hi everyone this is Miss O'Brien in this presentation we are going to be going over chapter 18 of your dental radiography principles and techniques book and this is the chapter on introduction to dental Imaging examinations okay and our objectives for this lesson are to define the key terms associated with dental Imaging examinations we are going to list the three types of intraoral Imaging examinations we are going to describe the purpose the type of receptor and the technique used for each of the three types of intraoral Imaging examinations we're going to list the various projections that comprise a complete mouth series which is referred to as a complete math series or full mouth series you'll see this abbreviated as either CMS FMS or fmx we're going to list the General Diagnostic characteristics for interural Imaging we're going to list examples of the extra oral Imaging examinations we're going to discuss the prescribing of dental images and we're going to describe when a complete math series or full mouth series for a new patient is needed or warranted okay so let's get started Dental Imaging exams so we talked a little bit about this before there's two broad categories of dental Imaging exams so we have intraoral Imaging exams and this is when the sensor is placed inside the patient's mouth so either a film or sensor is placed inside their mouth and then we have extra oral Imaging exams and this is when the film or sensor is placed outside the mouth so we had talked about panoramic machines when we went over the last chapter and panoramic radiographs would be an example of extraoral Imaging and then bite wings or full math series exams those would be examples of intraoral Imaging exams because that's when the sensor or the film whatever receptor you use goes inside the patient's mouth um so the foundation of dental Imaging uses intraoral receptors are placed inside the map for the intraoral exams and we examine teeth and intraoral adjacent structures and there's three types of intraoral exams this includes a periapical exam inter-proximal exam and occlusal examination so these are the three types of intraoral radiographic exams where the sensor or film goes inside the patient's mouth okay so again the three types of integral exams are periapical examination and for this we use periapical radiographs sometimes you will hear those referred to as Pas as a little abbreviation then we also use interproximal examination and we achieve interproximal examination by using bite Wing radiographs so we can see between the teeth and our proximal means between and then occlusal examinations for this we use occlusal radiographs and with these types of radiographs you can see a much larger portion of the oral cavity and the um the teeth and hard tissues so we'll go or all three of those so remember the complete or full mouth series um this examination includes both excuse me a periapical examination and an inner proximal examination they're combined so the full math series is actually a combination of periapical radiographs and bitewing radiographs and we'll talk a lot more about that okay so remember intraoral examinations the receptor is placed inside the mouth so of course the you know the unit the Radiology unit or the X-ray unit is outside of the mouth but the sensor is inside of the mouth so you can see this patient is biting on Bite Block which holds the uh the sensor in place and then there's the aiming ring outside of his mouth which is connected to a rod and then the the byte block or the stabilizer for the sensor and then you can see the sensor has a wire coming out and that connects to a computer because the images are sent to a computer as soon as you take them so this is the The Nomad unit that we talked about in the last chapter and this is a portable unit for taking intraoral exams or intraal images so again the sensor is in the mouth that's what makes it intraoral and then the the unit is held outside the mouth so I have a few problems with this picture it's it's not an accurate depiction of how you should be taking radiographs is probably for some brochure for Nomads or whatever but but this you know this practitioner this clinician is not wearing any PPE except for gloves which is incorrect you know she should have on glasses and a face mask and when you use these portable units you should be wearing a lead apron just like the patient you can see the patient has a lead apron on with a thyroid collar when practitioners use this Nomad they should also be wearing a lead apron in that area and then also she should have the unit held with straight arms you don't want to cradle it like that it is kind of heavy so it can be difficult but you want to have the unit out in front of you at arm's length that is actually the proper way to use it so and we'll go over this type of thing in lab okay so periapical radiographs if you look at the top of the screen you can see here's a periapical radiograph on the left of the molars and one of the premolars and these are the mandibular teeth or lower teeth and then on the right we have periapical radiographs of the incisors that's in the front of the mouth and again these are the mandibular or lower teeth so why do we take these Parable radiographs or PAs more commonly called they evaluate the crown the root and supporting bone around a tooth or teeth so if you look at at the molar image on the left you can see we can see the crown of the tooth you know that's the top of the tooth that you see in the mouth we can see the root of the tooth that's the part of the tooth that you don't usually see because it's embedded in bone and then we see the supporting bone around the tooth so you can see all this and we call it alveolar bone and this is part of the mandible and again you you can look at the incisor or the anterior PA and you can