Management Techniques

One of the most challenging tasks for the clinical staff is to obtain diagnostic quality radiographs on a young patient, (particularly those under three years of age) without causing psychological trauma. Radiographs are rarely taken for infants, for example, eruption cyst associated with natal or neonatal teeth. In such situations, the infant is held comfortably by the parent seated in the dental chair (Figure 6).

Figure 6.
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For toddlers, it is preferred to desensitize the child to the dental experience by explaining to the child what you plan to do in words easily comprehended by the child. Using a "tell, show, do" technique, the clinician explains to the child a tooth picture will be taken of the child's tooth with tooth film and a tooth camera. The child is allowed to touch and examine the radiographic film and camera. The child is positioned to gain maximum cooperation. In the child less than three years of age it may be necessary for the child to sit in the parent's lap while the radiograph is exposed (Figure 7).

Figure 7.
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Such positioning reduces the child's anxiety to such a degree that minimal restraint may be needed to successfully take the radiograph. The child is seated in the parent's lap with the parent resting their arms around the child's upper body and their legs wrapped around the child's lower body. Not only does this provide additional emotional security for the child and, thus, increased cooperation but also enables the parent to adequately restrain the child should there be any unexpected sudden movements.

A positioning device such as a Snap-A-Ray can be used to aid the parent in positioning and securing the film (Figure 8). Be sure to adequately protect the parent and child with lead aprons to reduce radiation exposure. Obtaining the least difficult radiograph first (such as an anterior occlusal) desensitizes the child to the procedure (Figure 9). Since many children have difficulty keeping the film in their mouth for extended periods of time, be certain the correct settings are made on the apparatus and the x-ray head is properly positioned before placing the film in the child's mouth. Once the child feels acclimatized with the setting, additional radiographs including left bitewing (Figure 10) and right bitewing can be obtained (Figure 11).

Figure 8.
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Figure 10.
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Figure 9.
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Figure 11.
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If the child is uncooperative, then additional restraint by a second adult may be necessary to successfully obtain the radiograph. With the first adult restraining the child as described previously, a second adult stabilizes the child's head with one hand while the other hand positions the x-ray holder in the patient's mouth. Under no circumstances should staff be asked to perform this task.

If a second adult is not available, it may be necessary to place the child in a mechanical restraining device (Papoose Board) to adequately restrain the child (Figure 12). This frees the parent to stabilize the child's head and properly position the radiograph in the child's mouth. This approach is particularly useful on an uncooperative child in emergency conditions like dental injury or facial abscess following dental infection. In such situations, diagnostic radiograph could be followed by treatment rendered whilst the child is still seated in the restraining device. This would potentially avoid placing child repeatedly in the restraining device.

Figure 12.
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If the child is still too uncooperative, it may be necessary to manage the child pharmacologically with inhalation, oral, or parental sedatives. Older children may also be uncooperative for a variety of reasons. These can range from the jaw being too small to adequately accommodate the radiograph, fear of swallowing the radiograph, fear of the procedure itself, or the patient exhibits a severe gag reflex. There are numerous techniques to overcome these problems. For the child with the small mouth, use the smallest size film available which is size 0 film followed by size 1 and size 2 films (Figure 13). Sometimes, rolling the film to avoid sharp bends can allow the film to accommodate the shape of the jaw and not impinge on the soft tissues (Figure 14).

Figure 13.
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Figure 14.
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Use of the Snap-A-Ray as a bitewing tab will reduce impingement on the soft tissue but unfortunately will reduce the amount of detectable tooth structure on the radiographs (Figure 15, 16).
Figure 15.
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Figure 16.
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This approach is particularly useful when conventional films are used which is relatively thinner compared to bulkier digital sensors (Figure 17).
Figure 17.
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