|Year : 2018 | Volume
| Issue : 1 | Page : 24-30
Radiation safety protocol in dentistry: A neglected practice
T. P Kumar, Rizwana Azmi, Anu Premkumar, S. Sujatha, B. K. Y Devi, N. Rakesh, V. Shwetha
Department of Oral Medicine & Radiology, Faculty of Dental Sciences, Ramaiah University of Applied Sciences, Bangalore, Karnataka, India
|Date of Web Publication||9-Jul-2018|
Dr. Anu Premkumar
Department of Oral Medicine & Radiology, Faculty of Dental Sciences, Ramaiah University of Applied Sciences, Bangalore 560054, Karnataka
Source of Support: None, Conflict of Interest: None
Aim: The ready availability of radiodiagnostic aids has led to its overuse in dental practice. In addition, failure to reinforce the radiation safety procedures has unknowingly resulted in the negligence of the as low as reasonably achievable (ALARA) principles among many dentists. Apart from patients, the dentists and dental assistants are being exposed to radiation in the clinics during regular practice. The current survey was designed to assess the awareness, concern, and practice of radiation protection in general dental practice. Materials and Methods: The survey consisted of 86 dentists in Bangalore city. A cross-sectional self-administered questionnaire consisting of a total of 31 items was used. The obtained data were compiled and analyzed using the Statistical Package for the Social Sciences version 20.0 software (IBM Corporation, New York, United States). Results: All the dentists responded in the study (100%); the participants had limited knowledge regarding the radiation equipment. Majority of the participants were using rounded collimator (96.5%) and short cone (61.6%). E-speed film was used by most of the dentists (90.7%). Bisecting angle technique was preferred by most of the practitioners (69.8%) for making periapical radiographs. Only 20.9% of the dentists made their patients wear lead apron during X-ray exposure. None of them were using thyroid collar. Most of the dentists practiced at a safe distance of 6 ft from the X-ray tube, whereas 10.5% of the dentists assisted holding the radiographic receptor beside the patient. Radiation monitoring was performed by only 20% of the practitioners. Conclusion: The knowledge and practice of radiation protection were not satisfactory. Repeated reinforcement in the form of continued dental education program is necessary, and, most importantly, change in the attitude of the dentist to follow ALARA should be advocated.
Keywords: ALARA, dental practitioners, intra oral radiograph, radiation protection
|How to cite this article:|
Kumar TP, Azmi R, Premkumar A, Sujatha S, Devi BY, Rakesh N, Shwetha V. Radiation safety protocol in dentistry: A neglected practice
. J Orofac Sci 2018;10:24-30
|How to cite this URL:|
Kumar TP, Azmi R, Premkumar A, Sujatha S, Devi BY, Rakesh N, Shwetha V. Radiation safety protocol in dentistry: A neglected practice
. J Orofac Sci [serial online] 2018 [cited 2020 Feb 22];10:24-30. Available from: http://www.jofs.in/text.asp?2018/10/1/24/236210
| Introduction|| |
Radiographic examination plays an important part of diagnosis in dental practice. As we are already exposed to many forms of radiations in our day-to-day life, the radiations used for diagnostic purposes must be as low as reasonably achievable (ALARA) to avoid any stochastic effects.,,,,
Technical advances in X-ray equipment and imaging systems have allowed significant reductions in radiation doses; despite this, stochastic effect, which is not dose dependent, can happen at any point of time.,
Apart from patients, dental surgeons and dental assistances are being exposed to radiations on a regular basis.,, Though the dental surgeons are aware of these protocols, how many of them adopt these safety procedures still remains unclear.
The aim of this study was to determine the extent to which the dentists in Bangalore comply with radiation protection measures while performing intraoral radiographs in their clinic.
| Materials and Methods|| |
A convenient stratified sampling was done, and the survey was performed among 86 dental practitioners from Bangalore city, India. A questionnaire consisting of 31 questions (Appendix 1) was prepared under the following sections:
- Demographic characteristics.
- Radiographic equipment and techniques.
- Methods used for patient and personnel protection.
