ORIGINAL ARTICLE

Comparison of adult and child radiation

equivalent doses from 2 dental cone-beam
computed tomography units
Anas Al Najjar,a Dan Colosi,b Lawrence T. Dauer,c Robert Prins,d Gayle Patchell,e Iryna Branets,f
Arthur D. Goren,g and Richard D. Faberh
Stony Brook and New York, NY, and Ft. Belvoir, Va

Introduction: With the advent of cone-beam computed tomography (CBCT) scans, there has been a transition
toward these scans’ replacing traditional radiographs for orthodontic diagnosis and treatment planning. Children
represent a significant proportion of orthodontic patients. Similar CBCT exposure settings are predicted to result
in higher equivalent doses to the head and neck organs in children than in adults. The purpose of this study was
to measure the difference in equivalent organ doses from different scanners under similar settings in children
compared with adults. Methods: Two phantom heads were used, representing a 33-year-old woman and
a 5-year-old boy. Optically stimulated dosimeters were placed at 8 key head and neck organs, and equivalent
doses to these organs were calculated after scanning. The manufacturers’ predefined exposure settings were
used. Results: One scanner had a pediatric preset option; the other did not. Scanning the child’s phantom
head with the adult settings resulted in significantly higher equivalent radiation doses to children compared
with adults, ranging from a 117% average ratio of equivalent dose to 341%. Readings at the cervical spine level
were decreased significantly, down to 30% of the adult equivalent dose. When the pediatric preset was used for
the scans, there was a decrease in the ratio of equivalent dose to the child mandible and thyroid. Conclusions:
CBCT scans with adult settings on both phantom heads resulted in higher radiation doses to the head and neck
organs in the child compared with the adult. In practice, this might result in excessive radiation to children
scanned with default adult settings. Collimation should be used when possible to reduce the radiation dose to
the patient. While CBCT scans offer a valuable tool, use of CBCT scans should be justified on a specific
case-by-case basis. (Am J Orthod Dentofacial Orthop 2013;143:784-92)

