Skip to main content

Best clinical practice guidance for prescribing dental radiographs in children and adolescents: an EAPD policy document



The European Academy of Paediatric Dentistry (EAPD) proposes this best clinical practice guidance to help practitioners decide when and how to prescribe dental radiographs in children and adolescents.


Four expert working groups conducted each a systematic review of the literature. The main subjects were radiation protection, intraoral dental radiography (bitewing and periapical radiographs), panoramic radiography (PR) and cone-beam computed tomography (CBCT). In addition, three workshops were held during the corresponding EAPD Interim Seminar in Chania (Crete, Greece) in 2019. On the basis of the identified evidence, all invited experts presented their findings and during the workshops aspects of clinical relevance were discussed.


Several clinical-based recommendations and statements were agreed upon.


There is no or low-grade evidence about the efficacy of dental radiographic examinations in young populations. The given recommendations and rationales should be understood as best clinical practice guidance. It is essential to respect the radiological principles of an individualized and patient-specific justification. When a dental radiograph is required, its application needs to be optimized, aiming at limiting the patient’s exposure to ionising radiation according to the ALADAIP principle (As Low As Diagnostically Achievable being Indication-oriented and Patient-specific).

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3


  • American Academy of Pediatric Dentistry (AAPD) Prescribing dental radiographs for infants, children, adolescents, and individuals with special health care needs. 2017. Accessed Sep 2, 2019.

  • Association Dental Association (ADA). Dental radiographic examinations: recommendations for patient selection and limiting radiation exposure. Columbia: American Dental Association; 2012.

    Google Scholar 

  • Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, DiAngelis AJ, Kenny DJ, Sigurdsson A, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Tsukiboshi M, International Association of Dental Traumatology. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries. 2. Avulsion of permanent teeth. Dent Traumatol. 2012;28:88–96.

    Article  Google Scholar 

  • Aps J, Lim LZ, Tong JH, Kalia B, Chou AM: Diagnostic efficacy of and indications for intraoral radiographs in paediatric dentistry: a systematic review. Eur Arch Paediatr Dent (in review).

  • Baelum V. What is an appropriate caries diagnosis? Acta Odontol Scand. 2010;68:65–79.

    Article  Google Scholar 

  • Brasil DM, Pauwels R, Coucke W, Haiter-Neto F, Jacobs R. Image quality optimization of narrow detector dental computed tomography for paediatric patients. Dentomaxillofac Radiol. 2019.

    Article  PubMed  PubMed Central  Google Scholar 

  • Canadian Dental Association (CDA). Control of x-radiation in dentistry. J Can Dent Assoc. 1999;65:610–1.

    Google Scholar 

  • DiAngelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A, Andersson L, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Pohl Y, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol. 2012;28:2–12.

    Article  Google Scholar 

  • Espelid I, Mejàre I, Weerheijm K. EAPD: EAPD guidelines for use of radiographs in children. Eur J Paediatr Dent. 2003;4:40–8.

    PubMed  Google Scholar 

  • European Commission (EC). Radiation protection 136. European guidelines on radiation protection in dental radiology. Luxembourg: office for official publications of the European Communities. 2004. Accessed Sep 2, 2019.

  • European Commission (EC). Radiation protection 172. Evidence based guidelines on cone beam CT for dental and maxillofacial radiology. Office for official publications of the European Communities: Luxembourg. 2012.

  • European Commission (EC). Radiation protection. No 180. Medical radiation exposure of the European population. Luxembourg: Publications Office of the European Union. 2015. Accessed Sep 2, 2019.

  • Council of the European Union. Basic safety standards for protection against the dangers arising from exposure to ionising radiation, and repealing Directives 89/618/Euratom, 90/641/Euratom, 96/29/Euratom, 97/43/Euratom and 2003/122/Euratom. 2013. Accessed Sep 2, 2019.

  • Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decis Making. 1991;11:88–94.

    Article  Google Scholar 

  • Goodwin TL, Devlin H, Glenny AM, O’Malley L, Horner K. Guidelines on the timing and frequency of bitewing radiography: a systematic review. Br Dent J. 2017;222:519–26.

    Article  Google Scholar 

  • Hayashi T, Arai Y, Chikui T, Hayashi-Sakai S, Honda K, Indo H, Kawai T, Kobayashi K, Murakami S, Nagasawa M, Naitoh M, Nakayama E, Nikkuni Y, Nishiyama H, Shoji N, Suenaga S, Tanaka R. A committee on clinical practice guidelines, Japanese society for oral and maxillofacial radiology. Clinical guidelines for dental cone-beam computed tomography. Oral Radiol. 2018;34:89–104.