see the the crowns of the incisors you can see the the roots of the teeth and you can see the bone levels so and if you look it looks like the bone levels are a little bit lower on these anterior teeth so this patient may have periodontitis but that's one of the things we look at what is the bone level around the tooth if you look at the radiograph on the left bone level looks pretty good it comes up pretty high on the tooth but on the right these incisors it looks like there may be some bone loss there it's a little bit hard to tell with angulation but it looks like there is so periapical where does that word come from so Perry this part of the word means around and then apical is you know basically means Apex which is the terminal end of the tooth root so when we talk about the apex of the root that's like the very tip of the root like I'm circling it here on the left on the smaller that's the apex of the root um so here's the apex of the roots of uh the second molar here so when we say periapical we want to see around the terminal end of the root so it's really important when you take these images and again we'll show you how in lab that you get the entire crown of the tooth and the entire root plus a little bit more you know you want to get about two to three millimeters beyond the tip of the root because you want to see you know if a tooth had an abscess for instance the abscess would would be like a dark area around the um the tip of the root and if you cut the image off here write it right at the end of the root and you didn't get anything underneath then you might miss that diagnosis or your your dentist might miss that diagnosis so peri means around apical means the um the terminal end of the tooth root so with the periapical radiographs really we want to see the entire tooth but we're especially interested in that area around the root of the tooth because there can be disease you know that we want to catch so when we take the PA radiographs we use a periapical receptor x-ray holder and these are usually the yellow ones and the Pas show the terminal end of the tooth root and the supporting bone so you know and and also the crown so we're looking at all of those things when we take these these types of radiographs so now there's two methods to take radiographs there's paralleling technique and bisecting technique and we'll get much more into these techniques in future chapters but spoiler alert you are probably going to be using the paralleling technique 90 of the time because when you use aiming Rings like we see in this picture she's using the paralleling technique so you know it's um that's what you use most of the time the bisecting technique it takes a lot more skill to to get a accurate image and it's a little trickier you need a little more experience to use it it's good if like somebody has a really small mouth or or extra bone in their mouth that makes the placement of the sensor difficult so but you know most people you you don't have to use the bisecting technique but occasionally you do okay so these are our interproximal radiographs um or bite Wing radiographs sometimes you'll see you'll well you'll see this quite a lot abbreviated bwx which stands for bite wings so um so bite wings are different than periapical radiographs so if we just go back and look at periapical radiographs you only see the lower teeth right on these images so with periapical radiographs you either see the lower teeth the mandibular teeth or the upper teeth the maxillary teeth you don't see both and you see the entire tooth from from the crown all the way to the tip of the root and then you know beyond that even so with bite Wings notice that we see the crowns of both the maxillary or upper teeth and the mandibular or lower teeth so we see those on a single image so what makes bite Wings valuable we we look at the um the area in between the teeth because a lot of times cavities develop between the teeth and by taking bite Wing x-rays we can examine those areas very closely and see if there's any cavities beginning to form and do fillings if that's necessary so so the bite Wing x-rays allow you to see adjacent tooth surfaces so tooth surfaces next to each other and crestal interdental Bone so the crustal incidental bone is the you can see the bone levels between the teeth I'm highlighting it with my cursor so again this is called the alveolar bone and in some people the alveolar bone is is pretty high on the tooth and it looks real healthy but in some people you know you begin to lose bone around the tooth which can be an indication of disease you know periodontitis specifically so you know so we look for that so so again the inner proximal radiographs these bite Wings they show us the areas between the teeth a little bit better than these type of radiographs you know sometimes you can see between the teeth on the periapical radiographs but not always you know sometimes you get this they call it overlap so really we have to have two separate views one to see the crown to the root that's the periapical radiograph and one to see the um you know specifically to see the areas between the teeth and then we also look at the bone levels as well um so for the bite Wing radiographs you're going to use a bite Wing receptor or x-ray holder and it has a a wing or tab that the patient bites on so the bite Wings they got their name because you know in the old days they would take um some cardboard with adhesive on it and stick it to the film and then the person would bite on that you know it looked like a wing so they would bite on it to hold the film in place and so it got the name bite wings so um so anytime you take inner proximal radiographs these are bite wings okay and then occlusal radiographs so these are are different and you probably you probably won't do very many of these um if ever