Radiology and Radiography for Students – PS011

Protrusive Dental Podcast

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25d ago 42:36

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What’s the difference between radiolucency and burnout?

When’s the best time to use a bitewing vs a periapical radiograph?

When should we pick up the bur for interproximal caries?

Have you heard about the 4 white lines an OPG radiograph?

https://youtu.be/wCV3U8-OAvI

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This episode is packed full of great tips and techniques that will help you understand how to produce great radiographs as well as being able to properly figure out what they are trying to tell us. Radiographs can be tricky, whether that’s due to them being flipped, upside down or due to cone cut, that’s why this will help shine some light on how to get comfortable with radiographs as well as how to manage our patients after we know what we are dealing with.

Need to Read it? Check out the Full Episode Transcript below!

Don’t miss the special notes on Radiology and Radiography for Students available exclusively in the Protrusive Guidance app! (Join the free Students Section)

This episode is not eligible for CPD/CE points, but never fear, there are hundreds of hours of CPD for Dentists waiting for you on the Protrusive App!

For the full educational experience, our Ultimate Education Plan gives you access to all our courses, webinars, and exclusive monthly content.

If you love this episode, check out PS003 – Routine Checkup

Click below for full episode transcript:

Teaser: This episode is the bare basics of radiography and radiology, i.e. the taking of the radiograph and the interpretation. How do you really know if that radiolucency you see is cervical burnout or is it actually caries? What are the four white lines on an OPG radiograph and why are they important? And why you should be really careful with radiographic interpretation? And it's really important to marry the clinical picture, because that's how you come up with a clinical diagnosis.

[Jaz]
Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. This is for young dentists, students, but a lot of qualified dentists have been really enjoying this basic series, this Protrusive Student series.

And so what we’re going to do from the next episode is we’re going to make it CE eligible. The next episode is actually on basics of extraction, but before we do that extraction, we need a radiograph. And it’s a topic that you guys asked for on the YouTube comments. So there we have it. And remember, if you are a dental student, make a free Protrusive account.

Go to protrusive.app and then email your username or your name on the platform to student@protrusive.co.uk. And you’re going to get access to a secret area, which has a bit more of the premium goodies inside. Every PS episode, we have some student notes to provide you as well, made by Emma Hutchison, our Protrusive student. And the ones today are all about radiography and radiology. Hope you enjoyed the main episode, I’ll catch you in the outro.

Main Episode:
Emma Hutchison, our Protrusive Student. Welcome back to the student’s edition of the podcast. I know you’ve got exam results coming up and you’re going on your elective soon. How exciting.

[Emma]
Yes, very exciting. So I’m just finishing up the last bits and bobs of my elective project and then I’m going traveling for two months. So, I should also get my exam results next week sometime when I’ll be away. So, hopefully everything’s good.

[Jaz]
We’re all rooting for you. We know, you know, fingers crossed you’ll do well and you’ll report back to us. If anyone in Asia is a dental student or a dentist, and you happen to see Emma walking in a mall, an air conditioned mall, take a selfie with her and tag us on Protrusive. Let’s see if this social experiment works. Let’s see how much we’re spending. That’d be cool, right?

[Emma]
Yeah, it would have to be an air-conditioned place because I’m from Scotland, so I’m not going to do well with the heat over there at all.

[Jaz]
Excellent. Well, today’s chat and the subsequent protrusive notes which will go on the Protrusive Student Section at of Protrusive Guidance, which is our app, our community, is about radiology and radiography, right? And before we go further, I kind of have like to put a disclaimer and a lot of the Protruserati are used to me using this disclaimer now and again.

There are some things that I teach and there are just a small part of dentistry. Most of dentistry, that I do, I share. I don’t teach, I share, because to be honest with you, I’m not in a position to teach that kind of stuff, but I’m there to share my own experiences, and there’s some that my unknown unknowns I’m always just seeking to learn more and more and more.

So when it comes to radiology and radiography, I’m sharing, and what I have on you, Emma, is I’ve got like, 13, 14 years of experience over you. And that’s why I have to offer you in terms of the kind of things that used to bother me when I was a student. But I want to just say that take everything with a pinch of salt what I’m saying, because I’m trying my best to guide you and students and young dentists listening, but I’m not the radiology expert here. So it’ll be just to unpack the experience that I have.

[Emma]
Yeah, not a problem. Not a problem. I think in dentistry, there’s always so many opinions and everyone has so many different experiences. So everyone will have an opinion, everyone will think differently, this, that and the next thing. So yeah, we’re all just learning. So.

[Jaz]
Well said. Well said. So come at me, Emma. What have you got?

[Emma]
So first question, I’m going to say. For yourself, Jaz, we’re always taught to be really methodical. Let’s say you’ve got a pair of bite wings there. What are your essential steps in reading and interpreting dental radiographs? Like, what should students look for?

What does your method look like? Because it can be really overwhelming, especially in an exam. I was faced with full mouth peri-apicals, and it was just questions, boom, boom, boom, boom, boom. And you just had to be really methodical. But what does that look like for you?

[Jaz]
Great question. I think I’m a big believer in checklists when it comes to radiographs. So first thing to do is make sure it’s rotated and flipped correctly. The right way, like usually I don’t have to flip it, but make sure it is correct and it’s orientated correctly. The next thing to check for is that is it good enough quality doesn’t need repeating and you’d hope that 95 percent plus a time it’s acceptable quality.

