Running head: RADIATION EXPOSURE

Evidence Based Practice Paper

Dental Radiography; a Comparison of Radiation Exposure in the Dental Office
EVBP 5500
Alisha Allan, Kimberly Hay-Esquivel, and Rebecca Bastian
Date: July 19th, 2016
Submitted to: Carrie Maynard RDH

Running head: RADIATION EXPOSURE

Some clients wonder about the radiation when they may receive radiographs. They may
be unaware of the data the dentist must consider before prescribing radiographs. It is not a
routine procedure for everyone to be prescribed radiographs based on age or frequency. Digital
radiograph technology is ever evolving and has improved image quality and client exposure. The
effects of radiation have been known to compound and measures should be taken to reduce any
unnecessary exposure. Researchers have concluded that based on the method of exposure, digital
radiographs are superior to film. Digital radiography requires less radiation, but the dentist
should ensure that all precautions are taken to reduce radiation exposure. When radiographs are
prescribed, the dentist should ensure that all precautions are taken to reduce radiation exposure
as although digital radiography requires less radiation.
When clients are told that the supervising dentist would like to take radiographs it is with
some hesitation that clients often respond. Clients really wonder, if the radiographs are really
necessary, if they will receive a lot of radiation, if there is the potential for misdiagnosis if x-rays
are declined, and if there is less radiation from the digital exposure. When radiographs are
indicated, they are prescribed by the dentist as specific to the clients needs. Dentists are unlikely
to prescribe radiographs unless they suspect that there may be a problem or a condition that
needs monitoring. Radiographs are necessary to detect early problems in hard and soft tissues
before disease can cause major problems. Many practices are in place to ensure the clients safety
is always the number one consideration. Dental professionals are to follow ALARA, which is an
acronym that represents As Low As Reasonably Achievable. This protection principal is possible
by doing the following: using the lead apron and thyroid collar, using the correct exposure as
well as processing practices, using the fastest film speed or digital, and reducing the beam size in
relation to receptor size where applicable. The dentist will use many factors when deciding who

Running head: RADIATION EXPOSURE

receives radiographs such as age, previous medical and dental history, and risk of experiencing
oral disease or any other symptoms one may report (American Dental Association, 2011).
Communication with your dentist and dental professional is key.
In the US during the year 2006, 500 million dental radiographic examinations involving
ionizing radiation took place compared to the much larger doses of the 395 million necessary for
routine medical examination (Mettler, 2009). In 2006 just about half the collective radiation
doses that were coming from medical procedures were due solely to CT scanning, however CT
scanning accounts for only 17% of the total number of procedures performed (Mettler, 2009).
This can be interpreted that CT scanning is one of the largest sources of medical radiation. AS
cited in Mettler (2009), the Radiological Society of North America says natural background
radiation is approximately 2.4 mSv per person per year (pp/yr). Of the 3.1Sv total, 0.53mSV is
due to medical examination including dental exams, and 0.05mSV for all other collective
sources, for an approximate total of 3.1mSv pp/yr (Mettler, 2009). According to the study by
Radiologic and Nuclear Medicine Research (as cited by Mettler, 2009), that the annual mSv in
2006 for dental radiation was 0.008mSV pp/yr, comparingly the total natural background
radiation was 2.4mSV, of which 0.13mSv was provided by our consumer products. In a 2006
study the largest source (68%) of background radiation is radon gas which can be found in
building material, basements, and soil (Bolus, 2013). This accounts for 37% of all radiation
exposure from any source (Bolus, 2013). Based on this information it proves that the radiation
for necessary medical evaluations, such as dental exams, is minimal compared to daily
background radiation levels.
The dentist prescribing radiographs will weigh the efficacy, risks, and benefits of
radiographs of certain areas required for a dental exam. The decision process which is known as

