Strategies for Optimal Intraoral Digital Imaging Part I: Intraoral Receptors, Techniques, and Instrumentation

Earn 3 CE credits This course was written for dentists, dental hygienists, and assistants.

For additional information on this topic, please see “Strategies for Optimal Intraoral Digital Strategies for optimal Imaging, Part 2” on www.DentalAcademyofCE.com intraoral digital imaging Part I: Intraoral receptors, techniques, and instrumentation

A Peer-Reviewed Publication Written by Gail F. Williamson, RDH, MS

Abstract Educational Objectives: Author Profile Radiographic examinations should be made only The goal of this course is to provide the reader Gail F. Williamson, RDH, BS, MS, is a professor of Dental Diagnostic Sciences in when the dentist has determined they are necessary with contemporary information on intraoral the Department of Oral Pathology, Medicine and Radiology at Indiana University for diagnostic and treatment purposes. Radiographic digital radiography. Upon completion of Part I of School of Dentistry in Indianapolis, Indiana. She received an A.S. in Dental Hygiene, selection criteria have been published by the American this course, the reader will be able to a B.S. in Allied Health, and a M.S. in Education, all from Indiana University. She Dental Association (ADA) to assist dentists in decision- 1. List and describe the types of digital recep- serves as Director of Allied Dental Radiology and Course Director for Dental Assist- making and justification of the prescription (See table tors used for intraoral radiographic imaging; ing and Dental Hygiene Radiology courses. A veteran teacher, Prof. Williamson has 1).1 Once such a determination has been made, it is 2. List and describe the principles of paralleling, received numerous awards for teaching excellence throughout her career. She is a the responsibility of the dentist to ensure that optimal bitewing, and bisecting angle techniques for published author and presents numerous continuing education courses on Oral and radiographic images are obtained at the lowest possible effective intraoral digital imaging; Maxillofacial Radiology on the national level. In addition, she is actively involved in dose of radiation. Because radiographic procedures are 3. List and describe the intraoral receptor the American Academy of Oral and Maxillofacial Radiology and currently serves as delegated to dental hygienists and dental assistants, it instruments that can be used to acquire a radiology expert on the American Dental Association’s Dental Hygiene National is important that these radiographers have the knowl- periapical and bitewing images. Board Test Construction Committee B. She can be reached at [email protected] . edge, skill, and technical acumen to obtain optimal results. Increasingly, digital radiographic imaging is Author Disclosure being used with two types of receptors: photostimulable Gail F. Williamson, RDH, BS, MS has no commercial ties with the sponsors or the phosphor plates and solid-state detectors. providers of the unrestricted educational grant for this course. INSTANT EXAM CODE 15135 Go Green, Go Online to take your course

Publication date: Aug. 2010 This educational activity was made possible through an unrestricted educational grant by Dentsply. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Review date: Oct. 2013, Supplement to PennWell Publications Educational Methods: This course is a self-instructional journal and web activity. Sept. 2016 Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or Expiration date: Aug. 2019 third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many PennWell designates this activity for 3 Continuing Educational Credits educational courses and clinical experience that allows the participant to develop skills and expertise. Dental Board of California: Provider 4527, course registration number CA# 03-4527-15135 Image Authenticity Statement: The images in this educational activity have not been altered. “This course meets the Dental Board of California’s requirements for 3 units of continuing education.” Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. The PennWell Corporation is designated as an Approved PACE Program Provider by the Known Benefits and Limitations of the Data: The information presented in this educational activity is derived Academy of General Dentistry. The formal continuing dental education programs of this from the data and information contained in reference section. The research data is extensive and provides direct benefit program provider are accepted by the AGD for Fellowship, Mastership and membership to the patient and improvements in oral health. maintenance credit. Approval does not imply acceptance by a state or provincial board of Registration: The cost of this CE course is $59.00 for 3 CE credits. dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full (10/31/2019) Provider ID# 320452. refund by contacting PennWell in writing. Educational Objectives Introduction The goal of this course is to provide the reader with con- temporary information on intraoral digital radiography. Digital Radiographic Imaging: A Primer Upon completion of Part I of this course, the reader will To meet clinical requirements, dental radiographic im- be able to ages must be as accurate and detailed as possible. Digital 1. List and describe the types of digital receptors used for imaging has surpassed film radiography as the primary intraoral radiographic imaging; modality for acquiring and archiving intraoral images. 2. List and describe the principles of paralleling, bitewing, Digital imaging offers several advantages over film radi- and bisecting angle techniques for effective intraoral ography, including digital imaging; • the visualization of images on a monitor; 3. List and describe the intraoral receptor instruments that • computerized archiving of images; can be used to acquire periapical and bitewing images. • the ability to enhance acquired images; • the potential for radiation exposure reduction; and Abstract • rapid image acquisition without the need for chemi- Radiographic examinations should be made only when the cal processing, darkroom maintenance, and chemical dentist has determined they are necessary for diagnostic waste disposal. and treatment purposes. Radiographic selection criteria In order to produce high-quality diagnostic images, have been published by the American Dental Association careful technique is required. A clinician’s technique (ADA) to assist dentists in decision-making and justifica- must consider best practices, imaging principles, and tion of the prescription (See table 1).1 Once such a determi- patient comfort. Proper technique, effective patient nation has been made, it is the responsibility of the dentist management, and proper exposure maximize the infor- to ensure that optimal radiographic images are obtained at mation available from intraoral images and, therefore, the lowest possible dose of radiation. Because radiographic their diagnostic value. procedures are delegated to dental hygienists and dental Typically, clinicians perform radiographic examina- assistants, it is important that these radiographers have the tions to evaluate oral disease states such as periodontal knowledge, skill, and technical acumen to obtain optimal disease, caries, and periapical pathoses. For periodontal results. Increasingly, digital radiographic imaging is being disease and periapical pathoses, the radiographic projec- used with two types of receptors: photostimulable phos- tion of choice is usually a periapical image or series of phor plates and solid-state detectors. images that record the entire tooth and supporting bone.

