Dose and Risk in Radiography

This section considers governmental dose limits on individuals who are occupationally exposed and members of the general population, amounts of radiation received by patients in dental and medical radio- graphy, and the estimated risks from these exposures.

DOSE LIMITS
Recognition of the harmful effects of radiation and the risks involved with its use led the National Council on Radiation Protection and Measurements (NCRP) and the International Commission on Radio- logical Protection (ICRP) to establish guidelines for limitations on the amount of radiation received by both occupationally exposed individuals and the public. Since their establishment in the 1930s, these dose limits have been revised downward several times. These revisions reflect the increased knowledge concerning the harmful effects of radiation and the increased ability to use radiation more efficiently. The current occupational exposure limits have been established to ensure that no individuals will have deterministic effects and that the probability for stochastic effects is as low as reasonably and economically feasible (Table 3-2). Note that there are no limits on the exposure a patient can receive from diagnostic or therapeutic exposures. Dose limits from man-made sources for members of the general public, not occupationally exposed, have been established at 10% of that of occupationally exposed individuals. The negligible individual dose, established by the NCRP, is considered to be the dose below which any effort to reduce the radiation exposure may not be costeffective. In spite of the NCRPs endorsement of the nonthreshold hypothesis for purposes of radiation safety, it is thought that the impact on society of radiation exposure of this magnitude is negligible. Dentists and their staff are occupationally exposed workers and are allowed to receive up to 50 mSv of whole-body radiation exposure per year (Table 3-2). Although this is considered to present only a minimal risk, every effort should be made to keep the dose to all individuals as low as practical. As a profession we do rather well. The average dose for individuals occupationally exposed in the operation of dental x-ray equipment is far less than the limit: 0.2 mSv, or 0.4% of the allowable exposure.

PATIENT EXPOSURE AND DOSE

Patient dose from dental radiography is usually reported as the amount of radiation received by a target organ. Although the actual exposures may vary considerably, Table 3-3 shows typical doses from various examinations. The equivalent exposure from natural and man-made background sources is shown. It may be seen that dental exposures are a small fraction of the annual average background expo- sure. The most radiosensitive target organs commonly studied include bone marrow, thyroid gland, brain, and salivary glands. The mean active bone marrow dose is an important measurement because bone marrow is the target organ thought

responsible for radiation-induced leukemia. Particular concern has been expressed over exposure of the thyroid because this gland has one of the highest radiation-induced cancer rates. There are also reports of brain and salivary gland tumors after therapeutic and diagnostic x-ray examinations.

Reducing Dental Exposure

There are three guiding principles in radiation protection; the first is the principle of justification. In making dental radiographs this principle obligates the dentist to do more good than harm. In radiology this means the dentist should identify those situations where the benefit to a patient from the diagnostic exposure exceeds the low risk of harm. In practice this principle influences what patients we select for radiographic examinations and what examina- tions we choose. These matters are considered in Chapter 15, Guidelines for Prescribing Dental Radiographs. The second guiding rule is the principle of optimization. This prin- ciple holds that dentists should use every means to reduce unneces- sary exposure to their patient and themselves. This philosophy of radiation protection is often referred to as the principle of ALARA (As Low As Reasonably Achievable). ALARA holds that exposures to ion- izing radiation should be kept as low as reasonably achievable, eco- nomic and social factors being taken into account. The means to accomplish this end are considered later in this chapter. The third principle is that of dose limitation. Dose limits are used for occupational and public exposures to ensure that no individuals are exposed to unacceptably high doses. There are no dose limits for individuals exposed for diagnostic or therapeutic purposes. The dentist in each facility is responsible for the design and conduct of the radiation protection program. In this section, methods of exposure and dose reduction are described that can be used in dental radiography. Each subsection begins with a recommendation of the American Dental Association (ADA) Council on Scientific Affairs. This is followed by a discussion of ways in which these recom- mendations can be satisfied.

