Transcribed by Anam Khalid July 3, 2014

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[Radiology] [2] [Image Formation] by [Dr. Alan Friedman]

[7] [Ionization]
[Dr. Friedman] Okay, good morning. Worst thing about a nothing worse than a
two-hour lecture except a two-hour lecture at 8 oclock in the morning. Anyway,
what were going to be covering today last time we covered the production of the
x-rays in the x-ray tube and some of the devices inside the x-ray tube. What Id like
to do today is review some of the major topics that we covered last time because I
know we went very quickly and I need to clear up some information. I think your
class president found an error in one of the slides so Ill point that out to you. Only
one error out of quite a few slides is pretty good. We were talking and then after
we review some of the information about production of x-rays, were actually going
to go ahead and see how the image is produced, how we can get the best possible
image for the best diagnostic purposes. Remember, as dentist, were imaging head
and neck areas and especially for beginning students, general dentists, were
imaging teeth. So, whenever we say the object ... the object is the tooth. So well
cover that. We spoke about ionization. Ionization is the removal of an electron off a
neutral atom. Certain energy, certain types of electromagnetic energies can ionize
tissues because they have enough energy. They have enough energy because theyre
very short wavelengths and the short wavelengths have a high amount of energy.
And thats why radiation, x-radiation is harmful due to its ability to ionize tissues.

[8] [Properties of Radiation]
Properties of radiation, very quickly, they have no mass. Commonalities, speed of
travel, 186 miles per second and no weight. They have no mass. The differences:
whats the difference between light and x-rays? The wavelength. X-rays have short
wavelengths. You have short wavelengths, you have penetrating ability. Because of
the shortness of the wavelength and the frequency, they have a short wavelength
but high frequency. So the penetrating ability has to do with the wavelength and the
frequency.

[10] [Wavelengths]
And these are just an example of short by the way, all of the most of these
slides, most of these diagrams are in the textbook that I pointed out last time. I
believe theyre in VitalBook. Dr. Frommers textbook is in VitalBook, very easy
reading. There may be 35 pages to the chapter but out of the 35 pages there are
about 27 diagrams. So, its really not that bad. You just read over the information.
Any of the information that youre having difficulty with.

[13] [Properties of Radiation]
And of course, these are the properties, we spoke about them. They travel at the
speed of light.

[12] [Electromagnetic Spectrum]
And x-rays belong to a grouping of radiations called electromagnetic radiation.
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And again, a spectrum is a grouping from the long wavelengths on this side and
short wavelengths on that side and x-rays form this category over here.

[16] [The Dental X-ray Tube and Its Components]
Okay again all of this information we covered. I just want to pick up on some of
the information. Just to review, we went over some of this material very quickly and
I threw a lot of terms out at you. The different components of the x-ray machine of
the x-ray tube. Remember the x-ray tube is a little glass tube thats evacuated. It has
it has different circuits in it. It has a high-tension circuit which is at the anode. It
has a low-tension circuit, which is at the cathode. The anode contains the sleeve or
stem and the tungsten target. The tungsten target. Tungsten is chosen as a target
material because it has a high atomic number. So what happens is, as the electrons
bombard it, it can go into the atom and it bends and veers off course and thats
Bremsstrahlung radiation. It can also knock off one of the inner shell electrons, well
see that in a moment, and thats characteristic radiation.

[17] [The Dental X-ray Tube and Its Components]
And the port is the opening. Theres an aluminum filter. Very important. What is the
aluminum filter do? What is the purpose of the aluminum filter? We know that the x-
rays coming off the anode, off the target, have different wavelengths. Why do they
have different wavelengths? It has to do with a multiple Bremsstrahlung. Each time
an electron, a high-speed electron goes into another atom, it veers off course, theres
less energy. So the initial Bremsstrahlung has short wavelengths. Those are the ones
that we want to use. The aluminum filter removes the long wavelengths so that
theres less radiation to the patient. Whats another reason we have a
heterogeneous type of radiation coming out of there? It has to do with the sin wave
of the alternating current. Remember the alternating current goes up. Well see that
in a moment. It goes up to 90 kVp. Well at 90 kVp, when it reaches that peak, we
have very very, very very short wavelengths, high-energy radiations. As its going up
the peak, lower and lower wavelengths. We need to remove those. So by filtering out
the term filtering is removing the long wavelengths. What is the ultimate effect of
the aluminum filter? Protection for the patient. Everything is protection for the
patient. We can get the least amount of radiation with the best possible film.
Inherent filtration means whats built into the machine. The glass in the tube
removes some of the wavelengths as it leaves the porte. And also the oil
surrounding the x-ray tube. The oil is there to dissipate some of the heat. Remember
heat is very important in this process. 99% of the energy of the high speed, kinetic
energy of the high speed electron is converted to heat. Only 1% is useful radiation.
Also, heat is important in which part of the x-ray machine? In the x-ray tube? The
cathode. Because when you turn your machine on, what are you doing? You are
heating the tungsten filament. By heating the tungsten filament youre boiling off
electrons, thermionic emission effect. Those electrons are in the form of an electron
cloud. Well see that in a moment. Very quickly.


[18] [The Dental X-ray Tube]
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Thats the x-ray tube


[19] [X-ray Production]
and these are the terms we spoke about. Thermionic emission effect. What part of
the x-ray tube does that occur at? It occurs at the cathode, the little tungsten
filament. The amount of voltage is about 2 to 5 volts. How do we get 2 to 5 volts?
Step-down transformer. Okay? Electron cloud is the electrons after they boil off.
Theyre not going anywhere because theres no positive charge. Right now youre
just heating the filament. The way you get the positive charge is you walk out of the
room press the exposure switch. When you press the exposure switch, that causes
the anode to become positive. The electrons will shoot across at high speed. Now,
what controls the speed of the electrons? Only one thing: kVp. The higher the kVp,
the faster the electrons shoot across. What controls the amount of radiation or the
quantity of radiation? Miliamperage at the cathode. Okay? So, when we increase the
miliamperage, there are more electrons available to shoot across. Will those
electrons be more penetrating? Not necessarily. It has to do with the kVp. Now, if we
increase the miliamps, then we need less exposure time. Thats the miliamps
seconds, which Ill show you. There was an error on that calculation there. So, the
quality of the x-ray, the quality has to do with the kVp. Quality is the penetrating
power. The higher the kVp, the faster the electrons shoot across. The more energy,
the more kinetic energy they contain, the Bremsstrahlung reaction will give off
radiations of shorter wavelengths. The cathode ray, the cathode ray is the stream of
electrons shooting across. When does that occur? When you make your exposure
switch. The kilovoltage has to do, again, with the speed of the electrons coming
across.

