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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 32  |  Issue : 1  |  Page : 46-49

Need for dental radiology regulatory board: A review


1 Department of Oral Medicine and Radiology, I.T.S Dental College, Hospital and Research Centre, Knowledge Park III, Greater Noida, Uttar Pradesh, India
2 Department of Oral Medicine and Radiology, ITS Dental College, Delhi-Meerut Road, Muradnagar, Ghaziabad, Uttar Pradesh, India
3 Department of Oral Medicine and Radiology, ITS Dental College and Hospital, Greater Noida, Uttar Pradesh, India
4 Professor Oral Medicine and Radiology, Private Practitioner, Bangalore, India

Date of Submission30-Nov-2019
Date of Acceptance05-Mar-2020
Date of Web Publication17-Apr-2020

Correspondence Address:
Dr. Manisha Lakhanpal Sharma
Professor and Head of the Department, Department of Oral Medicine and Radiology, I. T. S.Dental College and Hospital, Greater Noida - 201 308, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_196_19

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   Abstract 


Since, there is an increase in the instances of flaunting of the radiation safety rules, dumping of radiation waste, unethical practices both at procuring and reporting of conventional and higher imaging, therefore, setting up of a Dental Radiology Regulatory Board is an unquestionable, undisputed call of the hour. This article draws light on a pertinent concern and stresses upon the need for strong surveillance and standardization.

Keywords: Dental radiology regulations, radiation safety, radiation waste, training program


How to cite this article:
Sharma ML, Dhillon M, Srivastava S, Mehrotra G, Krishnamoorth B. Need for dental radiology regulatory board: A review. J Indian Acad Oral Med Radiol 2020;32:46-9

How to cite this URL:
Sharma ML, Dhillon M, Srivastava S, Mehrotra G, Krishnamoorth B. Need for dental radiology regulatory board: A review. J Indian Acad Oral Med Radiol [serial online] 2020 [cited 2020 Jun 5];32:46-9. Available from: http://www.jiaomr.in/text.asp?2020/32/1/46/282614




   Introduction Top


In the recent past, several studies have been conducted to assess the knowledge, attitude, and practice of the dentists towards dental radiology and the results were appalling. Understandably, there is a lot of documentation in the scientific literature about the judicious use of X-rays. Commandments have been clearly laid down by both national and international bodies, but, in India, there is a lack of a dedicated organization for surveillance. In 2012, an embarrassing revelation during a parliamentary session by the radiation safety enforcement organization in India, Atomic Energy Regulatory Board (AERB), reported that there were more than 50,000 X-ray and other diagnostic units presently operating through the length and breadth of the country, out of which, only 80 had been duly inspected for compliance of radiation norms. The response of the government panel to such flaunting of rules was addressed with extreme displeasure and termed as total anarchy in the usage of ionizing radiation (AERB's sloppiness leads to flouting of radiation norms: India Today). Since, we live in a country where we are still trying to discipline basic civic mannerisms, which people are truly aware of, through hefty fines and penalization, the absence of policing in the sphere of dental radiology is leading to absolute malpractice and abuse. Considering the density of dental population in India and the quantum of radiation installations are being done in the dental setups, there is definitely an indisputable need for a Dental Regulatory Board to monitor and fine tune the various aspects of Dental Radiography around.


   Curb the Practice of Trampling over the Radiation Safety Rules Top


Oral radiography, which is the art of recording images of a patient's oral structures on a film by using X-rays (Roentgen rays) introduced by Dr. Otto Walkoff, opened the gates for diagnosis and treatment of dental conditions.[1] Unfortunately, in 1898, Dr. William Rollins, a Harvard graduate and Boston dentist, also known as the ”dentistry's forgotten man” received a scalding burn on his arm while exposing his hand to the X-ray beam. This event was an eye-opener as it stimulated his interest and tailored his research in the arena of radiation protection. Consequentially, he recommended several methods for radiation protection such as use of leaded glasses, enclosure of the X-ray tube in a leaded housing, recording only the area of interest, and shielding the rest. In addition, he also suggested filtration of the X-ray beam and developed a rectangular collimation to restrict the size of the X-ray beam.[2] Therefore, these gamut of incidences led to the construction of radiation safety guidelines. These radiation protection measures form a pertinent part of the dental radiology curriculum and are emphatically taught at both the graduation and post-graduation level, but ironically they are reduced to bookish discourse. These guidelines remain as mug and purge for a short or a long question in the professional examination and are forgotten thereafter. Therefore, most of the clinics ignore the mandatory usage of radiation protection armamentarium like lead aprons and thyroid collars which is a prerequisite in their dental practices.

