Special Radiographic Examination
Exequiel Mondragon
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Radiographs and other imaging modalities are used to diagnose and monitor oral diseases, as well as to monitor dentofacial development and the progress or prognosis of therapy. Radiographic examinations can be performed using digital imaging or conventional film. The available evidence suggests that either is a suitable diagnostic method.2-4 Digital imaging may offer reduced radiation exposure and the advantage of image analysis that may enhance sensitivity and reduce error introduced by subjective analysis.5
A study of 490 patients found that basing selection criteria on clinical evaluations for asymptomatic patients, combined with selected periapical radiographs for symptomatic patients, can result in a 43 percent reduction in the number of radiographs taken without a clinically consequential increase in the rate of undiagnosed disease.6,7
Along the horizontal axis of the matrix, patient age categories are described, each with its usual dental developmental stage: child with primary dentition (prior to eruption of the first permanent tooth); child with transitional dentition (after eruption of the first permanent tooth); adolescent with permanent dentition (prior to eruption of third molars); adult who is dentate or partially edentulous; and adult who is edentulous.
In the practice of dentistry, patients often seek care on a routine basis in part because oral disease may develop in the absence of clinical symptoms. Since attempts to identify specific criteria that will accurately predict a high probability of finding interproximal carious lesions have not been successful for individuals, it was necessary to recommend time-based schedules for making radiographs intended primarily for the detection of dental caries. Each schedule provides a range of recommended intervals that are derived from the results of research into the rates at which interproximal caries progresses through tooth enamel. The recommendations also are modified by criteria that place an individual at an increased risk for dental caries. Professional judgment4 should be used to determine the optimum time for radiographic examination within the suggested interval.5
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.16-18 However, evidence suggests that many of these lesions will remain in the enamel for at least 12 months or longer depending on fluoride exposure, allowing sufficient time for implementation and evaluation of preventive interventions.19-21 A periapical/anterior occlusal examination may be indicated because of the need to evaluate dental development, dentoalveolar trauma, or suspected pathoses. Periapical and bitewing radiographs may be required to evaluate pulp pathosis in primary molars.
Therefore, 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 is recommended. Patients without evidence of disease and with open proximal contacts may not require radiographic examination at this time.
Although periodontal disease is uncommon in this age group,26 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.27,28
A periapical or panoramic examination is useful for evaluating dental development. A panoramic radiograph also is useful for the evaluation of craniofacial trauma.15,29,30 Intraoral radiographs are more accurate than panoramic radiographs for the evaluation of dentoalveolar trauma, root shape, root resorption31,32 and pulp pathosis. However, panoramic examinations may have the advantage of reduced radiation dose, cost and imaging of a larger area.
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 pathosis exists.32-34
Caries in permanent teeth declined among adolescents, while the prevalence of dental sealants increased significantly.35 However, 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, although uncommon, is the increased incidence of periodontal disease found in this age group compared to children.36
Panoramic radiography is effective in dental diagnosis and treatment planning.30,37,38 Specifically, the status of dental development can be assessed using panoramic radiography.39 Occlusal and/or periapical radiographs can be used to detect the position of an unerupted or supernumerary tooth.40-42 Third molars also should be evaluated in this age group for their presence, position, and stage of development.
Therefore, an individualized radiographic examination consisting of posterior bitewings with panoramic examination or posterior bitewings and selected periapical images is recommended. A full mouth intraoral radiographic examination is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment.
The overall dental caries experience of the adult population has declined from the early 1970s until the most recent (1999-2004) National Health and Nutrition Examination Survey.43 However, risk for dental caries exists on a continuum and changes over time as risk factors change.44 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.45 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.46
The incidence of periodontal disease increases with age.47 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.
Taking posterior bitewing radiographs of new adult patients was found to reduce the number of radiological findings and the diagnostic yield of panoramic radiography.48,49 In addition, the following clinical indicators for panoramic radiography were identified as the best predictors for useful diagnostic yield: suspicion of teeth with periapical pathologic conditions, presence of partially erupted teeth, caries lesions, swelling, and suspected unerupted teeth.50
Therefore, an individualized radiographic examination, consisting of posterior bitewings with selected periapical images or panoramic examination when indicated is recommended. A full mouth intraoral radiographic examination is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment.
The clinical and radiographic examinations of edentulous patients generally occur during an assessment of the need for prostheses. The most common pathological conditions detected are impacted teeth and retained roots with and without associated disease.51 Other less common conditions also may be detected: bony spicules along the alveolar ridge, residual cysts or infections, developmental abnormalities of the jaws, intraosseous 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 prostheses. Secondly, the original recommendation considered edentulous patients to be at increased risk for oral disease.
Studies have found that from 30 to 50 percent of edentulous patients exhibited abnormalities in panoramic radiographs.51-55 In addition, the radiographic examination revealed 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.51,53,55 However, in studies that considered treatment outcomes, there was little evidence to support screening radiography for new edentulous patients. For example, one study reported that less than 4 percent of such findings resulted in treatment modification before denture fabrication, and another showed no difference in post-denture delivery complaints in patients who did not receive screening pretreatment radiographs.54,56
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,57 radiographs can be an important aid in diagnosis, prognosis, and the determination of treatment complexity.
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