So you have to grade your radiograph. So it used to be like grade one, two, three. Now it’s like A or N. So it’s either acceptable or not acceptable. And you have to obviously justify in your notes the reason for taking a radiograph. So Emma, what would be the typical reason to justify a bite wing from what you’ve learned?

[Emma]
Caries and bone levels, perhaps?

[Jaz]
Yeah. And specifically, it’s interproximal caries, right?

[Emma]
Interproximal caries, yeah.

[Jaz]
What I say to my patients is that, I need to take these x rays because there are bits of teeth that I can’t see. I can’t see between the teeth. This is where x rays help me. And so it’s very important when writing the justification.

It’s interproximal caries. And so really interesting point. Early on in practice, you just get into a rhythm of doing things and you need to start questioning why we do certain things. Why do we take this bite registration? Why do we do a certain stage in dentures? And so, I remember being a newly qualified dentist and just, oh okay this patient hasn’t had bite wings in like three years, let’s take some bite wings.

And you take a bite wing and you see that actually this patient has like every other tooth missing and no history of periodontal disease. So if I can see the interproximal surfaces, why did I just take this bite wing? You see what I mean? So you really have to think critically and I’ll share a, I guess an honest mistake I made recently.

Okay, I’ll share an honest mistake. I know this is deviating a little bit, but I think it’s really nice to learn from the failures and mistakes of others. Had this really nice gentleman who has had an issue whereby the wisdom tooth was causing decay in the second molar. So low wisdom tooth impacted, that wisdom tooth was removed.

Okay, and the decay seemed minimal and it was really deep down. It was like covered by the gum. So I thought, okay, maybe we can just safely monitor this. When we came around to the interval of taking bite wings. Okay, I did not capture the distal of that second molar.

[Emma]
Right. Okay.

[Jaz]
Didn’t capture it. And so lo and behold, he came in an emergency and he had pain from that tooth and there was a much, much bigger caries than what we initially had some years ago. And so it’s really important that, yes, we want to see the interproximals, but we have to tailor it to the individual. If we know that actually someone’s not got any restorations or no historical caries, or you’re not watching the premolars, then maybe in that patient, the distal of the second molar for those patients is more important.

And sometimes you can’t capture everything. So it’s important to tailor it to that individual. Going back to what you asked, though, in terms of the checklist and actually being systematic about it, totally the right word is systematic here. So what I would do is once I’ve made sure everything’s correct and orientated and acceptable quality, I will always just start with the bone levels.

I’m having a look at bone levels and I’m reporting on that. So I’m doing as a percentage bone loss, although. Arguably, you need a PA to see a percentage because you can’t see the whole root. But you can kind of guesstimate. We know average how long teeth are. So it’s not like a mild bone loss, moderate or severe bone loss.

And then I’m looking at the interproximal surfaces where they touch very, very carefully. It might be changing the contrast. And what we do in practice, actually, is we have this code that we use on the charting. So you guys are probably, are you guys computerized? Are you guys like paper notes?

[Emma]
We’re still paper notes, yeah.

[Jaz]
Okay. So what we do is on the computer, like do from previous bite wings stuff. If we know it’s like a little radiolucency, we’re going to mark on the chart, on the digital chart, a WB. WB stands for watch bite wing. That means we’re watching this area on bite wings. So as well as clinically, we’re checking on bite wings.

So I will have a look at my chart on one screen. I say, hmm, there was a watch bite wing place in 2017 on the distal of the upper left second molar. Let me have a look now. And often it’s nice to compare old radiographs. to see any changes and that’s really important stuff. So maybe I’ll have the left bite wing from a few years ago and left bite wing now and I’ll just compare the bone levels and I’ll compare any watch bite wings, any changes.

I’m then looking at the restorations and any sort of radiolucencies or any ledges or all the issues with restoration. So starting with the bone, then the heart structures and I would report on those.

[Emma]
Okay. Yeah. So just your checklist, like you were saying, I know for me when I’m in clinic and I’m doing a radiographic report, I have everything written down, like, teeth present, restorations present, boom, boom, boom, and just keep yourself right in that respect. I think that’s a very important thing to do.

[Jaz]
In the real world, like, to write teeth present, I just feel it’s very laborious, right?

[Emma]
Yeah, yeah.

[Jaz]
So we’ve got the chart already, right? I’m looking more for, like we did the routine checkup episode we did, and we added the video. I don’t know, did you watch that video, Emma, of the routine checkup I did, yeah?

[Emma]
Yes, yes, I have done, yeah.

[Jaz]
Was it useful?

[Emma]
Yeah, I think it was. I think it’s always useful to see other people’s methods and how they go through things, et cetera. I think it’s definitely-

[Jaz]
Even some dentists have messaged on there saying, well, you know what Jaz, I’ve been a dentist for so many years and it was just nice to see some validation routine, check up how you do things. So that was good. So in that one, you’ll see that I’m comparing previous radiographs and we know we have the charting already. So I just feel like in a time efficiency, when I’m doing a report, I’m not reporting on all the teeth present. That goes without saying, but I know at your stage, that’s what you’re expected to do because you’re learning the bare foundations.

But in the real world, I don’t report on all the teeth present. It’s like, okay, teeth present as expected. Okay, I’m just looking for, okay, good bone levels and no obvious caries. And then I’m looking for the actual things to watch out for, and that’s just the honest truth.

