Guidelines for dental radiographs for pediatric and adolescent

1. Guidelines for dental radiographs for
pediatric and adolescent
Dr. Alaa Jaajaa BDS
Dr. Stephanie Chahrouk BDS

2. Outline
1. Introduction
2. Indications of radiographs
3. Guidelines for prescribing dental radiograph
4. Guidelines of dental x-rays for pediatric
patients
5. Guidelines of dental x-rays for adolescent
6. Certain modifications for taking radiographs
7. Guidelines of Specialized Radiographic
Techniques

3. Introduction
• Dental radiology is one of best and useful diagnostic
aid for accurate examination of the child oral cavity.
• It is the most valuable and reliable diagnostic tool
especially for children, infant, adolescent and
patients with special health care needs.

4. Clinical situations for which radiographs may
be indicated include, but are not limited to:
A. POSITIVE HISTORICAL
FINDINGS
B. POSITIVE CLINICAL
SIGNS/SYMPTOMS

5. A. Positive
Historical
Findings
Previous periodontal or endodontic treatment
History of pain or trauma
Familial history of dental anomalies
Postoperative evaluation of healing
Remineralization monitoring
Presence of implants, previous implant-related
pathosis or evaluation for implant placement

6. B. Positive
Clinical
Signs/Symptoms
• Clinical evidence of periodontal disease
• Large or deep restorations
• Deep carious lesions
• Malposed or clinically impacted teeth
• Swelling
• Evidence of dental/facial trauma
• Mobility of teeth
• Sinus tract (“fistula”)
• Clinically suspected sinus pathosis
• Growth abnormalities
• Oral involvement in known or suspected systemic
disease

7. B. Positive
Clinical
Signs/Symptoms
(cont.)
• Positive neurologic findings in the head and neck
• Evidence of foreign objects
• Pain and/or dysfunction of the temporomandibular joint
• Facial asymmetry
• Abutment teeth for fixed or removable partial prosthesis
• Unexplained bleeding
• Unexplained sensitivity of teeth
• Unusual eruption, spacing or migration of teeth
• Unusual tooth morphology, calcification or color
• Unexplained absence of teeth
• Clinical tooth erosion
• Peri-implantitis

8. The major reasons for radiographs
Caries detection
Dental injuries
Disturbances in tooth development
Examination of pathological conditions other than caries
Use for infants, children, adolescents, and
persons with special health care needs
Diagnose and monitor oral diseases
Evaluate dentoalveolar trauma
To monitor dentofacial development and
the progress of therapy

9. Guidelines
recommendations
of the ADA/FDA

10. EXPLANATION OF
RECOMMENDATIONS
FOR PRESCRIBING
DENTAL RADIOGRAPHS
For New Patient Being
Evaluated for Oral
Diseases

11. Guidelines for prescribing dental radiograph
according to ADA/FDA
Type of
encounter Child with Primary
Dentition
Child with Transitional
Dentition

12. 1) New patient (evaluating oral for diseases )
“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”
Child with
Primary Dentition
“Individualized radiographic exam consisting of posterior bitewings with panoramic exam or
posterior bitewings and selected periapical images”
Child with
Transitional
Dentition

13. Child with 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.
• 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.
• 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.

14. Child with
Transitional Dentition
• Tooth decay affects more than one-fourth of U.S. children aged 2–5 years
and half of those aged 12-15years; 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.
• Children and adolescents of some racial and ethnic groups and those
from lower-income families have more untreated tooth decay. therefore,
important to consider a child’s risk factors for caries before taking
radiographs.
• Although periodontal disease is uncommon in this age group, 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.

15. Child with Transitional
Dentition(cont.)
• A periapical or panoramic examination is useful for
evaluating dental development.
• A panoramic radiograph also is useful for the
evaluation of craniofacial trauma.
• Intraoral radiographs are more accurate than
panoramic radiographs for the evaluation of
dentoalveolar
• Trauma, root shape, root resorption and pulp
pathosis. However, panoramic examinations may have
the advantage of reduced radiation dose, cost and
imaging of a larger area.
• Occlusal radiographs may be used separately or in
combination with panoramic radiographs in the
following situations:
1. Unsatisfactory image in panoramic
radiographs due to abnormal incisor
relationship,
2. Localizations of tooth position, and
3. When clinical grounds provide a
reasonable expectation that pathosis
exists.
• Therefore, an individualized radiographic
examination consisting of posterior bitewings with
panoramic examination or posterior bitewings and
selected periapical images is recommended.