Running head: RADIATION EXPOSURE

justification for action is both a legal and ethical necessity. The prescribing dental professional
must keep the radiation risk in mind when prescribing or taking any radiographs. However a
more significant position may be taken to suggest that radiographs are a practical tool used to
help prevent and solve problems. Using this tool in the correct manner, location and at the
correct time will enhance the outcome for a client (American Dental Association, 2011).
Dentists should weigh the benefits of dental radiographs against the consequences of
increasing a patients exposure to radiation, the effects of which accumulate from multiple
sources over time. (Shousha, Hafez, & Ahmad, 2011, p.67). Using x-ray imaging too often,
incorrectly giving undiagnostic images, or taking radiographs of the wrong location will end in
poor client care and create avoidable costs for the client and the future health care system
(Horner, 2013). Therefore it is important for radiation operators to realize that radiograph
selection is not only an ethical and legal issue, rather an economical issue for clients as well
(Horner, 2013).
According to the American Academy of Pediatric Dentistry (2011) x-rays should not be
prescribed based on the clients age, rather the individuals circumstances and needs including;
medical and dental histories, clinical examinations and the environmental factors that may
contribute or protect against oral diseases.
When exposing radiographs for young children it is important to be mindful that they are
sensitive to the effects of radiation (Williamson, 2005). This is why the clients individual
circumstances are considered to weigh the benefits and risks of all procedures, including
radiographs. With digital radiography utilizing quicker exposure times, this may reduce the
number of image retakes associated with patient movement (Williamson, 2005). This further
supports the position that although there is radiation exposure for dental x-rays, clients can be

Running head: RADIATION EXPOSURE

assured that the dental professional is taking radiographs to diagnose and interpret oral diseases
which may not be visible otherwise.
Dental professionals should utilize client protection following the ALARA principal
should always be observed and practiced. Using client protection such as a lead apron was
popular among those surveyed, but surprisingly a very small portion of dental professionals were
using thyroid shielding and rectangular collimation (Annissi and Geibel, 2014). Use of these
types of protection has proven time and time again to effectively reduce client exposure when
radiographs are necessary. 88.4% of professionals are taking advantage of lead apron protection
for clients; however, only one-third are using the more effective radiation protection measures
such as thyroid collars and rectangular collimation (Annissi and Geibel, 2014). Despite the
evidence outlining that gonadal exposure during dental imaging is extremely low, a lead apron
can offer protection from the minimal exposure; however, it would be more beneficial to the
client to have thyroid protection (Sheikh, Bhoweer, Arya, & Arora, 2010). Comparatively to the
research showing 5-56% reduction in dose when using a thyroid shield for periapical films
(Annissi and Geibel, 2014). Despite the research strongly recommending thyroid protection,
more dentists employ the use of the less useful lead apron, rather than a combination of apron
and thyroid shield (Sheikh et al., 2010). Using other protection such as rectangular collimation
reduces patient exposure by up to 60% and will also increase image quality due to reduced
scattered radiation (Annissi and Geibel, 2014).
Another consideration regarding digital radiographs is sterilization and sanitary
cleanliness of the sensors. Infection control must always be taken into consideration when
working with digital receptors as they cannot be sterilized (Williamson, 2005). Clinicians must

Running head: RADIATION EXPOSURE

use barriers and proper disinfection techniques to avoid cross-contamination between

examinations.
It is to be noted that there is a difference in film speed which changes the amount of
radiation required to expose the film. Almost 75% of film using dentists use E-or F-speed film
(Annissi and Geibel, 2014). While 45% of these film users are strongly opposed to changing to a
digital system, despite the known lower doses associated with digital radiography (Annissi and
Geibel, 2014). Dentists may still be skeptical of quality, put off due to the costs of a digital
system, or they may also prefer to avoid the stress of staff education that is often required to
transition from film to digital. However a dose reduction of up to 50% may be seen using
radiation safeguards and high speed film when operating a film-based system (Annissi and
Geibel, 2014). There is an overall reduction in radiation exposure, being half that when using Eor F- speed, when compared to D-speed film. Although disappointedly, 25% of film users are
still using D-speed film despite current evidence (Annissi and Geibel, 2014).
When compared to film radiation dosage, radiation of digital systems are considered to be
lower. That being said, caution must still be used with regards to digital imaging systems and
radiograph prescriptions. Inadvertent excess exposure may be noted due to easy and quick image
generation. This may encourage the operator to expose more films than necessary (Annissi and
Geibel, 2014). Incorrect exposure techniques and exposing additional radiographs may outweigh
the dose exposure reduction of digital systems. When compared with film, digital users took 49%
more images (Annissi and Geibel, 2014). Surveyed professionals were questioned regarding the
need to expose more radiographs than their film counterparts (Annissi and Geibel, 2014). When
asked they noted that poor image quality and difficulties in sensor positioning, was the main
reason for requiring multiple image retakes (Annissi and Geibel, 2014).

