CHAPTER

Other Imaging Modalities

14
OUTLINE
Computed Tomographic Scanning Resonance Single Photon Emission Computed Tomographic
Computed Tomographic Scanners Magnetic Resonance Signal Imaging
X-Ray Tubes T1 and T2 Relaxation Positron Emission Tomographic Imaging
Detectors Radiofrequency Pulse Sequences (and Image Ultrasonography
Image Reconstruction Contrast) Conventional Tomography
Computed Tomographic Image Tissue Contrast
Artifacts Scanner Gradients
Contrast Agents Magnetic Resonance Images
Applications Applications
Magnetic Resonance Imaging Nuclear Medicine
Protons Radionuclides
Precession Gamma Camera

T
he imaging modalities described in this chapter employ that exit the patient. This information can be used to construct a
equipment and techniques that are beyond the routine cross-sectional image of the patient. In early versions of CT scan-
needs of most general dental practitioners. Each of these ners, both the x-ray tube and the detectors rotated synchronously
techniques makes a tomographic image—that is, a slice through around the patient. In more recent designs, the detectors form a
tissue—rather than a simple projection image. The most versatile continuous ring around the patient, and the x-ray tube moves in
of these modalities are computed tomographic (CT) scanning and a circle within the fixed detector ring (Fig. 14-1, B). Originally,
magnetic resonance (MR) imaging. Nuclear medicine, ultrasonog- patients would lie on a stationary table while the x-ray source
raphy, and positron emission tomographic (PET) imaging are used rotated one cycle around them. Then the table would move 1 to
for more specialized applications. Film tomography, a mainstay 5 mm for the next scan. CT scanners that used this type of “step
imaging technique during the twentieth century, has been largely and shoot” movement for image acquisition are called incremen-
replaced by CT scanning, MR imaging, and cone-beam imaging tal scanners. The final image set consists of a series of contiguous
(see Chapters 11–13). Each of these imaging modalities is used to or overlapping axial images, made at right angles to the long
aid in the diagnosis of conditions in the oral cavity. Thus, dentists axis of the patient’s body. These two-dimensional slices are cross
should have a basic understanding of their operating principles sections, typically 1 mm thick.
and clinical applications. In 1989, CT scanners were introduced that acquire image data
in a helical fashion (Fig. 14-2). With helical scanners, the gantry,
COMPUTED TOMOGRAPHIC SCANNING containing the attached x-ray tube and detectors, continuously
revolves around the patient, while the table on which the patient
In 1972, Hounsfield, an engineer, announced the invention of a is lying continuously advances through the gantry. A continuous
revolutionary imaging technique that used image reconstruction helix of data is acquired as the x-ray beam moves down the patient.
mathematics developed by Cormack in the 1950s and 1960s to Helical CT imaging is now the standard. In helical CT scanners,
produce cross-sectional images of the head. This form of imaging pitch refers to the amount of patient movement compared with
is called computed tomographic (CT) scanning. Hounsfield and the width of the image acquired. More precisely, the equation is
Cormack shared the Nobel Prize in Physiology or Medicine in 1979 as follows:
for their pioneering work.
Table travel per x-ray tube rotation
COMPUTED TOMOGRAPHIC SCANNERS Pitch =
Image thickness
In its simplest form, a CT scanner consists of an x-ray tube that
emits a finely collimated, fan-shaped x-ray beam directed through A pitch of 1 means that the image width is equal to the amount
a patient to a series of scintillation detectors or ionization cham- of patient movement per slice. A pitch of 2 means that the patient
bers (Fig. 14-1, A). These detectors measure the number of photons moves twice as far as the detector is wide, and only half the tissue

229
230 P A RT II Imaging

Third generation
rotate-rotate

Fourth generation
rotate-stationary
FIGURE 14-2 Helical CT imaging. In helical scanners, the patient is moved continuously
through the gantry, and the x-ray source moves continuously around the patient in a circle. The
net effect is to describe a helical beam—and image—path through the patient. True axial
sections are reconstructed in the software.
B

imaging and multirow CT imaging. MDCT imaging has become

widely used and has had a pronounced clinical impact. With this
method, usually 64 or 128 adjacent detector arrays are used in
conjunction with a helical CT scanner (see Fig. 14-1, C). Addition-
ally, the time for the x-ray tube to make a full cycle around the
patient has been reduced to 0.25 second (four rotations per
second). These developments allow images from multiple slices to
Third generation
be captured quickly and simultaneously, thus greatly reducing both
MDCT
exposure time and motion artifact from breathing, peristalsis, or
heart contractions; this is important for patients who cannot hold
their breath for long periods and for pediatric and trauma patients.
The quality of axial, reformatted, and three-dimensional images is
C also greatly improved with MDCT scanners compared with single-
slice scanners. The meaning of pitch with MDCT scanners varies
with the individual manufacturer but often means table travel per
x-ray tube rotation divided by total active detector width. In
general, the patient dose is higher with MDCT scanners than with
FIGURE 14-1 Geometry of CT scanners. A, In CT scanners, the x-ray source emits a single-slice scanners.
fan beam. In third-generation CT scanners, both the x-ray source and the detector array rotate
around the patient in a circular path. The patient is moved incrementally between each rotation X-RAY TUBES
of the source. B, In fourth-generation CT scanners, the x-ray tube rotates around the patient, CT scanners use x-ray tubes with rotating anodes (see Fig. 1-9).
and the remnant beam is detected by a fixed circular array. C, Most contemporary CT scanners These tubes have a high heat capacity, up to 8 million heat units
use a third-generation design with a relatively wide multidetector helical computed tomographic (compare with dental tubes of 20,000 heat units). They operate at
(MDCT) array having 64 to 128 rows. In these scanners, all parts of the detector array arc are typically 120 kVp (range, 80 to 140 kVp) and 200 to 800 mA. Focal
equidistant from the x-ray source. spot sizes range from 0.5 to 2.0 mm. The high x-ray output mini-
mizes exposure time and improves image quality by increasing the
signal-to-noise ratio. The high kVp also provides a wide dynamic
is exposed. A pitch of 0.5 means that half the image is overlapped range by reducing bone absorption compared with soft tissue and
in each slice. Overlapping reconstructions result in the highest extends tube life by reducing tube loading. The tubes operate
spatial resolution but also the highest patient dose. Compared with continuously by using three-phase or high-frequency generators.
incremental CT scanners, helical scanners provide improved multi- To minimize patient exposure the beam is collimated to a thin fan
planar image reconstructions, reduced examination time, and a beam before it enters the patient. Some of the x-ray photons
reduced radiation dose. interact with the patient and are scattered. To improve image
The most recent major advance was the introduction of multi- quality the residual beam is again collimated to remove the scat-
detector helical computed tomographic (MDCT) scanners in 1998. tered photons. Postpatient collimation controls slice thickness.
Alternative terms for the same technology are multislice CT Slice thickness is typically 1 to 3 mm. Thinner slices result in
 C H A PTE R 14 Other Imaging Modalities 231

higher spatial resolution and contrast, less partial volume effect (about 0.6 mm) is determined partly by the computer program
(see later), and higher patient dose. used to construct the image, the length of the voxel (about 1 to
20 mm) is determined by the width of the x-ray beam, which is
DETECTORS controlled by the prepatient and postpatient collimators. An inter-
The x-ray beam exiting the patient is captured by an array of solid- polator algorithm is used to correct for the helical motion of the
state detectors. These detectors are usually made of rare earth scanner and to construct planar cross sections from the helical
materials, such as Gd2S2O. The spaces between the ceramic scintil- information.
lators or crystals are heated into a ceramic, sawn into small ele- The methods used to reconstruct images are complex. Initially,
ments, and coupled to a photodiode. The ceramic is scored with an object with four compartments, as shown in Figure 14-4, should
a saw or laser, and the spaces are filled with an opaque material to be pictured. The linear attenuation coefficients (densities) of each
create individual pixels 0.625 mm across. These detectors are about of the four cells can be computed by using four simultaneous
80% efficient. The signal from the detector is amplified, digitized, equations to solve for four unknowns. This method becomes
and sent to a computer for analysis. computationally impracticable when there are 5122 or 10242
cells. Instead, methods called filtered back-projection algorithms
IMAGE RECONSTRUCTION involving Fourier transformations are used for rapid image recon-
The photons recorded by the detectors represent a composite of struction. A modification of these methods, called the Feldkamp
the absorption characteristics of all elements of the patient in the reconstruction, is used for MDCT and cone-beam reconstructions
path of the x-ray beam. Computer algorithms use these photon to account for the diverging x-ray beam. This same principle is
counts to construct one or, more often, many digital cross-sectional used in cone-beam imaging (see Chapter 11). After reconstruction,
images. The CT image is recorded and displayed as a matrix of various image processing filters are applied. Typically, these are
individual blocks called voxels (volume elements) (Fig. 14-3). Each smoothing filters to minimize noise in low-contrast objects such
square of the image matrix is a pixel. Images are typically 512 × as soft tissue and edge-sharpening filters to improve visualization
512 pixels or 1024 × 1024 pixels. Although the size of the pixel of fine bony detail. In recent years, an image processing technique

A
C
B FIGURE 14-3 CT image formation. A, Data for a single-plane
image are acquired from multiple projections made during the course of
a 360-degree rotation around the patient. Slice thickness (c) is controlled
by the width of the postpatient collimator. B, A single-plane image is
constructed from absorption characteristics of the subject and displayed
as differences in optical density, ranging from −1000 to +1000 HU.
Several planes may be imaged from multiple contiguous scans. C, The
image consists of a matrix of individual pixels representing the face of a
volume called a voxel. Although dimensions a and b are determined partly
by the computer program used to construct the image, dimension c is
C C controlled by the collimator as in A. D, Cuboid voxels can be created
b from the original rectangular voxel by computer interpolation. This allows
a the formation of multiplanar and three-dimensional images (E).

D
E
C3
C2
C1
232 P A RT II Imaging

FIGURE 14-4 Image reconstruction. A, Assume N0

N0
four volumes with differing linear attenuation coefficients
(μ). A beam entering the object with N0 photons is
reduced in intensity by object. The intensity of the
remnant beam is measured by the detector array. The
N0 N1 13
value of each cell in the object can be determined by 1 2 8 5
solving four (or more) independent simultaneous equa-
tions. Such a brute-force approach is computationally N0 N2 11
intensive, and in practice much faster algorithms are 3 4 7 4
used to reconstruct images. B, This task is conceptually
similar to sudoku problems in that the exposure to the
detector is known, and the filtered back-projection algo- A N3 B 12
rithms estimate the exposure intensity at each voxel. N4 9

called iterative reconstruction has been used instead of filtered

back-projection to reduce noise from images. This technique allows T AB L E 1 4 -1 Typical Hounsfield Units for Air
the use of low-dose protocols yet still produces images with com- and Tissues
parable or better image quality. More recent research in CT imaging
includes using dual-energy CT imaging and spectral CT imaging Tissue Hounsfield Units (CT Numbers)
to remove bone from soft tissue images and to facilitate tissue Bone +400 to +1000
characterization.
Soft tissue +40 to +80
COMPUTED TOMOGRAPHIC IMAGE Water 0
For image display, each pixel is assigned a CT number represent-
ing tissue density. This number is proportional to the degree to Fat −60 to −100
which the material within the voxel has attenuated the x-ray Lung −400 to −600
beam. CT numbers, also known as Hounsfield units (HU), in
honor of the inventor Hounsfield, range from −1000 to +1000, Air −1000
each corresponding to a different level of beam attenuation (Table
14-1). Some newer CT machines have a range of up to 4000 HU. CT Numbers
Because the human eye can detect only about 40 shades of gray,
it is useful to adjust the range and mean of CT numbers displayed Bone Original Soft tissue
window scan window
on a monitor (Fig. 14-5). An image optimized for viewing bone, 850 1000 Bone 240
a “bone window,” may have a range (window width [WW]) of
700 units and mean (window level [WL]) of 500 units. Alterna-
tively, an image optimized to view soft tissues may have a WW
of 400 units and a WL of 40 units. In these images, bone is
white or light grey, soft tissue is medium gray, and air is dark
grey to black. By convention, these images are displayed as if the - 0 Water
clinician is standing at the feet of the patient who is lying on
his or her back. Thus, the patient’s anterior structures appear at
the top (Fig. 14-6, A), and the patient’s right side appears on the
left (Fig. 14-6, B and C).
CT imaging has several advantages over conventional film radi-
ography and tomography. First, CT imaging eliminates the super- 150 1000 Air 160
WW = 700 WW = 400
imposition of images of structures outside the area of interest. WL = 500 WL = 40
Second, because of the inherent high-contrast resolution of CT
imaging, differences between tissues that differ in physical density FIGURE 14-5 Window width and level. CT numbers (HU) are scaled on cortical bone
by less than 1% can be distinguished; conventional radiography (+1000), water (0), and air (−1000). Viewing bone or soft tissue is optimized by improving
requires a 10% difference in physical density to distinguish between the contrast of the appropriate region of the original image. Window width (WW) is the range
tissues. Third, data from a single CT imaging procedure, consisting of CT numbers used, and window level (WL) is the midportion of the range. Bone and soft
of either multiple contiguous or one helical scan, can be viewed tissue window views are used to enhance visualization of those tissues. In this example, a bone
as images in the axial, coronal, or sagittal planes or in any arbitrary window may have a range of 700 units and a mean of 500 units, whereas a soft tissue window
plane depending on the diagnostic task; this is referred to as mul- may have a range of 400 units and a mean of 40 units.
tiplanar reformatted imaging. Having the capability of viewing
normal anatomy or pathologic processes simultaneously in three limitation has led to the development of computer programs that
orthogonal planes often facilitates radiographic interpretation (see reformat data acquired from axial CT scans into three-dimensional
Fig. 14-6). images. The use of three-dimensional images has been boosted by
Multiplanar images are two-dimensional and require a certain the use of MDCT imaging as a means of reviewing large amounts
degree of mental integration by the viewer for interpretation. This of information collected at each examination.
 C H A PTE R 14 Other Imaging Modalities 233

A B C

FIGURE 14-6 Multiplanar reconstruction views facilitate interpretation of complex anatomy. A, CT images demonstrating the sagittal
plane through lateral incisors and foramen lacerum. Note the frontal, ethmoid, and sphenoid sinuses. B, Coronal view through the ethmoid
and maxillary sinuses and mental foramen in the left mandible. C, Axial view through the level of maxillary sinuses and mandibular
condyles. The patient’s right side appears on the left side of the coronal and sagittal images as if the patient is lying on the back with the
toes pointed toward the observer.

Three-dimensional reformatting requires that each original

voxel, shaped as a rectangular solid, be dimensionally altered into
multiple cuboidal voxels. This process, called interpolation,
creates sets of evenly spaced cuboidal voxels (cuberilles) that
occupy the same volume as the original voxel (see Fig. 14-4, D).
The CT numbers of the cuberilles represent the average of the
original voxel CT numbers surrounding each of the new voxels.
Isotropic voxels 0.24 mm in size can be achieved. Creation of these
new cuboidal voxels allows the image to be reconstructed in any
plane without loss of resolution by locating the position of each
voxel in space relative to one another. In constructing the three-
dimensional CT image, only cuberilles representing the surface of
the object scanned are displayed on the monitor. The surface
formed by these cuberilles, either solid or partially transparent, is
made to appear as if illuminated by a light source located behind
the viewer (Fig. 14-7). In this manner, the visible surface of each
pixel is assigned a gray-level value, depending on its distance from
and orientation to the light source. Thus, pixels that face the light
source or are closer to it appear brighter than pixels that are turned FIGURE 14-7 Three-dimensional rendering. Three-dimensional images can be recon-
away from the source or are farther away. After construction, three- structed from the cuberilles, thresholded for bone (left) or soft tissue (right), oriented in any
dimensional CT images may be manipulated further by rotation arbitrary direction, and made to appear to have depth by highlighting structures near the front
around any axis to display the structure imaged from any angle. and shadowing structures near the back. This patient has hemifacial microsomia and demon-
Also, external surfaces of the image can be removed electronically strates incomplete development of the left frontal, sphenoid, temporal maxillary, zygomatic,
to reveal concealed deeper anatomy. and mandibular bones. Note also the reduced size of the left orbit, depression of the tip of the
nose, missing and incompletely erupted left maxillary teeth, deviation of the right mandible to
ARTIFACTS the left, sunken left midface, and malformation of the left ear. (Images courtesy Dr. P.-L.
Different types of artifacts may degrade CT images. Partial volume Westesson, University of Rochester, NY).
artifact occurs because a voxel has finite dimensions. When a voxel
contains tissues of differing densities (e.g., bone and soft tissue),
the resulting CT number for that voxel is an intermediate value artifacts occur because of the near-complete absorption of x-ray
that does not represent either tissue. The resulting image may be photons by metallic restorations. They appear as opaque streaks in
a blurring of the junction of the tissues or a loss of part of a thin the occlusal plane (see Figs. 14-6, B, and 14-7).
cortical layer of bone. Beam-hardening artifact results by the
preferential absorption of lower energy photons in the heteroge- CONTRAST AGENTS
neous x-ray beam. Because the distance through the center of the Contrast agents are substances used to improve visualization of
head is longer than along a path closer to the surface, there is structures. CT imaging frequently uses iodine, administered intra-
beam hardening seen as darkening in the middle of an axial slice. venously, to enhance soft tissue and vascular image detail. The
Software algorithms may minimize this artifact. Metal streaking iodine in the contrast medium has a large atomic number and
234 P A RT II Imaging

FIGURE 14-8 Contrast agents. Iodine may be

administered intravenously to enhance blood vessels and
structures with a rich vascular supply, including the periph-
ery of some tumors. A, CT image through the mandible
in the soft tissue window and after administration of
iodine. Note prominent great vessels lying just anterior and
lateral to the cervical vertebrae and muscles of the floor
of the mouth and neck. B, The same axial slice displayed
in the bone window. Note the presence of fine detail in
the mandible and cervical spine, such as cortical and
cancellous bone and teeth, including their pulp chambers,
but loss of soft tissue contrast.
A B

effectively absorbs x rays (Fig. 14-8). Malignant facial tumors often N S

are more vascularized than surrounding normal tissues; thus, the
presence of the iodine perfusing these tissues increases their radio-
graphic density and makes their margins more detectable. Contrast
medium also helps to visualize enlarged lymph nodes containing
metastatic carcinoma. However, contrast dye can be toxic to the
kidneys in elderly patients with kidney disease. N
N
S S
APPLICATIONS
CT imaging is useful for diagnosing and determining the extent
of a wide variety of infections, osteomyelitis, cysts, benign and
malignant tumors, and trauma in the maxillofacial region. The N
ability of CT imaging to display fine bone detail makes it an ideal
modality for lesions involving bone. Three-dimensional CT
S
imaging has been applied to trauma cases and craniofacial recon-
N
structive surgery and has been used for treatment of both con-
genital and acquired deformities. The availability of data in a
three-dimensional format also has allowed the construction of
life-sized models that can be used for trial surgeries and the con- S
struction of surgical stents for guiding dental implant placement FIGURE 14-9 Magnetic dipoles. Hydrogen nuclei within a patient normally have randomly
and for the creation of accurate implanted prostheses. oriented dipoles and thus no net magnetic vector.

