Xray - Outcome 9

Question 1

Patients with a Gag Reflex

Answer 1

The term gagging refers to the strong involuntary effort to vomit. The gag reflex (also called the pharyngeal reflex) can be defined as retching that is elicited by stimulation of the sensitive tissues of the soft palate region. This gag reflex is a protective mechanism of the body that serves to clear the airway of obstruction. All patients have a gag reflex; some are more sensitive than others. A hypersensitive gag reflex is a common problem in dental radiography

Question 2

Factors that are responsible for initiating the gag reflex include..

Answer 2

-psychogenic stimuli - stimuli originating in the mind

• tactile stimuli - stimuli originating from touch

To suppress the gag reflex, the operator must elimate or decrease these precipitating factors

Question 3

Areas that are most likely to elicit the gag reflex hen stimulated include..

Answer 3

the soft palate and the lateral posterior third of the tongue

Question 4

Prior to the gag reflex, two reactions occur:

Answer 4

-cessation of respiration
-contraction of the muscles of the throat and abdomen

Question 5

Importance of the operator’s attitude..

Answer 5

The attitude of the operator is critical to preventing the gag reflex. The operator must convey a confident attitude. The patient must feel secure in the radiographer’s ability to perform the clinical procedures. If the operator appears nervous or unsure of oneself, this may act as a psychogenic stimulus and elicit the gag reflex

The operator must also convey patience, tolerance, and understanding. Every effort should be made to relax and reassure the patient with a hypersensitive gag reflex. As always, the operator should explain the procedures to be performed and then compliment the patient as each exposure is completed. As the patient becomes more comfortable, confidence increases and he/she is less likely to gag

Question 6

Time when exposing intra oral xrays

Answer 6

Every effort should be made to limit the length of time that a film remains in the mouth. The longer a film stays in the mouth, the more likely the patient is to gag. Have everything prepared in advance of film placement to decrease the likelihood of stimulating the gag reflex

Question 7

Exposure Sequence and the gag reflex

Answer 7

Exposure sequencing plays an important role in preventing the gag reflex. As previously discussed, the operator should always start with the anterior exposures. Anterior films are easier for the patient to tolerate, less likely to elicit the gag reflex, and therefore, begin to build up the patient’s confidence

Question 8

Film placement and the gag reflex

Answer 8

Film placement and technique also play an important role in preventing the gag reflex. To avoid stimulating the gag reflex, each film must be placed and exposed as quickly as possible.

Another suggestion is to run your finger along the tissues near the intended area of film placement, telling the patient, “This is where the film will be positioned”. Then, quickly place the film. This technique is used to desensitize the tissues in the area.

Question 9

Helpful hints for preventing gag reflex

Answer 9

-Never suggest that the patient might gag! The power of suggestion can act as a strong psychogenic stimulus and can elicit the gag reflex.

-Reassure the patient. If the patient gags, the operator should reassure the patient that such a response is not unusual.

-Suggest breathing. Tell the patient to “breathe deeply” through the nose during film placement and exposure. The breathing should be audible. (You can also suggest very quick little breaths.)

-Distract the patient. Instruct the patient to do one of the following during film placement and exposure:
*bite hard on the film holder
*suspend a leg or arm in the air
*breathe through their nose
These acts divert the patient’s attention and lessen the likelihood of eliciting the gag reflex.

-Reduce tactile stimuli. Reducing tactile stimuli helps to prevent the gag reflex. Before placing and exposing the film:
*have the patient drink a glass of ice water
*have the patient rinse with mouthwash
*place a small amount of table salt on the tip of the tongue
These techniques help to confuse the sensory nerve endings and lessen the likelihood of stimulating the gag reflex.

Question 10

Topical Anesthetic for Gag Reflex

Answer 10

Should all other tactics fail, consult the dentist regarding the possibility of applying a topical anesthetic sufficient to permit the placement of the film. The use of topical anesthetic is not advocated as a standard procedure, but only for those rare situations when all other means of controlling the gag reflex fail and when the radiograph(s) is essential for diagnostic purposes.
Occasionally, you might encounter a patient with a gag reflex that is uncontrollable. In such a patient, extra-oral films must be used to obtain diagnostic data

Question 11

Importance of xrays for children

Answer 11

Radiographs of children are necessary if a complete and thorough diagnosis is to be made. The roots of erupted primary teeth as well as the developing permanent teeth located within the alveolar bone are seen on these radiographs. So much development is taking place underneath the surface of the gingiva that this is the only accurate way of examining the area. Many carious lesions, which are quite prevalent in this age bracket, are overlooked without radiographs. An X-ray can demonstrate interproximal decay in the early stages so that it can be remedied before the tooth is placed in jeopardy. Without radiographs, up to 50% of carious lesions may be overlooked

Disturbances in normal development generally can be diagnosed only through adequate radiographs. Periapical infection and other disease processes are diagnosed with radiographs of the area. Quite frequently, children injure their teeth in a fall or a blow to the mouth. The extent of damage as a result of the trauma needs to be determined with a radiograph

Question 12

Frequency of xrays for children

Answer 12

Interproximal surveys are made at definite intervals - usually once a year - although some children’s specialists suggest bite-wing radiographs every six months.