PATIENT SELECTION CRITERIA

Dentists should not prescribe routine dental radiographs at preset intervals for all patients. Instead, they should prescribe radiographs after an evaluation of the patients needs that includes a health history review, a clinical dental history assessment, a clinical examination, and an evaluation of susceptibility to dental diseases. (ADA, 2006) Radiographic selection criteria are clinical or historical findings that identify patients for whom a high probability exists that a radiographic examination will provide information affecting their treatment or prognosis. These criteria satisfy the principle of justification and are considered in Chapter 15.

Dosis dan Resiko pada Radiografi

Pada bagian ini dibahas batas dosis yang dikeluarkan pemerintah pada individu yang terekspos sinar x karena pekerjaannya dan masyarakat umum pada suatu populasi, jumlah radiasi yang diterima pasien di radiografi kedokteran gigi dan kedokteran dan memperkirakan resiko dari paparan tersebut.

BATAS DOSIS
Karena efek berbahaya dari radiasi dan resiko yang ada pada penggunaanya. Maka National Council on Radiation Protection and Measurements (NCRP) dan International Commission on Radiological Protection (ICRP) menetapkan panduan untuk pembatasan jumlah radiasi yang diterima baik oleh individu yang terekspos karena pekerjaannya maupun masy masyarakat umum. Sejak penetapannya tahun 1930, batas dosis telah direvisi beberapa kali. Revisi - revisi ini mencerminkan peningkatan ilmu pengetahuan mengenai bahaya efek radiasi dan meningkatnya kemampuan untuk menggunakan radiasi dengan lebih efisien. Batas paparan pada pekerja terkini telah ditetapkan untuk memastikan tidak ada individu yang mempunyai efek deterministic dan kemungkinan untuk efek stochastic serendah dan seekonomis mungkin.(Tabel 3-2). Note that there are no limits on the exposure a patient can receive from diagnostic or therapeutic exposures. Dosis batas dari buatan manusia sumber bagi anggota masyarakat umum, bukan pekerjaannya terekspos, telah didirikan di 10% dari individu pekerjaannya terekspos. Dosis individu yang diabaikan, yang ditetapkan oleh NCRP tersebut, dianggap merupakan dosis bawah yang setiap upaya untuk mengurangi paparan radiasi mungkin tidak efektif secara finansial. Meskipun pengesahan NCRP terhadap hipotesis tanpa

ambang bertujuan untuk keamanan radiasi, diperkirakan bahwa dampak terhadap masyarakat dari paparan radiasi sebesar ini diabaikan. Mereka yang pekerjaannya terekspos sinar x seperti dokter gigi dan staf pekerja diperbolehkan untuk menerima hingga 50 mSv dari seluruh tubuh paparan radiasi per tahun (Tabel 3-2). Meskipun hal ini dianggap hanya menyajikan risiko minimal, setiap upaya harus dilakukan untuk menjaga dosis untuk semua individu serendah mungkin.

Sumber: STUART C. WHITE, 2009. Oral Radiology PRINCIPLES and INTERPRETATION, Missouri: Mosby.

SPECIAL CONSIDERATIONS
Pregnancy Occasionally it is desirable to obtain radiographs of a woman who is pregnant. The x-ray beam is largely confined to the head and neck region in dental x-ray examinations; thus, fetal exposure is only about 1 microgray (Gy) for a full-mouth examination. This exposure is quite small compared with that received normally from natural back- ground sources. However, concerns have been raised about a possible relationship between maternal radiation dose to the thyroid gland from dental radiographs and low birth-weight babies, prompting the ADA to recommend the use of protective thyroid collars and aprons during dental radiography, especially of children, women of child- bearing age,

and pregnant women. Because the use of radiographs in all patients is predicated on there being a diagnostic need for them, the guidelines apply to patients who are pregnant as well as those who are not. Radiation Therapy Patients with a malignancy in the oral cavity or perioral region often receive radiation therapy for their disease. Some oral tissues receive 50 Gy or more. Although such patients are often apprehensive about receiving additional exposure, dental exposure is insignificant com- pared with what they have already received. The average skin dose from a dental radiograph is approximately 3 milligrays (mGy), less if faster film or digital imaging is used. Furthermore, patients who have received radiation therapy may have radiation-induced xerostomia and thus are at a high risk for development of radiation caries, which may produce serious consequences if extractions are needed in the future. Accordingly, patients who have had radiation therapy to the oral cavity should be carefully followed up because they are at special risk for dental disease.