A written questionnaire was distributed by visiting each dental clinic; the questionnaire was distributed among 86 private dental practitioners. Dentists were assured anonymous processing of the questionnaire, and the purpose of the research was explained. A second follow-up was conducted to collect the completed questionnaire. Ethical approval for this study (No: FDS/EC/2014-2016/STSOR/41) was provided by the Ethical Committee of Faculty of Dental Sciences, Ramaiah University of applied sciences, Bangalore, on 14th October 2017.
Statistical analysis was performed using MS Excel, Statistical Package for the Social Sciences version 20.0 software (SPSS Inc., Chicago, IL, United States), and frequency table was used.
| Results|| |
The response among the dentists was 100%, among which 51 were males and 35 were females. Among the dentists, 68.3% were having <5 years of experience. Moreover, 56% were general practitioners, and 44% were specialists. With regard to age, 31% were above 35 years of age.
Characteristics of radiographic equipment
All the dental practitioners who participated in the study were having X-ray equipment. Among them, 90.7% of the dentists were having only intraoral X-ray machines, and 9.3% were having both intraoral and extraoral X-ray machines. In addition, 87.2% of the practitioners were having one X-ray equipment, and the remaining 12.8% of the dentists had two X-ray equipments. The dental practitioner’s knowledge regarding the technical specification of the equipment such as tube voltage (kVp) and tube current (mA) were limited to only 58.1% of them, and the rest were uncertain about the same. Moreover, 30.2% of the practitioners were using alternating current (AC) machine, 43% were using direct current (DC) machine, and 11.6% were unaware of the type of machine.
It was noted that 80.2% of the practitioners preferred conventional radiographs [Graph 1]. Among them, 90.7% were using “E” speed and 4.7% were using “F” speed; only 1.2% practitioners were still using “D”-speed films. About 3.5% of the dentists were using two or more types of films [Graph 2].
Moreover, 88.4% of the practitioners were using Kodak films, 4.7% were using AGFA-Dentus, and 7% were using other brands. It was also noted that 19.8% of the dentists were using digital receptors in their clinic [Graph 1].
Radiographic technique and film holders
Among the practitioners, 69.8% were using bisecting angle technique for making periapical radiographs, only 2.3% were using paralleling technique, and 27.9% were using both the techniques depending on the case scenario [Graph 3]. Majority of the dental practitioners (67.4%) were using film holders. However, 16.3% of the dentists/dental assistants held the film themselves while making radiographs. The remaining 16.3% of them made the patients hold the film.
Dentists using rectangular collimator were only 3.5%, and the rest (96.5%) were using rounded collimator. Most of the dentists were using short cone (61.6%).
Radiographs made per month
Most of the dentists (51.2%) were making 10–20 radiographs per week, and a meagre number of dentists (3.5%) were making more than 20 radiographs per week. Majority of the dentists (83.7%) were making intraoral periapical radiographs with an average exposure time of 0.5–0.8 s. None of the dentists were making more than 10 radiographs for children per week.
Radiation protection for patient and personnel
Almost 86% of the dental practitioners made radiographs by themselves; only 14% of them employed dental assistance for making radiographs, and none had employed an X-ray technician. Most of them (86%) did not have a separate radiology room. In addition, almost 84.9% of the dental practitioners did not have lead barriers in their clinics. Only 20.9% of the practitioners were using lead aprons as per patient’s radiation protection protocol, and none of them were using thyroid collars. Most of the operatory room walls were made of normal brick (95.3%), and lead fused walls were sparse (4.7%). Only half of the dentists (55.8%) were practicing at the recommended 6-ft distance from the radiation tube, 10.5% of the dentists are making radiographs standing beside the patient, and the rest 33% were making radiographs at convenient distances [Graph 4].
Monitoring radiation exposure
Approximately 20% of the dental practitioners used thermoluminescent dosimeters for the periodic monitoring of personal radiation exposure.
Maintenance of radiographic equipment
About 72.1% of the dentists calibrated the X-ray machine in case of necessity. In addition, only 7% followed periodic maintenance; the remaining 20.1% did not calibrate their machines.
| Discussion|| |
The results of this survey, which highlights the lack of knowledge regarding the various aspects of dental radiography and radiation protection among the dental practitioners, need to be considered in the global scenario. Dentists should continuously evaluate the quality of the images produced in their offices to ensure that they are optimally exposed. To ensure the optimum exposure conditions, a quality assurance of the radiographic system should be performed. One of the basic steps of quality assurance is the proper maintenance of the X-ray machine with periodic calibration., In our study, we found that only 7% of the dental practitioners calibrated their X-ray machines periodically, and most of them did it when necessary; which was not consistent with the study done by Math et al., who reported the figure at 57%.
