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The Selection of Patients for Dental Radiographic ExaminationsAlso available at: www.ada.org
Revised 2004AMERICAN DENTAL ASSOCIATION
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Type of Encounter |
Patient Age and Dental Developmental Stage |
||||
---|---|---|---|---|---|
Child with Primary Dentition (prior to eruption of first permanent tooth) |
Child with Transitional Dentition (after eruption of first permanent tooth) |
Adolescent with Permanent Dentition (prior to eruption of third molars) |
Adult, Dentate or Partially Edentulous |
Adult, Edentulous |
|
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.
|
Individualized radiographic exam, based on clinical signs and symptoms. |
|
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
|
Posterior bitewing exam at 6-18 month intervals |
Not applicable |
||
Recall patient* with no clinical caries and not at increased risk for caries** |
Posterior bitewing exam at 12-24 month intervals if proximal surfaces cannot be examined visually or with a probe
|
Posterior bitewing exam at 18-36 month intervals |
Posterior bitewing exam at 24-36 month intervals |
Not applicable |
Guidelines for Prescribing Dental Radiographs, cont’d.
Type of Encounter |
Patient Age and Dental Developmental Stage |
||||
---|---|---|---|---|---|
Child with Primary Dentition (prior to eruption of first permanent tooth) |
Child with Transitional Dentition (after eruption of first permanent tooth) |
Adolescent with Permanent Dentition (prior to eruption of third molars) |
Adult Dentate and Partially Edentulous |
Adult Edentulous |
|
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 is not limited to, selected bitewing and/or periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be identified clinically. |
Not applicable |
|||
Patient for monitoring of growth and development |
Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development
|
Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development. Panoramic or periapical exam to assess developing third molars |
Usually not indicated
|
||
Patient with other circumstances including, but not limited to, proposed or existing implants, pathology, 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 circumstances.
|
*Clinical situations for which radiographs may be indicated include but are not limited to:
A. Positive Historical Findings
* * Factors increasing risk for caries may include but are not limited to:
Patient Age and Dental Developmental Stages
Child (Primary Dentition): prior to eruption of first permanent tooth
Child (Transitional Dentition): after eruption of first permanent tooth
Adolescent (Permanent Dentition): prior to eruption of third molars
Adult (Dentate or Partially Edentulous)
Adult (Edentulous)
Rationale by Type of Encounter and Patient Age and Dental Developmental Stages
Row: New Patient Being Evaluated for Dental Diseases and Dental Development
Column: Child (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 (17-19). However, studies suggest that many of these lesions will remain in the enamel for at least 12 months, allowing sufficient time for implementation and evaluation of preventive interventions (20). A periapical/anterior occlusal examination may be indicated because of the need to evaluate dental development, dentoalveolar trauma or suspected pathology. Periapical and bitewing radiographs may be required to evaluate pulp pathology in primary molars.
Therefore, the Panel recommends 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. Patients without evidence of disease and with open proximal contacts may not require radiographic examination at this time.
Row: New Patient Being Evaluated for Dental Diseases and Dental Development
Column: Child (Transitional Dentition)
There has been a dramatic decrease in the incidence of dental caries over the last 30 years (21-23). However, the decrease has not been a uniform one. For example, 80% of the dental caries in permanent teeth of U.S. children aged 5-17 years occurs in 25% of those children (23). It is, 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 (24).
A periapical or panoramic examination is useful for evaluating dental development. A panoramic radiograph also is useful for the evaluation of craniofacial trauma (12). Intraoral radiographs are more accurate than panoramic radiographs for the evaluation of dentoalveolar trauma, root shape, root resorption (25) and pulp pathology. However, panoramic examinations may have the advantage of reduced radiation dose, cost and larger area imaged.
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 pathology exists (26,27).
Therefore, the Panel recommends an individualized radiographic examination consisting of posterior bitewings with panoramic examination or posterior bitewings and selected periapical images be performed.
Row: New Patient Being Evaluated for Dental Diseases and Dental Development
Column: Adolescent (Permanent Dentition)
Within the pediatric population, the adolescent age group has the most decayed, missing or filled surfaces (DMFS) (23,28). The pattern of decay according to tooth surface type changes from primary to permanent dentition (23). 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 is the increased incidence of periodontal disease found in this age group compared to children (29).
