Referral Guidelines for Imaging of Adult Patients

General Dentistry and Endodontics

CLINICAL TASKINVESTIGATIONDOSERECOMMENDATIONCOMMENTS
Caries diagnosis: initial assesmentClinical examinationNoneIndicatedCaries risk must be assessed for all new patients and then subsequently a recall appointment as risk factors may change in the intervening period. The initial clinical examination must include an assessment of caries risk (as high, medium or low)(RP136)
Intraoral bitewingradiographsIndicatedPrescription of bitewing radiographs for caries diagnosis should be based upon caries risk assessment. Intervals between subsequent bitewing radiographic examinations must be reassessed for each new period, as individuals can move in and out of caries risk categories with time (RP136)
Intraoral periapical radiographsNot Indicated
Panoramic radiographsNot indicated
CBCT  toNot indicated
Caries diagnosis: monitoringClinical examinationNoneIndicated
Intraoral bitewing radiographsIt is recommended that adults designated as high caries risk have six monthly posterior bitewing radiographs taken until no new or active lesions are apparent and the individual has entered another risk category.It is recommended that adults designated as moderate caries risk have annual posterior bitewing radiographs taken until no new or active lesions are apparent and the individual has entered another risk category.It is recommended that adults designated as low caries risk have posterior bitewing radiographs taken at approximately 24-month intervals. More extended intervals may be used where there is continuing low caries risk.(RP136)
Intraoral periapical radiographsNot indicated
Panoramic radiographsNot indicated
CBCT toNot indicated
Periapical health and diseaseClinical examinationNoneIndicated
Intraoral bitewing radiographsNot indicated
Intraoral periapical radiographsA periapical radiograph provides essential information about pulp and root canal anatomy that cannot be obtained in any other way. In addition it provides information about periradicular anatomy that may contribute to treatment planning or be essential if surgical endodontic treatment is being considered.(RP136)
Panoramic radiographsNot indicated
CBCTtoIndicated only in specific circumstancesCBCT is not indicated as a standard method for identification of periapical pathosis. Limited volume, high resolution CBCT may be indicated for periapical assessment, in selected cases, when conventional radiographs give a negative finding when there are contradictory positive clinical signs and symptoms (RP136)Where CBCT images include the teeth, care should be taken to check for periapical disease when performing a clinical evaluation (RP172)
Endodontic (root canal) treatmentClinical examinationNoneIndicated
Intraoral bitewing radiographsNot indicated
Intraoral periapical radiographsIndicatedIt is recommended that radiographic examinations are carried out at the following stages of endodontic treatment:·                    Pre-operative assessmentA baseline radiograph is essential for treatment planning in vital pulp procedures. (RP136,UKFGDP)·                    Working length estimationPeriapical radiography is often still required during working length estimation. It may be necessary to take two (or more) radiographs in order to determine the length of all the root canals in multi-rooted teeth.If there is doubt about the integrity of the apical constriction, a check radiograph should be taken of the master gutta-percha cone before final condensation/obturation.·                    Post-operativeA periapical radiograph should be taken immediately following obturation as this gives a basic assessment of the quality of the root filling and a reference image of the periapical condition for subsequent review (RP136)·                    At 1-year review or if symptomatic (UKFGDP)
Intraoral occlusal radiographNot Indicated
Panoramic radiographsNot indicated
CBCT  toIndicated only in specific circumstancesCBCT is not indicated as a standard method for demonstration of root canal anatomy. Limited volume, high resolution CBCT may be indicated, for selected cases where conventional intraoral radiographs provide information on root canal anatomy which is equivocal or inadequate for planning treatment, most probably in multi-rooted teeth.Limited volume, high resolution CBCT may be indicated for selected cases when planning surgical endodontic procedures. The decision should be based upon potential complicating factors, such as the proximity of important anatomical structures.Limited volume, high resolution CBCT may be indicated in selected cases of suspected, or established, inflammatory root resorption or internal resorption, where three-dimensional information is likely to alter the management or prognosis of the tooth.Limited volume, high resolution CBCT may be justifiable for selected cases where endodontic treatment is complicated by concurrent factors, such as resorption lesions, combined periodontal/endodontic lesions, perforations and atypical pulp anatomy (RP172,UKFGDP).If high resolution CBCT is already available, then this may allow measurement of working length, but CBCT should not be used as the normal method of working length estimation (UKFGDP).