Some practitioners routinely take full-mouth surveys; others only if they suspect a problem. As with any patient, the number of radiographs prescribed is based on individual need, taking into consideration the patient’s caries history and clinical presentation. This is always keeping in perspective that the benefit outweighs the risk specifically being developing cells are extremely sensitive to x-radiation

The frequency of interproximal radiographic exposure is based on the history of caries activity. A pantomograph or full mouth series (FMS) would only be requisitioned when clinically demonstrated circumstances exist.

Question 13

Suggested films for Primary Dentition (6 months to 5.5 years)

Answer 13

2 bite-wings
#0 film

Initial bite-wing examination may be made by 3½ years of age. Subsequent BW exposures or selected PA exposures would be based upon the frequency and extent of interproximal carious lesions.

At the mixed dentition stage, occlusal films using #2 size film may be made.

Question 14

Xray taking for Pediatric Patients

Answer 14

Children have the same basic needs for dental treatment as adults and the proper care of children’s teeth is one of the responsibilities of the dentist; however, because of their sensitivity to ionizing radiation, caution should be exercised when taking radiographs of the pediatric patient.

If it is necessary to radiograph an infant, the child sits or lies on a parent’s lap, both with lead aprons in place. Both parent and child face the same way with the child’s head cradled against the parent. The parent’s left arm and hand encompass the child and restrain his hands. The parent’s right hand supports the head and x-ray film

Because the child patient is smaller than the adult patient, and the bone is less dense, the exposure factor should be reduced accordingly.

A thyroid collar should be used during all exposures.

Child-size film holders are available. It may be necessary to use the bisecting angle technique because of the size of the mouth.

Question 15

Suggested films for Early Transitional Dentition (5.5 to 9 years)

Answer 15

Pantomograph (after the eruption of first molars and lower incisors) 2 bite-wings
#0 film

Question 16

Suggested films for Mid to Late Transitional Dentition (9-13 years)

Answer 16

-2 bite-wings
-#2 film
-pantomograph (if not made during early transitional period)

Question 17

Suggested films for Young Permanent Dentition (13 years to third molar eruption)

Answer 17

-4 bite-wings
-#2 film

Question 18

Importance of first impressions for children xrays

Answer 18

First impressions are important - and lasting! Unless an emergency makes it impossible, the child’s first visit to the x-ray room should be as pleasant as possible. After he is seated in the dental chair, establish rapport with him by discussing personal subjects (age, family, hobbies) and by complimenting him on his appearance or clothes.

Before proceeding with the radiographic examination, explain - in terms they can understand - what you’re going to do. Let him handle a film; describe the x-ray unit as a camera that will take “pictures” of his teeth. Show him “pictures” of other children’s teeth. If necessary, practice placing a film in his mouth before actually taking the radiograph.

No exposure should be attempted before the child is emotionally prepared and understands what is to be done.

As with adult patients, the easiest exposure should be made first to gain the child’s confidence and get him used to the procedure. Stress his part in obtaining a good “picture” by sitting still. Repeat instructions with each exposure. Children have a short attention span so exposures should be made as quickly as possible. Continually praise him for his cooperation.

Question 19

Xrays for difficult children..

Answer 19

When you encounter a difficult child, be firm and let him know you are in command of the situation.

Question 20

Helpful Reminders for Children Xrays

Answer 20

-Tell children how much they are helping you when they hold the film in position. Involve them as much as possible and use PRAISE.

-Some children need to be managed firmly. Once they know YOU are in control of the situation, a smoother X-ray procedure usually results.

-Considerable softening of bite-wing films will make occlusion on the tab much easier.

-Explain the procedure in terms that they comprehend.

-Once the film is positioned, move fast!

Question 21

Edentulous Patients - reason for xrays

Answer 21

Although there are no teeth present a radiographic examination of an edentulous and partially edentulous patient is still recommended. The fact that there are no teeth present in an area of the mouth does not preclude the possibility of retained roots, impacted teeth, cysts, and other pathologic conditions present in the bone. These conditions could adversely affect the patient’s health or compromise their ability to tolerate partial or complete dentures.

Question 22

Partially edentulous patients - technique

Answer 22

With partially edentulous patients, film placement may be more difficult in the areas of missing teeth. To stabilize the film packet or film holder, place a cotton roll or rolls in the edentulous area. If the patient has a partial denture, it must be removed before radiographs of the arch are made

Question 23

Technique for exposing edentulous patient xrays

Answer 23

Fundamentally, the technique for exposing radiographs on fully edentulous patients is the same as the techniques already discussed. A pantomograph is an excellent alternative to peri-apical films. An occlusal radiograph could also be used.

