Intra-oral Radiographs For The

Pediatric
Dental Patient
Introduction
Principles
Clinical situations for which radiographs may be indicated
Guidelines for Prescribing Radiographs
Paralleling Technique & Bisecting-angle technique
Management Techniques
Positioning the Radiograph
Desensitization Techniques
Procuring Posterior Radiographs
Projections
Probable Technical Errors & Radiation hygiene measures
Size of Intra-oral films
Introduction
Plays a vital role in the diagnosis and treatment planning of
both children and adults.
Plays a significant role in the assessment of growth and
development.
At the simplest level, help in the detection of dental caries
and at the most complex level, in the diagnosis of cysts,
tumors or any other major craniofacial disorders.
Three types of intra-oral projections;
Intra-oral Periapical Radiographs (IOPA)
Useful in the evaluation of teeth and their associated
structures.

Bitewing Radiographs
 Useful to detect the incipient proximal caries.
 The coronal portion of both the maxillary and mandibular
teeth of the required area can be visualized on the film.
Occlusal Radiographs
 Used in the evaluation of entire maxillary arch or mandibular
arch.
Principles
 The dentist should follow guidelines as recommended by
representatives from the American Dental Association.

X-rays should not be taken routinely.  Children’s teeth

should be first examined by a dentist or hygienist before
deciding on the number and types of radiographs. 

The number and types of radiographs necessary is

dependent on the age of the child, the presence of decay
that can be detected visually, the child’s and family’s history
of dental treatment, and spaces between teeth.
Use only those views needed to complete the diagnostic
task.
If possible, obtain any prior radiographs (from another
office if available).
The patient should be protected with a lead apron and
thyroid collar to reduce body exposure to radiation.
Use the proper time and temperature for processing as
recommended by manufacturers.
The highest speed and largest size film the child can
tolerate should be used to reduce the number of X rays
needed to obtain the necessary information.
Clinical situations for which radiographs may be indicated :
 Positive Historical Findings
a. Previous periodontal or endodontic treatment
b. History of pain or trauma
c. Familial history of dental anomalies
d. Postoperative evaluation of healing
e. Remineralization monitoring
f. Presence of implants or evaluation for implant
placement
 
 Positive Clinical Signs/Symptoms
a. Clinical evidence of periodontal disease
b. Large or deep restorations
c. Deep carious lesions
d. Swelling
e. Evidence of dental/facial trauma
f. Mobility of teeth
g. Sinus tract (“fistula”)
h. Clinically suspected sinus pathology
i. Growth abnormalities
j. Oral involvement in known or suspected systemic disease
k. Positive neurologic findings in the head and neck
l. Evidence of foreign objects
m. Pain and/or dysfunction of the temporomandibular joint
n. Facial asymmetry
o. Abutment teeth for fixed or removable partial
prosthesis
p. Unexplained bleeding
q. Unexplained sensitivity of teeth
r. Unusual eruption, spacing or migration of teeth
s. Unusual tooth morphology, calcification or color
t. Unexplained absence of teeth
u. Clinical erosion
Guidelines for Prescribing Radiographs in the Pediatric
Patient
1.Child Patient before eruption of first permanent tooth
 New Patient : 2 bitewing projections of the posterior
region
 Recall Patient : Bitewing examination at 6 months interval
 Clinically no caries or no susceptibility to caries :
Bitewing radiograph at 12 to 24 months interval.
 Deep Caries : Selected IOPA radiograph
2. Child patient after eruption of the first permanent
tooth
 New patient : Selected IOPA radiographs, posterior
bitewings, occlusal views and OPG
 Recall patient : Bitewing radiograph and selected IOPA
radiographs, if indicated.
 Clinically no caries : Posterior bitewing radiographs
 Deep caries : Selected IOPA radiograph
3. Adolescent (permanent dentition and before eruption of
third molars)
 New patient : Posterior bitewing radiographs and selected
IOPA radiograph.
 Recall patient : Posterior bitewing radiograph at 6 to 12
month intervals.
 Clinically no caries : Posterior bitewing radiographs
 Deep caries : A selected IOPA radiograph and or bitewing
radiograph.
Paralleling Technique
The essence of the paralleling technique (also called the
right angle or long-cone technique) is that the x-ray film is
supported parallel to the long axis of the teeth and the
central ray of the x-ray beam is directed at right angles to
the teeth and film.
This orientation of the film, teeth and central ray minimizes
geometric distortion.
To reduce geometric distortion further, the x-ray source
should be located relatively distant from the teeth.
The use of source-to-object distance reduces the apparent
size of the focal spot. These factor result in images with
less magnification and increased definition.
Bisecting-Angle Technique
It is based on simple geometric theorem, Cieszynski’s rule of
isometry, which states that two equal angles when they
share one complete side and have two equal angles.
Position of the film as close as possible to the lingual surface
of teeth, resting on the palate or in the floor of the mouth.
The plane of the film and the long axis of the teeth form an
angle with its apex at the point where the film is in the
contact with the teeth.
An imaginary line bisects this angle and direct the central
ray of the beam at right angles to this bisector.
When this conditions are satisfied, the images cast on the
film theoretically are the same length as the projected
Management Techniques
One of the most challenging tasks for the clinical staff is to
obtain diagnostic quality radiographs on a young patient
(under three years of age) without psychological trauma.
The first step is to desensitize the child to the dental
experience
By explaining to the child what you plan to do in words easily
comprehended by the child. 
Using a "tell, show, do" technique. 
The child is positioned to gain maximum cooperation. 

