Previous Radiographs Be Reviewed in Conjunction With Current Radiographs
Clinical justification of dental radiology in adult patients: A review of the literature
Yolanda Martínez Beneyto1, Miguel Alcaráz Baños2, Leonor Pérez Lajarínthree, Vivian East. Rushtoniv
(i) Profesor Ayudante Doctor Odontología Preventiva y Comunitaria. Universidad de Murcia, España
(2) Profesor Titular Radiología y Medicina Física. Universidad de Murcia, España
(3) Profesor Titular Odontología Preventiva y Comunitaria, Universidad de Murcia, España
(four) Profesor Titular Radiología Oral y Maxilofacial, Universidad de Manchester, Reino Unido
Correspondence
Abstruse
Although the radiological doses used by dentists are low individually, patients are frequently exposured to many repeat dental radiographic examinations. The 'routine' use of dental radiography, such as screening of all patients using dental panoramic radiography (DPRs) or a random determination to take a dental radiograph, will inevitable lead to unnecessary patient exposure.
The apply of Radiographic Referral Criteria has now become a legal requirement for all practitioners following the adoption of European Legislation. All exposures to 10-rays should exist clinically justified and each exposure should exist expected to give the patient a positive net benefit.
Recently the European Commission has published guidelines (1) on radiation protection in dental radiology. Guidelines have previously been available in a number of European countries (ii,3) and also within the United States (iv,5). At the nowadays time, no specific guidelines take been published within Spain.
The aim of this review article is to provide the Spanish dentist with guidance as to the appropriateness of different radiographic techniques for a variety of clinical conditions and also the frequency with which they should exist taken. It is hoped that this document will act every bit a useful work tool in daily dental practice.
Fundamental words: Radiation protection, dentistry, European guidelines, dental radiology, regulations.
RESUMEN
Aunque generalmente las dosis de radiación empleadas por los odontoestomatólogos no suelen ser altas, consideradas individualmente, las exposiciones a las que algunos y determinados pacientes están sometidos pueden ser excesivas.
En este sentido, hay que evitar radiaciones rutinarias innecesarias para no incrementar la dosis de irradiación recibidas por los pacientes.
El empleo de criterios de selección radiográfica se ha convertido en requerimientos legales europeos a cumplir por todos los dentistas. Todas las exposiciones a los rayos 10 deberían de estar clínicamente justificadas y, a la vez, proporcionar un beneficio neto para el paciente.
Recientemente, la Comisión Europea ha publicado unas Guías (1) sobre Protección Radiológica Dental, existentes ya en numerosos países de la Unión Europea (2, 3) y en Estados Unidos (four, 5); sin embargo, en España no se ha publicado ningún documento propio específico que permita difundir united nations protocolo de actuación en radiología dental.
El objetivo de este artículo es proporcionar al odonto-estomatólogo general español guías de actuación en radiología dental apropiadas para cada situación clínica y, además, recomienda la frecuencia con la que se deben de realizar dichas exploraciones.
Palabras clave: Protección radiológica, odontología, Guías europeas, radiología dental, legislación.
Introduction
The employ of 10-rays requires the adoption of measures to limit the exposure to both the patient and the clinian. One of the basic tenets of radiation rubber is to ensure that all exposures to ionising radiation are clinically justified.
All radiations exposures must be kept equally depression equally reasonably achievable (ALARA principle). This is accomplished in three ways, using physical methods of minimising dose (i.eastward. equipment and picture factors), the application of Pick Criteria when choosing whether or not to employ a radiographic examination and, finally past Quality Assurance Programmes. In the latter, efforts are fabricated to ensure the consistent production of loftier quality radiographs, thereby avoiding repeat exposure and maximising the do good to the patient.
The dentist is the person who takes responsibily for the necessity of a radiographic exam and its frequency. The clinician must review whatever previous radiographs as these may well provide useful information on the patient's present symptoms. If these radiographs are non useful, then farther radiography is may well be justified. Selection criteria assist the clinician in choosing the appropriate radiographic examination to maximise the diagnostic yield while limiting the dose to the patient. The use of Pick Criteria is well established within many countries of the European Marriage. However, Spain has not adopted the routine apply of selection criteria although several published papers take highlighted the importance of implementing radiographic guidelines within dental practise (6-eight).
