Radiation Safety FDA Guidelines

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Dental Radiation and Radiography Safety

FDA uvvdn e Guaidlan ds
MaryLou Austin, RDH, MS

Michelle Jameson, MA
Hd let Siadn id Eiaecvs fcv uvvdn e Publai Dcm an Eiui ticn an Ddn tisevy
3 vdiae Hcuvs (3 Es)
Publai ticn D ed:

J n u vy 2019
Expav ticn D ed:

Ddidmbdv 2020
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Ttd iuvvdn e edvm cf ppvce l dxedn is fvcm J n u vy 1, 2019 ec Ddidmbdv 31, 2020. Pvceaidv ID# 373218. lafcvn a iP
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1
© 2019 Austin edia Asscia eds LL All iahtes idsdvedi
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TABLE OF CONTENTS
INSTiU TIONS ............................................................................................................................................................2

LEAiNING OBJE TIVES ...............................................................................................................................................4
BA KGiOUND ............................................................................................................................................................4
INTiODU TION ..........................................................................................................................................................5
PATIENT SELE TION iITEiIA ....................................................................................................................................5
RECOMMENDATIONS FOR PRESCRIBING DENTAL RADIOGRAPHS .......................................................................................... 6
EXPLANATION OF RECOMMENDATIONS FOR PRESCRIBING DENTAL RADIOGRAPHS ............................................................ 9
LIeITING iADIATION EXPOSUiE ............................................................................................................................ 15
RECEPTOR SELECTION ........................................................................................................................................................... 16
RECEPTOR HOLDERS .............................................................................................................................................................. 16
COLLIMATION ........................................................................................................................................................................ 17
OPERATING POTENTIAL AND EXPOSURE TIME ..................................................................................................................... 17
PATIENT SHIELDING AND POSITIONING ................................................................................................................................ 17
OPERATOR PROTECTION ....................................................................................................................................................... 18
HAND-HELD X-RAY UNITS ...................................................................................................................................................... 18
FILM EXPOSURE AND PROCESSING ....................................................................................................................................... 18
QUALITY ASSURANCE ............................................................................................................................................................ 19
TECHNIQUE CHARTS/PROTOCOLS ......................................................................................................................................... 19
RADIATION RISK COMMUNICATION ..................................................................................................................................... 19
TRAINING AND EDUCATION .................................................................................................................................................. 21
2014 FDA UPDATE: DOSES AND FILe SPEED .......................................................................................................... 21

ON LUSION ........................................................................................................................................................... 23
iEFEiEN ES ............................................................................................................................................................ 23
EXAe – iADIOGiAPHY SAFETY: FDA UiiENT ...................................................................................................... 25
FAX ANSWEi SHEET ................................................................................................................................................ 28
3
Click HERE to Access
ONLINE EXAM
LEARNING OBJECTIVES
Upon completion of this course, the dental professional will:
 Un idvse n i etd FDA’s vcld an etd vdhul eacn n i pvcmceacn cf v ia eacn safety in clinical dentistry.
 Know updated FDA recommendations for patient selection criteria in prescribing dental
radiographs.
 Understand basic radiography technique and rationale for clinical choices in types of dental
radiography.
 Review criteria for radiographic screening with regard to patient medical history, clinical
presentation and risk assessment.
 Know clinical methods to limit radiation exposure for operator and patient.
 Know FDA recommendations for particular clinical situations (highlighted in green).
BACKGROUND
Dental professionals are committed to delivering the highest quality of care to each individual patient
and to applying advancements in technology and science in order to continually improve the oral
health status of the U.S. population. Guaidlan ds wdvd idedlcpdi ec sdved s n ijun ie ec etd idn ease’s
professional judgment of how to best use diagnostic imaging for each patient. Radiographs can help
dental practitioners evaluate and definitively diagnose many oral diseases and conditions. However,
dentists must weigh the benefits of taking dental radiographs against the risk of exposing a patient to
x-rays, the effects of which accumulate from multiple sources over time.
Dentists, knowing patients' health histories and vulnerabilities to oral disease are in the best position
to make this judgment call in the interest of each patient. For this reason, guidelines are intended to
serve as resources for practitioners and are not intended as standards of care, requirements or
regulations.
Guidelines are not substitutes for clinical examinations and health histories. Dentists are advised to
conduct clinical examinations, consider patients’ signs, symptoms and oral and medical histories, as
well as consider patients’ vulnerability to environmental factors that may affect oral health. Diagnostic
and evaluative information informs the type of imaging to be used and/or frequency of its use. Dentists
should only order radiographs when they expect additional diagnostic information will affect patient
care.
Based on this premise, guidelines can be used by dentists to optimize patient care, minimize radiation
exposure and responsibly allocate health care resources.
This course deals only with standard dental imaging techniques of intraoral and common extra-oral
examinations, excluding cone-beam computed tomography (CBCT). At this time, indications for CBCT
examinations are not well developed and are still under consideration by the FDA and ADA.
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INTRODUCTION
Ttd huaidlan ds eaeldi, “Ttd Sdldieacn cf P eadn es fcv X-i y Ex man eacn ” wdvd favse idedlcpdi an 1987 by
a panel of dental experts convened by the Center for Devices and Radiological Health of the U.S. Food
and Drug Administration (FDA). At that time, the development of the guidelines was spurred by
icn idvn bcue etd U.S. pcpul eacn ’s ece l dxpcsuvd ec v ia tion from all sources. Thus, guidelines were
developed to promote the appropriate use of x-rays. In 2002, the American Dental Association,
recognizing that dental technology and science continually advance, recommended to the FDA that the
guidelines be reviewed for possible updating. Ttd FDA wdlicmdi cvh n azdi idn easevy’s an edvdse an
maintaining the guidelines, and so the American Dental Association, in collaboration with a number of
dental specialty organizations and the FDA, published updated guidelines in 2004. This course reviews
the 2004 guidelines and includes recommendations for limiting exposure to radiation. FDA materials
issued are in the public domain and dental professionals are encouraged to use this information to
make better clinical choices for patient and operator safety.
PATIENT SELECTION CRITERIA
Radiographs and other imaging modalities are used to diagnose and monitor oral disease, as well as to
monitor dento-facial development and the progress or prognosis of therapy. Radiographic
examinations can be performed using digital imaging or conventional film. The available evidence
suggests that either is a suitable diagnostic method. Digital imaging may offer reduced radiation
exposure and the advantage of image analysis that may enhance sensitivity and reduce errors
introduced by subjective analysis.
A study of 490 patients found that basing selection criteria on clinical evaluations for asymptomatic
patients, combined with selected periapical radiographs for symptomatic patients, can result in a 43 %
reduction in the number of radiographs taken without clinically consequential increases in the rate of
undiagnosed disease. The development and progress of many oral conditions are associated with a
p eadn e’s hd, se he of dental development and vulnerability to known risk factors. Therefore,
guidelines in Table 1 are presented within a matrix of common clinical and patient factors which may
determine the type (s) of radiographs commonly needed. Guidelines assume that diagnostically
adequate radiographs can be obtained. If they cannot, appropriate management techniques should be
used after consideration of relative risks and benefits to the patient.
Along the horizontal axis of the matrix, patient age categories are described, each with its usual dental
developmental stage: child with primary dentition (prior to eruption of the first permanent tooth),
child with transitional dentition (after eruption of the first permanent tooth), adolescent with
permanent dentition (prior to eruption of third molars), adult who is dentate or partially edentulous
and adult who is edentulous.
Alcn h etd edveai l xas, etd eypd cf dn icun edv waet etd idn e l sysedm as i edhcvazdi ( s “Ndw P eadn e”
cv “idi ll P eadn e”) lcn h waet ilan ai l iaviumse n ies and oral diseases present during such an
dn icun edv. Ttd “Ndw P eadn e” i edhcvy vdfdvs ec p eaents who are new to the dentist and thus, are
being evaluated for oral disease and status of dental development. Typically, such a patient receives a
comprehensive evaluation or, in some cases, a limitei de lu eacn fcv spdiafai pvcbldm. Ttd “idi ll
5
P eadn e” i edhcvads idsivabd p eadn es wtc t ed t i vdidn e icmpvdtdn saed de lu eacn by etd idn ease
and, typically, have returned as a patient of record for a periodic evaluation or for treatment.
However, “idi ll P eadn e” m y lsc vdeuvn fcv lamaedi de lu eacn cf spdiafai pvcbldm, ide aldi
and extensive evaluation for a specific problem(s) or for a comprehensive evaluation.
Both categories are marked with a single asterisk that corresponds to a footnote that appears below
the matrix. Ttd fccen ced lases “Pcsaeaed Hasecvai l Fan ian hs” n i “Pcsaeaed lan ai l Sahn s/Sympecms” fcv
which radiographs may be indicated. The lists are not intended to be all-inclusive, rather they offer
clinicians further guidance to help clarify his or her specific judgment on a case.
Clinical circumstances and oral diseases presented with the types of encounters include: clinical caries
or increased risk for caries, no clinical caries or no increased risk for caries, periodontal disease or a
history of periodontal treatment, growth and development assessment and other circumstances. A few
dx mplds cf “Oetdv aviumse n ids” pvcpcsdi vd: dxasean h ampl n es, cetdv idn e l n i iv n acf ia l
pathoses, endodontic/restorative needs and remineralization of dental caries. These examples are not
intended to be an exhaustive list of circumstances for which radiographs or other imaging may be
appropriate.
Ttd i edhcvads, “ lan ai l vads cv In ivd sdi iask fcv vads” n i “Nc lan ai l vads n i No Increased
iask fcv vads” vd m vkdi waet icubld sedvask et e icvvdsponds to a footnote appearing below the
matrix. The footnote contains links to the ADA Caries Risk Assessment Forms (0 – 6 years of age and
over 6 years of age). It should be noted et e p eadn e’s vask se eus i n it n hd cedv eamd n i stculi bd
periodically reassessed.
The panel has also made the following recommendations applicable to all categories:
 Intraoral radiography is useful for evaluation of dento-alveolar trauma. If the area of interest
extends beyond the dento-alveolar complex, extra-oral imaging may be indicated.
 Care should be taken to examine all radiographs for evidence of caries, bone loss from periodontal
disease, developmental anomalies and occult disease.
 Radiographic screening for the purpose of detecting disease before clinical examination should not
be performed. A thorough clinical examination, consideration of the patient’s history, review of any
prior radiographs, caries risk assessment and consideration of boet etd p eadn e’s idn e l n i general
health needs should precede radiographic examination.
Patients often seek care on a routine basis in part, because oral disease may develop in the absence of
clinical symptoms. Since attempts to identify specific criteria in which to accurately predict finding
interproximal carious lesions have not been successful for individuals, the panel recommended time-
based schedules for taking radiographs intended for detection of dental caries. Each schedule provides
a range of recommended intervals derived from research results into rates at which interproximal
caries progress through tooth enamel. Recommendations are modified by criteria that place individuals
at increased risk for dental caries. Professional judgment should be used to determine optimum times
for radiographic examination within suggested intervals.
RECOMMENDATIONS FOR PRESCRIBING DENTAL RADIOGRAPHS

