Introduction

Radiographic selection criteria were developed to assist the dentist in making informed decisions about diagnostic imaging for patients under their care. The guidelines are intended to serve as an adjunct to the dentist’s professional judgment following a clinical examination, consideration of the patient’s medical and dental histories and assessment of the patient’s signs, symptoms and susceptibility to environmental factors that may impact oral health.1 The recommendations are based on evidence from the scientific literature.1 The information may facilitate the determination of the type and frequency of a radiographic examination when indicated. A radiographic examination should only be prescribed by the dentist when it is expected that the additional diagnostic information will affect the delivery of patient care.1 The intended goal is to optimize patient treatment while at the same time limit radiation exposure.

There have been several iterations of the selection criteria guidelines. The guidelines were originally developed in 19872 by a panel of dental experts and the U.S. Food and Drug Administration (FDA) with subsequent updates by the American Dental Association (ADA) and the FDA in 20043 and in 2012.1 The most recent document, Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure, will be the focus of this discussion.1 The general framework of the guidelines includes these major categories:

  • type of encounter - new or recall
  • patient age designation – child, adolescent, adult
  • stage of dental development – primary, transitional, permanent dentitions and partially/completely edentulous
  • vulnerability to risk factors – caries, periodontal disease
  • growth and developmental monitoring/assessment of dental or skeletal relationships
  • other circumstances

The last category takes into consideration such circumstances as proposed or existing implants, dental and craniofacial pathoses, restorative and/or endodontic needs, treated periodontal disease and caries remineralization, although it is not limited to these entities alone.

Recommendations applicable to all of the categories above include the use of intraoral or extraoral imaging for the evaluation of dentoalveolar trauma; examination of all radiographic images for evidence of caries, alveolar bone loss, developmental anomalies and occult disease; a thorough clinical examination, consideration of the patient history, review of prior radiographs, caries risk assessment and consideration of the general and dental health needs of the patient before proceeding with a radiographic imaging examination. Radiographic screening of the patient for detecting disease prior to a clinical examination should not be performed.1

In addition, the dentist can consider indicators such as caries risk as well as historical findings and positive clinical signs and symptoms to determine the need for dental imaging (Table 1).

Table 1. Historical and Clinical Situations Indicative of the Possible Need for Radiographs.1
Clinical Indicators
Positive Historical Findings Positive Clinical Signs and Symptoms
  1. Previous periodontal or endodontic treatment
  2. History of pain or trauma
  3. Familial history of dental anomalies
  4. Postoperative evaluation of healing
  5. Remineralization monitoring
  6. Presence of implants, previous implant related pathosis or evaluation for implant placement
  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 and/or facial trauma
  7. Teeth mobility
  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(s)
  15. Facial asymmetry
  16. Abutment teeth for fixed or removable partial prosthesis
  17. Unexplained bleeding
  18. Unexplained teeth sensitivity
  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

The guidelines for selecting patients for dental radiographic examinations are not intended to be used as standards of care, requirements or regulations, but rather as a resource for the dentist before prescribing a radiographic examination if indicated.1 The ethical principles underlying radiation protection include justification (benefit vs. risk decision), optimization (use of all reasonable means to reduce unnecessary radiation exposure) and dose limitation (ensure that no individuals are exposed to unacceptable high radiation doses).4,5

The guidelines focus on conventional dental imaging including intraoral and common extraoral projections such as panoramic and cephalometric imaging. The current document excludes cone beam computed tomography (CBCT), a three-dimensional imaging modality, which is being used increasingly in dentistry for specific diagnostic tasks. The American Academy of Oral and Maxillofacial Radiology (AAOMR) has developed several position papers regarding CBCT that can be consulted for further information6-9 and the ADA has developed a statement on the use of CBCT as well.10