The chief objetive of this study was to review some of the more relevant aspects of the guidelines that appear in the recent publication of the European Commission (i) on dental radiographic option criteria in developed patients.
European and Spanish regulations
Inside the European Marriage, the most recent ICRP recommendations were incorporated into several Euratom Directives (9-11). These directives outline the best radiographic practice and also include many recommendations to ensure high quality radiography. These recommendations include: justification and optimization of the radiographic exam; measures on quality control of radiolographic equipment; procedures for the annual evaluation of the doses received by patients in the nigh frequently conducted radiographic examinations; the evaluation of the image quality and also an assessment of almanac dose levels. These directives were implemented inside Spanish legislation by 2 Royal Decrees 1976/1999 (12) and 783/2001(xiii).
The command of the doses to patients combined with the production of high quality images constitutes the start cess of the state of the radiological equipment used and, also, of the grooming of personnel involved with ionising radiation.
The necessity of pick criteria in dental radiology: frequency of radiographic examinations
The Scientific Commission on the Atomic Furnishings of Radiation inside the United Nations noted that dental radiography was the near frequent radiographic technique in medical practice. Dental radiography accounts for nearly one tertiary of all the total number of radiological examinations conducted within the European Wedlock (14) (see Table i).
Within Spain, there are believed to be approximately 440 dental sets per million of the population, although this figure has not been reliably confirmed. This figure represents 57% of the full medical X-ray units in clinical pracrice. Throughout the European Union, the number of dental x-ray sets per million of population varies enormously with 1534 sets in Sweden, 975 to Kingdom of denmark, 667 sets in Greece, 631 to France and 350 within the UK (fourteen).
Vaño and colleagues (xv) in a contempo written report assessed the number of dental sets within Spanish dental practices and the number of dental radiographs taken per annum compared with medical exposures. The study found that the number of medical and dental ten-ray machines in clinical practise totalled 14,411, of which vii,327 (l.viii%) were dental 10-rays sets. The annual number of medical radiolographic examinations has been assessed every bit 25,058,622, representing an annual charge per unit of 629 examinations per yard habitants. Corresponding figures for the 5,226,823 dental ten-ray examinations undertaken in Spain translates into 131 dental ten-ray exposures per 1,000 inhabitants.
In the last xx years inside England and Wales, dental panoramic radiography (DPR) has become well-stablished in full general dental do, as evidenced by a seven-fold increase when compared with intra-oral radiography over the aforementioned period (2). Betwixt 1998 and 1999, approximately 2,05 million panoramic radiographs were taken in the full general dental service in England and Wales (16).This increasing use of panoramic radiography has been observed in other countries. Within the U.s., it was estimated xx years ago that 60% of all practioners had admission to panoramic equipment (17).
Panoramic equipment often delivers a broad range of doses to patients and these tin can vary past a factor of 200. In Spain, the published data of a recent report illustrates that in the region of 3,1% of the panoramic equipment fail to reach the manufacturers' nominal kilovoltage and machines also brandish timer inaccuracies. These innacuries have decreased from 12% of all equipment for the year 1997 to three% in 2001 following the adoption of compulsory almanac quality control assessment of 10-ray equipment (xviii).
Although a large number of dental radiographs are exposed within primary dental intendance, a large proportion of these exhibit poor prototype quality. These films stand for a cumulative increment in dose to the exposed population without benefit as often these films are essentially not-diagnostic considering of faults in technique and/or processing. Research has shown that 42% of dental practitioners in the United Kingdom practise 'routine screening' of new adult patients using panoramic radiography without whatever clinical findings to back up such a radiographic examination (19). Of these 'screening' panoramic films, when the yield from posterior bitewing radiographs and the radiological findingsof no relevance to treatment were excluded, 57% of patients received no benefit from these panoramic films.
Several inquiry studies have shown that the frequency of unacceptable panoramic films ranges from 18% to 33% of the total panoramic radiographs taken. These unacceptable panoramic films limit the diagnostic yield that the practitioner can obtain from the radiographic epitome. The faults range from inadequate processing to technical technical faults, such equally movement of the patient. More often inadequate panoramic films exhibit a combination of both technical and processing errors (xx). Films faults are not confined solely to panoramic radiography as a recent study has reported levels of unacceptable intraoral films ranging betwixt 45.2-56.4% (21).
Similarly, in the Us, it has been estimated that the elimination of non-productive examinations could lead to the reduction of the collective population dose from medical radiography past xxx% (4)
The method proposed to eliminate unnecessary 10-ray examinations is past the adoption of selection criteria in radiography. Pick criteria take been defined as "descriptions of clinical weather condition observed from patient signs, symptoms and history that identify those patients who are likely to do good from a particular radiographic examination" (22).
Radiation dose and risks
The biological effects of ionizing radiation can be extremely damaging. Somatic deterministic effects predominate with high doses of radiations, while somatic stochastic effects predominate with low doses. Dental radiology employs depression doses and the take a chance of stochastic furnishings is very small (23). The estimated gamble of a fatal cancer developing from 2 intraoral bitewing exposures, or from a dental panoramic tomography, is of the order of one neoplasm for every 2 million exposures (24).
In the case of panoramic radiology, the weighted dose equivalent from a panoramic examination was calculated to be 3,85-30 μSv , corresponding to a lifetime take a chance of fatal cancer (per million) of 0,21-one,9 (25,26). For an intra-oral radiograh the effective dose is ane-viii.3 μSv and the adventure of cancer is 0,02-0,6 (26, 27). These figures assume best practice is employed. A panoramic radiograph may be associated with an effective dose the aforementioned as ane-5 days additional groundwork radiation, while 2 bitewing radiographs would be equivalent to nearly one solar day.
Notwithstanding lower levels of take a chance are associated with newer equipment and techniques. Contempo studies have showed that the 72,79% of dental ten-ray sets in Spain operate at lxx kVp, 88,02% utilise a 20 cm of focus-to-film distance (PID) and the bulk of this equipment utilize a half-dozen cm diameter circular beam. Ekta-speed dental film was used in the ten,24 % of the cases and intraoral digital imaging was used by eleven,95% of practitioners (28-thirty)
A particular problem arises from the inclusion or exclusion of the salivary glands in the adding of dose. The salivary glands have previously not been included equally an organ in effective dose calculations (31). Even so, the almost recent document from the International Commission on Radiations Protection (ICRP) has recognised this omission in view of the credible human relationship between dental radiography and increased chance of salivary gland tumours (32). The most recent ICRP document has included salivary tissue every bit a balance organ and their inclusion in dose calculations increases the rate of risk of inducing tumours by a factor of two.
Methodology
A review of the literature relating to European guidelines and the protocols of functioning of option criteria in dental radiology was undertaken.
This report was specially related to the European Guidelines on Radiation Protection in Dental Radiology (ane) which had been developped by a Committe of European Experts in Radiation Protection. Information technology has been designed to be used equally a guide for both full general dental practitioners and dental specialists. This document (1) has been developed using a methodology supported in a critical review of the literature following an 'prove-based practice'. Depending on the bachelor evidence, the recommendations given were graded to reflect their relevance. A like document was produced past the Royal College of Surgeons, London using identical techniques leading to the product of "Pick Criteria for Dental Radiography [2nd edition, The Faculty of Full general Dental Practitioners, The Majestic College of Surgeons, London WC2A 3PE] (33).
New adult patients
In some centres, it has become routine to have a panoramic moving picture or total-mouth intraoral radiography of all new patients and this 'routine' practice is not aceptable (34, 35).