16. 2) Recall Patient (with clinical caries or at
increased risk for caries)
Posterior bitewing
exam at 6-12
month intervals if
proximal surfaces
cannot be
examined visually
or with a probe
Child with
Transitional
Dentition
Child with
Primary
Dentition

17. 3) Recall
Patient(with no
clinical caries) • “Posterior bitewing exam at 12-24
month intervals if proximal surfaces
cannot be examined visually or with a
probe”
Child with
Primary
Dentition
Child with
Transitional
Dentition

18. 4) Patient (for
monitoring of
dentofacial
growth and
development, 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
or assessmentof dental and skeletal
relationships”
Child with
Primary
Dentition
Child with
Transitional
Dentition

19. 5) Patient with other
circumstances
including, but not
limited to, proposed
or existing implants,
other dental and
craniofacial pathoses,
restorative/
endodontic needs,
treated periodontal
disease and caries
remineralization
“Clinical judgment as to need for and type
of radiographic images for evaluation and/or
monitoring in these conditions”
Child with
Primary
Dentition
Child with
Transitional
Dentition

20. • “Such patients cannot or will not open
their mouth for radiographic
procedures. In these cases, extraoral
radiographs like panoramic, lateral jaw
or 45° projections are used”
• “Use of intraoral holder at times
becomes diffi cult in handicapped
children or young patients, wherein
Rinn SnapA-Ray is used instead of the
use of conventional holders”

21. Guidelines of dental
x-rays for adolescent
1. Patient with Permanent
Dentition
2. Partially Edentulous
3. Edentulous

22. 1. Patient
with
Permanent
Dentition
• Caries in permanent teeth declined among adolescents, while the prevalence
of dental sealants increased significantly.
• However, increasing independence and socialization, changing dietary
patterns, and decreasing attention to daily oral hygiene can characterize this
age group.
• Each of these factors may result in an increased risk of dental caries. Another
consideration, although uncommon, is the increased incidence of periodontal
disease found in this age group compared to children.
• Panoramic radiography is effective in dental diagnosis and treatment
planning. Specifically, the status of dental development can be assessed using
panoramic radiography.
• Occlusal and/or periapical radiographs can be used to detect the position of
an unerupted or supernumerary tooth. Third molars also should be evaluated
in this age group for their presence, position, and stage of development.
• Therefore, an individualized radiographic examination consisting of posterior
bitewings with panoramic examination or posterior bitewings and selected
periapical images is recommended.
• A full mouth intraoral radiographic examination is preferred when the
patient has clinical evidence of generalized oral disease or a history of
extensive dental treatment.

23. 2. Partially edentulous
patient
• “It is important to evaluate proximal surfaces in the new adult patient for carious lesions. In
addition, it is important to examine patients for recurrent dental caries”
• “The incidence of root surface caries increases with age”
• “Bitewing radiographs can assist in detecting root surface caries in proximal areas, the usual
method of detecting root surface caries is by clinical examination”
• “The incidence of periodontal disease increases with age. Although new adult patients may
not have symptoms of active periodontal disease, it is important to evaluate previous
experience with periodontal disease and/or treatment. Therefore, a high percentage of adults
may require selected intraoral radiographs to determine the current status of the disease”
• “Taking posterior bitewing radiographs of new adult patients was found to reduce the number
of radiological findings and the diagnostic yield of panoramic radiography”
• “In addition, the following clinical indicators for panoramic radiography were identified as the
best predictors for useful diagnostic yield: suspicion of teeth with periapical pathologic
conditions, presence of partially erupted teeth, caries lesions, swelling, and suspected
unerupted teeth”
• “Therefore, an individualized radiographic examination, consisting of posterior bitewings with
selected periapical images or panoramic examination when indicated is recommended”
• “A full mouth intraoral radiographic examination is preferred when the patient has clinical
evidence of generalized oral disease or a history of extensive dental treatment”

24. 3. Edentulous patient
• The clinical and radiographic examinations of edentulous patients generally occur during an assessment of the need for prostheses.
• The most common pathological conditions detected are impacted teeth and retained roots with and without associated disease.
• Other less common conditions also may be detected: bony spicules along the alveolar ridge, residual cysts or infections, developmental
abnormalities of the jaws, intraosseous tumors, and systemic conditions affecting bone metabolism.
• The original recommendations for this group called for a full-mouth intraoral radiographic examination or a panoramic examination for the new,
edentulous adult patient.
• Firstly, this recommendation was made because examinations of edentulous patients generally occur during an assessment of the need for
prostheses.
• Secondly, the original recommendation considered edentulous patients to be at increased risk for oral disease.
• A full mouth series of periapical radiographs or a combination of panoramic, occlusal or other extraoral radiographs may be used to achieve
diagnostic and therapeutic goals.

