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Dental Radiation Safety: Guidelines for Prescribing Radiographs and Limiting Radiation Exposure

Knowledge for Clinical Practice

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DENTAL LEARNING

Integrated Media Solutions/Dental Learning LLC is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp. Integrated Media Solutions/Dental Learning LLC designates this activity for 1 continuing education credit.

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Dental Learning, LLC is a Dental Board of California CE Provider. The California Provider # is RP5062. All of the information contained on this certi� cate is truthful and accurate. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type. This course meets the Dental Board of California’s requirements for 1 unit of continuing educa-tion. CA course code is 02-5062-13020.

Lynn Marsh, RDH, EdD

EDUCATIONAL OBJECTIVES

The overall goal of this course is to provide the reader with infor-mation on dental radiation safety. On completion of this course, participants will be able to:

1. Describe the responsibilities of the healthcare provider in reducing patient exposure to radiation;

2. Review the use and effect of collimation;3. List and describe the elements involved in ALARA; and4. Discuss the guidelines for prescribing radiographs.

SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from Dentsply Rinn. DESIGNATION STATE-MENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning, LLC designates this activity for 1 CE credit. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Ap-proval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2012 - 1/31/2016. Provider ID: # 346890. EDUCATIONAL METHODS: This course is a self-instructional journal and online activity. Information shared in this course is based on current information and research based evidence. REGISTRATION: The cost of this CE course is $19.00 for 1 CE credit. PUBLICATION DATE: November, 2013. EXPIRATION DATE: October, 2016. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 1 CE credit for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the � eld related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Casey Warner, does not have a leadership or commercial interest in any products or services discussed in this educational activity. She can be reached at [email protected]. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satis� ed with this course can request a full refund by contacting Dental Learning, LLC in writing or by calling 1-888-724-5230. Please direct all ques-tions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. Go Green, Go Online to www.dentallearning.net to take this course. © 2013

Dental radiation safety is a critical component of patient care. Responsibilities of the healthcare provider include reducing patient exposure to radiation by utilizing appropriate procedures during patient assessment. Exposure to radiation must follow the ALARA principle, meaning that it is “As Low As Reasonably Achievable.” The principles involved include the use of as small an X-ray beam as possible, lead aprons and collars, the fastest � lm available or digital radiography, and the use of proper processing. Guidelines for prescribing radiographs and limiting radiation exposure have been recommended by professional societies, and should be utilized by the oral health care provider. Dental radiation safety and guidelines for prescribing radiographs and limiting radiation exposure are essential safety measures for patient protection.

ABSTRACT


Dental radiographs are valuable in helping the oral health care provider evaluate and treat oral health problems at an early stage. Since many oral diseases

cannot be detected during a clinical examination alone, dental radiographs are an important adjunctive aid in assessing a patient’s overall oral health. Dental radiographs help the oral health care provider identify diseases and developmental problems before they become serious health issues. Early detection can limit, or prevent, further progres-sion of infections and diseases in the oral cavity. Dental Radiation Protection Standards are basic requirements that ensure patient safety. These standards contain requirements regarded as necessary for best practices in radiation protec-tion; they include fundamental quantitative requirements, such as exposure limits to protect both the oral health care provider and the patient.

CE EditorFIONA M. COLLINS

Director of ContentJULIE CULLEN

Creative DirectorMICHAEL HUBERT

Art DirectorMICHAEL MOLFETTO

Copyright 2013 by Dental Learning, LLC. No part of this publication may be reproduced or transmitted in any form without written permission from the publisher.

500 Craig Road, First Floor, Manalapan, NJ 07726

DENTAL LEARNING

DENTAL LEARNING

ABOUT THE AUTHOR

Lynn Marsh, RDH, EdD Lynn Marsh is an associate professor in the Department of Dental Hygiene at Farming-dale State College, Farmingdale, NY, and a member of the National Dental Hygiene Honor Society, Sigma Phi Alpha. Her teaching responsibilities include radiology laboratory, current issues in dental hygiene, practice management for quality assur-

ance, pain management laboratory, and clinical instruction. She practiced dental hygiene for more than 20 years.

