0

Patient Management
Ordering Films

The following slides describe Patient

Management and Ordering Films.

In navigating through the slides, you should click

on the left mouse button when you see the
mouse holding an x-ray tubehead or you are
done reading a slide. Hitting “Enter” or “Page
Down” will also work. To go back to the previous
slide, hit “backspace” or “page up”.
 Patient Management
General Guidelines
• Try to appear confident: this will help to relax the
patient and will make them more accepting of what
you are trying to do.

• Explain what/why: Let the patient know what you

are
planning to do, especially the number of films you
will be taking.

• Answer questions: Quick responses to questions or

concerns will make the patient more at ease
 Patient Management
General Guidelines
• Don’t volunteer unnecessary information: “This
film will be way back in the mouth”, “This may
hurt”, “This is the first film I’ve ever taken”, etc.,
are statements that will make the patient more
apprehensive and less cooperative.

• Take more anterior films first: Anterior films are

easier for the patient to tolerate. By starting with
these, the patient gets used to the procedure and
will have fewer problems with the posterior films.
 Patient Management
General Guidelines
• Work quickly but efficiently: Have everything set
up and ready to complete the procedures as
quickly as possible. Have the tubehead
positioned next to the patient’s head on the side
you are imaging so you can rapidly align the
tubehead after film placement.

• “Empathize”: If the patient reacts negatively to

the procedure due to discomfort, gagging, etc.,
explain that this is a common occurrence due to
patient anatomy, location of film, etc., and that
you will do your best to position the film in a
more comfortable location and will complete the
procedure very quickly.
 Patient Management
General Guidelines
• Compliment patient: Identify something that the
patient did well during the procedure and
compliment them. This is especially important with
children, making them feel good about themselves
and increasing the likelihood that they will exhibit
similar behavior at subsequent appointments.
Patient Management

Special Situations
 Gagging
Some patients may have difficulty tolerating film
placement due to the gag reflex. Methods used to
reduce or control the gag reflex include:
• Proper patient management (anterior films first, etc.)
• Distractors: Tell the patient to raise the arm or leg,
count backwards from 100, etc.
• Have patient breathe rapidly through the nose
• Salt on tongue: place some salt in the patient’s hand
and have them lick the salt with the tip of the tongue
• Flavor films by dipping in mouthwash
• Topical anesthetic: spray topical anesthetic on both
sides of palate
 Children
Because their mouths are small and because
they are naturally a little “fidgety”, children can
be a challenge to radiograph. In general, the more
you explain the procedure and enlist their help,
the more cooperative children will be. You need
to be firm but not threatening when working with
children. Take the minimum number of films
needed to make a diagnosis and use the
appropriate size film for the size of the mouth.
Bitewings, anterior occlusal films and panoramic
films are usually tolerated by children; periapical
films may require a little more effort. As
mentioned previously, be sure to compliment
children for a job well done.
 Anatomical Variations
The following anatomical situations (to be
discussed on subsequent slides) may require
alteration of radiographic techniques:

• Third Molars

• Maxillary Canine

• Tori

• Space limitations

• Ankyloglossia (Tongue-tied)
 Third Molars
Sometimes it is difficult to get the film far enough back to
cover the third molar region due to gagging or anatomy,
and all of the third molar will not be seen on the film (see
diagram bottom left). By rotating the tubehead so that the
beam is directed more anteriorly (diagram bottom right), the
third molar is projected onto the film, giving us the needed
information. Note, however,
the increase in overlap that
results. If you plan on
extracting the third molar,
or you can get by without
the sharper image seen
on an intraoral film, a
panoramic film would be
the preferred method of
imaging this area.
 Maxillary Canine
Because of the prominent cusp tips on canines, it is
common for the film to tip when using the paralleling
technique. This may result in the failure to image the
apex of the canine. To avoid this, place a cotton roll
beneath the biteblock, against the mandibular teeth.
This will help to keep the film aligned with the canine.
 Maxillary Canine - Bisecting 0

In many patients, especially ones with narrow maxillary

arch widths, it is difficult to align the film ideally
because the top edge of the film contacts the palate on
the opposite side and doesn’t allow enough film to
register the apex of the canine. Using the bisecting
angle technique, the film can be rotated into a diagonal
placement, covering the entire canine.

Film can’t be placed

far enough into the diagonal placement
mouth (narrow arch)
 Palatal Torus
A palatal torus is a bony growth in the palate. A large
torus makes it difficult to position the film for maxillary
periapical films. In general, it is best to position the top
edge of the film between the torus and the teeth on the
opposite side of the mouth (away from teeth being
radiographed). The disadvantage to this placement is
that the radiopacity of the torus may be superimposed
over the roots of the teeth on the film.

palatal torus
 Mandibular Tori
Mandibular tori are bilateral bony growths found on
the lingual side of the mandible in the premolar
region. The film should be positioned between the
torus and the tongue, never resting on top of the
torus. Again, the radiopacity of a large torus may be
superimposed over the roots, but this is unavoidable.

