Intraoral Radiographic Techniques (Paralleling Technique)-Chapter 2

Basic Principles
The paralleling technique of intraoral radiography was developed by Gordon M. Fitzgerald, and is so named because the object (tooth), receptor (film packet), and end of the position indicating device (PID) are all kept on parallel planes.  Its basis lies in the principle that image sharpness is primarily affected by focal-film distance (distance from the focal spot within the tube head and the film), object-film distance, motion, and the effective size of the focal spot of the x-ray tube.
Successfully using the paralleling technique depends largely on maintaining certain essential conditions as illustrated in Figure 8.  These are: 1) the film packet should be flat; 2) the film packet must be positioned parallel to the long axis of the teeth; and 3) the central ray of the x-ray beam must be kept perpendicular to the teeth and film.

 

Figure 8
 

To achieve parallelism between the film and tooth (i.e., to avoid bending or angling the film) there must be space between the object and film.  However, remember that as the object-to-film distance increases, the image magnification or distortion also increases.  To compensate, manufacturers are recessing the target (focal spot) into the back of the tube head.  Depending on the machine's age, and placement of the focal spot within the tube head, you may encounter long, medium, or short cones/PIDs.  The goal is to have the focal spot at least 12" or 30 cm from the film to reduce image distortion.
The anatomic configuration of the oral cavity determines the distance needed between film and object and varies among individuals.  However, even under difficult conditions, a diagnostic quality radiograph can be obtained provided that the film packet is not more than 20 degrees out of parallel with the tooth, and that the face of the PID/cone is exactly parallel to the film packet to produce a central beam which is perpendicular to the long axis of the tooth and the film packet.
The major advantage of the paralleling technique, when done correctly, is that the image formed on the film will have both linear and dimensional accuracy.  The major disadvantages are the difficulty in placing the film packet and the relative discomfort the patient must endure as a result of the film holding devices used to maintain parallelism.  The latter is particularly acute in patients with small mouths and in children.  In certain circumstances the film and holder may be slightly tipped toward the palate to accommodate oral space and patient comfort.  Too much palatal tipping will throw off all parallel planes.

Beam Angulation
The position of the x-ray tube head is usually adjusted in two directions: vertically and horizontally.  The vertical plane is adjusted by moving the tube head up and down.  The horizontal plane is adjusted by moving the tube head from side to side.  By convention, deflecting the head so that it points downward is described as positive vertical angulation or + vertical.  Correspondingly, an upward deflection is referred to as negative vertical angulation or - vertical (Figure 9).  The degree of vertical angulation is usually described in terms of plus or minus degrees as measured by a dial on the side of the tube head.

Figure 9
 

When applying the paralleling technique, the vertical angulation is ALWAYS dictated to maintaining the parallel plane. There is no set degree number to follow.  As stated earlier under basic principles, the object (tooth), receptor (film packet), and end of the position indicating device (PID) are all kept on parallel planes.  If the vertical angulation is excessive the image will appear foreshortened.  Insufficient vertical angulation procedures an elongated image.
The beam’s horizontal direction determines the degree of overlap among the tooth images at the interproximal spaces.  If the beam is not perpendicular to the specific interproximal space(s) as it approaches several relatively aligned objects, the objects overlap and the space(s) between them close.  Imagine a flashlight beam approaching a picket fence perpendicularly at a 90-degree angle.  The spaces between the pickets will remain open in the shadow image unless the beam angle varies from perpendicular or 90 degrees.  The degree of overlapping of the image will increase or decrease as the beam angle increases or decreases from the perpendicular.
 

Film Holding Devices
The paralleling technique requires the use of film holding devices to maintain the relatively precise positioning needed.  A great variety of film holders are commercially available—simple, complex, light, heavy, reusable, disposable, autoclavable, and non-autoclavable.  A few of the more common include XCP (extension cone paralleling) with localizing rings, Snap-a-ray, Precision rectangular paralleling device, Uni-Bite, and Stabe biteblock (Figure 10 and 11).  Having several options available will provide the operator different opportunities for enhanced patient comfort.  It is not uncommon to employ more than one option during the same radiographic survey.
 

