RADIOGRAPHY AND

RADIATION PROTECTION

PRESENTED BY
DR SHARMILA S
J-2
DEPT OF CONSERVATIVE DENTISTRY &
ENDODONTICS
 INTRODUCTION
• Dental radiology uses X-ray technology to diagnose and
design treatment of various clinical problems related to the
oral cavity and surrounding tissues.
• Because dental X-rays are performed more on younger
individuals, whose teeth and dentition are still developing,
calls for increased need on radiation protection.
(Radiation protection in dental radiology – Recent advances and future directions V. Tsapaki)
 X-RAY TECHNOLOGY

• There are many types of X-ray machines using either two

dimensional (2D) or three-dimensional (3D) technology in
dental radiology.

(Radiation protection in dental radiology – Recent advances and future directions V. Tsapaki)
 INTRAORAL RADIOGRAPHY
• This is the most common type of 2D radiography during
which an image receptor such as direct exposure film (without
the use of any intensifying screen), photostimulable phosphor
(PSP), charge coupled device (CCD), or complementary metal
oxide semiconductor (CMOS) is placed in the patient mouth.

(Radiation protection in dental radiology – Recent advances and future directions V. Tsapaki)
Depending on the region of the mouth to be investigated it can be

Bitewing

Periapical

Occlusal

(Vandenberghe B, Jacobs R, Bosmans H. Modern dental imaging: a review of the current technology and clinical applications in
dental practice. Eur Radiol 2010;20(11):2637–55)
 PANORAMIC RADIOGRAPHY
• The panoramic X-ray machine utilizes an X-ray tube and an
image receptor which rotate around the patient imaging the
mandible and maxilla as well as the supporting structures.
• It is usually applied in cases of treatment planning or for
postoperative control
(Vandenberghe B, Jacobs R, Bosmans H. Modern dental imaging: a review of the current technology and clinical
applications in dental practice. Eur Radiol 2010;20(11):2637–55)
CEPHALOMETRIC RADIOGRAPHY
• Usually a cephalometric unit is incorporated in a panoramic
machine and uses a head positioning device to produce a 2D
extra-oral radiograph with a special head handling device.
• The image receptor is most often the same as the one used for
panoramic radiography.

(Vandenberghe B, Jacobs R, Bosmans H. Modern dental imaging: a review of the current technology and clinical
applications in dental practice. Eur Radiol 2010;20(11):2637–55)
 -Cephalometric radiography is applied to evaluate the head and neck as
well as the whole facial symmetry and also in orthodontic diagnosis and
treatment planning

(Vandenberghe B, Jacobs R, Bosmans H. Modern dental imaging: a review of the current technology and clinical applications in dental practice. Eur
Radiol 2010;20(11):2637–55)
 CONE-BEAM CT (CBCT)
• Dental CBCT that uses a cone- or pyramid-shaped X-ray beam
directed on the pursued maxillofacial field-of-view (FOV).
• The image receptor in this X-ray system is either a flat panel
detector (FPD) or a CMOS detector.
• The machine is similar to a panoramic unit that, apart from the
digital detector, has sophisticated software to produce 3D
images
(MacDonald D. Cone-beam computed tomography and the dentist. J Investig Clin Dent 2017;8)
 MULTI-DETECTOR CT (MDCT)
• This imaging procedure involves a conventional MDCT
scanner that has special dental software to image the whole
mouth area and surrounding tissues.
• Modern MDCTs use a widened fan-shaped beam and a 2D
detector that produces submillimeter images (as small as 0.5
mm) with sub-second rotation times.
( Widmann G, Al-Shawaf R, Schullian P, Al-Sadhan R, Hormann R, Al-Ekrish AA. Effect of ultra-low doses,
ASIR and MBIR on density and noise levels of MDCT images of dental implant sites. Eur Radiol
2017;27(5):2225–34)
 PATIENT DOSE ASSESSMENT
- Radiation dose measurement is a very important tool for
optimization.

-Varying radiation protection measures should be taken for the

patient and staff depending on type of x-ray procedure.
- As far as the X-ray machine is concerned, it must comply with
national laws and/or regulations.
( International Atomic Energy Agency (IAEA). Implementation of the International Code of Practice on Dosimetry in
Diagnostic Radiology (TRS 457): Review of Test Results. Vienna; 2011)
• Recognition of the harmful effects of radiation and the risks
involved with its use led the National Council on Radiation
Protection and Measurements (NCRP) and the International
Commission on Radiological Protection (ICRP) to establish
guidelines for limitations on the amount of radiation received

by both occupationally exposed individuals and the public.

