Dental X-ray Definition: And Mammography Safety
Definition: Radiation safety inspections of dental X-ray officesdetermine the type of imaging system, provide estimates of patientradiation dose, measure the quality of image processing and evaluateX-ray machine performance. An indicator of unnecessarily highradiation exposure is determined by comparing average estimatedpatient radiation exposure (entrance skin exposure) from dental intraoral X-ray procedures to national averages. Mammography facilityinspections provide estimates of radiation dose to the breast (glandulardose) and data on image quality score (the ability of the image to showfine detail). Indicators of mammography quality are mean glandulardose and the percent of mammography facilities issued violations fornot meeting Food and Drug Administration radiation standards. Imagequality score is used as an indicator of the ability of the mammographyX-ray system to allow accurate diagnoses to be made.Dental X-rayandMammographySafetySummarywhich is closer to the national average of 30%.The Washington State Department of Healthinspects X-ray facilities and equipment toimprove safety for patients, the generalpublic and healthcare workers. The goal is toachieve the best diagnostic quality imagewith the least amount of radiation exposure.Dental intra-oral X-rays and mammographyare two common healthcare proceduresusing X-rays.During 1998–2006, the increase in image qualityin Washington paralleled a rise in the meanradiation dose. During 2007–2011, the meandose went down due to the increasing use ofdigital imaging systems. The averagemammographic image quality score continued torise during the same period.IntroductionRadiation exposure from dental intra-oral Xrays depends primarily on the type ofimaging system used. Digital imagingsystems result in less radiation exposurethan older methods. In Washington, the useof digital systems increased steeply fromabout 1% in 1998 to about 63% in 2011. Theuse of D-speed film, which is the slowestspeed with the highest radiation exposure,decreased markedly from 78% ofWashington dental offices inspected in 1998to only 26% of Washington dental officesinspected in 2011.More than 6,150 X-ray facilities operate inWashington. Major fields using X-ray devices are:dentistry, industry, medicine, chiropractic medicine,veterinary medicine, podiatry, academic centers,scientific research organizations and lawenforcement agencies. The Washington StateDepartment of Health has inspection programs formost types of X-ray equipment.X-ray examinations account for much of the public’sexposure to ionizing radiation. Regulations andinspections of medical and dental X-ray devicesminimize unnecessary radiation exposure and helpassure that patients receive the best diagnosticquality images with the least amount of radiationexposure.The number of mammography facilities withinspection violations in Washingtondecreased from 53% in 2002 to 20% in 2005,then increased to a peak of about 70% in2008. This marked increase was primarilydue to intensified Food and DrugAdministration (FDA) education of ourinspectors and hence more rigorousmammography inspections starting around2005. As the facilities became morecompliant with the federal inspectionrequirements, the citations came down. In2011, the violations dropped to about 37%,Health of Washington StateWashington State Department of HealthThis chapter focuses on two common types of X-rayprocedures with national comparison values orstandards: dental intra-oral radiography andmammography.Description of IndicatorsThis chapter discusses radiation dose and type ofequipment to assess potential unnecessary radiationexposure from dental X-rays. For mammography,the chapter discusses radiation dose, image quality1Dental X-ray and Mammography Safetyupdated: 05/20/2013
and national standards. Radiation safetyinspectors estimate patient dose by measuringradiation at the point where it enters the patient(entrance skin exposure, ESE). (See TechnicalNotes for a discussion of radiation measurementunits.)quality. The department also reviews constructionplans for new or remodeled medical facilities foradequate shielding of scattered radiation to ensurethe safety of workers and the general public.This chapter does not include information on healthoutcomes. Modern dental and mammography X-raymachines do not cause immediate health conditionsdue to excessive radiation exposures. An exposuremust be nearly 200,000 times greater than a normaldental or mammographic X-ray to cause acuteradiation injuries such as burning of the skin andother tissues. Long-term effects, such as increasedrisk of X-ray radiation-induced cancer, are difficult ifnot impossible to attribute to modern medicalimaging X-ray procedures such as single intra-oraldental X-ray exposures and single mammographicX-ray doses.The principles of dose optimization and ALARA(As Low as Reasonably Achievable) apply toboth dental X-rays and mammography. Thetradeoff between higher radiation dose for betterX-ray image quality and lower radiation dose forgreater patient safety is termed radiation doseoptimization. The ALARA principle states that nolevel of radiation exposure to the humanpopulation is