MAGNETIC RESONANCE IMAGING

Lauterbur described the first MR image in 1973, and Mansfield PROTONS
further developed use of the magnetic field and the mathematical Individual protons and neutrons (nucleons) in the nuclei of all
analysis of the signals for image reconstruction. MR imaging atoms possess a spin, or angular momentum. In nuclei having
was developed for clinical use around 1980, and Lauterbur and equal numbers of protons and neutrons, the spin of each nucleon
Mansfield were awarded the Nobel Prize in Physiology or Medicine cancels that of another, producing a net spin of zero. However,
in 2003. nuclei containing an unpaired proton or neutron have a net spin.
To make an MR image, the patient is first placed inside a large Because spin is associated with an electrical charge, a magnetic field
magnet. This magnetic field causes the nuclei of many atoms in is generated in nuclei with unpaired nucleons, causing these nuclei
the body, particularly hydrogen, to align with the magnetic field. to act as magnets with north and south poles (magnetic dipoles)
The scanner directs a radiofrequency (RF) pulse into the patient, and having a magnetic moment. The most common of these
causing some hydrogen nuclei to absorb energy (resonate). When atoms, the MR active nuclei, are hydrogen, carbon 13, nitrogen
the RF pulse is turned off, the stored energy is released from the 15, oxygen 17, fluorine 19, sodium 23, and phosphorus 31. Hydro-
body and detected as a signal in a coil in the scanner. This signal gen is the most abundant of these atoms in the body.
is used to construct the MR image—in essence, a map of the dis- A hydrogen nucleus consists of a single unpaired proton and
tribution of hydrogen. therefore acts as a magnetic dipole. Normally, these magnetic
MR imaging has the particular advantages of being noninva- dipoles are randomly oriented in space (Fig. 14-9). When an exter-
sive, using nonionizing radiation, and making high-quality images nal magnetic field is applied, the hydrogen nuclear axes align in
of soft tissue resolution in any imaging plane. Disadvantages of the direction of the magnetic field (Fig. 14-10). Two states are pos-
MR imaging include high cost, long scan times, and the fact that sible: spin-up, which parallels the external magnetic field, and
various metals in the imaging field either distort the image or may spin-down, which is antiparallel with the field. Because more
move into the strong magnetic field, injuring the patient. energy is required to align antiparallel with the magnetic field,
 C H A PTE R 14 Other Imaging Modalities 235

antiparallel hydrogen nuclei are considered to be at a higher energy called precession, is similar to a spinning toy top, which rotates
state than hydrogen nuclei aligned parallel with the field. Nuclei around an upright position as it slows down. Similarly, the pres-
prefer to be in a lower energy state, and usually more are aligned ence of the magnetic field causes the axis of the spinning proton
parallel with the magnetic field. This situation results in a net to wobble (or precess) around the lines of the applied magnetic
magnetization vector in the direction of the magnetic field. Increas- field (Fig. 14-12). The rate or frequency of precession is called the
ing the magnetic field strength increases the magnitude of the net precessional frequency, resonance frequency, or Larmor fre-
magnetization vector. quency. The precessional frequency depends on the species of
nucleus (i.e., hydrogen nucleus or other) and is proportional to the
PRECESSION strength of the external magnetic field. The magnetic field in an
The magnetic moments of hydrogen nuclei in a magnetic field do MR scanner is provided by an external permanent magnet. MR
not align exactly with the direction of the magnetic field. Instead, field strengths range from 0.1 to 4 Tesla (T) with 1.5 T being the
the orientations of the axes of spinning protons actually oscillate most common (1.5 T is about 30,000 times the strength of the
with a slight tilt from a position absolutely parallel with the flux earth’s magnetic field). The Larmor precession frequency of hydro-
of the external magnet (Fig. 14-11). This tilting of the spin axis, gen is 63.86 MHz in a magnetic field of 1.5 T. Other MR active
nuclei precess at different frequencies in the same magnetic field.

N
RESONANCE
Nuclei can be made to undergo transition from one energy state
to another by absorbing or releasing energy. Energy required for
transition from the lower to the higher energy level can be supplied

S N
External magnetic field

External magnetic field

N S
S N

S
N
High-energy Low-energy High-energy Low-energy
state state state state

FIGURE 14-10 Hydrogen nuclei in an external magnetic field. In the presence of an FIGURE 14-11 Hydrogen nuclei in an external magnetic field. The magnetic dipoles are
applied strong external magnetic field, most nuclei are in the lower energy state and are aligned not aligned exactly with the external magnetic field. Instead, the axes of spinning protons
parallel with the magnetic field, whereas others align in the higher energy state antiparallel to actually oscillate or wobble with a slight tilt from being absolutely parallel with the flux of the
the magnetic field. external magnet.

Vertical Applied
magnetic field
Precession Precession
N FIGURE 14-12 Precession. Much as a top rotates around a vertical axis
when spinning, the spin axis of a spinning hydrogen nucleus rotates around
the direction of the external magnetic field. This movement is called precession,
and the rate or frequency of precession is called the precessional, resonance,
Spin or Larmor frequency. The Larmor frequency depends on the strength of the
Spin
external magnetic field and is specific for the nuclear species.

Spinning top Spinning H nucleus

236 P A RT II Imaging

by electromagnetic energy in the RF portion of the electromagnetic some of the low-energy nuclei (parallel) to gain energy to convert
spectrum. In an MR imaging scanner, the RF broadcast from an to the high-energy (antiparallel) state. As a consequence, the lon-
antenna coil is directed to tissue with protons (hydrogen nuclei) gitudinal magnetic vector is reduced. The longer the RF pulse is
aligned in the Z axis (long axis of a patient) by the external static applied, the less the longitudinal magnetic vector. The RF pulse
magnetic field (Fig. 14-13). When the frequency of the RF pulse also causes the protons to precess in phase with each other, result-
matches the Larmor frequency of the protons in the tissue, the ing in a net tissue magnetization vector in the transverse plane (XY
protons resonate and absorb the RF energy. This absorbance causes plane) perpendicular to longitudinal alignment (Z axis) (Fig. 14-14).

Z axis Z axis

Longitudinal
magnetization Longitudinal
vector magnetization
vector
Y axis Y axis

XY plane XY plane

X axis X axis

A B
FIGURE 14-13 Longitudinal magnetic vector. When hydrogen nuclei are in an external magnetic field, two energy states result:
spin-up, which is parallel to the direction of the field, and spin-down, which is antiparallel to the direction of the field. A, The combined
effect of these two energy states is a weak net magnetic moment, or magnetization vector parallel with the applied magnetic field.
B, When the frequency of the RF pulse matches the Larmor frequency, the protons absorb the RF energy causing some low-energy nuclei
to convert to the high-energy state, reducing the net longitudinal magnetic vector (vertical black arrow in Z axis).

Z axis Z axis

Y axis Y axis

XY plane XY plane

X axis X axis

Transverse Transverse
magnetization magnetization
vector vector

A B
FIGURE 14-14 Transverse magnetic vector. A, RF pulse also causes the protons to precess in phase with each other, resulting in
a net tissue magnetization vector in the transverse plane (XY plane). B, Increasing the intensity and duration RF of the pulse increases
the transverse magnetization vector because the nuclei are more nearly in phase (horizontal black arrow in X axis).
 C H A PTE R 14 Other Imaging Modalities 237

Z axis

Y axis

FIGURE 14-15 Receiver coil. The precession of the net transverse magnetic vector
in the XY plane induces a current flow in a receiver coil, the MR signal. The frequency of
Receiver this induced alternating current signal matches the frequency of the RF pulse and the Larmor
X axis coil precessional frequency of hydrogen nuclei.

Transverse
magnetization
vector

If the RF pulse is of sufficient intensity and duration, the longitu-

dinal magnetic vector is reduced to zero. An RF pulse that accom- T AB LE 1 4 -2 T1 and T2 Relaxation Times in
plished this is called a 90-degree RF pulse or having a flip angle a Main Field of 1.5 Tesla
of 90 degrees. At this time, the net magnetic vector in the trans-
verse plane is maximized because the magnetic moments of all Tissue Type T1 Time (ms) T2 Time (ms)
nuclei are in phase. Fat 240–250 60–80
MAGNETIC RESONANCE SIGNAL Bone marrow 550 50
The precession of the net magnetic vector—that is, the precession White matter of cerebrum 780 90
of the magnetic moments of the hydrogen nuclei in phase in the
transverse plane—induces a current flow in a receiver coil (Fig. Gray matter of cerebrum 920 100
14-15), the MR signal. The frequency of this alternating current Muscle 860–900 50
signal matches the frequency of the RF pulse and the Larmor
precessional frequency of hydrogen nuclei. The magnitude of this CSF (similar to water) 2200–2400 500–1400
signal is proportional to the overall concentration of hydrogen CSF, Cerebrospinal fluid.
nuclei (proton density) in the tissue. This strength of the signal
also depends on the degree to which hydrogen is bound within a
molecule. Tightly bound hydrogen atoms, such as hydrogen atoms decay signal. The free induction decay of the MR signal results
present in bone, do not align themselves with the external mag- from the loss of the transverse net magnetization vector; this
netic field and produce only a weak signal. Loosely bound or results from return of the net magnetization vector to the longitu-
mobile hydrogen atoms, such as those in soft tissues and liquids, dinal plane and dephasing of the hydrogen nuclei.
react to the RF pulse and produce a detectable signal at the end
of the RF pulse. The concentration of loosely bound hydrogen T1 AND T2 RELAXATION
nuclei available to create the signal is referred to as the proton Relaxation at the end of the RF pulse results in recovery of the
density or spin density of the tissue in question. The higher the longitudinal magnetization; this is accomplished by a transfer of
concentration of these nuclei of loosely bound hydrogen atoms, energy from individual hydrogen nuclei (spin) to the surrounding
the stronger the net transverse magnetization, the more intense the molecules (lattice). This is an exponential process, and the time
recovered signal, and the brighter the corresponding part of the required for 63% of the net magnetization to return to equilibrium
MR image. (the time constant) by this transfer of energy is called the T1
When the RF pulse is turned off, the nuclei begin to return to relaxation time or spin-lattice relaxation time. The T1 relaxation
their original lower energy spin state, a condition called relaxation. time varies with different tissues and reflects the ability of their
As they give up the energy absorbed by the RF pulse, some of the nuclei to transfer their excess energy to surrounding molecules
high-energy nuclei return to the low-energy state, and the net (Table 14-2). Tissues with a high fluid content, such as cerebrospi-
longitudinal magnetic vector returns to its original state. Addition- nal fluid (CSF), tend to have long T1 times because the high
ally, and independently, the individual magnetic moments of the inherent energy of water inhibits the transfer of energy from
protons begin to interact with each other and dephase. This excited hydrogen nuclei. However, tissues with a high fat content,
dephasing results in reduction of the magnetization in the trans- such as bone marrow, tend to have short T1 times reflecting the
verse plane, a condition called decay. As a result of the loss of low inherent energy of fat and the relative ease by which energy is
transverse magnetization and the dephasing of the hydrogen transferred from excited hydrogen nuclei.
nuclei, there is a loss of intensity of the MR signal. The reduced Additionally, at the end of the RF pulse, the magnetic moments
voltage induced in the receiving coil is called the free induction of adjacent hydrogen nuclei begin to interfere with one another,
238 P A RT II Imaging

causing the nuclei to dephase with a resultant loss of transverse

magnetization. The time constant that describes the exponential T2-Weighted Image
rate of loss of transverse magnetization is called the T2 relaxation A T2-weighted image emphasizes differences in T2 values of tissues
time or the spin-spin relaxation time. As the transverse magneti- (Fig. 14-17, B); this is accomplished by use of long TR (2000 ms)
zation rapidly decays to zero, so does the amplitude and duration and long TE (typically ≥60 ms). In such images, tissues with long T2
of the detected radio signal. T2 relaxation occurs more rapidly than times, such as CSF or temporomandibular joint (TMJ) fluid, appear
T1 relaxation. Similar to T1 times, T2 times are also a feature of bright, whereas tissues with short T2 times, such as fat, appear dark.
the tissues being examined. Fatty tissues have short T2 relaxation Images with T2 weighting are most commonly used for identifying
times, whereas tissues containing more fluid have long T2 relax- pathology because pathologic tissue usually contains more water
ation times. The closely packed molecular structure of fat results than surrounding tissues, owing to inflammation.
in more potent dephasing interactions between adjacent hydrogen There are many pulse sequences varying the strength and timing
nuclei compared with the spaced molecular arrangement of water. of the RF pulses that emphasize or suppress various tissues in the
resultant images. Techniques such as turbo spin echo and gradient
RADIOFREQUENCY PULSE SEQUENCES echo allow images to be captured rapidly. Other techniques allow
(AND IMAGE CONTRAST) the signal from fat or water to be enhanced or suppressed. A tech-
The components of the RF pulse sequence are set by the operator nique called fat saturation, seen commonly in short tau inversion
and determine the appearance of the resultant image. The most recovery (STIR) sequences, minimizes the signal from fat allowing
basic features of a pulse sequence are the repetition time (TR) and improved visualization of adjacent structures. Similarly, fluid
echo time (TE). The TR is the duration between repeat RF pulses attenuated inversion recovery (FLAIR) sequences minimize the
(Fig. 14-16). The time between pulse repetitions determines the signal from fluid, allowing for better visualization of pathology
amount of T1 relaxation that has occurred at the time the signal adjacent to the CSF.
is collected. The TE is the time after application of the RF pulse
when the MR signal is read. It controls the amount of T2 relaxation Contrast Agents
that has occurred when the signal is collected. There are many Contrast agents, most commonly gadolinium, may be adminis-
sequences that can be used to emphasize various features of the tered intravenously to improve tissue contrast (Fig. 14-17, C).
tissues being examined. Gadolinium is not imaged itself, but rather it shortens the T1
relaxation times of enhancing tissues, making them appear brighter.
TISSUE CONTRAST Tissues that enhance include normal tissues, such as vessels with
Image contrast between tissues is governed both by intrinsic fea- slow-flowing blood, sinus mucosa, and muscle. Pathologic tissues
tures of the tissues, including the proton density and T1 and T2 often enhance allowing them to be better differentiated from sur-
times of the issues being imaged, and by extrinsic parameters of a rounding normal tissue. Pathologic tissues include tumors, infec-
given pulse sequence, such as the TR and TE, which can be tions, inflammations, and posttraumatic lesions. For imaging the
adjusted to emphasize those features. For instance, a tissue that has head and neck, it is common practice to obtain T1 images, T1
a high proton density and strong transverse magnetization vector images after gadolinium administration and with fat saturation,
(protons precessing in phase) at TE produces a strong MR signal and T2 images with fat saturation. There is more recent evidence
that appears bright on an MR image. Conversely, a tissue with a that gadolinium-based contrast media could be a cause of a debili-
low proton density or low transverse magnetization vector at TE tating disease called nephrogenic systemic fibrosis in some patients
produces a weak signal and appears dark on an MR image. with renal dysfunction. The implications of this finding are under
active study.
T1-Weighted Image
A T1-weighted image emphasizes differences in T1 values of tissues SCANNER GRADIENTS
(Fig. 14-17, A); this is accomplished by use of short TR (typically To generate an image, an MR signal must be collected from a
300 to 700 ms) and short TE (20 ms). In such images, tissues with discrete slice of tissue in the patient. Image production is accom-
short T1 times, such as fat, appear bright, whereas tissues with long plished by using three gradient coils within the bore of the imaging
T1 times, such as CSF (water), appear dark. T1-weighted images magnet oriented in the X (left to right), Y (anterior to posterior),
are more commonly used to demonstrate anatomy. and Z (head to toe) planes. The intensity of the magnetic field

TR

RF pulse RF pulse
FIGURE 14-16 RF pulse sequences. The most basic features of a pulse
sequence are the TR, the replication time, the duration between repeat RF TE TE
pulses, and the TE, the echo time, the time after application of the RF pulse
when the MR signal is read. TR determines the amount of T1 relaxation that
has occurred at the time the signal is collected, whereas TE controls the
amount of T2 relaxation that has occurred when the signal is collected.
MR signal MR signal

Time
 C H A PTE R 14 Other Imaging Modalities 239

A B

C
FIGURE 14-17 MR images. MR imaging examination performed to evaluate a neck mass in a patient with a known diagnosis of
multiple myeloma. A, Axial T1 precontrast (no fat saturation) image through the mandible. Note abnormally dark marrow in the posterior
right mandible (upper arrow, compare with left side) and mass in the right carotid space (lower arrow). B, Axial T1 postcontrast image
with fat saturation. Note abnormal enhancement of the mass in the right carotid space. C, Axial T2 with fat saturation demonstrating
an abnormally bright signal in both the marrow in the right mandible and the mass in the right carotid space. (Courtesy Dr. Thomas Underhill,
Radiology Associates, Richmond, VA.)

