Radiographic technique for the pediatric patient

-Objectives of this lecture Understand the rationale for radiographic examination in children and adolescents Be aware of the indications for radiographs in children and adolescents Use the indicated radiographic technique dependant on the age of the child and caries activity Review the principles of proper radiographic examination -Rationale-primary dentition In a population the use of bitewing radiography in addition to clinical examination increases the number of approximal lesions detection, so if you use just a clinical examination and the teeth were sound to you, you might miss some carious lesions and if u take an x ray especially bitewing x ray , you'll find that was approximal lesion that you couldn't see by your eyes ,so that's why after clinical examination always do bitewing so there are approximal lesions detected by a factor of between two and eight, 2-8 lesions can be missed. Recent studies have shown that even in population with an overall low caries prevalence , more than 1/3 of 5 year-olds in Sweden and Norway(well talk about development countries an d high standard of caries prevention) had approximal lesions that couldn't be detected by visual inspection this was around 1999-2000. In a Dutch study 1992 between 10 and 60 percent extra information was gained by bitewing radiographs.

- Rationale-the mixed dention At the age of 9 about 1/3 of Swedish children had dentin caries in at least one distal surface of the seconed primary molar (E) as judged radiographically Why is primary seconed molar important? because the distal surface of it is adjacent to the permanent first molar (6). It was also shown that enamel or dentin caries in the distal surface of the seconed primary molar increase the risk for the mesial surface of (6) in about 15 times and if you detect it or prevent it even in the incipient stage , that will be better and u will prevent a big problem in the (6) first permanent molar. What do we gain from all these studies? 1. Bitewing radiograph is important and it's useful for detecting unseen caries 2. Deciding the proper interval to the next bitewings for example :if we take radiograph today and there was no lesion or only one lesion (low caries patient ) the next check up after 1 year, if there were 2-3 lesions (moderate caries risk patient) u have to see him after 6 month but if there were eight lesions ,you have to see him after 3 months(high caries risk) Children who are caries -free in approximal surfaces in their primary teeth at the age of 8-9 are likely to remain so up to at least the age of 12.Therefore ,bitewing should be considered at the age of 8-9. -Rationale-the young permanent dentition Baseline bitewing radiograph in the permanent dentition should be considered at the age of 12-14,that is 1-2 years after eruption of premolars and seconed molars.This concerns also populations with an overall low caries prevalence.

-Rationale Should not be perform in a routine manner using the same practice for all individuals Should only performed when the patient history and/or objective findings and symptoms lead to the conclusion that further useful information might be obtained that means if u can see interproximal caries , so u dont need bitewing, bitewing is used to see interproximal lesions that u cant see them by ur eyes and can also be used in primary dentition to inspect the furcation area and can't be used to inspect periapical area. If a radiograph is not expected to change diagnosis then u don't need it. -The clinical situations for which radiographs may be indicated Positive historical findings for example familial history of dental anomaly so you put evaluation on healing, you did pulpotomy tonight and you have to check up after 3 months to check if the pulp is healed or the periapical area is healed Positive clinical signs/symptoms like mobility, evidence of facial trauma or evidence of foreign objects. -General indications for radiographs in children and adolescents The major reason for taking radiographs in pediatric dentistry of teeth and supporting tissues are : Detection of caries Dental injuries Disturbances in tooth development Examination of pathological conditions other than caries

This is an example here: Bitewing radiograph to detect interproximal caries Maxillary anterior occlusal radiograph to detect pathology like supernumerary teeth, cyst and if you need another x ray from another dimension means if u saw it by the panoramic or periapical u need another dimension(slope technique ,same lingual opposite buccal ) Panoramic radiograph gives a wide view of more than one tissue but it doesnt specifically tell that the first permanent molar (6) has perapical lesion u might reach some resolution cuz it will not be defined or clear, for you to precise if its odontogenic or not odontogenic so u still have to take periapical radiograph. Never rely on OPG to give u carious lesion or examine a periapical area or interproximal area, panoramic radiograph just give u a wide view of whole dentition, study the development of child teeth if has permanent or missing teeth or pathological bone ,examine the 8(wisdom teeth) and their angulation or traumatic injury of the face like bone fracture. -Clinical indication for bitewing radiographs Detect caries that cannot otherwise be detected Estimate the extent of lesion Monitor lesion progression Determine pulp chamber configuration Determine in some instances the presence of absence of premolar crowns Clinical indications for periapical radiography Detection of pathological changes associated with primary teeth (such as apical infection, inflammation or internal resorption)