acceptable unless the benefit tothe individual and society outweighs the risk ofadverse health effects from radiation exposure.This means that the radiation exposure from Xrays must be reduced to the lowest levelpossible. Radiation dose optimization issynonymous with ALARA. The Department ofHealth inspectors encourage all healthcareworkers to comply with ALARA principles.Radiation dose to patients, healthcare workersand the general public varies depending on thetype of equipment; manufacturer, model, age ofa given piece of equipment; and factors relatedto X-ray operator skill. For example:Dental X-ray ExposuresA dental facility provides care of the mouth, teeth,tongue, gums and jaw. More than 3,250 dental X-rayfacilities are located in Washington, and thedepartment inspects each one every four to fiveyears to determine if it meets state radiation safetystandards.A dental radiation safety inspection determines thetype of imaging system (D-speed film, E/F-speedfilm or digital), estimates patient exposure, measuresthe quality of the image processing and checks theX-ray machine settings and performance.Newer digital imaging equipment allowshigher quality clinical imaging with lowerradiation dose than older analog (film)imaging.Time TrendsNewer imaging equipment makes use ofautomatic exposure control (AEC)technology that automatically adjustsradiation levels to patient size (pediatricto adult) to obtain uniform image qualitywith the minimal dose. Older equipmentthat does not have AEC technologyrequires the operator to manuallyoptimize exposure based on the size ofthe patient, so optimization varies withoperator skill.Dental image systems using D-speed film, which isthe slowest speed film, require higher patient X-rayexposure than E/F-speed film or digital systems.Based on Washington State inspection data during2006–2011, use of D-speed film resulted in anaverage entrance skin exposure (ESE) of 274millirad, while E/F-speed film resulted in averageESE of 161 millirad. Use of a digital system resultedin an average ESE of 99 millirad, a 64% lowerpatient exposure than D-speed film. These doseshave not changed since 1998.State X-ray inspectors measure radiation outputof all dental X-ray and mammography machineswhen assessing X-ray safety in Washington’shealthcare facilities.The department not only measures an individualmachine’s radiation output but also the percentof facilities that do not maintain acceptableoperational safety standards. For example,mammography facilities can be shut down forcertain types of violations such as low imageDental X-ray and Mammography Safetyupdated: 05/20/20132Health of Washington StateWashington State Department of Health
MammographyScreening mammograms detect breast cancer at itsearliest, most treatable stage. Consistent with theU.S. Preventive Services Task Force, the Centersfor Disease Control and Prevention currentlyrecommends routine screening mammography everytwo years for women ages 50–74. A healthcareprovider might begin screening earlier orrecommend more frequent screening based onindividual circumstances. According to the 2011Washington Behavioral Risk Factor SurveillanceSystem, 76% ( 2%) of women ages 50–74 reportedreceiving a mammogram within the past two years,as did 63% ( 5%) of women ages 40–49.About 150 mammography facilities operate inWashington. Facilities are inspected annually toensure that standards are met in terms of facilitypersonnel experience and training; X-ray machineperformance, including mean glandular dose (patientdose to the breast in units of millirad) and imagequality or resolution score (ability to see fine detail);and quality control measures, such as weekly imagequality tests. A lower mean glandular dose is notnecessarily better, because image quality mightsuffer if the amount of radiation is not sufficient toensure a diagnostic-quality image. The image qualityscore is derived from the number of objects visible ina breast model and indicates the quality of fine detailin the X-ray image.As of 2012, the latest national comparison datafor patient exposures from dental intra-oral X-rayprocedures was from 1999. Comparing data for2006–2011, Washington State’s average ESEvalue for D-speed film was 274 millirad, whichexceeded the 1999 national average ESE valueof 195 millirad. The reason for this difference isnot known. Washington’s 2006–2011 averageESE value for E/F-speed film, 161 millirad, isclose to the 1999 national average ESE value of148 millirad. A national comparison value fordigital X-ray imaging systems is not available.Time TrendsIn Washington, the percent of facilities using Dspeed film decreased from about 78% in 1998 toabout 26% in 2011. In contrast, the use of digitalsystems rose from about 1% in 1999 to about63% in 2011. The percent of facilities using E/Fspeed film decreased from 18% to 11% during1998–2011.Health of Washington StateWashington State Department of HealthIn Washington, the mean glandular dose rose from150 millirad to 190 millirad during 1998–2006, butwas still well below the maximum glandular doseallowed by the FDA (300 millirad). During 2007–2011, Washington’s mean glandular dose declinedas did the national mean dose. In 2011 the national3Dental X-ray and Mammography Safetyupdated: 05/20/2013