Running head: RADIATION EXPOSURE

American Dental Association (2012) reviewed a recent study that is said to have
connected annual dental radiographs with developing meningioma, the most commonly
diagnosed brain tumor. Although the authors of the study done by the American Dental
Association (2012) did conclude due to the study having participants recall when, and how many
radiographs were taken, that this may have resulted in recall bias negatively influencing the
validity of the results (American Dental Association, 2012). This meaning that the studies
validity relies on participants memory to recall information, and this can often mean
inaccuracies of the study (American Dental Association, 2012). A meta-analysis of case control
studies by Ping Xu et al (2015) suggests otherwise. They describe that dental x-rays are unlikely
to contribute or increase the risk of developing meningioma.
Many benefits are seen in digital radiography over film; however, researchers have
identified several concerns with digital radiography. Hellen-Halme, Rohlin, & Peterson (2005)
Found that when conducting surveys it was found that very few practitioners were conducting
routine quality controls for their digital imaging system (Hellen-Halme et al., 2005). This
alarming study proves the need to update and regulate radiograph protocols to include digital
systems. The time period between checks was most often one year. The majority of these quality
assurance checks were performed by technicians and sales people from the digital systems
manufacturer (Hellen-Halme et al., 2005). Dentists utilizing digital imaging take more
radiographs than their film-using counterparts (Hellen-Halme et al., 2005). This is a cause for
concern as radiographs are in most cases considered necessary, but the amount taken should not
vary among method of exposure, rather the clients needs and treatment or diagnosis. More
digital radiographs are taken according to the dentists due to the lack of certainty of image
diagnostic quality (Hellen-Halme et al., 2005). They thought that with the lack of perceived risk

Running head: RADIATION EXPOSURE

from a digital system, they could expose more images if they felt they were necessary to obtain a
more precise idea of their diagnosis and treatments (Hellen-Halme et al., 2005). A study
conducted based on radiographs submitted for treatment approval thought he insurance company
found that errors were more common among digital images: furthermore, one out of every four
digital images were considered diagnostically unacceptable (Hellen-Halme et al., 2005).
Increased awareness of these aforementioned concerns will improve client management and
health during radiographic procedures.
Clients can control and minimize their exposure to dental radiation by advocating for
their own copies of recent radiographs. If clients change dentists they should be sure to ask for
copies of their radiographs, reducing the likelihood of having duplicate shots taken (American
Dental Association, 2011). Effects of radiation, even if considered small, have known to
compound over time; therefore, all precautions must be taken to reduce the clients exposure,
such as using lead aprons and beam collimation (Pediatric Dentistry, 2011).
People often refuse dental radiographs but are unaware of the true, almost minimal
exposure. Although there is radiation exposure required to take radiographs, the amount of
radiation required to expose two to four images of posterior molars does not even account for
one percent of yearly background radiation (American Dental Association, 2011). In the United
States the average person is exposed to 3.2 millisieverts (mSv) each year from a variety of
sources; however, the amount of exposure for two or four posterior bitewings is 0.005 mSv
(American Dental Association, 2011).
When compared to film, digital radiography requires less radiation and reduced exposure
time, reducing the overall dose of ionizing radiation the patient receives (Williamson, 2005).

