Dental Decks Part II (2007-2008)

RADIOLOGY
Digital Radiology

Image Characteristics Miscellaneous

Normal Anatomy Processing

Radiation Biology Radiation Characteristics Radiation Physics Radiation Protection Techniques

X-rays

DigRad 1m Char Misc.

NAnat Proc RBio RChar RPhys R Prot

Tech X-rays

Copyright©2007 - 2008 -DENTAl DECKS

RADIOLOGY

1m Char

The area from which x-rays emanate is called the:

• Target

• Focal spot

• Intensifying screen

• Cone

Copyright ©2007 - 2008 - DENTAL DECKS

• Focal spot

***The focal spot is the area of tungsten on the anode that receives the impact of the speeding electrons and converts them into x-ray photons. It is one of three factors influencing image sharpness (the others are film composition and movement).

The target (also called the tungsten target) is a wafer of tungsten embedded in the face of the anode at the point of electron bombardment. Tungsten is used due to its high atomic number (x-ray production), high melting point, high thermal conductivity (dissipates heat), and low vapor pressure (maintains vacuum at high temperature). Note: The focal spot is actually a small area of the target.

Remember: Intensifying screens are devices used in extraoral radiography that convert xray energy into visible light. The light, in turn, exposes the screen film. Therefore, the radiation that a patient receives is decreased. A cassette holder is a light-tight device used in extraoral radiography to hold film and intensifying screens.

Important; Target film distance (also called source-to-film distance) is the distance from the source of x-rays (focal spot on the tungsten target) to the film. It is determined by the length of the position-indicating device (also called PID). Two standard target-film distances are used in intraoral radiography:

1. 20 cm (8 inches) ~ is called the short cone, exposes more tissue by producing a more divergent beam.

2.41 cm (16 inches) ~ is called the long cone, reduces the amount of exposed tissue by producing a less divergent beam and a sharper image.

RADIOlOGY

1m Char

Which type of structure inhibits the passage of x-rays?

• Radiopaque

• Radiolucent


• Radiopaque

Radiopaque structures I materials:

• Less radiation penetrates the structure and reaches the film

• Radiopaque structures appear white on the processed film

• Dense materials such as metals, enamel, dentin, and bone

Radiolucent structures I materials:

• Allow radiation to pass through, absorbing very little

• More radiation penetrates the structure and reaches the film

• Radiolucent structures appear gray to black on processed film

• Less dense materials, including soft tissue and air space

Note: Radiographs show shading from black to white (most radiolucent to most radiopaque). Example: Least to most radiopaque: periodontal ligament space, dentin, enamel, ZOE, amalgam.

RADIOLOGY

Misc.

It is best to retain dental radiographs for how many years?

• 2 years

• 4 years ·6 years

• Indefinitely

Copyright ©2007 - 2008 -DENTAL DECKS

• Indefinitely

The dental record must include documentation of informed consent and the exposure of radiographs (e.g., the number and type of films, the rationale for exposure and the interpretation). Legally, dental radiographs are the property of the dentist. Patients do, however, have a right to reasonable access to the dental radiographs, which includes having a copy of the radiographs forwarded to another dentist.

Note: Patients may refuse dental x-rays, however, the dentist must decide whether an accurate diagnosis can be provided and whether treatment can provided.

Remember: No document can be signed by the patient that releases the dentist from liability.

-l

RADIOLOGY

Misc.

Osteoradionecrosis is more common:

• In the mandible

• In the maxilla


• In the mandible

Osteoradionecrosis is more common in the mandible than in the maxilla, probably because of the richer vascular supply to the maxilla and the fact that the mandible is more frequently irradiated.

Remember: Osteoradionecrosis is the necrosis of bone, produced by ionizing radiation.

The most common factors precipitating osteoradionecrosis are pre- and post-irradiation extractions and periodontal disease.

Note: Damage to the blood vessels (as opposed to nerves, muscle, etc.) predisposes a patient to the development of osteoradionecrosis.

To prevent osteoradionecrosis: extract all hopeless teeth three weeks prior to head I neck radiation treatment. If extracting after radiotherapy, the use of systemic antibiotics is recommended. Some studies suggest hyperbaric oxygen treatments before and after treatment to reduce the risk of osteoradionecrosis (this is somewhat controversial).

RADIOlOGY

Misc.

Your dental hygienist has a patient that says she needs bite-wing x-rays because it has been six months since the last films were taken. Your hygienist should respond in which manner listed below?

• Agree with the patient

• Tell the patient that bite-wing x-rays should be taken once a year

• Tell the patient that dental x-rays are taken only when needed as judged by each patient's needs

• None of the above


-Tell the patient that dental x-rays are taken only when needed as judged by each patient's needs

Decisions about the number, type and frequency of dental x-rays are determined by the dentist based on each patient's needs. Every patient has a different dental condition and thus the frequency of x-rays is different as well. There are guidelines published by the ADA that aid a dentist in prescribing the number, type and frequency of dental x-rays.

Note: Patients who have tooth decay, periodontal disease, tooth mobility, pain in one or more teeth or possible impacted teeth need more frequent radiographic examinations than patients without such problems. Remember: For a pediatric patient who is caries free (and asymptomatic), the first bite-wing radiographs should not be taken until the spaces between the posterior teeth have closed.

Note: Occult diseases (for example, small carious lesions, cysts and tumors) are those presenting no clinical signs or symptoms. Because occult disease in the perioral tissues is so rare (except for caries), a radiographic examination of the jaws should not be undertaken solely to look for it in an individual with teeth when there are no clinical signs or symptoms. However, every x-ray taken should be evaluated for these lesions.

Remember: Caries is an exception to the above rule because of its much higher prevalence as compared to occult cysts or tumors.

RADIOLOGY

NAnat

Identify the structure below that the arrows are pointing to:

Reprinted from Haring, Joen Iannucci and Laura Jansen: Dental Radiography: Principles and Techniques: Third Edition. © 2000, with permission from Elsevier

Copyright©2007 - 2008 -DENTAL DECKS

• The hamulus

The hamulus (also known as the hamular process) is a small hook-like projection of bone extending from the medial pterygoid plate of the sphenoid bone. The hamulus is located posterior to the maxillary tuberosity region.

On the radiograph its image is seen in proximity to the posterior surface of the tuberosity of the maxilla. It varies greatly in length, width and shape from patient to patient. It usually exhibits a bulbous point, but sometimes the point is tapered.