These recommendations are subject to clinical judgment and may not apply to every patient. They are
to be used by deneases cn ly fedv vdeadwan h p eadn es’ td let tasecvads n i icmpldean h clinical
examinations. Even though radiation exposure from dental radiographs is low, once a decision to
6
cbe an v iachv pts as m id, ae as etd idn tise's vdspcn sabalaey ec fcllcw etd ALAiA Pvan iapld (As Lcw s
id scn bly Aitade bld) ec man amazd p tidn e dxpcsuvd.
T bld 1 – bdlcw:
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
TYPE OF Child with Primary Child with Adolescent with Adult, Dentate or Adult, Edentulous
ENCOUNTER Dentition (pvacv ec Transitional Permanent Partially Edentulous
dvupeacn cf favse Dentition ( fedv Dentition (pvacv ec
pdvm n dn e eccet) dvupeacn cf favse dvupeacn cf etavi
pdvm n dn e eccet) mcl vs)
New Patient* In iaeaiu lazdi In iaeaiu lazdi In iaeaiu lazdi v iachv ptai dx m icn sasean h cf In iaeaiu lazdi
bdan h de lu edi fcv v iachv ptai dx m v iachv ptai dx m pcsedvacv baedwan hs waet p n cv mai dx m cv v iachv ptai
cv l iasd sds. icn sasean h cf icn sasean h cf pcsedvacv baedwan hs n i sdldiedi pdva pai l dx m, b sdi cn
sdldiedi pcsedvacv baedwan hs am hds. A full mcuet an ev cv l v iachv ptai ilan ai l sahn s
pdva pai l/ciilus l waet p n cv mai dx m dx m as pvdfdvvdi wtdn etd p eadn e t s n i sympecms.
eadws n i/cv cv pcsedvacv ilan ai l deaidn id cf hdn dv lazdi cv l iasd sd cv
pcsedvacv baedwan hs n i tasecvy cf dxedn saed idn e l evd emdn e.
baedwan hs af sdldiedi pdva pai l
pvcxam l suvf ids am hds.
i n n ce bd
easu lazdi cv
pvcbdi. P eadn es
waetcue deaidn id
cf iasd sd n i
waet cpdn
pvcxam l icn e ies
m y n ce vdquavd
v iachv ptai dx m
e etas eamd.
Recall Patient* Pcsedvacv baedwan h dx m e 6-12 mcn et an edve ls af pvcxam l Pcsedvacv baedwan h Nce pplai bld
waet ilan ai l i vads suvf ids i n n ce bd dx man di easu lly cv waet pvcbd. dx m e 6-18 mcn et
cv e an ivd sdi vask an edve ls.
fcv i vads. **
Recall Patient* Pcsedvacv baedwan h dx m e 12-24 mcn et Pcsedvacv baedwan h Pcsedvacv baedwan h Nce pplai bld
waet n c ilan ai l an edve ls af pvcxam l suvf ids i n n ce bd dx m e 18-36 dx m e 24-36 mcn et
i vads n i n ce e dx man di easu lly cv waet pvcbd. mcn et an edve ls. an edve ls.
an ivd sdi vask fcv
i vads. **
Recall Patient* lan ai l juihmdn e s ec etd n ddi fcv n i eypd cf v iachv ptai am hds fcv etd de lu eacn cf Nce pplai bld
waet pdvacicn e l pdvacicn e l iasd sd. Im han h m y icn sase cf, bue as n ce lamaedi ec, sdldiedi baedwan h n i/cv
iasd sd. pdva pai l am hds cf vd s wtdvd pdvacicn e l iasd sd (cetdv et n n cn spdiafai han haeaeas) i n bd
idmcn sev edi ilan ai lly.
7
PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE
TYPE OF Child with Primary Child with Adolescent with Adult, Dentate or Adult, Edentulous
ENCOUNTER Dentition (pvacv ec Transitional Permanent Partially Edentulous
dvupeacn cf favse Dentition ( fedv Dentition (pvacv ec
pdvm n dn e eccet) dvupeacn cf favse dvupeacn cf etavi
pdvm n dn e eccet) mcl vs)
Patient (New and lan ai l juihmdn e s Usu lly n ce an iai edi fcv mcn aecvan h cf
lan ai l juihmdn e s ec n ddi fcv n i eypd
Recall) ec n ddi fcv n i hvcwet n i idedlcpmdn e. lan ai l
cf v iachv ptai am hds fcv de lu eacn
fcv mcn aecvan h cf eypd cf v iachv ptai juihmdn e s ec etd n ddi fcv n i eypd cf
n i/cv mcn aecvan h cf idn ec-f ia l hvcwet
idn ec-f ia l am hds fcv v iachv ptai am hd fcv de lu eacn cf idn e l
n i idedlcpmdn e cv ssdssmdn e cf
hvcwet n i de lu eacn n i/cv n i skdlde l vdl eacn staps.
idn e l n i skdlde l vdl eacn staps.
idedlcpmdn e, mcn aecvan h cf
n i/cv idn ec-f ia l hvcwet
ssdssmdn e cf n i idedlcpmdn e,
idn e l/skdlde l cv ssdssmdn e cf
vdl eacn staps. idn e l n i skdlde l
vdl eacn staps.
P n cv mai cv
pdva pai l dx m ec
ssdss idedlcpan h
etavi mcl vs.
Patient waet cetdv

lan ai l juihmdn e s ec n ddi fcv n i eypd cf v iachv ptai am hds fcv de lu eacn n i/cv mcn aecvan h cf etdsd
iaviumse n ids
icn iaeacn s.
an iluian h, bue n ce
lamaedi ec,
pvcpcsdi cv
dxasean h ampl n es,
cetdv idn e l n i
iv n acf ia l
p etcsds,
vdsecv eaed/
dn icicn eai n ddis,
evd edi
pdvacicn e l
iasd sd n i i vads
vdman dv laz eacn .
* lan ai l saeu ticn s fcv wtait v iachv pts m y bd an iai edi an iluid, bue vd n ce lamaedi ec:
A. Pcsatied Hasecvai l Fan ian hs