[20] [The Dental X-ray Tube]
Here is the x-ray tube broken down, again, into the cathode and the anode. We also
have the aluminum filter here filtering the x-rays and we also have the diaphragm,
which is a device which collimates. Collimation is important. Why? What does
collimation do? If you say protect the patient, thats the answer. Everything is to
protect the patient. How? By making it a smaller beam as possible. We just want the
little x-ray film in the patients mouth to get hit by radiation. And, so, we collimate
beam. We can also collimate the beam with the position-indicating device, which is
lead-lined. And theres a circular one and theres a rectangular one. We use
rectangular collimating devices. Why do we use rectangular collimating devices?
Protect the patient. How do we protect the patient? Theres about 55-65% reduction
in the patient dose because of the rectangular collimator. Why? Its smaller. Less
radiation, less surface tissue is exposed.

[21] [Rotating Anode]
Okay? And, why dont we turn the miliamps up to a high number? Then well have a
hundredth of a second of exposure time. Because its miliamps seconds. What is the
limiting factor? Heat. Because if that little target area is so tiny and its bombarded
with so many electrons, itll just boil. Itll just heat up and get destroyed. And so,
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what we have in some x-ray machines, panoramic units, and extraoral units, catscan
machines, we have the same setup. Its all thanks to the guy Coolidge. Hes the guy
that came up with the hot filament circuit. This is what we have today, a hot filament
circuit. And, so, what happens is the anode is located here but there are several
anodes and it spins around as the x-rays come out. And so in those machines we can
crank up the miliamperage to a high number. What is the result of that? What is the
advantage? Less exposure time, less chance of the patient moving, especially when
were taking head films, or skull films. Thats the advantage of that.

[22] [Activated Filament Circuit]
So again, you walk into your office, you turn on your x-ray machine. What are you
doing? Youre not producing radiation. What youre doing is, youre simply heating a
little tungsten filament, which is embedded in a focusing cup called molybdenum.
Its hard to say. Molybdenum focusing cup. And what happens when you do make
your exposure, the molybdenum cup becomes negative. It repels the electrons. So
there are two things that are happening: the positive charge at the anode attracts
the electrons and the molybdenum focusing cup focuses the stream of electrons on
the smallest possible area. And well see in todays lecture why thats important for
image. The smaller the focal area is, the focal spot, the sharper your x-rays will be,
the better detail theyll have.

[23] [Activated High Tension Circuit]
And then when you make your exposure, that causes the electrons we now have a
cathode ray, which is a stream of electrons shooting across the x-ray tube at very
high speed again, the speed is controlled by the kVp striking the tungsten
target. And there are millions of atoms of tungsten.

[24] [X-ray Production]
When the high-speed electrons strike the tungsten target, then radiation is
produced.

[26] [Bremsstrahlung and Characteristic X-rays]
How is radiation produced? Well, Bremsstrahlung is one. The high-speed electron at
A enters into the atom and it is attracted to the nucleus. As it gets closer to the
nucleus, the rotating electrons kick it out of there. When it kicks it out of there, it
loses speed and it veers off course. Bremsstrahlung means braking or slowing down
of the radiation. There has to be a transference of energy from the kinetic energy to
the Bremsstrahlung radiation. Now that, in effect, A goes into another atom and
then we have the same thing happening over and over again. Hence, different
wavelengths of radiation. Hence, the need we get a heterogeneous grouping of x-
rays coming out of the machine. Weve got to get rid of the long wavelengths. The
short wavelengths are what we need. Another way that radiation is produced called
characteristic radiation. In this case we have another electron at B coming into the
atom and enters into the atom and instead of being veered off, it actually knocks the
inner shell electron out. How much energy is needed to do that? 69,000 volts. Thats
why we run kilovolts. 69,000 volts or 69 kilovolts. Thats why we run our
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machines 70 to 90 kilovolts in order to produce some of this characteristic
radiation. When the electron is knocked out, the k shell only the k shell electron
knocks out another electron you wont produce characteristic radiation knocks
out a k shell electron, the other electrons in the atom cascade into the inner shells to
fill those shells. And in the process they give off energy. The energy from going from
a higher energy level to a lower energy level is in the form of characteristic radiation
right here. Okay? So thats the production of the x-rays.

[27] [The Dental X-ray Machine and X-ray Production]
Now we spoke about current alternating current, direct current, self-rectification,
our machines in most of the clinics are current alternating machines. So what does
that mean to you? Youre the dentist; you dont need to know much about the
electrical circuitry in here. But what that means to you is that youre not getting a
continuous stream of radiation when you press your exposure switch. Youre getting
little pulses of radiation. In one second, there are 60 pulses of radiation. Our
machines are calibrated, the exposure time, in impulses. So if you see in the clinic 30
impulses and you need to know how long an exposure time that is, you divide by 60.
So 30 impulses is a half a second of radiation. Again, we use different impulses or
exposure time because we cant control the kVp and we cant control the miliamps.
Thats preset for us so it makes it easier. So if youre going to do a radiograph of an
anterior tooth you need less impulses, less exposure time, than a posterior tooth
because the posterior tooth is thicker and were going to talk about density of the
film in a little moment, and the contrast of the film. And rectification is just a
conversion of alternating current to direct current. So our machines are self-
rectified or half-wave rectified. Because half of the time they will be converted to
direct current. So, again, a lot of these terms consider how they affect you
clinically and what needs to be done. Clinically, the only thing you need to know is
that impulses because of the alternating current.

[28] [(sin wave slide)]
And this is what it looks like. So youre producing radiation in every cycle there are
1/60
th
of a second and 60 of these cycles in a second. And so at this point were
producing radiation and then when we have the conversion and then we have no
radiation here but look at the sin wave. Up at the top of the sin wave, 90 kVP, or if
youre using 70 that top would be 70. The kilovolt potential would be 70. Right at
that top point is when well have the most energetic radiation because the speed of
the electrons at that point will be higher because of the difference in potential there
will be a higher potential energy difference. Thats another reason why we have to
use filtration because we do have many many different wavelengths of radiation.

[29] [Components and Functions of the Dental X-ray Machine]
And again, some of the components in the machine. The step-down transformer.
Where do we have the step-down transformer? In the cathode. Why? 2 to 5 volts.
Converting 110 volts to 2-5 volts to boil off the electrons. So the step-down
transformer is in the controls the miliamperage, in order to get the boiling off of
the electrons. The step-up transformer is in the exposure when you make your
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exposure switch, the high-voltage or high-tension circuit. What do we need to do?
We need to get a potential difference in order to produce high-speed electrons of
about 70 kilovolts, 70,000 volts. So, we take 110 volts and we ramp it up to 70.000
volts using a step-up transformer.

[31] [Other Parts of the Control Panel]
Okay? Electronic timer.

[32] [Dental Control Panel]
This is the machine upstairs.

