Intraoral Radiography: Principles, Techniques

and Error Correction

Gail F. Williamson, RDH, MS
Continuing Education Units: 2 hours

Online Course: www.dentalcare.com/en-US/dental-education/continuing-education/ce137/ce137.aspx

Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or
procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.

Properly prescribed intraoral radiographs are an important component of patient diagnosis and treatment.
Radiographs are especially helpful in the diagnosis of dental caries, periodontal bone loss, periapical
pathosis, and for other observations that may impact patient treatment. It is imperative that dental
professionals are competent in taking intraoral radiographs to ensure diagnostically acceptable images,
while keeping the amount of radiation exposure to patients at a minimum.

Conflicts of Interest Disclosure Statement

The author reports no conflicts of interest associated with this work.

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The Procter & Gamble Company is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying
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or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised December 17, 2014

Overview

The dental radiographer must have a working knowledge of radiographic image receptors and intraoral
techniques. Occasionally, errors will occur which can result in a diagnostically unacceptable radiographic
image. A review of image receptors and the following problem-solving steps can help correct and
subsequently prevent common errors.

Learning Objectives

Upon the completion of this course, the dental professional will be able to:
Describe image receptors used to acquire intraoral radiographic images.
List and describe the principles of accurate image projection.
Identify and describe proper intraoral radiographic techniques.
Discuss patient management strategies to help avoid errors.
Identify and correct radiographic image technique errors.

Course Contents

manufacturer recommendations for proper infection

control procedures for digital receptors.

Overview of Intraoral Image Receptors

Principles of Accurate Image Projection
Intraoral Radiographic Techniques
Patient Management
Technique Errors
Miscellaneous Errors
Conclusion
Course Test Preview
References
About the Author

Rigid digital receptors are categorized as direct

digital receptors and are available in both wired
and wireless formats. These rigid receptors are
usually either a charge-coupled device (CCD)
or complementary metal oxide semiconductor
(CMOS) sensors. The same receptor can be used
for each projection by repositioning the receptor for
the next view after exposure. These direct digital
receptors convert the x-ray beam into an electronic
signal, which is then converted into a digital signal
displayed as a grayscale image and stored in a
computer. The digital image is displayed on the
computer monitor almost immediately.

Overview of Intraoral Image Receptors

Intraoral radiographic images can be acquired with

digital receptors or radiographic film. Digital image
receptors include rigid sensors and phosphor plate
receptors. Intraoral digital receptors are available
in sizes comparable to traditional dental film. Rigid
digital receptors are typically available in sizes 0,
1, and 2 while the plate receptors are available in
sizes 0, 1, 2, 3, and 4. The range of available sizes
is dependent on the specific product manufacturer.
Digital receptors cannot be sterilized. Therefore,
it is important to utilize proper infection control
techniques to prepare and cover digital receptors
for placement inside the mouth. Refer to

Rigid CCD Digital Sensor

Sirona Dental Systems, LLC

Indirect digital receptors known as storage

phosphor plates (SPP) or photostimulable
phosphor plates (PSP) are also available.
These plates have a europium-activated barium
fluorohalide emulsion which stores the latent
image after exposure. Phosphor plates require
careful handling to avoid abrasion of the emulsion
and resultant image artifacts.1 A separate plate is
needed for each projection and the plates must

Digital Phosphor Plate

Air Technique, Inc.

F-Speed Dental Film

Kodak Dental Systems

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be erased with white light before reuse. After the

plate is exposed, the receptor is laser scanned
and the image is digitized and displayed on the
computer monitor. In newer scanner models,
plate erasure occurs after the scanning step but
before exit of the plate from the device.

primary and scatter radiation which not only

benefits the patient but also improves image
quality.4 Because digital receptors are more
sensitive to scatter radiation than film, rectangular
collimation is recommended for use with digital
imaging systems. There are a number of
commercially available devices that the clinician
can utilize to achieve rectangular collimation and
reduce exposure.5 Current digital receptors offer
equal or greater dose reduction than F-speed film
and comparable diagnostic utility.2

Digital images can be adjusted to view the

information in different ways. Software
enhancement features include changes in density,
contrast, colorization, zoom or magnification
of particular areas of interest, measurement,
image reversal and the application of filters for
noise reduction or edge sharpening. Image
enhancement tends to be subjective and is
dependent on the visual preferences of the
clinician interpreting the image.2 Subtraction can
also be performed using digital images. This
is the process used to compare an area before
and subsequent to treatment to assess progress
or change. The computer subtracts the two
images and the image that remains represents
the difference or change between pre- and posttreatment. The challenge with digital subtraction
is the need to register the images prior to
subtraction. The images are seldom identical in
their placement or projection geometry and must
be matched structurally in order to determine the
actual change that occurred between the two
images taken at different points in time.3