While analyzing the questionnaire, we found that almost all the dentists had intraoral X-ray equipment, and only few of them used digital receptors. Most of the time, the dentists themselves were making the radiographs for their patients. We also found that most of them used the average exposure parameter between 0.5 and 0.8 s, and only 58.1% of the dentists were aware of the kVp and mA of their X-ray equipment, which was in accordance with the study done by Swarna et al. and was in contrast to the studies done by İlgüy et al. and Salti and Whaites.
Patient exposure in intraoral radiography with round collimator, which is larger than the Intra Oral Periapical Radiograph (IOPAR), results in 50% more tissue irradiation when compared to rectangular collimator. The use of a rectangular collimator has been known to reduce the tissue irradiation by five folds. As the volume of tissue irradiation is directly proportional to the scattered radiation, decrease in the same results in decreased image fogging, and the obtained image is of better diagnostic quality. Unfortunately, in our study, only 3.5% of the dentists were using rectangular collimator, which was in accordance with the study done by İlgüy et al. and Eskandarlou et al. Hence, dentists should be motivated to adopt rectangular collimator as a part of ALARA.
Good radiographic procedure includes the use of the fastest image receptors compatible with the diagnostic task (F speed or digital) (American Dental Association; ADA, 2012). E- and F-speed films are double times faster than the D-speed films. The usage of these films aids in decreasing the patient’s exposure. Our study revealed that most of the dentists (90.7%) used E-speed films, 4.7% used F-speed films, and only 1.2% used D-speed films. In addition, 3.5% of the dentists were using two or more types of films, which was in agreement with the previous studies done by Swarna et al., Kaviani et al., and Chaudhry et al., who have reported the usage of E-speed films in private dental practice to be up to 74, 70, and 69%, respectively. In this study, all the dentists were aware of the speed film used, which was in contrast with the study done by Swarna et al. and İlgüy et al., who reported that 16 and 65.8% of the dentists, respectively, were aware regarding the speed of the film used. In our study, 19.8% of the dentists used digital receptors, which was consistent with the studies conducted by İlgüy et al., Swarna et al., and Kaviani et al.
Another important criteria for reducing patient exposure involves avoiding retakes, which can be achieved by adopting patient positioning, X-ray tube alignment, the use of appropriate film holders, and last but not the least, the judicious use of proper radiographic technique, which is the paralleling technique. In our study, bisecting angle technique is commonly practiced (69.8%) because it is more convenient to the patients, which is in accordance to the study by İlgüy et al. and Swarna et al. Though bisecting angle technique is convenient, it has its own drawbacks such as overlapping, image distortion, and limited reproducibility, which can result in retakes. Hence, the practice of paralleling cone technique should be reinforced.
The safe distance of 6 ft and more was adhered to by most of the dental practitioners in our study (70.9%). We also found a shocking data that 10.5% of the dentists were standing beside the patients while making radiographs, which was consistent with the study done by Swarna et al. and Sitra et al. In our study, we found that very few dentists (20.9%) used lead aprons for their patients. However, because we know that lead aprons form a protective barrier in the case of pregnant women as well as patients who have been advised for full-mouth radiographs, the use of lead aprons remains mandatory.One of the most radiosensitive organs, the thyroid gland, when being exposed frequently to scattered radiation can be protected by using thyroid collar, especially in children and women. In our study, thyroid collar was not applied on any of the patients, which was consistent with the study done by Swarna et al. and İlgüy et al., who reported the usage of thyroid collar at only 3.7%.
In our study, we also gathered additional information regarding the quality of operatory room, because it plays an important role in the absorption and prevention of secondary radiation exposure to the environment. We found that most of the dental clinics did not have a separate radiology operatory room. In addition, walls were not infused with lead, and also the thickness of the walls was not adequate.
