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Radiology Review

The following slides provide a brief overview


of Radiology, including physics, image
characteristics, films, processing,
radiobiology and digital radiography.
If you right click anywhere on the screen and
select “Full Screen” the slides will be easier
to view.
X-ray Machine Components

timer kVp
Step-up
Auto Trans. PID

oil
filter
Step-down
mA Trans. collimator

exposure
switch

The low-voltage circuit (green in diagram above) controls the


heating of the filament in the x-ray tube. The mA control regulates
the amount of voltage that passes through the step-down
transformer, which in turn reduces the voltage to about 5 volts;
this is enough to heat the filament and produce electrons.
X-ray Machine Components

timer kVp
Step-up
Auto Trans. PID

oil
filter
Step-down
mA Trans. collimator

exposure
switch

The high-voltage circuit (red in diagram) controls the voltage across


the x-ray tube. It is regulated by the kVp selector (a rheostat) and the
step-up transformer, resulting in a very high voltage which pulls the
electrons from the filament to the target. The higher the kVp, the
greater the energy of the electrons
X-ray Tube molybdenum focusing cup
tungsten filament
electron flow
tungsten target
copper sleeve
unleaded glass window
leaded glass
vacuum inside tube
electrical connections
x-ray

When the exposure switch is depressed, the filament is heated,


producing a cloud of electrons around the filament. The high
voltage between the cathode (filament, focusing cup) and the
anode (target, copper stem) pulls the electrons across the x-ray
tube to interact with the target to produce x-rays.
Bremsstrahlung X-ray Production

high-speed
electron x-ray

+ decelerated
electron

The majority of x-rays produced are known as Bremsstrahlung.


These x-rays result from the attraction between the high-speed
electrons (negative charge) from the filament and the protons
(positive charge) in the nuclei of the target atoms. The attraction
causes the electron to slow down and change direction, resulting in
the release of energy in the form of an x-ray. The closer the
electron passes to the nucleus, the greater the energy of the
resultant x-ray. If the electron hits the nucleus, a maximum energy
60-cycle Alternating Current

Constant Potential (800 cycles.sec.)

With alternating current, x-rays are only produced during the


positive half of the cycle (red areas above). There is a large
fluctuation in the voltage between the filament and the target,
contributing to a wide range of x-ray energies. X-ray machines
with constant potential (“direct current”) are preferred over the
standard alternating current. This provides more efficient x-ray
production and less exposure time per radiograph. Most of the
newer x-ray machines utilize constant potential.
kVp determines the voltage across the x-ray tube. This
ultimately determines the energy (penetrating ability) of the x-
ray beam. Higher kVp = higher average energy (dotted lines
above) and higher maximum energy. There is also an increase
in the number of x-rays produced when kVp is increased.
Increasing the kVp allows you to reduce exposure time (An
increase of 15 kVp allows you to cut the exposure time in half).
It is recommended that at least one x-ray machine in the office
have the capability of varying the kVp (to image children,
patients with tremors, etc., which requires minimum exposure
time). In general, a higher kVp is preferred, especially for
periapical and periodontal diagnosis.
An increase in the mA setting or the exposure time
results in an increase in the number of x-rays
produced. There is no change in the average energy
of the x-ray beam. A machine with variable mA
settings would normally be set at the highest mA,
allowing for a reduced exposure time.
Exposure time: 60 impulses = 1 sec.
Density = degree of darkening. Affected by:
Exposure factors (Increase = increase in density)
Size of head (soft tissue, bone): Increase will result
in decrease in film density
Object density (bone, teeth, restorations): Increase
will result in decrease in film density
Film fog (scatter, storage): Results in increase in
overall film density

Contrast = density differences. Increased by:


Lowering kVp
An increase in subject contrast

Technically, higher contrast (lower kVp) is preferred for


caries detection. Lower contrast (higher kVp) is
recommended for imaging periapical and periodontal
changes. For general use, a medium kVp (70-75) is usually
selected.
Sharpness
Measures how well the details (boundaries) of
an object are reproduced on a radiograph
Increased by:
Source-object distance
Object-film distance
Film crystal size
Motion will decrease sharpness

Magnification
Decreased by:
Source-object distance
Object-film distance
16” FFD image
Target
16” from film Target
8” from film 8” FFD image
Film
Increasing the distance from the target of the x-ray tube (focal
spot, focus) to the object (teeth/film) (FFD = focus-film
distance) will result in an increase in sharpness and a
decrease in magnification. This results when a longer PID
(cone) is used.

