Paper
DOSES, BENEFITS, SAFETY, AND RISKS IN ORAL AND MAXILLOFACIAL
DIAGNOSTIC IMAGING
Alan G. Lurie1
Abstract—Diagnostic imaging is essential in dentistry. Doses range
from low to very low, benefits to patients can be immense, and safe
techniques are well known but widely ignored. Doses range from
very low with properly executed intraoral, cephalometric, and
panoramic imaging to higher than multidetector computed to-
mography with cone-beam computed tomography. Benefits are
substantial: imaged dental disease, often obscured from direct vi-
sion by size and anatomy, can pose a mortal threat to the patient.
Additionally, imaging is often central in planning complex dental
procedures. Safe imaging in dental environments is straightfor-
ward; the means for minimizing dose and maximizing diagnostic
efficacy have been widely and inexpensively available for decades.
Such techniques reduce patient dose by some 80% over tradi-
tional techniques but are infrequently used. Digital panoramic
equipment reduces doses markedly. For cone-beam computed to-
mography imaging, selection criteria are critical in defining ap-
propriate fields of view and presets; several publications address
this. It is treacherous to discuss risk in oral and maxillofacial radi-
ology. There are more than 330 million dental x-ray examinations
annually, the majority being intraoral examinations, with steady
increases in panoramic and cone-beam computed tomography.
Radiation carcinogenesis from conventional imaging is unlikely,
while large field-of-view, high-resolution preset cone-beam com-
puted tomography can be comparable in carcinogenesis risk to cra-
niofacial multidetector computed tomography. Uncertainties in risk
estimation from low doses coupled with the huge numbers of dental
images taken annually and the rapid growth of cone-beam com-
puted tomography dictate that safe oral and maxillofacial imaging
is in the interests of patients, staff, and the public. As low as rea-
sonably achievable (ALARA) practices and linear no-threshold
risk modeling continue to be prudent and appropriate.
Health Phys. 116(2):163–169; 2019
Key words: dose assessment; linear hypothesis; medical radiation;
safety standards
1
University of Connecticut School of Dental Medicine, Division of
Oral and Maxillofacial Diagnostic Sciences, Section of Oral and Maxillo-
facial Radiology, 263 Farmington Avenue, Farmington, CT 06030-1605.
The author declares no conflicts of interest.
For correspondence contact the author at the above address, or email
at lurie@uchc.edu.
(Manuscript accepted 14 October 2018)
0017-9078/19/0
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DOI: 10.1097/HP.0000000000001030
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INTRODUCTION
IMAGING IS essential in oral and maxillofacial (omf ) diagno-
sis and treatment planning for almost every patient. Most
dental pathology is unseen in the bone and soft tissues or
moves into these places from visible intraoral structures
where their deeper effects are often hardly evident or not
evident at all.
Radiation doses from omf imaging tend to be very
small, ranging from 3–15 mSv for single intraoral images
and 9–24 mSv for panoramic images (Table 1), with accom-
panying minimal risks to individual patients. However,
doses from large volume cone-beam computed tomography
(CBCT) imaging can approach, and even surpass, doses
from multidetector computed tomography (MDCT) head
and neck imaging. The fact that CBCT delivers multiplanar
views as well as aesthetically attractive three-dimensional
(3D) emulations allows ease of overuse, particularly in
younger, more radiation-sensitive patients.
The vast majority of omf imaging in the United States
is conventional and consists of bitewing and periapical
intraoral projections that give highly detailed images of
the teeth and supporting structures and are the first line of
imaging the most pervasive dental pathologies—dental
caries and periodontal disease. Fig. 1 shows bitewing and
periapical images of patients with normal dentitions and
supporting structures. Panoramic imaging is also widely
used for overall baseline evaluation of new patients, plan-
ning of third-molar extractions, evaluation of developing
mixed dentition, mandibulofacial trauma, and a variety of
other dental issues. Fig. 2 shows a panoramic image of a
patient with normal dentition and supporting structures.
Cephalometric imaging is used primarily by orthodontists
and oral and maxillofacial surgeons to evaluate patients
for malocclusion, monitor craniofacial growth and devel-
opment, and plan for orthodontic treatment and some
orthognathic surgical procedures.
