DENTAL RADIOGRAPHIC EXAMINATIONS: RECOMMENDATIONS FOR
PATIENT SELECTION AND LIMITING RADIATION EXPOSURE
REVISED: 2012
AMERICAN DENTAL ASSOCIATION
Council on Scientific Affairs
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Food and Drug Administration
,TABLE OF CONTENTS
Background............................................................................................................................ 1
Introduction ............................................................................................................................ 1
Patient Selection Criteria ...................................................................................................... 2
Recommendations for Prescribing Dental Radiographs ......................................... 5
Explanation of Recommendations for Prescribing Dental Radiographs ................ 8
New Patient Being Evaluated for Oral Diseases............................................ 8
Recall Patient with Clinical Caries or Increased Risk for Caries ............... 11
Recall Patient (Edentulous Adult) ................................................................. 11
Recall Patient with No Clinical Caries and No Increased Risk for Caries . 11
Recall Patient with Periodontal Disease ...................................................... 12
Patient (New and Recall) for Monitoring Growth and Development .......... 13
Patients with Other Circumstances .............................................................. 14
Limiting Radiation Exposure .............................................................................................. 14
Receptor Selection ................................................................................................... 14
Receptor Holders ...................................................................................................... 15
Collimation ................................................................................................................ 15
Operating Potential and Exposure Time ................................................................. 16
Patient Shielding and Positioning ........................................................................... 16
Operator Protection .................................................................................................. 16
Hand-held X-ray Units .............................................................................................. 17
Film Exposure and Processing................................................................................ 17
Quality Assurance .................................................................................................... 17
Technique Charts/Protocols .................................................................................... 18
Radiation Risk Communication ............................................................................... 18
Training and Education ............................................................................................ 20
Conclusion ........................................................................................................................... 20
References ........................................................................................................................... 21
, DENTAL RADIOGRAPHIC EXAMINATIONS: RECOMMENDATIONS FOR PATIENT
SELECTION AND LIMITING RADIATION EXPOSURE
BACKGROUND
The dental profession is committed to delivering the highest quality of care to each of its
individual patients and applying advancements in technology and science to continually
improve the oral health status of the U.S. population. These guidelines were developed
to serve as an adjunct to the dentist’s professional judgment of how to best use
diagnostic imaging for each patient. Radiographs can help the dental practitioner
evaluate and definitively diagnose many oral diseases and conditions. However, the
dentist must weigh the benefits of taking dental radiographs against the risk of exposing
a patient to x-rays, the effects of which accumulate from multiple sources over time.
The dentist, knowing the patient’s health history and vulnerability to oral disease, is in
the best position to make this judgment in the interest of each patient. For this reason,
the guidelines are intended to serve as a resource for the practitioner and are not
intended as standards of care, requirements or regulations.
The guidelines are not substitutes for clinical examinations and health histories. The
dentist is advised to conduct a clinical examination, consider the patient’s signs,
symptoms and oral and medical histories, as well as consider the patient’s vulnerability
to environmental factors that may affect oral health. This diagnostic and evaluative
information may determine the type of imaging to be used or the frequency of its use.
Dentists should only order radiographs when they expect that the additional diagnostic
information will affect patient care.
Based on this premise, the guidelines can be used by the dentist to optimize patient
care, minimize radiation exposure and responsibly allocate health care resources.
This document deals only with standard dental imaging techniques of intraoral and
common extraoral examinations, excluding cone-beam computed tomography (CBCT).
At this time the indications for CBCT examinations are not well developed. The ADA
Council on Scientific Affairs has developed a statement on use of CBCT. 1
INTRODUCTION
The guidelines titled, “The Selection of Patients for X-Ray Examination” were first
developed in 1987 by a panel of dental experts convened by the Center for Devices and
Radiological Health of the U.S. Food and Drug Administration (FDA). The development
of the guidelines at that time was spurred by concern about the U.S. population’s total
exposure to radiation from all sources. Thus, the guidelines were developed to promote
the appropriate use of x-rays. In 2002, the American Dental Association, recognizing
that dental technology and science continually advance, recommended to the FDA that
1
,the guidelines be reviewed for possible updating. The FDA welcomed organized
dentistry’s interest in maintaining the guidelines, and so the American Dental
Association, in collaboration with a number of dental specialty organizations and the
FDA, published updated guidelines in 2004. This report updates the 2004 guidelines
and includes recommendations for limiting exposure to radiation.
