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  1. 1. 0 Patient Management Ordering Films The following slides describe Patient Management and Ordering Films.In navigating through the slides, you should clickon the left mouse button when you see themouse holding an x-ray tubehead or you aredone reading a slide. Hitting “Enter” or “PageDown” will also work. To go back to the previousslide, hit “backspace” or “page up”.
  2. 2. Patient Management General Guidelines• Try to appear confident: this will help to relax the patient and will make them more accepting of what you are trying to do.• Explain what/why: Let the patient know what youare planning to do, especially the number of films you will be taking.• Answer questions: Quick responses to questions or concerns will make the patient more at ease
  3. 3. Patient Management General Guidelines• Don’t volunteer unnecessary information: “This film will be way back in the mouth”, “This may hurt”, “This is the first film I’ve ever taken”, etc., are statements that will make the patient more apprehensive and less cooperative.• Take more anterior films first: Anterior films are easier for the patient to tolerate. By starting with these, the patient gets used to the procedure and will have fewer problems with the posterior films.
  4. 4. Patient Management General Guidelines• Work quickly but efficiently: Have everything set up and ready to complete the procedures as quickly as possible. Have the tubehead positioned next to the patient’s head on the side you are imaging so you can rapidly align the tubehead after film placement.• “Empathize”: If the patient reacts negatively to the procedure due to discomfort, gagging, etc., explain that this is a common occurrence due to patient anatomy, location of film, etc., and that you will do your best to position the film in a more comfortable location and will complete the procedure very quickly.
  5. 5. Patient Management General Guidelines• Compliment patient: Identify something that the patient did well during the procedure and compliment them. This is especially important with children, making them feel good about themselves and increasing the likelihood that they will exhibit similar behavior at subsequent appointments.
  6. 6. Patient ManagementSpecial Situations
  7. 7. GaggingSome patients may have difficulty tolerating filmplacement due to the gag reflex. Methods used toreduce or control the gag reflex include:• Proper patient management (anterior films first, etc.)• Distractors: Tell the patient to raise the arm or leg, count backwards from 100, etc.• Have patient breathe rapidly through the nose• Salt on tongue: place some salt in the patient’s hand and have them lick the salt with the tip of the tongue• Flavor films by dipping in mouthwash• Topical anesthetic: spray topical anesthetic on both sides of palate
  8. 8. ChildrenBecause their mouths are small and becausethey are naturally a little “fidgety”, children canbe a challenge to radiograph. In general, the moreyou explain the procedure and enlist their help,the more cooperative children will be. You needto be firm but not threatening when working withchildren. Take the minimum number of filmsneeded to make a diagnosis and use theappropriate size film for the size of the mouth.Bitewings, anterior occlusal films and panoramicfilms are usually tolerated by children; periapicalfilms may require a little more effort. Asmentioned previously, be sure to complimentchildren for a job well done.
  9. 9. Anatomical VariationsThe following anatomical situations (to bediscussed on subsequent slides) may requirealteration of radiographic techniques:• Third Molars• Maxillary Canine• Tori• Space limitations• Ankyloglossia (Tongue-tied)
  10. 10. Third MolarsSometimes it is difficult to get the film far enough back tocover the third molar region due to gagging or anatomy,and all of the third molar will not be seen on the film (seediagram bottom left). By rotating the tubehead so that thebeam is directed more anteriorly (diagram bottom right), thethird molar is projected onto the film, giving us the neededinformation. Note, however,the increase in overlap thatresults. If you plan onextracting the third molar,or you can get by withoutthe sharper image seenon an intraoral film, apanoramic film would bethe preferred method ofimaging this area.
  11. 11. Maxillary CanineBecause of the prominent cusp tips on canines, it iscommon for the film to tip when using the parallelingtechnique. This may result in the failure to image theapex of the canine. To avoid this, place a cotton rollbeneath the biteblock, against the mandibular teeth.This will help to keep the film aligned with the canine.
  12. 12. Maxillary Canine - Bisecting 0 In many patients, especially ones with narrow maxillary arch widths, it is difficult to align the film ideally because the top edge of the film contacts the palate on the opposite side and doesn’t allow enough film to register the apex of the canine. Using the bisecting angle technique, the film can be rotated into a diagonal placement, covering the entire canine.Film can’t be placedfar enough into the diagonal placementmouth (narrow arch)
  13. 13. Palatal TorusA palatal torus is a bony growth in the palate. A largetorus makes it difficult to position the film for maxillaryperiapical films. In general, it is best to position the topedge of the film between the torus and the teeth on theopposite side of the mouth (away from teeth beingradiographed). The disadvantage to this placement isthat the radiopacity of the torus may be superimposedover the roots of the teeth on the film. palatal torus
  14. 14. Mandibular ToriMandibular tori are bilateral bony growths found onthe lingual side of the mandible in the premolarregion. The film should be positioned between thetorus and the tongue, never resting on top of thetorus. Again, the radiopacity of a large torus may besuperimposed over the roots, but this is unavoidable. mandibular torus
  15. 15. Space LimitationsA shallow palate or shallow floor of the mouthwill make it difficult to use the parallelingtechnique. In general, the bisecting angletechnique, using finger retention, is preferredfor periapical films in patients with theseanatomical restrictions.
