1. Dental Radiography Update Dental Radiography Update: Putting the Guidelines into Action Shaunda Clark, CDA, RDH, MEd

2. Course Objectives Identify the new FDA standards developed by ADA. Recognize changes in the type and number of radiographs, leading to improved patient care. Describe the concept of As Low As Reasonably Achievable. Summarize how the new standards can increase the safety and efficacy of radiographs utilized in private practice.

3. Recognizing New Procedures for Patient Protection

5. November 2004 FDA accepted updated guidelines for dental radiography to achieve ALARA as presented by ADA representing many dental professional organizations.

6. What do these updated guidelines mean? Very simply stated, treat each patient as an individual. Expose patients to radiographs as needed to provide them comprehensive care. Determine risk factors prior to exposing.

8. New Patients Child with primary dentition –BW only if interproximal spaces cannot be viewed or probed Child with transitional dentition –Add periapicals or panoramic to evaluate development Adolescents –Because of increase in possibility of periodontal disease panoramic is recommended

9. Adult –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 Adult edentulous –Individualized exam based on clinical signs and symptoms

10. Recall Patients

11. Recall patients with increased risk for caries Child or adolescent –Every 6-12 months Adult dentate or partially edentulous –Caries risk assessment should determine frequency –Every 6-18 months Adult edentulous –Radiographs should not be performed without evidence of pathology

12. Recall patients with no increased risk for caries Children with primary or transitional dentition –BW every 12-24 months –If proximal surfaces cannot be examined visually or with a probe Adolescents –BW every 18-36 months Adult –BW every 24-36 months

13. Recall patient with periodontal disease Clinical judgment as to the need for and type of radiographic images for the evaluation of periodontal disease. May include BW and or periapical images of selected areas where periodontal disease can be identified clinically.

14. Clinical situations for which radiographs may be indicated but are not limited to: 1. Positive clinical findings –Previous treatment –History of pain or trauma –Familial history of dental anomalies –Etc…. 2. Positive clinical signs and symptoms –Clinical evidence of periodontal disease –Large or deep restorations –Deep carious lesions –Malposed or impacted teeth –Swelling –Etc……

15. Factors increasing risk for caries may include but are not limited to: High level of caries experience or demineralization History of recurrent caries High number of cariogenic bacteria Poor quality of existing restorations And the list goes on…….

16. The concept of ALARA As Low As Reasonably Achievable

17. What does it mean? As Low As Reasonably Achievable Try to stay as far below dose limits as possible Be consistent with the purpose for which the activity is undertaken Use procedures that require the least amount of radiation exposure possible to produce the greatest amount of data

18. Protective Devices Lead apron-not required if all other guidelines in 2004 report are followed rigorously Thyroid Collars-provide for all children and for adults when it won’t interfere with examination

19. Collimation- Rectangular collimation should be used for periapical radiography and when feasible for bitewing radiography

20. Another note on collimation…. Round cones can be adapted rather than replaced……

21. Another thought…..

22. Protective Devices 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 Sight development-should not be used

23. Protective Devices Image receptor (film speed)-use no speed slower than E speed Shielding, barriers and dosimetry-shielding design should be provided by a qualified expert, operator should maintain visual contact with patient during exposure Selection criteria-Dentist must examine their patients before ordering radiographs

24. Office Radiation Protection Program Have a written quality assurance protocol manual Have equipment inspected by a qualified expert Evaluate chemistry daily Evaluate each type of film used monthly for fog or artifacts

25. Repair any defect found Evaluate darkroom monthly Visually inspect lead aprons monthly Provide training to all x-ray personnel in radiation protection

26. Improving Patient Care with ALARA

28. Patient A 22 year old female Recall patient-every 6 months Negative medical history Lives in a community with fluoridated water Has had no previous dental restorations in permanent teeth

29. When should BW radiographs be made? A. Every 6 months B. Every year C. Every 2 years D. None of the above

30. Answer C. Every two years

31. Patient B 5 year old male New patient Negative medical history No obvious carious lesions Interproximal surfaces can be easily viewed and explored

32. What type of radiographs should be made? A. 4 posterior periapicals and 2 BW B. 4 BW C. Panoramic D. Radiographs are not indicated

33. Answer D. Radiographs not indicated

34. Patient C 36 year old male Recall patient with sporadic appointments Medical history indicates –Takes several RX medications that have dry mouth as a side effect Poor diet, consumes sugared beverages regularly History of extensive dental treatment of carious lesions

35. When should bitewing radiographs be made? A. Every 6-18 months B. Every 24-36 months C. When obvious lesions are present D. None of the above

36. Answer A. 6-18 months

37. Patient D 74 year old female New patient-in good health Edentulous on maxillary Partially edentulous on mandibular Pt reports pain in maxillary right posterior Expresses an interest to have a lower partial denture made

38. Which of the following issues indicates the need to make radiographs? A. Pain reported on maxillary B. Interest in partial denture C. New patient D. A & B

39. Answer D. A & B

40. Patient E 46 year old male Recall patient Diagnosed with moderate chronic periodontitis Probing depths have increased by 2mm generalized in the posterior Patient has not had a full mouth series of radiographs since 2002

41. Are radiographs advised at this time? A. Yes B. No

42. Answer A. Yes

43. Sources Perry, D.A., Beemsterboer, P.L., & Taggart, E.J.(2001). Periodontology for the dental hygienist. Philadelphia, PA: W.B. Saunders Company. Iannucci-Haring, J. & Jansen, L. (2000). Dental radiography: Principles and techniques. Philadelphia, PA: W.B. Saunders Company. DiGangi, P. (2006) ALARA: What does it mean? Contemporary Oral Hygiene, March 2006, 22-28. Thompson, E.M. (2006) Radiation safety update. Contemporary Oral Hygiene, March 2006, 10-17.

44. Sources FDA website http://www.fda.gov/cdrh/radhlth/adaxray-1.html Radiation Health in Dentistry Procter & Gamble Website for Professionals Continuing Education Section www.dentalcare.com

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 www.iowadental.org

46. Thanks for your attention!