Patient A
Step 1: Do these radiographs exhibit the criteria for meeting minimal diagnostic
acceptability?
Note: All radiographs in this series exhibit faint radiopaque gridlines. These grids are
commercially available and can be applied to the front of the film so that the dentist can
estimate the amount of bone loss. Each square is 1 mm square.
This series of radiographs consists of 14 periapical radiographs and no bitewings/
interproximal radiographs. In general this is NOT a clinically acceptable set of
radiographs: the maxillary R 1st molar–2nd molar contact is not open, nor is the
maxillary R 1st premolar–canine contact. The distal half of the maxillary R cuspid is not
visible. The right molar and premolar periapical radiographs are not clear, suggesting
some type of motion unsharpness (movement of patient or tubehead during exposure).
The apices of the mandibular R & L 2nd molars are not visible. The presence of the
biteblock and alignment rod suggests the series was taken using the RINN XCP
instruments; in general there is good parallelism with the long axis of the teeth and the
film since the cusp tips are well superimposed.
Step 2: Are there any significant technique or processing errors that will influence my
ability to correctly evaluate all of the relevant dental structures?
Bottom line: Yes, there are packet placing and overlapped interproximal spaces that will
prevent evaluation of each root apex and contact area at least once somewhere in the
series.
Maxillary R Molar Region
The film is acceptably positioned; however, the overlap between the maxillary 1st and
2nd molar should be considered a technique error on this radiograph, since it is likely that
the direction of the contact will be more mesially inclined compared to the 2nd premolar–
1st molar position. The overlap is due to directing the CR too far from the distal. This
may be determined by observing that the distal-buccal and lingual roots of the 1st molar
are superimposed on each other (see your textbook: Clark’s Rule/buccal-object rule/shiftshot). The radiograph is blurred, suggesting motion unsharpness; compare to maxillary L
molar periapical.
Maxillary R Premolar Region
The film should have been positioned more mesial to include the distal half of the
maxillary canine. The open contact between the 2nd premolar and 1st molar suggests that
the horizontal direction of the CR was correct for this region; thus, the overlap between
the 1st and 2nd molar should be considered physiologic overlap. The radiograph is
blurred, suggesting motion unsharpness (compare to maxillary L premolar and molar
periapicals).
Patient Assessment Tutorials: A Step-by-Step Guide for the Dental Hygienist
Second Edition
Jill S. Nield-Gehrig
© 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins
Maxillary R Cuspid/Canine Region
Clinically acceptable film placement; the overlap between the canine and 1st premolar is
because of the position of the canine at the corner of the arch and the contact areas are not
parallel to each other.
Maxillary Central Incisor Region
Clinically acceptable radiograph
Maxillary L Cuspid/Canine Region
Film is not well centered behind the canine; the overlap between the canine and 1st
premolar is because of the position of the canine at the corner of the arch and the contact
areas are not parallel to each other. Film bending is noted along the upper mesial corner
of the radiograph.
Maxillary L Premolar
Overlapped interproximal spaces between the 1st and 2nd premolars and the 2nd
premolar and 1st molar. Excessive horizontal angulation: CR directed too far from the
mesial; the mesial buccal and lingual roots are overlapped and the only open contact is
the canine–1st premolar.
Maxillary L Molar
Overlapped interproximal spaces between the 1st and 2nd premolars and the 2nd
premolar and 1st molar. Excessive horizontal angulation: CR directed too far from the
mesial; the mesial buccal and lingual roots are overlapped and the only open contact is
the canine–1st premolar.
Mandibular R Molar Region
Incorrect film placement; the film should be positioned more distally to include all of the
3rd molar root apex. (It is assumed that the visible tooth is the 3rd molar since there is
such a wide separation between the molar and the 2nd premolar.)
Mandibular R Premolar Region
Minor error in film placement, it would be desirable to position the film more mesially to
include a bit more of the mandibular canine.
Mandibular R Cuspid/Canine Region
Clinically acceptable radiograph
Mandibular Central Incisor Region
Clinically acceptable radiograph
Mandibular L Cuspid/Canine Region
Clinically acceptable; film is slightly off center behind the lateral-canine interproximal
space instead of centered behind the canine.
Patient Assessment Tutorials: A Step-by-Step Guide for the Dental Hygienist
Second Edition
Jill S. Nield-Gehrig
© 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins
Mandibular L Premolar Region
Poor packet placement; the film should be positioned mesial to include the distal half of
the mandibular canine.
Mandibular L Molar Region
Incorrect packet placement; not all of the 3rd molar apex is visible; or at the very least the
film should be positioned distally to include at least 4 mm of bone beyond the apex of the
tooth. (It is assumed that the molars visible are 2nd and 3rd molars, primarily due to the
mesial angulation of the molar and close proximity of the mesial and distal roots to each
other, suggesting the anatomy of a 2nd molar rather than a 1st molar, which typically has
a wider separation between the mesial and distal roots. For reference, observe the 1st
molars on patients B and C.)
Step 3: Recognize the normal anatomic structures observable on the radiographs you will
be evaluating.
Maxillary R Molar Region
Anterior and lower border of the maxillary sinus, maxillary sinus, zygomatic process of
the maxilla (malar process), lower border of the zygomatic arch
Maxillary R Premolar Region
Anterior and lower border of the maxillary sinus, maxillary sinus, zygomatic process of
the maxilla (malar process), lower border of the zygomatic arch
Maxillary R Cuspid/Canine Region
Lower border of the nasal fossa, nasal fossa, anterior border of the maxillary sinus,
maxillary sinus
Maxillary Central Incisor Region
Lower border of the nasal fossa, nasal fossa, anterior nasal spine, tiny bit of the nasal
septum, incisive foramen
Maxillary L Cuspid/Canine Region
Anterior border of the maxillary sinus, maxillary sinus (upper distal corner of film)
Maxillary L Molar
Zygomatic process of the maxilla (malar process), tiny bit of the lower border of the
zygomatic arch, lower border of the maxillary sinus, maxillary sinus
Maxillary L Premolar
Zygomatic process of the maxilla (malar process), lower border of the maxillary sinus,
maxillary sinus
Patient Assessment Tutorials: A Step-by-Step Guide for the Dental Hygienist
Second Edition
Jill S. Nield-Gehrig
© 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins
Mandibular R Molar Region
Mental foramen; only a tiny portion of the mandibular canal is visible at the distal edge of
the radiograph
Mandibular R Premolar Region
Mental foramen
Mandibular R Cuspid/Canine Region
Mental ridge, lower border of the mandible
Mandibular Central Incisor Region
Mental ridge, lower border of the mandible, genial tubercles, lingual foramen
Mandibular L Cuspid/Canine Region
Mental ridge, lower border of the mandible
Mandibular L Premolar Region
Mandibular canal, mental foramen
Mandibular L Molar Region
Mandibular canal, mental foramen
Step 4: Begin a systematic and careful assessment of the teeth and their supporting
tissues and provide a written summary of your findings.
No obvious caries. Restorations appear acceptable. Generally visible calculus on
many teeth. Alveolar bone height: generalized moderate bone loss, with localized severe
bone loss distal of maxillary L 1st molar, maxillary R 1st and 2nd molar region. There is
a localized area of increased radiopacity in the area of the R mandibular 1st and 2nd
molar region, suggesting a possible residual root fragment.
Patient Assessment Tutorials: A Step-by-Step Guide for the Dental Hygienist
Second Edition
Jill S. Nield-Gehrig
© 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins