Radiography for special patient/endodontic courses

SEMINAR
ON
RADIOGRAPHY OF PATIENTS WITH SPECIAL
NEEDS
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Purpose statement
At the end of the presentation learner will be able to,describe
various conditions pertaining to physical & developmental
disability, enumerate their clinical features & enlist the steps
that are to be taken in performing dental radiographic
procedure for these patients.

S/No Learning objectives Domain Level Criteria Condition
1 Enlist the various physical &
developmentally disabled
conditions
Cognitive Must know All -
2 Enlist dental considerations of these
condition
cognitive and
psychomotor
MUST know - -
3 Describe modifications in dental
radiography of these patients.
cognitive &
psychomotor
Must know - -

Introduction
 Numerous conditions require special patient
management
 The dental professional have to endeavor to treat
each patient as an individual with unique needs
that may require modifications, additions or
deletions to the standard of care.
 People with special needs are those whose
dental care is complicated by a physical, mental,
or social disability.

 Children with disabilities may present challenges that
require special preparation before the dentist and office
staff can provide acceptable care.
 If a dentist becomes familiar with the special needs of a
child with disabilities and with the parents' concerns,the
dental management of the child can be quite gratifying.

Patients with special needs
 Physically disabled patient
 Visually impaired
 Hearing Impaired
 Mobility impairment
 Developmental disabilities
 ADHD
Attention Deficit
Hyperactivity Disorder
• Autism
 Down’s syndrome
 Mental Retardation
 Cerebral Palsy
 Seizure Disorderswww.indiandentalacademy.com

For
pediatric patients
Gagging reflex
Patient with trismus
Patients with poor hand control
The unconscious patient
The edentulous patient
The endodontic patient

Physically disabled patient

Vision impairment
 1. Visual impairment/ blindness
- Legal blindness is defined as a visual acuity of 20/
200 ( a person sees at 20 feet what a person with
normal vision sees at 200 feet ) or less after the best
optical correction
- Visual impairment refers to sight no better than 20/
70 after optical correction

Guidelines when working with the
visually impaired patients
 Lead the patient by standing slightly in front; the patient will hold
onto your bent arm near the elbow for guidance
 Indicate changes in the floor and prepare a path to the dental chair
that is free of obsacles
 Always describe procedures to the patient in a step by step fashion
using the patient’s own language to provide instructions
 If the patient is partially sighted , avoid the glare of light into his eyes.
 The dental radiographer must never gesture to another person in
presence of person who is blind.blind person are very ensitive to this
type of communication.

Hearing impairment
 Hearing impairment is defined as defective /
functional hearing with or without the assistance of
hearing aid
 Deafness is the inablility to understand speech even
with the use of a hearing device.
 Deafness can be associated with outer , middle and
inner ear mechanisms
 The leading causes of deafness are:
- heredity, prenatal, mother infections
- trauma
- toxic drug effects

During communication with the deaf
the following recommendations are
advised:
 1. Face the patient , remove your mask , speak normally
.Pause more frequently than usual, because many
patients rely on lip reading
 2. Avoid sittting in front of a window or bright light that
may cast a shadow on your face
 3. Use a pencil and paper to communicate oral care
recommendations if necessary

 4. Avoid backgroud noise. Ask the patient to turn off a
hearing aid when using high- pitched powered scaling
and toothbrush devices
 5. Become familiar with common sign language signals
that may be helpful during appointment, such as close,
open, rinse etc.
 6. Tell, show and do all procedures to reinforce them and
enhance the patient’s understanding

Mobility impairment
 If person is in wheelchair& not have use of lower limb
radiographer may offer help from care giver for
transferring patient to dental chair.
 If not possible to shift patient then can perform on
wheel chair.
 The caregiver can help the patient to hold the film if
upper limb cant use.
 In such cases caregiver should use lead apron &
thyroid coller.
 A short exposure time should be used to minimize
image unsharpness due to incresed patient
movement.www.indiandentalacademy.com

Developmental disabilities
 A substantial impairment of mental or physical
functioning that occurs before age of 22& is of
indefinite duration.
 Patient may have problems with coordination mild
sedation may be useful.
 If comprehension is problem & patient can not
hold film,caregiver can help.

