18 Patient Management and Special Problems










199
18
Patient Management and
Special Problems
EDUCATIONAL OBJECTIVES
Upon completing this chapter, the student will be able to:
1. Dene the key terms listed at the beginning of the chapter.
2. Describe the general management techniques that a dental
radiographer can employ while taking radiographs on
patients.
3. Discuss the following related to treating patients with
disabilities and special needs:
• Listthestepsthatthedentalprofessionalcantakein
treating a patient with mobility issues, including those
who are wheelchair bound, in the hospital, homebound,
bedridden, or in long-term care facilities.
• Discusssomeofthecommondevelopmentaldisabilities
that dental professionals may encounter in the dental
oce and what technique adjustments are required in
order to treat these patients.
• Discussthemodicationsnecessarywhenexposing
radiographsonpatientsthatarehearingorvision
impaired.
4. Describe the techniques that are useful for managing
pediatric patients in dental radiography.
5. Listtheareasintheoralcavitythatcantriggerthegag
reexandthevariousmanagementtechniquesusedto
helpthehypersensitivepatientcontrolthisbodydefense
mechanism.
6. Listthelocalizationtechniquesusedindentalradiography
and describe the clinical application for each technique.
7. Discusstheremediesthatcanbeutilizedwhenattempting
to radiograph third molars; teeth undergoing endodontic
treatment; and patients with anatomic constraints, such as
tori, trismus, a narrow arch, or a shallow palate.
KEY TERMS
arthrography
bedridden
buccal-object rule
Clark’s rule
developmental disability
disability
gag reex
hearing impaired
localization
marking grid
physical disability
radiopaque media
radiopaque medium
reverse bitewing
sialography
SLOB
trismus
tube shift
visually impaired
wheelchair access
are calm and cooperate easily. Some reveal their anxieties
through behavioral and speech patterns; others may hide
their anxieties.
Even with modern equipment, techniques, and attitudes,
dentistry remains a stressful experience for some patients.
As a profession, dentistry is still plagued by the image of
the unpleasant experience. It is within this societal context
that dental professionals must endeavor to serve patients.
With the modern technologies available and an emphasis
on behavior, this goal can be met.
Furthermore, dental radiographers must be able to alter
their skills to t the needs of the individual patient. is
chapter introduces various ways of managing patients with
Introduction
Patient management is important to all dental personnel
involved with patient care in a dental facility. Patient
understanding and consideration is a valuable tool in
helping dental professionals perform their chairside duties.
e dental team may be responsible for other patient man-
agement assignments, such as scheduling appointments,
handling and screening telephone calls, and collecting fees.
ese duties also demand the use of understanding and
empathy to manage patients successfully.
e dental professional encounters all types of personali-
ties in the dental oce. Some patients may be very appre-
hensive and tense about dental treatment, whereas others

200 CHAPTER 18 Patient Management and Special Problems
or treatment planning that cannot be answered with con-
dence, it should be referred to the appropriate member
of the dental team. Patients often ask about the need
for radiographs and the potential radiation risk. Because
these questions are usually asked before work begins, a
well-answered question will give the patient condence and
lessen apprehension about having the radiographs taken.
Answers to questions of this type are found in this text;
the fears and concerns of the patient can be allayed by
intelligent, meaningful answers.
Receptors must be placed in the patients mouth, and
directions must be given to the patient in a manner that
indicates self-condence. A patient likes to feel that the
operator is in full control of the situation at all times.
Instructions to the patient should be given in a rm but
polite tone. In addition, dental professionals should encour-
age and praise patients for their cooperation in an eort to
gain their condence and mutual respect. Every patient is
dierent, both in the anatomic conguration of the mouth
and in physical and psychological makeup. is is the
challenge of the profession—to perform ones duties and
maintain standards of excellence even as the clinical situa-
tion changes. rough study, practice, and self-evaluation,
these goals can be met.
Patients with Disabilities and
Special Needs
A disability can be dened as a physical or mental condition
that limits a persons movements, senses, or activities. ese
impairments often restrict the aicted persons life activities.
In the dental environment, it is imperative that all persons
are treated equally and with the same level of respect. e
dental professional should be able to modify radiographic
techniques to meet the needs of each individual patient.
Physical Disability
e obstacles in treating patients with physical challenges
in the dental oce vary according to the degree of their
disability. A physical disability may include problems with
mobility, hearing, or vision.
Mobility
With a patient conned to a wheelchair, it may be easier
to radiograph in the wheelchair than to transfer the patient
to the dental chair, as long as the procedure can be suc-
cessfully accomplished with the patient’s head positioned
and supported properly. When transferring the patient,
radiographers might ask patients how they would like to
be transferred, and they may also assist the accompanying
caregivers (if present) in transferring patients to the dental
chair. Most local building codes require wheelchair access
to the dental operatory so that the x-ray machine and
patient can be maneuvered into the proper relationship.
a variety of specic needs including, but not limited to,
patients with disabilities, pediatric patients, patients with a
sensitive gag reex, and patients with anatomic constraints
that require an alternate method of receptor placement.
Management
One of the important roles of the dental professional is to
try to relax the patient, which makes the work easier. e
dental hygienist or assistant may be the rst member of the
oce sta to greet the patient in the reception area. Patients
like to be recognized and greeted by name. However, to
conform to federal legislation (Health Insurance Portability
and Accountability Act [HIPAA]) patients should not be
addressed by their last names to ensure privacy (see Chapter
25). It is especially important to greet new or current patients
with an appropriate phrase, such as, “We shall be with you
shortly.” “We” implies the team concept of treatment and
stresses the importance of all of the constituents in the
oce, indicating that the whole dental team will take part
in the active treatment.
In performing dental radiography, the dental professional
also must develop an acceptable and respectful chairside
manner. Patients must be made to feel comfortable and
condent about the dental professional’s ability to perform
the radiographic examination.
In some dental oces, it is routine for any of the dental
professionals to perform the radiographic procedures. As
discussed in the preceding chapter, dental professionals
should strive for a high level of clinical prociency with
ecient and condent work patterns. e dental profes-
sional can achieve these objectives through experience and
honest self-evaluation and peer evaluation. e quality of
the nished radiograph should be the same regardless of
who performs the procedure. All members of the dental
team should be held to the same standard of quality
control.