surrounding a patient may be modified with these gradient coils. Y (transverse) planes of the selected longitudinal plane is derived
When one of the coils is turned on, it creates a gradient in the by switching off the Z-gradient coil followed by rapidly turning on
intensity of the magnetic field. Thus, in a 1.5 T scanner, when the the X-gradient and then the Y-gradient coils (phase encoding and
Z-axis gradient is turned on, the strength of the magnetic field at frequency encoding, respectively). This sequence alters the phase
the head might be 1.4 T and at the toe might be 1.6 T. When this and precessional frequencies of the nuclei in the selected slice. The
gradient field is applied, the precessional frequency of hydrogen resulting MR signal from the patient is read out while the frequency-
nuclei varies linearly along the magnetic gradient. When an RF encoding gradient is applied. The signal from the patient contains
pulse is applied, only nuclei precessing at the same frequency as many frequencies that are decomposed by the fast Fourier trans-
the applied signal resonate; this allows selecting the desired slice form into amplitude and frequency. This information, which
of tissue along the patient’s long axis (Z gradient). The slope of the reflects the number of hydrogen nuclei and their T1 and T2 prop-
gradient applied and the bandwidth of the RF pulse determine the erties at each X and Y location in the selected longitudinal plane,
thickness of this slice. The location of the signal within the X and is reconstructed into MR images.
240 P A RT II Imaging

MAGNETIC RESONANCE IMAGES NUCLEAR MEDICINE

MR imaging has several advantages over other diagnostic imaging Film radiography, CT imaging, MR imaging, and diagnostic ultra-
procedures. First, it offers the best contrast resolution of soft sonography are morphologic imaging techniques in that each
tissues. Although x-ray attenuation coefficients of soft tissues may requires a macroscopic anatomic change for information to be
vary by no more than 1%, T1 and T2 relaxation times may vary recorded by an image receptor. However, in some human diseases,
by up to 40%. Second, no ionizing radiation is involved with MR abnormal biochemical processes occur without anatomic change.
imaging. Third, because the region of the body imaged in MR Radionuclide imaging (a form of functional imaging) provides a
imaging is controlled with the gradient coils, direct multiplanar means of assessing such physiologic change. Nuclear medicine
imaging is possible without reorienting the patient. examinations are commonly used to assign function of the brain,
Disadvantages of MR imaging include relatively long imaging thyroids, heart, lungs, and gastrointestinal system as well as for
times and the potential hazard imposed by the presence of ferro- diagnosis and follow-up of metastatic disease, bone tumors, and
magnetic metals in the vicinity of the imaging magnet. This latter infection (Fig. 14-22).
disadvantage excludes from MR imaging any patient with Radionuclide imaging uses radioactive atoms or molecules that
implanted metallic foreign objects or medical devices that consist emit γ (gamma) rays. These atoms behave in an organism in a
of or contain ferromagnetic metals (e.g., cardiac pacemakers, some manner comparable to their stable counterparts because they are
cerebral aneurysm clips, or ferrous foreign bodies in the eye). The chemically indistinguishable. Radionuclides allow measurement of
strong magnetic fields may harm patients if they move these tissue function in vivo and provide an early marker of disease
objects, cause excessive heating, or induce strong electrical cur- through measurement of biochemical change. After the radionu-
rents. Gold and stainless steel are considered to be ferromagnetic, clides are administered, they distribute in the body according to
whereas nickel, titanium, amalgam restorations, and silver- their chemical properties. The gamma camera detects γ rays and
palladium are not. Metals used in dental restorations or orthodon- forms planar images showing the locations of the radionuclides in
tics do not move but may significantly distort the image in their the body. Single photon emission computed tomographic (SPECT)
vicinity. Accordingly, archwires and any removable appliances imaging and PET imaging are advanced nuclear medicine tech-
should be removed before scanning. Stainless steel brackets and niques that form tomographic views. More recently, molecular
bands should be checked to ensure that they are well cemented imaging of individual gene expression is being performed in the
and, if so, may be left in place unless they interfere with the region laboratory. As with CT imaging, iterative reconstruction tech-
of the image being examined. Titanium implants cause only minor niques improve the diagnostic quality of the images.
local image degradation. Finally, some patients have claustropho-
bia when positioned in an MR imaging machine. RADIONUCLIDES
The ideal radionuclide has a short half-life, emits γ rays but no
APPLICATIONS charged particles, and is capable of binding to various pharmaceu-
Because of its excellent soft tissue contrast resolution, MR imaging ticals. Although many gamma-emitting isotopes are used in radio-
is useful in evaluating soft tissue conditions, such as the position nuclide imaging, including iodine (131I), gallium (67Ga), and
and integrity of the disk in the TMJ (Fig. 14-18); evaluating soft selenium (74Se), the most commonly used is technetium 99m
tissue disease, especially neoplasia involving the soft tissues, such (99mTc). 99mTc has a half-life of 6 hours and emits primarily 140 keV
as tongue, cheek, salivary glands, and neck; determining malignant photons. As technetium pertechnetate, 99mTc mimics iodine distri-
involvement of lymph nodes; and determining perineural invasion bution when injected intravenously and is concentrated by the
by malignant neoplasia. In cases of osteomyelitis, it may be used to salivary and thyroid glands and gastric mucosa. When it is attached
visualize edematous changes in the fatty marrow as well as the sur- to various carrier molecules, it can be used to examine virtually
rounding soft tissue. It also may be useful in identifying the loca- every organ of the body.
tion of the mandibular nerve in cases where it is not clearly seen on To image bone, 99mTc is typically bound to methylene diphos-
panoramic or CBCT images. A technique known as sweep imaging phonate (MDP), and a dose of 20 to 30 mCi (740 to 1110 mega-
with Fourier transform (SWIFT) has proved useful in revealing the becquerels [MBq]) is injected intravenously. Immediately after
extent of penetration of carcinoma into the cortex of the mandible. injection, the tracer distributes intravascularly. Images made during
Similar to CT imaging, a contrast agent such as gadolinium can be this flow phase, the first 60 to 90 seconds, are called radionuclide
added to enhance the image resolution of neoplasia (Fig. 14-19). angiography. In the second, or blood pool, phase, the tracer
Also, it is customary to remove the high signal of surrounding fat quickly moves into the extracellular space. The third, or bone
tissue (fat suppression) to enhance the appearance of the neoplasm. scintigraphy, phase, is made 2 to 3 hours after injection. The MDP
A typical protocol would include T1 images, T1 images after gado- deposition in the skeleton depends both on osteoblastic activity
linium (with fat suppression), and T2 images (with fat suppression). and on blood flow (see Fig. 14-22). Images made 2 to 3 hours after
More recently, high-resolution SWIFT MR images of the dentition injection show most of the tracer activity in the skeleton, kidneys,
have been made with a 4 T system (Fig. 14-20). Although currently and bladder. Most metastatic tumors in bone induce formation of
in the research phase, this method holds promise for future clinical new bone and may be detected on such an examination.
use for dental imaging without ionizing radiation. Radionuclide-labeled tracers are used in quantities well below
MR angiography is used to visualize the blood flowing through amounts that are lethal to cells. However, although radionuclide
vessels. Although there are multiple pulse sequences that produce imaging is considered noninvasive, the radiation dose the patient
bright images of the vessels, most techniques currently use gado- receives as a result of intravenous injection of radionuclide-labeled
linium as an intravenous contrast agent. MR angiography is tracers should be considered. Injection of 740 MBq of 99mTc
mostly used to image arteries, including in the head and neck, pertechnetate delivers a whole-body radiation dose of 2 mGy. This
to examine for occlusion, aneurysms, or arteriovenous malforma- quantity is less than the average annual effective dose resulting
tion (Fig. 14-21). from natural radiation (see Chapter 3).
 C H A PTE R 14 Other Imaging Modalities 241

A B

FIGURE 14-18 MR imaging of TMJ. A, T1-weighted MR image of the TMJ. In this image, the jaw is partly open, as indicated by
the location of the condyle relative to the articular eminence. The articular disk, which has a “bow tie” appearance (arrows), is in a normal
position relative to the translating condyle. B, T2-weighted MR image of the TMJ illustrates both inflammatory effusion into the superior
joint space (arrow) and hyperemia caused by increased vasculature in the retrodiskal tissues (double arrows). C, In this proton or spin
density MR image of the TMJ, the disk is anteriorly displaced (arrow), with the posterior band in the 9 o’clock position relative to the
condylar head. (B and C, Courtesy Richard Harper, DDS, Dallas, TX.)
242 P A RT II Imaging

A B

FIGURE 14-19 Gadolinium enhancement of MR image. A, Axial T1 MR image of a rhabdomyosarcoma involving the soft tissues
of the right face. The tumor cannot be distinguished from the adjacent masseter and pterygoid muscles because both have the same tissue
signal. B, Axial T1 postgadolinium MR image. The tumor now has a brighter signal (lighter) than the adjacent muscles because of its
greater vascularity, enhanced by gadolinium. C, Axial T2 MR image. The tumor has a brighter signal than adjacent muscles because of
greater fluid content of the tumor.
 C H A PTE R 14 Other Imaging Modalities 243

Photograph
FIGURE 14-20 4T SWIFT MR images of denti-
tion. In these in vivo images, the four dotted lines
drawn on the bitewing radiograph and labeled a
B through d indicate the location of the axial slices of
the corresponding CBCT and SWIFT MR images. Note
a
the lack of metallic artifact on the MR images com-
b
pared with the CBCT image at level d. (From Idiyatul-
c lin D, Corum C, Moeller S, et al: Dental magnetic
d resonance imaging: making the invisible visible,
J Endod 37:745–752, 2011.)

2D
Radiograph

D
CBCT SWIFT

R L

Arteriovenous malformation
Left common carotid artery
Right common carotid artery

Brachiocephalic artery Left subclavian artery

Aortic arch

FIGURE 14-21 MR angiography of the head and neck. This image, made with gadolinium as a contrast agent, demonstrates an
arteriovenous malformation in the region of the right face. Note the widened carotid artery and rich vasculature supply in the right midfacial
region. This is a maximum intensity image made from a stack of individual slices. (Image courtesy Dr. Susan White, UCLA School of
Dentistry.)
244 P A RT II Imaging

Nal scintillator Lucite light pipe

Collimator Photomultiplier tubes

Analog to
digital

Anterior L Posterior R Rlat Llat

Pulse height
analyzer

Digital to
analog
FIGURE 14-22 Radionuclide image with increased uptake of 99mTc-MDP in the region of
the right TMJ. The planar images in the top row were captured with a gamma camera. The FIGURE 14-23 Gamma camera. The principal components of a gamma camera are a
lower two tomographic images were captured with SPECT imaging. collimator to limit γ rays to rays perpendicular to the surface of the camera, a sodium iodide
scintillator to absorb the γ rays and emit a flash of visible light, an acrylic (Lucite) light pipe
to conduct the visible light flash, photomultiplier tubes to count the flashes of light and measure
their energy, a pulse height analyzer to select only flashes from the administered radionuclide,
and a monitor to display the resultant image. γ rays traveling parallel to the plates in the collima-
GAMMA CAMERA tor pass through the collimator and contribute to the image. γ rays traveling obliquely are
Gamma cameras (also called Anger cameras and scintillation absorbed by the collimator and do not contribute to the image. The photon resulting from
cameras) are the most common means of forming an image (Fig. Compton scattering in the leg is rejected by the pulse height analyzer and does not contribute
14-23). These cameras capture photons and convert them to light to the image. This image is an anterior view of a patient after intravenous injection of
99m
and then to a voltage signal. This signal is reconstructed to a planar Tc-MDP.
image that shows the distribution of the radionuclide in the
patient. The first part of the gamma camera is a collimator. It
absorbs γ rays that do not travel parallel to the plates, improving to improve identification of the location of the radionuclide (see
image resolution. The γ rays that pass through the collimator strike Fig. 14-24, E).
a scintillation crystal. This crystal, often made of sodium iodide
with trace amounts of thallium, fluoresces when it absorbs γ rays. Applications
These flashes of light are detected by an array of photomultiplier The most common use of nuclear medicine in the maxillofacial
tubes coupled to the crystal with light pipes. The photomultiplier region is to investigate abnormal metabolic bone activity, for
tubes capture the flash and amplify the signal. The size of the signal instance, in assessing growth activity in cases of condylar hyper-
is proportional to the energy of the absorbed photon. The signals plasia and presence of metastatic lesions. Traditionally, a combina-
from the photomultiplier tubes go through an analog-to-digital tion of 99mTc MDP and gallium citrate was used to help diagnose
converter and then to a pulse height analyzer. This device detects osteomyelitis, but CT imaging is now used more frequently.
the intensity of the signal, and thus the energy of the incident SPECT images are used to assess mandibular growth in patients
absorbed photons, and uses only photons from the radionuclide with asymmetry and extent of bisphosphonate-induced osteone-
when forming the final image. Many of the γ rays released from crosis in the jaws (Fig. 14-25) and provide prognostic information
the radionuclide in the patient undergo Compton absorption at for patients with cancer and osteonecrosis of the jaws.
some distant site and result in a new scattered photon. If these
scattered, lower energy photons pass through the collimator of the POSITRON EMISSION TOMOGRAPHIC IMAGING
gamma camera, they may degrade image resolution. However, PET imaging is a more advanced imaging modality in nuclear
these scattered photons are detected by the pulse height analyzer medicine. PET imaging, which is reported to have a sensitivity
and are rejected so that they do not contribute to the image. nearly 100 times that of a gamma camera, relies on positron-
Gamma cameras have a spatial resolution of 3 to 5 mm. Use of a emitting radionuclides generated in a cyclotron. The utility of PET
scintillation crystal for acquisition of data for image formation has imaging is based not only on its sensitivity but also on the fact
led to the labeling of this technique as scintigraphy. that the most commonly used radionuclides (11C, 13N, 15O, 18F) are
isotopes of elements that occur naturally in organic molecules.
SINGLE PHOTON EMISSION COMPUTED Although fluorine does not technically fit into this category, it is
TOMOGRAPHIC IMAGING a chemical substitute for hydrogen. These radionuclides are used
SPECT imaging is a method of acquiring tomographic slices as is or, more commonly, incorporated into a radiopharmaceutical
through a patient (Fig. 14-24). Most gamma cameras have SPECT such as glucose or amino acids by use of a medical cyclotron. After
imaging capability. In this technique, either a single or a multiple the radiopharmaceutical is injected into the patient, the isotope
gamma camera is rotated 360 degrees around the patient. Image distributes within the body tissue according to the carrier molecule
acquisition takes about 30 to 45 minutes. The acquired data are and emits a positron. This positron interacts with a free electron
processed by filtered back-projection and, more recently, iterative and mutual annihilation occurs, resulting in the production of two
reconstruction algorithms, to form numerous contiguous axial 551-keV photons emitted at 180 degrees to each other. The PET
slices, similar to CT imaging by x ray. These data can be used to scanner consists of a ring of many detectors in a circle around the
construct multiplanar images of the study area (see Fig. 14-24, C). patient (Fig. 14-26). The detector crystals are often made of bismuth
Tomography enhances contrast and removes superimposed activ- germinate. Electronically coupled opposing detectors simultane-
ity. SPECT images have been fused with CT images more recently ously identify the pair of γ photons using coincidence detection
 C H A PTE R 14 Other Imaging Modalities 245

B D

C E

FIGURE 14-24 SPECT/CT imaging of a 14-year-old girl with chronic osteomyelitis of the mandible. A, Panoramic view demonstrating
expansion and sclerosis of the right mandible (arrow). B, Planar radionuclide image showing uptake throughout the mandible and especially
on the right side. C, SPECT axial image showing increased activity in the posterior regions of both sides of the mandible and especially
on the right side (arrow). D, CT axial image at the same level as the image in C. Note periosteal expansion and lytic areas in the right
mandible (arrow). E, SPECT/CT fusion image demonstrating the area of greatest activity in the right mandible (arrow). (Modified from
Strobel K, Merwald M, Huellner MW, et al: [Importance of SPECT/CT for resolving diseases of the jaw] [in German]. Radiologe
52:638–645, 2012.)
246 P A RT II Imaging

A B C

FIGURE 14-25 SPECT image of bisphosphonate osteonecrosis of the jaw in a woman with breast cancer treated with zoledronic
acid for 2 years because of a metastatic lesion to C2. A, Axial CT image demonstrating bisphosphonate-associated osteonecrosis of the
jaw (BRONJ) in the left mandible that is mostly lytic but also sclerotic more posteriorly. B, SPECT image showing extensive deposition of
99m
Tc pertechnetate in the left body of the mandible and region of right articular surface of C2. C, Fusion image demonstrating isotope
uptake most extensive in the sclerotic (posterior) portion of the BRONJ lesion and in the sclerotic metastatic lesion in C2. (Images courtesy
Dott.ssa Franca Dore, Azienda Ospedaliero-Universitaria Trieste.)

Applications
PET imaging is useful in skeletal imaging for assessing primary
bone tumors, locating metastases in bone, and detecting osteomy-
elitis. Fluorodeoxyglucose (FDG) is a radiopharmaceutical com-
monly used for studying glucose use in the brain and heart and to
look for cancer metastases. PET images are often fused with CT
scans to facilitate anatomic localization of radionuclide (Fig.
14-27). The PET/CT combination has been shown to be quite
helpful in staging and treatment planning of squamous cell carci-
noma in the head and neck.

ULTRASONOGRAPHY
Sonography is a technique based on sound waves that acquires
images in real time without the use of ionizing radiation. The
phenomenon perceived as sound is the result of periodic changes
in the pressure of air against the eardrum. The periodicity of these
changes ranges from 1500 to 20,000 Hz. By definition, ultrasound
FIGURE 14-26 PET scanner consists of a ring of detectors that measure pairs of 511 keV has a periodicity greater than 20 kHz, which is greater than the
γ rays traveling in opposite directions from positron annihilation. Each pair is recorded simultane- audible range. Diagnostic ultrasonography (or sonography), the
ously; thus, the location of the radionuclide can be determined as the intersection of the pairs clinical application of ultrasound, uses vibratory frequencies in the
of detectors recording simultaneous events. The location of the common source of the radionu- range of 1 to 20 MHz.
clide is readily determined as the intersection of the flight paths of the γ rays. Scanners used for sonography generate electrical impulses that
are converted into ultra-high-frequency sound waves by a trans-
ducer, a device that can convert one form of energy into another—
circuits that measure events within 10 to 20 ns. Thus, the annihila- in this case, electrical energy into sonic energy. The most important
tion event is known to have occurred along the line joining the component of the transducer is a thin piezoelectric crystal or mate-
two detectors. Raw PET scan data consist of many of these coin- rial made up of a great number of dipoles arranged in a geometric
cidence lines, which are reorganized into projections that identify pattern. A dipole may be thought of as a distorted molecule that
where isotope is concentrated within the patient. Image quality in appears to have a positive charge on one end and a negative charge
PET scans has been improved in recent years using time-of-flight on the other. The most widely used piezoelectric material is lead
techniques. The time-of-flight methods measure the slight differ- zirconate titanate. The electrical impulse generated by the scanner
ence in the arrival times of the two γ photons at the detectors and causes the dipoles in the crystal to realign themselves with the
use this information to determine the location of positron annihi- electric field and to change the crystal’s thickness suddenly. This
lation along the path. The spatial resolution of a PET scanner is abrupt change begins a series of vibrations that produce the sound
about 5 mm. waves that are transmitted into the tissues being examined.
 C H A PTE R 14 Other Imaging Modalities 247

A B C

FIGURE 14-27 PET scan and fused PET/CT scan. This patient has a known recurrent carcinoma at the base of the tongue. A, Soft
tissue algorithm CT image at the level of the inferior border of the mandible. The four metallic objects on the patient’s right side posterior
to the mandible represent vascular clips from prior surgery. B, FDG-PET scan showing an oval-shaped region of high metabolic activity of
tumor at the right tongue base. The FDG activity in the anterior mandible is related to low-level metabolic activity in the vicinity of a
reconstruction plate. C, Fused images A and B demonstrating the region of high metabolic activity superimposed on the CT anatomy.
The intensity of the FDG activity has been color-coded with red being the highest intensity and purple being the lowest. Images were acquired
on a combined PET/CT scanner. (Courtesy Dr. Todd W. Stultz, Cleveland Clinic, OH.)

