EDITORIAL

British Orthodontic Society revises guidelines

for clinical radiography
David L Turpin, Editor-in-Chief
Seattle, Wash

D
o you take a routine set of radiographs for all
patients seeking orthodontic treatment? Do you
ever take radiographs of the hand and wrist to
predict the onset of the pubertal growth spurt? Do you
take radiographs to diagnose temporomandibular joint
(TMJ) dysfunction or myofascial pain?
If your answer is “yes” to any of these questions,
you might not want to practice orthodontics in Great
Britain, or in most of Europe for that matter. The
British Orthodontic Society (BOS), in consultation with
dental and maxillofacial radiologists, recently pub-
lished the third edition of “Guidelines for the use of
radiographs in orthodontics.”1 As I reviewed this 24-
page document, I was impressed with the sensible
approach taken, based on published science. I am not
suggesting that these guidelines are absolute rules or
standards of care for orthodontic treatment as currently
practiced in the United States, but I do believe the BOS
points us in a direction that could result in more ideal
care for many patients. As radiologist D. L. Gander2
wrote in his review of the second edition of the
guidelines, “Perhaps the AAO might be inspired to
publish a more meaningful set of radiographic guide-
lines after the exceptional example set by their British
colleagues.”
The first edition of these radiographic guidelines,
written specifically for dentistry, was published by the
BOS in 1994; it was considered radical and controver-
sial in its recommendations for orthodontic radio-
graphs. The guidelines were based on the Ionizing
Radiation (Medical Exposure) Regulations 2000
(IRMER). The second edition, published in 2002, was
an attempt to interpret IRMER in the context of
orthodontic practice.
In reviewing the new edition, I found it helpful to
see the recommendations as a matter of common sense.
Radiographic exposure for any reason is an invasive
procedure, and it is appropriate to establish a sensible
risk/benefit ratio on its use. In line with current practice,
Am J Orthod Dentofacial Orthop 2008;134:597-8
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the BOS advocates that clinicians should note the
following.
● A radiograph should be taken only after a clinical
examination and when it is deemed to provide a
sufficient benefit to the exposed patient.
● All radiographs should be clinically evaluated and
the results recorded.
● There is no known safe level of radiation exposure.
● Generally the benefits of diagnostic radiology out-
weigh the risks.
● The level of risk is justified only when the patient
receives a commensurate health benefit from a min-
imum dose.
To address the first question I posed in this edito-
rial, always decide what radiographs are necessary for
a proper diagnosis after conducting an initial examina-
tion of the patient. For instance, if an 8-year-old
appears to have a good jaw relationship with normally
erupting teeth, a panoramic radiograph might not be
needed. On the other hand, if you try to palpate both
maxillary canines intraorally and suspect that they are
developing ectopically, you would then consider taking
a radiograph. According to the BOS guidelines, the
routine full-mouth periapical views would almost never
be indicated before orthodontic treatment of a child.
Looking again at my second question regarding the
desire to predict a patient’s pubertal growth spurt, it is no
longer considered necessary to take hand-wrist radio-
graphs to assess skeletal maturation. According to several
recent studies, the use of hand-wrist radiographs to predict
the growth spurt is not sufficiently accurate to be of value
in clinical orthodontics,3,4 and Baccetti et al5 reported a
method that uses stages of calcification of the cervical
vertebrae to assess maturation.
Regarding my third question, the Royal College of
Radiologists states that, in relation to TMJ dysfunction,
radiographs “do not add information as the majority of
these temporomandibular joint problems are due to soft
tissue dysfunction rather than bony changes, which
appear late and are often absent in the acute phase.”6
TMJ (myofascial) pain dysfunction syndrome is the
