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Medical Forum / General / Dentistry / January 2006Bite wing x-ray of every tooth?
Two months ago when I was having an abscessed wisdom tooth extracted I had a full panoramic x-ray taken. It was my first visit to that dentist. Today I went back in for a general check up, and to have any cavities filled that the dentist found. I was pleasantly surprised to find I had no cavities, and better yet that my gums were in good condition. But when I first arrived, prior to seeing the dentist, the assistant wanted to take individual x-rays of each tooth in my mouth. I told her I didn't need any x-rays today; I had a full panoramic taken just two months ago. She still wanted to take them, but I refused. The dentist didn't mention my refusal to take the numerous x-rays, and he did look at the panoramic x-ray. Is it common - and advisable - to do bite wings of every tooth? With a recent panoramic in hand, I just didn't see any medical necessity.  SignatureTony Sivori A Panoramic X-ray is NOT the standard of practice for Caries diagnosis. You may be able to detect very large caries on the film, however the smaller to medium size caries may not even show up. Bite wings and periapicals (a full mouth series) will detect much more. The resolution and quality is such a drastic difference. It is like comparing the view of the moon from the ground, with the naked eye versus using a telescope. A panoramic x-ray IS the standard of care when it comes to 3rd molar extraction. I heard it said that the slight amount of radiation from a full mouth series is only about the same as a full days exposure in the sun. Dr. Braces > Two months ago when I was having an abscessed wisdom tooth extracted I had > a full panoramic x-ray taken. It was my first visit to that dentist. [quoted text clipped - 13 lines] > Is it common - and advisable - to do bite wings of every tooth? With a > recent panoramic in hand, I just didn't see any medical necessity. > A Panoramic X-ray is NOT the standard of practice for Caries diagnosis. > You may be able to detect very large caries on the film, however the [quoted text clipped - 24 lines] > > The dentist didn't mention my refusal to take the numerous x-rays, and he > > did look at the panoramic x-ray. Dear Dr Braces, I do not mean to interrupt your conversaiton, but a while back you wrote a response here to the question that asked whether a patient can have/his/her teeth lightened while wearing braces. May I copy your entire post to another dental forum where this question was asked by a patient? The dental profesisonals on the other forum did not mention taking into consideration the patient's oral healthcare and habits, like you mentioned. Thank you for your consideration, Sue sue, please don't repost any of my replies, thank you > Dear Dr Braces, > [quoted text clipped - 9 lines] > Thank you for your consideration, > Sue > sue, please don't repost any of my replies, thank you > [quoted text clipped - 11 lines] > > Thank you for your consideration, > > Sue Dr Braces, I will honor your request. In the past, I was trying to refer patients here, but quite honestly, some did not want to post here. Some of the patients felt berated here, and/or frightened when they saw other patients called "dim," or "dumb" by anonymous professionals here. Some felt belittled, disregarded and ignored. I am sorry, but that was the reality. Most of the professionals here were well-meaning, patient and kind but some, in their arrogance, were very harsh. Maybe they di dnot relaize it, o rmaybe it was intentional. I do not know. But some seemed to look at this forum as their own meeting room (amongst themselves) first and foremost... patients and other interested parties as secondary. Granted, since the porfesisoanls are aswering questions out of the goodness of their hearts, they are entitled to some fun and comradery amongst peers too... but to use this forum as an outlet to demean patients that they tire of, and "play" and deeman other interested parties for fun is wrong, IMO. It only takes one or two arrogant voices, and a scared patient will leave for good and with a very bad taste for the dental profession as a whole, IMHO. I have to admit that I lost my temper with one of the anonymous professionals here, but after being called TRASH, slandered, lied about, seeing "made up" conversations that inferred that I had said some lewd things, that I never said... I am sorry... I LOST my temper. I am sorry to interrupt this discussion with my gripe, but I had some pent-up anger about the whole Sue-bashing party and all of the allegations that some of the "good" doctors and others here made. I will ceritnaly honor your request Dr. Braces. And now that things have calmed down here, I feel comfortable referring patients over here once again. Thank you for listening, Best wishes, Sue > A Panoramic X-ray is NOT the standard of practice for Caries diagnosis. > You may be able to detect very large caries on the film, however the > smaller to medium size caries may not even show up. Bite wings and > periapicals (a full mouth series) will