(Oral radiology principles and interpretation white and pharoah-6 th edition)

• Dentists and their staff are occupationally exposed workers
and are allowed to receive up to 50 mSv of whole-body
radiation exposure per year

(Oral radiology principles and interpretation white and pharoah-6 th edition)

• Determining the quantity of radiation exposure or dose is
termed as dosimetry.
• Dose-the amount of energy absorbed per unit of mass at a site
of interest.
• Exposure-measure of radiation on the basis of its ability to
produce ionization in air under standard conditions of
temperature and pressure(STP)
(Oral radiology principles and interpretation white and pharoah-6 th edition)
• According to the European BSS, DRL(Diagnostic reference
level) is the ‘‘dose level in medical radiodiagnostic or
interventional radiology practices, or, in the case of radio-
pharmaceuticals, levels of activity, for typical examinations
for groups of standard-sized patients or standard phantoms for
broadly defined types of equipment”.
 EXPOSURE
• Measure of radiation quantity,the capacity of radiation to
ionize air.
• SI unit-air kerma(c/kg)
• 1 C/kg=3876R

(Oral radiology principles and interpretation white and pharoah-6 th edition)

 ABSORBED DOSE
• Measure of the energy absorbed by any type of ionizing
radiation per unit of mass of any type of matter.
• 1gy-100 rad

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 EQUIVALENT DOSE
• Used to compare the biologic effects of different types of
radiation on a tissue or organ.
• 1 Sv=100 rem.

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 EFFECTIVE DOSE
• Used to estimate the risk in humans
• This allows the risk from exposure to one region of the body
to be compared with the risk from exposure to another region.
• SI unit-Sievert

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 RADIOACTIVITY
• Decay rate of a sample of radioactive material.
• SI unit-becquerel
• Traditional unit-curie

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 SOURCES OF RADIATION
EXPOSURE
Background radiation from cosmic and terrestrial sources
yields an average annual effective dose of about 2.4
millisieverts (mSv) worldwide

(Oral radiology principles and interpretation-white and pharoah-6th

edition)
(Oral radiology principles and interpretation-white and pharoah-6 th
edition)
(Oral radiology principles and interpretation-white and pharoah-6th edition)
 PRINCIPLES OF RADIATION
PROTECTION
• There are three guiding principles in radiation protection
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 PRINCIPLE OF JUSTIFICATION
• In making dental radiographs this principle obligates the
dentist to do more good than harm.
• In radiology this means the dentist should identify those
situations where the benefit to a patient from the diagnostic
exposure exceeds the low risk of harm.
• In practice this principle influences what patients we select for
radiographic examinations and what examinations we choose

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 PRINCIPLE OF OPTIMIZATION

• This principle holds that dentists should use every means to

reduce unnecessary exposure to their patient and themselves.
• Principle of ALARA ( A s Low As Reasonably Achievable)
• ALARA holds that exposures to ionizing radiation should be
kept as low as reasonably achievable, economic and social
factors being taken into account

(Oral radiology principles and interpretation-white and pharoah-6th edition)

 DOSE LIMITATION
• Dose limits are used for occupational and public exposures to
ensure that no individuals are exposed to unacceptably high
doses.
• There are no dose limits for individuals exposed for diagnostic
or therapeutic purposes

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

REDUCING DENTAL EXPOSURE
 PATIENT SELECTION CRITERIA

• Dentists should not prescribe routine dental radiographs at

preset intervals for all patients.
• Instead, they should prescribe radiographs after an evaluation
of the patient ’s needs that includes a health history review, a
clinical dental history assessment, a clinical examination, and
an evaluation of susceptibility to dental diseases. (ADA, 2006)

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 CONDUCTING THE
EXAMINATION
• The conduct of the examination may be divided into choice of
equipment, choice of technique, operation of equipment, and

processing and interpreting the radiographic image.

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 DIGITAL IMAGING AND DOSE
REDUCTION

-Film of a speed slower than E-speed should not be used for dental
radiographs. (ADA, 2006).

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

-The use of F-speed film can reduce exposure 20 to 50 percent
compared to use of E-speed film, without compromising
diagnostic quality.

-Faster films are desirable from the standpoint of exposure

reduction.

(Farman TT, Farman AG. Evaluation of a new F speed dental X-ray film. The effect of processing solutions and a comparison with
D and E speed films. Dentomaxillofac Radiol 2000;29(1):41-5)
• As digital detectors generally require lower exposure times it
is evident that this eventually leads to patient dose reduction.

