Besides concerns about low-dose radiation and variations in how images are interpreted by dentists, the main limitation is that the validity in diagnosing early lesions is rather low. Also, the bitewing radiograph cannot always distinguish between sound surfaces, those with initial caries activity and cavitated lesions, or non-carious demineralizations; so clinical inspection is still needed to determine what is happening to the tooth. Bitewing radiographs also tend to underestimate the depths of lesions, so a lesion that appears confined to the inner enamel on an image is often actually in the dentin, and this can lead to insufficient or improper treatment.2
