Review of Radiographic Review of Radiographic Techniques for the Paediatric Techniques for the Paediatric PatientPatient

Objectives of this LectureObjectives of this Lecture

Understand the rationale for radiographic examination in children and adolescents,

Be aware of the indications for radiographs in children and adolescents,

Use the indicated radiographic technique, dependant on the age of the child and caries activity,

Review the principles of proper radiographicexamination.

Rationale- Primary DentitionRationale- Primary Dentition

In a population the use of bitewing radiography in addition to clinical examination increases the number of approximal lesions detected by a factor of between two and eight (Faculty, 1998, Stephen et al.,

1987, Kidd and Pitts, 1990).

Cont…. Cont….

Recent studies have shown that even in populations with an overall low caries prevalence, more than 1/3 of 5-year-olds in Sweden and Norway had approximal carious lesions that could not be detected by visual inspection (Boman et al., 1999, Raadal et al., 2000).

In a Dutch study (Roeters, 1992) between 10 and 60% extra information was gained by the use of the bitewing radiographs in the 5-year old age group.

Rationale- The Mixed Dentition Rationale- The Mixed Dentition

At the age of 9 about 1/3 of Swedish children had dentin caries in at least one distal surface of the second primary molar as judged radiographically.

It was also shown that enamel or dentin caries in the distal surface of the second primary molar increased the risk about 15 times for the mesial surface of the first permanent molar to develop approximal caries. (Mejare and Stenlund, 2000, Kallestal et al., 2000).

Cont….Cont….

Bitewing radiographs are also useful for deciding the proper interval to the next bitewings.

Children who are caries-free in approximal surfaces in their primary teeth at the age of 8-9 are likely to remain so up to at least the age of 12 (Mejare et al., 2001). Therefore, bitewing radiographs should be considered at the age of 8-9.

Rationale- The Young Permanent Rationale- The Young Permanent Dentition Dentition

Baseline bitewing radiographs in the permanent dentition should be considered at the age of 12-14, that is 1- 2 years after eruption of premolars and second molars. This concerns also populations with an, overall low caries prevalence (de Vries et al., 1990).

RationaleRationale

Should not be performed in a routine manner using the same practice for all individuals.

Should only be performed when the patient history and/or objective findings and symptoms lead to the conclusion that further useful information might be obtained.

If a radiograph is not expected to change diagnosis or treatment or add other useful information, it should not be taken.

What are the clinical situations for What are the clinical situations for which radiographs may be indicatedwhich radiographs may be indicated

A. Positive Historical Findings,

B. Positive Clinical Signs/Symptoms

Positive Historical FindingsPositive Historical Findings

1. History of pain or trauma

2. Previous pulp therapy

3. Familial history of dental anomalies

4. Postoperative evaluation of healing

Positive Clinical Signs/SymptomsPositive Clinical Signs/Symptoms1. Deep carious lesions2. Large or deep restorations3. Swelling4. Fistula or sinus tract infection 5. Clinical evidence of periodontal disease 6. Mobility of teeth 7. Evidence of facial trauma8. Evidence of foreign objects 9. Oral involvement in known or suspected

systemic disease10. Clinically suspected sinus pathology

Cont….Cont….

11. Growth abnormalities

12. Missing teeth with unknown reason.

13. Unusual tooth morphology, calcification or color

14. Malposed or clinically impacted teeth

15. Unusual eruption, spacing or migration of teeth

16. Unexplained bleeding

17. Pain and/or dysfunction of the temporomandibular joint

18. Facial asymmetry

19. Positive neurologic findings in the head and neck

20. Unexplained sensitivity of teeth

21. Abutment teeth for fixed or removable partial prosthesis

General Indications for Radiographs in General Indications for Radiographs in Children and AdolescentsChildren and Adolescents

The major reasons for taking radiographs in paediatric dentistry of teeth and supporting tissue are: o Detection of caries; o Dental injuries; o Disturbances in tooth development,o Examination of pathological conditions other

than caries.

General Indications for Radiographs in General Indications for Radiographs in Children and AdolescentsChildren and Adolescents

Clinical Indications for the Clinical Indications for the Paediatric Patient’s RadiographyPaediatric Patient’s Radiography

Bitewing Radiographs

Periapical Radiographs

Occlusal Radiographs

Panoramic Radiographs

Clinical indications for Bitewing Clinical indications for Bitewing RadiographsRadiographs

Detect caries that cannot otherwise be detected,

Estimate the extent of lesions (3D??),

Monitor lesion progression,

Determine pulp chamber configuration,

Determine in some instances the presence or

absence of premolar crowns.

Clinical indications for Periapical Clinical indications for Periapical RadiographyRadiography

Detection of pathologic changes associated with primary teeth (such as apical infection/inflammation or internal resorption)

After trauma to the teeth and associated alveolar bone, Detect developmental abnormalities, Assessment of the presence and position of unerupted teeth, Assessment of the periodontal status, Assessment of root morphology before extractions, Detailed evaluation of apical cysts and other lesions within the

alveolar bone, In some space analysis techniques in the mixed dentition (e.g.