The maxillary tuberosity appears as a radiopaque distal to the third molar region

Reprinted from Haring. Joen Iannucci and Laura Jansen: Dental Radiography: Principles and Techniques: Third Edition. © 2000, with permission from Elsevier

RADIOLOGY

NAnat

The image of the coronoid process of the mandible often appears in periapical x-rays of:

• The incisor region of the mandible

• The molar region of the mandible

• The incisor region of the maxilla

• The molar region of the maxilla

Copyright ©2007 - 2008 -DENTAl DECKS

• The molar region of the maxilla

As the mouth is opened, the process moves forward, and therefore it comes into view most often when the mouth is opened to its fullest extent at the time the exposure is made. It is evidenced by a tapered or triangular radiopacity, which may be seen below, or in some instances, superimposed on the molar teeth and maxilla.

The coronoid process appears as a triangular-shaped radiopacity.

Reprinted from Haring, Joen Iannucci and Laura Jansen lind: Radiographic Interpretation for the Dental Hygienist. © 1993, with permission from Elsevier

RADIOLOGY

NAnat

Identify each structure that the arrows 1 -8 point to in the anterior region of the maxilla.

"Courtesy Dr. Stuart C. White, UCLA School of Dentistry."


1. The opaque line ~ Lateral wall of nasopalatine canal

2. The opaque line ~ Anterior wall of maxillary sinus

3. The radiolucent structure ~ Nasopalatine fossa

4. The opaque line ~ Floor of nasal fossa

5. The opaque structure ~ Soft tissue tip of nose

6. The opaque line ~ Lamina dura

7. The opaque line ~ Border of maxillary sinus

8. The radiolucent line ~ Periodontal ligament space

RADIOlOGY

NAnal

Identify each structure that the arrows 1 - 7 point to in the anterior region of the maxilla.

"Courtesy Dr. Stuart C. White, UClA Schoo! of Dentistry."

Copyright ©2007 - 200B - DENTAL DECKS

1. The opaque structure ~ Anterior nasal spine

2. The opaque line ~ Lateral wall of nasopalatine canal

3. The radiolucent line ~ Intermaxillary suture


5. The radiolucent structure ~ Nasopalatine fossa

6. The radiopaque line ~ Soft tissue tip of nose

7. The opaque structure ~ Alveolar crest

RADIOLOGY

NAnat

Identify each structure that the arrows 1 -5 point to in the mandibular molar region.


Copyright ©2007 -2008 - DENTAL DECKS

1. The radiopaque lines ~ Nutrient canal

2. The opaque line ~ Bony trabecular plate

3. The opaque line ~ Inferior border of mandibular canal

4. The radiolucent space ~ Submandibular gland fossa

5. The radiopaque structure ~ Inferior border of mandible

RADIOLOGY

NAnat

Identify each structure that the arrows 1 -8 point to in the maxillary molar region.

"Courtesy Dr. Stuart C, White, UCLA Schoo! of Dentistry."

Copyright &2007 - 2008 - DENTAL DECKS

1. The opaque line ~ Anterior wall of maxillary sinus

2. The opaque mass ~ Inferior concha


4. The opaque line ~ Inferior border of zygomatic process of maxilla

5. The opaque line ~ Posterior wall of zygomatic process of maxilla

6. The opaque line ~ Inferior border of zygoma (zygomatic arch)

7. The opaque line ~ Floor of maxillary sinus

8. The opaque structure ~ Mucosa over maxillary alveolar ridge

RADIOLOGY

NAnat

Identify each structure that the arrows 1 -7 point to in the mandibular incisor region.


Copyrtght©2007. 2008 -DENTAL DECKS

1. I ne opaque structure ~ lingual cusp ot 1 st premolar

2. The radiolucent line ~ Periodontal ligament space

3. The opaque mass ~ Film holder

4. The opaque mass ~ Genial tubercles

5. The radiolucent circle ~ Ungual foramen

6. The opaque line ~ Bony trabecular plate

7. The radiolucent space ~ Marrow space

RADIOLOGY

NAnat

Identify each structure that the arrows 1 -4 point to in the mandibular premolar region.


Copyright ©2007 - 2008 - DENTAl DECKS

1. The radiolucent line -+ Periodontal ligament space

2. The radiolucent space -+ Mental foramen

3. Large radiolucent space -+ Submandibular gland fossa

4. Dark dot -+ Film clip mark

RADIOLOGY

NAnal

Identify each structure that the arrows 1 -3 point to in the mandibular premolar region.



1. The opaque line ~ Cemento-enamel junction

2. The radiolucent space ~ Mental foramen

3. Large radiolucent space ~ Submandibular gland fossa

RADIOLOGY

Proc

X-ray developer contains all of the following except:

• A developing agent

• An antioxidant preservative

• A clearing agent

• An accelerator

• A restrainer



X-ray developing solution contains the following:

• A developing agent, such as hydroquinone, which is a chemical compound that is capable of changing the exposed silver halide crystals to black metallic silver. At the same time, it produces no appreciable effect on the unexposed silver halide crystals in the emulsion. Gives detail to the x-ray image. Note: Also Elon which quickly generates gray tones.

• An antioxidant preservative, for example, sodium sulfite, prevents the developer solution from oxidizing in the presence of air.

• An accelerator - an alkali (sodium carbonate) -0 activates the developing agents and maintains the alkalinity of the developer at the correct value. It softens gelatin of emulsion.

• A restrainer, such as potassium bromide, is added to developers to control the action of the developing agent so that it does not develop the unexposed silver halide crystals to produce fog.

Remember: Developer is a chemical solution that converts the invisible image on a film into a visible one composed of minute masses of black metallic silver.

Important: The function of developing solution is to reduce silver halide crystals to black metallic silver, while the function of fixing solution is to stop development and remove remaining unexposed crystals.

Film processing involves the following steps: immerse film in developer -0 rinse film in water bath -0 immerse film in fixer -0 wash film in water bath -0 dry film

RADIOLOGY

Proc

X-ray fixer contains all of the following except:


• An antioxidant preservative

• An accelerator

• An acidifier

• A hardener


• An accelerator

X-ray fixing solution contains the following:

• A clearing agent, such as sodium or ammonium thiosulfate, commonly called hypo, dissolves and removes the underdeveloped silver halide crystals from the emulsion (Note: this is one of the main functions of fixing solutions.) The chemical "clears" the film so that the black silver image produced by the developer becomes distinctly perceptible. When the film is improperly cleared, the remaining unexposed silver halide crystals darken upon exposure to light and obscure the image.

• An antioxidant preservative, for example sodium sulfite, prevents the decomposition of the fixer chemical.

• An acidifier such as acetic acid, that is necessary for the correct action of the other chemicals and also neutralizes any alkaline developer that may be carried over by the film or hanger.

• A hardener such as potassium alum that shrinks and hardens the gelatin in the emulsion. It shortens drying time and protects the emulsion from abrasion.

DIllS:

1. If a dried radiograph were processed a second time, there would be no change in contrast or density.

~. Fixing time is always at least twice as long as the developing time.

RADIOLOGY

Proc

Ashley has taken three panoramic x-ray films today. During the day as she developed each film, she noticed the films getting lighter and lighter. What needs to be done so that this problem can be corrected?

• Decrease the temperature of the developing solution

• Increase the temperature of the developing solution

• Replenish the developing solution

• Increase the mA setting

• Increase the kVp setting

Copyright ©2007 • 2008 - DENTAL DECKS

• Replenish the developing solution

As the developing solution gets weaker, the films will get lighter. Both the developing and fixing solutions should be replenished on a daily basis. These solutions also need to be changed on a regular basis, and the tanks need to be scrubbed and cleaned as well.The following factors affect the life of a developing solution: the cleanliness of the tanks, the size of the films processed, the number of films processed, and the temperature of the solution.

Notes:

1. Yellowish-brown film will result from insufficient fixing or rinsing (See figure #1).

2. Fogged film may also result from improper film storage or outdated films.

3. Low solution levels will appear as: developer cut-off (straight white border, see figure #2)or fixer cutoff (straight black border, see figure #3).

4. Light spots on film may result from contact with the fixer before processing (See figure #4). Developer spots appear dark or black (See figure #5).

Fig. #1

Fig. #3

Fig. #2

Fig. #4

Fig. #5

RADIOLOGY

Proc

After processing a film, you notice that it appears brown in color. What is the most likely cause?

• Solutions are too strong

• Solutions are too weak

• Fixing time was not long enough

• Fixing time was too long

• Film was under-developed


• Fixing time was not long enough

*** A film will appear brown when it is not completely fixed.

Some common errors made in the darkroom -+ cause:

• Mounted films are improperly labeled (wrong patient name) -+ racks not labeled properly

• Fogged film (gray / lack of contrast) -+ faulty safelight in darkroom; white light leaking into darkroom

• Lost films -+ films not secured properly on rack

• Static marks (multiple black lines) -+ friction when opening film packets causes static electricity

• Overdeveloped film (dark) -+ incorrect time (too long) and temperature (too hot)

• Underdeveloped film (light) -+ incorrect time (too shaft) and temperature (too cold); weak solutions too old or diluted)

• Torn emulsion -+ films were allowed to touch or overlap while they were drying

• Stained film (dark / white spots) -+ dirty work surfaces; person developing film was sloppy

• Scratched films (white lines) -+ film emulsion removed by sharp object (fingernails / rack touching)

• Clear films (emulsion washed away) -+ films left in water (wash) for over 24 hours

• Air bubbles (white spots) -+ air trapped on film surface while being placed in processing

RADIOlOGY

RaiD

The unit for measuring the absorption of x-rays is termed:

• REM

• RAD

• Roentgen

• QF


• RAD --+ radiation absorbed dose

The rad is a unit used to measure a quantity called absorbed dose. This relates to the amount of energy actually absorbed in some material, and is used for any type of radiation and any material. One rad is defined as the absorption of 100 ergs per gram of material. The unit rad can be used for any type of radiation, but it does not describe the biological effects of the different radiations.

The rem (roentgen equivalent man) is a unit used to derive a quantity called equivalent dose. This relates the absorbed dose in human tissue to the effective biological damage of the radiation. Not all radiation has the same biological effect, even for the same amount of absorbed dose. Equivalent dose is often expressed in terms of thousandths of a rem, or mrem. To determine equivalent dose (rem), you multiply absorbed dose (rad) by a quality factor (OF) that is unique to the type of incident radiation. The QF is a factor used for radiation protection purposes that accounts for the exposure effects of different types of radiation. For x-rays QF = 1.

The roentgen is a unit used to measure a quantity called exposure. This can only be used to describe an amount of gamma and X-rays, and only in air.

Exposure is a measure of radiation quantity, the capacity of the radiation to ionize air.

Equivalent dose is used to compare the biologic effects of different types of radiation to a tissue or organ.

Effective dose is used to estimate the risk in humans.

RADIOLOGY

RBio

Which of the following is considered radioresistant?

• Immature reproductive cells

• Young bone cells

• Mature bone cells

• Epithelial cells


• Mature bone cells

Cells in the body have different sensitivities to radiation than others.

Radiosensitive Cells

Small lymphocytes (immature blood cells) Bone Marrow

Reproductive cells (sperm and ova) Immature bone cells

Radioresistant Cells Mature bone

Muscle

Nerve

In general, the greater the rate or potential for mitosis and the more immature the cells and tissues are, the greater the sensitivity or susceptibility to radiation.

RADIOLOGY

RRio

It is recommended that the operator stand at least how many feet away from the patient when taking radiographs?

• Two feet

• Four feet

• Six feet

• Eight feet


• Six feet

Radiation exposure to the operator can be reduced by standing at least six feet away, behind a lead shield, or both when exposing radiographs. The operator should never remain in the room holding the x-ray packet in place for the patient. If a film must be held in place by someone else (for a child), drape the parent and have him or her hold the film. All dental personnel should wear film badges that monitor exposure dosages.

The operator must avoid the primary beam by positioning themselves at a 90 to 135 degree angle to the beam.

Note: Regarding the taking and processing of dental radiographs, always remember to maintain proper infection control at all times!!!

RADIOlOGY

Rehar

Kilovoltage controls the speed of:

• Photons

• Electrons

• Anodes

• Cathodes


• Electrons

The speed with which electrons travel from the filament of the cathode to the target of the anode depends upon the potential difference between the two electrodes (kilovoltage). This, in turn, has a very important effect on the x-rays produced at the focal spot.

