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DENTAL RADIOLOGY FOR

THE PEDIATRIC AND

SPECIAL NEEDS PATIENT

Dr. Tannen

St. Barnabas Hospital

NEW PATIENT- Posterior bitewings- 2

* if contacts are closed-* behavior dependent, sometimes try nitrous* 4 BW when 12 yr molars erupt

- Periapicals * if you require more than

4 PA’sand/or

- Panoramic (>5 years)*Caries is deep or clinical

pathology* Disturbance in

eruption sequence* Family history of

dental anomalies* Eruption of permanent

maxillary lateral incisors (8-9 years old)

- Occlusal

*History of trauma

*Disturbance in eruption sequence

•Do Not Take Routine Bitewings on orthodontic patients with wires

RECALL PATIENT

Clinical caries or HIGH risk

factors for caries• Primary and

Transitional Dentition

Posterior bitewings at 6 month intervals or until no carious lesions are evident

• Permanent Dentition

Posterior bitewings at 6-12month intervals or until no caries is evident

Panoramic /Periapical

* permanent maxillary lateral incisors

* Disturbance in eruption sequence

*Growth and Development

*Third Molar development and position

RECALL PATIENT

No Clinical caries and No risk

factors for caries

• Primary and Transitional Dentition

Posterior bitewings at 12-24 month intervals

if proximal surfaces are not visible

• Permanent Dentition

Posterior bitewings at 18-36 month intervals

Panoramic /Periapical

*Eruption of permanent maxillary lateral incisors

*Disturbance in eruption sequence

*Growth and Development

*Third Molar development and position

PATIENTS AT HIGH RISK FOR

CARIES High level of caries

History of recurrent caries

Existing restoration of poor quality

Inadequate fluoride exposure

Prolonged nursing

Diet with high sucrose frequency

High medication frequency

Developmental defects

Developmental disabilities, special health care needs

Xerostomia

Genetic abnormalities

Many multisurface restorations

Chemo/radiation therapy

Social, cultural, financial, psychological risk factors

POSITIVE CLINICAL

SIGNS/SYMPTOMS Clinical evidence of

periodontal disease

Large or deep caries

Malposed or clinically impacted teeth

Swelling

Evidence of facial trauma

Mobility of teeth

Fistula or sinus tract infections

Growth abnormalities

Oral involvement in known or suspected systemic disease

Positive neurologic findings in the head and neck

Evidence of foreign objects

Pain/or dysfunction of the TMJ

Facial asymmetry

Unexplained bleeding

Unusual sensitivity of teeth

Unusual eruption, spacing or migration of teeth

Missing teeth with unknown cause

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PANORAMIC RADIOGRAPH PERIODONTAL EVALUATION CLINICAL

Oral Hygiene

Width of attached gingiva and recession

Attachment Levels• Permanent incisors and

molars

Calculus• 10% children

• 33% adolescents

Gingival tissues• Redness

• Enlargement

• Bleeding

• Edema

RADIOGRAPHIC

Periapical• Evaluate peripapically

Bitewings• Normal crestal height

should be within 1-2 mm of the cemento-enamel junction

• Interdental horizontal or vertical bone loss

• Furcation involvement

RADIOGRAPHIC TECHNIQUES

FOR THE

* INFANT

* UNCOOPERATIVE CHILD

* SPECIAL NEEDS PATIENT

Parental, family, or friend assistance Informed consent Pharmacologic assistance (nitrous oxide,

sedative, oral/IM/IV sedation, general anesthesia)

Protective stabilization Digital Radiography is Visual!

POSITIVE INDICATIONS FOR

ALTERNATIVE TECHNIQUES

Developmentally disabled patient

Patients with exaggerated gag reflex

Pediatric patients

Dental phobic patients

Trauma/trismus patients

ALTERNATIVE TECHNIQUES

Horizontal versus vertical bitewings

Snap-a-ray/ rings / finger

Extra-oral

Digital radiography (visual)

Others (salt, distraction, accupuncture)

RADIATION PHYSICS

The image is a "photographic negative" of the object - the "shadows" are white regions (where the X-rays were blocked by the object)

90% of the xray photons are absorbed by the tissues

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RADIATION PHYSICS

A chest x-ray has almost three times the exposure of a periapical film because of the chest projection’s much larger field size

A full mouth series is not equal to the sum of the individual exposures because of movement of the tube (1-30% of total beam exposure, Alcox/Jameson, 1974)

RADIATION PHYSICS

As kVp (tube voltage) is increased there is an increase in the energy each electron has when it strikes the target

Increase the quality of the xray beam by removing the less penetrating photons with an aluminum filter in the path of the beam

Collimation reduces patient exposure and increases film quality by reducing the size of the xray beam and volume of irradiated tissue within the patient by reducing scattered radiation

If the kilovoltage is increased to reduce contrast than the mAs must be decreased or the radiograph will be over exposed

For a given beam, the intensity is inversely proportional to the square of the distance from the source (modify kVp or mA)

TECHNIQUES

The film should ideally be parallel to the object and the central ray should be perpendicular to the object and film

Bisecting the angle technique

Paralleling technique

What is the difference?

Foreshortening results when the central ray is perpendicular to film but object is not parallel to film

Elongation of radiographic image results when central ray is perpendicular to object but not film

TECHNIQUES

SLOB rule- if the tooth moves in the same direction of the central X-ray beam from the first film to the second, the tooth is lingual or palatal to the other teeth ( opposite – buccal)

OFFICE MAINTENANCE AND

QUALITY ASSURANCE

Protection of patients

Protection of personnel

Lead apron and thyroid collar

DIGITAL

RADIOGRAPHY Digital systems are

compared with film and those studies which have evaluated the effects • on diagnostic accuracy

of contrast and edge enhancement

• image size,• variations in radiation

dose and image compression are reviewed together with the use of automated image analysis for caries diagnosis

• as accurate as the currently available dental films for the detection of caries, sensitivities are relatively high (0.6-0.8) for detection of occlusal lesions into dentine with false positive fractions of 5-10%.

• for detection of approximal dentinal lesions, sensitivities, specificities as well as the predictive values are fair, but are very poor for lesions known to be confined to enamel

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THE SENSOR

is radiated precisely by your existing system at about 10% the exposure to radiation when compared to conventional film X-rays.

is connected to a computer in the operatory for file management of captured images

sensors are shared between rooms minimizing the cost of equipment duplication. Concise, Simple, Precise.

DIGITAL RADIOGRAPHY

Patient education

Patient visualization / distraction

Less radiation

ADVANTAGES OF

DIGITAL

RADIOGRAPHY

improve the contrast and enhance the density of the image immediately

computer based imaging facilitates automatic analysis of images and image reconstruction from two or more component images

EXTRAORAL RADIOGRAPHIC

TECHNIQUE MAXILLARY

• Open mouth as wide as possible

• Sensor is placed on the external surface of the cheek directly buccal to the tooth with a cotton roll between the sensor and face

• Xray cone is angled -55 degrees from the horizontal and perpendicular to the sensor

MANDIBULAR• Patient’s chin is raised

• Sensor is placed on the external surface of the cheek directly buccal to the tooth with a cotton roll between the sensor and face

• Xray cone is angled -35 degrees from the horizontal and perpendicular to the sensor

DOCUMENTATION

Document radiographic analysis and indication(s) for taking or not takingradiographs

Document number of radiographs, type and who took them

Documentation of succedaneous tooth when restorative or extraction is indicated

Document when you cannot obtain a radiograph and reason. Explain risks/benefits/alternatives

REVIEW AAPD GUIDELINES

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THE END

RADIATION EXPOSURE