Indicações Radiograficas Odontoped

European Archives of Paediatric Dentistry (2020) 21:429–462
https://doi.org/10.1007/s40368-020-00532-y
SYSTEMATIC REVIEW
Diagnostic efficacy of and indications for intraoral radiographs

in pediatric dentistry: a systematic review
J. K. M. Aps1 · L. Z. Lim2 · H. J. Tong3 · B. Kalia4 · A. M. Chou5
Received: 28 October 2019 / Accepted: 27 April 2020 / Published online: 10 May 2020
© European Academy of Paediatric Dentistry 2020
Abstract
Purpose To systematically evaluate the diagnostic efficacy of intraoral radiographs and evidence supporting the indications
for taking of intraoral radiographs in children in the following five clinical categories: caries, pathological conditions (includ-
ing acute odontogenic infections and periodontal disease), dental/developmental anomalies, dental trauma, and enhancement
of comfort/technique for taking radiographs in children. This was carried out to facilitate the updating of existing European
Academy of Paediatric Dentistry (EAPD) guidelines on dental radiography in pediatric dentistry.
Methods A systematic electronic literature search was conducted on Cochrane Library (1992–24 July 2018), MEDLINE
(PubMed, 1946–24 July 2018), EMBASE (Embase.com, 1974–24 July 2018) and Scopus (pre-1970–24 July 2018). Hand
search of handbooks and grey literature search was also performed. Study screening and study inclusions were agreed upon
by three authors. Data extraction, and methodological quality and risk of bias assessment were carried out in duplicate for
each of the included studies.
Results A total of 9581 papers were identified. Following the primary and secondary assessment process, 36 papers were
included in the final analysis. The included studies were further categorized into five main clinical categories for analysis:
caries, pathological conditions, dental/developmental anomalies, dental trauma and comfort/technique-related studies. Only
one paper was found to be of good quality and at low risk of bias; while, 9 papers were found of be at moderate risk of bias
and 26 papers were at high risk of bias. Meta-analysis was not possible for any of the aforementioned clinical situations, and
only a narrative synthesis was done.
Conclusion There is insufficient high-quality evidence for the use of intraoral radiographs in pediatric dentistry and current
guidelines are based largely on expert opinion. There is a clear need for well-conducted and standardized studies regarding
the use of intraoral radiography in pediatric dentistry.
Keywords Systematic review · Intraoral radiography
Electronic supplementary material The online version of this

article (https://doi.org/10.1007/s40368-020-00532-y) contains
supplementary material, which is available to authorized users.
* J. K. M. Aps School and Oral Health Centre of Western Australia,

johan.apsdmfr@hotmail.com University of Western Australia, M512, 17 Monash Ave,
Perth, Nedlands, WA 6009, Australia
L. Z. Lim
2
denllz@nus.edu.sg Oral and Maxillofacial Radiology, National University
of Singapore, Singapore, Singapore
H. J. Tong
3
jinn.tong@gmail.com Paediatric Dentistry, National University of Singapore,
Singapore, Singapore
B. Kalia
4
bkalia.06@gmail.com University of California San Francisco, San Francisco, USA
5
A. M. Chou National University of Singapore Libraries, Singapore,
amy.chou@nus.edu.sg Singapore
1
Division of Oral Diagnostic and Surgical Sciences,
Discipline Lead Dentomaxillofacial Radiology, Dental
13
Vol.:(0123456789)

430 European Archives of Paediatric Dentistry (2020) 21:429–462
Introduction Intraoral image detectors can be analog film (preferably

F-speed film), photo-stimulable phosphor storage plates
Intraoral radiography is one of the most common procedures and solid-state sensors [charged coupled devices (CCD)
in dentistry as it provides diagnostic information that can or complementary metal oxide semi-conductors (CMOS)].
alter or guide a therapeutic approach in a particular treat- Both analog film and phosphor-storage plates are available
ment plan. Clinicians have to justify every radiographic in a larger variety of sizes compared to solid-state sensors.
examination on a patient individual basis, weighing the For example, occlusal size number 4 image detectors are
potential benefit (changing of management/treatment plan) not available in solid-state sensors (Whaites and Drage
against the potential radiation risk (Oenning et al. 2018). 2015; Aps 2019). However, the image detectors will not
The latter is simply the justification principle in radiation be discussed thoroughly in this systematic review.
protection (NRPB 2001; European Commission 2004; ICRP There are currently two main radiography guideline
2007; Whaites and Drage 2015). The justification principle documents in use for pediatric dentistry in many parts
says that one shall not expose patients to ionizing radia- of the world: The 2003 European Academy of Paediat-
tion if the information can be obtained differently or if the ric Dentistry (EAPD) (Espelid et al. 2003) and the 2012
patient cannot cope with the procedure to obtain the neces- American Academy of Pediatric Dentistry (AAPD) guide-
sary images, and that the benefit gained from the exposure lines. The AAPD document, which is developed and based
should always outweigh the potential risk of the exposure. on the American Dental Association (ADA) recommenda-
The optimization principle implies the ALARA (as low as tion document, was last updated in 2012 with inclusion
reasonably achievable) rule. The latter means that one should of the use of cone beam computed tomography (CBCT)
always try to keep the radiation burden to the patient and the (AAPD 2017). Both organizations, though different in
staff as low as possible. This can be achieved by taking as some of their recommendations, share the common opin-
few as possible, but good-quality, radiographs and/or using ion that radiographs should only be taken based on the
the most sensitive (also called fast) image detectors. More clinician’s judgment and that no radiographic examination
recently, the abbreviations ALADA and ALADAIP have should be carried out prior to a comprehensive clinical
been introduced, meaning, respectively, “as low as diagnos- examination.
tically achievable” and “as low as diagnostically achievable The aim of this systematic review was to review the evi-
and individualized to the patient”. The bottom line is that dence for the diagnostic efficacy and indications of intraoral
each exposure should be justified and tailored to each indi- radiography in pediatric dentistry, to facilitate the updat-
vidual patient and circumstance. The limitation principle ing of existing European Academy of Paediatric Dentistry
provides dose limits for occupational and public exposures. (EAPD) guidelines on dental radiography in young indi-
It ensures that no individuals are exposed to unacceptably viduals. The following were the specific research questions
high radiation doses. This applies to the dentist and their imposed by EAPD and which this review sought to clarify:
staff who are exposed professionally. The limitation prin- When is intraoral radiography (e.g., periapical, bitewings
ciple does not count for patients as there are no dose limits and occlusal radiographs) indicated/contraindicated?
for individuals exposed for diagnostic radiation. Obviously,
many measures to achieve optimized exposures will result a. For caries diagnosis
in a reduced exposure to the dentist and their staff (White b. For diagnosis of acute dental infections
and Pharoah 2014). c. For diagnosis, management and review of dental trauma
Intraoral radiography comprises any technique that is and its sequelae
executed with the image detector placed intraorally and the d. For diagnosis and management of dental anomalies
X-ray source extraorally: bitewing radiographs, periapi- e. For diagnosis and management of developmental disor-
cal radiographs and occlusal/oblique occlusal radiographs. ders
The clinician’s challenge is to select the correct technique f. For diagnosis and management of pathological condi-
in each situation and occasionally to adjust or modify tions
the technique in particular patient cases. For instance, a
special needs patient requiring a periapical radiograph, Secondary research questions were:
may not be able to cope with the procedure of placing the
image detector parallel to the teeth, and hence might be 1. In which age groups would a–f be applicable?
better off with an occlusal radiograph, which avoids the 2. Which intraoral radiography techniques should be used
image detector being placed in contact with the floor of to make intraoral radiography more convenient/comfort-
the mouth or the palate (Whaites and Drage 2015; Parks able in children?
and Aps 2016; Aps and Lee 2018; Aps 2019).
13
European Archives of Paediatric Dentistry (2020) 21:429–462 431
3. Which intraoral techniques should be used to make • Studies that do not evaluate any of the five clinical situ-
intraoral radiography techniques more reliable in chil- ations (as above, including comfort and technique)
dren? • Studies that do not utilize intraoral radiography
• Epidemiological/prevalence studies
• Studies evaluating therapeutic outcomes of treatment
Materials and methods • Studies evaluating sensitivity/specificity and/or diagnos-
tic yield of caries detection devices
This review was designed, performed, and reported in • Surveys of radiographic practices
adherence to PRISMA standards of quality for reporting • Studies related to quality assurance
systematic reviews and meta-analyses. The study team • Studies evaluating theoretical algorithms, classification
included three dentists for screening (JA, LZL and HJT), systems or are descriptions of protocols
a student (BK) and a librarian (AC). A detailed system- • In vitro studies
atic review protocol was developed and is available online • Animal studies
on the international Prospective Register of Systematic • Editorials
Reviews (PROSPERO), which was approved and regis- • Letters to the editor
tered in the NHS Centre for Reviews and Dissemination • Other case reports/case series that were not related to
(CRD) at the University of York (ref: CRD42018105699). technique and comfort
A structured electronic search was undertaken. The fol- • Outdated radiography technique, device or technology
lowing electronic databases were searched with an Eng- which are not currently used
lish-language filter applied: Cochrane Library (1992–24 • Techniques that were performed under general anesthesia
July 2018), MEDLINE (PubMed, 1946–24 July 2018), • Systematic reviews
EMBASE (Embase.com, 1974–24 July 2018) and Scopus • Narrative reviews
(pre-1970–24 July 2018). The original search of comput- • Guidelines
erized databases was conducted on 24 July 2018. Hand
search of a reference list of included studies, related arti- Although systematic reviews, guidelines and narrative
cles and systematic reviews on the topic was performed. reviews that were related to the research question were not
Additional search was conducted in Google Scholar, and included as part of the data extraction for analysis, they
the top 100 results sorted by relevance were screened. were screened and evaluated for useful and relevant infor-
Additionally, hand books on pediatric dentistry were mation. Additionally, studies comparing other methods of
perused to verify if they reported any specific guidelines caries detection apart from visual examination (e.g., DIAG-
and/or recommendations or evidence based papers. A NODENT ™, FOTI, etc.) against intraoral radiographs (i.e.
search performed to identify information in TRIP data- bitewing or periapical radiography) were excluded from the
base, in publications from the World Health Organiza- review as systematic reviews were already available on these
tion, in Open Grey, in Science.gov, and in Epistemonikos topics.
between August and September 2018, did not add any Following the initial title–abstract screening, a further
additional manuscripts or reports. The search strategy assessment of the articles located by the search was carried
employed can be found in Online Appendix 1. out, and an article was selected for inclusion in the full text
The following inclusion criteria were used: review if it met the following criteria:
• Studies evaluating diagnostic value of imaging modal- • Studies on intraoral radiography involving human sub-
ity for the six clinical situations. Diagnostic value may jects who fall within the pediatric population (mean
be defined as diagnostic accuracy (sensitivity/specific- age < 18 years).
ity), effects on diagnostic thinking, effects on therapy, • Studies which provided original data generated by means
effects on patient outcome, effects on society (Fryback of a comparative randomized controlled clinical trial
and Thornbury 1991) design in a population which included pediatric partici-
• In vivo studies pants (mean age < 18 years)
• Case reports/case series related to technique and com-
fort The included studies were further categorized into five
main clinical categories for analysis:
The exclusion criteria were defined as:
(A) Caries
• Study population (or mean age of study population) is
above 18 years old
13

