Dentomaxillofacial Radiology (2004) 33, 211219 q 2004 The British Institute of Radiology http:/ /dmfr.birjournals.

org

RESEARCH

Radiation exposure in dental radiology: a 1998 nationwide survey in Switzerland

A Aroua*,1, I Buchillier-Decka1, K Dula2, Y Nedjadi1, M Perrier3, J-P Vader4 and J-F Valley1
1 e, Lausanne, Switzerland; 2Zahnmedizinische Kliniken der Universita t Bern, Institut Universitaire de Radiophysique Applique decine Sociale et Pre ventive, Switzerland; 3Policlinique Dentaire Universitaire, Lausanne, Switzerland; 4Institut Universitaire de Me Lausanne, Switzerland

Objectives: To measure the frequencies of dental radiological examinations in Switzerland and to determine the associated collective radiation doses. Methods: To evaluate the frequencies, a sample of 376 dental practitioners and other institutions performing dental radiology were requested to ll in questionnaires designed to measure, amongst others, frequencies of dental radiodiagnoses according to type of examination, patient age and gender, dental specialty and type of surgery. The associated collective radiation doses were determined by multiplying the relevant frequencies with dose estimates obtained from recent measurements and calculations. Results: The total number of dental examinations performed in Switzerland in 1998 was 4.1 million (581 per 1000 population). Periapical, bitewing and panoramic radiographs were the most frequent types of dental examinations. The collective dose associated with dental radiology was 71 person.Sv. This amounts to an annual average effective dose to the population of 10 mSv per caput, which is in agreement with the gures reported for countries of similar healthcare level. Various features such as the age distribution of the radiographed patients, the forms of collimators used, lm consumption and the use of digital imaging systems are presented. Conclusions: Several recommendations for dose reduction are made. These include the re-evaluation of the patterns and justication for prescribing some particular types of dental examinations as well as the avoidance of unnecessary irradiation by the use of rectangular collimation and high sensitivity F-speed lms. Dentomaxillofacial Radiology (2004) 33, 211219. doi: 10.1259/dmfr/26126766 Keywords: dental radiology; radiation exposure; dose to patient Introduction Dental examinations rank among the most frequent radiographic procedures. Their individual levels of exposure are low relative to other diagnostic procedures, but their high frequency and the youthfulness of the age groups predominantly exposed to them justify seeking an ever ner tuning of the radioprotection of the population from them. Understanding the patterns of such procedures and their associated radiation doses may open opportunities for doing just that. There has been an increasing interest for the international scientic community the last decade in determining the radiation doses and the risk associated with dental
*Correspondance to: Abbas Aroua, Institut Universitaire de Radiophysique e, Grand-Pre 1, 1007 Lausanne, Switzerland; E-mail: abbas@aroua.com Applique Received 6 October 2003; revised 4 May 2004; accepted 22 May 2004

radiology1 12 and in optimizing radiation protection in this eld.13 19 The last survey of the use of ionizing radiation for dental diagnostics in Switzerland dates back to 1978.20 This investigation was preceded by two earlier surveys: the survey performed by Zuppinger et al in 195721 and that performed by Poretti et al in 1971.22 All these studies, which were reviewed by Mini in 1992,23 found a steady increase in the frequencies of dental examinations and their associated collective doses. These surveys were carried out as part of the programme to inspect periodically the collective impact of radiation from radiodiagnostics on the Swiss population. Since the 1978 survey no average dose to the population due to dental radiology or radiological risk indicator has been determined. However, the average dose to the