• Digital sensors offer equal or greater dose savings(40-

60percent) than F speed film and comparable diagnostic utility

(Guidelines on Radiology Standards for Primary Dental Care. Report by the Royal College of Radiologists and the
National Radiological Protection Board (NRPB). Doc NRBP 1994; 5(3). [43] Chinem LAS, Vilella BdS, Maurí)
 INTENSIFYING SCREENS
• Rare-earth intensifying screens are recommended, combined
with high-speed film of 400 or greater. (ADA, 2006)
• Compared with the older calcium tungstate screens, rare earth
screens (gadolinium and lanthanum)decrease patient exposure
by as much as 55% in panoramic and cephalometric
radiography

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 SOURCE-TO-SKIN DISTANCE
• Use of long source-to-skin distances of 40 cm, rather than
short distances of 20 cm, decreases exposure by 10 to 25
percent.
• Distances between 20 cm and 40 cm are appropriate, but the
longer distances are optimal. (ADA, 2006)

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

• The use of a longer source-to-object distance also results in a
smaller apparent focal spot size and thereby theoretically
increases the resolution of the radiograph

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 CBCT
• The FOV size is one of the most important if not the most significant
factor that affects patient dose in CBCT
• It is also closely related to image quality due to X-ray scatter.
• Taking into consideration the fact that in most clinical cases a small
region of interest needs to be imaged, the user should select an X-ray
system with at least one small FOV in the range of 4x4 cm2

(International Commission on Radiological Protection (ICRP) Publication 129. Radiological Protection in Cone Beam Computed
Tomography (CBCT), 2015)
 EUROPEAN SOCIETY OF ENDODONTOLOGY
POSITION STATEMENT: THE USE OF CBCT
IN ENDODONTICS

“A request for a CBCT scan should only be considered if the

additional information from reconstructed three-dimensional
images will potentially aid formulating a diagnosis and/or
enhance the management of a tooth with an endodontic
problem(s).”
 USE OF SHIELDING
• Shielding of radiosensitive organs (gonads, eye lens, breast or
thyroid) must be used when it is needed based on an individual
patient by patient basis.
• The most important factor to consider when using shielding is
the correct positioning of these devices on the patient so that
no artefacts are produced and no intrusion is done to the work
of X-ray machine automatic exposure control
(European Commission. European Guidelines on Radiation Protection in Dental Radiology; Radiation
Protection Report 136, Luxembourg 2004)
• Regarding thyroid shielding, the literature data show that use
of thyroid shield is to be advised, when performing upper
anterior radiography and universal rectangular collimator used
alone was more effective at reducing thyroid exposure than a
thyroid shield used with circular collimation in intraoral
radiography

(European Commission. European Guidelines on Radiation Protection in Dental Radiology; Radiation Protection Report
136, Luxembourg 2004)
• Specifically for CBCT, the latest data indicate that leaded
glasses, thyroid collars and collimation minimize the dose to
organs outside the field of view.

(International Commission on Radiological Protection (ICRP) Publication 129. Radiological Protection in Cone Beam Computed
Tomography (CBCT), 2015)
• Bismuth shielding for the eyes, thyroid, breast, or other organs
in CBCT should be used with caution.

(Goren A, Prins R, Dauer L, Quinn B, Al-Najjar A, Faber R, et al. Effect of leaded glasses and thyroid shielding on cone beam CT
radiation dose in an adult female phantom. Dentomaxillofac Radiol 2013;42(6):20120260)
• On the possible routine use of lead apron, the UK Guidance
Notes state that routine use of lead aprons in dental
radiography is not justified whereas the European guidelines
report that there is no need to apply gonadal shielding.

(National Radiological Protection Board (NRPB). Guidance Notes for Dental Practitioners on the Safe Use of X-Ray Equipment;
2010; ISBN 0-85951-463-3).
PREGNANT PATIENTS AND STAFF
 PAEDIATRIC PATIENTS
• Paediatric patients are extremely radiosensitive, they have increased
mitotic activity and longer life expectancy compared to adults and
consequently a greater possibility for radiation-induced cancer
• Cancer risk is cumulative over time
• This means that each X-ray examination contributes to the total
exposure of an individual and therefore increases the possibility of
radiation induced cancer

(United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) 2013 Report to the General Assembly. Volume II:
Scientific Annex B: Effects of radiation exposure of children 2013)
• As recently reported, approximately 6– 21% of patients
exposed to dental radiographs are aged 15 years and below.
• Therefore accurate justification is needed as a first measure of
patient dose reduction.

(EzEldeen M, Stratis A, Coucke W, Codari M, Politis C, Jacobs R. As low dose as sufficient quality: optimization of
cone-beam computed tomographic scanning protocol for tooth autotransplantation planning and follow-up in
children. J Endod 2017;43(2):210–7)
• More attention has to be given for justification of these
patients.

• As far as optimization is concerned, smaller CBCT FOVs

specifically to fit paediatric patients are generally

recommended.