The transducer emitting ultrasound is held against the body

part being examined. The ultrasonic beam passes through or inter-
acts with tissues of different acoustic impedance. Sonic waves that Subcutaneous fat
reflect (echo) toward the transducer cause a change in the thickness
of the piezoelectric crystal, which produces an electrical signal that Sterno-
Thyroid
cleido-
is amplified, processed, and ultimately displayed as an image on a mastoid
Infrahyoid (isthmus)
monitor. Typically, the transducer serves as both a transmitter and muscles
muscle
a receiver. Current techniques permit echoes to be processed at a Trachea
sufficiently rapid rate to allow perception of motion; this is referred Thyroid
to as real-time imaging. (right lobe)
Internal
The ultrasound signal transmitted into a patient is attenuated Common
jugular
by a combination of absorption, reflection, refraction, and diffu- carotid
vein
artery Air
sion. The higher the frequency of the sound waves, the higher the
image resolution, but the less the penetration of the sound through
soft tissue. The fraction of the beam that is reflected to the trans-
ducer depends on the acoustic impedance of the tissue, which is
a product of its density (and the velocity of sound through it) and
the beam’s angle of incidence. Because of its acoustic impedance,
a tissue has a characteristic internal echo pattern. Consequently,
not only can changes in echo patterns distinguish between differ- FIGURE 14-28 Ultrasound examination (transverse section) of a healthy thyroid gland.
ent tissues and boundaries, but they also can be correlated with This image shows glandular, muscular, adipose, and vascular tissues because of the different
pathologic changes within a tissue. Tissues that do not produce acoustic impedance of these tissues. (Courtesy Dr. Christos Angelopoulos, Columbia University,
signals, such as fluid-filled cysts, are said to be anechoic and appear College of Dental Medicine, NY.)
black. Tissues that produce a weak signal are hypoechoic, whereas
tissues that produce intense signals, such as ligaments, skin, or
needles or catheters, are hyperechoic and appear bright. Thus, also used to guide fine-needle aspiration in the neck. More recent
interpretation of sonograms relies on knowledge of both the physi- advances include three-dimensional imaging to allow multiplanar
cal properties of ultrasound and the anatomy of the tissues being reformatting, surface renderings (e.g., of a fetal face), and color
scanned. Doppler sonography for evaluation of blood flow.
Ultrasonography is used in the head and neck region for evalu-
ation of neoplasms in the thyroid, parathyroid, salivary glands, or
lymph nodes; stones in salivary glands or ducts; Sjögren’s syn-
CONVENTIONAL TOMOGRAPHY
drome, and the vessels of the neck, including the carotid artery for Conventional tomography is a radiographic technique, usually
atherosclerotic plaques (Figs. 14-28 and 14-29). Ultrasonography is using film, designed to image a slice or plane of tissue. This
248 P A RT II Imaging

Parotid gland

Digastric (posterior belly)

Deep lobe of parotid gland

(difficult to visualize)
External carotid artery

Longitudinal section through parotid region

FIGURE 14-29 Doppler ultrasound examination. Longitudinal section through the parotid gland, including the deep lobe, and posterior
belly of digastric muscle. With Doppler ultrasound, the transducer records small changes in the direction of blood flow. In this image, the
external carotid artery is coded red where blood flows toward the transducer and blue where it moves away from the transducer. (Courtesy
Dr. Christos Angelopoulos, Columbia University, College of Dental Medicine, NY.)

L R
imaging is accomplished by blurring the images of structures lying
outside the plane of interest through the process of motion
“unsharpness.” Since the introduction of CT imaging, MR imaging,
and cone-beam imaging, which have superior contrast resolution,
film-based tomography has been used less frequently. When con-
ventional tomography is used in dentistry, it is applied primarily
to high-contrast anatomy, such as that encountered in TMJ and
dental implant imaging.
Conventional tomography uses an x-ray tube and radiographic
film rigidly connected and capable of moving about a fixed axis
or fulcrum (Fig. 14-30). The examination begins with the x-ray tube
and film positioned on opposite sides of the fulcrum, which is X
located within the body’s plane of interest (focal plane). As the
exposure begins, the tube and film move in opposite directions
simultaneously through a mechanical linkage. With this synchro-
A
nous movement of tube and film, the images of objects located
within the focal plane (at the fulcrum) remain in fixed positions B Focal plane
on the radiographic film throughout the length of tube and film
travel and are clearly imaged. The images of objects located outside C
the focal plane have continuously changing positions on the film;
as a result, the images of these objects are blurred beyond recogni-
tion by motion unsharpness. The resulting zone of sharp image is F
called the tomographic layer. Blurring of overlying structures is
R L
greatest (and the tomographic layer the thinnest) under the follow-
ing circumstances: C
• Overlying structures lie far from the focal plane. B
• The focal plane lies far from the film. A
• The long axis of the structure to be blurred is oriented perpen-
dicular to the direction of tube travel. FIGURE 14-30 Tomographic techniques. As the x-ray tube moves from left to right, the
• The distance of tube travel is large. film moves in the opposite direction. In this figure, points A and C lie outside the focal plane
There are at least five types of tomographic movement: linear, (the plane that contains the fulcrum), whereas object B lies at the center of tube/film move-
circular, elliptic, hypocycloidal, and spiral (Fig. 14-31). Mechani- ment. Only objects that lie in the focal plane (i.e., B) remain in sharp focus because the image
cally, the simplest tomographic motion is linear. More complex of B moves exactly the same distance (B′) as the film travels (F), and thus its image remains
movements, such as circular, elliptic, hypocycloidal, and spiral, stationary on the film. The image of point A moves more than the film (distance A′), and the
produce images without streaking artifacts common to the linear image of point C moves less than the film (distance C); therefore, the images of both are
movements. Many of the more expensive panoramic units are blurred. X is the tomographic angle. The greater the tomographic angle, the thinner the tomo-
capable of making tomographic sections of the jaws (Fig. 14-32). graphic layer.
 C H A PTE R 14 Other Imaging Modalities 249

Magnetic Resonance Imaging

Blink EJ: An easy introduction to basic MRI physics for anyone who
does not have a degree in physics: http://mri-physics.net/.
Bushberg JT, Seibert JA, Leidholdt EM Jr, et al: The essential physics of
medical imaging, ed 3, Baltimore, 2012, Lippincott Williams & Wilkins.
Linear Circular Trispiral Bushong SC: Magnetic resonance imaging: physical and biological principles,
ed 3, St Louis, 2003, Mosby.
Elison JM, Leggitt VL, Thomson M, et al: Influence of common
orthodontic appliances on the diagnostic quality of cranial magnetic
resonance images, Am J Orthod Dentofacial Orthop 134:563–572, 2008.
Idiyatullin D, Corum C, Moeller S, et al: Dental magnetic resonance
imaging: making the invisible visible, J Endod 37:745–752, 2011.
Kendi AT, Khariwala SS, Zhang J, et al: Transformation in mandibular
imaging with sweep imaging with fourier transform magnetic
Elliptical Hypocycloidal
resonance imaging, Arch Otolaryngol Head Neck Surg 137:916–919,
FIGURE 14-31 Tomographic movements. Linear movements, either vertical or horizontal, 2011.
are mechanically simple but result in streaking artifacts. More complex motions result in fewer Patel A, Bhavra GS, O’Neill JR: MRI scanning and orthodontics,
streaking artifacts and sharper images. J Orthod 33:246–249, 2006.
Tutton LM, Goddard PR: MRI of the teeth, Br J Radiol 75:552–562,
2002.
Weishaupt D, Koechli DC, Marincek B: How does MRI work? An
introduction to the physics and function of magnetic resonance imaging, ed 2,
Berlin, 2008, Springer.
Westbrook C, Roth CK, Talbot J: MRI in practice, ed 4, Oxford, 2011,
Wiley-Blackwell.

Nuclear Medicine
Christian P, Waterstram-Rich KM: Nuclear medicine and PET/CT:
technology and techniques, ed 7, St Louis, 2011, Mosby.
Dore F, Filippi L, Biasotto M, et al: Bone scintigraphy and SPECT/CT
of bisphosphonate-induced osteonecrosis of the jaw, J Nucl Med
50:30–35, 2009.
Hutton BF: Recent advances in iterative reconstruction for clinical
SPECT/PET and CT, Acta Oncol 50:851–858, 2011.
Krasny A, Krasny N, Prescher A: Anatomic variations of neural canal
structures of the mandible observed by 3-tesla magnetic resonance
A B imaging, J Comput Assist Tomogr 36:150–153, 2012.
Lois C, Jakoby BW, Long MJ, et al: An assessment of the impact of
FIGURE 14-32 Linear tomographic images made by panoramic unit. A, Mandibular incorporating time-of-flight information into clinical PET/CT
tomogram in the region of the mental foramen. B, Maxillary tomogram in the premolar region imaging, J Nucl Med 51:237–245, 2010.
acquired with an Orthopantomograph OP 100 panoramic unit (Instrumentarium Dental, Tuusula, Mettler FA, Guiberteau MJ: Essentials of nuclear medicine, ed 6,
Finland). Note the dome-shaped opacity in the floor of the maxillary sinus consistent with a Philadelphia, 2012, Saunders.
mucous retention phenomenon. (B, Courtesy Brad Potter, DDS, Augusta, GA.) Schiepers C: Diagnostic nuclear medicine, ed 2, Berlin, 2006, Springer.
Sharp PF, Gemmell HG, Murray AD: Practical nuclear medicine, ed 3,
London, 2005, Springer-Verlag.
Van den Wyngaert T, Huizing MT, Fossion E, et al: Prognostic value of
bone scintigraphy in cancer patients with osteonecrosis of the jaw,
BIBLIOGRAPHY Clin Nucl Med 36:17–20, 2011.
Wilson MA: Nuclear medicine, Philadelphia, 1998, Lippincott-Raven.
Computed Tomography
Bononmo L, Foley D, Imhof H, et al: Multidetector computed tomography Ultrasound
technology: advances in imaging techniques, London, 2003, Royal Society Emshoff R, Bertram S, Strobl H: Ultrasonographic cross-sectional
of Medicine Press. characteristics of muscles of the head and neck, Oral Surg Oral Med
Bushberg JT, Seibert JA, Leidholdt EM Jr, et al: The essential physics of Oral Pathol Oral Radiol Endod 87:93–106, 1999.
medical imaging, ed 3, Baltimore, 2012, Lippincott Williams & Goldman LW, Fowlkes JB, editors: Categorical course in diagnostic radiology
Wilkins. physics: CT and US cross-sectional imaging, Oak Brook, IL, 2000, RSNA
Buzug TM: Computed tomography: from photon statistics to modern cone-beam Publications.
CT, Berlin, 2008, Springer. Kremkau FW: Sonography: principles and instruments, ed 8, St Louis, 2010,
Fishman EK, Jeffrey RB Jr: Multidetector CT: principles, techniques, and Saunders.
clinical applications, Philadelphia, 2004, Lippincott Williams & Middleton WD, Kurtz AB, Hertzberg BA: Ultrasound: the requisites, ed 2,
Wilkins. St Louis, 2004, Mosby.
Kalender W: Computed tomography: fundamentals, systems technology, image Rumack CM, Wilson SR, Charboneau JW, et al: Diagnostic ultrasound, ed
quality, applications, ed 2, Erlangen, 2005, Publicis Corporate 4, Philadelphia, 2011, Mosby.
Publishing. Shimizu M, Okamura K, Yoshiura K, et al: Sonographic diagnostic
Knollmann F, Coakley FV: Multislice CT: principles and protocols, criteria for screening Sjögren’s syndrome, Oral Surg Oral Med Oral
Philadelphia, 2006, Saunders. Pathol Oral Radiol Endod 102:85–93, 2006.
Marchal G, Vogl TJ, Heiken JP, et al: Multidetector-row computed Tempkin B: Ultrasound scanning: principles and protocols, ed 3, St Louis,
tomography, Milan, 2005, Springer. 2009, Saunders.
CHAPTER

15 Quality Assurance and

Infection Control

OUTLINE
Radiographic Quality Assurance Monthly Tasks Infection Control
Daily Tasks Yearly Tasks Standard Precautions
Weekly Tasks

A
quality assurance program in radiology is a series of pro- processed with exact time-temperature technique is mounted on
cedures designed to ensure optimal and consistent opera- a corner of the viewbox. This image, with optimal density and
tion of each component in the imaging chain. When all contrast, serves as a reference for the radiographs made in the
components are functioning properly, the result is consistently following days and weeks (Fig. 15-1). All subsequent images should
high-quality radiographs made with low exposure to patients and be compared with this reference film.
office personnel. Comparison of daily images with the reference film may reveal
The goal of an infection control program in radiology is to problems before they interfere with the diagnostic quality of the
avoid cross-contamination among patients and between patients images. When a problem is identified, it is important to determine
and the dental staff in the course of imaging. the probable source and to take corrective action. For instance, if
the processing solutions have become depleted, the resultant radio-
RADIOGRAPHIC QUALITY ASSURANCE graphs are light and have reduced contrast. Both developer and
fixer should be changed when degradation of the image quality is
Because radiographs are indispensable for patient diagnosis, the evident. Light images may also result from cold solutions or insuf-
dentist must ensure that optimal exposure and film processing ficient developing time. Dark images may be caused by excessive
conditions are maintained. To reach this goal, a quality assurance developing time, developer that is too warm, or light leaks.
program includes evaluation of the performance of x-ray machines, There are two methods that are more accurate than a reference
manual and automatic film processing procedures, image recep- film but require additional equipment and more time to perform.
tors, and viewing conditions. Optimization of all steps in the These are use of a sensitometer and densitometer and the use of a
imaging chain results in the most diagnostic images and the lowest step wedge.
exposure for patients. Examples of common faults in digital sensor
handling are provided in Chapter 4, and problems with film pro- Sensitometer and Densitometer
cessing are presented in Chapter 5. To minimize these problems, The most accurate and rigorous method of testing film processing
it is best if one individual is given the responsibility for implement- solutions is to use a sensitometer and densitometer. A sensitometer
ing the quality assurance program and for taking corrective action exposes film to a calibrated light pattern. After processing, a den-
when indicated. Most of these tasks refer to film processing. Using sitometer is used to measure the optical density of each step in the
digital sensors greatly simplifies these tasks. Most of these steps are test pattern of the film exposed by the sensitometer. A change in
quickly accomplished, yet they can have a significant influence on the density readings from day to day indicates a problem in the
radiographic quality (Box 15-1). darkroom.

DAILY TASKS Enter Findings in Retake Log

Several tasks should be performed daily to ensure excellent Another simple and effective means of reducing the number of
radiographs. faulty radiographs is to keep a retake log. All errors for images that
must be reexposed are recorded. This process quickly reveals the
Compare Film Radiographs with Reference Film source of recurring problems.
One of the most common causes of poor film radiographs is
poor processing in the darkroom, in particular, the use of depleted Replenish Processing Solutions
solutions. A simple and effective means for constant monitoring At the beginning of each work day, the levels of the processing
of the quality of images produced in an office is to check daily solutions should be checked and replenished if necessary. The
films against a reference film. Soon after film processing solutions developer is replenished with fresh developing solution, and the
are replaced, a patient film that has been properly exposed and fixer is replenished with fresh fixing solution.

250
 C H A PTE R 15 Quality Assurance and Infection Control 251

BOX 15-1 Schedule of Radiographic Quality WEEKLY TASKS

Assurance Procedures Replace Processing Solutions
How frequently processing solutions are replaced depends primar-
DAILY ily on the rate of use of the solutions but also on the size of tanks,
• Check processing by comparing radiographs with reference film, step wedge, or whether a cover is used, and the temperature of the solutions. In
sensitometry and densitometry most offices, the solutions should be changed weekly or every
• Enter causes of retakes in a log other week. The results of the step-wedge test help determine the
• Replenish processing solutions proper frequency.
• Check temperature of processing solutions
• Run larger roller transport clean-up film through automatic processor Clean Processing Equipment
Regular cleaning of the processing equipment is necessary for
WEEKLY optimal operation. The solution tanks of manual and automatic
• Replace processing solutions processing equipment should be cleaned when the solutions are
• Clean processing equipment changed. The rollers of automatic film processors should be
• Clean viewboxes cleaned weekly according to the manufacturer’s instructions. After
• Review retake log cleaning, the tanks and rollers should be rinsed twice as long as
the manufacturer recommends to prevent the cleaner from inter-
MONTHLY
fering with the action of the film processing solutions.
• Examine photostimulable phosphor plates for scratches
• Check darkroom safelighting and for light leaks Clean Viewboxes
• Clean intensifying screens Viewboxes should be cleaned weekly to remove any particles or
• Rotate film stock defects that may interfere with film interpretation.
• Check exposure charts
• Inspect leaded aprons and thyroid collars for damage such as cracks or tears Review Retake Log
YEARLY The retake record should be reviewed weekly to identify any recur-
ring problems with film processing conditions or operator tech-
• Verify digital sensors with quality assurance apparatus
nique. This information can be used to educate staff or to initiate
• Calibrate x-ray machine
corrective actions.
MONTHLY TASKS
Photostimulable Phosphor Plates
Photostimulable phosphor (PSP) plates may become scratched in
the course of use. These scratches may be seen as light streaks on
processed images (see Fig. 4-22, A). Plates should be inspected
monthly for such defects and removed from service when such
defects are found.

