Guidelines for Prescribing Radiographs in the Pediatric Patient

Table 1. Guidelines for Prescribing Radiographs in the Pediatric Patient.1,2,3
Type of Encounter Child Adolescent
Primary Dentition
(prior to eruption of first permanent tooth)
Transitional Dentition
(after eruption of first permanent tooth)
Permanent Dentition
(prior to eruption of third molars)
New Patient
New patient* being evaluated for dental diseases and dental development. Individualized radiographic exam consisting of selected periapical/occlusal views and/or posterior bitewings if proximal surfaces cannot be visualized or probed. Patients without evidence of disease and with open proximal contacts may not require a radiographic exam at this time. Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images. Individualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images. A full mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized dental disease or a history of extensive dental treatment.
Recall Patient
Recall patient* with clinical caries or increased risk for caries.** Posterior bitewing examination at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe. Posterior bitewing examination at 6-18 month intervals.
Recall patient* with no clinical caries or increased risk for caries.** Posterior bitewing examination at 12-24 month intervals if proximal surfaces cannot be examined visually or with a probe. Posterior bitewing examination at 18-36 month intervals.
Recall patient* with periodontal disease. Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease. Imaging may consist of, but not limited to, selected bitewing and/or periapical images of areas where periodontal disease (other than non-specific gingivitis) can be identified clinically.
Patient for monitoring of dento/facial growth and development, and/or assessment of dental/skeletal relationships. Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development and development or assessment of dental and skeletal relationships. Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development or assessment of dental 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, pathology, restorative/endodontic needs, treatment periodontal disease and caries remineralization. Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring in these conditions.
* Clinical situations for which radiographs may be indicated include but are not limited to:
  1. Positive Historical Findings
    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 or evaluation for implant placement
  2. 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 pathology
    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 erosion
    23. Peri-implantitis
** Factors increasing risk for caries may include but are not limited to:
  1. High level of caries experience or demineralization
  2. History of recurrent caries
  3. High titers of cariogenic bacteria
  4. Existing restoration(s) of poor quality
  5. Poor oral hygiene
  6. Inadequate fluoride exposure
  7. Prolonged nursing (bottle or breast)
  8. Frequent high sucrose content in diet
  9. Poor family dental health
  10. Developmental or acquired enamel defects
  11. Developmental or acquired disability
  12. Xerostomia
  13. Genetic abnormality of teeth
  14. Many multi-surface restorations
  15. Chemo/radiation therapy
  16. Eating disorders
  17. Drug/alcohol abuse
  18. Irregular dental care

In addition new imaging technologies, (i.e., cone beam computer tomography (CBCT) provides many three-dimensional applications in dentistry. The use of CBCT is valuable adjunct in assessing and diagnosing pathology in endodontics, oral pathology, anomalies of the developing dentition (e.g. Impacted, ectopic, and supernumerary teeth), oral maxillofacial surgery (e.g.,) cleft palate, dental and facial trauma, orthognathic surgery and orthodontics.3

A CBCT scanner uses a collimated radiation source producing a cone or pyramid shaped beam of radiation in a single, full or partial revolution around the patient. Two dimensional images are reconstructed into three dimensional images which can be viewed in a variety of ways, including cross-sectional images and volume renderings of the oral cavity.

Although CBCT units produce higher radiation doses than from a single traditional dental radiogrpah, the radiation dose is delivered is typically less than that produced during a medical computed tomographic scan.

Table 2 compares estimated radiation doses for common dental radiographs and CBCT imaging.

Table 2.
Imaging Technique Estimated Dose
(microsieverts)
Conventional radigraphy
Four posterior bitewings with phosphor plates or F speed film 5.0
Panoramic radiograph 3.0-24.3
Cephalometric radiograph posterior or lateral 5.1-5.6
Full mouth radiographs
  • With phosphor plates or F speed film, rectangular collimation
  • With phosphor plates or F speed film, round collimation
34.9

170.7
CBCT*
Dento-alveolar CBCT (small and medium field of view) 11-674 (61)
Maxillo-facial CBCT (large field of view) 30-1073 (87)
*numbers in parenthesis indicates median values (ADA)

The use of CBCT should be considered when conventional radiographs are inadequate to complete diagnosis and treatment planning and potential beneefits outweigh the risk of additional radiation dose. It is not to be used routinely for diagnosis or screening purposes in the absence of clinical indication. Basic guidelines for the use of CBCT include:

  • Use of appropriate image size or field of view
  • Assessment of the radiation dose risk
  • Minimizing patient radiation exposure
  • Professional competancy in performing and interpreting CBCT studies

A written report of the imaging and full interpretation of the findings is required to be placed in the patients chart.4