Dental Radiology

digital rad
Which type of digital image receptor is most common at this time?
CID (charge injection device)
• CMOS/APS (complementary metal oxide semiconductor/active pixel sensor)
• CCD (charge-coupled device)
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RADIOLOGY
digital rad
Which of the following are advantages of direct digital radiography.
Select all that apply.
superior gray-scale resolution
' reduced patient exposure to x-radiation
• increased speed of image viewing
' lower equipment and film costs
• sensor size
i
• increased efficiency
• effective patient education tool
• enhancement of diagnostic image

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RADIOLOGY
^>tA4S03lS • CCD (charge-coupled device)
^
Digital imaging (CCDTjHiarge-coupled device)
• filmless imaging system • most common digital image receptor
• method of capturing a radiographic image • in the intraoral sensor, a solid-state detector
with a sensor, breaking the image into electronic that contains a silicon chip with an embedded
pieces and presenting & storing the image using electronic circuit
a computer • sensitive to light or x-rays
• 640 x 480 pixels in size
Direct digital image production requires
• x-ray source CMOS/APS (complementary metal oxide
• digital intraoral sensor semiconductor/active pixel sensor)
• computer •Jatest development in direct digital sensor
• high-resolution monitor tecnnSlogy
• software & printer • externally identical to CCD
i • differs in the way pixels are read
Digital intraoral sensor • • advantages include lower production cost of
• small intraoral detector used to capture a * the chip, lower power requirements & greater
radiographic image '. durability
• when x-rays strike the sensor, an electronic • • smaUef.acjtive a r e a f ° r image acquisition
charge is produced on the surface of the
sensor, this electronic charge is digitized or VCIDjJfcharge injection device)
converted to digital form • another sensor technology
• may be wired or wireless • silicon based solid-state imaging receptor
• sensor transmits information to computer similar to CCD
• no computer is required to process the images
Pixel or picture element
• system features CID x-ray sensor, cord and
• discrete unit of information plug that are inserted into a light source on a
• consists of a small electron well where the x- camera platform
ray or light energy is deposited upon exposure
(/digital image is composed ofpixejsh
' superior gray-scale resolution

' reduced patient exposure to x-radiation
> increased speed of image viewing
> lower equipment and film costs
' increased efficiency
' effective patient education tool
' enhancement of diagnostic image
Advantages of digital imaging Disadvantages of digital imaging
• superior gray scale resolution • sensor size
256 shades of gray used instead of the 16-25 shades some sensors are thicker and less flexible than
used with film film and may stimulate the gag reflex
• reduced exposure to radiation • initial set up costs
radiation exposure is 50% to 90% less than what is significant initial cost for purchase of digital
used to expose E-speed film equipment as well as maintenance and repairs
• increased speed of image viewing • resolution / image quality
images can be viewed instantly which allows for conventional x-ray film has a resolution of 12
immediate intetpretation •n - 20 lp/mm (linepairs per millimeter); digital
• lower equipment and film cost Mmaging using a CCD has a resolution of 10
no need for purchase of film and related processing 8 lp/mm; because human eye can only perceive 8
supplies and equipment N>- 10 lp/mm — digital imaging performs at
• increased efficiency least as well as traditional radiography
allows dental professionals to be more productive; • infection control
image storage and communication are easier with some sensors cannot withstand heat steriliza-
digital networking tion; barrier protection is required
• enhancement of diagnostic image • wear & tear
features such as colorization and zooming allow for sensors are subject to damage, wear & tear and
highlighting of conditions; the gray scale may be re- have a limited lifespan
YSBjed. (digital subtraction) • legal issues
• effective patient education tool because digital images can be enhanced, there
the size of images displayed monitor are easier for may be legal implications
the patient to see; allows for chairside education and
interaction
digital rad
A method of obtaining a digital image where the sensor captures the image
and immediately transfers it to a computer is termed:
indirect digital imaging
• direct digital imaging
• storage phosphor imaging
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RADIOLOGY
digital rad
A patient is extremely concerned about radiation exposure. Which of the fol-
lowing is best for limiting the amount of exposure he will receive during a full
mouth series?
• use of digital imaging
• use of E-speed films
• use of F-speed films
• substitute a panoramic image for the full mouth series
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RADIOLOGY
' direct digital imaging
Digital imaging Scanning of traditional films

• filmless imaging system • required components
• methods of obtaining a digital image: - CCD camera
direct and indirect - computer & monitor
• existing films are scanned and digitized using a
Direct digital imaging CCD camera
• required components • CCD camera scans radiograph, converts the
- x-ray machine image and displays it on monitor
- intraoral sensor • is inferior to direct digital imaging
- computer & monitor • image is a "copy" not an "original"
• utilizes a sensor with a fiberoptic cable that is
linked to a computer ^Steage, phosphor imaging ss P£{>
• sensor is placed intraorally and exposed to • required components
x-radiation .-phosphor- coated plate
• images are captured via a sensor - electronic processor/scanner
(CCD, CMOS/APS or CID) - computer & monitor
• the sensor transmits the image to a computer • a "wireless" digital imaging system
monitor • a reusable imaging plate coated with phosphors
• images appear on monitor within seconds of is used instead of a sensor with a fiberoptic cable
exposure • plates are similar to intraoral film in size, shape
• software is used to enhance & store the image & thickness
• image recorded on plate
Indirect digital imaging • after exposure, plate is placed in electronic
• scanning of traditional films processor where a laser scans the plate; image
• storage phosphor imaging is transferred to the monitor within time frame
nf'jQ.s.gcciridr1 to 5 minutes
• also referred to as photo-stimulable phosphor
imaging or PSP imaging
• use of digital imaging
Digital imaging
• requires LESS radiation than conventional films because the sensor is more sensitive to
x-rays than dental film
• exposure time for digital imaging is approximately 5-0% less than what is required for F-
speed film
• intraoral, panoramic and other extraoral films may all be obtained digitally
Intraoral film speed

• E-speed film is no longer available
• Only D-speed film and F-speed film are available for use with intraoral radiography
• F-speed film is recommended by the ADA
Q*^£^£Sdj!£2 u j r e s 6p%_qf the exposure time of D-speed
Other ways to limit exposure to x-radiation

• proper prescribing of dental radiographs based on individual needs of patient
• use of lead apron & thyroid collar
• use of proper dental x-ray equipment
• use of rectangular position-indicating device (PID)
• use of beam alignment devices
• use of proper technique
• proper sensor handing
• proper image retrieval
image char
A radiograph that exhibits areas of black and white is termed high contrast
and is said to have a short contrast scale; a radiograph the exhibits many
shades of gray is termed low contrast and is said to have a long contrast scale.
To limit image magnification, the longest target-receptor distance and short-

est object-receptor distance are used. ^He
• both statements are true
• both statements are false
• the first statement is true, the second is false
• the first statement is false, the second is true
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RADIOLOGY
image char
Rank the following from LEAST radiopaque to MOST radiopaque.
amalgam
• bone
• dentin
> maxillary sinus
• enamel
RADIOLOGY
contrast magnification
the difference in degrees of blackness (densi- a radiographic image that appears larger than
tjg£) between adjacent areas on a dental radi- the actual size of the object it represents; mag-
ograph. nification is influenced by the target-receptor
• high contrast describes an image that ap- distance and the object-receptor distance.
pears mostly black & white; shades of gray
are absent
target-receptor distance -
• low contrast describes an image with
• distance between the source of x-rays and
many shades of gray; few areas of black
the image receptor*film / W . * ^
and white
• a longer PID results in a longer target-recep-
tor distance and helps to limit magnification
scales of contrast
the range of useful densities seen on a dental
radiograph. object-receptor distance 's^*f- Q^*
• distance between the tooth and the image
receptor
short-scale contrast • the closer the receptor is to the tooth, the less
describes a high contrast image magnification is seen on the image
with densities of black & white
that results from using a .low to limit magnification
kilovoltage. • use a long target-receptor distance/I target-
^Milium V ,
receptor distance
long-scale contrast • use a short object-receptor distance/J, object
describes a low contrast image -receptor distance
with many shades of gray that
results from using a highkilo-
voltaee. i
bus cm
LOW CONTRAST •• LONG-SCALE CONTRAST 'image receptor=digital sensor or x-ray film

HV**t kvp
• sinus— b o n e — d e n t i n — enamel amalgam

fit
radiolucent structures radiopaque structures
• lack density • are dense
• permit the passage of x-radiation • resist the passage of x-radiation
• absorb very little x-radiation • absorb the x-radiation
'.a.fj.o.w more x-rays to reach the receptor* • allow few_xjay.s to reach the receptor
• appear dark or black on an image • appear light or white on an image
Examples of radiolucent structures/mate- Examples of radiopaque structures/mate-

rials — BLACK or DARK rials _ WHITE or LIGHT
• air space images • enamel
• soft tissue images • dentin
• canals •bone
• foramens • lamina dura
• fossas • septa
• sinuses • tubercles
• sutures • tuberosities
• caries • ridges
• pulp cavities • processes
• periodontal ligament space • amalgams, metal restorations
• denture acrylic • implants
• some composite restorations • gutta percha
LUCENT means TRANSPARENT and OPAQUE means NOT TRANSPARENT

suggests something that lacks density — and suggests something that is more dense
something that lacks density permits the pas- — something that is more dense resists the
sage of x-rays & appears RADIOLUCENT passage of the x-rays & appears RA-
DIOPAQUE
%^ S *receptot=digital sensor or x-ray film
misc.
Dental radiographs are the legal property of the:
patient
• dentist
• state
> none of the above
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RADIOLOGY
misc.
A dental hygienist in your practice has an adult recall patient without evi-
dence of caries who states she needs bite-wing x-rays because it has been 6
months since her last dental images. The hygienist should tell the patient
that:
• yes, she is correct, it is time for new x-ray images
• bite-wings should be taken only once per year, not twice
• images should be taken based on patient need instead of a set time frame
• none of the above
s
RADIOLOGY
• dentist
Dental radiographs Patients who refuse dental radiographs