Attention Deficit Hyperactive Disorder
 Condition affecting the CNS
characterized by increased motor activity and restlessness, short
attention span, and inability to concentrate
 Incidence: 3-5% / boys 4 to1
 Etiology: neurobiology, genetics
 environmental factors stimulated kids
 DISORDERS ASSOCIATED WITH ADHD
 Anxiety Disorders
 Learning Disabilities
 Disruptive Behavior Disorders/Conduct Disorders
 Mood Disorders/Depression/Bipolar
Disorder

DENTAL MANAGEMENT
 Behavior management techniques
 In some cases can use Nitrous Oxide for anxyolisis
 set rules, give short commands, be gentle but firm, be
quick!
 Morning appointments when meds max
 Avoid delays in waiting room
 short appointments (short attention span)

AUTISM
 Complex developmental disability that affects the
functioning of the brain
social interaction/communication skills
 Wide variety of combinations and severity of symptoms
 Mild cases are called Asperger syndrome (AS) deficiencies
in social skills, prefer sameness, tantrums, obsessive
routines, crying, showing distress for no reason can be
misdiagnosed with ADHD
 Marked overall hyperactivity, persistent bruxism, tongue
thrust, cariogenic food often used for rewards

 Unusual and unpredictable response to stimuli
 very sensitive to certain sounds, textures, tastes, and smells
 Seizures
 1 of 4% autistic children develops seizures .
 Usually anticonvulsants cause - Gingival Hyperplasia and
Gingivitis + poor oral hygiene
 Delayed tooth eruption, high risk dental trauma, bite tongue,
cheeks

DENTAL MANAGEMENT
 Autistic Children don’t like change
short appointments, same chair and assistant, be prepared,
firm but gentle, use exaggerated TSD technique. Observe
patient’s movements and look for patterns
 Regular dental examination can be difficult
 Restraint with bite blocks and sedation
 Avoid loud voices and bright lights, because they may upset
the patient

MENTAL RETARDATION
 Significantly subaverage general intellectual functioning existing
concurrently with deficits in adaptative behaviour and manifested
during the developmental period.
IQ Impairment Ability
68-83 Borderline Slow learner
52-67 Mild Educatable
36-51 Moderate Trainable
20-35 Severe Dependable
less 20 Profound

 Etiology Genetic- Down Syndrome
Physical-anoxia, prematurity
asphyxia, maternal infection
Dental Management
 MR children can learn in the same way as normal kids, but
at a slower rate
 Limited attention span and less ability to rationalize dental
procedures.
 Positive reinforcements, simple instructions and repeat
them constantly

DOWN SYNDROME
 Genetic Disorder associated with medical and physical
abnormalities
Characteristics
 MR with limited ability to learn and communicate
 Impaired Speech /Delayed Language development
 Cardiac Abnormalities :valve defects and dysfunctions.
 Delayed eruption of permanent teeth and over-retained primary
teeth
 Microdontia/enamel Hypoplasia/Oligodontia.
 Increased incidence of periodontal Disease
 Macroglossia
 Gingival hyperplasia
 Malocclusion
 Xerostomia-

managemenrt
 Determine level of comprehension and ability to cooperate and
then use appropriate management techniques.
 Use simple short instructions and repeat them is necessary.
 Scheduling appointments early in the day is beneficial – both
patient and operator are more rested
 First appointments should be for orientation only and subsequent
appointments may require a little more time what is usually
allowed

CEREBRAL PALSY
 Non-progressive disorders of the neuromuscular system with
wide range of symptoms and disabilities characterized by
paralysis, muscular weakness, and dysfunctions
 Etiology: prenatal dev. defects, anoxia narcotics, infections
 Classification: extrapyramidal/Ataxia/Spastic
 Spastic most common type (60%) increased muscle tension
and excessive involuntary contractions, Facial contractions,
drooling and excessive body movement

Recommendation for cerebral
palsy
 Scheduling the patients for morning appointments.
 Knowledge of wheelchair transfers.
 Head and arm restraining devices

EPILEPSY
 Epilepsy is a variable symptom complex that is characterized
by reccurent attacks of unconsciousness or impaired
consciousness usually accompanied by tonic or clonic spasms

The following considerations should be
taken to prevent a dental emergency (
seizures)
 Ask patient if prescribed medications have beeen taken: when
was the last seizure, was there an aura, how often do the
seizures occur and what events precipitate a seizure?
 Schedule short appointments in the morning; avoid anxiety or
stress-provoking situations and keep a calm atmosphere

Radiography for disable patient
The patients with very young,spastic,mentally retarded &
hyperactive & handicapped patients radiography
procedure include
 A fast exposure technique is used.
 In addition the operator assistant to help patient in
holding the film in mouth/to keep the patients head
motionless.
 This assistant person should not occupationally involve
with x rays preferably a gurdian of patient.www.indiandentalacademy.com

 The patients who are actually handicapped in
their ability to achieve & maintain a position for
proper IOPA radiograph the extraoral technique
is used.
 When extraoral tech.not used then patient may
be placed under GENERAL ANESTHESIA.
 Do not ask personal question about disability.
 Do talk directly to the person with a disability

Patient positioning for radiography under
general
anaesthesia. A Periapical radiography of
upper incisor teeth.
Note the film packet (arrowed) supported
in the desired position by a gauze pack.
B Oblique lateral radiography.
Note the tape used to stabilize the
cassette and maintain the correct
patient position.