Nance technique).

Clinical indications for Occlusal Clinical indications for Occlusal RadiographyRadiography

Determine the presence, shape and position of midline supernumerary teeth,

Determine impaction of canines,

Determine the presence or absence of incisors,

Asses the extent of trauma to teeth and anterior arches.

Clinical indications for Panoramic Clinical indications for Panoramic RadiographyRadiography

It’s supplement to rather than substitute for intra-oral radiographs.

Diagnose missing and supernumerary teeth, Detect gross pathoses, Asses development of the dentition, Estimate the dental age of the patient, Detect bone fractures, traumatic cysts, Detect anomalies, In some patients with disabilities (if the patient

can sit in a chair and hold head in position).

Radiography GuidelinesRadiography Guidelines

Guidelines are designed to:

o Avoid unnecessary exposure to X-radiation,

o Identify individuals who may benefit from a radiographic examination.

Every prescription of radiographs should be based on an evaluation of the individual patient benefit.

Radiography GuidelinesRadiography Guidelines

Routine survey by radiographs (except for caries) has not been shown to provide sufficient information to be justified considered the balance between cost (radiation and resources) and benefit.

Keywords for good practice are appropriate

selection criteria for the use of radiography, optimised radiation protection, and utilization of the total amount of information in each radiograph.

Patient Category

Child Adolescent

Primary Dentition (Prior to eruption of the 1st permanent tooth)

Mixed Dentition (Following eruption of the 1st permanent tooth)

Permanent Dentition (Prior to the eruption of the 3rd molars)

New Patient

All new patients in order to assess dental disease & growth & development.

1. Periapical /occlusal views &/or

2. Posterior bitewing exam’n if proximal surfaces of primary teeth

cannot be visualized.

Individualized radiographic examination consisting of:

1. Periapical /occlusal views and posterior bitewings or

2. Panoramic examination and posterior bitewings.

Individualized radiographic examination consisting ofPosterior bitewings and selected periapicals.

N.B: A complete mouth Radiographic examination is appropriated when the patient presents with clinical evidence of generalized dental disease or a history of excessive dental treatment.

Patient Category

Child Adolescent

Primary Dentition (Prior to eruption of the 1st permanent tooth)

Mixed Dentition (Following eruption of the 1st permanent tooth)

Permanent Dentition (Prior to the eruption of the 3rd molars)

Recall Patient

Clinical caries or high risk factors.

Posterior bitewing examination at 6-12 month intervals if proximal surfaces…...

Posterior bitewing examination at 6 to 18 month intervals

No clinical caries and no high risk factors for caries.

Posterior bitewing examination at 12 to 24 month intervals.

Posterior bitewing examination at 18 to 36 month intervals.

Patients at high risk for caries may Patients at high risk for caries may demonstrate any of the followingdemonstrate any of the following

1. High level of caries experience

2. History of recurrent caries

3. Existing restoration of poor

quality

4. Poor oral hygiene

5. Inadequate fluoride exposure

6. Prolonged nursing (bottle or

breast)

7. Diet with high sucrose

frequency.

8. Poor family dental health

9. Developmental enamel defects

10. Developmental disability

11. Xerostomia

12. Genetic abnormality of teeth

13. Many multisurface restorations

14. Chemo/radiation therapy

Patient Category

Child Adolescent

Primary Dentition (Prior to eruption of the first permanent tooth)

Transitional Dentition (Following eruption of the 1st permanent tooth)

Permanent Dentition (Prior to the eruption of the third molars)

Recall Patient

Periodontal disease, or a history of periodontal therapy.

CLINICAL JUDGMENTIndividualized radiographic examination consisting of selected periapicals and posterior bitewings for areas where periodontal disease (other than non-specific gingivitis) can be demonstrated clinically.

Growth and development

CLINICAL JUDGMENT

CLINICAL JUDGMENT

Periapical or panoramic examination to assess developing third molars.

Principles for Proper RadiographicPrinciples for Proper RadiographicExaminationExamination

The foundation of an accurate diagnosis and treatment plan is based on:

o Comprehensive medical and dental history,

o A thorough clinical examination,

o Diagnostic radiographs.

Of the three, obtaining diagnostic radiographs in the pediatric dental patient is probably the most difficult to accomplish, not only from a technical standpoint but because of parental fears and misconceptions.

Communicating with ParentsCommunicating with Parents

1. During the first appointment, the clinician reduces a parent’s resistance to the use of radiographs by informing the parents of the diagnostic need for radiographs and educating them about current radiation hygiene practices and radiographic techniques.

2. It should be emphasized that visual examination reveals only three of the five surfaces of the teeth because if the child’s teeth are close together the dentist cannot see between them..

Cont….Cont….

3. Furthermore, the dentist cannot see the insides of the teeth, their roots, nor the permanent teeth developing in the jaws

4. Although excessive radiation exposure can result in cancer, birth defects and genetic defects, the amount of radiation needed to expose the newer X-ray film has significantly reduced the amount of radiation to which patients are exposed.