• original radiographs are legally the • when a patient refuses to have dental ra-
property of the dentist even though the diographs, the dentist must decide whether
patient or an insurance company may have diagnosis and treatment can take place
paid for them without the recommended radiographs
• the radiographs are the property of the • no document can be signed by the patient
dentist because they are indispensable to the that releases the dentist from liability
dentist as part of the patient record
• radiographs should be kept indefinitely
Very important: the patient record, includ-
Patient access to radiographs
ing radiographs, is legal documentation of a
• patients have a right to reasonable access
patient's condition.
of their dental radiographs
• access includes copies of original radi-
ographs (not originals) forwarded to the
dentist who will be responsible for the pa-
tient's dental care
Patient record must contain documentation of

• informed consent
• number & type of radiographs exposed
• rationale for taking radiographs
• diagnostic information obtained from in-
terpretation
• images should be taken based on patient need instead of a set time
Prescribing dental radiographs

• the dentist is responsible for prescribing the number, type and frequency of dental ra-
diographs
• each patient's condition is different and therefore each patient must be evaluated for
radiographs on an individual basis
• a radiographic examination should never include a set number and type of images at
a set interval
• guidelines for prescribing dental radiographs are published by the American Dental
Association (ADA) in conjunction with the Food & Drug Administrations (FDA)
• visit www.ADA.org for current guidelines
• patients with caries, periodontal disease, tooth mobility, pain and impacted teeth need
more frequent radiographic examinations
Guidelines for radiographs in the recall patient

with clinical caries or risk of caries
• bite-wings at 6 - 12 month intervals
with no clinical caries or risk of caries
• bite wings at 24 - 36 month intervals
with periodontal disease
• clinical judgement for radiographs needed to evaluate periodontal disease; selected
bite-wings & periapicals
normal anat
Identify the structures indicated in the images below.
Image 1 Image 2
Reprinted from Haring, Joen Iannucci and Laura Jansen: Dental Radiography:
Principles and Techniques: Third Edition. © 2000, with permission from Elsevier.
RADIOLOGY
normal anat
The coronoid process often appears on what periapical image?
•maxillary incisor
• maxillary molar
• mandibular incisor
• mandibular molar
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RADIOLOGY
hamulus
' maxillary tuberosity
*b
Res Image 2- maxillary tuberosity
Image 1- hamulus v • rounded prominence of bone that ex-
• a.k.a. hamular process tends distal to the third molar region
• small, hook-like projection of bone • appears radiopaque
• extends ..fmm the medial Pterygoid • on a maxillary molar periapical
jg|atejofêmsjp;hjenoidjbone image, appears as a rounded ra-
• located posterior to the maxillary diopaque bulge distal to the third
tuberosity molar region
• appears radiopaque • varies in size, shape and density
• on a maxillary molar periapical image, • not always visible, depends on re-
appears as a hook-like radiopaque struc- ceptor placement
ture
• varies in length, shape & density
• not always visible, depends on receptor
placement
maxillary molar
Coronoid process
• coronoid means "resembling the beak of a crow"
• large prominence of bone on anterior ramus of mandible
• is thin and triangular in shape
• serves as an attachment site for one of the muscles of mastication
• appears radiopaque
• on a maxillary molar periapical image, appears as a beak-shaped radiopacity located
inferior to, or superimposed over, the maxillary tuberosity
• varies in shape and density
• not always visible, depends on receptor placement
Reprinted from Haring, Joen Iannucci and Laura Jansen Lind: Radiographic
Interpretation for the Dental Hygienist. © 1993, with permission from Elsevier.
normal anat
Identify the structures labeled 1 - 8 on the image below.
"Courtesy Dr. Stuart C. White, UCLA School of Dentistry." y\

RADIOLOGY
normal anat
Identify the structures labeled 1- 7 on the image below.
"Courtesy Dr. Stuart C White, UCLA School of Dentistry." 12
copyright ©2013-2014-Dental Decks
RADIOLOGY
' answers 1-8 below
1. lateral wall of the incisive (nasopalatine) canal

radiopaque line
2. anterior wall of the maxillary sinus

radiopaque line
3. nasopalatine fossa
radiolucent space
4. floor of nasal fossa

radiopaque line
5. soft tissue outline of the nose

slightly radiopaque outline
6. lamina dura
radiopaque line
"Courtesy Dr. Stuart C. White, UCLA
7. border of maxillary sinus School of Dentistry."
radiopaque line
8. periodontal ligament space

radiolucent line
• answers 1 - 7 below
1. anterior nasal spine

radiopaque line
2..lateral wall of nasopalatine canal

radiopaque line
3. median palatal suture

radiolucent line

radiopaque line
5. incisive (nasoplatine) foramen

radiolucent structure
6. soft tissue outline of tip of nose

slightly raôplique'ûTrihe
"Courtesy Dr. Stuart C White, UCLA
7. alveolar crest School of Dentistry."
radiopaque line
normal anat
Courtesy Dr. Stuart C. White, UCLA School of Dentistry."

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RADIOLOGY
normal anat
"Courtesy Dr. Stuart C. White, UCLA School of Dentistry.'

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RADIOLOGY
1. nutrient canal
radiopaque lines
2. bony trabecular plate

radiopaque line
3. inferior border of mandibular canal

radiopaque line
4. submandibular gland fossa

radiolucent space
5. inferior border of mandible

radiopaque structure
School of Dentistry."
< answers 1 - 8 below
1. anterior wall of maxillary sinus

radiopaque line
2. inferior nasal conchae A -

radiopaque mass

radiopaque line
4. inferior border of zygomatic process of maxilla

j-shaped radiopaque line C/*
5. posterior wall of zygomatic process of maxilla

radiopaque line
6.jnieiifljLboxd£t:.QLzygoma # ^
radiopaque line "Courtesy Dr. Stuart C. White, UCLA
7. floor of maxillary sinus

radiopaque line
8. mucosa over alveolar bone

slightly radiopaque structure
normal anat
"Courtesy Dr. Stuart C. White, UCLA School of Dentistry." .. _

copyright ©2013-2014- Dental Decks
RADIOLOGY
normal anat
"Courtesy Dr. Stuart C. White, UCLA School of Dentistry."

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1. lingual cusp of 1st premolar

radiopaque area

radiolucent line
3. film holder
radiopaque area
4. genial tubercles
donut shaped radiopacity
5. lingual foramen
radiolucent circle
6. bony trabeculations
radiopaque lines

7. marrow space School of Dentistry."
radiolucent area

radiolucent line
2. mental foramen
ovoid radiolucency

radiolucent area
4. film clip mark

radiolucent artifact

normal anat

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RADIOLOGY
normal anat
"Courtesy Dr. Stuart C. White, UCLA School of Dentistry." 18
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RADIOLOGY 18
1. cement-enamel junction (CEJ)

radiopaque line
2. mental foramen
ovoid radiolucency

large radiolucent area

1. inferior nasal conchae

radiopaque mass

radiopaque line

radiopaque line
4. maxillary sinus
radiolucent space

radiopaque line
6.inferior border of the zygomatic

TiVlllllllWWII » IIIIMI ijitilllll mi I I . Nil,? ,
process of the maxilla "Courtesy Dr. Stuart C. White, UCLA

radiopaque area

radiopaque band
normal anat

RADIOLOGY
normal anat

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RADIOLOGY

radiopaque line
2. lateral wall in incisive canal )

radiopaque line
3. ala of nose
radiopaque line

radiopaque line
5. maxillary sinus
radiolucent space

radiopaque band "Courtesy Dr. Stuart C. White, UCLA
' answers 1 - 6 below
1. dentino-enamel junction (DEJ)

radiopaque line

radiolucent line
3. lamina dura
radiopaque line
4. periodontal ligament space of

palatal root
radiolucent line
5. film holder
radiopaque area
6. mucosa over alveolar bone
slightly radiopaque structure
normal anat

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RADIOLOGY
normal anat

RADIOLOGY
1. mandibular tori
radiopaque masses
2. lingual foramen
radiolucent circle
3. genial tubercles
donut shaped radiopacity

1. alveolar crest of bone

2. lamina dura
radiopaque line

radiolucent line
radiopaque lines

normal ant
= = _ _ _ _ ^ _ _ ^ _ _ copyright ©2013-2014-Dental Decks
RADIOLOGY
normal anat

copyright ©2013-2014- Dental Decks
RADIOLOGY
1. marrow space
radiolucent space

radiolucent line
3. bony trabecular plate

radiopaque line
4. lamina dura
radiopaque line
5. pulp canal
radiolucent space
6. alveolar crest
radiopaque area
7. dentin
radiopaque area School of Dentistry."
8. enamel
radiopaque area
1. dentin
radiopaque area
radiopaque lines
3. marrow space
radiolucent area
4. pulp canal
radiolucent space

radiolucent line
6. lamina dura
radiopaque line
7. alveolar crest
8. enamel School of Dentistry."
radiopaque band
9. pulp chamber
radiolucent space
normal anat
Identify the structures labeled 1-12 on the image below.

