Digital imaging * filmless imaging system + method of capturing a radiographic image with a sensor, breaking the image into electronic pieces and presenting & storing the image using a computer Direct digital image production requires * x-ray source * digital intraoral sensor * computer * high-resolution monitor * software & printer Digital intraoral sensor * small intraoral detector used to capture a radiographic image when x-rays strike the sensor, an electronic charge is produced on the surface of the sensor, this electronic charge is digitized or converted to digital form + may be wired or wireless * sensor transmits information to computer Pixel or picture clement * discrete unit of information * consists of a small electron well where the x- ray or light energy is deposited upon exposure * digital image is composed of pixels ¢ CCD (charge-coupled device) CCD (charge-coupled device) + most common digital image receptor + in the intraoral sensor, a solid-state detector that contains a silicon chip with an embedded electronic circuit + sensitive to light or x-rays + 640 x 480 pixels in size CMOS/APS (complementary metal oxide semiconductor/active pixel sensor) « latest development in direct digital sensor technology * externally identical to CCD + differs in the way pixels are read + advantages include lower production cost of the chip, lower power requirements & greater durability + smaller active area for image acquisition CID (charge injection device) * another sensor technology « silicon based solid-state imaging receptor similar to CCD * no computer is required to process the images * system features CID x-ray sensor, cord and plug that are inserted into a light source on a camera platformAdvantages of digital imaging + superior gray scale resolution 256 shades of gray used instead of the 16-25 shades used with film + reduced exposure to radiation radiation exposure is 50% to 90% less than what is used to expose E-speed film increased speed of image viewing images can be viewed instantly which allows for immediate interpretation + lower equipment and film cost no need for purchase of film and related processing supplies and equipment increased efficiency allows dental professionals to be more productiv: image storage and communication are easier with digital networking + enhancement of diagnostic image features such as colorization and zooming allow for highlighting of conditions; the gray scale may be reversed (digital subtraction) + effective patient education tool the size of images displayed monitor are easier for the patient to see; allows for chairside education and interaction ¢ Sensor size Disadvantages of digital imaging + sensor size some sensors are thicker and less flexible than film and may stimulate the gag reflex + initial set up costs significant initial cost for purchase of digital equipment as well as maintenance and repairs + resolution / image quality conventional x-ray film has a resolution of 12 - 20 Ipimm (line pairs per millimeter), digital imaging using a CCD has a resolution of 10 Ip/mm; because human eye can only perceive 8 - 10 Ipfmm — digital imaging performs at least as well as traditional radiography + infection control some sensors cannot withstand heat steriliza- tion; barrier protection is required «wear & tear sensors are subject to damage, wear & tear and have a limited lifespan + legal issues because digital images can be enhanced, there may be legal implicationsDigital imaging + filmless imaging system + methods of obtaining a digital image: direct and indirect Direct digital imaging + required components - X-ray machine - intraoral sensor = computer & monitor * utilizes a sensor with a fiberoptic cable that is linked to a computer + sensor is placed intraorally and exposed to x-radiation + images are captured via a sensor (CCD, CMOS/APS or CID) + the sensor transmits the image to a computer monitor + images appear on monitor within seconds of exposure * software is used to enhance store the image Indirect digital imaging * scanning of traditional films + storage phosphor imaging * Direct digital imaging Scanning of traditional films quired components = CCD camera ~ computer & monitor + existing films are scanned and digitized using a CCD camera + CCD camera scans radiograph, converts the image and displays it on monitor + is inferior to direct digital imaging + image is a “copy” not an “original” Storage phosphor imaging + required components - phosphor- coated plate - electronic processor/scanner - computer & monitor +a “wireless” digital imaging system 1 reusable imaging plate coated with phosphor is used instead of a sensor with a fiberoptic cable + plates are similar to intraoral film in size, sha & thicknes + image recorded on plate after exposure, plate is placed in electronic processor where a laser scans the plate; image is transferred to the monitor within time frame of 30 seconds to 5 minutes + also referred to as photo-stimulable phosphor imaging or PSP imagingDigital imaging * requires LESS radiation than conventional films because the sens x-rays than dental film * exposure time for digital imaging is approximately 50% less than what is required for F-speed film * intraoral, panoramic and other extraoral films may all be obtained digitally $ more sensitive to Intraoral film speed + E-speed film is no longer available * Only D-speed film and F-speed film are available for use with intraoral radiography + F-speed film is recommended by the ADA + F-speed requires 60% of the exposure time of D-speed Other ways to limit exposure to x-radiation « proper prescribing of dental radiographs based on individual needs of patient ¢ use of lead apron & thyroid collar use of proper dental x-ray equipment * use of rectangular position-indicating device (PID) + use of beam alignment devices use of proper technique « proper sensor handing * proper image retrievalcontrast the difference in degrees of blackness (densi- ties) between adjacent areas on a dental radi- ograph. + high contrast describes an image that ap- pears mostly black & whites shades of gray are absent + low contrast describes an image with many shades of gray; few areas of black and white scales of contrast the range of useful densities seen on a dental radiograph. short-seale contrast describes a high contrast image with densities of black & white that results from using a low kilovoltage. long-seale contrast describes a low contrast image with many shades of gray that results from using a high kilo- voltage. LOW CONTRAST = LONG-SCALE CONTRAST * Both statements are true magnification a radiographic image that appears larger than the actual size of the object it represents; mag- nification is influenced by the target-receptor distance and the object-receptor distance. target-receptor distance * distance between the source of x-rays and the image receptor* +a longer PID results in a longer target-recep- tor distance and helps to limit magnification object-receptor distance + distance between the tooth and the image receptor + the closer the receptor is to the tooth, the less. magnification is seen on the image to limit magnification + use a long target-receptor distance/t target receptor distance * use a short object-receptor distance/| object -receptor distance image receptor=digital sensor or x-ray film° Sinus — Bone — Dentin — Enamel — Amalgam