GUIDELINES FOR PRESCRIBING DENTAL RADIOGRAPHS

A radiographic examination is necessary when

1. History And Clinical Examination not sufficient for complete evaluation of a patients condition and formulation of an appropriate treatment plan. 2. Reasonable probability that radiographs will provide valuable information about the disease that is not visible clinically. 3. Benefit factors > risk factors

ROLE OF RADIOGRAPHS IN DISEASE DETECTION AND MONITORING

1.

CARIES Most common Affect all ages Interproximal caries and secondary caries difficult to detect clinically Patients with good oral hygiene- infrequent radiographic examination History and clinical examination high caries indexfrequent and careful monitoring- radiographic examination

2. PERIODONTAL DISEASE Gingivitis- younger individuals Periodontitis- older adults Periodontitis- loss of teeth Radiographic examination- extent of alveolar bone support for dentition, local factors like calculus and/or faulty restorations, length and morphology of roots

3. DENTAL ANOMALIES Abnormality in teeth- number, size, morphology and location Most common- supernumerary teeth, developmentally missing teeth Consider both the radiation dose and anticipated diagnosis- select appropriate projection Panoramic radiograph observation of teeth in all four quadrants Periapical,occlusal radiograph- limited area

4. GROWTH AND DEVELOPMENT AND DENTAL MALOCCLUSION To assess the growth and development of the teeth and jaws Relationship between the jaws and to the soft tissues After consideration of the clinical examination, the study of plaster models, photographs, optimal time to initiate ortho treatment- select radiographs with maximum diagnostic information and minimal radiation exposure

5. OCCULT DISEASE Occult disease refers to disease that presents no clinical signs or symptoms. Occult disease dental and intraosseous Dental- incipient caries, resorbed or dilacerated roots, hypercementosis Intraosseous- osteosclerosis,unerupted teeth, periapical disease, and a wide variety of cysts and tumours Screening in edentulous patients Panoramic radiographs Screening above 55 yearscalcified atheromas- increased risk for stroke

6. JAW PATHOLOGY Jaw lesions extent of the lesion, expansion of the jaw, perforation of buccal or lingual cortical boneappropriate treatment If lesion too large, extends into maxillary sinus or other portions of the head outside the jaws, suspected malignancy- advanced imaging

7. TEMPOROMANDIBULAR JOINT Congenital and developmental malformations of the mandible and cranial bones; acquired disorders such as disk displacement, neoplasms, fracture, and dislocations ; inflammatory disease that produce capsulitis or synovitis; and arthritides like rheumatoid and osteoarthritis Decision to image TMJ based on 1. history and clinical findings 2. the clinical diagnosis 3. Results of prior examinations 4. treatment plan

5. treatment outcome 6. cost of examination 7. radiation dose

Panoramic radiographs, different TMJ views, conventional tomography, CT, MRI

8. IMPLANTS Preoperative planning adequacy of the height and thickness of bone for the desired implant, the quality of the bone, including proportion of medullary and cortical bone, the location of anatomic structures such as mandibular canal or maxillary sinus/ sntral septa, and presence of structural abnormalities such as undercuts.

Postoperative evaluation of implants- judge healing, assess complete seating of fixtures,ensure continued healing health of the surrounding bone.

Periapical and panoramic radiographs- vertical dimensions of the bone in the propose implant site CT- visualization of important anatomic landmarks, determination of size and path of insertion of implant, evaluation of the adequacy of the bone for anchorage of the implant

9. PARANASAL SINUSES

Sinus disease- pain in maxillary teeth Periapical inflammation of maxillary molars and premolars- changes in the maxillary sinus mucosa Periapical and panoramic radiographs- floor of maxillary sinus Waters view, CT- additional visualization

10. TRAUMA Periapical and panoramic radiographs- fracture of teeth Panoramic radiographs with images at 90 such as posterioroanterior view or reverse townes viewfracture of mandible OMV, CT- fracture of maxilla

11. FORENSIC PURPOSE Age and sex determination Mastoid triangle for sex determination Eruption pattern estimation to determine age

RADIOGRAPHIC EXAMINATIONS
Intraoral radiographs- X-ray film within the patients mouth. include 1. Periapical radiographs 2. Bitewing radiographs 3. Occlusal radiographs

1.

Extraoral radiographs- film outside the mouth. include Panoramic radiographs

2. 3. 4.

5. 6.

7. 8.

