs, an examination only detects the tipof the iceberg. It should be emphasized thatvisual examination reveals only three of the fivesurfaces of the teeth because if the child’s teethare close together the dentist cannot seebetween them. Furthermore, the dentist cannotsee the insides of the teeth, their roots, nor thepermanent teeth developing in the jaws.Radiographs enable the dentist to detect the startof visually undetectable cavities between teeth,infections of the teeth, gums and bones, theshape and presence of unerupted permanentteeth, potential orthodontic problems, and a hostof other pathological conditions.

Although excessive radiation exposure can resultin cancer, birth defects. and genetic defects, theamount of radiation needed to expose the newerX-ray film has significantly reduced the amount ofradiation to which patients are exposed. Asdigital radiography gains wider use in the dentalpractice, dental professionals who use this newtechnology should mention that it further reducesthe amount of X-radiation exposure to aminimum.

Principles for Proper RadiographicExamination

The foundation of an accurate diagnosis andtreatment plan is based on a comprehensivemedical and dental history, a thorough clinicalexamination, and diagnostic radiographs. Of thethree, obtaining diagnostic radiographs in thepediatric dental patient is probably the mostdifficult to accomplish, not only from a technicalstandpoint but because of parental fears andmisconceptions.

Communicating with Parents

The foundation of an accurate diagnosis andtreatment plan is based on a comprehensivemedical and dental history, a thorough clinicalexamination, and diagnostic radiographs. Of thethree, obtaining diagnostic radiographs in thepediatric dental patient is probably the mostdifficult to accomplish from a technical standpointand because of parental fears andmisconceptions.

With the news media reporting on a daily basisthe environmental insults experienced by thehuman body, parents may be preoccupied withthe effects of diagnostic and treatmentprocedures on their child’s health. Reducing thepossible deleterious effects of preventive andrestorative materials, sterilization protocols, anddiagnostic techniques should be a concern ofparents and dentists.

Along with the above explanation and use of the proper equipment, the dentist should follow guidelinesshown in Table 1. The guidelines are recommended by the American Dental Association.


Table 1.

Child Adolescent

Patient Category Primary Dentition Transitional Dentition Permanent Dentition(Prior to eruption of the (Following eruption of (Prior to the eruption offirst permanent tooth) the 1st permanent tooth) the third molars)

New Patient

All new patients in Posterior bitewing Individualized radiographic Individualized radiographicorder to assess examination of examination consisting of examination consisting ofdental disease & proximal surfaces of perioapical/occlusal views posterior bitewings andgrowth primary teeth cannot and posterior bitewings or selected periapicals.development. be visualized or panoramic examination

probed. and posterior bitewings. A complete mouthradiographic examinationis appropriated when the patient presents withclinical evidence of generalized dental diseaseor a history of excessivedental treatment.

Recall Patient

Clinical caries or Posterior bitewing examination at 6 month intervals Posterior bitewing high risk factors. or until no carious lesions are evident. examination at 6 to 12

month intervals or until nocarious lesions are evident.

No clinical caries Posterior bitewing examination at 12 to 24 month Posterior bitewingand no high risk intervals. examination at 18 to 36factors for caries. month intervals.Periodontal Individualized radiographic examination consisting of selected periapicals and disease, or a posterior bitewings for areas where peridontal disease (other than non-specifichistory of gingivitis) can be demonstrated clinically.periodontal therapy.

Growth and Usually not indicated. Individualized radiographic Periapical or panoramicdevelopment. examination consisting of examination to assess

perioapical/occlusal or developing third molars.panoramic images.

The Guidelines strongly suggest that:

• X-rays should not be taken routinely. A dentistshould first examine a child’s teeth and medicalstatus before ordering radiographs. Theguidelines suggest the number and types ofradiographs necessary depends on the age ofthe child, the presence and amount of visualdecay, the child’s and family’s history of dentaltreatment, and spaces between teeth.

• If possible, obtain copies of prior radiographs(from other office, if available).

• The patient should be protected with a leadapron and thyroid collar to reduce bodyexposure to radiation.

• The highest film speed and largest film that thechild can tolerate should be used so as toreduce the number of radiographs needed.

