Summary: The prefaceto the document is given below and providesthe background to the need for, and production of, the Guidance Notes. NairnWilson, the President of the General Dental Council, has provided a Foreword tothe Guidance Notes. The copyright of the Guidance Notes resides with theNRPB on behalf of the organisations represented by the Working Party. Link to supplementary text below.
Learn More About Dental X
There are two main types of dental X-rays: intraoral (meaning the X-ray film is inside the mouth) and extraoral (meaning the X-ray film is outside the mouth). Intraoral X-rays are the most common type of dental X-ray taken. These X-rays provide a lot of detail and allow your dentist to find cavities, check the health of the toothroot and bone surrounding the tooth, check the status of developing teeth, and monitor the general health of your teeth and jawbone.Extraoral X-rays show teeth, but their main focus is the jaw and skull. These X-rays do not provide the detail found with intraoral X-rays and therefore are not used for detecting cavities or for identifying problems with individual teeth. Instead, extraoral X-rays are used to look for impacted teeth, monitor growth and development of the jaws in relation to the teeth, and to identify potential problems between teeth and jaws and the temporomandibular joint(TMJ, see temporomandibular disordersfor more information) or other bones of the face.Types of Intraoral X-RaysThere are several types of intraoral X-rays, each of which shows different aspects of teeth. Bite-wing X-rays show details of the upper and lower teeth in one area of the mouth. Each bite-wing shows a tooth from its crown to about the level of the supporting bone. Bite-wing X-rays are used to detect decay between teeth and changes in bone density caused by gum disease. They are also useful in determining the proper fit of a crown(or cast restoration) and the marginal integrity of fillings.Periapical X-rays show the whole tooth -- from the crown to beyond the end of the root to where the tooth is anchored in the jaw. Each periapical X-ray shows this full tooth dimension and includes all the teeth in one portion of either the upper or lower jaw. Periapical X-rays are used to detect any abnormalities of the root structure and surrounding bone structure.Occlusal X-rays are larger and show full tooth development and placement. Each X-ray reveals the entire arch of teeth in either the upper or lower jaw.ContinuedTypes of Extraoral X-RaysThere are several types of extraoral X-rays that your dentist may take. Panoramic X-rays show the entire mouth area -- all the teeth in both the upper and lower jaws -- on a single X-ray. This type of X-ray is useful for detecting the position of fully emerged as well as emerging teeth, can identify impacted teeth, and aid in the diagnosis of tumors.Tomograms show a particular layer or "slice" of the mouth while blurring out all other layers. This type of X-ray is useful for examining structures that are difficult to clearly see -- for instance, because other structures are in very close proximity to the structure to be viewed.Cephalometric projections show the entire side of the head. This type of X-ray is useful for examining the teeth in relation to the jaw and profile of the individual. Orthodontists use this type of X-ray to develop their treatment plans.Sialography involves visualization of the salivary glands following the injection of a dye. The dye, called a radiopaque contrast agent, is injected into the salivary glands so that the organ can be seen on the X-ray film (the organ is a soft tissue that would not otherwise be seen with an X-ray). Dentists might order this type of test to look for salivary gland problems, such as blockages or Sjögren's syndrome.Computed tomography, otherwise known as CT scanning, shows the body's interior structures as a three-dimensional image. This type of X-ray, which may be performed in a hospital or radiology center or a dental office, is used to identify problems in the bones of the face, such as tumors or fractures. CT scans are also used to evaluate bone for the placement of dental implants and difficult extractions. This helps the surgeon avoid possible complications during and after a surgical procedure. Current TechnologyThere's a newer dental X-ray technique that your dentist already may be using or may soon be using. It's called digital imaging. Instead of developing X-ray film in a dark room, the X-rays are sent directly to a computer and can be viewed on screen, stored, or printed out. There are several benefits of using this new technology: The technique uses less radiationthan the typical X-ray and there is no wait time for the X-rays to develop -- the images are available on screen a few seconds after being taken.The image taken, of a tooth for example, can be enhanced and enlarged many times its actual size on the computer screen, making it easier for your dentist to show you where and what the problem is.If necessary, images can be electronically sent to another dentist or specialist -- for instance, for a second opinion on a dental problem -- to determine if a specialist is needed, or to a new dentist (if you move).Software added to the computer can help dentists digitally compare current images to previous ones in a process called subtraction radiography. Using this technique, everything that is the same between two images is "subtracted out" from the image, leaving a clear image of only the portion that is different. This helps dentists easily see the tiniest changes that may not have been noticed by the naked eye.