PATIENT SELECTION CRITERIA
Radiographs and other imaging modalities are used to diagnose and monitor oral
diseases, as well as to monitor dentofacial development and the progress or prognosis
of therapy. Radiographic examinations can be performed using digital imaging or
conventional film. The available evidence suggests that either is a suitable diagnostic
method.2-4 Digital imaging may offer reduced radiation exposure and the advantage of
image analysis that may enhance sensitivity and reduce error introduced by subjective
analysis.5
A study of 490 patients found that basing selection criteria on clinical evaluations for
asymptomatic patients, combined with selected periapical radiographs for symptomatic
patients, can result in a 43 percent reduction in the number of radiographs taken without
a clinically consequential increase in the rate of undiagnosed disease.6,7 The
development and progress of many oral conditions are associated with a patient’s age,
stage of dental development, and vulnerability to known risk factors. Therefore, the
guidelines in Table 1 are presented within a matrix of common clinical and patient
factors, which may determine the type(s) of radiographs that is commonly needed. The
guidelines assume that diagnostically adequate radiographs can be obtained. If not,
appropriate management techniques should be used after consideration of the relative
risks and benefits for the patient.
Along the horizontal axis of the matrix, patient age categories are described, each with
its usual dental developmental stage: child with primary dentition (prior to eruption of the
first permanent tooth); child with transitional dentition (after eruption of the first
permanent tooth); adolescent with permanent dentition (prior to eruption of third
molars); adult who is dentate or partially edentulous; and adult who is edentulous.
Along the vertical axis, the type of encounter with the dental system is categorized (as
“New Patient” or “Recall Patient”) along with the clinical circumstances and oral
diseases that may be present during such an encounter. The “New Patient” category
refers to patients who are new to the dentist, and thus are being evaluated by the
dentist for oral disease and for the status of dental development. Typically, such a
patient receives a comprehensive evaluation or, in some cases, a limited evaluation for
a specific problem. The “Recall Patient” categories describe patients who have had a
recent comprehensive evaluation by the dentist and, typically, have returned as a
patient of record for a periodic evaluation or for treatment. However, a “Recall Patient”
may also return for a limited evaluation of a specific problem, a detailed and extensive
evaluation for a specific problem(s), or a comprehensive evaluation.
2
,Both categories are marked with a single asterisk that corresponds to a footnote that
appears below the matrix; the footnote lists “Positive Historical Findings” and “Positive
Clinical Signs/Symptoms” for which radiographs may be indicated. The lists are not
intended to be all-inclusive, rather they offer the clinician further guidance on clarifying
his or her specific judgment on a case.
The clinical circumstances and oral diseases that are presented with the types of
encounters include: clinical caries or increased risk for caries; no clinical caries or no
increased risk for caries; periodontal disease or a history of periodontal treatment;
growth and development assessment; and other circumstances. A few examples of
“Other Circumstances” proposed are: existing implants, other dental and craniofacial
pathoses, endodontic/restorative needs and remineralization of dental caries. These
examples are not intended to be an exhaustive list of circumstances for which
radiographs or other imaging may be appropriate.
The categories, “Clinical Caries or Increased Risk for Caries” and “No Clinical Caries
and No Increased Risk for Caries” are marked with a double asterisk that corresponds
to a footnote that appears below the matrix; the footnote contains links to the ADA
Caries Risk Assessment Forms (0 – 6 years of age and over 6 years of age). It should
be noted that a patient’s risk status can change over time and should be periodically
reassessed.8
The panel also has made the following recommendations that are applicable to all
categories:
1. Intraoral radiography is useful for the evaluation of dentoalveolar trauma. If the
area of interest extends beyond the dentoalveolar complex, extraoral imaging
may be indicated.
2. Care should be taken to examine all radiographs for any evidence of caries, bone
loss from periodontal disease, developmental anomalies and occult disease.