Figure 10
 

Figure 11 

 
The dental radiographer should be able to assess which holder best conforms to the technical and diagnostic requirements of the job, the needs of the patient, and infection control protocols within the office.

(Table 1: Paralleling - Exposure Guide and Film Placement - Helpful hints when utilizing Stabe or Snap-a-ray film holders)

Paralleling - Exposure Guide and Film Placement 

Helpful hints when utilizing Stabe or Snap-a-ray film holders

BITEWINGS	Teeth to include	C.R. Entry Point	Vertical. Angulation
R Molar BWX	#1, 2, 3, 30, 31, 32 & D. of 4 & 29	contact of #2 & #3	+ 10 (down angle of PID)
R Premolar BWX	#4, 5, 28, 29 & D. of 6 and 27	contact of #4 & #5	+ 10 (down)
L Premolar BWX	D. of #11 and 22, and #12, 13, 20, 21	contact of #12 & #13	+ 10 (down)
L Molar BWX	D. of #13 and 20, 14, 15, 16, 17, 18, 19	contact of #14 & 15	+ 10 (down)

*     *     *     *     *

An imaginary plane can be visualized on the face to offer approximate C.R. placement. For Maxillary exposures, imagine the plane to extend between the ala of the nose and the tragus of the ear (a.k.a. the ala-tragus line.) For Mandibular exposures, imagine this plane to extend between the commissure of the mouth and the tragus of the ear (a.k.a. the commissure-tragus line.) Once this plane is established, the following entry points will be a guide for C.R. placement. Approximate vertical angulations are only guides and must be checked for paralleling before exposure as each person’s anatomy is different.

PERIAPICALS	Teeth to include	Approx. C.R. Entry Point	Approx. Vert. Ang.
UR Molars	#1, 2, half of #3	outer canthus of the eye	+20 - +30 (down)
UR Premolars	M. of #3, 4, 5, and half of #6	pupil of the eye	+30 - + 40 (down)
UR Canine	center #6 – c.r. at D. of 6	ala of the nose	+45 - + 55 (down)
Max. Incisors	center #7, 8, 9, 10 (I.U. method)	tip of the nose	+40 - +50 (down)
UL Canine	center #11 – c.r. at D. of 11	ala of the nose	+45 - + 55 (down)
UL Premolars	half of #11, and 12, 13, M. of 14	pupil of the eye	+30 - + 40 (down)
UL Molars	half of #14, and 15, 16	outer canthus of the eye	+20 - +30 (down)

LL Molars	#17, 18, and half of 19	outer canthus of the eye	- 5 – 0 (up angle of PID)
LL Premolars	M. of #19, and 20, 21, and half of 22	pupil of the eye	-10 - -15 (up)
LL Canine	center #22 – c.r. at D. of 22	ala of the nose	-20 - -30 (up)
Mand. Incisors	center #23, 24, 25, 26 (I.U. method)	cup the chin	-15 - -25 (up)
LR Canine	center #27 – c.r. at D. 27	ala of the nose	-20 - -30 (up)
LR Premolars	half of #27, and 28, 29 and M. of #30	pupil of the eye	-10 - -15 (up)
LR Molars	half of #30, and 31, 32	outer canthus of the eye	- 5 – 0 (up)

Care of: Willie Leeuw, CDA, BS - Indiana University Purdue University Fort Wayne , Department of Dental Assisting

Quiz

1. What is the basic principle of the paralleling technique?
2. What is the major advantage of the paralleling technique?
3. What are the major disadvantages?
4. What must be done to achieve parallelism between the tooth and film?
5. List several devices available to position the film properly when using the paralleling technique.

Answers

1. The film packet must be positioned parallel to the long axis of the teeth and the x-ray beam must be kept perpendicular to the teeth and film.
2. Linear and dimensional accuracy.
3. Difficulty in placement of the film packet, relative discomfort to the patient caused by film holding devices.
4. The film must be placed away from the tooth.
5. XCP with localizing rings, Snap-a-ray, Precision rectangular devices, Uni-Bite, and Stabe biteblock.