[33] [The X-ray Beam]
Just some terminology. Remember primary radiation is the radiation that hits the
patient. Before hitting the patient its called primary radiation. So think about
protection, radiation protection. The patient needs to be protected. Primary
radiation is the main concern for the patient. We need the least amount of primary
radiation. As operators, we walk out of the room. Are we concerned with primary
radiation? No. What were concerned with is, radiation hits the patient and
scatter radiation or secondary radiation is what we have to protect ourselves from.
How do we do that? Walk away a certain distance, stand behind a barrier and you
get zero amount of radiation. Remember, if youre behind the barrier, x-rays travel
in a straight line. So the x-rays are not going to come out of the room and make a
curve and zap you. That doesnt happen. Its in the cartoons. Doesnt happen in real
life. So, thats the difference between primary and secondary radiation. The central
ray, in a lot of textbooks will say, Aim your central ray at the tip of the canine when
they talk about taking radiographs on patients. Youll see that in a while.

[34] [The Divergent X-ray Beam]
Okay? Remember the x-rays, just like light, diverge. Divergence of the x-ray beam is
not good. We dont want the x-ray beam to diverge for several reasons. Again,
protection of the patient. What happens if the x-ray beam diverges? More of the
patients head is hit by radiation. So we have to collimate that beam and we have to
keep the way to collimate the beam is to use the longest position indicating device
that you possible can have. So one of my students said, well 16 inches is the longest
Ive seen, why dont we use the 32 inch or a collimator thats as long as this room?
Because studies were done that after 16 inches, there isnt any depreciable
reduction in the divergence of the beam. The other reason well see in our lecture
today, if we get to it, we will, is that divergence of the beam will cause magnification
of the image. So, if you are aiming at something and youre aiming at a tooth thats
25 mm long, if those x-ray beams are diverging, that tooth on the imaging device, on
the film, will not be 25 mm long. Itll be magnified. Magnification of the image is not
good for several reasons. It distorts the cavity or the bone levels that youre looking
at and also it produces a shadow around the tooth called a penumbra, which well
talk about in a little while. Okay?

[35] [Secondary Radiation/Scatter Radiation]
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Secondary radiation, thats the radiation after hitting an object. So, theres a lot of
scatter radiation with the plastic cones that we spoke about.

[36] [Filtration and Collimation]
Very quickly, filtration, whats the purpose of filtering the x-ray beam? To protect
the patient. How? Remove the long wavelengths. Theres a thin piece of aluminum.
What the aluminum does is it absorbs the long wavelengths, doesnt allow them to
penetrate. The short wavelengths couldnt care less that theres a thin piece of
aluminum. They just shoot right through that. And so those are the only one that will
get through to hit the patient and we can get a good image with the least amount of
radiation by removing them. What are the federal regulations as far as numbers,
memorization? 1.5 mm of aluminum, if youre less than 70 kVp machine. More than
70 kVp, 2.5 mm of aluminum. Whats collimation? Restricting the size of the beam to
the smallest possible beam. Whats the purpose of collimation? Protection of the
patient. Okay? Less radiation hitting the patient. How do we collimate the beam? We
spoke about that. The lead diaphragm which is basically a piece of lead thats put
into the you can unscrew that and actually look into it. You can look into it in the
clinic as well but dont look into it when someones pressing the button. Okay? Look
into it. Youll see two things. Youll see a little circular or if its a rectangular
collimator, a rectangular piece of lead. Theres a little rectangle in the center. Only
the x-rays will come through there. Now what happens to the short wavelengths
when its the lead? Theyre removed. Okay? Difference between lead is lead is a
better absorber than tungsten. And also the lead diaphragm is thicker. There are no
regulations on the thickness of the lead because only purpose of the lead is to get the
x-rays through a little tiny hole so we can collimate the x-ray beam. Okay? If you
have tungsten thats too thick, itll remove all of the wavelengths, including the short
wavelengths. So you gotta think about that. Quality and quantity of the x-rays. The
quality of the x-rays has to do with the penetrating power. It has to do with the kVp.
The higher the kVp, the more penetrating, the more quality of the beam will be
increased. Quantity of x-rays is controlled by the miliamperage. The number of
electrons that are boiled off and thats controlled at the low voltage, low tension
circuit. Half value layer, we spoke about kVp. KVp is an electrical term. If you wanna
know about the penetrating power of your x-ray machine in your office, you have to
look at a number called HVL. When you get your x-ray machine and you look at the
little label, itll say it has an HVL of 2.75 which is probably what you need because
2.5 mm of the aluminum filter and about another 0.25 of inherent filtration. So if
youre x-ray inspector comes to your office and says your HVL is 1, that means your
x-rays are not penetrating enough and youre gunna have to ramp up the exposure
time which is something you dont want to do. So thats something thats going to be
so its a measure of the penetrating ability of the x-rays. Its not an electrical term.

[37] [Rectangular Collimation]
These are some of the position indicating devices. Again, collimation, half filter.

[36] [Filtration and Collimation]
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Now this is where we had the little error. If you notice, the question asked how
many miliamps do you need. Okay? And this little s is not needed. Okay? So if you
lost any sleep over this, which you shouldnt anyway, there is no s after that,
okay?