T
a
Resident, Department of Orthodontics and Pediatric Dentistry, School of Dental he development of cone-beam computed
Medicine, State University of New York at Stony Brook, Stony Brook, NY. tomography (CBCT) has introduced a transition
b
Clinical assistant professor and director, Division of Diagnostic Imaging,
Department of Prosthodontics and Digital Technology, State University of New toward these scans' replacing traditional
York at Stony Brook, Stony Brook, NY. radiographs taken for orthodontic diagnosis and
c
Associate attending physicist, Departments of Medical Physics and Radiology, Me- treatment planning. Since children are a significant
morial Sloan-Kettering Cancer Center, New York, NY.
d
Chief, Consequence Management Assistance Program, Defense Threat Reduction proportion of orthodontic patients, the use of the
Agency, Ft. Belvoir, Va. same CBCT exposure settings for children and adults is
e
Radiologic technologist and instructional support, School of Dental Medicine, predicted to result in higher equivalent doses to the
State University of New York at Stony Brook, Stony Brook, NY.
f
Clinical instructor, Department of Cariology and Comprehensive Care, College of head and neck organs in children than in adults.1,2
Dentistry, New York University, New York, NY. The CBCT radiation exposure to the surface tissues
g
Clinical associate professor, Department of Prosthodontics and Digital Technology, of adults has been previously measured with adult
School of Dental Medicine, State University of New York at Stony Brook, Stony
Brook, NY; clinical associate professor, Department of Cariology and Comprehen- male phantom heads using thermo-luminescent
sive care, College of Dentistry, New York University, New York, NY. dosimeters (TLDs).3-5 However, to our knowledge,
h
Program director and clinical associate professor, Department of Orthodontics and a comparative characterization of the radiation
Pediatric Dentistry, School of Dental Medicine, State University of New York at
Stony Brook, Stony Brook, NY. exposure from different CBCT scanners in children and
The authors report no commercial, proprietary, or financial interest in the adults is not available.
products or companies described in this article. Once cancer risk from x-ray radiation was confirmed
Reprint requests to: Anas Al Najjar, Department of Orthodontics and Pediatric
Dentistry, SUNY at Stony Brook, Stony Brook University School of Dental Med- early in the 20th century, the International Commission
icine, Sullivan Hall, Stony Brook, NY 11794; e-mail, anas_82@hotmail.com. on Radiological Protection (ICRP) has worked hard to
Submitted, June 2012; revised and accepted, January 2013. develop guidelines for x-ray exposure and safety proto-
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists. col.6 In the 1990s, the ICRP moved toward using
http://dx.doi.org/10.1016/j.ajodo.2013.01.013 the equivalent and effective dose (measured in
784
Al Najjar et al
Fig 1. Anthropomorphic phantom head.
Table I. Dosimeters per site
Adult (n) Child (n)
Brain 8 3
Cranium 4 3
Eye 2 2
Mandible 2 2
Cervical spin 1 2
Thyroid 2 4
Parotid 2 1
Eye lens 2 2
microsieverts) as a measure of organ dose and biologic
risk, instead of the more traditional absorbed dose.5,7
The equivalent dose takes into account tissue
sensitivity to radiation and provides a more accurate
picture of the detrimental effects of radiation to the
patient. Although simple periapical x-rays expose
patients to the equivalent of a few days’ worth of
background radiation and potentially increase cancer
risk by less than 1 in 1,000,000, medical computed
tomography (CT) scans expose patients to the
equivalent of 2 to 3 years of background radiation and
potentially increase cancer risk by 1 in 1000 to 1 in
10,000.3 CBCT scans offer an alternative to medical CT
imaging, with comparable quality of bony images but
much less radiation, and they are significantly less ex-
pensive.
In recent years, more orthodontists have moved
toward using CBCT scans for diagnosis, as they offer
a “1 scan covers all” type of convenience to
practitioners.8 The rapid adoption of CBCT into practice
has outstripped the time needed to conduct well-
controlled studies on x-ray radiation from CBCT and
to implement or suggest guidelines on CBCT use.
Whereas radiation exposure from CBCT has been shown
American Journal of Orthodontics and Dentofacial Orthopedics
785
Fig 2. Optically stimulated luminescent dosimeter slots in
the phantom head.
to be less than that from multidetector CT used in med-
icine, it is still greater relative to conventional dental ra-
diographs.4
Radiographic examination should be performed only
when indicated by the patient’s dental history, the den-
tist’s physical examination, or laboratory findings.9 Jus-
tification of radiographic examination in children is
especially important since children’s tissues are different
in size and position and are under constant growth,
replication, and differentiation, making them signifi-
cantly more susceptible to radiation damage compared
with adult tissues. Radiation risk highly depends on
age, with risk inversely proportional to age; for
the same radiation doses, children less than 10 years of
age have about a 3-times higher risk than a 30-year-
old adult.7 In addition, the risk for females is typically
higher than that for males.2
Previous studies evaluating radiation doses to
phantom heads from CBCT scans have used TLDs on adult
male phantom heads.3-5 In this study, we used optically
stimulated luminescent (OSL) dosimeters (NanoDot;
Landauer, Glenwood, Ill). This is a newer technology of
dosimeters, which we used to characterize CBCT
radiation exposure to a woman’s phantom head and
a child’s phantom head. The advantages of OSL
dosimeters over TLDs include faster readouts and more
June 2013  Vol 143  Issue 6
786 Al Najjar et al