uh I've done occlusal radiographs only in academic settings I've never done them in clinical practice um there's just you know better methods now for for getting this information but we need to learn about them because you never know so the occlusal radiographs this examines large areas of the maxilla or mandible on one radiograph so if you look here this is the um the mandibular Arch right so um so you get all these teeth you know like a horseshoe shape on one film and here we see an anomaly where a tooth is unpacked it so you know these are the kind of things that you use occlusal films to look for impacted teeth or sometimes if an instrument breaks off in the mouth you might use an occlusal film to to locate that um but but again you examine large areas of the maxilla you know the upper Arch or the mandible the lower Arch on one radiograph um and for this we use an occlusal receptor or x-ray holder a lot of times you don't need an x-ray holder because you the size of the film the patient just kind of bites on it and it's held in place by the teeth but but you can use a holder if you need to so the patient bites on or occludes on the receptor film the film is like kind of larger much larger than the you know the periapical or bitewing films um it's you know it's several inches bigger and it's like a rectangular shape kind of like the size of a small piece of bread you know or somewhere along that you know smaller than that but and you bite down on it like a like a piece of bread basically so it's not a very hard image to take honestly um so be the occlusal radiographs you use the occlusal technique obviously okay so this is a complete or full math Series so some of you might have had this you know these types of images taken at a dental office um you know maybe not if you're a little bit younger um they they might not have done an entire you know full math series they might just do bite Wings on you um and occasionally a panorax but at some point in your life you should have an fmx or a full math Series so um so you can see the full Mount series It's a combination of of periapical images you can see all these images along the top are periapical images and all these images along the bottom are also periapical images so you actually take 14 per apical images because we want to look at the um what's going on at the tips of the root of teeth on every single tooth so that takes about 14 images then um your bite wings um so in addition to taking the periapical images so we can really get a good look at the roots of the teeth we want to take the bite wings so we can evaluate the bone levels and also the inner proximal areas to see if there's any cavities or Decay interproximally so um so these uh you know just grabbed this image but um it's not really the best image to use because you can see that some in some of these films the the tip of the roots are kind of cut off and you know the teeth are kind of elongated so this isn't exactly the best set of X-rays that I've seen but but it gives you an idea of you know what the fmx consists of and you'll do fmx's on a lot of patients usually they do fmx's about every three years depending on the needs of the patient and then they'll update the the bite Wings about once a year again depending on the needs of the patient some patients can go longer without taking x-rays some people need them you know almost every six months if they develop a lot of Decay quickly okay so the complete or full mouth series again you'll see this abbreviated as CMS FMS or fmx usually fmx that's the most common abbreviation um so this is a complete series of intra-oral radiographs again the sensor goes inside the mouth for all of these um fmx it's a set of intraoral dental X-rays that shows all tooth bearing areas of both of the Jaws the maxilla the upper jaw and the mandible the lower jaw so you can see here's all the maxillary teeth up at the top right and all the mandibular teeth down here at the bottom um so it includes tooth bearing locations as well as areas missing teeth um so what we the words we use for that is dentulous and edentulous dentulis means there are teeth there edentulous means you're missing teeth so sometimes you'll take an fmx and people might be missing several teeth you still want to take images of areas where people are missing teeth because there might be you know there could be a root tip that's retained there maybe the crown of the tooth broke off and the root tip still there there could be other pathology so we really want to look at all the bone around all the teeth right so the fmx includes a combination of periapical X-rays and bite Wing x-rays so again the periapical x-rays are all the ones on the very top and on the very bottom there's 14 of those then the bite wings are the ones in the middle so usually we take four bite Wings sometimes we take six bite Wings if somebody has their their wisdom teeth and they have like a large mouth large teeth or whatever and we can't see everything on the bite Wings then sometimes you take a third bite wing on each side and with this patient I would have taken a third bite wing on each side because you can't see you know beyond the second molar you notice that it cuts off there so you know so you should really take a third image to get that to get that area you know especially down here where it was cut off and over the side where it was cut off um okay so typically uh the fmx includes 14 Pas and four bite wings but you can have up to 20 images again it depends on the size of the mouth the size of the teeth and all that um an identialist patient will only need 14 images so again a dentist means missing teeth so a patient that's fully edentulous you know if they don't have teeth they would only need the Pas right they wouldn't need bite Wings because there's no teeth that you have to look