mandibular torus
 Space Limitations
A shallow palate or shallow floor of the mouth
will make it difficult to use the paralleling
technique. In general, the bisecting angle
technique, using finger retention, is preferred
for periapical films in patients with these
anatomical restrictions.
 Ankyloglossia (Tongue-tied)

Ankyloglossia results from a very short lingual

frenum, a mucosal fold under the tongue that
connects the tongue to the floor of the mouth
and the mandible. Tongue mobility is very
limited, making it difficult to place a film under
the tongue and push it down far enough to
image the roots of the incisors. In order to
image this area it is ususally necessary to use
the bisecting angle technique and in some
cases a tongue blade may be used to stabilize
the film (see next slide).
 A tongueblade can be 0

taped to the back of the

film. Using the
tongueblade for support,
the film is pushed down
into the top of the tongue
until the film is down far
enough to register the
apices of the anterior
teeth.

A portion of the tongue

will be superimposed
over the roots, adding
lingual frenum unwanted density to the
film in this area, but this
may be unavoidable.
 0

Trismus
Trismus (lockjaw) is caused by a prolonged spasm of
the jaw muscles due to infection, TMJ problems, etc..
Patients with trismus cannot open the mouth very
much and normal intraoral techniques are difficult.
Methods of imaging patients with trismus are:

• Panoramic film: this is the easiest and best method

• Occlusal film: a modified bisecting angle technique

is used with the occlusal film

• Periapical film with hemostat (see next slide)

 0
Using a periapical film with a hemostat for a
patient with trismus

1. Clasping the film with 2. Once the film has cleared

a hemostat, insert the the incisors, rotate the film
film in the mouth with the to a vertical position in
film parallel to the floor maxilla or mandible.
(horizontal)
 0
Edentulous
The best film for imaging edentulous patients is
the panoramic radiograph. It shows the entire
maxillary and mandibular arches and will reveal
pathology and impacted teeth. If a panoramic
machine is not available, occlusal films may be
used to image the edentulous ridges, although
the diagnostic value is not as good.
Periapical films may be indicated if suspicious
areas are seen on the panoramic or occlusal
films. The bisecting technique with finger
retention or the paralleling technique (with
cotton rolls placed above and below the
biteblock) may be used.
Mentally or Physically Challenged
Patients with disabilities may require
modification of normal techniques. In general,
film retention using some type of film holder is
required for these patients. In addition,
assistance from a relative or friend of the
patient may be needed to help secure the film
in place or stabilize the head during exposure.
(Lead aprons and lead gloves should be
provided for the “assistant”). As always, films
should be kept to the minimum needed for a
proper diagnosis.
 Hepatitis/HIV
Universal precautions should be followed for all
patients. We don’t always know if a patient has
a communicable disease and we therefore need
to treat all patients the same. If we do this, we
don’t have to change our routine with a known
HIV patient (or a patient with another condition)
and make them feel uncomfortable.
 Pregnancy
There is some debate about what films to take on
a pregnant patient. In general it is felt that there is
little risk to the fetus as long as a lead apron is
used. My position is that you should only take
those films needed to treat symptomatic teeth or
to plan treatment that can be completed during
the pregnancy. Obvious clinical indicators such
as large carious lesions, fractured teeth, soft-
tissue enlargements, etc., would require that
radiographs be taken.
 0

Ordering Films

When deciding what films are needed on a

patient, you must consider all of the following:

• Dental History

• Clinical exam

• Professional judgment

• Selection criteria
 Ordering Films 0

Review Dental History

Identify symptomatic teeth, most recent films,
frequency of visits, patient attitude toward
dental care

Conduct Clinical Exam

Chart the condition of the teeth (caries,
restorations, displacement, mobility, etc.), #
teeth present/abutment teeth, teeth removed for
ortho, endo treatment, status of third molars

Use Professional Judgment

Influenced by education, experience, and,
unfortunately, finances
 Selection Criteria 0

Selection criteria are used to identify teeth or areas of

the mouth that indicate an increased likelihood of
periapical or bony abnormalities. These criteria
include both historical and clinical components. Refer
to www.ada.org/prof/resources/topics/radiography.asp for
a more detailed discussion of selection criteria.
Historical Findings (based on dental history):
• Pain, swelling, bleeding, mobility
• Trauma to the teeth and jaws
• Endo
• Implants
• Family history
• TMJ pain
 Selection Criteria 0

Clinical Findings
• Large caries/restorations
• Periodontal disease/mobility/bleeding
• Evidence of trauma/swelling/fistula
• Potential abutment teeth
• Unusual tooth appearance/position
• Third molars partially or totally unerupted
• Facial asymmetry

Identification of any of these historical or clinical

findings indicate the need for periapical or
panoramic films (or both) for an adequate diagnosis.
 Using the selection criteria, what films would be0
indicated for this patient?
Symptomatic teeth: None
Fractured teeth: None
Large caries: None
Large restorations: None
Missing teeth: None (patient
says 3rds not extracted)
Gingiva: Healthy
Other historical findings: None

Film order: 4 bitewings, Pan. The bitewing films are

needed to check for interproximal caries. This is a
standard order for new or recall patients that have not
had bitewings for a while (see later slide for frequency of
taking bitewings). A panoramic film is also indicated
because there is no history of having the 3rds removed.
 Using the selection criteria, what films would be0
indicated for this patient?

