Dr.

EBTISAM
ELHAMALAWY
MFDS RSC (Edh.), MJDF RSC (Lon.), BDS ( Misr
International University)
??
X-ray generation
X-ray production
Cathode {negative} filament tungesten
Anode positive{ target that is placed in a cupper block}
A high KV accelerate the movement of the electrons
EFFECT
When an x-ray photon hits an atom:

1. Classical Scattering :the x-ray photon changes direction

2. Compton Effect : the atom hit gets ionised, and the x-ray photon changes
direction
3. Photoelectric effect: the atom hit gets ionised and gives off heat and
light. The x-ray photon is absorbed.
Focal spot
The focal spot actual area is about 1mm by 5mm. Because of the
angulation of the anode, the effective focal spot is 1mm x 1mm.
Absorbed Dose is just a measure of the amount of radiation received
Effective Dose is a reflection of the amount of biological damage done by
the x-rays.

Which do you think is more sensitive to x-ray damage: bone marrow or skin?
LEGISLAITON
The Ionising Radiations Regulations 1999 (IRR99)(5)
{ protection of workers and the public, but also address the equipment aspects of
patient protection}

The Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R2000)(6)

relate to patient protection
The Ionising Radiations Regulations
1999
LOCAL RULES
CONTENGIENCY PLAN
WORKING INSTRUCTIONS
Dose investigation levels
The Ionising Radiation (Medical
Exposure) Regulations 2000
Patient identification
Staff appointment
Accidental or unintended dose
Critical examination
Acceptance test
Routine test
LEGAL PERSON
person or body corporate that takes legal responsibility for implementing
both sets of regulations. Consequently it is recommended that the Local
Rules specify the person or body corporate with that legal responsibility
in respect of every dental x-ray set and every item of auxiliary equipment
that is associated
with radiation safety.
Radiation Protection Supervisor

Radiation Protection Supervisors (RPSs) whose function is to help

ensuring compliance with IRR99 and in particular to supervise the
arrangements set out in the Local Rule
dental practitioner or another Professional Complementary to Dentistry
(PCD)
REFERRER
In IR(ME)R2000, a referrer means a registered medical practitioner, dental
practitioner or
other health professional who is entitled in accordance with the Legal
Person’s procedures
to refer individuals for medical exposure to an IRMER practitioner
In the dental surgery the referrer will normally be a dental practitioner
Practitioner (IRMER practitioner)

In IR(ME)R2000, a ‘practitioner’ means a registered medical practitioner,

dental practitioner or other health professional who is entitled in accordance
with the Legal Person’s procedures to
take responsibility for an individual medical exposure.
OPERATOR
In IR(ME)R2000 an operator is any person who is entitled, in accordance with the
Legal Person’s procedures, to carry out all or part of the practical aspects
associated

with a radiographic examination. Practical aspects include:

(a) patient identification;
(b) positioning the film, the patient and the x-ray tube head;
(c) setting the exposure parameters;
(d) pressing the exposure button to initiate the exposure;
(e) processing films;
(f) clinical evaluation of radiographs;
(g) exposing test objects as part of the QA programme.
RPA
Implementation of the requirements for designated areas*
or modified dental x-ray equipment, with particular respect to
any engineering
controls, design features, safety features and warning devices
provided to restrict exposure to ionising radiation
advice on the suitability, use and checking of any instrument
provided to monitor
levels of ionising radiation* (it is recognised that such
instruments are currently of little practical value for staff in a
dental practice)
The drawing up of contingency plans.
The assessment and recording of radiation doses received by
staff, where this is applicable
Dose limitation for workers and the
public
(excluding patients)
IRR99 can be interpreted as follows:
Class of person Annual limit of effective dose in millisievert (mSv)
Any employee aged 18 years or above 20 mSv
Trainees aged under 18 years 6 mSv
Other persons (including any person below the age of 16 years, and all
members of the public) 1 mSv
 Where applicable, the following annual dose constraints are recommended
for dental radiography:
1 mSv for employees directly involved with the radiography (operators);
0.3 mSv for employees not directly involved with the radiography and for
members of the public.
CONCEPTS VV IMP
Justification
Before an exposure can take place, it must be justified by an IRMER
practitioner and

(a) the availability and findings of previous radiographs;

(b) the specific objectives of the exposure in relation to the history and
examination of the patient;
(c) the total potential diagnostic benefit to the individual;
(d) the radiation risk associated with the radiographic examination;
(e) the efficacy, benefits and risk of available alternative techniques having
the same
Optimisation

