#1 – X-rays | Dental Practice Coaching

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#1 – X-rays

a. Introduction Science

The purpose of this manual is to assure that this office’s x ray equipment is used in a safe manner. This will benefit you and our clients and will comply with the Ohio Administrative Code 3701 33 22(A) which requires:
“Each registrant shall inform individuals working in or frequenting any portion of a restricted area of the occurrence of radiation or radiation sources in such portions of the restricted area; shall instruct such individuals in the safety problems associated with exposure to such radiation sources and in precautions or procedures to minimize exposure; shall instruct such individuals in the applicable rules for the protection of personnel from exposure to radiation or radioactive materials; and shall advise such individuals of reports of radiation exposure which those individuals may request pursuant to this rule.”

Even though you don’t “have to” know the information, take the time to understand it. As a professional you should understand radiation before you subject a client to this dangerous media.

X rays are a form of electromagnetic radiation like microwaves, TV, radiowaves, and visible light. Since the wavelength is very short, it can penetrate structures that would normally reflect visible light.  Radiation travels in a straight wavy line at 186,000 miles per hour. It has no mass or weight. It is pure energy. The energy packet is called a photon.

Properties and action of matter.
1. BEIR – Biologic Effect of Ionizing Radiation
2. Stable atoms contain protons (+) and electrons (-)
3. Atomic bonding – 2 atoms with opposite electrical charges attract. They bond into a molecule.
4. Atom ionization: Ion charged particle with + or – electrical charge. Any radiation that is sufficient to dislodge an electron from an atom is ionizing radiation.
a. x-rays
b. gamma rays
5. When x-ray passes through something, it is ionizing. Most radiation is non-ionizing.
6. Measurements of ionizing radiation
a. Standard International Units (absorbed dose)
1: coulombs – degree of ion in the air
2: gray – absorbed dose in tissue
3: sievert – effects of radiation dose equivalent
b. Traditional
1: Roentgen (per kilo)
2: Rad (per gram), 100 rads = 1 gray
3: Rem (per gram), 100 rems = 1 sievert
7. Density = degree of blackness
8. Contrast = different gradations of gray on film
9. Electricity (flow of electrons through conductor)
a. amperage: rate of flow of charge/second
b. milliamperage: usually 7-15 ma’s
1:total number of x-ray photons that strike film
2: examples
.5 seconds (exposure) at 20 ma = 10 ma’s
1 second (exposure) at 10 ma = 10 ma’s
10 second (exposure) at 1ma = 10 ma’s
3: ideal – highest ma at shortest exposure time
c. voltage
1: force applied to move electrons across a conductor; pressure between 2 charges
2: Kilovoltage (KVP) – determines penetration
3: determines contrast (white = radiopaque, dark = translucent)
a: increase KVP = decrease contrast (longer gray scales, more diagnostic)
b: step wedge used to check contrast
10. X-ray unit parts
a. cathode filament (-) – heated wire (electron source)
b. tungsten target (Anode +) for cathode
c. copper anode – houses target
d. radiator – dissipates heat (1% of energy makes x-ray, 99% makes heat)
e. glass envelope – protects components
f. transformers – raise or lower voltage
g. timer control –
1: 1 second = 60 impulses
2: step up transformer – increases voltage & KV penetration
3: step down transformer – decreases voltage
11. Control of x-ray beam
a. filtration – aluminum disc absorbs long wavelengths (short exposes film)
1.5mm for 70 KVP, 2.5mm for 70 KVP+
b. collimation – reduce size of primary beam (rectangular cone used in dentistry) 1.2 –1.8
MSV with collimation reduces to .9MSV
c. shielding
d. distance – long cone
12. Secondary (scatter) radiation
a. When x-ray strikes an object it bounces off. This bouncing radiation is secondary radiation
b. less penetrating wavelengths
c. safety precautions
1:shielding Nucleus
2: distance C Chromosome
13. Effects of radiation on cell tissue
a. primary damage to Cell membrane
1: cell nucleus
2: cell cytoplasm
b. types of damage
1: somatic – body of cell
2: genetric – reproductive cells (egg and sperm)
3: ranking of tissues susceptible to damage: breast, thyroid, lung, white blood cells, adult bone, muscle
c. determinants of radiation injury
1: dose rate (overtime) – cumulative: total dose
2: areas involved (location and size)
3: relative radiosensitivity
4: age – rapidly dividing cells (fetus) most in danger
d. effects
1: short term – radiation therapy Chemobyl
2: long term – cumulative overtime (latent period)

Why is this office concerned with radiation?
X rays are a type of energy emission called ionizing radiation. Unlike visible light or radio waves, this type of emission is capable of exciting individual atoms and splitting apart molecules in the human body.

Different tissues vary in their sensitivity to x rays. Generally speaking, the faster growing cells are the most sensitive. These include gonadal tissues, stomach lining, bone marrow and lymph glands and unborn babies.

In theory, it only takes one hit to change a molecule of DNA which contains our genetic code. This could result in changing the rate of growth of that cell and its offspring, which is commonly called cancer, or it could cause a birth defect in our offspring.

The earth is constantly bombarded with all types of radiation and we have evolved with the ability to repair much of the damage. Our ability to damage with ionizing radiation however, has its limits. For this reason, the government has established limits for occupational exposure to ionizing radiation. These are shown in the Ohio Department of Health’s Radiation Protection Rules. The whole body exposure is limited to 3 REMS per quarter.

