* Final Exam Material *

Radiographic examination guidlines

Gazalla AlGali
Eman AlQudah & Batool Khaled

28 7 2015
2
 All the slides are AAPD : American Academy
included in bold . of Pediatric Dentistry .

* Radiographic examination guidelines , Caries risk & caries assessment

tool (CAT)

There are someuseful , good and summarized guidelines from the AAPD that we
shouldnt forget or ignore them .legally ,these guidelines will protect us as dentists .

We have 2 systems of guidelines :

-UK guidelines .both of them are written in a very good way so
- USA guidelines .everybody can go through them .
These guidelines give you fixed ranges for assessment of patients , in order not
to have big differences between us as dentists, for example : assessment of caries
respond , whether low , moderate or high , there are some obvious marks that help
us to decide to which category the patient belongs and without having differences
in the assessment .
Here we will talk about guidelines for taking radiographs , when we should take
a radiograph for a patient .

Decision to make radiographs is based on a thorough evaluation and

examination of the patient; based on professional judgment.
- WhenExpectation that disease is present or
- When an undetected condition left untreated.

Selection criteria:when to take a radiograph ?

-Clinical sign or symptoms
- Two important considerations :
1.Thestage of dentition development : sometimes we need the radiographs to
study the stage of dentition or bone development .
2.The risk of dental caries .
These 2 aims will make you think about taking a radiograph for the patient , but
in casewhere your patient has trauma , hemorrhage , swelling ,pathosis , tooth
mobility , caries or any emergent situation , you have to take a radiograph for
him.
It is your judgment as a professional .
If you did feel that your patient need a radiograph , you have to take it ,
And if your patient didn't need a radiograph , that does not mean that you have a
problem or you had done a mistake !
If you didn't have a radiograph for your patient because he didn't need it , there will
be no blame on you .And the opposite is incorrect , if he didn't need a radiograph,
and you do it for him , it is your fault , You have to take it only when the patient
needs it .

* Clinical evidences to describe radiograph *

Disease like caries .
Pulpal pathosis .
Delayed or accelerated eruption or exfoliation of teeth.
Swelling .
Hemorrhage .
Pain .
Ulceration .
Evaluation of treatment .

* Development as criteria *
- Primary teeth: open contacts , unocooperativeno need
- Closed contacts ,cooprativept indicated .
- If uncooperative then radiographs should be deferred until behavior
improves.
- Early transitional dentition: (after 6s and/ or centrals).
- Radiograph is indicated: to evaluate interproximal caries, developmental
anomalies of teeth, and pathologic conditions of hard and soft tissues of
mouth and jaws, and associated structures.
Is every patient candidate for radiographs ?
- unfortunately , children and uncooperative are not , sometimes we take
radiographs when they are under sedation or GA "general anesthesia" .

*NOTE* We have sizes of films (0,1,2) for

children , and we choose the size according to
their ages and the opening of their faces O.o ! I
guess the dr meant the opening of their mouths .
Sometimes, there is no contact between teeth ( you can see everything) , and
there are no pockets , so we don't need a radiograph .
If the patient was uncooperative , we can defer the radiographs until the
behavior and mental status of the patient is developed .
After tooth #6eruption , this erupted tooth willmake pressure on the remaining
teeth , so that will make a very good contact , before the eruption , there are open
contacts . * Natural spaces between children's teeth
with no occlusal problems ( where I can see
If there was crowding between primary the whole tooth ) are 3 types :
1) high mid space .
teeth , I will suspect that the permanent 2) Anthropoid space .
teeth will be also crowded , so we need 3) generalized space .
radiographs in such cases .

- As soon as the tooth #6 erupts , the spaces will be closed .

From: American Dental Association, U.S. Food & Drug Administration. The
Selection of Patients For Dental Radiograph Examinations. Available on
www.ada.org
GUIDELINES FOR PRESCRIBING DENTAL RADIOGRAPHS:
The recommendations in this chart are subject to clinical judgment and
may not apply to every patient. They are to be used by
dentists only after reviewing the patients health history and completing a
clinical examination. Because every precaution should be
taken to minimize radiation exposure, protective thyroid collars and
aprons should be used whenever possible. This practice is strongly
recommended for children, women of childbearing age and pregnant
women .

* Digital x-ray machines are better than the conventional ones ;

because they give smaller amounts of radiation .
* These guidelines are very important ,keep it with you always during your practice

If there was open contact and you could see everything , don't do a radiograph ,
But at the first visit , if there were contacts between teeth and you suspected some
problems , you have to do a radiograph .
From ADA , " The selection of patients for dental radiograph Examination"
When radiographs are indicated ?