mean glandular dose was about 154 milliradwhile Washington’s mean glandular dose was163 millirad. Washington’s peak in 2006 is mostlikely attributable to the mammography clinics’inclination to retain old film machines inanticipation of buying new digital equipment.This peak occurred in 2002 nationally.the change to digital imaging systems and the FDArequirements for continuing education forpractitioners and inspectors. By 2011, the citedviolation rate in Washington State was approachingthe national violation citation rate of 30%.From 2006 to 2011, image quality scores,ranging from 0 to 16, steadily increased inWashington State and nationally. Scores did notshow consistent patterns of increase ordecrease from 1998 to 2005. Washington’saverage image quality scores increased from13.3 in 2006 to 13.8 in 2011. The nationalaverage was 12.9 in 2011. The improvementssince 2006 are primarily due to the change fromfilm to digital imaging systems. FDArequirements for continuing education forpractitioners and inspectors might alsocontribute to the improvements.2010 and 2020 GoalsThere are no Healthy People 2010 or 2020objectives that pertain to X-ray procedures orinspections.Intervention StrategiesRegulatory and educational strategies seek toproduce the best diagnostic quality X-ray images forthe least amount of radiation exposure. Thesestrategies involve:Routinely inspecting X-ray facilities to assurecompliance with relevant radiation safetystandards, taking enforcement actions whenrequired and fielding an adequate number oftrained inspectors.Ensuring X-ray operator competence andcertification, proper maintenance of equipmentand safe operating procedures.From 2002 to 2011, the percent ofmammography facilities in Washington Statewith violations of the Mammography QualityStandards Act (MQSA) standards reached a lowof about 19% in 2005 and increased to a peak ofabout 67% in 2008 before decreasing to about37% in 2011. The department’s X-ray SafetyProgram reports that the peak in 2008 wasprimarily due to an FDA education class takenby all Washington State mammographyinspectors in 2007. Washington Statemammography inspectors subsequentlyconducted more rigorous and thoroughmammography facility inspections. WashingtonState mammography facilities subsequentlyachieved higher levels of compliance. Thecurrent violation rate reflects a combination ofDental X-ray and Mammography Safetyupdated: 05/20/2013Educational outreach to healthcare providers,workers and patients on ways to reduceunnecessary radiation exposure from X-rays andto improve facilities’ quality assurance practices.In Washington State, the Department of Healthoversees these educational outreach activities incooperation with the FDA.Once inspectors are trained, the FDA requiresthem to complete continuing education classesannually to keep up with rapid technologicaladvances, such as the move from analog todigital imaging. This facilitates inspectorscommunicating the latest advances in X-ray4Health of Washington StateWashington State Department of Health
See Related Chapters: Female Breast Cancer, OralHealthtechnology to the healthcare community andhelping healthcare workers to implementthese technologies.Data SourcesWashington State X-ray facility database, 1997-2011Conference of Radiation Control Program Directors (CRCPD).Nationwide Evaluation of X-ray Trends (NEXT) Tabulation andGraphical Summary of 1999 Radiography Survey, November2003, CRCPD publication E-03-6U.S. Food and Drug Administration (FDA) MammographyQuality Standards Act (MQSA) Facility Score /scorecardstatistics-archive.html#0107U.S. Centers for Disease Control and Prevention, BehavioralRisk Factor and Surveillance System survey, 2004To accomplish these strategies for facilitiesother than mammography facilities, senior (lead)inspectors in the department train otherdepartment inspectors to assess the quality ofX-ray imaging procedures. The departmentpurchases new equipment as needed to enableusing state-of-the-art X-ray diagnosticequipment to accomplish health industry bestpractice inspections. Senior inspectors also trainother department X-ray inspectors to educatehealthcare workers in methods to optimize X-rayimage quality with the lowest possible exposureto patients and workers.The Conference of Radiation Control ProgramDirectors (CRCPD) provides guidance forinspecting most facilities that use X-rays. Thedepartment has adopted many CRCPDsuggested state regulations for X-ray techniquesand incorporated them into Chapter 246-225 ofthe Washington Administrative Code (WAC).Having these standards incorporated into theWAC also assists with keeping patient andhealthcare worker X-ray exposure for facilitiesother than mammography facilities as low asreasonably achievable.For More InformationDepartment of Health X-ray Hotline: (800) 299-9729Department of Health X-ray ent/Radiation/XRay.aspxTechnical NotesX-Rays are electromagnetic waves emitted from the electronshells of the atom instead of the nucleus. They have no chargeand are best shielded by thick layers of lead or steel. X-rayenergy may cause an external or internal radiation hazard.1The FDA sets mammography quality standardsand regulates