Optimizing Radiation Safety in Dentistry

Publication Date: January 31, 2024
Last Updated: February 2, 2024

General Recommendations for All Modalities

  • 1.0.1 The practice shall comply with all applicable local, state, and federal regulatory requirements regarding the safe and effective use of radiography-based imaging modalities, including installation, usage, optimization, patient and operator protection, infection control, maintenance and training for radiographic equipment and procedures.
  • 1.0.2 New facilities, or facilities installing or relocating radiographic and CBCT∗ equipment must follow state and local regulations pertaining to radiation safety in effect at the time of construction or renovation.
  • 1.0.3 Follow manufacturer’s provided documentation for safe and proper operation, maintenance, and infection control procedures for radiographic, CBCT, and related radiographic imaging equipment.

Radiation Safety Programs and Training

  • 1.1.1 The dental practice shall develop and implement a radiation safety program that provides all staff members with instructions and guidance for maintaining a safe radiographic imaging program. The program should be consistent with nationally established recommendations for the radiation protection of both patients and staff members and adhere to all applicable state and local requirements, be developed and implemented under the guidance of a qualified expert, and should be regularly reviewed and updated to be current with applicable established guidance and regulations.
  • 1.1.2 Personnel performing radiography-based dental and maxillofacial imaging shall have the qualifications, education, training, and licensure as required by relevant federal, state, and local regulations.

Occupational and Operator Use of Ionizing Radiation

  • 2.0.1 When barrier protection or shielding is not available for intraoral imaging, the operator shall stand at least 2 meters from the tube head and out of the primary beam path.
  • 2.0.2 Access to radiation-producing devices shall be restricted, and handheld and portable devices shall be safely secured to prevent unauthorized use.
  • 2.1.1 Dental staff members who may be exposed to an annual effective dose that may exceed 1 mSv, or as otherwise determined by state or local guidance, should consider wearing dosimeters.
  • 2.1.2 Pregnant dental personnel who operate radiographic imaging equipment shall adhere to the relevant recommendations set forth in the facility’s radiation safety program, including the limitation of occupational exposure, and the use of protective barriers and personal dosimeters regardless of anticipated exposure levels.

Patient Safety and Protection

  • 3.0.1 Before conducting any type of radiographic examination, clinicians should complete a comprehensive clinical examination and patient assessment, with consideration of the patient’s oral and medical histories, including previous radiographs as well as the patient’s specific oral disease risk.
  • 3.0.2 Clinicians should prescribe dental radiographs and CBCT scans only when they expect that the diagnostic yield will benefit patient care, enhance patient safety, or substantially improve clinical outcomes.
  • 3.0.3 The clinical prescription of radiographic imaging, including CBCT, should be supported by professional judgment that is based on current, established selection and recall criteria to ensure that the benefit of the radiographic imaging procedure outweighs the associated radiation risk.
  • 3.0.4 Where possible the x-ray imaging equipment shall be configured to optimize imaging and dosimetric performance specific to the size and age of the patient.
  • 3.0.5 Abdominal and thyroid shielding during diagnostic intraoral, panoramic, cephalometric, and CBCT imaging is no longer recommended, and the use of these forms of protective shielding should be discontinued as routine practice.

Radiation Dose Minimization and Image Optimization for Traditional Modalities

  • 3.1.1.1 Digital rather than film-based imaging should be used because digital imaging allows for lower patient radiation exposure.
    • 3.1.1.2 If film is used, only E- or F-speed film shall be used because they require substantially lower patient radiation exposure compared with D-speed film. D-speed film shall be eliminated from clinical use.
    • 3.1.1.3 If film is used for panoramic or cephalometric imaging, rare-earth screens and high-speed film of 400 are recommended.
  • 3.1.2 The x-ray beam should be collimated to the receptor size and shape wherever possible, and rectangular collimation should be used for intraoral imaging.
  • 3.1.3 The intraoral radiograph system shall be configured so that the distance from the x-ray tube focal spot to the skin entrance surface (source-to-skin distance) is not < 20 cm.
  • 3.1.4 Intraoral radiography units should be operated at a minimum of 60 kV and not exceed 80 kV.
  • 3.1.5 Intraoral image receptor holders including beam-guiding devices should be used when possible.
  • 3.1.6 Handheld radiographic devices for intraoral imaging must be cleared by the US Food and Drug Administration, used according to manufacturer’s instructions, and restricted to use only by authorized operators with appropriate training in device use.

