Dental radiology - simplified and basic interpretation
DENTAL RADIOLOGY TECHNIQUES AND BASIC INTERPRETATION
Brook A. Niemiec, DVM, DAVDC, DEVDC, FAVD
Veterinary Dental Specialties & Oral Surgery
San Diego, CA, USA
Taking a dental radiograph:
Step 1: Patient positioning
Position the patient so that the area of interest is convenient to the radiographic beam. In general this is where the object is “up”. For maxillary teeth, the patient should be in ventral recumbency. For mandibular canines and incisors the pet should be in dorsal recumbency. Finally, for maxillary cheek teeth, the patient should be in lateral recumbency with the affected side up. This being said, in our practice virtually all radiographs are exposed in lateral recumbancy. This takes some getting used to, but decreases the number of times a patient must be rolled when doing surgical or endodontic procedures.
Step 2: Film Placement within the patient’s mouth
There is an embossed dot on the film. The convex side of this should be placed towards the x-ray beam. In most films, this side is pure white. The opposite or “back” side of the film will usually be colored (purple or green). Place the film in the mouth so that the entire tooth (crown and entire root surface) is covered by the radiograph. Remember, the roots of all teeth are very long. This is especially true of canine teeth, which are longer than you think. Always err on the side of having the film too far in the mouth to ensure you do not cut off the root apexes. The film should be placed as near as possible to the object to minimize distortion.
Step 3: Positioning the beam head
There are two major techniques for positioning the beam head in veterinary patients. Both of these techniques are used daily in veterinary practice.
Parallel technique: This is where the film is placed parallel to the object being radiographed and perpendicular to the beam. This is how standard (large) films are taken. This gives the most accurate image. Unfortunately this is only useful in the lower cheek teeth in the dog and cat. This is due to the fact that these patients don’t have an arched palate. The film cannot be placed parallel to the tooth roots because of the palate’s interference. Therefore this technique is not always possible.
Bisecting Angle Technique: This is the most common type of dental radiograph taken in veterinary patients. This uses the theory of equilateral triangles to create an image that accurately represents the tooth in question. To utilize this technique, the film is placed as parallel as possible to the tooth root. Then the angle between the tooth root and film is measured. This angle is cut in half (bisected) and the beam placed perpendicular to this angle. This gives the most accurate representation of the root.
If this angle is incorrect, the radiographic image will be distorted. This is because the x-ray beam will create an image that is longer or shorter than the object imaged. The best way to visualize this is to think of a building and the sun. The building will create a 90 degree (right) angle to the ground. The bisecting angle in this case is 45 degrees.
Early and late in the day, the sun is at an acute angle to the building and casts a long shadow. In radiology this occurs when the angle of the beam to the object is too small and is known as elongation. At some point in the late morning and early afternoon, the sun is at a 45 degree angle to the building, which is the bisecting angle. This gives an accurate representation of the building height. As the sun continues up in the sky, the shadow shortens. This occurs in veterinary radiology when the angle is too great and is known as foreshortening. Finally, at noon, the sun is straight up from the building, which gives no shadow.
The “Simplified Technique” as developed by Dr. Tony Woodward does not utilize direct measurement of any angle, instead relying on approximate angles to create diagnostic images. There are only 3 angles used for all radiographs in this system 20, 45, and 90.
Mandibular premolars and molars are exposed at a 90 degree angle, maxillary premolars and molars at a 45-degree angle, and incisors and canines at a 20 degree angle.
To initiate any radiograph, place the film in the mouth and set the positioning indication device (PID) perpendicular to the film. For mandibular cheek teeth, this is the correct placement. For the maxillary premolars and molars, rotate the beam to a 45 degree angle. For the incisors and mandibular canines rotate 20 degrees. For the maxillary canines an additional rotation 20 degrees lateral is necessary to avoid superimposition of the first and second premolars.
Step 4: Setting the exposure
If you are using a machine where you set the exposure manually, you will need to set up a technique chart similar to one for a standard (large) unit. The good news is that there is only one variable that needs to be adjusted.
If you are utilizing the computer controlled system, set the buttons for the species, size of the patient, and tooth to be imaged. If you have correctly set the machine and the image is incorrectly exposed, the easiest way to adjust is to change the f setting. By pressing this button, you will see the numbers go up on both sides. The one on the left is the f number and the one on the right is the exposure time. If you continue to press the button it will continue to increase the exposure until you reach 9 when it will markedly lower and the f number will go back to 1. If the radiograph is overexposed (too dark) lower the f number by 1. If it is underexposed (too light) increase the number by 1. Continue this process until you have the film that you want. Generally, the f number will be the same for all radiographs once you have discovered the correct setting for your machine start at that number in future sessions.
Step 5: Exposing the radiograph
Dental radiograph machines have a hand held switch to expose the radiograph. If it is possible, leave the room prior to exposing the radiograph. If it is not, stand at least 6 feet away at a 90 to 130 degree angle to the primary beam (meaning to the side or back of the tube head, not in front or behind). Once everything is set, press the button. It is important to remember, that these switches are “dead man’s”. This means if you let up during the exposure, it will stop the production of x-ray beams. On a standard unit, this will make a light radiograph, on a computer controlled one it will give an error message and you will need to start over. Make sure you hold the button down until the machine stops beeping.
Interpreting dental radiographs can be daunting, but it is very similar to interpreting a standard boney radiograph. The major difference is that dental radiographic changes are often more subtle. In addition, there are pathologic states that are unique to the oral cavity. Finally, there are several normal anatomic structures that may mimic pathologic changes.
Determining which teeth were imaged:
The first step in radiographic interpretation is determining which teeth have been imaged. This requires not a firm knowledge of oral anatomy as well as the architecture of dental films. Digital systems with veterinary templates do not require this step as long as the images are properly placed (DO NOT ASSUME THIS WAS DONE CORRECTLY). If your system does not support a veterinary template, there is a mark on the image which is in a consistent location. Review the owner’s manual for instructions on its use.
The key to properly identifying the imaged teeth is the embossed dot, which is on one corner of the film. When exposing a radiograph, if the film is properly positioned, the convex surface will point towards the radiographic tube head. There is no way to expose a diagnostic radiograph with the film in backwards, due to the lead sheet on the back side of the film. Therefore, when interpreting the film, the embossed dot is facing out of the mouth.
First, place the dot towards you (this is done for you on most digital systems). This means you are looking at the teeth as if you are the beam. Next, rotate the film so that the roots are in their natural position (up on maxillary and down on mandibular).
Canines and incisors: This orients the film so the right side of the mouth is on the left, and right side is on the left. This is like a VD abdomen radiograph.
Molars and Premolars: Ascertain mesial from distal. If the mesial side is on the left side of the film, it is a radiograph of the left side of the patient and vice versa for the right.