Paralleling Technique Methodology
When taking a full mouth survey, a definite order of exposure should be preplanned and then followed.  Since patients tolerate anterior films better, they should be done first.  Starting with the maxillary central incisors and proceeding distally, first along one side, then the other, is recommended.  The radiographic parameters or exposure factors should also be determined prior to placing films in the patient’s mouth. 

Patient Positioning
When positioning a patient, there are two imaginary planes that must be considered.  The occlusal plane runs horizontally, dividing the patient’s head into upper and lower portions. 

It can be visualized by imagining the patient holding a ruler between his or her teeth.  A midsagittal plane divides a mass (the patient’s head or body) on a vertical dimension into equal right and left portions.
When using the paralleling technique to examine the maxillary region, the patient is positioned so that the occlusal plane of the maxilla is parallel to the floor and the sagittal plane of the patient’s head is perpendicular to the floor.
When paralleling the mandibular region, the patient’s position must be modified slightly so that when the mouth is open, the mandible is parallel to the floor and the sagittal plane is perpendicular.  This could mean that the patient must be tilted back in the chair.
Before any radiographs are exposed, the patient must be protected with a lead apron and thyroid collar. The apron must be properly placed to avoid interference with the radiographic exposure.  (Figure 12)

Figure 12

Full Mouth Exposure with the Use of XCP Device

Procedure for the Maxillary Central/Lateral Incisors

Assemble the anterior film holder and insert the film packet vertically on the anterior biteblock. Use a #1 film.
Center the film on the central/lateral incisors (Figure 13). Position the film in the palate as posteriorly as possible so that the entire tooth length will appear on the film, with approximately a one-eighth inch border of the film extending below the incisal edge of the centrals. Position the biteblock on the incisal edges of the teeth to be radiographed (Figure 14). Proper positioning in this step will place the central ray of the x-ray beam at the interproximal contact desired.

 

Figure 13

Figure 14

1. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient comfort.  Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
2. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close to the aiming ring, and center (Figure 15).  
3. Follow the film and equipment manufacturer’s recommendation concerning exposure factors.  Make the exposure. 

Figure 15 

Procedure for the Maxillary Canines

1. Assemble the anterior film holder and insert the film packet vertically on the anterior biteblock.  Use a #1 film.
2. Center the film on the canine and first premolar (Figure 16).  Position the film in the palate as posteriorly as possible so that the entire tooth length will appear on the film with approximately a one-eighth inch border below the incisal edge of the canine.  Position the biteblock on the incisal edges of the teeth to be radiographed (Figure 17).  Proper positioning in this step will place the central ray of the x-ray beam at the interproximal contact desired.
3. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
4. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close to the aiming ring, and center (Figure 18).
5. Follow the film and equipment manufacturer’s recommendation concerning exposure factors. Make the exposure.

Figure 16

Figure 17

Figure 18

Procedure for the Maxillary Premolars

1. Assemble the posterior film holder and insert the film packet horizontally in the posterior biteblock.  Use a #2 film.
2. Center the film on the premolars so that it is parallel to the long axis of the teeth (Figure 19).  Position the film in the palate so that the entire tooth length will appear on the film with approximately a one-eighth inch border below the cuspal ridge.  Align the anterior edge of the film packet with the canine so that the image captured on the anterior border of the film will include the distal third of the canine.  Position the biteblock on the occlusal surfaces of the teeth to be radiographed (Figure 20).  Proper positioning in this step will place the central ray of the x-ray beam at the interproximal contact desired.
3. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient comfort.  Ask the patient to slowly, but firmly, bite onto the block to maintain film position.  (The occlusal border of the film tends to slip lingually.)
4. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close to the aiming ring, and center (Figure 21).
5. Follow the film and equipment manufacturer’s recommendation concerning exposure factors.  Make the exposure. 

Figure 19
 
Figure 20

Figure 21

Procedure for the Maxillary Molar Region

1. Assemble the posterior film holder and insert the film packet horizontally in the posterior biteblock.  Use a #2 film.
2. Center the film on the molars so that it is parallel to the long axis of the teeth (Figure 22).  Position the film in the palate so that the entire tooth length will appear on the film with approximately a one-eighth inch border below the cuspal ridge.  Align the anterior border of the film packet with the second premolar so that the image captured on the anterior edge of the film will be the distal third of the second premolar.  Position the biteblock on the occlusal surfaces of the teeth to be radiographed (Figure 23).  Proper positioning in this step will place the central ray of the x-ray beam at the interproximal contact desired.
3. A cotton roll may be inserted between the mandibular teeth and the biteblock for patient comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position.
4. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close to the aiming ring, and center (Figure 24).
5. Follow the film and equipment manufacturer’s recommendation concerning exposure factors.  Make the exposure.

