Key takeaways
|
Synthesis and comments
The heavy lead apron that dentists put over you during dental x-rays will soon be a thing of the past.
The American Dental Association (ADA) announced that its member dentists can do without aprons, technically called "thyroid collars" because they were used to protect that organ from radiation.
"After reviewing nearly 100 articles, guidance documents and regulations related to radiography, the expert panel determined that the use of thyroid and abdominal protection during dental imaging is no longer recommended, and that the use of these forms of Protective protection should be discontinued as a routine practice," the ADA said.
The organization notes that X-rays and other diagnostic technologies have become more accurate in recent decades, reducing the amount of radiation exposure.
Dentists should therefore do without lead aprons and think about which examinations and how many are really necessary.
In some cases, the use of lead aprons could block images and make diagnosis difficult, the organization added.
"When this happens, more x-rays need to be taken and what we want to avoid is unnecessary x-rays," said Dr. Purnima Kumar, chair of the ADA Council on Scientific Affairs.
"The focus of these recommendations is that physicians should order x-rays sparingly, to minimize exposure of both patients and dental professionals to ionizing radiation," Kumar added in an ADA news release.
The new recommendation to abandon aprons applies to all patients, including pregnant women, the ADA said.
To better protect patients, the group advises that:
- Dentists consult patients’ x-rays obtained in previous examinations, and if they need new ones, they only request those necessary to "optimize diagnostic information."
- Use digital radiographic film instead of conventional.
- Restrict the "beam size" of x-rays to only that area of the anatomy that needs to be evaluated.
- Position patients correctly for an x-ray.
- Use a higher radiation technology, called cone beam computed tomography (CBCT), only in cases where other technologies with lower radiation levels do not work.
- Comply with "all applicable federal, state, and local radiation safety regulations"
"We encourage dentists and their teams to review these best practice recommendations, adhere to radiation protection standards, and speak with their patients about any questions or concerns before requesting dental imaging," said Kumar, professor of dentistry and chair of the department. of periodontics. and oral medicine at the University of Michigan School of Dentistry.
SOURCE : American Dental Association, press release, February 1, 2024
Optimizing radiological safety in dentistry
Clinical recommendations and regulatory considerations.
In 2012, the American Dental Association (ADA) and the U.S. Food and Drug Administration (FDA) published Dental Radiographic Examinations: Recommendations for Patient Selection and Limitation of Radiation Exposure and the Council on Scientific Affairs of The ADA issued an advisory statement on the use of cone beam computed tomography (CBCT) in dentistry. This article provides updated evidence-based recommendations, consistent with ADA methodology, on components of the 2012 publications related to dental radiation safety, appropriate imaging practices, recommendations to reduce patient radiation exposure, and staff, and compliance with relevant regulatory requirements.
Background
The value of dental radiographs for oral health care decision making must be balanced with radiological safety to minimize patient exposure and occupational risk to oral health care providers. This review summarizes recommendations and regulatory guidance on dental radiography and cone beam computed tomography. An expert panel presents recommendations on radiation safety, proper imaging practices, and reducing radiation exposure.
Types of studies reviewed
A systematic search conducted in Ovid MEDLINE, Embase, and the Cochrane Database of Systematic Reviews identified topical systematic reviews, organizational guidelines, and relevant regulatory reviews published in the peer-reviewed literature since 2010. A complementary search in the gray literature (e.g. e.g., technical reports, standards and regulations) identified current non-indexed publications. Inclusion criteria required relevance to primary oral health care (i.e., general or pediatric dentistry).
Results
A total of 95 articles, guidance documents and regulations met the inclusion criteria. The resources were characterized as applicable to all modalities, operator and occupational protection, dose reduction and optimization, and quality assurance and control.
Priority recommendations
To emphasize the importance of practice-level considerations to reduce exposure to ionizing radiation while optimizing diagnostic quality, critically important recommendations are listed as priority recommendations in Table 1. When these recommendations are followed, exposure to ionizing radiation can be substantially reduced for both patients and staff members.
