Radiograph Techniques in Pediatric Dentistry

Arwa Mohammed Namnakani
R1 – 2019-

OUTLINES
 INTRODUCTION.
 HISTORY
 RADIATION SAFETY AND PROTECTION.
 RADIOGRAPHIC IMAGE RECEPTORS.
 RADIOGRAPHIC TECHNIQUES.
 INTERPRETATION OF RADIOGRAPHS
 SELECTION CRITERIA AND RADIOGRAPHIC
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 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.
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WILHELM
CONRAD
ROENTGEN
1845 - 1923
The first radiograph – Mrs. Roentgen’s hand
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THE THREE BASIC PRINCIPLES OF RADIATION PROTECTION ARE:
The justification
principle
• If there is no other way
to obtain the diagnostic
information
• Or if this exposure will
positively influence the
diagnosis, the
treatment, and the
patient’s health.
The Limitation
Principle
• radiation dose as
low as reasonably
achievable
(ALARA)
The Optimization
Principle
• Should obtain the
best quality images
as possible
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There are two
models have been
devised to explain
the effects of
radiation:
1- Non-threshold model
• It suggests that any dose of x-rays can cause
biological damage
2- Threshold model
• It suggests that no detrimental effects of ionizing
radiation occur below a particular level or
“threshold” of x-ray exposure.
• which means that a certain amount of radiation is
necessary before the response can be seen.
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Primary biological effects of
low-level radiation
Carcinogenesis Teratogenesis Mutagenesis
Somatic tissues Genetic tissue (gonads)
Have a threshold response
Sensitive to ionizing
radiation and are
believed to have no
threshold
(stochastic effects).
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PROTECTION OF THE DENTAL STAFF
-The best method for protecting dental staff from ionizing
radiation is the use of shielding or solid walls (preferably with a
lead glass window). However, some offices lack such walls, and
the radiographer must maintain a safe distance from the x-ray
source.
-The radiographer should stand either at 90° to or behind the
radiation source; at least 6 feet (2 m) from the radiation source.
-The 6-foot rule also applies to panoramic and cephalometric
imaging. For CBCT imaging, one should always stand behind a
radioprotective barrier.
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In addition to the three basic principles of radiation protection
(justification, limitation, and optimization), one can apply the following additional
techniques to reduce the radiation burden to the patient:
o Collimation of the x-ray beam
o More radiation-sensitive image receptors
o Lead apron with thyroid collar
PROTECTION OF THE
PATIENT
o Correct focus-to-skin distance15
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Collimation of the x-ray beam
-Collimator is the metallic barrier (usually lead) that used to reduce
the size of the x-ray beam and thereby the volume of irradiated
tissue.
-The use of rectangular collimation limits the surface being
irradiated to the size of the image receptor, reducing the radiation
dose by about 50%, compared with the (6 cm) circular collimator.
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Collimation of the x-ray beam
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focus-to-skin distance
(A minimum of 8 inches (20 cm))
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Lead apron with thyroid collar
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OUTLINES
• Lead apron with thyroid collar
ICRP guidelines suggest that the use of a lead apron is not
necessary with rectangular collimation, short exposure times,
adequate x-ray energies, and fast image receptors.
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• More radiation-sensitive image receptors
- Always try to use fast image receptors, which require less exposure time.
- Use of digital image receptors and E or F speed films are advised.
PROTECTION OF THE PATIENT

More radiation-sensitive image receptors
PROTECTION OF THE PATIENT
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OUTLINES
RADIOGRAPHIC IMAGE
RECEPTORS
ANALOG FILM DIGITAL FILM
Direct film
Indirect film
Photo-stimulable phosphor
storage plates (PSPPs)
Solid-state sensors
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ANALOG FILM
Direct film
- Used for intraoral radiography. It is called direct because of its high sensitivity
to x-rays. It comes in different sizes (0 – 4):
- (ISO format 0): bitwing and periapical in 1ry dentition (also called pedo size).
- (ISO format 1): used for the same purpose as size 0 .
- (ISO format 2): bitwing and periapical in mixed and permanent dentition and
occlusal radiograph of 1ry dentition (the most common size used).
- (ISO format 3): used only for bitewing images in the mixed and permanent
dentition.
- (ISO format 4): occlusal radiograph for mixed and permanent dentition.
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ANALOG FILM
Direct film
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ANALOG FILM
Indirect film
- Indirect analog film is sensitive to light more than x-rays and for this
reason it should be used only in a cassette with an intensifying screen.
- The intensifying screen converts the x-ray energy into light, which reaches
the film and forms the latent image.
- Used in panoramic imaging and cephalometric radiography.
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OUTLINES
ANALOG FILM
Indirect film
Intensifying screen 29Arwa Namnakani

