New ADA recommendations confirm dental imaging most effectively used in moderation

Paper addresses specific clinical scenarios

New recommendations from the American Dental Association confirm that dental imaging should only be ordered when clinically necessary to minimize both patients’ and dental professionals’ exposure to radiation.

Published jointly Jan. 5 in the January issue of The Journal of the American Dental Association and online ahead of print in the journal Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, these are the ADA’s first recommendations on patient selection for radiographic exams in more than a decade and the first to address both planar dental radiography and cone-beam computed tomography.

The recommendations address specific clinical scenarios for using dental imaging — updating and expanding upon recommendations from 2012. They emphasize the importance of performing a thorough clinical exam prior to taking images to determine whether they are necessary to support diagnosis, treatment planning and clinical management based on each individual patient’s needs.

“Dental imaging is an important diagnostic tool that can help improve oral and overall health outcomes when used appropriately,” said Erika Benavides, D.D.S., Ph.D., lead author and clinical professor in the Department of Periodontics and Oral Medicine at the University of Michigan School of Dentistry. “You wouldn’t get an X-ray of another part of your body unless the doctor believed there was reason to order one after an examination. Similarly, dental X-rays should be ordered only after first examining the patient’s medical and dental histories, prior X-ray images and current clinical exam findings.”

The recommendations, which were developed by an expert panel established by the ADA Council on Scientific Affairs, are endorsed by the American Academy of Oral and Maxillofacial Radiology.

“These updated clinical recommendations honor what we have used and learned and chart a clear path forward for patient care and effective use of radiation in dentistry,” said co-author Trishul Allareddy, B.D.S., professor at the University of North Carolina Adams School of Dentistry and immediate past president of the American Academy of Oral and Maxillofacial Radiology.

For caries detection, the panel provides specific recommendations for anterior proximal, posterior proximal and occlusal surfaces as well as for root and smooth surfaces. Decisions about the use of radiographs, such as choosing between bitewing or periapical views, should be guided by clinical judgment and take into account the lesion’s location and anatomical factors, including whether the anterior or posterior proximal spaces are closed, according to the recommendations.

For periodontal disease management, the panel states radiographic evaluation of the disease sites is important for diagnosis and determination of disease baseline. It advises that the frequency of radiographic examinations depends on the clinical findings and treatment response. Current evidence supports the use of a 2D full-mouth radiographic series in addition to a clinical examination as the gold standard for evaluating periodontal disease. There is currently no evidence to support the use of CBCT in the management of periodontal disease, except for treatment planning of complex cases, according to the recommendations.

The paper also includes recommendations based on the type of patient appointment — for example, a new patient evaluation or a recall visit. These recommendations are further organized based on patient age, dental development stage and risk factors for dental caries or periodontal disease.

Recommendations also address various specialty areas, including endodontics, orthodontics, oral and maxillofacial surgery and more. Some of these recommendations include:

• Using panoramic radiographs as the initial imaging modality for monitoring tooth eruption prior to initiating orthodontic treatment and for assessing root alignment during treatment.

• Prescribing radiographs judiciously and employing effective dose-reduction methods for children and young adults.

• Using panoramic radiography for assessment and treatment planning when there is a clinical indication for radiographic evaluation of third molars, supernumerary and supplemental teeth.

• Considering panoramic radiography for initial imaging of patients with suspected temporomandibular joint disorders to rule out gross osseous abnormalities. However, because of low sensitivity, panoramic imaging may not be sufficient for definitive TMD diagnosis.

• Using panoramic radiography for initial assessment before dental implant procedures and CBCT for presurgical planning and placement of dental implants.

• Using intraoral 2D radiographs as the primary imaging modality for initial endodontic evaluations. CBCT may be indicated after an initial clinical examination and assessment using 2D imaging. If CBCT is indicated, the smallest field of view consistent with the needed information should be used.

This paper is the second of two publications addressing the optimal use of diagnostic imaging in dentistry. The first set of recommendations, published in 2024 in JADA, focused on radiation safety and regulatory issues. Those recommendations found that thyroid and abdominal shielding during dental imaging should be discontinued as routine practice, building upon patient-shielding recommendations issued by the American Academy of Oral and Maxillofacial Radiology in 2023.

“Dental X-rays are safe. In some cases, a dental X-ray delivers less radiation than a single day of the natural radiation we are all exposed to just by living in the world,” Dr. Benavides said. “Yet it is important to follow the ALARA (As Low As Reasonably Achievable) principle recognized in both dentistry and medicine to minimize exposure over a patient’s lifetime and only order X-rays when clinically necessary. The ADA and AAOMR encourage all dentists and their teams to review these recommendations and talk with their patients about any questions they may have.”

To view the complete recommendations, visit JADA.ADA.org.