Moving the film closer to the teeth will also increase sharpness
and decrease magnification.
8" FFD

12" FFD

Most newer x-ray machines have a recessed target


(away from the PID). This helps to increase the focus-
film distance (FFD), resulting in a sharper image and
less magnification without an increase in the length
of the PID (position indicating device). A longer PID is
effective, but it makes positioning the tubehead more
difficult.
Intraoral Film
D-speed (Ultraspeed): Probably the
most commonly used film in private practice.
Technically will give you sharper image,
because of the smaller crystal size.

F-speed (Insight): Larger silver halide


crystals. 60% less radiation than D-speed.
Clinasept Barriers (see above) seal the film inside
plastic, protecting the film from saliva. When the
films are separated out of the plastic, the films can
be handled for processing with minimal risk of
contamination. The cost for the film/barrier
combination is more expensive than film alone, but
the advantages in infection control are obvious.
Extraoral film for panoramic or cephalometric
radiographs comes in various types/sizes. T-Mat
film is available as G (high contrast), L (wide
latitude) and H (used when taking two films at
same time to provide extra film). In general, T-Mat
L film is used because exposure factors are not
as critical for slight variations in patient size
(wider latitude). These films are used with rare
earth screens (emit green light).

Ektavision screen/film combinations are also


available (G, H, L films). This system produces
images with more detail than the T-Mat system
(same speed). Ektavision screens also emit green
light.
Intensifying Screens
Calcium Tungstate
speed

Barium Strontium Sulfate


Rare Earth
Lanex (used with T-Mat film)
Ektavision

Intensifying screens for panoramic or cephalometric


imaging should be a type of rare earth screen (green-
light emitting). These screens require less radiation
exposure (than blue light emitting) with no loss of
image detail. Patient exposure is reduced.
Film Viewing Guidelines

Mask viewbox (block light around film mount)


No distractions
View films when alert, refreshed (not at the end
of the day)
Use magnifying lens
Vary illumination of viewbox if possible (rheostat)
Reduce room light
Radiobiology
Some patients are very concerned about the
amount of exposure they are getting from a
series of radiographs. It is important to
understand the effects of x-rays and what the
approximate doses are from individual films.
The following slides briefly describe the
effects and doses associated with routine
radiographic procedures.
When x-rays enter the body, they interact with the
atoms of the various tissues, causing ionization
(removal of an electron from the atom). This results
in the formation of ions and free radicals which are
very reactive and join with other atoms/molecules to
form undesirable combinations (mutations). If the x-
ray interacts with a critical molecule, especially
DNA, the molecule’s chemical bonds are broken
and this may alter the function of the DNA and
ultimately the cellular activity. This is the direct
effect of radiation. If the x-ray interacts with
another, non-critical molecule (usually water), the
ions and free radicals produced may in turn interact
with a critical molecule and cause damage. This is
the indirect effect.
Permanent damage
Dose

According to the LNTH (Linear No-Threshold


Hypothesis; blue line above) any dose, no matter how
small, will result in some permanent damage within the
cells affected.
New molecular and cellular biology data demonstrate
that cellular control of massive natural DNA damage
rates contradicts the biological plausibility of the LNTH;
in other words, cellular repair takes care of any damage
below a certain dose. This is represented by the red line
above.
It has been estimated that 8,000 to 10,000 DNA-
damaging events occur spontaneously in each cell
every hour. This damage is successfully repaired
within minutes of its occurrence.

1 cGy (1 rad) of radiation produces 80 DNA damage


sites.

It is felt that if the cells can successfully repair the


damage from 8,000-10,000 spontaneous events, the
80 (1 %) more from x-ray exposure would also be
repaired.
Radiation Effects influenced by:

Total Dose: Higher dose = greater effect


Dose Rate (all at once = greater effect or
spread over a period of time = less damage)
Area covered (volume of tissue): more
tissue = greater effect
Type of tissue (radiosensitive = greater
effect, radioresistant = reduced effect)
Age: greater effects in young people
Background Radiation = 360 mrem/year
Radon 200 mrem (54%)
Cosmic (sun) 27 mrem (8%)
Rocks/soil 28 mrem (8%)
Internal 40 mrem (11%)
Medical x-rays* 39 mrem (11%)
Nuclear medicine 14 mrem (4%)
Consumer products 10 mrem (3%)
Other sources < 1 mrem (1%)
* Dental x-rays 0.1%

Everyone is exposed to certain amounts of background


radiation; the amount will vary depending on where you live,
the amount of outdoor activity, etc.. Radon is by far the largest
contributor to the background total and the radon levels in
your house should be checked. Dental x-rays contribute a very
small portion to the background total.
Surface X-ray Exposure
Periapical/BW: 100 mR (F-speed)
250 mR (D-speed)
Panoramic: 500 mR
AFM: 2.0 R* (F-speed)
Lateral Skull: 200 mR
Chest: 20-40 mR
*1 R = 1000 mR
These numbers will vary depending on the source
of the information, but they are in the ballpark.
Keep in mind that these numbers don’t take into
account the total area covered; the next slide
gives a more accurate indication of the total
exposure a person receives.
Effective Dose
AFM (round, F-speed) 6.7 mrem
AFM (rect., F-speed) 2.6 mrem
Panoramic 0.7 mrem
Skull 22.0 mrem
Chest 8.0 mrem