When the dental professional is seating patients and
draping them with the lead apron, some small talk may
help to relax them. Patients want to know that the dental
professional is interested in them and not just performing
a mechanical procedure. is is not wasted time, because
a relaxed, condent patient is much easier to work with.
Appearance is very important. All infection-control pro-
tocols must be followed. Hands should be washed; gloves,
masks, protective eyewear, and protective clothing worn;
and the prescribed infection-control procedures followed
after the patient is seated in the dental chair so that the
patient can take note of these procedures. If one sneezes,
coughs, picks up something from the oor, or has to leave
the treatment room, re-gloving is mandatory before resum-
ing work.
e dental professional should always explain to the
patient what procedures are to be performed and how many
projections will be taken. Any questions that the patient has
should be answered if the dental professional feels capable
of doing so. If the question involves diagnostic judgments

201CHAPTER 18 Patient Management and Special Problems
However, these Nomad units have recently been approved
for dental use by the U.S. Food and Drug Administration.
According to the manufacturers of the Nomad units, these
handheld devices have a shield that potentially protects the
patient and operator from unnecessary x-ray exposure.
Developmental Disability
Patients who are mentally disabled or have other physical
conditions, such as cerebral palsy or autism, and are aicted
before the age of 22 (developmental disability) may
present a management challenge in a dental facility. Unless
there is complete cooperation while exposing dental images,
the patient may move and render the radiographs useless.
e degree of cooperation varies among patients. Problem
situations should be recognized immediately. Repeated
attempts may only excite the patient, subject the patient
to unnecessary radiation, and prove fruitless. e dental
professional should elicit the help of the patients caregiver
when applicable in obtaining diagnostic radiographs. e
dental professional may also opt to take a panoramic or
another extraoral projection as opposed to intraoral radio-
graphs that require more tolerance and cooperation.
For a totally unmanageable patient or one with an
extreme physical disability, radiographs may have to be
taken with the patient under sedation or general anesthesia.
ese lms are usually developed immediately or digital
radiography is used, and the necessary dental procedures are
performed while the patient is still anesthetized.
Hearing Impairment
e obvious challenge in treating hearing impaired or deaf
patients is communication, as well as realization by the
operator of the disability and how it may modify usual
procedures. For example, the often-used command to the
patient to “hold still” as the operator leaves the room to
make an exposure is not applicable for patients with a
hearing impairment. Depending on the patients method of
communication, instructions may have to be given through
a translator, sign language, or in writing. Deaf patients
can usually read lips, therefore, operators must be sure
Also, panoramic and other extraoral equipment have been
manufactured to accommodate a patient in a wheelchair,
allowing these projections to be useful with this type of
patient.
Some homebound patients or those bedridden in hos-
pitals and long-term care facilities may not be able to visit
dental suites; their dental procedures and radiographs must
be done at the bedside. In the past, mobile dental x-ray
units could be brought to the bed and radiographs taken.
For the patient in the supine position, it is easier to use a
receptor-holding device with a localizing ring. In treating
a patient at home or at a site that does not have a dental
x-ray unit, portable x-ray units can be adapted for dental
use and assembled on site (Fig. 18.1). If digital radiography
is not available, then a small, portable, rapid-processing
tank also should be brought along so that the radiographs
can be processed and the patient treated during the
same visit.
With the more recent introduction of the handheld
portable dental x-ray machine, it is now possible to produce
quality images and have the ability to utilize the unit outside
of the dental facility in locations such as remote outreach
sites, long-term care facilities, and hospitals. ese units
are lightweight and battery powered. e most popular of
these systems are the Nomad models (Fig. 18.2). With this
system, the receptor (lm or sensor) is positioned in the
patient’s mouth while the exposure is made. e opera-
tor, while holding the device at chairside, directs it at the
receptor in the patients mouth and exposes it. e use of
this device has raised the question of increased radiation
exposure to both the patient and the operator in the past.
Figure 18.1 Portable dental x-ray unit. (From Bird DL, Robinson
DS: Modern Dental Assisting, ed 12, St Louis, 2018, Elsevier.)
Figure 18.2 NOMAD Pro 2 handheld x-ray unit. (Courtesy Aribex,
Charlotte, NC.)

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19918 Patient Management and Special ProblemsEDUCATIONAL OBJECTIVESUpon completing this chapter, the student will be able to:1. Dene the key terms listed at the beginning of the chapter.2. Describe the general management techniques that a dental radiographer can employ while taking radiographs on patients.3. Discuss the following related to treating patients with disabilities and special needs:• Listthestepsthatthedentalprofessionalcantakeintreating a patient with mobility issues, including those who are wheelchair bound, in the hospital, homebound, bedridden, or in long-term care facilities.• Discusssomeofthecommondevelopmentaldisabilitiesthat dental professionals may encounter in the dental oce and what technique adjustments are required in order to treat these patients.• Discussthemodicationsnecessarywhenexposingradiographsonpatientsthatarehearingorvisionimpaired.4. Describe the techniques that are useful for managing pediatric patients in dental radiography.5. Listtheareasintheoralcavitythatcantriggerthegagreexandthevariousmanagementtechniquesusedtohelpthehypersensitivepatientcontrolthisbodydefensemechanism.6. Listthelocalizationtechniquesusedindentalradiographyand describe the clinical application for each technique.7. Discusstheremediesthatcanbeutilizedwhenattemptingto radiograph third molars; teeth undergoing endodontic treatment; and patients with anatomic constraints, such as tori, trismus, a narrow arch, or a shallow palate.KEY TERMSarthrographybedriddenbuccal-object ruleClark’s ruledevelopmental disabilitydisabilitygag reexhearing impairedlocalizationmarking gridphysical disabilityradiopaque mediaradiopaque mediumreverse bitewingsialographySLOBtrismustube shiftvisually impairedwheelchair accessare calm and cooperate easily. Some reveal their anxieties through behavioral and speech patterns; others may hide their anxieties.Even with modern equipment, techniques, and attitudes, dentistry remains a stressful experience for some patients. As a profession, dentistry is still plagued by the image of the unpleasant experience. It is within this societal context that dental professionals must endeavor to serve patients. With the modern technologies available and an emphasis on behavior, this goal can be met.Furthermore, dental radiographers must be able to alter their skills to t the needs of the individual patient. is chapter introduces various ways of managing patients with IntroductionPatient management is important to all dental personnel involved with patient care in a dental facility. Patient understanding and consideration is a valuable tool in helping dental professionals perform their chairside duties. e dental team may be responsible for other patient man-agement assignments, such as scheduling appointments, handling