PARKINSON’S DISEASE
 Parkinson's Disease affects multiple regions of the nervous
system.
 40 percent Of Parkinson's Disease patients suffer from
depression.
 Patients with Parkinson’s disease have stiffness or rigidity of
muscles and tremor in one or two hands.
 Dental visits must be short

Radiography for poor hand control
patients
 The patient may be unable to use their hands to
support the film in mouth.
 The assistance of relative or other person to hold the
film for the patient.
 In most cases operator can use a bite block type of
film holder to keep the film in proper position in
which the requirement of patient only to bring jaws
together.

Patient with temporary useless hands using bite block to maintain
Film in patients mouthwww.indiandentalacademy.com

Special consideration

RADIOGRAPHY FOR GAGGING
PATIENT
 Gagging (retching/pharyngeal reflex) can be
defined as retching that is elicited by stimulation
of sensitive tissue of soft palate region.
 The maxillary posterior region(soft palate,lateral
posterior third of tongue) is most difficult for
gagging patient to tolerate for dental radiography.
 The operator should evaluate type & severity of
gag reflex.coz in gag both psychologic &
physiologic component are present.www.indiandentalacademy.com

 When gag reflex is due to psychologic
problem,the patients should be educated about
condition.
 Reflex should be explained & demonstrated to
patient.the patient can hold the film themselves
without gagging in this condition.
 The patients can be trained in this condition with
the use of models,to position the film themselves
often in subsequent visits to dental clinic.

 When the patient tolerates film placement in the
bicuspid area but not in molar area ,distal oblique
projection of the molar teeth using the paralleling
technique can be used.
 Distal oblique projection shows periapical tissues but
overlapping at proximal surface of teeth can occur
but it can be overcome by molar bitewing
radiograph.
 The technique of bending the film & using the bentwww.indiandentalacademy.com

• When IOPA is unable to take in molar region an
extra oral technique is used.a lateral jaw
/panoromic radiograph can be useful .
• In all gagging patients use
 a fast exposure technique .
 Preset the patient & machine
 Use quick angulation procedure & adjust machine
for short film exposure time
 Do try to distract the patient-bite as hard as
posible on film holder.2)suspend the arm /leg in
chair.www.indiandentalacademy.com

 Do suggest breathing deeply through nose during
film placement & exposure.
 Do try to reduce tactile stimuli which help to
prevent gag reflex.1)giving patient a cup of ice
water to drink. 2)placing a small amount of
ordinry salt on tip of tongue.
 Do use a topical anesthetic in patient with severe
hypersensitive gag reflex,a topical anesthetic
spray may be used.the spray is used to numb the
areas that elicit gag reflex.www.indiandentalacademy.com

PREGNANCY
X-rays are a type of electromagnetic radiation that have the
ability to ionize material through which it passes. Ionizing
living matter results in damage to cells or DNA.
 Depending on the amount of radiation and the stage of
pregnancy, damage to fetal cells may result in miscarriage,
birth defects, or mental impairment.
 Dental radiographs may be prescribed during pregnancy,
because radiation exposure to the fetus in utero is
negligible.
 The dose to the fetus is about 1/50 000 of the direct
exposure to the head. As a consequence, the effective body
dose from the full mouth series of D speed films is less than
1x10-6 Gy .

Teratogenecity of radiation depends on fetal age and
the dose of radiation. The greatest risk to the fetus
for teratogenecity and death is during the first 10
days after conception.
The most critical period of fetal development is
between 4 and 18 weeks after conception. The
chance of fetal teratogenecity with an exposure of
0.01Gy is about 0.1% and radiation doses of up to
0.05 Gy or less are not associated with significant
increase in teratogenecity.
Fetal exposure to radiation of more than 0.20 Gy will
cause microcephaly and mental retardation.

