When should X-rays (X-radiation) be used?

When to Use X-Ray Imaging

X-ray imaging should only be used when it is considered useful for the patient's health and when it may provide additional information helpful for treatment, complying with the "principle of justification." 1

General Principles for X-Ray Use

The decision to use X-ray imaging should be based on:

• Clinical necessity rather than routine practice
• Specific diagnostic needs of the individual patient
• Risk-benefit analysis considering radiation exposure
• Potential impact on treatment decisions

Specific Clinical Indications for X-Ray Use

Diagnostic Imaging in Medicine

1. Suspected Fractures

   • First-line examination for suspected fracture of vertebral body or other bones 1
   • Rated 9/9 (usually appropriate) for initial assessment of suspected fractures

2. Arthritis Evaluation

   • X-rays of affected joints should be performed at baseline when evaluating undifferentiated peripheral inflammatory arthritis 1
   • X-rays of hands, wrists, and feet should be considered as the presence of erosions is predictive for the development of rheumatoid arthritis 1
   • Follow-up X-rays should be repeated within 1 year 1

3. Bone Mineral Density Assessment

   • DXA (dual-energy X-ray absorptiometry) is the preferred method (rated 9/9) for identifying low bone mineral density in at-risk individuals 1
   • Appropriate for both initial diagnosis and follow-up of osteoporosis

Dental Radiography

1. Dental Development Assessment

   • Consider dental radiography for each child around 5 years of age even without visible caries 2
   • Additional assessments at 8-9 years and 12-14 years (1-2 years after eruption of premolars and second molars) 2

2. Endodontic Follow-up

   • Intraoral X-ray for assessment of periapical health after endodontic therapy at 3 months, 6 months, 1 year, and then annually for 3 years 1
   • For monitoring teeth that have undergone conservative pulp treatment to detect complications 1

3. Orthodontic Assessment

   • When dental anomalies are found upon clinical examination 1
   • When orthodontic treatment (corrective or interceptive) is needed 1

When NOT to Use X-Rays

1. COVID-19 Related Imaging

   • CT scans should not be used to screen for or as a first-line test to diagnose COVID-19 1
   • X-rays are not recommended for daily follow-up of patients with mild COVID-19 1

2. Routine Screening

   • Routine survey by radiographs has not been shown to provide sufficient information to be justified considering radiation exposure 2
   • X-ray examinations should not be based on the patient's age but on specific clinical needs 1

3. When Alternative Imaging Is Superior

   • For TMJ ligament-capsule tissue disorders, MRI is recommended instead of X-ray 1
   • For cranial suture anomalies, ultrasound examination is often sufficient 1

Radiation Safety Considerations

• Every prescription of radiographs should be based on an evaluation of individual patient benefit 2
• The "principle of justification" requires that X-rays only be used when benefits outweigh risks 1
• Special considerations for pregnant patients and children due to increased radiation sensitivity 3
• Healthcare workers must wear appropriate personal protective equipment when performing X-rays 1

Common Pitfalls to Avoid

1. Unnecessary Repeat Imaging

   • Avoid duplicate examinations when prior results are available
   • Follow recommended intervals for follow-up imaging

2. Inappropriate Imaging Selection

   • Using X-ray when another modality (MRI, ultrasound) would be more appropriate
   • Using advanced imaging (CT) when simple X-ray would suffice

3. Poor Communication

   • Failure to communicate clinical question clearly to radiologist
   • Inadequate patient preparation leading to motion artifacts and repeat exposures

4. Disregarding Radiation Protection

   • Not using appropriate shielding for patients
   • Exposing more anatomy than necessary for the clinical question

Remember that the decision to use X-ray imaging should always balance the potential diagnostic benefit against the radiation risk, with the ultimate goal of improving patient outcomes in terms of morbidity, mortality, and quality of life.