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DENTAL HYGIENE Applications to Clinical Practice Rachel Kearney Henry, RDH, MS | Maria Perno Goldie, RDH, BA, MS

Bridge the gap between theory & practice.

Rely on this comprehensive, core text to put theory into context. A rich supply of procedures and professional advice prepare your students to understand the importance of what they are learning and how to apply it to their future careers.

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radiographs. In most states, only a licensed dentist islegally able to prescribe radiographs. See Evidence-Based Practice.

RADIATION SAFETY

Radiation to children and pregnant women is frequentlyin the news as a developing fetus and child have in-creased susceptibility to ionizing radiation.14 There are a few historical examples (Japan and Chernobyl) of largedoses of ionizing radiation to pregnant women and children resulting in leukemia and various solid tumorsboth benign and malignant.15 This overwhelming nega-tive information about ionizing radiation can make itdifficult to assure patients that radiographs are necessaryto provide optimum care in a dental office.

Dental offices can help alleviate any concerns by es-tablishing radiation protection guidelines and makingthese readily available to staff and patients. These pro-cedures should include administration of the guidelines,criteria for exposure, and operating procedures. The ad-ministration of the guidelines determines who in theoffice is responsible for the x-ray–producing units. Thisis typically a dentist in the office. This person shouldcreate a quality-assurance program that monitors theimages made and x-ray units to ensure that diagnostic-quality radiographs are being produced. The criteria for exposure should state whether the office follows

266 PART IV ■ Assessment

Application to Clinical Practice

You are volunteering for Dental Day, a day-long clinicserving children from underserved areas around thestate. You have been assigned two patients aged 10 and12 years. The 10-year-old patient has brought horizontalbitewing radiographs. The 12-year-old patient has nothad radiographs in 3 years. A limited oral examinationshows pink, stippled gingiva with no existing restora-tions or evident carious lesions. What radiographs willyou recommend when discussing this case with the supervising dentist and why? ■

the FDA/ADA Guidelines for Prescribing Dental Radi-ographs or a different set of guidelines as determinedby the dentist(s) in the office. The operating proceduresshould include settings for x-ray units and other radia-tion safety precautions taken in the office including, butnot limited to, the thyroid collar, lead apron, infectiondisease control, pregnancy, and past radiation exposuremost commonly because of radiation therapy. Radiog-raphy is beneficial to patients, providing information tothe practitioner not visible to the naked eye, but properradiation protection guidelines must be followed witheach exposure. See Application to Clinical Practice.

Case StudyPaul, a 7-year-old boy, presents with hismother as a new patient in the dental of-fice. His last dental visit was 2 years prior.

No recent radiographs are available. A limited intraoralexamination reveals that Paul’s oral hygiene is poorwith red and swollen gingiva. The patient’s mothernotes that there is bleeding when he brushes andflosses. Generalized severe biofilm is present. There arerestorations on the mandibular permanent first molars(#19 and #30), which are erupted onto the plane of oc-clusion. Large occlusal carious lesions are evident on themaxillary and mandibular primary second molars (A, J,K, and T). After discussing this case with the dentist,bitewing and periapical radiographs of the posteriorteeth are recommended. The patient’s mother is hesi-tant about the radiographs due to a recent news seg-ment she saw involving over-radiation of children in anearby state.

Case Study Exercises1. What classification applies to this patient in the

FDA/ADA Guidelines for Prescribing Dental Radiographs?A. Child with primary dentition, new patientB. Child with transitional dentition, new patientC. Child with primary dentition, recall patientD. Child with transitional dentition, recall patient

2. The radiographs prescribed by the dentist are in accordance with the FDA/ADA guidelines. The patient has overall poor oral hygiene.A. Both statements are true.B. Both statements are false.C. The first statement is true, but the second

statement is false.D. The first statement is false, but the second

statement is true.

2568_Ch15_254-269 20/01/16 2:07 PM Page 266

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Evidence-Based Practice, Teamwork, & Professionalism boxes are integrated throughout the text to make sure your students are ready to collaborate with their peers, handle workplace issues, and incorporate the best possible clinical expertise into practice.

