Radiographic Examinations: Choosing the Right Patients & Equipment
You will receive 1 credit(s) of continuing education credit upon successful completion of this course. The purchase price of this course is $49.00


This course was developed to limit radiation exposure by emphasizing that routine radiographic examinations are not warranted, and the decision to use radiography should be based on the patient’s health history, vulnerability to oral disease and the results of the clinical exam. Technical aspects of choosing and using equipment will be explored as well.

Learning Objectives:

Upon completion of this course, participants should be able to do the following:

  1. Explain the importance of limiting radiographic exposure.
  2. Understand the guidelines for selecting patients for radiographic exams.
  3. Use knowledge of patients’ dental and medical history, the results of clinical exams, the ALARA principle and the guidelines to appropriately use X-rays.



This course summarizes the recommendations of the American Dental Association in collaboration with the U.S. Food and Drug Administration released in December 2012 that describe implementation of proper radiographic practices related to patient selection and limiting radiation exposure. In addition, dentists should be aware of, and comply with, applicable federal and state regulations. Dentists should weigh the benefits of dental radiographs against the consequences of increasing a patient’s exposure to radiation and implement appropriate radiation control procedures.

  1. The Basics
  2. Patient Selection Criteria
    1. Recommendations for Prescribing Dental Radiographs
    2. Explanation of Recommendations for Prescribing Dental Radiographs

      1. New Patient Being Evaluated for Oral Diseases
      2. Recall Patient with Clinical Caries or Increased Risk for Caries
      3. Recall Patient (Edentulous Adult)
      4. Recall Patient with No Clinical Caries and No Increased Risk for Caries
      5. Recall Patient with Periodontal Disease
      6. Patient (New and Recall) for Monitoring Growth and Development
      7. Patients with Other Circumstances
  3. Limiting Radiation Exposure
    1. Receptor Selection
    2. Receptor Holders
    3. Collimation
    4. Operating Potential and Exposure Time
    5. Patient Shielding and Positioning
    6. Operator Protection
    7. Hand-held X-ray Units
    8. Film Exposure and Processing
    9. Quality Assurance
    10. Technique Charts/Protocols
    11. Radiation Risk Communication
    12. Training and Education
  4. Conclusion