1. Pvdeacus pdvacicn e l cv dn icicn tii evd emdn e.
2. Hasecvy cf p an cv ev um .
3. F mala l tasecvy cf idn e l n cm lads.
4. Pcsecpdv tied de lu ticn cf td lan h.
5. idman dv laz ticn mcn aecvan h.
6. Pvdsdn id cf ampl n es, pvdeacus ampl n e-vdl edi p etcsas cv de lu ticn fcv ampl n e pl idmdn e.
B. Pcsatied lan ai l Sahn s/Sympecms
1. lan ai l deaidn id cf pdvacicn e l iasd sd.
2. L vhd cv iddp vdsecv ticn s.
3. Dddp i vacus ldsacn s.
4. e lpcsdi cv ilan ai lly amp iedi eddet.
5. Swdllan h.
6. Eeaidn id cf idn e l/f ia l ev um .
7. ecbalaey cf eddet.
8
8. San us ev ie (“fiseul ”).
9. lan ai lly suspdiedi san us p etcsas.
10. Gvcwet bn cvm latids.
11. Ov l an ecledmdn e an kn cwn cv suspdiedi sysedmai iasd sd.
12. Pcsatied n duvclchai fin ian hs an etd td i n i n dik.
13. Eeaidn id cf fcvdahn cbjdies.
14. P an n i/cv iysfun iticn cf etd edmpcvcm n iabul v jcan e.
15. F ia l symmdevy.
16. Abuemdn e eddet fcv fixdi cv vdmce bld p vti l pvcsetdsas.
17. Un dxpl an di blddian h.
18. Un dxpl an di sdn satieaey cf eddet.
19. Un usu l dvupticn , sp ian h cv mahv ticn cf eddet.
20. Un usu l eccet mcvptclchy, i liafii ticn cv iclcv.
21. Un dxpl an di bsdn id cf eddet.
22. lan ai l eccet dvcsacn .
23. Pdva-ampl n titis.
EXPLANATION OF RECOMMENDATIONS FOR PRESCRIBING DENTAL RADIOGRAPHS

Explanations below present rationale for each recommendation by type of encounter, patient age and
dental developmental stage.
New Patient Being Evaluated for Oral Diseases

Child (Primary Dentition)
Proximal carious lesions may develop after interproximal spaces between posterior primary teeth
close. Open contacts in primary dentition allows dentists to visually inspect proximal posterior
surfaces. Closure of proximal contacts requires radiographic assessment.16-18. However, evidence
suggests many lesions will remain in the enamel for sometimes 12 months or longer depending on
fluoride exposure, which allows sufficient time for implementation and evaluation of preventive
interventions. A periapical/anterior occlusal examination may be indicated because of the need to
evaluate dental development, dento-alveolar trauma or suspected pathoses. Periapical and bitewing
radiographs may be required to evaluate pulp pathosis in primary molars.
Therefore, an individualized radiographic examination consisting of selected

periapical/occlusal views and/or posterior bitewings if proximal surfaces cannot be examined
visually or with a probe is recommended. Patients without evidence of disease and with
open proximal contacts may not require radiographic examination at this time.
Child (Transitional Dentition)

Overall dental caries in the primary teeth of children from 2-11 years declined from the early 1970s
until the mid 1990s. From the mid 1990s until the 1999-2004 National Health and Nutrition
Examination Survey, there was a small, but significant, increase in primary decay. This trend reversal
was larger for younger children. Tooth decay affects more than one-fourth of U.S. children aged 2–5
years and half those aged 12-15 years. However, its prevalence is not uniformly distributed. About half
of all children and two-thirds of adolescents aged 12–19 years from lower-income families have had
decay.
9
Children and adolescents of some racial and ethnic groups and those from lower-income families have
more untreated tooth decay. Ttdvdfcvd, ae as ampcve n e ec icn saidv itali’s risk factors for caries
before taking radiographs.
Although periodontal disease is uncommon in children, when clinical evidence exists (except for
nonspecific gingivitis), selected periapical and bitewing radiographs are indicated in order to determine
the extent of aggressive periodontitis, other forms of uncontrolled periodontal disease and the extent
of osseous destruction related to metabolic disease.
Periapical or panoramic examinations are useful for evaluating dental development. Panoramic
radiographs are also useful for evaluation of craniofacial trauma. Intraoral radiographs are more
accurate than panoramic radiographs when evaluating dento-alveolar trauma, root shape, root
resorption and pulp pathosis. However, panoramic examinations may have the advantage of reduced
radiation dose, cost and imaging of a larger area.
Occlusal radiographs may be used separately or in combination with panoramic radiographs in the
following situations:
 Unsatisfactory image in panoramic radiographs due to abnormal incisor relationship.

 Localizations of tooth position.
 When clinical grounds provide a reasonable expectation that pathosis exists.
Therefore, an individualized radiographic examination consisting of posterior bitewings with

panoramic examination or posterior bitewings and selected periapical images is
recommended.
Adolescent (Permanent Dentition)

Caries in permanent teeth declined among adolescents, while the prevalence of dental sealants
increased significantly. However, increasing independence and socialization, changing dietary patterns
and decreasing attention to daily oral hygiene characterizes this age group. Each of these factors may
result in an increased risk of dental caries. Another consideration, although uncommon, is the
increased incidence of periodontal disease found in this age group compared to children.
Panoramic radiography is effective in dental diagnosis and treatment planning. Specifically, the status
of dental development can be assessed using panoramic radiography. Occlusal and/or periapical
radiographs can be used to detect the position of an unerupted or supernumerary tooth. Third molars
also should be evaluated in this age group for their presence, position and stage of development.
Therefore, an individualized radiographic examination consisting of posterior bitewings

with panoramic examination or posterior bitewings and selected periapical images is
recommended. A full mouth, intraoral radiographic examination is preferred when the
patient presents clinical evidence of generalized oral disease or a history of extensive
dental treatment.
10
Adult (Dentate or Partially Edentulous)
Dental caries prevalence in the US adult population has declined from the early 1970s until the most
recent (1999-2004) National Health and Nutrition Examination Survey. However, risk for dental caries
exists on a continuum and changes over time as risk factors change. Therefore, it is important to
evaluate proximal surfaces in the new adult patient for carious lesions. In addition, it is important to
examine patients for recurrent dental caries.
The incidence of root surface caries increases with age. Although bitewing radiographs can assist in
detecting root surface caries in proximal areas, the usual method of detecting root surface caries is
through clinical examination.
The incidence of periodontal disease increases with age. Although new adult patients may not have
symptoms of active periodontal disease, it is important to evaluate previous experience with
periodontal disease and/or treatment. Therefore, a high %age of adults may require selected intraoral
radiographs to determine the current status of the disease.
Taking posterior bitewing radiographs of new adult patients was found to reduce the number of
radiological findings and the diagnostic yield of panoramic radiography. In addition, the following
clinical indicators for panoramic radiography were identified as the best predictors for useful
diagnostic yield: suspicion of teeth with periapical pathologic conditions, presence of partially erupted
teeth, caries lesions, swelling and suspected un-erupted teeth.
Therefore, an individualized radiographic examination, consisting of posterior bitewings

