SHORT COMMUNICATION
Radiation protection guidelines for the
practicing orthodontist
Muralidhar Mupparapu
Newark, NJ
This article summarizes the most recent (December 2003) dental x-ray guidelines from the National Council
on Radiation Protection and Measurements report #145. The guidelines are intended for all dental
health-care providers. They address radiation dose limits for occupational and nonoccupational exposure
and radiation protection for operators, patients, and the public. Equipment design can play an important role
in radiation protection, and recommendations from the guidelines are discussed. (Am J Orthod Dentofacial
Orthop 2005;128:168-72)
T
he use of ionizing radiation in medical and
dental health care is well regulated in the
United States. The federal government has es-
tablished performance standards for the manufacture
and installation of x-ray equipment designed for clini-
cal use.1,2 In addition, some states have implemented
regulations that govern users, including dentists. These
regulations deal with the design of facilities, especially
radiation shielding, and the use and maintenance of
equipment.
The National Council on Radiation Protection and
Measurements (NCRP) is a nonprofit organization
chartered by Congress in 1964 to collect, analyze,
develop, and disseminate information and recommen-
dations in the public interest about (1) protection
against radiation and (2) radiation measurements, quan-
tities, and units related to radiation protection. The
NCRP is working to develop basic guidelines about
radiation quantities, units, and measurements and their
application to the field of radiation protection.
BIOLOGICAL EFFECTS OF RADIATION
Biological effects of radiation fall into 2 categories:
deterministic and stochastic. Deterministic effects oc-
cur in anyone who receives a dose of radiation that
exceeds a certain threshold. The severity of the effect is
proportional to the dose. Examples include acute radi-
ation sickness, cataracts, and epilation. Stochastic ef-
fects, such as cancer, are all-or-none effects. Either a
Associate professor and director, Division of Oral and Maxillofacial Radiology,
Department of Diagnostic Sciences, University of Medicine and Dentistry of
New Jersey Dental School.
Reprint requests to: Dr M. Mupparapu, Diagnostic Sciences, D-860, New
Jersey Dental School, 110 Bergen St, Newark, NJ 07101-1709; e-mail,
m.mupparapu@umdnj.edu.
Submitted, November 2004; revised and accepted, April 2005.
0889-5406/$30.00
Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.04.014
168
radiation-induced cancer occurs or it does not. There is
no threshold.
The NCRP has established recommended dose
limits for occupational and public exposure (Table I).
Annually, the average person in the United States
receives about 100 mrem (1mSv) of natural background
radiation excluding the radon measurement. The radi-
ation protection recommendations pertain to man-made
sources other than medical and dental diagnostic x-
radiation.
For continuous or repeated exposures, the annual
effective dose limit is 100 mrem or 1 mSv. Published
data3 indicate that average dental occupational expo-
sures are generally a small fraction of the limit and are
far less than that of most other health-care workers
(Table II).
NCRP report #145 supersedes the report for den-
tistry, #35, published in 1970.4 The NCRP uses shall
and shall not as well as should and should not in its
report. Shall and shall not mean that “adherence to the
recommendation is considered necessary to meet ac-
cepted standards of protection.” Should and should not
are used to indicate “a prudent practice to which
exceptions may occasionally be made in appropriate
circumstances.”
Although the guidelines cover broad areas for the
general dental practitioner, orthodontists should be
especially concerned with the recommendations for
extraoral radiography, including panoramic, lateral, and
posteroanterior cephalometric views. The general
guidelines govern the use of leaded aprons and thyroid
collars, rectangular collimation for intraoral radio-
graphs, selection criteria, radiation protection programs
in offices, radiation safety training for all staff, mea-
sures to minimize sight development for evaluation of
films, and qualified experts to determine the shielding
American Journal of Orthodontics and Dentofacial Orthopedics Mupparapu 169
Volume 128, Number 2

Table I. NCRP recommended radiation dose limits for occupational and public exposure
Dose limits