Dental implantology

CLINICAL TASKINVESTIGATIONDOSERECOMMENDATIONCOMMENTS
Planning dental implantsClinical examinationNoneIndicated
Intraoral bitewing radiographs Not indicated
Intraoral periapical radiographs Indicated·       Single implant planning: anterior maxilla and mandible in adition to panoramic radiographs.(RP172)·       During surgery If any radiography is needed then periapical radiographs are readily available and use of digital imaging should be considered which offers the benefits of ‘real-time’ imaging (UKFGDP)
Panoramic radiographs Indicated only in specific circumstances·       Single implant planing: anterior maxilla and mandible in adition to Intraoral radiographs.(RP172,UKFGDP)
CBCT  toIndicated·       A proportion of patients need advanced imaging especially in cases involving bone grafts and in those in which there are multiple potential implant sites. In these cases CT has been mandatory.·       Single and multiple implant planning.·       CBCT is indicated for cross-sectional imaging prior to implant placement as an alternative to existing crosssectional techniques where the radiation dose of CBCT is shown to be lower·       For cross-sectional imaging prior to implant placement, the advantage of CBCT with adjustable fields of view, compared with MSCT, becomes greater where the region of interest is a localised part of the jaws, as a similar sized field of view can be used.·       Implant therapy: end of treatment- Where there is suspected misplacement or damage to adjacent structures (e.g. mandibular canal).·       Implant therapy: review- Artefact around implants will reduce the value of images to examine the implant/bone junction.  CBCT useful in selected cases (e.g. suspected incorrect placement or for evaluation of bony defects).(IAEA)·       Post-operative review protocols appear to be the subjective opinion of authors. A radiograph at completion of the restoration and 12 months later may be considered essential in gaining baseline data and assessment of any changes in bone levels due to factors such as remodelling, function or inflammation. An ongoing review interval of one, three, or up to five years is suggested, to verify stability of bone levels or to detect progressive bone loss. A careful clinical examination should be able to indicate a stable situation, but it is advisable to obtain radiographic evidence of bone levels if signs are present that may suggest deterioration, eg.increased probing depth, bleeding, exudate, mobility.(RP172,UKFGDP)
MDCT to Not indicated

Examinations

CLINICAL TASKINVESTIGATIONDOSERECOMMENDATIONCOMMENTS

 

A patient with toothache

Clinical examinationNoneIndicated 
Intraoral bitewing radiographsNot indicated 
Intraoral periapical radiographsIndicatedPeriapical radiographs of selected teeth if there are symptoms.
Panoramic radiographsNot indicated 
CBCT to
Not indicated 

 

A new dentate patient

Clinical examinationNoneIndicatedFor a new adult dentate patient, the choice of radiography should be based upon history, clinical examination and an individualised prescription (RP136).
Intraoral bitewing radiographsIndicatedAfter clinical examination and pocket depth assessment. In pocket depth less than 6mm – posterior bitewings. In pocket depth more than 6mm – vertical posterior bitewing.(RP136, UKFGDP)
Intraoral periapical radiographsIndicated

Periapical radiographs of selected teeth if:

o    Symptoms

o    Signs

o    Evidence of gross caries

o    Previous endodontic treatment

o    Crowned teeth*

o    Bridge abutments*

o    Crown or bridge planned

*If signs or symptoms present

 Panoramic radiographsIndicated only in specific circumstances

For a new adult dentate patient, panoramic radiography may be indicated in a limited number of dental treatments, notably orthodontic assessment and certain oral surgical procedures (i.e. lower third molars).

For the patient with larger numbers of clinically determined caries lesions, old and destroyed dental fillings, possible periapical pathosis, or with established periodontal disease (other than simple gingivitis) a panoramic radiograph may be appropriate. In these cases, it may be expeditious to use panoramic radiography as a means of identifying teeth requiring a more detailed (intraoral) radiographic examination or, when limited to a hospital setting, prior to dental surgery under general anaesthesia. (RP136,UKFGDP)

CBCT  to
Not indicated

The presently available evidence does not support the routine prescription of CBCT imaging in the diagnosis of dental caries, periodontal disease or in endodontic therapy (RP172)

CBCT might be indicated when there is possibility of complicated tooth extraction, implant placement or endodontic treatment complications which might result in potential implant insertion area.