with selected periapical images or panoramic examination when indicated is
recommended. A full mouth intraoral radiographic examination is preferred when the
patient has clinical evidence of generalized oral disease or a history of extensive dental
treatment.
Adult (Edentulous)
Clinical and radiographic examinations of edentulous patients generally occur during an assessment of
the need for prostheses. The most common pathological conditions detected are impacted teeth and
retained roots with and without associated disease. Other, less common conditions also may be
detected: bony spicules along the alveolar ridge, residual cysts or infections, developmental
abnormalities of the jaws, intraosseous tumors and systemic conditions affecting bone metabolism.
Original recommendations for this group call for a full-mouth intraoral radiographic examination or a
panoramic examination for new, edentulous adult patients. This recommendation was made, because
examinations of edentulous patients generally occur during assessments for prostheses, and
edentulous patients are at increased risk for oral disease.
Studies have found that from 30 to 50 % of edentulous patients exhibited abnormalities in panoramic
radiographs. In addition, radiographic examinations reveal anatomic considerations that may influence
prosthetic treatment, such as the location of the mandibular canal, position of the mental foramen and
maxillary sinus and relative thickness of soft tissue covering the edentulous ridge. However, in studies
that considered treatment outcomes, there was little evidence to support screening radiography for
new edentulous patients.
11
For example, one study reported that less than 4 % of such findings resulted in treatment modification
before denture fabrication, and another study showed no difference in post-denture delivery
complaints in patients who did not receive screening pre-treatment radiographs.
The panel concluded that prescription of radiographs is appropriate as part of initial assessments of
edentulous areas for possible prosthetic treatment. A full mouth series of periapical radiographs or a
combination of panoramic, occlusal or other extra-oral radiographs may be used to achieve diagnostic
and therapeutic goals. Radiographs can be an important aid in diagnosis, prognosis and the
determination of treatment complexity particularly with the option of dental implant therapy for
edentulous patients
Therefore, an individualized radiographic examination based on clinical signs, symptoms,
and treatment plan is recommended.
Recall Patient with Clinical Caries or Increased Risk for Caries

Child (Primary and Transitional Dentition) and Adolescent (Permanent Dentition)
Clinically detectable dental caries may suggest the presence of proximal carious lesions that can only
be detected with a radiographic examination. In addition, patients who are at increased risk for
developing dental caries because of such factors as poor oral hygiene, high frequency of exposure to
sucrose-containing foods and deficient fluoride intake are more likely to have proximal carious lesions.
The bitewing examination is the most efficient method for detecting proximal lesions.
The frequency of radiographic recall should be determined on the basis of caries risk assessment. It
should be noted that a patidn e’s i vads vask se eus m y it n hd cedv eamd n i et e n an iaeaiu l’s
radiographic recall interval may need to be changed accordingly.
Therefore, a posterior bitewing examination is recommended at 6 to 12 month intervals if

proximal surfaces cannot be examined visually or with a probe.
Adult (Dentate and Partially Edentulous)

Adults who exhibit clinical dental caries or who have other increased risk factors should be monitored
carefully for any new or recurrent lesions detectable only by radiographic examination. Frequency of
radiographic recall should be determined on the basis of caries risk assessment. It should be noted that
p eadn e’s vask se eus i n it n hd cedv eamd n i et e n an iaeaiu l’s v iachv ptai vdi ll an edve l m y
need to be changed accordingly.
Therefore, a posterior bitewing examination is recommended at 6 to 18 month intervals.
12
Recall Patient (Edentulous Adult)
A study that assessed radiographs of edentulous recall patients showed previously detected incidental
findings did not progress and that no intervention was indicated. The data suggest patients who
receive continuous dental care do not exhibit new findings requiring treatment.
An examination for occult disease in this group cannot be justified on the basis of prevalence,
morbidity, mortality, radiation dose and/or cost.
Therefore, no radiographic examination is recommended without evidence of disease.
Recall Patient with No Clinical Caries and No Increased Risk for Caries
Child (Primary and Transitional Dentition)
Despite a general decline in dental caries prevalence, recent data show subgroups of children to have a
higher caries experience than the overall population. Identification of patients in these subgroups may
be difficult on an individual basis. For children who present for recall examination without evidence of
clinical caries and who are not considered at increased risk for development of caries, it remains
important to evaluate proximal surfaces by radiographic examination. In primary teeth, the caries
process can take approximately one year to progress through the outer half of the enamel and another
year to progress through the inner half. Considering the rate of progression of carious lesions through
primary teeth, a time-based interval for radiographic examination from one to two years for this group
appears appropriate. The prevalence of carious lesions increases during the stage of transitional
dentition. Children under routine professional care would be expected to be at a lower risk for caries.
Nevertheless, newly erupted teeth are at risk for development of dental caries.
Therefore, a radiographic examination consisting of posterior bitewings is recommended

at intervals of 12 to 24 months if proximal surfaces cannot be examined visually or with a
probe.

Adolescents with permanent dentition, who are free of clinical dental caries and factors that would
place them at increased risk for developing dental caries, should be monitored carefully for
development of proximal carious lesions, which may only be detected by radiographic examination.
The caries process, on average, takes more than three years to progress through the enamel. However,
evidence suggests that enamel of permanent teeth undergoes post-eruptive maturation and that
young permanent teeth are susceptible to a faster progression of carious lesions.

at intervals of 18 to 36 months.
13
Adult (Dentate and Partially Edentulous)
Adult dentate patients, who receive regularly scheduled professional care and are free of signs and
symptoms of oral disease, are at a low risk for dental caries. Nevertheless, consideration should be
given to the fact that caries risk can vary over time as risk factors change. Advancing age and changes
in diet, medical history and periodontal status may increase the risk for dental caries.

at intervals of 24 to 36 months.
Recall Patient with Periodontal Disease

Child (Primary and Transitional Dentition), Adolescent (Permanent Dentition) and Adults
For patients who have clinical evidence or a history of periodontal disease/treatment, the decision to
obtain radiographs should be determined on the basis of anticipating resultant, important diagnostic
and prognostic information. Structures or conditions assessed should include the level of supporting
alveolar bone, condition of the interproximal bony crest, length and shape of roots, bone loss in
furcations and calculus deposits. Frequency and type of radiographic examinations of these patients
should be determined based on clinical examinations of the periodontium and documented signs and
symptoms of periodontal disease. The procedure for prescribing radiographs for follow-up/recall
periodontal patients would be to use selected intraoral radiographs to verify clinical findings on a
patient-by-patient basis.
Therefore, it is recommended that clinical judgment be used in determining the need for,
and type of, radiographic images necessary for evaluation of periodontal disease.
Imaging may consist of, but is not limited to, selected bitewing and/or periapical images
of areas where periodontal disease (other than nonspecific gingivitis) can be identified
clinically.
Patient (New and Recall) for Monitoring of Dento-Facial Growth and Development, and/or
Assessment of Dental/Skeletal Relationships
Child (Primary and Transitional Dentition)
For children with primary dentition, before the eruption of the first permanent tooth, radiographic
examination to assess growth and development in the absence of clinical signs or symptoms is unlikely
to yield productive information. Any abnormality of growth and development suggested by clinical
findings should be evaluated radiographically on an individual basis. After eruption of the first
permanent tooth, the child may have a radiographic examination to assess growth and development.
This examination need not be repeated unless dictated by clinical signs or symptoms. Cephalometric
radiographs may be useful for assessing growth and/or dental and skeletal relationships.
and type of, radiographic images necessary for evaluation and/or monitoring of dento-
facial growth and development or assessment of dental and skeletal relationships. 14
During adolescence there is often a need to assess the growth status and/or dental and skeletal
relationships of patients in order to diagnose and treat their malocclusions. Appropriate radiographic
assessment of malocclusions should be determined on an individual basis.
An additional concern relating to patient growth and development in this age group is to determine
the presence, position and development of third molars. This determination can best be made by the
use of selected periapical images or a panoramic examination once the patient is in late adolescence
(16 to 19 years of age).
and type of, radiographic images necessary for evaluation and/or monitoring of dento-
facial growth and development or assessment of dental and skeletal relationships.
Panoramic or periapical examination may be used to assess developing third molars.
Adult (Dentate, Partially Edentulous and Edentulous)

In the absence of any clinical signs or symptoms suggesting growth and development abnormalities in
adults, no radiographic examinations are indicated for this purpose.
Therefore, in the absence of clinical signs and symptoms, no radiographic examination is
recommended.
Patients with Other Circumstances

(Including, but not limited to, proposed or existing implants, other dental and craniofacial pathoses,
restorative/endodontic needs, treated periodontal disease and caries remineralization)
All Patient Categories

The use of imaging as a diagnostic and evaluative tool has progressed beyond the longstanding need to
diagnose caries and evaluate the status of periodontal disease. Expanded imaging technology is now
used to diagnose other orofacial clinical conditions and evaluate treatment options. A few examples of
other clinical circumstances are the use of imaging for dental implant treatment planning, placement,
or evaluation, the monitoring of dental caries and remineralization, the assessment of restorative and
endodontic needs and diagnosis of soft and hard tissue pathoses.
and type of, radiographic images necessary for evaluation and/or monitoring in these
circumstances.
LIMITING RADIATION EXPOSURE