RADIOGRAPHIC TECHNIQUES FOR ENDODONTICS

Radiographs are essential to the practice of endodontics. Not only are they indispensable for determining the diagnosis and prognosis of pulp treatment, they also are the most reliable method of managing endodontic treatment. The presence of a rubber dam, rubber dam clamp, and root canal instruments may complicate an intraoral peri- apical examination by impairing proper receptor positioning and aiming cylinder angulation. Despite these obstacles, certain require- ments must be observed: 1. The tooth being treated must be centered in the image. 2. The receptor must be positioned as far from the tooth and apex as the region permits to ensure that the apex of the tooth and some periapical bone are apparent on the radiograph. For maxillary projections, the patient is seated so that the sagittal plane is perpendicular and the occlusal plane is parallel to the floor. For mandibular projections, the patient is seated upright with the sagittal plane perpendicular and the tragus-to-corner of the mouth line parallel to the floor. Specially designed receptor holders for end- odontic radiographs are available (Fig. 9-12). These instruments fit over files, clamps, and the rubber dam without touching the subject tooth. The aiming cylinder is aligned so as to direct the central ray perpendicular to the center of the receptor. Often a single radiograph of a multirooted tooth made at the normal vertical and horizontal projection does not display all the roots. In these cases, when it is necessary to separate the roots on multirooted teeth, a second projection may be made. The horizontal angulation is altered 20 degrees mesially for maxillary premolars, 20 degrees mesially or distally for maxillary molars, or 20 degrees distally for an oblique projection of mandibular molar roots.

If a sinus tract is encountered, its course is tracked by threading a No. 40 gutta-percha cone through the tract before the radiograph is made. It also is possible to localize and determine the depth of peri- odontal defects with this gutta-percha tracking technique. A final radiograph of the treated tooth is made to demonstrate the quality of the root canal filling and the condition of the periapical tissues after removal of the clamp and rubber dam.

PREGNANCY
Although a fetus is sensitive to ionizing radiation, the amount of exposure received by an embryo or fetus during dental radiography is extremely low. No incidences have been reported of damage to a fetus from dental radiography. Regardless, prudence suggests that such radiographic examinations be kept to a minimum consistent with the mothers dental needs. As with any patient, radiographic examination is limited during pregnancy to cases with a specific diag- nostic indication. With the low patient dose afforded by use of optimal radiation safety techniques (see Chapter 3), an intraoral or extraoral examination can be performed whenever a reasonable diagnostic requirement exists.

EDENTULOUS PATIENTS
Radiographic examination of edentulous patients is important, whether the area of interest is one tooth or an entire arch. These areas may contain roots, residual infection, impacted teeth, cysts, or other pathologic entities that may adversely affect the usefulness of pros- thetic appliances or the patients health. After a determination has been made that these entities are not present, repeated examinations to detect them are not warranted in the absence of signs or symptoms. If available, a panoramic examination of the edentulous jaws is most convenient. If abnormalities of the alveolar ridges are identified, the higher resolution of periapical receptor is used to make intraoral projections to supplement the panoramic examination. In a completely or partly edentulous patient, a receptor-holding device is used for intraoral radiography of the alveolar ridges. Place- ment of the receptor-holding instrument may be complicated by its tipping into the voids normally occupied by the crowns of the missing teeth. To manage this difficulty, cotton rolls are placed between the ridge and the receptor holder, supporting the holder in a horizontal position. An orthodontic elastic band to hold cotton rolls to the bite- block on the receptor holder often is useful when several such projec- tions must be exposed. With elastics, it is simple to maneuver the cotton rolls into the areas that require support. The patient may steady the receptorholding instrument with a hand or an opposing denture. If panoramic equipment is not available, an examination consist- ing of 14 intraoral views provides an excellent survey. The exposure required for an edentulous ridge is approximately 25% less than that for a dentulous ridge. This examination consists of

seven projections in each jaw (adult No. 2 receptor) as follows: Central incisors (midline): one projection Lateral canine: two projections Premolar: two projections Molar: two projections