Panoramic radiography is effective in dental diagnosis and treatment planning (30-36). Specifically, the status of dental development can be assessed using panoramic radiography (26). Occlusal radiographs can be used to detect the position of an unerupted or supernumerary tooth (37). Third molars also should be evaluated in this age group for their presence, position and stage of development.
Therefore, the Panel recommends an individualized radiographic examination consisting of posterior bitewings with panoramic examination or posterior bitewings and selected periapical images be performed. A full mouth intraoral radiographic examination is preferred when the patient has clinical evidence of generalized dental disease or a history of extensive dental treatment.
Row: New Patient Being Evaluated for Dental Diseases
Column: Adult (Dentate or Partially Edentulous)
The overall dental caries experience of the adult population appears to be declining (28). However, risk for dental caries exists on a continuum and changes over time as risk factors change (38). Therefore, 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 (39). Although bitewing radiographs can assist in detecting root surface caries in proximal areas, the usual method of detecting root surface caries is by clinical examination (39).
The incidence of periodontal disease increases with age (28). 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.
Occlusal radiographs can be used to detect the position of an unerupted or supernumerary tooth, to check for sialoliths and to assess the buccolingual extent of pathological lesions (21).
Therefore, the Panel recommends that an individualized radiographic examination, consisting of posterior bitewings with panoramic examination or selected periapical images be performed. A full mouth intraoral radiographic examination is preferred when the patient has clinical evidence of generalized dental disease or a history of extensive dental treatment.
Row: New Patient Being Evaluated for Dental Diseases
Column: Adult (Edentulous)
The clinical and radiographic examinations of edentulous patients generally occur during an assessment of the need for prosthetic appliances. 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, intrabony 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 prosthetic appliances. Secondly, the original recommendation considered edentulous patients to be at increased risk for oral disease. Studies have found that 33 to 41 percent of edentulous patients examined exhibited pathological conditions (40-42). A survey of 1,135 edentulous patients revealed that 14.2 percent had retained roots without pathology, 19.2 percent had retained roots with pathology or partly uncovered and 4.1 percent had retained teeth (43). In addition, the radiographic examination may reveal anatomic considerations that could influence prosthetic treatment, such as the location of the mandibular canal, the position of the mental foramen and maxillary sinus, and relative thickness of the soft tissue covering the edentulous ridge (44,45).
Screening radiography for new, edentulous patients has since been criticized because of the assertion that screening does not yield sufficient clinically relevant information (46-48). However, also there is support for screening (49-51).
This panel concluded that prescription of radiographs is appropriate as part of the initial assessment of edentulous areas for possible prosthetic treatment. 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. Particularly with the option of dental implant therapy for edentulous patients (52), radiographs can be an important aid in diagnosis, prognosis and the determination of treatment complexity (53).
Therefore, the Panel recommends that an individualized radiographic examination, based on clinical signs and symptoms be performed.
Row: Recall Patient with Clinical Caries or Increased Risk for Caries
Columns: Child (Primary and Transitional Dentition) and Adolescent (Permanent Dentition)
Clinically detectable dental caries may suggest the presence of proximal carious lesions that can only be detected with a radiographic examination. In addition, patients who are at increased risk for developing dental caries because of such factors as poor oral hygiene, high frequency of exposure to sucrose-containing foods and deficient fluoride intake (see chart footnotes for other factors) are more likely to have proximal carious lesions.
The bitewing examination is the most efficient method for detecting proximal lesions (17,18). The frequency of radiographic recall should be determined on the basis of caries risk assessment (9,12,14,19,54-57). It should be noted that a patient’s caries risk status may change over time and that an individual’s radiographic recall interval may need to be changed accordingly (8).
Therefore, the Panel recommends that a posterior bitewing examination be performed at 6 to 12 month intervals if proximal surfaces cannot be examined visually or with a probe.
Row: Recall Patient with Clinical Caries or Increased Risk for Caries
Column: Adult (Dentate and Partially Edentulous)
Adults who exhibit clinical dental caries or who have other increased risk factors should be monitored carefully for any new or recurrent lesions that are detectable only by radiographic examination. The frequency of radiographic recall should be determined on the basis of caries risk assessment (9,12,14,19,54-57). It should be noted that a patient’s risk status can change over time and that an individual’s radiographic recall interval may need to be changed accordingly (8).