most common clinical diagnosis applied to patients
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with pain in the muscles of mastication, and the bony
components are usually normal, so conventional imag-
ing is of limited value.7 Quoting the BOS guidelines,
“While it has been common practice to take conven-
tional radiographs of the joints in patients with TMJ
pain dysfunction, this can no longer be justified and is
therefore no longer recommended.” But one must
wonder whether there are not medico-legal reasons for
taking the appropriate radiographs when considering
any orthodontic treatment. It might actually be unethi-
cal to take radiographs for medico-legal or administra-
tive reasons if there is no clinical need.8 The Royal
College of Radiologists notes that, “if as a result of
careful clinical examination you decide that an X-ray is
not necessary for the future management of the patient,
your decision is unlikely to be challenged on medico-
legal grounds . . .”6 It is obviously the responsibility of
clinicians to be aware of all relevant current legislation
relating to radiography and the overall optimal care of
their patients.
What about the current increase in the use of cone-
beam computed tomography (CBCT) in orthodontics?
There has been considerable interest in CBCT imaging,
with some even suggesting routine use for all patients.9,10
A preliminary review shows that the current literature
does not yet support the universal use of this technology in
all patients.11 With this in mind and until the literature is
more robust, orthodontists are advised to use CBCT with
caution and always ask themselves whether the clinical
question can be answered by conventional radiography.
Radiographs should be taken only when justified clini-
cally.
To summarize the BOS guidelines as recently
published, there are NO orthodontic indications for the
following.
● Radiographs taken routinely before a clinical exam-
ination.
● A set of routine radiographs for all orthodontic
patients.
American Journal of Orthodontics and Dentofacial Orthopedics
November 2008
● Full-mouth periapical views before treatment.
● A single lateral cephalometric radiograph for the
prediction of facial growth.
● Radiographs of the hand and wrist to predict the
onset of the pubertal growth spurt.
● Routine radiographs to investigate TMJ (myofascial)
pain dysfunction.
● Prospective radiographs for medico-legal reasons.
● Radiographs after treatment purely for professional
examinations or for clinical presentations.
● CBCT taken routinely for all orthodontic patients.
REFERENCES
1. Isaacson KG, Thom AR, Horner K, Whaites E. Orthodontic
radiographs— guidelines for the use of radiographs in clinical
orthodontics. 3rd ed. London: British Orthodontic Society; 2008.
2. Gander DL. Guidelines for the use of radiographs in clinical
orthodontics [book review]. Dentomaxillofac Radiol 2002;31:
211.
3. Houston WJB, Miller JC, Tanner JM. Prediction of the timing of
the adolescent growth spurt from ossification events in hand-
wrist films. Br J Orthod 1979;6:145-52.
4. Flores-Mir C, Nebbe B, Major PW. Use of skeletal maturation
based on hand-wrist radiographic analysis as a predictor of facial
growth: a systematic review. Angle Orthod 2004;74:118-24.
5. Baccetti T, Franchi L, McNamara J. An improved version of the
cervical vertebral maturation (CVM) method for the assessment
of mandibular growth. Angle Orthod 2002;72:316-23
6. Making the best use of clinical radiology services: referral
guidelines. Royal College of Radiologists. 6th ed. 2007.
7. Ruf S. TMD and the daily orthodontic practice. World J Orthod
2005;6(Suppl):210.
8. Atchinson KA, Luke LS, White SC. An algorithm for ordering
pretreatment orthodontic radiographs. Am J Orthod Dentofacial
Orthop 1992;102:29-44.
9. Walker L, Enciso R, Mah J. Three-dimensional localization of
maxillary canines with cone-beam computed tomography. Am J
Orthod Dentofacial Orthop 2006;128:418-25.
10. Kau CH, Richmond S, Palomo JM, Hans MG. Three-dimen-
sional cone beam computerized tomography in orthodontics.
J Orthod 2005;32:282-3.
11. Farman AG, Scarfe WE. Development of imaging selection
criteria and procedures should precede cephalometric assessment
with cone-beam tomography. Am J Orthod Dentofacial Orthop
2006;130:257-65.