Radiographic Considerations for Special Patients -- Modifications, Adjuncts, and Alternatives

Paul S. Casamassimo, DDS, MS

Introduction The charge for this presentation is threefold: 1) To tives to usual techniques will be the opinion of this describe radiographic techniques advocated for special author. Manson-Hing’s criteria will be the basis for patient populations, 2) To comment on the adequacy critique of various techniques. of the techniques, and 3) To discuss alternatives to radiographic surveys. Alternatives to Radiographic Examinations Special Patient Populations Finally, the presentation will cover alternatives to The term special, as interpreted from the literature, radiographic eg~ninations in oral diagnosis. The few includes patients whose age, development, or disease available alternative techniques will be described requires modification of usual intraoral radiographic briefly and evaluated in relation to characteristics of technique or precludes its use. Special patients may special patient populations. require extraoral techniques or may have to be treated Radiographic Techniques for the Special without a radiographic diagnosis. Table 1 depicts the dental literature descriptions of special patients in de- Patient tail. Although these descriptions are somewhat vague, The dental literature provides mtmerous tech- they represent what is available and will be the work- niques which are purported to be effective with special ing definitions used in this presentation. patients. For the purposes of this presentation, the in- Criteria for Adequacy troral film -- the periapical or bitewing -- will be con- Determination of the adequacy of usual and modi- sidered usual and customary. All of the modifications, fied techniques requires application of criteria related to the patient, technician/diagnostician, and tech- Table 1. Characteristics of special patient populations as nique. Manson-HingI provides eight criteria for choos- describedin the dental literature. ing a technique. They are: 1. Time expended by personnel, 2. Effort expended by personnel, 3. Radiation dosage patient subjected to, 4. Accuracy of technique, 5. Ability of diagnostician to use the product of the technique, 6. Skill and familiarity of the technician, 7. Patient ability and needs, 8. Available equipment. Others have described criteria for determining adequacy of individual films, ~ Although the literature provides information on most of the criteria above for various techniques, the data using patient ability and needs as a main variable -- 7. above -- are scanty. This author could find only three studies that looked at patient ability or need in an organized fashion. Twoof these 4.~ compared the supine patient to the upright patient. Another compared intra- and extraoral film survey combinations for patient comfort using children as subjects. 6 Due to the lack of available data on accuracy, comments about the adequacy of altema-