 After trauma to the teeth and associated alveolar bone Detect developmental abnormalities Assessment of the presence and position of unerupted teeth Assessment of periodontal status Assessment of root morphology before extractions Detailed evaluation of apical cysts and other lesions within the alveolar bone In some space analysis techniques in the mixed dentition e.g(nance technique ) -Clinical indications for occlusal radiography Determine the presence, shape and position of midline supernumerary teeth Determine impaction of canine Determine the presence or absence of incisors Asses the extent of trauma to teeth and anterior arches -Clinical indications for panoramic radiography Its supplement to rather than substitute for intra-oral radiographs Diagnose missing and supernumerary teeth Detect gross pathoses Asses develpoment of the dentition Estimate the dental age of the patient Detect bone fractures,traumatic cysts

 Detect anomalies In some patients with disabilities(if the patient can sit in a chair and hold head in position). -Radiography guidelines: Guidelines are designed to Avoid unnecessary exposure to x radiation Identify individuals who may benefit from a radiographic examination Every prescription of radiographs should be based on an evaluation of the individuals patient benefit Routine survey by radiographs(except for caries)has not been shown to provide sufficient information to be justified considered the balance between cost (radiation and resources) and benefit We usually rely on tables from the american academy of pediatric dentistry and theyre used for children, adolescents and adults ,you have to memorize the tables by heart . *Note:the american table in the book that I applaud under the script on the group page # 49/52 (salam bataieneh) Please go back to the slides to study the table. -Patients at high risk for caries may demonstrate any of the following: High level of caries experience (a lot of carious teeth) History of recurrent caries (the patient came back with a new lesion, restore it and went back after three or six months or 1 year with more carious teeth and new lesions or even around the restorations)

 Existing restoration of poor quality(going to a terrible dentist) Poor oral hygiene Inadequate fluoride exposure Prolonged nursing(bottle or breast) Diet with high sucrose frequency due to eating or medical problems(medications) Poor family dental health Developmental enamel or dentin defects Developmental disability Xerostomia due to medications or radiotherapy Gentle abnormality of teeth Many multisurface restorations Chemo/radiation therapy -Principles for proper radiographic examination The foundation of an accurate diagnosis and treatment plan based on: Comprehensive medical and dental history A through clinical examination Diagnostic radiographs Thats how to reach the diagnosis Of the three, obtaining diagnostic radiographs in the pediatric dental patient is probably the most difficult to accomplish, not only from a

technical standpoint but because of parental fears and misconceptions. Please go back to the slides cuz the doctor didnt mention every thing in the slides The end of the first part // Done by Khansa al shaibany ....Best wishes

(Communicating with parents): -First of all, we inform the parents of the diagnostic need for radiographs and educating them about current radiation hygiene practices and radiographic techniques. -It should be emphasized that visual examination reveals only three of the five surfaces(occlusal , buccal , lingual ) because the other surfaces cant see by the dentist . -Furthermore , the dentist cant see the insides of the tooth, their roots , nor the permanent teeth developing in the jaws **Although excessive radiation exposure can result in cancer , birth defects and genetic defect , the amount of radiation needed to expose the newer X-ray film has significantly reduced the amount of radiation to which patients are exposed -The patient or parents have a legitimate right to be heard and approve the clinicians advice about any radiographic examination -The clinician has to consider and respect the views , values , preferences , which the patient and or family express after having received and understood the information provided. ( MANAGEMENT TECHNIQUES) :

-In the rare occasion when a very young dental patient under three years of age needs a radiograph, the dental office should be prepared with technique to reduce any psychological trauma . -We should explain to the patient what you plan to do in words that are easily comprehended **We use a tell , show , do technique: -explain to the child that a tooth camera will be used to take a picture of their tooth. -allow them to touch and examine the radiograph film and camera. It may be necessary for the child to sit in the parents lap while exposing the radiograph to gain maximum cooperation in children under three years. Start with least difficult radiograph first ( such as an anterior occlusal) -put the film horizontally in the mouth and make the child bite on it and for periapical put it vertically and can hurt the sulcus ( RADIOGRAPHIC FILM SIZES FOR PAEDIATRIC PATIENT) -Size 0 used for bitewing a nd periapical radiograph in young children ( up to 4-5 yrs) -Size 1 used in older children to take bitewing and periapical radiograph ( up to 7-8 yrs) -Size 2 used for anterior occlusal, periapical and birewing radiographs in the mixed and permanent dentition ^^^^^^^^^^^^^ ** CARIES RISK & CARIES ASSESSMENT TOOL ( CAT ) Age of the child : the earlier that a child becomes colonized with the cariogenic bacterial group,the greater is the childs caries risk.

