Why do my kids need x-rays?

Dr. Karen Benitez, founder & designer, board certified pediatric dentist at Chevy Chase Pediatric Dentistry will be writing a series of guest posts related to adolescent dentistry and questions she frequently receives from patients that may be of interest to you. If you have a topic you’d like to see her feature, leave it in the comments.

The first post was one that many parents wonder about; whether it is necessary for your child to visit a pediatric dentist and how the experience will differ from just taking them to the dentist you see. The second post below addresses the topic of why x-rays are important for your child to have.

I have chosen to follow the first blog subject; Why a pediatric dentist with the subject of x-rays since they are closely related. The primary goal of our specialty is prevention and yes, x-rays aid in this goal. Any dental exam is composed of two parts: a clinical and a radiographic exam. The same would apply for your child’s exam. When it comes to recommending x-rays, it is mostly a matter of when, under what circumstance and at what interval. So how do I begin an exam and what does it all include, upon leading to the discussion of x-rays?

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, 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? I show them our stuffed dinosaur we use for teaching. They explore the selection of superhero sunglasses and pick 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, become 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.

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. 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 medical history is always discussed, 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 through 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? 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.

Here are the common x-rays pediatric dentists request and the approximate ages:

Ages 3-4: OCCLUSAL X-RAY (cavity checking & for permanent teeth coming in) and BITEWING X-RAYS (baseline set for cavity detection). I consider these 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.
Ages 7-9: 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.

I’ve included a few x-rays that show situations I most commonly see with some explanation to each.

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.

Sometimes the ectopic molar remains caught on the back-side of the baby molar ahead, causing significant damage, as seen in both images below. 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.

It is my hope that you have been enlightened as to the importance of x-rays prescribed during the examination of your child and perhaps even answered any questions you may of had regarding your own child’s x-rays. 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.

Once again, we are pleased that you have taken an interest in our blog topics. Keep a look-out for our next topic: Why an Orthodontist for My 8 Year Old? in two weeks.

We at Chevy Chase Pediatric Dentistry welcome your child to come in and have a look. It would be our pleasure to have you!

You can also find us as Bethesda Magazine’s Face of Pediatric Dentistry, view our Top Docs video and read our stellar reviews on Yelp, Google and ZocDoc. Follow us on Facebook to learn more about what Chevy Chase Pediatric Dentistry is all about…Focusing on your kids.

-Dr. Karen Benitez, DDS

Location: 8401 Connecticut Ave #650 Chevy Chase, MD. 20815
Phone: 301-272-1246