Figure 22

Figure 23

Figure 24

Procedure for the Mandibular Central/Lateral Incisors

1. Assemble the anterior film holder and insert the film packet vertically on the anterior biteblock.  Use a #1 film.
2. Center the film on the mandibular central and lateral incisors (Figure 25).  It may be necessary to displace the tongue distally and depress the film onto the floor of the mouth so that the entire tooth length will show with approximately a one-eighth inch border above the incisal edges.  The film must be as posterior as the anatomy allows and the biteblock should be positioned on the edges of the incisors to be radiographed (Figure 26).  Proper positioning in this step will place the central ray of the x-ray beam at the interproximal contact desired.
3. A cotton roll may be inserted between the maxillary teeth and the biteblock for patient comfort.  Ask the patient to slowly, but firmly, bite onto the block to maintain film position.  The film should be straightened as the patient closes and the floor of the mouth relaxes.
4. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close to the aiming ring, and center (Figure 27).
5. Follow the film and equipment manufacturer’s recommendation concerning exposure factors.  Make the exposure.

Figure 25

Figure 26

Figure 27

Procedure for the Mandibular Canines

1. Assemble the anterior film holder and insert the film packet vertically on the anterior biteblock.  Use a #1 film.
2. Center the film on the mandibular canine (Figure 28).  It may be necessary to displace the tongue distally and depress the film onto the floor of the mouth so that the entire tooth length will show with approximately a one-eighth inch border above the cuspal edge.  The film must be as posterior as the anatomy allows and the biteblock should be positioned on the edges of the teeth to be radiographed (Figure 29).  Proper positioning in this step will place the central ray of the x-ray beam at the interproximal contact desired.
3. A cotton roll may be inserted between the maxillary teeth and the biteblock for patient comfort.  Ask the patient to slowly, but firmly, bite onto the block to maintain film position.  The film should be straightened as the patient closes and the floor of the mouth relaxes.
4. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close to the aiming ring, and center (Figure 30).
5. Follow the film and equipment manufacturer’s recommendation concerning exposure factors.  Make the exposure. 

Figure 28

Figure 29

Figure 30

Procedure for the Mandibular Premolars

1. Assemble the posterior film holder and insert the film packet horizontally on the posterior biteblock.  Use a #2 film.
2. Center the film on the premolars so that it is parallel to the long axis of the teeth (Figure 31).  The object-to-film distance in both the mandibular premolar and molar regions is minimal since the oral anatomy only allows the film to be positioned very close to the teeth and still remain parallel.  Align the anterior border of the film packet with the canine so that the image captured on the anterior edge of the film will be the distal third of the canine.  Position the biteblock on the occlusal surfaces of the teeth to be radiographed (Figure 32).  Proper positioning in this step will place the central ray of the x-ray beam at the interproximal contact desired.
3. A cotton roll may be inserted between the maxillary teeth and the biteblock for patient comfort. Ask the patient to slowly, but firmly, bite onto the block to maintain film position. The film should be straightened as the patient closes and the floor of the mouth relaxes.
4. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close to the aiming ring, and center (Figure 33).
5. Follow the film and equipment manufacturer’s recommendation concerning exposure factors.  Make the exposure. 