However, no x ray is considered by this office to be completely safe. Therefore, we all must work to limit exposure to both patients and staff to the absolute minimum. This will ensure the safest possible environment for both patients and office personnel.

Some properties of x rays:
1. Travels at the speed of light (186,000 miles/second)
2. Travels in a straight line
3. Has a wave form
4. Invisible
5. Can affect living tissue

X rays are produced in the head of the machine by a cathode producing a positive charge on a filament that generates a charge of electrons. When these electrons strike the nearby anode, x rays are formed. This x ray is surrounded by oil to absorb the tremendous heat given off by the electron surge. “Kilovoltage” (Kv) is the term used to describe the speed of these electrons. The higher the kilovoltage the more penetrating power of the x ray. Most dental units use 60 90 Kv. One kilovolt equals 1000 volts. The lower the Kv the more contrast on the x ray, but the longer the exposure time. Milliamperage (mA) the amount of electric current used to generate the flow of the electrons. Today’s units provide 7 15 mA. The higher the milliamperage, the greater the number of electrons. The higher the milliamperage the less time is needed to expose the radiograph.

The focal spot is the target on the anode from which x rays are emitted. The smaller the focal spot, the sharper the picture. “Hard radiation is the short wavelength x rays responsible for high quality x rays and lower client exposure. “Soft radiation” is long wavelengths that produce scatter secondary radiation that increases client radiation. 1.5 2.5 mm of Aluminum filters are used to absorb this soft radiation.

Maximum Permissible Dose (MPD) is 5 REMs per year for radiation workers and .5 REMs per year for the general public. The Maximum Accumulated Dose (MAD) is your age minus 18 multiplied by 5 REM. Example 27 years old: 27 18 = 9×5 = 45 REM/year. Any one 17 years or younger is only allowed .5 REM per year.

X ray film is an acetate base coated with a silver halide emulsion covered with gelatin. X rays change the color of these silver halide crystals to make the image. A layer of black paper covers the acetate. This keeps the film dry and helps protect from light exposure. The side of the film away from the x ray head is covered with a lead shield. This absorbs much of the scatter radiation that would otherwise go through your client and hit objects, scattering and radiating your client on the rebound. Finally, the plastic cover keeps light and saliva out. X ray film comes in four sizes
#0 Child decay or periapical
#1 Narrow anterior periapical (adult)
#2 Standard adult decay or periapical
#3 Long adult periapical
#4 Occlusal

The film comes in two speeds D and E. E is twice as fast (requires half the radiation to your client). The image is a little grainier and less distinct which makes them somewhat more difficult to read.

Another type of film is extraoral. It comes in a variety of sizes and speeds. Examples are panoramic, cephalometric, and transcranials. These films are much larger than films discussed earlier. To reduce the amount of radiation that would be required to expose the film, intensifying screens are used. These screens convert x rays to light energy to expose the film. They have phosphor crystals embedded in a plastic base. The film is placed into a metal cassette that has an intensifying screen on each side. There are two types of intensifying screens
1. Calcium Tungstate
2. Rare earth
Although, more expensive, rare earth is more efficient and requires less radiation. These screens must be kept clean according to manufacturer’s directions. A scratched or dirty screen will give you a false picture.

One serious responsibility that you will now be given is exposing our clients to radiation in order to gain x ray information.

b. Answering client concerns

Before taking an x ray, makes sure you have answered all 5 of these concerns.
1. Cost let them know how much the x ray will cost and why it is being taken
a. Decay (not bitewing) x rays are taken to check for decay between the teeth (where your doctor can’t see) and to see the bone level supporting the teeth
b. Periapical x rays (PA’s) are taken to look for abscesses and other problems in the bone around the tips of the roots (not seen on a decay x ray.
c. Panoramic x ray This large x ray shows both the upper and lower jaws and the TMJ. It’s not as clear as a PA or BWX, but delivers only about 20% of the radiation of a complete x ray series (18 small films).

2. Discomfort
a. Decay and PA x rays can hurt and gag. Good technique will minimize this.
b. Panoramic no discomfort

3. Radiation fear
a. Use these facts:

1. We are exposed to radiation from many sources,
Examples are
a. Cosmic rays
b. Radioactive materials in the ground
c. Microwaves
d. Television
e. Food
Over 30 years this radiation is the equivalent of 4000 CMX (complete x ray series)

2. Long cone x ray parallels radiation and reduces secondary radiation through collimation. The old pointed cones throw off great amounts of scatter radiation. They are no longer sold. The square cones limit the radiation better than the round cones. However, it is much easier to cone cut (leave part of the film unexposed by misdirecting the x ray beam).

3. Lead shielding (including thyroid shield)

4. Rectangular beam limiting device inserted in the cone reduces scatter radiation by 50%

5. Why we take x rays. They are our best source of information on
a. Decay between the teeth
b. Bone loss around the teeth
c. Bone support for drifting teeth
d. Abscessed teeth
e. Reference for the future
f. Extra teeth, wisdom teeth
g. Tumors

6. We protect the client by
a) Only taking necessary x-rays
b) Lead shield, thyroid protectors (.25 mm lead)
c) Open cones
d) Rinn Holders
e) Good processing techniques

7. Reduce/avoid exposure
a. pregnant
b. past radiation therapy
c. recent CMX
d. handicaps
e. age (children, reduce exposure by 25%)
f. edentulous (reduce exposure time by 25%)
g. obese, dense jaw bone (increase exposure by 25%)

c. Safety Precautions (National Regulatory Commission Maximum Permissable Dose is .055V or 50 MSV per year)

1. We do not wear badges anymore based on OSHA recommendation in 2002.

2. Every room with an x ray on the west side is shielded on each wall. These rooms are restricted areas. When you expose a film, make sure you are:
a. At least 6 feet and at a 450 angle to x ray head
b. Never in a direct line with the beam (front or back)
c. Out of room
d. The director of the Ohio Department of Health should be notified if a radiation source causes over radiation.