RADIOLOGY
normal anat
RADIOLOGY
• answers 1-12 below
radiopaque lines
2. marrow space
radiolucent area
3. tooth # 1 0
maxillary lateral incisor
4. lamina dura
radiopaque line
5. dentin
radiopaque area
radiolucent line
7. alveolar crest %
8. pulp canal
radiolucent space
9. pulp chamber
radiolucent space
10. enamel
radiopaque band "Courtesy Dr. Stuart C. White, UCLA
ll«jraU£dJiJmdot
radiopaque circle
12. dentino-enameTjunction
radiopaque line
1. tooth #3
maxillary first molar
2. amalgam restoration
3. plastic bite block

faint opacity
4. film dot
rounajradiolucency
5. black letters - PLS

indicates Kodak Ektaspeed plus film
6. lamina dura
radiopaque line
radiolucent line
8. lamina dura
radiopaque line
normal anat
Identify the structures labeled 1 -15 on the image below.
"Courtesy Dr. Stuart

C. White, UCLA
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RADIOLOGY
normal anat
Identify the structures labeled 1 -13 on the image below.
"Courtesy Dr. Smart

C. White, UCLA
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RADIOLOGY
answers 1-15 below
1. air in nasal fossa

raHTolucenTspace
2. nasal septum
radiopaque line
3-lateralwaU of nasal septum
medial wall of maxillary sinus
radiopaque lines
4. infraorbital rim
radiopaque line
5- wall of infraorbital canal
radiopaque line
6. pterveomaxillary fissure
radiolucent space
7. pterygoid spine of sphenoid
radiopaque line "Courtesy Dr. Stuart C. White, UCLA
8. zygomatic arch School of Dentistry."
radiopaque mass
9. posterior wall of maxillary sinus 12. inferior border of the mandibular canal
radiopaque line radiopaque line
10. posterior wall of the zygomatic 13. anterior nasal spine
process of the maxilla v-shaped radiopacity
radiopaque line 14. inferior border of the mandible
11. ear lobe radiopaque band
radiopaque mass 15. hyoid bone
1. tip of nose
radiopaque area
2. hard palate / floor of nasal fossa
radiopaque line
3. orbit
radiolucent area
4. hard palate / floor of nasal fossa
radiopaque line
radiopaque line
6. soft palate
7. air between soft palate & tongue
radiolucent space
8.._dorsum of the tongue
radiopaque line
9. ghost imaêofop^>ositerartius School of Dentistry."
^TndTcateTrjy radiopaque dote
10. mental foramen
ovoid radiolucency 12. submandibular gland fossa
11. shadow of cervical spine broad radiolucent area
diffuse opacity 13. articular eminence / articular tubercle
radiopaque prominence
processing
The pattern of stored energy on an exposed film is termed the latent image;
this image remains invisible until it undergoes processing.
The function of the developer solution is to chemically reduce the exposed,

energized silver halide crystals to black metallic silver.
29
RADIOLOGY
processing
Which ingredient in the fixer solution functions to remove all unexposed and
underdeveloped silver halide crystals from the emulsion?
• fixing agent
• acidifier
• hardening agent
• preservative
30
RADIOLOGY
both statements are true
Film processing Film processing steps
converts the latent image to a visible image and 1. development - developer solution removes
preserves the image on film halide portion of exposed silver halide crystals;
this reduction of exposed crystals results in pre-
Latent image
cipitated.Wackjnelîcjy]yer (6^FJsJheopti-
• the film emulsion absorbs x:rays during ex- mal temperature for developer)
jffgnni «r^ W e s the energy,within the silver
2. rinsing - water removes developer & stops
halide crystals development process
• the stored energy forms a pattern and creates
3. fixing - fixer solution removes unexposed sil-
an invisible image
ver halide crystals & hardens the film
• the pattern of stored energy cannot be seen
4. washing - water removesaTTexcess chemi-
and is referred to as the latent image; it re-
cals from the emulsion
mains invisible until chemical processing
5. drying
Black areas of the visible image
• appear radiolucent f-;y Developer composition
• created by deposits of black metallic silver • developing agent contains 2 chemicals hy-
• structures that permit the passage of the Cdroquinone & cloijj hydroquinone slpjvly con-
x-ray beam allow more x-rays to reach the verts silver halide crystals & generates black
film & energize more silver halide crystals tones ;elon-quickly converts silver halide crys-
• more energized silver halide crystals result tals & generates gray tones
in more deposits of black metallic silver • preservative is Sodium sulfite; prevents oxi-
White areas of the visible image dation of developer agents
• accelerator is sodium carbonate; activates
• appear radiopaque ^?Ci
the developer & softens emulsion
• results from .unexposed silver halide crystals ^ ^t^*-*******««..«——"""-'^
• structures that resist the passage of the x-ray • restrainer ts;potassium bromide; prevents
beam restrict or limit amount of x-rays that developer from deveToping unexposed crystals
reach the film resulting in no energized silver
halide crystals and no deposits of black metal-
lic silver
• fixing agent
Fixer composition Film processing steps

• fixing agent (a.k.a. clearing agent or 1. development
hypo) is^xliu^Jhiojul&teorammonium 2. rinsing
thiosulfate; removes or clears" all un- 3. fixing
exposed & underdeveloped silver halide 4. washing
crystals from emulsion; clears the film so 5. drying
that black image produced by the devel-
Manual film processing
oper can be seen
• a.k.a. hand processing or tank processing
• preservative is,si»{Uumjmlfite (same as
• method used to process films where all
in developer); prevents the deterioration of
steps are performed manually
the fixing agent
• equipment needed includes processing
• hardening agent is potassium alum;
tanks with covers, thermometer, timer,
shrinks and hardens the gelatin in the
film hangers and stirring rod
emulsion
• typical processing times include:
• acidifier is a c j ^ j i c i d j ) r sulfuric acid;
5 minutes in developer —> 30 second rinse
neutralizes the alkaline developer and
—> 10 minutes in fixer —• at leastdQanm-
stops development process & provides
utgsjriwash
necessary acidic environment for fixer
• as a rule, fixing time is twice as long as
Safelighting developing time
• lighting that is required in darkroom for Automatic film processing
safe illumination while processing x-ray • method used to process films using
film where all steps of film processing are au-
QJ^JJQdak^BXdt£S^hMM?r with a tomated
15-watt bulb at least 4 feet away from • automatic processor is required
working surface • total processing time is 4-6 minutes
processing
Your assistant has processed three panoramic films today. She noticed the
films are progressively getting lighter and lighter. What should be done to
correct the problem?
• decrease the temperature of the developer
• increase the temperature of the fixer
• replenish the developer
• process the films a second time
• decrease the time in the developer
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RADIOLOGY
processing
Your assistant has just processed a film that appears too dark. Identify each of
the potential causes of this problem.
• inadequate time in developer
• excessive time in developer
• developer solution too cool
• developer solution too hot
• depleted developer
• concentrated developer
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RADIOLOGY
' replenish the developer
Replenisher solutions Developer solution life is affected by

• a replenisher is a superconcentrated solu- • cleanliness of tank
tion that is added to the existing processing • size of films processed
solutions to compensate for the loss of vol- • number of films processed
ume and strength that occurs due to oxida- • temperature
tion • evaporation
• ' :-r'
• both the developer and fixer must be re-
Depleted developer
plenished daily to maintain adequate fresh-
• is weakened, lacks concentration
ness
• does not fully develop the latent image
• replenishment maintains adequate con-
• produces a non-diagnostic image with red-
centrations of chemicals which ensures uni-
uced density and contrast
form processing
• results in underdeveloped films
• failure to use replenishing solutions results
• underdeveloped films appear light
in non-diagnostic radiographs
Processing solutions
• include developer, fixer & replenisher Underdeveloped film
• must follow manufacturer directions for • appears light
storage, mixing & replenishing • causes
- time/inadequate time in developer
• the developer and fixer must be changed at
- temperature/developer too cool
the same time every 3-4 weeks or more often
- concentration/depleted developer
with high volume of processing
• solutions
• tanks must be scrubbed and cleaned when
- time/! time in developer
changing solutions
- temperature/t temperature
- concentration/replenish developer
• excessive time in developer

• developer solution too hot
• concentrated developer
Time and Temperature: Problems and Solutions

Example Appearance Problems Solutions
- Inadequate development time - Check development time
- Developer solution too cool - Check developer temperature
Underdeveloped Light - Inaccurate timer or thermometer - Replace faulty timer or thermometer
film - Depicted or contaminated - Replenish developer with fresh
developer solution solutions as needed
- Excessive developing time - Check development time
- Developer solution too hot - Check developer temperature
Overdeveloped Dark - Inaccurate timer or thermometer - Replace faulty timer or thermometer
film - Concentrated developer solution - Replenish developer with fresh
solutions as needed
Reticulation of Sudden temperature change Check temperature of processing
emulsion Cracked between developer and water bath solutions and water bath; avoid
drastic temperature differences
Reprinted from Iannucci, Joen M. and Laura Jansen: Dental Radiography Principles and Techniques. Fourth Edition, d 2012, with permission
from Elsevier Saunders
processing
Black branching lines appear on a processed him. Which of the following is
the most likely cause?
• fixer cut-off
• developer cut-off
• fingernail damage
• static electricity
• air bubbles
33
RADIOLOGY
rad biology
Dose equivalent is expressed in terms of:
• coulombs/kilogram (C/kg)
• gray (Gy)
• sievert (Sv)
• quality factor (QF)
34
RADIOLOGY
• static electricity
Film Handling: Problems and Solutions