[44] [Image Formation]
Alright, so now we know how x-rays are produced. Were ready to take our machine,
put a film in the patients mouth, were gunna aim that and we know the radiation
has been filtered and its been collimated and we have a PID and so we reduce the
amount of divergence of the x-ray beam and were ready to take our film. Okay? So
what are some of the characteristics of an acceptable radiograph? I mean some of
these things you can think of yourself. You dont want a film thats too dark. You cant
see it. You cant make out the enamel, the dentin. So thats not something you want.
And so thats number three. You dont want too dark a film. How do you get too dark
a film? Too much exposure time. Okay? One of the things youll find out in later
lectures you can get too dark a film when you process your films and you keep them
in the developer too long, theyll be too dark. How do you get a light film?
Underexposure. Youre supposed to use 10 impulses, you use 4 impulses. Thats
because you didnt change it from the patient before, it was a five-year old kid. You
get a light film. Why do you get a light film? Because with that amount of exposure
time youre not getting enough energy hitting the film. Any energy that hits the film
will convert as youll se in your processing lectures, converted to silver in the
developing solution. So, another way you can get a light film and I see this all the
time in the clinic: students have a perfect set of x-rays, one film is light. On that one
film they had their collimator too far away from the patient. The distance is very
important because x-rays, as they travel a distance, they will lose some of their
energy, just like light. And thats called the inverse square law, which well talk
about. You want the minimal amount of enlargement and distortion. Enlargement is
actually magnification of the image which is an equal magnification of the image.
Distortion is where one part of the image is larger than it should be or smaller and
the other part vice a versa. So, how do you and well see all of this in a couple of
minutes, well go over that. How do we reduce the enlargement? We have to restrict
the divergence of the x-ray beam. The x-ray beam, if it diverges, will cause a
magnification of the image. And we want detail sharpness. We want to be able to see
the enamel and right next to it, the dentin. We have to be able to see a clear
distinction of the two. One of the major causes of un-sharpness and a lot of the un-
sharpness were going to talk about, theoretical. Because the eye wont see it. But
one of the major causes of a blurred image does any one know? A blurred image?
Movement. Movement. So if the patient is moving or if youre collimator is moving
and you see this in the clinic. You have a moving collimator. Dont have the patient
hold the machine. Have someone fix it. Okay? But movement will cause a decrease in
sharpness of the image. One thing I forgot there contrast. And were going to talk
about this contrast here. Contrast has to do not with the degree of darkness on the
film, which is density. How dense a film is. Its the differences in degree of darkness
on a film. The contrast is the differences, the scope of shades of white, certain things
are very white on the film, okay? Things where the x-rays dont penetrate at all,
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okay? So if a patient has a crown, that area will be very white. Because all of the x-
rays are absorbed by the metal and none of them hit the film. Any time the x-ray
radiation hits the film; it converts the silver halide to silver, turning it black. So the
space between the teeth will be black. The pulp chamber, where the pulp is soft
tissue that will be black. So those differences are very important when viewing a
film. What is a cavity in a tooth? What does a cavity look like? Well, if you see a tooth
with the enamel and the dentin and theres a radiolucent ... Radiolucent means light
goes x-rays go through that area. It means that the tooth has been destroyed by
bacteria. So when the x-rays go through theres no enamel or dentin to absorb it. So
the way you find a cavity is look for radiolucent area. How do you find an infection
at the tip of the tooth? Periapical infection. Do you know what these things are?
Periapical means around the apex. The way you can tell theres an infection, patient
has a large filling and then theyre complaining of pain, you take whats called a
periapical film. What periapical film means is that youve got the entire crown, root
and apex, the bone below the apex. And what are we looking for? Were looking for a
radiolucency at the apex. What does that mean? Well it means the bone has been
destroyed by infection. So that tooth will probably need root canal therapy or
extraction. How do we know that? Because of the different densities and contrast
and thats how we diagnose these things. So its very important for diagnosis to have
the proper density, which is the degree of blackness on the film and the proper
contrast.

[45] [Image Formation]
and we can control these things with the x-ray machine. There are ways of
controlling them. So again, the definition of density: degree of blackness on a
radiograph. You want a radiograph of the proper density, not too dark, not too light.
The contrast is difference in densities between adjacent areas. Now, what is a high
contrast film? A high contrast film is you see black and white on the film, no shades
of grey. Black and white. A low contrast film is there are all kinds of shades are
there. You have some white, some black, thats low contrast. Because the differences
in density between the white and the little light grey are basically the same. Thats a
low contrast film. Now, what controls the density of the film? Were gunna talk
about that in a little while but think about it. The density is the darkness of the film.
So, kVp, the higher the kVp, becusae you have more penetrating x-rays coming
through, the higher the kVp the darker the film. So if youre film is dark, one way to
adjust that is to decrease the kVp. Again, we cant do that because our machines are
preset but you need to know the factor. What about miliamps? Miliamps, the
number of electrons that are produced. Well, if you have a lot more electrons
produced, then more of those electrons hit the film. So if you increase the miliamps,
not necessary penetrating power, but you increase the miliamps or you increase the
exposure time, the longer the exposure time the more x-rays will hit the film. The
other factor is distance. The closer you are to the patient, the higher the density is
going to be because x-rays travel. You move the collimator away, keeping every
factor the same, the exposure time, kVp, miliamps you move it away, those x-rays
have to travel a distance, the energy will dissipate. So some of the factors that
control the density of the film, kVp, miliamps, and distance, and exposure time. And
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all of those are pretty self-evident. And as far as contrast, thats a little tricky. The
only thing that controls the contrast in our machines is the kVp. Now, the higher the
kVp, you can write I have the students write this down but you have no notebooks
so you cant do this but think about it. The higher the kVp, you make a little
diagram, high kVp, low contrast. High kVp, low contrast. Low kVp, high contrast. So
thats the way it works. Again, if you have high kVp, low contrast and vice a versa.
This is gunna get a little confusing so Ill try to break it down for you.

[46] [(contrast gradient diagram slide)]
so this is what were gunna do. Were gunna take an aluminum step wedge. Okay?
Its a piece of aluminum that has different thicknesses. At the right hand side, the
aluminum is very very thin. On the left hand side its very thick. And then were
going to shoot x-rays through this at different kVps. Look what happens at low kVp
at 40 kVp, we have some of the x-rays in the thinner part of the aluminum step
wedge will go through because its very thin. Even at 40 kVp. But most of them will
not go through, theyre absorbed by the thicker part of the step wedge. So what kind
of a film will you call this? Low kVp, high contrast. White and black, big contrast
between those. As we increase the kVp, the x-rays have to go through varying
thicknesses again. But when you have very high kVp, what happens is theres
variations in the x-rays going through. Some of them, again, most of them will go
through the thin area and then more and more and more as you go up. So what you
have here is a low contrast. Theres black and a little less black, little white. So you
dont have that sharp contrast. So this is called a low contrast film, high kVp, low
contrast film. When youre looking for cavities in the patients mouth, you really
want a high contrast film. So you can see the enamel, the dentin, the cavity, this is
theoretical. What we do to make it easy is we go right in the middle. We go about 65-
70 kVp so we get the best of both worlds. Again, a lot of this is theoretical. The
human eye cant detect it. But from a scientific basis, this is what happens and well
go over this in a second. If youre looking for early bone changes or periapical you
dont have to know this for this course. But if youre looking for bone changes,
periapical pathologies, things like that, you probably want to be in the higher kVps.
But again, go right in the middle you get the best of both worlds. You see that
contrast. The contrast is important. Enamel, dentin, periodontal ligament which is
black, we need those contrast. If we have contrast that is similar contrast were not
gunna be able to see that. So we do need differences in the degree of blackness on
the film. So again, if you look at this over here you notice you have your step wedge,
the x-rays are going through and at A, do you think A is high kVp or low kVp? Low
kVp because those little squiggling lines are longer. These are shorter wavelengths.
See? These are shorter wavelengths. So what happens with that type of film because
the kVp is low, youll either get penetration or no penetration. Theres no in-
between. And so thats a high contrast film and the bottom one is a low contrast film.
High kVp, low contrast. Got it? Now Im really going to mix you up. In a lot of the
exams, they ask you about the scale of contrast, the scale. Okay? This is a short scale
... this is going to mix you up. This is short scale contrast. This is high scale. Scale.
Okay? So try to get that in your mind. Im not going to try to youll get mixed up.
So think about it and youll see. A high kVp, low contrast, but long scale contrast.
Transcribed by Anam Khalid July 3, 2014

11
Okay? Long scale contrast. Okay? Im gunna go onto the next thing because I see
everyone is

[47] [Overall Density and Contrast is Determined By:]
Okay? So the contrast has to do with the transmission of x-rays through an object as
we just saw. Changing the kVp is the main factor and it depends on object density.
Were lucky were only x-raying teeth and bone. So, we have a fixed the tissue that
we have has a fixed density. We know that. So the only way to control the contrast of
the film is with kVp. So film contrast were going to cover when we talk about
processing of films. All of these things have to do with the amount of x-rays hitting
the film. And when we process them, there are different factors. So, for our
purposes, density or darkness of the film is controlled by several factors but
contrast, one factor, kVp. KVp is the only factor in contrast.