Figure 31

Figure 32

Figure 33

Procedure for the Mandibular Molars

1. Assemble the posterior film holder and insert the film packet horizontally on the posterior biteblock.  Use a #2 film.
2. Center the film on the molars so that it is parallel to the long axis of the teeth (Figure 34).  Depress the film onto the floor of the mouth so the entire length of the teeth will appear with approximately a one-eighth inch border above the occlusal surface.  Place the film horizontally and position it lingually to the molars so that the long axis of the film is parallel to the long axis of the tooth.  Align the anterior border of the film packet with the second premolar so that the image captured on the anterior edge of the film will be the distal third of the second premolar.  Position the biteblock on the occlusal surfaces of the mandibular teeth (Figure 35).  Proper positioning in this step will place the central ray of the x-ray beam at the interproximal contact desired.
3. A cotton roll may be inserted between the maxillary teeth and the biteblock for patient comfort.  Ask the patient to slowly, but firmly, bite onto the block to maintain film position.  The film should be straightened as the patient closes and the floor of the mouth relaxes.
4. Slide the aiming ring down the indicator rod to the skin surface, align the x-ray tube close to the aiming ring, and center (Figure 36).
5. Follow the film and equipment manufacturer’s recommendation concerning exposure factors. Make the exposure.

Figure 34

Figure 35

Figure 36

 Quiz

1. What is the recommended patient positioning for examining the maxillary region using the paralleling technique?
2. What is the recommended patient positioning for examining the mandibular region using the paralleling technique?

Answers

1. The occlusal plane of the maxilla is parallel to the floor and the sagittal plane of the patient’s head is perpendicular to the floor.
2. When the mouth is open, the mandibular occlusal plane is parallel to the floor and the sagittal plane of the patient’s head is perpendicular to the floor.

Intraoral Radiographic Techniques- Introduction (Chapter 1)

Introduction
Radiography involves the use of x-radiation and thus is potentially dangerous if mishandled. For your own sake, and that of the staff, patient, and public, it is essential that you gain adequate knowledge of radiographic techniques and radiation health and safety, prior to performing clinical procedures.
This course is intended to provide current, vital information on film and tube head placement, to serve as a guide to acquire new skills or refine current skills, and allow you to test yourself as you progress through the pages.
When you complete a continuing education course on the Dental ResourceNet, a form will come up that requests your name, address, etc.  If you are a member of the AGD, make sure to fill out the field that asks for your AGD membership number (if you are not an AGD member, leave blank).  When you hit submit, a copy of the "proof of completion" is e-mailed directly to the AGD and P&G. For your records, make sure to print a copy of the "proof of completion" certificate.

Overview
Radiography involves the use of x-radiation and thus is potentially dangerous if mishandled. For your own sake, and that of the staff, patient, and public, it is essential that you gain adequate knowledge of radiographic techniques and radiation health and safety, prior to performing clinical procedures.
This course is intended to provide current, vital information on film and tube head placement, to serve as a guide to acquire new skills or refine current skills, and allow you to test yourself as you progress through the pages

Objectives of this Article
Upon the completion of this Article, the dental professional will be able to:

• Understand the basic principles and concepts of intraoral procedures.
• Demonstrate the paralleling technique of intraoral radiology.
• Explain the bisecting angle technique of intraoral radiology.
• Identify proper techniques for bitewing radiography.
• Describe intraoral occlusal techniques.

Article Contents

• Introduction
• Intraoral Procedures
• Paralleling Technique
• Paralleling Technique Methodology
• The Bisecting Angle Technique
• Bisecting Angle Methodology
• Bitewing Radiography
• Intraoral Occlusal Radiography
• Digital Radiology
• Summary
• Glossary
• Course Test
• About the Authors

Introduction

Radiography involves the use of x-radiation and thus is potentially dangerous if mishandled.  For your own sake, and that of the staff, patient, and public, it is essential that you gain adequate knowledge of radiographic techniques and radiation health and safety, prior to performing clinical procedures. 
This course is intended to provide current, vital information on film and tube head placement, to serve as a guide to acquire new skills or refine current skills, and allow you to test yourself as you progress through the pages.

