Patient Management in Radiology PDF

Radiology Radiography of patients Dr. Areej Ahmed with special need Objectives: Learning the management of special cases in radiology clinic including: Mandibular third molars Children Gagging reflex Patients wi...

Radiology Radiography of patients Dr. Areej Ahmed with special need Objectives: Learning the management of special cases in radiology clinic including: Mandibular third molars Children Gagging reflex Patients with disabilities. Not all dental radiographic techniques can be successfully performed on all patients. Radiographic examination techniques must often be modified to accommodate patients with special needs. The dental radiographer must be competent in altering radiographic techniques to meet the specific diagnostic needs of individual patients. 1. Mandibular third molars The difficulty is placement of the film sufficiently posteriorly to record the entire mandibular third molar. The solution is by using surgical needle holder to hold and position the film in the mouth. 2. Child patient Children are unlikely to be suggested to x-ray until five to six years old, except in cases of trauma and injury usually for upper anterior teeth. a. Describe the x-ray machine to the child; let him touch them before examination to be familiar with the film and machine. b. Show him a radiograph of another child's teeth and let him see the radiographic procedure on another member of the family. c. Use conveniently small intraoral films d. Use lead apron. e. Exposure factors (mA, kVp , time) must be reduced. f. Extraoral films can be used instead of intraoral. g. Radiographic procedures should not be hurried nor should the child be apprised of any negative possibility like you might hurt a bit or you may gag. h. Do not expose the young child to two or more circumstances simultaneously. i. A mirror enabling the child to observe the procedure, maybe helpful. j. If the child cannot hold or stabilize the film, ask his parent for assistance. 3. Gagging Reflex A gag reflex is a protective mechanism of the body that serves to clear the airway of obstruction. In the dental radiography a hypersensitive gag reflex is a common problem. This makes the film placement in the desired position particularly difficult especially in molar regions Some patients may unconsciously activate this reflex as a defense against anticipated unpleasantness. The areas that are most likely to elicit the gag reflex are the soft palate and the lateral posterior third of the tongue. The precipitating factors that are responsible for initiating the gag reflex include (psychogenic stimuli-originating in the mind) and (tactile stimuli- originating from touch) Patient management: there are some important hints to reduce gagging reflex, such as: a. Operator attitude: Most gagging can be controlled through the creation of the patient confidence or by-diverting the patient's concentration away from gagging reflex like asking the patient to breathe deeply through the nose or moving his/her arm. b. Patient and equipment preparations: In a patient with hypersensitive gag reflex, every effort should be made to limit the amount of time that a film remains in the mouth. The longer a film stays in the mouth, the more likely the patient to gag. c. Exposure sequencing: The dental radiographer should always start with anterior exposure; with posterior exposure the dental radiographer should always expose the premolar before molar. d. Film placement and technique: Each film must be placed and exposed as quickly as possible. Placement and technique modification include the following: Avoid the palate: position the film lingual to the teeth and then firmly bring the film in to palatal tissue using one decisive motion. Demonstrate film placement: in the areas that are most likely to elicit the gag reflex, rub a finger along the tissues near the intended area of film  placement, while telling the patient, “This is where the film will be positioned.” Then quickly place the film. e. Use of extraoral radiograph: In uncontrolled gag reflex, intra oral radiograph is impossible to obtain, so extra oral films such as panoramic or lateral jaw radiographs should be used. f. Using topical anesthetic agent : When the cause of gag reflex is tactile, we can use local anesthesia. Salt application on the palate said to be useful. 4. Physical Disabilities a. Vision impairment: if a patient is blind, we must communicate using clear verbal explanations. The dental radiographer must keep the patient informed of what is being done and explain each procedure before performing it. b. Hearing impairment: if a person is deaf or hearing impaired, the dental radiographer may ask the caretaker to act as interpreter, or use written instructions. When the patient can read lips, the dental radiographer must face the patient and speak clearly and slowly. c. Mobility impairment: if a person is in a wheelchair and does not have use of the lower limbs, assist the patient in transferring to the dental chair. If a transfer is not possible, we perform the procedure with the patient seated in the wheelchair. If a person does not have use the upper limbs and a holder cannot to stabilize the film placement, ask the caretaker to assist with film holding. The dental radiographer must never hold a film during exposure. 5. Developmental Disabilities (Autism, cerebral palsy, epilepsy and other neuropathies and mental retardation). A person with a developmental disability may have problems with coordination or comprehension of instruction. If coordination is a problem, mild sedation may be useful. If comprehension is a problem and the patient cannot hold a film, the caretaker may be asked to assist with film holding. It's important that the dental radiographer recognize situations in which the patient cannot tolerate intraoral exposure. In such cases no intraoral films must be used and change to extraoral films. 6. Neuromuscular problems Refer to patient inability to remain immobile a. Speed is essential in radiographic procedure. b. Minimization of the exposure interval through: *The use of fast films. *Decrease the source-object distance. *Maximally high kilo voltage. *Highest milli amperage c. Using of films holders that can be stabilized by another person but not by dental office staff. d. Extraoral films may be useful supplemented by intraoral films. e. Sedation sometimes is essential. f. Radiograph can be performed under anesthesia. ❖ Localization techniques It's a method used to locate the position of a tooth or object in the jaws. Localization technique may be used to locate the followings: 1) foreign bodies 2) impacted teeth 3) retained roots 4) salivary stones 5) root positions 6) jaw fractures 7) broken needles & instruments The radiograph presents as two dimensional image of a three-dimensional object. There is often a need for determining special relationship. So techniques for doing this are discussed as follows: A. 3D radiography (CBCT) B. Tube shift technique. C. Use of radio-opaque media Tube shift technique: : It employs the concepts called Clark's rule. The area in question is anesthetized, a small hypodermic needle is inserted in vertical position in mucobuccal fold near the object in question, a radiograph is taken, then insert another film and second radiograph is taken with mesial shifted tube. The 2 films are processed and compared. If the object in the second radiograph appears more mesialy, that means the object is located far lingualy or palately, while if it is more distally (in relation to the needle) it means it is buccaly positioned, and if it is not move it means that it is close to the needle. *note: to remember the tube shift technique. Keep in your mind the word (SLOB) Same = Lingual , Opposite = Buccal Use of radio-opaque media: Barium sulfate, lipiodol and dionosil can be used to demonstrate cavernous areas with hard and soft structures. After the injection of the radio-opaque media (mostly lipiodol) in cyst for example, film exposed, processed and viewed to see the extension of the cyst. Radio-opaque media also used in sialogram to demonstrate the salivary glands and their duct. Radiographic survey An examination of a part or an area designed to determine whether any abnormal changes exist within the part or area. It is either routine scanning procedure, or specific purpose survey for example cephalometric films designed to study growth pattern Routine: for children, adult and edentulous 14-17 periapical films with 2-4 posterior bite-wing films are necessary for adequate interpretation of oral conditions.