inspections of mammographyfacilities. For facilities in Washington, the FDAsubcontracts with the Washington StateDepartment of Health for these inspections. TheFDA trains and certifies department staff toconduct inspections. Inspectors must maintaincertification through a rigorous program ofcontinuing education.The following paragraphs explain radiation measurement unitsand how they are used in this chapter.2A Roentgen is a unit of exposure to ionizing radiation. It is thatamount of gamma or X-rays required to produce ions carryingone electrostatic unit of electrical charge in one cubic centimeterof dry air under standard conditions. It represents how muchionizing gamma or X-ray radiation enters from the air throughthe outer skin of a person’s body. It is of limited value inassessing health effects of radiation since it is only defined forair.Inspectors issue citations to facilities that do notcomply with standards. Facilities must correctthose violations within 14 days or risk the loss offederal certification for mammography.Rad is a special unit of radiation absorbed dose. It is a measureof ionizing radiation energy absorbed per unit mass (100ergs/gm) and used for both biologic and non-biologic materials.Dose to biological materials refers to the amount of radiationenergy that is actually absorbed per gram of tissues. One rad 1,000 millirads. The International System of Units (metricsystem) equivalent of the rad used in most countries other thanthe United States is the gray (Gy). One Gy 100 rad and 100millirad 1mGy.The Intersocietal Accreditation Commissionoffers voluntary accreditation to certain dentalfacilities, and the American College of Radiology(ACR) offers voluntary accreditation for hospitalsand some clinics that use X-ray equipmentincluding CT scan imaging centers. Most X-rayfacilities in Washington State have not soughtaccreditation but the academic medical centersin the state have obtained accreditation.Health of Washington StateWashington State Department of HealthREM (Roentgen Man Equivalent) reflects the radiation dosereceived by the body, after accounting for the potential forbiological harm from different types of radiation. To convert rad5Dental X-ray and Mammography Safetyupdated: 05/20/2013
to rem, the number of rad is multiplied by a number calleda quality factor (QF) that reflects the potential for biologicaldamage caused by a given type of ionizing radiation. Forbeta, gamma and X-ray radiation, the quality factor for softbiological tissues is generally close to one. For some othertypes of ionizing radiation such as neutrons, protons, oralpha particles, the quality factor to convert rad to remranges between 10 and 20.2 The metric system equivalentunit used for radiation absorbed dose in countries otherthan the United States is the sievert (Sv). One Sv 100rem.mammography (FFDM) systems, which are digital. After thenumber of digital FFDM mammography systems outnumberedthe film equipment, Washington’s mean glandular dose startedto trend downward and has continued decreasing through 2011.AcknowledgmentsUnless otherwise noted, authors and reviewers are with theWashington State Department of Health.Author:Daniel Van Gent, BS, MSThis chapter uses millirad as the unit of measure for bothexposure and dose. Technically, millirad is the unit forionizing radiation absorbed dose, millirem is a unit of doseequivalent and milliRoentgen is the unit used for radiationexposure. In the case of diagnostic X-rays and betaradiation, all three units are essentially equivalentnumerically for soft biological tissues. Bone is considered ahard biological material and is more efficient at absorbingX-rays than soft tissues such as muscle and glands. It isnoteworthy that Roentgens are not defined for ionizingradiation exposure by radiation other than X-ray andgamma ray radiation in air. This limits the usefulness ofRoentgens for describing radiation effects on biologicalsystems.Film speed used in dental intra-oral imaging systems:The X-ray film speed used for dental intra-oralexaminations is D-speed (slowest), E-speed (faster) and Fspeed (fastest). The faster the film used, the less exposurethe patient experiences. This means a dentist using Dspeed film uses
risk of X-ray radiation-induced cancer, are difficult if not impossible to attribute to modern medical imaging X-ray procedures such as single intra-oral dental X-ray exposures and single mammographic X-ray doses. Dental X-ray Exposures A dental facility provides care of the mouth,
MDC RADIOLOGY TEST LIST 5 RADIOLOGY TEST LIST - 2016 131 CONTRAST CT 3D Contrast X RAYS No. Group Modality Tests 132 HEAD & NECK X-Ray Skull 133 X-Ray Orbit 134 X-Ray Facial Bone 135 X-Ray Submentovertex (S.M.V.) 136 X-Ray Nasal Bone 137 X-Ray Paranasal Sinuses 138 X-Ray Post Nasal Space 139 X-Ray Mastoid 140 X-Ray Mandible 141 X-Ray T.M. Joint
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The PHOT-X IIs Model 505 is an extraoral source dental radiographic x-ray unit. This unit works as diagnostic purpose x-ray source for human teeth with resultant image recorded on intraoral dental x-ray film or image receptor. 3. PARTS IDENTIFICATION OF X-RAY SYSTEM "
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