OUTLINES
DIGITAL FILM
Photo-stimulable phosphor storage plates (PSPPs)
- Very similar to analog film and also come in different sizes
- Also referred to as indirect digital imaging because the image is captured
in an analog format and converted to a digital image.
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DIGITAL FILM
Photo-stimulable phosphor storage plates (PSPPs)
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DIGITAL FILM
Photo-simulable phosphor storage plates (PSPPs)
Phosphor plate that
has been bitten
Phosphor plate image with
several bitemarks
and scratches

DIGITAL FILM
Solid-state sensors
- Known as direct digital receptors because they display the radiographic
image instantaneously following exposure.
- Available in sizes 0, 1, and 2.
- The primary disadvantage is: bulky and not always easy to position in the
patient’s mouth
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SOLID-STATE
SENSORS 34Arwa Namnakani

INTRAORAL RADIOGRAPHY
Periapical Radiography
Bitewing Radiography
Anterior Maxillary
Occlusal Technique
Posterior Maxillary
Occlusal Technique
Anterior Mandibular
Occlusal Technique
Oblique Occlusal
Radiography
Localization
Techniques
Panoramic Imaging
EXTRAORAL RADIOGRAPHY
Medical Computed
Tomography
Cephalometric Imaging
Oblique Lateral Radiography
Cone Beam Computed
Tomography
Ultrasound Imaging
Magnetic Resonance Imaging
RADIOGRAPHIC TECHNIQUES
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OUTLINES
Bisecting Angle TechniqueParalleling Technique
Periapical radiographs should show the crown of the tooth
and at least 3 mm beyond the apex of the tooth.
To achieve this coverage, one can use either:
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1- Paralleling Technique
- The most accurate technique for taking intraoral radiographs.
- The image receptor should be positioned parallel to the long axis of the
teeth, while the x-ray beam is directed perpendicular to the image receptor.
- Ideally, image receptor holders that enable one to aim easily and correctly
should be used.
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1- Paralleling Technique
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2- Bisecting Angle Technique
- The image receptor is placed as close to the teeth as possible, and the x-ray
beam is directed perpendicular to a line that bisects the angle created by the
tooth and image receptor.
- This technique has more geometric errors (e.g. elongation, overlap) and
should not be regarded as the preferred technique.
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Bisecting Angle Technique
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- Assess interproximal caries and interproximal bone height.
- Based on the paralleling technique.
- Image receptor holders that enable one to aim easily and correctly should be used.
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Anterior Maxillary Occlusal Technique
- The patient’s occlusal plane should be parallel to the floor, and the sagittal plane
should be perpendicular to the floor.
- Size 2 image receptor is used and the patient is instructed to bite lightly to hold
the receptor.
- The anterior edge of the receptor should extend approximately 2 mm in front of
the incisal edge of the central incisors.
- The x-ray beam is directed to the apices of the central incisors with the vertical
angle being +60° . 48Arwa Namnakani

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Posterior Maxillary Occlusal Technique
The same as anterior maxillary occlusal technique.
The anterior edge of the receptor should extend just mesial to the
canine.
The x-ray beam is directed toward the apices of the primary molars
with the vertical angle being +50°.
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Anterior Mandibular Occlusal Technique
• The film placement for the anterior mandibular occlusal technique is
identical to that for the anterior maxillary occlusal technique, except
that the receptor must be placed so that the tube side faces the x-ray
source.
• When the patient bites on the receptor, the anterior edge of the
receptor is 2 mm beyond the incisal edge of the lower incisors.
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Anterior Mandibular Occlusal Technique
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Oblique Occlusal Radiography
Based on the bisecting angle technique.
Good alternative for patients with a severe gag reflex or who cannot tolerate the
positioning of the image receptor holder device.
It obtained by positioning the patient so that the occlusal plane is parallel to the
floor. Aim the x-ray beam perpendicular to the bisecting line between the long axis
of the tooth and the axis of the occlusal plane.
The result of this technique is a periapical view of the posterior teeth. 54Arwa Namnakani