  1. The American Dental Association Council on Scientific Affairs. The use of cone-beam computed tomography in dentistry. J Am Dent Assoc 2012;143(8):899-202.
  2. Anbiaee N, Mohassel AR, Imanimoghaddam M, Moazzami SM. A comparison of the accuracy of digital and conventional radiography in the diagnosis of recurrent caries. J Contemp Dent Pract 2010;11(6):E025-032.
  3. Senel B, Kamburoglu K, Ucok O, et al. Diagnostic accuracy of different imaging modalities in detection of proximal caries. Dentomaxillofac Radiol 2010;39(8):501-11.
  4. Ulusu T, Bodur H, Odabas ME. In vitro comparison of digital and conventional bitewing radiographs for the detection of approximal caries in primary teeth exposed and viewed by a new wireless handheld unit. Dentomaxillofac Radiol 2010;39(2):91-4.
  5. Tracy KD, Dykstra BA, Gakenheimer DC, et al. Utility and effectiveness of computer-aided diagnosis of dental caries. Gen Dent 2011;59(2):136-44.
  6. Atchison KA, White SC, Flack VF, Hewlett ER. Assessing the FDA guidelines for ordering dental radiographs. J Am Dent Assoc 1995;126(10):1372-83.
  7. Atchison KA, White SC, Flack VF, Hewlett ER, Kinder SA. Efficacy of the FDA selection criteria for radiographic assessment of the periodontium. J Dent Res 1995;74(7):1424-32.
  8. Pitts NB, Kidd EA. The prescription and timing of bitewing radiography in the diagnosis and management of dental caries: contemporary recommendations. Br Dent J 1992;172(6):225-7.
  9. Smith NJ. Selection criteria for dental radiography. Br Dent J 1992;173(4):120-1.
  10. Hintze H. Screening with conventional and digital bite-wing radiography compared to clinical examination alone for caries detection in low-risk children. Caries Res 1993;27(6):499-504.
  11. Hintze H, Wenzel A. Clinically undetected dental caries assessed by bitewing screening in children with little caries experience. Dentomaxillofac Radiol 1994;23(1):19-23.
  12. Ferguson F, Festa SA. Radiography for children and adolescents. N Y State Dent J 1993;59(2):25-9.
  13. Henderson NJ, Crawford PJ. Guidelines for taking radiographs of children. Dent Update 1995;22(4):158-61.
  14. Wenzel A. Current trends in radiographic caries imaging. Oral Surg Oral Med Oral Pathol 1995;80(5):527-39.
  15. White SC, Heslop EW, Hollender LG, et al. Parameters of radiologic care: An official report of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91(5):498-511.
  16. Newman B, Seow WK, Kazoullis S, Ford D, Holcombe T. Clinical detection of caries in the primary dentition with and without bitewing radiography. Aust Dent J 2009;54(1):23-30.
  17. Clark HC, Curzon ME. A prospective comparison between findings from a clinical examination and results of bitewing and panoramic radiographs for dental caries diagnosis in children. Eur J Paediatr Dent 2004;5(4):203-9.
  18. Hopcraft MS, Morgan MV. Comparison of radiographic and clinical diagnosis of approximal and occlusal dental caries in a young adult population. Community Dent Oral Epidemiol 2005;33(3):212-8.
  19. Tinanoff N, Douglass JM. Clinical decision-making for caries management in primary teeth. J Dent Educ 2001;65(10):1133-42.
  20. Arrow P. Incidence and progression of approximal carious lesions among school children in Western Australia. Aust Dent J 2007;52(3):216-26.
  21. Lith A. Frequency of radiographic caries examinations and development of dental caries. Swed Dent J Suppl 2001(147):1-72.
  22. National Institute of Dental Research. The prevalence of dental caries in United States children, 1979-1980. Department of Health and Human Services - National Institutes of Health. 1981;NIH publication no. 82-2245.
  23. National Institute of Dental Research. The national survey of dental caries in U.S. School Children: 1986-1987. Department of Health and Human Services - National Institutes of Health. 1989;NIH publication no. 89-2247.
  24. Kaste LM, Selwitz RH, Oldakowski RJ, et al. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United States, 1988-1991. J Dent Res 1996;75 Spec No:631-41.
  25. National Center for Chronic Disease Prevention and Health Promotion. Oral Health: Preventing Cavities, Gum Disease, Tooth Loss, and Oral Cancers at a Glance 2011. (accessed November 14, 2011).
  26. Research Science and Therapy Committee American Academy of Periodontology. Position paper: Periodontal diseases of children and adolescents. J Periodontol 2003;74(11):1696-704.
  27. Oh TJ, Eber R, Wang HL. Periodontal diseases in the child and adolescent. J Clin Periodontol 2002;29(5):400-10.
  28. Corbet EF, Ho DK, Lai SM. Radiographs in periodontal disease diagnosis and management. Aust Dent J 2009;54 Suppl 1:S27-43.