Radiolucent structures * lack density * permit the passage of x-radiation * absorb very little x-radiation + allow more x-rays to reach the receptor * appear dark or black on an image Examples of radiolucent structures/ materials — BLACK or DARK * air space images * soft tissue images * canals * foramens * fossas * sinuses * sutures * caries * pulp cavities * periodontal ligament space * denture acrylic * some composite restorations LUCENT means TRANSPARENT and suggests something that lacks density — something that lacks density permits the pas- sage of x-rays & appears RADIOLUCENT. Radiopaque structures * are dense * resist the passage of x-radiation * absorb the diation + allow few x-rays to reach the receptor* * appear light or white on an image Examples of radiopaque structures/ materials — WHITE or LIGHT * enamel dentin * bone * lamina dura * septa * tubercles * tuberosities * ridges * processes * amalgams, metal restorations * implants * gutta percha OPAQUE means NOT TRANSPARENT and suggests something that is more dense something that is more dense resists the passage of the x-rays & appears RADIOPAQUE *receptor=digital sensor or x-ray filmDental radiographs * original radiographs are legally the property of the dentist even though the patient or an insurance company may have paid for them « the radiographs are the property of the dentist because they are indispensable to the dentist as part of the patient record * radiographs should be kept indefinitely Patient access to radiographs * patients have a right to reasonable access of their dental radiographs * access includes copies of original radiographs (not originals) forwarded to the dentist who will be responsible for the patient's dental care Patient record must contain documentation of + informed consent + number & type of radiographs exposed * rationale for taking radiographs * diagnostic information obtained from interpretation ¢ Dentist Patients who refuse dental radiographs * when a patient refuses to have dental radiographs, the dentist must decide whether diagnosis and treatment can take place without the recommended radiographs * no document can be signed by the patient that releases the dentist from liability Very important: the patient record, including radiographs, is legal documentation of a patient’s condition,¢ Images should be taken based on patient need instead of a set time frame Prescribing dental radiographs e the dentist is responsible for prescribing the number, type and frequency of dental radiographs * each patient’s condition is different and therefore each patient must be evaluated for radiographs on an individual basis * a radiographic examination should never include a set number and type of images at a set interval e guidelines for prescribing dental radiographs are published by the American Dental Association (ADA) in conjunction with the Food & Drug Administrations (FDA) + visit www.ADA.org for current guidelines * patients with caries, periodontal disease, tooth mobility, pain and impacted teeth need more frequent radiographic examinations Guidelines for radiographs in the recall patient with clinical caries or risk of caries ¢ bite-wings at 6 - 12 month intervals with no clinical caries or risk of caries * bitewings at 24 - 36 month intervals with periodontal disease * clinical judgement for radiographs needed to evaluate periodontal disease; selected bite-wings & periapicalsImage 1- Hamulus * aka hamular process small, hook-like projection of bone * extends from the medial pterygoid plate of the sphenoid bone * located posterior to the maxillary tuberosity * appears radiopaque *ona maxillary molar periapical image, appears as a hook-like radiopaque structure ° varies in length, shape & density * not always visible, depends on receptor placement ¢Hamulus ° Maxillary tuberosity Image 2- Maxillary tuberosity * rounded prominence of bone that extends distal to the third molar region * appears radiopaque * on a maxillary molar periapical image, appears as a rounded radiopaque bulge distal to the third molar region * varies in size, shape and density not always visible, depends on receptor placement* Maxillary molar Coronoid process * coronoid means “resembling the beak of a crow” ¢ large prominence of bone on anterior ramus of mandible ¢ is thin and triangular in shape * serves as an attachment site for one of the muscles of mastication * appears radiopaque * ona maxillary molar periapical image. appears as a beak-shaped radiopacity located inferior to, or superimposed over, the maxillary tuberosity * varies in shape and density * not always visible, depends on receptor placement Reprinted from Haring, Joen lannucei and Laura Jansen Lind: Radiographic Interpretation for the Dental H © 1993, with permission from Elsevier.J, Lateral wall of the incisive (nasopalatine) canal radiopaque line 2, Anterior wall of the maxillary sinus radiopaque line 3. Nasopalatine fossa radiolucent space 4. Floor of nasal fossa radiopaque line 5. Soft tissue outline of the nose slightly radiopaque outline 6. Lamina dura radiopaque line 7. Border of maxillary sinus radiopaque line 8. Periodontal ligament space radiolucent line ° Answers 1-8 below “Courtesy Dr. Stuart C. White, UCLA ‘School of Dentistry.”+ Answers 1 - 7 below 1. Anterior nasal spine radiopaque line 2. Lateral wall of nasopalatine canal radiopaque line 3. Median palatal suture radiolucent line 4. Floor of nasal fossa radiopaque line 5. Incisive (nasoplatine) foramen radiolucent structure 6. Soft tissue outline of tip of nose slightly radiopaque outline “Courtesy Dr. Stuart C. White, UCLA 7. Alveolar crest Schoo! of Dentistry.” radiopaque line+ Answers 1- 5 below 1, Nutrient canal radiopaque lines 2. Bony trabecular plate radiopaque line 3. Inferior border of mandibular canal radiopaque line 4. Submandibular gland fossa radiolucent space 5. Inferior border of mandible radiopaque structure “Courtesy Dr. Stuart C. White, UCLA School of Dentistry.”+ Answers 1 - 8 below 1. Anterior wall of maxillary sinus radiopaque line 2. Inferior nasal conchae radiopaque mass 3. Floor of nasal fossa radiopaque line 4. Inferior border of zygomatic process of maxilla j-shaped radiopaque line 5. Posterior wall of zygomatic process of maxilla radiopaque line 6. Inferior border of zygoma radiopaque line “Courtesy Dr. Stuart C. White, UCLA School of Dentistry.” 7. Floor of maxillary sinus radiopaque line 8. Mucosa over alveolar bone slightly radiopaque structure* Answers 1 - 7 below 1. Lingual cusp of I premolar radiopaque area 2. Periodontal ligament space radiolucent line 3. Film holder radiopaque area 4, Genial tubercles donut shaped radiopacity 5, Lingual foramen radiolucent circle 6. Bony trabeculations radiopaque lines “Courtesy Dr. Stuart C, White, UCLA 7. Marrow space School of Dentistry.” radiolucent area1. Periodontal ligament space radiolucent line 2. Mental foramen ovoid radiolucency 3. Submandibular gland fossa radiolucent area 4. Film clip mark radiolucent artifact School of Dentistry.” ° Answers 1 - 4 below° Answers 1 - 3 below 1. Cemento-enamel junction (CEJ) radiopaque line 2. Mental foramen ovoid radiolucency 3. Submandibular gland fossa large radiolucent area ‘Courtesy Dr. Stuart C, White, UCLA School of Dentistry.”