– This was further sub-categorized into the following on%20Checklist.pdf). All articles were assessed indepen-
5 groupings of dentition type: (i) primary dentition, dently by two reviewers (JA and LZL), with information
(ii) mixed dentition, (iii) permanent dentition, (iv) collected using standardized data collection pro forma. In
mixed and permanent dentition, and (v) primary, cases of disagreements, the overall risk of bias was achieved
mixed and permanent dentition, as well as whether through consensus after discussions with all three investiga-
the caries risk of the studied population was low, tors (JA, LZL, HJT). The preliminary findings of the system-
high or uncertain risk. atic review were presented, and subsequently discussed in a
– Papers which included 6-year-old patients with workshop with representative participants from the EAPD
newly erupted first permanent molars were catego- member countries at the EAPD interim seminar in May 2019
rized as primary dentition. Longitudinal studies in Chania, Crete.
involving participants who were 12 years old, evalu-
ating caries increment in permanent dentition alone,
were classified as permanent dentition studies. Results
(B) Pathological conditions—this referred to studies on Search results
diagnosis of periodontal disease and acute odontogenic
infections. A total of 9581 titles were identified by the search. Fol-
(C) Dental/developmental anomalies—this was then sub- lowing the removal of duplicates, title and abstract screen-
categorized into papers on: (i) identification of dental ing was done for 4449 articles, of which 88 papers were
anomalies and (ii) evaluation of impaction and anoma- retrieved for full-text assessment. A total of 36 articles ful-
lies in eruption. filled the selection criteria and were included into the sys-
(D) Dental trauma—this included papers on diagnosis and tematic review. The PRISMA flowchart summarizing the
monitoring of injuries. systematic review process is detailed in Fig. 1.
(E) Comfort and technique—this was further sub-catego-
rized into: (i) comfort/reduction of patient anxiety and
(ii) techniques to enhance reliability/reproducibility of Results of individual studies according to their
radiographs taken in pediatric patients. clinical category
Data extraction was carried out by three reviewers (JA, As the studies were found to be largely heterogeneous in
LZL, HJT) who met to discuss and assess the findings of nature due to the broad array of clinical situations and dif-
the studies, and a standardized data extraction pro forma ferent outcome measures used, it was not possible to carry
was utilized to capture relevant data from included studies. out any quantitative synthesis of the studies. Hence, only
Risk of bias assessment was applied to both study meth- qualitative descriptive analysis of the included studies is pro-
odology and outcome measures of all included studies. The vided as below. Details of individual study characteristics
choice of risk bias assessment tool or quality appraisal tool and outcome measures reported can be found in Table 1.
was selected based on the study design and methodology;
the quality of observational studies (cohort, and case–control Caries (total number of studies: 17)
studies) were assessed using the Newcastle–Ottawa scale
(NOS) (Wells et al. 2019) and a modified Newcastle–Ottawa Primary dentition (total number of studies: 6)
scale was used to evaluate cross-sectional comparative stud-
ies (Modesti et al. 2016); the Cochrane risk of bias tool Six papers on primary dentition were identified, of which
was applied to randomized controlled trials (Sterne et al. four were in low-risk populations, and the other two were
2019); uncontrolled study designs (case series) were evalu- in high-risk populations. The overarching theme of these
ated using the Institute of Health Economics (IHE) Quality studies in both low and high caries risk populations suggest
Appraisal Checklist (https: //www.ihe.ca/resear ch-progra ms/ that clinical examination alone appears to underestimate the
rmd/cssqac /cssqac -about) ; studies reporting prevalence data presence of interproximal caries.
were evaluated using Joanna Briggs Institute (JBI) Criti-
cal Appraisal Checklist for Studies Reporting Prevalence Low‑caries‑risk patients (four studies) Even in low-risk
Data (https://joannabriggs.org/critical_appraisal_tools); populations, clinical exam alone was found to underesti-
interrupted time series were evaluated using the Cochrane mate the caries presence including that of occlusal caries,
Effective Practice and Organization of Care (EPOC) check with almost two times more carious surfaces being detected
list (https://methods.cochrane.org/sites/methods.cochrane. if bitewing radiographs were taken (Skold et al. 1997). In
org.bias/files/public/uploads/EPOC%20Data%20Collecti 4–6-year-old patients with closed interproximal contacts
13
Fig. 1 PRISMA 2009 flow

diagram
PRISMA 2009 Flow Diagram
Identification
Records idenfied through
database searching
(n = 9581)
Records aer duplicates removed

(n = 4449)
Screening
Records screened Records excluded

(n = 4449) (n = 4361)
Eligibility
Full-text arcles assessed Full-text arcles excluded,

for eligibility with reasons
(n = 88) (n = 52)
- Age (n =40)
- Discussed caries
progression but no
recommendaons for
radiographic intervals (n=7)
- Does not fit inclusion
criteria (n=2)
- Case report (n=1)
Included
- Editorial (n=1)
- Narrave (n=1)
Studies included in
qualitave synthesis
(n = 36)
that cannot be probed in the molar area, it is recommended possibility of instituting preventive measures for enamel
that clinical examination should be supplemented with lesions, restoring dentin lesions before they progress and
bitewing radiographs (Stecksen-Blicks and Wahlin 1983). planning intervals between examinations (Anderson et al.
Additionally, Roeters and co-workers reported that high- 2005).
level positive detection of lactobacilli and mutans strepto-
cocci in salivary bacterial tests and identification of more High‑caries‑risk patients (two studies) In the study by Cor-
than three discolored enamel lesions were good predictors tes and co-workers in children with high caries risk, it was
of additional dentinal lesions being detected on bitewing found that more than 80% of approximal lesions which were
radiographs that would otherwise be missed with clinical not identified by clinical examination were detected by bite-
examination alone (Roeters et al. 1994). wing radiographs (Cortes et al. 2017). They also recom-
Anderson and co-workers found that the clinician’s over- mended that children in high-caries-risk populations should
all judgement was the best predictor for identifying 5-year- get dental counseling from the age of 1 and should be fol-
old children who would benefit from bitewing examina- lowed up regularly, including having radiographs taken no
tion for the detection of approximal caries (Anderson et al. later than the age of 4 to control future caries development
2005). Provided that radiation protection is optimized, bite- (Cortes et al. 2017). Similarly, Poorterman and co-workers
wing examination should be considered at the age of 5, even recommended that clinicians should consider taking bite-
in low caries prevalence populations as the value lies in the wing radiographs when possible in 6-year-old children in
13

Table 1 Summaries of the papers used for the systematic review

434
References Country Topic/study design Participants number, gen- Intervention/methodology Conclusions

der and age or range
13
Primary outcome measures Secondary outcome
measures
Stecksén-Blicks and Sweden Caries (primary dentition 213 4-, 5-, and 6-year olds Clinical: None Clinical caries exam should be sup-
Wahlin (1983) and low risk)/cross- (M = 113, F = 100) born dmft and dmfs plemented with bitewing radio-
sectional (comparison) in 3rd quarter of year Number of approximal graphs in:
contacts in the primary 4-year olds with contacts in the
molar areas molar area that cannot be probed,
Radiographic: Initial or and with clinical evidence of caries
manifest caries on bitew- All 5- and 6-year olds with approxi-
ing radiographs mal surfaces in the molar area that
cannot be probed
Roeters et al. (1994) The Neth- Caries (primary dentition 182 5-year olds remained Additional dentinal lesions Risk factors = It is suggested that if lactobacilli and
erlands and low risk)/nested of the initial 252 children (dentinal lesions that Food intake (frequency) mutans streptococci are detected
case–control Gender distribution were only detected by Sugar intake (frequency) in saliva and if there are more than
unknown radiographs) Toothbrushing (fre- 3 discolored enamel lesions in
Clinical: Caries on quency) primary teeth, additional dentinal
approximal and occlusal Discolored enamel lesions may be detected on bitew-
surfaces lesions (number) ing radiographs
Radiographic: Caries on Dentinal lesions (num- These results can only be general-
bitewing radiographs ber) ized towards low caries prevalence
using a modified Mar- Streptococcus mutans in child populations in which regular
thaler criteria (1966) saliva (number/ml) preventive care is readily available
Streptococcus mutans in
plaque (number/ml)
Fluoride intake (mg/day)
Plaque (index)
Gingivitis (index)
Streptococcus Mutans
present
Lactobacilli present
Table 1 (continued)
measures
Sköld et al. (1997) Sweden Caries (primary dentition 179 5-year olds (M = 96, Clinical: Dental caries None Clinical exam only (without radio-
and low risk)/cross- F = 83) (defs + incipient lesions) graphs) underestimates correct
sectional (comparison) using WHO criteria caries status
Radiographic: Dental 1.8 more carious surfaces were
caries (defs + incipient detected when bitewing radio-
lesions) seen on bitewing graphs were available. Of these,
radiographs 0.8 were incipient lesions
Anderson et al. (2005) Sweden Caries (primary dentition 267 5-year olds—Stock- dmfs of the primary Other risk factors: 33% of the 5-year olds from a low
and low risk)/cross- holm—(M = 82, canines to second molars Toothbrushing (fre- caries prevalence population, ben-
sectional (comparison) F = 85), mean age = 5.0; based on: quency) efited from bitewing examination
SD = 0.24 years; Clinical: Visible plaque on 65B The ability to identify these children
Skellefteå—(M = 46, Moller and Poulsen crite- and/or on 85L (primary from the predictors was limited.
F = 54), mean age = 5.1; ria (1973) was used for second molars) The best predictor was the clini-
SD = 0.14 years pit/fissure caries and free In-between-meal sugary cian’s overall judgement
smooth surfaces snacks (frequency)
Radiographic: bitewing
radiographs
Poorterman et al. (2010) The Neth- Caries (primary dentition 50 6-year olds Caries examination: dmfs None Half of the carious lesions into
erlands and high risk*)/cross- Gender distribution (WHO criteria)—using dentine, and 23.7% of inadequate
sectional (comparison) unknown only the distal surfaces of restorations were discovered by
*Based on comparison the primary canines and bitewings only
to national levels (high the approximal surfaces Bitewing radiographs can reveal a
restorative index) which of the first and second considerable amount of carious
was provided within the primary molars surfaces and inadequate restora-
paper Dental plaque: simplified tions, which appear clinically
debris index (DI-S) sound or adequate
Radiographic: Approximal Bitewings are not possible in all
lesions/radiolucencies 6-year-old children
and fillings on bitewing
radiographs
13
435

436
13
measures
Cortes et al. (2017) Colombia Caries (primary dentition 600 2-, 4-and 6-year olds Clinical: Dental caries None More than 80% of the approximal
and high risk)/cross- (200 per cohort) using the ICDAS Clinical lesions were not identified at the
sectional (comparison) Gender distribution Scoring System clinical level but required radio-
unknown Radiographic: Dental graphic examination to be detected
caries on bitewing radio- Children and parents/caregivers
graphs using the ICDAS should be called to the clinic when
Radiographic Scoring the child is around age 1 to prevent
System caries in the incisor and first molar
teeth
The children should benefit from
caries risk-related visits, including
radiographs taken no later than the
age of 4 to control future caries
development
Ruiken et al. (1982) The Neth- Caries (mixed dentition 174 8-year-olds Clinical: defs and DMFS None Unlikely that omission of radio-
erlands and low risk)/cross- Gender distribution using Marthaler’s graphs in 8-year-old children
sectional (comparison) unknown reduced count method will result in substantial loss of
(1966) information
Radiographic: defs and Radiographic exam of approximal
DMFS on bitewings lesions in 8-year-old Dutch chil-
using the Plasschaert and dren are not feasible because:
Konig criteria (1973) 1. Low incident of lesions
2. Radiation hygiene
3. Considerations of efficiency
measures
Steiner et al. (2011) Switzer- Caries (mixed dentition 296 7-year olds* Target variables: Car- Predictor variables: For the 7-year-old schoolchildren
land and low risk)/prospec- 295 11-year olds** ies increment (quantity Caries experience at without any caries experience,
tive cohort Gender distributions of new radiolucencies the first examination an X-ray interval of 8 years is
unknown extending into the dentin on selected approximal proposed
*7-year olds were 6.5- to and/or fillings appear- surfaces: However, caution must be exercised
8-year olds ing on the approximal D14F6mes = Number of for the above group. Approximal
**11-year olds were 10.0- surfaces of the molars carious (D1, D2, D3, surfaces must be closely inspected
to 12.0-year olds and premolars within D4) or filled mesial during the yearly clinical examina-
4 years), based on: surfaces on the first tion. When approximal caries is
Clinical: dmfs and DMFS permanent molars suspected, bitewing examination
using the Marthaler (max. = 4) may be advisable
method (1966) D14FS = Number of For the 7-year-old schoolchildren
Radiographic: Approximal carious (D1, D2, D3, with caries experience, an X-ray
lesions/radiolucencies on D4) or filled approxi- interval of 1 year is proposed. This
bitewing radiographs mal surfaces on the may be prolonged if no progres-

permanent molars and sion of lesions is observed over 1
premolars (max. = 24) or 2 years
d14mf5dis = Number
of carious (d12, d34),
filled, or missing
distal surfaces on the
second primary molars
(max. = 4)
d14mfs = Number of car-
ious (d12, d34), filled,
or missing approximal
surfaces on the primary
molars (max. = 12)
D34FS = Number of cari-
ous (D3, D4) or filled
approximal surfaces
on the permanent
molars and premolars
(max. = 24)
13
437