Table 1: Recommendations for Patient Selection in Brief Type of Patient Child Primary Child Transitional Adolescent Adult Dentate / Adult Edentulous Encounter Dentition Dentition Permanent Dentition Partially Edentulous New Bitewings if contacts Bitewings/Panoramic Bitewings/Panoramic Bitewings/Panoramic Individualized exam Patient closed; Selected PAS/ or Bitewings/ FM when indicated FM when indicated based on signs/ Occlusals Selected PAS symptoms Recall – Clinical Bitewings at 6-12 Bitewings at 6-12 Bitewings at 6-12 Bitewings at 6-18 Not Applicable Caries; Increased month intervals month intervals month intervals month intervals Caries Risk Closed contacts Closed contacts Recall - No Bitewings at 12-24 Bitewings at 12-24 Bitewings at 18-36 Bitewings at 24-36 Not Applicable Clinical Caries; month intervals month intervals month intervals month intervals Low Caries Risk Closed contacts Closed contacts Recall Clinical judgment; Clinical judgment; Clinical judgment; Clinical judgment; Not Applicable Periodontal Selected PAS/BWS as Selected PAS/BWS as Selected PAS/BWS as Selected PAS/BWS as Disease needed needed needed needed New/Recall Clinical judgment Clinical judgment Clinical judgment for Not Applicable Not Applicable Growth as to need/type of as to need/type of growth/development for Growth/ for Growth/ Development radiographic images radiographic images Panoramic or PAS to Development; Development; Dental/Skeletal assess 3rd molars Clinical judgment Clinical judgment dental/skeletal dental/skeletal Other Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of conditions Circumstances Reference: American Dental Association, Council on Scientific Affairs and U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration. Dental radiographic examinations: Recommendations for patient selection and limiting radiation exposure. Rev. 2012.

2 www.DentalAcademyofCE.com Bitewing radiographs are the images of choice for the and reduce the amount of radiation needed to produce a detection and monitoring of dental caries in posterior diagnostic image. They are available in sizes comparable teeth, as well as the detection of alveolar bone levels. to film, most typically 0, 1, and 2. Posterior bitewings can be taken in either the horizontal Both receptor types are reusable but cannot be steril- or vertical plane. There is preference for vertical place- ized. Therefore, it is important for clinicians to consult ment in patients with moderate and higher amounts of manufacturer instructions for proper preparation, alveolar bone loss. In addition, vertical bitewings can disinfection, and coverage of the receptor as well as ef- be taken of the anterior teeth to evaluate alveolar bone fective barrier-removal techniques. Care must be taken levels in those sextants. to avoid direct contact between the receptor and saliva Many factors influence which radiographs are re- thus preventing cross-contamination. Several studies quired and when they should be obtained. These include have reported that all digital receptor types can become the patient’s medical and dental history; clinical signs directly contaminated with saliva during use. This can and symptoms of disease; risk factors; age and dentition; occur through barrier perforation or poor handling and new or recall patient. As previously mentioned, the techniques.2,3 Disinfection can be accomplished with ADA has published recommendations for appropriate, high-level disinfectant products and typical disinfection patient-specific selection of radiographs. It is important techniques followed by coverage with an effective bar- to note that there are several survey options the dentist rier. For rigid receptors, the Centers for Disease Control can consider when prescribing radiographs. The survey and Prevention recommend using both an internal and determination is dependent on the factors mentioned external (“double”) barrier.4 above and the condition(s) to be evaluated. When in- dicated, intraoral radiographs can be taken alone or in Photostimulable Phosphor Plates combination with panoramic imaging or other extraoral Phosphor plate receptors are wireless and more flexible imaging modalities. The overall objective, regardless of and thinner compared to solid-state detectors and tradi- survey type, is to minimize exposure to radiation while tional darkroom film. The key advantages of phosphor maximizing the diagnostic value of the radiographs, a plate receptors are their construction, greater active area goal achieved with digital intraoral imaging. of exposure, and lower retake frequency, which reduces patient exposure. Phosphor plate receptors have greater Digital Receptors latitude (the ability to capture a diagnostic image with a Digital receptors are available in two formats: range of exposures) than film and solid-state detectors. • photostimulable phosphor plates (PSP) / storage This helps to reduce exposure-related retakes.5 phosphor plates Exposed plate receptors store the latent image within • solid-state detectors in the form of rigid-wired or a europium-activated barium fluorohalide emulsion. The wireless sensors stored energy is released when the plate is scanned with The latter category includes charge-coupled devices a helium-neon laser beam. The light emitted is detected (CCD) and complementary metal oxide semiconductor and intensified by the photomultiplier tube and subse- (CMOS) receptors. Photostimulable phosphor plate quently converted from analog to digital data to form the and solid-state detector systems are computer-based visible image.6,7 Prior to reuse, the plate is erased in the technologies that require specific hardware and software digital scanner by exposure to light. This removes rem- components for operation (figure 1). Both of these digital nant images, returning the previously excited electrons receptor types are faster than chemically processed film to a “relaxed” state.