° Answers 1 - 7 below 1. Inferior nasal conchae radiopaque mass 2. Anterior wall of maxillary sinus radiopaque line 3. Floor of nasal fossa radiopaque line 4. Maxillary sinus radiolucent space 5. Floor of maxillary sinus radiopaque line 6. Inferior border of the zygomatic process of the maxilla ‘Courtesy Dr. Stuart C. White, UCLA radiopaque area School of Dentistry.” 7. Lingual cusp of 1* premolar radiopaque band+ Answers 1- 6 below 1. Floor of nasal fossa radiopaque line 2. Lateral wall in incisive canal radiopaque line 3. Ala of nose radiopaque line 4, Anterior wall of maxi radiopaque line lary sinus 5. Maxillary sinus radiolucent space 6. Lingual cusp of 1" premolar radiopaque band “Courtesy Dr. Stuart C. White, UCLA School of Dentistry.”* Answers 1- 6 below 1. Dentino-enamel junction (DEJ) radiopaque line 2. Periodontal ligament space radiolucent line 3. Lamina dura radiopaque line 4, Periodontal ligament space of palatal root radiolucent line 5. Film holder radiopaque area ‘Courtesy Dr. Swart C. White, UCLA School of Dentisiry. 6. Mucosa over alveolar bone slightly radiopaque structure° Answers 1 - 3 below 1. Mandibular tori radiopaque masses 2. Lingual foramen radiolucent circle 3. Genial tubercles donut shaped radiopacity tC, White, UCLA° Answers 1- 4 below 1. Alveolar crest of bone radiopaque structure 2, Lamina dura radiopaque line 3. Periodontal ligament space radiolucent line 4. Bony trabeculations radiopaque lines “Courtesy Dr. Stuart C. White, UCLA School of Dentistry.”¢ Answers 1- 8 below 1. Marrow space radiolucent space 2, Periodontal ligament space radiolucent line 3. Bony trabecular plate radiopaque line 4, Lamina dura radiopaque line 5. Pulp canal radiolucent space 6. Alveolar crest radiopaque area 7. Dentin radiopaque arca “Courtesy Dr. Stuart C. White, UCLA School of Dentistry.” 8. Enamel radiopaque area° Answers 1- 9 below 1. Dentin radiopaque area 2. Bony trabeculations radiopaque lines 3. Marrow space radiolucent area 4, Pulp canal radiolucent space 5, Periodontal ligament space radiolucent line 6. Lamina dura radiopaque line 7. Alveolar crest radiopaque structure “Courtesy Dr. Stuart C. White, UCLA 8. Enamel School of Dentistry.” radiopaque band 9, Pulp chamber radiolucent space° Answers 1 - 8 below 1. Tooth #3 maxillary first molar 2. Amalgam restoration 3. Plastic bite block faint opacity 4. Film dot round radiolucency 5. Black letters - PLS indicates Kodak Ektaspeed plus film 6. Lamina dura radiopaque line Schoo! of Dentistry.” 7. Periodontal ligament space radiolucent line 8. Lamina dura radiopaque line1. Air in nasal fossa radiolucent space 2. Nasal septum radiopaque line 3. Lateral wall of nasal septum medial wall of maxillary sinus radiopaque lines 4, Infraorbital rim radiopaque line 5, Wall of infraorbital canal radiopaque line 6. Pterygomaxillary fissure radiolucent space 7. Pterygoid spine of sphenoid radiopaque line 8. Zygomatic arch radiopaque mass 9. Posterior wall of maxillary sinus radiopaque line 10. Posterior wall of the zygomatic process of the maxilla radiopaque line 11. Ear lobe radiopaque me « Answers 1-15 below “Courtesy Dr. Stuart C. White, UCLA, School of Dentistry." 12. Inferior border of the mandibular canal radiopaque line 13. Anterior nasal spine v-shaped radiopacity 14, Inferior border of the mandible radiopaque band 15. Hyoid bone radiopaque structure. Bony trabeculations radiopaque lines . Marrow space radiolucent area . Tooth #10 maxillary lateral incisor |. Lamina dura radiopaque line . Dentin radiopaque area . Periodontal ligament space radiolucent line Alveolar crest radiopaque structure Pulp canal radiolucent space Pulp chamber radiolucent space 10. Enamel radiopaque band 11. Raised film dot radiopaque circle 12. Dentino-enamel junction radiopaque line Y wo 5 w EN oe - ° ° Answers 1 - 12 below “Courtesy Dr, Stuart C, White, UCLA School of Dentistry.”1. Tip of nose radiopaque area 2. Hard palate / floor of nasal fossa radiopaque line 3. Orbit radiolucent area 4, Hard palate / floor of nasal fossa radiopaque line 5. Floor of maxillary sinus radiopaque line 6. Soft palate radiopaque structure 7. Air between soft palate & tongue radiolucent space 8. Dorsum of the tongue radiopaque line 9. Ghost image of opposite ramus indicated by radiopaque dots 10. Mental foramen ovoid radiolucency 11. Shadow of cervical spine diffuse opacity ¢ Answers 1- 13 below “Courtesy Dr. Stuart C. White, UCLA School of Dentistry. 12. Submandibular gland fossa broad radiolucent area 13. Articular eminence / articular tubercle radiopaque prominenceFilm processing converts the latent image to a visible image and preserves the image on film Latent image + the film emulsion absorbs x-rays during exposure and stores the energy within the silver halide crystals * the stored energy forms a pattern and creates an invisible image * the pattern of stored energy cannot be scen and is referred to as the latent image; it remains invisible until chemical processing Black areas of the visible image * appear radiolucent * created by deposits of black metallic silver + structures that permit the passage of the x-ray beam allow more x-rays to reach the film & energize more silver halide crystals + more energized silver halide erystals result in more deposits of black metallic silver White areas of the visible image + appear radiopaque + results from unexposed silver halide crystals + structures that resist the passage of the x-ray beam restrict or limit amount of x-rays that reach the film resulting in no energized silver halide crystals and no deposits of black metallic silver ¢ Both statements are true Film processing steps 1. development - developer solution removes halide portion of exposed silver halide crystals; this reduction of exposed crystals results in precipitated black metallic silver (68°F is the optimal temperature for developer) 2. rinsing - water removes developer & stops development process 3. fixing - fixer solution removes unexposed silver halide erystals & hardens the film 4, washing - water removes all excess chemicals from the emulsion 5. drying Developer composition + developing agent contains 2 chemicals hydroquinone & elon; hydroquinone slowly converts silver halide crystals & generates black tones ;clon-quickly converts silver halide crystals & generates gray tones + preservative is sodium sulfite; prevents oxidation of developer agents * accelerator is sodium carbonate; activates the developer & softens emulsion + restrainer is potassium bromide; prevents developer from developing unexposed crystalsFixer composition * fixing agent (aka clearing agent or hypo) is sodium thiosulfate or ammonium thiosulfate; removes or “ clears” all unexposed & underdeveloped silver halide crystals from emulsion; clears the film so that black image produced by the developer can be seen * preservative is sodium sulfite (same as in developer); prevents the deterioration of the fixing agent ¢ hardening agent is potassium alum; shrinks and hardens the gelatin in the emulsion. ¢ acidifier is acetic acid or sulfuric acid; neutralizes the alkaline developer and stops development process & provides necessary acidic environment for fixer Safelighting * lighting that is required in darkroom for safe illumination while processing x-ray film ¢ use Kodak GBX-2 safelight filter with a 15-watt bulb at least 4 feet away from working surface ° Fixing agent Film processing steps 1. development 2. rinsing 3. fixing 4. washing 5. drying Manual film processing + aka hand processing