  29. Hollier LH, Jr., Sharabi SE, Koshy JC, Stal S. Facial trauma: general principles of management. J Craniofac Surg 2010;21(4):1051-3.
  30. Alcala-Galiano A, Arribas-Garcia IJ, Martin-Perez MA, et al. Pediatric facial fractures: children are not just small adults. Radiographics 2008;28(2):441-61; quiz 618.
  31. Sameshima GT, Asgarifar KO. Assessment of root resorption and root shape: periapical vs panoramic films. Angle Orthod 2001;71(3):185-9.
  32. Witcher TP, Brand S, Gwilliam JR, McDonald F. Assessment of the anterior maxilla in orthodontic patients using upper anterior occlusal radiographs and dental panoramic tomography: a comparison. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(5):765-74.
  33. Tai CC, Miller PA, Packota GV, Wood RE. The occlusal radiograph revisited. Oral Health 1994;84(11):47-50, 53.
  34. Taylor NG, Jones AG. Are anterior occlusal radiographs indicated to supplement panoramic radiography during an orthodontic assessment? Br Dent J 1995;179(10):377-81.
  35. Tomar SL, Reeves AF. Changes in the oral health of U.S. children and adolescents and dental public health infrastructure since the release of the Healthy People 2010 Objectives. Acad Pediatr 2009;9(6):388-95.
  36. Albandar JM, Tinoco EM. Global epidemiology of periodontal diseases in children and young persons. Periodontol 2000 2002;29:153-76.
  37. Atieh MA. Diagnostic accuracy of panoramic radiography in determining relationship between inferior alveolar nerve and mandibular third molar. J Oral Maxillofac Surg 2010;68(1):74-82.
  38. Le T, Nassery K, Kahlert B, Heithersay G. A comparative diagnostic assessment of anterior tooth and bone status using panoramic and periapical radiography. Aust Orthod J 2011;27(2):162-8.
  39. Nohadani N, Ruf S. Assessment of vertical facial and dentoalveolar changes using panoramic radiography. EurJ Orthod 2008;30(3):262-8.
  40. Garvey MT, Barry HJ, Blake M. Supernumerary teeth--an overview of classification, diagnosis and management. J Can Dent Assoc 1999;65(11):612-6.
  41. Tsai HH. Panoramic radiographic findings of the mandibular growth from deciduous dentition to early permanent dentition. J Clin Pediatr Dent 2002;26(3):279-84.
  42. Anthonappa RP, King NM, Rabie AB, Mallineni SK. Reliability of panoramic radiographs for identifying supernumerary teeth in children. Inter J Paediatr Dent 2012;22(1):37-43.
  43. National Institute for Dental and Craniofacial Research. Dental Caries (Tooth Decay) in Adults (Age 20 to 64). (accessed March 21, 2012).
  44. Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR 2001;50(No. RR-14).
  45. Ritter AV, Shugars DA, Bader JD. Root caries risk indicators: a systematic review of risk models. Community Dent Oral Epidemiol 2010;38(5):383-97.
  46. Topping GVA, Pitts NB. Clinical Visual Caries Detection. Monogr Oral Sci 2009;21:15-41.
  47. Hugoson A, Sjodin B, Norderyd O. Trends over 30 years, 1973-2003, in the prevalence and severity of periodontal disease. J Clin Periodontol 2008;35:405-14.
  48. Rushton VE, Horner K, Worthington HV. Screening panoramic radiography of new adult patients: diagnostic yield when combined with bitewing radiography and identification of selection criteria. Br Dent J 2002;192(5):275-9.
  49. Rushton MN, Rushton VE. A study to determine the added value of 740 screening panoramic radiographs compared to intraoral radiography in the management of adult (>18 years) dentate patients in a primary care setting. J Dent 2012;40(8)661-9.
  50. Rushton VE, Horner K, Worthington HV. Routine panoramic radiography of new adult patients in general dental practice: relevance of diagnostic yield to treatment and identification of radiographic selection criteria. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93(4):488-95.
  51. Jindal SK, Sheikh S, Kulkarni S, Singla A. Significance of pre-treatment panoramic radiographic assessment of edentulous patients--a survey. Med Oral Patol Oral Cir Bucal. Jul 2011;16(4):e600-6.
  52. Edgerton M, Clark P. Location of abnormalities in panoramic radiographs of edentulous patients. Oral Surg Oral Med Oral Pathol 1991;71(1):106-9.
  53. Sumer AP, Sumer M, Guler AU, Bicer I. Panoramic radiographic examination of edentulous mouths. Quintessence Int 2007;38(7):e399-403.
  54. Masood F, Robinson W, Beavers KS, Haney KL. Findings from panoramic radiographs of the edentulous population and review of the literature. Quintessence Int 2007;38(6):e298-305.
  55. Awad EA, Al-Dharrab A. Panoramic radiographic examination: a survey of 271 edentulous patients. Int J Prosthodont 2011;24(1):55-7.