Therefore, the Panel recommends that a posterior bitewing examination be performed at 6 to 18 month intervals.
Rows: Recall Patient
Column: Adult (Edentulous)
A study that assessed radiographs of edentulous recall patients showed that previously detected incidental findings did not progress and that no intervention was indicated (48). The data suggest that patients who receive continuous dental care do not exhibit new findings that require treatment.
An examination for occult disease in this group cannot be justified on the basis of prevalence, morbidity, mortality, radiation dose and cost (49,58-61).
Therefore, the Panel recommends that no radiographic examination be performed without evidence of disease.
Row: Recall Patient with No Clinical Caries and No Increased Risk For Caries
Columns: Child (Primary and Transitional Dentition)
Despite the general decline in dental caries activity, recent data show that subgroups of children have a higher caries experience than the overall population (23). The identification of patients in these subgroups may be difficult on an individual basis. For children who present for recall examination without evidence of clinical caries and who are not considered at increased risk for the development of caries, it remains important to evaluate proximal surfaces by radiographic examination. In primary teeth, the caries process can take approximately one year to progress through the outer half of the enamel and about another year through the inner half (62). Considering this rate of progression of carious lesions through primary teeth, a time-based interval of radiographic examinations from one to two years for this group appears appropriate. The incidence of carious lesions has been shown to increase during the stage of transitional dentition (28). Children under routine professional care would be expected to be at a lower risk for caries. Nevertheless, newly erupted teeth are at risk for the development of dental caries.
Therefore, the Panel recommends that a radiographic examination consisting of posterior bitewings be performed at intervals of 12 to 24 months if proximal surfaces cannot be examined visually or with a probe.
Row: Recall Patient with No Clinical Caries and No Increased Risk for Caries
Column: Adolescent (Permanent Dentition)
Adolescents with permanent dentition, who are free of clinical dental caries and factors that would place them at increased risk for developing dental caries, should be monitored carefully for development of proximal carious lesions, which may be detected only by radiographic examination. The caries process, on average, takes more than three years to progress through the enamel (62). However, evidence suggests that the enamel of permanent teeth undergoes posteruptive maturation and that young permanent teeth are susceptible to faster progression of carious lesions (63).
Therefore, the Panel recommends that a radiographic examination consisting of posterior bitewings be performed at intervals of 18 to 36 months.
Row: Recall Patient with No Clinical Caries and No Increased Risk for Caries
Column: Adult (Dentate or Partially Edentulous)
Adult dentate patients, who receive regularly scheduled professional care and are free of signs and symptoms of oral disease, are at a low risk for dental caries. Nevertheless, consideration should be given to the fact that caries risk can vary over time as risk factors change. Advancing age and changes in diet, medical history and periodontal status may increase the risk for dental caries.
Therefore, the Panel recommends that a radiographic examination consisting of posterior bitewings be performed at intervals of 24 to 36 months.
Row: Recall Patient with Periodontal Disease
Columns: Child (Primary and Transitional Dentition), Adolescent (Permanent Dentition) and Adult (Dentate or Partially Edentulous)
The decision to obtain radiographs for patients who have clinical evidence or a history of periodontal disease/treatment should be determined on the basis of the anticipation that important diagnostic and prognostic information will result. Structures or conditions to be assessed should include the level of supporting alveolar bone, condition of the interproximal bony crest, length and shape of roots, bone loss in furcations and calculus deposits. The frequency of radiographic examinations for these patients should be determined on the basis of a clinical examination of the periodontium and documented signs and symptoms of periodontal disease. The procedure for prescribing radiographs for the follow-up/recall periodontal patient would be to use selected intraoral radiographs to verify clinical findings on a patient-by-patient basis (64).
Therefore, the Panel recommends that clinical judgment be used in determining the need for, and type of radiographic images necessary for, evaluation of periodontal disease. Imaging may consist of, but is not limited to, selected bitewing and/or periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be identified clinically.
Row: Patient for Monitoring of Growth and Development
Columns: Child (Primary and Transitional Dentition)
For children with primary dentition, before the eruption of the first permanent tooth, radiographic examination to assess growth and development in the absence of clinical signs or symptoms is unlikely to yield productive information. Any abnormality of growth and development suggested by clinical findings should be evaluated radiographically on an individual basis. After eruption of the first permanent tooth, the child may have a radiographic examination to assess growth and development. This examination need not be repeated unless dictated by clinical signs or symptoms.