-results indicate that 72-81% of lesions remain in enamel after I year -progression in low risk groups took 3.5 yrs and in high risk group 1.5 yrs *( CARIES RISK ASSESSMENT) : All children should have an assessment of disease risk before the final treatment plan is determined -clinical decision making in the management of caries in children and adolescents requires an understanding of caries risk and risk indicators. Generally speaking, Risk is defined as the probability of incidence of an event within a certain period of time. - Caries risk is the probability that the lesion will develop or that an existing lesion will progress during a specified period. * ( RISK FACTOR) : A risk factor is defined as an environmental behavioral or biological factor confirmed by temporal sequence, usually in longitudinal studies which , if present, directly increases the probability of a disease occurring. If absent or removed , it reduces the probability. Risk factors are part of the causal chain or they expose the host to the causal chain. Once the disease occurs, removal of the risk factor may not result in cure. * ( CARIES RISK) : Low caries risk: -caries free now -access to water fluoridation -favorable history

Moderate caries risk: -One or two lesion per year High caries risk :-Three or more new lesions per year *And depend on the slides because the record is not very clear to be heard Forgive me if there is any mistake // Tara Ahmed

-Summery :
In a population the use of bitewing radiography in addition to clinical examination increases the number of approximal lesions detection (2-8 lesions can be missed). - enamel or dentin caries in the distal surface of the seconed primary molar increase the risk for the mesial surface of (6) in about 15 times and if you detect it or prevent it even in the incipient stage , that will be better and u will prevent a big problem in the (6) first permanent molar. -The clinical situations for which radiographs may be indicated: Positive historical findings ,Positive clinical signs/symptoms. -General indications for radiographs in children and adolescents: Detection of caries ,Dental injuries ,Disturbances in tooth development ,Examination of pathological conditions other than caries.

-Bitewing radiograph: used to see interproximal lesions that u cant see them by ur eyes and can also be used in primary dentition to inspect the furcation area and can't be used to inspect periapical area. -For Deciding the proper interval to the next bitewings for example :only one lesion (low caries patient ) the next check up after 1 year, if there were 2-3 lesions (moderate caries risk patient) after 6 month but if there were eight lesions ,you have to see him after 3 months(high caries risk) *bitewing should be considered at the age of 8-9 in children. -Baseline bitewing radiograph in the populations with an low caries prevalence in permanent dentition should be at the age of 12-14,that is 1-2 years after eruption of premolars and seconed molars. -Should not be perform in a routine manner for all individuals ,Should only performed when it give useful info& expect to change the diagnosis. -Bitewing radiograph> interproximal caries. Maxillary anterior occlusal radiograph> pathology like supernumerary teeth, cyst ,Panoramic radiograph(OPG)> gives a wide view of more than one tissue (development of child teeth, missing teeth, pathological bone ,examine the 8(wisdom teeth) and their angulation, traumatic injury of the face like bone fracture)but not specific & give bad resolution.