(EzEldeen M, Stratis A, Coucke W, Codari M, Politis C, Jacobs R. As low dose as sufficient quality:
optimization of cone-beam computed tomographic scanning protocol for tooth autotransplantation
planning and follow-up in children. J Endod 2017;43(2):210–7)
• As recently reported, substantial E reduction can be achieved by
using small CBCT FOVs and ultra-low-dose high definition
reconstruction while maintaining sufficient image quality .
• Lower exposure settings could also be applied provided image
quality is maintained

(EzEldeen M, Stratis A, Coucke W, Codari M, Politis C, Jacobs R. As low dose as sufficient quality: optimization
of cone-beam computed tomographic scanning protocol for tooth autotransplantation planning and follow-up
in children. J Endod 2017;43(2):210–7)
• Thyroid shielding is also recommended in paediatric patients
in big FOV CBCT scans.
• According to the authors, lead shielding material performed
just as well as more expensive non-lead-equivalent materials
and a thyroid shield that wraps around the neck may be
beneficial to aid further dose reduction.

(Hidalgo A, Davies J, Horner K, Theodorakou C. Effectiveness of thyroid gland shielding in dental CBCT using a paediatric
anthropomorphic phantom. Dentomaxillofac Radiol 2015;44(3):20140285)
 RECTANGULAR COLLIMATION

• Since a rectangular collimator decreases the radiation dose by

up to fivefold as compared with a circular one, radiographic
equipment should provide rectangular collimation for
exposure of periapical and bitewing radiographs(ADA, 2006)

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 FILTRATION
• When an x-ray beam is filtered with 3mm of aluminum, the
surface exposure is reduced to about 20% of that with no
filtration.
• 1.5 mm Al total filtration when operation from 50 to 70 kVp
and with 2.5 mm Al total filtration when operating above 70
kVp

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 FILM AND SENSOR HOLDERS
• Film holders that align the film precisely with the collimated
beam are recommended for periapical and bitewing
radiographs. (ADA, 2006)
• Dental professionals should not hold the receptor holder
during exposure.

(National Council for Radiation Protection & Measurements, ed. NCRP Report No. 145 - Radiation Protection in Dentistry.
Bethesda: National Council on Radiation Protection and Measurement; 2003)
• Under extraordinary circumstances in which members of the
patient’s family (or other caregiver) must provide restraint or
hold a receptor holder in place during exposure, such a person
should wear appropriate shielding

(National Council for Radiation Protection & Measurements, ed. NCRP Report No. 145 - Radiation Protection in Dentistry.
Bethesda: National Council on Radiation Protection and Measurement; 2003)
 KILOVOLTAGE
• The operating potential of dental X-ray machines must range
between 50 and 100 kilovolt peak but should range between
60 and 80 kVp. (ADA, 2006)
• A setting above 90 kV(p) will increase the patient dose and
should not be used

(National Council for Radiation Protection & Measurements, ed. NCRP Report No. 145 - Radiation Protection in
Dentistry. Bethesda: National Council on Radiation Protection and Measurement; 2003)
 MILLIAMPERE-SECONDS
• The operator should set the amperage and time settings for
exposure of dental radiographs of optimal quality. (ADA,
2006)
• Both overexposed and underexposed radiographs result in
repeat exposures, thereby leading to needless additional
patient exposure

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 FILM PROCESSING
• Radiographs should not be overexposed and then
underdeveloped, because this practice results in greater
exposure to the patient and dental health care worker and can
produce images of poor diagnostic quality.
• Dental radiographs should not be processed by sight, and
manufacturers ’ instructions regarding time, temperature and
chemistry should be followed. (ADA, 2006)
(Oral radiology principles and interpretation-white and pharoah-6 th edition)
 INTERPRETING THE IMAGES
• The dentist should view radiographs under appropriate
conditions for analysis and diagnosis. (ADA, 2006)
• Radiographs are best viewed in a semidarkened room with
light transmitted through the films; all extraneous light should
be eliminated

(Oral radiology principles and interpretation-white and pharoah-6 th edition)

 PROTECTING PERSONNEL
• Operators of radiographic equipment should use barrier
protection when possible, and barriers should 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 from the tube head and out of the path of the
primary beam. (ADA, 2006)
• (Oral radiology principles and interpretation-white and pharoah-6th edition)
 • Operator should take position behind
RADIATION SAFETY PROCEDURE
the suitable barrier
• Walls built with gypsum adequate for
dental office

•Operator should stand atleast 6 feet from the patient or an angle of 90-135 degrees to the central ray of
POSITION AND DISTANCE RULE x ray beam

NEVER HOLD A FILM •Neither patient nor dentist should hold film
• The best way to ensure that personnel are following office
safety rules such as those described previously is with
personnel-monitoring devices.
• Commonly referred to as film badges, these devices provide a
useful record of occupational exposure.
• Their use is not only recommended but also required by law
in certain states
(Oral radiology principles and interpretation-white and pharoah-6 th edition)
 QUALITY ASSURANCE
• Quality assurance protocols for the X-ray machine, imaging
receptor, film processing, dark room, and leaded aprons and
thyroid collars should be developed and implemented for each
dental health care setting. (ADA, 2006)