Film placement and stabilization can pose a problem for these patients. Cotton rolls should be attached to the bite block in order to provide the necessary vertical spacing on the radiograph and to assist in stabilizing the film position in the mouth. Be sure the cotton roll is not in alignment with the film but on the alternate side of the bite-block. Another option is to have the patient keep the opposing denture in place to assist in closing on the bite block. The denture covering the area to be radiographed must be removed.

Without teeth, the alveolar ridge attenuation factor is much less. Therefore, it may be necessary to decrease the exposure factors when radiographing edentulous ridges

Question 24

What is endodontics?

Answer 24

Endodontics is the branch of dentistry that deals with the prevention, diagnosis, and treatment of pulpal and periapical diseases. Endodontics (root canal therapy) eliminates the health hazard imposed by a tooth with a diseased pulp and yet maintains its function. This is usually achieved by the removal of all pulp tissue and necrotic debris from the pulp chamber and root canals and obturating (filling) the canals with an inert material

Question 25

Xrays during endodontic procedures

Answer 25

Radiographs allow us to visualize this periapical area. Quality radiographs are essential throughout the endodontic procedure; diagnosis and prognosis treatment planning, preparation and obturation of root canals, evaluation of root canal fillings, and monitoring healing of the treated tooth and surrounding tissues. Pre-operative diagnostic and post-operative follow-up radiographs can be taken using the standard paralleling technique (Robinson, 2024). Treatment radiographs are exposed under more challenging conditions because of the presence of a rubber dam and frame, clamps, files, or obturating materials interfering with the radiographic procedure. As well as these variables, visualization of the film placement is difficult because the rubber dam obstructs the view and the patient cannot close his mouth on a bite- block to stabilize the film.

Although it is more difficult to obtain accurate films under these conditions, this is just the time when the most accurate films are required. Some modifications in technique must be made in order to produce a radiograph that will provide sufficient information for properly performing root canal therapy

Question 26

Paralleling technique vs bisecting angle for endodontic radiographs

Answer 26

The paralleling technique is the preferred method because it provides images that more closely approximate the size of the teeth and thereby permit more accurate measurements. The bisecting angle technique involves dimensional distortion and potential foreshortening or elongation of the image. A diagnostic endodontic film should ensure that the tooth being treated is centered on the film, at least 5mm of bone beyond the apex of the tooth is visible, and that the image is as anatomically correct as possible. If parallel film placement cannot be obtained, the bisecting angle technique may be used as long as the clinician is aware of the inherent dimensional distortion.

Films may be held parallel to the long axis of the tooth with commercially available holders (some with offset bite blocks to accommodate the files), a RINN-DS, Snap-a-Ray, or a hemostat.

Question 27

Film Processing - for endodontic treatment radiographs

Answer 27

Endodontic treatment radiographs should be processed promptly to minimize the time that the patient is uncomfortable. The use of rapid processing solutions is recommended. Rapid processing may be done with an automatic processor on the fast setting or manually through Rapid X-Ray Developer, “dipping”. When manual processing dip cups is being used, the film can be read wet before it is fully processed. This is called a “Wet Read”. Although the contrast is somewhat lower than that achieved by the conventional processing chemicals (techniques), the radiographs have sufficient diagnostic quality to be used for treatment films and are obtained at great savings in time using both techniques.

When manually processing the film, it is recommended that after evaluation it be returned to the fixing solution and water bath for additional time to maintain the radiographic image for documentation

Question 28

Exposing radiographs - with visually impaired patient

Answer 28

If the patient is visually impaired, use clear, verbal explanations, explaining each procedure before doing it. It also helps to let the patient “feel” the film holder etc.

Question 29

Exposing radiographs - with hearing impaired patient

Answer 29

If the patient is hearing impaired, use gestures or written instructions. If the patient can read lips, remove your face mask, face the patient, and speak clearly and slowly. The caregiver may act as an interpreter.

Question 30

Exposing radiographs - with physically disabled patient

Answer 30

If a person is physically disabled (i.e. confined to a wheelchair), the operator or the caregiver may assist the patient in transferring to the dental chair. You might also try to perform the radiographic procedures with the patient seated in the wheelchair. If the caregiver is asked to assist with film holding, she must wear a lead apron and thyroid collar during film exposure. In addition, the caregiver must be given specific instructions on how to hold the film. As stated before, the operator must never hold a film for a patient during exposure.

Question 31

Exposing radiographs - with a mental/physical disability (ie. Autism, down syndrome, cerebral palsy)

Answer 31

A person with a mental/physical disability (i.e. Autism, Down syndrome, and Cerebral Palsy) may have problems with coordination or comprehension of instructions. The patient may require extra time and attention to assist in reassuring the patient (as well as extra supervision depending on circumstance). If the patient is apprehensive and uncooperative, mild sedation may be useful. In extreme circumstances, a general anesthetic may be a consideration. If comprehension is a problem, and the patient cannot hold the film in place, the caregiver may be asked to assist.