It is completely customary to abide by the AERB guidelines if in possession of any form of a radiation source. Apart from the safety measures, it is mandatory to regularly evaluate the radiation dosage that has been lucidly laid down in the guidelines designed by AERB.[3] Most of the practitioners think it as a vestigial practice as, in their opinion, the radiation exposure while making an IOPA is minuscule. Hence, this important parameter of radiation dosage evaluation is turned a blind eye to. According to a study conducted by Aravind et al., although 90% of the dentists were aware of the usage of TLD badges, only a paltry 2% were using them in their practices.[4] Furthermore, the machine provided with a quality licensing when bought is mostly never rechecked for any radiation leaks.

Also the guidelines titled, “The Selection of Patients for X-Ray Examination” first laid down in 1987 by a panel of dental experts convened by the Center for Devices and Radiological Health of the U.S. Food and Drug Administration emphasize on the fact that even though radiation exposure from dental radiographs is low, once a decision to obtain radiographs is made, it is the dentist's prime responsibility to follow the rule of As Low as Reasonably Achievable (ALARA), which has been recently conceptualized as ALADA (As Low as Diagnostically Achievable), in an endeavor to minimize patient's exposure. Despite this, numerous surveys have concluded that patients are subjected to unnecessary radiation exposure during dental radiography. In a survey of dental radiography practice in the states of Punjab and Haryana by Sheikh S. et al.[5] the respondents' knowledge concerning the technical details of their equipment was limited, with 82.3% not being aware of the kilo voltage peak of their machine and 10.8% dentists oblivious of the speed of film merely reflecting their ignorance toward radiation reduction parameters and radiographic quality assurance.[6] In yet another questionnaire-based survey conducted by Praveen et al. in 100 dental clinics in and around Bengaluru with a prime objective of understanding the level of knowledge of radiation protection among dentist population, it was observed that 60% of the dentists stood next to the patient while radiation exposure.[4] They also revealed that only 20% were using lead barrier and more than 60% of the dentists were disposing the radiation waste into a gutter. Therefore, they concluded that the radiation safety measures were being totally breached in Bengaluru. Most of the dental clinics and hospitals do not have important radiation protection signage boards displayed resulting in more casual approach towards radiation.

It is also a common observation that irrespective of any dental indication, intraoral periapical radiograph (IOPA) is the radiograph of choice and short cone is the technique generally adopted for obtaining the radiographs. This has been reiterated in a questionnaire-based study designed to assess awareness and attitude towards radiation protection and safety among dental community of North India by Harleen et al. where it was observed that 50.7% of the dentist advised periapical radiographs only and 8% prescribed panoramic only, while 32% used both panoramic and periapical on the first visit. It was also observed that 9.3% did not rely on radiographs for diagnosis. The results were similar in case of pediatric patients.[6]

Therefore, lack of radiography practice, lack of technical knowledge, dearth of trained auxiliary support, casual approach towards radiation, lack of knowledge by the patient about the number of permissible radiographs and rationale for repeats, unthoughtful attitude by the dentist lead to impertinent use of radiation. Times have come when even the usage and radiation emitted by mobile phones has become a point of talk among scientific circles. Under this scenario, the callous approach towards radiation is merely an act of irresponsible behavior and a crime of burdening the environment with unstable radiation molecules. Therefore, the rectification of this mayhem has to be carried out by a responsible and purposeful organization which focuses only on Oromaxillofacial Radiology. Thus, without much ado, it is time for the Dental Council of India to propose a ”Swachh Radiation Abhiyan.”