Dental Radiography: Film Faults. Quiz #1 : Enhanced Dental CPD Online
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. It shows a two-dimensionalview of a half-circlefrom earto ear. Panoramic radiography is a form of focal plane tomography; thus, images of multiple planesare taken to make up the composite panoramic image, where the maxillaand mandibleare in the focal trough and the structures that are superficial and deep to the trough are blurred. Other nonproprietary names for a panoramic radiograph are dental panoramic radiograph and pantomogram; Abbreviations include PAN, DPR, OPT, and OPG (the latter, based on genericizing a trade name, are often avoided in medical editing). Contents1 Types1.1 Films1.2 Digital2 Indications3 Mechanism3.1 Principal advantage of panoramic images4 Preparation5 Adverse effects6 History6.1 Historical milestones for digital panoramic systems7 Research7.1 Epidemiology: general public and high risk groups7.2 Dental infection and atherosclerosis8 See also9 ReferencesTypesDental panoramicradiographyequipment consists of a horizontal rotating arm which holds an X-ray source and a moving filmmechanism (carrying a film) arranged at opposed extremities. The patient's skullsits between the X-ray generator and the film. The X-raysource is rectangular collimatedbeam.Also the height of that beam covers the mandiblesand the maxillaregions. The arm moves and its movement may be described as a rotation around an instant center which shifts on a dedicated trajectory. The manufacturers propose different solutions for moving the arm, trying to maintain constant distance between the teeth to the film and generator. Also those moving solutions try to project the teeth archas orthogonallyas possible. It is impossible to select an ideal movement as the anatomy varies very much from person to person. Finally a compromiseis selected by each manufacturer and results in magnificationfactors which vary strongly along the film (15%-30%). The patient positioning is very critical in regard to both sharpness and distortions. FilmsThere are two kinds of film moving mechanisms, one using a sliding flat cassettewhich holds the film, and another using a rotating cylinder around which the film is wound. There are two standard sizes for dental panoramic films: 30 cm × 12 cm (12″ × 5″) and 30 cm x 15 cm (12″ × 6″). The smaller size film receives 8% less X-ray dosageon it compared to the bigger size. DigitalDental X-rays' radiology is moving from film technology (involving a chemical developing process) to digital X-raytechnology, which is based on electronic sensors and computers. One of the principal advantages compared to film based systems is the much greater exposure latitude. This means many fewer repeated scans, which reduces costs and also reduces patient exposure to radiation. Lost X-rays can also be reprinted if the digital file is saved. Other significant advantages include instantly viewable images, the ability to enhance images, the ability to email images to practitioners and clients (without needing to digitize them first), easy and reliable document handling, reduced X-ray exposure, that no darkroomis required, and that no chemicalsare used. One particular type of digital system uses a photostimulable phosphor plate(aka PSP - Phosphor Plate) in place of the film. After X-ray exposure the plate (sheet) is placed in a special scannerwhere the latentformed image is retrieved point by point and digitized, using a laser light scanning. The digitized images are stored and displayed on the computer screen. This method is in between old film based technology and the current direct digital imaging technology. It is similar to the film process because it involves the same image support handling and differs because the chemical development process is replaced by the scanning process. This is not much faster than film processing and the resolutionand sensitivity performances are contested. However it has the clear advantage of being able to fit with any existing equipment without any modification because it replaces just the existing film. Also sometimes the term "digital X-rays" is used to designate the scanned film documents which further are handled by computers. The other types of digital imaging technologies use electronic sensors. A majority of them first convert the X-rays in light (using a GdO2S or CsIlayer) which is further captured using a CCDor a CMOSimage sensor. Few of them use a hybrid analog-to-digitalarrangement which first converts the X-ray into electricity(using a CdTelayer) and then this electricity is rendered as an image by a reading section based on CMOS technology. In current state-of-the-art digital systems, the image quality is vastly superior to conventional film-based systems. The latest advancements have also seen the addition on Cone Beam 3D Technology to standard digital panoramic devices. IndicationsPanoramic radiograph showing horizontally impacted lower wisdom teeth.Minimally-displaced fracture in right mandibular. Arrow marks fracture, root canal on