[48] [Image Detail and Definition]
Now, that takes care of the density, darkness, and contrast of the film. Now we need
to see how we can get the sharpest image with the least amount of magnification.
And thats the object to make the proper diagnosis. So we want a film with detail.
The visual quality of a radiograph depends on definition or sharpness. Now what are
the sharp areas on the film? You see a tooth. The tooth itself is the umbra, the sharp
area. You wont see, but theoretically, around the edge of the tooth is an un-sharp
area called a penumbra. The penumbra is the un-sharpness or blurring that
surrounds the edge of a radiographic image. A lot of students come down to 1A,
when theyre there, Doctor Friedman, show me the penumbra, I want to see a
penumbra I cant show it to you. Its again its a theoretical thing. We need to
reduce that penumbra with the x-ray machine in order to get the sharpest image. So
we want to keep the penumbra as small as possible. That fuzzy area. Penumbra
actually comes from two latin words: pen is almost and umbra is shadow. So
theres a shadow around the outside of the object that youre imaging. So how do we
keep the penumbra as small as possible? And were going to go through these steps.
Small focal spot. Use the smallest focal spot you can. Do we have control over the
focal spot? No. its in the machine. The manufacturer of the machine selects the focal
spot. The smaller the focal spot is, the sharper the image is going to be. So, in our
current machines, the focal spot, focal area, is about 1 by 3 mm. You dont have to
memorize that. 1 by 3 mm, which is a small area. Why dont we use smaller than
that? Because of the problem of heating. So we are we cant get any smaller than
that. Why is the smallest focal spot very important? Well see that in a moment. The
angulation of the target, if you remember I showed you on the diagram. The target is
not perpendicular to the x-rays to the electrons coming across. Its tilted at about
20 degrees. Theres a 20 degree tilt in there. And geometrically what that does is the
effective focal spot well see the diagram in a moment is smaller than the actual
focal spot. And so by doing that little twist, we can get the focal spot a little smaller
without changing the actual physical size of it, which is restricted by the amount of
heat that the x-ray machine is putting out. Okay? And what else do we want to do?
Increase focal film distance. We want to have the longest distance we have. What is
focal film distance? The distance from the focal point to the film in the patients
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12
mouth. FFD. The longer that is the more parallel the x-rays are going to be. The more
parallel the x-rays are going to be, the less magnification and the less penumbra will
be formed. Well see diagrams of all of this. And we want to decrease the object film
distance. So if were taking a picture of a tooth. If this is the tooth, and this is the film,
we want the film as close to the tooth as possible. The object, which is in our case a
tooth, film distance, as short as possible. Why? Because as you get further away, the
x-rays penetrate and in order to hit the film they have to cross the distance. What
happens when the x-rays penetrate the tooth and have to travel this distance? They
again diverge. So we get magnification. The closer you are, the less magnification of
the image. And for those of you who get advanced, were gunna talk about this later.
The buccal cusp of a premolar and the lingual cusp of a premolar, which do you
think will be sharper on the film? Again, theoretical. If you can see this, you got
super eyes. What do you think will be sharper? The one closer to the film, or the one
further away? Closer. So the lingual cusp will be sharper. Thats a piece of
information youll never use in your life. Okay? But theoretically this is what they
tell you. If you read a textbook, they make a whole big deal about it but as a
practicing dentist, who cares? You can see the cusp. Look in the patients mouth if
you want to see it. Okay? But thats a theoretical thing. Okay? So those are the
factors that we need to use in order to get the sharpest possible image for the best
diagnosis. Weve already controlled the radiation. We protected the patient. Weve
collimated. Weve filtered. Weve done everything we possibly could do. Now we
want to get the best image with the least amount and we have to do some things in
the patients mouth: placement of the film and the other factors that are involved.
Okay? So, again, smallest focal spot, thats done by the manufacturer. You cant go in
there and chisel away your focal spot. Youll break the machine. Leave it alone. The
angulation of the target, also done by the manufacturer. And the smaller the focal
spot the sharper the image is going to be. Increased focal film distance, the reason
for that is the longer the film distance is the more parallel rays hit the film, less
divergence of the x-ray beam. The less divergence of the x-ray beam, why is that
important? Less magnification of the image and less penumbra. The penumbra is
increased when the magnification is increased. And again the object film distance,
the tooth has to be as close to the film. As the tooth gets further away, the x-rays
have to penetrate. And as they penetrate, they will diverge and you will get the
magnification of the image.

[49] [Image Penumbra]
Well be taking a break in a second. Okay? And, again, heres your source of
radiation. This is the recording plane. In our case, its the film. This is going to be a
tooth. And what happens is the more parallel your x-rays are, the less of the shadow
will be formed. If your x-rays are divergent and hit them at an angle like this, that
increases the penumbra. We need to keep the penumbra as short as possible. Okay?