The majority of technique and exposure errors

can be produced with digital receptors as
with conventional film with a few exceptions.
The greatest advantage of digital imaging is
elimination of processing errors which are the
most common causes of retakes in film-based
radiography. Digital imaging also eliminates the
darkroom, processor and chemical maintenance
which requires additional time and effort when
done properly, and lengthy processing time.
Regardless of the imaging system employed, the
clinician should take all necessary steps to reduce
the amount of radiation the patient receives in
compliance with the ALARA Principle (As Low
As Reasonably Achievable). Primary to dose
reduction is the application of selection criteria in
the determination of necessary radiographs.4

Principles of Accurate Image Projection

After the image has been obtained, it can

be stored in the computer, printed or sent
electronically in instances of referral or insurance
claims. Digital radiography facilitates storage
and easy access for image viewing, duplication,
printing or electronic transfer. Digital imaging is
an integral part of a complete electronic record
without the need for physical storage space
and fear that the images will be damaged or
destroyed. However, it is important to back-up
patient records daily to avoid lost data. There are
a variety of media that can be used for back-up
storage such external hard drives, CDs, DVD or
cloud technology.

To better understand x-ray imaging, it is helpful

to consider a radiograph as a picture of the
projected image of the teeth and surrounding
structures similar to a photograph. Whether
using rigid or phosphor plate digital receptors or
conventional film, the purpose of the receptor is
to record the projected image or area of interest.
In discussing the principles of accurate image
projection, the source of x-ray photons is the focal
spot on the anode target inside the x-ray tube
within the x-ray head. The principles of accurate
image projection can be summarized as follows:
Principle One: X-rays Should be Emitted from
the Smallest Source of Radiation as Possible.
As electrons strike the focal spot, x-rays are
emitted. The smaller the focal spot is inside the
x-ray tubehead, the greater the detail or resolution
of the resultant image. Manufacturers govern the
size of the focal spot, and it cannot be changed by
the operator. However, the focal spot can become

Digital imaging like film radiography utilizes

x-ray beam collimators to reduce the area of
exposure at the skin surface with a preference
for rectangular collimation and receptor holding
devices to reduce retakes. Rectangular
collimation more so than round reduces both
3

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enlarged over time due to continuous machine

use. When focal spot enlargement does occur, the
resultant radiographic image becomes less sharp.
The focal spot should be monitored through
a quality assurance program. Resolution test
devices will determine any change in the focal spot
size and can indicate when an x-ray head may
need to be replaced. These tests may be part of
state-mandated x-ray machine inspection.

object close to the receptor reduces magnification

and increases image sharpness. The bisecting
angle technique follows this single principle more
so than the paralleling technique. However, the
bisecting angle technique does not conform to the
other principles of accurate image projection. As
a result, it is more prone to shape distortion and is
not recommended as a primary technique. Shape
distortion is defined as deviation from the true
shape of the object.

Principle Two: The X-ray Source-to-Object

Distance Should be as Long as Possible.
The x-ray source-to-object distance refers to the
distance between the focal spot and the object
to be recorded. The use of a long open-ended
position indicating device (PID or cone) will
enable the x-ray photons to emerge in a straighter
line therefore producing a more dimensionally
accurate image. The straighter the x-ray photon
line, the less divergent the x-ray beam. The
resultant image will be a sharper, more accurate
representation of the structures being radiographed
and demonstrate less image magnification.

Principle Four: The Receptor and Long Axis of

the Tooth Should be Parallel to Each Other.
When the receptor and the long axis of the tooth
are parallel (as in the paralleling technique), the
distortion of the radiographic image is decreased.
Receptor to structure parallelism improves
anatomic accuracy and reduces shape distortion.

Principle Three: The Object-to-Receptor

Distance Should be as Short as Possible.
The object in this principle refers to the tooth
or structures being radiographed. Placing the

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Intraoral Radiographic Techniques

Principle Five: The X-ray Beam Should be

Directed Perpendicular to the Tooth and
Receptor.
The x-ray beam must be directed perpendicular
or at a right angle to the long axis of the tooth,
which ideally is also perpendicular to the receptor.
When this principle is not followed, an error in
vertical angulation or length is seen, and the
resultant image will appear either foreshortened
(shorter than the actual object) or elongated
(longer than the actual object). Right angle entry
of the x-ray beam improves anatomic accuracy
and reduces shape distortion.