Check Darkroom Safelighting

Film becomes fogged in the darkroom because of inappropriate
safelight filters, excessive exposure to safelights, and stray light
from other sources. These films are dark, show low contrast, and
have a muddy gray appearance. The darkroom should be inspected
monthly to assess the integrity of the safelights (preferably GBX-2
filters with 15-watt bulbs). The glass filter should be intact, with
no cracks. To check for light leaks in a darkroom, all lights are
FIGURE 15-1 Radiographs should be checked daily against a reference film made with
turned off; the individual allows his or her vision to accommodate
fresh solutions. As processing solutions become exhausted, the daily images become increasingly
to the dark and checks for light leaks, especially around doors and
light and lose contrast. When these changes are apparent, both the developer and the fixer
vents. Light leaks should be marked with chalk or masking tape.
should be changed.
Weather stripping is useful for sealing light leaks under doors.

Clean Intensifying Screens

Check Temperature of Processing Solutions All intensifying screens in panoramic and cephalometric film cas-
At the beginning of each work day, the temperature of the process- settes should be cleaned monthly. The presence of scratches or
ing solutions should be checked. The solutions must reach the debris results in recurring light areas on the resultant images. The
optimal temperature before use—68° F (20° C) for manual process- foam supporting the screens must be intact and capable of holding
ing and 82° F (28° C) for heated automatic processors. The instruc- both screens closely against the film. If close contact between the
tions accompanying the film and processor verify the optimal film and screens is not maintained, the image loses sharpness.
temperature. Unheated automatic processors should be located
away from windows or heaters that may cause their temperature Rotate Film Stock
to vary during the day. Proper temperature regulation is required Dental x-ray film is quite stable when it is properly handled. X-ray
for accurate time-temperature processing. film should be stored in a cool, dry facility away from a radiation
252 P A RT II Imaging

source. Stock should be rotated when new film is received so that qualified individual can confirm any cracks in the lead shielding.
old film does not accumulate in storage. The oldest film always These items should be replaced as necessary. Cracking is usually
should be used first but never after its expiration date. caused by folding the shields when not in use. It can be minimized
by hanging the aprons from a hook or draping them over a
Check Exposure Charts handrail.
Each month, inspection should be done of exposure tables listing
the proper peak kilovoltage (kVp), milliamperes (mA), and expo-
YEARLY TASKS
sure times for making radiographs of each region of the oral cavity Digital Sensors
that are posted by each x-ray machine (Fig. 15-2). One should Digital sensors and PSP plates should also be checked yearly for
verify that the information is legible and accurate. These tables signs of image degradation. Failing sensors may reveal loss of
help ensure that all operators use the appropriate exposure factors. sensitivity, contrast resolution, or spatial resolution. Phantoms
Typically, the mA is fixed at its highest setting; the kVp is fixed, designed for this purpose are available to aid in such testing
usually at 70 kVp; and the exposure time is varied to account for (Fig. 15-3).
patient size and location of the area of interest in the mouth.
Exposure times are initially determined empirically. In the case Calibrate X-Ray Machine
of PSP plates and digital sensors, one should start by using the When a new x-ray machine is purchased, state regulations require
exposure times suggested by the manufacturer. Exposure times are that it be installed by a qualified expert. When in use, x-ray
slowly and systematically reduced to the point that image degrada- machines are generally quite stable, and only rarely is a malfunc-
tion is noticed. With film, careful time-temperature processing tion of the machine the cause of poor radiographs. X-ray machines
(described in Chapter 5) must be used with fresh solutions during need to be calibrated annually only, unless a specific problem is
this initial determination of exposure times. identified or substantive repair is necessary that may affect opera-
tion. Usually, dental service companies or health physicists should
Check Leaded Aprons and Collars make these machine measurements because of the specialized
Leaded aprons and collars should be visually inspected for evi- equipment and knowledge required. The following parameters
dence of cracking. A fluoroscopic examination performed by a should be measured:
1. X-ray output. A radiation dosimeter should be used to measure
the intensity and reproducibility of radiation output (Fig. 15-4).
Acceptable values are shown in Figure 3-3.
2. Collimation and beam alignment. The field diameter for dental
intraoral x-ray machines should be no greater than 2 3 4 inches.
The tip of the position-indicating device (PID), or aiming cyl-
inder, should be closely aligned with the x-ray beam. For pan-
oramic machines, the beam exiting the patient should not be
larger than the film slit holding the film cassette; this may be
tested by taping dental films in front of and behind the slit. A
pin stick should be made through both films to allow subse-
quent realignment. Both films are exposed, processed, and
realigned. The exposure to the film in front of the slit should
be comparable in size to the film exposure behind the slit.
Service is required if the front film exposure is larger than or
not well oriented with the film exposure behind the slit.
3. Beam energy. The kVp or half-value layer (HVL) of the beam
should be measured to ensure that the beam has sufficient
energy for film exposure without excessive soft tissue dosage.
Measurement of kVp requires specialized equipment. It should
be accurate within 5 kVp. Measurement of HVL requires a
dosimeter. The HVL should be at least 1.5 mm aluminum (Al)
at 70 kVp and 2.5 mm Al at 90 kVp.
4. Timer. Electrical pulse counters count the number of pulses
generated by an x-ray machine during a preset time interval.
The timer should be accurate and reproducible.
5. mA. The linearity of the mA control should be verified if two
or more mA settings are available on the machine. An exposure
using the usual adult bitewing setting is made. The mA is then
reduced to the lower value, and another exposure time is
selected, ensuring that the product of the mA and time in
seconds (impulses) is the same as for the adult bitewing. For
FIGURE 15-2 Sample wall chart showing identification information for x-ray machine, example, if the machine has 10-mA and 15-mA settings, and
sensor or film type, mA and kVp settings, and appropriate exposure times for various anatomic 15 mA and 24 impulses are used for adult bitewings, one
locations and patient sizes. The optimal exposure times must be determined empirically in each should select 15 mA and 24 impulses for the first exposure and
office because they vary with the machine settings used, source-to-skin distance, and other measure the dose. A second exposure is made at 10 mA and 36
factors. impulses, and the dose is measured. The dose at each exposure
 C H A PTE R 15 Quality Assurance and Infection Control 253

FIGURE 15-3 Phantom for measuring image quality performance of digital dental x-ray systems. A, Plastic stand allows positioning
of the aiming tube of the x-ray machine over the test device, which is positioned over the digital sensor. B, Test device contains, from
the top, two rows of wells of varying diameter and depth in an acrylic background for measuring contrast detail, an etched pattern of slits
in a metallic background for measuring the spatial resolution in line pairs per millimeter, and a calibrated step wedge for measuring dose
response. C, Resulting image. (Images courtesy Dr. Peter K. Mah: www.dentalimagingconsultants.com.)

combination should be the same (15 × 24 = 10 × 36). A dis-

crepancy implies nonlinearity in the mA control or a fault in
INFECTION CONTROL
the timer. The step wedge described previously may also be used Dental personnel and patients are at increased risk for acquiring
in place of the dosimeter. In this case, the density of each step tuberculosis, herpes viruses, upper respiratory infections, and hepa-
of each image should be the same. titis strains A through E. After the recognition of acquired immu-
6. Tube head stability. The tube head should be stable when nodeficiency syndrome (AIDS) in the 1980s, rigorous hygienic
placed around the patient’s head, and it should not drift during procedures were introduced in dental offices. The primary goal of
the exposure. When the tube head is unstable, service is neces- infection control procedures is to prevent cross-contamination and
sary to adjust the suspension mechanism. disease transmission from patient to staff, from staff to patient,
7. Focal spot size. Measure the size of the focal spot because it and from patient to patient. The potential for cross-contamination
may become enlarged with excessive heat buildup within an in dental radiography is great. In the course of making radiographs,
x-ray machine. An enlarged focal spot contributes to geometric an operator’s hands become contaminated by contact with a
fuzziness in the resultant image. A specialized piece of equip- patient’s mouth and saliva-contaminated films and film holders.
ment is required for this test. The operator also must adjust the x-ray tube head and x-ray
254 P A RT II Imaging

STANDARD PRECAUTIONS
Standard precautions (sometimes called universal precautions)
are infection control practices designed to protect workers from
exposure to diseases spread by blood and certain body fluids
including saliva. Under standard precautions, all human blood
and saliva are treated as if known to be infectious for human
immunodeficiency virus (HIV) and hepatitis B virus. Accordingly,
the means used to protect against cross-contamination are used
for all individuals. The American Dental Association (ADA) and
the U.S. Centers for Disease Control and Prevention (CDC)
stress the use of standard precautions because many patients are
unaware that they are carriers of infectious disease or choose not
to reveal this information.

Wear Gloves during All Radiographic Procedures

Gloves are a critical factor in preventing contamination between a
patient and staff member. After the patient is seated, the practitio-
ner should wash his or her hands and put on disposable gloves in
sight of the patient if the operatory arrangement permits. The
practitioner should always wear gloves when making radiographs
or handling contaminated film packets or associated materials such
as cotton rolls and film-holding instruments or when removing
barrier protections from surfaces and radiographic equipment.
Staff should also wear personal protective equipment such as
eyewear, a mask, or face shield if exposure to bodily fluids is
anticipated.

Disinfect and Cover Clinical Contact Surfaces

Clinical contact surfaces are surfaces that might be touched by
gloved hands or instruments that go into the mouth. These include
the x-ray machine and control panel, chair-side computer, beam
FIGURE 15-4 Device for measuring exposure output of an x-ray machine. The probe on
alignment device, dental chair and headrest, leaded apron, thyroid
the left is intended to be included in a phantom to measure cone-beam computed tomographic
collar, and surfaces on which film is placed. The CDC classifies
exposure. The aiming cylinder of an intraoral dental x-ray machine may be positioned over the
these as noncritical items. These are objects that may come in
center of the device on the right, and an exposure may be made. These units measure average
contact with saliva, blood, or intact skin but not oral mucous mem-
and maximum kVp, dose, dose rate, HVL, and exposure time in seconds or pulses. (Image
branes. The goal of preventing cross-contamination is addressed in
courtesy Fluke Biomedical: www.flukebiomedical.com.)
part by disinfecting all such surfaces and by using barriers to isolate
equipment from direct contact. Barriers made of clear plastic wrap
should be changed when damaged and routinely after each patient.
BOX 15-2 Key Steps in Radiographic Barriers should cover working surfaces that were previously
Infection Control cleaned and disinfected. Barriers protect the underlying surface
from becoming contaminated. An effective barrier for the coun-
• Apply standard precautions tertops and x-ray control console is plastic wrap, which may be
• Wear gloves during all radiographic procedures conveniently stored in a butcher’s paper dispenser mounted on
• Disinfect and cover x-ray machine, working surfaces, chair, and apron a wall. When covering the x-ray control console, the operator
• Sterilize nondisposable instruments should be sure to include the exposure switch and the exposure
• Use barrier-protected film (sensor) or disposable container time control if they are integral parts of the unit (Fig. 15-5). An
• Prevent contamination of processing equipment x-ray exposure switch that is separate from the console should
be covered with a sandwich bag or food storage bag or wrapped
with plastic wrap.
The dental chair headrest, headrest adjustments, and chair back
machine control panel settings to make the exposure. These actions may be easily covered with a plastic bag (Fig. 15-6). The x-ray tube
lead to the possibility of cross-contamination. Cross-contamination head, PID, and yoke should be covered while they are still wet
also may occur when an operator handles digital sensors or opens with disinfectant with a barrier to stop any dripping (Fig. 15-7).
film packets to process the films in the darkroom. The procedures The bag should be secured by tying a knot in the open end or by
described in the following sections minimize or eliminate such placing a heavy rubber band over the x-ray tube head just proximal
cross-contamination (Box 15-2). Each dental office or practice to the swivel. Also, the leaded apron should be cleaned, disin-
should have a written policy describing its infection control prac- fected, and covered between patients because it is frequently con-
tices. It is best if one individual in a practice, usually the dentist, taminated with saliva as the result of handling (readjusting its
assumes responsibility for implementing these procedures. This position) during a radiographic procedure. The apron should be
person also educates other members of the practice. suspended on a heavy coat hanger to permit turning front to back.
 C H A PTE R 15 Quality Assurance and Infection Control 255

FIGURE 15-7 A plastic bag is slipped over the x-ray tube head with a large rubber band
just proximal to the swivel or tie ends, as shown here. The plastic is pulled tight over the PID
and secured with a light rubber band slipped over the PID and placed next to the head.

FIGURE 15-5 The exposure control console should be covered with a clean barrier and
changed after every patient.

FIGURE 15-8 Hanging apron is sprayed with disinfectant and then dried and covered
with a garment bag.

Although barriers greatly aid infection control, they do not

replace the need for effective surface cleaning and disinfection.
Experience has demonstrated that failure of mechanical barriers is
common during the daily activity of treatment. It is advantageous
and reassuring to the operator to know that whenever this happens,
FIGURE 15-6 A new plastic bag is placed over the chair and headrest for each patient. the surfaces that may become accidentally exposed are clean and
disinfected. Any surface that may be contaminated should be
It should be sprayed with a detergent-containing disinfectant and surface disinfected. Operators should avoid touching walls and
then wiped and covered with the same type of plastic garment bag other surfaces with contaminated gloves. Good surface disinfec-
used for the x-ray head and chair back (Fig. 15-8). Charts should tants include iodophors, chlorines, and synthetic phenolic com-
be kept away from sources of contamination and not handled pounds. Although the ADA does not recommend specific chemical
during the radiographic examination. disinfectants and sterilants, it does suggest that when dentists use
256 P A RT II Imaging

a chemical agent for disinfection or sterilization, the agent should problem, PSP plates should be disinfected between patients using
be an Environmental Protection Agency (EPA)–registered hospital a method recommended by the manufacturer.
disinfectant of low to intermediate activity. The agent should also
be tuberculocidal—an effective killer of tuberculosis—and capable Use Barrier-Protected Film (Sensor) or Disposable Container
of preventing other infectious diseases, including hepatitis B virus Film should be obtained in advance from a central source. To
and HIV. prevent contamination of bulk supplies of film, they should be
Panoramic and cephalometric equipment should receive the dispensed in procedure quantities. The required number of films
same maintenance for decontamination and disinfection as other for a full-mouth or interproximal series should be prepackaged in
equipment. Panoramic bite-blocks, chin rest, and patient handgrips coin envelopes or paper cups in the central preparation room.
should be cleaned with detergent-iodine disinfectant and covered These envelopes of films should be dispensed with the film-holding
with a plastic bag. Disposable bite-blocks may be used. The head- instruments. For unanticipated occasions in which an unusual
positioning guides, control panel, and exposure switch should be number of films are required, a small container of films can be on
carefully wiped with a paper towel that is well moistened with hand in the central preparation and sterilizing room. No one
disinfectant. The radiographer should wear disposable gloves while wearing contaminated gloves should retrieve a film from this
positioning and exposing the patient. The gloves should be supply. Films should be dispensed only by staff members with
removed before the cassette is removed from the machine for clean hands or wearing clean gloves.
processing because the cassette and film remain extraoral and Film packets may be prepackaged in a plastic envelope (Fig.
should not be handled with contaminated disposable gloves. 15-10), which protects the film from contact with saliva and blood
Cephalostat ear posts, ear post brackets, and forehead support or
nasion pointer should be cleaned and disinfected with iodine-
detergent disinfectant. These may then also be covered in plastic.
After patient exposures are completed, the barriers should be
removed, and contaminated working surfaces (including surfaces
in the darkroom) and the apron should be sprayed with disinfec-
tant and wiped as described previously. The barriers should be
replaced in preparation for the next patient.