or tank processing + method used to process films where all steps are performed manually * equipment needed includes processing tanks with covers, thermometer, timer, film hangers and stirring rod * typical processing times include: 5 minutes in developer — 30 second rinse — 10 minutes in fixer > at least 10 minutes in wash «asa rule, fixing time is twice as long as developing time Automatic film processing * method used to process films using where all steps of film processing are automated * automatic processor is required. * total processing time is 4-6 minutesReplenisher solutions * a replenisher is a superconcentrated solution that is added to the existing. processing solutions to compensate for the loss of volume and strength that occurs due to oxidation * both the developer and fixer must be replenished daily to maintain adequate freshness + replenishment maintains adequate concentrations of chemicals which ensures uniform processing * failure to use replenishing solutions results in non-diagnostic radiographs Processing solutions * include developer, fixer & replenisher + must follow manufacturer directions for storage, mixing & replenishing * the developer and fixer must be changed at the same time every 3-4 weeks or more often with high volume of processing * tanks must be scrubbed and cleaned when changing solutions ° Replenish the developer Developer solution life is affected by * cleanliness of tank * size of films processed + number of films processed * temperature * evaporation Depleted developer * is weakened, lacks concentration * does not fully develop the latent image + produces a non-diagnostic image with reduced density and contrast * results in underdeveloped films. + underdeveloped films appear light Underdeveloped film + appears light * causes = time/inadequate time in developer - temperature/developer too cool - concentration/depleted developer * solutions - time/f time in developer - temperature/t temperature - concentration/replenish developer* Excessive time in developer ¢ Developer solution too hot * Concentrated developer Weaning Seana Example __| Appearance Problems Solutions ~ Inadequate development time _ |- Check development time = Developer solution too cool | - Check developer temperature | Underdeveloped | Light - Inaccurate timer or thermometer | - Replace faulty timer or thermometer film - Depleted or contaminated - Replenish developer with fresh developer solution solutions as needed - Excessive developing time - Cheek development time - Developer solution too hot - Check developer temperature Overdeveloped | Dark ~ Inaccurate timer or thermometer |- Replace faulty timer or thermometer film ~ Concentrated developer solution |- Replenish developer with fresh solutions as needed Reticulation of Sudden temperature change Check temperature of process emulsion Cracked between developer and water bath | solutions and water bath; avoid drastic temperature differences wsen: Dental Radiography Principles and Techniques. Fourth Edition, © 2012, with permission Reprinted from Iannucei, Joen M. and Laura from Elsevier Saunderseee eee or ° Static electricity Example Appearance Problems Solut Developer | Straight white Underdeveloped portion of | Check developer level before cut-off | border film due to low level of processing; add solution if developer needed Fixer Straight black Unfixed portion of film due to. | Check fixer level before pro- cut-off | border low level of fixer cessing; add solution if'needed Over- White or dark areas |Two films contacting each —_| Separate films so that no contact lapped —_| appear on film where | other during proce: takes place during processing films overlapped Air White spots Air trapped on the film Gently agitate film racks after bubbles surface after being placed in | placing in processing solutions the processing solutions Fingernail | Black crescent- Film emulsion damaged by | Gently handle films holding artifact [shaped marks the operator’s fingernail during | them on the edges only rough handling inger- Black fingerprint Film touched by fingers that are contaminated with fluoride Wash and dry hands thoroughly before processing artifact or developer Static [Thin, black, = Occurs when film packet is |- Open film packet slowly electricity. | branching lines opened quickly ~ Occurs when film pack is |- Touch a conductive object opened before the radiographer | before unwrapping films touches a conductive object Scratched | White lines Soft emulsion removed from | Use care when handling films film the film by a sharp abject and film racks Reprinted from lannucei, from Elsevier Saunders Joen M, ud Laura Jansen: Dental R :adiography Principles and Techniques. Fourth Edition, © 2012, with permissionExposure measurement * exposure refers to the measurement of ionization in air produced by x-rays * roentgen (R) is a way of measuring radiation exposure by determining the amount of ionization that occurs in air * R is limited to measurement in air * there is no SI unit for exposure that is equivalent to the R * exposure expressed in Coulombs per kilogram (C/kg) Dose measurement * dose refers to amount of energy absorbed bya tissue + rad is a unit of absorbed dose that is equal to the deposition of 100 ergs/g of tissue * the SI unit for rad is gray (Gy) Dose equivalent * rem is traditional unit of dose equivalent used to compare the biologic effects of different types of radiation on a tissue or organ + is the product of Gy x QF (quality factor) specific for the radiation type © for x-rays, QF=1 * the SI unit for rem is sievert (Sv) * Sievert (Sv) Unit Definition Conversion ditional System (older system) roentgen (R) IR= 2.58 X 104 Clkg radiation absorbed close | 1 rad = 100 e Trad = 0.01 Gy rad) roentgen ‘equivalent (in) | 1 rem = rads X QF ]1 rem = 0.01 Sv man (rem) SI system (newer system) Coulombs per kilogram eee 1 Cikg = 3880 R (Cikg) gray (Gy) 1Gy=0.01 J/kg ]1 Gy = 100 rads sievert (Sv) |1Sv=GyX QF |1Sv= 100 remsMuscle — Thyroid gland — Skin — Small lymphocyte ¢ all ionizing radiations are harmful to living tissues radiation produces chemical changes that results in biologic damage in living tissues not all cells respond to radiation in the same manner * cells respond to radiation based on mitotic activity, differentiation and cell metabolism » cells that are dividing and immature are most susceptible to radiation * radiosensitive cells are susceptible to radiation exposure * the most radiosensitive cell is the small lymphocyte ¢ radioresistant cells are resistant to radiation exposure « the most radioresistant cells are muscle and nerve * radiation effects are classified as somatic (occur in person irradiated) or genetic (passed on to future generation) high small lymphocyte | muscle tissue low high bone marrow nerve tissue low high reproductive cells |mature bone/cartilage | fairly low high intestinal mucosa_ | salivary gland fairly low fairly high | skin thyroid gland fairly low fairly high | lens of eye kidney fairly low fairly high oral mucosa liver fairly lowMechanisms of radiation injury * ionization & free radical formation are responsible for cell injury + free radical formation is the primary mechanism responsible for damage Theories of radiation injury + direct theory - cell damage results when radiation directly hits critical areas within the cell & direct alteration of the cell occurs + indirect theory - suggests that x-ray photons are absorbed within the cell and cause the formation free radicals & toxins which result in cell damage Dose-response curve +a dose-response curve is used to demonstrate the response of tissues to the dose of radiation received + a threshold dose does not exist & response of tissues is directly proportional to the dose + injury from radiation depends on total dose, dose rate, amount of tissue affected, cell sensitivity and age Stochastic & nonstochastie effects + stochastic effects occur as a direct function of dose (cancer, genetic mutations) + nonstochastic effects have a threshold and increase in severity with increased dose (hair loss, decreased fertility) ¢ Latent period Radiation injury sequence + latent period - period of time between exposure and onset of symptoms + period of injury - follows latent period and may result in cell death, change in cell function or abnormal mitosis, + period of recovery - follows injury; depending on a number of factors, cells can repair the damage caused by radiation Radiation effects + short term effects occur when large amounts are absorbed in a short period of time (not applicable to dentistry) + long term effects occur when small amounts are absorbed over a long period of time; linked to induction of cancer, birth & genetic effects + cumulative effects occur; radiation damage is additive and unrepaired damage accumulates in the tissues and leads to health problems (cancer, cataract formation, birth defects) Radiation effects on cells + the cell nucleus is more sensitive to radiation than cytoplasm; DNA is affected * cell division is disrupted which may lead to disrupted cell function or cell death + radiation causes cell death by damaging chromosomesDefinition * most serious po: oral cancer patient + condition of non-vital bone in a site of radiotherapy; bone dies as a complication of radiotherapy * is not an infection le complication facing the Cause + radiation therapy destroys cancerous cells but also destroys normal cells, damaging small arteries and reducing circulation + insufficient blood supply to the irradiated area decreases the ability to heal, and any subsequent infections to the jaw can pose a huge risk to the patient + patients receiving high doses of radiation (©40 Gy) to the jaw area are at risk Histologic features- 3 H’s * hypocellular bone * hypovascular tissue * hypoxic tissue & bone Prevention + extract all hopeless teeth 3 weeks prior to radiotherapy + if extracting after radiotherapy, use of systemic antibiotics is warranted + hyperbaric oxygen treatments before and afier radiotherapy may be helpful ° Osteoradionecrosis Clinical features + may involve the maxilla or mandible + more common in the mandible + most frequently occurs when an insult to the bone is sustained in the irradiated area, such as related subsequent surgery, biopsy, tooth extractions or denture irritations + may also be precipitated by periodontal disease or occur spontaneously * symptoms may include pain, swelling, reduced mobility, drainage, exposed bone in the involved area and destruction of bone * symptoms may occur months or years after the radiotherapy Management + difficult to manage + prevention is key + debridement of infected bone may be required + advanced cases may require radical surgery + patients must be followed closely by physicia and dentist regularlyRadiation therapy of oral cavity + used to treat radiosensitive oral malignant tumors, usually squamous cell carcinoma + indicated when the tumor is radiosensitive, advanced, or, cannot be treated surgically because it is deeply invasive + fractionation - totai radiation dose is delivered in smaller multiple doses ~ provides greater tumor destruction than a single large dose - allows for increased cellular repair of normal tissues - increases mean oxygen tension resulting in tumor cells that are more radiosensitive Radiation effects on the teeth + irradiation of developing teeth severely retards growth * adult teeth are radioresistant Radiation effects on bone * irradiation of bone results in damage to the fine vasculature + normal marrow may be replaced with fatty marrow or fibrous connective tissue + necrosis may occur and exhibits loss of osteoblastic and osteoclastic activity ° Both statements are true Radiation effects on oral tissues * occurs by end of 2"'week of therapy + mucositis results; appears as areas of rednes inflammation + as therapy continues, the oral tissues break down resulting in formation of white pseudomembranes and + oral condition worsens with continued therapy and candidiasis often occurs + following therapy, oral tissues heal within approximately 2 months Radiation effects on taste buds + taste buds are radiosensitive + radiation therapy damages taste buds +a loss of taste may first occur during the 2™ or 3"! week of radiation therapy Radiation effects on salivary glands + radiation therapy damages salivary gland tissues + there is a marked & progressive loss of salivary secretion; extent of reduced flow is dependent on dose + causes decreas capacity + causes increased viscosity + dry mouth (xerostomia) results & makes the patient susceptible to radiation earies -a rampant form of caries + xerostomia causes tenderness of oral tissues and difficulty in swallowing es in sal iva, pH & bufferingX-ray beam quality & kVp * quality refers to the average energy or penetrating power of the x-ray beam and is controlled by the kilovoltage peak (kVp) * kVp controls the speed & energy of the electrons and determines the penetrating power of the beam * kVp range for dental radiography is 65-100 kVp X. y beam quantity & mA. * quantity refers to the number of x-rays produced and is controlled by the milliamperage (mA) *mA controls the amperage of the filament current and the amount of electrons that pass through the filament + mA controls the temperature of the filament * as the mA increases, more electrons pass through the filament and more x-rays are produced + mA range for dental radiography is 7-15 mA to remember, think alphabetical order ... KkVp= quality (k & 1) mA = quantity (m&n) ° Milliamperage (mA) X-ray beam intensity + intensity is the total energy contained in the x-ray beam at a specific area at a given time * intensity is affected by kVp, mA, exposure time and distanee rity Pups enya 4 [kVp [darker J fkVp [lighter T [mA darker L [ma righter T [time — [darker J time lighter to INCREASE film density & make it darker, INCREASE: omA *kVp * time to DECREASE film density & make it lighter, DECREASE: *mA *kVp timeInverse Square Law * defined as: the intensity of the radiation is inversely proportional to the square of the distance from the source of radiation * inversely proportional means that as one variable increases, the other decreases + when the target-receptor distance is increased, the intensity is decreased new intensity original distance? original intensity new distance” farther = less close: SiH ome. Reprinted from lannucei, Joen M. and Howerton, Laura Jansen: Dental Radiography Principles and Techniques. Fourth edition © 2012, with permission rom Elsevier Saunders. °1/4 as intense Example: Ifthe PID length is changed from 8” to 16”, how does this increase in target-receptor distance affect the intensity of the beam? plug numbers into the mathematical formula: T/1@ = x/8 solve for