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population has changed appreciably, and will do so in the future, due to the trend in the population, and new patterns in the prescription of radiodiagnostic examinations, and in the techniques used: (a) the increase in healthcare demand (increase in the population); (b) the easiness of access to healthcare (increase in the urban population); (c) the ageing of the population; (d) the increase in the sensitivities of dental lms; (e) the trend towards digital radiology; (f) the rapidly developing eld of implant dentistry; and (g) the introduction of quality controls required by the new radiation protection regulation. Given these developments, a new determination of the global impact of dental radiology on the population was imperative. The present work reports and analyses the frequencies found for dental radiological practice in Switzerland in 1998 as well as the associated collective dose to the Swiss population. Study design The present study was part of a larger one carried out in Switzerland in 1998 to determine the radiation doses delivered to the patient by the different types of X-ray examinations, the frequencies of radiodiagnostic examinations, and the overall radiological impact of diagnostic and interventional radiology on the Swiss population.24,25 This investigation covered more than 250 types of X-ray examinations from the various modalities in diagnostic radiology, including conventional radiography, angiography, uoroscopy, computed tomography, mammography, bone densitometry, conventional tomography and dental radiology, as well as interventional radiology. The inquiry sampled all the institutions that carry out X-ray examinations in Switzerland: university and non-university hospitals, general and specialized practitioners, dentists, chiropractors and other health institutions. During this study 376 dental practitioners were approached, corresponding to a 10% sample. The dentists were selected from the list of practitioners holding an authorization to run an X-ray unit, provided by the Swiss Federal Ofce of Public Health. The sample was stratied geographically over the seven Swiss geographic regions: Lemanic South-West Region, Midland Space, North-West Switzerland, Zurich canton, East Switzerland, Central Switzerland and Tessin canton. In addition to dentists all other institutions practicing dental radiology were considered: dental institutes, oral surgeons, school dentists, hospitals, prisons, etc. The selected dental practitioners were sent a questionnaire by post and asked to ll it in, their participation in the survey being on a voluntary basis. They were encouraged to do so by a letter co-signed by the head of the Swiss Federal Ofce of Public Health and the head of the Swiss Odonto-stomatology Association. The participants were asked to provide information concerning the examinations performed during a period of 1 week in May 1998. The age and gender of the patient as well as information on the radiological unit and the
Dentomaxillofacial Radiology

detection system were requested (manufacturer, brand, type of high voltage generator, year of rst use, sensitivity of the lm screen combination used, etc.). However, no information on the technical parameters of the examination (kV, mAs, etc.) was monitored. The questionnaires were sent at the end of April. One month later (end of May), a reminder was sent to all the participants and another month later (end of June), a letter was addressed to those who failed to respond. With regard to the dosimetric aspects, two approaches were used. Dental X-ray examinations excluding the periapical, full mouth survey, bitewing, occlusal, panoramic radiography and CT procedures were treated using the dosimetric model adopted for most radiographic examinations in the nationwide survey. The dose estimation approach used in this model involves three steps. First, each examination is fully dened in terms of the various projections and technical parameters. Second, the technical parameters of each radiological procedure (equipment and operation) are used to calculate the entrance surface air kerma (ESAK) using the following formula:   U 2 3 1 : :Q : ESAK mGy K: 100 FA FSD2 where U relates to the tube voltage expressed in kV, Q to the tube charge expressed in mAs, FA to the ltration expressed in mm of aluminium and FSD to the focus-toskin distance expressed in m. K, expressed in (mGy.m2) mAs21, is an empirically determined constant characterizing the radiological unit. Third, the ESAK is converted into organ doses and effective doses using the dose computer program ODS-60. A detailed account of this dosimetric model is available.25 As for periapical, full mouth survey, bitewing, occlusal, panoramic radiography and CT examinations, another approach was used. The dose factors determined recently by Dula and Mini26,27 by phantom dose measurements were adopted after a prior comparison with the alternative data sets available in the literature.4,6,8,10 For periapical procedures the dose factors are dependent on the tooth position: maxilla or mandible, molar, premolar, canine or incisor. Therefore the conversion dose factors for periapical examinations were evaluated by weighting the factors specic to the tooth position by the proportion of each tooth position to the total number of periapical examinations the data from the 1998 Swiss survey were used for this purpose.28 Since the dose factors are given for round and rectangular collimators separately, average dose factors were calculated by weighting the fractions of round and rectangular collimators estimated from the survey (85% for round and 15% for rectangular).28 The collective dose was calculated by multiplying the dosimetric data with the X-ray examination frequencies. This calculation took several correction factors into account. The patient age was included by using the age distribution of the frequencies of examination, in addition to age correction factors. The gender effect was taken into account through the gender distributions of the dental X-ray frequencies. Since differences in the sensitivity of