25. 4. Pregnant woman
• X-rays during pregnancy don't increase the risk of miscarriage or cause problems in
the unborn baby, such as birth defects and physical or mental development
problems.
• However, if a pregnant woman has an X-ray and is exposed to radiation there is a very
small increased risk that the baby may go on to develop cancer in childhood.
• Therefore the dose of radiation used in an X-ray is always as low as possible.
• he lead apron will protect your unborn child from virtually all of the c-arm radiation
exposure so there is no need for extra concern.
• In case of the treatment may be postponed until after birth it is better to postponed
it in case of previous abortion

26. There are
certain
modifications
for taking
radiographs
in:
Infants
young and
handicapped
children
children
with gag
reflex
in special
cases

27. In infants
• “Below 3 years of age, it is always recommended to
use size 0 intraoral periapical films”
• “It becomes difficult for a young child to manage the
films that have been placed for molar projections”
The patients head
is stabilized with
the parent's
shoulder
The parent is
asked to hold the
film or both the
child and the film
Parental help is
necessary to take

28. Mentally disabled children
To control film position, an intraoral film with
bitewing tabs is used for all bitewing and
periapical radiographs
An 18-inch length of floss is attached through
a hole made in the tab
The patient should wear a lead apron with a
thyroid shield

29. Children with Gag
Reflex
Also, it has been observed that the chance of gagging is reduced when the
stomach is empty or half filled.
Furthermore, it is advisable to perform the examination in the morning
when the individual is well rested, rather than in the afternoon or evening
One of the most effective methods of reducing gagging is a distraction.
The child is asked to concentrate intensely
on something spatially removed from the
oral cavity
The task may be to raise one leg, and his
toes, make a fist or hold his breath

30. Pharmacological
techniques
Use of sedative and
topical anesthetic
includes phenothiazine
derivatives,
antihistamines,
barbiturates, and nitrous
oxide
For temporary relieving
the gag reflex, use of local
anesthetics
such as xylocaine or
dyclone in topical or rinse
form appears to be
effective.
General anesthesia is generally not considered
as an approach for obtaining radiographs
Film size positioning and manner of placement
may also be varied to accommodate the child
who gags during radiography

31. Handicapped
children
• “Many mentally handicapped children
will not allow an intraoral film to be
placed in their mouths”
• “Intraoral radiographs of these
children are usually obtained with the
parent holding the film in position”
• “A holding device that fixes the film in
position while the patient occludes is
more effective technique”

32. Guidelines of Specialized Radiographic
Techniques
Specialized
Radiographic
Techniques
Computed
tomography (CT)
Xero radiography
Cone beam CT
(CBCT)
Magnetic
Resonance
Imaging (MRI)

33. Computed
tomography (CT)
• “Clinical application of CT in children includes
diagnosis of neonatal maxilla and disorders
involving the auditory ossicles and TMJ”
• “Scanning parameters affect the patient’s
radiation exposure but also the scan range and
the patient’s size affect patient’s individual
dose distribution and the organs exposed to
radiation”
• “Since the dose display values of a CT scanner
don’t consider the individual patient features,
the dose display values can’t be directly used
to assess the patient’s individual radiation risk
resulting from a CT scan, especially in the case
of children”

35. Xero
radiography
• Xeroradiography is a highly accurate electrostatic imaging technique that
uses a modified xerographic copying process to record images produced by
diagnostic X-rays.
• Xeroradiography is a newer technique of radiologic imaging which provides
both a wide recording latitude and the phenomenon of edge enhancement.
• It is the phenomenon of edge enhancement in particular which allows for
excellent imaging of mucous membrane anatomy and abnormalities

36. Cone beam CT (CBCT)
• “CBCT can be used in pediatric patients
having malocclusions and craniofacial
anomalies, including cleft lip and palate”
• “Although the radiation dose of CBCT is
generally lower than medical CT, 4 it is still
higher than conventional radiographs”

38. Magnetic Resonance
Imaging (MRI)
• “The highest effective doses in
neonates and the lowest effective
doses were observed in the 10–18
years age group”
• “It is estimated a 0.007% potential
increase risk in neonates and 0.001%
potential increased risk in teenagers
over the base risk”
• “Multiple head CTs in children equates
to a slight potential increase risk in
lifetime attributable risk over the
baseline risk for cancer, slightly higher
in neonates relative to teenagers”

39. References
• Kavita madan, Sudhindra baliga, Nilima thosar, Nilesh rathi. Recent advances in
dental radiography for pediatric patients: A review. Journal of medicine,
radiology, pathology & surgery. 2015 mar-apr. Vol. 1:2, 21–25
• Prescribing dental radiographs for infants, children, adolescents, and
individuals with special health care needs. The reference manual of pediatric
dentistry. Prescribing dental radiographs. 2017
• Dental radiographic examinations: recommendations for patient selection and
limiting radiation exposure. AMERICAN DENTAL ASSOCIATION, council on
scientific affairs. 2012