3. The lead shield for the panoramic film goes on the client’s back. Don’t use a thyroid shield. All lead shields should be hung on the holders. Don’t fold them. Folds can cause cracks that would allow radiation leaks.

4. Always use the Rinn paralleling devices. This reduces distortion. If the frame hurts to floor of the client’s mouth, you can use the bisecting angle technique as a less acceptable alternative.

5. If a child can’t support an x ray, have the parent hold the film and cover them both with lead shields. You must never hold an x ray.

6. Safe operating procedure guidelines are posted at every x ray.

7. A long cone is used to parallel the x rays and reduce scatter radiation. However for every doubling of the distance from the focal point to the film, the exposure time must be increased 4 times.

8. The cones are lead lined to reduce scatter radiation.

9. The old pointed cones produced great amounts of scatter radiation and have been outlawed in many states.

10. The safest units today have impulse timers on the control box. 60 impulses equal a one second exposure.

11. There are many different kinds of film. The more exposure a film requires, the easier to read since it has high dark/light contrast. We use the fastest film.

12. After exposing a film, place it on a paper towel behind a radiation barrier. Don’t remove your gloves until the films are processing. Remove the daylight loader cover and throw the used film packets and towel in the trash.

13. Copies of OAC 3701 38 01 to 3701 38 37 and OAC 3701 70 01 to 3701 71 02 are located in the vertical file in Dr. Smith’s office. You may read them anytime you wish.

14. Qualified personnel No one who hasn’t completed this manual and demonstrated their ability to operate this equipment to their dentist’s satisfaction should operate any x ray equipment.

15. Never take an x ray unless authorized by your dentist.

16. Infection control during processing
a. sterilization kills all germs
b. disinfection – eliminates pathogenic microorganisms

17. Only a dentist may order an X-ray exam.

Procedure Tips – decay/periapical
Evaluate your client
1. Anatomy
a. low palate – move film away from teeth toward midline
b. lack of teeth – support film with cotton roll or take a panoramic
c. tori – place films as needed for comfort, may need to increase exposure

2. When taking a decay x ray, get the distal of the lower canine.
3. If wisdom teeth are present, the second decay x ray on that side should begin at the distal of the second bicuspid.

4. Use cotton rolls to make the films more comfortable for your client
5. When taking a complete series, switch holders as little as possible by following this sequence and using molar holders rather than bicuspid if it’s comfortable for your client.

8 7 3 4

1 2 5 6
Right posterior Left posterior

6. The shorter the distance from the film to the tooth, the less the magnification.

7. You have taken an accurate x ray when:
a. Proximal contacts aren’t overlapped
b. The labial and lingual proximal crest of bone superimposes on each other
c. Buccal and lingual cusps of posterior teeth superimpose on each other
d. Zygoma superimposed over roots of maxillary molars
e. Lingual root not look much longer that buccal roots of upper molar

8. Whenever you can see the occlusal surface of a molar on an x-ray, it is distorted. The B-L cusps should be in the same plane.

9. The very white Zygoma should never be superimposed on the roots.

10. Short or long cone doesn’t matter as much as if use instrumentation or not.

11. As you double the source to film distance, you quadruple the exposure time.

12. As you increase the distance of the source from the patient you decrease his exposure.

13. Don’t worry about distal of cuspid overlap on cuspid shot, pick it up on front of bicuspid molar shot.

14. Best to use black mounts to increase contrast

15. Quality of film
a. density (Light dark) is controlled by MA and time, MA isn’t changed to darken film, increase exposure time
b. Contrast (shading, definition)
increase KV > increase contrast
increase contrast > increase diagnostic value
improve contrast by developing 1 min. longer than normal
c. In general 65-70 KV is best
65 KV needs 3 times as much time as 90 KV
90 – 15 takes .5 sec.
65 – 15 takes 1.5 sec.

16. If you thing that the film may be fogged:
a. Open a new pack and remove 2 films
b. Run 1 film through developer
c. Put 2nd film only in fix (not developer)
d. Both films should look the same

17. Don’t use the same exposure for all films
a. anteriors would be over exposed
b. upper molars would be under exposed

18.Digital X-Rays
1. Setting up computer to expose x-rays
a. Click on bridge icon
b. click on camera icon
c. Click on chart of client
d. Click on patient gallery
2. To change shading of x-ray
a. Click on_____________
b. Click on_____________

Decay/Periapical x-ray errors and cause
1. elongated image – poor angulation
2. foreshortened image – poor angulation
3. cone cut – cone not centered on film
4. dark – too much radiation
5. light – not enough radiation
6. horizontal overlap – poor angulation
7. root curves – film bent (small mouth)
8. herringbone effect – film backwards
9. double picture (2 views, 1 film) – same film used twice
10. blurred image – movement
11. blackspots – saliva leaked through
12. clear film – no radiation