    Article  Google Scholar 

  • Hidalgo Rivas JA, Horner K, Thiruvenkatachari B, Davies J, Theodorakou C. Development of a low-dose protocol for cone beam CT examinations of the anterior maxilla in children. Br J Radiol. 2015;88:20150559.

    Article  Google Scholar 

  • Horner K, Barry S, Dave M, Dixon C, Lap PC, Littlewood A, Srinivasan V, Sengupta A. Diagnostic efficacy of cone beam computed tomography in paediatric dentistry: a systematic review. Eur Arch Paediatr Dent (in review).

  • Horner K, Eaton KA. Faculty of general dental practice (FGDP) of the UK. Selection Criteria for dental Radiography. An updated 3rd edition (2018).

  • Horner K, Islam M, Flygare L, Tsiklakis K, Whaites E. Basic principles for use of dental cone beam computed tomography: consensus guidelines of the European academy of dental and maxillofacial radiology. Dentomaxillofacial Radiol. 2009;38:187–95.

    Article  Google Scholar 

  • Jacobs R, Salmon B, Codari M, Hassan B, Bornstein MM. Cone beam computed tomography in implant dentistry: recommendations for clinical use. BMC Oral Health. 2018;18:88.

    Article  Google Scholar 

  • Kühnisch J, Rahman A, Rahman A, Heinrich-Weltzien R. Röntgendiagnostik in der Kinder- und Jugendzahnmedizin. Dtsch Zanhärztl Z. 2018;74:438–46.

    Google Scholar 

  • Kühnisch J, Ekstrand K, Pretty I, Twetman S, van Loveren C, Gizani S, Spyridonos M. Best Clinical Practice Guidance for management of early caries lesions in children and young adults. An EAPD policy document. Eur Arch Paediatr Dent. 2016;17:3–12.

    Article  Google Scholar 

  • Le Heron J. Guidelines on patient dose to promote the optimisation of protection for diagnostic medical exposures: documents of the NRPB. Radiat Prot News Notes. 1999;10(1):17–8.

    Google Scholar 

  • Ludlow JB, Timothy R, Walker C, Hunter R, Benavides E, Samuelson DB, et al. Effective dose of dental CBCT-a meta analysis of published data and additional data for nine CBCT units. Dentomaxillofac Radiol. 2015;44(1):20140197.

    Article  Google Scholar 

  • Malmgren B, Andreasen JO, Flores MT, Robertson A, DiAngelis AJ, Andersson L, Cavalleri G, Cohenca N, Day P, Hicks ML, Malmgren O, Moule AJ, Onetto J, Tsukiboshi M, International Association of Dental Traumatology. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3 Injuries in the primary dentition. Dent Traumatol. 2012;28:174–82.

    Article  Google Scholar 

  • Minister of Public Works and Government Services (Canada). Radiation protection in dentistry recommended safety procedures for the use of dental X-ray equipment (1999).

  • National Radiological Protection Board (NRPB). Guidance notes for dental practitioners on the safe use of X-ray equipment. 2001: Department of Health; 2001.

    Google Scholar 

  • Noffke C, Nzima N, Farman A. Guidelines for the safe use of dental and maxillofacial CBCT: a review with recommendations for South Africa. S Afr Dent J. 2011;66:262–6.

    Google Scholar 

  • Oenning AC, Jacobs R, Pauwels R, Stratis A, Hedesiu M, Salmon B, DIMITRA Research group. Cone-beam CT in paediatric dentistry: DIMITRA project position statement. Pediatr Radiol. 2018;48:308–16.

    Article  Google Scholar 

  • Pauwels R, Horner K, Vassileva J, Rehani MM. Thyroid shielding in cone beam computed tomography: recommendations towards appropriate use. Dentomaxillofacial Radiol. 2019:20190014.

  • Pauwels R, Jacobs R, Bogaerts R, Bosmans H, Panmekiate S. Determination of size-specific exposure settings in dental cone-beam CT. Eur Radiol. 2017;27:279–85.

    Article  Google Scholar 

  • Pretty IA, Ekstrand KR. Detection and monitoring of early caries lesions: a review. Eur Arch Paediatr Dent. 2016;17:13–25.

    Article  Google Scholar 

  • Tsiklakis K, Mitsea A, Tsichlaki A, Pandis N. A systematic review of relative indications and contra-indications for prescribing panoramic radiographs in dental paediatric patients. Eur Arch Paediatr Dent. 2019.