Reference Imaging System, Norfolk, Va) corresponding

Table II. Exposure settings
to an average 33-year-old woman who is 160 cm in
Resolution Exposure Kilovoltage Current height and 55 kg in weight (Fig 1) and a child male
Type of scan (mm) time (s) (kV[p]) (mA) anthropomorphic phantom (model 705; Computerized
i-CAT Reference Imaging System) corresponding to an aver-
Full head 0.3 8.9 120 5
Maxilla 0.2 26.9 120 5
age 5-year-old boy who is 110 cm in height and 19
Maxilla 0.4 8.9 120 5 kg in weight. OSL dosimeters were placed at 8 key
Mandible 0.2 26.9 120 5 head and neck organs in the 2 phantom heads to as-
Mandible 0.4 8.9 120 5 sess the radiation doses (Table I; Fig 2). Equivalent
Iluma doses to the head and neck organs were calculated
Full head 0.3 7.8 120 3.8
Maxilla-mandible 0.2 40 120 3.8
based on the 2007 recommendations of the ICRP.3
Maxilla-mandible 0.4 20 120 3.8 The i-CAT Platinum CBCT scanner (Imaging Sciences
Maxilla-mandible 0.2 7.8 120 3.8 International, Hatfield, Pa) with 5 manufacturer-
predefined exposure settings and the Iluma CBCT
scanner (IMTEC, Ardmore, Okla) with 4 predefined set-
Table III. i-CAT ratio of child/adult equivalent dose tings were used in this study. Preset pediatric settings,
only available in the Iluma scanner, were used with the
Full head Maxilla Maxilla Mandible Mandible child phantom head. For the Iluma, 2 scanning
0.3 mm 0.2 mm 0.4 mm 0.2 mm 0.4 mm
(%) (%) (%) (%) (%) techniques were used: the full-head scan with no
Brain 152 200 214 233 180 collimation and the collimated scan (collimated to
Cranium 160 295 279 286 257 the maxillary-mandibular area, excluding the eyes).
Mandible 127 325 341 94 99 Both scanning techniques had the same machine pa-
Cervical spine 30 29 34 34 32 rameters of 120 kV(p) and 3.8 mA. For the i-CAT,
Thyroid 140 130 143 118 133
Parotid 90 92 101 115 119
full-head, maxilla-only, and mandible-only scans
Average 117 170 173 145 137 were taken, all using the same machine parameters
child/adult of 120 kV(p) and 5 mA. Table II shows the parameters
for each scan. The scans were repeated by the same in-
vestigators (L.T.D., G.P., R.P., A.D.G.) 3 times (scout
accurate readings, as the OSL dosimeters are optically and volumetric acquisitions), and radiation exposure
stimulated with green light, which is more efficient than to the OSL dosimeters was read with a MicroStar
the thermally stimulated TLDs. OSL dosimeters also allow reader (Landauer, Glenwood, Ill). Specific labeled do-
for multiple exposures and readouts from 1 dosimeter, simeters were used for each site. The dosimeters
have lower depletion over time, and are more sensitive were measured before exposure for a background
than TLDs.10,11 reading, exposed, and then read again. All dosimeters
Few studies have evaluated the differences in were read 3 times, and background radiation readings
radiation dose from CBCT scans to adults compared were subtracted from the average readings to give the
with children. Data characterizations of the equivalent radiation dose to the dosimeter. Individual readings of
organ doses from different CBCT scanners under absorbed dose for each scan (scout plus volumetric
similar controlled settings are limited in the litera- acquisitions) were obtained by dividing the average
ture.5,12 The purpose of this study was to measure readings minus the background by 3. Dosimetrical
the differences in equivalent organ dose from statistical evaluations were calculated using Excel (Mi-
different scanners under similar settings in children crosoft, Redmond, Wash). Averaged radiation readings
compared with adults. We investigated the equivalent were then converted to equivalent doses using the
doses to the lens of the eye, the thyroid, and several tissue-weighting factors of the 2007 ICRP’s recom-
head and neck organs of an anthropomorphic mendations.3 The calculated child equivalent doses
adult female phantom head and an anthropomorphic were divided by the adult equivalent dose, giving a per-
child male phantom head. The data were obtained centage ratio of child over adult comparison of the
from 2 commercially available dental CBCT scanners equivalent dose. This study will help to develop a base-
using several specific exposure settings. line for other CBCT studies to follow.
MATERIAL AND METHODS RESULTS
Two phantom heads were used: an adult female Readings from the i-CAT, which did not have
anthropomorphic phantom (model 702; Computerized a pediatric preset option, showed significantly higher

June 2013  Vol 143  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Al Najjar et al 787

Table IV. Iluma ratio of child/adult equivalent dose

Full scan Collimated maxilla-mandible Collimated maxilla-mandible Collimated maxilla-mandible
7.8 s (%) 40 s (%) 20 s (%) 7.8 s (%)
Brain 212 329 346 413
Cranium 479 373 378 367
Mandible 85 101 102 86
Cervical spine 68 61 54 63
Thyroid 93 75 77 75
Parotid 117 97 103 132
Average child/adult 176 173 177 189

Fig 3. Ratio of child/adult average equivalent doses by organ for all scans. C Spine, Cervical spine.