Informed consentInformed consent

The patient or parents have a legitimate right to be heard and approve the clinician’s advice about any radiographic examination.

The clinician has to consider and respect the views, values and preferences, which the patient and or family express after having received and understood the information provided.

However, strong recommendations might be appropriate when the clinician finds the examination highly beneficial for the patient.

If the recommendations of guidelines are not followed, the reasons should be discussed with the patient and recorded in the clinical case notes.

Management Techniques Management Techniques

In the rare occasion when a very young dental patient under three years of age needs a radiograph, the dental office should be prepared with techniques to reduce any psychological trauma.

Cont….Cont….

1. Explain what you plan to do in words that are easily comprehended.

2. Use a tell, show, do technique:

a. Explain to the child that a tooth camera will be used to take a picture of their tooth.

b. Allow them to touch and examine the radiographic film and camera.

3. To gain maximum cooperation in children under three years, it may be necessary for the child to sit in the parent’s lap while exposing the radiograph

Cont….Cont….

Start with the least difficult radiograph first (such as an anterior occlusal)

The correct settings are made on the apparatus and the X-ray head is properly positioned before placing the film in the child’s mouth.

A positioning device such as a Snap-A-Ray instrument can be used to aid the parent in positioning and securing the film.

Adequately protect the parent and child with lead aprons to reduce radiation exposure. If the child is uncooperative, then

Cont….Cont….

It may be necessary to

restrain the child in a

“papoose board”.

This frees the parent to

stabilize the child’s

head and properly

position the radiograph

in the child’s mouth.

Cont….Cont….

If the child is still uncooperative, it may be necessary to manage the child pharmacologically with inhalation, oral, or parental sedatives

Radiographic Film Sizes for the Radiographic Film Sizes for the Paediatric PatientPaediatric Patient

Size “0”: used for bitewing and periapical radiographs in young children (up to 4-5 yrs),

Size “1”: used in older children to take bitewing and periapical radiographs (up to 7-8 years),

Size “2”: used for anterior occlusal, periapical and bitewing radiographs in the mixed and permanent dentitions,

Occlusal: used for anterior occlusal views, complete quadrant views and survey the handicapped

Radiographic TechniquesRadiographic Techniques

The main technical problem encountered in children is the size of their mouths and the difficulty in placing the film packet intraorally. The paralleling technique is not possible in very small children, but can often be used (and is recommended) anteriorly, for investigating traumatized permanent incisors.

A modified bisected angle technique is possible in most children, with the film placed flat in the mouth (in the occlusal plane) and the position of the X-ray tube head adjusted accordingly

Film HoldersFilm Holders

A Hawe–Neos Superbite posterior holder (red). B Hawe–Neos Superbite anterior holder (green). C Rinn XCP posterior holder (yellow). D Rinn XCP anterior holder (blue) with film packet inserted. E Unibite® posterior holder.

A the Masel Precision all-in-one metal holder and B the Rinn XCP holder with its additional metal collimator attached to the white locator ring.

Snap-A-Ray

Examples Examples

Detection of Dental CariesDetection of Dental Caries

Coronal radiolucencyCoronal radiolucency

A term used to describe an anomaly presenting as an abnormal radiolucency resembling caries within the coronal tissues of unerupted teeth.

Several explanations have been offered: periapical infections of primary teeth, pre-eruptive caries, developmental aberrations, inclusions of uncalcified enamel matrix and idiopathic external resorption. Rutar (1997). Australian Dental Journal 1997;42:

(4):221-4

Dental Trauma- Hard TissuesDental Trauma- Hard Tissues

Dental Trauma- Soft TissuesDental Trauma- Soft Tissues

Technique: have the patient hold an anterior occlusal film vertically alongside the face so that the radiographic beam passes through the lips to impinge on the film.

Developmental Disturbances Developmental Disturbances

Systemic ConditionsSystemic Conditions

Sickle Cell DiseaseHistiocytosis X

Odontodysplasia

Hutchinson's incisors

Ectopic EruptionsEctopic Eruptions

AnkylosisAnkylosis

Intraoral view of the impacted mandibular left second primary molar

Radiograph taken at the first appointment

Altay & Cengiz (2002). International Journal of Paediatric Dentistry 12: 286–289

Space MaintainersSpace Maintainers

Hidden CariesHidden Caries

Radiographs can detect caries when none are observed clinically, but all too often there are caries present in the tooth that the radiograph will not reveal. This problem is known as hidden caries

Carious lesion not visible on radiography but seen on cross-section of the tooth.

Freedman et al (1999). J Canad Dent Ass. 65 (10): 579-81

Cont….Cont….

Further complicating this dilemma is the aggressive use of fluoride in fluoridated communities. The surface-hardening effect of fluoride on the enamel makes the tooth surface more impenetrable to exploration, thus masking the carious activity occurring just below the surface and along the dentino-enamel junction (DEJ).

Thank YouThank You