what's up everyone if you don't know me i'm Zoh i'm a foundation dentist working here in london
and in this video i'm going to cover how you can interpret and understand radiographs
and i also give you the best order for you to report and present them to your supervisor or
anyone else so you don't get roasted on clinic like i used to
so this video will be split into two parts and the first part i'll cover interpreting by wings
and peripherals and in the second part i'll cover a systematic way to present the radiographs to
make sure you don't miss anything out and i've also made a little acronym to help with that
now all the information like the images and radiographs in this video are from this book
called the essentials of dental radiography and radiology by eric waits so if you guys want to
learn about this stuff in even more depth then check out the book and i'll put a link in the
description and also put time stamps down below and in the comments so feel free to skip around
so let's start with bite links now i'm not going to bore you with how x-rays are taken
or how they work i'll let you bore you with that but let's talk about why we take bite rings in
the first place well the main indications are to detect carries monitor the progression of carries
and to assess any existing restoration so for example overhangs on amalgams or secondary carries
now some would say you can actually use bitewings to assess bone levels and to a certain extent you
can but according to the guidelines you won't be able to form a proper periodontal diagnosis
from it and that's because you can't see the full length of the route to be able to say what percent
of bone loss there is so for example let's say you look at this radiograph here this is all you would
basically see from a bitewing you might think that it looks like 40 to 50 bone loss but if you had a
full pa like this one here you can see the tooth actually has very long roots so it's more like 30
bone loss so this might be the difference between diagnosing them with stage three or stage two
but at the end of the day does that really matter you're still going to do the same period
treatment but the difference is you just called it something else so is it worth taking a periapical
that's where you need to decide for yourself as a dentist and it's out of my scope to tell you
but anyways let's move on to something i can tell you which is how often you should take bitewings
well the fgdp conveniently has a set of guidelines called selection criteria for dental radiography
and this is what they advise so pause the screen if you want to have a look and i'll put a link in
the description for the online version if you want to have a look but the basic just is the
higher the risk the shorter the interval and keep in mind you should keep repeating the bitewings
until no new or active lesions are apparent and the individual has entered another risk category
so now let's start analyzing a bitewing an ideal bitewing should start from the mesial of the upper
first molar and extend as far as the distal of the upper second molar as you can see here but
of course that won't always be the case so what can you see so of course you can see the upper
and lower teeth and on some of the teeth you can see the distinct layers between the enamel the
dentine and and the pulp as well and you can see the bone levels there and any restorations that
they might have so the order weights suggest to look up vitamins is to start in the corner so
for the right side it would be the distal aspect of the last standing tooth and you work your way
to the canine analyzing each tooth will be the distal aspect of this canine here then you work
your way down to the distal aspect of the lower canine and you go through each tooth two you get
to the last standing tooth of the of the lower arch and this way you don't just kind of glance
over the whole radiograph and miss anything and to analyze each tooth weights has a 10 step approach
but i've narrowed it down to just five but keep in mind as you practice and you see more and more
radiographs this will become much faster and you kind of learn the things to look out for
so the first step is to trace their outline of the enamel and the edj and note any alterations
in shape which might be like a possible cavitation so just trace the edges and see
if you notice anything and what you're looking for are radiolucencies on this radiograph there's not
much but if you zoom in you notice tiny enamel lesion which you might have missed if you didn't
bother to trace the whole enamel cap and one thing to remember as well is that carries are
usually larger clinically than they appear on the radiograph and the number that gets thrown
around is about 20 to 25 percent worse clinically than what it looks like on the radiograph itself
so next you want to check the interproximal for radiolucent triangular shadows caused by
carries but you want to watch out for mistaking cervical burnout for carries tobacco burnout is
this radiolucency you often see at the cervical margin of the teeth and it's actually an artifact
made by the anatomy of the teeth simply put in the cervical region there's less tissues for the x-ray
beam to pass through and so it appears radiolucent so this diagram on the left is showing where it
