Team-Based Adaptations for Panoramic Radiography in Children with Disabilities: An Experience ReportABSTRACT
Objective: To provide a descriptive evaluation of innovative, low-cost, and context-driven adaptations implemented by a multidisciplinary dental team in a Brazilian public university. Rather than isolated improvisations, the strategies were systematized to ensure their reproducibility and effectiveness in clinical environments with limited infrastructure.
Material and Methods: Adaptations included customized height adjustments using household objects, caregiver-assisted positioning, and tailored communication approaches based on the patient’s developmental profile. Data were obtained from clinical observations during radiographic procedures involving children and adolescents with disabilities, with a focus on image quality, patient cooperation, and the need for repeat exposures.
Results: Most procedures yielded diagnostically good images with minimal repetition. The collaborative team-based approach, combined with inclusive and rights-based adaptations, proved effective in overcoming structural and communicative barriers to panoramic radiography.
Conclusion: These findings highlight the potential to incorporate replicable, scalable practices into dental care for individuals with disabilities and reinforce the need to formalize these strategies in standard protocols to advance equity in oral health diagnostics.
Keywords:
Neurodevelopmental Disorders; Radiography; Panoramic; Dental Care for Persons with Disabilities; Children with Disabilities.
Introduction
Panoramic radiography is a cornerstone diagnostic tool in dentistry, offering broad anatomical coverage with relatively low radiation exposure and a favorable risk profile [1-3]. However, acquiring diagnostically acceptable panoramic images can be challenging in children and adolescents with disabilities, particularly those with skeletal deformities and neurodevelopmental disorders, due to difficulties in positioning, communication, and sustained immobility during exposure [4-7].
Positioning deviations, movements, and inadequate instructions (e.g., tongue positioning) may generate artifacts and distortions that compromise diagnostic value and may lead to repeat exposures [3,5,6]. Therefore, strategies that integrate adaptive communication, caregiver engagement, and practical positioning accommodations are crucial for reducing barriers and enhancing access to diagnostic imaging [8-11]. In this context, effective interprofessional collaboration and structured communication among imaging staff and clinical teams have been highlighted as key elements to ensure safety and effectiveness in pediatric imaging pathways [12].
Although the literature has explored panoramic errors and quality issues in pediatric and special care populations [4,6,7], there remains limited practical guidance on low-cost, reproducible, context-driven adaptations that can be implemented in routine services [13-15]. Thus, this experience report presents systematized strategies for performing panoramic radiographs in children and adolescents with skeletal deformities and neurodevelopmental disorders, emphasizing feasibility, reproducibility, and team-based care.
Material and Methods
This manuscript is structured as an experience report, derived from observations systematically recorded during the data collection phase of three independent research projects coordinated by one of the authors. The purpose of this report is not to present or reanalyze the samples, outcomes, or qualitative data of these studies, but rather to describe and systematize practical strategies adopted in routine clinical care to facilitate panoramic radiographic examinations in children and adolescents with disabilities.
The multidisciplinary team involved in this experience report comprised a graduate student, two professors - one specialist in care for patients with disabilities and an oral and maxillofacial radiologist - and experienced radiology technicians. All team members were trained to deliver patient-centered care, implementing individualized positioning strategies, adaptive communication techniques, and customized radiographic protocols. These measures aimed to minimize patient discomfort and optimize diagnostic outcomes. The systematic integration of radiographic expertise with specialized patient care enabled comprehensive diagnostic assessment, even in complex clinical contexts involving physical, developmental, or cognitive impairments.
The experiences described were documented contemporaneously during routine clinical activities, through systematic observation by the involved professionals and registration of radiographic images obtained as part of standard patient care within a university-based dental service. The images and photographs included in this report were obtained during the execution of panoramic radiographs on participants enrolled in studies conducted by Carneiro et al. [16], Prado et al. [17], and Silva et al. [18] at the Faculty of Dentistry, Universidade Federal de Minas Gerais, located in the Southeast Region of Brazil. All imaging sessions were performed using a Kodak 9000C 3D® apparatus (Kodak Dental Systems, Carestream Health Inc., Rochester, NY, USA).
This experience report is derived from clinical activities conducted during three previously approved research projects. Ethical approval for patient recruitment, data collection, and image acquisition was obtained for each study and is detailed in its respective publication. As this manuscript does not present identifiable patient data or new analyses of research datasets, no additional ethical approval was required. All procedures were conducted in accordance with ethical standards and institutional and national guidelines.