central incisor, teeth to the left of fracture do not touchPanoramic radiograph showing Stafne defect(arrowed).Dental panoramic radiograph showing dentigerous cyst(arrowed).OPTs are used by health care professionals to provide information on: Impacted wisdom teethdiagnosis and treatment planning - the most common use is to determine the status of wisdom teeth and trauma to the jaws.Periodontalboneloss and periapical involvement.Finding the source of dental pain, and when carrying out tooth-by-tooth diagnosis.Assessment for the placement of dental implantsOrthodonticassessment. pre and post operativeDiagnosis of developmental anomalies such as cherubism, cleido cranial dysplasiaCarcinomain relation to the jawsTemporomandibular joint dysfunctionsand ankylosis.Diagnosis of osteosarcoma, ameloblastoma, renal osteodystrophyaffecting jaws and hypophosphatemia.Diagnosis, and pre- and post-surgical assessment of oraland maxillofacial trauma, e.g. dentoalveolar fractures and mandibular fractures.Salivary stones (Sialolithiasis).Other diagnostic and treatment applications.MechanismNormally, the person bites on a plastic spatulaso that all the teeth, especially the crowns, can be viewed individually. The whole orthopantomogram process takes about one minute. The patient's actual radiation exposure time varies between 5.5 and 22 seconds for the machine’s excursion around the skull. The collimationof the machine means that, while rotating, the X-rays project only a limited portion of the anatomyonto the film at any given instant but, as the rotation progresses around the skull, a composite picture of the maxillo-facial block is created. While the arm rotates, the film moves in a such way that the projected partial skull image (limited by the beam section) scrolls over it and exposes it entirely. Not all of the overlapping individual images projected on the film have the same magnification because the beam is divergentand the images have differing focus points. Also not all the element images move with the same velocityon the target film as some of them are more distant from and others closer to the instant rotation center. The velocity of the film is controlled in such fashion to fit exactly the velocity of projection of the anatomical elements of the dental arch side which is closest to the film. Therefore, they are recorded sharply while the elements in different places are recorded blurred as they scroll at different velocity. The dental panoramic image suffers from important distortions because a vertical zoomand a horizontal zoom both vary differently along the image. The vertical and horizontal zooms are determined by the relative position of the recorded element versus film and generator. Features closer to the generator receive more vertical zoom. The horizontal zoom is also dependent on the relative position of the element to the focal path. Features inside the focal path arch receive more horizontal zoom and are blurred; features outside receive less horizontal zoom and are blurred. The result is an image showing sharply the section along the mandible arch, and blurred elsewhere. For example, the more radio-opaque anatomical region, the cervical vertebrae (neck), shows as a wide and blurred vertical pillar overlapping the front teeth. The path where the anatomical elements are recorded sharply is called "focal path". Principal advantage of panoramic imagesBroad coverage of facial bone and teethLow patient radiation doseConvenience of examination for the patient (films need not be placed inside the mouth)Ability to be used in patients who cannot open the mouth or when the opening is restricted e.g.: due to trismusShort time required for making the imagePatient's ready understandability of panoramic films, making them a useful visual aid in patient education and case presentation.Easy to store compared to the large set of intra oral x-rays which are typically used.PreparationPersons who are to undergo panoramic radiography usually are required to remove any earrings, jewellery, hair pins, glasses, denturesor orthodontic appliances.If these articles are not removed, they may create artifacts on the image (especially if they contain metal) and reduce its usefulness. There is also a need for the person to stay absolutely still during the 18 or so second cycle it takes for the machine to expose the film. For this reason, radiographers often explain to the person beforehand how the machine will move. Adverse effectsLike any medical imaging utilizing ionizing radiation, there will be a minute degree of direct ionizing damage and indirect damage from free radicalscreated during the ionization of water molecules within cells. A rough estimate of the risk of fatal cancer from a panoramic radiograph is about 1 in 20,000,000.The age of the person being imaged also alters the risk, with younger people having a slightly higher risk. E.g. the 1 in 10,000,000 risk would be doubled for someone in the 1-10 age group. HistoryHistorical milestones for digital panoramic systems1985–1991 – The first attempt to build a dental digital panoramic was of McDavid et al. at UTHSCSA.Their idea was based on a linear pixel array(single pixel column)sensor which was not appropriate for such an application because: a) there is no tomographic effect; b) huge difficulties to collimate the X-rays beam and to control the X-ray dose delivered to the patient; c) poor generator efficiency. DXIS - real time display1995 – DXIS, the first dental digital panoramic X-rays system available on the market, created by Catalin Stoichita at Signet (France). DXIS targeted to retrofit all the panoramic models. 