Figure 1 – Digital Receptors

www.DentalAcademyofCE.com 3 Disadvantages include plate scar artifacts that can Intraoral Techniques result in plate replacement and a delay between image acquisition and display.5–8 This occurs through rough Equipping Your Toolkit handling that can produce plate “scars” in the form The quality of an intraoral image is dependent upon of scratches or creases resulting in permanent image the clinician’s skill, command of technique, and patient artifacts that can necessitate plate replacement.8 These management. The more tools available to address chal- problems can result in retakes, thereby increasing pa- lenges, the more likely these problems can be overcome. tient radiation exposure. Recent improvements in plate Intraoral image receptors must be positioned accurate- technology have been directed toward making plates ly, which can be achieved using the proper technique more scratch resistant to improve longevity and reduce for the desired radiographic projection and anatomical replacement. situation. For maxillary projections and bitewings, par- alleling, bitewing, and bisecting angle techniques can Solid-state Detectors be employed. Regardless of the technique selected, it Solid-state digital receptors are wired or wireless rigid is recommended that the patient’s head be positioned devices often referred to as “sensors” or “detectors” with the occlusal plane parallel to the floor and their (these terms can be used interchangeably). CCD midsagittal plane be placed perpendicular to the floor (charge-coupled device) and CMOS (complementary (figure 2). For mandibular projections, it is recom- metal-oxide semiconductor) detectors are composed of a mended that the chin be raised so that the mandibular matrix of pixels that function as electron wells. The X- arch is parallel to the floor. In addition, there are facial ray or light energy generated by exposure is deposited in anatomic landmarks that can be used to guide the cen- the wells and forms a latent image. The intensity of the tering of the energy in each pixel/well determines the brightness or Xray beam for each periapical and bitewing image, density of the image. called central ray entry points (figure 2). Devices used The major difference between CCD and CMOS to accomplish intraoral imaging include receptor in- detectors is the manner in which data are transferred struments with and without ring guides, standard bite to the read-out amplifier for display.6 The actual active blocks, cotton rolls, and bitewing tabs. sensor surface area is slightly smaller than plates or film such that the overall area of coverage is reduced. In some Figure 2 – Central Ray Entry Points instances, additional images may be required to cover structures fully. Because of the rigid construction and attached wire, receptor placement can be challenging for the clinician and uncomfortable for some patients. These difficulties contribute to multiple retakes and undermine potential radiation dose reduction.5–12 Rigid digital receptors with rounded corner designs and more flexible wires tend to reduce the discomfort when acquiring bitewing images.13 The key advantages of solid-state digital receptors include rapid image acquisition and real-time image display. Disadvantages include rigid construction, placement difficulties, and a higher rate of retakes.5 Other problems associated with rigid digital receptors include • placement errors, especially in premolar and molar areas; Paralleling Technique • vertical angulation errors (particularly in the anterior The paralleling technique is the preferred and most ac- regions of the mouth) that result in incisal edge curate method for acquiring both periapical and bitewing cut-offs; images. The paralleling technique can be accomplished • horizontal overlapping, especially in premolar with the use of ringed instruments as well as standard periapicals and bitewings; bite blocks. It is the relationship established between • difficulties with bitewing placement, both in the receptor and the teeth that dictates the technique premolar views and vertical bitewings; and rather than the device used. The digital receptor should • discomfort due to bulk and corners.5–12 be placed both vertically and horizontally parallel with