and screening telephone calls, and collecting fees. ese duties also demand the use of understanding and empathy to manage patients successfully.e dental professional encounters all types of personali-ties in the dental oce. Some patients may be very appre-hensive and tense about dental treatment, whereas others 200 CHAPTER 18 Patient Management and Special Problemsor treatment planning that cannot be answered with con-dence, it should be referred to the appropriate member of the dental team. Patients often ask about the need for radiographs and the potential radiation risk. Because these questions are usually asked before work begins, a well-answered question will give the patient condence and lessen apprehension about having the radiographs taken. Answers to questions of this type are found in this text; the fears and concerns of the patient can be allayed by intelligent, meaningful answers.Receptors must be placed in the patient’s mouth, and directions must be given to the patient in a manner that indicates self-condence. A patient likes to feel that the operator is in full control of the situation at all times. Instructions to the patient should be given in a rm but polite tone. In addition, dental professionals should encour-age and praise patients for their cooperation in an eort to gain their condence and mutual respect. Every patient is dierent, both in the anatomic conguration of the mouth and in physical and psychological makeup. is is the challenge of the profession—to perform one’s duties and maintain standards of excellence even as the clinical situa-tion changes. rough study, practice, and self-evaluation, these goals can be met.Patients with Disabilities and Special NeedsA disability can be dened as a physical or mental condition that limits a person’s movements, senses, or activities. ese impairments often restrict the aicted person’s life activities. In the dental environment, it is imperative that all persons are treated equally and with the same level of respect. e dental professional should be able to modify radiographic techniques to meet the needs of each individual patient.Physical Disabilitye obstacles in treating patients with physical challenges in the dental oce vary according to the degree of their disability. A physical disability may include problems with mobility, hearing, or vision.MobilityWith a patient conned to a wheelchair, it may be easier to radiograph in the wheelchair than to transfer the patient to the dental chair, as long as the procedure can be suc-cessfully accomplished with the patient’s head positioned and supported properly. When transferring the patient, radiographers might ask patients how they would like to be transferred, and they may also assist the accompanying caregivers (if present) in transferring patients to the dental chair. Most local building codes require wheelchair access to the dental operatory so that the x-ray machine and patient can be maneuvered into the proper relationship. a variety of specic needs including, but not limited to, patients with disabilities, pediatric patients, patients with a sensitive gag reex, and patients with anatomic constraints that require an alternate method of receptor placement.ManagementOne of the important roles of the dental professional is to try to relax the patient, which makes the work easier. e dental hygienist or assistant may be the rst member of the oce sta to greet the patient in the reception area. Patients like to be recognized and greeted by name. However, to conform to federal legislation (Health Insurance Portability and Accountability Act [HIPAA]) patients should not be addressed by their last names to ensure privacy (see Chapter 25). It is especially important to greet new or current patients with an appropriate phrase, such as, “We shall be with you shortly.” “We” implies the team concept of treatment and stresses the importance of all of the constituents in the oce, indicating that the whole dental team will take part in the active treatment.In performing dental radiography, the dental professional also must develop an acceptable and respectful chairside manner. Patients must be made to feel comfortable and condent about the dental professional’s ability to perform the radiographic examination.In some dental oces, it is routine for any of the dental professionals to perform the radiographic procedures. As discussed in the preceding chapter, dental professionals should strive for a high level of clinical prociency with ecient and condent work patterns. e dental profes-sional can achieve these objectives through experience and honest self-evaluation and peer evaluation. e quality of the nished radiograph should be the same regardless of who performs the procedure. All members of the dental team should be held to the same standard of quality control.When the dental professional is seating patients and draping them with the lead apron, some small talk may help to relax them. Patients want to know that the dental professional is interested in them and not just performing a mechanical procedure. is is not wasted time, because a relaxed, condent patient is much easier to work with.Appearance is very important. All infection-control pro-tocols must be followed. Hands should be washed; gloves, masks, protective eyewear, and protective clothing worn; and the prescribed infection-control procedures followed after the patient is seated in the dental chair so that the patient can take note of these procedures. If one sneezes, coughs, picks up something from the oor, or has to leave the treatment room, re-gloving is mandatory before resum-ing work.e dental professional should always explain to the patient what procedures are to be performed and how many projections will be taken. Any questions that the patient has should be answered if the dental professional feels capable of doing so. If the question involves diagnostic judgments 201CHAPTER 18 Patient Management and Special ProblemsHowever, these Nomad units have recently been approved for dental use by the U.S. Food and Drug Administration. According to the manufacturers of the Nomad units, these handheld devices have a shield that potentially protects the patient and operator from unnecessary x-ray exposure.Developmental DisabilityPatients who are mentally disabled or have other physical conditions, such as cerebral palsy or autism, and are aicted before the age of 22 (developmental disability) may present a management challenge in a dental facility. Unless there is complete cooperation while exposing dental images, the patient may move and render the radiographs useless. e degree of cooperation varies among patients. Problem situations should be recognized immediately. Repeated attempts may only excite the patient, subject the patient to unnecessary radiation, and prove fruitless. e dental professional should elicit the help of the patient’s caregiver when applicable in obtaining diagnostic radiographs. e dental professional may also opt to take a panoramic or another extraoral projection as opposed to intraoral radio-graphs that require more tolerance and cooperation.For a totally unmanageable patient or one with an extreme physical disability, radiographs may have to be taken with the patient under sedation or general anesthesia. ese lms are usually developed immediately or digital radiography is used, and the necessary dental procedures are performed while the patient is still anesthetized.Hearing Impairmente obvious challenge in treating hearing impaired or deaf patients is communication, as well as realization by the operator of the disability and how it may modify usual procedures. For example, the often-used command to the patient to “hold still” as the operator leaves the room to make an exposure is not applicable for patients with a hearing impairment. Depending on the patient’s method of communication, instructions may have to be given through a