Running Case Studies with questions are featured in every chapter to help your students practice applying their knowledge to clinical situations.

QUESTIONS?

HistoryThe history of radiology started with Professor WilhelmRöntgen, a German physicist who discovered x-raysby accident.4 He was performing research using a cath-ode ray tube when he noticed a piece of bariumplatinocyanide glowing not far from the tube. He wasunsure what new rays were causing this and pro-ceeded to research them further. He called the new raysx-rays using the x, which represents unknown objectsin algebraic equations. This was on November 8, 1895.He published his results on December 28, 1895, in anarticle entitled “On a New Kind of X Rays,” which in-cluded the first radiograph, which was of his wife’shand. The exact exposure time for this radiograph haswidely varied from 15 minutes up to 30 minutes.

The first radiograph in Europe was made only 10days after the publication of the article on January 7,1896; it was of a hand and was made in England by anelectrical engineer. The first radiograph in the UnitedStates was made about 1 month later on February 3,1896. A radiograph was made of a forearm on a patientin a hospital. The first dental radiograph was made byOtto Walkhoff, a German dentist, on January 12, 1896.He used himself as a patient, holding a photographicplate in his mouth and sitting still for a 25-minute exposure. The resulting image does not show muchother than the outline of teeth, but it is the beginningof radiology in dentistry.

RADIOGRAPHIC TERMS

DefinitionA radiograph is the resultant image after a patient orobject is exposed to x-rays. Two groupings of radiographsare made in dentistry: intraoral, which refers to an imagemade with the image receptor in the patient’s mouth;and extraoral, which refers to an image made with theimage receptor placed outside the patient’s mouth. Theimage receptor may be either analog film or a digital imaging system.

There are three types of intraoral radiographs: peri-apicals, bitewings, and occlusal radiographs. Periapi-cal radiographs show an entire tooth on a singleimage (Fig. 15-1). They show the crown and root, in-cluding the surrounding bone of one jaw. These aremost commonly made to evaluate the bone aroundthe apex of a tooth to determine whether there is pe-riapical pathosis. Periapical radiographs are identifiedby the location of the oral cavity shown. Three mainidentifications should be included when describing orprescribing a periapical radiograph: the jaw (maxillaor mandible), the side (left or right), and the specificteeth captured (molar, premolar, canine, etc.). SeeTeamwork.

Bitewing radiographs show the crowns of teeth of both the maxilla and the mandible on a single image

256 PART IV ■ Assessment

Figure 15-1. Periapical radiograph. Maxillary central incisors periapical.

Teamwork

Kathy is working in the radiology clinic during a busySharing Clinic. She is primarily setting up and cleaningthe radiology cubicles. This aids the student operatorsby allowing more time for treatment. All the radiologycubicles are filled with patients and student operators.She notices Karen is struggling to take a maxillarymolar periapical on an adult male with a severe gag reflex. She offers to help by pressing the x-ray expo-sure button once Karen has left the radiology cubicleso that the PSP plate is in the patient’s mouth for aslittle time as necessary. With Kathy’s help, Karen isable to capture the radiograph in one take. Some patients require a faster radiographic experience(placing image receptor in mouth, positioning x-rayunit, and pressing x-ray exposure button) to preventpossible reactions such as severe coughing or vomiting,or both. Working together facilitates the delivery ofoptimum patient care while obtaining the necessaryradiographs. ■

(Fig. 15-2). These are most commonly made of the posterior teeth but can be made of the anterior teeth aswell. Bitewing radiographs are used to evaluate for in-terproximal caries and adjacent bone levels. They areideal for evaluating bone levels in relation to the teethdue to the near-perpendicular direction of the x-rays to the jaws. Horizontal bitewing radiographs are when

2568_Ch15_254-269 20/01/16 2:07 PM Page 256

loss. A common bitewing radiographic series consists of four radiographs: one molar bitewing radiograph andone premolar bitewing radiograph for each side. If thepatient has fewer teeth, less than four radiographs maybe necessary. Interproximal caries present as a radiolu-cent triangle in the enamel at the level just apical to thelevel of a contact with the point toward the dentin-enamel junction. Restorative materials have a range ofappearances on radiographs from completely radiopaque(metal) to radiolucent (some composites). Bitewing radiographs are identified by the side and location. Thereis no jaw identification because both the maxilla and themandible are captured on a single radiograph. See Professionalism.