448 SPECIALPATIENT CONSIDERATIONS: Casamassimo adjuncts, and alternatives will be considered depar- control, either for opening or closing, would be helped tures from the intraoral film or film survey in which by this technique. The Velcro strap and the helmet the patient provides complete cooperation. chin strap are used to keep the jaw closed after the The alternatives to usual and customary intraoral film or film holder has been placed. A similar tech- radiography comprise four major categories: nique is used for unconscious patients being treated 1. Modifications of the intraoral technique, under general anesthesia. ~4 The mouth props are used 2. Adjuncts in the form of devices, personnel, or in- to hold film holders against the teeth. duced changes in the patient, (1.4) Modifications of the film or film holder 3. Alternatives to intraoral filming which include position have been advocated for gagging, handicap- the extraoral film techniques, ping’5,~s conditions, and the young or recalcitrant child. 4. Miscellaneous approaches. One technique, the "reverse" bitewing, involves place- These four alternative approaches will be described ment of the film in the buccal vestibule and directing in this section. the beam through the jaws from the opposite side of 1. Modifications of the Intraoral Technique. the patient’s head. The buccal placement minimizes Table 2 (p. 450) depicts the manymodifications of in- gagging yet provides a radiograph that looks much traoral radiography described in the literature. These like a usual and customary periapical or bitewing, ex- modifications can be grouped very roughly into four cept for superimposition of the intervening structures. categories: This technique does require an immobile patient, and (1.1) Modifications of the film packet, with even minimal movement the already compro- (1.2) Modification of the film holder, mised quality is jeopardized. The technique may not (1.3) Supporting devices for the film holder or pa- work unless gagging is the sole problem. tient’s jaw, The occlusal film is often advocated as a substitute (1.4) Modification of the film or film holder posi- for periapical views in the young child ~7,~,~° and the tion. technique is described in several pediatric dentistry (1.1) Modifications of the film packet include textbooks2~ ~ The patient who has suspected trau- bending the corners, 7 using8 the smallest possible film, matic injury to the teeth and jaws can also be consid- or bending an occlusal film for use in either the ante- ered "special" and the occlusal film is indicated for rior or posterior area.9,1° All of these techniques are rec- emergency surveys. ommendedfor young children whose size, anxiety, or A final modification of film position is that de- both, require a minimumof discomfort. Another mod- scribed by Beaver~ in which a pedodontic film is insert- ification for comfort is that recommendedby Lewis et ed lengthwise in a Rinn Snaparay to provide the smal- al." in which cotton rolls are taped to the film packet lest mesial-distal length possible while still permitting to provide comfort and to maintain the plane of the representation of contacting tooth surfaces. film. All of the above techniques are suggested as al- 2. Adjuncts in the Form of Devices, Personnel, ternatives to usual and customary techniques. Mini- or Induced Changes in the Patient. Table 3 depicts mal criteria are provided to suggest when to use these the behavioral, pharmacological, and physical ad- and no data to show they are effective. The choice of juncts which can be used with usual and customary one or the other apparently is made from one’s experi- techniques, or with the modifications suggested earlier ence, or trial and error. in this presentation. (1.2) Modifications of film holder include using Behavior techniques used as adjuncts include fami- the Rinn Snap-A-Raya in place of another intraoral liarization with technique and machine (also knownto holder, or making a film holder from tongue depres- pediatric dentists as tell-show-do), ~ distraction of the sors and tape. ~2 The benefit of these modifications ap- young patient, ~ postponement of radiographic exami- pears to be the ease with which the handicapped or nation for two or three appointments, ~ and hypnos- young patient can hold the film. The method for is. ~,~ The young child mayrequire familiarization, dis- choosing these techniques, as well as their advantages, traction, or postponement while the gagging adult is reported empirically. Starkey ’3 also reported a may need help with hypnosis. All of these are usual bitewing technique using a rubber band held by the and customary techniques or modifications. Familiari- child, but did not suggest indications for the technique zation may take time, but the raport established may other than its use with children. carry over to continuing treatment. Postponement (1.3) Supporting devices for the film holder or presents the risk of having to begin treatment without patient’s jaw include mouth props, helmets with chin radiographs or asking parents to return for visits used straps, or straps with Velcro strips. TM Jaw control ap- mainly to condition the child. Hypnosis requires a pears to be the criterion for choosing any one of these skill manydentists do not have; manypatients cannot techniques. The handicapped patient with poor jaw be hypnotized. "RinnCompany, Elgin, Illinois Pharmacological agents have been advocated to se-

PEDIATRICDENTISTRY: Volume 3, SpecialIssue 2 449 Table 2. Modificationsof the intraoral periapical and bitewing film.

date patients with gag reflexes = or other uncontroll- rarily relieving gagging. General anesthesia does not able reflexes or movements. The literature provides appear to be considered a reasonable approach to ob- only limited support that pharmacological agents are tain radiographs, although radiographic’, examination effective in radiographic diagnosis. This support is is often done in conjunction with treatment in the empirical. Sedative agents carry with them the prob- operating room. Medical radiographs such as brain lems of drug choice, dosage, side effects, and possible scans are routinely done after the patient has been se- interaction with other drugs. The phenothiazine der- dated, but this practice has not extended to dentistry. ivatives, antihistamines, barbiturates, and nitrous Physical restraint or assistance is a re~ognized tech- oxide are just a few of the agents recommended. The nique,~ used both with children and the handicapped. use of local anesthetics such as xylocaine or dyclone in Parents are most frequent choices to assist, so that the topical or rinse form appears to be effective in tempo- dental personnel are not subjected to excess radiation.

