Background information (dental professionals)

Background information

The purpose of this website is to provide up-to-date information to dentists and dental specialists about recommended choices in X-ray imaging necessary to make the right diagnosis and implement a successful treatment.

For most patients that you see, after you have carried out a history and clinical examination, you will think about whether or not to request an X-ray examination.  If you decide that this is needed, you will need to consider which type of X-ray examination is appropriate and whether now is the right time to do it.  In some cases there may be alternative diagnostic methods not using ionising radiation.

Justification as a principle of radiation protection

Exposure to X-rays is associated with a certain risk, so it is essential that any X-ray examination should have a potential overall benefit to the patient, weighing the total diagnostic benefits against the potential detriment that the exposure might cause and taking into account the effectiveness, benefit, and risk of other available procedures and techniques that do not use sources of ionizing radiation or involve lower radiation exposure [1,2,3]. In other words, each medical exposure must be justified. Justification is the fundamental principle of radiation protection, which requires a good understanding of the risks of exposure to X-rays, particularly for paediatric patients, as well as the diagnostic efficacy of the X-ray imaging technique.

Why referral guidelines

Referral guidelines have been defined as “systematically developed statements designed to assist the clinician and patient in making decisions about appropriate healthcare for certain specific clinical circumstances” [3]. Having these available can assist you in the justification process. It is very important, however, to understand that referral guidelines are not rules that must always be followed.  They will probably be appropriate for the majority of patients, but sometimes a patient’s unique clinical findings and requirements will mean that you make a different choice.

Furthermore, Croatian regulations stipulate that dentists must have available referral guidelines related to the criteria for proposing medical X-ray examination using sources of ionizing radiation.

How were these guidelines developed?

The referral guidelines on this website were developed in two stages. First, existing referral guideline documents of good quality developed by different international, European and national professional associations in the field of dental medicine were reviewed, along with up-to-date systematic reviews (a very careful review of research publications which assesses their quality). After the first draft of the referral guidelines was developed, it was reviewed by specialist groups within the Croatian Dental Society of Croatian Medical Association, with their suggestions considered and consensus agreement achieved.

The referral guidelines we present here are not permanent. New evidence may appear that will mean that some recommendations change in the future. The Croatian Dental Society will routinely review the referral guidelines every three years, but will respond to any obvious need for change at the earliest opportunity.

We are thankful to the International Atomic Energy Agency and experts within the TC project RER/9/135 Strengthening Radiation Protection of Patients and Medical Exposure Control for their assistance and advice in the initial development of these referral guidelines.

How the referral guidelines are presented

Referral guidelines are divided between those for adults (>18 years) and children and young people (<18 years). Under each of these there are specific topics (for example caries diagnosis, dental trauma, etc.). For each topic, appropriate imaging (or alternative diagnostic technique) is listed, with an indication of the associated radiation dose and an indication of the level of evidence supporting the guideline.

The presentation of dose is as follows:

Nonetechniques using no ionising radiation
effective dose typically less than 25 µSv
effective dose typically less than 100
effective dose typically less than 500 µSv

Further details on doses and risks of X-ray exposure are provided here

The use of an imaging technique for a particular clinical purpose is given one of the following recommendations:

  • Indicated: normally an imaging method of choice.
  • Indicated only in specific circumstances: limited to specific clinical situations; requiring particular care over justification.
  • Specialised investigation: indicated, but may not be easily accessed by dentists or may require specialised training.

Imaging that is not indicated will usually not be listed for that clinical purpose. However, where it was considered important to highlight that a use of imaging for a particular purpose is not appropriate, Not indicated is used

Wherever possible, the level of evidence for recommendations is given, as follows:


randomised controlled trials (RCTs),
metaanalyses, systematic reviews


robust experimental or observational studies


other evidence where the advice relies on expert
opinion and has the endorsement of respected authorities

Not possible to allocate an evidence grade.

In some cases, however, it was not possible to provide an evidence grade and no grade is given.

In some cases, to add to the referral guideline recommendations, flow charts and tables have been provided to assist in the decision-making process.