Table V. i-CAT full-head 0.3-mm scan

Adult Child
Ratio of
Organ dose WT Equivalent Organ WT Equivalent equivalent dose
(cGy) SD (ICRP 103) dose (mSv) dose (cGy) SD (ICRP 103) dose (mSv) child/adult (%)
Brain 0.066 0.008 0.01 6.6 0.1 0.01 0.01 10.0 152
Cranium 0.05 0.01 0.01 5.0 0.08 0.01 0.01 8.0 160
Mandible 0.079 0.008 0.01 7.9 0.1 0.02 0.01 10.0 127
Cervical spine 0.109 0.002 0.01 10.9 0.033 0.0004 0.01 3.3 30
Thyroid 0.02142 0.00009 0.04 8.6 0.03 0.01 0.04 12.0 140
Parotid 0.11 0.02 0.01 11.0 0.0986 0.0001 0.01 9.9 90
Average child/adult 116

WT, Tissue weighting factor; cGy, centigray (absorbed dose).

equivalent doses to children compared with adults,
ranging from a 117% average ratio of equivalent
dose increase for a 3-mm full-head scan, to a 173%
average increase for the 0.4-mm maxilla scan
(Table III). The child’s mandible received an equivalent
radiation dose 341% higher than the adult dose for the
0.4-mm maxilla scan, the highest increase in relative
effective dose. Brain and cranial tissues received equiv-
alent doses of 152% to 295% higher than adults,
depending on the resolution of the scan and
collimation. Readings at the cervical-spine level, how-
ever, were decreased significantly to 30% of the adult
equivalent dose. The mandible and the parotid also
showed decreases in equivalent doses to children, al-
though not as dramatic as those at the cervical-spine
level (Table III).
On the other hand, the Iluma had a pediatric preset
that was used for the scans. Increases for average
equivalent dose ranged from 158% for the 7.8-second
full-head scan to 266% for the 20-second collimated

American Journal of Orthodontics and Dentofacial Orthopedics June 2013  Vol 143  Issue 6
788 Al Najjar et al

Table VI. i-CAT maxilla 0.2-mm scan

Adult Child
Ratio of
Organ dose WT Equivalent Organ WT Equivalent equivalent dose
(cGy) SD (ICRP 103) dose (mSv) dose (cGy) SD (ICRP 103) dose (mSv) child/adult (%)
Brain 0.03 0.02 0.01 3.0 0.06 0.03 0.01 6.0 200
Cranium 0.0088 0.0009 0.01 0.9 0.026 0.001 0.01 2.6 295
Mandible 0.083 0.001 0.01 8.3 0.27 0.02 0.01 27.0 325
Cervical spine 0.1074 0.0006 0.01 10.7 0.0315 0.0001 0.01 3.2 29
Thyroid 0.023 0.002 0.04 9.2 0.03 0.01 0.04 12.0 130
Parotid 0.3 0.02 0.01 30.0 0.277 0.004 0.01 27.7 92
Average child/adult 179

WT, Tissue weighting factor; cGy, centigray (absorbed dose).

Table VII. i-CAT maxilla 0.4-mm scan

Adult Child
Ratio of
Organ dose WT Equivalent Organ WT Equivalent equivalent dose
(cGy) SD (ICRP 103) dose (mSv) dose (cGy) SD (ICRP 103) dose (mSv) child/adult (%)
Brain 0.014 0.009 0.01 1.4 0.03 0.01 0.01 3.0 214
Cranium 0.0043 0.0009 0.01 0.4 0.012 0.001 0.01 1.2 279
Mandible 0.0411 0.0005 0.01 4.1 0.14 0.01 0.01 14.0 341
Cervical spine 0.0468 0.0008 0.01 4.7 0.016 0.003 0.01 1.6 34
Thyroid 0.0112 0.0006 0.04 4.5 0.016 0.007 0.04 6.4 143
Parotid 0.146 0.009 0.01 14.6 0.1469 0.0002 0.01 14.7 101
Average child/adult 185

WT, Tissue weighting factor; cGy, centigray (absorbed dose).

Table VIII. i-CAT mandible 0.2-mm scan

Adult Child
Ratio of
Organ WT Equivalent Organ WT Equivalent equivalent dose
dose (cGy) SD (ICRP103) dose (mSv) dose (cGy) SD (ICRP103) dose (mSv) child/adult (%)
Brain 0.009 0.006 0.01 0.9 0.021 0.009 0.01 2.1 233
Cranium 0.0028 0.0006 0.01 0.3 0.008 0.001 0.01 0.8 286
Mandible 0.28 0.02 0.01 28.0 0.262 0.006 0.01 26.2 94
Cervical spine 0.249 0.005 0.01 24.9 0.0856 0.0002 0.01 8.6 34
Thyroid 0.0593 0.0002 0.04 23.7 0.07 0.04 0.04 28.0 118
Parotid 0.25 0.02 0.01 25.0 0.288 0.004 0.01 28.8 115
Average child/adult 147