x Vi 16°/ 8 256 / 64 4/1 x V/4 « doubling the distance results in a beam that is 4 as intense * the x-ray beam that exits an 8” PID is more intense than one the exits a 16" PID (see diagram) answer The distance traveled by the x-ray beam affects the intensity; distances to be considered include the following: + target-surface distance is the distance from the source of radiation to the surface of the patient’s skin * target-object distance is the distance from the source of radiation to the tooth * target-receptor distance is the distance from the source of radiation to the receptor (film or sensor)Increased kVp + produces x-rays with increased energy (speed) and shorter wavelength + increases the penetrating power of the x-ray beam + is needed for larger patients with large bones and significant amounts of soft tissue * results in increased density (makes image darker) * results in reduced or low contrast which is Jong-scale contrast Contrast * refers to how sharply dark and light areas ate separated or differentiated on an image * the difference in degrees of blackness between adjacent areas on a dental radiograph Contrast & kVp + adjustment of kVp affects contrast + with low kVp (65-70), a high contrast image results + with high kVp (90), a low contrast image results ¢A more penetrating beam «A reduced subject contrast ¢ Long scale contrast Long-scale contrast + LONG scal LOW contras OTS of gray +a low contrast image exhibits many shades ofg + a low contrast image does not exhibit black & white T LONG (High)| kVp | lots of gray Low 4 SHORT black & white | HIGH (Low) | kVp Patient size & kVp + large patients need increased kVp; if not increased — image appears LIGHT + smalll patients need decreased kVp; if not decreased — image appears DARKDensity description +a visual characteristic of a radiographic image * overall blackness or darkness of an image + when a dental image viewed, the relative transparency of arcas depends on the distribution of black silver particles * density is the degree of silver blackening * an image of correct density allows one to view the black areas (air space images), white areas (enamel, dentin, bone) and gray areas (soft tissue) Factors that influence density + exposure factors -kVp -mA - exposure time + thickness of subject adjustments in kVp, mA and exposure time can be made to compensate for size variations * an increase in any exposure factor , separately or combined, increases the density of an image ¢ Use of a 2-film packet ‘Adjustment Density Film end T kVp 7 darker L kVp He lighter T mA J darker Lo mA L lighter T time T darker L time L lighter 4 thickness L lighter 4 thickness =P darker Size of patient * thickness of subject also affects density; with a large patient (thick bones, excess soft tissue), fewer x-rays reach the receptor and as a result, the image appears lighter + with inereased thickness, a decreased density results + with decreased thickness, an increased density results Note: The use of a 2-film packet does not affect the density of the imageX-ray tube * heart of the x-ray generating system * critical to the production of x-rays «glass vacuum tube from which all the air has been removed * component parts include leaded glass housing, negative cathode & positive anode Leaded-glass housing + leaded-glass vacuum tube that prevents x-rays from escaping in all directions +a “window” permits the x-ray beam to exit the tube ee Reprinted from lannucei, Joen M. and Howerton, Laura Jansen: Dental Radiography Principles and Techniques. Fourth edition © 2012 with permission from Elsevier-Saun- ders, ¢ Negative cathode to remember, think CATNAP cathode is negative Cathode/negative electrode * supplies electrons necessary to generate x-rays * consists of a tungsten wire filament in a molybdenum cup-shaped holder * tungsten filament (coiled tungsten wire) produces electrons when heated + molybdenum cup focuses the electrons into a narrow beam and directs the beam across the tube toward the tungsten target of the anode Anode/positive electrode + converts electrons into x-ray photons * consists of a wafer-thin tungsten plate embedded in a solid copper rod + tungsten target serves as a focal spot and converts bombarding electrons into x-ray photons * copper stem functions to dissipate the heat away from the tungsten targetProduction of x-rays tungsten filament is heated and electrons are produced + molybdenum cup focuses the electrons into a narrow beam and directs the beam towards the tungsten target in the anode + x-rays are generated when the beam is suddenly stopped by the tungsten target * the energy of motion is converted to x-ray energy (1%) and heat (99%) + insulating oil that surrounds the x: absorbs the heat * x-rays that are produced are emitted in all directions; leaded-glass housing of tube prevents the x-rays from escaping * small number of x-rays exit the x-ray tube through the unleaded glass window area * x-rays travel through unleaded glass window, through the tubehead seal and then the aluminium disks ¢ the lead collimator restricts the size of the beam and the x-ray beam travels down the lead lined position -indicating device (P/D) and exits at the opening ay tube Reprinted from Haring, Joen lannucei and Laura Jansen: Dental Radioge® phy; Principles and Techniques: Third Edition. © 2000, with pemnission fron Elsevier ¢ Molybdenum cup Component functions * tungsten filament of cathode produces electrons when heated * molybdenum cup of cathode focuses the electrons into a narrow beam and directs the beam towards the tungsten target in the anode * tungsten target in anode stops the electrons and converts the energy into x-rays & heat * copper stem serves to dissipate the heat that is created with the production of x-rays Neray tube - Stepdown Atansformer Tubehesd A juminui aan disks collimator window of sera tubeProperties of x-rays © appearance invisible and cannot be detected by any of the senses * mass have no mass or weight ° charge have no charge ° speed travel at the speed of light ¢ wavelength travel in waves and have short wave- lengths with a high frequency ¢ path of travel travel in straight lines and can be deflected, or scattered ¢ focusing capability cannot be focused to a point and always diverge from a point + No weight ¢ Have no charge ¢ Are invisible ¢ Are absorbed by matter ¢ penetrating power can penetrate liquids, solids, and gases: the composition of the substance deter- mines whether x-rays penetrate or pass through, or are absorbed ¢ absorption absorbed by matter; the absorption depends on the atomic structure of matter and the wavelength of the x-ray * ionization capability can interact with materials they penetrate and cause ionization ¢ fluorescence capability can cause certain substances to fluoresce or emit radiation in longer wavelengths (¢.g., visible light and ultraviolet light) ¢ effect on film can produce an image on photographic film * effect on living tissues cause biologic changes in living cells.