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Review of Radiographic

Techniques for the Paediatric

Objectives of this Lecture

 Understand the rationale for radiographic

examination in children and adolescents,
 Be aware of the indications for radiographs in
children and adolescents,
 Use the indicated radiographic technique,
dependant on the age of the child and caries
 Review the principles of proper radiographic
Rationale- Primary Dentition

 In a population the use of bitewing radiography

in addition to clinical examination increases the
number of approximal lesions detected by a
factor of between two and eight (Faculty, 1998, Stephen et al.,
1987, Kidd and Pitts, 1990).

 Recent studies have shown that even in

populations with an overall low caries
prevalence, more than 1/3 of 5-year-olds in
Sweden and Norway had approximal carious
lesions that could not be detected by visual
inspection (Boman et al., 1999, Raadal et al., 2000).
 In a Dutch study (Roeters, 1992) between 10 and 60%
extra information was gained by the use of the
bitewing radiographs in the 5-year old age
Rationale- The Mixed Dentition

 At the age of 9 about 1/3 of Swedish children

had dentin caries in at least one distal surface of
the second primary molar as judged
 It was also shown that enamel or dentin caries
in the distal surface of the second primary molar
increased the risk about 15 times for the mesial
surface of the first permanent molar to develop
approximal caries. (Mejare and Stenlund, 2000, Kallestal et al., 2000).

 Bitewing radiographs are also useful for

deciding the proper interval to the next
 Children who are caries-free in approximal
surfaces in their primary teeth at the age of 8-9
are likely to remain so up to at least the age of
12 (Mejare et al., 2001). Therefore, bitewing radiographs
should be considered at the age of 8-9.
Rationale- The Young Permanent

 Baseline bitewing radiographs in the permanent

dentition should be considered at the age of 12-
14, that is 1- 2 years after eruption of premolars
and second molars. This concerns also
populations with an, overall low caries
prevalence (de Vries et al., 1990).

 Should not be performed in a routine manner

using the same practice for all individuals.
 Should only be performed when the patient
history and/or objective findings and symptoms
lead to the conclusion that further useful
information might be obtained.
 If a radiograph is not expected to change
diagnosis or treatment or add other useful
information, it should not be taken.
What are the clinical situations for
which radiographs may be indicated

 Positive Historical Findings,

 Positive Clinical Signs/Symptoms

Positive Historical Findings

1. History of pain or trauma

2. Previous pulp therapy
3. Familial history of dental anomalies
4. Postoperative evaluation of healing
Positive Clinical Signs/Symptoms
1. Deep carious lesions
2. Large or deep restorations
3. Swelling
4. Fistula or sinus tract infection
5. Clinical evidence of periodontal disease
6. Mobility of teeth
7. Evidence of facial trauma
8. Evidence of foreign objects
9. Oral involvement in known or suspected
systemic disease
10. Clinically suspected sinus pathology
11. Growth abnormalities
12. Missing teeth with unknown reason.
13. Unusual tooth morphology, calcification or color
14. Malposed or clinically impacted teeth
15. Unusual eruption, spacing or migration of teeth
16. Unexplained bleeding
17. Pain and/or dysfunction of the temporomandibular joint
18. Facial asymmetry
19. Positive neurologic findings in the head and neck
20. Unexplained sensitivity of teeth
21. Abutment teeth for fixed or removable partial prosthesis
General Indications for Radiographs in
Children and Adolescents
 The major reasons for taking radiographs in
paediatric dentistry of teeth and supporting
tissue are:
o Detection of caries;
o Dental injuries;
o Disturbances in tooth development,
o Examination of pathological conditions other
than caries.
General Indications for Radiographs in
Children and Adolescents
Clinical Indications for the
Paediatric Patient’s Radiography

 Bitewing Radiographs

 Periapical Radiographs

 Occlusal Radiographs

 Panoramic Radiographs
Clinical indications for Bitewing
 Detect caries that cannot otherwise be detected,

 Estimate the extent of lesions (3D??),

 Monitor lesion progression,

 Determine pulp chamber configuration,

 Determine in some instances the presence or

absence of premolar crowns.
Clinical indications for Periapical
 Detection of pathologic changes associated with primary teeth
(such as apical infection/inflammation or internal resorption)
 After trauma to the teeth and associated alveolar bone,
 Detect developmental abnormalities,
 Assessment of the presence and position of unerupted teeth,
 Assessment of the periodontal status,
 Assessment of root morphology before extractions,
 Detailed evaluation of apical cysts and other lesions within the
alveolar bone,
 In some space analysis techniques in the mixed dentition (e.g.
Nance technique).
Clinical indications for Occlusal
 Determine the presence, shape and position of
midline supernumerary teeth,
 Determine impaction of canines,
 Determine the presence or absence of incisors,
 Asses the extent of trauma to teeth and anterior
Clinical indications for Panoramic
It’s supplement to rather than substitute for intra-
oral radiographs.
 Diagnose missing and supernumerary teeth,
 Detect gross pathoses,
 Asses development of the dentition,
 Estimate the dental age of the patient,
 Detect bone fractures, traumatic cysts,
 Detect anomalies,
 In some patients with disabilities (if the patient
can sit in a chair and hold head in position).
Radiography Guidelines