Panoramic X rays

A. A Panoramic x ray uses only the radiation needed for 2 decay x rays.

B. These x rays have several disadvantages.
1. Not a sharp enough image to diagnose decay
2. Extra light and dark areas caused by overlaps
3. The teeth will look 20 40% larger than they really are and it can vary from tooth to tooth

C. Advantages
1. Shows the entire lower one third of face
2. Quick
3. Comfortable for client

D. Ideas
1. Lead shields are worn backwards with no thyroid shields, Velcro will be on pts. chest
2. The white intensifying cassettes should be replaced every 7 years.
3. Cassettes should be kept clean and dry.
4. Remember to extend your client’s neck to eliminate the white streak on the film.
5. Use a special chin support for edentulous clients.
6. These x rays are great for severe gaggers, people who can’t open wide, or general scans for periodic check ups.
7. Always stand behind the wall next to the time clock when exposing this x ray. Use the mirror in the room to make sure the client is positioned correctly during the exposure.
8. The operating manual is kept on the bookcase shelves in Dr. Smith’s office.
9. Tips
a. client should stand “tall” and head straight ahead
b. impacted tooth B-L position; looks narrow means buccal, looks wide means ligual
c. if cassette won’t clear client’s shoulders, put heavy object in each hand to lower shoulders
d. remove glasses, jewelry, partial dentures, acomplete dentures
e. tilt the client’s head down enough
f. tongue flat in roof of mouth
g. line up midline
h. for large bone/obese clients, increase to the next KVp setting (remember to set back when you are done.
(see master manual for digrams to help understand what you are seeing)
d. Radiography Techniques

A. Bisecting the Angle for periapicals
This was the original positioning technique. It has several advantages.
1. Less time
2. No instruments to sterilize
3. More comfortable for the client
4. Particularly valuable for
a. Wisdom teeth
b. Narrow/shallow mouths

The disadvantages are that the image is much easier to distort and you will cone cut more often.

Technique

1. Show client how to put finger lightly on inside of film – if pushes too hard will distort film, if not enough film will shift when client swallows.

2. Turn the overhead light on so you can see the film.

3. The film should be 14 inches above the occlusal surface.

4. If you can’t get the distal of the wisdom tooth, place the film and then place the tube head more distal and angle it forward.

5. If your client has a shallow floor of the mouth, have him/her tilt the chin up as much as possible. This will lower the floor of the mouth and give you more room for the film.

6. Use the side of your hand to help you visualize the mid angle formed by bisecting the angle formed by the teeth and the film.

7. Line up the cone head parallel to this angle.

Types of film and function

A. Decay X rays(bitewings)- decay, boneloss

1. Maxillary arch should be parallel to the floor with the head against the headrest.

2. The front edge of the film should be in the center of the canine. If you are taking two decay x rays on one side to see wisdom teeth, the leading edge of the second film should be at the mesial of the first molar.

3. If you are not using an instrument, angle the tube head 10 degrees up from the horizontal.

B. Occlusal film- impacted teeth, fractures

1. Used to determine buccal lingual position of teeth, foreign bodies etc. that are in the bone.

2. Put the white side of the film flat on the occlusal surfaces of the teeth. Have your client bite down gently.

3. Lower arch chin as high as possible
Upper arch chin down on chest

C. Periapicals

1. disease (abscess, retained root tips)
2. root shape (root canals)
a. bone (periodontal disease)
b. decay

D. Panoramic

1. impacted teeth
2. cancer
3. TMJ

E. Cephalometric

1. orthodontic diagnosis
2. facial symmetry
3. growth and development

Criteria for Ideal Projection
1. tooth and film parallel to each other
2. radiation beam strike tooth at right angle to tooth
3. radiation source and tooth as far apart as possible
4. tooth and film as close as possible
5. radiation source as small as possible

A. Paralleling use film holder (see booklet in master manual)

1. Advantages
a. Very accurate
b. Shows true length

2. Disadvantages
a. Takes more time
b. Needs instruments

B. Endodontic film holder

1. Designed to fit over file when inserted in a posterior tooth

2. “Basket” fits over tooth

3. Use handle to parallel x ray cone

C. Occlusal Film
1. Use a paper film

2. Have child hold film with thumb and drop head down

3. Put x-ray head perpendicular to film

4. Expose at twice the exposure as a PA

D. Processing films
1. Always wear gloves when exposing x-rays
2. life of solution determined by
a. number of films processed
b. size of films processed
c. tank cleanliness
d. solution temperature

3. liquids
a. developer – alkaline (basic) – slippery, clear
b. fixer – acidic (smells like vinegar), contains silver

4. types of processing
a. automatic
b. digitally (FX)

E. Client management
1. general thoughts
a. remember that everyone dislikes x-rays
1. exposure
2. fear of radiation
3. uncomfortable feeling
b. gain your clients trust/confidence
1. be relaxed, confident, and caring
2. avoid technical words
a. bite wings = decay disclosing x-rays
b. PA’s = to see the roots and abscessed teeth
c. refer them for more information
1. www.ada.org
2. www.fda.gov/cdth
2. To avoid gagging.
1. Do front teeth first. They are the easiest.
2. Acknowledge gag, but then avoid further discussion about it
3. Anesthetize base of tongue and soft palate
4. Swallow before place film
5. If client starts to gag, remove the film quickly
6 Deep breathes in and out through the nose with eyes open.
7. Have all settings complete and tube head near, so film is in the mouthes little as possible
8. N20
9. Panoramic as alternative

3. Children
a. show the equipment/tell what it does
b. demonstrate what the child should do
c. praise each success

4. Client with disabilities
a. blind – lots of description
b. deaf – gestures
c. poor muscle control – have care giver hold (and use a head shield)
d. talk to the client, not the care giver, except for care giver instructions

e. Pano Troubleshooting

1. Film too light – increase radiation, incorrect developer time, weak developer

2. Film too dark – over developed, reduce radiation, light leak, solution too warm

3. A vertical spring shows on the film – cassette was in backwards

4. Overall grayness/dark – film exposed before/during loading (light leaks, wrong safelight, storage near heat, chemicals)

5. Skinny (narrow) and blurred anterior teeth pt. too far forward, make sure incisors in the groove and rod not bent

6. U/L teeth overlap biteblock not used

7. Anterior Teeth too wide, teeth blurred, condyles may not show pt. too far back

8. Teeth on one side too small other side too big head not centered (anterior teeth often missing)

9. Flat smile line
White line across teeth/apices Chin too high (ala-tragus line not postioned down 5 degrees)
Condyles cut off film
Apices of upper ant. teeth fuzzy
image non-symmetrical

10. White areas metal reflection (no earrings, napkin chains, partial dentures, glasses, watch, lead apron) or foreign object in cassette (paper, lint)

11. White area at center of film vertebrae not separate stretch client by standing tall

12. Exaggerated smile mandibular incisors blurred, may miss condyles chin down too far (client usually looks slumped) Condyles not show on film, posterior tooth overlap.

13. Darkness at teeth/apices tongue not at roof of mouth (pt. swallow 1st) This is the most common error.

14. Flat oval shadow in center of film clients lips spread apart

15. Blurred image client moved

16. Lightning like white areas static electricity caused by sliding the film out of film box too quickly

17. Crescent shaped dark area film crimped

18. Film too dark exposed to light

19. Lower border of mandible missing – cassette too high

20. One end of film has no border – cassette not well aligned in holder

21. Vertical white areas – button released during exposure

22. Top part of film not developed – not enough solution

23. Roots of anterior short – chin tipped too low

24. Black dots – powder from gloves

25. Wrinkles/ cracks – warm film in cold water or vice versa

26. Brown discoloration – not fixed long enough

27. Condyles not at same height – head rotated

28. Accentuated “V” shaped mandible, roots of lower incisors blurred – chin tipped too far down

29. Spinal column evident – client too far forward

30. Make sure the film cassette is cleaned properly
Look for worn or stained areas on the intensifying screens
Dampen a clean cotton ball or lint free cloth with screen cleaner
Wipe one screen at a time
Dry with another cotton ball or lint free cloth
Leave the cassette open until the screens are dry
After cleaning, an anti-static solution should be applied allow to dry completely before closing cassette

31. Exposure setting
Obese person next highest KVP or mA setting
Large bone structure next highest KVP or mA setting
Small bone structure next lower KVP or mA setting
Edentulous next lower KVP or mA setting

Periapical Errors
1. Elongated image – poor angulation
2. Foreshortened image – poor angulation
3. Cone cut – head too far off center
4. Dark film – too much radiation
5. Light film – Too little radiation
6. Teeth overlap – Poor angulation
7. Black line on film – Bent film
8. Herring bone effect – Film in backwards (smooth side toward client)
9. 2 images – Same film exposed twice
10. Blurred image – movement of film during exposure
11. Black marks on film – saliva leaked through plastic cover
12. Clear film – no exposure
13. Brown color – not fixed long enough
14. Fingerprints on film – handle film by edges only

X-ray Processor Maintenance

Each morning add enough fixer and developer to cover rollers. Place covers back on processor. Turn on unit and timer and run a cleaning film through the processor. When cleaning film is out, make sure it appears to be clear.

Each evening remove covers and allow processor to air overnight. Remember to turn unit off.

Weekly
Turn off unit, remove rollers and scrub with SOS pad and set aside to air dry overnight. Check to see if solutions need to be changed, if so remove plug and drain. Take sponge and wipe off mat inside processor. Then place a drop of lubricant in each hole of the processor unit.

Every 2 weeks
Rollers should be scrubbed with SOS pad, then left to soak in crystal solution.

Monthly
Check dry rack, remove, and scrub rollers with SOS pad.

g. Film Processing and Handling Errors for Paper Films

Problem Cause
1. Black spots on film Developer contamination before processing
2. White spots on film Fixer contamination before processing
3. Dark film Overdeveloped, Developer too warm, too much exposure time, developer to strong. Exposed film not shielded from further exposures, stored or exposed at elevated temperature, old film, depleted developer, not long enough develop or fix time, processing temperature too high
4. Light film Underdeveloped developer too cold too little time developer too weak or depleted
Over-fixed, processing temperature too low, contaminated with fixer, developed too quickly
5. Film fog Improper safelighting, light leaks, deteriorated film, contamination solutions
6. Yellow or Brown stain Depleted chemicals, inadequate washing, contaminated solutions
7. Black fingerprint Contaminated finger Poor film handling technique
8. Sharply demarcated
areas that are lighter
or greener than rest
of film Film stuck together during processing