. **for panoramic or periapical if u need another dimension use (slope technique ,same lingual opposite buccal ) -Clinical indication for bitewing radiographs: Detect caries that cannot otherwise be detected ,Estimate the extent of lesion ,Monitor lesion progression ,Determine pulp chamber configuration ,Determine in some instances the presence of absence of premolar crowns -Clinical indications for periapical radiography: Detection of pathological changes associated with primary teeth ,After trauma to the teeth and associated alveolar bone ,Detect developmental abnormalities ,Assessment of the presence and position of unerupted teeth , Assessment of periodontal status ,Assessment of root morphology before extractions ,Detailed evaluation of apical cysts and other lesions within the alveolar bone ,In some space analysis techniques in the mixed dentition e.g(nance technique ). -Clinical indications for occlusal radiography: Determine the presence, shape and position of midline supernumerary teeth ,Determine impaction of canine ,Determine the presence or absence of incisors ,Asses the extent of trauma to teeth and anterior arches -Clinical indications for panoramic radiography: **Its supplement to rather than substitute for intra-oral radiographs Diagnose missing and supernumerary teeth ,Detect gross pathoses ,Asses develpoment of the dentition ,Estimate the dental age of the patient ,Detect bone fractures,traumatic cysts ,Detect anomalies ,In some patients with disabilities(if the patient can sit in a chair and hold head in position). -Radiography guidelines: Avoid unnecessary exposure to radiation ,Identify individuals who may benefit from a radiographic examination ,Every prescription of radiographs should be based on an evaluation of the individuals patient benefit ,Routine survey by radiographs(except for caries)has not been shown to provide sufficient information to be justified considered the balance between cost (radiation and resources) and benefit . **table on slides

Patients at high risk for caries may demonstrate any of the following High level of caries experience, History of recurrent caries, Existing restoration of poor quality ,Poor oral hygiene ,Inadequate fluoride exposure ,Prolonged nursing ,Diet with high sucrose frequency due to eating or medical problems ,Poor family dental health ,Developmental enamel or dentin defects ,Developmental disability ,Xerostomia due to medications or radiotherapy ,Gentle abnormality of teeth ,Many multisurface restorations ,Chemo/radiation therapy The foundation of an accurate diagnosis and treatment plan based on: Comprehensive medical and dental history ,A through clinical examination ,Diagnostic radiographs the pediatric dental patient is probably the most difficult to accomplish, not only from a technical standpoint but because of parental fears and misconceptions.

- Communicating with parents: we inform the parents of the diagnostic need ,current radiation, hygiene practices ,radiographic techniques, emphasized that visual examination reveals only three of the five surfaces(occlusal , buccal , lingual ) because the other surfaces cant see by the dentist , the dentist cant see the insides of the tooth their roots nor the permanent teeth developing in the jaws - newer X-ray film has significantly reduced the amount of radiation to which patients are exposed. -The patient or parents have a legitimate right to be heard and approve the clinicians advice about any radiographic examination -The clinician has to consider and respect the views , values , preferences , which the patient and or family express after having received and understood the information provided. MANAGEMENT TECHNIQUES : -In the rare occasion when patient under three years of age needs a radiograph>> prepared with technique to reduce any trauma -explain what you plan to do in words that are easily comprehended tell , show , do technique:explain to the child that a tooth camera will be used to take a picture of their tooth ,allow them to touch and examine the radiograph film and camera, sit in the parents lap while exposing the radiograph to gain cooperation in children under three years ,Start with least difficult radiograph first ,put the film horizontally in the mouth and make the child bite on it and for periapical put it vertically and can hurt the sulcus.

( RADIOGRAPHIC FILM SIZES FOR PAEDIATRIC PATIENT) Size 0 bitewing and periapical radiograph in young children ( up to 4-5 yrs) ,,Size 1 same to 0 size but ( up to 7-8 yrs) Size 2 used for anterior occlusal, periapical and birewing radiographs in the mixed and permanent dentition. ** CARIES RISK & CARIES ASSESSMENT TOOL ( CAT ) Age of the child : the earlier child colonized with the cariogenic bacteria,the greater the caries risk ,most of lesions remain in enamel after I year ,progression in low risk groups took 3.5 yrs and in high risk group 1.5 yrs *( CARIES RISK ASSESSMENT) : All children should have an assessment of disease risk before the final treatment plan is determined - Risk is defined as the probability of incidence of an event within a certain period of time - Caries risk is the probability that the lesion will develop or that an existing lesion will progress during a specified period. *( RISK FACTOR) : Risk factors are part of the causal chain or they expose the host to the causal chain. Once the disease occurs, removal of the risk factor may not result in cure. * ( CARIES RISK) : Low caries risk: caries free now ,access to water fluoridation ,favorable history Moderate caries risk: One or two lesion per year High caries risk :Three or more new lesions per year

Done by:salam bataieneh . Sorry for any mistake or dereliction on this pedo course .. if u have any idea or note for next semesters pedo courses let me know please .. especial thanks for everyone work with me & help me study ..allah b3een 3la hal9eefe el3'areeb