 In the child less than three years of age it may be

necessary for the child to sit in the parent’s lap while the
radiograph is exposed.

 Such positioning reduces the child’s anxiety, provides

additional emotional security for the child, increases
cooperation and also enables the parent to adequately
restrain child and avoid any unexpected sudden movements.

 Obtaining the least difficult radiograph first (such as an

anterior occlusal) desensitizes the child to the procedure.
 Correct settings are made on the apparatus and the x-ray
head is properly positioned before placing the film in the
child’s mouth. 
A positioning device such as a Snap-A-Ray can be used to aid
the parent in positioning and securing the film. 
Adequately protect the parent and child with lead aprons to
reduce radiation exposure.
If the child is uncooperative, then additional restraint by a
second adult may be necessary.
A second adult stabilizes the child’s head with one hand
while the other hand positions the x-ray holder in the
patient’s mouth. 
 If a second adult is not available, it may be necessary to
place the child in a mechanical restraining device (Papoose
Board) to adequately restrain the child. 

 If the child is still too uncooperative, it may be necessary to

manage the child pharmacologically with inhalation, oral, or
parental sedatives.
Older children may also be uncooperative for a variety of
reasons. 
These can range from the jaw being too small to adequately
accommodate the radiograph, fear of swallowing the
radiograph, fear of the procedure itself, or the patient
exhibits a severe gag reflex. 
For the child with the small mouth, use the smallest size film
available (size 0 film).  Roll the film (do not place sharp
bends) to allow the film to accommodate the shape of the
jaw and not impinge on the soft tissues.
 Use of the Snap-A-Ray as a bitewing tab will reduce
impingement on the soft tissue but unfortunately will reduce
the amount of detectable tooth structure on the radiograph.
Positioning the Radiograph
Positioning the radiograph vertically in the mouth for both
periapical and bitewing radiographs reduces the distal
extension of the radiograph and may result in greater
tolerance by patients, especially those with a mild gag
reflex. 
The vertical bitewing radiograph provides greater detail of
the periapical area.
 The Snap-A-Ray is also useful for those patients that have a
fear of swallowing the radiograph. 
 By biting on the large positioning device and watching in a
mirror they are assured they will not swallow the radiograph.
A self sticking sponge tab may also reduce impingement of
the radiograph on the intraoral soft tissue.
For patients frightened of the procedure itself,
desensitization techniques may be necessary to gain the
patient cooperation.
Desensitization Techniques
Desensitization is defined as gradually exposing the child to
new stimuli or experiences of increasing intensity. 
An example of this is introducing the patient to x-rays by
initially taking an anterior radiograph which is easier to
tolerate than a posterior radiograph.
Another example of desensitization is the “Lollipop
Radiograph Technique.”  The child is given a lollipop to lick
(preferably sugarless). 
After a few licks, the lollipop is taken from the child and a
radiograph is attached to the lollipop using an orthodontic
rubber band.  The lollipop with the attached film is returned
to the child, who is told to lick the lollipop again. 
After a few licks, the child is told to hold the lollipop in his
mouth while we take a tooth picture.  The exposure is made.
Procuring Posterior Radiographs
Procuring posterior radiographs can be made more pleasant
by associating it with a pleasurable taste….bubble gum. 
Before placing the radiograph in the patient’s mouth apply
bubble gum flavored toothpaste to the film.  The child will
be more accepting of the radiograph.