Basis Occupational Public

Stochastic
Deterministic effects
Embryo and fetus
5 rem (50 mSv)* annual effective dose
1 rem (10 mSv) ⫻ age (y) cumulative effective dose
15 rem (150 mSv) for lens of eye
15 rem (150 mSv) for skin, hands, and feet
0.05 rem (0.5 mSv)/month once pregnancy is known
0.1 rem (1 mSv) frequent exposure
0.5 rem (5 mSv) for infrequent exposure
1.5 rem (15 mSv) for lens of eye
5 rem (50 mSv) for skin, hands, and feet

1 mSv (0.001Sv) ⫽ 0.1 rem.

*1 Sv ⫽ 100 rem.

Table II.Average dental exposure by mean whole-body dose (WBD) to health-care workers compared with other
occupations (data from Kumazawa et al3 and NCRP1)
Measurement Occupational subgroup

Type of exposure Hospital Medical offices Dental Podiatry Chiropractic Veterinary Total

WBD for all workers with potential 1.4 1.0 0.2 0.1 0.3 0.6 0.7
occupational exposure (mSv)
WBD in workers who are exposed (mSv) 2.0 1.8 0.7 0.3 0.8 1.1 1.5

1 mSv ⫽ 0.1 rem.

requirements for new equipment or when an older
facility is remodeled.
In addition, report #145 covers “collimation guide-
lines for cephalometric and panoramic radiography.”
This will be discussed later in this article.
The NCRP report includes some general guidelines
for all clinicians:
1. No one shall be permitted to receive an occupa-
tional effective dose in excess of 5 rem (50 mSv) in
any year (Table I).
2. Facility design, x-ray equipment performance, and
operating procedures should be established to main-
tain patient, occupational, and public exposures as
low as reasonably achievable, with economic and
social factors taken into account.
3. All radiographic examinations shall be performed
only on direct prescription of the dental practitioner
or physician after a clinical history and physical
examination of the patient, and determination of a
reasonable expectation of a health benefit to the
patient.
The report also lists radiation protection guidelines
for patients:
1. For each new or referred patient, the dentist shall
make a good-faith attempt to obtain recent, perti-
nent radiographs from the patient’s previous den-
tist. Radiographic examinations shall be performed
only when indicated by patient history, physical
examination, or laboratory findings.
2. For symptomatic patients, the radiographic ex-
amination shall be limited to images that are
required for the treatment planning of the current
disease.
3. For asymptomatic patients, the radiographic exam-
inations should be conducted based on published
selection criteria.5-7
4. Administrative use of radiation shall not be permit-
ted.
5. Radiation exposure that is desirable per image is
generally a function of the film/receptor speed and
based on published diagnostic reference levels at
skin entry; their applicability varies from state to
state.8
6. The x-ray equipment shall meet or exceed all
applicable government requirements and regula-
tions. Portable x-ray machines shall not be used
when fixed installations are available.
7. The operating potential of the x-ray machines
should be between 60 and 80 KVp. The operating
potential should not be lower than 50 KVp or
higher than 100 KVp.
8. All position-indicating devices shall be open-ended
with provision for attenuation of scattered radiation
arising from the collimator or filter.
9. Source-to-image receptor distance for intraoral ra-
diography should not be less than 40 cm.
10. Rectangular collimation of the x-ray beam shall be
routinely used for periapical and bitewing radiog-
raphy (Fig 1).
170 Mupparapu American Journal of Orthodontics and Dentofacial Orthopedics
August 2005