Sterilize Nondisposable Instruments

Film-holding instruments are classified by the CDC as semicritical
items—instruments that are not used to penetrate soft tissue or
bone but do come in contact with the oral mucous membrane. It
is best to use film-holding instruments that are heat sterilizable.
After using, these instruments, disassemble the aiming ring, support
arm, and bite-block. Each instrument should be cleaned with hot
water and soap to remove saliva and debris. The cleaned compo-
nents are then loaded into plastic or paper pouches and sterilized
with steam under pressure (autoclave). After sterilization, the instru-
ments should be kept in pouches for storage and subsequent
transport to the radiography area. When the instruments are taken
to the radiography area, it is good technique to keep them in the
pouch until immediately before use. After use, instruments should
be replaced in the pouch to reinforce cleanliness in the area. The
same sterilization pouch should be used to transport the contami- FIGURE 15-9 Film-holding instrument with barrier wrapping to protect sensor and cord
nated instruments back to the cleaning and sterilizing room. from saliva. (Image courtesy Dentsply Rinn: www.rinncorp.com.)
Use Barriers with Digital Sensors
Sensors for digital imaging cannot be sterilized, so it is important
to use a barrier to protect them from contamination when placed
in the patient’s mouth (Fig. 15-9). Typically, the manufacturers of
these sensors recommend the use of plastic barrier sheaths. The
supplemental use of latex finger cots provides significant added
protection and is recommended for routine use when using digital
sensors. Because such barriers may fail, the sensors should be
cleaned and disinfected with an EPA-registered, intermediate-level
hospital disinfectant after every patient. The manufacturer of such
equipment should be consulted for the proper disinfectant. PSP
sensors are placed in disposable plastic bags with a folded seal for
use in the mouth. Because the entire plastic bag goes into the
mouth with PSP sensors, these plates possibly can become con-
taminated with saliva when removed from the plastic bags for
processing. This contamination could lead to cross-contamination FIGURE 15-10 Dental film with a plastic barrier to protect film from contact with saliva.
of other plates and the processing equipment. To minimize this During opening, the plastic is removed and the clean film is allowed to drop into a container.
 C H A PTE R 15 Quality Assurance and Infection Control 257

during exposure. Barrier-protected film fits in most film-holding The procedure to remove film from a packet without touching
instruments. An attractive feature of the protective envelopes is the (contaminating) is simple. Figure 15-11 illustrates the method for
ease with which they may be opened and the film extracted. For opening a contaminated film packet while wearing contaminated
best results, the packet should be immersed in a disinfectant after gloves without touching the film. The practitioner dons a clean
the films have been exposed in the patient’s mouth. Then the pair of gloves, picks up the film packet by the color-coded end,
packet should be dried and opened, allowing the film to drop out. and pulls the tab upward and away from the packet to reveal the
The barrier envelopes can be conveniently opened in a lighted black paper tab wrapped over the end of the film. Holding the film
area, the film can be dropped onto a clean work area or into a over a cup, the practitioner carefully grasps the black paper tab
clean paper or plastic cup, and the film can be transferred to the that wraps the film and pulls the film from the packet. When the
daylight loader or darkroom for processing. film is pulled from the packet, it falls from the paper wrapping
If barrier-protected film is not used, the exposed film should into the cup. The paper wrapper may need to be shaken lightly to
be placed in a disposable container for later transport to the dark- cause the film to fall free. The packaging materials should be placed
room for processing. Paper film packets are exposed to saliva and on the first paper towel. After all films are opened, the practitioner
possibly blood during exposure in the patient’s mouth. To prevent gathers the contaminated packaging and container and discards
saliva from seeping into a paper film packet, a paper towel should them along with the contaminated gloves. The clean films are
be placed beside the container for exposed films. The practitioner processed in the usual manner. It is not necessary to wear gloves
should use this towel to wipe each film as it is removed from the when handling processed films, film mounts, or patient charts.
patient’s mouth and before it is placed with the other exposed An alternative procedure when exposing films in vinyl packag-
films. This problem may also be avoided by using film packaged ing is to place the exposed film, still in the protective plastic
in vinyl. envelope, in an approved disinfecting solution when it is removed
from the mouth and after wiping it with a paper towel. It should
Prevent Contamination of Processing Equipment remain in the disinfectant after the exposure of the last film for
After all film exposures are made, the operator should remove his the recommended time. Immersion for 30 seconds in a 5.25%
or her gloves and take the container of contaminated films to the solution of sodium hypochlorite is effective.
darkroom. The goal in the darkroom is to break the infection chain Automatic film processors with daylight loaders present a
so that only clean films are placed into processing solutions. Two special problem because of the risk for contaminating the sleeves
towels should be placed on the darkroom working surface. The with contaminated gloves or film packets. One approach is to clean
container of contaminated films should be placed on one of these the films by immersion in a disinfectant, with or without a plastic
towels. After the exposed film is removed from its packet, it should envelope, as previously described. With this method, the operator
be placed on the second towel. The film packaging is discarded on cleans the films, puts on clean gloves, and takes only cleaned film
the first towel with the container. packets into the daylight loader. An alternative approach is to open

FIGURE 15-11 Method for removing films from packet without touching them
A B
with contaminated gloves. A, Packet tab is opened, and lead foil and black interleaf
paper are slid from wrapping. B, Foil is rotated away from black paper and discarded.
C, Paper wrapping is opened. D, Film is allowed to fall into a clean cup.

C D
258 P A RT II Imaging

the top of the loader, place a clean barrier on the bottom, and Infection Control
insert the cup of exposed film packets into a clean cup. The opera- American Academy of Oral and Maxillofacial Radiology infection
tor closes the top, puts on clean gloves, pushes his or her hands control guidelines for dental radiographic procedures, Oral Surg Oral
through the sleeve, and opens the film packets, allowing the film Med Oral Pathol 73:248–249, 1992.
to drop into the clean cup. After all film packets have been opened, American Dental Association Council on Scientific Affairs and American
the contaminated gloves are removed, the films are loaded into Dental Association Council on Dental Practice: Infection control
the developer, and hands are removed. The top of the loader may recommendations for the dental office and the dental laboratory,
be removed, and the contaminated materials are then removed. J Am Dent Assoc 127:672–680, 1996.
Bartoloni JA, Chariton DG, Flint DJ: Infection control practices in
dental radiology, Gen Dent 51:264–271, 2003.
BIBLIOGRAPHY Hubar JS, Gardiner DM: Infection control procedures used in
conjunction with computed dental radiography, Int J Comput Dent
Quality Assurance 3:259–267, 2000.
American Dental Association Council on Scientific Affairs: The use of Kalathingal S, Youngpeter A, Minton J, et al: An evaluation of
dental radiographs: update and recommendations, J Am Dent Assoc microbiologic contamination on a phosphor plate system: is weekly
137:1304–1312, 2006. gas sterilization enough? Oral Surg Oral Med Oral Pathol Oral Radiol
American Dental Association Council on Scientific Affairs: Dental Endod 109:457–462, 2010.
radiographic examinations: recommendations for patient selection Kohn WG, Collins AS, Cleveland JL, et al; Centers for Disease Control
and limiting radiation exposure. Revised 2012: http://www.ada.org/ and Prevention: Guidelines for infection control in dental health-care
sections/professionalResources/pdfs/Dental_Radiographic_ settings—2003, MMWR Morb Mortal Wkly Rep 52(RR-17):1–61,
Examinations_2012.pdf. 2003.
Goren AD, Lundeen RC, Deahl ST II, et al: Updated quality assurance MacDonald DS, Waterfield JD: Infection control in digital intraoral
self-assessment exercise in intraoral and panoramic radiography, radiography: evaluation of microbiological contamination of
American Academy of Oral and Maxillofacial Radiology, Radiology photostimulable phosphor plates in barrier envelopes, J Can Dent
Practice Committee, Oral Surg Oral Med Oral Pathol Oral Radiol Endod Assoc 77:b93, 2011.
89:369–374, 2000. Miller CH, Palenik CJ: Infection control and management of hazardous
Kodak Dental Radiography Series: Quality assurance in dental radiography, materials for the dental team, ed 4, St Louis, 2009, Mosby.
N-416, Rochester, NY, 1998, Eastman Kodak. Palenik CJ: Infection control practices for dental radiography, Dent Today
Mah P, McDavid WD, Dove SB: Quality assurance phantom for digital 23:52–55, 2004.
dental imaging, Oral Surg Oral Med Oral Pathol Oral Radiol Endod Rutala WA, Weber DJ; Healthcare Infection Control Practices Advisory
112:632–639, 2011. Committee (HICPAC): Guideline for disinfection and sterilization in
Michel R, Zimmerman TL: Basic radiation protection considerations in healthcare facilities, Atlanta, GA, 2008, Department of Health and
dental practice, Health Phys 77:S81–S83, 1999. Human Services, Centers for Disease Control and Prevention.
National Council for Radiation Protection and Measurements: Radiation Thomas LP, Abramovitch K: Infection control for dental radiographic
protection in dentistry, NCRP Report No. 145, Bethesda, MD, 2003, procedures, Tex Dent J 122:184–188, 2005.
National Council on Radiation Protection and Measurement. U.S. Department of Labor, Occupational Safety and Health
National Radiological Protection Board: Guidance notes for dental Administration: Occupational exposure to bloodborne pathogens,
practitioners on the safe use of x-ray equipment (2001): needlestick and other sharp injuries, final rule, Fed Reg 66:5317–5325,
www.nrpb.org.uk. 2001.
Quality control recommendations for diagnostic radiography, Volume 1, Dental
facilities, CRCPD Publication 01-4, July 2001.
 CHAPTER

Prescribing Diagnostic Imaging

Sharon L. Brooks 16
OUTLINE
Role of Radiographs in Disease Detection and Jaw Disease Guidelines for Ordering Diagnostic Imaging
Monitoring Temporomandibular Joint Previous Diagnostic Images
Caries Implants Administrative Images
Periodontal Diseases Paranasal Sinuses Use of Guidelines to Order Dental Diagnostic
Periapical Inflammatory Disease Trauma Images
Dental Anomalies Radiologic Examinations Patient Examination
Growth and Development and Dental Intraoral Images Special Considerations
Malocclusion Extraoral Images Examples of Use of the Guidelines
Occult Disease

T
he decision to prescribe diagnostic images should be based • Consequences of undetected and untreated disease
on the individual needs of the patient. In this chapter, the • Impact of asymptomatic, anatomic, and pathologic variations
term diagnostic images includes conventional (film-based) detected in the image on patient treatment, including the need
radiographs as well as any digital image format produced by x rays. for follow-up
Likewise, the commonly used term radiograph is not restricted to • Impact of anatomic variations on dental treatment planning for
images produced on film, but rather it also includes common conditions such as dental implants, extractions, and orthodon-
intraoral and extraoral digital images. tic treatment
Patient imaging needs are determined by findings from the As a general principle, diagnostic imaging is indicated when a
dental history and clinical examination and modified by patient reasonable probability exists that it would provide valuable infor-
age and general health. Diagnostic imaging is necessary when the mation about a disease that is not evident clinically. Conversely,
history and clinical examination have not provided enough infor- radiographs are not indicated when they are unlikely to yield
mation for complete evaluation of a patient’s condition and for- information contributing to patient care. Information derived
mulation of an appropriate treatment plan. Patients should be from the image considered to be clinically useful includes data that
exposed to x rays only when, in the dentist’s judgment, it is reason- are valuable in detecting disease, in monitoring the progression of
ably likely that the patient would benefit by the discovery of clini- known diseases, and in planning dental treatment.
cally useful information in the resultant image. For many clinical situations, it is not readily apparent to the
practitioner whether diagnostic images have a reasonable probabil-
ity of providing valuable information. In these situations, the
ROLE OF RADIOGRAPHS IN DISEASE DETECTION practitioner must use clinical judgment after weighing the patient
AND MONITORING factors to decide whether imaging is indicated.
The philosophy of prescribing images only when there is a
The goal of dental care is to preserve and improve patients’ oral high probability of obtaining clinically useful information has
health, while minimizing other health-related risks. Although the been advocated by all the organizations responsible for develop-
diagnostic information provided by diagnostic imaging may be of ing or endorsing guidelines for ordering diagnostic imaging.
definite benefit to the patient, the radiologic examination does However, many dentists use radiographs as a screening tool, simply
carry the potential for harm from exposure to ionizing radiation. to see “what’s there,” without having a specific suspicion of disease
One of the most effective means of reducing possible harm is to arising from the dental history or clinical examination. There are
avoid making radiographs that would not contribute information probably numerous reasons for this use of radiographs. Some
pertinent to patient care. The judgment that underlies the decision dentists think that they have not provided an adequate service
to make a radiologic examination centers on several factors, includ- to their patients if they cannot assure them that they have searched
ing the following: diligently for disease with all reasonable diagnostic methods,
• Prevalence of the diseases that may be detected radiographically including diagnostic images. They may state that having complete
in the oral cavity information, regardless of whether it affects the treatment plan,
• Ability of the clinician to detect these diseases clinically and in is of such benefit that it outweighs the risk of the radiation
diagnostic images exposure. Other dentists raise medicolegal issues, stating fear of

259
260 P A RT II Imaging

lawsuits if they fail to detect disease. Others express concern countries have been decreasing since the 1970s, probably partially
about the effect on the efficiency of the dental office of the as a result of the widespread use of fluoride, increasing numbers
extended examinations required for prescribing diagnostic images of older adults are maintaining their teeth throughout their life-
on the basis of signs and symptoms. The next few paragraphs times, leaving them at risk for developing both coronal and root
address these concerns. caries. In addition, caries prevalence is not uniformly distributed
In contrast to dentistry, screening imaging is rarely used in throughout the population, with children of lower socioeconomic
medicine with the exception of mammography for women older background having a higher rate of untreated caries than other
than a certain age or with increased risk factors for breast cancer, children.
and there is controversy over whether even this type of examina- Although occlusal, buccal, and lingual carious lesions are
tion should be used as frequently as it is today. Breast cancer is reasonably easy to detect clinically, interproximal caries and
a relatively common yet serious disease that should be detected caries associated with existing restorations are much more dif-
early, before the cancer becomes large enough to be found clini- ficult to detect with a clinical examination only (see Chapter
cally. However, diseases of the jaws (with the exceptions of caries 18). Studies have repeatedly demonstrated that clinicians using
and periapical and periodontal disease) are rare and concentrated intraoral images detect caries not evident clinically, both in
in certain ages, sexes, and ethnicities. These diseases are unlikely enamel and in dentin. Although a radiologic examination is
to be discovered on routine screening radiographs before they very important for diagnosis of dental caries, the optimal fre-
have produced signs or symptoms that could be found with a quency for such an examination should be based on mitigating
thorough clinical examination and history. Periodontal disease features, such as the patient’s age, medical condition, diet, oral
can be diagnosed clinically, although diagnostic images are used hygiene practices, oral health status, and the nature of the caries
to determine the extent of bone loss and the presence of other process itself.
factors that may affect prognosis. Periapical disease is usually Carious lesions demonstrate one of three behaviors: (1) progres-
associated with extensive restorations or caries that can be detected sion, (2) arrest, or (3) regression. Only about 50% of lesions prog-
clinically. However, dental caries on proximal surfaces may not ress beyond the initial, just-detectable defect, and in most instances
be detectable on clinical examination until it has reached an the lesions demonstrate a slow rate of progression through enamel
advanced stage; thus, this is one occult disease for which screen- (months to years). Mechanisms are also in use to enhance remin-
ing radiographs are considered appropriate. Regarding the threat eralization of early enamel lesions. However, the rate of caries
of lawsuits for failure to diagnose, dentists who follow guidelines progression is significantly faster in deciduous enamel than in
on the use of diagnostic imaging developed or endorsed by permanent enamel, and patients vary widely in their rates of forma-
authoritative bodies that help establish the standard of care should tion of caries and in their rates of caries progression.
have no concerns. Although lawsuits can be filed for many reasons, Because the presence of caries cannot be determined with con-
it is unlikely that they will be successful if it can be shown that fidence by clinical examination alone, it is necessary to expose
the practitioner did a thorough clinical examination and history patients periodically through bitewing radiographs to monitor
and carefully considered the guidelines when determining whether dental caries. The length of the exposure intervals varies consider-
to order diagnostic imaging. ably because of different patient circumstances. For most patients
Some dentists set up their practices so that new patients are in good physical health with adequate oral hygiene, an infrequent
automatically seen first by the dental hygienist, who takes a pre- radiologic examination is needed to monitor dental caries.
determined set of diagnostic images at the first appointment, However, if the patient history and clinical examination suggest
before the dentist sees the patient. Although this may make effi- that the individual has a relatively high caries experience, shorter
cient use of the dentist’s time, it is contrary to the recommenda- intervals allow careful monitoring of disease.
tions of the American Dental Association (ADA) that the selection
of number and type of radiographs should be based on the findings PERIODONTAL DISEASES
of the clinical examination. Performing a thorough examination Some form of periodontal disease affects most people at some
before ordering images should not be an insurmountable obstacle point during their lives, gingivitis more often in younger individu-
for an efficient dental practice. als and periodontitis more commonly in older adults. Periodontal
Regarding the issue of cost versus benefit of diagnostic images, diseases are responsible for a substantial portion of all teeth lost.
there is little risk of harm for any individual patient from one set A consensus exists among practitioners that radiologic examina-
of images, even if no important diagnostic information is revealed. tions play an important role in the evaluation of patients with
However, there is a large societal cost, both in terms of health care periodontal disease after the disease is initially detected on clinical
dollars and radiation risk, if millions of dental patients receive examination (see Chapter 19). In addition to providing a picture
unproductive examinations, as would happen if routine screening of the extent of alveolar bone support for the dentition, radiologic
were widespread. In addition, there is a growing concern among examinations help demonstrate local factors that complicate the
the public and the medical profession about the increasing use of disease, including the presence of gingival irritants such as calculus
ionizing radiation in health care in general and the risks it poses and faulty restorations. Occasionally, the length and morphologic
to the public. features of roots, visible on periapical radiographs, are crucial
Our philosophy is that the prescription of diagnostic imaging factors in the prognosis of the disease. These observations suggest
should be based on the need for diagnostic information for patients that when clinical evidence exists of periodontal disease other than
on a case-by-case basis. The next section discusses some of the nonspecific gingivitis, it is appropriate to make intraoral images,
clinical situations that may call for a radiologic examination. generally a combination of periapical and bitewing images, to help
establish the severity of the disease. Follow-up images after therapy
CARIES is complete help the clinician monitor the progression of disease
Dental caries is the most common dental disease, affecting people and determine whether the destruction of alveolar bone has been
of all ages. Although the caries prevalence rates of developed halted.
 C H A PTER 16 Prescribing Diagnostic Imaging 261