438

13
measures
Hintze and Wenzel (1994) Denmark Caries (permanent 168 children mean age Clinical: Presence of caries None No convincing argument that
dentition and low risk)/ 14 years old (M = 93, (suspected cavitation or 14-year-old children with little car-
cross-sectional (com- F = 75) actual cavitation) and ies experience would benefit from
parison) fillings bitewing exams
Radiographic: Carious Radiography should be restricted
lesions/radiolucencies to clinically suspect occlusal and
and fillings on bitewing approximal surfaces
radiographs There is no indication for bitewings
The above was evalu- in cases were cavitation is already
ated on the occlusal and detected clinically
approximal surfaces
of permanent molars,
premolars and the distal
surfaces of canines
Llena-Puy and Forner Spain Caries (permanent 162 14-year olds (M = 79, DFT/S based on: None Prevalence of interproximal caries
(2005) dentition and low risk)/ F = 83) Clinical: Caries, filled is underestimated considerably
cross-sectional (com- and missing teeth on all when only clinical examination is
parison) permanent premolar and employed
molar surfaces The authors recommend taking two
Radiographic: Approximal bitewing radiographs of children’s
lesions/radiolucencies teeth before they are discharged
and fillings on permanent from public oral health programs
premolar and molar teeth
on bitewing radiographs
measures
Hietala-Lenkkeri et al. Finland Caries (permanent 363 4th graders, mean age Clinical: DMFS using the None In a low caries prevalence popula-
(2014) dentition and low risk)/ 14 years old (M = 165, ICDAS Clinical Scoring tion, both clinically examined
cross-sectional (com- F = 198) System DMFS = 0 and DMFS > 0 patients
parison) Radiographic: Dental benefit from bitewing examination
caries on bitewing radio- Most of the benefit was obtained on
graphs using a modified the occlusal surfaces of the first
Mejáre scoring system permanent molars, followed by
(1998) the occlusal surfaces of the second
Analysis was performed permanent molars
on the occlusal sur-
faces of the 1st and 2nd
permanent molars, the
mesial surfaces of the
2nd premolars, 1st and

2nd molars, and the distal
surfaces of the 1st and
2nd premolars and the
1st molars
Machiulskiene, et al. Lithuania Caries (permanent 872 12-year olds, Clinical: Evaluation of None The contribution of the two methods
(2004) dentition and high risk)/ mean age = 11.7, occlusal and approximal to caries diagnosis depends on the
cross-sectional (com- SD = 0.63 years, and surfaces (sound, intact, diagnostic threshold selected
parison) after 3 years, remaining discontinuous, cavity, Non-cavitated lesions were more
533 15-year olds filling, filling + caries, easily diagnosed with clini-
Gender distribution and activity level) cal examination only. Only for
unknown Radiographic: Approximal approximal lesions at the cavity/
lesions/radiolucencies dentine threshold did radiographs
and fillings on bitewing appear to be of value
radiographs In the current high caries preva-
Analysis was performed lence population, establishment of
on occlusal and proximal approximal contacts in the perma-
surfaces of permanent nent dentition did not increase the
teeth relative diagnostic yield of bitew-
ing radiography
The widespread recommendation of
regular use bitewing examinations
for caries diagnosis is not justified
by the results of this study
13
439

440

13
measures
Gowda et al. (2009) New Zea- Caries (permanent 171 12- and 13-year olds DMFT/S based on: None 41% of lesions are missed with clini-
land dentition and high risk)/ (M = 69, F = 102) Clinical: Dental caries on cal examination alone
cross-sectional (com- the surface level, using The greatest discrepancy between
parison) the BASCD Diagnos- clinical examination only and clini-
tic Criteria for Caries cal examination + radiographs are
Prevalent Surveys (Pitts seen with approximal lesions
et al., 1997) Bitewing exams should be a routine
Radiographic: Dental part of oral epidemiological
caries on bitewing surveys wherever logistics and
radiographs (only R3 and funding permit
4 lesions)
Analysis was performed
on the mesial, occlusal
and distal surfaces of the
posterior permanent teeth
Poorterman, et al. (2000) The Neth- Caries (permanent 115 14-year olds DMFT/S based on: None Bitewing radiography results in
erlands dentition and caries 120 17-year olds Clinical: Dentinal caries considerable increase in detection
risk uncertain)/cross- 117 20-year olds and fillings (adequate/ of approximal dentinal lesions and
sectional (comparison) 192 23-year olds inadequate) inadequate restorations for all age
Gender distribution Radiographic: Approximal groups, the largest contribution
unknown lesions/radiolucencies, being for the 17-year olds
fillings or missing sur- When bitewings are taken, more
faces from the distal sur- surfaces that require treatment are
face of the first premolar identified
to the mesial surface of
the second molar
Lith et al. (2002) Sweden Caries (mixed and per- 285 19-year olds, with Radiographic: Approximal None A restrictive attitude both to the fre-
manent dentition, and bitewing records from lesions/radiolucencies quency with which radiographs are
low risk*)/Interrupted the age of 6 and fillings on bitewing taken and to operative treatment of
time series Gender distribution radiographs proximal caries lesions seems to be
*In a fluoridated com- unknown Evaluation was done on the possible in low-caries-risk patients
munity with higher than occlusal and approximal When a patient’s individual charac-
average socioeconomic surfaces of permanent teristics are taken into considera-
status and education teeth, from the distal sur- tion, a management strategy aimed
levels face of the first premolar at minimal operative intervention
to the mesial surface of can be consistent with an overall
the second molar decrease in the frequency of radio-
graphic examinations, provided
that efficient preventive measures
are taken
measures
Torres et al. (2011) Brazil Caries (mixed and per- 47 10- to 18-year olds, Clinical and Radiographic: None In the majority of teeth diagnosed
manent dentition, and mean age = 12.78 Caries within enamel or on radiographs as having occlusal
caries risk uncertain)/ SD = 2.50 years, (M = 17, dentin and fillings, on enamel–dentin caries, these caries
cross-sectional (com- F = 30) the occlusal surfaces of lesions could not be detected by
parison) permanent premolars and clinical examination alone
molars using the Weer-
heijm, Gruythuysen and
Van Amerongen criteria
(1992)
Bitewing or periapical
radiographs were used,
depending possibility of
pulpal involvement
Kronmiller et al. (1986) USA Caries (primary, mixed 145 2- to 15-year olds Radiographic: Carious None Bitewing radiographs demonstrated
and permanent denti- (M = 61, F = 84) lesions/radiolucencies on new interproximal lesions 32% of
tion and caries risk bitewing radiographs the time
uncertain)/retrospective Average interval between Regardless of dentition stage,
cohort positive readings on average bitewing radiograph
bitewing radiographs interval with positive readings
was 17.7 months, consistent with
recommendations of 12–24-month
bitewing intervals
Use of shorter intervals for patients
with primary tooth contacts is not
supported
Bitewing radiograph inter-
vals > 6 months may be appropriate
even in patients with caries
Mann et al. (1985) Israel Periodontal/cross-sec- 69 12- to 16-year olds, Clinical: Loss of attach- None There was minimal agreement
tional (comparison) Gender distribution ment on 12 permanent between clinical and radiographic
unknown tooth surfaces using the assessment
Ramfjord criteria (1967) Early periodontal changes could not
Radiographic: Loss of be detected on bitewings by the
attachment on the same examiners using the determined
surfaces (except for radiographic criteria
incisors) on bitewing Bitewings are a poor screening tool
radiographs for assessment of early periodontal
disease in adolescents
13
441

442

13
measures
Albandar et al. (1991) Iraq Periodontal/longitudinal 422 14-year olds (M = 192, Radiographic (at baseline None 2 bitewings are adequate to identify
uncontrolled study F = 230) and at 1 year): Alveolar young adults at risk of develop-
bone height from the dis- ing periodontal lesion, although
tal surface of the canine radiographs significantly underesti-
to the mesial surface of mate the prevalence of periodontal
the 2nd molar on bitewing destruction in the risk group com-
radiographs pared to clinical measurements
Pattern of bone loss (verti-
cal vs. horizontal)
Amount of bone loss after
1 year
Additionally, for at-risk
patients, after 1 year:
Clinical: Loss of attach-
ment at radiographically
examined sites
Radiographic: Alveolar
bone height on the upper
and lower anterior teeth
using periapical radio-
graphs
measures
Sacal et al. (2001) USA Dental anomalies/cross- 500 3- to 5-year olds Radiographic: Frequen- None For the conditions observed in this
sectional (observa- (M = 236, F = 264) cies of dental anoma- survey, only 92 patients (18%)
tional) lies in primary* and showed no evidence of caries
permanent** dentition history, current pathological
on maxillary occlusal conditions, or other anomalies; the
radiographs remaining patients had one or more
* Primary dentition: of the conditions studied
Anomalies in number, A single occlusal radiograph taken
metamorphic calcifica- in 3- to 5-year-old children with
tion, fusion and gemina- E-speed film is associated with
tion, caries, internal and relatively low risk, but may provide
external resorption, peri- information that can be of potential
odontal ligament enlarge- value in the immediate- as well as
ment, dilaceration, crown long-term dental management of

and root fracture, and the child
periapical infection
**Permanent dentition:
Mesiodens, congenitally
missing teeth, supernu-
merary teeth, ectopic
position, macrodontia,
peg laterals, dens invagi-
natus, and cyst
Jacobs (2000a) Australia Impaction/case series One 10-year-old male and Radiographic: Labial/ None A panoramic radiograph with an
two 14-year-old females lingual positions of anterior occlusal radiograph is
unerupted mandibular the preferred combination of
anterior teeth, deter- radiographs to localize unerupted
mined by the vertical mandibular anterior teeth
parallax technique, using This combination uses a tube shift in
mandibular anterior the vertical plane. The panoramic
occlusal and panoramic radiograph is taken at an effective
radiographs angle of + 7° to the occlusal plane,
and the anterior occlusal radio-
graph is usually taken at − 55°, a
difference of 62°
13
443

444

13
measures
Jacobs (2000b) Australia Impaction/case series 7 10- to 18-year olds Radiographic: Labial/ None Vertical parallax technique with
(M = 3, F = 4) buccal or palatal/lingual a panoramic radiograph and an
positions of unerupted occlusal radiograph provides more
teeth, determined by the information than a panoramic
vertical and horizontal radiograph with an axial (vertex)
parallax technique, occlusal radiograph
using a combination of This is the preferred combination of
occlusal, periapical, and radiographs to localize unerupted
panoramic radiographs teeth, anterior to the molars in both
the maxillary and mandibular jaws
The occlusal radiograph should be
taken at 70°–75°. However, if the
incisors are retroclined, the angle
should not be increased above
60°–65°
Armstrong et al. (2003) UK Impaction/cross-sectional 39 12- to 28-year olds Radiographic: Labial/ None The horizontal parallax technique
(comparison) (mean age 14 years and palatal positions of is superior to the vertical parallax
11 months) ectopic maxillary canines technique for detecting palatal
Gender distribution (EMC), determined by EMCs, with 88% and 79% accu-
unknown horizontal and verti- racy respectively
cal parallax technique, Both techniques were poor at local-
using anterior maxillary izing buccal EMCs at only 63%
occlusal and periapi- accuracy using either technique
cal radiographs for the It is suggested that a panoramic
former, and anterior radiograph not be taken to localize
maxillary occlusal and EMCs. Instead, only radiographs
panoramic radiographs allowing the horizontal parallax
for the latter technique should be used to mini-
mize radiation exposure to patients
measures
Haney et al. (2010) USA, Impaction/cross-sectional 18 subjects, mean age Radiographic: Mesio- None The study does not address accuracy
(comparison) 16.9 years old (M = 6, distal, labio-palatal of either modality, but the impact
F = 12) and vertical positions on diagnosis and treatment plan
of impacted maxillary 2D and 3D images of impacted max-
canines; Root resorp- illary canines can produce different
tion; Need for additional diagnoses and treatment plans
imaging; Treatment plan; Individual tooth variations affect the
Confidence determination of the labio-palatal
Modalities used: Anterior position of an impacted maxillary
maxillary occlusal and canine
panoramic radiographs,
cone beam computed
tomography (CBCT)
Tsolakis et al. (2018) Greece Impaction/cross-sectional 20 10- to 17-year olds Radiographic: Buccal None Conventional radiography is more
(comparison) Gender distribution or palatal positions of prone to subjective interpretation
unknown impacted maxillary than cone beam computed tomog-
canines; Root resorp- raphy (CBCT)
tion of adjacent lateral Out of the conventional radiography
incisor, ipsilateral central techniques, panoramic radiogra-
incisor, or any other tooth phy is more sensitive in detecting
Modalities used: Anterior resorption and bucco-palatal tooth
maxillary occlusal and position, but occlusal and periapi-
panoramic radiographs, cal radiography provides higher
cone beam computed specificity and positive predictive
tomography (CBCT) value
CBCT is the only reliable and accu-
rate diagnostic method for the 3D
localization of impacted maxillary
canines and root resorption of
adjacent teeth
13
445