The kilovoltage has nothing to do with the number of electrons that compose the stream flowing from cathode to anode. The number of electrons (which determines the quantity of xrays produced) is controlled by the temperature of the tungsten filament (mil/iamperage setting). The hotter the filament, the more electrodes are emitted and available to form the electron stream (the x-ray tube current). In the x-ray tube the number of electrons flowing per second is measured in milliamperes. The intensity of x-rays produced at a particular kilovoltage depends on that number. Note: Setting the x-ray machine for a specific milliamperage actually means adjusting the filament temperature to yield the current flow indicated. The milliamperage range for dental radiography is 7-15 mA.

Iloles:

1. In dental radiography, the quality of the x-ray beam is controlled by kVp.

2. The kilovoltage range for most dental x-ray machines is 65-100 kV.

3. A higher kilovoltage produces x-rays with greater energy levels, shorter wavelengths and more penetrating ability.

~. To increase film density, you should increase mA, kVp and time. Also, you should decrease the source-object distance.

RADIOLOGY

Rehar

The inverse square law formula is:

• New intensity = Original distance-

Original intensity New distance/

• New intensity = New distance-

Original intensity Original dtstance-

• Original intensity = New intensity

New distanceOriginal olstance?

• None of the above


• Original intensity New intensity

=

New distance2 Original distance2

Important point: For a given beam of radiation the intensity is inversely proportional to the square of the distance from the source of radiation.

The intensity of an x-ray beam is the total energy of the x-ray beam; it is the product of the quantity (number of x-ray photons) and quality (energy of each photon) per unit of area per time of exposure.

The intensity of an x-ray beam at a given point is dependent on the distance of the measuring device from the focal spot. The reason for this decrease in intensity (why it is inversely proportional) is that the x-ray beam spreads out as it moves from the source. The "spread out" beam is less intense.

For example, when the PID length is changed from 8 to 16 inches, the source-to-film distance is doubled. According to the Inverse Square Law, the resultant beam is one-fourth as intense. When the PID length is changed from 16 to 8 inches, the source-to-film distance is reduced by one-half. According to the Inverse Square Law, the resultant beam is four times as intense.

Remember: The intensity of the radiation is inversely proportional to the square of the distance.

RADIOLOGY

Increasing the kilovoltage (kVp) causes the resultant x-ray to have:

• Decreased density

• More latitude

• A shorter scale of contrast

• A longer scale of contrast

Copyright ©2007 - 200B - DENTAL DECKS

Rehar

• A longer scale of contrast

Remember: Kilovoltage controls the speed of electrons.

One effect of a change in kilovoltage is a change in the penetrating power of the x-rays. Increasing kilovoltage reduces subject contrast (and the longer the scale of contrast); decreasing kilovoltage increases subject contrast (and the shorter the scale of contrast). A second effect of an increase in kilovoltage is that not only are new, more penetrating x-rays produced, but more of the less penetrating rays which were also produced at the lower kilovoltage are omitted.

Conclusion ~ kilovoltage influences the x-ray beam and radiograph by:

• Altering contrast quality (for patients with thick jaws, increase kilovoltage)

• Determining the quality of the x-rays produced

• Determining the velocity of the electrons to the anode

RADIOlOGY

Rehar

The quantity of radiation produced is controlled by:

• Kilovoltage (kVp)

• Milliamperage (rnA)

• Exposure time

• Milliamperage (rnA) and exposure time


• Milliamperage (rnA) and exposure time

The operator of an x-ray unit is in control of three factors:

1. Kiloyoltage ~ the quality or penetrating power of the x-ray beam

2. Milliamperage ~ the quantity or number of x-rays produced

3. Exposure time ~ the length of time x-rays are produced and patient is exposed to

them

Suitable ranges of dental x-rays are 65-100 kVp and 7-15 mAo

Some x-ray machines are calibrated in "impulses" (there are 60 impulses in 1 second). Density refers to the overall darkness (blackness) of a radiograph

• Density will increase as mA, kVp, or exposure time is increased

• Density will decrease as mA, kVp, or exposure time is decreased

Contrast refers to the difference in degrees of blackness between adjacent areas on a radiograph

• High ~ very dark and very light areas

• Low ~ many shades of gray ~ preferred in dentistry

• Only one exposure factor affects contrast -+ kiloYoltage (kVp) Note: Filtration plays a role here also. Higher kVp settings produce more shades of gray or low contrast.

Remember: Increasing milliamperage results in an increase in the number of x-rays produced and an increase in the temperature of the filament.

RADIOlOGY

Identify the following parts the dental x-ray tube.

12

18

16

11

Reprinted from Haring. Joen Iannucci and Laura Jansen: Dental Radiography: Principles and Techniques: Third Edition. © 2000, with permission from Elsevier


RPhvs

+

11. Filament

12. Molybdenum cup

13. Electron stream

14. Tungsten target

15. Copper sleeve I Anode

16. Vacuum

17. X-ray beam

18. Leaded glass housing

X-rays are generated when a stream of electrons (which are produced by the filament) travels from the cathode to the anode and is suddenly stopped by its impact on the tungsten target. The filament located in the cathode is made of tungsten wire. The small area on the target that the electrons strike is called the focal spot -) it is the source of x-rays.

~

1. The size of the focal spot directly influences the x-ray definition -) the larger the focal spot, the greater the loss of definition and sharpness of the image.

~. Copper is used to house the anode because it is a good thermal conductor, dissipating heat from the tungsten target and reducing the risk of melting the target.

3. The Molybdenum cup, also known as the electron focusing cup, electrostatically directs the electrons from the filament in the cathode to the focal spot on the anode.

RADIOLOGY

RPhvs

The amount of material that is required to reduce the intensity of an x-ray beam to half is called the:

• Value layer

• Intensity value layer

• Half-value layer

• Full-value layer


• Half-value layer

For x-ray beams, this is normally expressed in aluminum or copper thickness, but can also be expressed in other materials or media, such as water. Strictly, the half value layer is defined for different quantities: photon fluence (number of photonslcm2) , energy fluence (number of photons x photon energylcm2) or absorbed dose. The term intensity is commonly used but is too vague and should therefore be avoided.

Due to the spectral nature of x-rays, the half-value layer (HVL) is not constant. When measuring multiple half value layers, the second HVL is greater than the first. This is due to the fact that the mean energy of the x-ray spectrum is increased following passage of the first HVL, which results in the x-rays becoming more penetrating.

