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Extraoral x-ray film continues to evolve, improve.

The technology used for extraoral dental imaging is as old as the discovery of x-rays. Yet today, imaging scientists are still perfecting extraoral radiography radiography: see X ray. . They are finding new ways to improve its diagnostic qualities while, at the same time, reducing radiation exposure levels.

To understand how researchers continue to perfect this technology, it's helpful to review its history.

Fluorescence Discovered

Extraoral x-ray systems don't rely on exposing x-ray film directly. Instead, they are created by exposing x-ray film to visible light, in much the same way regular 35 mm film is exposed.

With x-rays, however, the light is created through a process called fluorescence. Fluorescence occurs when molecules struck by radiation of one wavelength become excited and emit radiation of a different wavelength.

Fluorescence created by x-ray radiation was discovered in 1895 in Wurzburg, Germany, by physicist Wilhelm Conrad Roentgen roentgen /roent·gen/ (rent´gen) the international unit of x- or ?-radiation; it is the quantity of x- or ?-radiation such that the associated corpuscular emission per 0. . Roentgen was experimenting with vacuum tubes in a dim room when he noticed that a nearby plate, that had been coated with barium platinocyanide plat·i·no·cy·a·nide  
A double salt of platinous cyanide and another cyanide.
, began to glow. When he moved the vacuum tube nearer to the plate, the material glowed more brightly, even if he covered the tube with black paper.

It was this experiment that led Roentgen to the discovery of x-rays, because he knew that some invisible energy was causing the fluorescent effect.

The First Screen Radiograph radiograph /ra·dio·graph/ (-graf?) the film produced by radiography.


It wasn't long after Roentgen's discovery that the first film/screen radiograph was made by Professor Michael Putin of Columbia University. In 1896, Putin sandwiched a film against a fluorescent intensifying screen intensifying screen,
n See screen, intensifying.

intensity of a radiographic beam,
n the amount of energy in a radiographic beam per unit volume or area.
 and x-rayed a hand.

Figure 1: First radiograph made using a fluorescent screen fluorescent screen,
n See screen, intensifying.
 in combination with a film, 1896. (Image originally published in the 1997 book, The Basics of Film Processing in Medical Imaging, by Art G. Haus and Susan Jaskulski ISBN ISBN
International Standard Book Number

ISBN International Standard Book Number

ISBN n abbr (= International Standard Book Number) → ISBN m 
 0-944838-78-2. Reprinted with permission.)


The process Putin used is identical to the way extraoral radiographs are exposed today: fluorescent light generated by the screen amplified the remnant x-rays that passed through the tissues and other structures of the hand. Most significantly, by using an intensifying screen, Putin was able to create the image with an exposure of only several seconds--a far shorter exposure than would have been required to expose the film using direct x-rays.

Further research on fluorescent materials was conducted by Thomas A. Edison that same year. Edison and his associate tested 8500 different materials, identifying about 1800 as fluorescent. One of these materials, calcium tungstate tung·state  
A salt of tungstic acid.

Noun 1. tungstate - a salt of tungstic acid
salt - a compound formed by replacing hydrogen in an acid by a metal (or a radical that acts like a metal)
, was found to fluoresce fluo·resce  
intr.v. fluo·resced, fluo·resc·ing, fluo·resc·es
To undergo, produce, or show fluorescence.

[Back-formation from fluorescence.
 with approximately six times the intensity of barium platinocyanide.

In 1918, the first commercial x-ray film was introduced, followed shortly by a double emulsion product. This was the foundation of modern extraoral radiography.

How Screen Cassettes Work

Extraoral radiograph screen-film systems are constructed using a piece of double-coated x-ray film: the film is sensitized sensitized /sen·si·tized/ (sen´si-tizd) rendered sensitive.


rendered sensitive.

sensitized cells
see sensitization (2).
 to light on both sides. This film is placed between two layers of phosphor A rare earth material used to coat the inside face of a CRT. When struck by an electron beam, the phosphor emits a visible light for a few milliseconds. In color displays, red, green and blue phosphor dots are grouped as a cluster. See screen burn.  material (Fig. 2). When the x-ray radiation strikes the object to be imaged, some of it is absorbed, some of it is blocked and some passes through, depending on how thick the object is and its other qualities. Amalgam, for example, blocks most radiation that strikes it, whereas soft tissue permits most radiation to pass through unobstructed.


The radiation that passes through the object strikes the phosphor layers of the screen, causing them to fluoresce, which in turn exposes the film. The more radiation striking the cassette, the greater the density or darkness created on the corresponding section of the film.

