The Image Gently in Dentistry campaign: promotion of responsible use of maxillofacial radiology in dentistry for children.

Abstract

The Image Gently in Dentistry campaign is an education and awareness initiative focusing on radiation safety in pediatric maxillofacial radiology. This effort is directed to both the dental professional community and the general public and is supported by numerous dental organizations including the American Dental Association (ADA) and the American Academy of Oral and Maxillofacial Radiology (AAOMR). The goal of this campaign is to raise awareness of the special considerations needed for pediatric dental radiology and to promote radiation safety by providing a “Six-Step Plan” of considerations to standardize clinical workflow and encourage team responsibility. Implementation of the recommendations in this plan can be an effective tool in the ongoing effort to maximize radiation safety during maxillofacial radiographic procedures on pediatric patients. In 1999 the Institute of Medicine (IOM) released a pivotal report concluding that some patient morbidity and mortality was a result of medical errors caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.1Institute of Medicine. To Error is Human: Building a Safer Health System 1999. Available at: http://www.iom.edu/∼/media/Files/Report Files/1999/To-Err-is-Human/To Err is Human 1999 report brief.pdf.Google Scholar IOM recommends “raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care.” Standards and expectations can be achieved through regulation; however, professional societies have a responsibility to establish their own performance standards and to communicate with practitioners and their patients about safety issues. Radiation protection is a safety issue of increasing public concern, because ionizing radiation at high doses is a recognized risk factor for leukemia and many solid tumors. Total radiation exposure to a member of the public includes sources of background radiation as well as artificial sources such as medical and occupational exposures. Since the 1980s, exposure of the population to ionizing radiation from medical imaging has increased tremendously such that in 2006, medical exposure constituted nearly half of the total radiation exposure of the US population from all sources.2National Council on Radiation Protection and Measurements. Ionizing radiation exposure of the population of the United States. Report No. 160. 2009.Google Scholar Computed tomography (CT) is the major single contributor of diagnostic radiation exposure. Recent publications have raised concerns regarding the appropriate use and safety of diagnostic x-ray imaging procedures in children, including the increased use of (and wide variations in exposure from) CT in children.3Brenner D.J. Hall E.J. Computed tomography—an increasing source of radiation exposure.N Engl J Med. 2007; 357: 2277-2284Crossref PubMed Scopus (6399) Google Scholar, 4Pearce M.S. Salotti J.A. McHugh K. et al.CT scans in young people in Northern England: trends and patterns 1993-2002.Pediatr Radiol. 2011; 41: 832-838Crossref PubMed Scopus (31) Google Scholar, 5Dougeni E. Faulkner K. Panayiotakis G. A review of patient dose and optimisation methods in adult and paediatric CT scanning.Eur J Radiol. 2012; 81: e665-e683Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar In addition, emerging epidemiologic data suggest a more direct link between exposure to radiation from CT and overall or organ-specific cancer risk in children.6Mathews J.D. Forsythe A.V. Brady Z. et al.Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians.BMJ. 2013; 346: f2360Crossref PubMed Scopus (1281) Google Scholar, 7Miglioretti D.L. Johnson E. Williams A. et al.The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk.JAMA Pediatr. 2013; 167: 700-707Crossref PubMed Scopus (880) Google Scholar, 8Pearce M.S. Salotti J.A. Little M.P. et al.Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study.Lancet. 2012; 380: 499-505Abstract Full Text Full Text PDF PubMed Scopus (2447) Google Scholar Radiation-associated risk to children has been a particular concern, as they are substantially more susceptible to the effects of radiation exposure for most cancers than adults, owing to their longer life expectancy and the increased radiosensitivity of some developing organs and tissues.3Brenner D.J. Hall E.J. Computed tomography—an increasing source of radiation exposure.N Engl J Med. 2007; 357: 2277-2284Crossref PubMed Scopus (6399) Google Scholar, 9UNSCEARSources, effects and risks of ionizing radiation. Scientific Annex B. Effects of radiation exposure of children. United Nations, New York, NY2013Google Scholar Although individual doses from radiographic procedures in dentistry are relatively low, these examinations are quite common. There were an estimated 500 million intraoral bitewing and full-mouth radiographic procedures performed in 2006 in the United States,2National Council on Radiation Protection and Measurements. Ionizing radiation exposure of the population of the United States. Report No. 160. 