446

13
measures
Holan and Yodko (2017) Israel Trauma/cross-sectional 674 children, mean age Clinical: Increased mobil- None 2.5% of the cases had radiographic
(comparison) 51 months (M = 342, ity, tenderness or dull findings without clinical findings.
F = 332) sound on percussion, There were 40.8% of cases that had
enamel fracture, crown clinical findings with no radio-
fracture with dentin graphic findings. Overall, 77.7% of
exposure or pulp expo- cases had no radiographic findings
sure, internal coronal Expansion of the dental sac of
discoloration, presence permanent incisors is significantly
of a draining sinus, and associated with traumatic dental
internal coronal discol- injury to their primary predeces-
oration sors
Radiographic: Root
fracture, pulp canal
obliteration, tube-like
mineralization, internal
resorption, arrested
dentin deposition, exter-
nal inflammatory root
resorption, and periapical
radiolucency and expan-
sion of the dental sac of
the permanent successors
Pierro, et al. (2008) Brazil Comfort/cross-sectional 66 3- to 5-year olds Patient’s acceptance of the Global evaluation: Sum The frequency of cooperative chil-
(observational) Gender distribution radiographic examination of all errors for each dren was higher with age
unknown based on their behavior pair of radiographs There was a statistically significant
(Cooperative/Uncoopera- correlation between the children’s
tive) cooperation and their acceptance
Patient’s perception of the of the radiographic examination
procedure using a modi- The diagnostic quality of bitewing
fied Manuksela et al. radiographs was not influenced by
scale (1987) (Satisfac- the children’s behavior
tion/ Indifference/ Dis- The modified bitewing film holder
satisfaction) produced adequate radiographs for
Bitewing image quality almost all parameters and was well
based on film coverage, accepted by the children
interproximal overlap- The high frequency of errors in the
ping, and visibility of the maxillary right quadrant might be
alveolar crest related to the modified holder’s
bilateral use. Adaptation of the
design of the holder is suggested to
produce a design for each side
measures
Mahiepala et al. (2015) Australia Comfort/cross-sectional 125 5- to 17-year olds Dental Anxiety Score None A higher level of dental anxiety was
(observational) (M = 62, F = 63) (DAS) using a Facial seen in children who were subject
Image Scale (FIS) by to radiographic examination
Townend et al. (2000) (including taking periapical radio-
graphs, bitewings or panoramic
radiographs)
There was also a decrease in the
level of anxiety after radiographic
examinations were performed
Elbay et al. (2016) Turkey Comfort/randomized, 25 6- to 12-year olds Gagging severity, using the None Gagging scores were higher in the
controlled, double-blind (M = 17, F = 8) Gagging severity (GS) control group than in the experi-
clinical trial criteria (Sewerin, 1984) mental (laser application) group,
Anxiety levels, using and these differences were statisti-
Corah’s Dental Anxiety cally significant

Scale (DAS) (1969) Patients who were unable to tolerate
the intraoral control radiography
were able to tolerate the procedure
after low-level laser therapy
▪ There was no significant correla-
tion between gagging severity and
anxiety score
▪ A negative correlation was found
between age and gagging score in
the control group
McDonald (1983) UK Technique/cross-sectional 4- to 8-year olds (sample Radiographic: Frequency None Bitewing radiographs taken using
(comparison) size not stated) and degree of interproxi- the bite registration technique
Gender distribution mal overlap on bitewing had fewer overlapping proximal
unknown radiographs contacts compared to radiographs
Reproducibility of bitew- taken without
ing radiographs taken This technique also demonstrated
using the bite registration good reproducibility between ini-
technique tial and subsequent radiographs
13
447

448

13
measures
Myers et al. (1984) USA Technique/cross-sectional 48 5- to 7-year olds Recommendations to Experience level of the Children with severe caries whose
(comparison) Gender distribution supplement bitewing dentist bitewing radiographs were taken
unknown radiographs taken with with No. 0 film required signifi-
No. 0 or No.2 films, with cantly more periapical radiographs
periapical radiographs than for those taken with No. 2
(Yes/No) films
When a child’s cooperative ability
permits, bitewing radiographs
should be exposed using No. 2
film, especially when extensive
carious lesions are noted in the pri-
mary molars. This will minimize
the need to expose supplemental
periapical radiographs
Harrison and Richardson Canada Technique/cross-sectional 338 5- to 11-year olds Radiographic: Degree of Location of the inter- There was no significant difference
(1989) (comparison) Gender distribution interproximal overlap proximal overlap observed in image quality for each
unknown on bitewing radio- (maxilla/mandible and of the 3 film sizes
graphs taken with either approximal molar or There was no significant statistical
cardboard tabs or Rinn® premolar surfaces) difference in the image quality
holders, and with size 0, between the bitewings taken with
1 or 2 films or without a Rinn® holder
There was no statistical significant
difference between the 2 tech-
niques with regard to frequency of
partial or complete interproximal
overlap
Proximal overlaps most commonly
occurred between the maxillary
second primary molar or second
bicuspid and the maxillary primary
first molar or first bicuspid on size
0 and size 1 films; and on size 2
between the maxillary first perma-
nent molar and the second primary
molar or second bicuspid
measures
Townsend (2000) UK Technique/cross-sectional 53 6- to 18-year olds Radiographic: Dentinal None There is a higher variation in caries
(comparison) (M = 52%, F = 48%) caries on the mesial, diagnosis using oblique lateral
occlusal and distal films, but the level of agreement
surface of each tooth on shown between oblique lateral
bitewing and oblique films and bitewings for approximal
lateral radiographs and occlusal caries showed a fair to
The level of agreement good agreement (beyond chance)
between bitewing If a child is unable to cooperate for
radiographs and oblique good bitewing radiographs, the
lateral radiographs with oblique lateral would be a good
regard to caries diagnosis alternative
Newman and Friedman USA Technique/case series One 16-year-old male and Ability to tolerate radio- None An extraoral radiography technique
(2003) one 8-year-old female graphic examination (where an intraoral image detector
is placed extraorally, and with

the X-ray source placed on the
opposite side of the jaw) is sug-
gested for patients who are unable
to tolerate conventional intraoral
radiography
Hamanaka et al. (2013) Brazil Technique/case report One 17-year-old male Radiographic: Length of None The development of an individu-
the central incisors on alized Rinn® holder using an
sequential periapical occlusal splint allows for standardi-
radiographs to verify zation of intraoral radiographs. It
reproducibility of the also allows for accurate gathering
projection geometry of information from radiographic
images and can be a useful tool
for follow-up in cases of dento-
alveolar trauma cases
13
449

450

13
measures
Hernan and Ashkenazi Israel Technique/cross-sectional 298 3- to 14- year olds, Radiographic (Bitewing Radiographic Quality The frequency of technical errors
(2013) (comparison) mean age 7.1 years radiographs): Number (Q): The percentage of was very high, and only 23.5% of
(M = 158, F = 140) of full crowns shown in parameters that had no bitewings were free of errors
one film (in mesio-distal shortcomings The frequency or degree of proximal
diameter), number and Quality of bitewings: overlapping was not related to the
percentage of overlap- Ratio of errors out of a type of film holder (Sticky tape,
ping surfaces, degree of total 8 possible errors KWIK-BITE or Snap-a-ray) or to
overlapping, presence of the type of behavioral modification
folds in the film, exist- approach used during treatment
ence of cone-cut, exist- (behavioral modification only or
ence of elongated teeth, in conjunction with nitrous oxide
the lack of visibility of or with sedation, or under general
upper or lower tooth anaesthesia)
crowns or of alveolar Uneven distribution of the film
bone crest in both jaws. between the upper and lower arch
Also (not used in analy- teeth were found most commonly
sis)—signs of defective in bitewing radiographs that were
film development taken with the KWIK-BITE holder.
However, the highest degree of
visibility of the alveolar bone crest
in both arches, and the lowest
frequency of fold marks was also
found with KWIK-BITE holders
Use of the KWIK-BITE holder was
associated with bitewing radio-
graphs with higher quality scores
The quality of radiographs was posi-
tively correlated with children’s
cooperation according to Frankl’s
scale
Bitewing radiographs of children
treated by nitrous oxide were of
lower quality than those taken in
children treated by other behavioral
methods, and the highest qual-
ity of radiographs was achieved
in children treated under general
anesthesia
M male, F female, BASCD British Association for the Study of Community Dentistry, defs number of decayed, extracted due to caries and filled surfaces in the primary dentition, DFT/S num-
ber of decayed and filled teeth/surfaces in the permanent dentition, dmfs/DMFS number of decayed, missing due to caries and filled surfaces in the primary dentition/permanent dentition, dmft/
DMFT number of decayed, missing due to caries and filled teeth in the primary dentition/permanent dentition, DMFT/S number of decayed, missing due to caries and filled teeth/surfaces in the
permanent dentition, ICDAS international caries detection and assessment system, ICCMS™ international caries classification and management system, WHO World Health Organization
high-caries-risk populations, to identify approximal caries first and second permanent molars. Additionally, it was sug-
and inadequate restorations which clinically look sound gested that older children with low caries experience who
(Poorterman et al. 2010). were completing a public oral health program should receive
bitewing radiographs mainly for the detection of approximal
Mixed dentition (total number of studies: 2) carious lesions prior to the patient’s discharge.
Only two papers evaluating solely mixed dentition in low- High‑risk patients (two studies) Gowda et al. (2009) found
caries-risk populations were found. In low-caries-risk that 41% of lesions were missed with clinical examination
patients, routine bitewing radiographs were not advocated alone, with the greatest discrepancy being that of approxi-
by both papers, but only indicated if there is a suspicion of mal lesions. They suggested that bitewing radiographs
approximal caries. Caries risk profiles which are susceptible should be a routine part of oral epidemiological surveys and
to change, due to individual-level factors, appeared to govern of the clinical management of patients wherever logistics
the recommendations of radiograph indications with respect and funding permit.
to their frequency and need. Similarly, the study by Machiulskiene et al. (2004) also
Steiner et al. (2011) proposed a long X-ray interval of concluded that bitewing examination is a valuable supple-
8 years for 7-year-old caries-free children. However, they mentary diagnostic tool for the detection of lesions which
cautioned that in these children, approximal surfaces must be were cavitated or had lesions with dentin involvement. In
closely inspected during the yearly clinical examination, and addition, in approximal surfaces, the ability of radiographs
that an unscheduled bitewing examination may be advisable to detect a carious lesion at the cavitated/dentin level was
when approximal caries is suspected, as individual’s caries four times higher than at the non-cavitated enamel level.
risks may also change. As for children younger than 7 or However, clinical examination alone was found to be bet-
those with delayed eruption of the first permanent molars, ter at detecting non-cavitated enamel lesions, and this
they recommended that bitewing examination should be was attributed to the fact that a certain amount of mineral
postponed for a year. must be lost before a lesion can be detected radiographi-
Contrastingly, an early study from The Netherlands cally. Therefore, the authors argued that the contribution of
(Ruiken et al. 1982) concluded that 8-year-old children clinical and radiographic examination for caries diagnosis
from lower-caries-risk populations may not benefit from depends more on the diagnostic threshold selected (cavi-
routine radiographic examination of approximal surfaces, tated/non-cavitated) than on the stage of maturation of the
and that the need for radiographs should be weighed against dentition, and, thus, did not recommend regular use bitewing
the population’s low incidence of lesions, radiation hygiene examinations for caries diagnosis.
and considerations of efficiency.
Uncertain caries risk (one study) Likewise, Poorterman
Permanent dentition (total number of studies: 6) et al. (2000) also found that more tooth surfaces with car-
ies requiring treatment were identified when bitewings were
A total of six studies were found under permanent dentition taken, with a considerable increase in detection of both
studies, of which three were in low-caries-risk populations, approximal dentinal lesions and inadequate restorations,
two in high-caries-risk populations, and one in a population which clinically appeared sound. This finding was irrespec-
with uncertain caries risk. tive of age groups, with the largest contribution being for the
older patients within their study.
Low‑caries‑risk patients (three studies) There were con-
tradicting conclusions from the studies on low-caries-risk Mixed and permanent dentition (total number of studies: 2)
patients. On one hand, Hintze and Wenzel (1994) opined
that 14-year-old children with little caries experience would Only two studies were found in this category, of which one
benefit from bitewing exams, and that radiographs be indi- was conducted in low-caries-risk patients, and the other was
cated only in the situations where there are clinically suspi- considered to be of uncertain caries risk. No studies on high-
cious occlusal and approximal surfaces. They also felt that caries-risk populations was found.
there was no indication for bitewings in cases where cavita-
tion is already detected clinically. Low‑caries‑risk patients (one study) Lith et al. (2002) felt
Conversely, in the studies by Llena-Puy and Forner that although the presence of a lesion is a good indicator
(2005) and Hietala-Lenkkeri et al. (2014), it was suggested of other hidden lesions, that in itself did not justify the tak-
that the absence of carious lesions evaluated by clinical ing of routine radiographs as prescribed by predetermined
examination alone may under-estimate the presence of schedules. Rather, they concluded that in the presence of
either interproximal caries or occult occlusal caries in the appropriate preventive measures, periodic radiographic fol-
13