Prior to presenting technique errors and the

means to correct them, a clear understanding
of technique must be established. Although
the bisecting angle technique is still utilized and
may be necessary in certain circumstances, the
paralleling technique is the method of choice
for intraoral radiography. However, the use of
bisecting angle technique remains relevant due
to the increasing use of rigid digital receptors for
intraoral radiography. Rigid digital receptors are
more difficult to place comfortably in the mouth
particularly in children and the posterior regions
of the mouth in adults.6-9 The use of rigid digital
receptors produces more retakes due to technical
errors than phosphor plate receptors or film.10 A
good understanding of bisecting angle technique
is necessary to correct dimensional errors
associated with placement difficulties as well as
instances when occlusal techniques are utilized
for intraoral radiographic imaging particularly with
rigid digital receptors.
Paralleling Technique
As previously discussed, the paralleling technique
is the most accurate intraoral radiographic
technique, meeting four of the five principles
of accurate image projection. The paralleling
technique does not allow for as short as possible
object-to-receptor distance (Principle Three) as
desired. In order to achieve parallelism, it is
necessary to place the receptor more lingual to the
structures. The use of receptor-holding devices
helps to standardize and execute this technique.

These same principles of accurate image

projection can be demonstrated by using a
flashlight and projecting the shadow of an object
onto a wall in a dark room. Completing this simple
exercise may help the novice radiographer to
better understand how to apply these principles
and their role in producing an accurate image.
Also, it provides insight into how and why technical
errors occur when the principles are violated.

The paralleling technique is accomplished by

placing the receptor parallel to the long axis of
the tooth. After this parallel relationship has been
established, the central ray must be directed
perpendicular to both the tooth and receptor.
Because the receptor cannot always be placed as
close as possible to the tooth due to the receptorholding device or anatomical obstacles, image
magnification may occur. However, this can be
compensated for by using an increased sourceobject distance, which decreases magnification
and unsharpness. The paralleling technique,
when performed correctly, is superior to the
bisecting angle technique by producing an image
with both linear and dimensional accuracy.

The "perfect" radiographic technique incorporates

all five principles of accurate image projection
simultaneously. Unfortunately, an ideal technique
which meets all the requirements for accurate
image projection has not been found. However,
the paralleling technique which typically utilizes
receptor-holding devices is the preferred intraoral
technique because it follows most of the principles
of accurate image projection listed above.

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Bisecting Angle Technique

The bisecting angle technique is accomplished
by placing the receptor as close to the tooth as
possible. The central ray of the x-ray beam should
be directed perpendicular to an imaginary line that
bisects or divides the angle formed by the long
axis of the tooth and the plane of the receptor.
Principle Three of accurate image projection is met
by using this technique.

Bitewing Technique
The bitewing radiographic image is used to
examine the interproximal surfaces of the teeth
and is particularly useful for the detection of dental
caries and alveolar bone levels. The receptor is
placed into the mouth parallel to the crowns of
the maxillary and mandibular posterior teeth. The
patient stabilizes the receptor by biting on a tab
or bitewing holder. The central ray of the x-ray
beam is then directed through the contacts of the
posterior teeth and at a +5 to +10 vertical angle.

Images produced by the bisecting angle method

are in true linear relationship. However, this
technique does not follow several of the principles
of accurate image projection and also requires
accurate visualization of the bisected angle in
order to accomplish it properly. Bisecting angle
images are not anatomically accurate and are
prone to shape distortion. However, the bisecting
angle provides an alternative technique when
parallel placement cannot be achieved or occlusal
techniques are employed.

Receptor-holding devices or bitewing tabs may

be used to stabilize the receptor in the mouth.
Receptors may be positioned in the horizontal or
vertical dimension with this technique, depending
upon the area to be examined. Bitewings may be
taken in the anterior segments of the dentition as
well. Some dentists, particularly periodontists, may
prescribe a 7 image bitewing survey consisting
of 4 vertical bitewings in the posterior with size 2
receptors and 3 vertical bitewings in the anterior
using size 1 receptors. This permits evaluation for
both alveolar bone loss and caries detection.