Dental radiographs account for approximately 2.5 % of the effective dose received from medical
radiographs and fluoroscopies. Even though radiation exposure from dental radiographs is low, once a
decision to obtain radiographs is made it is the dentist's responsibility to follow the ALARA Principle (As
15
Low as Reasonably Achievable) to minimize patient exposure. Examples of good radiologic practice
include:
 The use of the fastest image receptor compatible with diagnostic task (F-speed film or digital).
 The collimation of the beam to the size of the receptor whenever feasible.
 The proper film exposure and processing techniques.
 The use of protective aprons and thyroid collars, when appropriate.
 Limiting the number of images obtained to the minimum necessary to obtain essential diagnostic
information.
RECEPTOR SELECTION
The American National Standards Institute and the International Organization for Standardization have
established standards for film speed. Film speeds available for dental radiography are D-speed, E-speed
and F-speed with D-speed being the slowest and F-speed the fastest. According to the U.S. Food and
Drug Administration, switching from D to E speed can produce a 30 to 40 % reduction in radiation
exposure. The use of F-speed film can reduce exposure 20 to 50 % compared to use of E-speed film
without compromising image quality.
Exposure of extra-oral films such as panoramic radiographs requires intensifying screens to minimize
radiation exposure to patients. The intensifying screen consists of layers of phosphor crystals that
fluoresce when exposed to radiation. In addition to the radiation incident on the film, the film is
exposed primarily to light emitted from the intensifying screen. Previous generations of intensifying
screens were composed of phosphors such as calcium tungstate. However, rare-earth intensifying
screens are recommended, bdi usd etdy vdiuid p eadn es’ radiation exposure by 50 % compared with
calcium tungstate-intensifying screens. Rare-earth film systems, combined with high-speed films of 400
or greater can be used for panoramic radiographs. Older panoramic equipment can be retrofitted to
reduce radiation exposure to accommodate the use of rare-earth, high-speed systems.
Digital imaging provides an opportunity to further reduce radiation dosage by 40 to 60 %. In digital
radiography, there are three types of receptors that take the place of conventional film: charge-
coupled devices (CCD), complementary-metal-oxide-semiconductors (CMOS) and photo-stimulable
phosphor (PSP) plates. Systems that use CCD and CMOS-based, solid-state detectors are called
“iavdie.” Wtdn etdsd sensors receive energy from x- ray beams, the CCD or CMOS chip sends a signal
to the computer and an image appears on the monitor within seconds. Systems that use PSP plates are
i lldi “an iavdie.” Wtdn etdsd pl eds vd avv ia edi, l edn e am hd as seored on them. The plate is
scanned, and the scanner transmits the image to the computer.
RECEPTOR HOLDERS
Holders that align the receptor precisely with the collimated beam are recommended for periapical
and bitewing radiographs. Heat-sterilizable or disposable intraoral radiograph receptor-holding devices
are recommended for optimal infection control. Dental professionals should not hold receptor holders
during exposure. Under extraordinary circumstances, in which p eadn e’s f maly mdmbdv(s) or other
caregiver) must provide restraint or hold a receptor holder in place during exposure, he or she should
wear appropriate shielding.
16
COLLIMATION
Collimation limits the amount of radiation, both primary and scattered, to which patients are exposed.
Added benefits of rectangular collimation are improvements in contrast as a result of reductions in
fogging caused by secondary and scattered radiation. The x-ray beam should not exceed the minimum
coverage necessary, and each dimension of the beam should be collimated so that the beam does not
exceed the receptor by more than 2 % of the source-to-image receptor distance. Since a rectangular
collimator decreases a radiation dose by up to fivefold as compared to a circular one, radiographic
equipment should provide rectangular collimation for periapical and bitewing radiograph exposures.
Receptor-holding devices minimize the risk of cone-cutting (non-exposure of part of the image
receptor due to malalignment of the x-ray beam). Position-indicating devices should be open ended
and have metallic linings to restrict the primary beam and reduce the tissue volume exposed to
radiation. Use of long source-to-skin distances of 40 cm, rather than short distances of 20 cm,
decreases exposure by 10 to 25 %. Distances between 20 and 40 cm are appropriate, but longer
distances are optimal.
OPERATING POTENTIAL AND EXPOSURE TIME

Operating potentials of dental x-ray units affect radiation dosage and backscatter radiation. Lower
voltages produce higher-contrast images, higher entrance skin doses and lower deep-tissue doses and
levels of backscatter radiation. However, higher voltages produce lower contrast images that enable
better separation of objects with differing densities. Thus, the diagnostic purpose of the radiograph
should inform the kilovolt setting selection. A setting above 90 kVp will increase the patient dose and
should not be used. The optimal operating potential of dental x-ray units is between 60 and 70 kVp.
Filmless technology is much more forgiving to overexposure often resulting in unnecessary radiation
exposure. Dental practitioners should strive to set the x-ray unit exposure time to the lowest setting
that provides a diagnostic image. If possible, operators should always confirm the dose delivered falls
within the m n uf ieuvdv’s dxpcsuvd an idx. Imaging plates should be evaluated at least monthly and
cleaned as necessary.
PATIENT SHIELDING AND POSITIONING

The amount of scattered radiation striking a p eadn e’s bicmen during a properly conducted
radiographic examination is negligible. The thyroid gland is susceptible to radiation exposure during
dental radiographic exams given its anatomic position, particularly in children. Protective thyroid
collars and collimation substantially reduce radiation exposure to the thyroid during dental
radiographic procedures. Because every precaution should be taken to minimize radiation exposure,
protective thyroid collars should be used when possible. If all recommendations for limiting radiation
exposure are put into practice, the gonadal radiation dose will not be significantly affected by use of
abdominal shielding. Therefore, use of abdominal shielding may not be necessary.
Protective aprons and thyroid shields should be hung or l ai fl e n i n dedv fclidi, n i m n uf ieuvdv’s
instructions should be followed. All protective shields should be evaluated for damage (e.g. tears,
folds, and cracks) monthly using visual and manual inspection.
Proper education and training in patient positioning is necessary to ensure panoramic radiographs are
of diagnostic quality.
17
OPERATOR PROTECTION
Although dental professionals receive less exposure to ionizing radiation than do other occupationally
exposed health care workers, operator protection measures are essential to minimize exposure.
Operator protection measures include education, the implementation of a radiation protection
program, occupational radiation exposure limits, recommendations for personal dosimeters and the
use of barrier shielding. The maximum permissible annual dose of ionizing radiation for health care
workers is 50 millisieverts (mSv), and the maximum permissible lifetime dose is 10 mSv multiplied by a
pdvscn ’s hd an yd vs. Pdvscn l icsamdedvs stculi bd usdi by wcvkdvs wtc m y receive an annual dose
greater than 1 mSv to monitor exposure levels. Pregnant dental personnel operating x-ray equipment
should use personal dosimeters regardless of anticipated exposure levels.
Operators of radiographic equipment should use barrier protection when possible, and barriers should
ideally contain a leaded glass window to enable the operator to view the patient during exposure.
When shielding is not possible, the operator should stand at least two meters (6 feet) from the tube
head and out of the path of the primary beam. The National Council on Radiation Protection and
ed suvdmdn es vdpcve “i ia eacn Pvcedieacn an Ddn easevy” cffdvs ide aldi an fcvm eacn cn stadlian h n i
office design. State radiation control agencies can help assess whether barriers meet minimum
standards.
HAND-HELD X-RAY UNITS

Hand-held, battery-powered x-ray systems are available for intra-oral radiographic imaging.
A hand-held exposure device is activated by a trigger on the handle of the device. Dosimetry studies
indicate these hand-held devices present no greater radiation risk to the patient or operator than
standard dental radiographic units. No additional radiation protection precautions are needed when
the device is used according to m n uf ieuvdv’s instructions. These include: holding the device at mid-
torso height, orienting the shielding ring properly with respect to the operator and keeping the cone as
close to thd p eadn e’s f id s pv ieai l. If hand-held device is operated without the ring shield in
place, it is recommended the operator wear a lead apron.
All operators of hand-held units should be instructed on their proper storage. Due to the portable
nature of these devices, they should be secured properly when not in use to prevent accidental
damage, theft or operation by an unauthorized user. Hand-held units should be stored in locked
cabinets, locked storage rooms or locked work areas when not under the direct supervision of an
individual authorized to use them. Units with user-removable batteries should be stored with batteries
removed. Records listing names of approved individuals who are granted access and use privileges
should be prepared and kept current.
FILM EXPOSURE AND PROCESSING