between so um so yes we we actually even do these type of x-rays on people with no teeth because we want to see what's going on in the bone because you never know okay criteria that must exist for Diagnostic radiograph so you're going to hear this term quite often diagnostic you know is a radiograph diagnostic that means that we can see if there's disease right so let me show you um just go back here on this radiograph I'm circling with my cursor you can see that between these teeth I'm pointing to right here between the molar and the premolar and down here between the molar and the premolar there's a lot of overlap right they they didn't get the between the teeth you know you can't see between the teeth like if you look here between the canine and the premolar there's some space there right now if you look on the mandibular Arch between the um the premolar and the canine you can see between those teeth but you see here there's a lot of overlap so when there's overlap like that it's not diagnostic you can't tell if there's you know anything going on there so you can't make a diagnosis and and that's a problem if you take a film that's not diagnostic then you need to retake it basically again if you look here on the the lower right molar PA if you look at the second molar here I'm running over it with my cursor you can see they cut off the root right so if there's something if there's an abscess on that distal root at the tip of it we don't know that right so that that's a problem that's non-diagnostic if you look at the the incisors here the incisor PA right here in the middle circling it with my cursor that's diagnostic right you can see the tips of the roots you can see the the bone beneath them that's a good diagnostic image but you know these these non diagnostic images you have to retake them they don't really help you at all to to see if there's a disease or not so so that's what we mean when we talk about diagnostic radiographs or diagnostic images so um so General Diagnostic criteria for intra-oral images the dental images must display optimal density contrast definition and detail so if you took images that were way too light or way too dark you know maybe you had a pediatric patient and you had the X-ray unit set on the adult settings in that case you're going to get a very dark image again that's you know if you can't see what's going on in the mouth then that's a non-diagnostic radiograph so so we need to make sure that the density the contrast the definition the detail it's all there and that we can see what we need to see and again I keep saying this we're going to learn more and more about this during the semester you know the density the contrast all that stuff and then Dental images must display the least amount of distortion possible images must be of the same shape and size as the object being imaged so so Distortion you know let's say if a patient you were taking a radiograph and you stepped out of the room to press the exposure button and the patient sneezed or moved their head or whatever you could get a blurry radiograph and that would cause Distortion also if you don't put the film or the sensor in the mouth correctly if it's tilted one way or the other you might get a tooth that looks very very long long when it's not or a tooth that looks very very short you know that's called elongation or for shortening so we want to to avoid that because we want the the teeth the image to be a good representation of the teeth uh the complete math series must include images that show all tooth bearing areas including dentless and edentulous regions so even if somebody's missing teeth you're still going to take 14 at least 14 per apical images because we want to see the areas of bone even where there are no teeth edentulous areas okay and then periapical images these must show the entire crown and roots of the teeth being examined as well as two to three millimeters beyond the root apices okay why do we want to see two to three millimeters beyond the root apices or the tip of the root because if there is an abscess of that tooth has an infection and an abscess is formed you're going to see it below the root of the tooth so we go back to these X-rays and you can see um you know some of these some of these x-rays are cutting it close right so if you look down here on the mandibular left molar image you know if there was something going on under this root okay we could see that you've got a good you know at least two to three millimeters there again over here on the right side with the molars you you know maybe you could see an abscess maybe you couldn't definitely not on that distal root and then here with the premolar first they cut the roots off that's a problem that's non-diagnostic we need to see that area you know if you come over here to this image you can see the the premolar you know you see the first premolar here and the first premolar here you know there we can see the the root of the tooth and the the apices but you know but they this would have to be retaken because you can't see the tip of the root on the second premolar here that's a problem because if if there was disease there and the dentist didn't catch it because the sex ray is not diagnostic they could be sued potentially you know and it could lead to the person losing their tooth and and suffering so we don't want that to happen all right so the apical image must show the entire Crown the entire root and even two to three millimeters beyond the root apices or the tip of the root okay and then bite Wings bite Wings must show open contacts or interproximal tooth surfaces that are not overlapped so open contacts let's go back here again this is a very open contact and you know I suspect that the patient has a little space between those teeth which makes it easier this is overlap where my cursor is