low-up is not required at set intervals, and that a restrictive developing destructive forms of periodontal disease. While
attitude both to the frequency with which radiographs are bitewings seemed adequate for identification of subjects at
taken and to operative treatment of proximal caries lesions risk of developing periodontal disease, it detected fewer sites
may be possible in low-caries-risk patients. with periodontal destruction per subject compared to clinical
assessment of attachment loss.
Uncertain‑caries‑risk patients (one study) Torres et al. Similarly, Mann et al. (1985) found that there was poor
(2011) in a study of enamel–dentin caries found that clini- agreement between clinical and radiographic diagnoses of
cal examination alone was not able to detect enamel–dentin periodontal attachment loss. Examiners were not able to
lesions which were otherwise seen on bitewing radiographs. determine early periodontal changes radiographically even
However, radiographic examination is neither able to distin- when clinical changes were already observed, thus indicat-
guish severity or caries activity, nor if a lesion is cavitated. It ing the failure of bitewing radiographs to adequately detect
was concluded that bitewing radiographic images should be the early changes needed for screening or diagnosis of peri-
considered as part of the initial routine dental examination odontal disease in teenage patients.
in children, but subsequent follow-up exposures should be
individualized, based on each patient’s dental and general Dental and developmental anomalies (total number
health needs. of studies: 6)
Primary, mixed and permanent dentition (total number Only one study assessed the prevalence of observable den-
of studies: 1) tal anomalies and pathology in the premaxilla in children
between 3 and 5 years of age, utilizing single maxillary
In the study by Kronmiller et al. (1986), it was found that occlusal radiographs. Five other papers assessed either
45% of all patients demonstrated interproximal lesions at the eruption anomalies, of which two papers described cases
initial bitewing examination, thus supporting earlier recom- and detailed radiographic techniques to locate positions of
mendations of taking bitewings at initial visits. The average unerupted teeth, and three studies evaluated positions of
bitewing interval with demonstration of positive findings of ectopic or impacted maxillary canines.
radiolucent lesions in this study was 17.7 months, regardless
of dentition stage. Therefore, the authors felt that bitewing Frequencies of dental anomalies (one study)
intervals of more than 6 months may still be appropriate
even in children with caries, and recommended bitewing In a retrospective study by Sacal et al. (2001), maxillary
intervals to be not shorter than 12–24 months for the primary occlusal radiographs of 500 healthy preschool children
dentition. Additionally, the exclusive use of bitewings for between 3 and 5 years of age were reviewed to identify the
detection of other conditions/morbidities apart from approx- anomalies in number of teeth, metamorphic calcifications,
imal caries (e.g., ankylosis, non-interproximal caries and fusion or gemination of teeth, internal and external root
ectopic eruption) was not supported. resorption, periodontal ligament enlargement, dilaceration
of tooth roots, crown and/or root fractures, and periapi-
Pathological conditions (total number of studies: 2) cal infection. Of these, only 18% did not have any of the
above-listed pathology, and the others were found to have
Only two representative studies on periodontal disease in one or more pathology detected radiographically. Therefore,
children were included in our systematic review. No papers it was suggested that a single occlusal radiograph taken in
on intraoral radiographic evaluation of acute dental infec- 3–5-year-old children with E-speed film, that is associated
tions were found. with relatively low radiation risk, may be beneficial in the
diagnosis of dental anomalies and henceforth future dental
Periodontal‑related papers (two studies) management.
Both studies found that bitewing radiographs were not ideal Dental anomalies–anomalies in eruption (five studies)
for assessment of periodontal diseases in young patients,
and that radiographic assessment of attachment loss under- Three studies evaluated the localization of impacted canines.
estimated the clinical findings and measurements of peri- Two studies (Jacobs 2000a, b) assessed differences in out-
odontal attachment loss. comes between two-dimensional and three-dimensional
Albandar et al. (1991) found that loss of alveolar bone imaging modalities with respect to localization of the tooth
over time took place mainly in sites displaying vertical bone and its impact on diagnosis and, hence, treatment plans
loss, and that it occurred mainly in the 1st permanent molar for the patient; while, one study (Armstrong et al. 2003)
region, with females being at greater risk than males of
13
compared the vertical versus horizontal parallax methods Intraoral occlusal radiographs can be combined with pano-
used to determine the palatal versus buccal positions of the ramic radiographs in appropriate clinical situations to deter-
canines. mine the position of the impacted anterior tooth.
Two- and three-dimensional images of impacted max-
illary canines were found to produce different diagnoses, Dental trauma (total number of studies: 1)
which in turn can produce different treatment plans for the
same individual. Tsolakis et al. (2018) found that conven- Only one paper on dental trauma was evaluated for the
tional radiography is more prone to subjective interpretation systematic review, with the other papers found being the
than cone beam computed tomography (CBCT). Out of the International Association of Dental Traumatology (IADT)
conventional radiography techniques, panoramic radiogra- guidelines. In the study by Holan and Yodko (2017), it was
phy was found to be more sensitive in detecting resorption found that only 2.5% of the cases in their study demonstrated
and bucco-palatal tooth position; whereas, occlusal and peri- radiographic findings in the absence of clinical findings.
apical radiography provided higher specificity and positive However, 40.8% of cases that had clinical presentations had
predictive value. Haney et al. (2010) concluded that the use no radiographic findings. Overall, 77.7% of cases had no
of two- and three-dimensional images of impacted maxillary radiographic findings. Expansion of the dental sac of per-
canines can produce different diagnoses and treatment plans manent incisors was found to be significantly associated
for the same individual. Both papers concluded that CBCT is with traumatic dental injury to their primary predecessors.
a more reliable and accurate diagnostic method for localiza- This paper concluded that intraoral radiography can identify
tion of impacted maxillary canines and for identification of traumatic dental injuries to primary teeth better than clinical
root resorption of adjacent teeth. Three-dimensional imaging examination alone (Holan and Yodko 2017).
appears to improve the diagnosis and subsequent treatment
plans, which results in more successful treatment outcomes Comfort and technique (total number of studies: 10)
and better patient care.
Three papers discussed the parallax technique (also This section had three papers on comfort and seven papers
known as the SLOB rule or the tube shift technique or the on technique.
buccal object rule) to identify the location of an impacted
tooth by means of two-dimensional radiography (Jacobs Comfort (three studies)
2000a, b; Armstrong et al. 2003). One paper by Jacobs
(2000a) recommended the use of a panoramic radiograph Taking radiographs was found to result in greater anxiety
with an anterior occlusal radiograph as the preferred combi- levels in children, and that anxiety levels reduced after com-
nation of radiographs to localize unerupted mandibular ante- pletion of the radiographic examination (Mahiepala et al.
rior teeth; whereas, another paper (Jacobs 2000b) suggested 2015). It was observed that the frequency of cooperation
that the use of vertical parallax technique with a panoramic with radiographic examination increased with higher age,
radiograph and an occlusal radiograph provided more infor- and that there was a statistically significant correlation
mation than a panoramic radiograph with an axial (vertex) between the child’s cooperation level and their acceptance
occlusal radiograph, and that it is the preferred combina- of the radiographic examination (Pierro et al. 2008). Modi-
tion of radiographs to localize unerupted teeth which are fication of the image detector holder to accommodate the
positioned anterior to the molars in both the maxillary and smaller patient’s mouth has been suggested as a method to
mandibular jaws. improve patients’ acceptability of intraoral X-rays (Pierro
On the other hand, Armstrong et al. (2003) found that et al. 2008).
the horizontal parallax technique was superior to the ver- Taking intraoral radiographs in patients with a (strong)
tical parallax technique for detecting palatally positioned gag reflex can be challenging for both the clinician and the
maxillary canines with high accuracy, but both techniques patient. Gagging was found to be greater in younger patients
were equally poor at localizing buccally located maxillary (Elbay et al. 2016), which can be due to physical irritation
canines. However, unlike the papers by Jacobs (2000a, b), (e.g., contact of the X-ray film/image detector with the soft
they suggested that a panoramic radiograph should not be palate) or anxiety, or a combination of both. Elbay et al.
taken to localize ectopically erupting or localized maxillary (2016) investigated the use of low-level laser application on
canines, but instead take anterior maxillary occlusal and the pericardium six acupuncture point on the patient’s wrists
periapical radiographs which facilitate the horizontal paral- to help reduce gag reflex in young patients. They found that
lax technique to minimize radiation exposure to patients. following laser application, patients who were initially una-
In summary, both horizontal and vertical parallax tech- ble to tolerate intraoral radiography had radiographs suc-
niques appear to be useful radiograph techniques for accu- cessfully taken. There was no significant correlation between
rately determining the position of impacted anterior teeth. gagging severity and the level of anxiety, and the effect of
13

