Radiography of patients with special needs

In todays lecture were going to talk about dealing with patients with special needs , manage patients with hypersensitive gag reflex , patients with physical or developmental disabilities , pediatric patients , endodontic patients and edentulous patients .

Patients with gag reflex

Definition : Gagging \ retching : strong involuntary effort to vomit Gag reflex \ pharyngeal reflex : retching that is elicated by stimulation of the sensitive tissues of the soft palate region , it is a protective mechanism of the body that serves to clear the airway of obstruction Ps : all patients have gag reflex , but some are more sensitive than others Before the gag reflex is initiated , these two reactions occur : - cessation of respiration - contraction of muscles in the throat and abdomen

Factors responsible for initiating the gag reflex include : - Psychogenic stimuli : stimuli originating in the mind - Tactile stimuli : stimuli originating from touch : areas that elict gag reflex :

- soft palate - lateral posterior third of the tongue

Operator attitude : - Show confident attitude - If not , the patient will fell this and this may act as a psychogenic stimulus and elict gag reflex - You must convey patience , tolerance and understanding - Make effort to relax and reassure these pt - Explain the radiographic procedures to be performed and then compliment the pt as each exposure is completed - As the pt becomes comfortable with the radiographic procedures , hell becomes more confident and as a result hell be less likely to gag

Patient and equipment preparations : - In such pts every effort should be made to limit the amount of time that a film remains in the mouth , the longer the film stays in the mouth the more likely the pt is to gag . - So pt and equipment preparations must completed before film placement

Exposure sequence :

- Always start with the anterior exposures , anterior films are easier for the pt to tolerate and less likely to cause gag reflex - With posterior film placement you should always expose the premolar film before molar film - The maxillary molar film is the most likely to elict the gag reflex - In hypersensitive gag reflex , the exposure sequence should be altered so that the maxillary molar films are exposed the last .

Film placement and technique : - Each film must be placed and exposed as quickly as possible - AVOID THE PALATE : sliding the film along the palate stimulates sensitive areas and cause gag reflex , instead place the film lingual to the teeth , then firmly bring the film into contact with the palatal tissues using one decisive motion ( esp with maxillary posterior areas ) - Demonstrate film placement : rub a finger along the tissues near the intended area of film placement while telling the pt then quickly place the film ( this tech demonstrates where the film will be placed and desensitizes the tissues in the area )

Extreme cases of gag reflex : Pts with gag reflex that is uncontrollable , in such pts intraoral films are impossible to obtain , instead the dental

radiographer must use extraoral films such as panoramic or lateral jaw radiographs to obtain diagnostic information .

Helpful hints to reduce the gag reflex : Never suggest gagging or ask the pt if he is a gagger , instead when you explain to the pat what will happen refer to the gag reflex as a tickle in the back of the throat Do reassure the pt , if gag reflex happen you must remove the film as quickly as possible and then reassure the patient that such response is not unusual Instruct the pt to breath deeply through the nose during film placement and exposure Distraction often helps to suppress the gag reflex ( by asking him to bite as strong as possible on the holder , raise his arm or leg , etc ) Try to reduce tactile stimuli , before placing and exposing the film you can give the pt a cup of water or ice to drink , place salt on the tip of the tongue , these methods will help to confuse the sensory nerve endings and lessen the likelihood of stimulating the gag reflex Use topical anesthetic spray in pt with sever hypersensitivity gag reflex , the spray use to numb the areas that elicit the gag reflex , you should instruct the pt to exhale while the anesthetic is sprayed on the soft palate and posterior tongue , if the pt inhale it inflammation of the lungs

 Topical anesthetic sprays take action after 1 min and last for 20 mins, it should not be used in pts who are allergic to benzocaine .

Patients with disabilities

Disability is a physical or mental impairment that limit one or more of an individuals major life activities

Physical disabilities : May have problems with vision , hearing or mobility Often is accompanied to the dental office by a family member or other caregiver . Caregivers can be asked to asses the radiographer with communication or with the patients physical needs

Vision impairment : Communicate using clear verbal explanations Keep the pt informed of what is being done and explain each procedure before performing Never gesture to another person in the presence of a blind person they are sensitive

 Hearing impairment : You can ask the caregiver to act as an interpreter , use gestures ,lips Face the pt and speak clearly and slowly

Mobility impairment : - you may offer to assist in transferring to the dental chair or ask the caregiver to assist in the chair transfer - if a chair transfer is not possible the dental radiographer may attempt to perform the necessary radiographic procedures with the pt seated in the wheelchair - if pt cannot use his upper limp and a film holder cannot be used to stabilized the film , dental radiographer may ask the caregiver to assist with film holding . - a dental radiographer must never hold a film for a pt during an x-ray exposure .