A combination of periapical and bitewing radi-ographs, typically 18 to 20 radiographs, showing all theteeth in the oral cavity is referred to as a completemouth radiographic series (CMS) or full-mouth series (sometimes abbreviated FMX). These radiographicseries typically consist of four posterior bitewing radi-ographs, eight posterior periapical radiographs, and sixto eight periapical radiographs (based on the prefer-ences of the dental office). A CMS is frequently takenwith a new patient examination, especially with multi-ple existing restorations or evidence of current cariouslesions. This series shows detailed information of eachtooth, allowing the dental practitioner to provide a thor-ough treatment plan for a patient.

Occlusal radiographs show an entire tooth,similar to periapicals; however, they are made withdifferent angles, giving distorted images of thoseteeth (Fig. 15-3). Occlusal radiographs are identifiedby the jaw and the type.

Many different types of extraoral radiographs areavailable. The ones commonly seen in dentistry arepantomographs and lateral cephalometric skull radi-ographs. Pantomographs (also referred to as or-thopantomographs and panoramic radiographs) areradiographs that show the entire maxilla and mandible

Chapter 15 ■ Radiology 257

Figure 15-2. Bitewing radiograph. Left premolar bitewing.

the image sensor is placed such that the long axis is lateral. These are common with patients with minimalto no evident bone loss. Vertical bitewing radiographs arewhen the image sensor is placed such that the long axisis vertical. These are made when there is evident bone

Professionalism

You are in the radiology clinic to expose four bitewing radiographs on a 65-year-old woman. The patient hasbeen dismissive and rude when going over her medicalhistory insisting you do not need to know that informa-tion to clean or fix her teeth. She is visibly annoyed at having to have radiographs taken but agrees to them. Youare about to position and expose the first bitewing whenone of your classmates tries to strike up a conversationabout an upcoming examination. You politely tell yourclassmate that you are busy with a patient and will discuss it at a later time. Your classmate leaves and you continue to expose the four bitewings focusing on proper technique. No retakes are necessary, and youtake the patient back to the clinic chair to begin yourprophylaxis. You notice your patient is very cooperativeand no longer dismissive when you ask her questionsabout her oral hygiene. At the end of the appointmentyour patient thanks you for being so attentive whenworking with her. She states that during her last few appointments at the school she has felt ignored by thestudents treating her because they seemed more inter-ested in talking with classmates then providing her care.She insists on seeing you the next time she comes backand thanks you once more. Professionalism when work-ing with patients is important so that you are able toprovide the best care possible. ■

Figure 15-3. Occlusal radiograph. Maxillary standard occlusal.

2568_Ch15_254-269 20/01/16 2:07 PM Page 257

exposing this area of the patient. Because every statelaw differs in the use of the lead apron, it is importantto verify what your specific state laws are. Some statesrequire the lead apron at all times and others followthe National Council on Radiation Protection andMeasurements 145 (NCRP 145). According to theNCRP 145,1 the lead (or lead equivalency) apron is notrequired as long as the dental office is in compliancewith the following two recommendations:

• The office is using F speed film or a digital imagingsystem (CR or DR).

• All intraoral x-ray units use rectangular collimation.

A thyroid collar is a flexible shield with lead orlead equivalency that covers the neck, specifically thethyroid, blocking x-rays from exposing this area. Thethyroid is more sensitive to radiation, especially in chil-dren compared with adults.12 As with the lead apron,each state differs in the use of a thyroid collar and it is important to verify your specific state laws. Accord-ing to NCRP 145, the thyroid collar shall be used onchildren and should be provided for adults regardlessof the imaging system a dental office is using (analogx-ray film or digital). The only times a thyroid collarshould not be used on an adult, according to NCRP 145,is when it will interfere with the path of x-rays anddistort the final image.