[Emma]
Yep, no, a hundred percent. I think when you get into the real world, it’s a lot more fast paced. Not that that’s a bad thing. I mean, you have the time to report on your radiograph what you need to report, but at Glasgow we’re still expected at this stage to do full radiographic reports for absolutely everything, which takes such a long time, but it is good to getting you used to looking at radiographs.

Being methodical in your approach, and then by the time you get to your VT, hopefully and beyond, you’re a lot quicker at doing your radiograph reports and you see things straight away. Whereas at the moment, I still have, it’s still very overwhelming. So-

[Jaz]
Take your time. We’ll take several minutes at this stage. But just one thing on that, I think the most common mistake you can do is just like, imagine you’re taking bite wings because you suspect, okay, there’s something perhaps going on around the upper left first molar and you take your bite wings and your eye immediately goes to the upper left first molar and you kind of like skim over the rest.

It’s really important to check the follow, trace the bone levels everywhere. And the most common one is like the distal of the second molar. There’s something there and you just didn’t spot it. And then years later, you see a patient comes back with symptoms. Oh yes, there was something there I didn’t see at the time.

So it’s really important just to check every single area, like typically where you’d find cervical burnout, right? Like that radiolucency by the neck of the teeth. And just look at those areas and look at the contact areas where caries typically starts just for every single tooth, just tick it off mental checklist.

And the most important thing medical legally is have you justified the radiograph in your report? Have you graded it and have you noted that the findings and it’s really important just to comment on the bone levels and any radiolucency, anything of concern that you’re watching for?

[Emma]
Yeah, absolutely. Like, what is it called? I think it’s satisfaction of search. If you’re looking for one thing and you find that and then you just lose everything else. So it’s so important to have that wee checklist. Either in front of you, I have mine sitting in front of me, written down in a notebook or just mentally as you get a bit more experienced, I’m sure. But just as you were talking there about cervical burnout, what are some more common pitfalls or mistakes to avoid when you’re reading and interpreting dental radiographs?

[Jaz]
So common pitfalls, but also just rewinding a bit to what we said about satisfaction and looking at something and satisfying your query. OPGs are the big one. Like, OPGs, there’s a lot more noise, right? And then you see so much, but you were concerned about the wisdom teeth.

And so you look at the wisdom teeth, but there’s so much data in OPGs. So my top tip for OPGs, this is what I was taught in dental school, is that, what are the high risk areas? Like, think cancer, right? If there’s something cancerous going on, something worrisome going on, the four white lines. Have you heard of the four white lines for OPGs?

[Emma]
Four white lines. No, I don’t think I have. No, I don’t.

[Jaz]
No one else knows about this. It’s not just because you’re a student. Because when I speak to other dentists, I was like, I speak to them and said, do you guys report on the four white lines for OPGs?

Then they look at me like puzzles. So it must have been a Sheffield thing that we were taught basically. The four white lines we look for are the hard palette. Can you see the hard palette? Right? You see that? Okay. That’s the horizontal line radio. Opaque line going cross, right? So can we see the hard palette?

Are there any abnormalities there? The next one is the floor of the sinus. Okay. So you want to see, trace the form. You don’t want to see a break in the lining, the cortical lining of the sinus, because that could be a worrisome, that could be maxillary sinus cancer or whatever, or some sort of issue going on.

So really important to check that. So that’s the two white lines. The third one is the posterior wall of the sinus. So the way you see that is, although it’s a posterior wall, you will see it on OPG as a vertical line. So the floor becomes vertical, okay, as you go distal, and that’s the posterior wall of the sinus. So again, I’m just checking that white line. So that’s three white lines checked. And the last one is the zygomatic buttress. Okay, the zygomatic buttress. Are you familiar with the zygomatic buttress?

[Emma]
Yes. Yep.

[Jaz]
It’s kind of like where the zygoma bone makes like this radioopaque line as well. And it’s important just to trace that. And I just mentally tick those off. Now, to date, I have never found one that had an issue or a breakage, but this is where I report my OPG for white lines. Check, check, check, check, like a checklist. And then I check the border, the external border of the mandible, the ramus. I’m looking for like any fractures, any radiolucencies, basically.

So that’s usually intact as well. Then I comment on the bone levels. Then it’s really important to check systematically upper right last molar. So this could be the wisdom tooth, check tooth by tooth by tooth. You’re looking at the apices, any abnormalities, anything that you think needs more investigation.

So sometimes we supplement OPG with a PA to get a bit more data. Although nowadays the OPGs are so good. The qualities are so good that machines that we have that can really negate the need for additional PAs. But the common pitfalls is one of them. Yeah, looking for what you want and then skipping past it.

With bite wings and stuff, I think it would be like the actual taking of it would be like a cone cutting. Are you familiar with cone cutting?

[Emma]
Yeah. Is that your collimation is not quite right or?

[Jaz]
Correct. So you’ve got the beam and you’ve got the film and the kind of out of alignment. And so the x ray managed to miss the film a bit and therefore you get this like white space on the radiograph.

I mean, that may or may not be detrimental. If you get like half the radiograph gone and the reason why you took it was to see all the interproximal areas, then that’s not acceptable. And you have to repeat that basically. In terms of interpretation, the other common issue, other than like in a missing distals of certain areas because your eyes don’t go there is a confusing cervical burnout for caries.

