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Dental Radiology: Self-Regulation vs Government Intervention
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self-regulation vs government intervention The efforts of the dental profession and the federal government to ensure the safe use of low-level ionizing radiation in dentistry are discussed.
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ince the use of X rays in dentistry was first introduced in the late 1920s, the dental profession has endeavored to ensure the safe and effective use of dental radiography. Continued pressure from the public, however, has brought government to question the need to regulate the use of X rays in dentistry. In the past 15 years, Congress and the Executive Branch have studied a number of proposals designed to alleviate national con cerns about radiation and its potential hazards. On July 31, 1981, the US Congress approved legislation calling for fed eral standards for accrediting of train ing programs and licensing or credentialing of individuals who operate ra diographic equipment, excluding den tists, physicians, and chiropractors. PROFESSIONAL SELF-REGULATION The concerns expressed by the public and the legislators attempting to regu late dental radiography are shared by the American Dental Association and other professional groups. The ADA,
however, has long supported the con cept that regulation of use of ionizing radiation in dentistry is the responsi bility of the profession, not govern ment. The ADA also has consistently op posed federal government interven tion in accrediting and credentialing activities, saying there is no justifica tion for duplicating activities already being carried out by well-established private and state efforts. The Association cites many exam ples to support its contention that the dental profession is making every ef fort to control the use of ionizing radia tion in dentistry. ■ The ADA has policies regarding radiation equipment and radiation safety for practice. Specific policies also stipulate the need to use profes sional judgment in determining the number and frequency of radiographic examinations to secure necessary diagnostic information. In 1968, the ADA House of Delegates adopted a resolution stating that “Radiographic examination is a diagnostic procedure. The dentist’s professional judgment should determine the frequency and
“It’s the profession’s public responsibility to assure adequate protection of pu b lic health from unnecessary radiation exposure and to assure efficacious patient radiologic services.” Dr. W illia m E. B row n
DENTAL RADIOLOGY : SELF-REGULATION VS GOVERNMENT INTERVENTION ■ 389
extent of each radiographic examina tion.” ■ Ionizing radiation is used exclu sively for diagnostic and research purposes in d e n tis try and, u n lik e medicine, is not used for therapeutic reasons. ■ Significant improvements have been made to reduce ionizing radia tion delivered to patients through use of X-ray equipm ent manufactured under federal guidelines and stan
dards as well as the standards of the Association. Ionizing radiation also has been reduced through the use of filitratio n , co llim ation, open-end cones, electronic timers, lead aprons and thyroid protective collars, filmholding and cone-positioning devices, and rare earth screens. ■ The whole-body marrow dose from dental X-ray sources is very small. Dental radiography procedures contribute only approximately 3% of
the average total adult active bone marrow dose for a year. ■ D ental aux iliarie s u sin g ra diographic equipment function at the direction and under the supervision of dentists. ■ The American Association of Dental Schools (AADS) has adopted strong policies concerning the teach ing of radiology and use of ionizing radiation in dental, dental auxiliary, and dental specialty education.
Schools urged to review use of ionizing radiation In 1979, the American Association of Dental Schools (AADS) officially urged dental educators to review their schools’ procedures to control the use of ionizing radiation and to modify any practices that do not conform to acceptable standards. AAD S recom m endations in clude: ■ Physical facilities. All existing r a d io g r a p h ic e q u ip m e n t and facilities should be upgraded to meet all regulations specified and/or recommended by The Radia tion Control for Health and Safety Act of 1968, NCRP handbook 35 on dental X-ray protection, and the ADA recommendations on accept able radiographic practices. Radiographic facilities should be designed or modified to maximize student I operator / patient protec tion from unnecessary exposure to ionizing radiation. F ilm processing, in c lu d in g time-temperature relationships, should be monitored regularly (pre ferably daily) to assure film quality. ■ Instructional / teaching sup port for clinical activities. Faculty and supporting technical staff should be knowledgeable and skill ful in all radiographic procedures and preferably licensed in the field of dental radiology. S tu d e nts s h o u ld be clearly supervised by faculty or staff dur
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ing all clinical radiographic proce dures conducted on patients. Tech niques to minimize patient expo sure should be emphasized. ■ Institutional obligations to the patient. Patients should not be sub jected to a large number of retakes to satisfy technical perfection rather than clinical acceptability. (A m i n i m a l l y a c c e p t a b le complete-mouth radiographic sur vey should demonstrate, at least one time, each root apex and each interproximal space, without over lapping and with clarity and accu racy.) Students should not serve as live technique mannequins unless some benefit is to be received by taking and interpreting the radiographs. Patients should not be subjected to mass radiographic screening ex aminations before clinical exami nation to determine the need and desirability of specific radiographs to aid in evaluating their accepta bility as clinic patients. Radiographs should be made available to private practitioners or other appropriate professionals when so requested by patients who indicate they no longer desire treatment or care at the institution. Radiographs should be limited to the minim um number needed for a complete diagnostic workup of the patient’s dental needs.
