Based on the 2026 ADA and AAOMR Patient Selection Criteria for Dental Radiography and CBCT
Periodontal disease is one of the most prevalent conditions seen in dental practice, and radiographic imaging plays a central role in its diagnosis and management. Box 2 of the updated 2026 ADA and AAOMR Patient Selection Guidelines includes six specific recommendations for imaging in the context of periodontal disease.
Here’s a breakdown of each guideline and what it means in practice.
2.2.1 — Imaging Frequency Is Patient-Specific
Guideline: The frequency of radiographic examination for the patient with periodontal disease is dependent on clinical findings and treatment response.
What this means: There’s no universal schedule for periodontal radiographs. Imaging should be ordered on a case-by-case basis, driven by what you’re seeing clinically and how the patient is responding to treatment. Let the clinical picture guide your decision.
2.2.2 — Document Radiographically Before You Treat
Guideline: Radiographic documentation of the disease sites before periodontal treatment is important for diagnosis, baseline assessment, and treatment planning.
What this means: Before initiating any periodontal treatment, establish a radiographic baseline. This documentation serves multiple purposes: it confirms the diagnosis, gives you a starting point to measure against over time, and informs your treatment plan. It carries clinical value if questions arise later about disease progression.
2.2.3 — Bone Loss on a Radiograph Does Not Mean Active Disease
Guideline: Radiographic evidence of the presence and severity of bone loss does not indicate active disease. Radiographs only show bone levels relative to the teeth and cannot confirm whether disease is currently active or stable.
What this means: This is an important clinical distinction that’s easy to overlook. A radiograph showing bone loss tells you what has happened historically — not what’s happening right now. You cannot determine disease activity from an image alone. That requires clinical data: probing depths, bleeding on probing, suppuration, and patient history. Radiographs are one piece of the diagnostic puzzle, not the whole picture.
2.2.4 — Full-Mouth Series With Vertical Bitewings for Baseline Evaluation
Guideline: For evaluating periodontal structures after a comprehensive clinical examination, a full-mouth radiographic series — including vertical bitewing radiographs as necessary — is recommended to provide a baseline for treatment. In cases of advanced bone loss, CBCT may be considered, though vertical bitewing radiographs with digital sensors can be technically challenging due to sensor size.
What this means: When conducting a thorough periodontal assessment, a complete-mouth series (CMS) with vertical bitewings is the standard. This provides the most complete picture of bone levels throughout the dentition and forms the foundation for treatment planning. One practical note worth acknowledging: vertical bitewings with rigid digital sensors can be tricky due to size constraints and patient anatomy — this is a recognized limitation and not a reason to skip them.
2.2.5 — CBCT Is Generally Not Warranted for Periodontal Management
Guideline: Management of periodontal disease, in general, does not warrant use of CBCT, although CBCT may be indicated in complex cases — including those requiring surgical intervention and treatment planning.
What this means: For the vast majority of periodontal cases, conventional radiography is sufficient. CBCT should not be a default or routine part of periodontal assessment. Where it may be genuinely justified is in complex or surgical scenarios — for example, evaluating furcation involvement in detail, planning osseous surgery, or assessing specific anatomical features that conventional imaging cannot fully capture.
2.2.6 — Vertical Bitewings for Active or Historical Perio Patients
Guideline: For patients with a history of, or active, periodontal disease, vertical bitewing radiographs are recommended to assess bone levels in the permanent dentition — though this can be technically challenging with digital sensors and may not always be possible.
What this means: Vertical bitewings — not horizontal — are the preferred choice for monitoring periodontal patients because they give you the most accurate view of alveolar bone levels. Digital sensors can make this technically difficult in some patients, particularly those with limited opening, tori, or small arches. Work with your team to achieve the best possible projection, and document your clinical rationale when the ideal image isn’t achievable.
The Bottom Line
The periodontal imaging guidelines are grounded in clinical reasoning: individualize your approach, document before you treat, and choose the right radiograph for the job. Vertical bitewings over horizontal. Conventional radiography over CBCT in most cases. And always remember that radiographic findings tell part of the story — not the whole one. Bone on a film is a record of the past; your clinical exam tells you where the patient is today.
This post is part of a continuing series on the 2026 ADA and AAOMR guidelines.
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