Example Appearance Problems Solutions
Developer Straight white Underdeveloped portion of Check developer level before
cut-off border film due to low level of processing; add solution if
developer needed
Fixer Straight black Unfixed portion of film due to Check fixer level before pro-
cut-off border low level of fixer cessing; add solution if needed
Over- White or d a r k areas Two films contacting each Separate films so that no contact
lapped appear on film where other during processing takes place during processing
films overlapped
Air White spots Air trapped on the film Gently agitate film racks after
bubbles surface after being placed in placing in processing solutions
the processing solutions
Fingernail Black crescent- Film emulsion damaged by Gently handle films holding
artifact shaped marks the operator's fingernail during them on the edges only
rough handling
Finger- Black fingerprint Film touched by fingers that Wash and dry hands thoroughly
print are contaminated with fluoride before processing
artifact or developer
Static Thin, black, - Occurs when film packet is - Open film packet slowly
,eh?ctricity branching lines opened quickly
- Occurs when film pack is - Touch a conductive object
opened before the radiographer before unwrapping films
touches a conductive object
Scratched White lines Soft emulsion removed from Use care when handling films
film the film by a sharp object and film racks
Reprinted from lannucci, Joen M. and Laura Jansen: Denial Radiography Principles and Techniques. Fourth Edition. © 2012, with permission
from Elsevier Saunders
sievert (Sv)
Exposure measurement
• exposure refers to the measurement of ion-
ization in air produced by x-rays
• roentgen (R) is a way of measuring radia-
tion exposure by determining the amount of
ionization that occurs in air Unit Definition Conversion
• R is limited to measurement in air Traditional System (older system)
• there is no SI unit for exposure that is equiv-
roentgen (R) lR = 87erg/g 1R =
alent to the R 2.58X10 "'C/kg
• exposure expressed in Coulombs per kilo-
radiation
gram (C/kg) absorbed close 1 rad = 100 erg 1 rad = 0.01 Gy
(rad)
Dose measurement roentgen
• dose refers to amount of energy absorbed equivalent (in) 1 rem = rads X QF 1 rem = 0.01 Sv
man (rem)
by a tissue
• rad is a unit of absorbed dose that is equal SI system (newer system)
to the deposition of 100 ergs/g of tissue Coulombs
• the SI unit for rad is gray (Gy) per kilogram 1 C/kg = 3880 R
(C/kg)
Dose equivalent gray (Gy) 1 Gy = 0.01 J/kg
is*si«10 rads
• rem is traditional unit of dose equivalent sievert (Sv) lSv = GyXQF | 1: Sv = 100 rerh>
used to compare the biologi&.£ffects_of dif-
ferent Jypes of radiation on a tissue or organ
• is the product of Gy x QF (quality factor)
specific for the radiation type
• for x-rays, QF=1
5Tumt for rem is sievert (Sv)
rad biology
List the following cells from most RADIORESISTANT to most RADIOSENSITIVE.
muscle
small lymphocyte
skin
thyroid gland
35
RADIOLOGY
rad biology
After the bombings of Hiroshima, there were many persons exposed to radi-
ation. Symptoms such as hair loss did not occur until days following the ex-
posure. The time between exposure and onset of symptoms is termed:
latent period
• period of cell injury
• recovery period
• cumulative effects period
36
RADIOLOGY
muscle — thyroid gland — skin — small lymphocyte
• all ionizing radiations are harmful • radiosensitive cells are susceptible to ra-
to living tissues diation exposure
• radiation produces chemical changes • the most radiosensitive cell is the small
that results in biologic damage in living lymphjaq&e
tissues • radioresistant cells are resistant to radi-
• not all cells respond to radiation in the ation exposure
same manner • the most radioresistant cells are muscle
• cells respond to radiation based on mi- anrlnjejye
totic activity, differentiation and cell • radiation effects are classified as somatic
metabolism (occur in person irradiated) or genetic
• cells that are dividing and immature (passed on to future generation)
are most susceptible to radiation
Sensitivity Radiosensitive Radioresistant Cells Sensitivity

high small lymphocyte muscle tissue low
high bone marrow nerve tissue low
high reproductive cells mature bone/cartilage fairly low
high intestinal mucosa salivary gland fairly low
fairly high skin thyroid gland fairly low
fairly high lens of eye kidney fairly low
fairly high oral mucosa liver fairly low
latent period
Mechanisms of radiation injury Radiation injury sequence

• ionization & free radical formation are re- • latent period - period of time between exposure
sponsible for cell injury and onset of symptoms
• free radical formation is the primary mecha- • period of injury - follows latent period and may
nism responsible for damage result in cell death, change in cell function or ab-
normal mitosis
Theories of radiation injury • period of recovery - follows injury; depending on
• direct theory - cell damage results when ra- a number of factors, cells can repair the damage
diation directly hits critical areas within the cell caused by radiation
& direct alteration of the cell occurs
• indirect theory - suggests that x-ray photons Radiation effects
are absorbed within the cell and cause the for- • short term effects occur when large amounts are
mation free radicals & toxins which result in cell absorbed in a short period of time (not applicable
damage K- f*W+$wa - ^W, W * eeAi, to dentistry)
• long term effects occur when small amounts are
Dose-response curve absorbed over a long period of time; linked to in-
• a dose-response curve is used to demonstrate duction of cancer, birth & genetic effects
the response of tissues to the dose of radiation • cumulative effects occur; radiation damage is ad-
received ditive and unrepaired damage accumulates in the tis-
• a threshold dose does not exist & response of sues and leads to health problems (cancer, cataract
tissues is directly proportional to the dose formation, birth defects)
• injury from radiation depends on total dose,
.„dose ratejânjount of tissue affected, cgjl sen- Radiation effects on cells
sitivity and age • the cell nucleus is more sensitive to radiation than
cytoplasm; DNA is affected
Stochastic & nonstochastic effects
• cell division is disrupted which may lead to dis-
• stochastic effects occur as a direct function of
rupted cell function or cell death
dose (cancer, genetic mutations)
• radiation causes cell death by damaging chromo-
• nonstochastic effects have a threshold and in-
somes
crease in severity with increased dose (hair loss,
decreased fertility)
rad biology
A patient with a large squamous cell carcinoma of the lateral border of the
tongue is scheduled for a radical neck dissection. Prophylactic extractions of
hopeless teeth must be done to prevent which of the following?
osteoradionecrosis
bisphosphonate osteoradionecrosis
• periodontal disease
• rampant caries
none of the above
37
RADIOLOGY
rad biology
The most common oral problems that occur following radiation and
chemotherapy include mucositis, infection, pain and bleeding.
The oral cavity is irradiated during the course of treating radiosensitive oral
malignancies, usually squamous cell carcinoma.
> the first statement is true, the second is false
«the first statement is false, the second is true
38
RADIOLOGY
• osteoradionecrosis
Definition Clinical features
• most serious possible complication facing the • may involve the maxilla or mandible
oral cancer patient • more common in the mandible
• condition of non-vital bone in a site of radio- • most frequently occurs when an insult to the bone
therapy; bone dies as a complication of radio- is sustained in the irradiated area, such as related
therapy subsequent surgery, biopsy, tooth extractions or
• is not an infection denture irritations
• may also be precipitated by periodontal disease
Cause or occur spontaneously
• radiation therapy destroys cancerous cells but • symptoms may include pain, swelling, reduced
also destroys normal cells, damaging small ar- mobility, drainage, exposed bone in the involved
teries and reducing circulation
area and destruction of bone
• insufficient blood supply to the irradiated area
• symptoms may occur months or years after the
decreases the ability to heal, and any subse-
radiotherapy
quent infections to the jaw can pose a huge risk
to the patient Management
• patients receiving high dQjt££_Qf,xadiation
• difficult to manage
£>40 Gv) to the jaw area are at risk
• prevention is key
Histologic features- 3 H's • debridement of infected bone may be required
v* hypocellular bone • advanced cases may require radical surgery
v^hypovascular tissue • patients must be followed closely by physicians
v""hypoxic tissue & bone and dentist regularly
Prevention
• extract all hopeless teeth 3 weeks prior to ra-
diotherapy
• if extracting after radiotherapy, use of systemic
antibiotics is warranted
• hyperbaric oxygen treatments before and
after radiotherapy may be helpful
Radiation therapy of oral cavity Radiation effects on oral tissues Ks