 Guidelines are designed to:

o Avoid unnecessary exposure to X-radiation,
o Identify individuals who may benefit from a
radiographic examination.

 Every prescription of radiographs should be

based on an evaluation of the individual patient
Radiography Guidelines
 Routine survey by radiographs (except for
caries) has not been shown to provide sufficient
information to be justified considered the
balance between cost (radiation and resources)
and benefit.

 Keywords for good practice are appropriate

selection criteria for the use of radiography,
optimised radiation protection, and utilization of
the total amount of information in each
Child Adolescent
Primary Mixed Dentition Permanent Dentition
Dentition (Following (Prior to the eruption
(Prior to eruption of the 1st of
eruption of the permanent tooth) the 3rd molars)
Patient 1st permanent
Category tooth)
New Patient
All new 1. Periapical Individualized Individualized
patients in /occlusal radiographic radiographic
order to views &/or examination examination consisting
assess dental • Posterior consisting of: of
disease & bitewing • Periapical Posterior bitewings and
growth & exam’n if /occlusal views selected periapicals.
development. proximal and posterior N.B: A complete mouth
surfaces of bitewings or Radiographic examination is
primary • Panoramic appropriated when the patient
presents with
teeth examination
clinical evidence of
cannot be and posterior generalized dental disease or a
visualized. bitewings. history of excessive dental
Child Adolescent
Primary Mixed Permanent
Dentition Dentition Dentition
(Prior to (Following (Prior to the
Patient Category eruption of the eruption of the eruption of the 3rd
1st permanent 1st permanent molars)
tooth) tooth)
Recall Patient
Clinical caries or Posterior bitewing examination Posterior bitewing
high risk factors. at 6-12 month intervals if examination at 6
proximal surfaces…... to 18 month
No clinical caries Posterior bitewing examination Posterior bitewing
and no high risk at 12 to 24 month intervals. examination at 18
factors for caries. to 36 month
Patients at high risk for caries may
demonstrate any of the following
1. High level of caries experience 8. Poor family dental health
2. History of recurrent caries 9. Developmental enamel defects
3. Existing restoration of poor 10. Developmental disability
quality 11. Xerostomia
4. Poor oral hygiene
12. Genetic abnormality of teeth
5. Inadequate fluoride exposure
13. Many multisurface restorations
6. Prolonged nursing (bottle or
14. Chemo/radiation therapy
7. Diet with high sucrose
Child Adolescent
Primary Transitional Permanent
Dentition Dentition (Following Dentition
Patient (Prior to eruption eruption of the 1st (Prior to the
Category of the first permanent tooth) eruption of the
permanent tooth) third molars)
Recall Patient
disease, or a Individualized radiographic examination consisting of
history of selected periapicals and posterior bitewings for areas
periodontal where periodontal disease (other than non-specific
therapy. gingivitis) can be demonstrated clinically.
Growth and CLINICAL CLINICAL Periapical or
development JUDGMENT JUDGMENT panoramic
examination to
third molars.
Principles for Proper Radiographic
 The foundation of an accurate diagnosis and
treatment plan is based on:
o Comprehensive medical and dental history,
o A thorough clinical examination,
o Diagnostic radiographs.
 Of the three, obtaining diagnostic radiographs in the
pediatric dental patient is probably the most difficult
to accomplish, not only from a technical standpoint
but because of parental fears and misconceptions.
Communicating with Parents

1. During the first appointment, the clinician reduces

a parent’s resistance to the use of radiographs by
informing the parents of the diagnostic need for
radiographs and educating them about current
radiation hygiene practices and radiographic
2. It should be emphasized that visual examination
reveals only three of the five surfaces of the teeth
because if the child’s teeth are close together the
dentist cannot see between them..