■ Institutional obligations to the student. Students should be taught to assess critically the need for diagnostic radiographic informa tion and to evaluate the risk to the patient before ordering the ra diographs needed to determine the patients oral health needs. Students should be well prepared to assume the challenges of clinical dental radiography and should re ceive appropriate guidance from faculty and staff. T echn ical perfection in ra diographic procedures should be achieved on mannequins. Students should be taught to recognize clini cal situations in which it may be necessary to compromise technical perfection. Students should be allowed to take no more than three retakes on a complete-mouth radiographic sur vey without the direct supervision of faculty or staff. More than three retakes indicate a lack of minimally acceptable skills, and close super vision is justified. Students should be prepared to establish private practices in which adequate concern is given to select ing equipment and following pro cedures that will minimize radia tion to the patient and assure high quality film s for diagnostic in terpretation.
■ The AADS Section of Oral Ra diology, in cooperation w ith the Am erican Academy of Dental Ra diology, recently revised model cur ricular guidelines in radiology for use by educational institutions. ■ Dental radiology is an integral component of all dental and dental auxiliary curriculums. ■ The activities of the ADA Com mission on Dental Accreditation have been intensified in evaluating qualifi cations of faculty, instruction in ra diology, the clinical practices regard ing the control and monitoring of uses of sources emitting ionizing radiation, X-ray equipment and radiography and support facilities, and patient records. The self-regulatory activities of the dental profession were cited by Dr. W illiam E. Brown in testimony before a Congressional subcommittee study ing regulation of dental radiography. Dr. Brown is a member and former
“Federal regulation or leg islation should not be the necessary motivating force for the educational com munity or the profession to protect the safety and health of the public.” Dr. M a rio V. Santangelo
chairman of the ADA Council on Den tal Education and the Commission on Dental Accreditation. Organized dentistry’s efforts in these areas “demonstrate rather con clusively that the dental profession is not only interested in, but has taken positive steps to ensure that the na tion ’s public health and safety are safeguarded. . . . It’s the profession’s p u b lic r e s p o n s ib ility to assure adequate protection of public health from unnecessary radiation exposure and to assure efficacious patient ra diologic services,” Dr. Brown said.
FEDERAL REGULATION Despite the efforts of the dental profes sion, concerns about the alleged lack of regulation of dental radiology still flourish. In recent years, some mem bers of Congress have stepped up ef forts to regulate dental and medical radiology based on several studies and reports suggesting that health profes sionals unnecessarily subject patients to low levels of ionizing radiation. Other legislative initiatives have at tempted to reorganize the manage ment of the nation’s radiation protec tion activities by removing such ac tivities from the Food and Drug Ad ministration Bureau of Radiological Health to the Environmental Protec tion Agency. After the 1979 Three Mile Island in cident, President Jimmy Carter re sponded to public concern about radi ation and issued a presidential order announcing a series of initiatives on low-level ionizing radiation, includ ing establishment of a national advi sory Radiation Policy Council. The presidential council— which is devel oping a series of papers on radiation— is expected to be discontinued this fall. Although Congress has considered a number of radiation bills over the past ten years, the majority of the proposals sought to impose federal standards for the accrediting of training programs and licensing or credentialing of indi viduals who operate radiographic equipment, excluding dentists, physi
cians, and chiropractors. They in clude: ■ 97th Congress (1981-1982). HS 646, sponsored by Sen. Jennings Randolph (D-WVa), and added as an amendment to HR 3982 approved by Congress. HR 2457, identical to S 646, was re ferred to the House commerce health subcommittee. The ADA has opposed HR 2457 in a letter to subcommittee chairman Henry Waxman (D-Calif). ■ 96th Congress (1979-1980). S 8500, sponsored by Senator Ran dolph, was added as an amendment to the health manpower legislation and approved by Congress. However, House-Senate conferees were unable to resolve differences between their re spective health manpower bills and the measure died. HR 6023, HR 6057, and S 2539 were
“The conference supports the reality that only the den tist can determine the indi cated need for an X-ray ex amination. Thus, the dentist can m ake the procedure fit the patien t instead of m ak ing the patien t fit the proce dure.” Dr. Robert A . G oepp
DENTAL RADIOLOGY : SELF-REGULATION VS GOVERNMENT INTERVENTION ■ 391
