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The Use of Dental Radiographs Update and Recommendations

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The Use of Dental Radiographs Update and Recommendations ASSOCIATION REPORT The use of dental radiographs Update and recommendations American Dental Association Council on Scientific Affairs ental radiographs are a useful and necessary tool A D A in the diagnosis and ABSTRACT J ✷ ✷ treatment of oral dis- C N eases such as caries, peri- Background and Overview. The National O O N I Council on Radiation Protection & Measurements T odontal diseases and oral patholo- T D I A N updated its recommendations on radiation protection U C gies. Although radiation doses in I U A N G E D dental radiography are low,1,2 expo- in dentistry in 2003, the Centers for Disease Control R 4 TICLE sure to radiation should be mini- and Prevention published its Guidelines for Infection Con- mized where practicable. Dentists trol in Dental Health-Care Settings in 2003, and the U.S. Food and Drug should weigh the benefits of dental Administration updated its selection criteria for dental radiographs in radiographs against the conse- 2004. This report summarizes the recommendations presented in these quences of increasing a patient’s documents and addresses additional topics such as patient selection cri- exposure to radiation, the effects of teria, film selection for conventional radiographs, collimation, beam filtra- which accumulate from multiple tion, patient protective equipment, film holders, operator protection, film sources over time. The “as low as exposure and processing, infection control, quality assurance, image reasonably achievable” (ALARA) viewing, direct digital radiography and continuing education of dental principle should be followed to mini- health care workers who expose radiographs. mize exposure to radiation. Conclusions. This report discusses implementation of proper radi- This report discusses implemen- ographic practices. In addition to these guidelines, dentists should be tation of proper radiographic prac- aware of, and comply with, applicable federal and state regulations. tices. It addresses topics such as Clinical Implications. Dentists should weigh the benefits of dental patient selection criteria, film selec- radiographs against the consequences of increasing a patient’s exposure tion for conventional radiographs, to radiation and implement appropriate radiation control procedures. collimation, beam filtration, patient Key Words. Radiographs; X-ray; radiographic examination; radiation protective equipment, film holders, exposure; digital radiography; quality assurance. operator protection, film exposure JADA 2006;137:1304-12. and processing, infection control, quality assurance, image viewing, Address reprint requests to American Dental Association Council on Scientific Affairs, 211 E. Chicago direct digital radiography and con- Ave., Chicago, Ill. 60611. 1304 JADA, Vol. 137 http://jada.ada.org September 2006 Copyright ©2006 American Dental Association. All rights reserved. ASSOCIATION REPORT tinuing education of dental health care workers or referred patients, clinicians should obtain who expose radiographs. This report also summa- recent dental radiographs from the patient’s pre- rizes the updated recommendations of the vious dental health care provider.3 They also National Council on Radiation Protection & Mea- should review early radiographs, if available, for surements (NCRP) on radiation protection in den- comparative purposes. tistry3 (available for purchase on the Web at Dental radiographs may be prescribed for preg- “www.ncrppublications.org/index.cfm? nant patients with careful adherence to the FDA fm=Product.AddToCart&pid=1845765544” or by selection criteria guidelines.3,5 Dental disease left phone at 1-800-229-2652), the Centers for Disease untreated during pregnancy can lead to problems Control and Prevention’s Guidelines for Infection for both the mother and the fetus, and dental Control in Dental Health-Care Settings4 radiographs may be required for proper diagnosis (“www.cdc.gov/OralHealth/infectioncontrol/ and management.12 guidelines/index.htm”) and the U.S. Food and No special considerations apply to dental radi- Drug Administration (FDA) selection criteria for ographs for patients undergoing radiation dental radiographs (“www.ada.org/prof/resources/ therapy to the head and neck. These patients are topics/radiography.asp”).5 at a high risk of developing dental diseases, and In addition to these guidelines, dentists should the radiation exposure from dental radiographs is be aware of, and comply with, applicable federal negligible when compared with the therapeutic and state regulations. (The Web site of the Con- exposure they already are receiving in their ference of Radiation Control Program Directors at treatment.13,14 “www.crcpd.org/Map/map.asp” provides contact