• used to treat radiosensitive oral malignant tu- • occurs by end of 2nd weekpf therapy *5»jf
mors, usually squamous cell carcinoma • mucositis results; appears as areas of redness and
• indicated when the tumor is radiosensitive, inflammation
advanced, or, cannot be treated surgically be- • as therapy continues, the oral tissues break down
cause it is deeply invasive resulting in formation of white pseudomembranes
• fractionation • oral condition worsens with continued therapy
- total radiation dose is delivered in smaller and candidiasis often occurs
multiple doses • following therapy, oral tissues heal within ap-
- provides greater tumor destruction than a sin- proximately 2 months ifogut 8
gle large dose
- allows for increased cellular repair of nor- Radiation effects on taste buds /-'
mal tissues • taste buds are radiosensitive
- increases mean oxygen tension resulting in • radiation therapy damages taste buds
tumor cells that arc more radiosensitive • a loss of taste may first occur during the 2nd or
WMMIMM n
3rd week of radiation therapy
Radiation effects on the teeth
• irradiation of developing teeth severely retards Radiation effects on salivary glands
growth • radiation therapy damages salivary gland tissues
• adult teeth are radioresistant\3^<' • there is a marked & progressive loss of salivary
secretion; extent of reduced flow is dependent on
Radiation effects on bone dose
• irradiation of bone results in damage to the • causes decreases in saliva, pH & buffering ca-
fine vasculature pacity
• normal marrow may be replaced with fatty • causes increased viscosity
maiTOW or fibrous connective tissue • dry moutn (xerostomia) results & makes the pa-
• necrosis may occur and exhibits loss of os- tient susceptible to radiation caries - a rampant
teoblastic and osteoclastic activity form of caries
• xerostomia causes tenderness of oral tissues and
difficulty in swallowing
rad char
In the dental x-ray tube, the number of electrons flowing per second is meas-
ured by:
• kilovoltage peak (kVp)
• milliamperage (mA)
• time (in seconds)
• all of the above
39
RADIOLOGY
rad char
When the PID length is changed from 8" to 16", the target-receptor distance
is doubled. According to the Inverse Square Law, the resultant x-ray beam is:
• 1/4 as intense
• 1/8 as intense
• four times more intense
• eight times more intense
40
copyright e 2013-2014- Dental Decks
RADIOLOGY
W ~ TJu^-^ milliamperage (mA)
^rrv*4
x-ray beam quality & kVp ^ V t i x _ ray beam intensity
• quality refers to the average energyor 7 ^ intensity is the total energy contained in
penetrating power of the x-ray beam and the x-ray beam at a specific area at a given
is controlled by the kilovoltage peak (kVp) time
• kVp controls the speed & energy of the ~ Qrfntensity is affected by kVp, mA, exposure
electrons and determines the penetrating time and distance
power of the beam £>
• kVp range for dental radiography is A s^^k ^ Film
Adjustment appears
cîookvî Tt<y T kVp darker
x-ray beam quantity & mA ™«-*.
• quantity refers to the number of x-rays J ^ ^ H , a*1
1 kVp lighter
produced and is controlled by the mil-' e\^l% r mA darker

liamperage (mA) i mA lighter
• mA controls the amperage of the fila-
T time darker
ment current and the amount of electrons
that pass through the filament i time lighter
• mA controls the temperature of the fil- to INCREASE film density & make it darker,
ament INCREASE:
• as the mA increases, more electrons pass • mA
through the filament and more x-rays are •kVp
produced • time
•JTIA range for dental radiography is
j^l5mAP to DECREASE film density & make it lighter,
^ " T i H m m i i n i i M urn- DECREASE:
to remember, think alphabetical order ... • mA
kVp= quality ( k & 1) •kVp
mA = quantity ( m & n ) • time
• 1/4 as intense
Inverse Square Law Example:

• defined as: If the PID length is changed from 8" to 16", how
the intensity of the radiation is inversely does this increase in target-receptor distance af-
proportional to the square of the distance fect the intensity of the beam?
from the source of radiation plug numbers into the mathematical for-
• inversely proportional means that as one mula:
variable increases, the other decreases
• when the target-receptor distance is in-
\IW
solve for x
x/82 4* /UK
creased, the intensity is decreased 1 / x= 162 / 82
1 / x= 256 / 64
original intensity . new intensity 1 / x= 4/1
new distance2 original distance2 x= 1/4 answer
OS
"V£
• doubling the distance results in a beam that
is % as intense
• the x-ray beam that exits an 8" PID is more
intense than one the exits a 16" PID (see dia-
closer gram)
The distance traveled by the x-ray beam affects
the intensity; distances to be considered include
the following:
• target-surface distance is the distance from
the source of radiation to the surface of the pa-
Reprinted from lannucci, Jocn M. and Howerton, tient's skin
Laura Jansen: Dental Radiography Principles and • target-object distance is the distance from
Techniques. Fourth edition © 2012, with permission the source of radiation to the tooth
from Elsevier Saunders. • target-receptor distance is the distance from
the source of radiation to the receptor ffilm or
sensor)
rad char
A 6'5" muscular male with a large mandible requires a complete series of den-
tal images. You plan to increase the kVp because of his size. Identify each of
the following that results with the increased kVp:
• a more penetrating beam
' a less penetrating beam
• a reduced subject contrast
• an increased subject contrast
• long scale contrast
• short scale contrast
41
RADIOLOGY
rad char
Identify each of the following that influence the density of an image:
•kVp
• mA
• exposure time
• use of a 2-film packet
42
RADIOLOGY
• a more penetrating beam
• a reduced subject contrast
• long scale contrast
Increased kVp Long-scale contrast

• produces x-rays with increased energy • LONG scale =
(speed) and shorter wavelength JLOW contrast =
• increases the penetrating power of the x- LOTS of gray
ray beam • a low contrast image exhibits many shades
• is needed for larger patients with large of gray
bones and significant amounts of soft tissue • a low contrast image does not exhibit black
• results in increased density (makes image & white
darker)
• results in reduced or low contrast which is
long-scale contrast
Adjustment Contrast Contrast
scale
Contrast
• refers to how sharply dark and light areas T LONG
(High) kVp lots of gray LOW
are separated or differentiated on an image
• the difference in degrees of blackness be- 4 SHORT
tween adjacent areas on a dental radiograph (Low) kVp black & white HIGH
Contrast & kVp Patient size & kVp

• adjustment of kVp affects contrast • large patients need increased kVp;
• with low kVp (65-70), a high contrast if not increased — image appears LIGHT
image results • small patients need decreased kVp;
• with high kVp (90), a low contrast image if not decreased — image appears DARK
results
• kVp
• mA
. exposure time
Adjustment Densitv Film

Density description appears
• a visual characteristic of a radiographic
image T kVp t darker
• overall blackness or darkness of an image 4 kVp 4 lighter
• when a dental image viewed, the relative
transparency of areas depends on the distri- r mA t darker
bution of black silver particles 4. mA 4 lighter

• density is the degree of.silver blackening T time T darker
• an image of correct density allows one to
view the black areas (air space images), 4 time 4 lighter
white areas (enamel, dentin, bone) and gray t thickness 4 lighter
areas (soft tissue)
\9 x
4 thickness T darker
Factors that influence density Size of patient

• exposure factors • thickness of subject also affects density;
-kVp with a large patient (thick bones, excess soft
- mA tissue), fewer x-rays reach the receptor and
- exposure time as a result, the image appears lighter
• thickness of subject • with increased thickness, a decreased den-
adjustments in kVp, mA and exposure time sity results
can be made to compensate for size variations • with decreased thickness, an increased
• an increase in any exposure factor , sepa- density results
rately or combined, increases the density of
an image Note: the use of a 2-film packet does not affect
the density of the image
rad physics
Which of the following converts electrons into x-rays?
• positive anode
1
negative anode
' positive cathode
• negative cathode
43
RADIOLOGY
rad physics
Which of the following focuses the electrons into a narrow beam and directs
the beam across the tube toward the tungsten target of the anode?
• copper stem
• tungsten filament
• insulating oil
• molybdenum cup
• lead collimator
44
RADIOLOGY
•positive anode
X-ray tube to remember,

• heart of the x-ray generating system think C A T N A P . . .
• critical to the production of x-rays
cathode is negative
• glass vacuum tube from which all the air has
been removed
• component parts include leaded glass hous-
_ing, negative cathode & positive anode | Cathode/negative electrode!
• supplies electrons necessary to generate x-
rays
Leaded-glass housing
• consists of a tungsten wire filament in a
• leaded-glass vacuum tube that prevents x- molybdenum cup-shaped holder
rays from escaping in all directions • tungsten filament (coiled tungsten wire)
• a "window" permits the x-ray beam to exit produces electrons when heated
the tube
• molybdenum cup focuses the electrons
into a narrow beam and directs the beam
across the tube toward the tungsten target of
the anode
node/positive
An o •ode
electrode
isTnto x-
• converts electronslivto x-ray photons
• consists of a wafer-thin tungsten plate em-
bedded in a solid copper rod
• tungsten target serves as a focal spot and
converts bombarding electrons into x-ray
photons
Reprinted from Iannucci, Jocn M. and Howerton, Laura
Jansen: Dental Radiography Principles and Techniques. • copper stem functions to dissipate the heat
Fourth edition © 2012 with permission from Elsevier-Saun- away from the tungsten target
ders.
molybdenum cup
Production of x-rays
• tungsten filament is heated and electrons Component functions
are produced • tungsten filament of cathode produces
• molybdenum cup focuses the electrons electrons when heated
into a narrow beam and directs the beam to- • molybdenum cup of cathode focuses the
wards the tungsten target in the anode electrons into a narrow beam and directs
• x-rays are generated when the beam is sud- the beam towards the tungsten target in the
denly stopped by the tungsten target anode
•4fafi.en£igy_of motion is converted to x-ray • tungsten target in anode stops the elec-
energy (1%) and heat (99%) trons and converts the energy into x-rays &
• insulating oil that surrounds the x-ray tube heat
absorbs the heat •(copper stenijjserves to dissipate the heat
• x-rays that are produced are emitted in all that is createdwith the production of x-rays
directions; leaded-glass housing of tube pre-
vents the x-rays from escaping
• small number of x-rays exit the x-ray tube
through the unleaded glass window area |i_Metal
• x-rays travel through unleaded glass win- ji housing
£ of x-ray
dow, through the tubehead seal and then the 1 tube-
aluminium disks 1
• the lead collimator restricts the size of the a-lnsulating
beam and the x-ray beam travels down the : oil
lead lined position -indicating device (PID)