11. Image receptors of speeds slower than American

National Standards Institute (ANSI)11 speed E
films shall not be used for intraoral radiography.
Faster films should be evaluated and used if
acceptable.
12. For extraoral dental radiographic projections,
high-speed (400 or greater) rare-earth screen-film
systems or digital imaging systems of equivalent
or greater speed shall be used.
13. Dental radiographic films shall be developed ac-
cording to the time-temperature method and the
chemistry according to the manufacturer’s instruc-
tions. Sight development shall not be used.
14. Use of leaded aprons for full mouth or panoramic
examinations is a prudent but not essential prac-
tice. Gonadal doses from current full-month series Fig 1. Rectangular collimator (arrow) attached to open-
or panoramic examinations do not exceed 5 ␮Gy ended round x-ray position-indicating device (PID)
(0.0005 rad).9 A significant portion of this gonadal
dose results from scattered radiation in the pa-
tient’s body. Leaded aprons do not significantly
reduce these doses.1 The guidelines state that
leaded aprons on patients are not required if all
other recommendations in the report are rigor-
ously followed.
15. Thyroid collars shall be provided for children and
should be provided for adults (Fig 2), when they
will not interfere with the examination.
The report includes guidelines to protect the oper-
ator:

1. New or remodeled offices should have shielding

designed by a qualified expert to create adequate
protective barriers. The barriers shall be con- Fig 2. Thyroid collar and lead apron for intraoral
structed so that operators can maintain visual con- radiography.
tact and communication with patients throughout
the procedures.
ties shall be designed so that no member of the public
2. The operator should be standing at a minimum
will receive an effective dose in excess of 100 mrem or
distance of 2 meters from the tube head. If this
0.1 rem (1 mSv) annually.
minimum distance cannot be maintained, a barrier
shall be provided. EQUIPMENT DESIGN
3. Monitoring of individual occupational exposures
For optimal use of radiation in dentistry, the Food
for office staff and personnel is required for those
and Drug Administration has developed performance
reasonably expected to receive a significant dose.
standards for medical and dental x-ray machines. Com-
The NCRP recommends personal dosimeters for
pliance with these standards at installation is required
external exposure measurement for workers who
for all machines manufactured in the United States after
are likely to receive an annual effective dose in
1975.2 The NCRP recommends that the x-ray machines
excess of 1 mSv and also for pregnant occupation-
shall provide the range of exposures that are suitable for
ally exposed personnel.
use with the fastest image receptors available.
Finally, the report outlines steps that should be It is the responsibility of the clinician who owns the
taken to protect the public, including people in recep- office to make sure that the tube head is free of drifts
tion rooms, other treatment areas in the same office, and and oscillations. The operator is prohibited from hold-
adjoining corridors in the building. New dental facili- ing the tube head during exposure.10
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 128, Number 2
Equipment design for intraoral radiography shall be
capable of providing rectangular collimation. Collimat-
ing the x-ray beam to the precise size of the image
receptor eliminates scatter radiation. Scatter radiation
in general decreases the quality of the image. “Rectan-
gular collimation of the beam shall be used routinely
for periapical radiography. Each dimension of the beam
measured in the plane of the image receptor shall not
exceed the dimension of the image receptor by more
than 2% of the source-receptor distance. Similar colli-
mation should be used when feasible for interproximal
(bitewing) radiography.”
SPECIFIC GUIDELINES FOR THE ORTHODONTIST
For all intraoral radiography, the NCRP recommends
using ANSI11 film speeds E and above when available.
For extraoral radiography, blue fluorescing calcium tung-
state screens that are considered slow are no longer
recommended because they increase the patient’s skin and
absorbed x-ray dose. The specific NCRP recommendation
is: “The fastest imaging system consistent with the imag-
ing task shall be used for all extraoral dental radiographic
projections. High speed (400 or greater) rare-earth screen-
film systems or digital systems of equivalent or greater
speed shall be used.”
For direct digital radiograpy, in which the film-
