Step 1: Do These Radiographs Exhibit the Criteria for Meeting Minimal Diagnostic Acceptability?

Patient A

Step 1: Do these radiographs exhibit the criteria for meeting minimal diagnostic acceptability?

Note: All radiographs in this series exhibit faint radiopaque gridlines. These grids are commercially available and can be applied to the front of the film so that the dentist can estimate the amount of bone loss. Each square is 1mm square.

This series of radiographs consists of 14 periapical radiographs and no bitewings/ interproximal radiographs. In general this is NOT a clinically acceptable set of radiographs: the maxillary R 1st molar–2nd molar contact is not open, nor is the maxillary R 1st premolar–canine contact. The distal half of the maxillary R cuspid is not visible. The right molar and premolar periapical radiographs are not clear, suggesting some type of motion unsharpness (movement of patient or tubehead during exposure). The apices of the mandibular R & L 2nd molars are not visible. The presence of the biteblock and alignment rod suggests the series was taken using the RINN XCP instruments; in general there is good parallelism with the long axis of the teeth and the film since the cusp tips are well superimposed.

Step 2: Are there any significant technique or processing errors that will influence my ability to correctly evaluate all of the relevant dental structures?

Bottom line: Yes, there are packet placing and overlapped interproximal spaces that will prevent evaluation of each root apex and contact area at least once somewhere in the series.

Maxillary R Molar Region

The film is acceptably positioned; however, the overlap between the maxillary 1st and 2nd molar should be considered a technique error on this radiograph, since it is likely that the direction of the contact will be more mesially inclined compared to the 2nd premolar–1st molar position. The overlap is due to directing the CR too far from the distal. This may be determined by observing that the distal-buccal and lingual roots of the 1st molar are superimposed on each other (see your textbook: Clark’s Rule/buccal-object rule/shift-shot). The radiograph is blurred, suggesting motion unsharpness; compare to maxillary L molar periapical.

Maxillary R Premolar Region

The film should have been positioned more mesial to include the distal half of the maxillary canine. The open contact between the 2nd premolar and 1st molar suggests that the horizontal direction of the CR was correct for this region; thus, the overlap between the 1st and 2nd molar should be considered physiologic overlap. The radiograph is blurred, suggesting motion unsharpness (compare to maxillary L premolar and molar periapicals).

Maxillary R Cuspid/Canine Region

Clinically acceptable film placement; the overlap between the canine and 1st premolar is because of the position of the canine at the corner of the arch and the contact areas are not parallel to each other.

Maxillary Central Incisor Region

Clinically acceptable radiograph

Maxillary L Cuspid/Canine Region

Film is not well centered behind the canine; the overlap between the canine and 1st premolar is because of the position of the canine at the corner of the arch and the contact areas are not parallel to each other. Film bending is noted along the upper mesial corner of the radiograph.

Maxillary L Premolar

Overlapped interproximal spaces between the 1st and 2nd premolars and the 2nd premolar and 1st molar. Excessive horizontal angulation: CR directed too far from the mesial; the mesial buccal and lingual roots are overlapped and the only open contact is the canine–1st premolar.

Maxillary L Molar

Mandibular R Molar Region

Incorrect film placement; the film should be positioned more distally to include all of the 3rd molar root apex. (It is assumed that the visible tooth is the 3rd molar since there is such a wide separation between the molar and the 2nd premolar.)

Mandibular R Premolar Region

Minor error in film placement, it would be desirable to position the film more mesially to include a bit more of the mandibular canine.

Mandibular R Cuspid/Canine Region

Clinically acceptable radiograph

Mandibular Central Incisor Region

Clinically acceptable radiograph

Mandibular L Cuspid/Canine Region

Clinically acceptable; film is slightly off center behind the lateral-canine interproximal space instead of centered behind the canine.

Mandibular L Premolar Region

Poor packet placement; the film should be positioned mesial to include the distal half of the mandibular canine.

Mandibular L Molar Region

Incorrect packet placement;not all of the 3rd molar apex is visible; or at the very least the film should be positioned distally to include at least 4mm of bone beyond the apex of the tooth. (It is assumed that the molars visible are 2nd and 3rd molars, primarily due to the mesial angulation of the molar and close proximity of the mesial and distal roots to each other, suggesting the anatomy of a 2nd molar rather than a 1st molar, which typically has a wider separation between the mesial and distal roots. For reference, observe the 1st molars on patients B and C.)

Step 3: Recognize the normal anatomic structures observable on the radiographs you will be evaluating.

Maxillary R Molar Region

Anterior and lower border of the maxillary sinus, maxillary sinus, zygomatic process of the maxilla (malar process), lower border of the zygomatic arch

Maxillary R Premolar Region

Anterior and lower border of the maxillary sinus, maxillary sinus, zygomatic process of the maxilla (malar process), lower border of the zygomatic arch

Maxillary R Cuspid/Canine Region

Lower border of the nasal fossa, nasal fossa, anterior border of the maxillary sinus, maxillary sinus

Maxillary Central Incisor Region

Lower border of the nasal fossa, nasal fossa, anterior nasal spine, tiny bit of the nasal septum, incisive foramen

Maxillary L Cuspid/Canine Region

Anterior border of the maxillary sinus, maxillary sinus (upper distal corner of film)

Maxillary L Molar

Zygomatic process of the maxilla (malar process), tiny bit of the lower border of the zygomatic arch, lower border of the maxillary sinus, maxillary sinus

Maxillary L Premolar

Zygomatic process of the maxilla (malar process), lower border of the maxillary sinus, maxillary sinus

Mandibular R Molar Region

Mental foramen; only a tiny portion of the mandibular canal is visible at the distal edge of the radiograph

Mandibular R Premolar Region

Mental foramen

Mandibular R Cuspid/Canine Region

Mental ridge, lower border of the mandible

Mandibular Central Incisor Region

Mental ridge, lower border of the mandible, genial tubercles, lingual foramen

Mandibular L Cuspid/Canine Region

Mental ridge, lower border of the mandible

Mandibular L Premolar Region

Mandibular canal, mental foramen

Mandibular L Molar Region

Mandibular canal, mental foramen

Step 4: Begin a systematic and careful assessment of the teeth and their supporting tissues and provide a written summary of your findings.

No obvious caries. Restorations appear acceptable. Generally visible calculus on many teeth. Alveolar bone height: generalized moderate bone loss, with localized severe bone loss distal of maxillary L 1st molar, maxillary R 1st and 2nd molar region.There is a localized area of increased radiopacity in the area of the R mandibular 1st and 2nd molar region, suggesting a possible residual root fragment.

Patient Assessment Tutorials: A Step-by-Step Guide for the Dental Hygienist

Second Edition

Jill S. Nield-Gehrig