Patient Management

Correctly exposing intraoral receptors includes

four basic steps: receptor placement, vertical PID
(cone) angulation alignment, horizontal PID (cone)
angulation alignment, and central ray centering.
Technique errors can occur if any of these
procedures are completed improperly.
Patient Preparation Errors
Dental professionals should always explain the
radiographic procedure to the patient and give
clear instructions as to what the patient can do to

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Gagging/Swallowing
The gag reflex is a protective mechanism of the
body that serves to clear the airway of obstruction.
All patients have gag reflexes, some more sensitive
than others. The gag reflex can be stimulated
when the receptor contacts the soft palate, base
of the tongue, or the posterior wall of the pharynx.
When exposing a full mouth survey of radiographic
images, it is recommended to begin in the anterior
region of the mouth. An anterior placement is
less likely to stimulate the gag reflex and will also
help the patient become more accustomed and
comfortable with the procedure.

help ensure a quality image, avoid retakes and

reduce radiation exposure. The most common
error in this category is movement. Factors
causing a patient to move include:
discomfort
unsupported head position
gagging and/or swallowing
patient disability
Discomfort
Discomfort can be addressed by gentle, proper
receptor placement, instructing the patient to close
slowly, and the use of cushioned edges which can
be attached to the receptor. Receptors placed
more toward the midline of the palate and toward
the tongue on the mandible will make placement
more comfortable for the patient. Bending, folding
or creasing film or a digital phosphor plate receptor
will produce artifacts that may compromise the
diagnostic quality of the radiographic image.

To ensure a quick and smooth patient experience,

prepare all equipment before the receptor is placed
inside the mouth. The exposure settings should
be set in advance, and the tubehead should be
placed in the approximate area of exposure. It
may help to encourage the patient to swallow once
before the placement of the receptor. The patient
can be instructed to release the biting pressure
or remove the receptor as soon as the exposure
is complete. Other recommended procedures to
control gagging include deep breathing through
the nose or mouth, anesthetizing the mouth with
lozenges, mouthwash, topical anesthetic agents,
or refocusing the patient's attention.11 Distraction
techniques such as instructing the patient to
raise one leg, bend the toes toward the body,
etc. will focus attention on the task rather than on
gagging. When a patient begins to gag, remove
the receptor, be confident and reassuring, and
try again. A panoramic radiographic image may
be a useful supplement to intraoral radiographs

Head Support
The headrest on the dental chair should be
placed against the occipital lobe at the base of
the back of the head. This will support the head
during radiographic procedures and reduce the
chance of movement. Proper headrest placement
positions the occlusal plane parallel to the floor
and the midsagittal plane perpendicular to the
floor for maxillary periapicals and bitewings. It is
helpful to readjust the head to raise the patients
chin up slightly for mandibular periapicals. This
improves visibility into the floor of the mouth for
receptor placement and keeps the floor of the
mouth more relaxed.

Edge Ease and Slip Ease , Strong Dental Products, Crosstex International

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when the molar areas are extremely difficult for the

patient to tolerate or for the clinician to obtain.

Missing apices can be caused by a receptor

placement error. When using receptor holders,
the biteblock should be placed on the teeth to be
exposed and not on the opposing teeth. If the
biteblock is placed on the opposing teeth and the
patient is required to bite the receptor into place,
a placement error is likely to result. Placing the
receptor more lingual to the teeth where the palate
and floor are deeper will make placement easier
and more comfortable for the patient. Placement
of the biteblock and receptor in the correct position
first and then having the patient slowing bite to
maintain the placement is the preferred and most
effective approach.

Patient Disability
Some patients may need assistance during the
radiographic procedure due to physical or cognitive
disability, injury or medical condition. In such
circumstances, it may be necessary to ask a family
member or guardian to assist in holding the patient
in position. Shielding should be provided for both
the patient and person providing the assistance.
The clinician must consider what technique
would work best in the situation. For instance,
a patient with Parkinsons disease can better
tolerate intraoral radiographs which have short
exposure times rather than a panoramic image
which requires a sustained still position and longer
exposure cycle. Familiarity with the bisecting
angle and occlusal techniques may be useful in
situations that are less than ideal and require
alternative approaches to imaging.

Backward Placement
Placing the film backwards in the mouth causes
the lead foil inside the packet to face the radiation
source instead of the film. The x-ray beam is
attenuated by the lead foil before striking the film.
This causes the embossed pattern on the foil, a

Technique Errors
Receptor Placement Errors
Inadequate Coverage/Missing Apices
A common receptor placement error is
inadequate coverage of the area to be examined
radiographically. This typically occurs in molar
projections when the patient has difficulty maintaining
proper receptor placement. Each periapical and
bitewing in a complete survey has established criteria
which describes the structures of interest that should
be recorded on each view. Consistent application of
these criteria will minimize this error.

Backward receptor image

Non-exposure side of receptors on the top row with exposure side on the
bottom row.

Rigid CCD Digital Sensor

Sirona Dental Systems, LLC

F-Speed Dental Film

Kodak Dental Systems

Digital Phosphor Plate

Air Technique, Inc.