The objective was to obtain the highest possible quality panoramic radiographs under the given conditions. To this end, the team adhered to standard radiographic guidelines, including: (A) Proper positioning the patient within the focal trough to ensure accurate anatomical representation; (B) Removal of accessories that could interfere with X-rays penetration; (C) Ensuring the patient remained still during image acquisition; and (D) Correct alignment of the incisal edges on bite block, with adjustment of the chin and occlusal plane to minimize image distortions [19]. Image quality was assessed qualitatively by the clinical team based on routine diagnostic usability, including the absence of significant motion artifacts, adequate visualization of anatomical landmarks, and clinical interpretability for dental diagnosis, without the use of formal scoring systems.
To accommodate physical differences and skeletal deformities, a variety of materials - including books, boxes, and tables - were used to adjust the patient’s height relative to the equipment. These adaptations were intentionally selected for their low cost, accessibility, and reproducibility, enabling their application in public service settings. Stabilization devices, together with support from healthcare professionals and caregivers, were used to minimize movement and facilitate proper patient positioning throughout the imaging process.
When deemed appropriate, children and adolescents were advised to forgo shielding during diagnostic imaging procedures. In contrast, caregivers who actively assisted patients during image acquisition were instructed to use appropriate protective shielding to ensure their safety.
Results
The results are presented descriptively, focusing on the observed feasibility and clinical applicability of the proposed adaptations. No numerical data stratified by diagnosis are presented, as this report encompasses experiences from three independent studies with distinct designs and samples, and its objective is to systematize practical strategies rather than conduct comparative analyses.
A tell-show-do technique was consistently employed during radiography procedures. Patients received verbal instructions using concise, clear, and simple language. For non-verbal patients, communication and guidance were directed primarily toward their caregivers. The oral radiology team provided comprehensive support to all participants before, during, and after the image acquisition. Caregivers were present throughout all imaging procedures, as their involvement was encouraged to reduce the patient’s anxiety and promote cooperation during the examination. This inclusive approach contributed to a safer and more predictable environment for children who typically face communication and behavioral barriers in conventional diagnostic settings.
Before the procedure, the radiology technician explained to each patient and caregiver that dental radiographs would be taken to visualize the teeth and jaws. Operators described the functionality of the panoramic imaging equipment and implemented necessary modifications to accommodate patient-specific needs and facilitate proper positioning. No digital tools, such as video recordings, were used during imaging; the experience was documented through direct clinical observation and analysis of the obtained radiographic images. Throughout the procedure, healthcare professionals remained available to help as needed (Figure 1).
Positioning provided by the radiology technician, a PhD student from the clinical dental team specializing in the care of patients with special needs, and the patient´s caregiver. The patient remained seated in the wheelchair during an imaging procedure.
To achieve adequate height alignment with the imaging unit, various household objects, such as boxes and books, were strategically placed on chairs to elevate patients to the appropriate level (Figures 2 and 3). The use of these readily available materials reflected a conscious strategy to remove physical barriers in a low-cost, sustainable, and reproducible manner, particularly within resource-constrained public health contexts. For individuals who were unable to maintain the required posture independently, additional supports and fixators were utilized. In these cases, both healthcare professionals and caregivers played essential roles in immobilizing and stabilizing patients, ensuring safety and successful image capture.
Adaptation using a box to achieve proper height alignment with the imaging unit. The caregiver remains still and provides physical support to assist the patient during imaging acquisition.
Illustration of correct chin and occlusal plane alignment, contributing to reducing movement-related distortions and improving image quality.
In instances where a patient’s wheelchair interfered with equipment rotation or contributed to imaging artifacts, the patient was transferred to an alternative chair provided by the radiology service (Figures 4 and 5). These adaptations allowed for greater flexibility in accommodating patients with complex physical needs. Importantly, the type of adaptation employed did not negatively affect the diagnostic quality of the panoramic images. On the contrary, individualized adjustments facilitated adequate positioning and patient cooperation, contributing to clinically interpretable images.
In both images, head positioning was achieved with the assistance of caregivers, following instructions provided by the healthcare team. Figure 5. The caregiver specifically assists in aligning the patient´s spine and neck to facilitate proper positioning for image acquisition.
Despite the overall success of the adapted strategies, some cases required repeated exposures due to the persistent challenges with patient positioning. While most radiographs were of sufficient diagnostic quality, some exhibited distortions, and a limited number had to be discarded entirely when optimal positioning could not be achieved. Overall, most examinations yielded diagnostically acceptable panoramic images, reinforcing the feasibility of implementing barrier-reducing practices in real-world clinical settings (Figures 6 and 7).