kind of looks like on a radiograph and on the right you can see some really obvious ones there
and they don't always look this big and obvious but sometimes they can look as small as even this
one right here but there are some features you can look out for to distinguish between carries
and tobacco burnout so firstly it's always at the neck of the teeth and it's demarcated between the
enamel cap and the alveolar bone so for example you can tell this one is carries and not cervical
burnout because it goes above and under the enamel cap whereas cervical burnout wouldn't do that and
they also triangular in shape and they gradually become less radiolucent and you can see that right
here on this one but keep in mind you don't want to just diagnose them from radiograph so always
look back into the math as well to confirm if it's carries or not so moving on number one you check
the enamel and trace that number two you check the interproximal carries and checks for cervical
burnout now third is to check for root carries and denting carries like cervical and occlusal carries
so in this one you can see the root carries on the lower right seven and the upper right five here
and on this one you can just about see some of the occlusal carriers but if you adjust the contrast
you can see that's so much better and this is why digital x-rays are so much better because
if you just mess around with the contrast you can actually see so much more so fourth is to check
for existing restorations and you want to check to see if they're over contoured under contoured uh
how they adapted adjacent tooth like the contact points look for ledges overhangs secondary carries
and marginal fits of restorations like cramps so i'll go through some examples with you guys and
so for example on this one you can see the massive overhang on this amalgam and these can be quite
common and you really want to make sure that you treat this because it can be a massive plaque trap
for your patients and there's a lot going on in these radiographs you can see ledgers and you can
see overhangs and you can see how poorly contoured some of these amalgams are and on this one i just
wanted to show the marginal fit of this crown here and you can see the ledge right there so the fifth
and final thing to check is the pulp you want to check the size of the pop chamber and maybe see
pop stones that might affect any endo treatment you can see some of the back molars here seeing
pop stones like this might potentially give you an explanation as to why the tooth is not responding
to sensibility testing and also patients who have bruxes tend to have pop stones like this one
so that's how you can analyze a bitewing and to summarize the things to note are bone levels
carries secondary carries cervical burnout overhanging restorations ledgers and pop stones
okay so let's move on to periapicals and there's loads of reasons as to why you might want to take
a pa some of the main ones are detecting april pathologies assessing bone levels for perio
after trauma like a fractured tooth assessing root morphology before an extraction
for root canal treatment and evaluation of heavily restored teeth or implants okay so
let's look at one so this is a pa of the upper left four five six seven and as you can see the
main difference between the bitewing and the pa is that in the pa as the name suggests you
get a good view of the peripheral tissues and all the things i mentioned that you can assess in the
back ring you can assess in their pa as well but keep in mind pas are not as good as bite wings for
detecting carries so if you want to detect carries especially into proximal carriers you want to take
a bitewing and then if needed supplement it with a pa but pas are great for peripheral tissues and
when you're assessing the peripheral tissues there are three important features you need to look at
the periodontal ligament space the laminate juror and the surrounding bone so let's look at this
pa the pdl space is this dark radiolucent line that outlines the root of the tooth and all the
ligaments that hold the tooth are in place there the laminae juror is the continuous
radio opaque line just next to the pdl and again surrounds the root of the tooth the laminae juror
is actually just compact bone in the tooth sucker and it's where the periodontal ligaments attach to
these three things are key in analyzing the peripheral tissues because any changes to their
thickness continuity or radio density can be an indication of disease in our video on diagnosis
we talked about how after pop necrosis you can get an acute or chronic inflammatory response
check out that video if you haven't already at the start inflammatory exudate accumulates
in the pdl space and can cause what we call pdr widening as you can see on this radiograph here
now if it was only pdl widening that you saw on the radiograph then you might think it's in the
earlier stages of acute echo periodontitis but as the infection spreads you start to get resorption
of the bony socket and you will see lots of laminar juror as well and you can see the loss
of lamina dura here on this upper left one now this is more likely to be in the early stages
of acute apical abscess but as the abscess grows it can form an even larger radiolucency like the
one you can see on the upper left two here so here you can see all the three features that we talked