A high proportion of practitioners (57%) continue to rely on panoramic radiography alone to appraise common dental pathosis (34). Research has confirmed that intra-oral (bitewing and periapical) radiography is superior to panoramic radiography for the diagnosis of common dental pathology (i.e.caries, periodontal and periapical pathology). It is posible that anecdotal evidence of identifying a cyst or other uncommon lesion in a patient may reinforce this attitude. However, this standpoint ignores the low prevalence of the asymtomatic pathology and routine radiography without the presence of clinical signs or symptoms cannot be justified (35, 36). A panoramic radiograph may exist apropriate for the patient in certain cases such every bit i whom presents with a grossly neglected oral cavity with significant numbers of clinically-determined carious lesions and periapical pathology, along with established periodontal illness (35). In these cases, it may be expeditious to use panoramic radiography as a ways of identifying teeth requiring a more detailed (intra-oral) radiographic test or, when limited to a hospital setting, prior to dental surgery under general anaesthesia.
Total-mouth periapical radiography can be criticised in the aforementioned fashion as routine panoramic radiography.
For a new adult dentate patient, the choice of radiography should be based upon history, clinical examination and an individualised prescription every bit illustrated in Effigy 1.
Screening with panoramic radiography
40-two percent of practitoners were found to use panoramic radiography routinely to "screen" the jaws for clinically unsuspected pathology and 77.iv% of these do so for 'no specific reason'. Approximately, 65,3% of screening panoramic radiographs accept no relevance to handling rise to 71% in the screened asymptomatic attender. Some dentists defend routine screening on the basis of detecting of big cyst and tumours. These lesions are very rare and often have signs or symptoms, which would alert the practitioner to the need for radiography. The detection of a minor number of lesions, which are completely asymptomatic, does non justify the routine screening of the population.
Radiography in endodontics
Radiographs are essential for the mechanical aspects of endodontic treatment allowing evaluation of the root canal configuration and also for confirmation that treatment goals have been achieved. Radiographs should have optimum geometry obtained by using the paralleling technique and a beam-aiming device (37).
The radiographs recommendated for endodontic handling are shown inside Tabular array 2.
The edentulous patient
In the absense of whatever clinical signs or symptoms, there is no justification for any radiographic examinations unless implant treatment is planned (38). If implant treatment is extensive, other more avant-garde imaging techniques, such every bit Computed Tomography (CT) imaging, may well be appropriate. Where the clinical exam identifies the posible presence of an abnormality, such as a possible retained root, then an intra-oral radiograph of the site is the apropriate radiographic examination.
Referral criteria for dental radiology: prior to tertiary molars exodontia, simple extractions and surgery
The panoramic radiograph is commonly used to assess tertiary molars prior to their surgical renoval but this exam does not need to be carried out at the initial examination (iii). Routine radiography of unerupted 3rd molars is not recommended.
The techniques recommended in the extractions of the tertiary tooth vary depending on the geographic situation of the tooth:
Lower third molar: a panoramic radiograph provides data well-nigh the tooth position, the human relationship to the inferior dental canal and the altitude to the lower border. A periapical radiograph is indicated where there is whatsoever question of a circuitous root formation or an intimate relation between the molar roots and the ID culvert (3).
Upper tertiary molar: If the tooth is erupted fully then a periapical radiograph should be requested in the beginning instance, and remember to e'er check previous radiographs before requesting new films. Previous radiographs may bear witness that there are no contralateral 3rd molars present and thus avoid the need to have a full panoramic radiograph.
In other surgical situacions, such as apicectomy, root renoval or enucleation of small-scale cysts, an intra-oral radiograph may be all that is required for treatment planning.
There is no disarming evidence to support the need for radiography prior to uncomplicated routine extrabtions in adults; however, where a radiograph already exists, this should exist referred to earlier commencing the process.
Radiological recomendations for dental extractions are shown at Table 3 and clinical situations that point radiological examination at Tabular array iv.
Trauma
For unproblematic dental trauma, intraoral radiography volition provide greater diagnostic detail.
A panoramic radiograph is indispensble when assessing madibular fractures (39); however, poor panoramic film quality has been shown to severely bear upon diagnosis (40). Panoramic radiography has been shown to necesítate supplementary radiography in gild accurately to diagnose high condylar fractures (41).
If there is clinical evidence of a bony fracture, it is probably more appropriate for a dentist to refer the patient for a complete radiographic examination at the infirmary where treatment wil be performed. Panoramic radigoraphy has a express ability to detect mid-facial fractures.
