The importance of quality diagnostic radiographs
In the dental office, day in and day out we are snapping them. Some are digital, some are film, most are intra oral but the one thing that all of our radiographs should always be is "of clear diagnostic quality" (this said in your best College of Dental Surgeons voice).
It is all too easy for clinicians to get complacent and forget the importance of the procedures that we perform day to day. Bitewings, scaling, prophy, fluoride, recall, repeat, PA, specific exam, repeat.
We've all done it - taken a film with a partial denture in place; left earrings on for a pano. The example I've included here has been used more than once to get a reaction from a fellow clinician and really, the quality isn't too terribly bad if you can get the dentist to quit laughing long enough to read it. Sometimes the fault lies on the shoulders of a little kid who would rather chew the $70 sensor to bits than hold the paper tab of a bitewing in her mouth or maybe it's the 40 year old man who can't seem to tolerate that Rinn without a clinic shaking retch - of course he requires an endo on an upper 7.
At the end of the day, it is up to the dentist who prescribes the x-rays to decide if the quality is sufficient but as CDAs we have long struggled to show our distinction in the field. A large part of that identity has been gained by providing the best possible care we can. So if you're asking yourself, what is it we're looking for again? Let's do a little review:
Bitewings for Children: Interproximal decay, deficiencies in existing restorations and presence of adult teeth. Usually just one film per side with a size that is appropriate for the mouth you're working with. Little kid bitewings can be irksome especially when the kid watches you leave the room resulting in the cone pointing at his left eye while he spits out the film to ask you where you are going. Ask your nearest seasoned CDA for tricks on how to get these. My method is to pretend I'm the host of "Romper Room" and to talk incessantly in a cartoon voice. It can get on the nerves of the hygienist in the next room but it always works for me.
Bitewings on Teenagers: Interproximal decay, presence of 8s and anomalies in the bone. Most clinicians want 4 horizontal bitewings if the 7s are erupted but the patient is not quite old enough to have a pano to locate the 8s. These can also be useful in showing the posterior tooth alignment. The anterior shot should show the distal of the 3s with no overlap in the interproximals of the bicuspids and the posterior shot should show the mesial portion of the unerupted 8 and have no overlap in the interproximals of the molars. These are my favourite to take since teenagers rarely have anything to say and their air of "bored aloofness" is strikingly similar to "immobility" and makes for an easy capture.
Bitewings on Adults: Presence of calculus, evidence of bone loss, interproximal decay, deficiencies in existing restorations. Most clinicians prefer 4 vertical bitewings on an adult patient. These are simple to open the contacts on and they show more of the tooth as it sits o the bone making it easier to diagnose periodontal problems. (No witty comment here because there is nothing funny about bone loss).
Periapicals: Usually for the diagnosis of more severe perio cases, impacted teeth or periapical abscesses. Whenever the roots of the teeth need to be seen. Many of the anomolies that prompt you to ask your dentist, "What the heck is THAT?" will show up on PAs. Cysts the size of dimes, weird root resorbtions, supernumerary teeth lazing about in people's mandibles. Because of this variety you need to know exactly what your dentist is looking for on the PA so you can capture it. If it's for endo then you know you need to see the apex no matter what, but what if you need to come from an angle that will divide the roots to show multiple canals in a bicuspid? Knowing beforehand will save you a time-wasting retake.
Occlusals: Impactions in the palate, jaw fractures, cleft palate or foreign bodies. Occlusal films have lost their popularity with the advent of low radiation digital panos but they do have their uses. They can be difficult to take, especially the upper where the cone is resting against the patient's forehead and you must ALWAYS have your patient remove their tongue stud for lowers.
Panoramic Radiographs: I won't even bother with the italics because so many things can be identified in one clear pano. In children you can see the resorbtion of the deciduous roots and the development of the permanent teeth. In adults you see the sinuses, the TMJ joint, the roots of all of the teeth, any suspicious lesions in the bone, the proximity of the mandibular nerve to the lower 8s that your dentist would like referred to the nearest oral surgeon on the double. A good pano shows all of these things and more but a bad one can look like a smudgy blur with a couple of teeth on it. This is not only a waste of time and money but the retake means more exposure for your patient.
The bottom line is, if you take a radiograph that does not show exactly what it should, you need to take it again and capture what was missing. If your rads are flawed every time then you need to identify the problem and fix it. Always cone cutting? Move the cone! Got overlap? Have the patient grin an ear splitting grin so you can see your interproximal landmarks and open those contacts. Pano too flat or have a hump in it? Get the nose down. Do whatever it takes to fix the problem - including consulting your equipment rep and have their expert come to your office and give you a radiography lesson (yes, they do that).
No more annoying retakes and when your patient moves to Saskatoon in 6 months, you won't be too ashamed to send the rads you took along with them.