Radiation Dose Minimization and Image Optimization for CBCT

  • 3.2.1 CBCT imaging should not be used routinely. CBCT examinations shall not be used as the primary or initial imaging modality when a lower dose alternative is adequate for diagnosis and treatment planning.
  • 3.2.2 Use the smallest field of view necessary for imaging the specific anatomical area of interest consistent with the diagnostic and treatment planning needs.
  • 3.2.3 CBCT shall be conducted using technique factors and imaging protocols that are optimized to produce diagnostically acceptable images with the lowest radiation dose to the patient.
  • 3.3.1 Pediatric patients shall be imaged using radiographic device configurations as labeled by the manufacturer and optimized specifically for such patients.

Quality Assurance and Quality Control

  • 4.0.1 Staff members of facilities using radiographic imaging equipment shall establish a quality assurance and quality control program, implemented and monitored by a qualified expert and following updated quality assurance and quality control guidance (see Table 2 for list of external guidance).
  • 4.0.2 A qualified expert should survey all conventional radiography units at the time of installation, and should survey the equipment at least every 4 years, after any changes that may affect the radiation exposure to patients and staff members, or in accordance with state and local law, whichever is more stringent.
  • 4.1.1 The operator’s manual for all radiographic systems including applicable computer hardware and software systems must be readily available to the user. All imaging equipment shall be operated and maintained following the manufacturer’s instructions, including any appropriate adjustments for optimizing dose and image quality and quality control and quality assurance testing frequency.
  • 4.1.2 CBCT imaging and dosimetry performance shall be evaluated by a qualified expert at least every 2 years, but preferably annually.
  • 4.1.3 Special considerations for receptors
    • 4.1.3.1 Image receptor devices for film-based and digital systems shall undergo initial acceptance testing and be evaluated either monthly (film-based) or annually (digital), as recommended by relevant American National Standards Institute and American Dental Association standards.
    • 4.1.3.2 The film processor and phosphor plate scanners should be evaluated at initial installation and regularly afterward, according to the manufacturer’s instructions.
  • 4.1.3.3 Film shall be processed with active, properly replenished chemicals. Chemical solutions should be replenished daily and replaced when depleted. Film processor performance should be checked daily before developing the first patient radiograph, and each type of film should be evaluated monthly or when a new box or batch of film is opened.

Technique Charts

  • 4.2.1 A radiograph exposure factors chart shall be developed for each type of intraoral image receptor and radiograph unit combination and posted near the control panel of the radiographic unit. The charts and recommended exposure factors shall be updated when a different type of receptor or new radiograph unit are used.
  • 4.2.2 Technique charts for intraoral radiography should list the exposure settings based on the type of examination, the type of receptor, and the patient size (small, medium, large) for adults and pediatric settings.

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Optimizing Radiation Safety in Dentistry

Authoring Organizations

Publication Month/Year

January 31, 2024

Last Updated Month/Year

April 1, 2024

Supplemental Implementation Tools

Document Type

Consensus

Country of Publication

US

Document Objectives

The value of dental radiographs to oral health care decision making must be balanced with radiation safety to minimize patient exposure and occupational risk of oral health care providers. This review summarizes recommendations and regulatory guidance regarding dental radiography and cone-beam computed tomography. An expert panel presents recommendations on radiation safety, appropriate imaging practices, and reducing radiation exposure. Understanding factors affecting imaging safety and applying fundamental principles of radiation protection consistent with federal, state, and local requirements are essential for limiting patient ionizing radiation exposure, in conjunction with implementing optimal imaging procedures to support prudent use of dental radiographs and cone-beam computed tomographic imaging. The regulatory guidance and best practice recommendations summarized in this article should be followed by dentists and other oral health care providers.

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory

Intended Users

Dentist, nurse, nurse practitioner, physician, physician assistant

Scope

Management, Prevention

Diseases/Conditions (MeSH)

D011834 - Radiation Monitoring

Keywords

Dental radiography, radiation protection

Source Citation

Benavides E, Krecioch JR, Connolly RT, Allareddy T, Buchanan A, Spelic D, O'Brien KK, Keels MA, Mascarenhas AK, Duong ML, Aerne-Bowe MJ, Ziegler KM, Lipman RD. Optimizing radiation safety in dentistry: Clinical recommendations and regulatory considerations. J Am Dent Assoc. 2024 Jan 30:S0002-8177(23)00734-1. doi: 10.1016/j.adaj.2023.12.002. Epub ahead of print. PMID: 38300176.

Methodology

Number of Source Documents
103
Literature Search Start Date
July 31, 2020
Literature Search End Date
March 31, 2022