Running head: RADIATION EXPOSURE

When guidelines are created judiciously and updated or reviewed regularly, they are an excellent
mechanism for the clinician to use as a quick reference for the evidence (Horner, 2013). These
guidelines are also meant to control or influence those clinicians with non-specific prescriptions
for radiographs overall increasing client safety and reducing costs overall (Horner, 2013). Horner
(2013) reported the following:
Guidelines are sometimes misinterpreted as rules but have been sensibly
defined as systematically developed statements, to assist practitioner and
patient decisions about appropriate healthcare for specific clinical
circumstancesSelection criteria are descriptions of clinical conditions,
derived from patient signs, symptoms and history, that identify patients
who are likely to benefit from a particular radiographic technique; their
role is to assist in the justification process (p. 202).
Factors known to sway a radiograph prescription include: personal routine of clinician or
patient, financial coverage, pressure by the client, medico-legal referrals, and promotion by
radiograph manufacturers (Horner, 2013). Horner (2013) suggest that establishing these
guidelines during education at the undergraduate levels will foster good practices and future
integration of the guidelines into graduates practices. Therefore beyond having guidelines for
ethical and legal reasons, dental practitioners should look at radiograph guidelines as practical
application of research evidence into practice.
When comparing film and digital image quality numerous studies show that the image
quality for both are similar in their ability to capture disease and perform comprehensive
investigative evaluations. Regardless of film or digital sensors, the same image errors that are
most often seen are as follows: faulty placement, horizontal angulation, and cutting off of roots

Running head: RADIATION EXPOSURE

10

or crowns (Williamson, 2005). When offices make the switch to digital imaging, they benefit
from expedient image attainment and retrieval, simpler display, and storage and elimination of
the darkroom, along with the necessary chemicals, processing errors and disposal (Williamson,
2005). This can benefit offices that wish to eliminate or reduce their environmental footprint by
reducing chemicals or going paperless (Williamson, 2005). When compared to film, digital
radiography requires less radiation and reduced exposure time, reducing the overall dose of
ionizing radiation the client receives (Williamson, 2005).
In conclusion beyond having guidelines for ethical and legal reasons, radiograph
guidelines should be looked at as practical application of research evidence into practice. This
means that dental practitioners should look judiciously at these guidelines when deciding to
expose their clients when taking radiographs. The current research evidence suggests that digital
systems offer the same diagnostic quality as their film counterparts, while reducing the exposure
to the client; thus, it is recommended that all dental offices consider implementing digital
radiography.

Running head: RADIATION EXPOSURE

11

References
American Academy of Pediatric Dentistry. (2011) Guidelines on prescribing dental radiographs
for infants, children, adolescents, and persons with special health care needs. Pediatric
Dentistry, 33(6), 289-291.
American Dental Association (2011). Dental radiographs Benefits and safety. Journal of
American Dental Association, 142(9), 1101. Retrieved May 18, 2016, from
http://www.ada.org/~/media/ADA/Publications/Files/for_the_dental_patient_sept_2011.pdf?
la=en
American Dental Association (2012). ADA Says that Dental X-rays Should be Used Sparingly to
Reduce Radiation Risk. Retrieved May 18, 2016, from
http://search.proquest.com.dproxy.library.dcuoit.ca/docview/1641107114/B2452D693769425APQ/14?accountid=26375
Annissi, H., & Geibel, M. (2014). Intraoral radiology in general dental practices - a comparison
of digital and film-based X-ray systems with regard to radiation protection and dose
reduction. Retrieved May 18, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/24648236
doi: 10.1055/s-0034-1366256
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Medicine. Journal of Nuclear Medicine Technology, 41(4), 255-260.
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Hellen-Halme, K., Rohlin, M., & Peterson, A. (2005). Dental Digital Radiography. Swedish
Dental Journal, 29(1), 81-87. Retrieved May 24, 2016.
Horner, K. (2013). Radiographic selection criteria: New guidelines, old challenges. BDJ Br Dent
J, 214(4), 201-203. doi:10.1038/sj.bdj.2013.158

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12

Mettler, F., Bhargavan, K., Faulkner, K., Gilley, D., Gray, J., Ibbott, G., Lipoti, J., Mahesh,
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