Dental X Rays, FMX, and the Danger of the Corporate Template

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Categories: Imaging, CBCT, and Radiography;
Posted: July 5, 2026
By Howard Farran, DDS, MBA

Dental X Rays, FMX, and the Danger of the Corporate Template

A new patient walks in with a healthy smile, no symptoms, low caries risk, and recent records. Another arrives with bleeding, deep pockets, heavy calculus, failing restorations, mobility, and a mouth that has been patched together for 30 years. Giving both patients the identical radiographic series is not standardization. It is avoidance of clinical judgment.

That is the central message in the American Dental Association’s January 2026 recommendations on dental imaging. The ADA does not recommend a full mouth series for every patient. It also does not support a blanket policy that no patient receives one. Radiographs should be selected after reviewing the history, clinical examination, prior images, risk profile, and the diagnostic question that must be answered.

This is ALARA in its proper form. As low as reasonably achievable does not mean as little as possible. It means enough imaging to make a defensible diagnosis, plan appropriate treatment, and avoid exposing the patient to images that will not change care.

The debate has surfaced in dental offices where new patient imaging has become a fixed corporate template. A common protocol is four bitewings, four anterior periapicals, and a panoramic image. That may be perfectly adequate for some patients. It may also be inadequate for a patient with active periodontal disease, generalized bone loss, rampant caries, recurrent decay, multiple failing restorations, endodontic concerns, or a complex restorative plan.

A panoramic image is useful, but it is not a substitute for a full mouth series. It gives a broad survey of the jaws, teeth, eruption patterns, third molars, gross pathology, and many implant planning questions. It does not provide the same detail for crestal bone, interproximal decay, periapical changes, calculus, restoration margins, or localized periodontal defects. When the clinical examination raises questions that a pano and limited films cannot answer, the answer is not to hope the disease is absent. The answer is to take the images needed to see it.

The financial pressure is real. Many insurers will not reimburse a panoramic image and FMX on the same day. Some offices write off one of the services. Others steer patients toward whatever their plan covers. In a DSO, speed and delegation can add another layer. Bitewings and a pano can be captured quickly by an assistant, while a carefully positioned FMX takes more time, training, and patient cooperation.

Those are operational realities. They are not diagnostic criteria.

The phrase that should make every clinician cautious is, “The board blessed this.” State boards regulate safety, delegation, and minimum standards. They do not relieve the treating dentist of responsibility for diagnosing disease. If a patient later alleges missed pathology, the relevant question will not be whether the office followed a corporate imaging template. It will be whether the dentist had enough information to make a reasonable diagnosis, and whether the record documents why additional imaging was unnecessary, recommended, or declined.

The best imaging policy is neither automatic FMX nor automatic refusal. It is a simple doctor-directed pathway. Start with the exam, history, existing films, and risk assessment. Use bitewings, periapicals, panoramic imaging, FMX, or CBCT when each adds information that changes diagnosis or treatment. Document the rationale. If a patient declines recommended images because of cost or insurance, document that too.

This approach also improves patient communication. Instead of saying, “This is our standard series,” explain what the image will answer. “I can see some bone loss and bleeding around several teeth. I need a few more detailed images to determine whether this is early disease or whether we are missing deeper defects.” Patients are more likely to accept imaging when they understand the question behind it.

The radiograph is not the diagnosis. It is part of the evidence. But a dentist cannot diagnose what the office policy refuses to let the dentist see.

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Dental X Rays, FMX, and the Danger of the Corporate Template


Primary source

American Dental Association, New ADA Recommendations Confirm Dental Imaging Most Effectively Used in Moderation

https://adanews.ada.org/ada-news/2026/january/new-ada-recommendations-confirm-dental-imaging-most-effectively-used-in-moderation/

Clinical guideline

American Dental Association and American Academy of Oral and Maxillofacial Radiology, Dental Radiographic Examinations, Recommendations for Patient Selection

https://pubmed.ncbi.nlm.nih.gov/41500761/

Practice reference

American Dental Association, Radiographic Imaging

https://www.ada.org/resources/practice/practice-management/radiographic-imaging/

Patient education

American Dental Association, X Rays and Radiographs

https://www.ada.org/resources/ada-library/oral-health-topics/x-rays-radiographs/

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