the low level laser stimulation of the six acupuncture points modification techniques were required. Although they also
was found to be significant and all patients subjected to the found that uneven distribution of the film between the upper
laser treatment were able to tolerate the taking of intraoral and lower arch teeth were found most commonly in bitewing
radiographs. radiographs that were taken with the Kwik-Bite® holder,
they also observed that their use produced the highest degree
Technique (total seven studies) of visibility of the alveolar bone crest in both arches and the
lowest frequency of fold marks. In general, the use of the
Studies on technique generally focused on the evaluation Kwik-Bite® holder was associated with bitewing radiographs
of film sizes (Myers et al. 1984; Harrison and Richardson with higher-quality scores.
1989), X-ray holders (Harrison and Richardson 1989; Her- Overall, only 23.5% of bitewings evaluated in the study
man and Ashkenazi 2013) and radiographic techniques were free of errors. Bitewing radiographs of children treated
which improved the accuracy and reproducibility of radio- under nitrous oxide were of lower quality than those taken in
graphic images (McDonald 1983; Hamanaka et al. 2013). children treated by other behavioral methods, such as behav-
Two studies (Townsend 2000; Newman and Friedman 2003) ioral modification only or in conjunction with sedation, or
assessed alternative radiographic methods for use in those under general anesthesia; whereas, the highest quality of
who find difficulty coping with intra-oral radiographs. radiographs was achieved in children treated under general
anesthesia. The frequency or degree of proximal overlapping
Studies on X‑ray films, holders and resultant diagnostic was not related to the type of film holder (Sticky tape, Kwik-
quality and reproducibility Bite® or Snap-a-Ray®). Instead, the quality of radiographs
was positively correlated with the child’s cooperation level,
The use of smaller film sizes has been suggested to facili- rather than with the type of holders used.
tate taking of X-rays in young patients. However, a study by Two papers described techniques which allowed for
Myers et al. (1984) found that children with extensive car- reproducible and geometrically accurate imaging. The
ies whose bitewing radiographs were taken with No. 0 film study by Hamanaka et al. (2013) described an individualized
required significantly more periapical radiographs than for image detector holder for anterior teeth. They described an
those taken with No. 2 films. They recommended that when occlusal splint which allows for standardization of intraoral
a child’s cooperative ability permits, bitewing radiographs radiographs to enable ideal follow-up in cases of dento-
should be exposed using No. 2 film, especially in those with alveolar trauma (Hamanaka et al. 2013). A similar approach
severe caries in the primary molars. The latter would, thus, was taken by McDonald (1983) who used bite registration
minimize the need to expose them to supplemental periapi- material to individualize the bite block of the R inn® XCP
cal radiographs (Myers et al. 1984). instrument, which subsequently allowed for reproducible
Contrastingly, Harrison and Richardson (1989) did not bitewings to be taken.
find any significant difference in image quality when using
size 0, 1 or 2 films. Additionally, there was no statistical Alternative radiographic methods replacing intraoral
difference in the image quality between the bitewings taken methods
with a cardboard tab versus a Rinn® holder with regards
to frequency of partial or complete interproximal overlap. Townsend (2000) showed that the level of agreement
They also observed that proximal overlaps most commonly between oblique lateral films (an extraoral technique) and
occurred between the maxillary second primary molar or bitewings for approximal and occlusal caries had a fair to
second bicuspid and the maxillary primary first molar or first good agreement (beyond chance), but that clinicians had a
bicuspid on size 0 and size 1 films; and on size 2 between higher variation in caries diagnosis when using oblique lat-
the maxillary first permanent molar and the second primary eral films. However, they concluded that if a child is unable
molar or second bicuspid. to cooperate for good bitewing radiographs, the oblique lat-
Herman and Ashkenazi (2013) in a retrospective study eral technique would be a good alternative. Similarly, New-
found that the Snap-A-Ray® was used more frequently in man and Friedman (2003) described an extraoral technique
conjunction with a small film size, in younger and less coop- positioning the intraoral sensor on the external surface of
erative children, as well as those treated under sedation cir- the cheek with the X-ray beam passing to the sensor unob-
cumstances. Kwik-Bite® was used more frequently in chil- structed from the opposite side of the mouth in cases where
dren classified as fully cooperative, older children and those intraoral placement of the image detector is not possible.
treated under general anesthesia. Sticky tape was used more With this extraoral technique, there is a possible disadvan-
frequently in children with early mixed dentition, in children tage of increased radiation (increased exposure time) com-
showing partial cooperation and in those where behavioral pared to when conventional intraoral radiographs are used.
13
Grey literature results health needs. It should be noted that radiographic examina-
tion is neither able to distinguish severity or caries activity,
In general, handbooks on dentomaxillofacial radiology were nor if a lesion is cavitated. Hence, radiographic examination
found to primarily cover techniques for adult patients. Few should always be considered as part of the initial routine
mention children and/or patients with special needs. Three dental examination in children, but should not precede that
pediatric dentistry-related textbooks were found to cover the of clinical examination.
topics of imaging in pediatric dentistry. None of the studies in this review appear to agree upon a
Only one textbook was identified to be dedicated to imag- suitable review timing for repeat radiographs for monitoring
ing in pediatric dentistry (Aps 2019). This book contained of caries progression. In a review of guidelines on timing
explanations, however limited, about techniques for intraoral and frequency of bitewing radiographs for the diagnosis of
and extraoral radiography in children and patients with spe- caries (Goodwin et al. 2017), it was concluded that there
cial needs. The other two were pediatric dentistry handbooks was a significant variation and disagreement amongst the
which either had a full chapter (Parks and Aps 2016), or different guideline recommendations with regards to the age
only a short chapter to the topic of radiology and radiogra- and frequency of when radiography should be undertaken.
phy (Aps and Lee 2018). None of the information found in Furthermore, they found that most of the existing guide-
these chapters were included into this systematic review. It lines recommended bitewing frequency in the population
was difficult to evaluate the quality of the resources and the according to the age of the patients and their perceived risk
risk of bias of the references used in these book chapters, of further developing caries. The latter, in particular, should
and no concrete scientific was provided for the indications be interpreted with caution, as there is wide variability in the
or contra-indications for intraoral radiography in pediatric way current and future caries risk is evaluated and perceived
dentistry. among published studies.
In addition, they emphasized the need for better under-
Quality/risk of bias assessment standing of the rate at which carious lesions progress
through the enamel, the enamel–dentinal junction, and into
Table 2 shows the risk of bias (RoB) assessments for the the outer third of dentin. This is essential to help decide
included papers. Twenty seven of the 36 papers had high when and how frequent bitewing radiographs are indicated
risk of bias, whereas only 1 paper was deemed to be at low or recommended. A multitude of factors have to be taken
risk of bias, and 9 were considered to be at moderate risk of into account when assessing caries risk of the individual
bias. The majority of these papers (26 out of 37 papers) were patient. For instance, accessibility to fluoridated toothpaste
cross-sectional studies. The overall evidence of the included and preventive measures, the dentist’s ability to identify
studies was determined to be low. early caries lesions, and the individual and public health
level of consequences of failed caries detection. On all these
factors, there appears to be no consensus.
Discussion
Pathological conditions
Discussion of results
Only two papers on diagnosis of periodontal disease in chil-
Although a myriad of publications regarding intraoral radi- dren and adolescents were identified in the search under this
ography in pediatric dentistry was identified in this system- clinical category. There are relatively few studies evaluating
atic review, statistical pooling of studies was not possible the onset of periodontal diseases in young patients in the
due to varied outcome measures used. Therefore, this review prevailing dental literature. This is likely because aggressive
is limited to a narrative synthesis of the available studies in forms of periodontal disease rarely occur in the young popu-
pediatric intraoral radiography. lation, and when present is often related to specific popula-
tions with genetic predispositions. Hence, few studies have
Caries been designed to study the disease progression within this
age group.
The recurrent theme of studies on dental caries regardless of Radiographs are an essential component of the peri-
caries risk suggests that clinical examination alone appears odontal examination and are indispensable in establishing a
to underestimate the presence of interproximal caries. There periodontal diagnosis. While precise detection of proximal
is some evidence to show that as individual caries risks caries is considered an advantage of the horizontal bitew-
evolve, based on changes in physical and environmental fac- ing technique, vertical bitewing techniques have been sug-
tors, subsequent radiographic follow-up exposures should gested as a more valuable diagnostic tool for periodontal
be individualized based on each patient’s dental and general disease assessment as it provides an unobstructed view of
13

Table 2 Themes and risk of bias assessment of the papers involved in the systematic review
Topic/clinical categories References Assessment tool and overall
*Listed by ascending year risk bias assessment color
of publication coded
Bold = (very) good study/low
risk of bias
Italics = satisfactory study/
moderate risk of bias
bolditalics = Unsatisfactory
study/high risk of bias
Caries Primary dentition Low-risk population Stecksén-Blicks and Wahlin NOS Cross-Sectional (modi-
(1983) fied)
Roeters et al. (1994) NOS Case–control
Sköld et al. (1997) NOS cross-sectional (modi-
fied)
Anderson et al. (2005) NOS cross-sectional (modi-
fied)
High-risk population Poorterman et al. (2010) NOS cross-sectional (modi-
fied)
Cortes et al. (2017) NOS cross-sectional (modi-
fied)
Mixed dentition Low-risk population Ruiken et al. (1982) NOS cross-sectional (modi-
fied)
Steiner et al. (2011) NOS cohort
Permanent dentition Low-risk population Hintze and Wenzel (1994) NOS cross-sectional (modi-
fied)
Llena-Puy and Forner NOS cross-sectional (modi-
(2005) fied)
Hietala-Lenkkeri et al. NOS cross-sectional (modi-
(2014) fied)
High-risk population Machiulskiene et al. (2004) NOS cross-sectional (modi-
fied)
Gowda et al. (2009) NOS cross-sectional (modi-
fied)
Caries risk uncertain Poorterman et al. (2000) NOS cross-sectional (modi-
fied)
Mixed and permanent denti- Low-risk population Lith et al. (2002) Cochrane effective practice
tion and organisation of care
(EPOC) tool
Caries risk uncertain Torres et al. (2011) NOS cross-sectional (modi-
fied)
Primary, mixed and perma- Caries risk uncertain Kronmiller et al. (1986) NOS cohort
nent dentition
Pathological conditions Periodontal Mann et al. (1985) NOS cross-sectional (modi-
fied)
Albandar et al. (1991) JBI critical appraisal check-
list for studies reporting
prevalence data
Acute dental infection No papers found Not applicable
13
Topic/clinical categories References Assessment tool and overall
*Listed by ascending year risk bias assessment color
of publication coded
Bold = (very) good study/low
risk of bias
Italics = satisfactory study/
moderate risk of bias
bolditalics = Unsatisfactory
study/high risk of bias
Dental/developmental Identification of dental anomalies Sacal et al. (2001) NOS cross-sectional (modi-
anomalies fied)
Evaluation of impaction (defects in location) Jacobs (2000a) IHE quality appraisal check-
list for case series studies
Jacobs (2000b) IHE quality appraisal check-
Armstrong et al. (2003) NOS cross-sectional (modi-
fied)
Haney et al. (2010) NOS cross-sectional (modi-
fied)
Tsolakis et al. (2018) NOS cross-sectional (modi-
fied)
Dental trauma Holan and Yodko (2017) NOS cross-sectional (modi-
fied)
Comfort and technique Comfort/reduction of patient anxiety Pierro et al. (2008) NOS cross-sectional (modi-
fied)
Mahiepala et al. (2015) NOS cross-sectional (modi-
fied)
Elbay et al. (2016) Cochrane risk of bias tool
Technique McDonald (1983) NOS cross-sectional (modi-
fied)
Myers et al. (1984) NOS cross-sectional (modi-
fied)
Harrison and Richardson NOS cross-sectional (modi-
(1989) fied)
Townsend (2000) NOS cross-sectional (modi-
fied)
Newman and Friedman IHE quality appraisal check-
(2003) list for case series studies
Hamanaka et al. (2013) IHE quality appraisal check-
Herman and Ashkenazi NOS cross-sectional (modi-
(2013) fied)
NOS Newcastle–Ottawa Scale, IHE Institute of Health Economics, JBI Joanna Briggs Institute
the alveolar bone. However, it might prove to be more chal- posttreatment levels of radiographic bone loss (Wolf and
lenging to take vertical bitewings in young patients, espe- Lamster 2011). Secondly, as seen in both included studies,
cially in those with strong gag reflexes. radiographic presentations and assessment of attachment
Despite their value in periodontal diagnosis, radio- loss often under-estimated the clinical findings of peri-
graphs have several limitations as diagnostic tools. Firstly, odontal attachment loss, with early periodontal changes
they do not give any information about disease activity not showing up on radiographs although they were already
or progression. Therefore, a successfully treated case of observed clinically. This finding mirrors that seen in adult
periodontitis is likely to have similar pretreatment and populations (Shrout et al. 1991). This may be attributed to
13