   Monitoring of Radiation Waste Top


Apart from the natural radiation, modern technology is exploiting the environment with the damaging affects of radiation marring its beneficial effects. Conventional oral radiography has never gone out of practice and still plays a pivotal role in dentistry in this era of digitization. In a questionnaire-based study done on a sample size of 100 dentists, it was observed that almost 40% of the clinicians practice only conventional radiology and 28% practice digital radiography alone, while 32% practice both. It was also observed that 46% of the dentists collected lead foils and disposed them into the local waste collection body, whereas 20% disposed them along with the regular waste of the clinic and 12% handed over the foils to the patients along with the X-ray packet; the remaining 22% believed in recycling it. Astonishingly, only 48% responders firmly believed that X-ray films were hazardous waste, while 36% were unsure. The results for method of disposal of developer suggested that 38% clinicians disposed the solution offsite, considering it as a hazardous waste, whereas 32% and 17% disposed it blatantly into the sewage and soil, respectively. Only 13% stored it and then disposed it according to the guidelines mentioned. It has been reported that the lead foils from film packets merely have to be collected and returned periodically to the manufacturer for recycling.[7] The only cost is that of the postage. Unfortunately, some manufacturing companies report that only about 5% of products sold were being returned. In part, it appears that this is due to lack of awareness of the offered service. 87% responses were received for a need to setup an organizing authority to manage radiological waste in dentistry. Digitization has led to minimizing of the waste created from conventional means but still the wisdom of disposal methods of electronic waste is found to be less than expected. An organization, if founded, can help clinicians to learn and employ appropriate methods of disposal and thereby reduce the risk of pollution. Even the clinicians need to take initiative to enquire and acquaint themselves with the correct knowledge and change their perspective.[8],[9],[10],[11],[12]


   Training Dental Radiographers Top


There is a total dearth of dental radiology technicians in the country. Unlike other countries, in India, the radiology course caters to general radiological with very little emphasis on various intraoral and extraoral radiological training. Thus, it has been observed that on employment of a radiology technician, his training quotient in the field of Oromaxillofacial Radiology is limping. This qualitatively and quantitatively impacts dental radiography practice. To a great extend, expertize in dental radiology is a neglected area that has not been addressed till date.


   Role in Qualitative and Quantitative Standardization of Cone Beam Computed Tomography (Cbct) Top


Nowadays in dental office, Orthopantomography (OPG) and CBCT are becoming fairly popular. Mostly these imaging modalities are being installed by dentists from different specialities who believe very little in the ideology of radiation safety and radiographic reporting. This is definitely adding to the existing disarray. A study by Aditya et al. aimed to assess the current Knowledge Attitude Practice status of 50 dental practitioners towards CBCT revealed that there is a significant gap in the knowledge of CBCT applications among dental specialists.[13] Reporting of radiographs, especially CBCT scans has ironically become a matter of debate. In addition, the practice of replacing basic radiography with three-dimensional imaging can be observed from time to time not only in adults but also in children. Moreover, the practitioners have limited knowledge about the indications and FOV while advising a scan. This straight away translates into increased patients' radiation dosage. The radiation of CBCT is ten times more than that of an OPG and unnecessary repeats leading to inadvertent exposure are neither documented nor audited. This is truly an example of unethical practice. The survey quoted above also indicated that the dental specialists were well conscious of their lack of knowledge in the field of three-dimensional imaging and strongly acknowledged a need for some kind of training program for the same. Even the oral radiologist strongly believe that educational strategies should be chalked out for training in CBCT at the undergraduate as well as postgraduate level in the form of well-structured training modules held under the aegis of Oral Medicine and Radiology. Here comes the role of the dental radiology regulatory board that could take up the following responsibilities:

  • Ensure adherence of radiation safety measures in the imaging units
  • Make a standard format for communication between the practitioner and the radiologist
  • Audit the centres for repeats and erroneous scans
  • Audit the scans for judicious indication
  • Make radiographic reporting mandatory.