Panoramic radiographs may reveal calcifica- information for state radiation control and tions of the carotid artery through examination of protection programs.) the region 1.5 to 2.5 centimeters posterior and inferior to the angle of the mandible.15-19 It is not PATIENT SELECTION CRITERIA recommended that the clinician take dental There is little evidence to support radiographic panoramic radiographs specifically to evaluate for exposure of all dentulous areas of the oral cavity carotid artery calcification, but rather that he or in search of occult pathoses in the asymptomatic she evaluate radiographs taken for dental pur- patient.3,6-8 Studies have shown that basing selec- poses for this condition as well. If the dentist sus- tion criteria on clinical evaluations for asympto- pects this condition, he or she should refer the matic patients, combined with selected periapical patient to a physician for evaluation. radiographs for symptomatic patients, can result in a 43 percent reduction in the number of radi- FILM SELECTION FOR CONVENTIONAL RADIOGRAPHS ographs without a clinically consequential increase in the rate of undiagnosed disease.9,10 The American National Standards Institute and In collaboration with the ADA, the FDA has the International Organization for Standardiza- updated its guidelines for the selection of patients tion have established standards for film speed.20,21 for dental radiographic examination (Table 1).5 Film speeds available for dental radiography are These guidelines provide recommendations for D-speed, E-speed and F-speed, with D-speed radiographs with consideration given to a being the slowest and F-speed the fastest. The patient’s caries risk, periodontal status, stage of use of faster film speed can result in up to a 50 growth and development, and other specific cir- percent decrease in exposure to the patient cumstances. The guidelines recommend that radi- without compromising diagnostic quality.3,22 Film ographs be limited to the areas required for of a speed slower than E-speed should not be used adequate diagnosis and treatment on the basis of for dental radiographs.3,22,23 the sound exercise of professional judgment.3,5-8,11 Exposure of extraoral films such as panoramic Dentists should not prescribe routine dental radi- radiographs requires intensifying screens to mini- ographs at preset intervals for all patients.3 mize radiation exposure to patients. The intensi- Instead, they should prescribe radiographs after fying screen consists of layers of phosphor crys- an evaluation of the patient’s needs that includes tals that fluoresce when exposed to radiation. In a health history review, a clinical dental history addition to the radiation incident on the film, the assessment, a clinical examination and an evalu- film is exposed primarily to the light emitted from ation of susceptibility to dental diseases.3 For new the intensifying screen. Previous generations of JADA, Vol. 137 http://jada.ada.org September 2006 1305 Copyright ©2006 American Dental Association. All rights reserved. ASSOCIATION REPORT TABLE 1 U.S. Food and Drug Administration guidelines for prescribing dental radiographs.* The recommendations in this table are subject to clinical judgment and may not apply to every patient. They are to be used by dentists only after reviewing the patient’s health history and completing a clinical examination. Because every precaution should be taken to minimize radiation exposure, protective thyroid collars and aprons should be used whenever possible. This practice is strongly recommended for children, women of childbearing age and pregnant women. TYPE OF ENCOUNTER PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE Child With Primary Child With Adolescent With Adult, Dentate Adult, Dentition (Prior to Transitional Permanent or Partially Edentulous Eruption of First Dentition (After Dentition (Prior Edentulous Permanent Tooth) Eruption of First to Eruption of Permanent Tooth) Third Molars) New Patient† Being Individualized radio- Individualized Individualized radiographic exami- Individualized Evaluated for Dental graphic examination radiographic nation consisting of posterior radiographic Diseases and Dental consisting of selected examination bitewings with panoramic exami- examination, Development periapical/occlusal views consisting of posterior nation or posterior bitewings and based on and/or posterior bitewings bitewings with selected periapical images; a full- clinical signs if proximal surfaces cannot panoramic mouth intraoral radiographic and be visualized or probed; examination or examination is preferred when the symptoms patients without evidence posterior bitewings patient has clinical evidence of gen- of disease and with open and selected eralized dental disease or a history proximal contacts may not periapical images of extensive dental treatment require
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