3. Radiographic screening for the purpose of detecting disease before clinical
examination should not be performed. A thorough clinical examination,
consideration of the patient history, review of any prior radiographs, caries risk
assessment and consideration of both the dental and the general health needs of
the patient should precede radiographic examination.9-15
In the practice of dentistry, patients often seek care on a routine basis in part because
oral disease may develop in the absence of clinical symptoms. Since attempts to
identify specific criteria that will accurately predict a high probability of finding
interproximal carious lesions have not been successful for individuals, it was necessary
to recommend time-based schedules for making radiographs intended primarily for the
detection of dental caries. Each schedule provides a range of recommended intervals
that are derived from the results of research into the rates at which interproximal caries
progresses through tooth enamel. The recommendations also are modified by criteria
that place an individual at an increased risk for dental caries. Professional judgment
3
,should be used to determine the optimum time for radiographic examination within the
suggested interval.
4
,RECOMMENDATIONS FOR PRESCRIBING DENTAL RADIOGRAPHS
These recommendations are subject to clinical judgment and may not apply to every patient. They are to be used by dentists only after
reviewing the patient’s health history and completing a clinical examination. Even though radiation exposure from dental radiographs is
low, once a decision to obtain radiographs is made it is the dentist's responsibility to follow the ALARA Principle (As Low as
Reasonably Achievable) to minimize the patient's exposure.
Table 1.
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
Child with Primary Child with Adolescent with Adult, Dentate or Adult, Edentulous
TYPE OF ENCOUNTER
Dentition (prior to Transitional Permanent Partially Edentulous
eruption of first Dentition (after Dentition (prior to
permanent tooth) eruption of first eruption of third
permanent tooth) molars)
New Patient* Individualized
being evaluated for oral radiographic exam
diseases consisting of selected
periapical/occlusal
views and/or Individualized Individualized radiographic exam consisting of
posterior bitewings if radiographic exam posterior bitewings with panoramic exam or
proximal surfaces consisting of posterior posterior bitewings and selected periapical Individualized
cannot be visualized bitewings with images. A full mouth intraoral radiographic radiographic exam,
or probed. Patients panoramic exam or exam is preferred when the patient has based on clinical
without evidence of posterior bitewings clinical evidence of generalized oral disease signs and symptoms.
disease and with and selected or a history of extensive dental treatment.
open proximal periapical images.
contacts may not
require a
radiographic exam at
this time.
Recall Patient* with Posterior bitewing exam at 6-12 month intervals if proximal surfaces Posterior bitewing
clinical caries or at cannot be examined visually or with a probe exam at 6-18 month Not applicable
increased risk for caries** intervals
Recall Patient* with no Posterior bitewing exam at 12-24 month
Posterior bitewing Posterior bitewing
clinical caries and not at intervals if proximal surfaces cannot be
exam at 18-36 month exam at 24-36 month Not applicable
increased risk for caries** examined visually or with a probe
intervals intervals
5
, Child with Primary Child with Adolescent with Adult, Dentate and Adult, Edentulous
Dentition (prior to Transitional Permanent Partially Edentulous
TYPE OF ENCOUNTER
eruption of first Dentition (after Dentition (prior to
(continued)
permanent tooth) eruption of first eruption of third
permanent tooth) molars)
Recall Patient* with Clinical judgment as to the need for and type of radiographic images for the evaluation of
periodontal disease periodontal disease. Imaging may consist of, but is not limited to, selected bitewing and/or
Not applicable
periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be
demonstrated clinically.
Patient (New and Recall) Clinical judgment as
for monitoring of to need for and type
dentofacial growth and of radiographic
development, and/or images for evaluation
assessment of Clinical judgment as to need for and type of and/or monitoring of
Usually not indicated for monitoring of growth
dental/skeletal radiographic images for evaluation and/or dentofacial growth
and development. Clinical judgment as to the
relationships monitoring of dentofacial growth and and development, or
need for and type of radiographic image for
development or assessment of dental and assessment of dental
evaluation of dental and skeletal relationships.
skeletal relationships and skeletal
relationships.
