When is a jaw x-ray (radiograph) recommended?

When is a Jaw X-ray Recommended?

Jaw radiography is indicated for specific clinical scenarios including suspected caries, periapical infection, dental trauma, tooth impaction, endodontic procedures, and post-treatment monitoring—with the specific imaging modality (bitewing, periapical, or panoramic) determined by the clinical presentation and anatomic location.

Caries and Infection Evaluation

Primary Teeth

• Bitewing radiography is the first-line examination for all patients with suspected caries in primary teeth 1
• Follow with intraoral periapical X-ray only if the patient is classified as "high caries risk" 1
• Further radiographic examinations beyond these are not justified 1

Permanent Teeth

• Bitewing radiography is the preferred initial imaging for suspected carious lesions in permanent teeth, as this film size adequately evaluates the entire crown 1
• Add periapical X-ray when infection involving the pulp or apex is suspected 1
• Periapical swelling in either primary or permanent dentition justifies intraoral X-ray examination using a dedicated film holder and beam aiming device 1
• CBCT is not indicated in the initial diagnostic phase of periapical swelling 1

Special Infection Scenarios

• When a fistula is present, obtain intraoral radiograph with a gutta-percha cone inserted inside the fistula for precise localization 1
• Permanent teeth showing infection signs on the marginal gingiva warrant X-ray examination, especially in patients with confirmed high risk of periodontal disease 1

Dental Trauma

Periapical intraoral X-ray performed with an adequate paralleling system is the imaging technique of choice for dento-alveolar trauma 1

• In the majority of cases, periapical X-ray provides sufficient information for treatment planning 1
• Panoramic radiography (OPT) is NOT recommended for localized dental trauma due to lower spatial resolution compared to intraoral X-ray and risk of movement artifacts in children 1
• CT maxillofacial without IV contrast is usually appropriate for mandibular injury presenting with trismus, malocclusion, gingival/mucosal hemorrhage, or loose/fractured/displaced teeth 1
• CBCT may be indicated when clinical evaluation and periapical X-ray suggest root fracture, alveolar bone fracture, or tooth luxation that cannot be adequately assessed with 2D imaging 1

Endodontic Procedures and Follow-up

During Treatment

• Intraoral X-rays with dedicated holders and beam aiming devices are indicated for partial or complete root canal treatment (RCT), pulp regeneration, or canal shaping prior to root filling 1

Post-Treatment Monitoring

• For permanent teeth that underwent conservative pulp treatment: obtain follow-up images at 3 months, 6 months, 1 year, then annually for the next 3 years 1, 2
• For teeth that underwent endodontic treatment (apexification, pulp regeneration, or definitive RCT): radiographic follow-up at 3 months, 6 months, then annually for 3 years 1
• Monitor for crown discoloration, gingival swelling, increased mobility, and sinus tract formation 2

Dental Anomalies and Impaction

Age Considerations

• Do NOT perform radiological examination for suspected dental impaction or morphology anomalies before age 6 1, 3
• After age 6, orthopantomography (panoramic X-ray) should be obtained for suspected absent tooth development or numerical dental anomalies 3

Impacted Teeth

• Orthopantomography is the first diagnostic examination for suspected dental impaction 1
• Panoramic imaging is sufficient for treatment planning of third molar extraction in non-critical cases and can define risk of alveolar nerve injury 1
• Periapical intraoral imaging may be used for dental impaction of the upper incisor-canine region 1
• CBCT is essential for assessing the relationship between third molars and critical structures (mandibular canal for lower molars, maxillary sinus floor for upper molars) 1

Special Considerations

Missing Teeth

• Chest radiography may be warranted to exclude tooth aspiration if a tooth is absent following trauma 1
• An avulsed tooth in the airway requires physician or surgeon removal due to risk of obstructive pneumonia 1

Radiation Safety

• Always use the ALARA principle (As Low As Reasonably Achievable) 1, 3
• CBCT should be considered a level II examination, used only when 2D imaging is insufficient, with reduced field of view (FOV) to minimize radiation exposure 1, 3

Referral Indications

• All cases of confirmed absent tooth development require referral to a pediatric dentist for comprehensive evaluation and treatment planning 3
• Review medical history for congenital syndromic conditions (particularly ectodermal dysplasia) and genetic disorders that may affect tooth development 3

Common Pitfalls to Avoid

• Do not use panoramic radiography alone for diagnosis of periapical lesions, marginal bone loss, or caries—agreement with intraoral radiography is insufficient (34-55%) 4
• Do not obtain radiographs before age 6 for developmental anomalies, as permanent tooth buds are not adequately visible and radiation cannot be justified 1, 3
• Do not use CBCT as first-line imaging for periapical infection—reserve for complex cases where 2D imaging is inadequate 1