My clinical exam begins upon my first meeting with your child, either in the waiting room or in the dental chair. Initially, I am gathering information on their emotional acceptance of the office and who I am. How do they respond upon meeting me? Am I able to chat with them making eye contact? I am assessing if your child is drawn further into you, their parent or caretaker, when I approach them or if they engage in conversation with me with ease. I am also visually assessing their external self as a part of my dental exam: their stature and body build, their facial shape, their facial symmetry, their mouth posturing and of course, any visible cavities.
Once we are in the hygiene area where our exams mostly take place, I show your child all the fun parts of the experience designed to put them at ease. Do they see their name featured as our new patient on the board? Do they see my stuffed dinosaur we use for teaching? Do they see their selection of superhero sunglasses and are picking out a fun, new, animated toothbrush? There are even numerous toothpaste and vitamin flavor selections to be had. Which character will “tickle” your teeth today? All this BEFORE they even get into the dental chair. We try to engage them and enthrall them in all the autonomy we have offered them for their best dental experience. It really is all about them getting to touch my dental toys, becoming familiar with what we use and who I am, before laying back in the dental chair.
All this playful interaction helps me to understand how your child responds to the immediate environment, if there are any anticipated dental concerns and how to approach their exam or even how far I think we will be able to go for the visit. Some children will confidently touch what I give them to play with; others will withdraw, searching their parent’s face for reassurance.
You are asking, so how does this tie into my child needing x-rays. Well, the answer is that my recommendation of x-rays is NOT automatic. It’s not even in the beginning of an exam that I am calculating the needs. There is much knowledge to gain about your child in the time before I say “Open wide”. When it comes to x-rays in the pediatric dental world, there exists a concern that dentists are requesting x-rays on young children and they don’t understand their necessity, especially since their teeth will “all fall out”. This blog subject is to address the WHY behind the request. Also, to share just how I am assessing what I need before I request it.
A strong medical history is always indicated, as well as a family dental history. Any medications taken may heighten cavity risks, or even grinding. A history of snoring or apnea is important in determining approach to treatment, if any needs are found. A family history of numerous cavities or variations in the teeth are critical in my clinical exam of your child and a predictor of needed x-rays.
Most parents will automatically question me if I see any cavities as soon as I begin their cleaning. I do not begin my initial inspection for cavities so promptly. So why am I not quick to address the question of cavities as soon as your child opens? First, most children would become alarmed if my first engagement with them centered around the calling out of cavities. Children are just as sensitive as adults about these concerns and I am conscientious of this. Second, I am largely assessing their overall hygiene. By assessing their cavity risks thru learning more about their routine: Is brushing and flossing for the most part done twice daily? Are parents taking active roles in the brushing and flossing? What position are you as parent and child taking to brush? Is there visible moderate to heavy accumulation of plaque and redness of the gum tissues? What is their diet like? Not only should parents learn of a cavity diagnosis, but where to make modifications. I only see you twice a year, which is not very often. Educating my parents on what changes I recommend to better achieve oral home care and improved diet is more important than the initial diagnosis of cavities. Even when treatment is performed, fillings and advanced treatment needs still require good maintenance, so aiding parents in making changes is critical for me in the fight against high cavity risks in kids.
The recommendation of x-rays do follow a general guideline for the purpose of early diagnosis. This may be the diagnosis of cavities, possible injury sustained to the teeth or any variation of normal, an anomaly. The x-rays that follow show situations I most commonly see. Following some clinical exams I have been surprised to see perfectly intact baby teeth that show numerous in-between cavities on the x-rays. For this purpose, I start discussing cavity checking x-rays (bitewings and occlusal films) at approximately 3-4 years of age. I consider them a baseline to see what risks there are or if there are already cavities that could be treated with the most conservative and cosmetic treatment of a white filling. The occlusal films help to show if any cavities exist between the front teeth or any permanent teeth are missing or show extra teeth. Keep in mind that if I CAN clinically see an in-between cavity, advanced treatment needs are more likely, including a stainless steel crown. I prefer to discuss more cosmetic, conservative treatment options and so do parents!
Because of my strong age consideration during an exam or treatment planning, I often ask how old my patient is when I start an exam. I am assessing their development in considering what further investigative information I might need to pursue. I use this assessment to determine symmetry in their dental age as compared to their chronological age. Do they coincide or are they advanced or delayed? Asymmetry is strong predictor of any variation. I am often seen palpating to determine if teeth are felt coming in.