* Risk factor *
is defined as an environmental, behavioral, or biologic factor that directly
increases the probability that a disease will occur and, the absence or
removal of which reduces the possibility of disease. but once the disease
occurs, removal of a risk factor may not always result in the disease
process being halt ( because he already has the disease ) .
Caries assessment : it is an issue applied all over the world , if I can assess the
caries risk for my patient , I can treat him .

* Our job as dentists is'nt to treat the decayed teeth only , the patient will come back to
you again and again with the same problem , you have to treat the causes and reasons
which lead to caries , for example : If the patient takes high amounts of carbs and you
did'nt instruct him about diet and sugar intake , he will come back to you after 6 months
with new decayed teeth .
- So treat the cause "problem'' first , you have to discover the risk factors from the
beginning , then treat the existing disease and control it this is the strategy of the
successful dentist .
* Anything you do for your patient is your signature *
* Risk indicators are existing signs of the disease process *
How to know if the patient has a risk factor ?
Example : a patient has gingivitis ( inflammation ) due to plaque accumulation
and bacteria , he is not taking care of his oral hygiene , so he is under risk .
- Plaque and lack of oral hygiene are the risk factors which lead to Gingivitis or
caries ( decay) .
- If he maintained a good oral health and brushed his teeth , there will be no local
risk factors .
Another example : if a patient has white spot lesion ( active caries ) , this
indicates that he is prone to have cavity in his tooth if we neglected his case and
didn't treat it from the beginning .

* How to do risk assessment *

The first component in risk assessment involves identifying the childs
risk and protective factors.
Use information obtained in the interview, observation of parent-child
interaction, oral exam, and diagnostic procedures to identify the potential
risks to full attainment of good oral health outcomes.
identifies the protective factors that can reduce the negative impact of
risk factors and contribute to attaining those outcomes.

Normally , there should be balance between

demineralization and reminerlization to have
So we have to assess what are the risk stabilization and not to have demineralization
factors for our patient and also for "destruction" alone .
ourselves.

* The second part of risk assessment involves weighing the risk and
protective factors to determine an oral health supervision plan.(andto
prevent future problems ) .
*This is the best illustration so far .I guess the drsaid : it is from 1981 :(

If your patient has these types of bacteria , he is in risk of the decay , so you
have to prevent the existence of these bacteria in a high level .

If the child's immunity was law , he is prone to have problems , for example :
caries .
If the salivary flaw and composition wasn't normal ( low salivary flaw or very
viscous consistency ) , the patient is also prone to have decay and other problems ;
because saliva is our first line defense mechanism.

* Salivary flaw may be low due to calculus

which blocks the main salivary gland ducts .
So we have to investigate why salivary flaw is
not normal .
Tooth morphology if the teeth had deep pits and fissures , you have to
protect them with fissure sealants , even the primary teeth; to prevent decay in
future .

* If the primary teeth had

Family history the studies are different about it , problems , we suspect the
permanent teeth to have
some studies don't relate it directly to the patient's
problems too .
status ofdecay or whatever the problem is .

* For the Dr herselfand for the studies here in the Arabic world , it does relate , and
as she said : education and SEE ( socioeconomic status) are very important .
Any handicapped patient whether physically ,mentally or dentally handicapped ,
for example : diabetic , hypertensive or epileptic patient , is in a high risk of caries
development , As determined by AAPD .

* These are some questions by the AAPD , they help the dentists to determine
whether their patients are in risk or not .
* According to these answers , we can determine if the child is under risk or not .
* Overall assessment of the child's dental caries risk , whether high or law .
 Caries management protocol

-The table above shows an example of caries management protocol which clarifies when
to make interventions or restoration for a child

Example: for a child at low risk of having caries:

1diagnosis :he/she should be recalled every 12 months , and radiographs should be

taken every 12 to 24 months

2- intervention: a- fluoride application: the child should brush his teeth daily with
fluoridated tooth paste

b- diet consultation: the doctor said that the child's diet should be discussed and
instructions should be given to the mom but in the slides it's said that no interventions
should be done regarding diet

c-sealants should be applied

 3-restorations: no need because his/her oral health is under control

Unfortunately, in the final exam the Dr might ask us about each risk category !