a number of factors. There is indication that clinical bone above described intraoral radiographs, additional extraoral
loss presumably precedes that of radiographically detect- imaging may also be required, including three-dimensional
able bone loss by about 6–8 months (Goodson et al. 1984). imaging (Cohenca and Silberman 2017).
Additionally, should there be any difficulty in taking bite- Taking radiographs is challenging in young patients due
wing radiographs, some proximal sites may show over- to behavioral issues or difficulties with anatomical differ-
laps and, thus, be unreadable (Albandar et al. 1985), hence ences, e.g., shallower palates or floor of mouths. This can
reducing the proportion of assessable material. Ultimately, result in marked deviations in horizontal angulations, where
it is essential that clinicians understand that periodontal the resultant radiographs may not be meaningful for quanti-
disease diagnosis cannot be made solely based on radio- fication of continued root development. Our search revealed
graphs alone, but it nonetheless remains an essential part an interesting approach to accurate radiographic follow-up.
of the full examination of the patient (Greenstein 1997). To circumvent problems with errors of angulation, two stud-
ies (McDonald 1983; Hamanaka et al. 2013) described the
Dental/developmental anomalies use of an individualized bite blocks which would enable all
radiographs to be taken under the same reproducible geo-
The majority of papers regarding dental anomalies that were metrical conditions, thus allowing accurate comparison of
found in our search results were on localization of teeth with radiographic images taken. While this approach cannot be
ectopic eruption or impaction. In the studies evaluated, it generalized to daily clinical practice as it would be too costly
was found that the use of two- and three-dimensional images and time consuming to carry out for individual patients, it
can produce different diagnoses and treatment plans for the might be considered for future studies on pediatric radi-
same patient. This was because individual tooth variations, ography, especially those which require reproducible and
and superimpositions of structures can affect the determina- standardized radiographs for comparison and radiographic
tion of the labio-palatal position of an ectopic or impacted quantification of continued root development.
tooth. Therefore, three-dimensional volumetric imaging
should be considered for provision of additional information Comfort/technique
to the multi-disciplinary dental team, to improve diagnosis
and subsequent treatment plans, which may ultimately result The impact of radiography on the child’s first impression
in more successful treatment outcomes and better care for of dentistry should not be underestimated, and it is para-
young patients. mount that clinicians attempt to make the experience of
the child’s first dental visit as positive as possible. Other
Dental trauma methods of caries diagnosis, i.e., laser fluorescence devices
(e.g., DIAGNOdent®), temporary tooth separation (e.g., with
A systematic review on the topic of dental radiography orthodontic separators), etc. should be explored where avail-
immediately post dento-alveolar trauma, irrespective of the able, to aid in the diagnosis of interproximal caries (Novaes
child’s age, concluded that there was a lack of evidence- et al. 2010, 2012). Additionally, alternative extraoral radi-
based research and specific recommendations regarding ography techniques should be considered for use in children
this topic. While they suggested occlusal radiography as who are less cooperative, have special needs or a sensitive
the preferred intraoral technique, they also recommended gag reflex. Several authors have emphasized on the difficul-
that clinicians take into account the type of trauma and the ties of taking intraoral radiographs in children (Meyers et al.
extent of the traumatic injury sustained, and supplement 1984; Harrison and Richardson 1989; Pierro et al. 2008;
their examination with extraoral radiographs (e.g., pano- Mahiepala et al. 2015; Elbay et al. 2016). Elbay and co-
ramic radiography, cone beam computed tomography and workers focused on the gag issue in some children and sug-
even multi-slice computed tomography in certain cases) gested laser application on the wrist, which appeared to have
to ensure that a comprehensive diagnosis is achieved. In positive results. The other authors assessed image quality
cases of suspected root fractures, 4 intraoral radiographs, with regard to size of image detector, but their conclusions
with different horizontal and vertical angulations were differed. It is up to the clinician to decide on the appropri-
advised (Kullman and Al Sane 2012; Malmgren et al. 2016; ate technique to accompany each image detector size for
DiAngelis et al. 2017). The latter positions regarding type each individual patient, with the goal of capturing all the
and number of radiographs required are also supported by necessary and relevant information with the least number
the American Academy of Pediatric Dentistry. A 2017 paper of exposures.
recommended that simple appearing dento-alveolar trau-
mas require thorough radiographic evaluation in order not
to overlook condylar fractures, even in trauma cases which
seem to involve only the maxillary incisors. Besides the
13
Existing guidelines in dental radiography of studies upon which the guidelines were based on. Guide-
line development often involves the systematic evidence-
A 2013 publication (Horner 2013) regarding radiographic based appraisal of current scientific literature, as well as
selection criteria clearly stated that the published criteria the input of expert panels, and consensus processes of large
are not rules, but rather guidelines designed to help in clini- groups of stakeholders. There is currently a lack of high-
cal decision-making. Without forgetting the potential risk of quality scientific evidence in the published literature with
ionizing radiation, a practical approach is to look at dental respect to dental radiography, which is similarly reflected in
radiography as a tool to help solve problems. The right tool this present systematic review. This is further reiterated in
at the right time will improve the chances of success and a 2016 editorial in the International Association for Dental
avoids wrong or poor patient care and, hence, unnecessary and Maxillo-Facial Radiology journal (Schulze 2016), where
healthcare costs. researchers were urged to more carefully plan and conduct
Similarly, the AAPD 2017 guidelines on prescribing their studies to produce studies with higher efficacy levels.
dental radiographs for infants, children, adolescents and However, it should be acknowledged that there are often
individuals with special health care needs, as laid out in multiple challenges for researchers intending to conduct
the American Academy of Pediatric Dentistry, Recom- studies in radiography which involve children, for example
mendations: Best Practices states that the guidelines are patient motivation, obtaining parental consent, and obtaining
meant to be used to optimize patient care, minimize radia- ethical approval, thus deterring the conduct of such studies.
tion and allocate health care resources responsibly (AAPD
2017). Unlike the EAPD 2003 guidelines (Espelid et al. Limitations and future directions
2003), the AAPD guidelines do not mention patient age,
but dentition stage. Rather, they consider “type of encoun- The authors acknowledge that all the findings of this sys-
ter” (e.g., new patient, recall patient with clinical caries) tematic review are based on English language publications,
with a patient for their recommendations on whether or which may have influenced our findings. However other
not to take radiographs. With regards to pediatric den- reviews have indicated that this is not the case (Moher et al.
tistry, the ADA/FDA guidelines (AAPD 2017) clearly 2000; Juni et al. 2002).
state the following: “The recommendations in the ADA/ It should also be noted that the overall quality of the
FDA guidelines were developed to serve as an adjunct papers included was not high, with only one study deemed
to the dentist’s professional judgment. The timing of the to be at low risk of bias. The lack of scientific evidence on
initial radiographic examination should not be based intraoral radiography in pediatric dentistry may be attributed
upon the patient’s age, but upon each child’s individual to the following possible reasons:
circumstances. Radiographic screening for the purpose of
detecting disease before clinical examination should not • Setting up randomized controlled clinical trials especially
be performed. Because each patient is unique, the need for in pediatric dental radiography is challenging and may
dental radiographs can be determined only after considera- include ethical issues regarding perceived additional risk
tion of the patient’s medical and dental histories, comple- of unnecessary ionizing radiation exposure and/or suffer
tion of a thorough clinical examination, and assessment from huge numbers of drop-outs as the subjects are pedi-
of the patient’s vulnerability to environmental factors that atric patients and who may have challenging behavior-
affect oral health.” related issues.
In an investigation into the efficacy of FDA guidelines, • Intraoral radiography is deemed a less exciting or cut-
White and co-workers concluded that assiduous use of the ting edge field of study since the advent of cone beam
FDA guidelines for prescribing periapical radiographs (e.g., computed tomography
medium or large caries clinically detected, clinical signs • Intraoral radiography may be less frequently used since
of periodontitis, other than gingivitis, and missing teeth, the invention and availability of high technology equip-
except if there was a clear history of extraction) resulted in ment/techniques, such as laser operated diagnostic equip-
detection of virtually all intraosseous disease that a clini- ment (e.g., DiagnoDent®), or transillumination tech-
cian would consider treating. They added that the risk of niques (e.g., fiber optic transillumination)
undetected disease occurring in the jaws in the absence of • Lower scientific rigor of earlier studies
clinical signs or symptoms is slight (White et al. 1995). • Authors refer to a limited number of papers and/or to
Although that study was not specifically conducted on pedi- each other in journal publications and hand books,
atric patients, it is likely that this is also applicable to the because of the lack of high-quality papers to refer to
pediatric population. • Clinicians and researchers assume that intraoral radiog-
Another important aspect of guidelines which warrant raphy is a previously researched area and/or known ter-
discussion is regarding their quality and the level of evidence
13

ritory and that no new information can be added to the Research involving human participants and/or animals This is a sys-
existing literature. tematic literature review and therefore there was no need for an ethics
committee approval or advise.
Additionally, the lack of standardized outcome sets of Informed consent This systematic literature review does not involve
currently available data has greatly prevented the optimal patients or specific patient information. Therefore, there was no need
use and combination of results required for in depth and for an informed consent.
accurate determination of success and prognostic factors
affecting dental radiography in children. With this, it may
be timely for researchers and members of the EAPD to come References
up with a standardized outcome sets which may guide the
setting up of future research projects in dental radiography, Albandar JM, Abbas DK, Waerhaug M, Gjermo P. Comparison
especially in the pediatric and special needs population. between standardized periapical and bitewing radiographs in
assessing alveolar bone loss. Community Dent Oral Epidemiol.
Moving forward, the authors propose that a large mul-
1985;13(4):222–5.
ticenter study should be executed, perhaps guided by the Albandar JM, Baghdady VS, Ghose LJ. Periodontal disease progres-
EAPD, in which all aspects of intraoral radiography are sion in teenagers with no preventive dental care provisions. J Clin
investigated on a large enough sample of children of differ- Periodontol. 1991;18(5):300–4.
American Academy of Pediatric Dentistry (AAPD), Review Council.
ent ethnicity and socio-economical classes, preferably car-
Prescribing dental radiographs for infants, children, adolescents,
ried out in different European countries. This may, therefore, and individuals with special health care needs. AAPD Ref Man.
support the development of more concrete, evidence-based 2017;39(6):205–7.
radiography guidelines specifically for pediatric dental Anderson M, Stecksen-Blicks C, Stenlund H, Ranggard L, Tsilingaridis
G, Mejare I. Detection of approximal caries in 5-year-old Swedish
patients residing within the European region.
children. Caries Res. 2005;39(2):92–9.
Aps J. Imaging in Pediatric Dental Practice. A guide to equipment,
techniques and clinical considerations. Cham: Springer; 2019.
Conclusions https://doi.org/10.1007/978-3-030-12354-3.
Aps JKM, Lee J. Radiology. In: Nowak A, Casamassimo P, editors. The
handbook of pediatric dentistry. Chicago: American Academy of
Based on the results of this systematic review, due to the Pediatric Dentistry; 2018. p. 111–124.
lack of homogeneity and the overall high risk of bias of the Armstrong C, Johnston C, Burden D, Stevenson M. Localizing ectopic
majority of the included studies, there appears to be insuffi- maxillary canines—horizontal or vertical parallax? Eur J Orthod.
2003;25(6):585–9.
cient scientific evidence upon which the current radiography Cochrane Effective Practice and Organisation of Care (EPOC). https
guidelines can be based on with respect to indications and ://methods.cochrane.org/sites/methods.cochrane.org.bias/files/
contraindications for intraoral radiography in pediatric den- public/uploads/EPOC%20Data%20Collection%20Checklist.pdf.
tistry for caries, periodontal disease, trauma, acute infection, Accessed 29 July 2019.
Cohenca N, Silberman A. Contemporary imaging for the diagnosis and
developmental anomalies and pathology. Furthermore, little treatment of traumatic dental injuries. A review. Dent Traumatol.
evidence was found with regard to improvement of patient 2017;33(5):321–8.
comfort and new techniques in intraoral radiography for Cortes A, Ekstrand KR, Gamboa LF, Gonzales L, Martignon S. Caries
pediatric patients. status in young Colombian children expressed by the ICCMSTM
visual/radiographic combined caries staging system. Acta Odon-
The existing EAPD 2003 and AAPD 2017 guidelines tol Scand. 2017;75(1):12–20. https: //doi.org/10.1080/00016
still seem to be up-to-date and appear to reflect the find- 357.2016.1242154.
ings on caries progression and frequency in this systematic Dean J. McDonald and Avery’s dentistry for the child and adolescent.
review. With regard to dental trauma, the authors consider 10th ed. St Louis: Elsevier; 2016 (ISBN 978-0-323-28745-6).
DiAngelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sig-
the IADT guidelines as the best practice recommendations urdsson A, Andersson L, Bourguignon C, Flores MT, Hicks ML,
to be followed. Lenzi AR, Malmgren B, Moule AJ, Pohl Y, Tsukiboshi M. Guide-
lines for the management of traumatic dental injuries: 1. Fractures
Acknowledgements The authors wish to thank the participants of the and luxations of permanent teeth. Pediatr Dent. 2017;39(6):401–
EAPD meeting in Chania in May 2019, Greece, for their valuable con- 11. https://doi.org/10.1111/j.1600-9657.2011.01103.x.
tributions and suggestions, especially those who participated in the Elbay M, Tak O, Şermet Elbay Ü, Kaya C, Eryilmaz K. The use of
workshop that was held for this systematic review. low-level laser therapy for controlling the gag reflex in children
during intraoral radiography. Lasers Med Sci. 2016;31(2):355–61.
Espelid I, Mejàre I, Weerheijm K, EAPD. EAPD guidelines for use
Compliance with ethical standards of radiographs in children. Eur J Paediatr Dent. 2003;4(1):40–8.
European Commission. Radiation protection 136: European Guide-
Conflict of interest The authors have no potential conflict of interest to lines on Radiation protection in Dental Radiology. Luxembourg:
report with regard to the systematic review they are submitting. Publications Office of the European Union; 2004. https://ec.europ
a.eu/energy/nuclear/radioprotection/publication/doc/136_en.pdf.
Accessed 1 July 2019.
13
Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Kronmiller JE, Nirschl RF, Close JM. Evaluation of bitewing intervals
Decis Making. 1991;11(2):88–94. https://doi.org/10.1177/02729 in children. ASDC J Dent Child. 1986;53(2):110–4.
89X9101100203. Lith A, Lindstrand C, Gröndahl H-G. Caries development in a young
Goodson JM, Haffajee AD, Socransky SS. The relationship between population managed by a restrictive attitude to radiography and
attachment level loss and alveolar bone loss. J Clin Periodontol. operative intervention: 1. A study at the patient level. Dentomaxil-
1984;11(5):348–59. lofac Radiol. 2002;31(4):224–31.
Goodwin TL, Devlin H, Glenny AM, O’Malley L, Horner K. Guide- Llena-Puy C, Forner L. A clinical and radiographic comparison of
lines on the timing and frequency of bitewing radiography: a sys- caries diagnosed in approximal surfaces of posterior teeth in a
tematic review. Br Dent J. 2017;222(7):519–26. low-risk population of 14-year old children. Oral Health Prev
Gowda S, Thomson WM, Foster Page LA, Croucher NA. What dif- Dent. 2005;3(1):47–52.
ference does using bitewing radiographs make to epidemiologi- Machiulskiene V, Nyvad B, Baelum V. Comparison of diagnostic
cal estimates of dental caries prevalence and severity in a young yields of clinical and radiographic caries examinations in children
adolescent population with high caries experience? Caries Res. of different age. Eur J Paediatr Dent. 2004;5(3):157–62.
2009;43(6):436–41. Mahiepala NA, Phan VL, Kieu KD, Koppen JPL, Hussain BH,
Greenstein G. Contemporary interpretation of probing depth assess- Huang B. Influencing factors of paediatric dental anxiety lev-
ments: diagnostic and therapeutic implications. A literature els in an undergraduate dental clinic. Eur J Paediatr Dent.
review. J Periodontol. 1997;68(12):1194–205. 2015;16(2):159–62.
Hamanaka EF, Poi WR, Salzedas LM, Alves LC, Panzarini SR, Sonoda Malmgren B, Andreasen JO, Flores MT, Robertson A, DiAngelis
CK, Martins CM. A method for the geometric standardization of AJ, Andersson L, Cavalleri G, Cohenca N, Day P, Hicks ML,
intraoral radiographs for long-term follow up of replanted teeth; Malmgren O, Moule AJ, Onetto J, Tsukiboshi M. Guidelines for
a case report. Dent Traumatol. 2013;29(2):121–6. the management of traumatic dental injuries: 3. Injuries in the
Haney E, Gansky SA, Lee JS, Johnson E, Maki K, Miller AJ, Huang primary dentition. Pediatr Dent. 2016;38(6):377–85.
JC. Comparative analysis of traditional radiographs and cone- Mann J, Pettigrew J, Beideman R, Green P, Ship I. Investigation of
beam computed tomography volumetric images in the diagno- the relationship between clinically detected loss of attachment
sis and treatment planning of maxillary impacted canines. Am J and radiographic changes in early periodontal disease. J Clin
Orthod Dentofac Orthop. 2010;137(5):590–7. Periodontol. 1985;12:247–53.
Harrison R, Richardson D. Bitewing radiographs of children taken McDonald SP. A method to reduce interproximal overlapping and
with and without a film-holding device. Dentomaxillofac Radiol. improve reproducibility of bitewing radiographs for use in clini-
1989;18(3):97–9. cal trials. Community Dent Oral Epidemiol. 1983;11(5):289–95.
Herman HD, Ashkenazi M. Quality of bitewing radiographs in children Modesti PA, Reboldi G, Cappuccio FP, Agyemang C, Remuzzi G,
in relation to the type of film holder used. Eur Arch Paediatr Dent. Rapi S, Perruolo E, Parati G, ESH Working Group on CV Risk
2013;14(3):141–6. in Low Resource Setting. Panethnic differences in blood pres-
Hietala-Lenkkeri A-M, Tolvanen M, Alananen P, Pienihakkinen K. sure in Europe: a systematic review and meta-analysis. PLoS
The additional information of bitewing radiographs in the detec- ONE. 2016;11(1):e0147601. https: //doi.org/10.1371/journ
tion of established or severe dentinal decay in 14-year olds: a al.pone.0147601.
cross-sectional study in low-caries population. Sci World J. Moher D, Pham B, Klassen TP, Schulz KF, Berlin JA, Jadad AR,
2014;2014:175358. https://doi.org/10.1155/2014/175358. Liberati A. What contributions do languages other than Eng-
Hintze H, Wenzel A. Clinically undetected dental caries assessed by lish make on the results of meta-analyses? J Clin Epidemiol.
bitewing screening in children with little caries experience. Den- 2000;53(9):964–72.
tomaxillofac Radiol. 1994;23(1):19–23. Myers DR, Barenie JT, Bell RA. Requirements for supplemental
Holan G, Yodko E. Radiographic evidence of traumatic injuries to periapical radiographs following No. 0 and No. 2 bite-wings.
primary incisors without accompanying clinical signs. Dent Trau- Pediatr Dent. 1984;6(4):235–7.
matol. 2017;33(2):133–6. National Radiological Protection Board (NRPB). Guidance notes for
Horner K. Radiographic selection criteria: new guidelines, old chal- dental practitioners on the safe use of X-ray equipment. Chilton:
lenges. Br Dent J. 2013;214(4):201–3. https://doi.org/10.1038/ NRPB; 2001.
sj.bdj.2013.158. Newman ME, Friedman S. Extraoral radiographic technique: an
Institute of Health Economics (IHE). Quality appraisal of case series alternative approach. J Endod. 2003;29(6):419–21.
studies checklist. Edmonton (AB): Institute of Health Economics; Novaes TF, Matos R, Raggio DP, Braga MM, Mendes FM. Chil-
2014. https://www.ihe.ca/research-programs/rmd/cssqac/cssqa dren’s discomfort in assessments using different methods for
c-about. Accessed 29 July 2019. approximal caries detection. Braz Oral Res. 2012;26(2):93–9.
ICRP. The 2007 recommendations of the International Commission Novaes TF, Matos R, Raggio DP, Imparato JC, Braga MM, Mendes
on Radiological protection. ICRP Publication 103. Ann ICRP. FM. Influence of the discomfort reported by children on the
2007;37(2–4):1–332. performance of approximal caries detection methods. Caries
Jacobs SG. Radiographic localization of unerupted mandibular anterior Res. 2010;44(5):465–71. https://doi.org/10.1159/000320266.
teeth. Am J Orthod Dentofac Orthop. 2000a;118(4):432–8. Nowak AJ, Casamassimo PS. The handbook of pediatric den-
Jacobs SG. Radiographic localization of unerupted teeth: further find- tistry. 5th Ed. Chicago: American Academy of Pediatric
ings about the vertical tube shift method and other localization Dentistry; 2018. Caries Res. 2010;44(5):465–71. https://doi.
techniques. Am J Orthod Dentofac Orthop. 2000b;118(4):439–47. org/10.1159/000320266.
Juni P, Holenstein F, Sterne J, Bartlett C, Egger M. Direction and Oenning AC, Jacobs R, Pauwels R, Stratis A, Hedesiu M, Salmon
impact of language bias in meta-analyses of controlled trials: B, on behalf of the DIMITRA Research Group, https://www.
empirical study. Int J Epidemiol. 2002;31(1):115–23. dimitra.be. Cone-beam CT in paediatric dentistry: DIMITRA
Kullman L, Al SM. Guidelines for dental radiography immediately project position statement. Pediatr Radiol 2018;48(3):308–16.
after a dento-alveolar trauma, a systematic literature review. Parks ET, Aps JKM. Radiographic techniques. In: Dean JA, Jones
Dent Traumatol. 2012;28(3):193–9. https : //doi.org/10.111 JE, Walker Vinson LA, editors. McDonald and Avery’s dentistry
1/j.1600-9657.2011.01099.x. for the child and adolescent. St Louis: Elsevier; 2016. p. 17–38.
13