Intraoral Procedures

Introduction
The intraoral radiograph, when correlated with the case history and clinical examination, is one of the most important diagnostic aids available to the dental practitioner.  When examined under proper conditions, diagnostic-quality intraoral radiographs reveal evidence of disease that cannot otherwise be found. They also play a major role in forensic identification.
Two of the fundamental rules of radiography are that 1) the central beam should pass through the area to be examined, and 2) the x-ray film should be placed in position so as to record the image with the least amount of image distortion. Each of three types of intraoral radiologic examinations commonly used in dental practice—periapical, bitewing (interproximal), and occlusal examinations—depend on the operator’s adherence to these two rules even though specific techniques, processes, and indications differ widely among them.
Another aspect that these three examinations have in common pertains to the film packet.  The film packet has two sides, a tube side and a tongue side.  The tube side may be plain or textured.  When placed intraorally, the tube side always faces the radiation source, the tube head.  The tongue side may be colored and has a flange to open the packet and remove the film.  When placed intraorally, the tongue side always faces the patient’s tongue, except in the case of the mandibular occlusal examination.
Because of patient anatomic variations such as narrow arches, missing teeth, or the presence of tori, and limitations of the patient’s ability to open sufficiently (caused by age or other factors), or maintain the film placement, a clinical examination must precede the taking of films.  After the clinical examination, the operator can determine the number and size of films to expose, the technique modifications necessary, and the type of film retention devices to be employed.
Advancements are continually being made in the development and manufacturing of the actual film packet.  These advancements have helped to decrease radiation exposure.  Whenever possible the "fastest" film speed should be used.

Periapical Radiographs

The purpose of the intraoral periapical examination is to obtain a view of the entire tooth and its surrounding structures, as in Figure 1.  Two exposure techniques may be employed for periapical radiography: the paralleling technique and the bisecting angle technique.  The paralleling technique is the preferred method.  This technique provides less image distortion and reduces excess radiation to the patient.  The paralleling technique should always be attempted before other techniques.  The bisecting technique can be employed for patients unable to accommodate the positioning of the paralleling technique.  Candidates may include those with low palatal vaults and children.  Disadvantages to the bisecting technique include image distortion and excess radiation due to increased angulations involving the eye and thyroid glands.  Regardless of the technique, however, the rules of radiography referred to earlier must be followed.

 

Figure 1

Bitewing Radiographs
Bitewing examinations were introduced by Raper in 1925.  The greatest value of bitewing radiographs is the detection of interproximal caries in the early stages of development, before it is clinically apparent.  The arrows in Figure 2 indicate areas of interproximal caries.  Bitewing projections also reveal the size of the pulp chamber and the relative extent to which proximal caries have penetrated.
Bitewings also provide a useful adjunct to evaluating periodontal conditions, offer a good view of the septal alveolar crest, and, in addition, permit changes in bone height to be accurately assessed by comparison with adjacent teeth.  Bitewings do not show the apices of the teeth and cannot be used to diagnose in this area.

 

Figure 2

Occlusal Radiographs

Occlusal radiography is a supplementary radiographic examination designed to provide a more extensive view of the maxilla and mandible (Figure 3).

 

Figure 3

The occlusal radiograph is very useful in determining the buccolingual extension of pathologic conditions, and provides additional information as to the extent and displacement of fractures of the mandible and maxilla.  Occlusals also aid in localizing unerupted teeth, retained roots, foreign bodies, and calculi in the submandibular and sublingual salivary glands and ducts.  It should be noted that when imaging soft tissues exposure time needs to be appropriately reduced.

Dentulous Adult Survey
The number of films needed for a full mouth series varies greatly.  Some practitioners may prefer 10 films, while others may prefer 18, 20 or more exposures.
The selection of film sizes used in a full mouth series also varies.  A full survey can consist of narrow anterior film (size #1); standard adult film (size #2); #2 bitewing film or long bitewing film (size #3), (Figure 4) and may include anterior bitewings.  It is generally recommended to use 20 films --- four bitewings and 16 periapicals.  Eight anterior #1 films will allow for ease of film placement on patients with narrow palates.  However, in some cases six anterior periapicals will cover the area needed.  

By using #3 film only one film is used on both the right and left sides and opening both the premolar and molar contacts on one film is very difficult. (Figure 5)  With the use of #2 films for bitewings, the operator uses a total of four films. 

Each film is assigned either premolars or molars. (Figure 6)  Use of the #2 films instead of #3 films for bitewings is not only more comfortable for the patient but is easier for the operator to open the contacts.