4 www.DentalAcademyofCE.com the teeth that are being radiographed. The X-ray beam Bitewing tabs hold the digital receptor in position in- should be directed at right angles, perpendicular to the traorally, but they do not provide an external alignment teeth and receptor simultaneously. When the receptor is guide for the PID (position indicating device) or X-ray placed correctly, the vertical and horizontal angulations cone positioning and beam direction. Careful placement align with the planes of teeth and receptor (figure 3). and beam alignment are necessary to produce good re- sults. The vertical angulation for tab bitewings ranges Figure 3 – Head Position from 0° to +8° with +5° being the most typical angle used. The X-ray beam should be centered over the tab or the receptor. The lateral tab edge should be aligned parallel to the teeth contacts, which will indicate the correct horizontal angulation to use to direct the X-rays proximally. Another horizontal angulation alignment strategy is to have the patient smile so that the clinician can compare the buccal surfaces of the teeth to the open end of the PID or instrument ring. These should be parallel to each other. These strategies are important to avoid proximal horizontal overlapping, the leading cause of retakes in bitewing imaging. Central ray entry points will help the clinician with X-ray beam centering as does In the case of periapical imaging, the digital recep- using the lines on the PID that indicate the direction the tor should be placed parallel to the full length of the X-rays exit the collimator (figure 4). The latter strategy crown and apices of the teeth (figure 4). To achieve the will help the clinician avoid cone cuts or partial exposure best placement and patient comfort, the digital receptor of the receptor. should be placed more toward the midline of the mouth rather than close to the teeth. It is helpful to use a cot- Bisecting Angle Technique ton roll underneath the bite block to reduce the need for The bisecting angle technique is an alternate approach for heavy biting forces, which often result in patient discom- periapical imaging. With this technique, the receptor is fort and receptor displacement. Technique guidelines call placed in an angular position rather than parallel to the for precise location and inclusion of specific structures on long axes of the teeth. The X-ray beam is then directed each projection (figure 5). at a right angle (perpendicular) to the plane that divides or bisects the angle formed by the receptor and the teeth. Figure 4 - Paralleling Diagram This method produces less than optimal images because the receptor and teeth are not in the same verti- cal plane. However, it is a useful strategy when an ideal receptor position cannot be achieved due to anatomical obstacles or placement difficulties. This technique is more operator-sensitive and requires a good understanding of the underlying geometric principles of the bisecting angle technique. If the angle is not correctly divided, elongation (underangulation) or foreshortening (overangulation) will occur (figure 6). To achieve this, a variety of holders can be used for positioning the receptor in different locations in the mouth. What often happens is the clinician uses a paralleling Bitewing Technique instrument but is unable to achieve a parallel placement Regardless of approach, instrument or tab bitewings of the receptor. Therefore, the clinician must be able to are based on the paralleling technique. In the case of evaluate whether or not the receptor placement conforms bitewings, the focus is on the crowns of the teeth and to the parameters of the paralleling technique. A useful the alveolar bone crests, which assist in caries diagnosis strategy is to check the X-ray beam entry relative to the and periodontal bone loss evaluation. The digital recep- facial central ray entry point. If the center of the X-ray tor should be placed vertically and horizontally parallel beam is not in alignment with the facial central ray entry to the crowns of the teeth in the area of interest. For point, then the vertical angulation needs to be adjusted. It patients who gag easily and for children, tab bitewings is not sufficient for the ring to be parallel to the receptor are less cumbersome and often more comfortable. only; it must be parallel to the teeth as well. www.DentalAcademyofCE.com 5 Figure 5 – Technique Chart14

Projection Teeth Receptor Receptor Or View Receptor Placement Recorded Central Ray Entry Point Orientation Size Image MAXILLARY PERIAPICALS

Place the receptor toward the midline and the biteblock under the 2nd molar 1st, 2nd, 3rd molar Point down from the outer Horizontal Molar crown, and align the mesial edge of teeth crowns and canthus (corner) placement; Size 2 periapical the biteblock between the 1st and 2nd apices of the eye to midcheek area dot toward crown molar contact point

Place the receptor toward the midline Distal of the and the biteblock under the 2nd premo- canine, 1st and Point down from the pupil of Horizontal Premolar lar crown, and align the mesial edge of 2nd premolar, 1st the eye to placement; Size 2 periapical the biteblock between the 1st and 2nd molar crowns and mid-cheek area dot toward crown premolar contact point apices

Place the receptor lingual to the Vertical Canine canine, with the biteblock centered Mesial and apex Ala (corner) of the nose placement; Size 1 periapical with the cusp tip of the canine dot toward crown