All film should be processed following the film and processer manufacturer recommendations. Once
this is achieved, the x-ray operator can adjust the tube current and time and establish techniques that
provide consistent dental radiographs of diagnostic quality. Poor processing technique, including sight-
developing, most often results in underdeveloped films. This forces the x-ray operator to increase the
dose to compensate resulting in patient and operator being exposed to unnecessary radiation.
18
A safelight does not provide completely safe exposure for an indefinite period of time. Extra-oral film is
much more sensitive to fogging. The length of time for which a film can be exposed to the safelight
should be determined for the specific safelight/film combination in use.
QUALITY ASSURANCE
Quality assurance protocols for the x-ray unit, imaging receptor, film processing, dark room and patient
shielding should be developed and implemented in each dental health care setting. All quality
assurance procedures including date, procedure, results and corrective action should be logged for
documentation purposes. A qualified expert should survey all x-ray units on their placement and
should resurvey the equipment every four years or after any changes that may possibly affect radiation
exposure of the operator and others. State agencies typically perform surveys, and individual state
regulations should be consulted regarding specific survey intervals. Film processors should be
evaluated during their initial installations and on a monthly basis thereafter. Processing chemistry
should be evaluated daily, and each type of film should be evaluated monthly or when a new box or
batch of film is opened. Abdominal shielding and thyroid collars should be inspected visually for
creases or clumping that may indicate voids in their integrity on a monthly basis. Damaged abdominal
shielding and collars should be replaced. Table 2 (below) lists specific quality assurance procedures
covering x-ray units, film processors, image receptor devices and darkroom and abdominal shielding
and collars.
It is imperative ttd cpdv ecv’s m n u l fcv ll am han h iquasaeacn t viware is readily available to users
and that equipment is operaedi n i m an e an di fcllcwan h m n uf ieuvdv’s an sevuieacn s--including any
appropriate adjustments for optimizing dose and image quality.
TECHNIQUE CHARTS/PROTOCOLS
Size-based technique charts/protocols with suggested parameter settings are important for ensuring
radiation exposure is optimized for all patients. Technique charts should be used for all systems with
adjustable settings, such as tube potential, tube current and time or pulses. The purpose of using
charts is to control the amount of radiation to patients and the receptor. Technique charts are tables
that indicate appropriate settings on the x-ray unit for specific anatomical areas and will help ensure
the least amount of radiation exposure to patients and operators while consistently producing a good-
quality radiograph.
Technique charts for intraoral and extra-oral radiography should list type of exam, patient size (small,
medium, large) for adults and children. The speed of film used, or use of a digital receptor should also
be listed on technique charts. Charts should be posted near the control panel where the technique is
adjusted for each x-ray unit. A regularly updated technique chart should be developed for each x-ray
unit. Charts will also need to be updated when a different film or sensor, new unit or new screens are
used.
RADIATION RISK COMMUNICATION

Dentists should be prepared to discuss with their patients the benefits and risks of x-ray exams. To help
answer patient and parent questions about dental radiology radiation safety, the American Academy of
Oral and Maxillofacial Radiology and the Alliance for Radiation Safety in Pediatric Imaging partnered to
create a brochure written for parents and patients.
19
Table 2
The following procedures for periodic assessment of the performance of radiographic equipment, film
processing equipment, image receptor devices, dark room integrity and abdominal and thyroid
shielding are adapted from the National Council for Radiation Protection and Measurements report,
“i ia eacn Pvcedieacn an Ddn easevy.” Please refer to state guidelines for specific regulations.
Quality Assurance Procedures for Assessment of Radiographic Equipment
Equipment Frequency Method
X-v y e itan d On an se ll ticn In spditicn by qu lafidi dxpdve ( s spdiafidi by

Ae vdhul v an edve ls s hcedvn mdn e vdhul ticn s n i m n uf ieuvdvs
vdicmmdn idi by se ed vdicmmdn i ticn s).
vdhul ticn s.
Wtdn dedv etdvd vd n y it n hds
an an se ll ticn wcvklc i cv
cpdv tin h icn iaticn s.
On an se ll ticn . Method 1: Sensitometry and Densitometry

Falm Pvcidsscv D aly. A sdn saecmdedv as usdi ec dxpcsd film, fcllcwdi by
se n i vi pvcidssan h cf etd film. Ttd pvcidssdi film
wall t ed idfin di p ttdvn cf cptii l idn satids.
Ttd idn satids vd md suvdi waet idn saecmdedv.
Ttd idn saecmdedv md suvdmdn es vd
icmp vdi ec etd idn satids cf films dxpcsdi n i
pvcidssdi un idv aid l icn iaticn s.
A it n hd an idn saecmdedv e luds an iai eds
pvcbldm waet daetdv etd idedlcpmdn e timd,
edmpdv euvd cv etd idedlcpdv scluticn s.
Advantages
Aiiuv iy.
Spddi.
Disadvantage
Expdn sd cf iiaticn l dquapmdn e
Method 2: Reference Film

A film dxpcsdi n i pvcidssdi un idv aid l
icn iaticn s as tt itdi ec etd icvn dv cf eadw bcx s
vdfdvdn id film. Subsdqudn e films vd icmp vdi
waet etd vdfdvdn id film.
Advantage
cse dffditiedn dss.
Disadvantage
Ldss sdn satied
20
Quality Assurance Procedures for Assessment of Radiographic Equipment
Equipment Frequency Method
Im hd ididpecv Ddeaids. ecn etly. Method 1: Sensitometry and Densitometry

Waet d it n dw b eit cf film. ( s idsivabdi bced)
Method 2: Reference Image ( s idsivabdi
bced)
In edn safyan h Sivddn . Eedvy sax mcn ets. Vasu l an spditicn cf i ssdttd an edhvaey.
Ex man ticn cf an edn safyan h sivddn fcv siv eitds.
Exev -cv l ssdttds. Ddedlcpmdn e cf n un dxpcsdi film et e t s bddn an

etd i ssdttd dxpcsdi ec n cvm l lahttin h fcv cn d tcuv
cv mcvd.
D vkvccm In edhvaey. On an se ll ticn . Wtald an i vkvccm waet etd s fdlahte cn , pl id

ecn etly. mde l cbjdie (suit s ican ) cn un wv ppdi film fcv
Aftdv it n hd an etd lahttin h filedv pdvaci et e as dquae ldn e ec etd timd vdquavdi fcv
cv l mp. eypai l i vkvccm pvcidiuvd. Ddedlcp film.
Ddediticn cf etd cbjdie an iai eds pvcbldm waet etd
s fdlahte cv lahte ld ks an etd i vkvccm.
Abicman l n i Ttyvcai ecn etly. (easu l n i m n u l All pvceditied stadlis stculi bd de lu edi fcv
Stadlian h. an spditicn ) i m hd (d.h., ed vs, fclis, n i iv iks) mcn etly usan h
easu l n i m n u l an spditicn . If idfdie an etd
ttdn u tin h m edva l as suspdiedi, v iachv ptai cv
flucvcsicpai an spditicn m y bd pdvfcvmdi s n
ledvn tied ec ammdia edly vdmcean h etd aedm fvcm
sdveaid. cn saidv ticn stculi bd haedn ec
man amazan h etd v ia ticn dxpcsuvd cf an spdiecvs by
man amazan h un n didss vy flucvcsicpy.
TRAINING AND EDUCATION