MRINoneNot indicated 

A new edentulous patient

 

Clinical examinationNoneIndicatedThere is no justification for radiography of edentulous patients without a specific indication such as implant treatment or clinical signs or symptoms (RP136)
Intraoral bitewing radiographsNot indicated 
Intraoral periapical radiographsNot indicated 
Panoramic radiographsNot indicated 
CBCT to
Not indicated 

Oral medicine

CLINICAL TASKINVESTIGATIONDOSERECOMMENDATIONCOMMENTS
Oral medicine Intraoral periapical radiographIndicated·      to determine the presence or absence of apical disease
Anterior oblique occlusal of maxilla or mandibulaIndicated·      to determine the presence or absence sialolitiasis in mandibular salivary gland·      identification of abnormality and potential pathology
Panoramic radiographIndicated·      identification and screening of the dentition in diagnostic procedure·      confirmation of the presence/absence of potential focal lesions
CBCT RP 172  toIndicated only in specific circumstances·      confirmation of the presence/absence of potential focal lesions

Orthodontics (RP136 and IAEA)

CLINICAL TASKINVESTIGATIONDOSERECOMMENDATIONCOMMENTS
Orthodontic treatment Intraoral periapical radiographIndicated

·      to determine the presence and position of unerupted teeth

·      to determine the presence or absence of apical disease or root form periapical views can form part of a parallax technique for localisation of teeth

Anterior oblique occlusal of maxilla (standard occlusal) and mandibular anterior oblique occlusalIndicated

·      assessing the position of misplaced and unerupted canines (when lateral oblique films have been taken)

·      identification of abnormality potential patology

Occlusal view specifically:

1. Anterior oblique occlusal of maxilla (standard occlusal)

2. True occlusal of the mandible

  

·      localization of tooth/teeth by vertical parallax involving: anterior oblique occlusal in combination with panormalic film or anterior oblique occlusal in combination with a periapical film

·      localization of unerupted teeth

Periapicals  

·      to assess root morphology and angulation

·      to assess rooth resorption

·      to assess apical pathology

·      in combination with an oblique occlusal or second periapical to localise unerupted teeth by parallax

Bitewing  ·      caries identification and assessment of periodontal bone levels
Panoramic radiographIndicated

·      to confirm the presence, position and morphology of unerupted teeth when there are clinical indications of a disturbance of normal dental development

·      identification of the developing dentition

·      confirmation of the presence/absence of teeth

·      dental age assessment

Cephalometric radiographsIndicated

Latero-lateral cephalogram (LL)

·      to assess skeletal pattern and labial segment angulation

·      assessment of unerupted teeth

·      to monitor the effects of treatment

·      the end of functional appliance treatment

·      to see the position to which the lowers anterior teeth have been proclined

·      the end of presurgical treatment for orthognathic cases

·      just prior to the end of active fixed appliance treatment

·      to assess the position of the lower incisors and to make decision of retention regime

Postero-anterior cephalogram (PA)

·      in cases of patients who present with facial asymmetry

·      needed in patient with certain jaw anomalies

Hand or wrist radiography Indicated only in specific circumstancesto predict growth spurts
CBCT RP 172  to
Indicated only in specific circumstances

·      in selected cases to localise impacted teeth with particular reference to the position of adjacent teeth and possible resorption.

·      to assess dental structural anomalies. e.g. gemination, fusion, supernumerary teeth

·      for some complex cases of skeletal abnormality

·      for orthognathic surgery treatment planning

·      cleft palate cases

·      for assessment of the position of an unerupted tooth, particularly where the tooth is impacted. In these cases, an integral aspect of the assessment is often the accurate identification of any resorption of adjacent teeth

·      investigation of orthodontic – associated paresthesia

·      CBCT is not indicated as a standard and routine method for measuring bone dimension (bordline dimensions) for mini implant placement, for rapid maxillary expansion, 3-dimensional cephalometry, surface imaging intergration, airway assessment and age assessment. In some cases CBCT can provide additional information important for the proper treatment plan. The choice of CBCT should be based upon careful clinical examination.