[50] [Image Detail and Definition Depends On:]
Okay. So this is just a repeat of what we just spoke about. The image detail and
definition depends on size of the focal area at the anode. The smaller the focal area,
the sharper the image. The focal film distance. The longer the focal film distance is,
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13
the shaper the image is going to be. The shorter the object film distance is, get that
film as close to the tooth as possible, the less magnification, less penumbra, the
sharper the image is going to be. Another thing you want to do, and this youre going
to get in your lectures on taking the actual putting the film and youll actually see
teeth and I dont have any of those films for you. You want to position that object
and film parallel to each other. So when you take periapical films, there are two
techniques that youre going to learn. One is the paralleling technique. One is the
bisecting technique. What is the paralleling technique mean? It means the film is
parallel to the long axis of the tooth. Look in the patients mouth, you have a lower
molar, take your film and place it here. If you have an upper anterior thats tilted, ten
to fifteen degrees, take your film, put it in the patients mouth so its parallel. Why is
that important? Because as the x-rays travel through they come in at right angles. If
they come in right angles, they will record the size of the tooth exactly as the size of
the tooth. So if you have a tooth thats 25 mm long in the mouth, you know that,
okay? You put the film parallel to the long axis. These are the teeth, heres your film,
parallel. You direct your central ray perpendicular to the film, the size of the tooth
25 mm will be recorded as 25 mm geometrically. What happens if you dont shoot at
perpendicular? You come in at a steep angle. Thatll cause foreshortening. Youll
learn all of that. So its important to avoid elongation, magnification, and
foreshortening of the image. Factors in choosing the focal film distance. Something
called the inverse square law, which were going to talk about after the break.
Movement, object, film and tubehead, tubehead drift. So, to get the best possible
film, we need to reduce the movement. Obviously, if your collimator is moving that
is a no-no. If an inspector comes to your office, what theyll do is theyll get to your
x-ray machine and theyll aim it, theyll go right over the operatory. Ive had this
done about 25 times in my office. Theyll put the machine and theyll start telling me
about kVp and I said, okay, thank you. But you can talk to them about that because
he was telling me about the HVL and I disagreed with him and he said, How do you
know that? I said, Im a dentist, I know. Okay? So hes going to put the collimator
in different areas, the tubehead. And hes going to look for drift. If theres any drift in
that machine thats a violation. Thatll cost you $10,000. But the good news is, you
dont have to pay. Theyll give you a chance to fix it. So heres the thing, if you know
beforehand, you know that the inspectors coming to your office fix it before he
comes. Dont have the aggravation. You do that before he comes, you put the
collimator anterior teeth where the patient is, move it over to this side, posterior
teeth, you see its drifting, usually the way to fix that is simple. You call someone in
or if youre handy, you tighten a couple of screws and that prevents the movement
of the tubehead. And again, that will cause the most un-sharpness on the film. All of
these other things that we spoke about: magnification, small focal most of those
are theoretical and you get them on exams. But if you have a film where the patient
moved or the tubehead moved, youre gunna have a blurry image, its gunna be a
retake. Okay? And viewing conditions. This is important. You went through every
single step. Youve collimated. Youve filtered, you this and youre doing all this stuff.
And you put the film in the right place and your kVp and your miliamps was correct
and your exposure time and you went in and you developed it correctly. You have a
perfect film. Then you go over to a faculty member and he takes the film and he goes
Transcribed by Anam Khalid July 3, 2014

14
over to the window and he looks at it like that. Or he goes up to the light youre
gunna see that all the time. Youre losing a tremendous amount of information. What
you really need, and if you come into 1A and the viewing room and its a little dark
in there, its romantic, we have candles no we dont. the darkened conditions are
so that the way we diagnose a film is we look at a viewbox. And all of this is going to
be useless in a couple of months because were going digital. Theyre ripping out all
the viewboxes. So if you want to see a viewbox, come in there, or you can look at it in
a catalog. So you have a viewbox and you put the films on there you dont want any
light coming in from the sides. Because what were getting information is the light
being transferred through the film so we can see the contrast. Thats the enamel, its
very white and wait a second, right at the junction between the enamel and the
dentin, theres a radiolucency. Thats not supposed to be there. How did that get
there? That may be a cavity. Or you look at the tip of the root, and youre looking and
you see a nice area of the root perfectly, nice contrast but you see a circular
area around the root. Thats probably an infection, an abscess, and infection,
something like that. So you need the proper viewing conditions, theyre very
important. But after having said that youre going to have faculty upstairs that say,
let me see your x-rays and dont tell them that x-rays are invisible, a form of
electromagnetic radiation, they dont like that. Okay? They will take the films and
you can go and watch and theyll hold them up to the light, Yeah, yeah I think that
may be a cavity. Go drill that tooth. And you drill the tooth theres nothing there.
So, hold it up to the viewbox. And you should never drill a tooth based on one film.
Okay? Because there are a lot of things that look like cavities that may not be
cavities. Youll learn that a little bit in this course, things like cervical burnout or
indirect pulp capping, well learn all of those things. So well take a few minute
break. I think we can get out a little early today. But I need a five-minute break for
myself. When we get back well continue with this, were going to cover, again, some
of the factors that give us the best quality film, what we can do to get that.

[51] [Effective/Actual Focal Area]
Okay I think the mic is on I hope I shut the mic when I went to the restroom.
And if you hear a babbling brook on your itunes, thats my way of calming I dont
remember if I shut it off so, anyway if you hear that okay. So lets continue with
the how do we get sharpest image with the most definition and detail? One of the
ways we get that if you remember the list of objectives there is to have the smallest
focal spot possible. The smaller the focal spot, the sharper the image due to the
decrease in penumbra. The actual focal area measures about 1 by 3 mm. but because
of the tilt, the way the manufacturer puts this, remember, this is the cathode, the
electrons will come across here. This is the copper stem. And embedded in the
copper stem is a little piece of aluminum excuse me, tungsten okay. Theres a
little piece of tungsten in there called the focal spot or target. And by tilting it we
actually have the the x-rays will come out of here after striking the tungsten due
to the Bremsstrahlung and characteristic radiation. And we actually have whats
called an effective focal spot. The effective focal spot is always smaller than the
actual focal spot due to the tilting. So we dont have the problem with overheating
because the size the actual focal area is larger than the effective focal area. But we
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15
get the advantage of having the smallest focal area to get the sharpest possible
image. Okay? So thats one of the factors.

[52] [FFD and OFD]
another factor we spoke about focal film distance and object film distance. Thats
the focal point there. This is the object. So the focal film distance from the focal
point, the tungsten target to the film should be the longest possible distance to
reduce the magnification. And the object film distance okay? Object film distance
needs to be as short as possible. Okay? So youre looking at this and youre saying,
Dr. Friedman, why dont we move the film closer to the tooth? Well this is an
upper tooth, if you looked in the patients mouth, theres a palate, the vault and the
shape of the palate. If you get your film closer to the tooth, its no longer parallel.
Okay? So in the paralleling technique no technique is 100% effective. Think about
it. When youre doing a lower molar and youll learn all of this. The lower molars
have no inclination to the buccal or lingual. Theyre coming straight out of the jaw.
So if you take your film and put it in the patients mouth and its right up against the
molar, you have satisfied all the requirements. The film is parallel to the long axis of
the tooth and you also have this short object film distance, which will cut down on
magnification and penumbra. Why cant we do that with anterior teeth? That looks
like an anterior tooth. Has to do with the shape of the palate. The closer you get to
the tooth, the less parallel youre going to be. So this is a diagram of the paralleling
technique. This is a tooth here, thats the film, and it has to be placed there are
certain anatomical constraints that we have in placement of the film. If you place the
film closer, then thats called the bisecting technique. Ill show you that in a moment.
Okay? So, remember, a lot of this is theoretical. The human eye cannot tell the
difference if its 2 mm away, if its 3 mm away. A lot of these are theoretical
considerations.

