At some point in your career, you’re likely to have a patient who refuses, or is reluctant to have, radiographic images out of concern that they might cause cancer. The American Dental Association (ADA) has various policies and recommendations to help dentists ensure that patients’ radiation exposure is as low as reasonably achievable (ALARA) and in compliance with as low as diagnostically acceptable (ALADA) principles of good radiation hygiene. Under the ALARA principle, dentists are encouraged to take precautions to help ensure that:
- all X-ray exposures are justified in relation to their benefits
- necessary exposures are kept as low as reasonably achievable (i.e., ALARA)
- the doses received by patients and personnel are kept well below the allowable limits
Make sure your interpretation of the radiographic images is included in the patient’s clinical notes. Documentation is needed (even if findings indicate no pathosis) to support your treatment planning decisions.
The American Dental Association’s (ADA) Council on Scientific Affairs, in collaboration with the U.S. Food and Drug Administration (FDA), developed Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure. This resource serves as an adjunct to the dentist’s professional judgment of how to best use diagnostic imaging; it is not intended to be a standard of care or a framework for constructing requirements or regulations.
The ADA encourages dentists to:
- Be aware of their state’s laws and regulations which set specific requirements for the use of ionizing radiation (which includes X-rays).
- Order dental X-rays for patients only when necessary for diagnosis and/or treatment.
Recognize that “one size does not fit all” when it comes to establishing radiographic schedules.
- Remember to take into account the patient’s oral health condition, age, risk for disease and any signs and symptoms of oral disease that the patient might be experiencing.
- Minimize radiation exposure by using the appropriate protective shield.
- Use the fastest film speed or digital speed digital radiographs and, when using film, use E or F speed film because they are the two fastest film speeds available
Take the time necessary to talk with patients who express concern about radiographs.
- Reassure the patient that radiation exposure associated with dentistry represents a minor contribution to the total exposure from all sources, including natural and man-made.
- Explain how radiographic imaging is necessary to diagnosis oral conditions.
- This discussion should be part of your conversation about dental treatment recommendations, including the need for X-rays, to make informed decisions together.
Recognize that you may opt to dismiss the patient from the practice if he/she refuses to allow recommended diagnostic testing, including radiographs. Dentists are recommended to not take on this risk and to recognize that the patient cannot “release” the dentist from potential liability for failure to diagnose by signing a waiver of liability. Of course there are many variables involved, but routinely accepting patient refusals for radiographs can lead to non-defensible claims and/or lawsuits. Accepted refusals should be well-documented, with a clinically-supportable rationale, and a plan for gathering necessary diagnostic information within a reasonable time frame.
- While dismissing a patient is never an easy decision to make, there are times when it is the best decision.
- Dentists are not obligated to accept and treat every patient who comes into the practice.
- Dentists are also advised to consult state laws and regulations and the ADA Principles of Ethics and Code of Professional Conduct (Section 2.F.) for additional guidance.
Radiation Safety Requirements
Each state establishes its own laws and regulations regarding the use of ionizing radiation. Those rules may include requirements for:
- Inspection and testing for the facility, X-ray machine, radiation monitoring equipment and radiograph processing equipment
- Permits or licensing
- Supervision of personnel
- Use of dosimetry badges
- Training or certification
- Dental office design and radiation shielding
- Record keeping
Radiographs for Pregnant Women/Radiographs Being Taken by Pregnant Team Members
Radiographs are considered safe for pregnant patients at any stage during pregnancy with the proper shielding and only when necessary for the intended treatment to be rendered.
The ADA suggests that employee policy manuals include a statement notifying staff who take radiographs to inform the dentist, in writing, that they are pregnant as soon as they are aware of the pregnancy. It’s recommended that dentists provide pregnant staff members with dosimetry badges and that they limit exposure to 0.5 mSv/month. Your state’s radiation protection program may have additional requirements; see the map of all State Radiation Control Programs in the U.S., which is maintained by the Conference of Radiation Control Program Directors, Inc. (CRCPD).
Radiographs for Children
Be familiar with The Image Gently Alliance, an initiative that provides information to help healthcare providers to “child size” radiographic examination of children in medicine and dentistry. The campaign is supported by the ADA and more than 80 other health care associations. Through the campaign, providers are urged to:
- select X-rays for individual needs, not as a routine
- use the fastest image receptor available
- use cone-beam CT (CBCT) only when necessary
- collimate the beam to the area of interest
- always use a thyroid collar/shield
- “child-size” the exposure time
The campaign’s brochure Dental X rays for Children: What Parents Should Know offers answers to many of the questions parents ask when advised that their child needs to have X-rays done.
- FDI World Dental Federation Policy Statement on Radiation Safety in Dentistry
- The American Dental Association’s (ADA) Council on Scientific Affairs’ Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure (PDF)
- The ADA Guidelines for Practice Success™ (GPS™) module on The ADA Guidelines for Practice Success™ (GPS™) module on Managing Patient articles:
- The ADA Principles of Ethics and Code of Professional Conduct (Section 2.F.) (PDF)
- The Conference of Radiation Control Program Directors, Inc. (CRCPD) map of all State Radiation Control Programs in the U.S.
- Image Gently Alliance