In oral diagnostic radiography, the half-value layer of the beam of radiation is approximately 2 mm of aluminum. This means that half of the x-rays exiting the vacuum tube are absorbed by 2 mm of aluminum. It should be noted that doubling the thickness of aluminum will not absorb all of the x-rays, but only half of the remaining x-rays.

Important point to remember: The half-value layer is an indicator of the penetrating quality of an x-ray beam. The higher the half-value layer, the more penetrating the beam. Note: X-rays and gamma rays are examples of non-particulate radiation energy.

RADIOLOGY

RPhvs

The radiation generated at the anode of the x-ray tube is called:

• Primary radiation

• Scattered radiation

• Potential radiation

• Reverse radiation


• Primary radiation

It is attenuated by the filter and the object. The amount of primary radiation follows the inverse square law measured from the focal spot. The attenuation of primary radiation should be measured with a narrow beam geometry to exclude all secondary (i.e., scattered radiation).

Secondary radiation (scattered radiation) which arises from interactions of the primary radiation beam with the atoms in the object being imaged. Because the scattered radiation deviates from the straight line path between the x-ray focus and the image receptor, scattered radiation is a major source of image degradation in both x-ray and nuclear medicine imaging techniques. When x-ray radiation passes through a patient, three types of interactions can occur, including coherent scattering (coherent scatter), photo electric absorption and Compton scattering. Of these three events, the great majority of scattered x-rays in diagnostic x-ray imaging arise from Compton scattering .

.!!.ot8S:

1. Lead is most effective in stopping x-rays (patients should always wear a lead apron and thyroid col/ar).

12. X-rays have more energy than light.

~. The following belong to a group of radiations known as electromagnetic radiations: microwaves,

x-radiation, visible light, and gamma radiation.

~. Approximately 1% of the energy released in the x-ray tube is released as x-rays. p. MPD stands for maximum permissible dose of radiation exposure.

~. The yearly MPD for a non-occupationally exposed person is 0.5 REM compared with 5 REM for someone who works near radiation.

17. The type of cone (PID) that best reduces the amount of scatter radiation that the patient receives is a leaded, rectangular one since this greatly reduces the size of the beam.

RADIOLOGY

RProt

The removal of parts of the x-ray spectrum using absorbing materials in the x-ray beam is called:

• Elimination

• Filtration

• Collimation

• Reduction

Copyright ©2007 - 2008 -DENTAl DECKS

• Filtration

The x-ray spectrum reaching the patient is filtered by attenuating material in its path. Filtering of the beam is used in order to modify the spectral or spatial distribution of x-rays, or both. Filtration is in principal divided in two parts:

1. Inherent filtration ~ the filtration of an x-ray beam by any parts of the x-ray tube or tube shield through which the beam must pass. The parts include the glass envelope of the x-ray tube, the oil cooling the tube and the exit window in the tube housing. The inherent filtration corresponds to approximately 0.51 mm of aluminum.

2. Added filtration ~ is obtained by placing thin sheets of aluminum in the cone to filter the useful beam further.

The total filtration of the x-ray beam before it reaches the patient consists of the inherent filtration plus the added filtration. Recommended total: equivalent of 0.5 mm (below 50 kVp) and 2.5 mm (over 70 kVp) of aluminum.

lOIs:

1. Longer wavelength x-rays (those produced at lower kilovoltages) are easily absorbed.

2. Shorter wavelength x-rays (those produced at higher kilovo/tages) penetrate objects more readily (they form the image on the film).

Remember: The x-ray beam is composed of rays of different wavelengths and penetrating power (the term used for this is polychromatic) because the potential across the tube changes constantly as the voltage varies.

RADIOLOGY

RPrOI

The most effective means in reducing the time of exposure, the amount of radiation reaching the patient and the amount of radiation scattered to the dentist is:

• A lead apron

• Ekta-speed film

• Lead diaphragms

• Increasing target-film distance


• Ekta-speed film

A" of the following reduce the amount of radiation to the patient:

• A lead apron

• Increased filtration using an aluminum disk

• Ekta-speed film

• Lead diaphragms placed within the cone of an x-ray tubehead

• Collimating an x-ray beam

• Increasing source-film distance

• Intensifying screens (used for all extraoral radiography ~ panoramic, cephs.)

Note: The Committee on Radiation Protection of the National Bureau of Standards recommends that a person who works near radiation be exposed in one year to a maximum dose of 5 REM (0.1 REM per week). Secondary (scatter radiation) pose the greatest hazard to the dental team.

Important: Carcinogenesis and genetic mutation are important and serious effects of repeated exposure to low doses of x-radiation. The mechanisms involved may be frameshift mutations, synergism with chemical carcinogens and altered DNA repair enzyme functions.

RADIOlOGY

RPrOI

The use of metal plates, slots, bars, etc., to confine and direct radiation (e.g., x-rays or gamma-rays) to a specific region and / or to discriminate against radiation from unwanted directions (e.g., scattered radiation) is called:

• Discrimination

• Collimation

• Filtration

• Coning

Copyright ©2007 • 2008 - DENTAL DECKS

• Collimation

Collimation refers to the control of the size and shape of x-ray beam.

In x-ray imaging systems, a collimator mounted to the x-ray tube is used to define the dimensions of the beam which is to be incident on the subject and the detector. To minimize radiation dose and to comply with government regulations, a certain level of precision must be maintained.

It is a basic rule of radiation hygiene that the radiation beam be as small as practical. For intraoral radiography, by state law, the diameter of a circular beam of radiation at the patient's skin can be no greater than 2.75 inches. One can use a diaphragm or metal cylinders, cones or tubes to collimate the beam.

These devices do not reduce the amount of radiation received by the exposed tissues, but reduce the radiation to surrounding tissues due to x-ray beam divergence.

Remember ~ The x-ray beam consists of many different wavelengths. The short wavelength (high energy) rays have great penetrating power; long wavelength (lOW energy) rays have low penetrating power and do not reach the film in reasonable quantities since they are attenuated by the soft tissues. Low energy rays add only to the total amount of radiation the patient receives. Aluminum discs are used to filter out the useless long wave rays, increasing the overall quality of the beam.

Important: Filtration reduces patient dose, decreases contrast and decreases the density of the film.