Caries typically starts at or just below the contact area. So if you’re seeing another radiolucency a little further down by the bone level, you really have to question, hmm, could this be cervical burnout? And cervical burnout happens because as the radiograph goes through the tooth and at the neck area where there’s little curvatures and how thin it is, it appears a slightly radiolucent there.

And so we don’t want to confuse that as caries. Have I ever done this before? Yes, I have. I have confused cervical burnout as caries before. And you go and you think, whoa, okay, fine. That was not caries. Okay. And so it really needs to be hot on it. So little clues you can have is, you look at the mouth in general.

If someone’s generally not got many restorations and you’re seeing this area, then you’re probably thinking, hmm, it’s not the typical place that I’d find caries. This could be cervical burnout. The other thing to do is remember, that radiographs are just one data point, we do not treat radiographs.

Technically one of my, I think Prof Avijit Banerjee taught me that you cannot diagnose caries from radiographs. You can only diagnose radiolucencies. It’s up to you to add the clinical picture to then be able to diagnose caries. So actually, technically, if I ever write and I do this, I’m being honest, I write sometimes, yes, caries, we see, we do this, right?

Caries noted on the radiograph, upper right 5 distal. That’s technically wrong. Radiolucency noted, upper right five distal in the inner third or in the outer third of dentine, for example, you make that comment, but we cannot technically say it’s caries. So we to add now are clinical checks. So clinically I would check on the high magnification, my lighting, feel gently with my probe, not to like probe hard into it, but check like the surface, right.

Using the sort of sideways of my probe or maybe even using a ball ended probe. And if in doubt, there’s a really cool technique whereby if you’re really unsure where there’s a cavitation. Because the difference between, I don’t know if you guys are taught this, but the difference between potentially restoring something that’s early, enamel or just interdentine and not restoring that one is whether it’s cavitated. Do you guys follow this as well?

[Emma]
Yes, more so in, like, paediatric patients, maybe. What do you mean? Do you mean, like, for whether you would restore it or not, like, early caries, or?

[Jaz]
Yeah, so let’s imagine we have a lower molar, right? And mesially, you see that the enamel’s got full radiolucency, okay? And now, it’s just into dentine. There are so many factors to consider whether you treat this or not, right? Like the patient’s oral hygiene status, their dry mouth status, are they using a fluoride toothpaste, their history of caries, all this stuff is really, really important, their caries risk in general. But actually, at a tooth level, If that enamel is still uncavitated, so still a shell of enamel that’s not broken, that potentially may sway you to, hmm, let me tell the patient that there is some decay there and talk about perhaps being conservative and monitoring it very closely and doing repeat radiographs in the future.

But the deal breaker often is if it’s cavitated, i. e. there’s a surface breakage, then that is a deal breaker to perhaps, okay, we need to restore this. And so do you know about any ways that you could check if it’s cavitated or not clinically?

[Emma]
Clinically? I don’t know, actually. No, like, apart from just looking, like, clinically and seeing if it’s cavitated, or would you call it clinically?

[Jaz]
You would, but it’s very, very difficult. And you try and fill with your probe, but you often can’t get to that area. And it’s tricky and it’s very difficult to do. So can you think of another way? I was blown away when I first saw this as a student, by the way.

[Emma]
I don’t know if this would just be for paediatric patients, but could you put a separator in there?

[Jaz]
Yes. Well, you could put a separator. It’s more amenable in paediatric dentistry, but a really cool way to do it. Now, I don’t know if you’ve heard of Louis Mackenzie.

[Emma]
No, I don’t think so. No.

[Jaz]
Fantastic dentist. Unfortunately, he passed away last year. So, you know, rest in peace, Lewis. He did an episode with us called To Drill or Not To Drill. It’s one of the early episodes of the podcast and this guy was a fantastic speaker, really humble man, really one of the sweetest dentists ever. So his presence in dentistry will always be missed. So just paying a tribute to him. I saw one of his lectures, I was a fourth year student, it was the BDA conference, saw one of his lectures and he described this exact scenario.

It was like, hmm, how can you tell if a tooth is cavitated or not? And this is what he said, he said, I am so sad that this is what I will do. I’ll place a wooden wedge inside. So now you get some separation. And now, he will squirt some light bodied silicon into that interproximal area. Let it set a bit and then use the tweezers to pull it out. And now that will show you whether if it’s smooth in that area or has the light body silicon actually, for want of a better word, evaginated or extended into that cavitation. And that can be the difference between whether it’s restoring or not. So when I saw that, and I’ve used that a few times and I’ve been unsure basically. So it’s another little trick that you could use.

[Emma]
That’s very, very interesting. Very interesting. The only other way that I’d heard of was pediatric patients may be using a separator to open that space a wee bit, but even I don’t imagine you would ever do that on your adult patients.

[Jaz]
You could do and I know some people that can do this, but I think with this little trick it saves the patient some grief and going home and having the inconvenience of having a separator.

[Emma]
So another question that I had for you Jaz was, what sort of strategies do you use to use your radiographs as a communication aid with your patients, like I’ve seen a lot of clinicians do this very well, but how do yourself use these bite wings to say to your patient and even motivate your patient, this is what we’ve got going on and this is what we need to do to treat it to get them to understand.

