Part 2: How to Take Radiographs in Young Children – Practical Tips for Success

In Part 1, we explored the clinical reasoning and evidence behind radiographic examinations in paediatric dentistry. Now in Part 2, we shift focus to what is often the greater challenge: how to actually take radiographs on young children in a way that is efficient, gentle, and effective.

1. Equipment

Many clinics have phosphor plates, which are easier to use than sensors. We usually use size 0 for bitewings (BWs) up until around 7 and then we start going for size 1. Size 2 is used for maxillary occlusals.

For those of you with sensors, I feel your pain. I use them when I work in regional Queensland (Hervey Bay) and I only have a size 2! You just need to generally vary the technique (see below). But you can still definitely get x-rays. You can buy soft holders to use with sensors.. We get ours from:

2. Build Trust First – The Most Important Step

When it comes to young children, building trust is always the most important step — whether you're taking a radiograph, giving an injection, or just doing a check-up. Make sure they know they are in control however, do emphasize the importance of what you are doing and explain why. Start by getting to their level — literally and emotionally. Use simple, reassuring language:

“We are going to take some pictures of your teeth. First one is to see if you have any boogers in your nose (size 2 for max occlusal – eg for a trauma or anterior decay. Not every child requires this). Then we will take photos of your back teeth. Once we have taken the photos, we will go to the toy machine to get you a prize”.

Let them hold the sensor/plate. Show them how it works on a puppet or on your own hand.  Show them the ‘camera’. At this point I also show them the tab on the plate, or the sensor holder/crocodile for the sensor. I use my fingers to demonstrate. My language is:

“See this little piece of paper, I need you to close your teeth together and hold it for 3 seconds. If you stop halfway (using fingers to show) we can’t finish. If you bite it and then let it go too quickly, we can’t finish. So I need you to listen to me and follow my instructions hold it with your teeth and I will count 3 seconds.”

Take it slow. This is the longest part of the process. The more you rush this step, or worse, skip it, the less likely you are to get the radiograph at all. That’s because once a child feels overwhelmed or unsure, it’s much harder to regain their cooperation.

3. Use Your Finger First

Now they have felt the film/sensor and know why, show them where it will go. Use your finger to rub on the palate and in the lingual sulcus. This does a few things

1.     If they gag here – get salt

2.     Shows them where it goes and also that it will feel ‘weird’

3.     If they panic a bit here – go back to step 1!

You’re laying the foundation for success by showing, not just telling.

4. Tips for Gaggers: Salt Works Wonders

For children with a sensitive gag reflex (probably 1 in 3), we use some salt. This is such an important component of being able to take x-rays. So if they gag during the exam or when you are using your finger – don’t stuff around, just get the salt. How I talk to them about it:

“I can see that when I used my finger it felt like it was going to far down the back. Do you like chips? I have some chippy salt here that will help with that strange feeling.”

Then I simply get a pinch of salt and drop it on the tongue. You don’t need heaps! If they do not like the taste etc, just tell them: “…that when you are finished taking the photos you will get them some water.” But they don’t get the water until they are finished!

5. Modify the Technique When Needed

You don’t have to stick strictly to textbook techniques — especially for very young or anxious patients. Adapt your approach to suit their age and temperament:

  • You do not need PAs for anterior primary teeth (yes for permanent). So use a size 2 maxillary occlusal. It is a lot easier. Start with this one first,

Parent assisting with a Maxillary Occlusal - size 2 taped to a paddlepop stick.

  • I prefer tabs, as I can see more. A holder (crocodile) takes up about 1/3 of a size 0 film, so I start with tabs. If they does not work, I then move to a holder.

  • If they cannot do a BW, you can rotate the film vertically, this is so it does not go too far down the ‘back’

  • ·Finally, if they cannot do the BW at all, I will more to quadrant ‘PA’s. These do not need to be perfect, I am just aiming to catch the canine to the mesial surface of the second primary molar. See photo below for how to set it up. I also get the parents to hold it.

Modified ‘PA’ technique as they child was unable to do BWs.

6. I have overlap and it was just hard. So I will move on with treatment now OR take an OPG and go off that…

No! If you cannot get intra-oral x-rays and/or they are non-diagnostic, you need to vary your technique as above and try again if you want to do treatment. There are very few occasions we are unable to get x-rays on children. Even if we are going to do a general anaesthetic, we will still get x-rays prior, so we have an indication of what we need to do.

 

As mentioned in Part 1 it is medico-legally indefensible to do invasive treatment on children without x-rays. They are also a great indicator of compliance. If they cannot put up with the mild discomfort from say a BW, how are they going to tolerate local anaesthetic, an extraction, rubber dam, a filling etc… So if you are unable to take intra-oral x-rays and they have issues present, this is probably the time for a referral to a paediatric dentist.

 

OPGs and the BW function on OPGs are not diagnostic enough to go off for treatment. We do not use OPGs to diagnose decay, they are used as an ‘overview’ of the developing jaws. So this is not a fall back.

Diagnostic for decay?

Conclusion

Radiographs can be one of the trickiest tasks in paediatric dentistry, but they’re also one of the most valuable. With a child-centred approach, thoughtful preparation, and a few creative tricks, you’ll be surprised how often you succeed.

In part 3 we will look at indications for OPGs and when they are recommended. We hope this has helped. We do spend a bit of time on our courses running through how to take radiographs with ‘how-to’ videos. Our courses can be found: https://www.kidsdentaltips.com/products

Tim Keys