translator, sign language, or in writing. Deaf patients can usually read lips, therefore, operators must be sure Also, panoramic and other extraoral equipment have been manufactured to accommodate a patient in a wheelchair, allowing these projections to be useful with this type of patient.Some homebound patients or those bedridden in hos-pitals and long-term care facilities may not be able to visit dental suites; their dental procedures and radiographs must be done at the bedside. In the past, mobile dental x-ray units could be brought to the bed and radiographs taken. For the patient in the supine position, it is easier to use a receptor-holding device with a localizing ring. In treating a patient at home or at a site that does not have a dental x-ray unit, portable x-ray units can be adapted for dental use and assembled on site (Fig. 18.1). If digital radiography is not available, then a small, portable, rapid-processing tank also should be brought along so that the radiographs can be processed and the patient treated during the same visit.With the more recent introduction of the handheld portable dental x-ray machine, it is now possible to produce quality images and have the ability to utilize the unit outside of the dental facility in locations such as remote outreach sites, long-term care facilities, and hospitals. ese units are lightweight and battery powered. e most popular of these systems are the Nomad models (Fig. 18.2). With this system, the receptor (lm or sensor) is positioned in the patient’s mouth while the exposure is made. e opera-tor, while holding the device at chairside, directs it at the receptor in the patient’s mouth and exposes it. e use of this device has raised the question of increased radiation exposure to both the patient and the operator in the past. • Figure 18.1 Portable dental x-ray unit. (From Bird DL, Robinson DS: Modern Dental Assisting, ed 12, St Louis, 2018, Elsevier.)• Figure 18.2 NOMAD Pro 2 handheld x-ray unit. (Courtesy Aribex, Charlotte, NC.) 202 CHAPTER 18 Patient Management and Special Problemsto remove their mask and always face the patients when speaking to them.Vision ImpairmentVisually impaired patients may have to be escorted into the operatory and directed or assisted into the dental chair. Because these patients cannot see what is going on, it is essential that the patient be kept informed of the treatment being rendered and why it is necessary. Patient education is extremely important. e dental professional must remem-ber that the patient may have never seen a radiograph; thus, the explanation may require extra time and thought. An awareness of the disability is ultimately needed to treat visually impaired patients.Pediatric Patientse number and timing of radiographs for pediatric patients is discussed in Chapter 9 of this textbook. Dental radiog-raphy requires the complete cooperation of the patient. If the patient moves, the radiographic image is blurred and the image is rendered useless. In radiography, the patient must hold still while the exposure is made. e unknown is frightening to any child, and very few children know anything about x-rays. In fact, the dental radiograph may be their rst introduction to radiography. e procedure must be explained to the child in terms that the child can easily understand. For example, the radiographer should talk of taking a “picture” of the tooth with a “camera” as opposed to using the terms “x-ray” and “radiography” to explain the procedure. Remind children that they must hold still when the picture is taken. Show children the lm packet or digital sensor and possibly let them put it in their own mouths.Children like to see pictures; it is sometimes helpful to show them what a radiograph of a tooth looks like. e dental professional should follow up with a promise to show them what their teeth look like on the nished radiograph. In certain instances, children have even been taken into the darkroom and allowed to help process the lms. Children are fascinated by the darkroom with its tanks, automatic processing machines, and chemicals. Any eort expended to relax children and make them feel at ease will reap benets at later appointments. If there is lack of cooperation and there is no emergency that requires immediate treatment, radiographs may be postponed to a second visit, in which the children may be more cooperative as they get to feel more at home in the dental oce.Children usually tolerate periapical receptors; the receptor can be held in place with a bite block or any receptor-holding device to perform either the paralleling or bisecting technique. It is advised to use a #0- or #1-sized receptor as opposed to the #2 adult-sized receptor with pediatric patients.In children, it is acceptable to use the bisecting tech-nique. If the child resists periapical receptor placement, have the patient close down on the receptor and increase • Figure 18.3 Technique for periapical projections that allows a child to bite on receptor. Note the increase in vertical angulation. the vertical angulation to bisect the angle so that the pro-cedure resembles an occlusal projection (Fig. 18.3). is type of projection is not as desirable as that obtained by the regular technique, but it is better than no image at all. is method will work for any area of the child’s mouth, and a full-mouth series can be taken this way if necessary. Either an adult-sized or an occlusal receptor can be used for this technique (Fig. 18.4).Reverse BitewingsSome children have diculty tolerating placement of the bitewing projection. When instructed to close on the tab, BA• Figure 18.4 Radiographs taken by having the child bite the recep-tor. A, Adult-sized periapical receptor (note odontoma blocking tooth eruption). B, Occlusal image. 203CHAPTER 18 Patient Management and Special Problemsway, but the central ray is directed from behind the angle of the mandible on the opposite side (Fig. 18.8). Again, the radiograph is not as diagnostic as an intraoral image but is better than none (Fig. 18.9).If there is no extraoral cassette in the oce, an occlusal receptor can be substituted but with the resulting increase of radiation exposure to the patient (Fig. 18.10). e radiograph produced will be of some diagnostic value they push the lower part of the receptor out of the oor of the mouth with their tongue and then close their teeth on the receptor. If after repeated attempts proper place-ment meets with failure, a reverse bitewing technique can be substituted. In this method, the receptor is placed on the cheek side of the teeth in the buccal sulcus (Fig. 18.5). e child bites on the tab to hold the receptor in place, and the radiographer can position the receptor as the patient closes without the hazard of being bitten. e x-ray beam is directed extraorally from under the opposite side of the mandible as in a lateral oblique projection (Fig. 18.6). e resulting image will not have the detail of an intraoral bitewing radiograph but will be a useful substitute (Fig. 18.7).If intraoral receptor placement is not possible for the child, an extraoral projection can be substituted. e view that is most diagnostic is also a slight variation of the lateral oblique technique. e cassette is positioned in the usual • Figure 18.5 Receptor placement for a reverse bitewing radiograph. • Figure 18.6 Tube position for reverse bitewing radiograph. Note that the central ray is directed from underneath the mandible of the opposite side while being aimed at the bitewing receptor. • Figure 18.7 Reverse bitewing radiograph. • Figure 18.8 Lateral oblique technique for detecting caries and pathologic conditions in children. Note that the central ray is aimed from behind the angle of the mandible on the opposite side. • Figure 18.9 Radiograph taken through use of the lateral oblique technique. NOTEWhen the digital radiographic technique is used in a dental facility, it is advised to use the photostimulable phosphor (PSP) plate sensors rather than the direct digital sensors (charge-coupled device [CCD] or complementary metal oxide semiconductor [CMOS]) with pediatric patients. The PSP sensors are thinner and more exible than the CCD or CMOS sensors and are easier placed and better tolerated in the small mouths of pediatric patients. 