WT, Tissue weighting factor; cGy, centigray (absorbed dose).

maxilla-mandible scan (Table IV). Brain and cranial
tissues received an equivalent radiation dose increase
of up to 479% in the 7.8-second full-head scan.
Preliminary data on the eye dosimeters measured the
highest increase at 671% in equivalent dose for the
20-second collimated maxilla-mandible scan. Further
findings on the eye and lens dosimeters will be published
later. Similar to the i-CAT measurements, the cervical
spine showed significant decreases in equivalent radia-
tion, down to 54% to 68% of the adult equivalent
dose. The mandible and thyroid also showed decreases
in equivalent doses relative to the adult readings, to as
low as 75% (Table IV).
Comparing the equivalent dose percentages between
the i-CAT and the Iluma showed that the Iluma’s
pediatric settings decreased the radiation to the
mandible and thyroid, with similar results at the parotid.
However, the i-CAT had significantly lower radiation
delivery to the brain, cranium, and cervical spine
(Tables III and IV; Fig 3). Tables V through XIII show
the equivalent radiation dose readings for adults and
children for each organ from the various scans.

June 2013  Vol 143  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Al Najjar et al 789

Table IX. i-CAT mandible 0.4-mm scan

Adult Child
Ratio of
Organ WT Equivalent Organ WT Equivalent equivalent dose
dose (cGy) SD (ICRP 103) dose (mSv) dose (cGy) SD (ICRP 103) dose (mSv) child/adult (%)
Brain 0.005 0.003 0.01 0.5 0.009 0.004 0.01 0.9 180
Cranium 0.0014 0.0003 0.01 0.1 0.0036 0.0001 0.01 0.4 257
Mandible 0.136 0.003 0.01 13.6 0.135 0.008 0.01 13.5 99
Cervical spine 0.132 0.001 0.01 13.2 0.0425 0.0001 0.01 4.3 32
Thyroid 0.03 0.001 0.04 12.0 0.04 0.02 0.04 16.0 133
Parotid 0.123 0.003 0.01 12.3 0.146 0.004 0.01 14.6 119
Average child/adult 137

WT, Tissue weighting factor; cGy, centigray (absorbed dose).

Table X. Iluma full-head 7.8-second scan

Adult Child
Ratio of
Organ WT Equivalent Organ WT Equivalent equivalent dose
dose (cGy) SD (ICRP 103) dose (mSv) dose (cGy) SD (ICRP 103) dose (mSv) child/adult (%)
Brain 0.042 0.001 0.01 4.2 0.089 0.004 0.01 8.9 212
Cranium 0.0169 0.0004 0.01 1.7 0.081 0.002 0.01 8.1 479
Mandible 0.101 0.002 0.01 10.1 0.086 0.004 0.01 8.6 85
Cervical spine 0.066 0.001 0.01 6.6 0.045 0.003 0.01 4.5 68
Thyroid 0.0204 0.0005 0.04 8.2 0.019 0.02 0.04 7.6 93
Parotid 0.097 0.002 0.01 9.7 0.1135 0.0002 0.01 11.4 117
Average child/adult 176

WT, Tissue weighting factor; cGy, centigray (absorbed dose).

Table XI. Collimated maxilla-mandible 40-second scan (Iluma)

Adult Child
Ratio of
Organ WT Equivalent Organ WT Equivalent equivalent dose
dose (cGy) SD (ICRP 103) dose (mSv) dose (cGy) SD (ICRP 103) dose (mSv) child/adult (%)
Brain 0.045 0.002 0.01 4.5 0.148 0.004 0.01 14.8 329
Cranium 0.015 0.001 0.01 1.5 0.056 0.002 0.01 5.6 373
Mandible 0.35 0.01 0.01 35.0 0.36 0.01 0.01 35.5 101
Cervical spine 0.347 0.009 0.01 34.7 0.212 0.006 0.01 21.2 61
Thyroid 0.106 0.004 0.04 42.5 0.08 0.003 0.04 32.0 75
Parotid 0.395 0.008 0.01 39.5 0.385 0.008 0.01 38.5 97
Average child/adult 173

WT, Tissue weighting factor; cGy, centigray (absorbed dose).