  16. 16. Ankyloglossia (Tongue-tied)Ankyloglossia results from a very short lingualfrenum, a mucosal fold under the tongue thatconnects the tongue to the floor of the mouthand the mandible. Tongue mobility is verylimited, making it difficult to place a film underthe tongue and push it down far enough toimage the roots of the incisors. In order toimage this area it is ususally necessary to usethe bisecting angle technique and in somecases a tongue blade may be used to stabilizethe film (see next slide).
  17. 17. A tongueblade can be 0 taped to the back of the film. Using the tongueblade for support, the film is pushed down into the top of the tongue until the film is down far enough to register the apices of the anterior teeth. A portion of the tongue will be superimposed over the roots, addinglingual frenum unwanted density to the film in this area, but this may be unavoidable.
  18. 18. 0 TrismusTrismus (lockjaw) is caused by a prolonged spasm ofthe jaw muscles due to infection, TMJ problems, etc..Patients with trismus cannot open the mouth verymuch and normal intraoral techniques are difficult.Methods of imaging patients with trismus are:• Panoramic film: this is the easiest and best method• Occlusal film: a modified bisecting angle technique is used with the occlusal film• Periapical film with hemostat (see next slide)
  19. 19. 0 Using a periapical film with a hemostat for a patient with trismus1. Clasping the film with 2. Once the film has cleareda hemostat, insert the the incisors, rotate the filmfilm in the mouth with the to a vertical position infilm parallel to the floor maxilla or mandible.(horizontal)
  20. 20. 0 EdentulousThe best film for imaging edentulous patients isthe panoramic radiograph. It shows the entiremaxillary and mandibular arches and will revealpathology and impacted teeth. If a panoramicmachine is not available, occlusal films may beused to image the edentulous ridges, althoughthe diagnostic value is not as good.Periapical films may be indicated if suspiciousareas are seen on the panoramic or occlusalfilms. The bisecting technique with fingerretention or the paralleling technique (withcotton rolls placed above and below thebiteblock) may be used.
  21. 21. Mentally or Physically ChallengedPatients with disabilities may requiremodification of normal techniques. In general,film retention using some type of film holder isrequired for these patients. In addition,assistance from a relative or friend of thepatient may be needed to help secure the filmin place or stabilize the head during exposure.(Lead aprons and lead gloves should beprovided for the “assistant”). As always, filmsshould be kept to the minimum needed for aproper diagnosis.
  22. 22. Hepatitis/HIVUniversal precautions should be followed for allpatients. We don’t always know if a patient hasa communicable disease and we therefore needto treat all patients the same. If we do this, wedon’t have to change our routine with a knownHIV patient (or a patient with another condition)and make them feel uncomfortable.
  23. 23. PregnancyThere is some debate about what films to take ona pregnant patient. In general it is felt that there islittle risk to the fetus as long as a lead apron isused. My position is that you should only takethose films needed to treat symptomatic teeth orto plan treatment that can be completed duringthe pregnancy. Obvious clinical indicators suchas large carious lesions, fractured teeth, soft-tissue enlargements, etc., would require thatradiographs be taken.
  24. 24. 0 Ordering FilmsWhen deciding what films are needed on apatient, you must consider all of the following:• Dental History• Clinical exam• Professional judgment• Selection criteria
  25. 25. Ordering Films 0Review Dental HistoryIdentify symptomatic teeth, most recent films,frequency of visits, patient attitude towarddental careConduct Clinical ExamChart the condition of the teeth (caries,restorations, displacement, mobility, etc.), #teeth present/abutment teeth, teeth removed forortho, endo treatment, status of third molarsUse Professional JudgmentInfluenced by education, experience, and,unfortunately, finances
  26. 26. Selection Criteria 0Selection criteria are used to identify teeth or areas ofthe mouth that indicate an increased likelihood ofperiapical or bony abnormalities. These criteriainclude both historical and clinical components. Referto fora more detailed discussion of selection criteria.Historical Findings (based on dental history):• Pain, swelling, bleeding, mobility• Trauma to the teeth and jaws• Endo• Implants• Family history• TMJ pain
  27. 27. Selection Criteria 0Clinical Findings• Large caries/restorations• Periodontal disease/mobility/bleeding• Evidence of trauma/swelling/fistula• Potential abutment teeth• Unusual tooth appearance/position• Third molars partially or totally unerupted• Facial asymmetryIdentification of any of these historical or clinicalfindings indicate the need for periapical orpanoramic films (or both) for an adequate diagnosis.
  28. 28. Using the selection criteria, what films would be0 indicated for this patient? Symptomatic teeth: None Fractured teeth: None Large caries: None Large restorations: None Missing teeth: None (patient says 3rds not extracted) Gingiva: Healthy Other historical findings: NoneFilm order: 4 bitewings, Pan. The bitewing films areneeded to check for interproximal caries. This is astandard order for new or recall patients that have nothad bitewings for a while (see later slide for frequency oftaking bitewings). A panoramic film is also indicatedbecause there is no history of having the 3rds removed.