based image is replaced by a digital image consisting of
a 2-dimensional array of pixels, the latent image is
recorded directly on a suitable digital sensor. Receptors
include photostimulable phosphors, charge-coupled de-
vices, and complementary metal-oxide semiconductors,
which are also known as active pixel sensors. The latent
image is later digitally processed to produce an elec-
tronic image. The electronic image can be displayed on
a computer monitor, converted to a hard copy, or
transmitted electronically. Although the guidelines dis-
cuss the use of direct digital radiography at length,
there are no specific recommendations to replace the
existing fast film for intraoral radiography. The report
agreed with the current published literature regarding
the detection efficiency of digital receptors with that of
conventional film when investigating occlusal and
proximal caries, periodontal bone lesions, periapical
bone lesions, and root canal systems.12-14
Rotational panoramic machines use a narrow verti-
cal beam, exposing only a small portion of the image
receptor at any time. The NCRP’s recommendation is:
“The x-ray beam for rotational panoramic tomography
shall be collimated such that its vertical dimension is no
greater than that required to expose the area of clinical
interest. In no case shall it be larger than the slit in the
image-receptor carrier plus a tolerance of two percent
of the source-to-image receptor distance.”
Mupparapu 171
Clinicians who routinely perform cephalometric
radiography should note the following. Generally, the
area of clinical interest in cephalometric radiography is
significantly smaller than the image receptor. The
central axis of the beam is usually aligned through the
external auditory canals, positioned by the ear rods of
the cephalostat. Imaging of the structures superior to
the superior orbital rim, posterior to the occipital
condyles, and inferior to the hyoid bone is clinically
unnecessary. This prevents unnecessary exposure to the
patient’s hard and soft tissues. It is also a standard
recommendation from the NCRP that the soft tissue
facial profile should be imaged along with osseous
structures of the face. This is accomplished by reducing
exposure to anterior soft tissues.
Clinicians should switch from the slower, blue
fluorescent screens to the faster green fluorescent
screens. Kodak T mat G or Kodak Ektavision15 (East-
man Kodak Company, Rochester, NY) screens with
their speed-matched film combinations are examples of
fast screens. Filters for imaging the soft tissues of the
facial profile and the facial skeleton shall be placed at
the x-ray source rather than at the image receptor. This
equipment modification might not be easy to achieve
without purchasing new cephalometric or panoramic-
cephalometric combination machines (Fig 3). The new
digital cephalometric machines come with this kind of
built-in soft tissue filtering. This might be an added
incentive for the practitioner to convert to digital
receptors when replacing older equipment. The dose
reduction might be substantial, because digital systems
are much thriftier than existing screen-film systems,
and the built-in soft tissue filters will eliminate the
external cassette-side filtration. According to the NCRP
report, “Practitioners need to remember that all struc-
tures recorded on the image need to be interpreted for
evidence of disease or injury as well as for cephalo-
metric analysis.”
CONCLUSIONS
NCRP report #145 is relatively new, and many in
the dental profession have not yet taken a serious look
at it. This important report defines standards of care in
terms of radiation protection for the operator, the
patient, and the public. It is certain to make an impact
on the radiographic practices in most oral health-care
settings.16 It is the responsibility of all dental health-
care providers to reexamine their practices, equipment,
protective devices, and receptor selection.
Clinicians should consider converting to digital
radiographic modalities for improved compliance, ra-
diation dose reduction, and ease of storage, retrieval,
and transfer of information.
172 Mupparapu
Fig 3. Newer-generation digital radiography machine
has built-in soft tissue filter. (Planmeca Promax pan-
oramic-cephalometric combination machine).
REFERENCES
1. National Council on Radiation Protection and Measurements.
Radiation protection in dentistry (report no. 145). Bethesda, Md:
NCRP; 2003.
2. Food and Drug Administration. Performance standards for ion-
izing radiation emitting products, 21 CFR Sect. 1020 (1995).
3. Kumazawa S, Nelson DR, Richardson ACB. Occupational ex-