[Jaz]
Yeah, really great. And I don’t know if you’ve heard of this relatively new ish software called Pearl. There’s some other ones as well, basically, I think. But this is like AI to read the radiographs. And basically, their slogan is Radiographs now in color. So what it does, it like, instead of the radiolucency, it’ll like paint it red. And so the patient can see clearly.

[Emma]
Wow.

[Jaz]
‘Cause quite often in the scenarios you’re showing the patient like, can you see the radiolucency? And they’re look at you blank. Like, no, I cannot see that. And that’s happened to me. Like, when you are learning, probably you will not see things that I can see ’cause of the difference experience.

But are patients are the same, like you show them a radiolucency and like, wait a minute, what are you sure I can’t see it. So sometimes having it colored by AI is just so some of these softwares are great. I don’t use them myself yet, but that’s cool. That’s very exciting, right? So what I would do is I’d have it on my flat screen TV I’d stand next to a radiograph is that can you see this is your tooth over here.

See this white area here That’s a big metal filling you have in the tooth. Can you see where the teeth kiss together where the teeth kiss together? That’s called the contact and that’s where decay starts. This is why it’s really important to floss or teepee, etc. Can you see there’s a shadow over here?

The shadow is a black area. It’s black because the x ray goes through mush. The mush can’t stop the x ray. So the x ray goes right through the mush and it’s not as hard. It’s softness. It’s soft mush inside your tooth. And so I’ve counted them and you have X number of areas. Now, these ones are gonna be okay.

But can you see this one over here? Can you see that it’s much, much bigger? And hopefully they can see it and you highlight it. That’s the one that we need to treat. Because if you don’t treat it, it’ll become here. And can you see this other little black area? That’s the nerve. So every tooth has a nerve.

And although you’re not feeling pain yet, most dental conditions are painless. When the pain starts, that is too late. That is a very late stage start. So most dentistry is painless, but when the pain comes, it’s often too late. This is what we’re presenting to you in the x ray. So then I’d maybe describe the bone level as well.

I often describe the bone as these are your roots and this is your bone. Thankfully, Mrs. Smith, you got plenty of soil around your roots, okay? Your soil is good, okay? And it helps them to understand it.

[Emma]
Yeah, no, that’s good. A few wee tips in there, I think. It can be really difficult.

[Jaz]
Because your experience as a nurse, right? What have you seen that you liked? Anything that you remember that you, oh, I really like this.

[Emma]
A dentist that I worked with, John McCall, I remember him talking through radiographs with patients. Just making it really simple, again, big TV in the practice, radiographs up there. So these are your teeth, this is the upper, this is the lower, this is the left, this is the right, and the spongy bit round here is your bone.

And just sort of setting that base for your patient to know what you’re looking at, first of all. And then, like you said, again, just going in, can you see this, this darker area here? And just going from there. I think it can be really difficult for students to do that in layman’s terms. If you’re with a patient, you just want to dive right in and then, oh, you’re pulp, blah, blah, blah, and they don’t have any idea of what you’re talking about.

I find that quite hard to use radiographs as a communication aid at the moment, because at the moment they overwhelm me, but I think definitely that’s something that will come with experience.

[Jaz]
100 percent.

[Emma]
Yeah. Just quickly looking at a radiograph and then instantly knowing what to say to your patient and using that in a way that they can understand can be huge for patient motivation as well and just getting them to understand your treatment options.

[Jaz]
It’s about the understanding and communicating the issue well. The radiographs are very important and the explanation, but that will come. The more you do it, the more second nature it will become and the more layman’s terms you will use, which is so, so important. In the routine checkup video, which is available on the student section again, I’m just reminding everyone.

I made a mistake because I never had done this before. I promise you that I would. And so usually I record procedures and it’s just me in silence recording procedure. And then later I might narrate it. For example, in sectioning school series, we have all these extractions that I’ve done and I’ve narrated it.

But when I was doing this, like the whole conversation with the patient was being recorded. And so I was a little bit self conscious about that. And so they came to one bit of explaining some treatment. And you might’ve seen my commentary on that saying there was too much jargon here. This is not how to do it.

So, very often you’ll feel that way. And it’s really important to, after every patient says, hmm, what went well? What went wrong? What, how can I improve my communication? If you keep doing that for years and years and years, you’ll find that actually, the more you simplify, the more you go back to basics, the more you make it softer and easy to understand, the more effective of a communicator you become.

[Emma]
Yep. And I think radiographs are obviously hugely essential in dentistry, but they just have so many other benefits in terms of communication with your patients. But that’s a really good skill to have is just putting that into something that the patient will understand, which of course, like I’ve said, just comes with experience.

So my last question for you, Jaz, was, and this might be a big question, but let’s just see quite generally. Let’s say a patient has irreversible pulpitis, it’s going to need an extraction or a root canal. You take a peri-apical at what point does the extent of the caries call for an extraction over a root canal?

[Jaz]
Oh, I love this question so much. A reason is because I’ve just posted a radiograph yesterday on the community on Protrusive Guidance, okay? And I said, okay, what are you guys gonna do? I sort of pitched it. Okay. So this is the scenario and what I used to see as the worst part of dentistry. It’s like everyone’s got different opinions.

I now see it as the beauty of dentistry. Okay, so you must see it like this, otherwise you will have a miserable career. So the beauty of dentistry revealed that everyone has, okay, some people use some sort of bioceramic materials. Some people say root canals. Some people say, actually give the pulp a chance.