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herringbone or diamond effect, to appear on the

processed film. This error also results in a lighter
image and confusion about the correct anatomical
area recorded when mounting the processed
film. This error is also possible with phosphor
plate receptors. In either instance, attention to
the orientation of the receptor inside the mouth
is critical for diagnostic results and avoidance of
diagnostic errors.

Rigid digital receptors cannot be bent but as

previously indicated phosphor plate receptors can
be creased, bent, scratched or folded. These
alterations result in permanent damage of the
plate and produce artifacts on the current and
any subsequent image.1 Damaged plates should
be replaced when the artifacts interfere with the
production of diagnostic images. Tissue cushions
are better alternatives than bending or creasing a
plate or film receptor.

Backwards placement is less likely with rigid digital

receptors because of the wire attachment on the
non-exposure side of the sensor. The exposure
side of any receptor must be directed toward the
x-ray source to produce an acceptable image.

Tilted Occlusal Plane

When the receptor is not placed perpendicular
to the occlusal plane, the occlusal plane will
appear slanted or diagonal. When exposing
bitewing radiographs, the top edge of the receptor
may come in contact with the palatal gingiva or
curvature of the palate. When this occurs, the
occlusal plane will appear crooked. The receptor
must be placed straight or perpendicular with
the occlusal plane, or placed farther away from
the teeth to avoid this error. Always place the
biteblock in contact with the occlusal or incisal
surfaces of the teeth you are imaging not on
the opposing teeth. Placement on the opposing
teeth will cause the receptor to displace when it
contacts bony anatomy. Preferably, the receptor
orientation dot should be placed toward the
crowns of the teeth for periapical images and
toward the mandible for bitewing images to
reduce interference with viewing structures of
interest on the recorded image.

Bending
Plate or film bending may occur due to contact
with the curvature of the palate or lingual arch
and/or mishandling of receptors. These receptors
can be flexed but should never be bent. If the
receptor is too large for the area, bending can also
occur. Select a receptor size that will adequately
cover the area without producing excessive
discomfort to the patient. Crimping, creasing
or folding a plate or film receptor damages
the emulsion and compromises the quality of
the image. Careful handling, use of a smaller
receptor, and correct placement will address the
problems of bending and image artifacts.

Tilted Occlusal Plane

Receptor bending

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Vertical Alignment Errors

When using the paralleling technique and
receptor holders, the vertical angulation is
dictated by the holding device to enable the x-ray
beam to be perpendicular to both the receptor
and teeth. Therefore, it is important that the
clinician place the receptor parallel to the teeth
to ensure proper vertical angulation. In contrast,
when using the bisecting angle technique, the
beam is perpendicular to the plane that bisects
or divides the angle formed by the teeth and the
receptor. Vertical alignment errors often occur
with the bisecting angle technique and can result
in elongation or foreshortening of the teeth.
Other errors which can occur causing teeth to
appear elongated or foreshortened include:
receptor position
patient position

elongation occurs using the paralleling technique,

the angulation of the x-ray beam is less than the
long axis plane of the teeth. To correct this error
the operator must increase the vertical angulation.
In other words, for the maxillary arch, the positive
angulation must be increased (PID pointing down);
for the mandibular arch, the negative angulation
must be increased (PID pointing up).
This error can also occur when using the
bisecting angle technique. Often the error is
caused by the x-ray beam being perpendicular to
the long axis of the teeth, rather than bisecting
the angle between the teeth and the receptor.
Foreshortening
Foreshortening or shortening of the teeth and
surrounding structures can also result from
improper vertical angulation. Foreshortening is
the result of overangulation of the x-ray beam.
When foreshortening occurs when using the
paralleling technique, the angulation of the x-ray
beam is greater than the long axis plane of the
teeth. To correct foreshortening when using
the paralleling technique, the operator should

It is important to determine the cause of the error.

Elongation
Elongation or lengthening of the teeth
and surrounding structures results from
underangulation of the x-ray beam. When

Receptor Angular

Elongation

Foreshortened

Receptor Angular

Beam Under-Angulated

Beam Over-Angulated

10

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decrease the positive vertical angulation for

maxillary projections, and decrease the negative
vertical for mandibular projections. This error can
also occur if the receptor is not placed parallel to
the long axis of the teeth.

central ray must pass through the teeth where the

contacts need to be open.
When using receptor holding devices, horizontal
errors can occur by improper horizontal alignment
of the receptor. These errors can be avoided by
placing the receptor relationship in alignment with
the teeth so that the x-ray beam travels directly
through the contact areas. This will place the
receptor parallel to the buccal plane of the teeth
of interest as well as the parallel to the instrument
indicator ring.

Horizontal Alignment Errors

Proper horizontal alignment of the x-ray beam
will open interproximal contacts and facilitate
a thorough caries evaluation and assessment
of bone levels, which are all components of a
thorough clinical and radiographic examination.
The x-ray beam should be aimed directly between
the targeted teeth in order to open interproximal
surfaces. Horizontal alignment errors cause the
image to shift anteriorly or posteriorly, resulting in
the overlapping of the interproximal surfaces.

Beam Centering Errors

The central ray should be aligned over the
center of the receptor with the x-ray beam
directed perpendicular to the receptor. When this
alignment is not observed, a cone-cut occurs.
Cone-cuts appear as a clear zone on traditional
radiographs after processing, due to the lack
of x-ray exposure in the area of the cut. When
using digital imaging, the cone-cut appears as
an opaque or white area. The shape of the
cone-cut depends on the type of collimator used
when exposing the receptor. For example, if a

To determine if the horizontal angulation is

positioned incorrectly, evaluate the extent of
the overlap. The Buccal Object Rule can be
used to determine the movement buccal and
lingual cusps when trying to define the error.
The Buccal Object Rule states: Buccal objects
move in the opposite direction compared to the
direction of the x-ray tubehead while lingual
objects move in the same direction as the
movement of the x-ray tubehead.12 Application of
the Buccal Object Rule to determine the cause
of interproximal overlapping requires evaluation
of the position of the x-ray tubehead and the
direction of the overlapping on the bitewing
image. For example, if the x-ray head is placed
too posterior in position, the buccal cusps will
overlap in an anterior direction as demonstrated
in the molar bitewing image illustration. By way
of comparison, if the x-ray head is placed too
anterior in position, the buccal cusps with overlap
in a posterior direction. To avoid this error, the

Cone-Cutting

Horizontal Overlapping

11

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round collimator is used, a curved cone-cut will

appear. Square cone-cuts occur when using a
rectangular collimator. To correct a cone-cut error,
the beam should be re-centered toward the area
of non-exposure. Improper assembly of receptor
holding devices can also cause cone-cuts. When
assembling these devices, make certain that the
entire receptor can be seen while looking through
the indicator ring.

also be caused by an increase in the sourceobject distance, or not placing the tubehead close
enough to the patient's face during exposure.
Exposure times are prescribed on the assumption
that the tubehead is no more than 2 centimeters
away from the face of the patient. Receptors
can be underexposed if the exposure switch is
not activated for the indicated or correct length
of time. In other words, the clinician let go of the
exposure button too soon. Overexposure results
in a high-density or dark image. The causes
include improper exposure factor settings or
improper assessment of patient size and stature.

Miscellaneous Errors
Exposure Errors

When using digital image receptors, the density

can be adjusted by specific enhancement features
of the computer software program. However,
images that are too light or low in density make
it difficult to visualize the differences in structures
and typically cannot be improved by software
adjustments.3 Digital images that are dark or high
in density can usually be salvaged by software
adjustments in density unless the image appears
totally black.3 This adjustment in density should
be accomplished prior to printing or archiving
the image. Extreme under or overexposure by
necessity will result in retakes, thus exposing the
patient to unnecessary radiation.

Time Setting
Incorrect exposure can be caused by many factors;
the most common being improper exposure factor
settings. Improper time selection is the most likely
error, because most intraoral x-ray units have
fixed or unchangeable milliamperage (mA) and
kilovoltage (kVp) settings. Time and milliamperage
control density or the overall darkness of an image
while kilovoltage controls contrast or the differences
in darkness. The exposure time settings should
be based on the receptor speed, the area being
exposed, and patient size and stature. Every
treatment room should have an exposure factor
chart to guide the operator in selecting the
appropriate kVp, mA and time settings for each
periapical and bitewing. Refer to the recommended
manufacturer settings for specific intraoral views or
projections. Generally speaking, the recommended
time setting for each area is based on the size of
an average adult patient.

Double Exposure
Double exposure results when the receptor
is exposed twice and two images appear
superimposed onto each other. This error results
in two errors; one receptor that was doubleexposed and another that was not exposed. It is
extremely important to avoid this error because it
exposes the patient to radiation twice. To avoid

Improper exposure time settings can also result from

an inaccurate evaluation of patient size and stature.
The operator should use longer times for largerthan-average patients and shorter times for smallerthan-average patients. Usually one step up for large
patients and one step down for small patients will
be adequate adjustment for each periapical and/
or bitewing. Failing to adjust exposure time will
result in images that are either too light or too dark.
Generally speaking child exposure time settings are
lower than adult exposure time settings because of
the childs smaller size.
Under/Over Exposure
Underexposed receptors result in images that
are too light or low in density. Light images can

Double exposure

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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised December 17, 2014

this error, maintain an organized work space in

which exposed receptors are placed in one area or
turned over to separate from unexposed receptors.

Eyeglass frames or stems may appear in maxillary

periapical radiographs of patients with large
eyeglasses and/or when extreme vertical angulation
is utilized. Glasses should be removed prior to
radiographic procedures. Facial jewelry in the path
of the x-ray beam should be removed as well to
avoid unwanted artifacts and unnecessary retakes.

Double exposure of rigid digital receptors is not

possible but phosphor plate receptors can be
double-exposed just like film.

Thyroid collars or lead aprons can also be

recorded on radiographic images. This is normally
caused by the collar being placed on too loosely
or too high on the neck or when the vertical
angulation is so steep that the collar is in the path
of the x-ray beam.

Poor Image Definition

Poor image definition or resolution can be the
result of patient movement, receptor movement,
and/or vibration of the x-ray tubehead. Movement
has been discussed previously. Receptor
movement may occur when the receptor is not
properly stabilized in the mouth or when the
patient moves the receptor because it feels
uncomfortable.

Another technical error that occurs occasionally

is when the receptor yields no image. This error
can be caused by mechanical problems such as
electrical failure, faulty generator, timer inaccuracy
or faulty exposure switch. Failure to turn on the

To help prevent tubehead vibration or drifting,

place the arm against the wall with the tubehead
pointing down after each use. When the arm is
fully extended for long periods of time, the joints
can become weakened and fatigued, resulting
in drifting and vibration. Tubeheads and arms
should be professionally serviced if drifting and
movement persist.
Miscellaneous Objects
When a removable prosthesis is left in the mouth
during exposure, a superimposed image of the
appliance will appear over the teeth. Prior to
radiographic procedures, ask patients to take
out all removable items from the mouth, such as
retainers, partial dentures, complete dentures, etc.

Thyroid collar

Nose Ring

Partial

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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised December 17, 2014

machine, placement of the receptor between the

cheek and teeth, failure to line-up the x-ray beam
and backward placement of digital receptors
can also produce a blank or white image
representative of this error.

ensure the production of high-quality diagnostic

images, the clinician must attend to the principles
of accurate image projection when acquiring
intraoral radiographic images. In addition, the
clinician must be able to manage the patient
effectively during radiographic procedures and
be well-versed in the identification and correction
of errors when they occur. The clinician is also
responsible for eliminating unnecessary retakes
and minimizing radiation exposure to the patients
under their care.

Conclusion

Intraoral radiographic imaging is an invaluable

tool for proper patient care providing critical
information for the diagnosis and treatment of
dental disease and other oral conditions. To

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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised December 17, 2014

Course Test Preview

To receive Continuing Education credit for this course, you must complete the online test. Please go to:
www.dentalcare.com/en-US/dental-education/continuing-education/ce137/ce137-test.aspx
1.

Unlike conventional dental film, digital receptors can be sterilized prior to use inside the
patients mouth.
a. True
b. False

2.

Which of the following is NOT an advantage of digital radiography?

3.

Each of the following is a type of digital receptor except one. Which is the exception?

4.

Which of the following are advantages of using a long position-indicating device (PID)?

5.

Which Principles of Accurate Image Projection are met by the paralleling technique?

6.

Each of the following are descriptive of the paralleling technique except one. Which one is
the exception?

a.
b.
c.
d.
e.
a.
b.
c.
d.
e.
a.
b.
c.
d.
e.
a.
b.
c.
d.
e.

a.
b.
c.
d.
e.

7.

Technical image errors are eliminated.

Images can be enhanced and viewed in different ways.
Subtraction can be used to compare pre and post treatment.
Equal or greater dose reduction can be achieved compared to intraoral film.
Image can be viewed almost immediately on the computer monitor.
PID
CCD
PSP
SPP
CMOS

Enables the x-ray photons to emerge in a straighter line.

Aids in producing a more accurate image.
Reduces magnification of the image.
Improves sharpness of the image.
All of the above.
Principles
Principles
Principles
Principles
Principles

1,
3,
2,
1,
1,

2,
4,
3,
2,
2,

3
5
4, 5
4, 5
3, 4, 5

Allows placement of the receptor in contact with the structures.

Radiographs are easier to standardize with paralleling technique.
Technique is easier to execute than the bisecting angle technique.
Produces more accurate images than the bisecting angle technique.
Directs the x-ray beam at a right angle to the structures and the receptor.