posure to ionizing radiation in the United States: a comprehen-
sive review for the year 1980 and a summary of trends for the
years 1960-1985. EPA 520/1-84/005 (National Technical Infor-
mation Service, Springfield, Va).
4. National Council on Radiation Protection and Measurements
(NCRP). Dental x-ray protection (report no. 35). Bethesda, Md:
NCRP; 1970.
5. Joseph LP. The selection of patients for x-ray examinations:
dental radiographic examinations. HHS Publication No. FDA
88-8273. Rockville, Md: The Dental Radiographic Patient Se-
lection Criteria Panel, DHHS, Center for Devices and Radiolog-
ical Health; 1987.
6. Matteson SR, Joseph LP, Bottomley W, Finger HW, Frommer
HH, Koch RW, et al. The report of the panel to develop
radiographic selection criteria for dental patients. Gen Dent
1991;39:264-70.
7. ADA Council on Scientific Affairs. An update on radiographic
practices: information and recommendations. J Am Dent Assoc
2001;132:234-8.
8. Conference of Radiation Control Program Directors, Inc. Patient
exposure and dose guide. CRCPD publication E-03-2. Frankfort,
Ky: Conference of Radiation Control Program Directors Inc;
2003.
9. White SC. 1992 assessment of radiation risk from dental radi-
ography. Dentomaxillifac Radiol 1992;21:118-26.
10. International Electrotechnical Commission. Medical electrical
equipment. Part I: general requirements for safety. 3. Collateral
standard: general requirements for radiation protection in diag-
nostic x-ray equipment. SS-EN 60601-1-3. Geneva, Switzerland:
International Electrotechnical Commission; 1994.
11. American National Standards Institute. Photography-intraoral
dental radiographic film specifications: ANSI/ISO 3665. New
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12. Kullendorf FB, Nilsson M, Rohlin M. Diagnsotic accuracy of
direct digital dental radiography for the detection of periapical
bone lesions: overall comparison between conventional and
direct digital radiography. Oral Surg Oral Med Oral Pathol
Radiol Endod 1996;82:344-50.
13. Hintze H, Wenzel A, Jones C. In vitro comparison of D and E
speed film radiography, RVG and Visualix digital radiography
for the detection of enamel approximal and dentinal occlusal
caries lesions. Caries Res 1994;28:363-7.
14. Sanderink GC, Huiskens R, van der Stelt PF, Welander US,
Stheeman SE. Image quality of direct digital intraoral x-ray sensors
in assessing root canal length. The RadioVisioGraphy, Visualix/
VIXA, Sens-A-Ray and Flash Dent systems compared with Ekta-
speed films. Oral Surg Oral Med Oral Pathol 1994;78:125-32.
15. Kodak T-MAT G dental film and Kodak Ektavision G dental
film. Available at: http://www.kodak.com. Accessed November
20, 2004. Accessed April 27, 2005.
16. Miles DA, Langlais RP. NCRP report no. 145. New dental x-ray
guidelines: their potential impact on your dental practice. Dent
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COMMENTARY
The NCRP guidelines state that “all radiographic
examinations shall be performed only on direct prescrip-
tion of the dental practitioner or physician after conduct of
a clinical history and physical examination of the patient,
and determination of a reasonable expectation of a health
benefit to the patient.” The guidelines also direct clinicians
to “make a good-faith attempt to obtain recent, pertinent
radiographs from the patient’s previous dentist. Radio-
graphic examinations shall be performed only when indi-
cated by patient history, physical examination or by
laboratory findings.”
It has become common practice in orthodontic clinics
to “quick start” potential patients on the first visit to the
office. Some practice consultants advise giving the pro-
spective patient an “office tour” that includes a stop at the
x-ray machine to take panormic and cephalometric films,
before introducing the patient to the orthodontist. This is
done under the assumption that many patients will actu-
ally begin treatment that day, including spacers.
Of course, not all prospective patients are ready to
start treatment immediately or to commit to being treated
at that particular office, so this practice results in unnec-
essary exposure for some and is a violation of the guidelines.
Also, more effort should be made to obtain previously taken
films to avoid duplication of exposure, even though it seems
faster and more cost-efficient to take new films. This is a
good example of the push/pull of orthodontic marketing and
the resulting impact on patient care.
Jan Bell
Seattle, Wash
Am J Orthod Dentofacial Orthop 2005;128:172
0889-5406/$30.00
Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.04.015