Where permitted by law, auxiliary dental personnel can perform intraoral and extra-oral imaging.
Personnel certified to take dental radiographs should receive appropriate education. Practitioners
should remain informed about safety updates and the availability of new equipment, supplies and
techniques that could further improve the diagnostic quality of radiographs and decrease radiation
exposure. Free training materials are available for limiting radiation exposure in dental imaging
through the International Atomic Energy Agency.
2014 FDA UPDATE: DOSES AND FILM SPEED
Ttd FDA as dn icuv han h idn e l pvcfdssacn ls ec m kd sampld n i dicn cmai swaeit ec "f sedv" X-v y
film ec fuvetdv vdiuid v ia ticn dxpcsuvd. Ttd fcllcwan h vtiild dxpl an s wty.
21
Dental intraoral radiography is a very common exam performed in the United States, with
approximately 100 million done each year. In 1999, The Nationwide Evaluation of X-ray Trends (NEXT)
program performed a survey of dental facilities performing this exam throughout the United States.
NEXT is a federal and state cooperative effort to document, through annual surveys, the state of
clinical practice for selected radiographic examinations.
The 1999 NEXT Dental survey provided insights into dental radiography practice. Among the extensive
information gathered, the survey documented the number of films taken per visit, the types of film
used by dental practitioners and measures of patient exposure. Among the findings, the survey
illustrated that the majority of films taken during a routine dental intraoral examination involved either
two films (32% of facilities surveyed) or four films (35% of facilities surveyed) with an overall average of
close to four (3.5) films observed. The film typically used for the intraoral bitewing exam falls into three
film speed classes: D (slowest), E and F-speed (fastest). Like photographic film, the faster the film the
less exposure it needs. Film speed can be an important aspect in determining the amount of radiation
exposure received by a patient. The greater the film speed the lesser the exposure received by the
patient. The types of film used by dental practices in this survey varied, with D-speed film comprising
approximately 70% of film used, E-speed film about 21% and F-speed film about 9%.
For the 1999 survey, the amount of radiation a person is typically subjected to for D-speed film was 1.7
milligray (mGy) (a unit of radiation exposure) per film and 1.3 mGy for E-speed film. These results show
a 23% reduction in exposure with the use of E-speed film over D-speed film. Major dental film
manufacturers and literature on this subject have extensively reported similar differences in exposure
between film speeds. Results reported in literature illustrate that switching from D to E-speed
produced a 30-40% reduction in exposure. Switching from E to F-speed produced a 20-25% reduction
in exposure and switching from D to F-speed film produced a 60% reduction in exposure.
When considering these results, one should ask whether there is need or cause for concern. As noted
in the NEXT survey, 70% of dental practitioners chose D-speed film with its higher patient dose. Dental
procedures are repeated from childhood throughout life. There is a slight risk of excess cancers with
today's children at greater risk. The limited use of E or F-speed films compared with D-speed films is
often due to misconceptions about price, clinical film quality and processing. A comparison of one
manufacturer's D-speed film to E-speed or F-speed film shows no significant clinical differences in
quality between the films. Using E-speed or F-speed film provides a similar mean-correct diagnosis,
comparable sensitometric properties (i.e. technical aspects of film imaging) and similar clarity of film
compared to D-speed film. E-speed or F-speed film is processed without significant changes in
processing practices to those used for D-speed film.
Regarding the price difference between E or F-speed film and D-speed film, the related costs boil down
to a matter of several cents increase per film from D to F! As listed by an internet on-line, dental film
vendor, a package (usually containing 100 or 150 films) of F-speed film is only $4.00 more than for the
same package of D-speed film. This amount averages to only pennies per film, with a one-third
reduction in exposure to patients.
Conclusion: The facts that E and F-speed film products offer significant exposure reduction compared
with D-speed film and that they cost approximately the same and offer comparable clinical benefits
strongly support a change of practice for those facilities that continue to use slow-speed film products
that contribute to patients' exposures which are greater than necessary. Ask your dentist or dental
technician if they use the faster E or F-speed film and tell them the reasons for your inquiry.
22
ARTICLE REFERENCES
 Conference of Radiation Control Program Directors, Inc. (CRCPD), Publication E-03-6, "NEXT
Tabulation and Graphical Summary of the 1999 Dental Radiography Survey", November 2003.
 ADA Council on Scientific Affairs "An update of Radiographic Practices: Information and
Recommendations", JADA, Vol. 132, February 2001.
 Academy of Dental Therapeutics and Stomatology, Continuing Education Course, "Successful
Intraoral Radiography.
CONCLUSION
Ddn eases stculi icn iuie ilan ai l dx man eacn , icn saidv etd p eadn e’s cv l n i medical histories, as
wdll s icn saidv p eadn es’ euln dv balaeads to environmental factors that may affect oral health before
conducting a radiographic examination. This information should guide dentists in determining type of
imaging to be used, frequency of its use and number of images to obtain. Radiographs should be taken
only when there is an expectation that the diagnostic yield will affect patient care.
Dentists should develop and implement a radiation protection program in their offices. In addition,
practitioners should remain informed on safety updates and the availability of new equipment,
supplies and techniques that could further improve the diagnostic ability of radiographs and decrease
exposure.
REFERENCES
*Original FDA reference list to support evidence based material as presented in the course.
1. The American Dental Association Council on Scientific Affairs. The Use of Cone-Beam Computed Tomography in
Dentistry. J Am Dent Assoc 2012;143(8):899-202.
2. Atchison KA, White SC, Flack VF, Hewlett ER. Assessing the FDA Guidelines for Ordering Dental Radiographs. J Am Dent
Assoc 1995;126(10):1372-83.
3. Atchison KA, White SC, Flack VF, Hewlett ER, Kinder SA. Efficacy of the FDA Selection Criteria for Radiographic
Assessment of the Periodontium. J Dent Res 1995;74(7):1424-32.
4. Pitts NB, Kidd EA. The Prescription and Timing of Bitewing Radiography in the Diagnosis and Management of Dental
Caries: Contemporary Recommendations. Br Dent J1992;172(6):225-7.
5. Smith NJ. Selection Criteria for Dental Radiography. Br Dent J 1992; 173(4):120-1.
6. Hintze H. Screening with Conventional and Digital Bite-Wing Radiography Compared to Clinical Examination Alone for
Caries Detection in Low-Risk Children. Caries Res 1993;27(6):499-504.
7. Wenzel A. Current Trends in Radiographic Caries Imaging. Oral Surg Oral Med Oral Pathol 1995;80(5):527-39.
8. White SC, Heslop EW, Hollender LG, et al. Parameters of Radiologic Care: An Official Report of the American Academy
of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91(5):498-511.
9. Newman B, Seow WK, Kazoullis S, Ford D, Holcombe T. Clinical Detection of Caries in the Primary Dentition With and
Without Bitewing Radiography. Aust Dent J 2009;54(1):23-30.
10. Clark HC, Curzon ME. A Prospective Comparison between Findings from a Clinical Examination and Results of Bitewing
and Panoramic Radiographs for Dental Caries Diagnosis in Children. Eur J Paediatr Dent 2004;5(4):203-9.
23
11. Lith A. Frequency of Radiographic Caries Examinations and Development of Dental Caries. Swed Dent J Suppl
2001(147):1-72.
12. National Institute of Dental Research. The Prevalence of Dental Caries in United States Children, 1979-1980.
Department of Health and Human Services-National Institutes of Health. 1981;NIH publication no. 82-2245.
13. National Institute of Dental Research. The National Survey of Dental Caries in U.S. School Children: 1986-1987.
Department of Health and Human Services–National Institutes of Health. 1989;NIH publication no. 89-2247.
14. National Center for Chronic Disease Prevention and Health Promotion. Oral Health: Preventing Cavities, Gum Disease,
Tooth Loss, and Oral Cancers at a Glance 2011. www.cdc.gov/chronicdisease/resources/publications/AAG/doh.htm
(accessed November 14, 2011).
15. Research Science and Therapy Committee American Academy of Periodontology. Position paper: Periodontal Diseases
of Children and Adolescents. J Periodontol 2003;74(11):1696-704.
16. Anthonappa RP, King NM, Rabie AB, Mallineni SK. Reliability of Panoramic Radiographs for Identifying Supernumerary
Teeth in Children. Inter J Paediatr Dent 2012;22(1):37-43.
17. National Institute for Dental and Craniofacial Research. Dental Caries (Tooth Decay) in Adults (Age 20 to 64).
http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesAdu lts20to64 (accessed March
21, 2012).
18. Centers for Disease Control and Prevention. Recommendations for Using Fluoride to Prevent and Control Dental
Caries in the United States. MMWR 2001;50(No. RR-14).
19. National Council on Radiation Protection and Measurements, ed NCRP Report No. 160-Ionizing Radiation Exposure of
the Population of the United States. Bethesda: National Council on Radiation Protection and Measurements; 2009.
20. American National Standards Institute. Photography-Intra-Oral Dental Radiographic Film-Specification. New York:
American National Standards Institute. 1997;ANSI/NAPM IT2.49-1997. ANSI/ISO 3665:1996.
21. American National Standards Institute. Photography-Direct-Exposing Medical and Dental Radiographic Film/Process
Systems-Determination of ISO Speed and ISO Average Gradient. New York: American National Standards Institute.
1983;ISO 5799:1991. ANSI PH2.50-1983.
22. U.S. Food and Drug Administration. Dental Radiography: Doses and Film Speed. http://www.fda.gov/Radiation-
Emitting Products/Radiation Safety/Nationwide Evaluation of X-Ray Trends NEXT/ucm116524.htm. (accessed August
2011).
23. National Council for Radiation Protection & Measurements, ed. NCRP Report No. 145-Radiation Protection in
Dentistry. Bethesda: National Council on Radiation Protection and Measurement; 2003.
24. Centers for Disease Control and Prevention. Guidelines for Infection Control in Dental Health-Care Settings-2003.
MMWR 2003;52(No. RR-17):31.
25. Alliance for Radiation Safety in Pediatric Imaging in Partnership with the American Academy of Oral and Maxillofacial
Radiology. What Parents Should Know about the Safety of Dental Radiology. 2011
http://www.pedrad.org/associations/5364/files/What%20Parents%20Should%20Know%20aboutthe%20Safety%20of
%20Dental%20Radiology.pdf. (accessed August 2012).
26. International Atomic Energy Agency. Diagnostic and lnterventional Radiology. 2012
https:llrpop.iaea.org/RPOPIRPoP!Content!Additiona/Resources/Training/1_TrainingMateriai!Radiology.htm.
(accessed August 2012).