1997 – SIDEXIS, of Siemens(currently Sirona Dental Systems, Germany) offered a digital option for Ortophos Plus panoramic unit, DigiPan of Trophy Radiology (France) offered a digital option for the OP100 panoramic made by Instrumentarium (Finland). 1998–2004 – many panoramic manufacturers offered their own digital systems. ResearchArrows point to two vertical white lines which is how calcifications in the first part (proximal component) of the internal carotid artery appear on panoramic radiographs.A line drawing depicting a panoramic radiograph with an ovoid atheroma in the bifurcation region of the common carotid artery (CCA) as it bifurcates (divides) in the neck into the internal carotid artery (ICA) which supplies blood to the brain and the external carotid artery (ECA) which supplies blood to the face and mouth.Panoramic radiographs have the capability to demonstrate a portion of the neck and display atheromas (calcifications in the carotid artery) which are an indication of both local and generalized (systemic) atherosclerosis. Atherosclerosis of the coronary arteriesleading to myocardial infarction(heart attack), and atherosclerosis of the carotid artery leading to strokeare the number one and number three most common causes of death in the United States. There is interest to look at panoramic radiographs as a screening tool, however further data is needed with regards if it is able to make a meaningful difference in outcomes. Epidemiology: general public and high risk groupsAdditional research projects have further determined the prevalence rate of these atheromas in the general population (3–5%)and among high-risk groups (over 25% in: recent stroke victims,individuals with obstructive sleep apneasyndrome,postmenopausalwomen,[non-primary source needed] type 2 diabetics,individuals with dilated cardiomyopathy,and among individuals who have received radiotherapydirected at the neck,[non-primary source needed][non-primary source needed]). These findings have been corroborated by other several other researchers. Dental infection and atherosclerosisAtherosclerosis is attributed to risk factors that include cigarette smoking, hyperlipidemia, obesity, diabetes mellitus, and hypertension(high blood pressure). These factors, however, do not fully account for the risk of disease. Atherosclerosis has been conceptualized as a chronic inflammatory response to endothelial cellinjuryand dysfunction possibly arising from chronic dental infection. In 2010, using the previously validated Mattila panoramic radiographic index to quantify the totality of dental infection (i.e., periapical and furcal lesions, pericoronitissites, carioustooth roots, teeth with pulpalcaries, and vertical bony defects), Friedlander’s group determined that individuals with carotid artery atheromas on their panoramic radiographs had significantly greater amounts of dental infection/inflammation than atherogenic risk-matched controls devoid of radiographic atheromas.[non-primary source needed][non-primary source needed] While the Mattila index had been previously used to relate the extent of dental infection to coronary artery disease, this research is the first to link the full range of dental disease that it measures to panoramic radiographs evidencing calcified carotid artery atherosclerosis. See alsoOral and maxillofacial radiologyWikimedia Commons has media related to Orthopantomograms.References^Langlais, Robert. "RECTANGULAR COLLIMATION No longer a matter of choice!"(PDF).^Dental Radiographic Examinations: Recommendations For Patient Selection And Limiting Radiation Exposure. Am Dent Assoc, U.S. Dept of Health and Human Services, FDA. Revised: 2012^Stuart C. White, Micheal J Pharoh, Oral Radiology and Interpretation Mosby 2005^ abcdWhaites E, (foreword by Cawson RA) (2007). Essentials of dental radiography and radiology (4th ed.). Edinburgh: Churchill Livingstone. pp. 187–206. ISBN 978-0-443-10168-7.^http://www.google.com/patents/US5018177^American Heart Association‚Äôs Heart Disease and Stroke Statistics‚Äî2010 Update ^Roldán-Chicano, R; Oñate-Sánchez, RE; López-Castaño, F; Cabrerizo-Merino, MC; Martínez-López, F (May 1, 2006). "Panoramic radiograph as a method for detecting calcified atheroma plaques. Review of literature". Medicina Oral, Patologia Oral y Cirugia Bucal. 11 (3): E261–6. PMID 16648765.^Friedlander, AH; Garrett, NR; Chin, EE; Baker, JD (2005). "Ultrasonographic confirmation of carotid artery atheromas diagnosed via panoramic radiography". Journal of the American Dental Association. 