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the detection systems do affect the collective dose, appropriate correction factors were included using the lm sensitivity data gathered in the survey. The survey also investigated a number of parameters not directly relevant to the dosimetric calculations but useful for characterizing the Swiss national radiological stock. The surveyed data covered radiological equipment brands, the use of automatic cells, lm consumption and the use of digital radiology, in addition to the forms of collimators of dental radiology tubes. The data acquisition was performed using a Microsoft Access database, which served also for the data analysis. Several cross-checks were undertaken to avoid typing errors. Results and discussion Among the 376 dentists selected 237 responded positively, leading to a response rate of 63%. To demonstrate the typicality of the sample of dental practitioners we approached and the representativeness of the responses to the questionnaires, Table 1 presents a comparison of the samples of dental practitioners with the rest of their population, along with a comparison of positive respondents with non-respondents included in the sample set at the start. There is no signicant difference between the sample and the whole population of dental professionals with regard to the age, gender or years of practice. The average age in the sample is 48.1 years, whilst that of the population of dental professionals is 47.9 years; the proportion of women is 12% in the former and 10% in the latter; and the average length of practice is 21.3 years in the sample against 21.5 years for the population of dental professionals. Clearly, the sample of dental practitioners is representative, thus justifying the extrapolation of the sample-based results to all the dental practitioners. To probe whether the answers of those who responded to the survey are not too different from the replies of those who did not, a survey was carried out on a sample of nonrespondents, and the comparisons are reported in the last two columns of Table 1.
Table 1 Samples and response rates of dentists

Several comparisons were made but no statistically signicant differences between the respondents and nonrespondents were found. It can therefore be reasonably inferred that the samples results are representative. The number of examinations per year can thus be calculated by multiplying that of the sample by the ratio of the number of dentists in the population over the same number in the sample. Frequencies of dental radiographic procedures For a Swiss population of 7 096 894 inhabitants, the total annual number of dental examinations found for 1998 was 4 123 478 (581 per 1000 population). This gure represents 43% of the total number of X-ray examinations performed in Switzerland in all the modalities of diagnostic and interventional radiology (9.5 millions). The 1998 result represents a 37.8% increase compared with 1978 in terms of the absolute number of dental radiographs (see Table 2). Most of this increase is due to changes in dental radiological practice in the country rather than to the increase in the size of the population. This can be ascertained by the 23.3% increase in the average number of dental radiographs per 1000 population between 1978 and 1998. Note that this upward trend is part of a wider increasing pattern in the country since 1957. Figure 1 provides a comparison of the Swiss annual average number of dental radiological examinations per 1000 population with the corresponding gures for some other countries of similar healthcare level. The United Nations Scientic Committee on the Effects of Atomic Radiation (UNSCEAR) denes four healthcare levels according to the number of physicians per unit of population: level I (at least 1 physician per 1000 population), level II (1 physician for 1000 3000 population), level III (1 physician for 3000 10000 population) and level IV (1 physician for more than 10000 population). The healthcare level I average and the values for the UK, the Netherlands, Sweden and Japan are UNSCEAR estimates,29 while the values for Switzerland are taken from former Swiss surveys. Note that the Swiss gures are generally larger than the annual total averages for countries of healthcare level I. They are larger than the corresponding numbers

Sampled Non-sampled Region Lemanic region Midland space North-West Switzerland Zurich Eastern Switzerland Central Switzerland Tessin All Switzerland Males (%) Females (%) Average SD Average SD 630 738 459 630 450 306 171 3384 90.2 9.8 47.9 10.1 21.5 10.7 Total 70 82 51 70 50 34 19 376 88 12 48.1 10.1 21.3 10.5 Respondents 42 52 35 40 38 18 12 237 87.8 12.2 48.1 10.0 21.3 10.4 Non-respondents 28 30 16 30 12 16 7 139 88.5 11.5 48.3 10.3 21.2 10.9
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Gender of dentist Age of dentist Years of practice SD, standard deviation

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Table 2 Annual frequency of dental radiological examinations in Switzerland Year of the survey Total number of dental radiographs Average number per 1000 population 1957 1102050 214 1971 2404523 383 1978 2991885 471 1998 4123478 581

for the Netherlands and the UK, but smaller than those of Sweden and Japan. What distinguishes the Swiss annual number of dental radiological examinations per 1000 population is its steady increase in the last two decades, in contradistinction to the annual frequency averaged over countries of healthcare level I, which has decreased during the same period. The annual frequency of dental radiological examinations per 1000 population has decreased or remained constant for most countries, except in Switzerland and the UK where it has grown substantially. This pattern reects closely the annual trend of acquisitions of new radiological installations in dental practices and institutes in the country, as obtained from our survey of the ageing of the national stock of dental radiological units. The analysis of a 534 respondent sample shows that about 87% of the radiological installations were acquired in the last two decades, 59% were less than 10 years old and 37% less than 5 years old. Table 3 presents the annual number of radiodiagnostic dental examinations by type of examination, healthcare provider and medical specialty. Figure 2 displays the proportions of the most frequent dental examinations relative to the total annual dental radiodiagnostic procedures. Clearly periapical, long and short bitewings, and panoramic radiography examinations account for the bulk of the dental radiodiagnostic activity in the country. Turning now to the annual number of radiodiagnostic dental examinations by healthcare provider, it was found that 95.68% of this volume of dental examinations is carried out in dental practices, 3.62% in dental institutes and the remaining 0.7% is performed in other institutions,