DENTAL LEARNING www.dentallearning.net

4

State laws and regulations set speci�c requirements for the use of ionizing radiation, which includes X-rays. Radio-graphic training requirements for dental of�ce personnel frequently differ from, and are less rigorous than, those of medical personnel who expose X-rays. Training require-ments for dental of�ce personnel are typically found in state dental practice acts or dental board regulations.1

It is the responsibility of the oral health care provider to be cognizant in reducing patient exposure to radiation by utilizing appropriate procedures during patient assessment. This includes providing radiographic images with maximum diagnostic information, while at the same time minimizing unnecessary patient exposure to radiation. Dental radiation safety guidelines include the use of lead aprons and thyroid collars, particularly for patients younger than 20 years, to protect the radiosensitive thyroid gland and reproductive system (Fig. 1).2

CollimationOther dental radiation safety guideline recommendations

include the use of rectangular collimation. This will reduce patient exposure to radiation to less than half of the expo-sure associated with the use of traditional round collimation (Figs. 2, 3).3

A collimator, housed within the X-ray tube head, is

a metallic barrier with an opening in the center used to decrease the size and shape of the X-ray beam. The collima-tor reduces the amount of irradiated tissue exposure for the patient. Filtration and collimation of the X-ray beam are vital safety measures. The �lter and collimator block the majority of the unwanted X-ray photons.4 Rectangular collimators restrict the size of the X-ray beam to just larger than that of the number 2 size traditional �lm. To lessen excessive patient exposure to radiation, the size of the X-ray beam should be restricted to the size of the �lm being exposed. Use of a rectangular collimator instead of a round collimator also decreases scatter radiation and �lm fog, and improves image quality. Furthermore, the reduction in the size of the X-ray beam enhances image de�nition and sharpness.4

High-speed �lm and digital radiographyThe use of higher speed �lm (F-speed �lm) or digital

radiography will further reduce patient exposure to radia-tion considerably, when compared with the use of slower speed �lm (D-speed �lm).2 On the other hand, the ease-of-use of direct digital radiographic imaging systems increases the likelihood of an unwarranted number of radiographs, in an attempt to attain a diagnostically acceptable image. Consequently, the use of fast �lm/screen combinations for extraoral radiography, or digital alternatives, will consider-ably reduce patient exposure to radiation only provided care is taken to avoid unnecessary radiographs.

The speed of traditional �lm is related to the size of the silver bromide crystals. These are very sensitive to light, and contained in the emulsion of the �lm. The larger the crystals, the faster the speed of the �lm. Given that the crystals in high speed �lm are larger and more sensitive to light, less exposure time is required to record the radiographic image. Exposure settings on the X-ray machine vary, depending on the speed of the �lm, the length of the position indicating device, KvP, and mA. It should be noted that to obtain the advantages of reduced patient radiation exposure, intraoral or extraoral digital radiograph systems should use the mini-mum radiation necessary for the generation of a diagnosti-Figure 1. Thyroid collar and lead apron


5november 2013

cally acceptable image. Any bene� ts derived from using a digital radiographic imaging system can be negated by an overexposed radiograph that is digitally enhanced to have acceptable brightness and contrast.2

Other considerationsAdditional factors regarding dental radiation safety

apply in the darkroom used to process traditional � lm. Proper � lm processing procedures are essential to ensure the production of a diagnostically acceptable � lm. The dark-room must be free of any light leaks, as this can cause � lm fog. An appropriate safelight, placed at a minimum of 4 feet from the working area, must be used in the darkroom, to al-low the oral health care provider to handle � lms in the dark without producing � lm fog during processing.

Processing solutions should be changed regularly, and not subjected to high temperatures. Quality control checks should be performed to ensure optimal process-ing and quality radiographs. Depleted or contaminated processing chemicals also can result in nondiagnostic radiographic images that would necessitate a retake, thus re-exposing the patient to unnecessary radiation.5

In addition, to produce diagnostically acceptable � lms and limit radiation exposure, the rollers and tanks must be cleaned. When utilizing an automatic processor, the operator should use separate sponges to clean each roller. This prevents potential cross-contamination of the chemicals; for example, a drop of � xer later entering the developer due to prior use of a sponge for the � xer’s roller. Such contamination can compromise the quality of the radiograph, � xer, developer, and water. Warm running water or the manufacturer’s spray also may be used while rotating the gears in each roller, and a soft brush can be used to loosen and remove debris build-up on the roll-ers. Detergent, soap, or household cleaners should not be used on � lm processing rollers.

ALARAOral health care providers must follow the ALARA prin-

ciple, which stands for “As Low As Reasonably Achievable,” when exposing radiographs. This radiation safety principle limits patient exposure by incorporating the following techniques:2

• Use of the fastest image receptor (the fastest traditional � lm speed or digital sensor).