Effective dose is the approximate whole-body dose


received from the various x-ray procedures. A full
series of intraoral films, with round collimation and
F-speed film, results in less exposure than a chest
film, which uses intensifying screens and is
looking at soft tissue.
MPD
Maximum Permissible Dose
The MPD represents the amount of radiation an
individual is allowed to receive from artificial
sources (such as x-ray machines). The values
listed below are per year.

Occupationally exposed
50 mSv (5 rem) NCRP*
General Population
5 mSv (.5 rem) NCRP
*National Council on Radiation Protection
The exposure a patient receives from a full-mouth
series of x-ray films is approximately the same as
the exposure received while traveling from New
York to LA on a plane. (Using F-speed film).
One-in one million chance of dying:
AFM
Smoking 1 cigarette
Riding a bicycle 10 miles
Driving a car 300 miles
Flying 1000 miles
Obviously, we don’t want to mention dying in
connection with x-rays, but it puts things into
perspective regarding the effects/risks of taking
radiographs.
Patient Protection

Film ordering (Risk vs. Benefit)


Equipment reliability
Filtration
Collimation
Film/screen speed
Lead apron/thyroid collar
Technique
Processing
Ordering Films
Clinical exam – should be done before deciding
what films are needed.

Selection Criteria – developed by ADA and other


groups; these serve as guides in deciding what
films are necessary. (See next slide).

Professional Judgment – based on clinical


experience, didactic training, etc.
Selection Criteria
Symptomatic teeth
Fracture/chipped tooth
Large caries
Large restorations
Abutment teeth
Gingival condition

Selection criteria are used to identify teeth


which are potentially at risk (or are to be used
as abutments) and require periapical films to
identify periapical changes.
Equipment Reliability
Leakage Radiation
Timer Accuracy
X-ray production (kVp, mA)

State Inspection by Ohio Department of Health

X-ray machines are required to be inspected


every five years in Ohio. If you take over an
existing practice, I recommend that you contact
the ODH to schedule an inspection if one has
not been done recently.
Filtration
Aluminum filter(s)

Added

2.5 mm
Total 70 kVp
Glass window Oil/metal barrier 1.5 mm
of x-ray tube
Inherent
The amount of filtration is regulated by the government
(NCRP). Any machine capable of operating at a kVp of
70 or above must have 2.5 mm aluminum equivalent of
total filtration. If the maximum kVp of the machine is 65,
only 1.5 mm aluminum equivalent is needed. The
manufacturer automatically provides this on x-ray
machines.
Collimation controls the size of the x-ray beam.
Allowed beam size is a maximum of 2.75 inches
(7 cm) in diameter at skin surface.

7 cm
6 cm If you switch from a 7
cm round PID to a 6
6 cm round
cm round PID, the
patient receives 25%
# 2 film less radiation.
(4.5 cm long) Switching from 7cm
round PID to
entrance rectangular PID
entrance reduces dose by
exit 55%.
exit
Lead Apron/
Thyroid Collar
Some people are suggesting
that lead aprons are not
needed. However, most feel
that any reduction in patient
exposure is beneficial and, since the cost and time
of placement of the apron are minimal, the use of
the apron is encouraged.
I recommend a lead apron with a separate, but
attached, thyroid collar for intraoral films. For
panoramic or ceph films, a double-sided apron with
no collar is used. There are multiple sources for
lead aprons.
Pregnancy
….the fetal exposure is only about 1 microGray for a
full-mouth series. Accordingly, the guidelines for
ordering films can be used with pregnant patients
just as with other patients.

The unborn child is very sensitive to ionizing


radiation. Limit radiographic examination during
pregnancy to cases with a specific diagnostic
indication. Postpone elective procedures until the
termination of the pregnancy.