Figure 5

Figure 6

Edentulous Adult Survey
By definition, an edentulous patient is one without the natural dentition, and a partially edentulous patient is one who retains some, but not all of the natural dentition.  Merely because a patient’s clinical exam reveals an edentulous state does not disqualify him or her from diagnostic radiographic examination.  In fact, it is commonly accepted that certain areas of the patient’s jaws may contain tooth roots or impacted teeth.  Residual infection, tumors, cysts, or related pathology may also be found, which, while not visible to the clinician, would hinder the effectiveness and comfort of an appliance such as a denture and could potentially cause life threatening conditions to the patient.  In addition to the hidden pathology mentioned above, edentulous surveys reveal the position of the foramina and the type of bone present.
In the case of the partially edentulous patient, placement of the film holding device may be complicated by its tendency to tip or slip into the voids which would normally be occupied by the crowns of the missing teeth.  This can usually be overcome by placing cotton rolls between the patient’s alveolar ridge and the film holder, thereby supporting the film holding device in position.
A 14 or 16 film intraoral periapical survey will usually examine the tooth bearing region in most edentulous patients (Figure 7).  Bitewings are not needed because there are no interproximal areas to be examined.

Figure 7

The use of film holders allow the paralleling technique to be used with edentulous patients.  The operator may be able to reduce radiation exposure in the edentulous patient by 25% by using the paralleling technique.  The film can be held in biteblocks to which cotton rolls have been taped.  To prevent patient discomfort on biting due to missing teeth and resultant over-closing of the arches, the cotton rolls can be attached to the upper and lower surfaces of the biteblocks.  Opposing arch denture or partial denture appliances can be left in place to make contact with the biteblock.
The radiographic film should be positioned with approximately one-third of the film’s vertical dimension protruding beyond the alveolar ridge; that is, the radiographic image should occupy two-thirds of the film. The horizontal angulation of the central beam is perpendicular to the film in the horizontal plane.  If bisecting, the vertical angulation of the central beam is much increased for an edentulous patient with minimal ridges.  The film placement may be similar to that of an occlusal film, and this flat film placement is the principal cause of dimensional distortion.  To determine vertical angulation it is necessary to estimate the long axis of the ridge instead of the tooth.



Mixed Dentition Survey
The full mouth survey for pediatric patients may vary, depending on the patient’s age, eruption pattern, behavior, and the size of the child’s mouth. In the six to nine-year-old group, a 12 film survey, using #1 narrow film is recommended, and would include:

• Maxillary:
• Central incisors
• Right and left lateral incisors and canines
• Right and left primary/permanent molars
• Mandibular:
• Central incisors
• Right and left lateral incisors and canines
• Right and left primary/permanent molars
• Bitewings:
• Right and left primary/permanent molars

An adult-sized periapical film is used in the posterior region if the child’s first permanent molar is fully developed.  The size of the tooth requires the use of a large periapical film to capture the complete image.

Pre-School Child Survey
Since pre-school children have smaller mouths, reduced size pediatric films (film size #0) are used to examine the posterior teeth, and adult films are used for anterior examinations in children who have only primary (deciduous or "baby") teeth.  For this group, an eight film survey is recommended.

• Maxillary:
• Central incisors
• Right and left primary molars
• Mandibular:
• Central incisors
• Right and left primary molars
• Bitewings:
• Right and left primary molars 
  

The paralleling technique should be used whenever possible.  This technique delivers the lowest dose of radiation possible.  The bisecting angle technique is a viable alternative for pediatric radiography because the apices of the permanent molar teeth tend to lie above the palate and below the floor of the mouth in the undeveloped mandible.  These positions prevent the image of the apices of the teeth from being projected into the oral cavity when the x-ray beam is perpendicular to the long axis of the teeth as it is when using the paralleling technique.

Quiz

1. What should be done before any radiographic examination?
2. What are the fundamental rules of radiography?
3. What is the purpose of the intraoral periapical examination?
4. What are the two primary techniques used in periapical radiography?
5. What is the primary purpose of bitewing radiographs?
6. What else can be accurately assessed with bitewings?
7. List five indications for taking occlusal radiographs.
8. What sizes of periapical films are commonly used in a dentulous adult survey?
9. Why should a radiographic examination be performed for a clinically edentulous patient?
10. How should film be positioned relative to the alveolar ridge?