Temporomandibular joint bug
The panoramic radiograph shows an epitome of the mandibular condyles and is often used equally a outset choice imaging technique for those patients with TMJ symptoms.
A recent study (42) of patients with TMJ symptoms constitute that panoramic radiography provided little or no information that influenced diagnosis or patient management in the majority of cases examined.
The overwhelming majority of patients with symptoms and signs related to the TMJ region are suffering from myofacial hurting/disfunction or internal disc derangements.
Radiography is not recommended for patients with articulation sounds ('clicking') in the absence of other signs or symptoms (43). Radiographic examination is indicated where there is recent evidence of progressive pathology (contempo trauma, alter in occlusion, madibular shift, sensory or motor alterations or modify in range of move).
To assess disc position in cases of internal derangement in which simple treatments take been unsuccessful, information technology may exist useful to utilize Magnetic Resonance Imaging.
In the situation where a clinical diagnosis of condylar hyperplasia is suspected, it should be necessary to use Computed Tomography (CT).
Periodontal disease
There is bereft show from research studies to develop robust evidence-based radiographic selection criteria for periodontal disease. While the panoramic radiograph tin offer a dose advantage over large numbers of intra-oral radiographs, it may be considered as an alternative imaging modality, if available. This may be the example when at that place are other concurrent problems for which radiography is indicated (i.e. symptomatic 3rd molars, multiple existing crowns/heavily restored teeth, and/or multiple endodontically-treated teeth in a patient new to a exercise). The use of radiography should be view as secondary to a detailed clinical exam in the diagnosis of periodontal diseases. Access to previous radiographs may be useful in assessing the rate of disease progression (5).
Guidelines for the use of dental radiography in periodontal disease are shown in Table 5.
Suggested choice criteria for panoramic radiography
The general recommendations are detailed below:
• Where a bony lesion or unerupted tooth is of a size or position that precludes its complete demostration on intra-oral radigraphs.
• In the example of a grossly neglected mouth, with significant numbers of clinically-determined carious lesions and periapical pathology, forth with established periodontal affliction (other than simple gingivitis) and where there is pocketting greater than vi mm in depth.
• For the cess of wisdom teeth prior to planned surgical intervention. Routine radiography of unrerupted third molars is not recommended.
• As a part of an orthodontic assessment where there is a clinical need to know the state of the dentition and the presence/absence of teeth. The employ of clinical criteria to select patients rather than routine screening of patients is essential
• Panoramic radiographs should only be taken in the presence of specific clinical signs and symptoms. At that place is no justification for review panoramic radiography at arbitrary time intervals
The European Recommendations have been shaped to reflect the near frequent radiographic practices within Full general Dentistry.
Conclusion
The main determination of this study was to emphasise that 'All patients must have a clinical history taken prior to any radiological examination and when radiographs are clinically indicated, intra-oral radiographs should exist considered start because of their better detail and lower radiations dose".
Within Spain, information technology is necessary to change the dentist's attitude to the apply of ionising radiation. This requires a readjustment to the new regulations on radiological safety of the patient and also to reinforce the need for justification for all radiographic examinations used in dental radiological diagnosis.
Acknowledgement
This paper has been made thanks to a Post Doctoral Grant of the University of Murcia for the broadcasting of the European Dental Guidelines on Radiations Protection in Dental Radiology. Acknowledgement is made to the staff of the Department of Dental and Maxillofacial Radiology, The Schoolhouse of Dentistry, The Academy of Manchester, M15 6FH, U.K. In improver, the authors would like to express their cheers to The Faculty of General Dental Practitioners (U.k.) and The Royal Higher of Surgeons of England for allowing the utilize of their material to be translated into Spanish and to be published within this document.
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C orrespondence:
Prof. Yolanda Martínez Beneyto
Hospital Universitario Morales Meseguer
2ª Planta, Clínica Odontológica Universitaria
Marqués de los Vélez s/northward, 30008 Murcia
Electronic mail: yolandam@um.es
Received: fifteen-02-2006
Accepted: 30-01-2007
Source: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1698-69462007000300015