other conditions of interest in orthodontics. The American Asso-

PERIAPICAL INFLAMMATORY DISEASE ciation of Orthodontists and the American Academy of Oral and
When a patient presents with a toothache, deep caries, or a large Maxillofacial Radiology more recently developed a joint position
or deep restoration, the likelihood of an inflammatory lesion of statement on the use of CBCT imaging in orthodontics. Broadly,
pulpal origin occurring at the apex of the tooth increases. Usually the statement recommends using CBCT imaging only when justi-
the clinical examination combined with a periapical radiograph is fied by individual need and the clinical question cannot be
sufficient to make the diagnosis and plan the treatment, endodon- answered by using lower dose conventional imaging. Dose-
tic therapy, or extraction. However, in cases with complex root reduction protocols should be used when possible. CBCT imaging
canal anatomy, evidence of failed endodontic treatment, intraop- is also used in some cases of impacted mandibular third molars
erative or postoperative complications, or situations where the when the relationship of the inferior alveolar nerve to the root
periapical view does not provide adequate information, a limited- apex is unclear with conventional images.
volume, high-resolution cone-beam computed tomographic The dentist who is the primary provider of orthodontic treat-
(CBCT) examination might be useful. ment should select the number and type of images needed. The
needs of each patient should be considered individually. Selecting
DENTAL ANOMALIES the appropriate images should allow a maximal diagnostic yield
Abnormal formation of teeth may be manifested as deviations in with a minimal radiation exposure after consideration of the clini-
number, size, and composition. These abnormalities in dental cal examination, the study of plaster models and photographs, and
development occur more frequently and are more likely to have a the optimal time to initiate treatment.
serious impact in the permanent dentition than in the primary
dentition. The most frequently encountered anomalies are the OCCULT DISEASE
presence of supernumerary teeth, usually mesiodens, or develop- Occult disease refers to disease that presents no clinical signs or
mentally absent teeth, usually second premolars (see Chapter 31). symptoms. Occult diseases in the jaws include a combination of
Only a few anomalies exist for which orthodontic treatment or dental and intraosseous findings. Dental findings may include
surgical correction or modification must start at an early age. When incipient carious lesions, resorbed or dilacerated roots, and hyper-
the dentist suspects an abnormality requiring treatment, diagnostic cementosis. Intraosseous findings include osteosclerosis, unerupted
images to confirm and localize it are not required until the time teeth, periapical disease, and a wide variety of cysts and benign
when the treatment is most appropriate. For example, a panoramic and malignant tumors (see Chapters 20 to 26). Small carious
examination of a 5-year-old child to determine the presence or lesions, resorption of root structure, and bony lesions may go
absence of permanent teeth may be poorly timed. Although the unnoticed until signs and symptoms develop.
examination provides evidence that one or more second premolars Although the consequences of some occult diseases may be
or lateral incisors are developmentally missing, this information quite serious, most serious diseases are rare. Often a historical or
usually does not influence the current treatment plan. When exam- clinical sign or symptom of intraosseous disease suggests its pres-
ination for dental anomalies is appropriate, both the radiation dose ence. For instance, an unusual contour of bone or an absent third
and the anticipated diagnostic benefit should be considered. Pro- molar, not explained by a history of extraction, suggests the pos-
jections that best demonstrate the required diagnostic information sibility of an impaction with the potential for an associated den-
should be selected. A panoramic image of the lower face is usually tigerous cyst. Although patient history and clinical signs and
best for observing the presence or absence of teeth in all quadrants, symptoms do not always accurately predict dental and intraosseous
although a periapical or occlusal radiograph is sufficient for an findings, most of these true occult diseases are not clinically rele-
examination limited to one area. vant, or they are so rare that except for caries as described previ-
ously the dentist need not obtain a radiologic examination of the
GROWTH AND DEVELOPMENT jaws solely to screen for them in dentate individuals in the absence
AND DENTAL MALOCCLUSION of unusual clinical signs or symptoms. Caries is an exception
because of its much higher prevalence than other occult diseases.
Children and adolescents are often examined to assess the growth There is a considerable difference of opinion regarding whether
and development of the teeth and jaws. This assessment considers asymptomatic edentulous patients seen for routine denture con-
the relationship of one jaw to the other and to the soft tissues. An struction should have screening images taken to look for occult
examination of occlusion, growth, and development requires an disease. Several studies have demonstrated a relatively large number
individualized radiologic examination that may include periapical of findings in diagnostic images of edentulous patients, including
radiographs or a panoramic view to supplement other images retained root tips and areas of sclerotic bone, but almost all these
ordered to assess dental disease. In addition, a patient of any age findings required no treatment and did not affect the outcome
group who is being considered for orthodontic treatment may of care. For that reason, some experts recommend no images of
need other images, such as lateral or posteroanterior cephalomet- edentulous patients if the clinical examination is negative for signs
ric, occlusal, carpal index (wrist), or temporomandibular joint and symptoms of disease. Others think that screening radiographs
(TMJ) images, depending on the clinical findings (Fig. 16-1). of these patients are of value. As the standard of care for com-
CBCT imaging is being used increasingly frequently for orth- pletely or partially edentulous patients moves toward dental
odontic evaluation to provide three-dimensional information implants rather than removable prosthetics, imaging to assess the
about jaw relationships and to substitute for multiple other imaging quantity and quality of bone available for implants is gaining in
examinations (see Chapters 11 and 12). At the present time, it is importance.
unclear which patients would benefit from CBCT imaging in terms There has been increasing interest in the last few years in using
of treatment considerations. There is adequate information in the panoramic images to screen patients for the presence of calcified
literature to demonstrate the value of CBCT imaging in the evalu- atheromas in the bifurcation of the carotid artery, a finding
ation and treatment of impacted teeth but less information on that may indicate an increased risk for the development of a
262 P A RT II Imaging

Patient
presents for
orthodondic
care

Evaluate
patient’s No
individual Is the patient a candidate for
radiographic comprehensive orthodontic
needs treatment?

Yes

No Is the patient heavily restored Yes

Obtain bitewings and selected
or exhibit clinical evidence of Obtain FMX
periapical radiographs
periodontal problems?

Does the patient have Yes Obtain TMJ

significant TMJ signs or radiographic
symptoms? examination

No

During the end stages of growth, is Yes

Obtain carpal
significant growth required for treatment
index
or is orthognathic surgery contemplated?

No Does the patient have a Yes

Obtain panoramic and
severe facial asymmetry
lateral cephalogram
or disharmony?

Does the patient have evidence of

root resorption or reposition > 2mm?

No

Does the patient have impacted Yes

Obtain cone-beam
maxillary cuspids or are
examination
minidental implants considered?

No

Diagnose
and treat
patient

FIGURE 16-1 Example of a clinical algorithm to order radiographs for orthodontic patients. Selected radiographs are ordered after
the dentist’s consideration of the patient’s history and clinical characteristics. FMX, Full-mouth examination; TMJ, temporomandibular joint.
(Modified from White SC, Pae E-K: Patient and image selection criteria for cone-beam imaging, Semin Orthod 15:19–28, 2009.)
 C H A PTER 16 Prescribing Diagnostic Imaging 263

cerebrovascular accident (stroke). However, the value of this imaging is not capable of providing the detailed images of osseous
finding has been questioned more recently because a noncalcified structures as seen with CBCT imaging. The subtlety of the expected
vulnerable plaque, which is not visible on panoramic radiographs, findings and the amount of detail required should be considered
may put the patient at more risk for stroke than a more stable calci- when selecting the examination to perform. However, according
fied plaque. Nevertheless, the general consensus at this time is that to the International Consortium on Diagnosis of Temporoman-
panoramic images made for dental purposes should be evaluated dibular Disorders, the only imaging technique with adequate valid-
for this calcification, particularly in patients older than 55 years, ity to diagnose degenerative joint disease is CT imaging. If soft
but that these images should not be made simply to screen for tissue information such as disk position is necessary for patient
atheromas without other dental indications. (See Chapter 28 for care, MR imaging is appropriate.
more details.)
IMPLANTS
JAW DISEASE Use of osseointegrated implants, metal screws that are inserted into
Imaging of known jaw lesions, such as fibro-osseous diseases or the mandible or maxilla, is an increasingly common method of
neoplastic diseases, before biopsy and definitive treatment, is also replacing missing teeth. Prosthetic appliances are affixed to the
important for appropriate management of the patient. For small screws after a period of healing. Preoperative planning is crucial
lesions of the jaws, periapical or panoramic radiographs may be to ensure success of the implants. The dentist must evaluate the
enough as long as the lesion can be seen in its entirety. If clinical adequacy of the height and thickness of bone for the desired
evidence of swelling exists, some type of radiograph at 90 degrees implant; the quality of the bone, including the relative proportion
to the original plane (often an occlusal image) should be made to of medullary and cortical bone; the location of anatomic structures
determine whether there is expansion of the jaw or perforation of such as the mandibular canal or maxillary sinus; and the presence
the buccal or lingual cortical bone. If lesions are too large to fit of structural abnormalities such as undercuts that may affect place-
on standard dental radiographs, extend into the maxillary sinus or ment or angulation of the implant (see Chapter 33).
other portions of the head outside the jaws, or are suspected to be Standard periapical and panoramic images can supply informa-
malignant, additional imaging such as medical computed tomo- tion regarding the vertical dimensions of the bone in the proposed
graphic (CT) imaging or CBCT imaging is appropriate before implant site. However, some type of cross-sectional imaging, pref-
biopsy (see Chapters 11 to 14). Both of these types of images can erably CBCT imaging, is recommended before implant placement
provide excellent bone detail, but if there is a suspicion that the for visualization of important anatomic landmarks, determination
lesion may involve the surrounding soft tissue, medical CT imaging of size and path of insertion of implant, and evaluation of the
should be used instead of CBCT imaging because it can provide adequacy of the bone for anchorage of the implant. There is also
images of the soft tissue. These types of imaging can define the increasing use of implant planning software and preparation of
extent of the lesion, indicate an appropriate biopsy site, suggest an surgical drilling guides, which require the three-dimensional data
operative approach, and provide information about the nature of from medical CT imaging or CBCT imaging. Postoperative evalu-
the lesion. If the lesion is not based in bone but in the adjacent ation of implants may be needed later on to judge healing, assess
soft tissue, magnetic resonance (MR) imaging, which has superior complete seating of fixtures, and ensure continued health of the
contrast resolution of soft tissue, should be used. In the initial steps surrounding bone.
of the investigation, referral to an oral and maxillofacial radiologist
to order and report on the most appropriate diagnostic imaging PARANASAL SINUSES
before the biopsy procedure is reasonable. Because dentists are not usually the primary providers of treatment
for acute or chronic sinus disease, the necessity to perform sinus
TEMPOROMANDIBULAR JOINT imaging may be limited in general dental practice. However,
Many types of diseases affect the TMJ, including congenital and because sinus disease can manifest as pain in the maxillary teeth
developmental malformations of the mandible and cranial bones; and because periapical inflammation of maxillary molars and pre-
acquired disorders such as disk displacement, neoplasms, fractures, molars can also lead to changes in the mucosa of the maxillary
and dislocations; inflammatory diseases that produce capsulitis or sinus, circumstances occur in which the dentist needs to obtain an
synovitis; and arthritides of various types, including rheumatoid image of the maxillary sinus. Another reason to image this area is
arthritis and osteoarthritis. The goal of TMJ imaging, similar to to assess the need for bone augmentation or sinus lift before
that for imaging other body parts, should be to obtain new infor- implant placement in the posterior maxilla. Periapical and pan-
mation that would influence patient care. Radiologic examination oramic radiographs demonstrate the floor of the maxillary sinus
may not be needed for all patients with signs and symptoms refer- well, but visualization of other walls requires additional imaging
able to the TMJ region, particularly if no treatment is contem- techniques, such as occipitomental (Waters) view, CBCT imaging,
plated (see Chapter 27). The decision regarding whether and how or medical CT imaging. For the investigation of diseases of the
to image the joints should depend on the results of the history and maxillary sinus, referral to an oral and maxillofacial radiologist
clinical findings, the clinical diagnosis, degree of diagnostic cer- would be a reasonable step (see Chapter 26).
tainty required, and results of prior examinations as well as the
tentative treatment plan and expected outcome. TRAUMA
The cost of the examination and the radiation dose should also Patients who have sustained trauma to the oral region may visit a
influence the decision if more than one type of examination can dentist for evaluation and management of the injuries. For proper
provide the desired information. For example, information about management, it is important to determine the full extent of the
the status of the osseous tissues can be obtained from panoramic injuries. Periapical or panoramic views are helpful for evaluation
radiographs, medical CT imaging, or CBCT imaging. For investi- of fractures of the teeth. If a suspected root fracture is not visible
gation of the soft tissue joint components, such as the disk, and on a periapical radiograph, a second image made with a different
for viewing the surrounding soft tissues, MR imaging is used. MR angulation may be helpful. A fracture that is not perpendicular to
264 P A RT II Imaging

the beam may not be detectable unless root resorption is present. weigh these factors. Examples of all these image types can be found
Occasionally, limited-volume, high-resolution CBCT imaging may in previous chapters.
provide important information about tooth fractures, although
artifacts owing to the presence of metallic restorations or dense INTRAORAL IMAGES
root canal fillings may obscure a fracture. Thus, a tooth with a Intraoral images are examinations made by placing the x-ray film
history of trauma should be monitored and evaluated radiologi- or digital imaging receptor within the patient’s mouth during the
cally on a periodic basis, even if the original image is negative. exposure. These exposures offer the dentist a high-detail view of
Fractures of the mandible frequently can be detected with the teeth and bone in the area exposed. Such views are most
panoramic radiographs, supplemented by images at 90 degrees, appropriate for revealing caries and periodontal and periapical
such as a posteroanterior or reverse-Towne view (see Chapter 30) disease in a localized region. A complete-mouth or full-mouth
or occlusal view. Trauma to the maxilla and midface requires examination consists of periapical views of all the tooth-bearing
medical CT imaging or CBCT imaging for a thorough evaluation. regions as well as interproximal views (see Chapter 7).
Affected patients are more likely to report to a hospital emergency
department than to a general dental office. The hospital may have Periapical Views
a standard protocol for trauma cases. Ideally, the clinician respon- Periapical views show all of a tooth and the surrounding bone and
sible for managing care determines the appropriate diagnostic are very useful for revealing caries and periodontal and periapical
images for the specific case. disease. These views may be made of a specific tooth or region or
as part of a full-mouth examination.
RADIOLOGIC EXAMINATIONS Interproximal Views
After concluding that a patient requires a diagnostic image, the Interproximal views (bitewings) show the coronal aspects of both
dentist should consider which examination is most appropriate to the maxillary and the mandibular dentition in a region as well as
meet all the patient’s diagnostic and treatment planning needs. the surrounding crestal bone. These views are most useful for
Various image projections are available. When choosing a projec- revealing proximal caries and evaluating the height of the alveolar
tion, the dentist should consider the anatomic relationships, the bony crest. They can be made in either the anterior or the posterior
size of the field, and the radiation dose from each view. Table 16-1 region of the mouth.
summarizes common types of radiologic examinations for general
dental patients and factors to consider in choosing the most appro- Occlusal Views
priate one. For example, a panoramic image provides broad area Occlusal views are intraoral images in which the film or digital
coverage with moderate resolution. Intraoral images give more image receptor is positioned in the occlusal plane. They are often
detailed information but a significantly higher radiation dose per used in lieu of periapical views in children because the small size
unit area exposed. The clinician must use clinical judgment to of the patient’s mouth limits the film or receptor placement. In

T AB LE 16 -1 Dental Radiographic Examinations and Their Properties

Type of Examination Coverage Resolution Relative Exposure* Detectable Disease
I NT RA O R AL R AD IOG RA PHS
Periapical Limited High 1 Caries, periodontal disease, occult disease
Bitewings Limited High 10 Caries, periodontal bone level
Full-mouth periapical Limited High 14–17 Caries, periodontal disease, dental anomalies, occult disease
Occlusal Moderate High 2.5 Dental anomalies, occult disease, salivary stones, expansion of jaw
E XT R AOR AL RAD IO GRA PHS
Panoramic Broad Moderate 1–2 Dental anomalies, occult disease, extensive caries, periodontal disease, periapical disease,
TMJ
Film tomography/slice Moderate Moderate 0.2–0.6 TMJ, implant site assessment
CBCT imaging Broad Moderate to high 4–42 Implant, TMJ, craniofacial relationships, dental anomalies, extent of disease, fracture
CT/head imaging Broad High 25–800 Extent of craniofacial disease, fracture, implants
MR imaging Broad Moderate — Soft tissue disease, TMJ
Skull Broad Moderate 30 Fracture, anatomic relation, jaw disease
Note. The relative exposures assume use of F-speed film and rectangular collimation for periapical films, round collimation for bitewings and occlusal views, and rare-earth screens for panoramic examinations. With
D-speed film, the intraoral values are more than doubled compared with F-speed film, and with round collimation the periapical values increase by 2.5 times compared with rectangular collimation. CBCT, cone-beam
computed tomography; CT, computed tomography; MR, magnetic resonance; TMJ, temporomandibular joint.
*From Frederiksen N, Benson B, Sokolowski T: Effective dose and risk assessment from computed tomography of the maxillofacial complex, Dentomaxillofac Radiol 24:55–58, 1995; Scaf G, Lurie AG, Mosier KM,
et al: Dosimetry and cost of imaging osseointegrated implants with film-based and computed tomography, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 83:41–48, 1997; White SC: 1992 assessment of radiation
risks from dental radiology, Dentomaxillofac Radiol 21:118–126, 1992; Ludlow JB, Davies-Ludlow LE, Brooks SL, et al: Dosimetry of 3 CBCT devices for oral and maxillofacial radiology: CB Mercuray, NewTom 3G
and i-CAT, Dentomaxillofac Radiol 35:219–226, 2006.
 C H A PTER 16 Prescribing Diagnostic Imaging 265

adults, occlusal images may supplement periapical views, provid- As more dentists acquire CBCT units for their office, questions
ing visualization of a greater area of teeth and bone, and can will arise about the most appropriate use of this technology. Posi-
provide a right-angle view. They are useful for demonstrating tion statements on the use of CBCT imaging in endodontics and
impacted or abnormally placed maxillary anterior teeth or visual- implant dentistry have been developed. The ADA has also devel-
izing the region of a palatal cleft. Occlusal views may also demon- oped basic guidelines on the use of CBCT imaging in general in
strate buccal or lingual expansion of bone or presence of a sialolith dentistry. In all of these documents, there is a single basic theme:
in the submandibular duct. this technology should be used only when the three-dimensional
information provided would be of direct benefit in the diagnosis
EXTRAORAL IMAGES and treatment of the patient’s condition because the radiation dose
Extraoral images are examinations made of the orofacial region by is generally higher than with conventional imaging. The higher
use of imaging receptors located outside the mouth. The relation- radiation dose is particularly of concern when imaging children,
ships among patient position, receptor location, and beam direc- who are more sensitive to the effects of radiation than are adults.
tion vary depending on the specific information desired. The
standard technique for making several extraoral images is discussed
in Chapter 9. Only the panoramic image is described here because GUIDELINES FOR ORDERING
it has common use as a radiologic examination for general dental
patients.
DIAGNOSTIC IMAGING
The ADA has issued the following guidelines recommending
Panoramic Images which images (radiographs) to make and how often to repeat them:
Panoramic images provide a broad view of the jaws, teeth, maxil- • Make radiographs only after a clinical examination and only
lary sinuses, nasal fossa, and TMJs (see Chapter 10). They show when there is an expectation that the diagnostic yield would
which teeth are present, the relative state of development, the affect patient care.
presence or absence of dental abnormalities, and many traumatic • Order only images that directly benefit the patient in terms of
and pathologic lesions in bone. Panoramic images are the tech- diagnosis or treatment plan.
nique of choice for initial examinations of edentulous patients. • Use the least amount of radiation exposure necessary to gener-
Because this system is an extraoral technique and sometimes uses ate an acceptable view of the imaged area.
intensifying screens and because the image receptor and x-ray tube
are in motion during the patient exposure, the resolution of the PREVIOUS DIAGNOSTIC IMAGES
images is less than with intraoral images (see Chapter 10). Increas- Most patients have been seen previously by a dentist and have
ingly, panoramic radiographs are made with digital sensors rather already had radiographs made. These images are helpful regardless
than film. Panoramic images are also susceptible to artifacts from of when they were exposed. If they are relatively recent, they may
improper patient positioning that negatively affect the image. Con- be adequate to the diagnostic problem at hand. Even if they were
sequently, this system is generally considered inadequate for inde- made so long ago that they are not likely to reflect the current
pendent diagnosis of caries, root abnormalities, and periapical status of the patient, they may still prove useful. These previous
changes. images may demonstrate whether a condition has worsened, has
In most dental patients, oral disease involving the teeth or remained unchanged, or has shown healing, such as in the progres-
jaw bones lies within the area imaged by periapical images. sion of caries or periodontal disease.
Therefore, when a full-mouth set of radiographs is available, a
panoramic examination is usually redundant because it does not ADMINISTRATIVE IMAGES
add information that alters the treatment plan. However, situ- Administrative images are images made for reasons other than
ations may exist in which a panoramic image may be preferred diagnosis, including images made for an insurance company or for
over a periapical examination, such as for assessing growth and an examining board. The authors think that it is appropriate to
development in a child or adolescent. Panoramic views are most expose patients only when it benefits their health care. Most
useful when the required field of view is large but the need administrative images do not serve such an objective. This recom-
for high resolution is of less importance. However, the image mendation is often not adhered to in practice, and dentists are left
quality of digital panoramic examinations is frequently higher to sort out the most appropriate criteria to use in their practices.
than their film counterparts, and thus in many cases a digital
panoramic image, supplemented with bitewings, may be preferred
over periapical images. Although the selection of a radiologic USE OF GUIDELINES TO ORDER DENTAL
examination should be based on the extent of the expected
information it is likely to provide, the relatively low dose of
DIAGNOSTIC IMAGES
radiation from the panoramic examination should also be a At any time, patients generally have a combination of diseases that
qualifying factor. the clinician must consider. Therefore, guidelines specify not only
which examinations to order but also which specific patient factors
Advanced Imaging Procedures influence the number and type of images to order.
Various advanced imaging procedures, such as medical CT imaging, A panel of individuals was convened in the mid-1980s at the
CBCT imaging, MR imaging, ultrasonography, and nuclear medi- request of a branch of the U.S. Food and Drug Administration
cine scans, may be required in specific diagnostic situations. These (FDA) to develop a set of guidelines for the making of dental
techniques are discussed in Chapter 14, although in general the radiographs. The panel addressed the topic of appropriate images
dentist should refer the patient to an oral and maxillofacial radiolo- for an adequate evaluation of a new or recall asymptomatic patient
gist or a medical imaging center for these procedures rather than seeking general dental care. The guidelines were updated in 2004
performing them in the dental office. to reflect changes in technology and to address situations not
266 P A RT II Imaging