Lateral Place the receptor lingual to the Mesial, distal, and Vertical incisor lateral incisor and the biteblock under apex of the lateral Nares (nostril) of the nose placement; Size 1 periapical the lateral incisor crown incisor dot toward crown

Central Place the receptor lingual to the cen- Mesial, distal, Vertical incisor tral incisors, and center the biteblock and apices of the Tip of the nose placement; dot Size 1 or 2 periapical with the central incisor contact point central incisors toward crown

OPTION

Mesial and apex Canine- Place the receptor lingual to the ca- of the canine, Vertical lateral nine and lateral; center the biteblock mesial, distal, and Ala (corner) of the nose placement; Size 2 periapical with the lateral-canine apex of the lateral dot toward crown contact point incisor

BITE-WINGS

Maxillary and Horizontal or Molar Align the mesial edge of the tab be- mandibular Point down from the outer vertical place- bite-wing tween the 1st and 2nd molar contact molar crowns in corner of the eye ment; dot toward Size 2 on the mandible occlusion to the occusal plane mandible

Distal of the max- illary and man- Horizontal or Premolar Align the mesial edge of the biteblock dibular canine, Point down from the pupil of vertical place- bite-wing between the 1st and 2nd premolar premolar and 1st the eye to the ment; dot toward Size 2 contact on the mandible molar crowns in occusal plane mandible occlusion

MANDIBULAR PERIAPICALS

Place the receptor toward the tongue, Point down from the outer place the biteblock on the 2nd molar 1st, 2nd, 3rd molar Horizontal Molar crown, and align the mesial edge of teeth crowns and canthus (corner) placement; Size 2 periapical the biteblock between the 1st and 2nd apices of the eye to the mid- dot toward crown molar contact point mandible area

Place the receptor toward the Distal of the tongue, place the biteblock on the 2nd canine, 1st and 2nd Point down from the pupil of Horizontal Premolar premolar, and align the mesial edge of premolar, 1st mo- the eye to placement; Size 2 periapical the biteblock between the 1st and 2nd lar teeth crowns mid-mandible area dot toward crown premolar contact point and apices

Distal of the Canine- Place the receptor lingual to the lateral and mesial Point down from the ala Vertical lateral canine and lateral with biteblock of the canine (corner) of the nose placement; dot Size 1 or 2 periapical centered with the contact point and apices to the chin corner toward crown

Mesial and distal Central Place the receptor lingual to the cen- of the central in- Point down from the tip of Vertical incisor tral©PENNWELL®2016 incisors, and center the biteblock cisors and mesial the nose to the placement; dot Size 1 or 2 periapical with the central incisor contact point of the lateral inci- chin center toward crown sors and apices

6 www.DentalAcademyofCE.com Figure 6 – Vertical Image Errors to overangulation and image foreshortening. Reduction A. Elongation B. Foreshortening of the vertical angulation will compensate for the lack of receptor parallelism to the structures of interest.

Occlusal Technique Topographical occlusal radiography is based on the bi- secting angle technique. It can be used to take periapical images in the anterior regions of the mouth when the arch is too narrow to permit normal placement of the receptor or when mouth opening is limited. Occlusal imaging is technique sensitive in that the patient’s head alignment, the vertical angulation, and the central ray entry must be aligned correctly to produce optimal results. The receptor should be oriented vertically and placed against the occlusal plane of the teeth of inter- est. The patient should bite lightly to secure the receptor Another strategy that the clinician can use is to ini- in position. To maintain a level and secure placement for tially align the PID parallel to the receptor or ring guide rigid wired sensors, cotton rolls can be placed under the and then reduce (decrease) the vertical angulation by ap- receptor adjacent to the wire. The technique parameters proximately 10° which will approach the bisecting angle. for incisor and lateral-canine views for either arch are out- Also, starting angles can be used to approximate the bi- lined in table 2. The horizontal angulation and exposure secting plane in each area of the mouth when nonringed time remain the same as conventional periapicals of the instruments or devices are used (table 2). These starting respective area of interest. angles can be aligned using the angle meter on the X-ray head, which indicates in degrees the angulation of the Table 3: Occlusal Techniques for Anterior Views15 PID (figure 7). Positive angulations position the X-ray Periapical Head Central Vertical head above 0° with the PID directed downward, while View Position Ray Entry Angulation negative angulations position the X-ray head below 0° Maxillary Occlusal plane ½” above +55° to with the PID directed upward. Generally, positive angu- Incisor parallel to the the tip of +60° lations are used on the maxilla and negative angulations floor the nose are used on the mandible. Maxillary Occlusal plane Center of -10° to -15° Lateral- aligned at the chin Table 2: Bisecting Angle Technique Starting Angulations15 Canine -45° View Maxillary Arch Mandible Arch Mandibular Occlusal plane Corner of -10° to -15° Lateral- aligned at the chin Molar +15° to +25° +5° to -5° Canine -45° Premolar +25° to +35° -10° to -15° Canine +40° to +50° -10° to -15° Occlusal techniques can be utilized to obtain ante- Incisor +40° to +50° -10° to -15° rior images on children (figure 8). In these instances, the receptor is placed in the horizontal rather than the vertical plane. One anterior view is taken on either or Figure 7 – Angle Meter both the maxilla and mandible. The technique includ- ing head position and angulation is the same in both instances, but the exposure time should be adjusted to a child setting.