Developmental disabilities : - is a substantial impairment of mental or physical functioning occurs before the age of 22 and is of indefinite duration - examples : autism , cerebral palsy, epilepsy and other neuropathies , and mental retardation . - such pts may have problems with coordination or comprehension of instructions as a result the dental radiographer may experience difficulties in obtaining intraoral films - if comprehension is a problem and the pt cannot hold a film

, the caregiver may be asked to assist with film holding . - extraoral films may be used . - DO not ask personal questions about a disability . - Do offer assistance to a person with disability - DO talk directly to the person with a disability

pediatric patients
=> definitions : - pediatric is the branch of dentistry dealing with the diagnosis and treatment of dental disease in children

in children , dental radiographes are useful in : - detecting lesions and conditions of teeth and bones - showing changes secondary to caries and trauma - evaluating growth and development

=> prescribing of dental radiographs : for pediatric pts the prescribed number number and type of dental films depend on the individual needs of the child , the age of the child and his ability to cooperate with the procedures .

=> patient and equipment preparations :

these preparations are identical to those prescribed for adult pts , but with pediatric pts special attention must be devoted to the following preparations : explanation of procedure in a way that is easily understood . Lead apron and thyroid collar must be placed on a child before exposure . Exposure factors ( milliamperage , kilovoltage ,time ) must be reduced because of the size of the pediatric pt , the shorter the exposure time will reduce the chance of a blurred film because of the child movement .. all exposure factors should be set according to the manufacturers. Film size : size ) film is recommended for use in pedo with a primary dentition because of the small mouth size in child with transitional dentition size 1 or 2 film is recommended ( size 2 film is preferred for maxillary and mandibular occlusal pedo projections )

=> Recommended techniques : in children with a primary or transitional dentition , the bisecting technique is preferred because the small size of the mouth precludes the placement of a film beyond the apical regions of the teeth the bite wing and occlusal techniques are also used .
Dentition Number of films Type of projection Film size

Primary (3-6 years )

1 1 2 2 2

Occlusal : Mx occlusal : Mn bite-wing periapical : Mx molar periapical : Mn molar Periapical : Mx anterior periapical : Mn anterior bite-wing periapical : Mx molar periapical : Mn molar 1 1 1 or 2 1 or 2 1 or 2

Transitional (7-12 years )

3 3 2 2 2

=> helpful hints for managing a pediatric patient : be confident and be patient and do not rush the radiographic procedures show and tell reassure the child and allay any fears about the procedures demonstrate the desire behavior to show the child exactly what to do request assistance if a child cannot hold still or stabilize the film

 postpone the examination : only in emergencies should a child be forced to undergo a radiographic examination , it is much better to postpone the examination until the second or third visit rather than instill a fear of visiting the dental office .

Endodontic patients
is the branch of dentistry concerned with the diagnostic and treatment of diseases of the dental pulp within the tooth endodontic treatment usually involves removal of of the dental pulp (nerve tissues ) from the pulp chamber and canals within the tooth , then filling the empty pulp champer and canals with materials such as gutta percha or silver points

=> film placement : during a root canal procedure , film placement is difficult because of the poor visibility of the tooth and the equipment used in RCT . The EndoRay film holder can be used to aid in positioning the film during RCT , this holder fits around a rubber dam clamp and allows space for root canal instruments and filling materials to protrude from the tooth

=> Recommended technique : the length of the pulp canals must be accurately measured without distortion (elongation or foreshortening) , to avoid distortion the paralleling technique should be used whenever possible where the use of a film holder ( EndoRay , hemostat , tongue depressor ) is strongley recommended . The use of bisecting technique may result in elongated or foreshortened images .

Edentulous Patients
edentulous pts require the use of dental radiographs for the following reasons : - to detect the presence of root tips , impacted teeth , and lesions ( cysts , tumors ) - to identify objects embedded in bone - to establish the position of normal anatomic landmarks ( eg :mental foramen )relative to the crest of the ridge . - To observe the quantity and quality of bone that is present the radiographic examination of edentulous pts may include a panoramic radiograph , periapical or a combination of occlusal and periapical radiographs .

=> Panoramic Radiographs : the most common way of examining the edentulous jaw quick and easy for the pt and requires only one film if a panoramic radiograph reveals any root tips , impacted teeth , foreign bodies , or lesions in the jaw , a periapical film of that specific area must be exposed , bcz the peiapical radiograph has more definition and permits the area in question to be examinated in greater details .

=> peripaical Examination 6 anterior and 8 posterior (used if a panoramic x-ray machine is not avaolable ) size 2 film is typically used for the edentulous examination either paralleling technique or the bisecting technique can be used if the parallel technique is used , cotton rolls must be placed on both sides of the bite block to take the place of the missing teeth if the bisecting technique is used , the edentulous ridge and the film form the angle to be bisected , the film should be positioned so that approximately 1/3 of it extends beyond the edentulous ridge

 if the alveolar ridges of the pt are severely resorbed the bisecting technique is recommended

=> occlusal and periapical examination : the mixed occlusal and periapical examination consists of a total of six films one maxillary topographic occlusal projection (size 4 film ) one mandibular cross-sectional occlusal projection (size 4 film ) and four standard molar periapical films ( size 2 film ) as the panoramic radiograph : if an object is identified on an occlusal film , a periapical film of that specific area should be exposed

the End done by : RMZ .H. RABADI this lecture summarizes the book too , Enjoy