Panoramic or
periapical exam to
assess developing
third molars
Patient with other
circumstances including,
but not limited to,
proposed or existing
implants, other dental and Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of these conditions
craniofacial pathoses,
restorative/endodontic
needs, treated periodontal
disease and caries
remineralization
*Clinical situations for which radiographs may be
indicated include, but are not limited to:
A. Positive Historical Findings
1. Previous periodontal or endodontic treatment
2. History of pain or trauma
3. Familial history of dental anomalies
6
, 4. Postoperative evaluation of healing
5. Remineralization monitoring
6. Presence of implants, previous implant-related pathosis or evaluation for implant placement
B. Positive Clinical Signs/Symptoms
1. Clinical evidence of periodontal disease
2. Large or deep restorations
3. Deep carious lesions
4. Malposed or clinically impacted teeth
5. Swelling
6. Evidence of dental/facial trauma
7. Mobility of teeth
8. Sinus tract (“fistula”)
9. Clinically suspected sinus pathosis
10. Growth abnormalities
11. Oral involvement in known or suspected systemic disease
12. Positive neurologic findings in the head and neck
13. Evidence of foreign objects
14. Pain and/or dysfunction of the temporomandibular joint
15. Facial asymmetry
16. Abutment teeth for fixed or removable partial prosthesis
17. Unexplained bleeding
18. Unexplained sensitivity of teeth
19. Unusual eruption, spacing or migration of teeth
20. Unusual tooth morphology, calcification or color
21. Unexplained absence of teeth
22. Clinical tooth erosion
23. Peri-implantitis
Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0 – 6 years of age and
over 6 years of age).
7
, EXPLANATION OF RECOMMENDATIONS FOR PRESCRIBING DENTAL RADIOGRAPHS
The explanation below presents the rationale for each recommendation by type of encounter
and patient age and dental developmental stages.
New Patient Being Evaluated for Oral Diseases
Child (Primary Dentition)
Proximal carious lesions may develop after the interproximal spaces between posterior primary
teeth close. Open contacts in the primary dentition will allow a dentist to visually inspect the
proximal posterior surfaces. Closure of proximal contacts requires radiographic assessment. 16-
18
However, evidence suggests that many of these lesions will remain in the enamel for at
least 12 months or longer depending on fluoride exposure, allowing sufficient time for
implementation and evaluation of preventive interventions. 19-21 A periapical/anterior occlusal
examination may be indicated because of the need to evaluate dental development,
dentoalveolar trauma, or suspected pathoses. Periapical and bitewing radiographs may be
required to evaluate pulp pathosis in primary molars.
Therefore, an individualized radiographic examination consisting of selected
periapical/occlusal views and/or posterior bitewings if proximal surfaces cannot be examined
visually or with a probe is recommended. Patients without evidence of disease and with open
proximal contacts may not require radiographic examination at this time.
Child (Transitional Dentition)
Overall dental caries in the primary teeth of children from 2-11 years of age declined from the
early 1970s until the mid 1990s.22-24 From the mid 1990s until the 1999-2004 National Health
and Nutrition Examination Survey, there was a small but significant increase in primary decay.
This trend reversal was larger for younger children. Tooth decay affects more than one-fourth
of U.S. children aged 2–5 years and half of those aged 12-15 years; however, its prevalence is
not uniformly distributed. About half of all children and two-thirds of adolescents aged 12–19
years from lower-income families have had decay.25
Children and adolescents of some racial and ethnic groups and those from lower-income
families have more untreated tooth decay. For example, 40 percent of Mexican American
children aged 6–8 years have untreated decay, compared with 25 percent of non-Hispanic
whites.25 It is, therefore, important to consider a child’s risk factors for caries before taking
radiographs.
Although periodontal disease is uncommon in this age group,26 when clinical evidence exists
(except for nonspecific gingivitis), selected periapical and bitewing radiographs are indicated to
determine the extent of aggressive periodontitis, other forms of uncontrolled periodontal
disease and the extent of osseous destruction related to metabolic diseases. 27,28
A periapical or panoramic examination is useful for evaluating dental development. A
panoramic radiograph also is useful for the evaluation of craniofacial trauma. 15,29,30 Intraoral
radiographs are more accurate than panoramic radiographs for the evaluation of dentoalveolar
8