[53] [FFD/Recessed Target]
Okay. Also when purchasing a now you understand this a little better when
purchasing an x-ray machine this is, by the way, the tubehead. Thats the
tubehead here and thats your collimator or position indicating device and of course
you have your filtration and your lead diaphragm here. This is the focal point here.
Now the distance from here to the end of the position indicating device is measured.
So lets say youre looking at it and your collimator is 8 inches. So thats an 8-inch
focal film distance. However, you can have the electrical component of the anode
can be recessed back in the machine. Some machines do that. What is the advantage
of that? Well you have a longer focal film distance which is what we want. But we
dont have this monstrosity sticking out at the patient. Look at that, it looks like a
cannon. These long 16-inch collimators. So understand that before you set up your
exposure times in your office, and this will be given to you by your manufacturer,
the exposure time has to do with the focal film distance. Because the longer the focal
film distance the more exposure youre gunna have to give. Because the distance is
longer. So we have the advantage of long focal film distance but we have to change
our exposure time. Well set that up because of the variable of the distance. On the
shorter collimator, you need less exposure time because the x-rays travel a shorter
Transcribed by Anam Khalid July 3, 2014

16
distance. So were going to talk about that when we see the inverse square law in a
moment.

[54] [Paralleling vs. Bisecting Techniques]
So these are the two techniques used in clinical dentistry for radiographing teeth.
Two techniques. Paralleling technique. What does the word paralleling mean?
Simple. The tooth is parallel to the long axis of the film. The film and the tooth are
parallel to each other. Direct your central ray perpendicular to the film or the tooth
and what does that do? It gives you a true representation of the size of the tooth.
Geometrically, that tooth, whatever the size it actually is in the mouth, will be
imaged that way in the film. The other technique which were going to quickly talk
about because youre gunna have a whole lecture on this you actually place the
film right up against the lingual surface of the tooth. So you do that in the patients
mouth and what happens is that an angle is formed between the long axis of the
tooth and the film and what you have to do as the radiographer, think about this, is
figure out what the angle is by looking. Then, in your mind, youve gotta draw a line
that bisects that angle go that? Alright. And after you have that bisected line, you
direct your central ray perpendicular to the bisected line. Got it? If you can do that,
youre a genius. Cant do it. Every textbook that has a discussion on the bisecting
technique will show you this diagram but then theyll give you a number. Theyll say
when you do anterior teeth, put your collimator at 50 degrees. For the anterior
teeth. Molars, 30 degrees. Whats the problem with that? Well the problem is, I can
show you five different textbooks written by professors of their colleges and they
have different numbers. Its a guess. So you will get the tooth on the film because the
x-rays go through the tooth. The film is behind the tooth so youll see the tooth but
you wont have the true representation of the tooth. Theres a lot of distortion. So
the best technique of course is the paralleling technique and of course thats what
we teach you. But there are certain cases where you cannot use the paralleling
technique. For example, think about this, patient has some missing teeth and you
suspect some kind of pathology in there, theres a root left in there or theres a cyst
and you want to get a picture of the edentulous are. Which technique would you
use? Theres only one technique. Because whats the definition of the paralleling
technique? The film is parallel to the long axis of the teeth. There are no teeth; you
have to use the bisecting technique. So when you get to the preclinical lab, well
show you how to use the bisecting technique. But from an image standpoint, the
best image would be using the paralleling technique. The least amount of distortion
and magnification of the image. Okay?

[55] [Intensity]
Now, we spoke about the density and the contrast. Theres another factor here
which is almost exactly as the density. Density is the darkness on a film. The
darkness on a film has to do with the intensity of the x-ray beam. The intensity of
the x-ray beam is basically the total energy contained in the beam. So, what is the
beam intensity affected by? Several factors. Almost the same factors as density: kVp,
the higher the kVp, the more intense the beam will be because there are more
penetrating x-rays. The intensity is measured at the film or at the patients face. So
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17
the higher the kVp, the more intense, the more energy contained in the beam. The
more miliamps, the higher the miliamps the more electrsons, the more electrons
hitting the face, theres a higher intensity of the beam. Exposure time, the longer the
exposure time, okay? The longer the x-rays are hitting the patient, the more energy,
the more intensity the beam will have. And the focal film distance. How does the
focal film distance control the intensity of the beam? The further you are away, the
less intense the beam is going to be. So, we see students coming in, theyve got a
light film. The reason the film is light, the exposure time is correct, the process is
correct, they had their collimator instead of being next to the patients face, they had
the collimator out here. And we calibrate our machines to be 1 or 2 inches away
from the patient. You move away, even though you have the same miliamps, the
same kVp, and the same exposure time, by moving that collimator away, youre
decreasing the intensity of the beam. So, basically, you dont need to know this
formula. Forget it. Were not plugging numbers in, its the concept of quality times
quantity. Whats the quality? kVp times the miliamps over the area that youre
doing. The larger the area is, the less intense the beam is going to be. And the
exposure rate, not the exposure time. Im not going to go into this too much because
its a little complicated. What I need you to know is that the intensity of the beam is
controlled by kVp, miliamps, exposure time, and focal film distance. Okay? The
higher the kVp, miliamps, the increase in exposure time will increase the x-ray
intensity. What about focal film distance? The further the focal film distance is, the
less intensity of the x-ray beam. Now

[56] [Inverse Square Law]
How do we measure the intensity? By something called the inverse square law. Now,
you move the x-ray collimator away from the patients face. Its supposed to be 1
inch away from the patient. You move it to 2 inches. So youve doubled the distance,
correct? You double the distance. So, in order to get the same intensity, what will we
have to do to the exposure time? Someone said 4, which is correct. But Im from
Brooklyn. I say, Wait, you double the distance, you double the exposure time. That
makes sense, right? But it doesnt work scientifically. The intensity of radiation
varies inversely with the square of the distance. So what youre going to do is
intensity is equal to 1 over the distance squared. 1/distance
2
. And Im going to show
you how we use this. Again, Im not throwing this stuff in for you to know, physics.
This is a clinical situation, which youll be faced with many, many times in the clinic.
One of the clinical considerations of the inverse square law has to do with the
proximity of the collimator to the patient. You think, Well, Im just moving it back, I
just moved it a little away. Well, if you moved it an inch away, double what it was
before, youre actually decreasing the density by 1/4
th
. So youd have to increase
your exposure time 4 times. If you have 10 impulses, in order to get the same film,
with the same density, contrast, you would have to increase your exposure time.
And Ill tell you how we clinically do that in a moment. So what happens is the
further away you get, if the focal film distance doubles, the exposure time has to
quadruple. Now, when do we use that? Very simple. You buy an x-ray machine and it
has an 8-inch collimator and Dr. Friedman said you get better pictures with a 16-
inch collimator. So what do you do? You call up the Schein or whatever and you
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18
order another they unscrew you order a 16-inch collimator. Boy, Im gunna get
beautiful pictures here. Alright? And then you dont change the exposure time. What
do you think your films are going to look like? Theyll be extremely light because
those x-rays are traveling a longer distance now. So you wanna change the exposure
time. You got beautiful films with 10 impulses for anteriors. So what do you have to
change your exposure time to get the exact same intensity and the same film? You
have to change it to 40. Now, heres a patient getting 40 impulses. Boy, youre really
zapping that patient. 40 impulses. Thats a lot of impulses compared to 10. Which
patient is getting more radiation? Theyre getting the same amount of radiation
because the distance traveled, the intensity measured at the patients face will be
exactly the same. So, if you have to change or youre in an office and you got this
long collimator, its 16-inches long because the dentist was there before said the
longer the collimator is, the less divergence, the better the image is going to be. But
you dont like it, its bumping into the wall. Its hard to work with. You unscrew it;
you put in an 8-inch collimator on there. Okay? Now, the x-rays dont have to travel
that distance. So, 40 impulses. What do you gotta do? 10 impulses. So even though
you double the distance from 8 to 16, you dont double the exposure time if youre
going from 8 to 16. You quadruple the exposure time. And the same thing if you
move three times away, if you triple the distance, okay? If you triple the distance.
1/distance
2
. You gotta do whatever that distance is, you gotta square that distance
there. So if youre going from one area, three times the distance, probably its 1/9
th

