Question

What are the clinical indications for radiographic examination of the pediatric patient?

Answer 1

Purpose

The American Academy of Pediatric Dentistry (AAPD) intends

these recommendations to help practitioners make clinical

decisions concerning appropriate selection of dental radiographs

as part of an oral evaluation of infants, children, adolescents,

and individuals with special health care needs. The recom-

mendations can be used to optimize patient care, minimize

radiation burden, and allocate health care resources responsibly.

Methods

In 1981, the Ad Hoc Committee on Pedodontic Radiology of

the American Academy of Pedodontics developed guidance

on radiographic examination of pediatric dental patients.1

Six

years later, the U.S. Food and Drug Administration (FDA)

published recommendations2

developed by an expert dental

panel, which included a representative of the AAPD, convened

“to reach a consensus on standardizing dental radiographic

procedures”3

. In 2002, the American Dental Association

(ADA) initiated a review of that document. The AAPD, along

with other dental specialty organizations, participated in the

review and revision of these guidelines. The FDA accepted

the revision in November 2004,4

and the AAPD endorsed it

the following Spring. This review includes a new search of the

PubMed®/MEDLINE database using the terms: dental radiology,

dental radiographs, dental radiography, cone-beam computed

tomography AND guidelines, recommendations; fields: all;

limits: within the last 10 years, humans, and English. The

ADA Council on Scientific Affairs has published updates to

their recommendations for dental radiographs.5,6 The AAPD’s

Council of Clinical Affairs has developed these best practices

and continues to endorse the ADA/FDA’s recommendations.

Background

Radiographs are valuable aids in the oral health care of infants,

children, adolescents, and individuals with special health care

needs. They are used to diagnose and monitor oral diseases,

evaluate dentoalveolar trauma, as well as monitor dentofacial

development and the progress of therapy. The recommenda-

tions in the ADA/FDA guidelines were developed to serve as

an adjunct to the dentist’s professional judgment. The timing

of the initial radiographic examination should not be based

upon the patient’s age, but upon each child’s individual

circumstances. Radiographic screening for the purpose of

detecting disease before clinical examination should not be

performed.6 Because each patient is unique, the need for dental

radiographs can be determined only after consideration of the

patient’s medical and dental histories, completion of a thorough

clinical examination, and assessment of the patient’s vulnera-

bility to environmental factors that affect oral health. AAPD’s

recommendations for assessing risk for caries development in

children ages 0-5 years and ≥6 years can be found in Caries-

risk Assessment and Management for Infants, Children, and

Adolescents.7

Review of prior radiographs, when available

from within the same practice or through record transfer, also

contributes to the decision of radiographic necessity.

Radiographs should be taken only when there is an ex-

pectation that the diagnostic yield will affect patient care. The

AAPD recognizes that there may be clinical circumstances

for which a radiograph is indicated, but a diagnostic image

cannot be obtained. For example, the patient may be unable to

cooperate or the dentist may have privileges in a health care

facility lacking intraoral radiographic capabilities. If radio-

graphs of diagnostic quality are unobtainable, the dentist

should confer with the parent to determine appropriate man-

agement techniques (e.g., preventive/restorative interventions,

advanced behavior guidance modalities, deferral, referral),

giving consideration to the relative risks and benefits of the

various treatment options for the patient.

Because the effects of radiation exposure accumulate over

time, every effort must be made to minimize the patient’s

exposure. Good radiological practices are important in mini-

mizing or eliminating unnecessary radiation in diagnostic

dental imaging. Examples of good radiologic practice include:

1) use of the fastest image receptor compatible with the

diagnostic task (F-speed film or digital), 2) collimation of the

beam to the size of the receptor whenever feasible, 3) proper

film exposure and processing techniques, 4) use of protectiveaprons and thyroid collars, when appropriate, and 5) limiting

the number of images to the minimum necessary to obtain

essential diagnostic information.6

The dentist must weigh the

benefits of obtaining radiographs against the patient’s risk of

radiation exposure.

New imaging technology [i.e., cone beam computed tom-

ography (CBCT)] has added three-dimensional capabilities

that have many applications in dentistry. The use of CBCT

has been valuable as an adjunct diagnostic tool in assessing

periapical pathosis in endodontics, oral pathology, anomalies

in the developing dentition (e.g., impacted, ectopic, or super

numerary teeth), oral maxillofacial surgery (e.g., cleft palate),

dental and facial trauma, and orthodontic and surgical pre-

paration for orthognathic surgery. The American Academy of

Oral and Maxillofacial Radiology (AAOMR) has published

position statements which summarize the potential benefits

and risks of maxillofacial CBCT use in orthodontic and

endodontic diagnosis, treatment, and outcomes and providesclinical guidance to dental practitioners.10,11 The AAOMR’s

position statements support and affirm the position of the

ADA Council on Scientific Affairs in that the selection of

CBCT imaging must be justified based on individual need.10-12

Because this technology has potential to produce vast amounts

of data and imaging information beyond initial intentions, it

is important to interpret all information obtained, including

that which may be beyond the immediate diagnostic needs

or abilities of the practitioner.

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