detect much more. That is surprising to me since I have never had any dentist want to x-ray each tooth individually. > The resolution and quality is such a drastic difference. It is like > comparing the view of the moon from the ground, with the naked eye [quoted text clipped - 3 lines] > I heard it said that the slight amount of radiation from a full mouth > series is only about the same as a full days exposure in the sun. Still, it would be concentrated in a much smaller area, mostly the salivary glands if what I read is correct. Not to mention, I wouldn't dream of spending a full day in the sun unprotected. SignatureTony Sivori Dental caries cannot be accurately diagnosed from panoramic films. Bitewing films are necessary to locate carious lesions and to determine the height of crestal bone. Pocket probing is also necessary to determine the presence of periodontal pockets. Periapical films are often needed in addition to bitewings, as neither the bitewings nor the panoramic film will show detail in the periapical regions of the teeth. Best regards, - dentaldoc > Dental caries cannot be accurately diagnosed from panoramic films. > [quoted text clipped - 3 lines] > often needed in addition to bitewings, as neither the bitewings nor the > panoramic film will show detail in the periapical regions of the teeth. Heh, in that case the doc took it very well when I refused them. I guess he knows a stubborn old fart when he sees one. :-) SignatureTony Sivori Toni You seem to be looking for every reason to avoid radiographs. So sign a paper stating you do not wish radiographs and when they are diagnosed on your next panoramic x ray and they need endodontic and crowning procedures at 15 times the fee a restoration (filling) would be you won't be able to compain. Dr harry >> A Panoramic X-ray is NOT the standard of practice for Caries diagnosis. >> You may be able to detect very large caries on the film, however the [quoted text clipped - 15 lines] > salivary glands if what I read is correct. Not to mention, I wouldn't > dream of spending a full day in the sun unprotected. > > A Panoramic X-ray is NOT the standard of practice for Caries diagnosis. > > You may be able to detect very large caries on the film, however the [quoted text clipped - 18 lines] > -- > Tony Sivori "Not to mention, I wouldn't dream of spending a full day in the sun unprotected." Tony, Have you been diagnosed with melanoma in the past? -Sue >> Not to mention, I wouldn't dream of spending a full day in the sun >> unprotected. > Have you been diagnosed with melanoma in the past? I've never been diagnosed with any cancer. I'm just cautious and conservative when it comes to radiation. SignatureTony Sivori > >> Not to mention, I wouldn't dream of spending a full day in the sun > >> unprotected. [quoted text clipped - 6 lines] > -- > Tony Sivori Dear Tony, I am happy to hear that you have never been diagnosed with cancer. Cancer surviviors are often more emotionally conservative (understandably so) when it comes to sun exposure and exposure to medical diagnostic xrays. Best wishes, Sue (patient only) PS I obviously cannot answer these questions. But I think you need to do what is most comfortable for you. Seems there are trade-offs both ways. It sounds like your dentist is willing to compromise some diagnostic ability in order to keep your exposure low. This is what you are most comfortable with and s/he is complying to your wishes. I may be wrong, but this is JMHO as a patient. Take Care. Just for understanding, a few teeth fit on each xray film and not every tooth is taken indivually. see this link below (not endorsing them just for info) http://www.dentalgentlecare.com/necessary_x-rays.htm Dr. Braces > That is surprising to me since I have never had any dentist want to x-ray > each tooth individually. > Just for understanding, a few teeth fit on each xray film and not every > tooth is taken indivually. > > see this link below (not endorsing them just for info) > > http://www.dentalgentlecare.com/necessary_x-rays.htm I'm not sure I understand what the site means regarding the recommended time interval. Does the 5 to 7 years between the panoramic and full mouth series mean that is the recommended limit for the radiation, or does it mean that the average patient will not need them more often than 5 to 7 years? SignatureTony Sivori Dr.Braces wrote: > Just for understanding, a few teeth fit on each xray film and not every > tooth is taken indivually. > see this link below (not endorsing them just for info) > http://www.dentalgentlecare.com/necessary_x-rays.htm I'm not sure I understand what the site means regarding the recommended time interval. Does the 5 to 7 years between the panoramic and full mouth series mean that is the recommended limit for the radiation, or does it mean that the average patient will not need them more often than 5 to 7 years? -- Tony Sivori _________________________________________ It means that the average patient will not need them more often than every 5 to 7 years. In my experience, many patients can go much longer than that, between full mouth series, if they