considered in the first document, and they were updated again in is so low that making a periapical or panoramic survey just to look
2012 (Table 16-2). However, there was no change in philosophy for such disease is not indicated.
between the original and current guidelines.
The guidelines describe circumstances (patient age, medical PATIENT EXAMINATION
and dental history, and physical signs) that suggest the need for The ordering of diagnostic images requires a reasonable expecta-
diagnostic images. These circumstances are called selection cri- tion that they would provide information that would contribute
teria. The guidelines also suggest the types of examinations most to solving the diagnostic problem at hand. The first step is a careful
likely to benefit the patient in terms of yielding diagnostic infor- examination of the patient, including transillumination of the
mation. They recommend that images not be made unless some anterior teeth to evaluate for interproximal decay. The clinical
expectation exists that they would provide evidence of diseases examination provides indications regarding the nature and extent
that would affect the treatment plan. The ADA was an equal of the radiologic examination appropriate to the situation.
partner with the FDA in the revision of the guidelines and rec- A team of dentists tested the ability of the original ADA guide-
ommends their use. lines to reduce the number of intraoral images, while still offering
These guidelines also form the basis of the recommendations adequate diagnostic information. This testing of the use of selec-
in this chapter. Use of the guidelines can help optimize patient tion criteria demonstrated that a small but significant number of
care, minimize the total diagnostic radiation burden, and respon- findings were not 100% covered in the anterior region if only
sibly allocate health care resources. However, the practitioner, who posterior interproximal and selected periapical images were used.
is the only one who knows the patient’s dental history and suscep- The testing suggested that anterior interproximal or anterior peri-
tibility to oral disease, must make the ultimate decision on whether apical images are also indicated to detect interproximal caries and
to order images, using the guidelines as a resource, not as a stan- periodontal disease in the anterior region, specifically for patients
dard of care or a regulation. with high levels of dental disease. A panoramic radiograph could
Central to the guidelines is the idea that dentists should expose be made in place of the periapical images to supplement the pos-
patients to radiation only when they reasonably expect that the terior bitewings if the totality of the disease expected indicates a
resulting diagnostic image would benefit patient care. Two situa- broad area of coverage and fine detail is not required.
tions mandate a need for radiology: some clinical evidence of an In the ADA/FDA guidelines, patients are classified by stage of
abnormality that requires further evaluation for a complete assess- dental development, by whether they are being evaluated for the
ment or a high probability of disease that warrants a screening first time (without previous documentation) or being reevaluated
examination. during a recall visit, and by an estimate of their risk for having
Selection criteria for images are signs or symptoms found in dental caries or periodontal disease. A footnote to Table 16-2 also
the patient history or clinical examination that suggest that a outlines some other clinical findings that indicate when diagnostic
radiologic examination would yield clinically useful information. images are likely to contribute to a complete description of the
A key concept in the use of selection criteria is recognition of the asymptomatic patient.
need to consider each patient individually. Prescription of diagnos- Applying these guidelines to the specific circumstances with
tic images should be decided on an individual basis according to each patient requires clinical judgment and an amalgamation of
the patient’s demonstrated need. knowledge, experience, and concern. Clinical judgment is also
The guidelines include a description of clinical situations in required to recognize situations that are not described by the
which images are likely to contribute to the diagnosis, treatment, guidelines but in which patients would need diagnostic images
or prognosis. Two examples highlight the differences between nonetheless.
ordering images for dental diseases with clinical signs and symp-
toms and dental diseases with no clinical indicators but high Initial Visit
prevalences. In the first situation, a patient has a hard swelling in The guidelines recommend that a child with primary dentition
the premolar region of the mandible with expansion of the buccal who is cooperative and has closed posterior contacts have only
and lingual cortical plates. The clinical sign of swelling alerts the interproximal views to examine for caries. Additional periapical or
dentist to the need for a diagnostic image to determine the nature occlusal views are recommended only in the case of clinically
of the abnormality causing the swelling. evident diseases or specific historical or clinical indications such
An example of the second situation is a patient who comes as those listed at the footnote of Table 16-2. Patients without
seeking general dental care after not having seen a dentist for many evidence of disease and with open proximal contacts may not
years. Even without clinical evidence of caries, bitewings are indi- require a radiologic examination at this time.
cated because of the prevalence of dental caries in the population. For radiologic examination of a new patient in the transitional
Because this patient has not had interproximal radiographs for dentition, after eruption of the first permanent tooth, the guide-
many years, it is reasonable to assume that the patient may benefit lines recommend interproximal views to assess for dental caries
from the examination by the detection of interproximal caries. and a panoramic radiograph or selected periapical or occlusal views
Although no clinical signs exist that predict the presence of early to evaluate growth and development, this being a time when
caries, the dentist relies on clinical knowledge of the prevalence of management of dental anomalies might begin.
caries to decide that this radiograph has a reasonable probability The guidelines group adolescents and dentate adults together
of finding disease. to identify the kind and extent of appropriate radiologic exami-
Without some specific indication, it is inappropriate to expose nation. The guidelines recommend that these patients receive
the patient “just to see if there is something there.” The major an individualized examination consisting of interproximal views
exception to this rule is the use of interproximal images for caries and panoramic or periapical views selected on the basis of
when no clinical signs exist of early lesions. The probability of specific historical or clinical indications. The presence of gen-
finding occult disease in a patient with all permanent teeth erupted eralized dental disease often indicates the need for a full-mouth
and no clinical or historical evidence of abnormality or risk factors examination. Alternatively, the presence of only a few localized
 C H A PTER 16 Prescribing Diagnostic Imaging 267

T AB L E 1 6 -2 American Dental Association Recommendations for Prescribing Dental Radiographs*

Type of Encounter PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Child with Primary Dentition (before Child with Transitional Dentition (after Eruption
Eruption of First Permanent Tooth) of First Permanent Tooth)
New patient* being evaluated for oral diseases Individualized radiographic exam consisting of Individualized radiographic exam consisting of posterior
selected periapical/occlusal views and/or bitewings with panoramic exam or posterior
posterior bitewings if proximal surfaces cannot be bitewings and selected periapical images
visualized or probed. Patients without evidence of
disease and with open proximal contacts may not
require a radiographic examination at this time
Recall patient* with clinical caries or at increased risk for Posterior bitewing exam at 6- to 12-mo intervals if proximal surfaces cannot be examined visually or with a
caries† probe
Recall patient* with no clinical caries and not at increased Posterior bitewing examination at 12- to 24-mo intervals if proximal surfaces cannot be examined visually or
risk of developing caries† with a probe
Recall patient* with periodontal disease Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease.
Imaging may consist of, but is not limited to, selected bitewing and/or periapical images of areas in which
periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Patient (new and recall) for monitoring of dentofacial Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of
growth and development and/or assessment of dentofacial growth and development or assessment of dental and skeletal relationships
dental/skeletal relationships
Patient with other circumstances, including, but not Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of these
limited to, proposed or existing implants, other dental conditions
and craniofacial pathosis, restorative/endodontic needs,
treated periodontal disease, and caries remineralization
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Adolescent with Permanent Dentition (before
Eruption of Third Molars) Adult, Dentate or Partially Edentulous Adult, Edentulous
Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and Individualized radiographic exam, based on clinical
selected periapical images; full-mouth intraoral radiographic exam is preferred when patient has clinical evidence of signs and symptoms
generalized dental disease or a history of extensive dental treatment
Posterior bitewing exam at 6- to 12-mo intervals if Posterior bitewing examination at 6- to 18-mo Not applicable
proximal surfaces cannot be examined visually or with intervals
a probe
Posterior bitewing exam at 18- to 36-mo intervals Posterior bitewing exam at 24- to 36-mo intervals Not applicable
Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease. Not applicable
Imaging may consist of, but is not limited to, selected bitewing and/or periapical images of areas in which
periodontal disease (other than nonspecific gingivitis) can be demonstrated clinically
Clinical judgment as to need for and type of radiographic Usually not indicated for monitoring of growth and development. Clinical judgment as to the need for and type
images for evaluation and/or monitoring of dentofacial of radiographic images for evaluation of dental and skeletal relationships
growth and development or assessment of dental and
skeletal relationships. Panoramic or periapical exam to
assess developing third molars
Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of these conditions
Note. The recommendations in this table are subject to clinical judgment and may not apply to every patient. They are to be used by dentists only after reviewing the patient’s health history and completing a clinical
examination. Because every precaution should be taken to minimize radiation exposure, protective thyroid collars and aprons should be used whenever possible.
*Clinical situations for which radiographs may be indicated, but are not limited to, include the following: positive historical findings—previous periodontal or endodontic treatment, history of pain or trauma, familial
history of dental anomalies, postoperative evaluation of healing, remineralization monitoring, presence of implants, previous implant pathoses, or evaluation for implant placement; positive clinical signs/symptoms—
clinical evidence of periodontal disease, large or deep restorations, deep carious lesions, mal-posed or clinically impacted teeth, swelling, evidence of dental/facial trauma, mobility of teeth, sinus tract (“fistula”), clinically
suspected sinus pathosis, growth abnormalities, oral involvement in known or suspected systemic disease, positive neurologic findings in the head and neck, evidence of foreign objects, pain and/or dysfunction of
TMJ, facial asymmetry, abutment teeth for fixed or removable partial prosthesis, unexplained bleeding, unexplained sensitivity of teeth, unusual eruption, spacing or migration of teeth, unusual tooth morphology,
calcification or color, unexplained absence of teeth, clinical dental erosion, or peri-implantitis.
†
Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0-6 years old) and (>6 years old): http://www.ada.org.
Adapted from the U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration; and American Dental Association, Council on Dental Benefit Programs, Council on Scientific
Affairs.
268 P A RT II Imaging

abnormalities or diseases suggests that a more limited examina- background sources. Because the use of radiologic procedures in
tion consisting of interproximal and selected periapical views all patients is predicated on there being a diagnostic need for them,
may suffice. In circumstances with no evidence of current or the guidelines apply to pregnant patients as well as patients who
past dental disease, only interproximal views may be necessary are not pregnant. However, the ADA recommends the use of
for caries examination. protective thyroid collars and aprons during dental radiography
For an edentulous patient presenting for prosthetic treatment, for all patients as well as the use of all other dose-limiting tech-
an individualized examination that is based on clinical signs niques, following the principle of ALARA (As Low As Reasonably
and symptoms should be performed. This may include a pan- Achievable).
oramic image or selected periapical or occlusal views, with some
type of cross-sectional examination if dental implants are being Radiation Therapy
considered. Patients with a malignancy in the oral cavity or perioral region
often receive radiation therapy for their disease. Some oral tissues
Recall Visit receive 50 Gy or more. Although such patients are often apprehen-
Patients who are returning after initial care require careful exami- sive about receiving additional exposure, dental exposure is insig-
nation before determining the need for diagnostic images. As at nificant compared with what they have already received. The
the initial examination, selected periapical views should be average skin dose from an intraoral radiograph is approximately
obtained if any of the historical or clinical signs or symptoms 3 mGy, less if faster film or digital imaging is used. Patients who
listed in the footnote to Table 16-2 are present and need further have received radiation therapy may have radiation-induced xero-
evaluation. stomia and are at a high risk for development of radiation caries,
The guidelines recommend interproximal radiographs for recall which may produce serious consequences if extractions are needed
patients to detect interproximal caries. The optimal frequency for in the future. Patients who have had radiation therapy to the oral
these views depends on the age of the patient and the probability cavity should be carefully followed up because they are at special
of finding this disease. If the patient has clinically demonstrable risk for dental disease.
caries or the presence of high-risk factors for caries (poor diet, poor
oral hygiene, and others that can be assessed via the ADA Caries EXAMPLES OF USE OF THE GUIDELINES
Risk Assessment forms: http://www.ada.org), bitewings are exposed at Consider the ways in which the guidelines can be applied to dif-
fairly frequent intervals (6 to 12 months for children and adoles- ferent clinical situations:
cents and 6 to 18 months for adults) until no carious lesions are • The first visit of a 5-year-old boy to a dental office. A careful
clinically evident. The recommended intervals are longer for indi- clinical examination reveals that the patient is cooperative and
viduals not at high risk for caries: 12 to 24 months for a child, 18 that the posterior teeth are in contact. Posterior bitewings are
to 36 months for an adolescent, and 24 to 36 months for an adult. recommended to detect caries. If all of this patient’s teeth are
Individuals can change risk category, going from high to low risk present, no evidence exists of decay, a reasonably good diet
or the reverse. is being observed, and the parent seems well motivated to
Clinical judgment about need for and type of radiologic exami- promote good oral hygiene, no further radiologic examination
nation should be used for other circumstances, such as evaluating is required at this time. Images for the detection of develop-
the status of periodontal disease, monitoring growth and develop- mental abnormalities are not in order at this age because a
ment, and endodontic or restorative considerations. The inter- complete appraisal cannot be made at age 5 years. Even if it
proximal examination may be supplemented by a panoramic, could be made, it is too early to initiate treatment for such
selected periapical or occlusal, or advanced imaging examination, abnormalities.
depending on the patient’s specific needs. • A 25-year-old woman receiving a 6-month checkup after her last
A radiologic examination may be required in many other treatment for a fractured incisor. No caries is evident on inter-
situations, such as for patients contemplating orthodontic or proximal images made 6 months ago; currently no clinical signs
implant treatment or patients with intraosseous lesions. The goal suggest caries, and the patient does not have high-risk factors
should be to obtain the necessary diagnostic information with for caries. No evidence exists of periodontal disease or other
the minimal radiation dose and financial cost, which can be remarkable signs or symptoms in general or associated with the
substantial for advanced imaging procedures such as MR imaging. recently fractured tooth. As long as the fractured incisor shows
The dentist should determine specifically what type of informa- normal vitality testing, no radiographs are recommended for
tion is needed and the most appropriate technique for obtaining this patient. If the incisor is nonvital, a periapical view of this
it. An example of a clinical algorithm for ordering diagnostic tooth should be exposed.
images before orthodontic treatment is shown in Figure 16-1, • A 45-year-old man returning to the dentist’s office after 1
using guidelines endorsed by the American Academy of Ortho- year. At his last visit, two three-surface amalgam restorations
dontics. Because guidelines for ordering diagnostic images for were placed on premolars, and root canal therapy was per-
other situations are not as well developed, the dentist must rely formed on number 30. The patient has a 5-mm pocket in the
on clinical judgment. buccal furcation of number 3 but no other evidence of peri-
odontal disease. The guidelines recommend that this patient
SPECIAL CONSIDERATIONS receive interproximal images to see whether he still has active
Pregnancy caries and periapical views of numbers 3 and 30 to evaluate
Occasionally, it is desirable to obtain diagnostic images of a preg- the extent of the periodontal disease and periapical disease,
nant patient. The x-ray beam is largely confined to the head and respectively.
neck region in dental x-ray examinations; fetal exposure is • A 65-year-old woman coming to the office for the first time.
only about 1 μGy for a full-mouth examination. This exposure is No previous diagnostic images are available. The patient has a
quite small compared with that received normally from natural history of root canal therapy in two teeth, although she does
 C H A PTER 16 Prescribing Diagnostic Imaging 269

not know which teeth were treated. Clinical examination reveals revised ed (2012): http://www.fda.gov/Radiation-EmittingProducts/
multiple carious teeth, multiple missing teeth, and pockets of RadiationEmittingProductsandProcedures/MedicalImaging/
more than 3 mm involving most of the remaining teeth. The MedicalX-Rays/ucm116504.htm.
guidelines recommend a full-mouth examination, including White SC, Heslop EW, Hollender LG, et al: Parameters of radiologic
care: an official report of the American Academy of Oral and
interproximal images, for this patient because of the high prob-
Maxillofacial Radiology, Oral Surg Oral Med Oral Pathol Oral Radiol
ability of finding caries, periodontal disease, and periapical Endod 91:498–511, 2001.
disease.
Disease Detection
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