MDCT
to
Indicated only in specific circumstances

for some complex cases of skeletal abnormality, primary for skeletal deformities. In the cases of orthodontic skeletal anomalies that require orthognatic surgery treatment planning CBCT should be substituted where this involves a lower radiation dose and adequate images

cleft palate – widely accepted method of assessing cleft, despite the significant radiation dose (three -dimensional information can be used to determine the volume of bone needed for grafting and the adequacy of bone fill after surgery)

CBCT in orthodontics (Kapila and Nervina, DMFR, 2015.)

Indicated (scientific evidence: information will likely after dx and/or tx plans in a significant number of cases)

Definitive evidence:

· impacted teeth (most common indication: a) canine inclination on a conventional 2D panoramic radiograph exceeds 30° relative to a perpendicular midline, b) suspected root resorption (special in the buccolingual direction, c) suspected root dilaceration)

· cleft lip and palate (quantifying and outcomes of alveolar bone graft)

· orthognathic surgery, craniofacial anomalies

Positive benefit – risk ratio (case based and evolving evidence of CBCT in reported cases)

Anomalies of teeth and roots:

· unerupted teeth (identification of root resorption caused by unerupted teeth)

· transpositions

· supernumeraries (localization and morphology) root resorption, angulation and morphology

· facial asymmetry

· TMJ degeneration

· TMJ morphology and pathology contributing to malocclusion: a) osteoarthritis, b) rheumatoid arthritis, c) idiopathic condylar resorption (CBCT has been shown to be more efficacious than conventional tomography and MRI in detecting osseous changes)

Clinical Judgment:

· unerupted teeth, congenitally missing teeth

· boundary conditions (depth, height, and morphology of alveolar bone)

· airway difficulties (Obstructive sleep apnoea – to measure the cross-sectional area, minimum cross-section and total volume of the airway)

· anterior open bite (vertical malocclusion)

· quantity and quality of bone and anatomical consideration in temporary anchorage device placement (TADs)

·       maxillary transverse dimension, maxillary expansion

Not indicated (no research or clinical evidence that CBCT will provide additional information that will after dx and/or tx plan

1. Most other routine cases with no clinical indicators for CBCT (craniofacial morphometrics analyses and superimposition)

2. Information about root parallelism

3. External apical root resorption (EARR)

*CBCT should be performing using the smallest possible field of view needed for the specific clinical scenario

Periodontology

CLINICAL TASKINVESTIGATIONDOSERECOMMENDATIONCOMMENTS
Periodontal bone assessmentClinical examinationNoneIndicated·         The primary diagnostic method is clinical examination using a periodontal probe, with full pocket charting if required (IAEA).·         The decision to take further radiographs for the purpose of assessing changes in periodontal support over time should be on a case-by-case basis. Radiographs should be secondary to the clinical examination and should be taken when they have the potential to change patient management.·         It is recommended that clinical judgment be used in determining the need for, and type of radiographic images necessary for, evaluation of periodontal disease. Imaging may consist of, but is not limited to, selected bitewing and/or periapical images of areas where periodontal disease (other than nonspecific gingivitis) can be identified clinically (USA_Dental_radiographic_Examinations).
Intraoral bitewing radiographsIndicated only in specific circumstances/ Indicated·         The posterior bitewing projection offers both optimal geometry and the fine of intraoral radiography for patients with small amounts of uniform bone loss. Bitewings have the additional advantage in that they may have already been indicated for caries assessment, providing information about bone levels without the need for an additional radiation dose. More complex or extensive bone loss would require different imaging. There is insufficient evidence to propose robust guidelines on choice of radiography for periodontal diagnosis and treatment, but existing radiographs e.g. bitewing radiographs taken for caries diagnosis should be used in the first instance (RP 136 Dental).·         If a patient has generalised pocketing of 4–5 mm (BPE scores of maximum Code 3 in any sextant) and little or no recession, horizontal bitewings are recommended. These may be supplemented by intraoral periapicals for selected anterior teeth, but only if this is likely to change management of the patient (UK FGDP).·         If a patient has pocketing of 6 mm or more (BPE scores of Code 4), vertical bitewing radiographs are recommended, supplemented by intraoral periapical views using the paralleling technique at sites where alveolar bone image is not included. these may be supplemented by intraoral periapicals for selected anterior teeth, but only if this is likely to change management of the patient (UK FGDP).
Intraoral periapical radiographsIndicated only in specific circumstances/ Indicated·         Provides an image of the whole tooth. Consider when there is advanced bone loss (IAEA).·         Full-mouth series of periapical radiographs and panoramic radiographs with supplementary periapicals have been used for periodontal evaluation, with the latter potentially affording a radiation dose advantage over large numbers of intraoral radiographs. The dose from periapical radiographs may, however, be less than that from panoramic and supplementary periapical combinations, if periapicals are restricted to affected teeth (UK FGDP).
Panoramic radiographs Indicated only in specific circumstances/ Indicated·         Provides an alternative to multiple intraoral radiographs but with inferior image details (IAEA).
CBCT   toLimited indication/ Indicated only in specific circumstances·         CBCT is not indicated as a routine method of imaging periodontal bone support (RP 172 CBCT).·         Limited volume, high resolution CBCT may be indicated in selected cases of infra-bony defects and furcation lesions, where clinical and conventional radiographic examinations do not provide the information needed for management (RP 172 CBCT).·         Where CBCT images include teeth, care should be taken to check for periodontal bone levels when performing a clinical evaluation (RP 172 CBCT).·         May have value in assessment of complex bone defects if surgery planned, or for “perio-endo” lesions (IAEA).

