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The dental auxiliaries are often the members of the dental team to broach the subject of dental radiographs with patients. As a result, the entire dental team is well aware of patients’ emotions and concerns associated with radiographs. While many factors may be involved with regards to patients’ hesitation to consent to radiographs, the concerns about radiation, costs, and lack of knowledge about the benefits of radiographs are common sources contributing to patients’ caution regarding radiographs. Even though the decisions regarding radiographs are made by the dentist, the entire team plays an important role in patient education and acquisition process. With the purpose of reinforcing everyone’s knowledge about oral radiographs and radiation safety in order to address patients’ fears and concerns, this article will review the purpose of radiographs, highlight the guidelines to which dentists may refer when prescribing dental radiographs, discuss radiation safety and dosage, and provide resources regarding radiation safety for the dental team and patients.
Patient concern: Why are radiographs necessary?
The necessity and benefit of dental radiographs (often times called erroneously referred to as X-rays) may be trivialized and misunderstood when the situation is presented to patients with comments such as “It’s time for check-up X-rays” by the allied health professional. The patient should be informed and understand that the dental hygienist and/or other oral health professionals are executing the dentist’s recommendation and prescription for necessary dental/oral radiographic images to obtain a proper diagnosis.
Radiographs provide valuable information to the dentist that may not otherwise be accessible based on a visual examination alone, such as decay between the teeth and under restorations; cracks and other damage; periodontal disease; abscesses, infections or cysts; and developmental abnormalities.1-3 Furthermore, radiographs are useful tools to treatment plan procedures such as implants, orthodontics and dentures.3 Radiographs have the ability to reveal conditions at an early enough stage for the situation to be addressed, treated, and/or cured.4
By explaining the purpose of radiographs and their importance, the practitioner gives the patient a better understanding that obtaining radiographic images is not an arbitrary process. Instead, it is a recommendation made by the dentist, often performed by the dental hygienist or other allied dental health professional, in order to provide a more complete view of the health of the mouth.
Patient concern: “Didn’t I just have dental X-rays? How often am I supposed to get them?”
As previously mentioned, it is important for the patient to understand that the dentist, not the allied health professional, has made the recommendation for the radiographs, including their frequency, based on that patient’s need.5 Factors such as the patient’s present oral health condition, caries risk, age/stage of growth and development, periodontal status, and signs and symptoms of oral disease may all be weighed when determining frequency and type of radiographs necessary.3,5,6
The American Dental Association (ADA), in collaboration with the U.S. Food and Drug Administration (FDA), developed guidelines (ALARA, or as low as reasonably achievable) for dentists for the prescription of radiographs, including frequency, patient selection and appropriate areas of the mouth to X-ray (See Table I).6-8 It is important to note that these guidelines provide recommendations; they are not standards of care or regulations.5,6 The patient should be made aware that the radiographic decision was based on a combination of factors including, but not limited to, the dentist’s clinical judgment, patient history and reference to the recommendations.5-7
Patient Concern: “I don’t want X-rays because they are dangerous and I’ve had too many other medical X-rays this year.”
When discussing X-rays and radiation, it is important to note that dental radiographs are the images that are created when X-ray radiation passes through the mouth and strikes a film or digital sensor (these images are often erroneously called X-rays for shorthand).1,9 However, the X-rays themselves are actually a form of electromagnetic radiation, which is a form of energy transmitted through the air9,10
Radiation occurs in two forms—ionizing and non-ionizing. X-rays are a form of ionizing radiation10,11 Ionizing radiation can be natural or manmade. Natural sources of ionizing radiation (known as background radiation) include minerals in the earth, cosmic radiation from the sun, air, soil, radon gas, foodstuffs and water.10-12 Manmade ionizing radiation exposure occurs when humans participate in activities that enhance our exposure to ionizing radiation, such as flying at high altitudes; undergoing medical radiation treatment, medical, and dental radiographs; using computers/other devices and through the generation of nuclear energy.10-12
Natural and manmade sources expose humans to a wide range of radiation. The total amount of background radiation (natural radiation) humans receive per year is 2.4 mSv worldwide, and 3.0 mSv in the U.S.6,10 (the millisievert—mSv—is a unit used to express radiation exposure). On average, Americans are exposed to 0.6 mSv of manmade ionizing radiation per year, though this can vary greatly.6
The majority of manmade exposure is medically related.6,12 However, dental X-rays contribute to only less than one percent of the total dose of exposure in medical settings, and are a minor contribution to the total exposure from all manmade and natural sources (about 0.2 percent).6 Table II13 provides annual doses of common radiation exposure.