Using screens for extraoral radiography allows an image to be formed using far less radiation than would be required to expose the film directly. In fact, to get the same density without screens, exposure would have to be increased by 200-600 times.

Manufacturers that design film/screen systems have learned a great deal about how to deliver the highest possible image quality. Great care must be taken, for example, to coat the screen phosphors uniformly during manufacture. The film itself must be designed so that it is precisely sensitized to the light emitted by the chosen phosphorous phos·pho·rous
Of, relating to, or containing phosphorus, especially with a valence of 3 or a valence lower than that of a comparable phosphoric compound.

In addition, the cassette system itself must do two things. It must prevent any ambient "room" light from reaching the film after it's been loaded. Second, it must exert uniform contact between the screen and the film. It's a good practice to check screen/film contact annually using a wire mesh test imaging protocol.

Good quality cassettes also have a lead foil backing (Fig. 3). This helps reduce a phenomenon called "backscatter backscatter

in radiology, radiation deflected by scattering processes at angles greater than 90 degrees to the original direction of the beam of radiation. Important in radiotherapy when estimating surface exposure dose.
." Backscatter is caused when x-ray radiation passes through the cassette, bounces and reenters the cassette. It forms unwanted, nondiagnostic density on the film that manifests as a veil of fog. Some cassettes sold as "lightweight" unfortunately are built without a lead backing. While they are lighter, they sacrifice image quality and should be avoided.


Cassettes must also be handled carefully. Cleaning screens with the wrong solvent, exposing them to nail polish, or even scratching them, can render them unusable. With care, however, a screen can last for five years or more.

"Blue" and "Green" Screens

Today there are two types of extraoral film-screen systems, commonly referred to according to the color of the visible light emitted by their fluorescent materials. Blue-emitting screens use materials such as calcium tungstate and have been in use since the 19th century. When exposed to x-ray radiation, these screens give off visible blue light.

In the 1970s, experiments were conducted with "rare-earth" or green-emitting phosphors, including lanthanum lanthanum (lăn`thənəm) [Gr.,=to lie hidden], metallic chemical element; symbol La; at. no. 57; at. wt. 138.9055; m.p. about 920°C;; b.p. about 3,460°C;; sp. gr. 6.19 at 25°C;; valence +3.  and gadolinium gadolinium (gădəlĭn`ēəm), metallic chemical element; symbol Gd; at. no. 64; at. wt. 157.25; m.p. 1,312°C;; b.p. 3,233°C;; sp. gr. 7.898 at 25°C;; valence +3. . Imaging scientists immediately recognized the value of this type of fluorescent material: for every 100 units of x-ray radiation, the old blue screens emit five units of visible light, while the new materials emit 18 units of visible light (Fig. 4). This increase in efficiency enabled a substantial reduction in x-ray exposure levels without compromising image quality, and x-ray film manufacturers moved quickly to develop x-ray film that was sensitized to green light.


Today, as a result, dental offices that use a green-emitting screen system expose their patients to one-half the radiation as those that continue to use the older "blue" screen systems (Fig. 5).


Reducing "Crossover"

Cutting exposure levels was one important modern innovation in extraoral x-ray film. The other was the development of new barriers in the film/screen system to reduce a phenomenon called "crossover."

To understand what creates crossover, remember that extraoral x-ray film is double-sided. The reason for this is to maximize the benefit of the fluorescence step of the exposure process. Imaging scientists need to balance two factors: the thicker the fluorescent layer, the more light is emitted, which exposes the film faster and more effectively. However, light photons tend to scatter; therefore, thicker fluorescent layers can cause a diffusing of the light which in turn reduces the sharpness of the diagnostic image (Fig. 6).


Scientists discovered long ago that two thin fluorescent layers deliver the benefit of a single thicker layer, without as much scattering. However, some scattering does occur as light from one fluorescent layer passes through the film base; this creates unwanted exposure and reduces the clarity of the diagnostic image.

In 2001, Kodak introduced a new generation of extraoral film, Kodak Ektavision Extraoral Imaging Film, that uses crossover barriers--an absorbing dye layered in the film--to reduce this unwanted exposure by 97 percent. Since this film was introduced, clinicians have reported a noticeable improvement in image clarity and detail (Fig. 7).


Switching to Green

With improvements in extraoral film technology continuing into the 21st century, there are more film choices available for today's dental practice than ever before.