-We can decide whether it's low, moderate or high risk according to clinical findings and
radiographs

-The previous diagram shows the Interactive Cariogram program for estimation of
individual caries risk
Estimation of the individual's cares risk is according to:
1- Circumstances around the child
2-susceptibility example: the presence of deep fissures
3-bacteria 4-diet 5-chance

caries assesment tool (CAT)

-The following table shows CAT "caries assesment tool" , which helps us assesting caries risk of the
patient.
-It's provided by the american academy of pediatric dentistry

Example:
-if a patient had no caries in the past 24 months and has an optimal topical and systematic fluoride
exposure , then the patient is at low risk

Notes:- all handicapped patients and orthodontically treated children are at high risk
-the abbreviation SCHIP in the tale stands for: State Children's Health Insurance Program , which is
a prevention program is used in the USA.
Caries management by caries risk assessment is beneficial because:

1) This process provides an individualized evaluation of a patients pathologic factors and

protective factors (like salivary flow) and assesses the patients risk for developing future disease.
2) Helps in managing the caries disease process using a medical model it means that if a patient
has a low salivary flow because of taking certain medications like tranquilizers send him to a
physician so the medication will be changed.
3) The risk assessment is used to develop an individualized evidence-based caries management
plan that would involve all aspects of nonsurgical therapeutics and dental surgical interventions.
4) Both risk assessment and patient-centered interventions are based on the concept of caries
balance minimizing demineralization factors and enhancing the protective factors-.
5) Risk assessments are important in determining the frequency of re-care visits and the treatment
protocols for follow-up visits.
6)Restorative decisions in terms of materialused composite, SS crowns etc- and cavity
preparation design are also influenced by the information gathered in the risk assessments.
7) The systematic use of risk assessment profiles is essential in uncovering risk factors that are
present before expression of the disease. This information can be useful in the prevention of
caries lesions in patients who have risk factors present but no disease expression and then
experience a lifestyle change that adds additional risk factors.
8) Risk assessments lead to better treatment outcomes for patients.

Dental caries
is a multifactorial, transmissible could be transmitted to the child by his/her siblings-, infectious
oral disease caused primarily by the complex interaction of cariogenic oral flora (biofilm) with
fermentable dietary carbohydrates on the tooth surface over time.

-you have to analyze the case and make sure that the child's behavior is not cariogenic to prevent
having dental caries
-the following figure shows the etiology of the decay; the factors which may affect the child teeth
and lead to dental caries
*take a look at the primary and the secondary modifying factors

Caries process:
In order to have dental caries, this process has to occure in a continous manner , any pause at any
stage means that no dental caries will occur
Example: -if bacteria's count was normal there will be no decay
-if there was no drop in the pH of the biofilm, caries won't occur
-caries won't occur if there was a balance between demineralization and remineralization
 -notice that calcium and
phosphorus have a role in
remineralization
-there are some antibacterials
which contribute greatly as
protective factors
-normal saliva is also a protective
factor from dental caries
-if a patient came to the clinic
with white spot lesion , you have
to apply fluoride and ask the
patient to improve the oral
hygiene as a result , there will be
remineralisation of these white
spots

The caries balance model is based on minimizing pathologic factors while maximizing protective
factors to attain a balance that favors no disease occurring, or health.
 Dentine

Note: -Affected dentine is capable of self-repair by reparative dentine which is produced by

odontoblasts close to the pulp
Modifying factors of dental caries
Saliva
-Saliva is natures first line of defense against dental caries.
-composition and flow of saliva have to be checked
-Saliva works by diluting acid produced in plaque biofilm, washing the acid away (swallowing),
buffering the produced acid , and assisting in remineralization
-Saliva helps in forming the pellicle
When attempting to improve salivary flow rates:
1-a consultation with the patients physician may be ordered.
2-Prescribing salivary stimulants can be very beneficial in patients with functioning salivary glands
but who have xerostomia because of medications.
3-Chewing sugar-free candies or mints several times a day and the use of xylitol chewing gum.
Social, economic and educational status
-Social status and economic status are not directly involved in the disease process ,but it was
proven that it is involved in our society , they are important because they affect the expression
and management of the caries disease they have implications on the necessary compliance and
behavioral changes that can decrease the risk for caries in patients.
These are predictive at the population level but are generally inaccurate at the individual level.

Diet
-Caries activity is most strongly stimulated by the frequency, rather than the quantity of sucrose
ingested.
-Evidence of new caries activity in adolescent and adult patients indicates the need for dietary
counseling.
--The goals of dietary counseling should be to identify the sources of sucrose and acidic foods in
the diet and to reduce the frequency of ingestion of both.
-For high-risk patients, a formal diet analysis should routinely be undertaken to identify cariogenic
foods and beverages that are frequently ingested.
-This analysis should be conducted over a 4-day period with 2 of the days surveyed being weekend
days.
Remember: disaccharides like sucrose are more cariogenic than monosaccharides , but both are
cariogenic , that's why there are non-cariogenic sugars like xylitol which can't be metabolized by
bacteria therefore there will be no acid production and no demineralization of teeth , we're going
to talk about this topic next year inshallah

Oral hygiene
-at every stage of the patient's life there are specific instructions regarding oral hygiene (infancy, 2
year old, five year old , teenage and adolescence)
-Biofilm-free tooth surfaces do not decay. Daily removal of plaque biofilm by dental flossing, tooth
brushing, and rinsing is the best patient-based measure for preventing caries and periodontal
disease.
-Mechanical plaque biofilm disorganization by brushing and flossing has the advantage of not
eliminating the normal oral flora.