3. Furthermore, the dentist cannot see the insides

of the teeth, their roots, nor the permanent teeth
developing in the jaws
4. Although excessive radiation exposure can
result in cancer, birth defects and genetic
defects, the amount of radiation needed to
expose the newer X-ray film has significantly
reduced the amount of radiation to which
patients are exposed.
Informed consent
 The patient or parents have a legitimate right to be
heard and approve the clinician’s advice about any
radiographic examination.
 The clinician has to consider and respect the views,
values and preferences, which the patient and or
family express after having received and
understood the information provided.
 However, strong recommendations might be
appropriate when the clinician finds the
examination highly beneficial for the patient.
 If the recommendations of guidelines are not
followed, the reasons should be discussed with the
patient and recorded in the clinical case notes.
Management Techniques

 In the rare occasion

when a very young
dental patient under
three years of age needs
a radiograph, the dental
office should be
prepared with techniques
to reduce any
psychological trauma.

1. Explain what you plan to do in words that are

easily comprehended.
2. Use a tell, show, do technique:
a. Explain to the child that a tooth camera will be
used to take a picture of their tooth.
b. Allow them to touch and examine the
radiographic film and camera.
3. To gain maximum cooperation in children under
three years, it may be necessary for the child to sit
in the parent’s lap while exposing the radiograph

 Start with the least difficult radiograph first (such

as an anterior occlusal)
 The correct settings are made on the apparatus and
the X-ray head is properly positioned before
placing the film in the child’s mouth.
 A positioning device such as a Snap-A-Ray
instrument can be used to aid the parent in
positioning and securing the film.
 Adequately protect the parent and child with lead
aprons to reduce radiation exposure. If the child is
uncooperative, then

 It may be necessary to
restrain the child in a
“papoose board”.
 This frees the parent to
stabilize the child’s
head and properly
position the radiograph
in the child’s mouth.

 If the child is still

uncooperative, it may
be necessary to manage
the child
with inhalation, oral, or
parental sedatives
Radiographic Film Sizes for the
Paediatric Patient
 Size “0”: used for bitewing and periapical
radiographs in young children (up to 4-5 yrs),
 Size “1”: used in older children to take bitewing
and periapical radiographs (up to 7-8 years),
 Size “2”: used for anterior occlusal, periapical
and bitewing radiographs in the mixed and
permanent dentitions,
 Occlusal: used for anterior occlusal views,
complete quadrant views and survey the
Radiographic Techniques
 The main technical problem encountered in
children is the size of their mouths and the
difficulty in placing the film packet
intraorally. The paralleling technique is not
possible in very small children, but can
often be used (and is recommended)
anteriorly, for investigating traumatized
permanent incisors.
 A modified bisected angle technique is
possible in most children, with the film
placed flat in the mouth (in the occlusal
plane) and the position of the X-ray tube
head adjusted accordingly
Film Holders


A Hawe–Neos Superbite
posterior holder (red). B
Hawe–Neos Superbite
A the Masel Precision
anterior holder (green). C
all-in-one metal holder
Rinn XCP posterior holder
and B the Rinn XCP
(yellow). D Rinn XCP
holder with its
anterior holder (blue) with
additional metal
film packet inserted. E
collimator attached to
Unibite® posterior holder.
the white locator ring.
Detection of Dental Caries
Coronal radiolucency
 A term used to describe an
anomaly presenting as an
abnormal radiolucency
resembling caries within the
coronal tissues of unerupted
 Several explanations have been
offered: periapical infections of
primary teeth, pre-eruptive
caries, developmental
aberrations, inclusions of
uncalcified enamel matrix and
idiopathic external resorption. Rutar (1997). Australian Dental Journal
Dental Trauma- Hard Tissues
Dental Trauma- Soft Tissues

 Technique: have the

patient hold an
anterior occlusal film
vertically alongside
the face so that the
radiographic beam
passes through the
lips to impinge on the
Developmental Disturbances
Systemic Conditions

Hutchinson's incisors


Histiocytosis X Sickle Cell Disease

Ectopic Eruptions

 Intraoral view of the

impacted mandibular left
second primary molar

 Radiograph taken at the

first appointment

Altay & Cengiz (2002). International Journal of Paediatric Dentistry 12: 286–289
Space Maintainers
Hidden Caries

 Radiographs can detect

caries when none are
observed clinically, but all
too often there are caries
present in the tooth that the
radiograph will not reveal.
This problem is known as
hidden caries
 Carious lesion not visible
on radiography but seen on
cross-section of the tooth.
Freedman et al (1999). J Canad Dent Ass. 65 (10): 579-81

 Further complicating this dilemma is the

aggressive use of fluoride in fluoridated
communities. The surface-hardening effect of
fluoride on the enamel makes the tooth surface
more impenetrable to exploration, thus masking
the carious activity occurring just below the
surface and along the dentino-enamel junction
Thank You