If your practice is using a blue screen system, you should seriously consider upgrading to green screen technology. Upgrading involves changing both the screens and the film together since one must be changed at the same time as the other.

Switching is economical and simple. For newer x-ray units, simply reduce exposure times by 50 percent after the new screens have been installed. For older x-ray units that will not allow such a big exposure reduction, purchase an inexpensive beam filter kit and install it in the port of the x-ray tube X-ray tube

An electronic device used for the generation of x-rays. X-rays are produced in the x-ray tube by accelerating electrons to a high velocity by an electrostatic field and then suddenly stopping them by collision with a solid body, the so-called
 head. Your exposure will be cut by 50 percent automatically. With these simple steps, you'll reduce radiation exposures significantly, a great enhancement to your practice's standards of care Standards of care are medical or psychological treatment guidelines, and can be general or specific. They specify appropriate treatment protocols based on scientific evidence, and collaboration between medical and/or psychological professionals involved in the treatment of a given .

In addition, take the time to educate yourself and your office about the newer extraoral film products. Today, dental professionals are becoming aware of the important role extraoral imaging can play in quality patient care. Researchers have shown that extraoral imaging not only allows dentists to visualize dentition dentition, kind, number, and arrangement of the teeth of humans and other animals. During the course of evolution, teeth were derived from bony body scales similar to the placoid scales on the skin of modern sharks. , but also to flag a variety of other pathology, ranging from lesions to metabolic disorders, even carotid artery carotid artery
1. An artery that originates on the right from the brachiocephalic artery and on the left from the aortic arch, runs upward into the neck and divides opposite the upper border of the thyroid cartilage, with the external and
 blockages. (1,2,3,4) For this reason, it's more important than ever to select a film-screen system that does the best possible job of producing sharp, high-contrast images.


(1.) Tetradis, S, Kantor, ML: Prevalence of skeletal and dental anomalies and normal variants seen in cephalometric and other radiographs of orthodontic orthodontic (ôr´thdän´tik),
 patients. Am J Orthod Dentofacial Orthop, 166(5):572-7, 1999.

(2.) Carillo R, Morales A, Rodriguez, Peralto, JL et al. Benign fibro-osseous lesions in Paget's disease Paget's disease
1. A disease, occurring chiefly in old age, in which the bones become enlarged and weakened, often resulting in fracture or deformation. Also called osteitis deformans.

 of the jaws. Oral Surg, Oral Med, Oral Pathol, 71:588-92, 1991.

(3.) O'Carroll MK, Krolls SO, Mosca NG, Metastatic Metastatic
The term used to describe a secondary cancer, or one that has spread from one area of the body to another.

Mentioned in: Coagulation Disorders


pertaining to or of the nature of a metastasis.
 carcinoma to the mandible mandible /man·di·ble/ (man´di-b'l) the horseshoe-shaped bone forming the lower jaw, articulating with the skull at the temporomandibular joint.mandib´ular

: report of two cases. Oral Surg, Oral Med, Oral Pathol, 76:368-374, 1993.

(4.) Friedlander AH, Gratt BM, Panoramic dental radiography as an aid in detecting patients at risk for stroke, J Oral Maxillofac Surg 1994 Dec;52(12):1257-62.

(Note: Kodak and Ektavision are trademarks of Eastman Kodak Company.)

For more information such as this or on other current topics, visit the dental hygienist/assistants section of the Kodak website at, or subscribe online to the Kodak dental e-newsletter.

Tony Rostron R.T.C.I.M., is Western U.S. Channel Manager, Dental Business Division, Eastman Kodak Company. He is a graduate of the Medical Radiography Technologist program, McGill University, and of the Canadian Institute of Management This article or section is written like an .
Please help [ rewrite this article] from a neutral point of view.
Mark blatant advertising for , using .
, University of Toronto Research at the University of Toronto has been responsible for the world's first electronic heart pacemaker, artificial larynx, single-lung transplant, nerve transplant, artificial pancreas, chemical laser, G-suit, the first practical electron microscope, the first cloning of T-cells, . His background includes the London Polytechnic Institute of Photography, past presidency of the Society for Non Destructive Testing (Canada), former Canadian and U.S. Regional Manager for Eastman Kodak's Medical Imaging Division, and a continuing education continuing education: see adult education.
continuing education
 or adult education

Any form of learning provided for adults. In the U.S. the University of Wisconsin was the first academic institution to offer such programs (1904).
 provider for the California Dental Association.
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No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Rostron, Tony
Publication:The Dental Assistant
Date:Sep 1, 2003
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