Radiographs employed in dentistry such as the
panoramic and full mouth intraoral series are generally
safe during pregnancy.
The average radiation doses absorbed by the fetus in
panoramic and full mouth radiographs are 1.5x10-4 Gy
and 10-5 Gy respectively.
The dental radiation received is also 40-fold less than
the naturally occurring background radiation.

 Although the risk of teratogenecity is exceedingly low with
dental radiographs, the amount of radiation exposure to
the pregnant mother and fetus can and must be minimized
even further by
 using bitewing radiographs instead of panoramic
radiographs,
 using high-speed films (E speed)
 the use of rectangular collimation instead of circular
collimation
 properly collimated beam
 lead aprons over the abdomen.

Radiography for patient with trismus
 A patient may be unable to open the mouth due to trauma,
infection,ankylosis,or other causes.
 Mandibular & maxillary teeth are in contact & no space
between them to place film then extraoral lateral jaw &
panoromic radiographs are possible.
 When small sepration of upper & lower teeth possible then
film can be placed with haemostat without a biteblock.
 The patient should cooperate by moving tongue around
palate & allowing film placement.

Hemostat film holder,with bite block removed ,being used to insert
Film into mouth with little intermaxillary seprationwww.indiandentalacademy.com

 The bitewing films are used only.
 Operator can not see the film in patients mouth external
anatomic landmarks are used to achieve average verticle
angulation.
 Horizontal angulation is achieve by the planeof the buccal
/labial surfacesof the teeth being examined.

Unconscious patients
 The most common condition is need for radiograph during an
operation when patient is under GA.
 .
 The biteblock film holderis used;that require patient jaws to
close upon block.
 The anesthetist can hold the patients head otherwise patients
head can be positioned by wedge shaped pillow & jaws can
bekept together by passing a soft rubber tube under
mandible & tieing it above patients head.
 A portable x ray machine can be used.

RADIOGRAPHIC
EXAMINATION FOR CHILDREN
 Adequate radiographic records are often necessary in
planning dental treatment for the child with disabilities.
 Through appropriate behavior management of the child,a
dentist can usually perform a complete radio-graphic
examination of the teeth when indicated

 Occasionally, assistance from the parent and dental
auxiliaries and the use of immobilization devices may be
necessary to obtain the films.
Better cooperation may be elicited from some children by
delaying radiography until the second visit, when they are
familiar with the dental office and have found it a friendly place.
For patients with limited ability to control film position,
 intraoral films with bite-wing tabs are used for all bitewing and
periapical radiographs.

 An 18-inch (46-cm) length of floss is attached through a
hole made in the tab, as shown in to facilitate retrieval of
the film if it falls toward the pharynx.
 Regardless of the types of radiographs to be made, the
patient should wear a lead apron with a thyroid shield, and
anyone who helps hold the patient and the film or sensor
steady should wear a lead-lined apron and gloves .

An accessible dental operatory floor plan designed
for either a straight or side access doorway. (From Bill D,
Weddell JA: Spec Care Dentist 7:246-252, 1987.)www.indiandentalacademy.com

 The film size used should be 0,81 *1.25 inches is used
 The adult size films should always be used for
posterior tooth in children.
 The bisecting angle tecnique is used because
 Apices of permanent teeth lie above the younge
maxilla & below floor so prevent image to be projected
in oral cavity by x-rays perpendicular to long axis of
teeth.
 This technique examine beyond the apices of teeth
without cutting images of crown.www.indiandentalacademy.com

 For cooperative child
but can not hold the
film bite block can be
used.
 With apprehencive
patient the tell show
do method along
with reassurance to
patient that they
would not be touched.
 For posterior teeth
extraoral approch
OPG can be taken.
Bite-wing radiographic film secured with floss.

Extra assistance in holding the patient's head steady to prevent movement
while a

 So while dealing with pedo patients
 Be confident.
 Show & tell.
 Reassure the patient.
 Demonstrate the behavior.
 Request assistance.
 Postpone examination.

Edentulous patients
 Dental radiography needed for following reason
 To detect presence of root tip,impacted teeth,& lesions.
 To identify objects embeded in bone.
 To observe quantity & quality of bone.
 To establish position of sinus,mental foramen,incisive foramen.

• It include OPG,IOPA or combination of occlusal &
periapical radiography.
• Panoramic survey does not provide sharp images
of short objects.so it should be supplemented
with intraoral periapical radiograph.
 Right & left lateral jaw plus anterior topographic
occlusal radiograph of maxilla & mandible used in
combination of periapical radiogarph.