CBCT imaging was introduced to dentistry at the end
of the 20th century, and its use has been steadily increasing
since then. CBCT is a powerful diagnostic and treatment
planning tool, especially in areas of dental implant treatment
163
164 Health Physics February 2019, Volume 116, Number 2
a
Table 1. Effective dose from conventional radiographic examinations
(adapted from White and Pharoah 2014, 2014–2015 NEXT survey, and
multiple other sources).
Examination Effective dose (mSv)

Rectangular collimation
Single posterior bitewing: PSP or F-speed film 3–5
Full-mouth: PSP or CCD 17–35
Round collimation
Single posterior bitewing: D-speed film 11–15
Single posterior bitewing: F-speed film, CCD 6–10
or PSP
Full-mouth: D-speed film 388–1,000
Full-mouth: Digital or F-speed film 85–171
Panoramic with contemporary digital equipment 9–24
Cephalometric with contemporary digital equipment 2–6
a
Full-mouth is 2–4 bitewings plus 14–18 periapicals; PSP: photostimulable
phosphor plate; CCD: charge-coupled device; film speeds are American National
Standards Institute (ANSI).
planning, 3D positioning of impacted teeth, detailing bone
lesions, and defining root canal configurations and possible
root fractures in endodontic therapy (root canal treatment).
Unfortunately, due to its 3D capabilities and beautiful soft-
ware emulations, as well as a widely held perception that
it is a fancy panoramic machine, CBCT has the capacity
to be markedly overused. Effective dose ranges vary greatly,
depending on presets and field of view (FOV), and range
from 19–1,073 mSv (Table 2).
DOSES FROM CONVENTIONAL
DENTOMAXILLOFACIAL IMAGING
Doses from conventional intraoral, panoramic, and
cephalometric imaging are very small but highly variable
depending on collimation and receptor type. The most sig-
nificant factors that control dose in intraoral imaging are
(1) rectangular collimation, (2) receptor speed, (3) thyroid
shielding, and (4) selection criteria.
Representative doses from conventional imaging proce-
dures are shown in Table 1. Clearly, rectangular collimation
Fig. 2. Panoramic image of a normal patient. This variable-thickness,
curved-surface tomogram is widely used in dentistry throughout the
world for a variety of purposes, ranging from intake baseline data to
evaluation of third molars and osseous temporomandibular joint
structures. The image shows all of the teeth and gnathic bones, as
well as parts of midfacial structures such as maxillary sinuses, orbital
floors, and buttress osteology.
and F-speed film or digital detectors have dramatic and
patient-friendly effects on dose reduction from these image
acquisitions with no loss of diagnostic efficacy.
DOSES FROM CBCT
Doses from CBCT acquisitions are extremely variable.
FOV, voxel size, full-swing vs. half-swing exposures, and
machine presets are the major variables that determine the
patient dose. Small FOV is used primarily for endodontic
diagnosis, third-molar evaluation, and single-site dental im-
plants. Large FOV is used primarily for dentomaxillofacial
(DMF) trauma, complex orthognathic surgical treatment
planning, and, at times, orthodontic care. Medium FOV is
used for most other applications and is likely the most
widely used FOV in CBCT imaging.
Presets vary greatly amongst manufacturers. They
carry names such as high resolution, standard, low dose,
super detail, etc. These presets are controlled primarily
by voxel size, with smaller voxel sizes resulting in higher
resolution and higher doses while larger voxel sizes result
in lower resolution and lower doses. High-resolution images
are usually the most esthetically pleasing and as a result are

Fig. 1. Conventional intraoral images of normal patients. Left bitewing (a) shows crowns, coronal roots, interproximal bone, and alveolar crestal
bone for both maxillary and mandibular arches. Right mandibular molar periapical (b) shows crowns, complete roots, and surrounding alveolar
bone for these mandibular posterior teeth.
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 Oral and maxillofacial imaging c A.G. LURIE
Table 2. Effective doses from full-arc CBCT and MDCT DMF imaging
(adapted from White and Pharoah 2014, Table 3-3).
Examination Effective dose range (mSv)
Cone beam CT
Large FOV 68–1,073
Medium FOV 45–860
Small FOV 19–652
Multidetector CT
Head; conventional protocol 860–1,500
Head; low-dose protocol 180–534
seductive, especially when the images are being shown to
patients and parents. However, for most diagnostic needs,
standard settings or low-dose settings generate more than
adequate images for the required diagnostic task due to
the inherently superb spatial resolution of this modality.