Oblique Occlusal Radiography
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Localization Technique (SLOB)
 This technique is used to localize embedded or unerupted teeth.
 Also called parallax technique.
 The SLOB role states that the image of any buccally oriented object appears to move in the
opposite direction from a moving x-ray source.
 The practitioner should make two radiographs of the unerupted tooth, the first one is taken
by the paralleling technique. The second film is placed in the mouth in the same position as
the first film, with the patient’s head position remaining the same, but with the horizontal
angle shifted either anteriorly or posteriorly depending on the site.
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Localization Technique
SLOB Technique
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Panoramic Imaging
Useful alternative when a patient
cannot tolerate the intraoral image
receptor.
Can give a bitewing look-alike images.
It should not be used as a standard
bitewing radiograph because
panoramic images are magnified (by a
factor of around 1.3).
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Cephalometric Imaging
 Usually used in orthodontics and
orthognathic surgery.
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Excellent alternative to bitewing, periapical, or panoramic images, when patients are
unable to tolerate these techniques.
Should not be regarded as a standard for every patient.
Special-needs patients and small children can definitely benefit from this technique.
The technique requires the film to be held parallel to the midsagittal plane of the
patient, while the x-ray beam is directed perpendicular to the cassette from behind
or below the mandibular body. 60Arwa Namnakani

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Cone Beam Computed Tomography
Ideal for imaging
hard tissues.
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Cone Beam Computed Tomography
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Medical Computed Tomography
Useful for the imaging of hard and soft tissues.
Responsible for the highest radiation doses a
patient can receive from diagnostic imaging.
Usually used to identify malignancies, tumors,
and other symptoms of pathology, with or
without the use of contrast medium.
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Ultrasound Imaging
Most people associate ultrasound imaging
with pregnancy, but this technique also is
excellent for investigation of soft tissues,
such as the floor of the mouth, salivary
glands, and lymph nodes in the head and
neck region. Since the technique does not
involve ionizing radiation, it can be
repeated as many times as necessary,
without exposing the patient to any risks.
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Magnetic Resonance Imaging
This technique is especially useful
with soft tissue.
The most common dental
indication for the use of MRI is
for imaging the soft tissues of the
temporomandibular joint.
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OUTLINES
Radiographs should be evaluated under ideal conditions.
Density and contrast enhancements are essential tools for the assessment of digital
images.
Software filters can also assist in obtaining better images, but one should never
overlook the fact that filtering means loss of information.
The initial diagnosis should not be made at the chair side monitor, but rather in an
area of the office where the light is dimmed.
In case one has an image that cannot be diagnosed, the assistance of an oral and
maxillofacial radiologist may be advisable.
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SELECTION CRITERIA AND
RADIOGRAPHIC EXAMINATIONS

• For all radiographic examinations, justification and professional judgment on
an individual patient basis should apply.
• There are no guidelines per age group, gender, or dentition stage.
The American Dental Association (ADA), the American Academy for Pediatric
Dentistry (AAPD), the European Academy for Pediatric Dentistry (EAPD), and
other organizations have published criteria to guide the dental professional in
decision-making regarding appropriate radiographic imaging:
 These guidelines clearly state that if the patient cannot cope with the
procedure, one should attempt other strategies to handle the situation.
CRITERIA FOR EXPOSING CHILDREN TO IONIZING RADIATION
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 In some cases, radiographs are not possible, one should balance
the benefit against the risk even more carefully.
 Sometimes it is better to postpone the radiographic exposure
until the patient is older or better conditioned.
 The guidelines also clearly state that if there are no clinical signs
of pathology, the need for a radiographic assessment is up to the
professional’s judgment on an individual patient basis.
 Radiographs are never to be used for economic and screening
reasons since they involve a potential health risk for the patient.
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OUTLINES
RADIOGRAPHIC EXPOSURES IN
SPECIAL-NEEDS PATIENTS
• This group of patients should not be exempted
from radiographic assessment.
• The same selection criteria apply, but the
clinician must assess the ability of the patient
to cooperate before performing any imaging.
• Lateral oblique or oblique lateral radiographs
and (oblique) occlusal radiographs may prove
to be very useful in this patient population.
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OUTLINES
RADIOGRAPHIC EXPOSURES IN
SPECIAL-NEEDS PATIENTS
• If the patient cannot tolerate or cope with the
technique required, the clinician may have to
pursue an alternative treatment plan and
postpone the taking of radiographs until a more
suitable moment.
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• Dean J, Avery D, McDonald R. McDONALD AND AVERY’S DENTISTRY
FOR THE CHILD AND ADOLESCENT. 10th edition. Elsevier; 2016.
Chapter 2: Radiographic techniques.
• AAPA. Guideline on Prescribing Dental Radiographs for Infants,
Children, Adolescents, and Persons with Special Health Care Needs.
Reference Manual. 2012. 38:6; 355-357.
REFERENCES
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Arwa Namnakani

Radiograph Techniques in Pediatric Dentistry

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