2009.Google Scholar almost twice the number of conventional medical radiographic and fluoroscopic examinations combined. Furthermore, studies of various dental populations have found that there is a broad range of exposures used in dental offices.10Brink JA, Boone JM, Feinstein KA, et al. Reference levels and achievable doses in medical and dental imaging: recommendations for the United States. NCRP Report No. 172. 2012.Google Scholar The typical effective doses associated with intraoral examinations such as the bitewing (5 μSv) and full-mouth series (range, 34-388 μSv) or extraoral imaging such as panoramic radiography (range, 14-24 μSv)5Dougeni E. Faulkner K. Panayiotakis G. A review of patient dose and optimisation methods in adult and paediatric CT scanning.Eur J Radiol. 2012; 81: e665-e683Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, 11Smith-Bindman R. Lipson J. Marcus R. et al.Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer.Arch Intern Med. 2009; 169: 2078-2086Crossref PubMed Scopus (1741) Google Scholar are substantially lower than those typically provided by conventional head CT (median, 2000 μSv; range, 300-6000 μSv).12Ludlow J.B. Davies-Ludlow L.E. White S.C. Patient risk related to common dental radiographic examinations: the impact of 2007 international commission on radiological protection recommendations regarding dose calculation.J Am Dent Assoc. 2008; 139: 1237-1243Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar Nonetheless, recent concerns over radiation risks associated with these procedures have also been raised in dentistry,13Lin M.C. Lee C.F. Lin C.L. et al.Dental diagnostic X-ray exposure and risk of benign and malignant brain tumors.Ann Oncol. 2013; 24: 1675-1679Crossref PubMed Scopus (21) Google Scholar particularly in association with intracranial meningioma14Longstreth Jr., W.T. Phillips L.E. Drangsholt M. et al.Dental X-rays and the risk of intracranial meningioma: a population-based case-control study.Cancer. 2004; 100: 1026-1034Crossref PubMed Scopus (100) Google Scholar, 15Claus E.B. Calvocoressi L. Bondy M.L. Schildkraut J.M. Wiemels J.L. Wrensch M. Dental x-rays and risk of meningioma.Cancer. 2012; 118: 4530-4537Crossref PubMed Scopus (130) Google Scholar and thyroid cancer.16Neta G. Rajaraman P. Berrington de Gonzalez A. et al.A prospective study of medical diagnostic radiography and risk of thyroid cancer.Am J Epidemiol. 2013; 177: 800-809Crossref PubMed Scopus (35) Google Scholar, 17Memon A. Godward S. Williams D. Siddique I. Al-Saleh K. Dental x-rays and the risk of thyroid cancer: a case-control study.Acta Oncol. 2010; 49: 447-453Crossref PubMed Scopus (80) Google Scholar Although the validity of these epidemiologic studies has been called into serious question,18White S.C. Hildebolt C.F. Lurie A.G. Dental x-rays and risk of meningioma.Cancer. 2013; 119: 464Crossref PubMed Scopus (7) Google Scholar, 19Tetradis S. White S.C. Service S.K. Dental x-rays and risk of meningioma: the jury is still out.J Evid Based Dent Pract. 2012; 12: 174-177Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar the contribution of x-ray exposure from dentistry to per capita annual dose may well be increasing, as is the case in diagnostic imaging in general, which now accounts for almost 50% (3000 μSv) of annual per capita radiation dose in the United States (6200 μSv).2National Council on Radiation Protection and Measurements. Ionizing radiation exposure of the population of the United States. Report No. 160. 2009.Google Scholar Perhaps the major contributing factor in the general rise of dose in dentistry has been the rapid rise in the availability and use of cone beam computed tomography (CBCT) in clinical practice.20US Food and Drug Administration. Dental cone-beam computed tomography. Available at: http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm315011.htm.Google Scholar The number of CBCT units21Freedman G. Buyer’s guide to 3-D imaging/cone beam computed tomography: cone beam tomography produces 3-D image ideal for dentists.Dent Today. 2009; 28 (Available at:): 102-112http://digi.dentistrytoday.com/publication/index.php?i=203065PubMed Google Scholar will likely soon surpass the number of standard CT systems in the United States, estimated to be 10 335 in 2007.22National Center for Health StatisticsHealth, United States 2011: With Special Feature on Socioeconomic Status and Health. National Center for Health Statistics, Hyattsville, MD2012Google Scholar Although the reported range of effective doses for examinations conducted on CBCT units (20 μSv to approximately 500 μSv)23Ludlow J.B. Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 106-114Abstract Full Text Full Text PDF PubMed Scopus (612) Google Scholar, 24Pauwels R. Beinsberger J. Collaert B. et al.Effective dose range for dental cone beam computed tomography scanners.Eur J Radiol. 2012; 81 ([published online December 31, 2010]): 267-271Abstract Full Text Full Text PDF PubMed Scopus (386) Google Scholar, 25Rottke D. Patzelt S. Poxleitner P. Schulze D. Effective dose span of ten different cone beam CT devices.Dentomaxillofac Radiol. 2013; 42: 20120417Crossref PubMed Scopus (46) Google Scholar is lower than that of examinations performed using standard CT systems by a factor of 4 to 100, there should still be concern in dentistry, because some CBCT unit doses to specific organs are high and CBCT examinations are being proposed, by some, as substitutes for conventional imaging. Despite our understanding of tissue (deterministic) and carcinogenic (stochastic) effects from radiation biology, risk models and the concept of radiation exposure risk for diagnostic imaging procedures remain, to some extent, controversial. However, greater availability of diagnostic imaging in dentistry and increasing options for acquisition settings between brands and models as well as within a particular unit imply that there are multiple opportunities to reduce patient exposure. Taking advantage of these opportunities to reduce radiation exposure is especially important for children, as the cancer risk per unit dose of ionizing radiation is generally higher for younger patients than for adults, and younger patients have a longer lifetime for the effects of radiation exposure to manifest. Also, the use of x-ray equipment settings designed for adults can result in a larger radiation dose than necessary to produce a useful image for a smaller pediatric patient. In 2007, the Society for Pediatric Radiology reached out to organizations representing members of the entire health care team in pediatric radiology including radiologists (American College of Radiology), radiologic technologists (American Society of Radiologic Technologists), and medical imaging physicists (American Association of Physicists in Medicine) to found the Alliance for Radiation Safety in Pediatric Imaging (www.imagegently.org). The mission of the Alliance is to improve the safety and effectiveness of the imaging care of children worldwide. This can be achieved through increased awareness, education, and advocacy for parents, patients, and medical professionals on the need for the appropriate examination methods and radiation dose when imaging children. Since 2007, more than 80 organizations, medical societies, agencies, and regulatory groups have joined the Alliance forces to improve patient care and change practice through an educational and awareness campaign called Image Gently. Almost all of the dental specialty organizations in the United States are members of the Alliance, including the AAOMR, the American Academy of Oral and Maxillofacial Pathology, the American Academy of Pediatric Dentistry, the American Academy of Periodontology, the American Association of Endodontists, and the American Association of Oral and Maxillofacial Surgeons. The ADA (representing organized dentistry), the American Dental Education Association, the Canadian Association of Oral and Maxillofacial Radiology, and the European Academy of DentoMaxilloFacial Radiology are also members of the Image Gently alliance. Other interested organizations are encouraged to join this campaign. Image Gently provides guidance to professionals, parents, and patients in specific areas of diagnostic imaging including CT, fluoroscopy, digital radiography, interventional radiology, nuclear medicine, and ultrasonography. The newest initiative, set for public launch in September 2014 (to coincide with the annual session of the AAOMR in Orlando, FL, USA, and immediately before the annual meeting of the ADA in October in San Antonio, TX, USA), is the Image Gently in Dentistry campaign. The campaign will comprise advertising and outreach programs through professional media promoting the responsible use of dental and maxillofacial radiographic imaging for children. Six simple steps will be advocated by the campaign to improve radiation safety in pediatric imaging in dental practice. These steps, based on the concepts of justification for use and reduction of radiographic exposures as low as diagnostically acceptable (ALADA)26ALADA (as low as diagnostically acceptable) was proposed by Dr. Jerrold Bushberg at the 2014 NCRP Annual Meeting as a variation of the acronym ALARA (as low as reasonably achievable) to emphasize the importance of optimization in medical imaging.Google Scholar are intended to assist the dental care provider in providing diagnostically acceptable images while minimizing patient and operator exposure. We use the term x-ray as a synonym for radiograph throughout these steps because of its accepted usage in conversations with patients on dental practice. The need for and types of x-rays to be performed should be customized for each patient and based on individual need, such that for each exposure the benefits to diagnosis or the treatment plan (or both) outweigh the small potential risks of radiation dose. This requires professional clinical judgment based on patient presentation, including considerations of the chief complaint, medical and dental history, availability of previous x-ray examinations, and a thorough clinical intraoral examination. Appropriate image selection criteria are available to assist the practitioner in this decision-making process for common dental office imaging procedures27American Dental Association Council on Scientific Affairs. The selection of patients for dental radiographic examinations. 2012. Available at: http://www.fda.gov/downloads/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/UCM329746.pdf.Google Scholar and, more recently, for CBCT.28Carter L. Farman A.G. Geist J. et al.American Academy of Oral and Maxillofacial Radiology executive opinion statement on performing and interpreting diagnostic cone beam computed tomography.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: 561-562Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar, 29American Dental Association Council on Scientific AffairsThe use of cone-beam computed tomography in dentistry: an advisory statement from the American Dental Association Council on Scientific Affairs.J Am Dent Assoc. 2012; 143: 899-902Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar Specific guidelines are also available for prescribing CBCT imaging in orthodontic treatment.30Clinical recommendations regarding use of cone beam computed tomography in orthodontics [corrected]. Position statement by the American Academy of Oral and Maxillofacial Radiology.Oral Surg Oral Med Oral Pathol Oral Radiol. 2013; 116 (Erratum in Oral Surg Oral Med Oral Pathol Oral Radiol 2013;2116:2661): 238-257Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar The fastest film (E- or F-speed) or digital system available should be used for intraoral radiography to reduce exposure dose without compromising image quality. D-speed film, which requires approximately twice the exposure of F-speed film and comparable solid state and storage phosphor digital systems, should not be used. For panoramic radiography, newer digital equipment is recommended. For film-based panoramic systems, rare-earth intensifying screens, combined with a high-speed film of 400 or greater, are recommended because they reduce a patient's radiation exposure by 50% compared with calcium tungstate intensifying screens. Restriction of the x-ray beam by the use of physical collimation limits the amount of radiation, both primary and secondary, to which the patient is exposed. Intraoral radiographic equipment should provide rectangular collimation for exposure of periapical and bitewing radiographs. Intraoral rectangular collimation is the most efficient dose-reduction technique, because it can decrease exposure by up to 5-fold as compared with circular collimation.12Ludlow J.B. Davies-Ludlow L.E. White S.C. Patient risk related to common dental radiographic examinations: the impact of 2007 international commission on radiological protection recommendations regarding dose calculation.J Am Dent Assoc. 2008; 139: 1237-1243Abstract Full Text Full Text PDF PubMed Scopus (274) Google Scholar Marked dose reductions can be achieved in CBCT examinations by reducing the field of view to the region of interest.31Grünheid T. Kolbeck Schieck J.R. Pliska B.T. Ahmad M. Larson B.E. Dosimetry of a cone-beam computed tomography machine compared with a digital x-ray machine in orthodontic imaging.Am J Orthod Dentofacial Orthop. 2012; 141: 436-443Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 32Roberts J.A. Drage N.A. Davies J. Thomas D.W. Effective dose from cone beam CT examinations in dentistry.Br J Radiol. 2009; 82: 35-40Crossref PubMed Scopus (264) Google Scholar During dental radiographic procedures, the amount of scattered radiation striking a patient's abdomen is negligible. However, the thyroid gland, located in the anterior neck and in the vicinity of primary exposure in all dental radiographic procedures, is sensitive to radiation, particularly in children.33Royal HD, Becker DV, Brill AB, et al. Risks to the thyroid from ionizing radiation: National Council on Radiation Protection & Measurements. NCRP Report No. 159. 2008.Google Scholar Protective thyroid collars are recommended for both dental intraoral and CBCT radiographic procedures, because their use reduces radiation exposure to the thyroid gland by about 50%.34Qu X.M. Li G. Sanderink G.C. Zhang Z.Y. Ma X.C. Dose reduction of cone beam CT scanning for the entire oral and maxillofacial regions with thyroid collars.Dentomaxillofac Radiol. 2012; 41: 373-378Crossref PubMed Scopus (28) Google Scholar, 35Goren A.D. Prins R.D. Dauer L.T. et al.Effect of leaded glasses and thyroid shielding on cone beam CT radiation dose in an adult female phantom.Dentomaxillofac Radiol. 2013; 42: 20120260Crossref PubMed Scopus (36) Google Scholar, 36Stenstrom B. Rehnmark-Larsson S. Julin P. Richter S. Radiation shielding in dental radiography.Swed Dent J. 1983; 7: 85-91PubMed Google Scholar Leaded aprons should include thyroid collars. There are differences in the size and morphology of the teeth and jaws of children compared with those of adults, and less radiation is required to provide optimal image quality than would be required in an adult. Particular attention must be paid to reducing exposure times in offices using storage phosphor plates, because the wide latitude of these systems will allow visually acceptable images to be made in children even when using exposure settings more appropriate for adults. In addition, the inadvertent use of adult settings for pediatric CBCT imaging may result in an overall increase of up to 29% in effective dose37Theodorakou C. Walker A. Horner K. et al.Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms.Br J Radiol. 2012; 85: 153-160Crossref PubMed Scopus (113) Google Scholar and an increase of 17% to over 278% in specific organ doses.37Theodorakou C. Walker A. Horner K. et al.Estimation of paediatric organ and effective doses from dental cone beam CT using anthropomorphic phantoms.Br J Radiol. 2012; 85: 153-160Crossref PubMed Scopus (113) Google Scholar, 38Al Najjar A. Colosi D. Dauer L.T. et al.Comparison of adult and child radiation equivalent doses from 2 dental cone-beam computed tomography units.Am J Orthod Dentofacial Orthop. 2013; 143: 784-792Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Because CBCT systems generally expose the child to greater doses than conventional imaging, CBCT exposures should be considered only when lower-dose techniques are unable to answer the clinical question that prompts imaging. If possible and appropriate in the sense of ALADA, reduced scan angles (e.g., a 180° scan) should be applied. Specific recommendations for appropriate CBCT imaging in orthodontic treatment have been published.30Clinical recommendations regarding use of cone beam computed tomography in orthodontics [corrected]. Position statement by the American Academy of Oral and Maxillofacial Radiology.Oral Surg Oral Med Oral Pathol Oral Radiol. 2013; 116 (Erratum in Oral Surg Oral Med Oral Pathol Oral Radiol 2013;2116:2661): 238-257Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar The Image Gently in Dentistry campaign to be launched in September 2014 is a specific initiative of the Alliance for Radiation Safety in Pediatric Imaging, supported by organized dentistry and dental education as well as many dental specialty organizations. The objective of the campaign is to change practice by increasing awareness of the opportunities to improve radiation protection when imaging children in dental practices. Six practical steps are provided that underline the principle that one size does not fit all, especially when it comes to using radiography during pediatric dental procedures. When we image children, let us image gently: More is often not better.