9. Irregular areas that
are lighter than the
rest of the film Moisture contamination of film (Saliva)
10. Black Hair-like lines Moisture contamination of inner wrapping
11. Straight black lines Dirty rollers in automatic processor
12. Radiopaque line Scratched emulsion
13. Black “lightning” Static electricity extraoral films pulled apart too fast
14. Black crescent Film crimping
15. Blurred image client or x ray head moved

How to check the dark room safelight
1. Turn on safelight (GBW 2, Kodak) in dark room
2. Open E film and place coin on it
3. Wait two minutes and process
4. If image of coin shows, film is fogged
5. Show film to Dr. Smith

h. Digital x-rays
– Handling, processing and tips when working in PatientGallery software
– Take x-ray(s) using digital film
– Black side towards cone
– Number side towards tongue
– Open film packets by ripping the notch at the top and drop film (blue side down) onto soft padding in the plate transfer boxes. Only touch edges of each film
For pano
– Pano plate “L” facing “LL” in cassette
– Place cassette into x-ray unit blank side out
– Put in one at a time into the scanner – push down until it clicks.

To scan an x-ray:
1. Select your patient in the Dentrix Patient Chart (you must enter PatientGallery through the tooth chart)
2. Click & Open the BridgeGallery icon to open PatientGallery software
3. Click on the ScanX icon (looks like our processor)
4. For CMX, PA’s, BWX click Layout: Intraoral – Single image
5. For pano click Layout: Pan
6. If the layout is not correct, you can select Template – Load Template – and then select the one you want.
7. Click Start
8. Now –When green lights are on load the x-rays into the slot on the Scanner with black side toward you and push down gently.
9. You don’t have to wait for all the image to load before moving the xrays into position.
10. If you started processing xrays and forgot to select a layout, move all the xrays to the thumbnail bar and then go to change layout.
11. You can scan half the xrays and reopen and finish later – click the xrays under the patient name, select scanner icon, then start. The xrays that have already been processed must be selected also.
12. To change contrast or any xray view, click the blue water icon on the toolbar and then click lightbulb icon for the exposure level and gamma for the brightness level.
a. Gamma – Don’t go below .5
b. Exposure – The higher the more definition, not higher than 10% – 20%
c. Edge – To sharpen an image
13. After changing settings, click the Save icon – either as a new session or replacing the original xrays.
14. Remember, do not erase your xrays until you put them into a layout.
15. Close PatientGallery
16. Now you can go to your operatory & pull up the images there!
-Pick up Film by the edges and place blue side up into the eraser
-Put eraser lid down – wait till light turns off, about 20 seconds
-Remove film by the edges & place in packages with “Air Techniques” visible
-Peel off white strip and close – Be Careful! The films scratch easily & are very expensive. Each individual bwx plate costs $25 and the Pano plate costs $800.

X-ray Length Determination
1. Open x-ray image in Image Fx software
2. Tag X-ray with “checkmark” in upper left corner of image
3. Click “X-Ray Analysis” icon top right corner (blue on white icon)
4. Click on yellow “Measure” icon on left of left of screen…measurement window should appear
5. On the X-ray, draw a line horizontally, or vertically on the film from one edge to the other, and then click the “calibrate” button.
6. “Which direction would you like to calibrate” window appears. Click “vertical” or “horizontal”
7. “Enter Length” window appears. Our digital x-ray films are 31mm X 41 mm
8. Now click on “crosshair” or “line Segment” on the “Measurement” window and go to the x-ray. With the cursor you can drag the points you want to measure. This will be displayed in the “Measurement widow”
9. Click “Clear” for a new measurement.
Adding a single x-ray to a CMX
1. Click on Pt’s name
2. Click on “FX”
3. Click on CMS you want to add to
4. Click on ” ” will allow you to make any changes you want to make
5. Click on right side of mouse to “add images”
6. Tag the x-ray you want to add / “ok”
7. Bring down to spot on CMX
8. Save – “the disc”
9. Exit out of screen

To Darken Light X-rays
1. Click Pt’s. name
2. Click Patient Chart
3. Click Bridge Gallery
4. Check mark box, you would want to darken
5. Click “x-ray icon”
6. Click on individual x-ray
7. Click on “light bulb”
8. Increase exposure (usually 5-10)
9. Click “floppy disc icon”
10. Replace original
11. Start over at #1 for additional x-rays

To find lost x-rays
Occasionally, you will lose an x-ray that you have scanned. This can happen when the image is still being scanned & you close the ScanX program. It can also happen if the green lights on the scanner are not ready and you close the ScanX program.
To find these x-rays, you need to run a utility in Image FX & put them into the patient named Lost N Found.
1. Open Image FX through programs – not through the Dentrix Link.
2. Make sure you are not inside a patients file
3. Click File
4. Select File Maintenance
5. This brings up a window that tells you it will take several minutes to run this utility. It is a great idea to run this on the server because it will go much more quickly.
6. Once these images are found, transfer them to your patient, Lost N Found (Found is the last name).

Importing electronic x-rays
● Open patient’s file in ImageFX
● Click the image pull down menu
● Click Import image (or import tagged images)
● In the ‘Select Images to Import’ window, select the file and highlight the images to import and click open

(When receiving x-rays electronically, save the images to the desktop or another file first.)