Box 1 Priority recommendations Familiarity with and compliance with all applicable local, state, and federal laws (recommendation 1.0.1) Radiographs should be ordered based on diagnostic and treatment planning needs, and dentists should make a good faith attempt to obtain radiographs from previous dental examinations (recommendation 3.0.1). Use digital receivers instead of film for intraoral, panoramic, and cephalometric images (recommendation 3.1.1.0) Use rectangular collimation whenever possible for intraoral images (recommendation 3.1.2) Use cone beam computed tomography only when lower exposure options do not provide the necessary diagnostic information (recommendation 3.2.1). |
Occupational radiation safety
Table 2 Recommendations for the safe and appropriate use of ionizing radiation in dentistry. 1. General recommendations for all modalities 1.0 Regulatory and industry oversight 1.0.1 The practice shall comply with all applicable local, state, and federal regulatory requirements regarding the safe and effective use of radiography-based imaging modalities, including installation, use, optimization, patient and operator protection, control of infections, maintenance and training for radiographic equipment and procedures. 1.0.2 New facilities, or facilities installing or relocating radiography and CBCT∗Equipment must follow state and local regulations related to radiation safety in effect at the time of construction or renovation. 1.0.3 Follow the documentation provided by the manufacturer for safe and appropriate operation, maintenance, and infection control procedures for radiographic, CBCT, and related radiographic imaging equipment. 1.1 Radiation safety programs and training 1.1.1 The dental practice shall develop and implement a radiation safety program that provides all staff members with instructions and guidance to maintain a safe radiographic imaging program. The program must be consistent with nationally established recommendations for the radiation protection of both patients and staff members and comply with all applicable state and local requirements, be developed and implemented under the direction of a qualified expert, and must be reviewed and updated periodically to be up to date with established applicable guidelines and regulations. 1.1.2 Personnel performing radiography-based dental and maxillofacial imaging shall have the qualifications, education, training, and licensure required by applicable federal, state, and local regulations. 2. Occupational and operator use of ionizing radiation 2.0 Operator Training Requirements and Performance 2.0.1 When no protective barrier or shielding is available for intraoral imaging, the operator must remain at least 2 meters from the head of the tube and out of the path of the primary beam. 2.0.2 Access to radiation-producing devices will be restricted and portable and handheld devices will be securely protected from unauthorized use. 2.1 Dosimetry 2.1.1 Dental staff members who may be exposed to an annual effective dose that may exceed 1 mSv, or as determined by state or local guidelines, should consider the use of dosimeters. 2.1.2 Pregnant dental personnel operating radiographic imaging equipment shall comply with relevant recommendations established in the facility’s radiation safety program, including limiting occupational exposure and using protective barriers and personal dosimeters regardless of levels. anticipated exposure. 3. Patient safety and protection 3.0 General recommendations for patient safety and protection 3.0.1 Before performing any type of radiographic examination, physicians should perform a comprehensive clinical examination and evaluation of the patient, taking into account the patient’s medical and oral history, including previous radiographs, as well as the specific risk of oral disease. of the patient. 3.0.2 Dentists should prescribe dental radiographs and CBCT scans only when they expect the diagnostic performance to benefit patient care, improve patient safety, or substantially improve clinical outcomes. 3.0.3 Clinical prescription of radiographic imaging, including CBCT, should be supported by professional judgment based on current and established screening and withdrawal criteria to ensure that the benefit of the radiographic imaging procedure outweighs the associated radiation risk. 3.0.4 Where possible, X-ray imaging equipment will be configured to optimize dosimetric and imaging performance specific to the size and age of the patient. 3.0.5 The use of abdominal and thyroid protection is no longer recommended during diagnostic intraoral, panoramic, cephalometric, and CBCT imaging, and the use of these forms of protective protection should be discontinued as standard practice. 3.1 Radiation dose minimization and image optimization for traditional modalities 3.1.1.1 Digital images should be used instead of film because digital images allow for less patient exposure to radiation. 3.1.1.2 If film is used, only speed E or F film should be used because they require substantially less patient radiation exposure compared to speed D film. Speed D film should be eliminated from clinical use. 3.1.1.3 If film is used for panoramic or cephalometric imaging, rare earth screens and 400 high speed film are recommended. 3.1.2 The X-ray beam should be collimated to the size and shape of the receptor whenever possible, and rectangular collimation should be used for intraoral images. 3.1.3 The intraoral radiography system shall be configured so that the distance from the focal point of the X-ray tube to the entrance surface of the skin (source-to-skin distance) is not < 20 cm. 3.1.4 Intraoral radiography units must operate at a minimum of 60 kV and not exceed 80 kV. 3.1.5 Whenever possible, intraoral image receptor holders that include beam guiding devices should be used. 3.1.6 Portable radiographic devices for intraoral imaging must be licensed by the US Food and Drug Administration, used according to the manufacturer’s instructions, and their use must be restricted only to authorized operators with appropriate training in the use of the device. device. 3.2 Radiation dose minimization and image optimization for CBCT 3.2.1 CBCT images should not be used routinely. CBCT examinations will not be used as a primary or initial imaging modality when a lower dose alternative is appropriate for diagnosis and treatment planning. 