RADIOLOGY

A herringbone or diamond effect will appear on the processed film when:

• The film is bent

• The film is placed backwards in the mouth

• An improper vertical angulation is used

• An improper horizontal angulation is used

Copyright ©2007- 2008 - DENTAL DECKS

Tech

• The film is placed backwards in the mouth (See figure #1)

Figure #1.A reversed film appears light with a herringbone effect.

Figure #3. The bent film appears distorted.

double exposure

image.

RADIOLOGY

Tech

Image magnification may be minimized by:

• Using a short cone

• Placing the film as far from the tooth as possible

• Using a long cone

• Shortening the exposure time


• Using a long cone

Five rules for accurate image formation when taking x-rays:

1. Use the smallest focal spot that is practical.

Note: The size of the focal spot influences radiographic definition or sharpness. They are inversely proportional. The operator cannot control the size of the focal spot.

2. Use the longest source-film distance that is practical in the particular situation.

3. Place the film as close as possible to the structure being radiographed.

4. Direct the central ray at as close to a right angle to the film as anatomical structures will allow.

5. As far as is practical, keep the film parallel to the structure being radiographed.

RADIOLOGY

Tech

Foreshortening and elongation are produced by:

• Incorrect horizontal angulation

• Incorrect vertical angulation

• Either of the above


• Incorrect vertical angulation

Vertical angulation is directing x-rays so that they pass vertically through the part being examined. This is accomplished by positioning the tubehead and direction of the central ray in an up-and-down (vertical) plane. Important: Foreshortening (See figure #1) refers to a shortened image and elongation (See figure #2) refers to an elongated image. Both are produced by an incorrect vertical angulation. Excessive vertical angulation causes foreshortened images, while insufficient vertical angulation causes elongated images.

Figure #1. If the vertical angulation is too steep, the images are foreshortened.

Figure #2. If the vertical angulalion is too nat, the images are elongated.

Horizontal angulation is maintaining the central ray at 0 degrees as the tube is moved around the head. This is accomplished by positioning the tubehead and direction of the central ray in a side-to-side (horizontal) plane. Note: The general rule for horizontal angulation is that the central ray should be perpendicular to the mean anteroposterior plane of the teeth being x-rayed. Important: Incorrect horizontal tube angulation causes overlapping (teeth images are superimposed on each other).

The central ray is said to be at 0 degrees when the x-ray tube is adjusted so that the central ray is parallel to the floor. If the tubehead is directed at the floor, it is called positive angulation; if it is directed toward the ceiling, it is called negative angulation.

RADIOLOGY

Tech

The two radiographs below were taken with the buccal object rule in mind. In film #2, the x-ray tube was directed from a mesial angulation. What is the spacial position of the circular object in these radiographs?

• The object lies lingual to the first molar

• The object lies buccal to the first molar

• The object lies between the second premolar and the first molar

• The object lies directly apical to the first molar

Film #1

Film #2

Copyright ©2007 ·2008 - DENTAL DECKS

• The object lies lingual to the first molar

The buccal object rule (a/so called the tube shift technique) is used to determine an object's spacial position within the jaws. This technique utilizes two radiographs of an object exposed with slightly different tube angulations. It then compares the object's position on the radiograph with respect to a reference point (e.g., the root of a tooth).

If the tube is shifted and directed from a more mesial direction, and the object in question appears to have moved mesially with respect to the reference point, then the object lies lingual to that reference point. Conversely, if the tube is shifted mesially and the object in question moves distally, it lies on the buccal aspect of the reference object.

Remember the acronym SLOB ~ §.ame-bingual, Qpposite-.§_uccal.

***If the object in question appears to move in the same direction as the x-ray tube, it is on the lingual aspect. If it appears to move in the opposite direction as the x-ray tube, it is on the buccal aspect.

RADIOLOGY

Tech

Which of the following errors in radiographic technique is the most likely reason that an image on a radiograph would appear elongated?

• Too much vertical angulation

• Too little vertical angulation

• Incorrect horizontal angulation

• Beam not aimed at center of film


• Too little vertical angulation

Some errors often made when taking dental radiographs:

• Elongation (most common error) --.. teeth appear too long ---? may be caused by too little vertical angulation, the film not parallel to the long axis of the teeth or the occlusal plane not being parallel to the floor.

• Foreshortening --.. teeth appear too short ---? may be caused by too much vertical angulation or poor chair position.

• Cone cutting --.. portion of film will appear clear with a curved line ---? the beam was not aimed at the center of the film. See figure #1.

• Herringbone effect --.. zigzagged pattern appears on the film ---? the film was placed backwards in the mouth.

• Poor film placement --.. the film was not placed far enough back or not forward enough in the mouth.

See figure #2.

• Overlapping --.. interproximal areas are overlapped, reduces diagnostic quality of film ---? due to incorrect horizontal angulation (the central x-ray was not directed perpendicular to the curvature of the arch and through the contacts). See figure #3.

Figure #1. A cone-cut appears as a curved unexposed (clear) area on a radiograph.

Figure #2. Improper film placement: no apices appear on this film.

Figure #3. Incorrect horizontal angulation results in overlapped contact areas.

RADIOLOGY

Tech

Which of the following positioning errors is the most likely cause of the reverse occlusal plane curve on the panorex below?

• Chin tilted too far upward

• Chin tilted too far downward

• Head turned slightly


• Chin tilted too far upward

***Mandibular structures look narrower and maxillary structures look wider (looks like a "frown'?

Chin tilted too far downward:

1. Occlusal plane shows an excessive upward curve (looks like a "big smite"). See figure below.

2. Severe interproximal overlapping, anterior teeth appear very distorted

RADIOLOGY

Tech

The periapical x-ray below appears distorted. What is the most likely cause of this?

• Overbent film

• Patient had glasses on

• Exposure to secondary radiation

• Cone cutting

• X-ray arm drifted

Copyright ©2007 ·2008 -DENTAL DECKS

• Overbent film ~ cracked emulsion

Some other common errors made when taking dental radiographs ~ cause:

• Light films (underexposed / image NOT dense enough) ~ incorrect milliamperage (too low) or exposure (too short); incorrect focal film distance; cone too far from patient's face, film placed backwards. See figure # 1.

• Dark films (overexposed / image too dense) ~ incorrect milliamperage (too high), exposure (too long),

incorrect kVp (too high). See figure # 2.