204 CHAPTER 18 Patient Management and Special Problemsfor stimulation of the gag reex presents more of a problem in intraoral radiography than those who are not quite as hypersensitive.Very few patients, probably fewer than 0.1%, have a gag reex so active that intraoral radiography is virtually impossible. e following are a set of generally accepted suggestions and techniques that can be used to prevent gagging and overcome it when it occurs. Not all techniques are applicable, nor will they prove successful with every patient. e dental radiographer must be able to determine which technique best suits the individual patient. It has been shown that the technique, authority, and self-condence of the operator are major factors in preventing and suppressing gag reexes during dental radiography.Attitudee operator should always maintain the appearance of being well trained and condent when dealing with patients. e patient wants to believe that the operator is so competent that it would be impossible for the receptor to slip and lodge in the throat. Firm positioning of the receptor-holding device with explicit instructions to the patient and proper body language are all necessary.ink positively: Never mention the possibility of gagging. e worst thing the operator can say to a patient is, “is won’t make you gag,” or “Do you gag?” e patient (Fig. 18.11). Box 18.1 provides tips to help a dental profes-sional take radiographs of a pediatric patient.Special ProblemsGaggingOf all the problems one may encounter in intraoral radiog-raphy, gagging is probably the most troublesome. Gagging, more properly referred to as the gag reex, is a body defense mechanism. e coughing and retching produced in the gag reex are meant to expel any foreign body from the throat and thus protect the airway from obstruction. All patients have gag reexes, with some more active and more hypersensitive than others.e two types of stimuli for the gag reex are psy-chogenic and tactile. Some patients start to feel the reex coming on just by thinking about or anticipating the receptor placement. e areas that are most sensitive to tactile stimuli producing the gag reex are the palate, base of the tongue, and posterior wall of the pharynx. Gagging occurs most often during exposure of the maxillary molar projection. e level of excitation of these reexes varies from person to person. e patient with a low threshold • Figure 18.10 Occlusal receptor used as an extraoral receptor. • Figure 18.11 Radiograph produced by using an occlusal receptor extraorally. • BOX 18.1 Helpful Hints for Radiographing the Pediatric Patient1. Be condent. Most children react favorably to the authority of a condent and capable operator. The dental professional must secure the child’s condence, trust, and cooperation. In addition, the dental professional must be patient and not rush through the radiographic procedures.2. Show and tell. The typical pediatric patient is curious. The dental professional can use a “show and tell” approach to prepare the patient for radiographic procedures. Before beginning the procedure, the operator can show the child the equipment and materials that will be used and tell the child what will happen. The child should be encouraged to touch the tube head, receptor holder, and lead apron.3. Reassure the patient. Children usually fear the unknown. The operator should reassure the patient and allay any fears about the procedures to prevent the uncooperative behavior of a frightened child.4. Demonstrate behavior. The operator should demonstrate the desired behavior to show the child exactly what to do. For example, the radiographer can demonstrate “how to hold still” and then ask the child to do the same thing.5. Request assistance. If a child cannot hold still or stabilize the receptor, the dental professional can ask the parent or accompanying adult to provide assistance. The adult can hold the receptor or the child during the exposure while wearing a lead glove, apron, and thyroid collar.6. Postpone the examination. Only in emergencies and under general anesthesia should a child be forced to undergo a radiographic examination. It is much better to postpone the examination until the second or third visit rather than instill a fear of visiting the dental ofce. 205CHAPTER 18 Patient Management and Special ProblemsBite Blocks and Receptor-Holding DevicesAny receptor-holding device that requires the patient to bite and maintain pressure also may help to prevent gagging. Again, the patient is given something positive to do. Another tactile sensation, that of biting and the pressure of the bite block against the teeth, may distract the patient from thoughts of gagging.Lozenges, Gargles, and SpraysLozenges, gargles, and sprays may be of some help in certain situations. e key is to make the patient believe that these over-the-counter antidotes will have an eect. is placebo eect has been seen in many other areas of dental practice.Many viscous topical anesthetics (e.g., Cetacaine) are available for rinsing the mouth, gargling, or spraying the palate to produce a numbing sensation, intended to block the gag reex. An undiluted mouthwash with high alcohol concentration may have some anesthetic eects on the palate. Many cough lozenges contain some local anesthetic; having the patient suck on a lozenge before radiography may be helpful. In all these cases, it may not be so much the anesthetic vehicle used as the manner of presentation to the patient that produces the desired results.HypnosisAlthough the practice of hypnosis is out of the province of the dental professional, its use in dentistry should be mentioned. In intractable gaggers, hypnosis by trained, competent practitioners may be necessary to permit intra-oral radiography.Convincing a patient that something (such as, gagging) may not occur can be considered a form of hypnosis. An application of this principle is to tell gagging patients that the anti-gag nerve located in their neck or the temple is going to be pressed or tapped. ere is no anti-gag nerve, and the temple does not control gagging either. However, the patient may not know this. If the area in the neck is pressed hard or the radiographer taps three times on the temple, some sensation will result, and the patient may become convinced that gagging will not occur. e power of suggestion often serves to foster the patient’s mind control over the matter at hand. It also helps to tell patients that they could have control over the gag reex themselves; often, this suggestion causes the patient to gain the control needed to suppress the gag reex.SaltOne of the more amusing techniques described in the lit-erature to stop gagging is to place ordinary table salt on the tip of the tongue of the gagging patient. e salt is placed in the palm of the patient’s hand; the patient is asked to touch the tip of the tongue to the salt and then raise the tongue to touch the palate. is method may be worth trying at least once in one’s professional career.For the intractable gagger, when all else fails, one must then resort to accessory techniques. Panoramic projections and other extraoral projections, previously discussed, may never have thought of gagging until reminded of the possibility.Film Order and TechniqueWhen taking a radiographic survey, the dental professional should start taking the anterior projections rst and working posteriorly. e receptor placement in the maxillary molar area is the one most likely to excite the gag reex. Once the reex is excited, the patient may continue to gag even on anterior projections.It is recommended to start the radiographic