Dental Radiographic Examinations: Recommendations For Patient Selection And Limiting Radiation Exposure

ADA_Radiographic

The American Dental Association (ADA) has recently revised their recommendations, see here [pdf]. They might be useful in our IKO student clinic. Note, that

“[t]hese 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 ALARA Principle (As Low as Reasonably Achievable) to minimize the patient’s exposure.” (Emphasis added.)

As regards asterisks in the above table, (*) refers to clinical situations for which radiographs may be indicated including, but not limited to: (A) Positive historical findings such as (1) previous periodontal or endodontic treatment, (2) history of pain or trauma, (3) familial history of dental anomalies, (4) postoperative evaluation of healing, (5) remineralization monitoring, and (6) presence of implants, previous implant-related pathosis or evaluation for implant placement; and (B) Positive clinical signs or symptoms such as (1) clinical evidence of periodontal disease, (2) large or deep restorations, (3) deep carious lesions, (4) malposed or clinically impacted teeth, (5) swelling, (6) evidence of dental/facial trauma, (7) mobility of teeth, (8) sinus tract (“fistula”), (9) clinically suspected sinus pathosis, (10) growth abnormalities, (11) oral involvement in known or suspected systemic disease, (12) positive neurologic findings in the head and neck, (13) evidence of foreign objects, (14) pain and/or dysfunction of the temporomandibular joint, (15) facial asymmetry, (16) abutment teeth for fixed or removable partial prosthesis, (17) unexplained bleeding, (18) unexplained sensitivity of teeth, (19) unusual eruption, spacing or migration of teeth, (20) unusual tooth morphology, calcification or color, (21) unexplained absence of teeth, (22) clinical tooth erosion, (23) peri-implantitis. And (**) refers to factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms (0 – 6 years of age and over 6 years of age).

It is suggested that both clinical instructors and students read carefully the respective document. As is listed in the table, in particular in new adult dentate patients, an

“[i]ndividualized radiographic exam consisting of posterior bitewings with panoramic exam or posterior bitewings and selected periapical images [is suggested]. A full mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment.”

Addendum

I had informed clinical instructors in the IKO student clinic on screening for periodontal disease some time ago. Screening for periodontal disease should allow assessment of extent (localized, generalized) and severity (attachment loss and aveolar bone loss beyond certain thresholds) of periodontal disease. Note that respective recommendations for screening still apply.

  • In patients up to about 25 years mainly gingivitis (meaning no alveolar bone loss and no loss of attachment) or mild periodontitis (beginning bone loss, for instance loss of lamina dura which might be diagnosed on bitewing radiographs; clinically one might notice subgingval calculus in particular lingually at posterior teeth in the mandible) is to be expected. Selective measurements of probing pocket depth around 1st molars and incisors may be sufficient. If an indication for a panoramic exposure exists (for instance in case of partially erupted wisdom teeth), it should be done in the same session. NB: Any case of rare aggressive periodontitis or necrotizing periodontal disease has to be diagnosed during screening and further diagnostic measures initiated as appropriate.
  • When in older patients deep pockets are found during selective probing (note that a systematic approach such as Periodontal Screening and Recording is highly recommended), a panoramic exposure is indicated. Bone loss can be estimated and a preliminary diagnosis acuieved, for instance “localized moderate periodontitis” (bone loss up to about 1/3 of the root length at less than 30% teeth), or localized or generalized severe (i.e. advanced) periodontitis (bone loss of more than 1/3 of rot length, advanced furcation involvement of degree 2 or 3, and infrabony lesions). NB: Generalized severe periodontitis should only be referred to students when a preliminary treatment plan reveals that most affected teeth have to be extracted.
  • Students in semester 6 should mainly treat patients with gingivitis and mild periodontitis. Students in semester 8 are supposed to treat patients with moderate or localized advanced periodontitis while more complex cases including restorative treatment should be dealt with in semester 9.
  • During periodontal screening new patients who had never been treated for periodontal disease should be differentiated from already treated patients where periodontal recall may be sufficient. Note that not more than 5 pockets of not more than 5 mm depth can be managed during supportive periodontal therapy. If a higher number of pockets, furcation involvement, and not responding infrabony lesions are present the proper diagnosis was recurrent periodontitis and treatment had to be repeated.

6 January 2013 @ 11:40 am

Last modified January 7, 2013.

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