Let’s try and restore it. Unless you can get a seal. Some people suggested a hemisection, all sorts. All right. So it was all in there. And it goes down to that question where, at what point do you decide, it’s a question whether it’s restorable or root canal is an optional, just remind me the question again precisely.

[Emma]
Between extraction and root canal, like at what point does it just need to go?

[Jaz]
Okay, so, extraction and root canal, the other way of pitching that is restorable or unrestorable.

[Emma]
Okay, cool.

[Jaz]
Should we go with that? Because sometimes a tooth may be restorable, but the patient will not consent to a root canal. It may be restorable, but to restore it, it needs a root canal because the pulp is either necrotic or it’s irreversibly inflamed, and therefore it needs a root canal. But actually what we’re going to gain more from is, okay, what are the radiographic parameters to use when we’re deciding whether if root canal is even an option here, right?

Okay. So if we have a PA, okay, and you’re getting to the territory where you’re thinking, hmm, I’m not sure if this tooth is restorable, the first thing to do is take a bite wing. Have you heard of this one?

[Emma]
No, I don’t think so.

[Jaz]
PAs often vastly overestimate how much caries there is. And they can make the situation much worse or, or different to what is going on. Sometimes by having a bite wing, because the angulation, you get a much better degree of assurance of the exact level of the caries. So in those cases, you should supplement your PA with a bite wing. So now you have a bite wing and now you can better access the exact extent of that radiolucency.

A really good tip that was given to me by a guy called Dr. Barber from Sheffield. This was when I was at DCT was when the radialucency extends below the floor of the pulp chamber. Let’s look at a molar, lower molar. Okay. Imagine young patient, large pulp chamber. We have the top of the pulp chamber and the floor of the pulp chamber. Imagine now the radialucency is getting towards the pulp chamber, but now it’s getting so far low that it’s getting to the floor of the pulp chamber.

When it gets towards the floor of the pulp chamber, that is one consideration. it’s not a hard and fast rule, but if it’s getting that deep now that it’s at towards the floor, it’s gone beyond the top. It’s now approaching the floor of the pulp chamber. It’s now on very shaky grounds. So the one I posted is on very, very shaky grounds.

So now you’re thinking, okay, how important is this tooth in this patient’s mouth? How strategically important is it? What kind of patient do we have here? Do we have an A plus patient with fantastic oral hygiene? With the otherwise low care he’s experienced? Bit of bad luck here? Maybe a wisdom tooth kind of issue?

And how much are we willing to fight for this tooth? And what is a patient’s attitude? And the way we sometimes, if we have those 50/ 50 scenarios, It’s really nice to pitch it to a patient in this way. I like to say this to a patient inspired by some communication tips I picked up from Lincoln Harris.

I said to him, imagine, dear patient, that you spent a fair chunk of change on this tooth. Imagine six months later it had to be extracted, because the root canal failed, because you never got a good seal. Would you say, you know what, I’m glad I tried, because there was a chance that this could have lasted 10, 20 years.

Or would you feel absolutely devastated? We feel like an idiot for spending money on it. What would your mindset be? And that will answer it sometimes. If they say that, they’ll be absolutely devastated. That’s six months later to have tooth out, then that answers it because it’s not very predictable.

Predictability is the key word here because when it gets that level of deepness of the caries, then it’s not as predictable. To get that seal is not as predictable. So that’s number one, right? If they say, oh, you know what? I’m, I’d be glad because I really want to say this truth and willing to give it a shot and willing to accept that in six months time, I’m not going to cry about it.

I’m going to be a big boy kind of thing. Okay. So if they say that, then, okay, if you think that your clinical skills are good enough and the patient’s up for it, then that may still sway you. Now, if it’s going well below the floor of the pulp chamber, then okay. That’s bad news. Because then you’re really, by the time you restore that A, to get the seal, to get the matrices that far down low is very, very difficult to actually do a good precise job is very, very difficult. Also biomechanically, that tooth is very weakened. The next thing to consider is would you perhaps need something like a crown lengthening? Do you know what a crown lengthening is, Emma?

[Emma]
Yeah, I’ve nursed in a few crown lengthening surgeries. Do you use like an electrocautery or something?

[Jaz]
It can do, to remove the gum.

[Emma]
Yeah. That’s I’ve only ever seen it on a few anterior teeth.

[Jaz]
It’s more common on anterior teeth and so, posteriorly, so there’s aesthetic crown lengthening whereby we’re changing the gum levels to get a nicer smile, and then there’s functional crown lengthening, we’re making the tooth a bit bigger by removing some bones, so imagine you’ve got distal caries and a molar really deep, like almost kissing the bone, so if we can make the bone go more apical, drill away some bone there, and allow us to restore this tooth in a much easier fashion, i. e. allow our matrix, allow our wedge to actually get down there and make a seal, allow our crown to actually sit, our future indirect restoration. Sit on healthy tooth structure and not near the bone, basically, that’s a good thing to do. So, we have to then think about finance as well. So whilst it could be restorable and it’s debatable, we have to think, hmm, at what expense?

Once you factor in crown lengthening privately, once you factor in a root canal, once you factor in a crown, you might be in implant territory. And so, cost benefit analysis, and how predictable and how easy or otherwise it is to get a seal. These all will play in in the real world when you’re decision making.

So in terms of purely a radiographic level, I very much look at this where it is in relation to a pulp chamber. I look at the patient as a whole. You take a step back, look at the patient. Is this patient deserving? And it’s not a nice way to think about it. But really, if they’ve got a gob rot, this one tooth is the last of your worries, right?

In that mouth, the most predictable thing for sure would be an extraction. But if it’s a well cared for mouth, then sometimes we do do a little bit of heroic dentistry as long as the patient understands that what we’re doing here is really higher risk, higher reward. We get to keep the tooth, which is great, but it’s higher risk, higher reward.

[Emma]
Yep, that makes sense actually. And I’ve never really thought about it in that sort of way where you do need to take a step back and look at the patient. The patient, there’s so much room for the patient to make decisions in their treatment planning and I think coming back to communication, like for me if I was a patient that could be quite hard to grasp without being shown, okay this is where this dark bit is and I don’t think that’s going to be able to be saved xyz. I think that’s a good way to look at it, your landmarks and being able to show that on a radiograph can be good for the patient as well. But no, that’s interesting.

[Jaz]
So top tip there, remember to supplement with a bite wing. Really important as well. And so, yeah, to look at the bigger picture. I remember being a DCT at Guy’s Hospital, oral surgery department, and all day long we’d be doing extractions and extirpations, right? I remember these two American students came to Shadow, for like the elective kind of thing, right? And so I think they’re American Australian. I forget now. Anyway, I saw this one lady, And she had caries and a molar that was causing pain and the diagnosis, the official diagnosis was irreversible pulpitis.

The tooth was restorable. Like, it was a home run. It was like way above the bone. It was a home run. It was decay into the nerve, but it was a home run root canal. But after having a discussion with the patient, we decided that the extraction would be the best for her. And she left and she went to get an extraction and these students were gobsmacked.

They’re like, wait a minute. What? This tooth was savable. Why didn’t you do the excavation and send this patient back for root canal? And it was an important lesson I was able to pass on to them because it’s a lesson I’d learned some years ago was actually, yes, it’s restorable, but just because you can doesn’t mean you should, because that patient, okay, you have to look at the tooth factors.

If that tooth, right, doesn’t have an opposing tooth, then what value does that have compared to, okay, it doesn’t have a tooth now or an implant in the future. If the patient is really not in a financial position to consider and they express that, like, look, I’m actually not looking to spend any money on this tooth.

I would actually like to have my patient preference is to have this tooth out. You’ve got to take that preference. Now, if it’s healthy pulp and it’s reversible pulpitis, I would dress that tooth. Right? I would not extract it. I’d be like, no, I don’t think there’s a reasonable option for what you present with.

But when the alternative is a root canal and the patient doesn’t want that, then you have to think about the patient as a whole. So it’s not just about the depth of radiolucency and whatnot. It’s about looking at the patient, their own preferences, their history of dental work, what’s opposing it and all these factors.

[Emma]
Yep. And I think that can be quite frustrating when you’re going through, not frustrating, but you’re going through dental school, learning how to save all these teeth, and then when it comes to the real world, sometimes that’s just not feasible. And like you said, you have to go with the option that A, the person can afford, or that the treatment that they are willing to tolerate.

[Jaz]
Tolerate, afford, and maintain as well. Like you might be able to afford it, they got gob rot everywhere. They got super, super dry mouth, and it’s going to be difficult for them to maintain. But equally, Emma, you might have a scenario where in anyone else’s mouth, you’d extract. But because that patient is on bisphosphonates, IV bisphosphonates, they are higher risk of things going wrong and the bone not healing.

And therefore, in that patient, you’re going to really do a bit more heroic dentistry and try and do what you can to save that tooth. So this is where the patient’s medical history and all those factors come into play as well. One last thing, which you haven’t mentioned, which I think is really worth mentioning in the realms of if predicting if something is restorable or not on a radiograph is remember that the radiolucency you see on the radiograph, the clinical caries will be 33% more. I remember this being taught this. It’ll be worse clinically than it is on the radiograph. Always remember that.

[Emma]
Okay. Yeah, that’s a good one to remember. And also a good exam question. A good exam question.

[Jaz]
Yes. And I was, it reminds me of another lesson I was taught as a third year dental student. I had this really carious premolar I was treating and it was making me stressed. Like as a student, like just, seeing so much caries was a stressful experience for me. I was stressing. I was sweating. I was like, Oh my God, when do I stop? There’s still more caries. I’ve got to go. There’s still more caries. I’ve got to go. And it took me like two hours to put this GIC, right? And the patient leaves and the tutor looks at me and he wrote a comment.

His name is Abdul Rahman Elmougy. He’s now a restorative consultant. So Abds, if you’re watching, listen to this shout out to you, my friend. He wrote in the book, he’s like, don’t be shy with a tooth of poor prognosis. Let me say that again. Don’t be shy with a tooth prognosis, okay? We didn’t owe that tooth anything, okay?

The tooth had served its time, okay? We were doing this tooth a favor. We were trying our best, okay? This tooth was on shaky grounds. So the way I approach this situation now is A, you tell the patient this is an investigation. We’re not doing a filling. We’re actually just seeing if this tooth can be saved or not.

I will tell you what the outcome is once I remove all the decay and I address it, okay? So you’re going to walk away with this information whether we can even save this tooth or not. Your tooth. This is like doing CPR for the tooth. Right. So that’s what I pitch it. But when you’re removing caries on a tooth, which is already really poor prognosis, don’t be shy.