Lead
K. . - J
Unleaded glass
and exits at the opening collimator window of
x-ray tube
Reprinted from Haring, Joen Iannucci and Laura lansen: Dental Radiogra 'osition
phy: Principles and Techniques: Third Edition. © 2000, with permission front indicating
Elsevier. device
rad physics
Identify each of the following that are properties of x-rays:
• no weight
• travel at speed of sound
• have no charge
• cannot be deflected or scattered
• are invisible
• are absorbed by matter
• do not damage living cells
• do not cause fluorescence

45
RADIOLOGY
rad physics
Rectification is the conversion of a direct current (DC) to an alternating cur-
rent (AC).
The dental x-ray tube acts as self-rectifier in that in changes DC to AC while

producing x-rays.
46
copyright ® 2013-2014- Dental Decks
RADIOLOGY
• no weight
• have no charge
• are invisible
• are absorbed by matter
Properties of x-rays
• penetrating power
• appearance can penetrate liquids, solids, and gases;
invisible and cannot be detected by the composition of the substance deter-
any of the senses mines whether x-rays penetrate or pass
• mass through, or are absorbed
have no mass or weight • absorption
• charge absorbed by matter; the absorption de-
have no charge pends on the atomic structure of mat-
• speed ter and the wavelength of the x-ray
travel at the speed of light • ionization capability
• wavelength can interact with materials they pene-
travel in waves and have short wave- trate and cause ionization
lengths with a high frequency\V"" • fluorescence capability
• path of travel can cause certain substances to fluo-
travel in straight lines and can be de- resce or emit radiation in longer wave-
flected, or scattered lengths (e.g., visible light and
• focusing capability ultraviolet light)
cannot be focused to a point and al- • effect on film
ways diverge from a point can produce an image on photographic
film
• effect on living tissues
cause biologic changes in living cells
• electricity is the energy used to make x- • low voltage/filament circuit uses 3 to 5

rays; electrical energy consists of a flow of volts, regulates the flow of electrical current
electrons through a conductor; this flow is to the filament; controlled by mA settings
known as the electrical current • high-voltage circuit uses 65,000 to 100,000
• electrical current is termed direct current volts, provides the high voltage required to
(DC) when the electrons flow in one direc- accelerate; controlled by kVp settings
tion through the conductor • transformer is a device that is used to either
• alternating current (AC) describes an elec- increase or decrease the voltage in an electri-
trical current in which the electrons flow in cal circuit; it alters the voltage of the incom-
two, opposite directions ing current and then routes the electrical
• rectification is the conversion of AC to DC energy to the x-ray tube; three types of trans-
• dental x-ray tube acts as a self-rectifier in formers are used to adjust the electrical cir-
that it changes AC into DC while producing cuits (see below)
x-rays; ensures that current is always flowing • step-down transformer is used to decrease
in the same direction from cathode to anode the voltage from the incoming 110- or 220-
• amperage is the measurement of the num- line voltage to the 3 to 5 volts used by the fil-
ber of electrons moving through a conductor,^, ament circuit
c7irrentls~measured in amperes (A) or mil- * % . • high-voltage circuit uses both a step-up
liampcres (mA) transformer and autotransformer
• voltage is the, measurement of electrical • step-up transformer is used to increase the
force that causes electrons to move from a voltage from the incoming 110- or 220-line
negative pole to a positive one; measured in voltage to the 65,000 to 100,000 volts used
volts (V) or kilovolts (kV) by the high-voltage circuit
• circuit is a path of electrical current; two • autotransformer serves as a voltage com-
electrical circuits are used to produce x-rays: pensator that corrects for minor fluctuations
a low-voltage/filament circuit and a high- in the current
voltage circuit
rad physics
Which of the following occurs only at 70 kVp or higher and accounts for a very
small part of the x-rays produced in the dental x-ray machine?
• compton scatter
• coherent scatter
• characteristic radiation
• general (Bremsstrahlung) radiation
47
RADIOLOGY
rad protection
Identify each component of inherent filtration:
• insulating oil
• unleaded glass window
• lead lined PID
• tubeheadseal
48
RADIOLOGY
> characteristic radiation
Types of x-rays Definitions

• not all x-rays produced in the x-ray tube are • primary radiation is the penetrating x-ray
the same; x-rays differ in energy and wave- beam that is produced at the target of the
length anode and exits the tubehead; a.k.a. primary
• energy and wavelength varies based on how or useful beam
the elections interact with the tungsten in the • secondary radiation is x-radiation that is
anode created when the primary beam interacts with
• kinetic energy_of electrons isconverted to matter; ig less penetrating thanprimaryradia-
x-ray photons via general (braking or Brem- tion
sstrahlui'g) radiation or characteristic radiat- • scatter radiation, a form of secondary rad-
ion iation, is the result of an x-ray deflected from
• general/braking radiation is produced its path by the interaction with matter; deflect-
when speeding electrons slow down due to in- ed in all directions by the patient's tissues;
teractions with the nuclei of the tungsten tar- detrimental to tissues
get atoms • id Compton scatter] ionization takes place;
- braking refers to the sudden stopping or & \§ an x-ray photon collides with an n outer-shell
slowing of high-speed electrons when they C^*> > electron and gives up part of its energy to
hit or come close to the tungsten target '£% eject the electron from its orbit; x-ray photon
- 70% of the x-ray energy produced is gen- •*J*Hoses energy and continues in a different dir-
eral radiation % ection (scatters) at a lower energy level; ac-
• characteristic radiation is produced when counts forJ>2% of the scatter that occurs
a high-speed electron dislodges an inner-shell • coherent or unmodified scatter occurs
electron from the tungsten atom and causes when a low-energy x-ray photon interacts
ionization "I with an outer-shell electron; no change in the
- the remaining electrons rearrange to fill the atom occurs; x-ray photon of scattered radiat-
vacancy resulting in a loss of energy & pro- ion is produced; x-ray photon is scattered in
duction of x-ray photon a different direction from that of the incident
- only a small % of x-rays produced; occurs photon; noJoss of energy and no ionization
only at > 70 kVp occur; accounts for 8% of the interactions
insulating oil
< unleaded glass window
' tubehead seal
• inherent filtration takes place when the • added filtration refers to the placement
primary beam passes through the glass of aluminum discs in the path of the x-
window of the x-ray tube, the insulating ray beam between the collimator and the
oil, and the tubehead seal tubehead seal
• inherent filtration of the dental x-ray • aluminum discs can be added to the
machine is approximately 0.5 to 1.0 milli- tubehead in 0.5 mm increments
meter (mm) of aluminum • purpose of the aluminum discs is to fil-
• inherent filtration alone does not meet ter out the longer-wavelength, low-en-
the standards regulated by state and federal ergy x-rays from the x-ray beam
laws; added filtration is required • low-energy, longer wavelength x-rays
are harmful to the patient and are not
useful in diagnostic radiography
• filtration of the x-ray beam results in
a higher energy & more penetrating
useful beam
OvtiioKjljtJ • state and federal laws regulate the re-
Aluminum filter quired thickness of total filtration = in-
r>K . i herent filtration + added filtration
~ - 1 OMMUMHW <k<» • dental x-ray machines operating at ,<
4r
70 kVp require a minimum total of 1.5
Long and short
wavelengths
Short
wavelenotbs
^> -stow e*<av* mm aluminum filtration
Enlargement o! detail • dental x-ray machines operating at
Reprinted from Iannucci, Joen M. and Howerton, Laura Jansen: D e n ^ ' **^5l$
lal Radiography Principles and Techniques. Fourth edition © 2012 (/
> 70 kVp require a minimum total of 2.5
willi permission from Elsevier-Saunders. mm aluminum filtration
rad protection
Identify each of the following that is recommended for operator protection
during exposure.
• stand 3 feet away from x-ray tubehead
• stand at a 45-75 degree angle to the beam
• wear a lead apron
• stand behind a barrier
• hold the PID
• hold the film if the patient cannot stabilize it
49
RADIOLOGY
rad protection
Prior to x-ray exposure, the proper prescribing of radiographs and the use of
proper equipment can minimize the amount of radiation that a patient re-
ceives.
Radiographs must be prescribed by the dentist based on the individual needs

of the patient.
50
RADIOLOGY
rad protection
Identify each of the following that is recommended for operator protection
during exposure.
• stand 3 feet away from x-ray tubehead
• stand at a 45-75 degree angle to the beam
• wear a lead apron
•holdthe PID
• hold the film if the patient cannot stabilize it
49
RADIOLOGY
rad protection
Prior to x-ray exposure, the proper prescribing of radiographs and the use of
proper equipment can minimize the amount of radiation that a patient re-
ceives.
Radiographs must be prescribed by the dentist based on the individual needs

of the patient.
50
RADIOLOGY
Operator protection guidelines Position recommendations
• must use proper protection during exposure • must stand perpendicular to the primary
to avoid the primary beam, scatter radiation beam, or, at a £0-135 degree angle to the
etc. beam " ' •
• must avoid the primary beam • never hold a film in place for a patient dur-
• distance, position and shielding are all im- ing exposure
portant for protection • never hold the PID during exposure
Distance recommendations Shielding recommendations
• must stand at least 6' away from the tube- • whenever possible, stand behind a protec-
head tive barrier, such as a wall
• if distance is not possible, a protective bar-
rier must be used Maximum permissible dose (MPD)
• MPD is the dose of radiation the body can
endure with little or no injury
• for non-occupationally exposed person limit
is 0.001 Sv/year
Primary beam • for occupationally exposed person limit is
0.05 Sv/year
Y '
• for occupationally exposed pregnant person
— limit is 0.001 Sv/year
".••••.. ' -:.,.\:.-: ••:.:•.-:•• ' $ 'l W'
ALARA concept
•As Low As Reasonably Achievable concept
Radiographer
states that all exposure to radiation must be
135" kept to a minimum
• applies to patients & operators
Reprinted from Iannucci, Joen M. and Howerton, Laura Jansen:
Dental Radiography Principles and Techniques. Fourth edition
•D 2012 with permission from Elsevier-Saunders.
Patient protection before exposure Patient protection after exposure

