Transcript Radiography for Children

Radiography for Children
Radiographs: Supplemental Data Base
• Radiographs for children are a component of the supplemental data base; not a
component of the defined data base.
• Consequently, the exposure of radiographs on a child is based on a documented need
for a specific radiograph in order to render a thorough diagnosis.
• The decision to expose radiographs should only be made after a thorough clinical
examination by the dentist.
• Exposure of radiographs is not a routine procedure or a component of any standard
protocol.
• Only a dentist can determine when and what radiographs are required. This decision
cannot be delegated.
• When radiographs are required, an informed consent from the child’s parent is
required.
• The “adequate information” of an informed consent would include explaining to the
parent the justification for exposing the radiographs for which consent is
requested.
Radiation Safety
• Parents are increasingly concerned regarding radiation
exposure of their children…as they and we should be.
• There is credible scientific evidence of a small increase in
cancer risk in individuals exposed to radiation levels
encountered in diagnostic imaging procedures.
• This is particularly important in children whose tissues are
more radiosensitive in general and whose life expectancy
provides a longer time to develop cancers resulting from
radiation exposure.
• Health professionals account for 50% of the annual per
capita radiation exposure in the United States.
Radiation Safety: Image Gently
• An initiative was launched nationally in 2007 by the Society for
Pediatric Radiology to establish an “Alliance for Radiation Safety
in Pediatric Imaging.”
• The alliance now includes over 80 organizations committed to
change clinical practices through an education and awareness
campaign called Image Gently.
• The various dental specialty organizations have joined the
effort, and in September of 2014 dentistry as a profession
officially joined the movement.
• An Image Gently website has been developed to provide
information to parents, and includes answers to frequently asked
questions.
• The website is at: www..imagegently.org
Image Gently Webpage
Six-Step Plan to Minimize Radiation Exposure
to Children in the Dental Office
1. Select radiographic views that match a patient’s individual
need for diagnosis and are not merely a routine.
2. Use the fastest image receptor possible: E or F film or
comparable digital storage system.
3. Collimate the x-ray beam to only expose the area of
interest.
4. Always use a thyroid collar.
5. Child –size the exposure. Do not use adult exposure times.
6. Use cone beam CT only when absolutely necessary, as
results in higher dose exposure.
Lead Apron with Thyroid Collar
Criteria for Exposing Radiographs
on a New Patient
• In the primary dentition, bitewing radiographs should be exposed, but
only if the proximal surface of the posterior teeth cannot be clinically
visualized.
• In the transitional dentition (after the eruption of the first molar)
bitewings and a panoramic radiograph should be exposed.
• Contacts between the primary posterior teeth become tighter as a
result of the mesial eruptive force of the first permanent molar,
closing more tightly the inter-proximals spaces between primary
molars, making them more difficult to clinically visualize.
• A panoramic film in the early transitional dentition (age 6) permits the
determination of any developmental anomalies such as congenitally
missing or supernumerary teeth.
• Individual periapicals are indicated in both the primary and
transitional dentitions based on the need to evaluate specific
circumstances, e.g. required extraction of a tooth, endodontic
procedures, or trauma to a tooth.
Criteria for Exposing Radiographs
at the Periodic Oral Examination
• The periodicity of examining a child subsequent to their initial examination
as a patient is based on the caries risk of the child, as well as the
developmental milestones.
• A discussion of assessing caries risk will occur in our next Minicourse on
Preventive Dentistry. Development milestones, and the implication for
radiographic assessment, will be discussed in our Third Year course, PDO
834.
• Based on caries risk assessment and development, children are generally
re-examined (recall appointment) at 3, 6, 12, or 18 month intervals.
• Children at low risk for dental caries may only require bitewing radiographs
infrequently, every 12-18 months.
• Children at high risk for dental caries may require bitewing radiographs at 6
month intervals, or until their risk for caries has declined.
Common Radiographic Images
• Bite-wing: To visualize proximal tooth surfaces unable to be
visualized clinically in order to determine the existence of dental
caries on the proximal surfaces. The crowns of the teeth and
only part of the root is visualized. Occlusal carious lesions are
diagnosed clinically, not radiographically.
• Periapical: To visualize the entire tooth, including the root apex.
Necessary when a tooth is indicated for extraction, for assessing
trauma, and for endodontic procedures.
• Panoramic: To visualize the entire dentition as well as the
supporting craniofacial complex.