• Double exposure ~ film was used twice.

• Fogged films ~ exposed to radiation other than primary beam. See figure # 3.

• Artifacts ~ patient didn't remove eyeglasses, earrings, or removable prosthetic appliances.

• Poor contrast ~ incorrect kVp (too high).

• Blurred image ~ patient movement or drifting of x-ray arm.

• Clear films ~ were not exposed to radiation.

Figure #1. An underexposed film appears light.

Figure #2. An overexposed film appears dark.

Figure #3. A fogged film appears gray and lacks detail and contrast.

RADIOLOGY

Tech

Which of the following is a major disadvantage of the paralleling technique?

• The image formed on the film will not have dimensional accuracy

• Due to the amount of distortion, periodontal bone height cannot be accurately diagnosed

• An increase in exposure time is necessary due to the use of a long cone

• An increase in exposure time is necessary due to the use of a short cone

Copyright ©2007 - 2008 ~DENTAL DECKS

• An increase in exposure time is necessary due to the use of a long cone

The paralleling technique is based on the concept of parallelism. Other names for this technique include XCP (extension cone paralleling technique), right-angle technique, and long-cone technique. Basic Principles:

• Film is placed parallel to the long axis of the tooth being x-rayed.

• Central x-ray is directed perpendicular to both the film and the long axis of the tooth.

• A film holder (XCP) must be used to keep the film parallel to the long axis of the tooth.

• The object-film distance must be increased to keep the film parallel. This results in image magnification and loss of definition.

• The source-film distance must also be increased to compensate for the image magnification and to make sure that only the most parallel rays will be aimed at the tooth and the film. Using a long cone (16 inch target-film distance) results in greater definition and less image magnification.

Long axis of tooth

Film(\~~

"."-,~

PID

Positions of the film. teeth, and central ray of the x-ray beam in the paralleling technique. The film and long axis of the tooth are parallel. The central ray is perpendicular to the tooth and film. An increased target-film distance (16 inches) is required.

RADIOLOGY

Tech

Which of the following is not a disadvantage of the bisecting technique?

• Image on x-ray film may be dimensionally distorted (amount may vary)

• Increased exposure time

• Due to the use of a short cone (which results in divergent rays), the image is not a true reproduction of the object

• May not be able to judge the correct alveolar bone height


• Increased exposure time

***The exposure time is actually decreased.

The bisecting angle technique is based on the geometric principal known as the rule of isometry. The rule states that two triangles are equal if they have two equal angles and share a common side.

The following best describes the bisecting technique:

• The dental x-ray film is placed along the lingual surface of the tooth.

• At the point where the film contacts the tooth, an angle is formed by the plane of the film and the long axis of the tooth.

• The person taking the x-ray needs to visualize a plane that bisects this angle. This plane is called the imaginary bisector ~ this creates two equal angles and provides a common side for the two imaginary equal triangles.

• The central ray is positioned perpendicular to the imaginary bisector.

Important: When this technique is followed strictly, the image of the tooth produced is accurate. long axis of tooth

Central ray

RADIOlOGY

Name the two x-ray projection techniques used in dental radiography.


Teell

1. Bisecting technique (See Figure #1)

2. Paralleling technique (See Figure #2)

Central ray of the

X-ray beam aimed through the tooth apex

A

2-3 mm of film "'>-11' visible beyond th~ .. incisal edge

Vertical angulation

Minimal magnification of the image

Figure #2. Diagrams showing the magnification of the image that results from using (A) a short cone and a diverging x-ray beam and (6) a long cone and a near-parallel xray beam.

Figure #1. Theoretical basis of the bisected angle technique. The angle between the long axes of the tooth and film is bisected and x-ray beam aimed at right angles to this line, through the apex of the tooth. With this geometrical arrangement, the length of the tooth in the mouth is equal to the length of the image of the tooth on the film, but as shown, the periodontal bone levels will not be represented accurately.

RADIOLOGY

I-ravs

Which of the following projections is best for examination of fractures of the zygomatic arch?

• Waters projection

• Submentovertex projection

• Reverse Towne projection

• Lateral cephalometric projection



For this projection the neck is maximally extended and the film cassette touches the top of the head. The x-ray beam enters the head under the chin (near the mental tubercle of the mandible) and exits at the vertex. This view is used in conjunction with other projections, and allows direct visualization of the base of the skull. The zygomatic arches stand out like the handles of a jug on this view.

FP

[}~

X-ray unit :

Film

____ cassette

Floor

RADIOLOGY

I-rals

Which of the following projections is best for examination of the maxillary sinus?

• Lateral jaw projection

• Reverse Towne projection


• Subrnentovertex projection



This is a posterior-anterior projection with the patient's face lying against the film and the x-ray source behind the patent's head. Waters' projection is the most useful conventional radiographic technique to image the maxillary sinuses. In this projection, the radiographic densities of normal maxillary sinuses are the same on both sides and equal to those of the orbits. If one of the sinuses is diseased, Waters projection will exhibit either a radiopaque (fluid) level, a sinus opacification, mucosal hyperplasia, a radiopaque growth or a loss of cortical borders of sinus. Other useful projections include periapical. panoramic, occlusal, lateral head, and Caldwell. It is also one of the best films for radiographic diagnosis of mid-facial fractures.

X-ray unit

Film cassette

RADIOLOGY

X-rays

Which of the following projections is best for examination of the condyles and neck of the mandible (from an anterior-posterior projection)?


• Transcranial projection

• Townes projection



• Townes projection

The patient lies on his back with the film under his head. The x-ray source is from the front, but rotated 30 degrees from the Frankfort plane and is directed right at the condyles.

The Townes projection is often of value in assessing the status of the condyles, condylar neck and rami because superimposition of the mastoid and zygoma over the condylar neck region in the straight postero-anterior projection often makes interpretation difficult. The Townes projection eliminates this superimposition, thus giving good visualization of the condylar area and rami.

Note: The "reverse Towne projection" is used to identify ~

fractures of the condylar neck and ramus area.