Symptomatic teeth: None

Fractured teeth: None
Large caries: None
Large restorations: # 30
Large restoration
Missing teeth: #’s 5, 12, 21, 28
(patient says 3rds have
not been removed)
Gingiva: Mild gingivitis
Other historical findings: None

Film order: 2 BW, 1 PA, Pan. With only one premolar and
two molars in each quadrant, only one bitewing per side
is needed. The large restoration on # 30 requires a
periapical. A pan is needed for the third molars.
 Using the selection criteria, what films would be0
indicated for this patient?

Symptomatic teeth: # 8
Fractured teeth: # 8
Large caries: None
Small restoration Large restorations: None
Fracture Missing teeth: #’s 1, 16, 20, 32
(patient says # 17 has
not been removed)
Gingiva: Healthy
Other historical findings: None

Film order: 4 BW, 2 PA, Pan. 4 bitewings to check for

interproximal caries. 2 periapical films: one for
symptomatic and fractured tooth # 8 and one for
potential bridge abutments # 19 and # 21 (The premolar
film covers both teeth). A pan will show if # 17 is present.
 Using the selection criteria, what films would be0
indicated for this patient?
bridge
Symptomatic teeth: #’s 3 and 10
Fractured teeth: None
Small restoration Large caries: #’s 15 and 32
Large restoration Large restorations: #’s 3, 6, 8, 12,
Crowns 13, 17, 21, 23, 24, 25, 26, 28, 29, 30
Large caries
Missing teeth: #’s 1, 2, 7, 14, 18
Gingiva: General redness,
inflammation
Other historical findings: None

Film order: 4 BW, 15PA (AFM). This patient has

something going on in every area of the mouth, including
periodontal involvement, so a complete series of films
needs to be taken. A panoramic film would not be
needed, since we should be covering the third molar
areas with the periapicals.
Just based on your clinical observation of this 0
patient, what periapical films would you order for
the maxillary arch?

Film order: 1 PA. In general

the teeth look good and the
gingiva appears healthy.
There is a large occlusal
restoration on # 3; it is wide
buccolingually and the
caries was probably pretty
deep. A periapical would be
indicated for this patient. If
you wanted to look at the
bitewings before ordering
periapicals, that would be
acceptable.
 Just based on your clinical observation of this 0
patient, what periapical films would you order for
the maxillary arch?

Film order: 3 PA. There is a bridge from # 3 to # 6 and

large restorations on #’s 2, 13 and 14. (#’s 5 and 12 were
extracted for ortho; # 4 is missing). One film needed for
# 6, one for #’s 2 and 3, and one film for #’s 13, 14 and 15.
 Based on what you see in this photo, what films0
would be indicated for this patient?

Film order: 4 BW, 15 PA. With limited information

relating to this patient’s restorative needs, the film
order is based on the gingival hypertrophy seen here
(dilantin hyperplasia).
 Using the selection criteria, what films would be0
indicated for this patient?

Film order: AFM (4 BW, 15 PA) or Pan. This patient

obviously has extensive carious involvement. Although
we can only see a portion of the mouth, it is unlikely
that other areas are any better. If it is felt that the patient
will need complete dentures, based on the clinical
exam, a panoramic film may be all that is needed;
otherwise an AFM is indicated.
The previous slides provide some examples of
what to look for when ordering films. There will
always be some variability between practitioners
regarding the proper film order, but it is
important to follow as closely as possible the
suggestions made by groups such as the
American Dental Association. A standard film
order for every patient or taking films purely for
monetary gain are to be discouraged.
 Frequency 0

Deciding when to take additional or follow-up films can

be difficult. The ADA website referenced under
selection criteria (slide # 27) identifies situations in
which bitewings are to be taken, primarily based on
caries activity and age. However, the frequency of
taking periapical films is more obscure. The selection
criteria identify which periapicals to take on the
patient’s initial visit, but how much time should elapse
before repeating these films? In the absence of
symptoms, the frequency is based primarily on the
patient’s dental history; the more problems they have
had (previous endo, aggressive caries, perio., etc.), the
more often films are indicated.
 Frequency
Bitewings: 6 months - 3 years, depending on
age and caries activity (see ADA guidelines)

Periapicals : 1 - 5 years depending on patient’s

dental history or whenever teeth are symptomatic

Panoramic: 1 - 5 years depending on patient’s

dental history or whenever symptoms develop

This is just one viewpoint. Other approaches can

be justified. The ultimate objective is to take
those films you feel are necessary to make a
proper diagnosis during recall or new patient
examinations.
 0

This concludes the section on Patient

Management and Ordering Films.

Additional self-study modules are available

at: http://dent.osu.edu/radiology/resources.htm

If you have any questions, you may e-mail

me at: jaynes.1@osu.edu

Robert M. Jaynes, DDS, MS

Director, Radiology Group
College of Dentistry
Ohio State University