+ electricity is the energy used to make x-rays; electrical energy consists of a flow of electrons through a conductor; this flow is known as the electrical current * electrical current is termed direct current (DC) when the electrons flow in one direction through the conductor + alternating current (AC) describes an electrical current in which the electrons flow in two, opposite directions * rectification is the conversion of AC to DC * dental x-ray tube acts as a self-rectifier in that it changes AC into DC while producing x-rays; ensures that current is always flowing in the same direction from cathode to anode * amperage is the measurement of the number of electrons moving through a conductor; current is measured in amperes (A) or milliamperes (mA) * voltage is the measurement of electrical force that causes electrons to move from a negative pole to a positive one; measured in volts (V) or kilovolts (kV) ¢ circuit is a path of electrical current; two electrical circuits are used to produce x-rays: a low-voltage/filament circuit and a high- voltage cireuit * Both statements are false * low voltage/filament circuit uses 3 to 5 volts, regulates the flow of electrical current to the filament; controlled by mA settings + high-voltage circuit uses 65,000 to 100,000 volts, provides the high voltage required to accelerate; controlled by kVp settings * transformer is a device that is used to either increase or decrease the voltage in an electrical circuit ; it alters the voltage of the incoming current and then routes the electrical energy to the x-ray tube; three types of transformers are used to adjust the electrical circuits (see below) + step-down transformer is used to decrease the voltage from the incoming 110- or 220- ine voltage to the 3 to 5 volts used by the filament circuit + high-voltage cireuit uses both a step-up transformer and autotransformer + step-up transformer is used to inerease the voltage from the incoming 110- or 220-line voltage to the 65,000 to 100,000 volts used by the high-voltage circuit + autotransformer serves as a voltage compensator that corrects for minor fluctuations in the current‘Types of x-rays * not all x-rays produced in the x-ray tube are the same; x-rays dilfer in energy and wave- length * energy and wavelength varies based on how the electrons interact with the tungsten in the anode + kinetic energy of electrons is converted to x-ray photons via general (braking or Bremsstrahlung) radiation or characteristic radiation * general/braking radiation is produced when speeding electrons slow down due to interactions with the nuclei of the tungsten target atoms - braking refers to the sudden stopping or slowing of high-speed electrons when they hit or come close to the tungsten target - 70% of the x-ray energy produced is general radiation * characteristic radiation is produced when ahigh-speed electron dislodges an inner-shell electron from the tungsten atom and causes ionization - the remaining electrons rearrange to fill the vacancy resulting in a loss of energy & production of x-ray photon - only a small % of x-rays produced; occurs only at>70 kVp ¢ Characteristic radiation Definitions * primary radiation is the penetrating » beam that is produced at the target of the anode and exits the tubehead; aka primary or useful beam * secondary radiation is x-radiation that is created when the primary beam interacts with matter; is less penetrating than primary radiation * scatter radiation, a form of secondary radiation, is the result of an x-ray deflected from its path by the interaction with matter; deflected in all directions by the patient's tissues; detrimental to tissues + in Compton scatter, ionization takes place; an x-ray photon collides with an n outer-shell electron and gives up part of its energy to eject the electron from its orbit ; x-ray photon loses energy and continues in a different direction (scatters) at a lower energy level; accounts for 62% of the scatter that occurs * coherent or unmodified scatter occurs when a low-energy x-ray photon interacts with an outer-shell electron; no change in the atom occurs; x-ray photon of scattered radiation is produced; x-ray photon is scattered in a different direction from that of the incident photon; no loss of energy and no ionization occur; accounts for 8% of the interactions -ray¢ inherent filtration takes place when the primary beam passes through the glass window of the x-ray tube, the insulating oil, and the tubehead seal * inherent filtration of the dental x-ray machine is approximately 0.5 to 1.0 millimeter (mm) of aluminum ¢ inherent filtration alone does not meet the standards regulated by state and federal laws; added filtration is required Laura Jansen: Den tal Radiography Techniques, Fourth edition © 2012 ¢ Lead lined PID added filtration refers to the placement of aluminum discs in the path of the x-ray beam between the collimator and the tubehead seal ¢ aluminum dises can be added to the tubehead in 0.5 mm increments * purpose of the aluminum discs is to filter out the longer-wavelength, low-energy x-rays from the x-ray beam * low-energy, longer wavelength x-rays are harmful to the patient and are not useful in diagnostic radiography * filtration of the x-ray beam results in a higher energy & more penetrating useful beam * state and federal laws regulate the required thickness of total filtration = inherent filtration + added filtration ¢ dental x-ray machines operating at < 70 kVp require a minimum total of 1.5 mm aluminum filtration * dental x-ray machines operating at > 70 kVp require a minimum total of 2.5 mm aluminum filtrationOperator protection guidelines © must use proper protection during exposure to avoid the primary beam, scatter radiation etc. + must avoid the primary beam * distance, position and shielding are all important for protection Distance recommendations * must stand at least 6° away from the tube- head + if distance is not possible, a protective barrier must be used — Xray whch Rodionrontor ae Reprinted from lannucei, Joen Mand Howerton, Laura Janse: Dental Radiography Principles and Techniques. Fourth edition © 2012 with permission Irom Elsevier Saunders. ¢ Stand behind a barrier Position recommendations + must stand perpendicular to the primary beam, or, at 4 90-135 degree angle to the beam + never hold a film in place for a patient during exposure + never hold the PID during exposure Shielding recommendations * whenever possible, stand behind a protective barrier, such as a wall Maximum permissible dose (MPD) * MPD is the dose of radiation the body can endure with little or no injury + for non-occupationally exposed person limit is 0.001 Sv/yea + for occupationally exposed person limit is 0.05 Sw/year + for occupationally exposed pregnant person — limit is 0.001 Sw/year ALARA concept * As Low As Reasonably Achievable concept states that all exposure to radiation must be kept to a minimum + applies to patients & operatorsPatient protection before exposure * proper prescribing of dental radiographs ¢ use of proper equipment including filtration, collimation and PID ¢ the rectangular PID (instead of round) is most effective in reducing patient exposure ¢ use of a long PID is more effective than use of a short PID Patient protection during exposure ¢ use of thyroid collar for intraoral films and lead apron for all films + use of digital imaging or use fastest film available (F-speed) use of beam alignment devices * use of correct exposure factors (kVp, mA & exposure time) use of proper technique ° Both statements are true Patient protection after exposure + proper sensor or film handling * proper image retrieval or film processing Guidelines for prescribing of dental radiographs * dentist is responsible for