High resolution is rarely needed for the vast majority of
DMF situations and should be avoided as such settings
can markedly increase patient dose. Some CBCT machines
now have the option for a 222° or a 180° arc rather than
360° arc. Several studies have shown minimal or no loss
of detail on the resultant images (Tadinada 2017a and b;
Yadav 2015), and absorbed dose is markedly reduced in
almost all head and neck tissues with the half-arc acquisi-
tion.2 Table 2 shows the range of doses from 360° arc
small, medium, and large FOV CBCT acquisitions. The
numbers and manufacturers of such machines are con-
stantly changing, seeming to vary almost monthly. Thus,
these numbers are accurate for the instruments measured
at the time, but they are estimates for what is available today.
BENEFITS OF DMF IMAGING
Diagnosis and treatment planning of most DMF pa-
thology heavily relies on traditional or advanced imaging.
The benefits of dentomaxillofacial imaging are substantial,
especially when appropriate selection criteria and acquisi-
tion techniques are used.
Detection of common dental diseases with traditional
intraoral imaging
Dental caries is the most prevalent infectious disease
worldwide in both children and adults (Fejerskov et al. 2015;
Ozdemir 2013). An infection resulting from the confluence
of tooth, substrate, and cariogenic bacteria if untreated results
in progressive demineralization of the enamel and dentin, inva-
sion and necrosis of pulpal tissues, and spread into the adjacent
alveolar bone. Complications from dental caries, usually in the
form of an abscess at the root apex which may break through
the bone and into the fascial spaces, can lead to extensive
cellulitis and possibly to death (Kim et al. 2013). Dental
2
Private communication with Dr. Sunil Mutalik, University of Con-
necticut School of Dental Medicine, OMF Radiology, Farmington,
CT 06032; July 2018.
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165
caries is largely preventable through diet and home oral hy-
giene. The critical factor in treating existing dental caries is
to find it early. Carious lesions on the interproximal surfaces
where the teeth contact each other are not clinically visible
unless large; radiology is the key diagnostic entity. The bite-
wing radiograph remains the gold standard for early inter-
proximal caries detection (White and Pharoah 2014). This
technique is highly reliable for detecting cavitated lesions
and 70–80% reliable for detecting lesions confined to
enamel (White and Pharoah 2014).
Periodontal disease is a complex, multifactorial
inflammatory/infectious process which affects the gingiva
and alveolar bone that support the teeth. Periodontal disease
has been shown to have associations with the overall health
of the patient (Cullinan et al. 2009). Inflammatory peri-
odontal disease begins in the gingival tissues and spreads
progressively into the tooth-supporting periodontal liga-
ment (PDL) and alveolar bone where it becomes the de-
structive form of periodontal disease called periodontitis
(Newman et al. 2014). This can ultimately lead to irrevers-
ible bone loss and subsequent tooth loss. Moderate peri-
odontal diseases affect a majority of adults greater than
50 y of age, and severe periodontitis effects 5–15% of adults
(NIH 2017). Mild or moderate periodontal disease is treat-
able by conventional, noninvasive methods. Severe peri-
odontitis requires more invasive treatments including efforts
to regenerate supporting bone but will often result in tooth
loss. The progression of periodontal disease into and through
the alveolar bone results in loss of the periodontal ligament
attachment between teeth and bone and loss of bone in a va-
riety of patterns. Thus, as with dental caries, early detection
is critical to maintaining the health of the teeth and their
supporting structures. Marginal periodontal structures and
their relationships to the teeth are best imaged with bitewing
projections in the posterior areas and periapical projections
in the anterior areas. These projections show the details of
the bone structure and its relationships to the teeth.
Apical periodontitis is usually the outcome of dental
caries penetrating into and infecting the pulp. Following
pulp infection, microbial products may leach into the
periapical tissues and cause periapical inflammation (apical
periodontitis). Periapical inflammatory diseases manifest
themselves in a wide variety of clinical and radiographic
features, which include apical osteolysis which may be seen
as a periapical radiolucent area in the radiograph. Transitory
bacteria in periapical tissues may cause periapical infection
that can lead to severe and potentially life-threatening
perioral infections (Hargreaves and Berman 2015). Tradi-
tional imaging has been with periapical radiographs, and
panoramic images show overt periapical lesions; however,
early apical periodontitis with minimal bone demineraliza-
tion will often not be detected with any conventional imag-
ing techniques. The essence of the imaging diagnosis is
166 Health Physics
bone change at and surrounding the root apex and in the
case of maxillary posterior teeth, changes in the cortical
floor and mucoperiosteal lining of the maxillary sinus.