Don’t be like little tickles. Okay. Get the big bur out. Okay. Be responsible, be precise, but don’t like be very gentle. Start tickling. You need to get this mush out. Go for it. Okay. Yeah. See what’s left. And so that really served me well, actually don’t start stressing because there’s huge caries.

That’s it’s the patient’s fault. You didn’t put the caries there. And sometimes hit the patient who sometimes you get certain types of personalities and they get very like, well, but do this and do that. And just remember, hey, well hang on a minute. I didn’t put the decay there.

I’m helping you, but I didn’t put the decay there. So it might take some years, Emma, to be able to be confident enough to say that to a patient, but it’s one to have up your sleeve.

[Emma]
Yeah. I’ve heard people saying before it might have been yourself actually like you didn’t put the caries there, and if there’s moosh there, then it needs to go. I think a lot of patients sort of demonize dentists. Like, I didn’t do that to your tooth. That’s hard to sort of, I wouldn’t ever say, oh, it’s your fault, blah, blah, blah.

[Jaz]
But it’s a hard one. I hear, Emma, is patients saying that, Oh, my dentist drilled too much. And so that really for me is a failure in the communication department. So it just means that, oh, we’re going to do a filling today. There’s some decay. Let’s crack on. Really? That kind of conversation should be like, there’s some decay here. I don’t know how deep it is. I think it’s actually, look at the radiograph here. So look at this x ray. This is the dark area. That’s the mush.

But actually in the real world, this mush is going to be much deeper. So I’m telling you now, although you’re not in pain now, there’s a real chance. Your nerve might be in pain because your decay is really uncontrollable. And although you’re not in any pain now, this could become a painful scenario. If you’d wish not to have this treatment done, that’s fine.

But you’re looking at having this tooth out. But if you still wish to try and save this tooth, remember the kind of symptoms to look out for are X, Y, and Z. And now your patient is really much more informed than their understanding that actually is their problem, not yours.

[Emma]
Yeah. No, definitely. I think and another one is I wasn’t in pain before I went to the dentist and-

[Jaz]
Classic.

[Emma]
I don’t need treatment done because it’s not sore. But again, that communication like, well, if you don’t get something done, then it will be sore down the line but she pick up along the way.

[Jaz]
A hundred percent. And as per the GC criteria in the UK, we have to tell the patient the risk of the treatment, but always the risk of not doing treatment. So, Miss Smith, I know you’re concerned the decay is deep, and actually after this procedure, you might be in a lot of pain, you might have a sleepless night because it’s very, very close to your nerve, and this is the reality of the really deep decay that you have in your tooth, Miss Smith, right? So your tooth is in a really troubled state, so we need to do CPR for the tooth here, but if you want an alternative, the option of not doing anything, although you’re not in pain now, this is going to be potentially a very painful issue in the future and whilst we might be able to save it now, we probably won’t be able to save it in the future. So the risk of doing nothing is not recommended and I’m not recommending this treatment, although you may choose to do nothing because you are well within your right.

[Emma]
Yes. Yep. The option of doing nothing is always there, but it’s not often recommended.

[Jaz]
Correct. And patients have to consent to doing treatment or not doing treatment. And so we put it on the table, but it’s the way we communicate and the gravitas that we explain things, which is really important.

[Emma]
Yep. Yep. Absolutely.

[Jaz]
Amazing. Emma. So we’ve covered now some degree of real world radiography. We talked a little bit about OPGs, periapicals, and grading and assessing. Looking at things in a systematic way and actually drawing out the real world, the communication gems, which I think this episode really evolved into in the second half. Please tell us about the notes, the Protrusive Student notes that you’re adding on every time you do an episode. Tell us about what you’re going to cover in this round.

[Emma]
So this month’s notes about radiography, of course, I’m going to go through what we’re taught at Glasgow about your radiographic reports and your checklist. And what I personally have in my wee book that I carry about with me, a bit of localization and parallax technique, common mistakes that we make when we’re interpreting radiographs and it’s just, yeah, basic interpretation, things like that.

[Jaz]
Excellent. Very excited to put that on. So Emma, thanks so much for all the hard work you do for Protrusive and I hope you have a fantastic elective. We will meet again. Obviously, people will not know the difference because we’re recording ahead of time, but we can’t wait to hear in the next episode your stories about your elective and from the Protrusive Community, we’re thankful for all that you’ve done so far, but we look forward to rejoining and continuing your good work.

[Emma]
Perfect. Thank you so much.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for making it all the way to the end. Please let us know what should we cover next in this basic series, in this Protrusive Student Series. Like I said, the next one’s on extractions, and it will be CE eligible because I find that so many dentists are also tuning in, and it’s nice to reconnect for validation when it comes to the basics.

If you know a colleague who will benefit from these episodes, please send them a link to our podcast, and at least join the community of the nicest and geekiest dentists in the world. That’s Protrusive Guidance. You can get it on iOS and Android, and our thriving community is absolutely awesome.

Nice people. Not like what you see on Facebook. Facebook is junk, in my opinion. So if you are a keen listener of Protrusive and you want to connect with other Protruserati, that’s the place to be. Thank you so much for listening all the way to the end. Once again, I’ll catch you same time, same place next week. Bye for now.

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