ordering images & uses professional judgment to make decisions concerning the number, type and frequency of dental radiographs ¢ radiographic exam should never include a predetermined number of films ¢ radiographs should never be taken at predetermined time intervals ¢ radiographs should be ordered based on the individual needs of the patient ¢ guidelines for prescribing dental radiographs have been determined by the ADA and FDACollimation used to restrict the size and shape of the x-ray beam & to reduce patient exposure ° a collimator is a lead plate with hole in the middle, is fitted over the opening of the machine housing where the beam exits * collimator may have a round or rectangular opening * rectangular collimator restricts the size of the beam to slightly larger than a size 2 film and significantly restricts patient exposure ¢ circular collimator produces a cone shaped beam & restricts the size of the beam to 2.75” in diameter ¢ when using a circular collimator, federal regulations re quire that the beam be restricted to 2.75” as it exits the PID and reaches the skin of the patient ° Collimation Position indicating device (PID) ¢ the PID or cone is an extension of the x-ray tubehead used to direct the beam * types of PID include conical, round and rectangular * a conical PID is a closed plastic cone that produces scatter radiation:no longer used in dentistry ¢a round PID is a tubular open ended lead- lined extension; no PID scatter is produced * a rectangular PID is a rectangular open ended lead-lined extension; is most effective in reducing patient exposure; no PID scatter is produced * both round and rectangular PIDs are available in two lengths: short (8”) and long (16”) + the long PID is preferred because less divergence of the x-ray beam occurs° The film was bent during placement A reversed film is light & exhibits a herringbone pattern. A double exposure appears dark & exhibits a double image. ‘A bent film appears stretched & distorted With movement of the patient or PID, a blurred image results. Images reprinted from lannucei, Joen M. and Howerton, Laura Jansen; Dental Radiography Principles ané Techniques, Fourth edition © 2012 with permission fiom Elsevier-Saunders,Magnification * enlargement of an image that results from the divergent paths of x-ray beam * some degree of magnification is present in every image due to divergent paths * influenced by target-receptor distance and object-receptor distance + target-receptor lance (or source to receptor distance) is the distance between the source of x-rays & image receptor * PID determines target-receptor distance * shorter PID results in more magnification; longer PID results in less magnification * object-receptor distance is the distance between the tooth & image receptor * if there is decreased distance between the tooth & receptor, less magnification occurs + if there is increased distance between the tooth & receptor, more magnification occurs * Focal spot size Focal spot size * tungsten target in anode is focal spot * size ranges from 0.6 -1.0 mm? and is determined by the manufacturer (cannot be controlled by operator) * the size of focal spot influences the image sharpness * the smaller the focal spot, the sharper the image In dental radiography, the most accurate image: use the smallest focal spot size use the LONGEST target-receptor distance * use the SHORTEST object-receptor distance ¢ direct the central ray of the x-ray beam perpendicular to the receptor and tooth * keep the receptor parallel to the tooth being imagedVertical angulation + refers to the positioning of the PID in a vertical, or up-and-down plane * correct vertical angulation results in an image that is the same length as the tooth + incorrect vertical angulation results in ELONGATION or FORESHORTENING + an elongated image appears long & results from too flat vertical angulation +a foreshortened image appears short & results from too steep vertical angulation +0 degree vertical angulation = PID parallel with floor * positive vertical angulation = PID pointing DOWN to floor/PID above occlusal plane + negative vertical angulation = PID point- ing UP to ceiling/PID below occlusal plane Horizontal angulation + refers to the positioning of the PID in a horizontal or side-to-side plane + when the central ray is directed through the interproximal contacts of the teeth, correct horizontal angulation results and open contacts on seen the dental image * incorrect horizontal angulation results in overlapped contacts (contacts are superimposed over each other) ¢ Vertical angulation is exces: ELONGATION results when the vertical angula- tion is TOO FLAT; teeth look long & stretched FORESHORTENING results when the vertical angulation is TOO STEEP; teeth look short Both photos reprinted from Haring, Joen lannucei and Laura Jansen; Dental Radiography: Principles and Techniques: Third Edition. © 2000, with permission from ElseviBuccal object rule * aka tube shift technique used to determine an object’s spatial position/buccal-lingual relationship within the jaws * two images are obtained, each exposed with a different angulation * used to compare the object’s position with respect to a reference point (e.g., root, of a tooth) Example * if the PID is moved mesially and the object in the second image appears to have moved in the same direction, the object lies to the lingual ¢ if the PID is moved mesially and the object in the second image appears to have moved in the opposite direction, the object lies to the buccal «use the acronym SLOB to remember the buccal object rule ¢ Lingual to the first molar I image #1, note the location of the . object in reference to the mesial root of the first molar. In image #2, the KAY ea PID was moved CX mesially; the object in reference to the mesial root of the first molar has also moved mesially. S-L-O-B_ RULE Same = LingualOverlapped contacts + if the central ray is not directed through the interproximal contacts of the teeth, the horizontal angulation is incorrect + incorrect horizontal angulation results in overlapped contacts seen on the image ‘Cone-cut + if the beam is not centered over the receptor, a clear unexposed area or cone-cut is seen on the image # the PID or “cone” is said to “cut” the image * a cone-cut may occur with the use of a rectangular or round PID * a conecut may occur with or without the use of a beam alignment device poor receptor placement + a periapical image shows the entire tooth and root, including the apical area and must be placed to cover those areas * incorrect periapical receptor placement may result in absence of apical structures or a tipped or tilted occlusal plane + a bite-wing image shows the crowns of both the maxillary and mandibular teeth, the interproximal areas and crestal bone * incorrect bite-wing receptor placement may result in absence of teeth or teeth surfaces on an image, tipped occlusal plane ¢ Incorrect horizontal angulation Incorrect hori- zontal angulation results in over- lapped contacts. Ifthe beam is not centered over the receptor, a eone-cut results & a clear unexposed area is seen. Improper place- ment (if entire root is not cov- ered) will result in no apices appear ing on the image. Images reprinted from Haring, Joen fannucei and Laura Jansen: Dental Radiography: Principles and Techniques: Third Edition. © 2000, with permission from Elsevier,