Analysis
Dietary Analysis
Sugar intake in the form of fermentable carbohydrates and increased frequency of intake are
conditions that increase the risk of caries
1) by providing energy to the acidogenic and aciduric bacteria
2) influencing the pH of the biofilm to support cariogenic bacteria.

Bacterial Biofilm Analysis

-Use of supplemental tests to analyze the bacterial component of the biofilm can help determine
the patients risk level.
- These tests are also done for infants and moms to determine the caries risk in the future
-The measurement of adenosine tri phosphate (ATP) activity of the biofilm bacteria as a surrogate
measure of caries activity.
-control of the bacterial levels is done by atraumatic restorative technique which is done by
excavating caries on the decayed teeth in the first visit

Dental Clinical Analysis (Dental Examination)

The dental examination determines risk indicators more than risk factors, this is also important as
many of the indicators are directly related to the current caries activity, the indicators and current
caries activity drive the decision making process for the type of intervention that the clinician
would prescribe like making prevention program for the patient-.

Risk Considerations for Children Under 6 Years Old:-

Risk factors and indicators for this age group include:
1-Presence of active caries in the primary caregiver in the past year
2-Feeding on demand past 1 year of age
3-Bedtime bottle or sippy cup with anything other than water;
4-No supervised brushing; and severe enamel hypoplasia.

-dental education should start during pregnancy , it continues after delivery , and progresses as
the child grows ( when he gets 2 years old , then 5 , through teen age and then adolescence)
 Management of dental caries
A)Preventive treatment methodsit will be given to us in details next year inshallah in the
first semester-
Preventive treatment methods are designed to limit tooth demineralization caused by cariogenic
bacteria and preventing cavitated lesions. These methods include:-
(1) Limiting pathogen growth and altering metabolism,
(2) Increasing the resistance of the tooth surface to demineralization
(3) Increasing biofilm pH.

1-Fluoride exposure

-Fluoride in trace amounts increases the resistance of tooth structure to demineralization and is
particularly important for caries prevention
-The availability of fluoride to reduce caries risk is thought to be primarily achieved by fluoridated
community water systems but also may occur from fluoride in the diet, toothpastes, mouth rinses,
and professional topical applications.
-The clinicians goal is to choose the most effective combination for each patient. This choice must
be based on the patients age, caries experience, general health, and oral hygiene.
-systemic fluoride exposures are preferred
-Topical fluoride exposures are advisable for patients who are at high risk of having dental caries

2-Sealants
-sealing deep pits and fissures help in preventing dental caries
-for white-spot caries lesions on smooth surfaces, extremely low-viscosity resin sealants and
composite are used for better infiltration
-sealants are used for white spot lesions for prevention of further decay
-sealants have 3 important preventive effects
(1) Sealants mechanically fill pits and fissures with an acid-resistant resin.
(2) Acts as a mechanical barrier against bacterial accumulation.
(3) Sealants make cleaning of pits and fissures easier by tooth brushing and mastication.

3-diet modifications
4-oral hygiene instructions
5-checking the salivary flow and composition
B)Surgical management of cariesusing the handpiece-
The biomechanical excision of caries lesions and the restoration of the resultant tooth preparation
to form and function with a restorative material.
Dealing only with the end result of the disease and not addressing its etiology for each individual
patient is not successful in controlling the caries disease process.

Question
The diagnosis of dental caries lesions should include whether they are actively
processing , why?
Because inactive lesions may remineralizeandnot require operative intervention
by:
(1) a positive shift in protective factors
(2)change in oral hygiene,
(3) reduction of negative risk factors

-I apologize for any mistake and for any deficiency , there are few words which I didn't manage to
know because they weren't said clearly at all in the record ,I rearranged the topics in the slides in a
more simple way hopefully- , there were some topics which I rejoined because they were
repeated at the beginning of the slides and at the end of them but when they were repeated I just
included the title without the explanation as it was mentioned before

Good luck ^_^

Corrected by :Doha Toghoj&SumayyaRabab'ah .