  56. Bohay RN, Stephens RG, Kogon SL. A study of the impact of screening or selective radiography on the treatment and postdelivery outcome for edentulous patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86(3):353-9.
  57. Feine JS, Carlsson GE, Awad MA, et al. The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Montreal, Quebec, May 24-25, 2002. Int J Oral Maxillofac Implants 2002;17(4):601-2.
  58. da Silva RP, Assaf AV, Pereira SM, et al. Validity of caries-detection methods under epidemiological setting. Am J Dent 2011;24(6):363-6.
  59. Steiner M, Buhlmann S, Menghini G, Imfeld C, Imfeld T. Caries risks and appropriate intervals between bitewing x-ray examinations in schoolchildren. Schweiz Monatsschr Zahnmed 2011;121(1):12-24.
  60. Patel S, Bay RC, Glick M. A systematic review of dental recall intervals and incidence of dental caries. J Am Dent Assoc 2010;141(5):527-39.
  61. Pitts NB. The use of bitewing radiographs in the management of dental caries: scientific and practical considerations. Dentomaxillofac Radiol 1996;25(1):5-16.
  62. Garcia RI, Valachovic RW, Chauncey HH. Longitudinal study of the diagnostic yield of panoramic radiographs in aging edentulous men. Oral Surg Oral Med Oral Pathol 1987;63(4):494-7.
  63. Dye BA, Thornton-Evans G. Trends in oral health by poverty status as measured by Healthy People 2010 objectives. Public Health Rep 2010;125(6):817-30.
  64. Dye BA, Arevalo O, Vargas CM. Trends in paediatric dental caries by poverty status in the United States, 1988-1994 and 1999-2004. Int J Paediatr Dent 2010;20(2):132-43.
  65. Shwartz M, Grondahl HG, Pliskin JS, Boffa J. A longitudinal analysis from bite-wing radiographs of the rate of progression of approximal carious lesions through human dental enamel. Arch Oral Biol 1984;29(7):529-36.
  66. Berkey CS, Douglass CW, Valachovic RW, Chauncey HH. Longitudinal radiographic analysis of carious lesion progression. Community Dent Oral Epidemiol 1988;16(2):83-90.
  67. Mejare I, Kallest l C, Stenlund H. Incidence and progression of approximal caries from 11 to 22 years of age in Sweden: A prospective radiographic study. Caries Res 1999;33(2):93-100.
  68. Sheiham A, Sabbah W. Using universal patterns of caries for planning and evaluating dental care. Caries Research 2010;44(2):141-50.
  69. Chankanka O, Marshall TA, Levy SM, et al. Mixed dentition cavitated caries incidence and dietary intake frequencies. Pediatr Dent 2011;33(3):233-40.
  70. Gruythuysen RJ, van der Linden LW, Woltgens JH, Geraets WG. Differences between primary and permanent teeth in posteruptive age dependency of radiological changes in enamel during the development of approximal caries. J Biol Buccale 1992;20(1):59-62.
  71. Kotsanos N, Darling AI. Influence of posteruptive age of enamel on its susceptibility to artificial caries. Caries Res 1991;25(4):241-50.
  72. Woltgens JH, Etty EJ, Geraets WG. Posteruptive age dependency of cariogenic changes in enamel of permanent teeth of children. J Biol Buccale 1990;18(1):49-53.
  73. Cardoso CA, Magalhaes AC, Rios D, Lima JE. Cross-sectional hardness of enamel from human teeth at different posteruptive ages. Caries Res 2009;43(6):491-4.
  74. Gutteridge DL. The use of radiographic techniques in the diagnosis and management of periodontal diseases. Dentomaxillofac Radiol 1995;24(2):107-13.
  75. National Council on Radiation Protection and Measurements, ed NCRP Report No. 160 - Ionizing Radiation Exposure of the Population of the United States. Bethesda: National Council on Radiation Protection and Measurements; 2009.
  76. American National Standards Institute. Photography - Intra-oral dental radiographic film - Specification. New York: American National Standards Institute. 1997;ANSI/NAPM IT2.49-1997. ANSI/ISO 3665:1996.
  77. American National Standards Institute. Photography - Direct-exposing medical and dental radiographic film/process systems - Determination of ISO speed and ISO average gradient. New York: American National Standards Institute. 1983;ISO 5799:1991. ANSI PH2.50-1983.
  78. U.S. Food and Drug Administration. Dental Radiography: Doses and Film Speed. (accessed August 2011).
  79. Farman TT, Farman AG. Evaluation of a new F speed dental X-ray film. The effect of processing solutions and a comparison with D and E speed films. Dentomaxillofac Radiol 2000;29(1):41-5.
  80. Hadley DL, Replogle KJ, Kirkam JC, Best AM. A comparison of five radiographic systems to D-speed film in the detection of artificial bone lesions. J Endod 2008;34(9):1111-4.