similar to Senator Randolph’s bill but died in committee. HR 6745 sought to reorganize all governmental agencies responsible for ad m in istering io n iz in g radiation under the Environmental Protection Agency. As of Sept 15, 1980, the ADA had testified three times during the past 14 months in opposition to proposals im posing federal standards and reor g a n iz in g ad m in istra tiv e re sp on sibilities. ■ 95th Congress (1977-1978). S 1695, introduced by Senator Ran dolph, and HR 431, HR 4573, HR 6948, and HR 8691. All bills would have set federal guidelines as under the ap proved 1981 Randolph amendment. ■ 94th Congress (1975-1976). S 1261, sponsored by Senator Ran dolph, HR 559, and HR 12548 again
“In spite of the risk to indi viduals from radiation ex posure and the known ad verse health effects that m ay result, in 39 of our states any individual m ay operate X-ray equipment, regardless of training or qualifications. ” Sen. Jennings R a n d o lp h
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seeking federal standards. ■ 93rd Congress (1973-1974). S 667, sponsored by Senator Ran dolph, and HR 673, HR 1113, and HR 9126 to establish m inim um federal guidelines. S 2724, to establish a federal radia tion prospection agency. HR 672, HR 1526, and H R 9125 to di rect the Secretary of Health, Educa tion, and Welfare to set radiation stan dards for and to conduct regular in-
spections of diagnostic and other X-ray systems. ■ 92nd Congress (1971-1972). S 426, sponsored by Senator Ran dolph. S 3588, to establish an independent agency. Earlier legislation in cluded HR 16920 in the 89th, 1965-1966 Congress that sought to authorize grants to states that agreed to m a in ta in record keeping systems for employees who
A D A ’s history in promoting The American Dental Association has consistently and emphatically sought to ensure the safety of dental X-ray examinations. Since 1966, the ADA has had formal policy on radiation hygiene. Following is a chronological listing of all policies and activities of the Association re lated to radiation hygiene in dental practice: ■ October 1965. The ADA House of Delegates calls for the Council on Dental Research to expand efforts to emphasize the principles of protec tion from unnecessary exposure to ionizing radiation through educa tion of the profession. The House also directs the ADA, through its program for evaluating devices, to encourage and stimulate the search for new materials and techniques which would further reduce expo sure to radiation by reasonable means. ■ February 1968. The ADA Councils on Dental Materials and Devices and Dental Research issue their first set of recommendations on radiation hygiene and practice to the profession. The lead-off rec o m m e n d a tio n states that ra diographic examination is “a diag nostic procedure. The dentist’s pro fessional judgment should deter mine the frequency and extent of each radiographic examination.” ■ October 1968. The ADA House
of Delegate amends Association policy on radiation hygiene to read “ Radiographic examination is a diagnostic procedure. The dentist’s professional judgment should determine the frequency and extent of each radiographic examination.” ■ May 1972. The Council on Dental Materials and Devices re peats in The Journal of the Ameri can Dental Association its recom mendations on radiographic prac tices first published in 1968. a November 1972. The ADA H o u s e of D e le g a te s a d o p ts “Guidelines on Use of Radiographs in Dental Care Programs” which stipulate that the use of radiographs should only be for determining the extent of liability of the program and in no case should infringe on the professional judgment of the dentist or the dentist-patient rela tionship. ■ November 1974. The ADA House of Delegates adopts policy on a d m in is tr a tiv e use of radiographs indicating that a diag nosis and treatment plan cannot be made from radiographs alone. The policy also stipulates that benefits shall not be determined solely on the basis of radiographic evidence. ■ November 1974. The ADA House of Delegates amends the “Guidelines on Use of Radiographs in Dental Care Programs” to indi-
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are or may be exposed to ionizing radi ation, and HR 1267 in the 87th, 19611962 Congress to establish a work m e n ’s com pensation program for people handling radiology equipment. Such legislation has failed to be enacted until the recent passage of HR982, the 1981 Omnibus Reconcilia tion Act, w hich included such an amendment sponsored by Senator Randolph. However, an important difference in
this proposal, now public law, is that there are no provisions to impose any penalties or conditions on the states which do not comply with its require ments. The law requires the Secretary of Health and Human Services, “in con sultation with specified federal and state agencies an d pro fessio n al societies,” such as the ADA, to estab lish m inim um federal standards for 1J the accreditation of educational pro