Figure 8 – Pediatric Occlusals

Using the bisecting angle is more common with rigid sensors because achievement of true parallelism be- tween the receptor and the tooth structure is more dif- ficult. As a result, the crowns are frequently cut off due www.DentalAcademyofCE.com 7 Intraoral Receptor Instruments 7. White SC, Pharoah MJ. Oral radiology: Principles and interpretation. 7th ed. St Louis, MO: Mosby-Elsevier; 2013. Available Instruments 8. Bedard A, Davis TD, Angelopoulos C. Storage phosphor plates: How durable are they as a digital dental radiographic As previously discussed, there is a variety of intraoral system? J Contemp Dent Pract. 2004;5(2):57-69. imaging instruments available to position and stabilize 9. Matzen LH, Christensen J, Wenzel A. Patient discomfort and the receptor in the patient’s mouth during exposure (fig- retakes in periapical examination of mandibular third molars ure 5). Most instruments can tolerate heat sterilization, using digital receptors. Oral Surg Oral Med Oral Pathol Oral which permits reuse and may be more cost effective in Radiol Endod. 2009;107(4):566-572. the long term. Disposable, single-use bite blocks and tabs 10. Versteeg CH, Sanderink GCH, van der Stelt PF. An evaluation are available for periapical and bitewing imaging as well. of periapical radiography with a charge-coupled device. Dentomaxillofac Radiol. 1998;27(2):97-101. Disposable bite blocks can be used in conjunction with 11. Sommers TM, Mauriello SM, Ludlow JB, Platin E, Tyndall ringed instruments for periapical imaging. The use of DA. Pre-clinical performance comparing film and CCD-based specific instrumentation depends on clinician preference, systems. J Dent Hyg. 2002;76(1):26-33. consistent diagnostic outcomes, the treatment schedule, 12. Bahrami G, Hagstrom C, Wenzel A. Bitewing examination patient volume, and the ability to sterilize instruments to with four digital receptors. Dentomaxillofac Radiol. meet imaging demands throughout the day. 2003;32(5):317-321. Receptor instruments with X-ray beam ring guides 13. Jorgensen PM, Wenzel A. Patient discomfort in bitewing examination with film and four digital receptors. improve accuracy and help ensure correct beam angula- Dentomaxillofac Radiol. 2012;(4)41:323-327. tion and centering. Remember that the use of an instru- 14. Williamson GF. Best practices and patient comfort with digital ment alone does not assure accuracy: the clinician must intraoral radiography. Academy of Dental Therapeutics and use the device correctly or make necessary adjustments Stomatology. Tulsa, OK: PennWell Corporation; 2010. when receptor placement is not ideal. 15. Williamson GF: Chapter 28, Radiographic Techniques, in Textbook of Oral Medicine, Oral Diagnosis and Oral Summary Radiology, 2nd Ed. Editors: Ravikiran Ongole and Praveen Dental radiographs are valuable diagnostic tools and Birur N. Chennai, India: Reed Elsevier India Private Limited; 2013. expose the patient to minimal amounts of radiation when the examination is conducted in an optimal man- ner. To achieve diagnostic results, the clinician must be Author Profile knowledgeable and well-versed in intraoral radiographic Gail F. Williamson, RDH, MS is a professor of dental techniques used for patient imaging. In addition, the cli- diagnostic sciences in the Department of Oral Pathol- nician must be skilled in receptor placement to produce ogy, Medicine, and Radiology at the Indiana University optimal results. Receptor instruments are valuable tools School of Dentistry in Indianapolis, Indiana. She holds that guide the an associate’s degree in dental hygiene, a bachelor’s de- X-ray beam and thereby assist in the accuracy of den- gree in allied health, and a master’s of science degree in tal radiographic images and retake avoidance. education, all from Indiana University. She has served as director of allied dental radiology and course director References for dental assisting and dental hygiene radiology courses. 1. Dental Radiographic Examinations: Recommendations for A veteran teacher, Williamson has received numerous Patient Selection and Limiting Radiation Exposure, Revised awards for teaching excellence throughout her career. She 2012. American Dental Association and US Dept. of Health is a published author and presents numerous continuing and Human Services; 2012. education courses on oral and maxillofacial radiology on 2. Kalathingal SM, Moore S, Kwon S, Schuster GS, Shrout MK, Plummer K. An evaluation of microbiologic contamination on the national level. In addition, she serves as the associate phosphor plates in a dental school. Oral Surg Oral Med Oral executive director of the American Academy of Oral and Pathol Oral Radiol Endodo. 2009;107(2):279-282. Maxillofacial Radiology and serves as a radiology expert 3. Choi JW. Perforation rate of intraoral barriers for direct digital on the American Dental Association’s Joint Commission radiography. Dentomaxillofac Radiol. 2015;44:20140245. on National Board Examinations Dental Hygiene Na- 4. Centers for Disease Control and Prevention. Guidelines for tional Board Review Committee. Currently, Williamson infection control in dental healthcare settings 2003. http:// serves as the director of faculty enhancement both at the www.cdc.gov/mmwr/preview/mmwrhtml/rr5217a1.htm. Published December 19, 2003. Accessed August 4, 2016. campus and school levels. 5. Wenzel A, Moystad A. Work flow with digital intraoral radiography: A systematic review. Acta Odontologica, Author Disclaimer 2010;68(2):106-114. The author of this course has no commercial ties with the 6. Parks ET, Williamson GF. Digital Radiography: An Overview. sponsors or the providers of the unrestricted educational J Contemp Dent Pract. 2002;3(4):001-013. grant for this course.