  • Valentin J (ed.): The 2007 recommendations of the international commission on radiological protection. ICRP publication 103. Ann ICRP. 2007. Accessed Sep 2, 2019.

  • Van Acker JWG, Rajasekharan S, Aps JKM, Pauwels NS, Cauwels RGEC: Outcomes of different radioprotective precautions in children undergoing dental radiography, a systematic review of the literature. Eur J Paediatr Dent (in review).

  • White SC, Scarfe WC, Schulze RK, Lurie AG, Douglass JM, Farman AG, Law CS, Levin MD, Sauer RA, Valachovic RW, Zeller GG, Goske MJ. The image gently in dentistry campaign: promotion of responsible use of maxillofacial radiology in dentistry for children. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;118:257–61.

    Article  Google Scholar 

  • White SC, Heslop EW, Hollender LG, Mosier KM, Ruprecht A, Shrout MK, American Academy of Oral and Maxillofacial Radiology, ad hoc Committee on Parameters of Care. Parameters of radiologic care: an official report of the American academy of oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91:498–511.

    Article  Google Scholar 

Download references


The European Academy of Paediatric Dentistry wants to thank the Hellenic Society of Paediatric Dentistry for organizing the 11th EAPD Interim Seminar and Workshop in Chania, Greece May 3rd─4th, 2019 on “Conventional and modern imaging tools in Paediatric Dentistry: from intraoral radiographs to 3D technologies”. Special thanks to the chair of the local organizing committee, Dr. Nick Lygidakis and the president of the Hellenic Society of Paediatric Dentistry, Dr. Sofia Gkeki, as well as all involved in arrangements, for organizing a successful and memorable seminar. Furthermore, the EAPD wants to express gratitude to all participants of the workshops from the member countries for their valuable contributions.

Workshop I “Intraoral radiography” A. De Grauwe (Belgium), N. Kokkinos (Cyprus), C. Onisiforou (Cyprus), J. Vasakova (Czech Republic), P. Hess (Denmark), D. Emmanouil (Greece), D. Kavoura (Greece), A. Ní Chaollaí (Ireland), M. Ashkenazi (Israel), C. Silvia (Italy), A. Jacobsen (Norway), M. Tanase (Romania), T. Tomaževič (Slovenia), M. Ivanovic (Serbia), N. Sabel (Sweden), S. Selvi Kuvvetli (Turkey), T. Kandiah (UK), O. Hrynyshyn (Ukraine), U. Schiffer (Germany), L.Z. Lim (Singapore, expert), J. Tong (Singapore, expert), J. Aps (Australia, expert), M. Sobczak (Poland, moderator), S. Rajasekharan (Belgium, moderator).

Workshop 2 “Panoramic radiography” R. Billen (Belgium), H. Juric (Croatia), P. Kokkinos (Cyprus), V. Merglova (Czech Republic), E. Esclasson (France), K. Arapostathis (Greece), Z. Yfanti (Greece), A. Shmueli (Israel), A. Majorana (Italy), I.J. Brusevold (Norway), C. Bica (Romania), T. Leban (Slovenia), Z. Mandinic (Serbia), E. Esclasson (Sweden), L. Vasquez (Switzerland), D. Özge Yilmaz (Turkey), P. Ashley (United Kingdom), T. Lysak (Ukraine), K. Tsiklakis (Greece, expert), J. Kühnisch (Germany, moderator, chair of CAC), V. Anttonen (Finland, moderator).

Workshop 3 “Cone-beam CT” S. Theys (Belgium), J. Kaiferova (Czech Republic), M.-C. Maniére (France), K. Bücher (Germany), A. Mitsea (Greece), D. Finucane (Ireland), E. Davidovich (Israel), S. Friedlander-Barenboim (Israel), G. Fabrizio Ferrazzano (Italy), K. van Nes (Netherlands), A. J. Schmalfuss (Norway), C. Antohi (Romania), L. Hočevar (Slovenia), B. Wondimu (Sweden), D. Dagassan (Switzerland), D. Tabakcilar (Turkey), J. Monteiro (United Kingdom), M. Dolhova (Ukraine), K. Horner (United Kingdom, expert), M. Duggal (Singapore, moderator), E. Stratigaki (Switzerland, moderator).

Author information

Authors and Affiliations


Corresponding author

Correspondence to J. Kühnisch.

Ethics declarations

Conflict of interest

All authors declare that they have no conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kühnisch, J., Anttonen, V., Duggal, M.S. et al. Best clinical practice guidance for prescribing dental radiographs in children and adolescents: an EAPD policy document. Eur Arch Paediatr Dent 21, 375–386 (2020).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: