Is it ethical not to...?

Abstract

Recently, during an oral radiology class for first-year dental and dental hygiene students, we were discussing ways to reduce radiation risk to the patient. We talked about the benefits of using fast film or digital imaging and rectangular collimation of the x-ray beam. I also mentioned that even though the leaded apron has been in general use in dental offices for many years, it really doesn’t appear to offer much in the way of dose reduction to the patient because the abdominal dose from dental radiography is so low to begin with. In fact, I told the class, its use has been discontinued in a number of other countries. A few days later, I received an e-mail message from one of those students, obviously concerned about this issue. She asked whether it wasn’t unethical to not use every means available to reduce radiation risk. That question started me thinking. The leaded apron is a simple—and visible—sign to our patients that we care and are trying to limit their exposure. It makes us feel good, maybe even virtuous. Yet, how many dentists are really doing everything they can to decrease radiation dose? How many are using E-speed film, let alone the newly released F-speed film? Not a majority, even though there are no diagnostic differences between D-speed and E-speed film. Yes, the faster film has to be handled properly, but keeping processing solutions fresh and darkrooms truly “safe” should not be too much of a burden and could reduce the patient’s exposure by about half. Even more dismal is the acceptance by the dental profession of the use of rectangular collimation. The “square cones” are not new. At my school, we have been using them in our main radiology clinic for well over 15 years, yet I could probably count on a couple hands (I’m not pessimistic enough to say one hand) the number of our graduates who have adopted the technique in their practices after they leave school. In fact, even in some of the satellite facilities throughout our building, only round cones are to be found. To the student who asked the question about the ethics of not using a leaded apron, I reply, “What about the ethics of not using fast film and rectangular collimation?” These can reduce the patient’s dose significantly more than a whole stack of leaded aprons, and, yet, few dentists seem to have adopted them. Why not? Are they too difficult to use? (Not really.) Is it perhaps because the patient wouldn’t even notice? Possibly we don’t really need to worry at all because, after all, the effective dose from dental radiography is pretty low. However, most organizations concerned with radiation protection recommend using the ALARA (As Low As Reasonably Achievable) principle as a guide in diagnostic imaging. In this issue of the Journal, the American Academy of Oral and Maxillofacial Radiology has published Parameters of Radiologic Care,1White SC Heslop EW Hollender LG Mosier KM Ruprecht A Shrout MK. Parameters of radiologic care. An official report of the American Academy of Oral and Maxillofacial Radiology.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001; 91: 498-511Google Scholar in which the use of dose-reduction techniques is advocated (but the use of leaded aprons is considered optional except where mandated by law). In the newest version of the American Dental Association’s recommended radiographic practices, they also push dose reduction (although they haven’t discontinued the apron).2Council on Scientific Affairs ADA An update on radiographic practices: information and recommendations.J Am Dent Assoc. 2001; 132: 234-238Google Scholar What’s an ethical practitioner to do? What’s a frustrated oral and maxillofacial radiologist to do? Anyone have any suggestions for getting our point across?