The extent of bone demineralization and sclerosis, the pres-
ence of cortical perforation, and the possible presence of
root fractures are also critical features to demonstrate as they
effect treatment decisions. Additionally, it is important to
develop a map of the root canal system so that all of the pulp
can be removed and all of the canals can be obturated if end-
odontic treatment is planned. Traditional periapical imaging
tends to show the canal system of single-rooted teeth rela-
tively well; however, multirooted teeth such as molars and
some premolars can have extra canals and require more
advanced imaging techniques to properly demonstrate
the canal system. CBCT has become the primary imaging
modality for situations that demand detailed imaging of
roots, canal morphology, extension of periapical lesions,
and identifying possible causes of prior endodontic treat-
ment failure (AAE/AAOMR 2015).
Imaging other DMF diseases and conditions
There is a vast array of odontogenic cysts, neoplasms,
dental abnormalities, extensive infections, temporomandib-
ular joint disorders, and salivary gland disorders as well as
trauma to the teeth, supporting structures, and facial bones.
Extensive DMF diseases which involve salivary glands and
fascial spaces are the domain of MDCT and magnetic
resonance imaging (MRI) and will not be discussed here.
Diagnostic evaluation of growth and development abnormal-
ities is complex and may involve panoramic, cephalometric,
CBCT, MDCT, and MRI imaging of the craniofacial and
gnathic structures. Treatments are often multimodality,
involving teams of health care providers from a variety
of domains.
Bone lesions of the gnathic structures and temporo-
mandibular joint (TMJ) disorders present, more often than
not, with neurologic signs and/or swelling. Imaging such le-
sions usually begins with a panoramic image. This may be
sufficient, but it is often followed by advanced imaging,
with CBCT being superior for bone lesions due to its su-
perior spatial resolution. Where soft tissue involvement is
suspected, MDCT and/or MRI become the imaging of
choice. CBCT is especially effective in defining the ex-
tent of intraosseous lesions and bone involvement by
extraosseous lesions. CBCT is the imaging of choice for
defining the extent and severity of medication-related
osteonecrosis of the jaws (MRONJ) in patients receiving
anti-bone-resorptive pharmacotherapy as part of treatment
for malignant lesions. Osteoarthritic changes are frequently
encountered in the TMJ. Evaluating TMJ area pain for
osseous pathology is the realm of CBCT, which gives
tremendous detail of the osseous fine structures, enabling
identification of the presence and severity of these changes.
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February 2019, Volume 116, Number 2
Treatment planning implant and extensive
surgical procedures
Replacement of missing teeth with dental implants is a
widespread and rapidly growing procedure: over 5.5 million
implants were placed by US dentists in 2006, growth is some
500,000 per year, and it is estimated that the US market for
implants and their restorations will reach $6.5 billion by
2018 (American Academy of Implant Dentistry 2017).
CBCT imaging demonstrates bone quality, quantity, and lo-
cation of critical structures in the projected implant sites
with great spatial resolution; as such, it is the gold standard
for implant treatment planning (Tyndall et al. 2012). Fig. 3
shows a multiplanar display and maximum-intensity 3D
rendering (MIP) from a large-volume CBCT acquisition,
taken to plan mandibular implant placements in a young
man with Ehlers-Danlos syndrome.
Oral and maxillofacial surgery (omfs) can be complex
and require precise advanced imaging, at times to specific
protocols, for orthognathic surgical procedures. Most omf
surgeons will image their patients initially with panoramic
acquisitions. Advanced imaging—MDCT, MRI, or CBCT—
is dictated by historical, clinical, and panoramic findings.
Typical imaging needs of omfs include impacted third mo-
lars, bone lesions, infections, TMJ disorders, dental implant
treatment planning, and growth and development disorders.