this is overlap that overlap exists because the um the person taking the x-rays didn't line up the X-ray unit or the PID at the proper angle when taking the image so um you know and it's it's hard to it can be hard to get open contacts but you know as you get more experience you take better images so we want to avoid this overlap and we'll teach you how this this premolar image on the left side you can see here's a good open contact here's a good open contact this is better than the one on the right side but um you know it's pretty good so we we want those open contacts okay um so no overlap all right and that's the criteria that must exist for Diagnostic radiographs quote-unquote diagnostic very important okay learning check um I like this little question mark guy he almost looks distressed somehow but hopefully we'll get the question right and he'll be happy on the next slide but I don't know um which of the following types of radiographs will show the crowns of both the maxillary and mandibular teeth on one image okay is this going to be your periapical radiographs your occlusal radiographs or your interproximal radiographs which one is it you guys know all right all right the question mark is still upset for some reason I don't know why but uh but anyway interproximal is the answer so so what is the other name for inner proximal radiographs if you said bite Wings you are correct right because bite wings or inner proximal radiographs they will show the crowns of both the maxillary and the mandibular teeth on one image and and we use these inner proximal or bitewing radiographs to see if there's cavities between the teeth and then also look for the bone level around the teeth so again let's just pop back here real quick here are your bite Wing or interproximal radiographs the ones in the middle they have the crowns of the maxillary teeth and the crowns of the mandibular teeth notice that we don't see the entire root on bite wings or in our proximal radiographs we're not supposed to right that's what periapical radiographs are for so hopefully our little question mark I will be happier in the future since we got that question right all right extra oral examinations so this is when the receptor is located outside the mouth and we talked a little bit about that last chapter so here is um you know I'm not sure if this is a regular panorex machine or a cbct or some combination there are machines that do both but this is basically your basic extra oral examination the patient stands stands in the machine um sometimes they sit they put their chin in a chin cup they bite on a little bite block to separate their teeth then they have these these holders that hold their head in place and the um the X-ray unit this is you know this is basically where everything happens um the receptor is in here and also the the two pet is in this area then this goes around the head the patient holds real still it takes you know probably 10 seconds or so for panoramic it takes a little longer for a cbct because that's 3D and requires more images so anyway this is basically your extra oral exam again the receptor is in this unit it's not inside the patient's mouth okay and this is a panoramic image that's what this this is the result of this guy standing here right so um so the extra oral Imaging um whether it's panoramic you know panoramic or flat they're two-dimensional we also have uh like cbcts and those are three-dimensional so um but again with both of those with any extra oral Imaging it's going to examine large areas of the skull or Jaws so you can see you know here we see the mandible we see all parts of the mandible the condyle all that stuff we see the maxilla we see the sinuses we see all the teeth so this gives us like a really great large overview but the problem is that you don't see a lot of detail on the teeth I mean it looks like a lot but it really you know you wouldn't be able to diagnose a small cavity or a small you know bit of Decay on here so um so really we use these you know we look for the wisdom teeth if you look here here's a little wisdom tooth one two three four so this person is probably on the young side because there was some teeth aren't fully developed and they haven't erupted so I'd say they're probably you know teen early teenager uh so um so anyway uh we use this to look at um you know the third molars to assess those we look for any um you know pathology in the jaw you know sometimes you'll find a cyst or something like that so so this is just really useful at giving us an overview so we use extra role Imaging receptors or holders that are placed outside the mouth so they're built into the machine the person bites on a bite stick but they don't have a film inside their mouth each extra oil image has specific purposes and each requires specific receptors or holders and techniques so examples include panoramic images so this is a panoramic image and and this is probably this is the most popular extra oral image that's taken most General dentists have panoramic machines in their office and there's also lateral jaw images lateral cephalimetric images transcranial and tomographic projections so some of those are used by Oral Surgeons some of those are used by orthodontists you know more specialty practices but the the panoramics are are the ones that are done by you know most General dentists and some Specialists as well okay and then here's a cephalometric radiograph so you know that can be used if somebody's going through orthodontic treatment or if they've had their jaw broken um you know if they need a wired shut or pins or anything like that so um so the cephalometric image is is helpful with that okay so prescribing Dental radiographs so um so you can't just walk into a dental office if you're an assistant you know or a hygienist and just start taking radiographs