450 SPECIALPATIENT CONSIDERATIONS: Casamassimo Lead gloves and aprons are standard equipment to child or handicapped patient may be filmed lying on protect those assisting. One difficulty with parental his or her side with the film between face and dental assistance is their lack of familiarity with technique. chair. A lead shield can be placed on half the film or This lack of skill often necessitates repeated filming. cassette and the same cassette used to display both The use of restraining devices such as the Papoose sides of the patient. boardb or Pediwrapc is poorly documented. These devi- The panoramic film~ (Panorex ~, Orthopantom- ces restrain the body, but may not adequately control ographe) is another extraoral technique used for the head or mouth movements. young child, the trauma victim, or the handicapped 3. Alternatives to Intraoral Filming -- Extrao- patient. The technique yields a general survey cover- ral Techniques. Whenintraoral filming is not possi- ing a large proportion of the face, but in detail too ble or practical due to a child’s age or a patient’s poor for early caries detection or identification of handicap, extraoral techniques maybe the only alter- minor periodontal problems,sl Oral structures are also native. The lateral jaw or lateral oblique and the pan- distorted, but with a head positioner the distortion oramic films are the most commonsubstitues for in- may be predictable. ~ The dose administered is less traoral surveys. Table 4 shows three alternatives to in- than that for a full mouth survey, ~ although in chil- traoral techniques. dren, the thyroid receives a dose higher than that re- The lateral jaw exposure provides a unilateral view ceived by an adult, u The technique also allows filming of the posterior dentition and jaws2,~~ Traumatic in- of the handicapped patient without transfer. juries, periapical pathosis, and dental developmental Valachovic and Lurie ~ feel that the indications for status can be seen on the lateral jaw film. The tech- panoramic radiography are limited from the stand- nique involves an occlusal film or lateral film cassette point of decreased radiation exposure since, in many on the side to be filmed. The X-ray head is placed on cases, additional intraoral films are taken when the opposite side and the beam directed through the pathosis is identified. face to the cassette or film packet. The patient or par- The Siemens Status-x f provides still another option ent can hold the film, or it can be taped to the face. A for extraoral filming. This machine is not commonin bOlympic MedicalCorporation, Seattle, Wash. dS.S. White Penwalt Corporation, X-rayDivision cClarkAssociates, Inc., Worchester,Mass. eSiernensElectric Ltd., Medical Systems ~SiemensElectric Ltd., Medical Systems

Table 3. Adjunctsto the intraoral or modifiedintraoral film.

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PEDIATRICDENTISTRY: Volume 3, SpecialIssue 2 451 Table 4. Extraoralradiographic techniques.

Table 5. Miscellaneous approaches.

the United States, but is used extensively in Europe. data are availableon the effectivenessof this It has been recommended for the young child, the technique(Table 5). child with a high palate, or crowded teeth, s and the bedridden patient. ~ The intraoral X-ray source and Adequacy of Techniques extraoral~ film placement provide lower patient dose Noneof the techniquesdescribed above have been and, in many projections, an adequately detailed rigorouslytested using all the criteriaof Manson- film. ~ The rapid exposure makes the technique good Hing.~ Thepanoramic, ~3~uStatus-x, s and recliningpo- for the handicapped and young child who have prob- sition4.shave been evaluated according to eitherac- lems with movement. Disadvantages include the unfa- curacy,comfort, radiation dose, or technicianability. miliar modeof display, the unorthodox technique, and Whetheror not anyof the otheralternatives are really distortion.~ effectiveor evenadequate remains to be seen.All we 4. Miscellaneous Approaches. At least two haveto relyon is the familiar"it worksin my hands" authors~ have evaluated radiographs taken on the su- dentalempiricism. pine patient. This technique, which would be used for A subjectiveview of these techniquesby this the bedridden or handicapped patient, appears to pro- authorsuggests that theireffectiveness may be in vide films of high quality, is acceptable to the patient, question.The mostobvious problem is the lackof de- and minimizes both time expenditures and radiation tailedcriteria or indicationsfor choosing to usea mod- to the gonads. ificationover usual and customary techniques. The The literature also describes the use of portable ra- terms "handicapped," "young child" or "management diographic equipment 4’ for the homebound, but no problem" provide little in the way of specific guidance

