Recognizing New Procedures for Patient Protection

The concept of
ALARA As Low As Reasonably Achievable

November 2004
FDA accepted updated guidelines for dental radiography to achieve ALARA as presented by ADA representing many dental professional organizations.

What does it mean?

Very simply stated, treat each patient as an individual Selection criteria-Dentist must examine their patients before ordering radiographs Try to stay as far below dose limits as possible Be consistent with the purpose for which the activity is undertaken Use procedures that require the least amount of radiation exposure possible to produce the greatest amount of data Determine risk factors prior to exposing.

Protective Devices
Lead apron-not required if all other guidelines in 2004 report are followed rigorously Thyroid Collars-provide for all children and for adults when it wont interfere with examination

Protective Devices
Cephalometric imaging-filters for imaging the soft tissues of the facial profile together with the skeleton should be placed at the x-ray source rather than at the image receptor, the x-ray beam should be collimated to the area of clinical interest Image receptor (film speed)-use no speed slower than E speed

 CollimationRectangular collimation should be used for periapical radiography and when feasible for bitewing radiography

Another note on collimation.

Round cones can be adapted rather than replaced

Risk in relation to age

based upon a relative risk of 1 at age 30 Age Group (years) <10 10-20 20-30 30-50 50-80 80+ Multiplication factor for risk x3 x2 x 1.5 x 0.5 x 0.3 Negligible risk

It assumes the multiplicative risk projection model, averaged for the two sexes. In fact, risk for females is always relatively higher than for males.

Radiation Bone Marrow Effects Radiation Effects to Thyroid Embryo/Fetus Radiation Effects

Radiation Effects to Gonads

Radiation Bone Marrow Effects

Risk to marrow is induction of leukemia < 1% bodys total marrow exposed to dental x-rays (mandibular marrow spaces) FMXR with round collimation is 0.142 mSv FMXR with rectangular collimation is 0.06mSv. Total Mean Active Bone Marrow Dosage 0.01 mSv for Pano The mean active bone marrow dose from one chest film is 0.03 mSv Threshold leukemia induction estimated whole-body exposure of 50 mSv

Radiation Effects to Thyroid

100 mSv reported for thyroid carcinoma induction FMXR thyroid exposure < 0.3 mSv Panoramic thyroid dose 0.04 mSv Effects may be more significant in children because of more active metabolic rates 50% reduction in exposure by using thyroid collar on apron

Radiation Effects to Gonads

Gonadal dental x-ray exposure result of secondary (scatter) radiation Gonadal scatter exposure from FMXR is approximately 0.002 mSv DOSE IS REDUCED 98% BY LEADED APRON!! FMXR gonadal exposure with leaded apron is 10 times less than average background daily exposure!

Embryo/Fetus Radiation Effects

Pregnant patients should have radiographs taken if needed for diagnosis Congenital defects negligible from gonadal exposures < 200 mSv (Hiroshima survivor study)

Single x-ray exposure < 0.001 mSv with leaded apron

Probability of 1st generation defect from dental x-rays is 9 in one billion

Basic Principles
Time

Distance

Shielding

Dose Equivalents for Dental Films

Full-mouth series
D Speed Film .084 mSv F Speed Film <.033 mSv

BWXR (4 films)
D Speed Film .017 mSv F Speed Film <.007 mSv

Panoramic radiograph .007 mSv Average natural background radiation 3 mSv / yr (.01 mSv / day)

Compared to Other X-ray Exams

Chest x-ray Skull x-ray Abdomen x-ray Barium exam Head CT Body CT 0.01 0.05 mSv 0.1 0.2 mSv 0.6 1.7 mSv 3 8 mSv 2 4 mSv 5 15 mSv

Estimates of Life Expectancy Loss

Health Risk Smoking 20 cigs/day Overweight (15%) Alcohol (US Average) All accidents All natural hazards Rad dose of 3 mSv/yr Time Lost 6 years 2 years 1 year 207 days 7 days 15 days
Cohen, Health Physics, 1991

New Patients

 Child with primary dentition

BW only if interproximal spaces cannot be viewed or probed

Child with transitional dentition

Add periapicals or panoramic to evaluate development

Adolescents
Because of increase in possibility of periodontal disease panoramic is recommended

 Adult
Posterior bitewings, and selected periapicals or panoramic, a full-mouth series is preferred when the patient has evidence of disease or history of extensive treatment

Adult edentulous
Individualized exam based on clinical signs and symptoms

Recall Patients

Recall patients with increased risk for caries

Child or adolescent
Every 6-12 months

Adult dentate or partially edentulous

Caries risk assessment should determine frequency Every 6-18 months

Adult edentulous
Radiographs should not be performed without evidence of pathology

Recall patients with no increased risk for caries

Children with primary or transitional dentition
BW every 12-24 months If proximal surfaces cannot be examined visually or with a probe

Adolescents
BW every 18-36 months

Adult
BW every 24-36 months

Recall patient with periodontal disease

Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease. May include BW and or periapical images of selected areas where periodontal disease can be identified clinically.

Clinical situations for which radiographs may be indicated

1. Positive clinical findings
Previous treatment History of pain or trauma Familial history of dental anomalies Etc. Clinical evidence of periodontal disease Large or deep restorations Deep carious lesions Malposed or impacted teeth Swelling Etc

2. Positive clinical signs and symptoms

Factors increasing risk for caries may include

High level of caries experience or demineralization History of recurrent caries High number of cariogenic bacteria Poor quality of existing restorations And the list goes on.

Improving Patient Care with ALARA

Patient A
22 year old female Recall patient-every 6 months Negative medical history Lives in a community with fluoridated water Has had no previous dental restorations in permanent teeth

When should BW radiographs be made?

A. B. C. D. Every 6 months Every year Every 2 years None of the above

Answer
C. Every two years

Sources
Perry, D.A., Beemsterboer, P.L., & Taggart, E.J.(2001). Periodontology for the dental hygienist. Philadelphia, PA: W.B. Saunders Company. Iannucci-Haring, J. & Jansen, L. (2000). Dental radiography: Principles and techniques. Philadelphia, PA: W.B. Saunders Company. DiGangi, P. (2006) ALARA: What does it mean? Contemporary Oral Hygiene, March 2006, 22-28. Thompson, E.M. (2006) Radiation safety update. Contemporary Oral Hygiene, March 2006, 10-17.

Sources
FDA website
http://www.fda.gov/cdrh/radhlth/adaxray-1.html

Radiation Health in Dentistry Procter & Gamble Website for Professionals Continuing Education Section www.dentalcare.com

Thanks for your attention!