on people right you're not legally allowed to prescribe those radiographs a dentist has to prescribe the radiographs before anybody can take radiographs on the patients so sometimes you'll you'll get into offices where the dentist tells you you know take radiographs on you know everyone once a year or whatever um and then you know the the Personnel take the radiograph so you know that's considered prescribing the dental radiographs they don't necessarily write out a prescription like you do with you know an antibiotic or something um so but the dentist is is the one that prescribes the dental radiographs and they're responsible for that so you can't just um you know for instance retake radiographs uh you have to have the dentist you know it at least verbally tell you that you can and that needs to be documented in the chart beforehand or after the fact so sometimes in the dental hygiene clinic we'll have students that are authorized to take you know four bite Wings on a patient and they might mess one up and uh and try to retake it themselves which is illegal the dentist has to if the dentist is prescribed for bite Wing x-rays even if you mess one up you can't retake it on your own you have to get permission so you know so Dennis prescribed the dental radiographs not the assistant not the hygienist not anybody else the dentist so just remember that now the prescription is based on the individual needs of the patient you really shouldn't be saying every patient in this practice will have bite Wings once a year that's not good because not everybody needs bite Wings once a year some people might need them once every two years some people might need them once every six months you really have to look at the individual needs of the patient and see you know is this person very prone to developing Decay well then you know maybe we need to do x-rays every six months in order to catch that decay before it's gotten to you know too large or destroyed too much tooth structure maybe somebody is never ever ever in their entire life had Decay or a cavity in that case maybe you don't want to take X-rays every year maybe you want to take them every two years so again you have to look at the individual needs of the patient this isn't a one-size-fits all necessarily so every patient is unique and evaluated on an individual basis you know we look at their history of Decay we look at any systemic diseases they might have that might influence their their dental health um you know for instance like things like diabetes patients with diabetes they generally develop periodontitis and it generally progresses more rapidly in patients with diabetes than in healthy patients so you know so we look at things like that to decide you know should how often should we be taking these X-rays and various combinations of x-rays might be taken so it just again it just depends on the patient so some examples some offices if they have a new adult patient that presents with generalized periodontal disease they'd probably do an fmx you know 18 images if they have a patient that presents with extensive restorative dental treatment if they have a lot of fillings in their mouth a lot of crowns Bridges things like that again you'd want to take an fmx an adult patient without periodontal disease maybe they they don't need an fmx maybe you could do just bite wings and periapical images of the anterior teeth or bite wings and a panoramic image so again this is another thing that we'll learn a lot more about but just remember that you know the important things are that only the dentist prescribed the radiographs and it is not a one-size-fits all kind of thing you need to consider the individual needs of the patient there's no everybody gets bite Wings every year or everybody gets an fmx every three years you have to you know look at the patient before you say those things okay learning check this guy's still upset what's going on we got the last one right I don't know why he's still upset all right which of the following Dental Health Care Professionals May prescribe Dental radiographs you've got to get this right is it the dentist is it the dental hygienist is it the dental assistant or is it all of them who can prescribe radiographs let's say oh is the dentist right only the dentist can prescribe radiographs do not forget that very important okay summary uh we're almost done Dental Imaging examinations may involve either intraoral or extra oral images or both uh intraoral Imaging examination is an inspection of the teeth and intraoral structures using x-rays three common types of intraoral images are periapical interproximal AKA bite wings or occlusal examinations the periapical examination is used to inspect the crowns and roots of the teeth and surrounding bone the interproximal examination also called The Bite wings that's used to examine the crowns of the maxillary and mandibular teeth on a single image the bitewing technique is used for interproximal examination and then the occlusal examination remember that's where you bite down on the film it's kind of like biting on a piece of bread this is used to examine large areas of the maxilla and mandible on one image so you either get the maxillary Arch on one image or the mandibular Arch on one image not both and then the complete math series or full mouth series this shows all of the tooth bearing areas of the maxilla and mandible and consist of 14 to 20 images periapical and interproximal and I'm just going to add that when you do an fmx you take images of both the dentulous areas that's the areas that have teeth and the edentulous areas and that is the areas that are missing teeth so that's it that's our summary and that's it for the slideshow um all right I hope you guys enjoyed this or found it interesting at least and I will see you in class thank you for listening