Pierro VS, Barcelos R, de Souza IP, Raymundo RJ. Pediatric bite- Higgins JPT. RoB 2: a revised tool for assessing risk of bias in
wing film holder: preschooler’s acceptance and radiographs’ randomised trials. BMJ. 2019;28(366):l4898.
diagnostic quality. Pediatr Dent. 2008;30(4):342–7. The Joanna Briggs Institute Levels of Evidence and Grades of Recom-
Poorterman JHG, Aartman IH, Kieft JA, Kalsbeek H. Value of bite- mendation Working Party*. Supporting Document for the Joanna
wing radiographs in a clinical epidemiological study and their Briggs Institute Levels of Evidence and Grades of Recommenda-
effect on the DMFS index. Caries Res. 2000;34(2):159–63. tion. The Joanna Briggs Institute 2014. https://joannabriggs.org/
Poorterman JH, Vermaire EH, Hoogstraten J. Value of bitewing critical_appraisal_tools. Accessed 29 July 2019.
radiographs for detecting approximal caries in 6-year old chil- Torres MG, Santos Ada S, Neves FS, Arriaga ML, Campos PS,
dren in the Netherlands. Int J Paediatr Dent. 2010;20(5):336–40. Crusoe-Rebello I. Assessment of enamel-dentin caries lesions
Roeters FJ, Verdonschot EH, Bronkhorst EM, Hof MA. Predic- detection using bitewing PSP digital images. J Appl Oral Sci.
tion of the need for bitewing radiography in detecting caries 2011;19(5):462–8.
in the primary dentition. Community Dent Oral Epidemiol. Townsend D. Detection of dentine caries using the oblique lateral
1994;22(6):456–60. radiograph. Int J Paediatr Dent. 2000;10(2):145–9.
Ruiken HM, Truin GJ, König KG. Feasibility of radiographical diag- Tsolakis AI, Kalavritinos M, Bitsanis E, Sanoudos M, Benetou V,
nosis in 8-year -old schoolchildren with low caries activity. Car- Alexiou K, Tsiklakis K. Reliability of different radiographic
ies Res. 1982;16(5):398–403. methods for the localization of displaced maxillary canines. Am
Sacal C, Echeverri EA, Keene H. Retrospective survey of dental J Orthod Dentofac Orthop. 2018;153(2):308–14.
anomalies and pathology detected on maxillary occlusal radio- Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al.
graphs in children between 3 and 5 years of age. Pediatr Dent. The Newcastle-Ottawa Scale (NOS) for assessing the quality if
2001;23(4):347–50. nonrandomized studies in meta-analyses. https://www.ohri.ca/
Schulze RK. Editorial: guidelines for oral and maxillofacial radiol- programs/clinical_epidemiology/oxford.htm. Accessed 29 July
ogy. Dentomaxillofac Radiol. 2016;45(3):20160034. https://doi. 2019.
org/10.1259/dmfr.20160034. Whaites E, Drage N. Essentials of dental radiography and radiology.
Shrout MK, Hildebolt CF, Vannier MW. The effect of alignment errors 5th ed. Edinburgh: Churchill Livingstone Elsevier; 2015.
on bitewing-based bone loss measurements. J Clin Periodontol. White SC, Atchinson KA, Hewlett ER, Flack VF. Efficacy of FDA
1991;18(9):708–12. guidelines for prescribing radiographs to detect dental and intra-
Sköld UM, Klock B, Lindvall AM. Differences in caries record- osseous conditions. Oral Surg Oral Med Oral Pathol Oral Radiol
ing with and without bitewing radiographs. A study on 5-year Endod. 1995;80(1):108–14.
old children in the County of Bohuslän, Sweden. Swed Dent J. White SC, Pharoah MJ. Safety and protection. In: White SC, Pharoah
1997;21(3):69–75. MJ, editors. Oral radiology principles and interpretation. St.
Stecksén-Blicks C, Wahlin YB. Diagnosis of approximal caries in pre- Louis: Elsevier Mosby; 2014. p. 29–40.
school children. Swed Dent J. 1983;7(5):179–84. Wolf DL, Lamster IB. Contemporary concepts in the diagnosis of peri-
Steiner M, Buelhmann S, Menghini G, Imfeld C, Imfeld T. Caries odontal disease. Dent Clin N Am. 2011;55(1):47–61. https://doi.
risk and appropriate intervals between bitewing X-ray exami- org/10.1016/j.cden.2010.08.009.
nations in schoolchildren. Schweiz Monatsschr Zahnmed.
2011;121(1):12–24. Publisher’s Note Springer Nature remains neutral with regard to
Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, jurisdictional claims in published maps and institutional affiliations.
Cates CJ, Cheng HY, Corbett MS, Eldridge SM, Emberson JR,
Hernán MA, Hopewell S, Hróbjartsson A, Junqueira DR, Jüni P,
Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shep-
perd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF,
13

Indicações Radiograficas Odontoped

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Indicações Radiograficas Odontoped

Uploaded by

Copyright:

Available Formats

European Archives of Paediatric Dentistry (2020) 21:429–462

Diagnostic efficacy of and indications for intraoral radiographs

Keywords Systematic review · Intraoral radiography

Electronic supplementary material The online version of this

* J. K. M. Aps School and Oral Health Centre of Western Australia,

Introduction Intraoral image detectors can be analog film (preferably

Fig. 1 PRISMA 2009 flow

Records aer duplicates removed

Records screened Records excluded

Full-text arcles assessed Full-text arcles excluded,

Table 1 Summaries of the papers used for the systematic review

References Country Topic/study design Participants number, gen- Intervention/methodology Conclusions

References Country Topic/study design Participants number, gen- Intervention/methodology Conclusions

bitewing radiographs mal surfaces on the may be prolonged if no progres-

References Country Topic/study design Participants number, gen- Intervention/methodology Conclusions

2nd premolars, 1st and

References Country Topic/study design Participants number, gen- Intervention/methodology Conclusions

References Country Topic/study design Participants number, gen- Intervention/methodology Conclusions

ment, dilaceration, crown long-term dental management of

References Country Topic/study design Participants number, gen- Intervention/methodology Conclusions

References Country Topic/study design Participants number, gen- Intervention/methodology Conclusions

Corah’s Dental Anxiety cally significant

References Country Topic/study design Participants number, gen- Intervention/methodology Conclusions

is placed extraorally, and with

References Country Topic/study design Participants number, gen- Intervention/methodology Conclusions

You might also like

Fig. 1 PRISMA 2009 flow

Records aer duplicates removed

Full-text arcles assessed Full-text arcles excluded,

Table 1 Summaries of the papers used for the systematic review