Radiographic Reporting

Question 1

What is clinical evaluation?

Answer 1

This term covers the interpretation & documentation of any findings relevant to the patient’s management, treatment or prognosis
* Covers the entire image (not just the teeth & alveolar bone)
* Must be recorded for every exposure
* Should be completed on the same day
It is the minimum, legal requirement for every exposure

Question 2

What is a radiograph report?

Answer 2

Like a clinical evaluation but more comprehensive
* Includes all radiographic findings
* Includes any information needed for quality assurance procedures
* e.g. image quality rating
* e.g. exposure factors like kV & mAs (unless recorded elsewhere)

Question 3

Example of clinical evaluation vs radiograph report?

Answer 3

Clinical evaluation:
No caries, periodontal bone loss or deficient restorations

Radiograph report:
* Justification: routine caries investigation
* Type: left bitewing radiograph
* Image quality rating: A
* Teeth present: 23
* Periodontal bone levels: normal
* Restorations: 24do (amalgam), 25mod (amalgam), 26mod (amalgam), 37o (amalgam), 36mo (composite), 35do (amalgam)
* Restoration overhangs: none
* Caries: none
* Other findings: 33 rotated

Question 4

What is the template?

Answer 4

• Justification: Should demonstrate why you need the radiograph & what you want to gain from it
• Type:
• Image quality rating:
• Teeth present: Could change to “Teeth absent” if simpler (e.g. for a panoramic radiograph with most/all teeth present
• Periodontal bone levels: If bone loss present, preferably use % bone loss (except for bitewing radiographs where you cannot see full root lengths - then give mm’s instead)
• Restorations: Cannot tell bucco-lingual position of restorations from radiographs alone so use charting to help, No need to include/guess restorative material if already noted in the charting
• Caries: Should state whether enamel only or into dentine &, if dentine, how deep (e.g. outer/middle/inner third of dentine)
• Other findings: e.g. periapical radiolucencies, abnormal root morphology, inferior alveolar canal position, bony abnormalities