What Parents Should Know about the Safety of Dental Radiology.

There are many different types of x-ray images (pictures) that can be taken of children in the dental office to assist in diagnosis. These include the panoramic and orthodontic (cephalometric) extraoral images, intraoral images such as bitewings and periapicals (little films that go inside the mouth) and cone beam computed tomography (CBCT). All of these dental images use ionizing radiation (x-rays), and therefore parents may be concerned about the increased cancer risk (because of the x-rays) to their children. The following provides information on the risks of dental images in relation to their benefits.

What are X-rays?
X-rays are invisible beams of ionizing radiation. X- rays that are directed to the body do not pass through without changes but are absorbed differently by various tissues of the body. Once they pass through a body part, they are captured by the film and produce images in tones of gray showing calcified structures such as the jaw bones, teeth, and other bony structures. The use of x-rays to create dental images is not painful, but during the procedure, the child must stay still or else the image may be fuzzy. In some circumstances, parents may be asked to help keep their children still while dental images are taken. Depending on the area of the jaw imaged and the type of dental image, a lead body apron or thyroid shield may be used to reduce radiation exposure to other body areas not being imaged.

What is a panoramic film?
Panoramic films belong to the extraoral category of dental x-rays because the film is outside the mouth. The panoramic film provides to the dentist a good view of the maxilla and mandible as well as the whole dentition. Panoramic films also provide a partial view of the temporo- mandibular joint. One of the major advantages of the panoramic films is the short time required to acquire the image. Panoramic films are widely used by dentist because it provides a comprehensive “panoramic” view of the maxilla and mandible. It is commonly used for evaluation of the wisdom teeth or for the evaluation of potential fractures in trauma cases. [Figure 1]

What is a periapical film?
Periapical films belong to the intraoral category of dental x-rays because the film is inside the
mouth. The name “periapical “means that this film is designed to evaluate the root and crown
of the teeth. The dentist usually takes periapicals of the back and anterior teeth. [Figure 2]

What is a bitewing film?
The name “bitewing” refers to a little tab of paper or plastic situated in the center of the x-ray
film, which when bite on, allows the film to hover so that it captures an even amount of the
maxillary and mandibular teeth. Bitewings are designed to evaluate the crowns and the most
superior part of the bone around the teeth. They do not provide information of the roots of the
teeth. Dentist usually uses bitewings for evaluation of the area in-between teeth looking for
caries. [Figure 3] The American Dental Association (ADA) recommends bitewings for children
(until the eruption of the first permanent molars) only if the spaces between teeth cannot
visualized in the clinical exam. For children with high risk of decay, the recommendation is to
take bitewings every 6 to 12 months (if the spaces between teeth cannot be visualized in the
clinical exam). For children with low risk of decay, the recommendation is every 12 to 24
months. The clinical judgment of the dentist is at the end, the most important criteria.

What is Cone Beam Computed Tomography (CBCT)?
Over the past 10 years, cone beam computed tomography (CBCT) has become increasing
available for use in dental offices. CBCT produces images similar to computed tomography (CT)
used in medicine except that CBCT may expose a child to less radiation dose. In CBCT an x-ray
device rotates around the head to create many individual pictures of the child’s jaw and teeth,
and these individual images are used to build a virtual three-dimensional (3D) representation
(main advantage of CBCT vs. other dental radiographs).  This virtual image may
contain diagnostically important information that is not present in other dental images such as
a bitewing or panoramic image. Taking a CBCT image may result in more radiation when older
generation or high dose CBCT units are utilized for imaging. Recent advances of low-dose CBCT
option exposes the patient to less or equivalent radiation to commonly used dental imaging
modalities (Ludlow 2013).

There are many different types of machines used to take a CBCT image. These
machines may be called a scanner, and while some may look similar to medical CT scanners,
others are similar to panoramic x-ray units. Depending on the type of scanner used, the child
may sit, stand, or lie down while the scanner moves around the head. The CBCT procedure is
quick and painless, with nothing touching the child. Some children may be apprehensive of the
procedure because of the size of the scanner and its motion.