Postero anterior view, Anteroposterior view Lateral cephalograms TMJ views like transpharyngeal. transorbital, transcranial views Conventional tomography Computed Tomography, Cone Beam CT, Spiral CT Magnetic resonance Imaging Skull Views

COMMON DENTAL RADIOGRAPHIC EXAMINATIONS

TYPE OF EXAMINATION PERIAPICAL RELATIVE EXPOSURE 1 DETECTABLE DISEASE

CARIES, PERIODONTAL DISEASE, OCCULT DISEASE CARIES, PERIODONTAL BONE LEVEL CARIES, PERIODONTAL DISEASE, DENTAL ANAMOLIES, OCCULT DISEASE DENTAL ANAMOLIES, OCCULT DISEASE, SALIVARY STONES, EXPANSION OF JAWS

BITEWNIGS

10

FULL MOUTH PERIAPICAL

14-17

OCCLUSAL

2.5

1-2 PANORAMIC

DENTAL ANAMOLIES, OCCULT DISEASE, EXTENSIVE CARIES, PERIODONTAL DISEASE, PERIAPICAL DISEASE, EXTENT OF CYSTS AND TUMORS, TMJ TMJ, IMPLANT SITE ASSESSMENT, TUMORS

CONVENTION AL TOMOGRAPH Y CT

0.2- 0.6

25- 800

EXTENT OF CRANIOFACIAL PATHOLOGY, FRACTURE, IMPLANTS SOFT TISSUE DISEASE, TMJ

MRI

SKULL

30

FRACTURE, ANATOMIC RELATION, JAW PATHOLOGY

GUIDELINES FOR ORDERING RADIOGRAPHS

Make radiographs only after clinical examination Order only those that directly benefit the patient in terms of diagnosis or treatment plan Use the least amount of radiation exposure necessary to generate an acceptable view of the imaged area

PREVIOUS RADIOGRAPHS Helpful regardless of when they were taken Demonstrate whether a condition worsened, has remain unchanged or improving

ADMINISTRATIVE RADIOGRAPHS Made for reasons other than diagnosis, including those made for an insurance company or for an examination board

GUIDELINES FOR PRESCRIBING DENTAL RADIOGRAPHS

A panel of the Food and Drug Administration (mid 1980s) set guidelines for making dental radiographs ADA recommends use of these guidelines It addressed 1. The topic of appropriate radiographs for an adequate evaluation of a new or recall patient seeking general dental treatment

 Circumstances(age, medical and dental history, and physical signs) that suggest the need for radiographs  Types of radiographic examinations likely to benefit the patient
These circumstances are called SELECTION CRITERIA The recommendations are subject to clinical judgement / may not apply to every patient Used only after reviewing the patients general health history and completing clinical examination Do not need to be altered because of pregnancy

Clinical situations for prescribing radiographs  Positive history findings: 1. Previous periodontal or endodontic therapy 2. History of pain or trauma 3. Postoperative evaluation of healing 4. Presence of implants

1. 2. 3. 4. 5. 6. 7.

Positive clinical signs or radiographs Clinical evidence of periodontal disease Large or deep restorations Deep carious lesions Malposed or clinically impacted teeth Swelling Evidence of facial trauma Mobility of teeth

8. Fistula or sinus tract infection 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 TMJ

15. Facial asymmetry 16. Abutment for fixed or removable partial denture 17. Unexplained bleeding 18. Unexplained sensitivity of teeth 19. Unusual eruption, spacing, migration of teeth 20. Unusual tooth morphology, calcification, or colour 21. Missing teeth with unknown reason

NEW PATIENT

ALL NEW PATIENTS TO ASSESS DENTAL DISEASES AND GROWTH AND DEVELOPMENT

CHILD
Primary dentition (before eruption of First permanent molar)


Posterior bitewing examination if proximal surfaces of primary teeth cannot be visualized or probed

Transitional Dentition(after Eruption Of First Permanent Molar )



Individualized radiographic examination consisting of periapical and/or occlusal views and posterior bitewings or panoramic examination and posterior bitewings

ADOLESCENT Permanent dentition(before eruption of third molars)



Individualized radiographic examination consisting of posterior bitewings and selected periapicals ; a full mouth intraoral radiographic examination when generalized dental disease or a history of extensive dental treatment

ADULT Dentulous  Same as adolescent

Edentulous  Full mouth intraoral radiographic examination or panoramic examination

RECALL PATIENT CLINICAL CARIES OR HIGH-RISK CARIES FACTORS FOR CARIES CHILD Primary dentition (before eruption of first permanent molar) and Transitional dentition(after eruption of first permanent molar)


Posterior bitewing examination at 6 month intervals or until no carious lesions evident

ADOLESCENT

Permanent dentition(before eruption of third molars)

Posterior bitewing examination at 6 to 12- month intervals or until no carious lesions are evident

ADULT

DENTULOUS


Posterior bitewing examination at 12- to 18- months intervals

EDENTULOUS


Not applicable

NO CLINICAL CARIES AND NO HIGH RISK FACTORS FOR CARIES CHILD

Primary dentition (before eruption of first permanent molar)



Posterior bitewing examination at 12 to 24 month intervals if proximal surfaces of primary teeth cannot be visualized or probed

Transitional Dentition (after Eruption Of First Permanent Molar)



Posterior bitewing examination at 12- to 24 month intervals

ADOLESCENT Permanent dentition(before eruption of third molars)



Posterior bitewing examination at 18- to 36 month intervals

ADULT Dentulous  Posterior bitewing examination at 24- to 36 month intervals Edentulous



Not applicable

PERIODONTAL DISEASE OR HISTORY OF PERIODONTAL TREATMENT CHILD Primary dentition (before eruption of first permanent molar) and Transitional dentition(after eruption of first permanent molar)

Individualized radiographic examination consisting of selected periapical and/or bitewing radiographs for areas where periodontal disease can be demonstrated

ADOLESCENT AND DENTULOUS ADULTS



Individualized radiographic examination consisting of selected periapical and/or bitewing radiographs for areas where periodontal disease(other than nonspecific gingivitis) can be demonstrated clinically EDENTULOUS ADULTS

Not applicable

GROWTH AND DEVELOPMENT ASSESSMENT

CHILD Primary dentition (before eruption of first permanent molar)



Usually not indicated

Transitional dentition(after eruption of first permanent molar)



Individualized radiographic examination consisting of a periapical and/or occlusal or panoramic examination

ADOLESCENT Permanent dentition(before eruption of third molars)  Periapical or panoramic examination to assess developing third molars

ADULTS Dentulous And Edentulous



Usually not indicated

Patient at high risk of dental caries may demonstrate High level of caries experience History of recurrent caries Existing restorations of poor quality Poor oral hygiene Inadequate fluoride exposure Prolonged nursing Diet with high sucrose frequency Poor family dental health

1. 2. 3. 4. 5. 6. 7. 8.

9.Developmental enamel defects 10. Developmental disability 11. Xerostomia 12. Genetic abnormality of teeth 13. Many multisurface restorations 14. Chemotherapy or radiation therapy

SPECIAL CONSIDERATIONS

PREGNANCY

  

X-ray beam largely confined to the head and neck region Only 1Gy for full mouth examination Apply guidelines just as other patients, using an appropriate lead apron to shield the abdominal area

 

RADIATION THERAPY Patient undergoing radiation therapy - Apprehensive about receiving radiation exposure for dental radiographs May be suffering from xerostomia ,radiation caries Careful follow up

EXAMPLES OF USE OF THE GUIDELINES

First visit of a 5- year old boy Cooperative, posterior teeth in contact Posterior bitewings of posterior teeth All teeth present, no evidence of caries , good diet, motivated parents no further radiographic examination

25 year old woman receiving 6 month checkup after her last treatment for fracture tooth C/F- No clinical evidence of caries, no caries on bitewing radiographs made 6 months back, No high risk factors for caries, no periodontal disease, fracture tooth vital no radiographs recommended If tooth non-vital periapical radiograph of the tooth

45 year old man- after one year (H/O two MOD restorations done on premolars and RCT on lower right first molar) C/F- 5mm periodontal pocket in the buccal furcation area upper right first molar Full mouth Bitewing radiographs to rule out active caries Periapical radiograph of upper right first molar-extent of periodontal disease Periapical radiograph of lower right first molar-periapical changes

65 year old woman first time, no previous radiographs( h/o RCT done in two teeth- not aware which) C/F multiple carious teeth, multiple missing teeth, generalized periodontal pockets> 3 mm full mouth radiographic examination

CONCLUSION

The decision to conduct a radiographic examination should be based on the individual needs of the patient. Needs determined by Dental history and clinical examination and modified by patient age and general health.