DISCUSSION
Despite the spike in the use of CBCT scans for rou-
tine examinations, characterization of the radiation ex-
posure from different CBCT scanners to adults and
children is still incomplete. Furthermore, previous char-
acterizations were done with TLDs, which may be less
accurate than OSL dosimeters in the lower radiation
dose range.10,11 Here, we aimed to assess the
differences in organ doses from several scanners
under similar settings and analyzed the differences in
equivalent doses to children compared with adults to
the lens of the eye, the thyroid, and other key head
and neck organs. Because no male adult phantom
head was available that accommodated OSL
dosimeters, we were limited to using a female adult
phantom head. The data were obtained from 2
commercially available dental CBCT scanners using
several specific exposure settings. The equivalent
doses for the child phantom head for a specific scan
was divided by the equivalent dose measured for the
adult phantom head with the same scan, and this
number was multiplied by 100 to give a percentage
ratio of the child-to-adult radiation comparison.

American Journal of Orthodontics and Dentofacial Orthopedics June 2013  Vol 143  Issue 6
790 Al Najjar et al

Table XII. Collimated maxilla-mandible 20-second scan (Iluma)

Adult Child
Ratio of
Organ WT Equivalent Organ WT Equivalent equivalent dose
dose (cGy) SD (ICRP 103) dose (mSv) dose (cGy) SD (ICRP 103) dose (mSv) child/adult (%)
Brain 0.024 0.002 0.01 2.4 0.083 0.003 0.01 8.3 346
Cranium 0.008 0.001 0.01 0.8 0.031 0.002 0.01 3.1 378
Mandible 0.19 0.01 0.01 19.1 0.194 0.003 0.01 19.4 102
Cervical spine 0.201 0.006 0.01 20.1 0.108 0.006 0.01 10.8 54
Thyroid 0.054 0.004 0.04 21.5 0.042 0.002 0.04 16.6 77
Parotid 0.199 0.004 0.01 19.9 0.204 0.005 0.01 20.5 103
Average child/adult 177

WT, Tissue weighting factor; cGy, centigray (absorbed dose).

Table XIII. Collimated maxilla-mandible 7.8-second scan (Iluma)

Adult Child
Ratio of
Organ WT Equivalent Organ WT Equivalent equivalent dose
dose (cGy) SD (ICRP 103) dose (mSv) dose (cGy) SD (ICRP 103) dose (mSv) child/adult (%)
Brain 0.0081 0.0008 0.01 0.8 0.033 0.001 0.01 3.3 413
Cranium 0.0029 0.0007 0.01 0.3 0.011 0.001 0.01 1.1 367
Mandible 0.1 0.01 0.01 9.7 0.083 0.004 0.01 8.3 86
Cervical spine 0.065 0.003 0.01 6.5 0.041 0.004 0.01 4.1 63
Thyroid 0.023 0.003 0.04 9.3 0.017 0.001 0.04 7.0 75
Parotid 0.087 0.006 0.01 8.7 0.115 0.005 0.01 11.5 132
Average child/adult 189

WT, Tissue weighting factor; cGy, centigray (absorbed dose).

It is evident from the i-CAT radiation readings that
higher equivalent doses were found in children than in
adults with the same exposure settings (no pediatric
setting was available on this model of i-CAT) (Table
III). This increase in equivalent dose was generalized
over most of the child’s tissues and was significant,
with the exception of the cervical spine and the parotid
tissues. These differences can be explained by a number
of factors, including the difference in the size of the
child’s organs compared with the adult, the difference
in the position of these organs, and the difference in
tissue penetration and thickness, allowing more
radiation to penetrate through the child’s tissues and
perhaps also leading to increased internal scatter
radiation.
The position of the cervical spine is lower relative to
the mandible in children than in adults and thus is out of
the collimation range in children. This explains the sig-
nificantly lower radiation received by those tissues in
children.
The full-head scan resulted in the lowest increase in
the ratio of equivalent dose to children relative to adults;
however, the absolute absorbed doses of the collimated
scans were significantly less than a full-head scan
(Tables V-IX). Thus, collimation when possible is an
important modality for reducing radiation exposure to
patients. Similarly, reducing the resolution of
the scan reduced the absorbed dose significantly; the
absorbed dose for the maxilla 0.4-mm scan or
the mandible 0.4-mm scan was about half that of the
maxilla 0.2-mm scan or the mandible 0.2-mm scan
(Tables VI-IX).
The Iluma CBCT scanner had a pediatric setting,
which was used for the child scans. A similar pattern of
percentage increases of child to adult was observed,
with the brain and cranium receiving significant
increases in equivalent radiation (Table IV). The cervical
spine in children received a lower equivalent dose
relative to adults because of its size and its position in-
ferior to the border of the mandible. Pediatric exposure
settings lowered the child dose to the inferior head
and neck organs compared with the adult dose when
using adult exposure settings (cervical spine, thyroid,
and mandible).
In all cases, the mandibular scan resulted in the
highest equivalent dose to the thyroid compared with
the maxilla and full-head scans (Tables III-XIII). The
variability in measured doses when comparable