sequence as close to the midline as possible even when the radiographic prescription is for four bitewings only. It is advised to start with the premolar bitewings before exposing the molar bitewings.When placing the receptor in the patient’s mouth for maxillary molars and premolars, one should not slide the receptor along the palate. e receptor is placed in the desired position near the lingual surface of the teeth. en, with one decisive motion, the receptor is brought into contact with the palate.e exposure time for the desired exposure is always set before the receptor is placed in the patient’s mouth. e tube head is positioned on the side of the patient’s face that is to be radiographed, with the position-indicating device (PID) at the approximate vertical angulation. e object is to minimize the amount of time that the receptor has to remain in the patient’s mouth. Preparations like these can save valuable seconds and lessen the likelihood of the patient gagging. Generally, the longer the receptor stays in the mouth, the greater the likelihood of gagging.Deep BreathingIt is often helpful to instruct the patient to take deep breaths through the nose as the receptor is placed and remains in a gag-sensitive area, such as the palate. Why this works is debatable, but it may be that breathing through the nose prevents the rush of air across the sensitive tissues of the palate. Another explanation is that it gives the patient something to do and distracts the patient from thinking about gagging. e operator should use a rm tone of voice when instructing the patient to take these deep breaths and also may take some audible deep breaths to encourage the patient to do likewise. It is also advisable to instruct the patient to keep their eyes open during the procedure. is serves as a distraction as well, keeping the patient’s mind o gagging.HELPFUL HINTIt also helps to tell patients to keep their eyes open and not to close them when the receptor is placed and remains in their mouth. Patients who have a hypersensitive gag reex have a tendency to immediately close their eyes during the radiographic procedure. This does not allow for any distraction and helps to keep the patient’s thoughts focused on gagging. 206 CHAPTER 18 Patient Management and Special Problemsdenition. Because an intraoral receptor is positioned lin-gually in the patient’s mouth, the superimposed structure that is more sharply dened is positioned lingually in rela-tion to the other structures (Fig. 18.14). An advantage of this technique, when compared with the others that follow, is that it requires no further x-ray exposures of the patient. It is, however, the least reliable of the techniques mentioned and is not recommended.Tube Shifte tube shift method uses what is referred to as Clark’s rule, or the buccal-object rule (Figs. 18.15 and 18.16). Its advantage to the practitioner is that it can be accomplished by using a standard periapical technique. To determine the relative buccolingual relationship between two structures that appear radiographically superimposed, a second radio-graph is taken with a dierent horizontal angulation (or a horizontal tube shift). All factors remain the same for the second exposure, except that the tube is shifted about 20 degrees either mesially or distally. e point of entry, receptor position, and vertical angulation remain the same as in the previous projection. When the two radiographs are compared, the buccal object appears to have moved in the opposite direction from the direction of the tube shift when because of their extraoral receptor placement circumvent the gag reex.Localization ProblemsStandard intraoral periapical and bitewing images show the teeth and bone in only two planes: superoinferior and anteroposterior. However, many clinical situations require a proper radiographic diagnosis to establish the position of structures in the buccolingual plane. Clinical examples include localization of impactions, foreign bodies, and areas of pathologic ndings, as well as dierentiating buccal and palatal roots in endodontic procedures (Figs. 18.12 and 18.13). is information is essential to the dentist before any treatment can be instituted.e four techniques that can be used for localization are (1) denition evaluation, (2) tube shift, (3) right-angle tech-nique, and (4) pantomography (panoramic radiography).Denition EvaluationStructures that lie closer to the receptor have better radio-graphic denition than those that are farther from the recep-tor. is is true for both intraoral and extraoral lms. It is sometimes possible, depending on the quality of the radio-graph, to determine the relative position of superimposed structures by determining which has better radiographic • Figure 18.12 Impacted maxillary canine. Is the tooth positioned buccally or palatally to the alveolar ridge? • Figure 18.13 Maxillary rst premolar with endodontic lling. Which canal is buccal and which is palatal? • Figure 18.14 Localization by denition. Is the impacted supernu-merary tooth more clearly dened than the rest of the teeth? If not, it is probably positioned buccally. AABB• Figure 18.15 Buccal-object rule. As the tube position is shifted mesially (position B), the buccal object is seen to move relatively in the opposite direction, distally. 207CHAPTER 18 Patient Management and Special Problemstwice (once on each half of the image). A recommended technique is to compare the relative movement of the object with adjacent structures from one side of the image to the other with the direction that the clinician reads the image (e.g., left to right). e object seems to move in the same direction as the clinician’s viewing movement if it is lingually positioned and in the opposite direction if it is on the buccal side (Fig. 18.17).Third Molar Problemse third molars are in an area of the mouth that is dif-cult to radiograph. In many cases, it may not be possible to position the receptor intraorally to visualize these areas adequately on radiographs. is is especially true if the teeth are impacted. In these cases, it may be necessary to use the extraoral and panoramic techniques described in Chapters 12 and 13. e entire third molar area must be seen to make a complete diagnosis. is means that the entire tooth and at least 3 mm of surrounding bone in every direction must be imaged. If it cannot be seen on periapical projections, other methods must be used.MaxillaAs the receptor is placed increasingly more distally toward the patient’s throat, the likelihood of exciting the gag reex increases. It may be helpful to hold the receptor with a hemostat to maintain a minimum of contact with the palate. e receptor should be kept as parallel to the palatal vault as possible. To avoid distortion, the vertical angula-tion must be increased, with the resulting relationship of the central ray to the receptor looking very much like an occlusal projection.Mandiblee most common diculty in radiographing lower third molars is the inability to place the receptor distal enough to record the image of the whole tooth and root structure. is placement is prevented by the muscles of the oor of the mouth and tongue. To overcome this problem, the tongue can be deected to the opposite side of the mouth by the operator’s nger or a mouth mirror. e oor of the mouth is gently depressed, almost massaged, to relax the mylohyoid compared with other structures on the radiograph (see Figs. 18.15 and 18.16). If the tube is shifted mesially by chang-ing the horizontal angulation, the buccal object appears to have moved distally. Conversely, a distal shift results in the more buccal object moving mesially. Furthermore, if on the second radiograph the object does not appear to move after the tube is shifted horizontally, the object is said to be situated more lingually. is can be demonstrated on the ngers by holding the hand so that the second and third ngers are superimposed when sighting