ONLINE EXAM
24
EXAM–RADIATION SAFETY: FDA CURRENT GUIDELINES
1. Digital imaging may offer reduced radiation exposure and the advantage of image analysis that may
enhance sensitivity and reduce error introduced by subjective analysis.
a. True
b. False
2. Even though radiation exposure from dental radiographs is low, once a decision to obtain
radiographs is made, it is the dentist's responsibility to follow the ALARA Principle (As Low as
Reasonably Achievable) to minimize the patient's exposure.
a. True
b. False
3. Intraoral radiographs are less accurate than panoramic radiographs for the evaluation of dento-
alveolar trauma, root shape, root resorption and pulp pathosis.
a. True
b. False
4. In pediatric patients, occlusal radiographs may be used separately or in combination with

panoramic radiographs in the following situations:
a. Unsatisfactory image in panoramic radiographs due to abnormal incisor relationship.
b. Localizations of tooth position.
c. When clinical grounds provide a reasonable expectation that pathosis exists.
d. All of the above.
5. Although bitewing radiographs can assist in detecting root surface caries in proximal areas, the
usual method of detecting root surface caries is by clinical examination.
a. True
b. False
6. Studies have found that from 10 to 30 % of edentulous patients exhibited abnormalities in

panoramic radiographs.
a. True
b. False
25
7. The bitewing examination is the most efficient method for detecting proximal lesions.
a. True
b. False
8. In adolescents, a radiographic examination consisting of posterior bitewings is recommended at

intervals of 18 to 36 months.
a. True
b. False
9. Dental radiographs account for approximately 10 % of the effective dose received from medical
radiographs and fluoroscopies.
a. True
b. False
10. Ttd ALAiA Pvan iapld se n is fcv “As Lcw s id scn bly Aitade bld”.
a. True
b. False
11. Digital imaging provides an opportunity to further reduce a patient’s radiation dose by 40 to 60 %.
a. True
b. False
12. Collimation does not appear to limit the amount of radiation, both primary and scattered, to which
the patient is exposed.
a. True
b. False
13. Use of long source-to-skin distances of 40 cm, rather than short distances of 20 cm, decreases
exposure by 10 to 25 %.
a. True
b. False
14. A setting above 90 kV(p) will increase the patient dose and should not be used.
a. True
b. False
26
15. The optimal operating potential of dental x-ray units is between 60 and 70 kVp.
a. True
b. False
16. The most vulnerable organ for patients in radiographic exposure is:
a. The parotid gland.
b. The thyroid gland.
c. The parathyroid gland.
d. The submandibular gland.
17. All protective shields should be evaluated for damage (e.g. tears, folds, and cracks) annually using
visual and manual inspection.
a. True
b. False
18. Operator protection measures include:

a. Education.
b. The implementation of a radiation protection program.
c. Occupational radiation exposure limits, recommendations for personal dosimeters and the use
of barrier shielding.
d. All of the above.
19. Dentists should develop and implement a radiation protection program in their offices.
a. True
b. False
20. Technique charts for intraoral and extra-oral radiography should list the type of exam, the patient
size (small, medium, large) for adults and in a pediatric setting.
a. True
b. False

ONLINE EXAM
27
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Dental Radiation and Radiography Safety FDA Current Guidelines
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Dental Radiation and Radiography Safety

MaryLou Austin, RDH, MS

3 vdiae Hcuvs (3 Es)

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INSTiU TIONS ............................................................................................................................................................2

2014 FDA UPDATE: DOSES AND FILe SPEED .......................................................................................................... 21

Upon completion of this course, the dental professional will:

PATIENT SELECTION CRITERIA

RECOMMENDATIONS FOR PRESCRIBING DENTAL RADIOGRAPHS

PATIENT AGE AND DENTAL DEVELOPMENTAL STAGE

Patient waet cetdv

A. Pcsatied Hasecvai l Fan ian hs

EXPLANATION OF RECOMMENDATIONS FOR PRESCRIBING DENTAL RADIOGRAPHS

New Patient Being Evaluated for Oral Diseases

Therefore, an individualized radiographic examination consisting of selected

Child (Transitional Dentition)

 Unsatisfactory image in panoramic radiographs due to abnormal incisor relationship.

Therefore, an individualized radiographic examination consisting of posterior bitewings with

Adolescent (Permanent Dentition)

Therefore, an individualized radiographic examination consisting of posterior bitewings

Therefore, an individualized radiographic examination, consisting of posterior bitewings

Recall Patient with Clinical Caries or Increased Risk for Caries

Therefore, a posterior bitewing examination is recommended at 6 to 12 month intervals if

Adult (Dentate and Partially Edentulous)

Therefore, a posterior bitewing examination is recommended at 6 to 18 month intervals.

Therefore, no radiographic examination is recommended without evidence of disease.

Therefore, a radiographic examination consisting of posterior bitewings is recommended

Adolescent (Permanent Dentition)

Therefore, a radiographic examination consisting of posterior bitewings is recommended

Therefore, a radiographic examination consisting of posterior bitewings is recommended

Recall Patient with Periodontal Disease

Adult (Dentate, Partially Edentulous and Edentulous)

Patients with Other Circumstances

All Patient Categories

LIMITING RADIATION EXPOSURE

OPERATING POTENTIAL AND EXPOSURE TIME

PATIENT SHIELDING AND POSITIONING

HAND-HELD X-RAY UNITS

FILM EXPOSURE AND PROCESSING

RADIATION RISK COMMUNICATION

Quality Assurance Procedures for Assessment of Radiographic Equipment

Equipment Frequency Method

X-v y e itan d On an se ll ticn In spditicn by qu lafidi dxpdve ( s spdiafidi by

On an se ll ticn . Method 1: Sensitometry and Densitometry

Method 2: Reference Film

Equipment Frequency Method

Im hd ididpecv Ddeaids. ecn etly. Method 1: Sensitometry and Densitometry

Exev -cv l ssdttds. Ddedlcpmdn e cf n un dxpcsdi film et e t s bddn an

D vkvccm In edhvaey. On an se ll ticn . Wtald an i vkvccm waet etd s fdlahte cn , pl id

TRAINING AND EDUCATION

2014 FDA UPDATE: DOSES AND FILM SPEED

Click HERE to Access

4. In pediatric patients, occlusal radiographs may be used separately or in combination with

6. Studies have found that from 10 to 30 % of edentulous patients exhibited abnormalities in

8. In adolescents, a radiographic examination consisting of posterior bitewings is recommended at

18. Operator protection measures include:

Click HERE to Access

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Phone: _________________ Fax: _________________ Email: ___________________________

City: ___________________ State: _ Zip Code: ___________

Phone: _________ Fax: _ Email: ___________________