Prosthodontics

CLINICAL TASKINVESTIGATIONDOSERECOMMENDATIONCOMMENTS
Planning a single crownClinical examinationNoneIndicated
Intraoral bitewing radiographsNot indicated
Intraoral periapical radiographsIndicated·         Most teeth requiring full coronal coverage restoration will be heavily restored and/or root-filled. These criteria are also both good predictors of periapical inflammatory pathosis (IAEA).·         Periapical radiograph is indicated for heavily restored teeth and/or root filled teeth and teeth that are clinically not vital.
Panoramic radiographs Not indicated
CBCT  toNot indicated
Planning multiple crownsClinical examinationNoneIndicated
Intraoral bitewing radiographsNot indicated
Intraoral periapical radiographsIndicated·         Most teeth requiring full coronal coverage restoration will be heavily restored and/or root-filled. These criteria are also both good predictors of periapical inflammatory pathosis (IAEA).·         Periapical radiograph is indicated for heavily restored teeth and/or root filled teeth and teeth that are clinically not vital.
Panoramic radiographsIndicated only in specific circumstancesProvides an alternative to multiple intraoral radiographs but with inferior image details.
CBCTtoNot indicated
 Planning a bridge (tooth-supported fixed prosthesis)Clinical examinationNoneIndicated
Intraoral bitewing radiographsNot indicated
Intraoral periapical radiographsIndicated only in specific circumstances·         For abutment teeth, which are heavily restored and/or root-filled, the same justification exists as for planning a crown.  For unrestored or minimally restored abutments and where an adhesive bridge is planned, a radiograph might not be required (IAEA).·         Periapical radiograph is indicated for heavily restored teeth and/or root filled teeth and teeth that are clinically not vital.
Panoramic radiographsIndicated only in specific circumstancesProvides an alternative to multiple intraoral radiographs but with inferior image details.
CBCT  toNot indicated

Temporomandibular disorders

CLINICAL TASKINVESTIGATIONDOSERECOMMENDATIONCOMMENTS
Temporomandibular disordersClinical examinationNoneIndicated

Radiographs do not add information as the majority of these TMJ problems are due to soft tissue dysfunction rather than bony changes (British Orthodontic Society).

Usually provides the information required for diagnosis (IAEA).

Radiography is not recommended for patients with joint sounds (‘clicking’) in the absence of other signs or symptoms. Radiographic examination is indicated where there is recent evidence of progressive pathology (recent trauma, change in occlusion, mandibular shift, sensory or motor alterations, change in range of movement) (UK FGDP).