as indicated in Table 3. In the case of dentists, assuming they work 200 days a year, it follows that a Swiss dentist performs on average 5.25 radiodiagnostic X-rays per working day. The comparison of the Swiss annual average number of dental radiological examinations per 1000 population with those of the UK30 and the Netherlands31 is presented in Table 4 according to the type of examination and healthcare provider. Intraoral examinations account for most of the dental radiodiagnostic activity in the three countries; dental practices contribute the bulk of the examinations in the three cases, but note that British hospitals perform more dental radiological procedures than in Switzerland, a reection of their different health systems. The survey researched the age distribution of the examinations as well, since the risks associated with exposures are age dependent. Figure 3 shows how the annual number of dental procedures is distributed by age groups. From the 10 14 years age group onward, this distribution follows roughly the age distribution of the general population. The age distribution of the gross annual number of all diagnostic and interventional radiographs in the country has a bias towards old age groups and peaks at the 60 64 years age group population, but dental examinations are distributed predominantly among younger age groups, peaking at the 30 34 years age group. The age distribution of the most frequent types of X-ray examinations (periapical, bitewings and panoramic radiography) are displayed in Figure 4. Panoramic procedures are mainly youth targeted whereas periapical ones are most numerous at mature ages. The ages of the patients exposed to X-rays from bitewing examinations follow a distribution intermediate between the panoramic radiography and periapical age apportionments. The survey also probed possible gender differences in the contribution to the gross number of dental radiodiagnostic examinations (Table 5). The overall proportion if all types of examinations are considered is 55% females and 45% males. The gures are different if specic types of examinations are considered but there is always a higher

Figure 1

Comparison of the Swiss data with those of other countries of similar healthcare level

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Table 3

Annual number of radiodiagnostic dental examinations by type of examination, healthcare provider and medical specialty Dentists 1925920 43260 5981 796061 870279 18328 15802 725 544 1133 6015 63003 2730 11 195603 3945395 Dental institutes 86083 1352 74 14481 7780 469 152 1 2296 145 6439 765 634 36 36 602 72 217 397 27395 202 149628 School dentists 3568 4301 637 99 1556 126 2411 12698 Hospital , 500 beds 99 7 24 1893 2023 Hospital . 500 beds 773 11 1 242 332 1 1 7 32 201 2 9 1 4 3649 5266 Facial surgery 578 5 16 99 3392 4090 Othersa 5 2319 2324 Prisons 1639 77 136 198 2 2 2054 Total 2018660 44700 6056 815221 879226 18899 15957 726 544 3429 6167 71042 982 636 123 36 50 3459 72 217 412 236662 202 4123478

Examination Periapical 14-exposure full mouth survey 18-exposure full mouth survey Short bitewing Long bitewing Upper occlusal view Lower occlusal view Lower occlusal view, soft tissue Nose lateral view Skull, PA Skull, close range prole Teleradiography Skull, according to Blondeau Skull, according to Clementschitsch ller TMJ, according to Schu Jawbone prole Maxillary (overall view) Hand Mandible, premolar region Mandible, molar region Sinus Panoramic radiography CT Total
a

Dental radiology in Switzerland A Aroua et al

Surgery, reconstructive surgery, oto-rhino-laryngology and radiology PA, posteroanterior; TMJ, temporomandibular joint