To print a PA from a CMS:
1. Click on Patient’s name
2. Click on “FX”
3. Tag the CMS
4. Go to the icon that is a box that is ½ white & ½ bright blue “X-ray Analysis”
5. Double click on PA that you want to be printed (Don’t bring CMS up to full screen-
also make sure that the single PA is highlighted at the top-bright blue not gray)
6. “Print”

Rearrange CMX-pics in wrong slots
1. click on patient
2. bring up tooth chart
3. bring up bridge gallery
4. once in bridge gallery click on the full series you want to change
5. click on air techniques scan x icon
6. arrange how you want and make desired changes
7. click the save button once the changes are made
8. exit back to bridge gallery
9. check the series to make sure the changes were saved

i. Quality checklist
a. x-ray unit maintenance regularly
b. processors maintenance regularly
c. film stored corrected
d. fastest film used
e. well skilled operator

Adding and Subtracting x-rays from CMS
A. Adding
– Click on Pt then on FX
– Click on x0ray and check mark box
– Click on “contact sheet” at top of screen (looks like 4 sm. Boxes) then click on “organize images freely” button at bottom of screen (looks like CMS set up)
– Click on an image to get a box around x-ray.
– Right click on mouse
– Click on “Add Images”
– Click on x-ray you would like to add, click open
– Pull image from top of screen into place.
– Click on green arrow
– Click Sm. Disc to save- always click Duplicate
– Current Layout Box
– Hit OK
– Click on arrow out the door
– Image should be there.
B. Subtracting
– Click on Pt then on FX
– Click on x-ray and check mark box
– Click on “Contact Sheet” at top of screen (looks like 4 sm. Boxes) then click on “organize images freely” button at bottom of screen (looks like CMS set up)

– Click on the x-ray you would like to subtract to get a box around x-ray.
– Right click
– Select “remove images” – image should disappear
– Click green arrow
– Click sm. Disc to save- always click duplicate current layout box
– Hit OK
– Arrow out the door.
– Images should appear correctly in pt’s file.

C. To Prevent Losing X-rays when Processing
– After all x-rays are put through, and motor sound stops, let computer rest for 5 to 10 secs. Before starting to arrange images.
– If anything seems unusual during the developing process (Example: Errors popping up, processing stopping too soon) Save images and hit duplicate box. This will put 2 separate boxes of x-rays on screen. Leave them there. Do not delete any for now. Sometimes the computer will delete them on its own.
– Another problem is when arranging, if an x-ray is left at top of screen, x-ray will not save correctly. Never do this.
– If 2 sets of x-rays show up on the screen after processing. Never delete. Coputer might do it on it’s own. One image is not real.
– If ever in question on if an x-ray is good or not, try clicking on it and seeing if it blows up or doesn’t change. (Image should increase in size_ If x-ray does not get bigger, it is a false image.

j. Ohio Regulatory Requirements
(sign this page)

1. Only a dentist can give authorization for you to take an x ray.

2. You can take an x ray under supervision only until someone who has passed this section passes you. Then show one of the dentists you have these skills. When approved by the dentist, you will no longer need to be supervised.

3. The Ohio Radiation Protection Rules have been posted in the back hallway over the fire extinguisher. Be sure to read and understand them.

4. Don’t take an x ray with anyone other than the client (including parents!) being x rayed within range of the radiation. Consider each room that contains an x ray to be a restricted area when the x ray in that room is activated. Consider each room that contains an x ray to be a restricted area when the x ray in that room is activated.

5. If you are unable to take an accurate x ray or if the client is not comfortable, stop and get help. Don’t guess.

6. If you have any questions that aren’t answered to your satisfaction, you may contact the Ohio Dental Association for further information.

7. If any unusual event occurs, of any sort, contact your supervising dentist immediately.

8. Always keep your radiation exposure as low as possible. If you have any suggestions, please contact Dr. Smith.

9. You understand the provisions of the facilities safe operating procedures.

10. You understand the applicable provisions of the Ohio Radiation Protective Rules.

11. The Ohio Radiation Protection Rules are in the vertical file in Dr. Smith’s office.

12. Follow this protocol for periapical x-rays.
a. Place surface covers on x-ray head, chair cover, instrument tray.
b. Provide patient with appropriate shielding apron.
c. Wash hands, dry well, and put on examination gloves.
d. After exposure and with gloved hands, dry each film with disposable paper towel to
remove patient fluids.
e. Repeat process until all films are exposed
f. Transport films in disposable containers.
g. Unwrap films and process: hold films only by their edges.
h. While films are developing, discard all contaminated disposable materials.
i. Disinfect uncovered surfaces of the developing equipment
j. Remove covers (barriers) from the surfaces protected and discard
k. Disinfect uncovered surfaces that were contaminated while wearing gloves.
l. Removes gloves and wash hands properly.

13. Follow this protocol (for panoramic x-rays)
a. Wash and dry hands – extraoral cassettes can be handled with ungloved hands
b. Use sterile reusable or single-use disposable bite guides
c. If deemed necessary, barrier protect chin rests, head positioning guides, and handgrips.
d. After exposure of the film, ask the patient to remove the bite guide and barrier covers.
e. If patient cannot or will not comply, the DHCP must put on gloves and handle bite guide and surface covers.
f. Remove gloves and wash hands prior to handling film cassettes.
g. Transport film to developer.
h. Open extraoral cassettes and process: hold film only by the edges.
i. Label film.