 For intraoral periapical radiography excessive
bending of film produces streaky distorted images.
 When a bite block is used a cotton roll can be used
to replace the crowns of missing tooth,support the
biteblock & prevent overclosure of jaws with film
extending too much in floor of mouth.
 An orthodontic elastic to hold cotton rolls to
biteblock on film holder can be used.
 Exposure required for edentulous patient is 25%less
than that for a dentulous ridge.

 The vertical angulation is made as bisecting angle
technique,using the buccal /labial bone instead of
long axis of missing tooth to form one side of angle.
 The projection used are for
 central incisor 1 projection
 Lateral-canine 2 projection
 Premolar 2 projection
 Molar 2 projection

Radiography using buccal bone to form angle to be bisected & positioning of central ray
To ,bisector.www.indiandentalacademy.com

Endodontic patient
 When the length of tooth is to be measured the technique of
choice is Paralleling technique.
 In modern root canal treatment employing the use of rubber
dam, technique of choice for calculating the working length,
is Bisecting angle technique.
 The problem of superimposition of buccal and palatal roots
in endodontic procedures can be overcome by changing the
horizontal angle of the x-ray beam.

 For better visualisation of the apex, the low kVp(60-65)
and low radiographic fog can improve the contrast.
 The film fogging caused by secondary scattering of
radiation can be reduced by irradiating a small area of
tissue,(use smaller x-ray beam).

Alteration for Control of
infection
 The main risk of cross infection is from one patient to another
from salivary contamination of work areas and equipment.
 Operators themselves are not at great risk during radiography
but there are no grounds for complacency.
 Main infections of concern
 Infective hepatitis caused by hepatitis B (HBV) or
hepatitis C
 HIV disease
 Tuberculosis (TB).
 Cold sores caused by herpes simplex virus (HSV).
 Operator are at risk of getting herpetic whitlow, a painful
finger infection.
 Rubella (German measles)..

 Syphilis.
 Diphtheria.
 Mumps.
 Influenza.
 Transmissible spongiform encephalopathies (TSEs), e.g. Creu
tzfeldt-Jakob disease.
Infection control measures
 As mentioned previously, in dental radiography the main
concerns arise from salivary contamination of work areas and
equipment. Suitable precautions include

 All clinical staff should be vaccinated against
hepatitis B
 Open wounds on the hands should be covered with
waterproof dressings.
 Latex or vinyl non-sterile, non-powdered medical
gloves should be worn for all radiographic
procedures and changed after every patient.
 .All required film packets and holders should be
placed on disposable trays to avoid contamination
of work surfaces.
 To prevent salivary contamination of film packets,
they can be placed in small barrier envelopes or
preferably purchased pre-packed in such
envelopes, before use.
 After being used in the mouth, the film packet can be

 Film packets must only be introduced into
daylight-loading processors using clean hands or
washed gloves. Powdered gloves may cause
artefacts on the films.
 Contaminated disposable trays, barrier envelopes
and film packaging should be discarded directly
into suitable clinical waste disposal bags

 All film holders/bite blocks/bite pegs should be washed after
use and then autoclaved or discarded, if disposable.
 X-ray equipment, including the tubehead, control panel, timer
switch and cassettes which have been touched during the
radiographic procedure should be wiped after each patient with
a suitable surface disinfectant, e.g.Mikrozid®.
 Alternatively, all pieces of equipment can be covered, for
example with cling film, which can be replaced after every
patient.

 Soiled gloves and cleaning swabs should be
placed in suitable disposal bags and sealed for
incineration.
 avoid salivary contamination, whenever possible
films should be processed immediately and not
left on work surfaces.
 If intraoral techniques are necessary, disposable
film holders should be used

Conclusion
 A dentist should be familiar with the special
needs of a patients with disabilities and with
their care givers concerns,the dental
management of these patients can be quite
gratifying.
 Alteration in normal techniques are needed
regarding the patients having physical
disabilities,developmental
disabilities,paediatric patients,gag
reflex,trismus,edentulous patients.

REFERENCES
 Stuart White, and Michael Pharaoh; Oral Radiology
Principles and Interpretation; 5th Edition
 Lincoln R. Manson-Hing; Fundamentals of Dental
Radiography; 3rd Edition
 HAERING AND HOARTEN;ORAL RADIOLOGY;3RD’EDITION
 RALPH E. McDONALD, DAVID R. AVERY;Dentistry for the
Child and Adolescent;8TH’EDITION
 Eric WhaitesEssentials of Dental Radiography and
Radiology;3rdedition

THANK YOU

Radiography for special patient/endodontic courses

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Radiography for special patient/endodontic courses