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proportion of females. The only exception appears for the case of 14-exposure full mouth survey, but this may simply be a spurious effect due to the small size of the associated sample. Dose estimates of dental radiographic procedures Table 6 presents the dosimetric results by examination category. The rst column gives the individual effective doses delivered to patients during examinations. These are averages for both patient genders. The second column provides the collective doses for each dental X-ray procedure while the last column gives the corresponding average effective dose per caput. The values of the effective doses delivered to patients range between 0.3 mSv and 2.2 mSv. As expected, these doses t within the lowest part of the spectrum of doses delivered in Swiss diagnostic and interventional radiology.28 Skull examinations deliver the largest doses. Intraoral and panoramic radiography procedures expose patients to roughly comparable doses; more precisely, the full mouth survey and panoramic radiography induced doses are commensurate, and both are larger than the irradiation generated by periapical, bitewing and occlusal X-ray examinations. To gauge how the effective doses found in this study measure up to those of countries of similar healthcare level, Table 7 reports a comparison of the Swiss average effective doses per examination, for different X-ray procedures, with the corresponding gures for some other countries of similar healthcare level. The healthcare level I average and the values for the UK, Sweden and Japan are UNSCEAR estimates,29 while the gures for the Netherlands are from the 1998 nationwide Dutch survey.31 The last row in Table 7 provides a gross average effective dose per dental examination.

Figure 2

Proportions of the most frequent dental examinations

Table 4 International comparison of the annual average number of dental radiological examinations per 1000 population by examination and healthcare provider Examination category Intraoral Panoramic radiography Skull Others Country Switzerland UK The Netherlands Switzerland UK The Netherlands Switzerland UK The Netherlands Switzerland UK The Netherlands Dentists 534.79 161.43 304.00 31.76 49.59 7.87 11.55 4.95 0.70 4.99 Hospitals 0.21 2.99 0.78 6.63 0.04 0.01

Figure 3

Age distribution of the gross annual number of dental X-rays

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Figure 4

Age distribution of the three most frequent dental examinations

Table 5

Gender distribution of the frequency of dental examinations Number 3114 1204 1323 789 162 73 Females (%) 53.8 58.9 55.6 54.4 52.5 32.9 Males (%) 46.2 41.1 44.4 45.6 47.5 67.1

Examination Periapical Long bitewing Short bitewing Panoramic radiography Teleradiography 14 exposure status

The Swiss average effective dose per intraoral examination is of the same order of magnitude as those measured internationally, but for panoramic procedures the Swiss average effective dose is about ve times higher than the international norms. It is not clear what underlies this high dose, but this issue should be investigated further, especially since panoramic procedures target predominantly teenagers as is shown in Figure 4. The Swiss

Table 6

Full dosimetric results by examination category Effective dose per examination (1026 Sv) 3.9 54 70 4.5 9 7.2 7.2 7.2 1.7 1220 489 60 2210 921 444 254 319 0.26 466 466 216 60 728 Collective effective dose (person.Sv) 11.5 3.5 0.6 5.3 11.6 0.2 0.17 0.008 0.001 6 4.4 5.2 3.2 0.85 0.08 0.013 0.023 0.0013 0.049 0.15 0.13 18.8 0.14 71.9 Effective dose per caput (1026 Sv) 1.6 0.5 0.09 0.7 1.6 0.03 0.024 0.001 0.0002 0.8 0.6 0.73 0.44 0.12 0.011 0.002 0.003 0.0002 0.007 0.02 0.018 2.6 0.02 10.1

Examination Periapical 14-exposure full mouth survey 18-exposure full mouth survey Short bitewing Long bitewing Upper occlusal view Lower occlusal view Lower occlusal view soft tissue Nose lateral view Skull, PA Skull, close range prole Teleradiography Skull, according to Blondeau Skull, according to Clementschitsch ller TMJ, according to Schu Jawbone prole Maxillary (overall view) Hand Mandible, premolar region Mandible, molar region Sinus Panoramic radiography CT Total

PA, posteroanterior; TMJ, temporomandibular joint

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Table 7

Dental radiology in Switzerland A Aroua et al

International comparison of average effective doses per dental examination (mSv) Switzerland 5.91 59.9 179 5.5 13.2 Healthcare Level I 13 12 16 The Netherlands 3.9 10 10 10 4.2 UK 10 11 10 Sweden 10 10 10 Japan 14 11 14