• Occlusal: To visualize the maxillary or mandibular anterior
segment of the arches in order to view present and developing
teeth. Most frequently used in the primary dentition.
Bitewing Radiographs
Bitewing Radiographs
• A #0 film is the size used for exposing bitewings on a child in the primary dentition.
• As the first permanent molar erupts at age 6,
it is advisable to use the larger #2 bitewing
film.
• Child’s head is positioned so that ala-tragus is
parallel with the floor.
• Film is positioned in the floor of the mouth
between the tongue and lingual aspect of the
mandible. The bite-tab is positioned on the
occlusal surfaces of the posterior teeth.
• The child is instructed to close slowly.
• The X-ray cone is positioned such that it
parallels the bite-wing film and is at a vertical
angle of +10°.
Bitewing Radiograph
Diagnosing Dental Caries
on a Bitewing Radiograph
Diagnosing Dental Caries
on a Bitewing Radiograph
Periapical Radiographs
• Paralleling Technique
Rinn XCP positioning instruments
for paralleling technique to expose
periapical view.
• Bisecting Angle Technique
Rinn Snap-A-Ray Universal Sensor
Holder for Digital Radiography
Rinn Snap-A-Ray Holder
for Conventional Film
Posterior Periapical Radiographs Using
Rinn Snap-A-Ray Holder
Periapical Radiograph
Posterior Periapical to Evaluate Eruption
of First Permanent Molar
Ectopic Eruption
Maxillary Occlusal Radiograph
• Occlusal plane parallel to the
floor.
• #2 film placed with long axis
left to right, and with anterior
edge of the film extending
approximately 2 mm beyond
the incisal edge.
• Patient instructed to bite
lightly on the film.
• Central ray of the film
directed to the apices of the
central incisors.
• Vertical angle of X-ray cone is
a +60°.
Maxillary Occlusal to Identify a
Developmental Anomaly
Gemination
Maxillary Occlusal on an Asymptomatic
4 Year Old Child
Mesiodens
Mandibular Occlusal Radiograph
• Film placement for the
mandibular occlusal is
identical to that of the
maxillary.
• Film placement should be
2mm in front of incisal edge
mandibular incisors.
• Child’s head positioned so
that occlusal plane is at -45°
angle.
• The cone is aligned at a -15°
angle.
Digital Systems
• Some digital systems utilize solid-state detector technology
such as charge-coupled devices or complementary metal
oxide semiconductors for image acquisition.
• These systems are not ideal for children as young children
do not tolerate the wired sensors well.
• A phosphor-based digital system is more ideal for the child
patient. The phosphor plates have no wire to the computer
and resemble intraoral film in every way.
Panoramic Radiograph
• Panoramic radiographs can be helpful with anxious children as the
radiograph is obtained without placement of film in the mouth.
• However, remaining immobile for the required 15 seconds of the
exposure may be challenging.
• While not a substitute for intra-oral films, the panoramic radiograph
does provide a comprehensive view of the teeth and supporting craniofacial cranio-facial complex.
• Typically, a panorex is exposed at age 6-7. It provides little data of
diagnostic value prior to that age. That is the reason insurance carries
will not pay for a panorex prior to the eruption of the first permanent
molars at age 6-7.
• The major weakness of the panoramic image is that it does not
provide the detail required for diagnosing dental caries.
Panoramic Radiograph
Behavior Management
• Tell.Show.Do : TELL and SHOW the child what you are going to DO.
• For young children, the X-ray cone can be referenced as a “nose,” or
“elephant’s trunk.”
• Let the child hold the film/sensor.
• Never ask the child if you may do it…they could say “No;” an answer to be
honored.
• Work as rapidly as possible.
• Do not say “this will not hurt”…if could be somewhat uncomfortable.
• Have the X-ray cone properly positioned before placing the film in the
mouth.
• Have the child focus on an object straight ahead so that s/he does not
follow your movements.
• Use DESCRIPTIVE praise.
• For the uncooperative child, “expose” at least one film and tell the child will
finish at the next visit.
X-ray versus Radiograph
• X-rays have short wave lengths,
size of an atom. Obviously, xrays cannot be seen.
• Cause ionisations (removing or
adding electrons to atoms.)
• Affect photographic film the
same way as light: turn it black.
• Absorbed; stopped by metal and
bone.
• Pass through healthy body tissue.
• These properties make x-rays
useful in medical diagnosis and
treatment.
This is a radiograph;
it is not an x-ray!