CBCT is especially useful in defining the relationships
between third-molar roots and the inferior alveolar canal;
showing bone quality, dimensions, and locations of critical
structures for implant treatment planning; defining extent
of bone lesions and extensive infections and their effects
on adjacent structures; and planning complex surgical pro-
cedures for patients with craniofacial deformities. Imaging
needs tend to be more extensive in this domain than for
other DMF diagnosis and treatment planning. Fig. 4 shows
a multiplanar display from a small-volume CBCT acquisi-
tion, taken to evaluate the relationship between an impacted
third molar and the inferior alveolar canal.
RISKS FROM DMF IMAGING
Risks from DMF imaging are generally confined to
radiation carcinogenesis, as absorbed doses are far too
small to have tissue effects or transmissible genetic effects
be considered. In general, the risks from DMF imaging are
extremely small. Doses from conventional intraoral imag-
ing, panoramic imaging, and cephalometric imaging are
almost always in the low microgray values (Table 1). Thus,
estimation of risk is based on studies of populations ex-
posed to larger doses with extrapolations to very low doses.
Layered on these extrapolations are the unknown and con-
flicting potential mechanistic modifiers of other carcino-
genic and tumor promotor agents, sensitive and resistant
human subpopulations, adaptive response, and bystander
 Oral and maxillofacial imaging c A.G. LURIE 167

Fig. 3. Large volume CBCT of a young adult patient with Ehlers-Danlos syndrome who is being treatment planned for implant-supported full
dentures. Multiplanar views and a coronal 3-D, maximal-intensity projection are shown with the two projected implant fixtures superimposed
on the images where possible. Such imaging allows optimal implant size and position to be determined prospectively and minimizes risk to
nearby critical structures. It is the gold standard for imaging of planned dental implants.

effect. Thus, such risk calculations at doses less than
100 mSv are fraught with uncertainties (NCRP 2012;
UNSCEAR 2015), and assigning risk values to individuals
undergoing DMF imaging is equivocal and controversial.
The linear no-threshold hypothesis for cancer induction at
doses below 100 mGy has been a prudent and practical
guideline for decades, and continues to be so. The 296 mil-
lion intraoral examinations (CRCPD in press) and over
30 million panoramic images (CRCPD 2003) exposed an-
nually in the United States require careful consideration of
risks to the population. CBCT is the fastest growing imag-
ing modality in the United States with over 7,000 units in
use and more than 5 million examinations conducted annu-
ally in 2014–15 (CRCPD in press). Given that CBCT doses
can equal or exceed those of MDCT for comparable exami-
nations, risk to the individual, while small, is considerably

Fig. 4. Small volume CBCT of a patient with an impacted mandibular left third molar (wisdom tooth). This display shows axial, corrected sagittal,
and multiple corrected coronal sections through the area of interest. The relationship of the crown and roots of this tooth to the inferior alveolar canal
are clearly defined and allow the surgeon to employ a surgical technique that minimizes risk of damage to the inferior alveolar nerve.
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168 Health Physics February 2019, Volume 116, Number 2

greater than with conventional DMF imaging and needs to
be considered even more carefully.
SAFETY IN DMF IMAGING
The safest practices of oral and maxillofacial imaging
are easily and inexpensively accomplished using appropri-
ate selection criteria, appropriate image acquisition presets
on CBCT equipment, rectangular collimation for intraoral
imaging, contemporary digital receptors or E/F speed film,
and thyroid shielding for children and young adults.
Intraoral imaging is by far the most widely used mo-
dality in dentistry, with between 1 and 2 billion exposures
annually in the United States. Such imaging delivers very
low doses, in the 3–20 mGy range with correct techniques
and equipment; however, the lower doses arise from using
ideal techniques. Rectangular collimation, which restricts
the size of the incident x-ray beam to the size of the image
receptor, lowers the dose per image by 50–80% when
compared with round collimation and less-than-the-fastest
receptors (White and Pharoah 2014). Several rectangular
collimators are available commercially which adapt to
existing intraoral imaging equipment, are relatively inex-
pensive, and often are integrated with image receptor-
holder beam-guiding devices (Fig. 5). The upper lobes
of the thyroid gland may be exposed during intraoral im-
aging, especially of the maxillary structures as the beam
is directed inferiorly; this is especially true with children
whose thyroid glands are higher in the neck than in adults.
