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Prescribing Dental Radiographs for Infants, Children, Adolescents, and Individuals with Special Health Care Needs

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 recommendations 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 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 and the AAPD 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 recommendations 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 vulnerability 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 Cariesrisk 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 expectation 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 radiographs of diagnostic quality are unobtainable, the dentist should confer with the parent to determine appropriate management 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 minimizing 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 protective aprons 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 tomography (CBCT)] have 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 preparation 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 provides clinical 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.

Recommendations

The recommendations of the ADA/FDA guidelines are contained within the accompanying Table. “These recommendations are subject to clinical judgment and may not apply to every patient. They are to be used by dentists only after reviewing the patient’s health history and completing a clinical examination. Even though radiation exposure from dental radiographs is low, once a decision to obtain radiographs is made it is the dentist’s responsibility to follow the as low as reasonably achievable (ALARA principle) to minimize the patient’s exposure.”6

Intraoral imaging should be maintained as the standard diagnostic tool. The use of CBCT should be considered when conventional radiographs are inadequate to complete diagnosis and treatment planning and the potential benefits outweigh the risk of additional radiation dose. It must not be routinely prescribed for diagnosis or screening purposes in the absence of clinical indication. Basic principles and guidelines for the use of CBCT include: 1) use of appropriate image size or field of view, 2) assess the radiation dose risk, 3) minimize patient radiation exposure and, 4) maintain professional competency in performing and interpreting CBCT studies.10-13  When using CBCT, the resulting imaging is required to be supplemented with a written report placed in the patient’s records that includes full interpretation of the findings.

References

  1. American Academy Pediatric Dentistry. Oral health policy on dental radiographs in children. Pediatr Dent 1991;13(6):27-8.
  2. Joseph LP. The Selection of Patients for X-ray Examinations: Dental Radiographic Examinations. Rockville, Md.: The Dental Radiographic Patient Selection Criteria Panel, U.S. Department of Health and Humans Services, Center for Devices and Radiological Health; 1987. HHS Publication No. FDA 88-8273.
  3. American Academy Pediatric Dentistry. Guidelines for prescribing dental radiographs. Pediatr Dent 1995;17(6):66-7.
  4. American Dental Association, U.S. Department of Health and Humans Services. The selection of patients for dental radiographic examinations—2004. Available at: "https://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm116505.pdf ”. Accessed November 6, 2016. (Archived by WebCite® at: “http://www.webcitation.org/6owR38t1A”)
  5. American Dental Association Council on Scientific Affairs. The use of dental radiographs: Update and recommendations. J Am Dent Assoc 2006;137(9):1304-12. 
  6. American Dental Association Council on Scientific Affairs, U.S. Department of Health and Humans Services Public Health Service Food and Drug Administration. Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure. Chicago, Ill.; 2012:5-7. Available at: “http://www.ada.org/~/media/ADA/Publications/ADA%20News/Files/Dental_Radiographic_Examinations_2012.pdf”. Accessed November 6, 2016. (Archived by WebCite® at: “http://www.webcitation.org/6tv6SjRaF”)
  7. American Academy Pediatric Dentistry. Caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent 2017;39(6):197-204.
  8. American Dental Association. Caries risk form (Ages 0-6 years). ADA Resources: ADA Caries Risk Assessment Forms. Caries Risk Assessment and Management. Chicago, Ill. Available at: “http://www.ada.org/~/media/ADA/Member%20Center/FIles/topics_caries_under6.pdf?la=en”. Accessed September 27, 2016. (Archived by WebCite® at: “http://www.webcitation.org/6tvAwgomN”) 
  9. American Dental Association. Caries risk form (Over 6 years). ADA Resources: ADA Caries Risk Assessment Forms. Caries Risk Assessment and Management. Chicago, Ill. Available at: “http://www.ada.org/~/media/ADA_Foundation/GKAS/Files/topics_caries_educational_over6.pdf?la=en”. Accessed September 27, 2016. (Archived by WebCite® at: “http://www.webcitation.org/6tvB0CMMs”)
  10. American Academy of Oral and Maxillofacial Radiology. Clinical recommendations regarding use of cone beam computed tomography in orthodontics. Position statement by the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116(2):238-57. Erratum in Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116(5):661.
  11. Special Committee to Revise the Joint AAE/AAOMR Position Statement on use of CBCT in Endodontics. AAE and AAOMR joint position statement: Use of cone beam computed tomography in endodontics 2015 Update. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;120(4):508-12. 
  12. American Dental Association Council on Scientific Affairs. The use of cone-beam computed tomography in dentistry. An advisory statement from the American Dental Association Council on Clinical Affairs. J Am Dent Assoc 2012;143(8):899-902.
  13. SEDENTEXCT Project (2008-2011). Radiation protection: Cone beam CT for dental and maxillofacial radiology. Evidence-based guidelines. Available at: “https://ec.europa.eu/energy/sites/ener/files/documents/172.pdf”. Accessed November 6, 2016. (Archived by WebCite® at: “http://www.webcitation.org/6owRWlv64”)