have bitewings and an occasional periapical with their normal dental checkups. - dentaldoc Jeez, its more an insurance thing ...... the dentists go wild when they hear insurance, then the insurance gots to make some rules. As for radiation, its ALARA. As Low As is Reasonably Allowable. There's NO PROOF of harm but like amalgamitis, it could be! Radiation in general causes mutations! Amalgamitis is worse. Joely >Dr.Braces wrote: >> Just for understanding, a few teeth fit on each xray film and not every [quoted text clipped - 13 lines] > >years? Out of interest: how common would it be for individual periapicals (rather than bitewings) to be taken as a precautionary measure (and - is there an Atlantic divide on this issue, as in the case of asymptomatic wisdom teeth)? > A Panoramic X-ray is NOT the standard of practice for Caries diagnosis. > You may be able to detect very large caries on the film, however the [quoted text clipped - 3 lines] > comparing the view of the moon from the ground, with the naked eye > versus using a telescope. There was an article in the Journal of the Canadian Dental Association (May 2005, Vol 71, Number 5 - Point of Care Question 2) which stated that open panoramic interproximal contacts were not statistically differetnt from bitewing radiographs for detection of interproximal caries? The article is available here: http://www.cda-adc.ca/jcda/vol-71/issue-5/341.html (click on Full Text). Comments appreciated! Dr. Braces is correct. Its a screening tool, not a diagnostic tool. I can quote the ADA directives if anyone is interested. Joel >> A Panoramic X-ray is NOT the standard of practice for Caries diagnosis. >> You may be able to detect very large caries on the film, however the [quoted text clipped - 12 lines] >Text). >Comments appreciated! I was just a bit surprised at that article, that's all - and was wondering what people make of it. > Dr. Braces is correct. Its a screening tool, not a diagnostic tool. > [quoted text clipped - 18 lines] > >Text). > >Comments appreciated! Panorex has been pushed by people who do not know what they are doing and prefer the nice lazy way to practice. There is nothing like a clear, crisp diagnostic level peripaical film. Secondly, detecting carious lesions requires high contrast (low kVp). A screening tool for maxillary sinuses, cysts, and periapical lesions is best obtained with a low-contract, higher (90 kVp) x-ray generator. I will refer people to a step-wedge which is found in all the Radiology texts, but I am certain no one knows or cares what that is. Joel >I was just a bit surprised at that article, that's all - and was >wondering what people make of it. [quoted text clipped - 21 lines] >> >Text). >> >Comments appreciated! > Panorex has been pushed by people who do not know what they > are doing and prefer the nice lazy way to practice. There is nothing > like a clear, crisp diagnostic level peripaical film. I suppose what I really wanted to find out was: "why would the Canadian Dental Association choose to publish an article that basically states that a panoramic x-ray can be used instead of bitewings?" As someone previously involved in research, one of the first steps in evaluating data is to see who funded the study and exactly where it was published. There are many private interests that skew the data to show this or that. Joel >> Panorex has been pushed by people who do not know what they >> are doing and prefer the nice lazy way to practice. There is nothing [quoted text clipped - 3 lines] >Dental Association choose to publish an article that basically states >that a panoramic x-ray can be used instead of bitewings?" That is true. Still, I would've thought that the JCDA has an editorial team. > As someone previously involved in research, one of the first steps > in evaluating data is to see who funded the study and exactly where [quoted text clipped - 10 lines] > >Dental Association choose to publish an article that basically states > >that a panoramic x-ray can be used instead of bitewings?" Well, here in Israel they don't perform wisdom tooth surgery without a panoramic as fresh as 2 months.period. orders from ministry of health (And insurances companies, like say... dura lex stuff) for diagnosis and treatment plans they do what they call a "status", which I used to know as the "Serial X Ray" which means 14 to 16 rxs from all your mouth, but as it should be, for cavities diagnosis I prefer just two bite wings (It's funny the way Israelis pronnounce "Byt vink") and mebbe 1 o' 2 periapicals although I've got to admit that as an endodontist I do indiscriminated use of periapicals without hessitation ;-p in a bite wing you get (mostly) (2digits system) 4?...567...8? upper AND 4?...567...8? lower, for knowing if ther're posts or rtcs or just caries under fillings they're GRRREAT! One of my biggest problems is the measure x ray with the files inserted in the root cannals, 'cause...patients CHOKE! the pre and post I do with the help of a "Crocodile", I tell them..."-Ya bite tha Crock BEFORE tha Crock bites ya!!!