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  1. 1. Dental Radiography Update Dental Radiography Update: Putting the Guidelines into Action Shaunda Clark, CDA, RDH, MEd
  2. 2. Course Objectives <ul><li>Identify the new FDA standards developed by ADA. </li></ul><ul><li>Recognize changes in the type and number of radiographs, leading to improved patient care. </li></ul><ul><li>Describe the concept of As Low As Reasonably Achievable. </li></ul><ul><li>Summarize how the new standards can increase the safety and efficacy of radiographs utilized in private practice. </li></ul>
  3. 3. Recognizing New Procedures for Patient Protection
  4. 5. November 2004 <ul><li>FDA accepted updated guidelines for dental radiography to achieve ALARA as presented by ADA representing many dental professional organizations. </li></ul>
  5. 6. What do these updated guidelines mean? <ul><li>Very simply stated, treat each patient as an individual. </li></ul><ul><li>Expose patients to radiographs as needed to provide them comprehensive care. </li></ul><ul><li>Determine risk factors prior to exposing. </li></ul>
  6. 8. New Patients <ul><li>Child with primary dentition </li></ul><ul><ul><li>BW only if interproximal spaces cannot be viewed or probed </li></ul></ul><ul><li>Child with transitional dentition </li></ul><ul><ul><li>Add periapicals or panoramic to evaluate development </li></ul></ul><ul><li>Adolescents </li></ul><ul><ul><li>Because of increase in possibility of periodontal disease panoramic is recommended </li></ul></ul>
  7. 9. <ul><li>Adult </li></ul><ul><ul><li>Posterior bitewings, and selected periapicals or panoramic, a full-mouth series is preferred when the patient has evidence of disease or history of extensive treatment </li></ul></ul><ul><li>Adult edentulous </li></ul><ul><ul><li>Individualized exam based on clinical signs and symptoms </li></ul></ul>
  8. 10. Recall Patients
  9. 11. Recall patients with increased risk for caries <ul><li>Child or adolescent </li></ul><ul><ul><li>Every 6-12 months </li></ul></ul><ul><li>Adult dentate or partially edentulous </li></ul><ul><ul><li>Caries risk assessment should determine frequency </li></ul></ul><ul><ul><li>Every 6-18 months </li></ul></ul><ul><li>Adult edentulous </li></ul><ul><ul><li>Radiographs should not be performed without evidence of pathology </li></ul></ul>
  10. 12. Recall patients with no increased risk for caries <ul><li>Children with primary or transitional dentition </li></ul><ul><ul><li>BW every 12-24 months </li></ul></ul><ul><ul><li>If proximal surfaces cannot be examined visually or with a probe </li></ul></ul><ul><li>Adolescents </li></ul><ul><ul><li>BW every 18-36 months </li></ul></ul><ul><li>Adult </li></ul><ul><ul><li>BW every 24-36 months </li></ul></ul>
  11. 13. Recall patient with periodontal disease <ul><li>Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease. </li></ul><ul><li>May include BW and or periapical images of selected areas where periodontal disease can be identified clinically. </li></ul>
  12. 14. Clinical situations for which radiographs may be indicated but are not limited to: <ul><li>1. Positive clinical findings </li></ul><ul><ul><li>Previous treatment </li></ul></ul><ul><ul><li>History of pain or trauma </li></ul></ul><ul><ul><li>Familial history of dental anomalies </li></ul></ul><ul><ul><li>Etc…. </li></ul></ul><ul><li>2. Positive clinical signs and symptoms </li></ul><ul><ul><li>Clinical evidence of periodontal disease </li></ul></ul><ul><ul><li>Large or deep restorations </li></ul></ul><ul><ul><li>Deep carious lesions </li></ul></ul><ul><ul><li>Malposed or impacted teeth </li></ul></ul><ul><ul><li>Swelling </li></ul></ul><ul><ul><li>Etc…… </li></ul></ul>
  13. 15. Factors increasing risk for caries may include but are not limited to: <ul><li>High level of caries experience or demineralization </li></ul><ul><li>History of recurrent caries </li></ul><ul><li>High number of cariogenic bacteria </li></ul><ul><li>Poor quality of existing restorations </li></ul><ul><li>And the list goes on……. </li></ul>
  14. 16. The concept of ALARA As Low As Reasonably Achievable
  15. 17. What does it mean? <ul><li>As Low As Reasonably Achievable </li></ul><ul><li>Try to stay as far below dose limits as possible </li></ul><ul><li>Be consistent with the purpose for which the activity is undertaken </li></ul><ul><li>Use procedures that require the least amount of radiation exposure possible to produce the greatest amount of data </li></ul>
  16. 18. Protective Devices <ul><li>Lead apron-not required if all other guidelines in 2004 report are followed rigorously </li></ul><ul><li>Thyroid Collars-provide for all children and for adults when it won’t interfere with examination </li></ul>
  17. 19. <ul><li>Collimation-Rectangular collimation should be used for periapical radiography and when feasible for bitewing radiography </li></ul>
  18. 20. Another note on collimation…. <ul><li>Round cones can be adapted rather than replaced…… </li></ul>
  19. 21. Another thought…..
  20. 22. Protective Devices <ul><li>Cephalometric imaging-filters for imaging the soft tissues of the facial profile together with the skeleton should be placed at the x-ray source rather than at the image receptor, the x-ray beam should be collimated to the area of clinical interest </li></ul><ul><li>Sight development-should not be used </li></ul>
  21. 23. Protective Devices <ul><li>Image receptor (film speed)-use no speed slower than E speed </li></ul><ul><li>Shielding, barriers and dosimetry-shielding design should be provided by a qualified expert, operator should maintain visual contact with patient during exposure </li></ul><ul><li>Selection criteria-Dentist must examine their patients before ordering radiographs </li></ul>
  22. 24. Office Radiation Protection Program <ul><li>Have a written quality assurance protocol manual </li></ul><ul><li>Have equipment inspected by a qualified expert </li></ul><ul><li>Evaluate chemistry daily </li></ul><ul><li>Evaluate each type of film used monthly for fog or artifacts </li></ul>
  23. 25. <ul><li>Repair any defect found </li></ul><ul><li>Evaluate darkroom monthly </li></ul><ul><li>Visually inspect lead aprons monthly </li></ul><ul><li>Provide training to all x-ray personnel in radiation protection </li></ul>
  24. 26. Improving Patient Care with ALARA
  25. 28. Patient A <ul><li>22 year old female </li></ul><ul><li>Recall patient-every 6 months </li></ul><ul><li>Negative medical history </li></ul><ul><li>Lives in a community with fluoridated water </li></ul><ul><li>Has had no previous dental restorations in permanent teeth </li></ul>
  26. 29. When should BW radiographs be made? <ul><li>A. Every 6 months </li></ul><ul><li>B. Every year </li></ul><ul><li>C. Every 2 years </li></ul><ul><li>D. None of the above </li></ul>
  27. 30. Answer <ul><li>C. Every two years </li></ul>
  28. 31. Patient B <ul><li>5 year old male </li></ul><ul><li>New patient </li></ul><ul><li>Negative medical history </li></ul><ul><li>No obvious carious lesions </li></ul><ul><li>Interproximal surfaces can be easily viewed and explored </li></ul>
  29. 32. What type of radiographs should be made? <ul><li>A. 4 posterior periapicals and 2 BW </li></ul><ul><li>B. 4 BW </li></ul><ul><li>C. Panoramic </li></ul><ul><li>D. Radiographs are not indicated </li></ul>
  30. 33. Answer <ul><li>D. Radiographs not indicated </li></ul>
  31. 34. Patient C <ul><li>36 year old male </li></ul><ul><li>Recall patient with sporadic appointments </li></ul><ul><li>Medical history indicates </li></ul><ul><ul><li>Takes several RX medications that have dry mouth as a side effect </li></ul></ul><ul><li>Poor diet, consumes sugared beverages regularly </li></ul><ul><li>History of extensive dental treatment of carious lesions </li></ul>
  32. 35. When should bitewing radiographs be made? <ul><li>A. Every 6-18 months </li></ul><ul><li>B. Every 24-36 months </li></ul><ul><li>C. When obvious lesions are present </li></ul><ul><li>D. None of the above </li></ul>
  33. 36. Answer <ul><li>A. 6-18 months </li></ul>
  34. 37. Patient D <ul><li>74 year old female </li></ul><ul><li>New patient-in good health </li></ul><ul><li>Edentulous on maxillary </li></ul><ul><li>Partially edentulous on mandibular </li></ul><ul><li>Pt reports pain in maxillary right posterior </li></ul><ul><li>Expresses an interest to have a lower partial denture made </li></ul>
  35. 38. Which of the following issues indicates the need to make radiographs? <ul><li>A. Pain reported on maxillary </li></ul><ul><li>B. Interest in partial denture </li></ul><ul><li>C. New patient </li></ul><ul><li>D. A & B </li></ul>
  36. 39. Answer <ul><li>D. A & B </li></ul>
  37. 40. Patient E <ul><li>46 year old male </li></ul><ul><li>Recall patient </li></ul><ul><li>Diagnosed with moderate chronic periodontitis </li></ul><ul><li>Probing depths have increased by 2mm generalized in the posterior </li></ul><ul><li>Patient has not had a full mouth series of radiographs since 2002 </li></ul>
  38. 41. Are radiographs advised at this time? <ul><li>A. Yes </li></ul><ul><li>B. No </li></ul>
  39. 42. Answer <ul><li>A. Yes </li></ul>
  40. 43. Sources <ul><li>Perry, D.A., Beemsterboer, P.L., & Taggart, E.J.(2001). Periodontology for the dental hygienist. Philadelphia, PA: W.B. Saunders Company . </li></ul><ul><li>Iannucci-Haring, J. & Jansen, L. (2000). Dental radiography: Principles and techniques. Philadelphia, PA: W.B. Saunders Company . </li></ul><ul><li>DiGangi, P. (2006) ALARA: What does it mean? Contemporary Oral Hygiene, March 2006, 22-28. </li></ul><ul><li>Thompson, E.M. (2006) Radiation safety update. Contemporary Oral Hygiene, March 2006, 10-17. </li></ul>
  41. 44. Sources <ul><li>FDA website </li></ul><ul><li>Radiation Health in Dentistry </li></ul><ul><li>Procter & Gamble Website for Professionals </li></ul><ul><li>Continuing Education Section </li></ul>
  42. 45. To print 6 slides per page, when you click on the print button and get the print menu, where it says print what, change to handouts and select 6 per page. Print handouts for this lecture at
  43. 46. Thanks for your attention!