CollimationCollimation refers to shaping the x-ray beam to thearea that is to be imaged. In dentistry, there are rectan-gular and round position-indicating devices (PIDs) orcones (Fig. 15-15). The PID/cone is the part of the x-rayunit where x-rays exit. Rectangular collimation createsa smaller x-ray beam that narrowly covers a size 2 ana-log film. Round collimation covers a much larger areaof the patient than just the area to be imaged. Using arectangular collimation with the same settings (mA,kVp, exposure time) as a round collimation results in aradiation exposure reduction to the patient by 60%.6

Radiation Exposure to the OperatorOperators can take several precautions to ensure thatthey are exposed to minimal, if any, amounts of ioniz-ing radiation while exposing patients.

• The operator should be a minimum of 6 feet awayfrom the source of radiation or behind a leaded (or leadequivalency thickness) barrier, typically a wall. Mostdental operatories are designed such that the exposurebutton is in a location meeting this requirement.

• If the operator is not behind a barrier, but at a dis-tance of 6 feet, he or she should be positioned 90 to135 degrees to the x-ray beam to decrease any possi-ble radiation exposure.6

• The operator should not hold the image receptor inthe patient’s mouth during exposure. Holding theimage receptor in the patient’s mouth results in directexposure of the x-ray beam. This leads to an increasedrisk for radiation-induced damage.

Prescription of RadiographsRadiographs should be ordered and made only after re-viewing the patient’s medical history and a limited oralexamination. A limited oral examination is the gather-ing of information from interview, medical and dentalhistories, observation, and clinical examination focus-ing on a specified issue. Radiographs should not be or-dered on a routine basis. For new patients, effortsshould be made to acquire radiographs from existingoffices to aid in reduction of radiation exposure to thatpatient. The Food and Drug Administration (FDA) andAmerican Dental Association (ADA) combined to cre-ate Guidelines for Prescribing Dental Radiographs13 in2004 to aid dental professionals in minimizing radia-tion exposure to patients (Table 15-4). It is necessaryto review your state laws that determine who can order

264 PART IV ■ Assessment

Figure 15-15. Rectangular collimation (A) and round collimation (B).

Evidence-Based Practice Research shows that the 2004 FDA/ADAGuidelines for Prescribing Dental Radi-

ographs13 are effective at providing minimal radiation exposure to patients with optimal diagnostic radiographs.By adhering to these guidelines, radiation exposure islimited, thereby decreasing the total lifetime radiationexposure for the patient.19 ■

2568_Ch15_254-269 20/01/16 2:07 PM Page 264

Custom Packaging

Looking for a package specifically designed for your course? All of the titles your students need to excel in class, on exams, and in the lab are available in a customized money-saving package!

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More Must-Haves ...................................... 6-8Check out more resources for Dental Hygiene & Dental Assisting success.

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ONLINE LEARNING PLATFORM

DentalCareDecisions.com Rachel Kearney Henry, RDH, MS | Maria Perno Goldie, RDH, BA, MS

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§ 2-year, online access is available for FREE with a new purchase of the text! § Includes a fully searchable interactive eBook version of the text.

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1. Identify the papilla of the mandibular central incisors.

3. Identify the area specific explorer.

STUDENT EXPERIENCE

Hot Spot Exercises focus on identifying specific aspects of anatomy & physiology, instruments, and equipment.

Fill-In Procedure Exercises present all of the steps in a procedure with one key step missing. Students must select the correct missing step.

Proceed to the suprasternal notch.

Proceed to the sternocleidomastoid muscle.

Proceed to the carotid groove.

1. Identify the missing step for the text’s recommended approach to palpating the midline.

1. Bidigitally palpate from the symphysis of the mandible to the hyoid bone.2.

3. Palpate the thyroid cartilage.

4. Ask the patient to swallow and note whether there is deviation.

Audio Interactive Case Studies feature short audio scenarios followed by multiple-choice questions that ask students to make critical decisions.

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Customize your course. The Instructor Dashboard gives you full control of how you create and manage your classes--all on one screen. You will find that it is very user friendly and incredibly intuitive.