the exposure. Youre never gunna do that because its only 8 and 16 inch collimators.
So from a clinical standpoint you wont do that. So, as the distance increases,
intensity decreases and therefore the exposure time must also increase. Whats the
factor? How much do you have to increase it by? The square of the distance. So if
youre going from an 8-inch to a 16, this is a typical board question, Ill tell you what
its going to say. You came to your office, you decided to change your collimator
from 8-inch to 16-inches, the old exposure time for proper density and contrast was
12 impulses. What will be the new exposure time to get the same density and the
same picture? Remember, if you increase the distance, you have to increase the
exposure time by a factor of 4 if youre doubling that. Okay?

[57] [Inverse Square Law]
And this explains the inverse square law a little bit. This is 2 times as far away as
this is. And look what happened. Because of that distance, youre getting divergence
of the x-ray beam. So here you can see the intensity is a little darker because of the
distance, getting lighter over a larger area. So, to compensate for that doubling of the
distance, its 1 over the distance
2
. So the inverse square law does have clinical
applications when youre changing your position indicating device or when youre
taking films, make sure youre as close to the patients face as possible. Because our
machines are calibrated and your machines will be calibrated by the type of film
that you use. Well talk about that later. But also by the distance you are away from
the patient.

[58] [Movement = Blurred Image]
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19
Ah! We see teeth. I finally showed you teeth. I got thousands of pictures of teeth and
youre going to see thousands of pictures of teeth but we wanted to show you what
happens when a patient moves. We dont have detail. We cant make out the
difference between this and this. They all look the same. The density that you see
here, this is an opaque, a radiopaque object. Thats how we get the term, the white
area is radiopaque. Can anybody guess as to what that is? Its some kind of metallic
object. Is it gold or silver? Cant tell the difference. Because both of those will absorb
radiation. So the patient can have a silver amalgam filling or they can have a gold
inlay or onlay, you cant tell the difference. If a patient has a composite filling, that
will not be as opaque. The reason is, the composite fillings allow more radiation to
go through. So youll see this when you learn about the diagnosis. But what happens,
x-rays go through the tooth, they hit the film. No x-rays are going to hit the film in
this area. Why? Because the crown or the filling has absorbed the x-rays. What do
we see here? Thats the pulp of the tooth, the pulp chambers of the tooth. Why are
those radiolucent? Because soft tissue. The x-rays can readily go through that soft
tissue area. And right behind this third molar, you can see the bone structure, the
trabeculation. But again, because of the movement, thats the number one way of
getting an un-sharp image all the other ways are theoretical is some kind of
patient movement or collimator drift. Were speaking to someone about, they were
gong through the clinic and they see the collimators are moving. If the collimators
are moving, thats usually due to the fact that if youre taking an upper film on a
patient and you have your chair very high. You try to lift your x-ray machine. As it
gets to the top, it will drift down because its reached its maximum height and itll
just fall down. So, lower the chair, number one. If the student is taking a radiograph
on a molar on this side and then you come in and youre taking a molar on this side,
sometime you have to move the entire arm apparatus to the other side. If we just
move part of the arm, it will drift. So before you go ahead and take out your tools to
fix these things, try to adjust the arm, try to adjust the chair. But if theres any
movement, dont have the patient hold the collimator up against the face. Thats a
big the radiation police will get you for that. Okay? And you can see all kinds of
things going on in the clinic I was telling one of the students about, the student
kept missing the film because of the rectangular collimator. You know, if you miss
part of the film, thats called collimator cutoff. So whats the effect of that? Half the
film is not diagnostic. Patients getting radiation and youre not getting any
information. So, you know these collimators screw off. So what the student did is
unscrew the collimator. He understood that thats collimating and if you unscrew it,
the patient is showered with radiation. So he didnt miss the film but the patient got
a radiation shower. So dont do that, okay? Thats movement.

[59] [Viewbox]
Okay. And again, the last thing I just wanted to show you very quickly and we get out
a little early is the proper viewing conditions in a darkened room. You have your set
of x-rays and theres even a magnifying glass. Some of these things like incipient
lesions which mean beginning lesion are very difficult to see. Dont drill a tooth
based on one film. Always we had a patient here on, whats today, Thursday?
we had a patient on Tuesday and the student dismissed the patient. We looked at
Transcribed by Anam Khalid July 3, 2014

20
the panoramic film of the image and there was a looked like a fracture in the
lower jaw. And the patient was let-go. Now that could be an artifact because the
patient had no history of trauma, had no pain, had no swelling. So why did we
diagnose that and I have the film if anyone is interested. Why did we diagnose that
as a fracture? Because it looks like a fracture. Are we going to do any surgery? No.
you know what were going to do? Were going to get the patient back next time and
were going to take another film. Thats what were going to do. Because if its an
artifact it wont show up in the exact same place. If it is a true fracture, itll show up.
So, again, even in a cavity, you see something that looks like a again, you need the
proper density and contrast, if it looks like a cavity, many times youre tempted to go
ahead and drill that tooth and many times it may not be a cavity. So be careful about
that. Okay? So I expect to see in the news next week, beaches, and people with Dr.
Frommers textbook on the beach no. But again, please. To tie all of this together,
if you have the time, because the information I gave you, if you understand, it is
sufficient for exam purposes. But if you want to tie all of this together and get
another view of what I spoke about, thats a very good textbook. You can use the
White and Pharaoh as well. Have a great weekend. Okay? Okay.