   Surveillance in Cases of Insurance and Medical Data Handling Top


Dental Insurance Dental Radiology Regulatory Board (DRRB) shall be like a bridging body between the practitioners and the Insurance companies, ensuring the protection of the rights of a dentist towards medicolegal cases, pertaining to usage of radiography. In addition, India, with its exploded population, has become a huge source for medical and dental data. Therefore, an expert team is required to monitor the influx and outflux of the radiographic patient data by the primary health providers to the public health agencies to ensure lawful exchange.


   Key Responsibilities of Drrb Top


Dental Radiography is a specialized branch, wherein, a professional in a tenure of 3 years gathers fine training and experience into the various aspects of dental radiology which is certified only after undergoing a rigorous evaluation procedure. Therefore, a panel of experienced qualified dental radiologists should be formed not only to monitor the radiation burden being delivered into the environment but also to monitor the judicious use of radiography along with the qualitative upliftment of the same. It shall be the duty of this panel to do value addition to the knowledge bank by keeping the fraternity abreast of any new scientific technology or data that has surfaced out. They should also be considered as a vital advisory to the Dental Council of India for formulation and up-gradation of the dental radiology curriculum. Therefore, the onus of driving small training programs and workshops for apprising professionals of the latest shall lie on them.

”A Dental Radiology Regulatory Board should not be a choice but a mandate

for regulating the visible effects of the invisible rays.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
White S, Pharoah M. Oral Radiology Principles and Interpretation. 4th ed. Mosby; 2000. p. 42-61.  Back to cited text no. 1
    
2.
White SC. Assessment of radiation risks from dental radiography J Dento Maxillo Facial Radiology 1992;21:118.  Back to cited text no. 2
    
3.
AERB safety code (Code No. AERB/SE/MED-2) Mumbai 2001 (1-20).  Back to cited text no. 3
    
4.
Aravind BS, Joy ET, Kiran MS, Sherubin JE, Sajesh S, Manchil PR. Attitude and awareness of general dental practitioners toward radiation hazards and safety. J Pharm Bioallied Sci 2016;(Suppl 1):S53-8.  Back to cited text no. 4
    
5.
Sheikh S, Pallagatti S, Singla I, Gupta R, Aggarwal A, Singh R, et al. Survey of dental radiographical practice in states of Punjab and Haryana in India. J Investig Clin Dent 2014;5:72-7.  Back to cited text no. 5
    
6.
Harleen B, Mishra N, Kaur P, Sharma S, Muthunagai R, Shraddha S. Awareness and attitude towards radiation protection and safety among dental community of North India. J Res Adv Dent 2018;9:32-42.  Back to cited text no. 6
    
7.
Needleman H. Lead poisoning. Annu Rev Med 2004;55:209-22.  Back to cited text no. 7
    
8.
Praveen BN, Shubhasini AR, Bhanushree R, Sumsum PS, Sushma CN. Radiation in dental practice: awareness, protection and recommendations. J Contemp Dent Pract 2013;14:143-8.  Back to cited text no. 8
    
9.
Firdous S, Sodhi S, Farha SS. Knowledge and perspective of dental clinicians toward radiological waste management in dentistry. JIndianAcadOralMedRadiol 2018;30:126-31.  Back to cited text no. 9
    
10.
Narayanan P. Radiological safety in health care: Guidelines, practice and outcome. Med Phys Chronicle 2010;2 (1).  Back to cited text no. 10
    
11.
Silva MA, Santos-Neto OS, Amorim JM, Bauer J. Evaluation of radiographic waste management in dental offices and radiology clinics of São Luís (ma). RevistaSulBrasilieraDeOdontologia 2007;9:260-5.  Back to cited text no. 11
    
12.
Brahmankar U. Hazardous waste from dental radiology. Int J Med Public Health 2015;5:123.  Back to cited text no. 12
  [Full text]  
13.
Aditya A, Lele S, Aditya P. Current status of knowledge, attitude, and perspective of dental practitioners toward cone beam computed tomography: A survey. J Oral Maxillofac Radiol 2015;3:54-7.  Back to cited text no. 13
  [Full text]  




 

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