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www.DentalAcademyofCE.com 9 Online Completion INSTANT EXAM CODE 15135 Use this page to review the questions and answers. Return to www.DentalAcademyofCE.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

Questions 1. Dental radiographic examinations are 12. To achieve proper placement with 22. For a maxillary central incisor taken ______. the paralleling technique, the receptor periapical image, a ______should be a. only when indicated must be placed ______. used for the receptor orientation. b. as prescribed by the dentist a. vertically parallel to the teeth c. for diagnosis and treatment b. horizontally parallel to the teeth a. horizontal placement d. all the above c. toward the midline of the mouth b. vertical placement 2. ______is an advantage of the use of d. all the above c. diagonal placement solid-state detectors over film. 13. For patients who gag easily or for d. any of the above a. Computerized archiving and image display children, tab bitewings are ______for b. Chemical processing of the receptor the patient. 23. For a molar bitewing radiographic c. Reduction in the number of retakes a. less convenient image, a ______can be used for the d. Active surface area for image acquisition b. less cumbersome receptor orientation. 3. To evaluate periapical pathosis, the c. less comfortable a. horizontal placement radiographic projection of choice is d. b and c b. vertical placement usually a ______. 14. Central ray entry points are most a. bitewing image useful for ______. c. diagonal placement b. periapical image a. positioning of the receptor d. horizontal or vertical placement c. series of periapical and bitewing images b. X-ray beam angulation 24. Image foreshortening is caused by d. topographical occlusal image c. X-ray beam centering ______. 4. The images of choice for the detection d. patient head positioning a. improper beam centering and monitoring of dental caries in the 15. The bisecting angle technique can be posterior teeth are ______. used for ______. b. overangulation in the vertical plane a. bitewing images a. bitewing radiography c. underangulation in the vertical plane b. periapical images b. periapical radiography c. occlusal images d. incorrect horizontal angulation c. occlusal radiography d. full mouth survey d. b and c 25. ______is the most common cause for 5. Digital receptors are available as 16. Application of the bisecting angle retakes in bitewing imaging. ______. a. Proximal horizontal overlap a. charge-coupled devices technique has become more common b. photostimulable phosphor plates with the use of ______. b. Image elongation c. complementary metal oxide semiconductors a. phosphor plate receptors c. Image foreshortening d. all of the above b. rigid digital receptors c. radiographic film d. Cone cut 6. A common error associated with solid- d. none of the above 26. Positive vertical angulations are most state digital receptors is ______. a. elongation 17. When taking maxillary periapicals typically used for ______. b. cone cutting and bitewing images, the preferred a. maxillary periapical images head position aligns the ______. c. placement b. mandibular periapicals d. exposure a. occlusal plane parallel to the floor b. midsagittal plane perpendicular to the floor c. bitewing images 7. To prepare digital receptors for use, c. occlusal plane perpendicular to the floor d. a and c the clinician should avoid use of d. both a and b ______. 27. The correct vertical angulation for 18. When using the bisecting angle tech- a. heat-sterilization the maxillary incisor view when using b. high-level disinfection nique for a maxillary molar projection, c. a double-barrier technique the starting angulation will range from the occlusal technique is ______. d. manufacturer instructions ______. a. +25° to +35° 8. Phosphor plate receptors ______. a. +15° to +25° b. +45° to +55° b. +25° to +35° a. are wired digital receptors c. +55° to +60° c. +40° to +50° b. provide real-time image display d. +60° to +65° c. require laser scanning d. +55° to +60° d. are solid-state detectors 19. When using the bisecting angle 28. Topographical occlusal imaging can 9. Phosphor plate receptors are suscep- technique for a mandibular canine be used ______. tible to ______. projection, the angulation ranges from a. when mouth opening is limited ______. a. overexposure b. to obtain anterior images on children b. scar artifacts a. +10° to +15° c. more retakes b. +25° to +35° c. as anterior periapical replacements on adults d. scan errors c. +5° to -5° d. all of the above d. -10° to -15° 10. To capture the distal surface of 29. Receptor instruments with ring 20. For a periapical radiograph of the canines with rigid sensors, it may be guides ______. easier to take an additional anterior maxillary canine area, the central ray periapical on each arch to capture the entry point should be the ______. a. must be used correctly by the clinician ______. a. corner of the eye b. assure image accuracy and quality a. central-lateral incisor contact b. tip of the nose c. require disinfection before reuse c. ala of the nose b. canine-lateral contact d. are disposable c. canine-1st premolar contact d. center of the cheek d. 1st premolar-2nd premolar contact 21. For a periapical radiograph of the 30. The use of specific receptor instru- 11. The paralleling technique is used for mandibular incisor area, the central mentation is a function of ______. ______radiographs. ray entry point should be the ______. a. clinician preference a. periapical a. lower border of the lip b. consistent diagnostic outcomes b. bitewing b. corner of the mouth c. panoramic c. nares of the nose c. patient volume d. a and b d. center of the chin d. all of the above