How Much Radiation is a Child Exposed to during Dental Radiography.
Every day we are exposed to small amounts of radiation from our environment. This radiation
comes from outer space, the ground, building materials, air, and water. This is called natural
background radiation. The amount of this radiation to which we are exposed depends upon
where we live. For example, those who live in higher elevations (such as Denver, Colorado) are
exposed to more radiation from outer space than people who live at sea level. To minimize the
amount of radiation used to create a dental image, the settings on the X-ray device should be
adjusted depending upon the child’s size. The millisievert (mSv) is a measure of effective
radiation dose to the body. One way of assessing the dental radiation risks is to compare the
radiation doses that result from dental images with estimates of equivalent amounts of natural
background radiation.

What are the Risks to a Child from Radiation from Dental Radiography?
There is no conclusive evidence that radiation from dental diagnostic x-rays causes cancer.
However, major national and international organizations responsible for evaluating radiation
risks agree that we should act as if even low doses of radiation may potentially cause harm and
should always try to minimize radiation exposure. This is particularly important in children as
they are at an approximately 3 to 5 times higher radiation-induced cancer mortality risk than
adults. This is because their developing tissues are inherently more radiosensitive and because
they have more remaining years of life during which a radiation-induced cancer could develop.
It is estimated that approximately 1 in 1,000 individuals will develop cancer from an exposure
of 10 mSv. Therefore a relative radiation level (RRL) can be provided when considering the risk for a single x-ray exposure or a course of treatment involving multiple images.

Despite several limitations of estimating radiation dose risk, comparison of the radiation
Effective Dose from various dental Imaging Procedures (Table 1) to the RRL (Table 2) shows that
for children all dental radiographic procedures have minimal risk. For CBCT the risk can vary
from low to medium depending on the scanner used.

How can Radiation Risk to a Child be Minimized?
The Image Gently Campaign provides guidance to dental practitioners to minimize radiation
exposure to children. These involve numerous strategies and include:

  • Only perform imaging when there is a clear medical or dental benefit to the child.
  • Use the lowest amount of radiation for adequate imaging based on the size of the child.
  • Only take images on the indicated area and always using the thyroid collar
  • Avoid multiple unnecessary images.
  • Use alternative diagnostic studies (such as ultrasound or MRI), if possible.

If a child’s dentist requests a dental image should the parent allow it to be done?
As with any dental procedure, the benefit of the procedure should always outweigh the risk.
Dental images can improve diagnoses and dental care. Dental images can help determine the
best treatment option, avoid other tests or surgery, and improve health outcome. With any
dental imaging procedure, it is appropriate to ask that appropriate low dose techniques be used
to minimize radiation exposure.

How can I be sure that the imaging facility or dental office is using appropriate radiation
reduction techniques?
The dentist or his/her staff should be able to provide information about how radiation dose is
minimized in their specific facility. If requested, they should be able to provide information
about the facility’s accreditation by the state’s radiation safety office (or equivalent) or board of
dentistry.

Should there be alternatives to CBCT?
For many years prior to the use of CBCT, conventional dental techniques provided images that in
many cases were adequate for diagnoses of most dental conditions . CBCT is not a replacement for
common dental imaging modalities, when prescribed utilizing appropriate selection criteria it can
add valuable additional diagnostic information to the traditional dental imaging and improve the
treatment outcome. While ultrasound and magnetic resonance imaging (MRI) are imaging
techniques that do not use radiation, there are few situations in childrens’ dentistry where these
would be appropriate alternatives to CBCT. MRI usually takes a long time (compared with CBCT)
and because of this, children may require sedation, which involves risk. The dentist should be
asked whether or not alternative examinations would be appropriate.

If no abnormality is detected with a dental image does this mean the image was
unnecessary?
Dental x-ray images should be considered only after a thorough clinical examination of the
child. Dental images are taken either to confirm a clinical suspicion of a certain condition or to
eliminate it from further consideration. In the latter case the dental image does not provide a
positive result but is of value in that it may avoid additional tests or procedures.

Whom should I contact if I have further concerns regarding radiation exposure?
The clinician who originally ordered or performed the x-ray examination on your child should
always be the first person you should approach with any questions regarding the procedure. If
this individual is unable to answer satisfactorily your questions, you can request that your
dentist consult with an oral and maxillofacial radiologist, or you can ask to be referred to one.
Oral and maxillofacial radiologists are specialist dentists who have received additional training
(beyond dental school) and expertise in dental radiography.

_________________

Image Gently
The information contained in this publication is provided through Image Gently, the educational
and awareness campaign created by the Alliance for Radiation Safety in Pediatric Imaging,
formed in July 2007. It is a coalition of healthcare organizations dedicated to providing safe,
high quality pediatric imaging nationwide. The Society for Pediatric Radiology as well as over 33
other societies (including the American Academy of Oral and Maxillofacial Radiology) are
members of this coalition representing more than 500,000 health care professionals in
radiology, dentistry, pediatrics, medical physics, and radiation safety.

References

  • American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction
    http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/RRLInformation.aspx Accessed
    May 23, 2011. Rev. 2010. 2 p.
  • Amis ES, Jr., Butler PF, Applegate KE, et al. American College of Radiology white paper on radiation dose in
    medicine. Journal of the American College of Radiology 2007; 4:272-284.
  • Arch ME, Frush DP. Pediatric body MDCT: A 5-year follow-up survey of scanning parameters used by pediatric
    radiologists. American Journal of Roentgenology 2008:191;611-617
  • Brenner DJ, Doll R, Goodhead DT, et al. Cancer risks attributable to low doses of ionizing radiation: Assessing what
    we really know. Proceedings of the National Academy of Sciences of the United States of America 2003;100:13761-
    13766.
  • Brenner DJ, Elliston CD, Hall EJ, Berdon WE. Estimated risks of radiation-induced fatal cancer from pediatric CT.
    American Journal of Roentgenology 2001; 176:289-296.
  • Brenner DJ, Hall EJ. Current concepts – Computed tomography – An increasing source of radiation exposure. New
    England Journal of Medicine 2007; 357:2277-2284.
  • Brody AS, Frush DP, Huda W, Brent RL, Radiology AAP. Radiation risk to children from computed tomography.
    Pediatrics 2007; 120:677-682.
  • Cardis E, Vrijheid M, Blettner M, et al. The 15-country collaborative study of cancer risk among radiation workers in
    the nuclear industry: Estimates of radiation-related cancer risks. Radiation Research 2007; 167:396-
    416.
  • Chodick G, Ronckers CM, Shalev V, Ron E. Excess lifetime cancer mortality risk attributable to radiation exposure
    from computed tomography examinations in children. Israel Medical Association Journal 2007;9:584-587.
  • Frush DP, Applegate K. Computed tomography and radiation: understanding the issues. Journal of the American
    College of Radiology2004; 1:113-119.
  • Frush DP, Donnelly LF, Rosen NS. Computed tomography and radiation risks: What pediatric health care providers
    should know. Pediatrics 2003; 112:951-957.
    Goske MJ, Applegate KE, Boylan J, et al. The ‘Image Gently’ campaign: increasing CT radiation
    10 dose awareness through a national education and awareness program. Pediatric Radiology 2008; 38:265-269.
    Huda W, Vance A. Patient radiation doses from adult and pediatric CT. American Journal of Roentgenology2007;
    188:540-546.
  • Larson DB, Rader SB, Forman HP, Fenton LZ. Informing parents about CT radiation exposure in children: It’s OK to
    tell them. American Journal of Roentgenology 2007; 189:271-275.
  • Ludlow JB. Regarding influence of CBCT exposure conditions on radiation dose. Oral Surg Oral med Oral Pathol Oral
    Radiol Endod 2008; 106: 627-628
  • Ludlow JV, Davies LE, White SC. Patient risk related to common dental radiographic examinations: the impact of
    2007 International Commission on Radiological Protection recommendations regarding dose calculation. Journal of
    the American Dental Association 2008; 139: 1237-1243
  • Ludlow JB, Walker C. Assessment of phantom dosimetry and image quality of i-CAT FLX cone-beam computed
    tomography. Am J Orthod Dentofacial Orthop. 2013 Dec;144(6):802-17.
    NAS. Health risks from exposure to low levels of ionizing radiation: BEIR VII phase 2. Washington D.C.: National
    Academy of Sciences, 2005.
  • Pierce DA, Preston DL. Radiation related cancer risks at low doses among atomic bomb survivors. Radiation
    Research 2000; 154:178-186.
  • Preston DL, Ron E, Tokuoka S, et al. Solid cancer incidence in atomic bomb survivors: 1958-1998. Radiation
    Research 2007; 168:1-64.
  • Slovis TL. The ALARA (as low as reasonably achievable) concept in pediatric CT intelligent dose reduction.
    Multidisciplinary conference organized by the Society of Pediatric Radiology. August 18-19, 2001. Pediatric
    Radiology 2002; 32:217-317