For every x-ray exposure, the operators must ensure that doses arising from
the exposure are
kept as low as reasonably practicable and consistent with the intended
diagnostic purpose.
This is known as ‘Optimisation’ of protection.
 Malfunction or Defect in equipment
A detailed investigation must then be carried out and should be in
conjunction withan RPA. The purpose of this investigation is to:
(a) establish what happened;
(b) identify the failure;
(c) decide on remedial action to minimise the chance of a similar failure;
(d) estimate the doses involved.
The report of this investigation must be retained, by the Legal Person, for at
least 50 years.
CONTROLLED AREA
the controlled area will only exist whilst x-rays are being generated. In
deciding on the extent of the controlled area it will normally be satisfactory
if the controlled area is chosen to be:
1. within the primary x-ray beam until it has been sufficiently attenuated
by distance or shielding, and
2- within 1.5 m of the x-ray tube and the patient, in any other direction
 DOSE
Intraoral (bitewing, peri-apical) Effective dose: 2-10 micro Sieverts
LIMITATION
For intra-oral radiography, the fastest available films
the focus-to-film distance should be greater than 1m and ideally within the
range 1.5 to 1.8 m [ CEPHALO.}
Protective aprons, having a lead equivalence of not less than 0.25 mm,
should be provided for any adult who provides assistance by supporting a
patient
The total filtration of the beam (made up of the inherent filtration and any
added filtration) should be equivalent to not less than the following:

(a) 1.5 mm aluminium for x-ray tube voltages up to and including 70 kV

(b) 2.5 mm aluminium, of which 1.5 mm should be permanent, for x-ray

tube voltages above 70 kV
LIMITATION
Medium frequency dental x-ray generators with an
effectively constant potential (DC) output are preferred
to one and two pulse (AC) generators.

For intra-oral radiography the nominal tube potential

should not be lower than 50 kV. New equipment should
operate within the range 60 to 70 kV.
For panoramic and cephalometric radiography with manual control, a range of
tube
potential settings should be available, preferably from 60 to 90 kV.
Rectangular collimators { 40 by 50 mm }
focus-to-skin distance (FSD) of 200 mm for equipment operating at 60 kV or
greater
QA PROGRAMME
a) image quality;
(b) patient dose and x-ray equipment;
(c) darkroom, films and processing;
(d) training;
(e) audits.
QUALITY ASSURANCE
refers to the systematic monitoring and evaluation of the all the various
aspects of radiography to ensure that standards of quality are being met.
There are three main phases of testing.

1. Critical examination of installation plans,

2. The Acceptance Test. When new equipment has been installed, and is
about to be used for the first time.
3. Routine Tests. These are undertaken at timetabled intervals.
CRITICAL EXAMINATION
Who does it?
A qualified expert in radiation physics or medical physics.

What needs to be considered?

The main points are:
• Location, including checking that radiation can not escape for example
through floor and walls in the x-ray room.
• The position of the operator when taking an x-ray.
• Warning signs and alarms.
• Access to the Exposure Control.
• Safety cut-outs, and the ability to electrically isolate the equipment in an
emergency.
Routine Tests

The frequency of routine tests varies in different countries. The timetable

should be at least every 3 years. For UK, Ireland, Canada, and others, 1
year
Subjective quality rating of radiographs

Rating Quality Basis

[1 ] Excellent
No errors of patient preparation, exposure, positioning, processing or film
handling

[2] Diagnostically acceptable

Some errors of patient preparation, exposure, positioning, processing or
film handling, but which do not detract from the diagnostic utility of the
radiograph
[3] Unacceptable
Errors of patient preparation, exposure, positioning, processing, or film
handling, which render the radiograph diagnostically unacceptable
Minimum targets for radiographic quality
Minimum targets for radiographic quality
Rating Percentage of radiographs taken Target Interim target

RATE TARGET INTREIM TARGET

1 Not less than 70% Not less than 50%
2 Not greater than 20% Not greater than 40%
3 Not greater than 10% Not greater than 10
UNACCEPTABLE x-ray
This record should be made whatever the cause of the problem, and include:
(a) the date
(b) nature of the deficiency;
(c) known or suspected cause of this deficiency;
(d) number of repeat radiographs
Biological effects
Somatic DETERMINISTIC EFFECT:
Damaging effect that will definitely occur to the body from a specific high
dose of radiation
{skin reddening / cataract formation} a threshold dose exist below which
there will be no effect
Somatic stocastic
Damaging effect the MAY occur when the body is exposed to ANY dose of
radiation
There is no threshold dose and every exposure caries the possibility of
inducing a stochastic effect
Modernbitewings/ periapicals:
1 in 20 000 000
Genetic stocastic effect
Radiation to the reproductive organs MAY result in damages of the DNA of
the sperm or egg cells. This may result in congenital anomalies of the
offspring of the irradiated person.
KVP
When kVp is low, subject contrast is comparatively high. When kVp is
high, subject contrast is comparatively low.
X-ray processing
The light bulb should be positioned 1.2 m from the working surface with
25W bulbs and filters suitable for the type of the film being used.
Coin test: quality control measure to ensure the effectiveness of a dark
room
Step wedge phantom radiograph to monitor the deterioration of the
chemicals
From the X-ray what is the age f the
patient?
ERUPTION DATES
Tooth Eruption root completion
U1 7-8 10
U2 8-9 11
U3 11-12 13-15
U4 10-11 12-13
U5 10-12 12-14
U6 6-7 9-10
U7 12-13 14-16
U8 17-21 18-25
L1 6-7 9-10
L2 7-8 10
L3 9-10 12-14
L4 10-12 12-13
L5 11-12 13-14
L6 6-7 9-10
L7 11-13 14-15
From the X-ray what is the age f the
patient?
From the X-ray what is the age f the
patient?
Fracture lines may be identified at the both inner and outer cortices
RADIOGRAPHY
INTRAORAL VIEWS
BITEWING
OCCLUSAL RADIOGRAPHS
EXTRAORAL PROJECTIONS
Panoramic
Oblique lateral
Posteroanterior (PA) jaw
Reverse Towne’s projection
Occipitomental
Submentovertex (SMV)
Lateral cephalometrics review
IOPA