• Reduction in the size of the X-ray beam to the size of the image receptor whenever possible (Figs 2, 3).3 The posi-tion indicating device should have rectangular collima-tion to reduce the size of the X-ray beam to the size of the image receptor whenever possible.

• Use of proper exposure and processing techniques.• Use of leaded aprons, including thyroid collars.

It is important that oral health care providers have cop-ies of any existing radiographs, to avoid re-exposing the patient to radiation.

Figure 2. Collimation and radiation exposure

Figure 3. Round and square collimation.

Images courtesy of: Castellanos S, Jain R. Reduce radiation with rectangular col-limation. Dimensions of Dental Hygiene. 2013;11(2):46, 48-50.

Table 1. Guidelines for prescribing radiographs6

TYPE OF ENCOUNTER

PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE

Child with Primary Dentition (prior to eruption of �rst permanent tooth)

Child with Transitional Dentition (after eruption of �rst permanent tooth)

Adolescent with Permanent Dentition (prior to eruption of third molars)

Adult, Dentate or Partially Edentulous

Adult, Edentulous

New Patient* being evaluated for oral diseases

Individualized radiographic exam: Selected periapical/occlusal views and/or posterior bitewings if proximal surfaces cannot be visualized or probed. Patients without evidence of disease and with open proximal con-tacts may not require a radiographic exam at this time.

Individualized radiographic exam: Posterior bitewings with panoramic exam or posterior bitewings and selected periapi-cal images.

Individualized radiographic exam: Posterior bitewings with panoramic exam or posterior bitewings and se-lected periapical images. A full mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized oral disease or a history of extensive dental treatment.

Individual-ized radio-graphic exam, based on clinical signs and symptoms.

Recall Patient* with clini-cal caries or at increased risk for caries**

Posterior bitewing exam at 6-12 month intervals if proximal surfaces cannot be examined visually or with a probe

Posterior bitewing exam at 6-18 month intervals

Not applicable

Recall Patient* with no clinical caries and not at increased risk for caries**

Posterior bitewing exam at 12-24 month intervals if proximal surfaces cannot be examined visually or with a probe

Posterior bitewing exam at 18-36 month intervals

Posterior bite-wing exam at 24-36 month intervals

Not applicable

Recall Patient* with peri-odontal disease

Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease. Imaging may consist of, but is not limited to, selected bitewing and/or periapical images of areas where periodontal disease (other than nonspeci�c gingivitis) can be demonstrated clinically.

Not applicable

Patient (New and Recall) for monitoring of dentofa-cial growth and develop-ment, and/or assessment of dental/skeletal relation-ships

Clinical judgment on need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development or assessment of den-tal and skeletal relationships

Clinical judgment on need for and type of radiographic images for evaluation and/or monitoring of dentofacial growth and development, or assessment of dental and skeletal relation-ships. Panoramic or periapical exam to assess developing third molars

Usually not indicated for moni-toring of growth and develop-ment. Clinical judgment as to the need for and type of radiographic image for evalu-ation of dental and skeletal relationships

Patient with other circum-stances including, but not limited to, proposed or existing implants, other dental and craniofacial pathoses, restorative/en- dodontic needs, treated periodontal disease and caries remineralization

Clinical judgment as to need for and type of radiographic images for evaluation and/or monitoring of these conditions

*Clinical situations for which radiographs may be indicated can be found in “The Selection of Patients for Dental Radiographic Examinations.” **Factors increasing risk for caries may be assessed using the ADA Caries Risk Assessment forms. Table courtesy of The Food & Drug Administration. Radiation-Emitting Products: The Selection of Patients for Dental Radiographic Examinations.

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7november 2013

Oral health care providers should decide when radio-graphs are needed, based on each patient’s individual oral examination �ndings, any symptoms reported, a review of the health history, risk of experiencing oral disease, patient’s age, or any combination of these.7

Guidelines for prescribing radiographs and limiting radiation exposure

The American Dental Association, in collaboration with the Food and Drug Administration, developed recommenda-tions for dental radiographic examinations, to serve as an adjunct to the oral health care provider’s professional judg-ment on how to best use diagnostic imaging.1 While dental radiographs are important in assessing and diagnosing oral diseases and conditions, the oral health care provider must consider the bene�ts of dental radiographs and weigh this against the risk of exposing a patient to radiation, the effects of which are cumulative over time. Each individual patient’s health history, need, and susceptibility to oral disease should be taken into consideration. For this reason, the recom-mendations are intended to serve as a resource and are not projected to be standards of care, or requirements or regula-tions, for prescribing radiographs.