Type of examination Intraoral Panoramic Skull Others Average

average effective dose per skull prole is also found to be much higher (18 times) than the analogous Dutch dose. Note however that the Swiss gross average effective dose per dental X-ray matches well the corresponding averages measured internationally. Turning now to the collective dose, the total dental radiological irradiation was 71.9 person.Sv in Switzerland in 1998. It is of the same order of magnitude as the doses induced by mammography and conventional tomography, but one order of magnitude smaller than those contributed by angiography and interventional procedures, and two orders of magnitude lower than the doses transferred through CT and radiography types of examinations.24 Thus dental radiology, which accounts for 43% of the total number of examinations, contributes only 1.01% of the annual collective dose delivered by diagnostic and interventional radiology and estimated at 7110 person.Sv by this survey. Intraoral examinations account for 45.3% of the collective dental X-ray dose bitewing gives (23.5%), periapical (16%) and full mouth survey (5.8%). Panoral procedures contribute 26.2% to this dose while skull proles represent 27.4% of the whole dose. The calculation of the distribution of the dose by type of healthcare institution shows that dental practices generate 80.9% of the dose, dental institutes produce 16.1% of the whole, whereas hospitals contribute only 1.6%. The annual collective dose from dental X-ray examinations per caput measures the radiation exposure of the population while affording meaningful international comparisons. The Swiss value is 10.1 mSv, but it gets renormalized to 9.1 mSv on average once corrected for the patients age according to various age correction models.28 The Swiss value agrees with the corresponding average for countries of similar healthcare level,29 but it is about ten times larger than those of the UK and the Netherlands for 1998.30,31 This reects both the higher Swiss average effective dose per dental X-ray and the larger Swiss number of dental X-ray examinations per 1000 population. Use of collimators and digital imaging systems With regard to the use of collimators, the analysis of a sample of 486 responses indicates that round collimators are used in 85% of cases whereas the rectangular form is used in 15% of cases. For comparison, a recent study showed that in Belgium rectangular collimation is used by only 6% of the dentists.32 This practice is not dose economical since circular collimation involves X-ray beam areas much larger than the areas of lms. It has been shown that rectangular collimation that restricts the X-ray beam to
Dentomaxillofacial Radiology

the size of the lm can decrease the effective dose to the patient by a factor of four to ve without degrading the image quality.3,5,11 Recommendations should be formulated to address this needless irradiation of the patients. Concerning the use of digital imaging systems, the analysis of a sample of 218 dentists who answered the related question shows that less than 3% of them use digital radiology.

Conclusions This work brought to light the frequency patterns of dental radiological practice in Switzerland and determined its consequent effective and collective radiation doses. The nationwide survey indicates that 4.1 million dental radiological examinations were performed in 1998, i.e. about 581 dental X-ray procedures per 1000 population. This accounts for 43% of all X-ray examinations performed in the country. This number of dental radiographs per 1000 population is about 20% higher than the gure for 1978, and is part of a wider increasing pattern in the country during the past four decades. This Swiss frequency is higher than the UNSCEAR average for countries of similar healthcare level. Periapical, bitewing and panoramic examinations account for the bulk of the dental radiodiagnostic activity in the country. The collective dose associated with dental radiology was found to be 71 person.Sv, i.e. only 1% of the total collective dose associated with diagnostic and interventional radiology in the country. This collective dose amounts to an annual average effective dose to the population of 10 mSv per caput, which agrees with the corresponding UNSCEAR average effective dose for countries of similar healthcare level, but is about ten times larger than the analogous doses delivered in the Netherlands and the UK. Intraoral procedures contribute 45.3% of this collective dose, skull proles account for 27.4%, while panoramic examinations represent 26.2% of this dose. Since the Swiss average effective dose per panoral examination is about ve times higher than the international norms (healthcare level I average), and considering that the age distribution of patients undergoing panoramic procedures was found to contain a high fraction of children, care should be taken to investigate this radiological practice further and look for dose reduction opportunities. This probe should include the re-evaluation

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of the patterns and justication for prescribing this kind of examination. The investigation of the forms of collimators of dental radiology tubes and lm consumption found that round collimators are used in 85% of cases whereas the rectangular form is used in 15% of cases. This exposes patients to unnecessary irradiation because circularly collimated X-ray beams impinge on areas much larger than the areas of lms. Rectangular collimation and the use of sensitive F-speed lms can decrease the effective dose to the patient by a factor of four to ve without deteriorating the image quality. The investigation of the use of digital imaging systems showed that less than 3% of the dentists
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use this new technology. The evolution of digital radiology in dental medicine must be followed closely in order to assess its impact on the patient doses.

Acknowledgments This research project was funded by the Swiss Federal Ofce of Public Health (Contract no. 316.96.0576). A group of experts made up of the representatives of the major Swiss medical societies was in charge of following the progress of the survey. This group provided valuable assistance in the set up of the methodology, in getting the information from the practitioners and hospitals contacted and in the nal analysis of the results.

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