The factor that would most likely be increased when taking radiographs on larger than
average patients is:
a.
b.
c.
d.
e.

mA
kVp
Time
Distance
Filtration

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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised December 17, 2014

8.

The error present in the molar bitewing radiograph would be identified as:

a.
b.
c.
d.
e.

Horizontal overlap
Underexposure
Elongation
Cone-cutting
Film bending

9.

A cone-cut is the result of improper:

10.

Identify the error present on this radiograph:

a.
b.
c.
d.
e.

a.
b.
c.
d.
e.

11.

Vertical angulation
X-ray beam centering
Horizontal angulation
Patient instruction
Backward placement

Foreshortening
Patient preparation
Double exposure
Overlapping
Cone-cut

Foreshortening and elongation errors can be caused by:

a.
b.
c.
d.
e.

Receptor position
Vertical alignment
Horizontal alignment
A and B
B and C

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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised December 17, 2014

12.

The error present in this periapical image is due to:

a.
b.
c.
d.
e.

13.

14.

To correct the error observed in question #12, the clinician would:

a.
b.
c.
d.
e.

Increase vertical angulation.

Decrease vertical angulation.
Instruct the patient to sit very still.
Realign the horizontal beam placement.
Reposition the receptor more mesially.

The error demonstrated on this radiograph is the result of:

a.
b.
c.
d.
e.

15.

Horizontal beam angulation

Vertical beam angulation
Patient movement
Improper exposure
Processing error

Improper vertical angulation

Incorrect receptor placement
Partial denture left in place
Overexposure to x-rays
Patient movement

When choosing the time for radiographic exposure, which of the following should be taken
into consideration?
a.
b.
c.
d.
e.

Receptor speed
Projection being taken
Patient size and stature
Child or adult patient
All of the above.

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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised December 17, 2014

References

1. Bedard A, Davis TD, Angelopoulos, C. Storage phosphor plates: How durable are they as a digital
dental radiographic system? J Contemp Dent Pract 2004;5:057-69.
2. White SC, Pharoah MJ: Oral Radiology: Principles and Interpretation, 6th Ed. St. Louis: Mosby 2009.
3. Parks ET and Williamson GF: Digital Radiography: An Overview. J Contem Dent Prac 2002,
November;(3)4:023-039.
4. American Dental Association Council on Scientific Affairs, US Department of Health and Human
Services, Public Health Service, Food and Drug Administration: Dental radiographic examinations:
Recommendations for patient selection and limiting radiation exposure. Revised: 2012. Retrieved
August 8, 2014.
5. Zhang W, Abramovitch K, Thames W, et al. Comparison of the efficacy and technical accuracy
of different rectangular collimators for intraoral radiography. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2009;108:e22-e28.
6. Versteeg CH, Sanderink GCH, Ginkel FC, van der Stelt PF. An evaluation of periapical radiography
with a charge-coupled device. Dentomaxillofac Radiol 1998;27:97-101.
7. Bahrami G, Hagstrom C, Wenzel A. Bitewing examination with four digital receptors.
Dentomaxillofac Radiol. 2003 Sep;32(5):317-21.
8. Sommers TM, Mauriello SM, Ludlow JB, et al. Pre-clinical performance comparing film and CCDbased systems. J Dent Hyg. 2002 Winter;76(1):26-33.
9. Matzen LH, Christensen J, Wenzel A. Patient discomfort and retakes in periapical examination of
mandibular third molars using digital receptors. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2009;107:566-572.
10. Wenzel A, Mystad A. Work flow with digital intraoral radiography: A systematic review. Acata
Oncologica Scand. 2010 Mar;68:106-14.
11. Iannucci JM, Howerton LJ. Radiation biology. Dental Radiography Principles and Techniques,
4th Ed, St. Louis: Elsevier, 2012.
12. Miles DA, Van Dis ML, Williamson GF, Jensen CW: Radiographic Imaging for the Dental Team.
4th Ed. St. Louis, Saunders, 2009:139-52.

About the Author

Gail F. Williamson, RDH, MS
Professor
Department of Oral Pathology, Medicine & Radiology
Indiana University School of Dentistry
Gail Williamson received an AS in Dental Hygiene, a BS in Allied Health and a
MS in Education from Indiana University. A veteran teacher, Prof. Williamson has
received numerous awards for teaching excellence during her academic career. She
is a published author and presents continuing education courses on topics in Oral and Maxillofacial
Radiology nationally.
Email: [email protected]

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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised December 17, 2014