 Some patients, young and old, have an exaggerated gag

reflex.  The etiology of an exaggerated gag reflex had been
attributed to psychological and physical factors. 
The easiest is through diversion and positive suggestion. 
The operator suggests to the patient the gag reflex can be
reduced by concentrating on something other than the
procedure.
The patient’s palate can be sprayed with a topical anesthetic
to reduce the sensation of the radiograph on the palate and
tongue.
An alternative is the use of nitrous oxide analgesia. 
Another alternative is to place the radiograph in such a
manner to not come in contact with the palate or tongue. 
This is accomplished by either extraoral placement of the
film or placing the film between the cheek and the tooth and
exposing the film from the opposite jaw. 
The film side of the packet (the solid color side) is facing
the buccal surface of the tooth.
The x-ray head is placed at the opposing side, and the cone
is positioned under the angle of the ramus on the opposite
side. 
As the x-ray beam is traveling a longer distance to the film
than in the typical positioning, it is necessary to double the
exposure time.
It is imperative that after mounting radiographs are
reversed. 
Incorrect mounting and labeling of the reverse radiograph
can result in misdiagnosis and treatment of the wrong tooth.
Projections
 For projection of the maxillary teeth, the head of the
patient should be kept upright.
 The vertical angulations used are :
 Anterior teeth +50
 Premolars +30
 Molars +25
 The film is positioned on the palatal aspect of teeth by using
film holders.
 For projection of mandibular teeth, the following vertical
angulations are used :
 Anterior teeth -20
 Premolars -10
 First and Second Molars -5
 Third Molars 0
 For the lower anterior projection, the film is kept on the
floor of the mouth, on the lingual side of the teeth.
 For the posterior projection, the film is kept on the lingual
sulcus.
 The central X-ray beam is directed in such a way that it hits
the film almost perpendicularly to avoid cone-cut appearance
image formation.
Primary dentition (3 to 6 years)
Maxillary anterior occlusal projection
 Place no. 2 film with its long axis perpendicular to the
sagittal plane and the pebbled surface towards maxillary
teeth.
 Direct the central ray at a vertical angulation of +60 degrees
through the tip of the nose towards the center of the film
Mandibular anterior occlusal projection
 Seat the child with the head tipped back so that the occlusal
plane is about 25 degrees above the plane of the floor.
 Place a no. 2 film with the long axis perpendicular to the
sagital plane and the pebbled surface towards the
mandibular teeth.
 Orient the central ray at -30 degrees vertical angulation and
Bitewing projection
 Use no. 0 film with paper loop holder.
 Place the film in the child’s mouth as in the adult premolar
bitewing projection.
 The image field should include the distal half of the canine
and the deciduous molars.
 Positive vertical angulation of +5 to +10 degrees.
Decidious maxillary molar periapical projection
 Use no. 0 film
 Position the film in the midline of the palate with anterior
border extending to the maxillary primary canine.
 The image field should include the distal half of the primary
canine and both primary molars.
Deciduous mandibular molar projection
 Projection a no. 0 film
 The exposed radiograph should show the distal half of the
mandibular primary canine and the primary molar teeth.
Mixed dentition(7 to 12 years)
Maxillary anterior periapical projection
 Center a no.1 film on the embrasure between the central
incisors in the mouth behind the maxillary central and lateral
incisors.
 Center the film on the midline.
Mandibular anterior periapcal projection
 Position no.1 film behind the mandibular central and lateral
incisors.
Canine periapical projection
 Position no. 1 film behind each of the canines.
Decidious and permanent molar periapical projection
 Position no.1 or no. 2 film with anterior edge behind the
canine
Posterior bitewing projection
 Use no.1 or no. 2 films as previously described
 Expose four bitewings projections when the second
permanent molars have erupted
Probable Technical Errors
Improper placements of films.
Cone cutting
Incorrect horizontal angulations
Incorrect vertical angulations
Over exposure due to defective devices.
A high exposure of the patient to radiation because of
repetition of taking X-rays due to an uncooperative child.
Radiation hygiene measures
Proper registration and maintenance of radiographic units
Training of personnel who are associated with radiography
Dosage monitoring
Radiation protection of the child patients by using lead apron
with thyroid collar.
Use of long lead-lined cylinder and cone positioning devices
Use of electronically controlled exposure timer
Use of high speed films
Use of automatic processing machines that give good
consistent result
Employing proper technique to avoid the chances of
repeating exposure.
Size of Intraoral films
Size 0 (22x35mm) used for bitewing and periapical
radiographs of small children
Size 1 (24x40mm) used for radiographing anterior teeth in
adults.
Size 2 (31x41mm) used for anterior occlusal radiograph,
periapical radiograph and bitewing survey in mixed and
permanent dentition.
Occlusal films have a size of 57x76 mm and are taken for
viewing entire maxillary and mandibular arches.
Conclusion
Through the use of proper and innovative radiographic
techniques the dentist can obtain diagnostic radiographs
with minimum harm and maximum comfort for the pediatric
patient.
References
Textbook Of Pedodontics (Mc Donald & Avery)
Textbook Of Pedodontics (Shobha Tandon)
Comprehensive Pediatric Dentistry (Nikhil Marwah)
Oral Radiology (White & Pharoah)
Web Pages-Radiographic Techniques for the Pediatric
Patients (Steven Schwartz) dentalcare.com