Intraoral bitewing radiographsNot indicated 
Intraoral periapical radiographsNot indicated 
Panoramic radiographsNot indicated

This practice can no longer be justified and is therefore no longer recommended (British Orthodontic Society).

Panoramic radiography provided little or no information that influenced diagnosis or patient management in most cases examined (UK FGDP).

CBCT  to
Indicated only in specific circumstancesIn patients suspected of having disease affecting the bones of the TMJ, conventional radiographs, are still only of limited value. These patients could possibly benefit from CBCT imaging but only if the additional information obtained is likely to influence management or subsequent treatment (British Orthodontic Society).
MRINoneIndicated only in specific circumstances

Although much attention is given to the position of the disc within the TMJ, the disc cannot be visualized directly on conventional radiographs or on CBCT. Satisfactory soft tissue images can be obtained using MRI which does not use ionizing radiation. However, abnormal position of the disc does not necessarily equate with disease. MRI imaging of the TMJ is generally reserved for those patients with persistent symptoms following conservative treatment when surgical intervention is being considered (British Orthodontic Society).

In cases where there is uncertainty about the origin of the symptoms, e.g. potentially juvenile rheumatoid arthritis (IAEA).

MSCT 
to
Indicated only in specific circumstancesWhere the existing imaging modality for examination of the TMJ is MSCT, CBCT is indicated as an alternative where radiation dose is shown to be lower (RP 172 CBCT).

Trauma and root fractures

CLINICAL TASKINVESTIGATIONDOSERECOMMENDATIONCOMMENTS

Trauma [teeth and alveolar bone]

Clinical examinationNoneIndicatedTeeth that have been subjected to trauma require careful examination, which includes the use of radiographs. A baseline intraoral radiograph is mandatory following all but minor tooth trauma.
Intraoral bitewing radiographs Not indicated 
Intraoral periapical radiographs Indicated

Combinations of intraoral radiographs using different perspectives provide fine detail and are usually sufficient for dental trauma (IAEA).

Follow-up radiographs should be taken at six months after treatment, and then annually until root formation is complete. While expert opinion supports the taking of review radiographs, there is no evidence to support any particular frequency or duration of review (UK FGDP).

Depending on the nature of the injury it may be necessary to take several intraoral radiographs from different angles (UK FGDP).

Intraoral occlusal radiograph Indicated
Panoramic radiographs IndicatedProvide more extensive coverage of bone for suspected dento-alveolar fracture (IAEA).
CBCT  to
Indicated only in specific circumstances

Limited volume, high resolution CBCT is indicated in the assessment of dental trauma (suspected root fracture) in selected cases, where conventional intraoral radiographs provide inadequate information for treatment planning (RP 172 CBCT).

CBCT in dental trauma for: root fractures, luxation injuries, avulsion, root resorption as a post-trauma complication (RP 172 CBCT).

Trauma [maxillofacial]

Clinical examinationNoneIndicatedIf there is clinical evidence of a bone fracture, it is probably more appropriate to refer the patient for a complete radiographic examination at the hospital, where treatment will be performed (UK FGDP).
Intraoral bitewing radiographs Not indicated 
Intraoral periapical radiographs Not indicated 
Panoramic radiographs Indicated

Combinations of panoramic and facial bone radiographs are the traditional methods of detecting bony injuries.

CBCT and MDCT are increasingly replacing these (IAEA).

Panoramic radiography has a limited ability to detect mid-facial fractures (UK FGDP).

A panoramic radiograph is, however, the first-choice method for imaging mandibular fractures, although poor panoramic image quality has been shown to limit diagnostic accuracy. Supplementary imaging is often required to diagnose high condylar fractures. Panoramic radiography has a limited ability to detect mid-facial fractures (UK FGDP).

CBCT
to
Indicated

 For maxillofacial fracture assessment, where cross-sectional imaging is judged to be necessary, CBCT may be indicated as an alternative imaging modality to MSCT where radiation dose is shown to be lower and soft tissue detail is not required (RP 172 CBCT).

In foreign body detection and localization, CBCT is suitable for imaging high attenuation materials but not as effective as MSCT for lower attenuation objects (RP 172 CBCT).

MSCT
 to
IndicatedFractures are conventionally imaged using plain radiography or MSCT, depending on custom and practice (RP 172 CBCT).