• proper prescribing of dental radi- • proper sensor or film handling
ographs • proper image retrieval or film pro-
• use of proper equipment including cessing
filtration, collimation and PID
• the rectangular PID (instead of
Guidelines for prescribing of dental
round) is most effective in reducing pa-
tient exposure radiographs
• use of a long PID is more effective • dentist is responsible for ordering im-
than use of a short PID ages & uses professional judgment to
make decisions concerning the num-
ber, type and frequency of dental radi-
Patient protection during exposure ographs
• use of thyroid collar for intraoral • radiographic exam should never in-
films and lead apron for all films clude a predetermined number of
• use of digital imaging or use fastest films
film available (F-speed) • radiographs should never be taken at
• use of beam alignment devices predetermined time intervals
• use of correct exposure factors (kVp, • radiographs should be ordered based
mA & exposure time) on the individual needs of the patient
• use of proper technique • guidelines for prescribing dental ra-
diographs have been determined by
the ADA and FDA
rad protection
Which of the following is used to restrict the size and shape of the x-ray beam
and to reduce patient exposure?
• aluminum discs
• collimation
• inherent filtration
• total filtration
51
copyright €> 2013-2014- Dental Decks
RADIOLOGY 51
tech
If a processed film appears light with herringbone or tire track pattern on it,
which of the following is the likely cause?
• the film was bent during placement
• the film was reversed (placed backwards) during exposure
• the film was exposed twice
• the patient moved during exposure
52
RADIOLOGY
collimation
Collimation Position indicating device (PID)

• used to restrict the size and shape of • the PID or cone is an extension of the
the x-ray beam & to reduce patient x-ray tubehead used to direct the
exposure beam
• a collimator is a lead plate with hole • types of PID include conical, round
in the middle, is fitted over the open- and rectangular
ing of the machine housing where the • a conical PID is a closed plastic cone
beam exits that produces scatter radiation;no longer
• collimator may have a round or rec- used in dentistry
tangular opening • a round PID is a tubular open ended
• rectangular collimator restricts the lead- lined extension; no PID scatter is
size of the beam to slightly larger than produced
a size 2 film and significantly re- • a rectangular PID is a rectangular
stricts patient exposure open ended lead-lined extension; is
• circular collimator produces a cone most effective in reducing patient ex-
shaped beam & restricts the size of the posure; no PID scatter is produced
beam to 2.75" in diameter • both round and rectangular PIDs are
• when using a circular collimator, fed- available in two lengths: short (8")
eral regulations re quire that the and long (16")
beam be restricted to 2.75" as it exits ^"VtMJangPID is preferred because less
the PID and reaches the skin of the pa- V'uivergence of me*x-ray beam occurs
tient
• the film was reversed (placed backwards) during exposure
A reversed
film is light &
exhibits a
herringbone
pattern.
A double exposure appears dark &

exhibits a double image.
A bent film appears stretched & distorted. With movement of the patient or PID, a blurred
image results.
Images reprinted from Iannucci, Joen M. and Howerton, Laura Jansen: Dental Radiography Principles and Techniques. Fourth edition © 2012
with permission from Elsevier-Saunders.
tech
Of the following factors that influence the geometric characteristics of an
image, which one is NOT able to be changed by the operator?
• target-receptor distance
• object-receptor distance
• film composition
• focal spot size
• object-receptor alignment
53
copyright© 2013-2014- Dental Decks
RADIOLOGY
tech
A periapical image shows stretched and elongated maxillary central incisors.
Which of the following is the likely cause?
• vertical angulation is excessive/too steep
• vertical angulation is insufficient/too flat
• incorrect horizontal angulation
• any of the above
54
copyright © 2013-2014- Dental Decks •-.
RADIOLOGY
• focal spot size
Magnification Focal spot size

• enlargement of an image that results • tungsten target in anode is focal spot
from the divergent paths of x-ray beam • size ranges from0.6 -1.0 minj^nd is de-
• some degree of magnification is pres- termined by the manufacturer (cannot be
ent in every image due to divergent paths controlled by operator)
• influenced by target-receptor distance • the size of focal spot influences the
and object-receptor distance image sharpness
• target-receptor distance (or source to • the smaller the focal spot, the sharper
receptor distance) is the distance be- the image
tween the source of x-rays & image re-
ceptor In dental radiography, the most accurate
• PID determines target-receptor distance image:
• shorter PID results in more magnifi- • use the smallest focal spot size
cation; longer PID results in lessjnagni- • use the LONGEST target-receptor dis-
JBcatjori tance
• object-receptor distance is the dis- • use the SHORTEST object-receptor
tance between the tooth & image recep- distance
tor • direct the central ray of the x-ray beam
• if there is decreased distance between perpendicular to the receptor and tooth
the tooth & receptor, less magnification • keep the receptor parallel to the tooth
occurs being imaged
• if there is increased distance between
the tooth & receptor, more magnification
occurs
Vertical angulation
• refers to the positioning of the PID in a
vertical, or up-and-down plane
• correct vertical angulation results in an
ELONGATION results
image that is the same length as the tooth when the vertical angula-
• incorrect vertical angulation results in tion is TOO FLAT;
ELONGATION or FORESHORTENING teeth look long &
• an elongated image appears long & results stretched
from too flat vertical angulation
• a foreshortened image appears short & re-
sults from too steep vertical angulation
• 0 degree vertical angulation = PID parallel
with floor
• positive vertical angulation = PID pointing
DOWN to floor/PID above occlusal plane
• negative vertical angulation = PID point-
ing UP to ceiling/PID below occlusal plane
FORESHORTENING
H results when the vertical
Vortical angulation angulation is TOO
• refers to the positioning of the PID in a STEEP; teeth look short
horizontal or side-to-side plane
• when tire central ray is directed through the
interproximal contacts of the teeth, correct
horizontal angulation results and open con-
tacts on seen the dental image Both photos reprinted from Haring, Joen Iannucci and Laura
• incorrect horizontal angulation results in Jansen: Dental Radiography: Principles and Techniques: Third
Edition. © 2000, with permission from Elsevier.
overlapped contacts (contacts are superim-
posed over each other)
tech
Identify the cause of this panoramic image error seen below:
chin tipped too far upward

• chin tipped too far downward
' head tipped to one side
RADIOLOGY
tech
Identify the cause of this distorted periapical film seen below:
• film bending
• film creasing
Reprinted from Haring,
• phalangioma Joen Iannucci and
Laura Jansen: Dental
Radiography: Princi-
• double exposure ples and Techniques:
Third Edition. © 2000,
with permission from
Elsevier.
• movement
58
RADIOLOGY 58
• chin tipped too far downward
chin tipped too far downward \ / chin tipped too far forward A
(see image on reverse side) (see image below) ' ^
• mandibular incisors appear blurred • hard palate & floor of nasal cavity ap-
• loss of detail in anterior apical region pear superimposed over maxillary teeth
• condyles may not be visible • maxillary incisors appear blurred
• results in severe interproximal over- • maxillary incisors appear magnified
lapping • occlusal plane downward curve
• occlusal plane has excessive upward • reverse smile line (frown) is seen
curve
• exaggerated smile line is seen
film bending
Film bending Black film
• images appear stretched & distorted • exposed to light
• occurs due to curvature of hard palate
Clear film
Film creasing • film is unexposed
• crease appears as a thin black line
• represents where the emulsion of the film has
cracked
Phalangioma A light film results from
• the bone of the patient's finger seen on the underexposure
image
• results when finger is in front of the receptor
instead of behind it (seen with use of bisecting
technique where patient holds the film— not
recommended)
Light film a dark film results

• may result from underexposure— too short from overexposure
of exposure time, too low kVp or too low mA
Dark film
• may result from overexposure - too long of
exposure time, too high kVp or too high mA
Fogged film -s^-"""
• appears gray & lacks contrast a fogged film ap-
• occurs when film is exposed to radiation other pears gray and
than primary beam (e.g., scatter) lacks contrast
• may result from improper safelighting or light
leaks in dark room
All three photos reprinted from Haring, Joen iannucci and Laura Jansen:
Dental Radiography: Principles and Techniques: Third Edition. © 2000,
with permission from Elsevier.
tech
A periapical image shows overlapped contacts. This error is cause by:
• vertical angulation is excessive/too steep
• beam not centered over receptor
• poor receptor placement
56
RADIOLOGY
tech
Use the two images below to determine the spatial position of the round ob-
ject. Following the exposure of image #1, the x-ray tubehead was moved and
the beam was directed from a mesial angulation in image #2. Given this in-
formation, where is the round object located?
<
c
• lingual to the first molar 6>
• buccal to the first molar
• in soft tissue
• in bone
Film #1 Film #2
55
RADIOLOGY
Overlapped contacts
• if the central ray is not directed through Incorrect hori-
zontal angulation
the interproximal contacts of the teeth, the results in over-
horizontal angulation is incorrect lapped contacts.
• incorrect horizontal angulation results in
overlapped contacts seen on the image
Cone-cut
• if the beam is not centered over the recep-
tor, a clear unexposed area or cone-cut is
seen on the image If the beam is not cen-
• the PID or "cone" is said to "cut" the image tered over the recep-
• a cone-cut may occur with the use of a rect- tor, a cone-cut results
angular or round PID & a clear unexposed
• a conecut may occur with or without the area is seen.
use of a beam alignment device
poor receptor placement
• a periapical image shows the entire tooth
and root, including the apical area and must
be placed to cover those areas Improper place-
• incorrect periapical receptor placement ment (if entire
may result in absence of apical structures or root is not cov-
a tipped or tilted occlusal plane ered) will result in
• a bite-wing image shows the crowns of both no apices appear-
the maxillary and mandibular teeth, the inter- ing on the image.
proximal areas and crestal bone
• incorrect bite-wing receptor placement
may result in absence of teeth or teeth surf- Images reprinted from Haring, Joen Iannucci and Laura Jansen: Dental
Radiography: Principles and Techniques: Third Edition. © 2000, with
faces on an image, tipped occlusal plane permission from Elsevier.
lingual to the first molar
Buccal object rule