Answers

1. A good clinical examination should be carried out before every radiographic examination.
2. The central beam should pass through the area to be examined and the x-ray film should be placed in position to record the image with the least amount of distortion.
3. To obtain a view of the entire tooth and surrounding structures.
4. Paralleling and bisecting angle technique.
5. The detection of caries in the early stages of development.
6. The detection of periodontal disease in the early stages.
7. Detection of pathological lesions; fractures of the mandible and maxilla; foreign bodies; salivary calculi; localizing unerupted teeth.
8. Number 1, 2 and 3 film.
9. It is commonly accepted that certain areas in the jaws may contain roots, impacted teeth, residual infections, tumors, cysts, etc.
10. The film should be placed with approximately one-third of the vertical dimension protruding beyond the alveolar ridge.

Vital Signs: Respiratory Rate

There  is  only  limited  research  relating  to monitoring  respiratory  rate,  and  these studies  focused  on  issues  such  as  the inaccuracy of respiratory rate measurement and  respiratory  rate  as  a  marker  for respiratory dysfunction. 

Inaccuracies  in  respiratory  measurement have  been reported in the literature. One study  compared  respiratory  rate  counted using a 15 second count  period, to  a full minute,  and  found  significant  differences in the rates. Respiratory rates measurement in children under five years, for a 30 second  or  60  second  period,  suggesting the 60 seconds resulted in the least variability. 

Another study found that rapid respiratory rates  in  babies,  counted  using  a  stethoscope, were 20% to 50% higher than those counted from beside the cot without the aid of the stethoscope. 

The value of respiratory rate as an indica- tor of potential respiratory dysfunction has been investigated but findings suggest it is of limited value. One study found that only 33% of people presenting to an emergency department  with  a  oxygen  saturation  below 90% had an increased respiratory rate. 

An  evaluation  of  respiratory  rate  for  the differentiation  of  the  severity  of  illness  in babies under  6 months found it  not  to be very useful. Approximately half of the babies  had  a  respiratory  rate  above  50 breaths per minute, thereby questioning the value  of having a "cut-off" at 50 breaths per minute as the indicator of serious respiratory illness. It has also been reported that factors such as crying, sleeping, agitation and age have a significant influence on the respiratory rate. As a result of these and  similar  studies  the  value  of  respiratory rate as an indicator of serious illness is limited.

Vital Signs: Pulse Rate

There  has  been  very   little  research evaluating the measurement of pulse rates. It  is  likely,  that  when  heart  rate  is  of concern,  cardiac  monitors  are  used  to determine not  only rate, but  also rhythm. The  role  of the "pattern of the pulse", for example  regular  pulse  versus  irregular pulse  or  strong  pulse  versus  weak  pulse, have not been addressed in the context of vital signs or patient observations. On this basis,  an  important  role  of  pulse  rate monitoring will likely be  to  identify when more advanced monitoring is required. 

Measurement  of  a  person's  pulse  rate  in the  presence  of  atrial  fibrillation  was evaluated  and  results  suggest  that  pulse rate,    measured    apically    using    a stethoscope for a 60 second count period, is likely to be the most accurate rate. This study  noted  that  86%  of  nurses  underestimated  the  pulse  rate,  and  that  as  the heart rate increased the magnitude of error also      increased.      Another      study recommended a 30 second count  period as the most accurate and efficient way of measuring  pulse  rate,  noting  that  the  15 second count time was the least accurate. A  third  study  found  that  there  was  no advantage in using the longer 60 seconds, over  the  15 or  30 second count  periods. These researchers suggest that counting an accurate pulse rate may be more difficult than commonly recognised. 

A study assessing infants apical pulse rate using a stethoscope, suggested that length of  time  may  not  be  the  primary  factor  in errors, and that like respiratory rate, pulse rate also appears to be influenced by infant states in addition to illness.

While these studies have identified that the accuracy  of  pulse  rate  measurements  is influenced by the number of seconds that the   pulse   is   counted,   the   clinical significance of these findings is unclear. The contradictory  findings  of  studies  suggest that  the  count  period  used  to  determine pulse rate is of only limited significance.