June 2013  Vol 143  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Al Najjar et al
settings were used with the different CBCT scanners
shows that different CBCT scanners produce different
amounts of radiation, and that one size does not fit
all (Tables V-XIII). Therefore, each CBCT scanner
requires its own calibration readings and dosage
measurements, and a universal statement for all CBCT
scanners would be inherently inaccurate. Future
directions include comparisons of adult and pediatric
settings of the radiation dose to children’s organ sites
in different scanners, as well as an accurate
characterization of the difference in readouts between
TLDs and OSL dosimeters in the range of low radiation
doses encountered in CBCT applications. Furthermore,
image quality assessment at various settings, to ensure
clinically diagnostic images at lower settings, would be
a valuable assessment and would allow clinicians to
maintain the “as low as reasonably achievable” (ALARA)
principle with CBCT scans. Evaluating the effects of
body mass index, ethnicity, age, and sex would also
add an interesting dimension to the necessary knowl-
edge on the effects of radiation.
Although radiographic examinations are an impor-
tant component of dental care, they should be taken
only after a thorough clinical examination and
consideration of the patient’s dental history, preferably
including a study of any previous dental radiographs.13
In addition, adequate education and practical training
in radiologic protection should be provided for all who
work with radiation in dentistry. This is especially
important in CBCT dental radiography. The basic
principles recommended by the National Council on
Radiation Protection and Measurements for radiation
protection in dentistry, as well as the European CBCT
radiation protection guidelines, are important starting
points for developing a comprehensive radiation
protection policy for CBCT use.9,12-28
CONCLUSIONS
Equivalent doses for children’s organs were
generally higher than for adults when similar exposure
settings were used. Pediatric settings (Iluma) resulted in
lower equivalent doses to some child organs compared
with those calculated for the adult phantom head
scanned using standard settings (i-CAT). Certain organs
received more radiation in children than adults, most
likely due to the difference in their size and location.
Different CBCT scanners expose patients to different
amounts of radiation. Equivalent doses to most organs
varied with the center, size, and height of the field of
view. When possible, collimation should be used to re-
duce the field of view as much as possible. Despite the
reduction in the field of view, collimation increases the
resolution of the image obtained while reducing the
American Journal of Orthodontics and Dentofacial Orthopedics
791
overall radiation dose to the patient and thus is an im-
portant part of achieving the ALARA principle.
CBCT scans can be beneficial, but they should not be
used for routine diagnosis, screening, and
examination and should be reserved for complex cases
on a specific case-by-case basis, such as those involv-
ing dento-osseous pathology, impacted canines, dental
anomalies, cleft lip and palate patients before bone
grafting, and patients with dentofacial deformities.
Facilities must develop a comprehensive radiation
protection policy with regard to CBCT use in accor-
dance with national and international recommended
radiation protection principles and guidelines.
REFERENCES
1. Prins R, Dauer LT, Colosi DC, Quinn B, Kleiman NJ, Bohle GC,
et al. Significant reduction in dental cone beam computed to-
mography (CBCT) eye dose through the use of leaded glasses.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:
502-7.
2. Committee to Assess Health Risks from Exposure to Low Levels
of Ionizing Radiation; Board of Radiation Effects, Research
Division on Earth and Life Studies,National Research Council
of the National Academies. Health risks from exposure to low
levels of ionizing radiation: BEIR VII, Phase 2. National
Academy of Sciences. Washington, DC: National Academies
Press; 2006.
3. Ludlow J, Davies-Ludlow L, White S. Patient risk related to
common dental radiographic examinations. The impact of 2007
International Commission on Radiological Protection recommen-