Here are the common x-rays I will request and the approximate ages. Most pediatric dentists encourage bitewing x-rays once yearly and the panoramic x-ray every 3-5 years (with more variation).
- OCCLUSAL X-RAY (cavity checking & for permanent teeth coming in)
- BITEWING X-RAYS (baseline set for cavity detection)
- PANORAMIC X-RAY (angulations of teeth, exfoliation, accounting for teeth)
Most bitewing x-rays are taken on an annual basis. The panoramic x-ray is repeated every 3-5 years and is also used by orthodontists during braces to manage the alignment of tooth roots. We discuss this x-ray again in later teen years to discuss wisdom teeth.
Here are some images of various concerns, I generally am pursuing radiographic interest for.
This first clinical photo shows a variation in the eruption of the permanent tooth where the matching tooth on the patient’s right side remains a baby tooth. Further investigation would be pursued to determine if a permanent tooth is not developing, which is less likely considering it is a central incisor tooth. It is more likely that something is blocking the transition, as seen in the 2nd image (maxillary occlusal x-ray), a supernumerary –extra tooth.
Note: these images are not all serial, case-pertinent, but are used to demonstrate variations seen clinically and the logic behind pursuing x-rays.
Below are other examples of a supernumerary, called a mesiodens. This is an occurrence of an extra tooth positioned at the midline. A wide gap between the two front baby teeth, called a diastema, may prompt me to ask for any family history of extra teeth or request a maxillary occlusal x-ray to not only rule out cavities, but such pathology. The second image shows an inverted supernumerary. An oral surgeon would evaluate and perform such removal.
This panoramic image below demonstrates my concern about symmetry. Clinically, a 7-1/2 year-old should have all the permanent molars coming in. The variation in that the noted lower left molar was not at all clinically detected in the mouth warranted further investigation. An oral surgeon can prompt (luxate) this tooth to come in since it shows nearly fully formed roots.
Again, this image is important starting at approximately age 7-9 years age to determine that all permanent teeth are developing and the angulations of such teeth. In children with numerous, large cavities or extraction needs, we request this panoramic x-ray to determine if the permanent replacement tooth is in development or not—agenesis/congenitally missing. Many conversation points may follow this image considering the findings.
Below are bitewing x-rays of a younger child who otherwise presented with clinically intact teeth. Only shadows were noted in some of the molar regions. The bitewing x-ray taken shows treatable cavity sizes in red versus incipient lesions (starter, non-treatable size) in green.
The red lesions are ones I would recommend fillings, whereas the green arrows indicate areas to monitor. Some variations in this may occur according to age and patient tolerance. Each case varies based on numerous reasons. It is important to note that not every x-ray diagnosis warrants immediate treatment.
The panoramic image below is an example of numerous missing permanent teeth. Clinically, there was very little indication of such a finding besides the initial interest of an upper right permanent molar that was coming in incorrectly, ectopic. The immediate goal is to maintain all baby molars and teeth until a long-term plan is devised with the consultation of an experienced orthodontist and possibly an oral surgeon.
Sometimes the ectopic molar remains caught on the back-side of the baby molar ahead, causing significant damage, as seen in both images. The difference in the molars depicted below is that the top left molar self-corrected it’s path, whereas the top right did not. Either way, significant resorption was caused on the baby teeth, lending to extraction needs. Correcting the forward position and numerous missing teeth requires a multi-disciplinary team.
My last image is a panoramic showing a deflected permanent central and lateral incisor. Several permanent teeth are also congenitally missing (more than are circled). Many of these cases result in the need for an orthodontist and oral surgeon to work closely with us. Remaining with your trusted dentist is essential to best long-term results.
It is my hope that you have been enlightened as to the importance of x-rays prescribed during the examination of your child. There is not enough room for all the variations of anomalies that may be detected in x-rays, but the above examples serve my most common findings. It is my hope that with due diligence during an exam, I am able to convey the importance of knowing the whole patient thru appropriate use of x-rays. Not every visit requires an x-ray, but I guide my families as to my rationale in requesting them. Mi8Numerous factors are assessed for before the recommendation of x-rays.