• Use the manufacturer’s recommended time andtemperature for processing.

Parents have the right to ask that the dentistrefrain from taking radiographs. However, thedentist has the responsibility to refuse treatment ifnot taking the radiograph compromises thepatient’s treatment. Parents cannot relinquish theright to competent care by a dentist.

Management Techniques

In the rare occasion when a very young dentalpatient under three years of age needs aradiograph, the dental office should be preparedwith techniques to reduce any psychologicaltrauma.

The first step in desensitizing a child to the dentalexperience is to explain what you plan to do inwords that are easily comprehended. Using a tell,show, do technique, the clinician explains to thechild that a tooth camera will be used to take apicture of their tooth. The child is allowed totouch and examine the radiographic film andcamera. To gain maximum cooperation in thechild under three years of age, it may benecessary for the child to sit in the parent’s lapwhile exposing the radiograph. This position mayreduce the child’s anxiety to such a degree thatminimal restraint may be needed to successfullytake the radiograph. The child is seated in the

parent’s lap with the parent’s arms around thechild’s upper body (Figure 1) and the legswrapped around the child’s lower body. (Figure 2)

Figure 1.

Figure 2.

Not only does this provide the child additionalemotional security thus increased cooperation,but also enables the parent to adequately restrainthe child should there be any unexpected sudden movements.

Obtaining the least difficult radiograph first (suchas an anterior occlusal) desensitizes the child tothe procedure. Since many children havedifficulty keeping the film in their mouth forextended periods of time, be certain the correctsettings are made on the apparatus and the X-rayhead is properly positioned before placing the filmin the child’s mouth. A positioning device such asa Snap-A-Ray instrument can be used to aid theparent in positioning and securing the film. (Figure 3) Be sure to adequately protect the parent andchild with lead aprons to reduce radiationexposure. If the child is uncooperative, then


additional restraint by a second adult may benecessary to successfully obtain the radiograph.With the first adult restraining the child asdescribed previously, a second adult stabilizes thechild’s head with one hand while the other handpositions the Snap-A-Ray instrument in thepatient’s mouth. (Figure 4) Under nocircumstances should staff be asked to performthis task.

Figure 3.

Figure 4.

If a second adult is not available, it may benecessary to restrain the child in a “papooseboard”. (Figure 5) This frees the parent tostabilize the child’s head and properly position theradiograph in the child’s mouth. (Figure 6)

Figure 5.

Figure 6.

If the child is still uncooperative, it may benecessary to manage the child pharmacologically with inhalation, oral, or parental sedatives. (Figure 7)

Figure 7.



Older children may also be uncooperative for avariety of reasons. These can range from the jaw being too small to adequately accommodate theradiograph, fear of swallowing the radiograph,fear of the procedure itself, or a severe gag reflex.There are numerous techniques to overcomethese problems.

Bitewing radiographs are usually used to detectproximal decay, so for the child with a smallmouth use the smallest size film available (size 0film). As a less desirable alternative, roll the film(don’t place sharp bends) to allow the film toaccommodate the shape of the jaw and notimpinge on the soft tissues. (Figure 8) It shouldbe noted that rolling the film increases thedistortion of the radiographic image at its edges.

Figure 8.

Use of the Snap-A-Ray instrument with a #1 sizefilm (Figure 9) as a bitewing tab will reduceimpingement on the soft tissue. Using a #0 size filmwith this device will unfortunately reduce the amountof detectable tooth structure on the radiograph.

Figure 9.

The Snap-A-Ray instrument is also a usefuladdition to the radiographic technique for thosepatients who have a fear of swallowing theradiograph. By biting on the large positioningdevice and watching in a mirror they are assuredthey won’t swallow the radiograph. (Figure 10)

Figure 10.

For patients who are frightened of the procedureitself, desensitization techniques may benecessary to gain the patient cooperation.Desensitization involves gradually exposing thechild to new stimuli or experiences of increasingintensity. An example of this would be the“Lollipop Radiograph.”

Figure 11.

The child is given a sugarless lollipop to lick.(Figure 11)

I ,

Figure 12.