10 www.DentalAcademyofCE.com INSTANT EXAM CODE 15135 ANSWER SHEET Strategies for optimal intraoral digital imaging Part I: Intraoral receptors, techniques, and instrumentation

Name: Title: Specialty:

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Lic. Renewal Date: AGD Member ID: Requirements for successful completion of the course and to obtain dental continuing education credits: 1. Read the entire course. 2. Complete all information above. 3. Complete answer sheets in either pen or pencil. 4. Mark only one answer for each question. 5. A score of 70% on this test will earn you 3 CE credits. 6. Complete the Course Evaluation below. 7. Make check payable to PennWell Corp. For Questions Call 800-633-1681

Educational Objectives If not taking online, mail completed answer sheet to 1. List and describe the types of digital receptors used for intraoral radiographic imaging; PennWell Corp. Attn: Dental Division, 2. List and describe the principles of paralleling, bitewing, and bisecting angle techniques for effective intraoral digital imaging; 1421 S. Sheridan Rd., Tulsa, OK, 74112 3. List and describe the intraoral receptor instruments that can be used to acquire periapical and bitewing images. or fax to: 918-831-9804 Course Evaluation For IMMEDIATE results, go to 1. Were the individual course objectives met? Objective #1: Yes No Objective #2: Yes No www.DentalAcademyofCE.com to take tests online. Objective #3: Yes No Answer sheets can be faxed with credit card payment to 918-831-9804. Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. Payment of $59.00 is enclosed. 2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 (Checks and credit cards are accepted.)

3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 If paying by credit card, please complete the following: MC Visa AmEx Discover 4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 Acct. Number: ______5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 Exp. Date: ______6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 Charges on your statement will show up as PennWell

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0

9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0

10. Do you feel that the references were adequate? Yes No

11. Would you participate in a similar program on a different topic? Yes No

12. If any of the continuing education questions were unclear or ambiguous, please list them. ______

13. Was there any subject matter you found confusing? Please describe. ______

14. How long did it take you to complete this course? ______

15. What additional continuing dental education topics would you like to see? ______AGD Code 731

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COURSE EVALUATION and PARTICIPANT FEEDBACK PROVIDER INFORMATION RECORD KEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association PennWell maintains records of your successful completion of any exam for a minimum of six years. Please with the course. Please e-mail all questions to: [email protected]. to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP contact our offices for a copy of your continuing education credits report. This report, which will list all does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. Participants will Completing a single continuing education course does not provide enough information to give the receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP at www.ada. participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of mailed within two weeks after taking an examination. org/cotocerp/. many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General CANCELLATION/REFUND POLICY All participants scoring at least 70% on the examination will receive a verification form verifying 3 CE Dentistry. The formal continuing dental education programs of this program provider are accepted by the Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/ AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from © 2016 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell their state dental boards for continuing education requirements. PennWell is a California Provider. The (11/1/2015) to (10/31/2019) Provider ID# 320452 California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00. RDH1016INS Customer Service 800-633-1681