about you've got pdr widening you've got lots of laminator and you have bone resorption now
tooth like this will most likely need root canal treatment if you want to save it or an extraction
and those two are a big reason as to why you might want to take a pa as well for example if
you plan to do a root canal treatment on this tooth you would assess the canals and the roots
for example there's a molar tooth you'd want to know how many roots does it have is it curved but
on this one you can notice something that's even more important which is that they have
a rare developmental anomaly called denzin dente which is like an in-folding of enamel into dentine
so straight away you know this is a specialist drop another thing with piers is that you can
also estimate the length of the canals so you can get an estimate of the working length like on this
tooth here you can also measure the distance to the pop digitally as well so you can know how deep
to drill when making your access cavity and if you have a physical radiograph you can just hold up
your bur against the radiograph and you'll see the length of the bur compared to how deep your access
cavity needs to be now if you want to extract a tooth like this upper left six for example so when
you're looking at pa there's a few things you want to know firstly how many roots are there on this
one you can see three are they curved this one you can see they're kind of slightly distally curved
and you want to know any major structure so for example in this one it's the maxillary sinus and
you can trace the outline of it right there so you know there's a risk of an oac with an extraction
like this one you also want to know the density of the bone and how much coronal tooth structure is
left as well if you put forceps on this will this crumble and you also want to look for
radiolucencies in the vacation which might make it easier for you to grip the tooth with forceps
okay so that was it for pas as well now let's move on to the second part of the video which
is reporting on the radiographs which will also help you with presenting them as well
a few things to know when reporting or presenting in terms of terminology we take x-rays to produce
radiographs so when you're presenting on clinic make sure you use the right words you present a
radiograph so don't call it an x-ray because some supervisor might actually call you up on that and
also keep in mind radiographs can give us clues as to what might be happening clinically so for
example on this bitewing you can see a massive radiolucency and i know it looks like carriers
but when presenting you can't say distal occlusal carries on lower left six because it could be a
lost filling or something you don't know so the phrase you have to use to be correct is distal
occlusal radiolucency on lower left six indicative of carries okay so now we've got the terminology
out of the way let's move on to what you should actually write in your radiographic report in your
notes so the first thing you want to mention is what type of radiograph is it is it a pa is it a
bitewing is it a dpt then you want to mention the location so if it's a bitewing is it left by wing
is it a right bitewing is that a pa of an upper right five and then you also want to give it a
grade so from the fgdp guidelines you know grade one is excellent so there's no errors or anything
grade two is diagnostically acceptable so there might be some comb cut or something like that
and grade three is unacceptable where you're going to have to redo that one and next you want
to write your actual report and this is where i made the acronym creps so the first part of the
creps acronym is c which is caries and you want to note the site and depth of any radiolucencies
which are indicative of carries next is r which is restorative you want to mention any deep fillings
any crowns bridges implants failing restorations open margins overhangs
literally anything to do with restorative e is the endodontics so do they have a root filling
what's the quality of it is it well condensed is it to length you want to mention the root
or the canal shapes any root resorption any root fractures so again anything to do with endodontics
p is for periapical and this is where there are three things that we mentioned before
the pdl the laminator and the bone resorption and s is for structures and so this is where
you mentioned the bone levels any structures like the maxillary sinus or the mental nerve
or the id nerve or any pathologies that you notice in the bone and so to recap creps
c is for carries r is for restorative e is for endodontics p is for periapical and s is
for structures and you can kind of have this on the back of your head as you're presenting
or when you're writing your radiographic report just so you don't miss anything out all right
guys that was it for this video i hope you found that useful and if you did i'd appreciate it if
you gave us a like and subscribed you might also enjoy some of the other videos we have on this
channel so why don't you check out some of the suggestions here let us know in the comments
below if you have any acronyms that you like to use i have a quite a funny one for partial denture
design so if you guys want to see a video on that let me know alright guys see you in the next video