Panoramic radiographs exhibiting distortions and overlapping structures. Despite these artifacts, the diagnostic evaluation of the teeth and jaws remained uncompromised.
Table 1 summarizes the adaptive strategies used to acquire the panoramic X-ray.
Summary of adaptive strategies used for panoramic radiography in children and adolescents with disabilities.
Discussion
This experience report highlights the importance of individualized accommodations and adaptive strategies in clinical settings to ensure equitable access to diagnostic procedures, such as panoramic radiography, for patients with skeletal deformities and neurodevelopmental disorders. The central contribution of this report lies in systematizing feasible, low-cost, and reproducible strategies for routine clinical practice, addressing a persistent gap in dental care for individuals whose physical and cognitive characteristics often exclude them from standard imaging protocols.
The collaborative efforts and expertise of the multidisciplinary team were essential in overcoming barriers to image acquisition. Despite some image distortion and data loss, most diagnostically acceptable panoramic radiographs were successfully obtained, reinforcing the feasibility of inclusive practices even in public health services with a limited infrastructure. These findings support the adoption of flexible, patient-centered approaches as an alternative to exclusion or repeated failed examinations.
Effective communication emerged as a critical factor in fostering patient collaboration during radiographic procedures. The use of simplified language, adapted communication strategies, and caregiver mediation proved particularly relevant for patients with limited verbal skills or heightened anxiety. Previous studies have demonstrated that appropriate verbal and non-verbal communication significantly reduces fear and distress during imaging procedures, promoting greater cooperation [20,21]. The consistent presence of caregivers further enhanced this process by providing emotional support and reinforcing procedural instructions [22-28].
Improper posture and positioning remain significant challenges when performing panoramic radiographs in this population. Adapted wheelchairs, although essential for mobility, often include metallic components that interfere with image acquisition and degrade diagnostic quality. In line with previous reports, transferring patients to alternative seating with non-obstructive features was an effective strategy for reducing artifacts and improving positioning [14,15,19,29]. When conventional seating proved insufficient, low-tech adaptations - such as stable surfaces combined with height-adjustable objects - enabled adequate alignment of the focal trough and occlusal plane, with active caregiver support playing a key role in stabilization.
The relevance of contextual and operational factors during image acquisition is underscored by the findings of Fux-noy et al. [4], who reported a higher frequency of low-quality images among children with developmental delays. While their study relied on retrospective image analysis, the present report complements this evidence by providing real-time clinical insights into the human, behavioral, and environmental challenges that influence imaging outcomes, thereby enriching the existing literature.
In certain situations, lead aprons were omitted during imaging in accordance with the principles of justification, optimization, and dose limitation. Technological advancements in radiographic equipment have further reduced exposure, enhancing safety for all patients, particularly children and adolescents [30].
Overall, this experience report demonstrates that interprofessional collaboration is a key mechanism for operationalizing inclusive diagnostic care. Rather than proposing rigid protocols, the strategies described emphasize adaptability, responsiveness, and clinical judgment. Simple, readily available materials were effectively repurposed to facilitate positioning, prioritize patient comfort, and improve cooperation. These pragmatic adaptations, grounded in principles of equity and accessibility, represent an important step toward integrating inclusive practices into routine dental radiology services.
This experience report has some limitations that should be acknowledged. First, as a descriptive report based on three independent studies, no quantitative analysis or diagnostic stratification was performed, limiting the ability to generalize outcomes or compare effectiveness across diagnostic categories. Second, image quality assessment was qualitative and based on routine clinical usability, without the application of formal scoring systems. Finally, the strategies described reflect the context of a university-based public service with a trained multidisciplinary team, which may influence their applicability in settings with different structural or human resources. Nevertheless, these limitations are inherent to the nature of experience reports and do not detract from the practical value of the strategies presented.
Conclusion
This experience report underscores the critical role of individualized strategies and multidisciplinary collaboration in promoting equitable access to diagnostic imaging for patients with skeletal deformities and neurodevelopmental disorders. The professional expertise of the healthcare team was instrumental in adapting techniques and tools to accommodate diverse patients’ needs, ultimately supporting the acquisition of diagnostically useful radiographs. By intentionally addressing physical, cognitive, and environmental barriers, the approach described here offers a feasible and scalable model for inclusive radiographic care in public health settings. These findings reinforce the importance of low-cost, rights-based adaptations as essential components of accessible and equitable services for individuals with disabilities.
Financial Support
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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