dations regarding dose calculation. J Am Dent Assoc 2008;139:
1237-43.
4. Ludlow J, Ivanovic M. Comparative dosimetry of dental CBCT
devices and 64-slice CT for oral and maxillofacial radiology.
Oral Surg Med Oral Pathol Oral Radiol Endod 2008;106:
106-14.
5. Roberts JA, Drage NA, Davies J, Thomas DW. Effective dose from
cone beam CT examinations in dentistry. Br J Radiol 2009;82:
35-40.
6. Committee on the Biological Effects of Ionizing Radiations. Board
of Radiation Effects, Research Division on Earth and Life Studies,
National Research Council of the National Academies. Health
effects of exposure to low levels of ionizing radiation: BEIR V.
National Academy of Sciences. Washington, DC: National
Academies Press; 1990.
7. 1990 recommendations of the International Commission on
Radiological Protection. Ann ICRP 1991;21:1-201.
8. National Committee on Radiation Protection. Radiation protection
in dentistry. Report no. 145. Bethesda, Md: National Council on
Radiation Protection and Measurements; 2004.
9. Brenner DJ. Effective dose: a flawed concept that could and should
be replaced. Br J Radiol 2008;81:521-3.
10. Lian OB. Luminescence dating: optically stimulated luminescence.
Encyclopedia of quaternary science. University of London, UK:
Royal Holloway; 2007. p. 1491-505.
11. Zacharias N, Stuhec M, Knezevic Z, Fountoukidis E, Michael CT,
Bassiakos Y. Low dose environmental dosimetry using thermo- and
optically stimulated luminescence. Nuclear instruments
and methods in physics research section A. Accelerators, Spectrome-
ters. Detectors and Associated Equipment 2007;580:698-701.
June 2013  Vol 143  Issue 6
792
12. Radiation protection: cone beam CT for dental and maxillofacial
radiology, evidence based guidelines. SEDENTEXCT Project Con-
sortium. Version 2.0; 2011.
13. Hechler SL. Cone-beam CT: applications in orthodontics. Dent Clin
North Am 2008;52:809-23.
14. Nakajima A, Sameshima GT, Arai Y, Homme Y, Dougherty H Sr. Two-
and three-dimensional orthodontic imaging using limited cone
beam-computed tomography. Angle Orthod 2005;75:895-903.
15. Holberg C, Steinhauser S, Geis P, Rudzki-Janson I. Cone-beam
computed tomography in orthodontics: benefits and limitations.
J Orofac Orthop 2005;66:434-44.
16. Mah JK, Huang JC, Choo H. Practical applications of cone-beam
computed tomography in orthodontics. J Am Dent Assoc 2010;
141(Supp 3):7S-13S.
17. Kapila S, Conley RS, Harrell WE Jr. The current status of cone beam
computed tomography imaging in orthodontics. Dentomaxillofac
Radiol 2011;40:24-34.
18. Merrett SJ, Drage NA, Durning P. Cone beam computed tomogra-
phy: a useful tool in orthodontic diagnosis and treatment
planning. J Orthod 2009;36:202-10.
19. Cattaneo PM, Melsen B. The use of cone-beam computed
tomography in an orthodontic department in between research
and daily clinic. World J Orthod 2008;9:269-82.
20. Fanning B. CBCT—the justification process, audit and review of the
recent literature. J Ir Dent Assoc 2011;57:356-61.
June 2013  Vol 143  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Al Najjar et al
21. Scarfe WC, Farman AG. What is cone-beam CT and how does it
work? Dent Clin North Am 2008;62:707-30.
22. Tetradis S, Ansley P, Graff-Radford S. Cone beam computed
tomography in the diagnosis of dental disease. Tex Dent J 2011;
128:620-8.
23. Kaeppler G. Applications of cone beam computed tomography
in dental and oral medicine. Int J Comput Dent 2010;13:
203-19.
24. Dawood A, Patel S, Brown J. Cone beam CT in dental practice. Br
Dent J 2009;207:23-8.
25. Vos W, Casselman J, Swennen GRJ. Cone-beam computerized
tomography (CBCT) imaging of the oral and maxillofacial region:
a systematic review of the literature. Int J Oral Maxillofac Surg
2009;38:609-25.
26. Quereshy FA, Barnum G, Demko C, Horan M, Palomo JM, Baur DA,
et al. Use of cone beam computed tomography to volumetrically
assess alveolar cleft defects—preliminary results. J Oral Maxillofac
Surg 2012;70:188-91.
27. Radiological protection of the worker in medicine and dentistry.
Ann ICRP 1989;20:1-83.
28. Use of cone-beam computed tomography in endodontics. Joint
position statement of the American Association of Endodontists
and the American Academy of Oral and Maxillofacial Radiology.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:
234-7.