I certify that ______________ has a working knowledge of all the information presented in this section on x rays and can take adequate x rays.

______________ __________________________________________
Date Team Leader

Please bring a complete series that you have taken to show Dr. Smith.
Get the ADAA text to help you pass this test.

I have read and understand all information on radiology in this section. I feel competent to take dental x rays.

______________ _____________________________________________
Date Your signature

See the information in the manual.

Steps to get certified to take x-rays:

1. Take the home study course offered by the Dayton Dental Society (fee paid by our office)
2. At successful completion, you will be given a “Certificated Completion” from the Dayton Dental Society. Begin Clinical hours
3. Call DANB to have them send you a Radiation Health and Safety application.
4. Fill out and send this application and a copy of your certificate of Application to DANB
5. Take the home study written test at a Sylvan testing center (100 questions, you get instant pass/fail results) fee paid by HealthPark
6. The paperwork goes from Sylvan to the Ohio State Dental Board who issues your license (4 weeks).

DANB – Dental assisting national board
Contact: Karen Lauerman x119
676 N. St. Clair, Ste. 1880
Chicago, IL 60611
Phone: 800-367-3262
Fax: 312-642-8507

Ohio State Dental Board
Suzanne Curry
77 S. High St., 18th floor
Columbus, OH 43266-0306
Phone: 614-466-2580
Fax: 614-752-8995

Sylvan Learning Center Sinclair College Contact: Sue Raeffe

875 S. Dixie Dr. 444 W. Third St.
Vandalia, OH 45377 Dayton, OH 45402
Ph: 937-898-6686 Ph: 937-512-2500

How to obtain your OHIO RADIOLOGY CERTIFICATE -2 choices

A. Through the Cincinnati Dental Society

The Ohio Radiology Certificate is issued by the Ohio State Dental Board (OSDB). Before a dental assistant can apply for their certificate they must complete a training course which has been approved by the OSDB. The Cincinnati Dental Society offers a home study course, which has been approved by the OSDB. The individual will work at their own pace under the supervision of a dentist

Step 1
Visit our website at www.cincinnatidental.org or contact the Cincinnati Dental Society’s Executive Office, (513) 984-3443, to order the “Introduction to Basic Concepts in Dental Radiography” manual. The cost of the manual is as follows:
Staff of Cincinnati Dental Society Members – $85
Staff of American Dental Society Members – $100
Staff of Non-American Dental Society Members – $115

Step 2
Study the manual completely and take the post-test which is located in the back of the
manual. There will be an answer sheet included with your packet of information.

Step 3
Mail the answer sheet to the Cincinnati Dental Society, 9200 Montgomery Road, #21-A,
Cincinnati, OH 45242. We will grade the test and send you a letter stating whether you
passed or not.

Step 4
Once you receive the letter stating you passed the test, begin the clinical training. This
training is also required in order to successfully pass the home study course. There will
be an “Affidavit of Clinical Radiography Training” sheet in your packet of information.
This form must be completed by the dentist who supervised your training.

Step 5
Mail the affidavit to Cincinnati Dental Society, 9200 Montgomery Road, #21-A,
Cincinnati, OH 45242. Upon receipt of the affidavit our office will issue you a “Radiology Class Record”. This shows proof that you successfully completed the required course needed to obtain your Ohio Radiology Certificate.

B. Recommended Alternative
We recommend that you take Dr. Kroger’s and Armstrong’s course on x- rays. See the master manual for an outline of their course. They will also examine you so you can take x-rays in Ohio.
Complete the Ohio State Dental Board’s application, which is also included with your packet of information. The OSDB requires specific information to be included with your application, so please read it carefully. Upon their approval, the OSDB WILL SEND YOU a Radiology Certificate. Only after you receive this certificate are you allowed to take radiographs in your dental office.

If you have any questions regarding the above steps or need additional clarification, please contact the Ohio State Dental Board at (614) 466-2580 or office at (513) 984-3443.

Radiologic License Renewal

To renew a license you must complete 2 hours of continuing education. Every 2 years you must also show current immunity to hepatitis B.

Expires biennially on the license holder’s birthday. Exception: the initial license expires on the license holder’s birthday following 2 years after it is issued.

Reinstating your x-ray license
1. take an Ohio State Dental Board approved 2 hour x-ray course
2. Pay an
a. application fee
b. late fee
3. apply to the OSDB for reinstatement 614-466-2580 or http:// www. Dental.ohio.gov.ohdental@mail.peps.state.oh.us

Dexis instructions

Select your patient and open their tooth chart
Click on the black scanner button which will open dexis into the x-ray screen
Select full series, btw, or select the single tooth to be x-rayed
Place rinn with scanner in it in the patients mouth, aim x-ray head, and push button, move rinn to the next position the computer prompts
Follow the prompts to take x-rays in the correct order
Click next or cancel when done
Dexis will automatically save images

To send an x-ray via email:

Select your patient in family file
Go to the tooth chart
Open Dexis – make sure the patient name is at the top
Click the icon that looks like the arrow points to the right, away from the folder – this is Export Images – this brings up a new window
Click the Browse button to choose the folder where you want to save the image
Make sure the hard disk button is selected and the jpg format is selected
Checkmark the x-rays you want to export
Then at the bottom, click Export Images

Now, create your email – and click Attach File – then go to the folder where you saved it and select the xray.