  81. Alkurt MT, Peker I, Bala O, Altunkaynak B. In vitro comparison of four different dental X-ray films and direct digital radiography for proximal caries detection. Oper Dent 2007;32(5):504-9.
  82. Schulze RK, Nackat D, D'Hoedt B. In vitro carious lesion detection on D-, E-, and F-speed radiographic films. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97(4):529-34.
  83. Sheaffer JC, Eleazer PD, Scheetz JP, Clark SJ, Farman AG. Endodontic measurement accuracy and perceived radiograph quality: effects of film speed and density. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96(4):441-8.
  84. Syriopoulos K, Velders XL, Sanderink GC, van Der Stelt PF. Sensitometric and clinical evaluation of a new F-speed dental X-ray film. Dentomaxillofac Radiol 2001;30(1):40-4.
  85. Woolhiser GA, Brand JW, Hoen MM, et al. Accuracy of film-based, digital, and enhanced digital images for endodontic length determination. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99(4):499-504.
  86. National Council for Radiation Protection & Measurements, ed. NCRP Report No. 145 - Radiation Protection in Dentistry. Bethesda: National Council on Radiation Protection and Measurement; 2003.
  87. Gratt BM, White SC, Packard FL, Petersson AR. An evaluation of rare-earth imaging systems in panoramic radiography. Oral Surg Oral Med Oral Pathol 1984;58(4):475-82.
  88. Kaugars GE, Fatouros P. Clinical comparison of conventional and rare earth screen-film systems for cephalometric radiographs. Oral Surg Oral Med Oral Pathol 1982;53(3):322-5.
  89. Goren AD, Lundeen RC, Deahl II ST, et al. Updated quality assurance self-assessment exercise in intraoral and panoramic radiography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89(3):369-74.
  90. Gavala S, Donta C, Tsiklakis K, et al. Radiation dose reduction in direct digital panoramic radiography. Eur J Radiol 2009;71(1):42-8.
  91. Alcaraz M, Parra C, Martinez Beneyto Y, Velasco E, Canteras M. Is it true that the radiation dose to which patients are exposed has decreased with modern radiographic films? Dentomaxillofac Radiol 2009;38(2):92-7.
  92. Dannewitz B, Hassfeld S, Eickholz P, Muhling J. Effect of dose reduction in digital dental panoramic radiography on image quality. Dentomaxillofac Radiol 2002;31(1):50-5.
  93. Kaeppler G, Dietz K, Herz K, Reinert S. Factors influencing the absorbed dose in intraoral radiography. Dentomaxillofac Radiol 2007;36(8):506-13.
  94. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings - 2003. MMWR 2003;52(No. RR-17):31.
  95. Freeman JP, Brand JW. Radiation doses of commonly used dental radiographic surveys. Oral Surg Oral Med Oral Pathol 1994;77(3):285-9.
  96. Gibbs SJ. Effective dose equivalent and effective dose: comparison for common projections in oral and maxillofacial radiology. Oral Surgery Oral Med Oral Pathol Oral RadiolEendod 2000;90(4):538-45.
  97. Gibbs SJ, Pujol A, Jr., Chen TS, James A, Jr. Patient risk from intraoral dental radiography. Dentomaxillofac Radiol 1988;17(1):15-23.
  98. Gibbs SJ. Biological effects of radiation from dental radiography. Council on Dental Materials, Instruments, and Equipment. J Am Dent Assoc 1982;105(2):275-81.
  99. Hujoel P, Hollender L, Bollen AM, et al. Head-and-neck organ doses from an episode of orthodontic care. Am J Orthod Dentofacial Orthop 2008;133(2):210-7.
  100. Ohman A, Kull L, Andersson J, Flygare L. Radiation doses in examination of lower third molars with computed tomography and conventional radiography. Dentomaxillofac Radiol 2008;37(8):445-52.
  101. Kircos LT, Angin LL, Lorton L. Order of magnitude dose reduction in intraoral radiography. J Am Dent Assoc 1987;114(3):344-7.
  102. Sinnott B, Ron E, Schneider AB. Exposing the thyroid to radiation: a review of its current extent, risks, and implications. Endocr Rev 2010;31(5):756-73.
  103. Lambert K, McKeon T. Inspection of lead aprons: criteria for rejection. Health Phys 2001;80(5 Suppl):S67-9.
  104. Michel R, Zorn MJ. Implementation of an X-ray radiation protective equipment inspection program. Health Phys 2002;82(2 Suppl):S51-3.
  105. U.S. Food and Drug Administration. Pediatric X-ray Imaging. 2012 (accessed August 2012).
  106. Alliance for Radiation Safety in Pediatric Imaging in partnership with the American Academy of Oral and Maxillofacial Radiology. What Parents Should Know about the Safety of Dental Radiology. 2011 (accessed August 2012).
  107. International Atomic Energy Agency. Diagnostic and Interventional Radiology. 2012 (accessed August 2012).

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