Cephalometric radiographs may be useful for assessing growth and planning orthodontic treatment (65,66).
Therefore, the Panel recommends that clinical judgment be used in determining the need for, and type of radiographic images necessary for, evaluation and/or monitoring of dentofacial growth and development.
Row: Patient for Monitoring of Growth and Development
Column: Adolescent (Permanent Dentition)
The major concern relating to growth and development for patients in this age group is to determine the presence, position and development of third molars. This determination can best be made by the use of selected periapical images or a panoramic examination, once the patient is in late adolescence (16 to 19 years of age).
Therefore, the Panel recommends that clinical judgment be used in determining the need for, and type of radiographic images necessary for, evaluation and/or monitoring of dentofacial growth and development be used. Panoramic or periapical examination may be used to assess developing third molars.
Row: Patient for Monitoring of Growth and Development
Columns: Adult (Dentate, Partially Edentulous and Edentulous)
In the absence of any clinical signs or symptoms suggesting abnormalities of growth and development in adults, no radiographic examinations are indicated for this purpose.
Therefore the Panel recommends that, in the absence of clinical signs and symptoms, no radiographic examination be performed.
Row: Patients with other circumstances including, but not limited to, proposed or existing implants, pathology, restorative/endodontic needs, treated periodontal disease and caries remineralization
Columns: All patient categories
The use of imaging, as a diagnostic and evaluative tool has progressed beyond the longstanding need to diagnose caries and evaluate the status of periodontal disease. The expanded technology in imaging is now used to diagnose other orofacial clinical conditions and evaluate treatment options. A few examples of other clinical circumstances are the use of imaging for dental implant treatment planning, placement or evaluation; the monitoring of dental caries and remineralization; the assessment of restorative and endodontic needs; and the diagnosis of soft and hard tissue pathology.
Therefore the Panel recommends that clinical judgment be used in determining the need for, and type of radiographic images necessary for, evaluation and/or monitoring in these circumstances.
Adolescent Dentition: The state of dental development when all permanent teeth, except the third molars, should have erupted.
Bitewings: A form of dental radiograph that may be taken with the long axis of the film oriented either horizontally or vertically, that reveals approximately the coronal halves of the maxillary and mandibular teeth and portions of the interdental alveolar septa on the same film.
Cephalometric Radiograph: A standardized, extraoral projection, either in a lateral or frontal view, that shows the relationships between the jaws and other skeletal structures, usually used for orthodontic evaluation.
Dentate : Having one or more natural teeth present in the mouth. Individuals with only natural roots of teeth (e.g., patients with overdenture) are considered dentate as they are subject to caries, periodontal disease and other dental diseases.
Diagnostic Imaging: A visual display of structural or functional patterns for the purpose of diagnostic evaluation.
Edentulous: Toothless or without any natural teeth. Individuals without natural teeth but with implants are considered edentulous although they are subject to special problems associated with implants.
Full Mouth Intraoral Radiographic Examination (FMX): A set of intraoral radiographs usually consisting of 14 to 22 periapical and posterior bitewing images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone crest.
Guidelines: A set of recommendations or decision rules to assist dentists in the selection of patients who are likely to exhibit useful findings resulting from a radiographic examination.
Individualized Radiographic Examination: A combination of periapical, bitewing (vertical or horizontal), panoramic or other views selected for an individual patient on the basis of patient signs, symptoms and historical findings.
New Patient: A patient who visits a specific dental practice or other patient care facility for the first time to initiate a course of care.
Occult Disease: Disease that is not accompanied by readily detectable clinical signs, symptoms or history.
Occlusal Projection: An intraoral projection whereby the film packet is held in position by having the patient bite lightly on the film to support it between the occlusal surfaces of the jaws.
Panoramic Radiograph: An extraoral projection whereby the entire mandible, maxilla, teeth and other nearby structures are portrayed on a single film, as if the jaws were flattened out.
Recall Patient: A patient who has made a previous visit(s) to a specific dental practice, or other patient carefacility, and is receiving ongoing care.
Selection Criteria: Descriptions of clinical conditions and historical data that identify patients who are most likely to benefit from a particular radiographic examination.
Document created: November 2004
Updated January 4, 2005
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