136 (5): 635–40. doi:10.14219/jada.archive.2005.0235. PMID 15966651.^Almog, DM; Illig, KA; Carter, LC; Friedlander, AH; Brooks, SL; Grimes, RM (November 2004). "Diagnosis of non-dental conditions. Carotid artery calcifications on panoramic radiographs identify patients at risk for stroke". The New York State Dental Journal. 70 (8): 20–5. PMID 15615333.^Friedlander, AH; Manesh, F; Wasterlain, CG (1994). "Prevalence of detectable carotid artery calcifications on panoramic radiographs of recent stroke victims". Oral Surgery, Oral Medicine, and Oral Pathology. 77 (6): 669–73. doi:10.1016/0030-4220(94)90332-8. PMID 8065736.^Friedlander, AH; Yueh, R; Littner, MR (1998). "The prevalence of calcified carotid artery atheromas in patients with obstructive sleep apnea syndrome". Journal of Oral and Maxillofacial Surgery. 56 (8): 950–4. doi:10.1016/s0278-2391(98)90657-7. PMID 9710189.^Friedlander, AH; Friedlander, IK; Yueh, R; Littner, MR (1999). "The prevalence of carotid atheromas seen on panoramic radiographs of patients with obstructive sleep apnea and their relation to risk factors for atherosclerosis". Journal of Oral and Maxillofacial Surgery. 57 (5): 516–21, discussion 521–2. doi:10.1016/s0278-2391(99)90065-4. PMID 10319824.^ abcdAlves, N; Deana, NF; Garay, I (2014). "Detection of common carotid artery calcifications on panoramic radiographs: prevalence and reliability". International Journal of Clinical and Experimental Medicine. 7 (8): 1931–9. PMID 25232373.^Friedlander, AH; Altman, L (2001). "Carotid artery atheromas in postmenopausal women. Their prevalence on panoramic radiographs and their relationship to atherogenic risk factors". Journal of the American Dental Association. 132 (8): 1130–6. doi:10.14219/jada.archive.2001.0340. PMID 11575022.^Friedlander, AH; Garrett, NR; Norman, DC (2002). "The prevalence of calcified carotid artery atheromas on the panoramic radiographs of patients with type 2 diabetes mellitus". Journal of the American Dental Association. 133 (11): 1516–23. doi:10.14219/jada.archive.2002.0083. PMID 12462696.^Friedlander, AH; Maeder, LA (2000). "The prevalence of calcified carotid artery atheromas on the panoramic radiographs of patients with type 2 diabetes mellitus". Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 89 (4): 420–4. doi:10.1016/S1079-2104(00)70122-3. PMID 10760724.^Sung, EC; Friedlander, AH; Kobashigawa, JA (2004). "The prevalence of calcified carotid atheromas on the panoramic radiographs of patients with dilated cardiomyopathy". Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 97 (3): 404–7. doi:10.1016/j.tripleo.2003.08.025. PMID 15024368.^Friedlander, AH; Eichstaedt, RM; Friedlander, IK; Lambert, PM (1998). "Detection of radiation-induced, accelerated atherosclerosis in patients with osteoradionecrosis by panoramic radiography". Journal of Oral and Maxillofacial Surgery. 56 (4): 455–9. doi:10.1016/s0278-2391(98)90712-1. PMID 9541345.^Friedlander, AH; August, M (1998). "The role of panoramic radiography in determining an increased risk of cervical atheromas in patients treated with therapeutic irradiation". Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 85 (3): 339–44. doi:10.1016/S1079-2104(98)90020-8. PMID 9540095.^Carter, LC; Haller, AD; Nadarajah, V; Calamel, AD; Aguirre, A (1997). "Use of panoramic radiography among an ambulatory dental population to detect patients at risk of stroke". Journal of the American Dental Association. 128 (7): 977–84. doi:10.14219/jada.archive.1997.0338. PMID 9231602.^Lewis, DA; Brooks, SL (1999). "Cartoid artery calcification in a general dental population: a retrospective study of panoramic radiographs". General Dentistry. 47 (1): 98–103. PMID 10321159.^Almog, DM; Illig, KA; Khin, M; Green, RM (2000). "Unrecognized carotid artery stenosis discovered by calcifications on a panoramic radiograph". Journal of the American Dental Association. 131 (11): 1593–7. doi:10.14219/jada.archive.2000.0088. PMID 11103578.^Farman, AG; Farman, TT; Khan, Z; Chen, Z; Carter, LC; Friedlander, AH (2001). "The role of the dentist in detection of carotid atherosclerosis". South African Dental Journal. 56 (11): 549–53. PMID 11885436.^Epstein, Franklin H.; Ross, Russell (1999). "Atherosclerosis — an Inflammatory Disease". New England Journal of Medicine. 340 (2): 115–26. doi:10.1056/NEJM199901143400207. PMID 9887164.^Mattila, KJ; Nieminen, MS; Valtonen, VV; Rasi, VP; Kesäniemi, YA; Syrjälä, SL; Jungell, PS; Isoluoma, M; et al. (25 March 1989). "Association between dental health and acute myocardial infarction". BMJ (Clinical Research Ed.). 298 (6676): 779–81. doi:10.1136/bmj.298.6676.779. PMC 1836063. PMID 2496855.^Friedlander, AH; Sung, EC; Chung, EM; Garrett, NR (2010). "Radiographic quantification of chronic dental infection and its relationship to the atherosclerotic process in the carotid arteries". Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 109 (4): 615–21. doi:10.1016/j.tripleo.2009.10.036. PMID 20097109
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