How often the patient should be exposed to dental radiographs also depends on the patient’s oral health condi-tion, age, risk for disease, and any signs and symptoms of oral disease that the patient might be experiencing. The recommendations are subject to clinical judgment and may not apply to every patient. They are to be used by the oral health care provider only after reviewing the patient’s health history and completing a clinical examination. Although radiation exposure from dental radiographs is low, once a

decision to take radiographs has been made, it is the oral health care provider’s responsibility to follow the ALARA principle to minimize the patient’s exposure to radiation (Table 1).6

SummaryDental radiation safety, radiograph selection, and optimi-

zation of exposure limitations, should be implemented for every patient in the dental practice. Guidelines for pre-scribing radiographs and limiting radiation exposure have been recommended by professional societies, and should be utilized by the oral health care provider. Dental radia-tion safety and guidelines for prescribing radiographs and limiting radiation exposure are essential safety measures for patient protection.

References1. American Dental Association. Oral health topics: X-rays. Available at: http://www.ada.org/2760.aspx#safety. Accessed November 20, 2013.

2. Tetradis S, White S. What are the risks of dental X-rays. 2012. Available at: http://www.medscape.com/viewarticle/768817_3. Accessed November 20, 2013.

3. Langland O, Langlais R, Preece J. Principles of Dental Imaging. Baltimore, Md: Lippincott, Williams & Wilkins; 2002.

4. Dental radiographs: Benefits and safety. J Am Dent Assoc. 2011;142(9):1101.

5. Castellanos S, Jain R. Reduce radiation with rectangular collimations. Dimensions of Dental Hygiene. 2013;11(2):46, 48-50.

6. Razzano M, Miles D, Hoos J. ALARA, rectangular collimation, and profitable practice growth. Available at: http://www.dentaleconomics.com/articles/print/volume-101/issue-4/features/alara-rectangular-collimation-and-profitable-practice-growth.html.

7. The Selection of Patients for Dental Radiographic Examinations. 2012. Available at http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProducts andProcedures/MedicalImaging/MedicalX-Rays/ucm116504.htm.

WebliographyAmerican Dental Association. Dental radiographs. Benefits and safety. Available at: http://www.ada.org/sections/scienceAndResearch/pdfs/forthedentalpatient_sept2011.pdf.

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1. _____________ set(s) speci�c requirements for the use of ionizing radiation, which includes X-rays.a. OSAP b. The ADAc. State laws and regulationsd. all of the above

2. Dental radiation safety guidelines include the use of lead aprons and thyroid collars to protect the radiosensitive ______________.a. parotid glandb. thyroid glandc. tibiad. all of the above

3. The American Dental Association, in collaboration with the _____________, developed recommendations for dental radiographic examinations.a. Environmental Protection Agencyb. American Radiation Associationc. Food and Drug Administration d. all of the above

4. ALARA stands for _____________.a. “As Little As Requirements Allow” b. “As Low As Radiation Allows” c. “As Low As Reasonably Achievable” d. none of the above

5. Proper �lm processing procedures are necessary to

ensure the production of ___________.a. minimal chemical vaporizationb. a diagnostically acceptable �lmc. lightd. extra �lms

6. Using a rectangular collimator instead of a round collimator _________.a. decreases scatter radiationb. decreases �lm fogc. improves image quality d. all of the above

7. An appropriate safelight, placed at a minimum of _____________ from the working area, must be used in the darkroom.a. 2 feet b. 3 feet c. 4 feet d. 5 feet

8. A collimator is _____________.a. housed within the X-ray tube head b. used to decrease the size and shape of the X-ray beam c. used to reduce the amount of irradiated tissue exposure

for the patientd. all of the above

9. Oral health care providers must follow the ALARA principle, when exposing radiographs, to _______________.a. increase �lm accuracy b. limit patient radiation exposurec. protect the operatord. increase �lm brightness

10. When deciding whether to take radiographs, each individual patient’s ______________ should be taken into consideration.a. health historyb. need c. susceptibility to oral diseased. all of the above

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EDUCATIONAL OBJECTIVES• Describe the responsibilities of the healthcare provider in reducing patient exposure to radiation • Review the use and effect of collimation• List and describe the elements involved in ‘ALARA’• Review the guidelines for prescribing radiographs.

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