• a.k.a. tube shift technique
• used to determine an object's spatial po-
In image #1, note
sition/buccal-lingual relationship within the location of the
the jaws object in reference
• two images are obtained, each exposed to the mesial root
of the first molar.
with a different angulation
• used to compare the object's position
with respect to a reference point (e.g., root
of a tooth)
In image #2, the
Example PID was moved
• if the PID is moved mesially and the ob- mesially; the ob-
ject in reference
ject in the second image appears to have
to the mesial root
moved in the same direction, the object of the first molar
lies to the lingual has also moved
• if the PID is moved mesially and the ob- mesially.
ject in the second image appears to have
moved in the opposite direction, the ob-
ject lies to the buccal
• use the acronym SLOB to remember the L - O - B RULE
buccal object rule
Same = Lingual
extraoral
Identify the radiopaque areas labeled 1 & 2 on the image below.
Reprinted from Iannucci, Joen M. and Howerton, Laura Jansen: Dental Radiography Principles and
Techniques. Fourth edition © 2012 with permission from Elsevier-Saunders.
72
RADIOLOGY
extraoral
Based on the image below, identify the approximate age of the patient.
Reprinted from Iannucci, Joen M. and Howerton, Laura Jansen: Dental Radiography Principles and Techniques.
Fourth edition © 2012 with permission from Elsevier-Saunders.
73
copyright o 2013-2014- Dental Decks
RADIOLOGY
Reprinted from Iannucci, joen M. and Howerton, Laura Jansen: Dental Radiography
Principles and Techniques. Fourth edition © 2012 with permission from Elsevier-Saunders.
1. Hoop earring Ghost image appearance

2. Ghost image of hoop earring
• resembles its real counterpart
Ghost image • found on the opposite side of the image;
• defined as a radiopaque artifact on a appears indistinct, larger, & highepthan
panoramic image that is produced when a its actual counterpart
radiodense object is penetrated twice by the • a ghost image of a hoop earring appears
x-ray beam on the opposite side of the image as a ra-
• occurs If all metallic or radiodense ob- diopacity that is larger & higher than the
jects (e.g., eyeglasses, earrings, necklaces, real hoop earring; appears blurred in both
hairpins, removable partial dentures, com- horizontal and vertical directions
plete dentures, orthodontic retainers, hear- • to avoid ghost images, instruct the pa-
ing aids, napkin chains) are not removed tient to remove all radiodense objects in the
before exposure of panoramic receptor head-and-neck region prior to exposure of
• obscures diagnostic information the panoramic receptor
' < 9 years old
Reprinted from Iannucci, Joen M. and Howerton, Laura Jansen: Dental Radiography Prin-
ciples and Techniques. Fourth edition © 2012 with permission from Elsevier-Saunders.
The erupted permanent teeth are highlighted in gray in the charts below. Based on this in-
formation, the panoramic film appears to represent a child of < 9 years old.
Maxillary Age at eruption Mandibular Age at eruption
Permanent teeth Central incisor 7-8 Central incisor 6-7
eruption charts Lateral incisor 8-9 Lateral incisor 7-8
Canine 11-12 Canine 9-10

First premolar 10-12 First premolar 10-12
Second premolar 10-12 Second premolar 11-12

First molar 6-7 First molar 6-7
Second molar 12-13 Second molar 11-13
Third molar 17-21 Third molar 17-21
tech
Identify each one of the following that is an advantage of using the parallel-
ing technique.
' receptor placement
i comfort
• accuracy
•simplicity
' duplication
59
RADIOLOGY
tech
Identify each one of the following that is a disadvantage of using the bisect-
ing technique.
• decreased exposure time
• can be used without a beam alignment device
• distortion
• angulation problems
60
RADIOLOGY
• accuracy
• simplicity
• duplication
Parelling technique Advantages

• based on concept of parallelism • accuracy - image is highly representative
• preferred technique for intraoral films of the actual tooth
• simplicity - simple & easy to learn and use
Basic principles
• duplication - easy to standardize and can be
• receptor is placed parallel to the long axis
accurately duplicated when serial images are
of the tooth being imaged
needed
• central ray is directed perpendicular to
both the receptor & long axis of the tooth Disadvantages
• a beam alignment device must be used to • receptor placement - it may be difficult for
keep the receptor parallel to the tooth
operator to place the beam alignment device
• the object-receptor distance must be in- in some patients
creased to keep the receptor and tooth paral- • discomfort - the beam alignment device
lel
may cause discomfort
• the target-receptor distance must be in-
creased to make certain the most parallel rays
will be aimed at the tooth and receptor (16"
target-receptor distance)
Long axis
ol toolh ^to Positions of the receptor, tooth and central ray in the paral-
>ft ^% leling technique. The receptor & long axis of the tooth are par-
**»<*• allel. The central ray is perpendicular to the tooth and receptor.
An increased target-receptor distance (16") is required.
Reprinted from Haring, Joen Iannucci and Laura Jansen: Dental Radiography:
Principles and Techniques: Third Edition. © 2000. with permission from El-
sevier.
• distortion
• angulation problems
Bisecting technique Advantages

• based on rule of isometry • can be used without a beam alignment
• technique used for periapicals device and therefore may be more read-
ily accepted by patients
Basic principles • requires a shorter exposure time
• receptor must cover area of interest
• receptor must be placed so 1/8" ex- Disadvantages
tending beyond the occlusal or incisal • image distortion (magnification) oc-
surfaces curs when a short (8") PTD is used
• central ray is directed perpendicular • angulation problems may occur be-
to the imaginary bisector cause no beam alignment device is used
• central ray is directed through the resulting in images that are elongated or
contact areas of the teeth foreshortened
• x-ray beam must be centered over the
receptor so that the entire receptor is ex-
posed
The image on the receptor is equal to the length of the

tooth when the central ray is perpendicular to the "imag-
inary bisector". A short (8 ") target-receptor distance is
required.
Length of image Reprinted from Haring, Joen Iannucci and Laura Jansen: Dental Radiography: Princi-
ples and Techniques: Third Edition. © 2000, with permission from Elsevier.

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digital rad

Which type of digital image receptor is most common at this time?

CID (charge injection device)

• CMOS/APS (complementary metal oxide semiconductor/active pixel sensor)

• CCD (charge-coupled device)

superior gray-scale resolution

' reduced patient exposure to x-radiation

• increased speed of image viewing

' lower equipment and film costs

• effective patient education tool

• enhancement of diagnostic image

' superior gray-scale resolution

indirect digital imaging

• direct digital imaging

• storage phosphor imaging

• use of digital imaging

• use of E-speed films

• use of F-speed films

• substitute a panoramic image for the full mouth series

Digital imaging Scanning of traditional films

• use of digital imaging

Intraoral film speed

Other ways to limit exposure to x-radiation

To limit image magnification, the longest target-receptor distance and short-

• both statements are true

• both statements are false

• the first statement is true, the second is false

• the first statement is false, the second is true

> maxillary sinus

copyright © 2013-2014- Dental Decks

LOW CONTRAST •• LONG-SCALE CONTRAST 'image receptor=digital sensor or x-ray film

• sinus— b o n e — d e n t i n — enamel amalgam

Examples of radiolucent structures/mate- Examples of radiopaque structures/mate-

LUCENT means TRANSPARENT and OPAQUE means NOT TRANSPARENT

> none of the above

• yes, she is correct, it is time for new x-ray images

• bite-wings should be taken only once per year, not twice

• none of the above

Dental radiographs Patients who refuse dental radiographs

Patient record must contain documentation of

• images should be taken based on patient need instead of a set time

Prescribing dental radiographs

Guidelines for radiographs in the recall patient

copyright © 2013-2014- Dental Decks

"Courtesy Dr. Stuart C. White, UCLA School of Dentistry." y\

"Courtesy Dr. Stuart C White, UCLA School of Dentistry." 12

copyright ©2013-2014-Dental Decks

1. lateral wall of the incisive (nasopalatine) canal

2. anterior wall of the maxillary sinus

4. floor of nasal fossa

5. soft tissue outline of the nose

8. periodontal ligament space

1. anterior nasal spine

2..lateral wall of nasopalatine canal

3. median palatal suture

4. floor of nasal fossa

5. incisive (nasoplatine) foramen

6. soft tissue outline of tip of nose

Courtesy Dr. Stuart C. White, UCLA School of Dentistry."

"Courtesy Dr. Stuart C. White, UCLA School of Dentistry.'