Part 3: When to Use (and When to Skip) OPGs in Paediatric Dentistry.

Radiographic imaging in children should always balance diagnostic benefit with radiation exposure. This article summarises when to take panoramic radiographs (OPGs) and when to avoid them, anchored to current guidance from the European Academy of Paediatric Dentistry (EAPD) and the American Academy of Pediatric Dentistry (AAPD). We also include a concise section on indications for CBCT. This is the 3rd article in the radiographic series. Please see
Part 1: Evidence for Radiographic Examinations in Paediatric Dentistry — Kids Dental Tips
Part 2: How to Take Radiographs in Young Children – Practical Tips for Success — Kids Dental Tips

All guidelines for children emphasise the importance of reducing exposure (ALARA). There should be a justification for taking a radiograph, other than simple ‘screening’. Particularly OPGs

OPGs

They paint a good overview of the developing dentition. But could you reliably use this to confirm any carious lesions in interproximal areas?

When to take an OPG

·        Suspected mandibular fracture from a trauma. Multiple dental traumas are better imaged with intra-oral radiographs or possibly a CBCT

·        Suspected developmental anomalies: delayed or failed eruption, supernumerary teeth, hypodontia/oligodontia.

·        Pre‑orthodontic assessment where a panoramic view aids appraisal of impactions, tooth development, and overall pattern.

·        Suspected jaw pathology (e.g., cysts, tumours, fibro‑osseous lesions) or extensive periapical change beyond localised views. This is very rare in children!

·        Complex diagnostic scenarios where intraoral imaging is insufficient to answer the clinical question.

When NOT to take an OPG

·        Asymptomatic, low‑risk children with no clinical indications—avoid routine panoramic screening.

·        Very young children (e.g., <5 years) without clear clinical need. They are NOT a replacement for BWs

·        Questions confined to a single tooth or small region—prefer targeted periapical or bitewing radiographs.

·        When required information is adequately provided by lower‑dose intraoral imaging or clinical observation. This is the VAST majority of cases.

A note on extraoral bitewings

Although some panoramic machines are capable of producing extraoral bitewings, these are not a substitute for traditional intraoral bitewings. The radiation dose is comparable to a full panoramic radiograph (i.e., approximately 3 to 11 times greater than a conventional intraoral bitewing). Furthermore, the image quality is insufficient to reliably guide diagnosis and treatment planning

CBCT in paediatric patients — a concise overview

CBCT involves higher radiation than conventional 2D imaging and should not be used for screening. We should take a CBCT only when the diagnostic advantage clearly outweighs risk, after history and clinical exam, and ensure interpretation by clinicians trained in CBCT. Optimise exposure parameters and field‑of‑view to the smallest necessary volume (ALARA).

Common indications include:

·        Localising and assessing impacted teeth and complex eruption patterns (e.g., canines) when 2D imaging is inconclusive.

·        Evaluating pathology (extent and relationship to vital structures) to aid surgical planning.

·        Selected endodontic cases where root morphology, resorption, or periapical disease is unclear on 2D radiographs.

·        Complex orthodontic/orthognathic planning where 3D information changes management.

Take away points

There are not many occasions you will need an OPG in children younger than 8. If we summarise the above. The main reason you would take one is you ‘suspect something is not right’. So lets review some common scenarios

Decay: OPG not recommended. IO films are superior

Necrosis/Periapical pathology: OPG not recommended. IO films are superior

Trauma: Very rarely IO films are superior and CBCT on occasion

Supernumerary teeth: If you have detected this with a maxillary occlusal a CBCT is better value as surgical extraction is commonly required (avoids 2 extra oral images)

Hypomineralisation of first permanent molars:  More common to help guide treatment decision for extraction or preservation even in younger patients (eg 7 yrs of age)

So what do we mean about ‘something doesn’t smell right’. An example a scenario such as a 7 yr old with 3 fully erupted 6’s (first permanent molars) and one not in the mouth. To us, that doesn’t feel right and therefore may justify an OPG.  

A practical framework for everyday decisions

1.      1) Start with history, clinical exam, and caries‑risk assessment.

2.      2) Ask: will an OPG change the diagnosis or plan? If not, avoid it.

3.      3) Prefer the lowest‑dose modality that answers the question (intraoral > OPG > CBCT).

4.      4) If 3D is necessary, restrict CBCT field‑of‑view and exposure; document justification.

We hope this has been helpful! We will do one more post on shielding for taking radiographs in children.

References & Guideline Links

EAPD — Best clinical practice guidance: Use of radiographs in children and adolescents — https://www.eapd.eu/uploads/files/EAPD_Radiographs_2019.pdf

AAPD — Prescribing Dental Radiographs for Infants, Children, Adolescents, and Individuals with Special Health Care Needs — https://www.aapd.org/globalassets/media/policies_guidelines/bp_radiographs.pdf