When a dental radiograph is taken, the radiation penetrates body tissue. Some of this radiation exposes film/is absorbed by a digital sensor to create an image, and some is absorbed by the tissues.9 It is this amount of radiation absorbed by the body that can cause adverse health outcomes.9,10 If ionizing radiation damages critical components within cells (such as DNA) the cells can be damaged.9 Radiation damage can be repaired by the cell; kill the cell; or in the least likely scenario, cause a mutation in the DNA that is replicated as the cell divides.10 The first two outcomes can result in a variety of conditions including cataracts, skin burns and hair loss and are usually associated with very high levels of radiation over a significant period of time.9,10
The more common fear associated with the dose of radiation from dental radiographs involves the latter outcome of radiation damage, the mutation in the DNA being replicated as the cell divides, which could eventually lead to the formation of a cancer or other adverse health outcomes.9,10,14 The risk of cancer as a result of medical X-rays depends on several factors, including increased risk with the number of X-rays exposures over time (the accumulated dose increases), and increased risk for individuals who were exposed to X-rays at a younger age versus someone who received X-rays at an older age.9
When faced with patients’ concerns about the safety of dental radiographs, the practitioner should explain that the benefits of acquiring the appropriate dental radiographs weighed against the risks of exposure to radiation.2 The patient should know that the benefit of radiographic images can outweigh the risks.9 Addressing dental issues at an early stage can prevent time wasted, money spent and discomfort associated with dental problems; radiographs can be a useful tool in this diagnostic process.1 Furthermore, to expose patients to the lowest level of radiation possible, dental professionals should be using the correct film or sensor with regard to speed, the optimal settings on the X-ray generator and patient protective equipment.5 Patient fears may be eased when the observance of these factors is made known.
The dental hygienist and other team members can play a role in educating patients about the factors and procedures that work together to make dental radiography safer by explaining X-ray radiation, providing examples of radiation doses from background and common manmade sources to put dental radiation exposure into perspective, and highlighting the methods and precautions utilized to reduce their exposure level.
Conclusion
Obtaining dental radiographs can inspire fear, anger and hesitation from our patients. Since the dental hygienist and auxiliary staff members are often the first member of the dental team to address this topic with patients, they are in the position to educate our patients about radiation safety and address their fears. Team should highlight the guidelines to which dentists may refer when prescribing dental radiographs and discuss radiation safety and dosage. Furthermore, guiding patients to reliable sources about radiation safety such as the American Dental Association, the U.S. Food and Drug Administration, the U.S. Environmental Protection Agency and the Centers for Disease Control and Prevention. With an ample knowledge base and the skills to address patient concerns, the hesitation and fears associated with radiation safety can be eased and assist them in making the best decision with regard to their oral health.
References
1. American Dental Association. Public resources. Oral health topics a-z.radiography (x-ray). Available at www.ada.org/5169.aspx?currentTab=1.Accessed Nov. 20, 2011.
2. For the dental patient: dental radiographs: benefits and safety. J Am Dent Assoc. 2011; 142(9): 1101. Available at: jada.ada.org/content/142/9/1101.full?sid=c084b721-05e8-4ece-97e1-cd8b80953eae. Accessed Nov. 20, 2011.
3. Colgate Oral and Dental Health Resource Center. X-rays and intraoral pictures. Available at www.colgate.com/app/CP/US/EN/OC/Information/Articles/Oral-and-Dental-Health-Basics/Checkups-and-Dental-Procedures/X-Rays/article/X-rays-and-Intraoral-Pictures.cvsp. Accessed Nov. 20, 2011.
4. U.S. Department of Human and Health Services. U.S. Food and Drug Administration. Radiation-emitting products. medical x-rays. Available at: www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/default.htm. Accessed Nov. 20, 2011.
5. American Dental Association Council on Scientific Affairs. The use of dental radiographs update and recommendations. J Am Dent Assoc. 2006; 137:1304-12. Available at: ada.org/sections/professionalResources/pdfs/report_radiography.pdf. Accessed Nov. 20, 2011.
6. American Dental Association. Public resources. Oral health topics a-z. radiography (x-ray). Available at: ada.org/5160.aspx?currentTab=2. Accessed Nov. 20, 2011.
7. U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration; and American Dental Association, Council on Dental Benefit Programs, Council on Scientific Affairs. The selection of patients for dental radiographic examinations. Rev. ed. 2004. Available at: ada.org/sections/professionalResources/pdfs/topics_radiography_chart.pdf.Accessed Nov. 20, 2011.
8. National Council on Radiation Protection and Measurements. Radiation protection in dentistry. Report No. 145. NRCP Publications, Bethesda, MD. 2003. Available at: http://www.ncrponline.org/pubs.html.
9. U.S. Department of Human and Health Services. U.S. Food and Drug Administration. Consumer updates. reducing radiation from medical x-rays. Available at: www.fda.gov/ForConsumers/ConsumerUpdates/ucm095505.htm#HowMuch. Accessed Nov. 20, 2011.
10. United Nations Scientific Committee on the Effects of Atomic Radiation. Frequently asked questions. Available at: www.unscear.org/unscear/en/faq.html. Accessed Nov. 20, 2011.
11. Centers for Disease Control and Prevention. Radiation and your health. Available at: www.cdc.gov/nceh/radiation/default.htm. Accessed Nov. 20, 2011.
12. U.S. Environmental Protection Agency. Sources of radiation exposure. Available at: www.epa.gov/radiation/sources/index.html. Accessed Nov. 20, 2011.
13. American Nuclear Society. Radiation dose chart. Available at: www.new.ans.org/pi/resources/dosechart/msv.php. Accessed Nov. 20, 2011.
14. U.S. Environmental Protection Agency. Radiation protection. health effects. Available at: www.epa.gov/radiation/understand/health_effects.html. Accessed Nov. 20, 2011.