  29. 29. Using the selection criteria, what films would be0 indicated for this patient? Symptomatic teeth: None Fractured teeth: None Large caries: None Large restorations: # 30Large restoration Missing teeth: #’s 5, 12, 21, 28 (patient says 3rds have not been removed) Gingiva: Mild gingivitis Other historical findings: NoneFilm order: 2 BW, 1 PA, Pan. With only one premolar andtwo molars in each quadrant, only one bitewing per sideis needed. The large restoration on # 30 requires aperiapical. A pan is needed for the third molars.
  30. 30. Using the selection criteria, what films would be0 indicated for this patient? Symptomatic teeth: # 8 Fractured teeth: # 8 Large caries: NoneSmall restoration Large restorations: NoneFracture Missing teeth: #’s 1, 16, 20, 32 (patient says # 17 has not been removed) Gingiva: Healthy Other historical findings: NoneFilm order: 4 BW, 2 PA, Pan. 4 bitewings to check forinterproximal caries. 2 periapical films: one forsymptomatic and fractured tooth # 8 and one forpotential bridge abutments # 19 and # 21 (The premolarfilm covers both teeth). A pan will show if # 17 is present.
  31. 31. Using the selection criteria, what films would be0 indicated for this patient? bridge Symptomatic teeth: #’s 3 and 10 Fractured teeth: NoneSmall restoration Large caries: #’s 15 and 32Large restoration Large restorations: #’s 3, 6, 8, 12,Crowns 13, 17, 21, 23, 24, 25, 26, 28, 29, 30Large caries Missing teeth: #’s 1, 2, 7, 14, 18 Gingiva: General redness, inflammation Other historical findings: NoneFilm order: 4 BW, 15PA (AFM). This patient hassomething going on in every area of the mouth, includingperiodontal involvement, so a complete series of filmsneeds to be taken. A panoramic film would not beneeded, since we should be covering the third molarareas with the periapicals.
  32. 32. Just based on your clinical observation of this 0patient, what periapical films would you order forthe maxillary arch? Film order: 1 PA. In general the teeth look good and the gingiva appears healthy. There is a large occlusal restoration on # 3; it is wide buccolingually and the caries was probably pretty deep. A periapical would be indicated for this patient. If you wanted to look at the bitewings before ordering periapicals, that would be acceptable.
  33. 33. Just based on your clinical observation of this 0 patient, what periapical films would you order for the maxillary arch?Film order: 3 PA. There is a bridge from # 3 to # 6 andlarge restorations on #’s 2, 13 and 14. (#’s 5 and 12 wereextracted for ortho; # 4 is missing). One film needed for# 6, one for #’s 2 and 3, and one film for #’s 13, 14 and 15.
  34. 34. Based on what you see in this photo, what films0 would be indicated for this patient?Film order: 4 BW, 15 PA. With limited informationrelating to this patient’s restorative needs, the filmorder is based on the gingival hypertrophy seen here(dilantin hyperplasia).
  35. 35. Using the selection criteria, what films would be0 indicated for this patient?Film order: AFM (4 BW, 15 PA) or Pan. This patientobviously has extensive carious involvement. Althoughwe can only see a portion of the mouth, it is unlikelythat other areas are any better. If it is felt that the patientwill need complete dentures, based on the clinicalexam, a panoramic film may be all that is needed;otherwise an AFM is indicated.
  36. 36. The previous slides provide some examples ofwhat to look for when ordering films. There willalways be some variability between practitionersregarding the proper film order, but it isimportant to follow as closely as possible thesuggestions made by groups such as theAmerican Dental Association. A standard filmorder for every patient or taking films purely formonetary gain are to be discouraged.
  37. 37. Frequency 0Deciding when to take additional or follow-up films canbe difficult. The ADA website referenced underselection criteria (slide # 27) identifies situations inwhich bitewings are to be taken, primarily based oncaries activity and age. However, the frequency oftaking periapical films is more obscure. The selectioncriteria identify which periapicals to take on thepatient’s initial visit, but how much time should elapsebefore repeating these films? In the absence ofsymptoms, the frequency is based primarily on thepatient’s dental history; the more problems they havehad (previous endo, aggressive caries, perio., etc.), themore often films are indicated.
  38. 38. FrequencyBitewings: 6 months - 3 years, depending onage and caries activity (see ADA guidelines)Periapicals : 1 - 5 years depending on patient’sdental history or whenever teeth are symptomaticPanoramic: 1 - 5 years depending on patient’sdental history or whenever symptoms developThis is just one viewpoint. Other approaches canbe justified. The ultimate objective is to takethose films you feel are necessary to make aproper diagnosis during recall or new patientexaminations.
  39. 39. 0This concludes the section on PatientManagement and Ordering Films.Additional self-study modules are availableat: you have any questions, you may e-mailme at: jaynes.1@osu.eduRobert M. Jaynes, DDS, MSDirector, Radiology GroupCollege of DentistryOhio State University