3.2.2 Use the smallest field of view necessary to image the specific anatomical area of interest according to diagnostic and treatment planning needs. 3.2.3 CBCT will be performed using technical factors and imaging protocols that are optimized to produce diagnostically acceptable images with the lowest radiation dose to the patient. 3.3 Special considerations for pediatric patients for all modalities 3.3.1 Pediatric patients will be imaged using radiographic device configurations as labeled by the manufacturer and optimized specifically for such patients. 4. Quality assurance and control 4.0 General recommendations for staff members and team 4.0.1 Facility staff members using radiographic imaging equipment must establish a quality assurance and quality control program, implemented and supervised by a qualified expert and following updated quality assurance and quality control guidelines (see Table 2 for obtain a list of external guidelines). 4.0.2 A qualified expert must inspect all conventional radiography units at the time of installation and must inspect the equipment at least every 4 years, following any changes that may affect the radiation exposure of patients and staff members , or in accordance with state and local laws. whichever is stricter. 4.1 Image quality and equipment- and modality-specific dose optimization 4.1.1 The operator’s manual for all radiographic systems, including applicable computer and software systems, must be available to the user. All imaging equipment will be operated and maintained following the manufacturer’s instructions, including appropriate adjustments to optimize dose and image quality and the frequency of quality control and assurance testing. 4.1.2 A qualified expert should evaluate the performance of CBCT imaging and dosimetry at least every two years, but preferably annually. 4.1.3 Special considerations for receivers. 4.1.3.1 Image receiving devices for digital and film-based systems shall undergo initial acceptance testing and be evaluated monthly (film-based) or annually (digital), as recommended by relevant Institute standards American National Standards and American Dental Association. 4.1.3.2 The film processor and phosphor plate scanners should be evaluated during initial installation and periodically thereafter, according to the manufacturer’s instructions. 4.1.3.3 The film will be processed with active chemicals and appropriately replenished. Chemical solutions should be replenished daily and replaced when depleted. Film processor performance should be checked daily before developing the patient’s first radiograph, and each film type should be evaluated monthly or when a new box or batch of film is opened. 4.2 Technical tables 4.2.1 A table of radiography exposure factors will be developed for each type of intraoral image receptor and radiography unit combination and will be posted near the control panel of the radiographic unit. The tables and recommended exposure factors will be updated when a different type of receiver or a new radiography unit is used. 4.2.2 Technical charts for intraoral radiography should list exposure settings based on exam type, receptor type, and patient size (small, medium, large) for adult and pediatric settings. ∗ CBCT: Cone Beam Computed Tomography. |
Practical implications
Understanding the factors that affect imaging safety and applying fundamental radiation protection principles consistent with federal, state, and local requirements are essential to limiting patient exposure to ionizing radiation, along with implementing optimal imaging procedures to support judicious use of dental x-rays and cone beam computed tomography. Dentists and other oral health care providers should follow the regulatory guidance and best practice recommendations summarized in this article.
Discussion
This review of radiation protection and safety recommendations and regulatory oversight has established several critical recommendations that significantly reduce patient dose and occupational risk from radiographic imaging and CBCT : Cone Beam Computed Tomography. These priority recommendations include compliance with local, state and federal regulations; a good faith attempt to obtain images from previous examinations; use digital receivers instead of movies; using rectangular collimation; and use CBCT only as a complement.
The practice of dentistry continues to evolve, with the use of electronic dental records, precision dental medicine, advances in imaging equipment, and artificial intelligence applications driving the way dentistry is practiced. Trends in technology use are likely to be affected not only by its availability but also by the frequency with which patients seek routine care and the treatment options available. However, fundamental compliance with radiation protection standards and best practice recommendations is a central component of quality dentistry. Regulatory compliance is essential, as is the proper and safe use of radiographic imaging systems.
Although CBCT: Cone Beam Computed Tomography can provide improved visualization of dental and related structures beyond that provided by conventional two-dimensional images, its misuse results in unwarranted patient exposure to ionizing radiation. It is incumbent on those influencing clinical practice, including academics and journal editors, to consult the latest professional recommendations on the clinical indications for CBCT: Cone Beam Computed Tomography to ensure that such imaging is appropriate and justified.
Conclusions The ALARA concept, introduced in 1977, is firmly entrenched as a general principle for radiation protection in medical and dental imaging guidance and regulatory standards. With the increasing availability of CBCT: Cone Beam Computed Tomography and digital imaging, the panel recommends that dental office staff members integrate the recommendations presented here, weighing the benefits of newer imaging technologies against the specific risks of radiation (particularly for children) and perform imaging procedures with the goal of obtaining optimal image quality with radiation doses as low as diagnostically acceptable. |
* Access the complete document in English by clicking from this link