452 SPECIAL PATIENT CONSIDERATIONS: Casamassimo for the clinician. Gaggingis probably the clearest cri- also has to ask if an occasional occlusal film will suf- terion for modification of technique, but no author fice, since studies comparing a 3-film survey to an 8- provides a suitable method for identifying this prob- film survey show that the former missed a large pro- lem or measuring its severity other than trial and portion4~ of congenital anomalies. error. The handicapped patient presents dental needs Manson-Hing~ considers time and effort of person- today which are vastly different from even a decade nel a prime consideration in choosing a technique. It ago. The panoramic film or lateral jaw that would should be obvious that both additional time and effort have been sufficient for the extractions that were the will be expended if adequate criteria are not available rule in the handicapped population before will not suf- for choosing a technique suitable for a special patient. fice today for the handicapped person whose oral In addition, the rarity with which these techniques health has improved with increased awareness. To- are used in general dental practice make one suspect day’s handicapped person tends to have fewer carious that additional time and effort will be expanded to ob- lesions than in the past, but is still plagued with perio- tain a suitable product. The technical process is not dontal disease. Bitewing films or the panoramic film, rote and may require repetition to obtain even a com- which would be the minimum of a "survey" for the promised product. handicapped patient, do not show either occlusal car- This lack of familiarity leads to several other short- ies, or early interproximal lesions respectively, a This is comings related to radiation dose and quality or ac- the disease state being seen more and more often with curacy of films. Both the panoramic film and the lat- the handicapped, especially those who have benefited eral jaw deliver less radiation than a full-mouth series from fluoride. of intraoral films, but if patient selection is poor or if Periodontal disease, which is the more critical prob- the technician is not familiar with the technique, films lem for the handicapped person today, is resistant to will have to be retaken because of a nondiagnostic radiographic examination in its early stages. ~ Even product. The low dosage advantages may be lost in longstanding periodontal defects can be missed on ra- order to obtain diagnostic quality. diographic~ examination, depending on location. Another major shortcoming of these techniques is Based on the above discussion, this author con- the need for additional equipment or supplies. Many cludes that the available techniques are a last resort practitioners do not have the option of a panoramic when all other possibilities have been tried. They film. Parental assistance requires both a lead apron should be considered 1) adjunctive and 2) most effec- and lead gloves which accounts for an expenditure of tive when used only as indicated. about $200 and parental willingness. As a ’final commenton adequacy, it should be noted A factor mentioned by Manson-Hing which might that we are currently investigating several of these go unnoticed is the ability of the diagnostician to read techniques in an organized fashion at the University films of varying quality and format. The lateral jaw of Colorado. Wehope to be able to determine specific and panorex present views which are less familiar to indications as well as effectiveness according to the the general dentist. Their detail is limited and struc- criteria1 of Manson-Hing tures are not only in strange relationships to one another, but distorted in size and form. Whether or not Alternatives to Radiographic every clinician can sort out these variations from Examination pathosis has not been clearly demonstrated in the Very few alternatives to radiographic examination literature. exist in the special patient population. The reasons for To determine whether a technique is adequate one this are that most other adjuncts to a clinical exami- must also consider the patient’s needs. The panoramic nation require a subjective evaluation by the patient film has been shown to be inadequate for diagnosis of as well as the clinician. The radiograph obtains objec- fine~1 detail such as early or incipient dental caries. tive data from the patient which the clinician looks at The lateral jaw provides even less information in less subjectively. Pulp testing and percussion, for example, detail, and in a more distorted and unusual view. require patient input which is difficult to obtain from These are not diagnostically equivalent to a full- the handicapped or young child patient. mouth intraoral survey. Transillumination is one objective technique, but it The young child appears to have need for only the also has limitations in terms of its diagnostic yield. In- most simple of surveys, and postponement is often ad- terproximal caries of anterior teeth can be noted, as vocated except for clarification of obvious problems can be crown fractures and some forms of soft tissue first observed clinically ’; Most authors who advocated pathosis. Transillumination does not provide informa- deferring radiographic examination did so prior to tion about deep structures, nor details about existing Headstart program data which indicate that about pathosis. half of two-year-old children have dental decay. One In summary, short of a thorough clinical examina-

PEDIATRICDENTISTRY: Volume 3, Special Issue 2 453 tion, no suitable alternatives exist. It would appear 18.Williamson, G. F. Alternatives to full-mouth radiographs. J that the ready availability of radiographic examina- Amer Dent Hyg Assn 53:118-120, 1979. tion may have deterred development of other useful 19. Davis, J. M., Law, D. B., and Lewis T. An Atlas of Pedodontics, 2rid Edition. Philadelphia, W. B. Saunders Company,1981. techniques. Perhaps in the future, we may have tech- 20. McDonald, R. E. and Avery, D. R. Dentistry for the Child and niques comparable to ultrasound or automated serum Adolescent, 3rd Edition. St. Louis, C. V. MosbyCompany, 1978. testing which are used widely in medicine. 21. Braham, R. L. and Morris, M. E. Textbook of Pediatric Den- tistry. Baltimore, Williams and Wilkins Company,1980. Summary 22. Koppelman, E. S. The philosophy of radiographic examination of the child. J NewJersey St Dent Soc 36:200, 1965. 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454 SPECIAL PATIENT CONSIDERATIONS:Casamassimo