them from the side. Move the head either to the left or to the right (mesially or distally) and imagine the images of the ngers being recorded on the receptor. Two distinct ngers can now be seen and not the ngers superimposed. Now, apply the buccal-object rule. e key phrase is “same lingual, opposite buccal;” the acronym is SLOB. is procedure can also be applied to objects for use in the superior inferior plane.Right-Angle Techniquee right-angle technique uses two projections taken at right angles to each other—rst, a periapical projection and then an occlusal projection of the same area, for exam-ple. e planes radiographed are at right angles to each other. e occlusal techniques and examples are discussed in Chapter 10.Pantomographye redundant images produced in the anterior region by some older-model pantomographic units, such as the Panorex, can be used to localize objects in repeated areas. In viewing the image, the object in question will be seen BA• Figure 18.16 A and B, Radiographs illustrating the buccal-object rule. The tube in B was shifted mesially, indicating that the short endodontic point is in the mesiobuccal canal. • Figure 18.17 Localization of an object by a pantomographic redundant image. 208 CHAPTER 18 Patient Management and Special Problemsthere is the greatest palatal height. e number of times that the paralleling technique cannot be used is quite small.e bisecting-angle technique compensates for the shallow palate by increasing the vertical angulation. e receptor must be in the patient’s mouth with a 3-mm border projecting beneath the incisal or occlusal edge of the teeth and the central ray bisecting the angle formed between the receptor and the long axis of the tooth (Fig. 18.20). As an alternative, the operator may choose to change the receptor size.Lingual FrenulumIt is extremely dicult to radiograph patients who have a large, tight, lingual frenulum attached close to the tip of the tongue. ese patients are sometimes referred to as “tongue-tied,” because they cannot protrude their tongues very far out of their mouths.e paralleling technique is not the method of choice for these patients, because the tight frenulum does not allow placement of the receptor deep in the oor of the mouth. One option is to use the bisecting technique. Because the receptor cannot be placed very deep in the mouth, negative vertical angulations in the range of −40 to −60 degrees can be expected. Another option is to hold the receptor at an angle and, as the patient starts to close and the mylohyoid muscle relaxes, to slowly place the receptor in a more upright, parallel position.Torie maxillary torus (torus palatinus), if present, usually causes no problems in periapical radiography. It is located muscle. While this is being done, the receptor is slid along the lingual surface of the mandible as far distally as possible. In certain horizontal impactions of the mandible, it may be necessary to distort the image in the horizontal plane to visualize the entire tooth with intraoral radiography. is is done by changing the horizontal angulation of the x-ray beam so that it is not at right angles to the receptor, which is the usual procedure. Instead, the beam comes from the distal side, and the central ray makes an acute angle with the receptor.Receptor Placement ProblemsNarrow ArchIn some mouths, it may be impossible to place anterior re-ceptors properly without excessive bending, with resultant distortion of the radiographic image. is is a major prob-lem when using direct digital radiography with its rigid sensor. e best way to overcome this problem is to vary the receptor size. e #1 narrow anterior receptor is recom-mended, although it may be necessary to use #0. ere is no rule stating that one cannot use dierent-sized intraoral re-ceptors in the same full-mouth series. Pediatric or narrow receptors may be used as the situation dictates (Fig. 18.18).If radiographs show overlapping teeth, especially in the anterior region, it does not necessarily indicate that the images were taken improperly. If the teeth are overlapped in the mouth, they appear overlapped radiographically.Shallow Palatee shallow palatal vault presents a problem in the paral-leling technique. Fortunately, this does not occur so often and severely that the bony structures make it impossible to place the receptor parallel to the long axis of the tooth and high enough to record the radiographic image (Fig. 18.19). In these rare cases, the bisecting-angle technique may be the better choice. Before changing techniques, one should always check to see that the receptor is in the midline, where BA• Figure 18.18 Periapical radiographs of the lower anterior region using a narrow anterior (#1) receptor seen in A and pediatric size (#0) receptor seen in B. • Figure 18.19 Problem of receptor placement in paralleling tech-nique with patients who have low palatal vaults. Note that the receptor cannot be placed high enough to record the image of the root apices. Central rayReceptor• Figure 18.20 Vertical angulation overcomes the problem of a low palatal vault in the bisecting-angle technique. 209CHAPTER 18 Patient Management and Special Problemsby the large palatal cusp of the rst premolar. e problem can be solved by changing the horizontal angulation so that the central ray comes more from the distal side, as in a premolar periapical projection (Fig. 18.21). en, the palatal cusp is not superimposed. Overlapping does not occur in the mandible, because the rst premolar has a very small lingual cusp.TrismusTrismus is the condition in which a patient is unable to open the mouth. It may be partial or complete and is usually caused by infection or trauma. To make an adequate diag-nosis and identify the infected tooth or area, radiographs are necessary. If the patient’s mouth cannot be opened at all, extraoral or panoramic projections are necessary. If there is partial opening, it may be possible to place an intraoral receptor by modifying the usual technique. A hemostat is used to hold the receptor, because it is much narrower than a receptor-holding device. e receptor is placed in the mouth by sliding it between the partially opened anterior teeth in the horizontal plane. Once beyond the teeth, the posteriorly in the midline of the palate and does not hinder periapical placement. e best way to radiograph a torus palatinus is by use of an occlusal projection.e mandibular tori—or torus, as the case may be—are located on the lingual aspect of the mandible in the premo-lar area. eir presence prevents the placement of the recep-tor in its usual position. is diculty is more accentuated in the bisecting-angle technique than in the paralleling tech-nique. e receptor cannot be depressed into the oor of the mouth and still be kept close to the lingual surface of the teeth. e only possible solution is to place the recep-tor over the torus. is increases the angle between the re-ceptor and the long axis of the tooth; increasing the vertical angulation to bisect the angle compensates for the change. In the paralleling method, with its increased object-lm dis-tances, the receptor is positioned behind the tori.Canine OverlapOverlapping the image of the mesial portion of the maxil-lary rst premolar with the image of the distal surface of the canine is a common problem. e overlapping is caused CBAACanineoverlapBBA• Figure 18.21 A, Changing horizontal angulation to prevent distal overlap of maxillary canine. B, Overlapped canine. C, Overlapping eliminated. 