After a few licks, the lollipop is taken from thechild and a radiograph is attached to the lollipopwith an orthodontic rubber band on the lingualside of the film. (Figure 12)

Figure 13.

The lollipop with the attached film is returned tothe child, who is told to lick the lollipop again.After a few licks, the child is told to hold thelollipop in his mouth while we take a tooth picture. The exposure is made. (Figure 13)

The child has now associated the radiographprocedure with a pleasurable experience (thelicking of the lollipop) and has been desensitizedto the extent that the more difficult posteriorradiographs can be attempted.

Posterior radiographs can be made more pleasantby associating them with a pleasurable taste suchas bubble gum. Before placing the radiograph inthe patient’s mouth apply bubble gum flavoredtoothpaste to the film. (Figure 14) The child willbe more accepting of the radiograph.

Figure 14.

Some patients, young or old, may have anexaggerated gag reflex. The etiology of anexaggerated gag reflex has been attributed topsychological and physical factors. There arenumerous techniques to control the gag reflexduring the radiographic procedure.

The easiest is through diversion and positivesuggestion. It is advisable to avoid suggesting toa patient that the film may cause them to gag. Indoing so it is likely you are psychologicallypreparing the patient to respond to yoursuggestion. As a diversion, the patient can beinstructed to hum a tune, raise a leg, or look atthemselves in a mirror. However, this techniqueis not always successful, so other techniquesmust be brought into play.

Using a cotton tip applicator, the patient’s palateand tongue can be coated with a topicalanesthetic to reduce the sensation of theradiograph. This technique is more successfulwith adults rather than children since a pleasanttasting topical anesthetic has yet to be inventedand children often object to the numb feeling.

An alternative is the use of nitrous oxideanalgesia. One of the effects of nitrous oxideanalgesia is that it reduces the gag reflex, butunlike general anesthesia does not affect thecough reflex. (Figure 15)


Figure 15.

Another alternative is to place the film in such amanner so that is does not come in contact withthe palate or tongue. This is accomplished byeither extraoral placement of a #4 sized film, orplacing the film between the cheek and the tooth.The film is then exposed from the other side ofthe jaw.

Figure 16.

The film is placed on the buccal surface of the tooth between the tooth and the cheek. The film side of the packet (the white side) is facing the buccal surface of the teeth. (Figure 16)

Figure 17.

The X-ray head is placed at the opposing sideand the cone is positioned under the angle of theramus. The radiation is directed through thetongue, through the tooth structure, and onto thefilm. (Figure 17) As the X-ray beam is traveling a longer distance to the film than in the typicalpositioning, it is necessary to double the exposuretime.

Figure 18.

In spite of increased magnification of the imageand loss of detail due to scatter radiation (Figure18), this can provide adequate information todevelop an accurate diagnosis. It is imperativewhen the radiographs are mounted you note thatthe radiographs are reversed. What appears tobe a radiograph of the right side is really aradiograph of the left side and vice versa.Incorrect mounting and labeling of theseradiographs can result in misdiagnosis andtreatment of the wrong tooth.


Conclusion

Through the use of proper and innovative radiographic techniques, dental professionals can obtain diagnostic radiographs with minimum harm and maximum comfort for the pediatric patient.

References

1. The Handbook - Pediatric Dentistry, 2nd Edition, American Academy of Pediatric Dentistry, Chicago 1998.2. Reference Manual 1998-1999, American Academy of Pediatric Dentistry, Pediatric Dentistry,

Volume 20, Number 6, pp. 42-43.

About the Author


http://www.wowseminars.com

ashok

Sticky Note

Corresponding Author- Dr. Steveen Schwartz has maintained a successful pediatric dental practice dental practice since 1976. He is a diplomate of the american Board of Pediatric Dentistry and director of pediatric dentistry at Staten island University Hospital. He is the Author of numerous scientific and practice management articles, a member of the National Speakers Association and the primary lecturer for WOW! Seminars. Additional information can be found at WWW.WOWSEMINARS.COM and he can be contacted be e-mail at: [email protected]

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Radiographic Techniques for the Pediatric Patient