The monitoring of the personal radiation exposure serves as another criteria in radiation protection. In our study, we found that only 20% of the practitioners adopted the use of dosimeter, which is not in accordance with the study done by Swarna et al. and Kaviani et al.
| Conclusion|| |
The results indicate that for minimizing any unnecessary radiation, attempts should be made to improve the dentist’s knowledge about radiation dose reduction techniques. One of the limitations of an investigation of this nature is the possibility of bias. It is possible that some answers may represent the ideal situations intended by the respondents, but adherence to these standards may be lax at times or in certain areas of practice. Thus, variation in standards may occur within dental clinics, which is not reflected in our results. Continuing educational programs can help to improve radiation safety for dental patients as well for the operators.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
White SC, Heslop EW, Hollender LG, Mosier KM, Ruprecht A, Shrout MK. Parameters of radiologic care: An official report of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:498-511.
Okano T, Sur J. Radiation dose and protection in dentistry. Jpn Dent Sci Rev 2010;46:112-21.
Shahab S, Kavosi A, Nazarinia H, Mehralizadeh S, Mohammadpour M, Emami M. Compliance of Iranian dentists with safety standards of oral radiology. Dentomaxillofac Radiol 2012;41:159-64.
Izawa M, Harata Y, Shiba N, Koizumi N, Ozawa T, Takahashi N et al.
Establishment of local diagnostic reference levels for quality control in intraoral radiography. Oral Radiol 2017;33:38-44.
Agarwal SR, Waingade M, Garcha V, Jangam D. Knowledge, awareness and practice regarding radiographic techniques and radiation protection among general dental practitioners in Pimpri-Chinchwad city: A questionnaire-based cross-sectional survey. Int J Recent Sci Res 2016;7:13310-5.
Agrawal B, Dosi T, Hazari A, Maheshwari C, Rajput R, Yadav N. Evaluation of radiation protection awareness amongst general dental practitioners of western Rajasthan in India. J Int Oral Health 2015;7:51-5.
Tugnait A, Clerehugh DV, Hirschmann PN. Radiographic equipment and techniques used in general dental practice. A survey of general dental practitioners in England and Wales. J Dent 2003;31:197-203.
Ludlow JB, Platin E. Densitometric comparisons of Ultra-speed, Ekstaspeed and Ekstaspeed Plus intraoral films for two processing conditions. Oral Surg Oral Med Oral Pathol Oral Radio Endod 1995;79:105-13.
Price C. Sensitometric evaluation of a new E-speed dental radiographic film. Dentomaxillofac Radiol 1995;24:30-6.
Horner K. Review article: Radiation protection in dental radiology. Br J Radiol 1994;67:1041-9.
Aravind BS, Joy ET, Kiran MS, Sherubin JE, Sajesh S, Manchil PR. Attitude and awareness of general dental practitioners toward radiation hazards and safety. J Pharm Bioallied Sci 2016;8:S53-8.
Salti L, Whaites EJ. Survey of dental radiographic services in private dental clinics in Damascus Syria. Dentomaxillofac Radiol 2002;31:100-5.
İlgüy D, İlgüy M, Dinçer S, Bayirli G. Survey of dental radiological practice in Turkey. Dentomaxillofac Radiol 2005;34:222-7.
Math SY, Murugeshappa DG, Annigeri R, Kalra D. Compliance of Indian dentists with oral radiology safety measures. J Oral Maxillofac Radiol 2013;1:104-10. [Full text]
Eskandarlou A, Sani KG, Rostampour N. Observance of radiation protection principles in Iranian dental schools. J Res Med Sci 2010;15:292-3.
Kaviani F, Esmaeili F, Balayi E, Pourfattollah N. Evaluation of X-ray protection methods used in dental offices in Tabriz in 2005–2006. J Dent Res Dent Clin Dent Prospects 2007;1:49-52.
Chaudhry M, Jayaprakash K, Shivalingesh KK, Agarwal V, Gupta B, Anand R et al.
Oral radiology safety standards adopted by the general dentists practicing in National Capital Region (NCR). J Clin Diagn Res 2016;10:42-5.
Sitra G, Daniel MJ, Srinivasan SV, Prashad KV. Radiation protection protocol observed amongst dentist population in the union territory of Puducherry. J Indian Acad Oral Med Radiol 2008;20:45-8. [Full text]