210 CHAPTER 18 Patient Management and Special Problemsmeasurement grids are available that superimpose thin radi-opaque or radiolucent lines in the vertical and horizontal planes in 1-mm gradations (Figs. 18.24 and 18.25). e marking grid is axed to the front of the receptor when the exposure is made. No increase in exposure is necessary with the use of the marking grid. e measurement or receptor can be turned to its proper vertical orientation. If possible, the patient then holds the hemostat with the recep-tor attached to it in position while the exposure is made.Endodontic ProblemsIn patients undergoing endodontic treatment, it is necessary to take working and measurement images while the rubber dam is in place. e bisecting method can be used, with the patient supporting the receptor under the rubber dam with a bite block, but it is not recommended. Using the paralleling method with the dam in place is dicult because of the lack of working space in the mouth and the patient’s inability to bite on any receptor-holding device, because of the presence of the rubber dam clamp and protrud-ing endodontic les from the tooth. e best course is to disengage the rubber dam frame, keeping the saliva ejector in place, and position the receptor in a hemostat or “Snap-a-Ray” parallel to the tooth and held by the patient. is is especially true for digital radiography in which the sensor is thicker and more rigid than lm. Care should be taken with the sensor-holding device not to damage the fragile sensor. ere are also special receptor-holding devices with localizing rings that have an open bite piece to allow for the les and gutta percha to go through that are made specically for endodontic radiography (Fig. 18.22).Plastic rubber dam frames and saliva ejectors should be used to prevent superimposition of their images on the radiograph (Fig. 18.23). Punching a hole in a predetermined corner of the dam makes it easier to reorient the dam in the frame once the exposure has been made.To save time and not have the patient sit in the chair with the rubber dam in place, rapid processing, as discussed in Chapter 11, can minimize working time and can be adequately diagnostic in endodontic working lms.Digital radiography with its instantaneous image forma-tion is a very fast and eective approach to endodontic radiography. e working image is obtained quickly and is stored for archival life.Grid MeasurementSome dentists use grid markings to quantify and evaluate bone levels or for endodontic measurements. Intraoral • Figure 18.22 Endodontic receptor-holding device with localizing ring. • Figure 18.23 Radiograph with superimposition of rubber dam frame. • Figure 18.24 Intraoral grid placed on dental receptor. • Figure 18.25 Radiograph with grid markings. 211CHAPTER 18 Patient Management and Special Problemse technique of sialography involves injecting radi-opaque media into salivary ducts and glands and then visualizing these soft tissues radiographically. is method is used in diagnosing ductal and glandular obstructions, salivary stones, infections, and tumors of the major salivary glands. e contrast medium used is usually an iodine-containing formula in either an aqueous or oil suspension (Fig. 18.27). Contrast media are also used in radiograph-ing the temporomandibular joint (TMJ) to visualize the articular disc with a procedure called arthrography (Fig. 18.28). Because the disc is brocartilage, it is not seen on radiographs; but if a radiopaque medium is injected into the upper and lower joint spaces, then the void between them represents the articular disc (see Chapter 14).marking grid should not be confused with the grid used in extraoral projections (see Chapter 13) to absorb object scatter. Furthermore, in digital radiography, endodontic measurement is easily accomplished directly through use of the corresponding computer program.Radiopaque Mediae use of radiopaque media has many applications in dental practice. It is used routinely in endodontics, with the radiopaque le, to determine root length. Gutta-percha or silver points can be placed in periodontal soft tissue pockets to determine pocket depth and direction. Fistulous tracts can be traced to their origin using thin, exible wire or gutta-percha points (Fig. 18.26).• Figure 18.26 Fistulous tract traced back from palatal opening to its origin by insertion of gutta-percha point. • Figure 18.27 Sialograph outlining submandibular duct and gland. • Figure 18.28 Arthrography of the temporomandibular joint (TMJ) in the closed (A) and open (B) positions. Note the radiolucent space between radiopaque areas that represents the articular disk. 212 CHAPTER 18 Patient Management and Special ProblemsSewrine I: Gagging in dental radiography, Oral Surg Oral Med Oral Pathol 58:725–728, 1984.White SC, Pharoah MJ: Oral radiology: Principles and interpretation, ed 7, St Louis, MO, 2013, Mosby.BibliographyIannucci JM, Howerton LJ: Dental radiography: Principles and tech-niques, ed 5, St Louis, MO, 2016, Elsevier Saunders.Chapter Summary• Dentalimagingtechniquesmaybemodiedtoaccom-modate patients with physical and developmental dis-abilities, including those patients with mobility, hearing, or vision impairment.• Pediatric patients have special needs when managingthem in the dental oce, including technique modica-tions when exposing intraoral and extraoral radiographs on them. Care should be taken to gain pediatric patients’ condence when explaining procedures and helping them to feel comfortable in the dental oce setting• All patients have a “gag reex;” however, this bodydefense mechanism is more sensitive in some patients than in others. ere are various ways to manage patients with hypersensitive gag reexes, including those that concern the operator’s attitude, the exposure sequence and radiographic technique, deep breathing through the nasal cavity, and others.• Other special-needs situationsexist in dental radiogra-phy, including localization, third molar, and endodontic issues. It is necessary for the dental radiographer to know the appropriate remedies for these issues and to learn how to modify their patient management techniques accordingly.Chapter Review QuestionsMultiple Choice1. e gag reex is: a. Always more active with posterior projections b. Resolved with slow, deep breathing c. A body defense mechanism d. Both a and c only e. Answers a, b, and c are all correct2. A reversed bitewing is usually used when: a. An adult patient gags b. A pediatric patient constantly cries c. A pediatric patient is not sitting in the chair properly d. An adult patient does not want radiographs e. A pediatric patient consistently moves the bitewing receptor out of the mouth with their tongue3. e SLOB rule states that objects that move in the same direction when a second radiograph is taken for localization are usually positioned: a. Mesially in the mouth b. Lingually in the mouth c. Distally in the mouth d. Bucally in the mouth e. All of the above are incorrect answers4. e best way to radiograph an impacted third molar is to: a. Ask the patient to hold the receptor with their nger to place it in the most posterior position possible b. Take a panoramic radiograph c. Use a bitewing projection d. Take an intraoral photograph e. Both a or c are acceptable techniques to capture impacted third molars on a radiographic image5. When managing patients with a hearing impairment, the dental professional should: a. Face the patients when speaking to them b. Remove their mask when speaking to them c. Turn their backs on the patients when speaking to them d. Use sign language when communicating with them e. All of the above except c are acceptable answersCritical Thinking Exercise1. e oce that you are employed in wants to publish a manual for the sta describing the technique modica-tions needed when exposing radiographs on patients with special needs. e oce manager is asking for input from every member of the dental team. Your task is to list the suggested management techniques for each of the following special-needs situations: a. Endodontic radiographs b. Localization techniques c. Patients with anatomic constraints, such as a narrow arch, shallow palate, tight lingual frenum, tori, or trismus d. Hypersensitive gag reex e. Pediatric patients f. Vision impairment g. Hearing impairment h. Mobility constraints

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