Function and feature of briault probe:

• Detection of caries on mesial and distal
surfaces

• The angled working ends facilitate
adaptation to interproximal surfaces)
Impacted canines??
??

-impacted canine
children unable to tolerate periapical
ant cyst / tumours
INTRAORAL X-RAYS

Roots displaced in antrum/ tuberosity/ cyst /

tumours size extent in posterior
maxilla
??
????
BIMOLAR
Shows the oblique lateral views of the right and the left sides of the jaw on
the different halves of the same radiograph
IMPACTED CANINE
VERTICAL PARALLEX
{ OPG / Standard anterior occlusal }
HORIZONTAL PARALLEX
{ OPG / Periapical}

SLOB rule Same Lingual Opposite Buccal

EXTRAORAL X-RAY
STANDERED OCCIPITOMENTAL
1. Indications:
1. fractures: { Le Fort I, Le Fort II, Le Fort III}
2. Coronoid process fracture
3. Zygomatic complex
4. Nasoethmoidal complex
5. Orbital blow out fracture
???????
30 OCCIPITOMENTAL
Indications:
1. fractures: { Le Fort I, Le Fort II, Le Fort III}
2. Coronoid process fracture
Winters lines
The method used to asses the tooth depth in the alveolar bone
It employs three imaginary lines
Winter`s lines
Inferior alveolar nerve
OPG: molar lines in close proximity to the IAN when:
1.loss of the tramlines
2. Narrowing of the tramlines
3. Alternation in the direction of the ID canal at the apex
4. Radiolucent band across the apex
??
Radiographic appearance in fibrous
dysplasia:
Radio density: Initially radiolucent (but rarely seen clinically at this stage). Gradually
becomes opaque to produce the typical {{ gound glass,orange peel and finger print
appearances resulting from superimposition of many fine, poorly-calcified bone
trabeculae arranged in a disorganized fashion. Cotinuing to become more opaque
with age.
Axial CT
Sagittal CT
Coronal CT
Bilateral fracture of condyles is best seen on which radiograph?
Best option: Reverse Towne’s
Radiographic view, salivary calculi in submandibular duct
lateral oblique of jaw
AIR SINUSES
FRONTAL SINUS
0° occipitomental (0° OM)
PA skull
True lateral skull
MRI

SPHENOIDAL SINUS
0° occipitomental
True lateral skull
Submento-vertex (SMV)
CT
MRI
AIR SINUS
FOR ETHMOIDAL SINUS

0° occipitoment al

True lateral skull

Submento-vert ex

CT

MRI

FOR MAXILLARY SINUS

Periapical (paralleling or

bisected angle technique

Dental panoramic

tomograph

0° occipitoment al

Upper oblique occlusal

True lateral skull

Linear or spiral tomography

in coronal or sagittal plane

Computed tomography

(CT) or MRI
QUESTIONS
1. In a panoramic if the anterior teeth look narrow what could be the
possible cause for that?
Patient too far from the machine
Patient too close to the machine
Patient rotated posteriorly
2. Annual dose limit for classified non-worker ?
3. X-RAY FOR VIEWING THE FRONTAL SINUS?
What is the differential diagnosis?
What is your differential diagnosis?
What is your differential diagnosis?
??
Movement of film
patient during exposure (image completely blurred),
excessive bending of film packet image is partially blurred.
X-ray faults

splash of developer Black spots /Yellow Brown spots

splash of fixer before developing

XRAY FAULTS
Questions

What is he film film speed used for optimal dose limitation?

classes - D , E and F-speed .
What is the x-ray indicated for a { 4*} BPE ?
What is the x-ray of choice for a new patient?
Oral pathology
X-ray for a patient with flattened zygoma &
bilateral black eyes? Le fort 2

Occipito mental
-Submento vertex – cervical spine intact
-Posterio anterior only of C-spine is confirmed to be intact
ERIC WHITES
CH 7 IMAGE PROCESSING
COVER CH 8 VERY IMP ((RADIATION PROTECTION AND LEGISLATION))
CH 12 OCCLUSAL RADIOGRAPHY
CH 14 SKULL AND MAXILLOFACIAL RADIOGRAPHY
CH 17 PANORAMIC RADIOGRAPHY
CH 18 THE QUALITY OF RADIOGRAPHIC IMAGES AND QUALITY
ASSURANCE
CH 27 AND 28 ARE IMP THEY WILL ALSO HELP IMPROVE UR ORAL
PATHOLOGY