The apparently contradictory views above came from the


same textbook. Bottom line: Do what you think is best
for your pregnant patient.
X-ray Protection for the Operator

• Do not hold films for patient

• Utilize barriers if possible


Door with leaded glass
Wall of room (drywall adequate protection);
need mirror mounted opposite doorway
so that you can see patient in operatory

• Adhere to position-and-distance rule


if no barriers available (see next slide)
Position and Distance Rule
135° 135°

6 fe f e et
et 6

90° 90°

If no barriers are available, you should stand at


least six feet away from the patient at an angle of
90-135 degrees to the direction of the x-ray beam,
on either side of the patient (footprints in diagram
above).
Film badges are only required if you expect to exceed
10% of the MPD (0.05 Sv or 5 rem) during the year. Since
you should not exceed this amount if you follow routine
radiation protection procedures, film badges are not
required in the State of Ohio. However, I feel it is a good
idea to provide badges for your assistants/hygienist for
their peace of mind, at least for a 3-month period. If no
exposure is recorded during that time, it is unlikely that
any future exposure will occur and the badges can be
discontinued.
Ohio Department of Health
Radiologic Health Program
Registration
For purchase, transfer, or disposal
of x-ray equipment
Biennial registration fee

Inspection
Every five years (private practice)
Inspection fee per machine
State Requirements
Radiation Safety Officer (Dentist, hygienist,
or assistant)
Notice to Employees (Must be prominently
displayed); available from state.
Safe Operating Procedures (List of x-ray
machines, settings, usage, etc.)
Instruction of Individuals (Signed form
indicating employee familiar with x-ray
procedures)
Contact the Ohio Department of Health, Radiologic
Technology section for information and guidelines to
satisfy above requirements. (614) 752-4319.
Ohio State Dental Board
(614) 466-2580

Assistants need Radiographer’s


license to take radiographs. Need 7
hours of CE followed by in-office
training. Two hours of radiology CE
then required every two years.
Digital Radiography Advantages
Reduced patient exposure (Intraoral)
Ability to manipulate image
Patient consultation/education
“Instant” image (CCD, CMOS)
No chemical processing
Environmentally friendly (no processing
chemicals, silver, lead)
Remote consultation
Lower long-term cost?
Digital Radiography Components

X-ray machine: Standard intraoral or


pan/ceph machine
Sensor (CCD, CMOS, PSP; see next slide)
Laser scanner (PSP only)
Computer with monitor and modem or
high-speed cable connection
Printer
Direct Digital
(Sensor connected directly to computer)

CCD: Charged Coupled Device


CMOS: Complimentary Metal Oxide
Semiconductor

Indirect Digital
(Requires laser scan of sensor)

PSP: Photo-Stimulable Phosphor


PSP

plastic
sensor sleeve*
* Protects film from saliva

CCD, CMOS

sensor
to computer

covered with plastic sleeve and


finger cot before placing in mouth
CCD, CMOS

These digital sensors are composed of a pure


silicon chip divided into an array of pixels (picture
elements). When x-rays strike the surface of the
sensor, energy is stored in the pixel; the amount
of energy stored is determined by the strength of
the x-ray hitting a particular pixel. These charges
are then removed electronically, in sequence,
creating an output signal with a voltage
proportional to the energy stored in each pixel.
These signals produce the digital image seen on
the monitor.
PSP (Photostimulable phosphor)

These phosphors absorb x-ray energy in a manner


similar to the phosphors used in intensifying
screens. X-rays striking the phosphor excites
electrons in the atoms, some of which produce
light but the majority of which are trapped within
the phosphor. When the sensor is scanned with a
ruby laser, the trapped electrons are released,
causing emission of shorter-wavelength light in
the blue region of the spectrum. The more x-rays
absorbed by the phosphor, the brighter the light.
The emitted light is detected by a photomultiplier
tube and the information is digitized to form the
image.
CCD and CMOS systems produce an
“instant” image and can be useful for
endo or emergencies. The sensor is
very thick and rigid and can be more
difficult to place in the mouth. The
sensors cost several thousand dollars
to purchase or replace. Pan/ceph
systems are much more expensive.
PSP systems require laser scanning of the
sensors which takes several minutes (time to
load films in scanner and scan). Sensors are
actually thinner than x-ray film and are more
comfortable for the patient. Intraoral sensors
cost about $35; you would need to have enough
sensors for at least two full series in order to
function effectively. Pan/ceph sensors cost
around $800-900.
The initial cost of the PSP system is higher than
CCD or CMOS systems because of the cost of
the laser scanner. (This assumes you only have
one CCD/CMOS sensor).
Schick has developed a wireless sensor that will
produce an “instant” image as do the corded
sensors. However, the wireless sensor is much
thicker and more expensive.

Several systems use laptop style computers for


imaging. This allows easy portability between
operatories.

The old-style CRT monitors will give you better x-


ray images, but many feel the overall space-
saving and great color for intraoral pictures
make flat-panel monitors the best choice in the
operatory.
All systems differ slightly in their
software but all allow you to change
brightness and contrast, reverse
black and white, colorize, measure,
etc.. In choosing a system, evaluate
size of sensor, # of different sensor
sizes available (#0, 1, 2), overall cost
of system, extended warranty costs,
tech support, etc..
Below are two good sources for
information on digital radiography.

http://www.odont.au.dk/rad/Digitalx.htm

http://www.learndigital.net