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GENERAL AND ORAL PATHOLOGYfor Dental Hygiene PracticeSandra L. Myers, DMD | Alice E. Curran, DMD, MS

Engage learning. Enhance retention. Apply to practice.

Our authors have integrated just the right depth of basic science with clinical application features to prepare your students for the NBDE and professional practice.

Each chapter begins with concise, foundational and basic principles of pathology to provide need-to-know background knowledge, while Critical Thinking Exercises, Clinical Implication Boxes, Chapter Review Questions, and hundreds of real-life photographs help your students apply what they’ve learned to clinical practice.

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Photographs, tables, radiographs, & animations of the most commonly seen disorders and pathological processes make recognition easy.

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Table of Contents

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STRUCTURES OF THE HEAD AND NECKFrank J. Weaker, PhD

The best of both worlds...

Expert anatomist and author Frank J. Weaker takes anatomy to the next level with his innovative, blended regional and systemic approach to teaching & learning the structures of the head and neck.

From his 30 years of teaching experience, Dr. Weaker has seen how this integrated method has helped students gain a more complete understanding of anatomy and its relevance to clinical practice and body functions.

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CHAPTER 10 Fascial Spaces and the Spread of Infection 159

Figure 10–8 Progression of odontogenic infection to the mediastinum.

Figure 10–7 The submental space is bordered by the anteriorbellies of the digastric muscles and the hyoid bone. The floor is the mylohyoid muscle, and the roof is the cervical investingfascia. Note the close relationship of the submandibular and submental space, which allows the spread of infection between these two spaces.

Mandible

Submandibulargland

Posterior bellyof digastric muscle

Styloglossus muscle

Hyoid bone

Submentalspace

Submandibularspace

Anterior belly ofthe digastric muscle

Sublingual space

Submandibular space

Danger space #3

Danger space #4

Mediastinum

Lateral pharyngealspace

Submental space

Retrovisceral space

and 10–9). This space is shaped like an inverted cone. Itis located between the pharyngeal wall medially, the medial pterygoid muscle on the surface of the mandiblelaterally, and the prevertebral fascia posteriorly. Thespace contains the styloid process and the carotid sheathand its contents (Fig 10–9).

RETROVISCERAL SPACE OF THE NECKOnce infection reaches the lateral pharyngeal space, itcan spread down the back of the neck through the retro-visceral space (Figs. 10–8 and 10–9). This space is lo-cated between the vertebral column and the visceralcompartment of the neck. The space is bordered supe-riorly by the base of the skull, inferiorly by the root ofthe neck (Fig. 10–9), laterally by the carotid sheaths(Fig. 10–1A), posteriorly by the prevertebral fascia, andanteriorly by the buccopharyngeal fascia (Figs. 10–1A,10–9, and 10–10).

This space is divided by a linear layer of alar fascia ori-ented in a frontal plane. The alar fascia is attached supe-riorly to the base of the skull, laterally to the carotidsheath, and anteriorly to the buccopharyngeal fascia at theroot of the neck. The space between the alar fascia andthe buccopharyngeal fascia is called the retropharyngealspace or danger space #3 (Fig. 10–10). This space is con-tinuous with the lateral pharyngeal space superior to thehyoid bone, but is closed inferiorly by the fusion of thealar fascia with the buccopharyngeal fascia. Infection inthis space causes swelling of the neck and difficulty inbreathing (Fig 10–8). Danger space #4 is located betweenthe alar fascia and the prevertebral fascia (Fig. 10–10).This space is closed superiorly by the skull and is contin-uous inferiorly with the thorax. Swelling in this area cancause difficulty in swallowing and breathing.

Review Question Box 10-31. What is the difference between the lateral pharyngeal

space and the retrovisceral space?

2. What is the difference between danger space #3 and

danger space #4?

3. Compare the pathways of infection from the first

mandibular premolar and the second mandibular molar

teeth into danger space #3.

4. How can an infection spread from danger space #3 into

danger space #4?

5. What can happen if an infection spreads into danger

space #4?

2958_Ch10_154-163 05/07/13 2:25 PM Page 159

Over 400 vividly colored and labeled illustrations, tables, & flowcharts let your students easily examine every detail.

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