-" Shalom Gabriel SignaturePor favor, si va a reenviar este correo electrónico (1) Borre la dirección de la persona que lo envía así como cualquier otra que aparezca (2) Proteja las direcciones de sus destinatarios colocando las mismas en la línea de BCC (CCO) (Blind Copy o copia oculta). Gracias > That is true. Still, I would've thought that the JCDA has an editorial > team. [quoted text clipped - 13 lines] >> >Dental Association choose to publish an article that basically states >> >that a panoramic x-ray can be used instead of bitewings?" If you do lots of endo, an apex locator or a digital x-ray output is excellent. Joel >Well, here in Israel they don't perform wisdom tooth surgery without a >panoramic as fresh as 2 months.period. orders from ministry of health (And [quoted text clipped - 15 lines] >Shalom >Gabriel > If you do lots of endo, an apex locator or a digital x-ray output is > excellent. > > Joel I guess you're right about that, just I'm working in 9 different clinics right now and not everybody has all the equipment, also the dental insurance companies many times "force" me to take Xrays that I don't feel they're necessary for the treatment but for the money being collected, sad, but a reality. I DON'T take insurance in most of the places I work, not just because of the problematic work conditions they put the dental professional up to, also because of... lousy payings, they pay about 35 % of what I take on the private market, if that isn't exploitation. then... what is it? so again... upper or lower mollar??? Gabriel (Jew-Boy) > If you do lots of endo, an apex locator or a digital x-ray output is > excellent. [quoted text clipped - 21 lines] >>Shalom >>Gabriel >I was just a bit surprised at that article, that's all - and was >wondering what people make of it. [quoted text clipped - 4 lines] >> >> Joel ************************* SEE BELOW 4. Adult dentulous The Panel recommends an individualized radiographic examination consisting of selected periapicals with posterior bitewings for a new dentulous adult patient. ***************************** Surprising, isn't it? Joely Radiology Requirements Note: Please refer to benefit tables for radiograph benefit limitations. Doral utilizes the guidelines published by the Department of Health and Human Services, Center for Devices and Radiological Health. These guidelines were developed in conjunction with the Food and Drug Administration. A. Radiographic Examination of the New Patient 1. Child primary dentition The Panel recommends posterior bitewing radiographs for a new patient, with a primary dentition and closed proximal contacts. 2. Child transitional dentition The Panel recommends an individualized periapical/occlusal examination with posterior bitewings OR a panoramic radiograph and posterior bitewings, for a new patient with a transitional dentition. 3. Adolescent permanent dentition prior to the eruption of the third molars The Panel recommends an individualized radiographic examination consisting of selected periapicals with posterior bitewings for a new adolescent patient. 4. Adult dentulous The Panel recommends an individualized radiographic examination consisting of selected periapicals with posterior bitewings for a new dentulous adult patient. 5. Adult edentulous The Panel recommends a full-mouth intraoral radiographic survey OR a panoramic radiograph for the new edentulous adult patient. B. Radiographic Examination of the Recall Patient 1. Patients with clinical caries or other high risk factors for caries a. Child primary and transitional dentition The Panel recommends that posterior bitewings be performed at a 6-12 month interval for those children with clinical caries or who are at increased risk for the development of caries in either the primary or transitional dentition. b. Adolescent The Panel recommends that posterior bitewings be performed at a 6-12 month interval for adolescents with clinical caries or who are at increased risk for the development of caries. **************************** >> >> A Panoramic X-ray is NOT the standard of practice for Caries diagnosis. >> >> You may be able to detect very large caries on the film, however the [quoted text clipped - 12 lines] >> >Text). >> >Comments appreciated! i would rather u quote shakespeare Dr. Braces is correct. Its a screening tool, not a diagnostic tool. I can quote the ADA directives if anyone is interested. Joel On 28 Jan 2006 10:37:22 -0800, "letsconnect" <letsconnect@myway.com> wrote: > >Dr.Braces wrote: >> A Panoramic X-ray is NOT the standard of practice for Caries diagnosis. >> You may be able to detect very large caries on the film, however the >> smaller to medium size caries may not even show up. >> Bite wings and periapicals (a full mouth series) will detect much more. >> The resolution and quality is such a drastic difference. It is like >> comparing the view of the moon from the ground, with the naked eye >> versus using a telescope. > >There was an article in the Journal of the Canadian Dental Association >(May 2005, Vol 71, Number 5 - Point of Care Question 2) which stated >that open panoramic interproximal contacts were not statistically >differetnt from bitewing radiographs for detection of interproximal >caries? The article is available here: >http://www.cda-adc.ca/jcda/vol-71/issue-5/341.html (click on Full >Text). >Comments appreciated! a catscan is good too Dr.Braces wrote: > A Panoramic X-ray is NOT the standard of practice for Caries diagnosis. > You may be able to detect very large caries on the film, however the > smaller to medium size caries may not even show up. > Bite wings and periapicals (a full mouth series) will detect much more. > The resolution and quality is such a drastic difference. It is like > comparing the view of the moon from the ground, with the naked eye > versus using a telescope. There was an article in the Journal of the Canadian Dental Association (May 2005, Vol 71, Number 5 - Point of Care Question 2) which stated that open panoramic interproximal contacts were not statistically differetnt from bitewing radiographs for detection of interproximal caries? The article is available here: http://www.cda-adc.ca/jcda/vol-71/issue-5/341.html (click on Full Text). Comments appreciated! > Two months ago when I was having an abscessed wisdom tooth extracted I had > a full panoramic x-ray taken. It was my first visit to that dentist. [quoted text clipped - 16 lines] > -- > Tony Sivori Tony, FYI. PLEASE Read this: http://www.doctorspiller.com/Dental%20_X-Rays.htm And Study (below) done ~10 years ago on this subject found: "Agreement between panoramic and intraoral radiography is not sufficient for panoramic radiography to be used alone to diagnose periapical lesions, marginal bone loss and caries. It is possible to perform a full-mouth survey with a combination of panoramic and intraoral radiography but when limited regions need to be examined intraoral radiography is the method of choice." Best, Sue (nondentist) Swed Dent J Suppl. 1996;119:1-26. Related Articles, Links Panoramic radiography in dental diagnostics. Molander B. Department of Oral Diagnostic Radiology, Faculty of Odontology, Goteborg University, Sweden. Panoramic radiography was studied with the aim to answer some questions about technical and diagnostic properties regarding dental diagnostics. A unit with an intraoral X-ray tube was studied regarding radiation beam area, absorbed doses, and image quality for various screen-film combinations. The beam area for lateral views was wider than optimal and the contact dose high. Modifications of shielding cylinders would reduce both radiation beam and contact dose. One screen-film combination was most sensitive and produced radiographs with best subjectively perceived image quality. Agreement between panoramic (rotational and intraoral X-ray tube techniques) and intraoral radiography in diagnosis of periapical pathology, assessment of marginal bone height, and caries diagnosis was evaluated in 400 patients. Average agreement between panoramic and intraoral radiographs in periapical diagnosis was 55% for the rotational and 46% for the intraoral tube technique. Agreement in marginal bone height was 55% and 49%, respectively and in caries diagnosis 34% and 46%. Radiographs from 40 patients were used to evaluate a procedure starting with rotational panoramic radiography followed by intraoral radiographs considered necessary to achieve a comprehensive examination of teeth and surrounding bone. The number of intraoral radiographs, information loss, and monetary costs with this procedure were evaluated. Mean number of adjunct intraoral radiographs was 5.1 per patient whilst 8.5 should have been chosen to satisfy a "gold standard" used. Monetary costs were similar for an optimal combination of panoramic and intraoral radiography as for a survey with 20 intraoral images Sensitivity for a combination of radiographs was 80-96% in periapical diagnosis and marginal bone loss assessment, and 42-96% in caries diagnosis. Specificity was 95-97% for periapical and caries diagnosis and 50-92% for marginal bone loss. Radiographs from six conventional units and two programs ("dental" and "jaw" panorama) of a new multi-modal unit were compared in diagnostic quality of periapical and crestal bone areas. Number of adjunct intraoral radiographs to achieve a comprehensive evaluation of periapical and marginal bone was estimated. Quality of the "dental" panorama was significantly better than that of other machines/programs. There were no significant differences between images obtained with conventional units and the "jaw" panorama. Number of adjunct intraoral radiographs was lowest for the "dental" panorama. Quality obtained with an old unit was similar to that from modern machines. Rotational and intraoral X-ray tube panoramic radiography perform equally well. Agreement between panoramic and intraoral radiography is not sufficient for panoramic radiography to be used alone to diagnose periapical lesions, marginal bone loss and caries. It is possible to perform a full-mouth survey with a combination of panoramic and intraoral radiography but when limited regions need to be examined intraoral radiography is the method of choice. Publication Types: Review
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