The following can be demonstrated on conventional TMJ radiographs:

• Position of the condyles in the glenoid fossa

• The range of antero-posterior movement of the condyles

• Areas of bone destruction on condylar heads

.

omi§jjTh

RADIOLOGY

All of the following are advantages of a panoramic radiograph except:

• It shows areas that may not be visible on a full mouth series

• It shows both arches on the same film

• It gives better detail and definition than periapical radiographs

• It is more comfortable for the patient (eliminates gagging)

• It requires less time than a full mouth series


X-rays

• It gives better detail and definition than periapical radiographs

"""This is false; a panoramic radiograph gives less detail and definition than periapical radiographs due to intensifying screens, movement of the x-ray tube and film and increased object-film distance.

Indications for a panoramic radiograph:

• Diagnosis of oral pathology that may not be visible on periapical radiographs

• Treatment planning (especia((y orthodontic cases)

• Evaluation of anomalies

• As one part of the follow-up evaluation in surgical and trauma cases

• Edentulous patients (prior to constructing fu(( dentures)

• Patients that are unable to tolerate intra-oral x-rays

"""The drawback of a panoramic radiograph is that there is a loss of image detail (it is hard to diagnose early carious lesions). Bite-wing x-rays are required for the diagnosis of carious lesions.

Other disadvantages of a panoramic radiograph:

• Distortion of image due to increased object-film distance

• Inadequate for interproximal caries detection or for detecting periodontal breakdown (bone loss)

• Proximal overlapping (especia((y in premolar and molar areas)

• Added exposure to a large area of body tissue, in addition to the oral tissues

RADIOLOGY

Identify each structure numbered in the partial panoramic radiograph below?

"Courtesy Dr. Stuart C. White, UCLA School of Dentistry," Copyright©2007 - 2008 -DENTAL DECKS

X-ravs

1. The opaque mass ~ Inferior concha

2. The opaque line ~ Medial wall of maxillary sinus

3. The opaque line ~ Posterior wall of zygomatic process of maxilla

4. The opaque line ~ Posterior wall of maxillary sinus

5. The opaque mass ~ Zygomatic arch

6. The opaque line ~ Hard palate I floor of nasal fossa

7. The opaque line ~ Floor of maxillary sinus

8. The line of contrast ~ Dorsum of tongue

9. The opaque line of contrast ~ Inferior border of pterygoid plates

10. The vertical line of contrast ~ Posterior wall of nasopharynx

11. The opaque mass ~ Soft palate

12. The line of contrast ~ Dorsum of tongue

13. The opaque mass ~ Calcified stylo-hyoid ligament

14. The opaque mass ~ Ear lobe

15. The line of contrast ~ Inferior border of opposite mandible

The panoramic radiograph is excellent for third molar pathology as well as to observe the TMJ, the sinuses, and sialography (which is a technique used in radiology in which a salivary gland is filmed after an opaque substance is injected into its duct). A sialolith which is located in Wharton's duct, however, can best be viewed by using a cross-sectional occlusal x-ray.

RADIOLOGY

X-rays

A phenomenon caused by a relatively lower x-ray absorption on the mesial or distal aspect of teeth, between the edge of the enamel and the adjacent crest of the alveolar ridge is called:

• Apical burnout

• Cervical burnout

• Coronal burnout

• Root burnout


• Cervical burnout

Because of the relative diminished x-ray absorption, these areas appear relatively radiolucent with ill-defined margins.

It is caused by the normal configuration of the affected teeth (the cementoenamel junction), which results in decreased x-ray absorption in those areas.

Important: These radiolucencies should be anticipated when viewing x-rays of almost any tooth and should not be mistaken for a carious lesion.

RADIOLOGY

Identify this view?

X-ravs

What are its indications?

How is the patient positioned?


• Lateral cephalometric

• Evaluation of growth and development of face

• Left side near film, 60 inches between anode and sagittal plane, soft tissue filter near source

The lateral cephalometric x-ray must be compared with "normal" lateral radiographs from an accepted norm. Linear and angular measurements are obtained utilizing known anatomical landmarks in the lateral head radiography of the patient. These measurements are then compared with those considered within normal limits and in that way enable the orthodontist to assess aberrations in the dentition and jaw structures which result in malocclusion.

Analysis of cephalometric radiographs is not limited to the hard structures such as bone and teeth, but also includes measurements of soft tissue structures such as the nose, lips, and soft tissue chin.

Superimposition in longitudinal cephalometric studies is generally on a reference plane and a registration point. This will best demonstrate the growth of structures farthest from the plane and the point. The most stable area from which to evaluate craniofacial growth is the anterior cranial base because of its early cessation of growth.

Cephalometries are useful in assessing tooth-to-tooth, bone-to-bone, and tooth-to-bone relationships. Serial cephalometric films can show the amount and direction of growth.

RADIOLOGY

X-rays

Which of the following types of intra-oral radiographs are most useful in detecting interproximal caries?

• Periapical radiographs

• Bitewing radiographs

• Occlusal radiographs


• Bitewing radiographs

.... *These x-rays show the crowns of both Max. and Mand. teeth; not root apices.

The primary reason for taking bitewing radiographs is to detect interproximal caries. They are also useful in monitoring the progression of periodontal disease. These films show crestal bone levels as well as interproximal areas of both arches. In order for the film to be of diagnostic use, the quality of the following must be excellent: dimensional accuracy, open contacts, and optimum contrast and clarity of the image.

When taking bitewing radiographs, the film must be placed in either a horizontal or vertical position. Vertical bitewings provide more periodontal information, such as bony defects and furcation involvement. A fuzzy or indistinct image of crestal bone is often associated with early periodontitis. Two bitewings are usually taken on a child, one on each side. If the child has primary dentition only, number "0" film is used. If the child has mixed dentition, number ''1'' film is utilized. Once the individual has second molars, two to four number "2" films are conventionally utilized. If using four films, one film images the premolar area, while the other images the molar area. Sometimes two, long, number "3" films are utilized (one for each side) instead of two number "2" films on each side. This practice is not recommended due to the curvature of the arch making it difficult to open all contacts on one film.

~

1. The vertical angulation for bitewing radiographs should be between +8 and +10 degrees. ~. Adjust horizontal angulation to direct the central ray toward the center of the film.

~. Alveolar bone resorption is best demonstrated on bitewing x-rays.

~. Vertical bitewing x-rays will show more alveolar bone than traditional horizontal bitewings.

5. The largest intraoral film size is # "4".

6. The standard film size is # "2".

7. The ideal temperature and humidity levels for film storage is 50 to 70° F and 30 to 50%.

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