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SHORT COMMUNICATION Use of extraoral periapical radiography in Indian population:Technique and case reports
Rahul Kumar, Neha Khambete1
Department of Conservative Dentistry and Endodontics, MGM Dental College and Hospital, Navi Mumbai, 1 Department of Oral Medicine and Radiology, CSMSS Dental College and Hospital, Aurangabad, India

ABSTRACT
Performing intraoral radiography in certain patients is difficult as these patients are unable to tolerate intraoral film placement. To assist such patients a new technique has been innovated using extraoral film placement. Use of this technique has been documented in Caucasian and Taiwanese populations. In this paper we report use of this technique for Indian population. We have done about 40cases using this technique and have found the average angulation for maxillary(-25+/-5 degrees) and mandibular(-15+/-5 degrees) teeth for Indian population. We recommend use of this technique in the personal dental clinics where panoramic radiographic machines are not readily available. Here we report the technique and cases where diagnostic imaging was performed in patients using the extraoral periapical technique. Key words: Extraoral radiography, intraoral films/sensors, periapical radiographs

Received : 22-02-11 Review completed : 18-05-12 Accepted : 07-02-13

The need for intraoral periapical radiographs is well established in all branches of dentistry. However, a large group of patients are unable to tolerate the intraoral film/ sensor placement. To overcome this, Michael Newmann and Seymour Friedman in 2003 developed an alternative technique for treating a wide spectrum of patients which included developmentally disabled patients, patients with exaggerated gag reflex, pediatric dental patients, anxious dental patients, patients with trauma and patients with limited mouth opening.[1,2] Chia-Hui-Chen etal., in 2007 developed a sensor beam alignment aiming device for performing radiographs using this technique.[3] Both of these reports document use of extraoral periapical technique in Caucasian and Taiwanese population, respectively.

as wide as possible, to allow the Xray beam to pass to the sensor unobstructed from the opposite side of the mouth. The sensor was placed on the external surface of the cheek, directly buccal to the tooth. A cotton roll was placed between the sensor and the cheek to parallel the sensor with the buccal surface of the tooth. The Xray cone was angled approximately25+/5 degrees from the horizontal plane (for Indian population). Additionally, the Xray beam was aligned perpendicular to the sensor to provide an accurate image[Figure1a and b].

For mandibular teeth

TECHNIQUE
For maxillary teeth
The patient sits upright, with his/her mouth was opened
Address for correspondence: Dr.Rahul Kumar E-mail:dr.rahul1982@gmail.com Access this article online
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The patient sits upright with raised chin. The sensor was placed on the external surface of the cheek, directly buccal to the tooth. The Xray cone was angled approximately15+/5 degrees from the horizontal plane(for Indian population). The Xray beam was aligned perpendicular to the sensor to provide an accurate image[Figure2a and b]. The images were obtained using SOPRO digital imaging system(Acteon Group, Marseills, France) and a 30 40 mm standard intraoral sensor SOPIX(Acteon Group, Marseills, France). An intraoral Xray machine (Biomedicare, Thane, India) was used to take the radiographs set at 65kVp, 10 mA, 0.45-0.55seconds.

Website: www.ijdr.in PMID: *** DOI: 10.4103/0970-9290.116689

CASE SERIES
Application in patients with trismus
A 24yearold male patient reported to us with chief complaint of extraoral swelling and dull, throbbing pain in maxillary left posterior region. The patient was a diagnosed case of oral submucous fibrosis and the interincisal distance
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Extraoral periapical radiography

Kumar and Khambete

was 15mm. Thus, it was not possible to placethe Xrayfilm intraorally. Thus, it was decided to use the extraoral technique for radiograph, which provideduswith essential diagnostic information[Figure3].

Application in pediatric patients

Application in patients with severe gag reflex

Patients with severe gag reflex are unable to tolerate intraoral film placement. Hence, radiographs were taken for such patients with extraoral film placement which provided us with necessary diagnostic information[Figure4ac].

Pediatric patients are generally apprehensive and reluctant to intraoral film placement. We used the extraoral technique to obtain radiographs of such apprehensive patients. The radiographs provide us with essential diagnostic details[Figure6]. Also, patients found this technique less traumatic and it was easier to obtain patient cooperation.

DISCUSSION
In 1974, Fisher proposed an extraoral radiographic technique for obtaining images of third molars using occlusal films, but

Application in patients with rubber dam

Taking intraoral radiographs in patients with placement of rubber dam is time consuming and uncomfortable for patients. Hence, using the extraoral technique in such patients results in increased patient compliance and also requires lesser time providing essential diagnostic information[Figure5a and b].

Figure 2 (a and b): Patient positioning for taking extraoral radiographs of mandibular teeth

Figure 1 (a and b): Patient positioning for taking extraoral radiographs of maxillary teeth a b

c Figure 4 (a-c): Extraoral periapical radiograph of patients with severe gag reflex

Figure 3: Extraoral periapical radiograph of patient with trismus

b Figure 6: Extraoral periapical radiograph of pediatric dental patient 272

Figure 5 (a and b): Extraoral periapical radiographs of dental patients with rubber dam Indian Journal of Dental Research, 24(2), 2013

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Extraoral periapical radiography

Kumar and Khambete

the requisite high kVP(as high as 90 kVP) had limited its daily clinical application.[4] We found that, using a digital imaging system 65 kVP was sufficient to produce image with adequate diagnostic quality comparable with the conventional intraoral periapical radiographs. The extraoral radiographic technique is a useful alternative technique and has proved to be effective for the patients who are unable to tolerate the conventional technique. Appropriate images having been successfully acquired which provide us with adequate details and diagnostic quality. However, the disadvantages of this technique are the procedure being technique sensitive, slightly lower resolution of images and inability to obtain radiographs of anterior teeth. With recent advances in dental radiology, various techniques like panoramic radiography are available to manage such patients. However, we recommend use of this technique in the personal dental clinics where panoramic

radiographic machines are not readily available. Also, this technique can be used where active treatment is being carried out. To conclude, this technique is not meant for replacing conventional intraoral radiography. However, it can be used where intraoral film placement is difficult to achieve.

REFERENCES
1. 2. 3. 4. NewmanME, FriedmanS. Extraoral radiographic technique: An alternative approach. JEndod 2003;29:419-21. IngleJI, BaklandLK, BaumgartnerJC. Ingles Endodontics. 6th ed. USA: PMPH Publisher; 2008. p.554-600. ChenCH, LinSH, ChiuHL, LinYJ, ChenYK, LinLM. An aiming device for an extraoral radiographic technique. JEndod 2007;33:758-60. FisherD. Extraoral radiographic technique of third molars. Aust DentJ 1974;19:306-7.

How to cite this article: Kumar R, Khambete N. Use of extraoral periapical radiography in Indian population: Technique and case reports. Indian J Dent Res 2013;24:271-3. Source of Support: Nil, Conflict of Interest: None declared.

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Indian Journal of Dental Research, 24(2), 2013