Thus, thyroid shielding is an important safety factor in
pediatric and adolescent intraoral imaging.
Safe and effective CBCT imaging does not require
purchasing anything extra for the instrument. It is a matter
of applying proper selection criteria and using factors and
presets which minimize the FOV and the technical expo-
sure factors. FOVs should be the smallest that still pro-
vide coverage of the anatomic sites that are needed to
correctly diagnose and plan treatment for the patient
problem. Most equipment comes with a variety of preset
factors, carrying names such as high resolution, high detail,
regular detail, low exposure, etc. High-resolution acquisi-
tions deliver substantially larger radiation doses to the pa-
tient and often do not provide information beyond that
from lower-dose protocols that are necessary to properly di-
agnose the patient problem. Table 2 shows the effective
dose ranges for CBCT images based on FOV; the low doses
(19–68 mSv) are from low-mid dose protocols and presets,
and the high doses (652–21,073 mSv) are from high-
resolution and high-detail protocols and presets (White
and Pharoah 2014). Significantly, high-detail/resolution
CBCT protocols can deliver doses higher than MDCT pro-
tocols, regardless of FOV. Additionally, some CBCT equip-
ment now has the option for a 180° rotational arc rather
than a 360° arc. The 180° acquisition has been shown to
have diagnostic efficacy comparable to that of a 360° acqui-
sition for a variety of dental applications (Tadinada et al.
2017a and b; Yadav 2015) and has the promise of dramatic
dose reduction (Mutalik and Lurie, private communica-
tion).2 Finally, thoughtful use of appropriate selection
criteria for acquiring CBCT images and for the acquisition
parameters is the most significant of all safety steps, as
with all x-radiation-based imaging.

Fig. 5. Rectangular collimation of intraoral image acquisitions. Originally invented by Dr. Fred M. Medwedeff and Dr. William H. Knox in July
1961, this type of instrument restricts the size of the entry beam to slightly greater than the size of the intraoral rectangular image receptors used
in dentistry. This instrument is shown in the upper left of this figure, the “Precision Instrument.” Two representative contemporary rectangular
collimators, the XDR ALARA (XDR Imaging Through Science, Los Angeles, California, US) and RINN Universal (Dentsply RINN, Rinn Corp.,
Elgin, Illinois, US), are shown on the right. The lower left image shows the substantial reduction in incident radiation when the rectangular collimator
is used vs. the round collimator.
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 Oral and maxillofacial imaging c A.G. LURIE
SUMMARY AND CONCLUSION
Conventional dentomaxillofacial imaging, consisting
of intraoral and panoramic images, is by far the most fre-
quently used imaging in dentistry. The benefits to the
patient in terms of revealing a wide variety of hidden
and potentially serious pathology, as well as extensive
and often complex treatment planning, are substantial.
Modern technology, namely digital imaging and intraoral
rectangular collimation, has dramatically reduced the pa-
tient dose per image during the past three decades. The at-
tendant risk from such imaging is now so small that it is
almost negligible for individual exposures. Given the fact
that well over a billion intraoral images are acquired annually
in the United States, there is certainly a risk consideration,
albeit small, to the population. Use of widely available
and inexpensive techniques reduces this risk by well over
50%, a significant population dose reduction in view of
the numbers of such images acquired nationally every year.
CBCT imaging is a rapidly growing imaging modality
in dentistry, with powerful diagnostic applications in end-
odontic treatment, impacted tooth assessment, and implant
and orthognathic surgical treatment planning. As with MDCT,
there are many acquisition settings and presets that profoundly
affect the patient exposure. Thus, the risk to the individual pa-
tient can be comparable to or greater than that from MDCT
imaging of the same area of interest. The smallest field of
view and the largest voxel size compatible with the diagnos-
tic task must always be used to maximize safety and diag-
nostic efficacy of the examination.
Finally, ALARA considerations and uncertainties in
carcinogenesis risk estimation at low and very low doses
make it prudent and practical to continue using the linear
no-threshold model for risk of carcinogenesis at doses
below 100 mSv. The best way to minimize radiation dose
and risk and maximize benefit to the patient is to have
strong, valid reasons to use x-ray-based imaging; i.e., use
established, strong selection criteria when ordering and
acquiring diagnostic images in dentistry and acquire these
images with the best techniques possible to yield the re-
quired diagnostic information.
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