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cate that the “Association is op posed to any third party’s policy or attempts to require a mandatory submission of radiographs in every case or on a blanket, automatic basis.” New guidelines adopted in 1976 reiterate the ADA position on m an d a to ry s u b m is s io n of ra diographs. ■ January 1975. The Council on Dental Materials and Devices pub lishes an updated version of its 1968 recom m endations on radiographic practices. The update reiterates diagnostic need for ra diographic examination of the pa tient and that the frequency and ex tent of each X ray depend on the dentist’s professional judgment. ■ March 1978. The Council on Dental Materials and Devices issues an upd ated version of recom mendations on radiographic prac tices reiterating that both the dental and general health needs of a pa tient must be considered before taking diagnostic X rays. ■ May 1980. The ADA Commis sion on D ental A c c re d ita tio n adopts standards for training dental assistants and dental hygienists in radiographic procedures. The standards became effective Jan 1, 1981. m October 1980. The ADA House of Delegates adopts a resolution supporting the principle that den tists who choose to delegate the task
of exposing radiographic films should delegate the function to per sonnel who have had sufficient training in quality and safety of such procedures. The resolution states that the Association “sup ports the principle that dentists delegate the responsibility of ex posing radiographic film only to dental assistants who have had adequate formal education in such procedures. . . . Qualifications for the exposure of radiographic films by dental assistants should be de termined and evaluated on a state level.” In forwarding the resolution to the House, the ADA Council on Dental Education notes that it be lieves the profession is responsive to the need for adequate training of all dental assistants who use ioniz ing radiation. The Council also said it believes there is a need to estab lish m inim um qualifications for dental assistants who expose ra diographic film and that the re sponsibility for determining and evaluating these qualifications should rest with the states. ■ July 1981. The Council on Den tal Materials, Instruments, and Equipment issues an updated ver sion of recommendations on ra diographic practices. The update appears inThe Journal of theAmerican Dental Association.
grams to train individuals performing X-ray procedures, excluding dental and medical schools, and 2) the certifi cation of persons, other than dentists, physicians, and chiropractors, who administer radiographic procedures. The Secretary also is required to provide a m odel state law for ra diographic procedure safety, and to write guidelines for the safe and effec tive use of radiation— to minimize un necessary exposure. Because there are no penalties for noncompliance with the regulations, the legislation is based on the assump tion that the states will comply within the specified three-year period. In introducing the measure earlier this year, Senator Randolph acknowl edged the benefits of radiologic ser vices in the diagnosis and treatment of injuries and illness. He said, however, that “there is evidence that current procedures result in a greater risk to consumer patients than is necessary.” “In spite of the risk to individuals from rad iation exposure and the known adverse health effects that may result, in 39 of our states any in d i vidual may operate X-ray equipment, regardless of training or qualifications. Of the estimated 130,000 to 170,000 persons who operate the n a tio n ’s 250,000 pieces of medical (and dental) X-ray equipment, only 85,000 have demonstrated their competence in voluntary certification or state licens ing examinations. Seventy-five per cent of all nonhospital radiological procedures in the United States are performed by noncredentialed ra diologists,” he said. “Medical and dental sources of radi ation currently account for over 90% of all hum an exposures to manmade ionizing radiation. By contrast, the normal operation of nuclear power plants accounts for less than 1% of the consumer’s exposure to ionizing radi ation,” he said. Health care costs also would be cut through better regulation of low-level ionizing radiation, Senator Randolph added. “The annual cost of radiation ser-
DENTAL RADIOLOGY : SELF-REGULATION VS GOVERNMENT INTERVENTION ■ 393
State regulation of radiology Most states now have active regula tory programs for the registration and inspection of X-ray equipment, according to the National Center for Health Care Technology (NCHCT). In conjunction with federal per formance standards, “ these pro grams have been instrumental in correcting equipment-related radi ation exposure problems. In the past, significant exposure reduc tions were achieved through atten tion to such factors as beam filtra tion. collimation, and timer accu racy," according to the NCHCT re port, An Overview of Dental Ra diology. A 1977 US Department of Health, E ducation, and Welfare report found that 38 states had regulatory programs for dental I medical X-ray activities, five states had voluntary activities, and eight states com bined regulatory and voluntary programs. A lthough the number of m a chines increased between 1975 and 1977, the number of inspections decreased slightly, NCHCT said. Of the estimated 145,000 dental X-ray machines in the United States in 1977, 92.6% were registered with state agencies. The 24,833 inspections con ducted represented 17.2% of the total estimated number of machines reported. Of the estimated 82,123 facilities, 5% were not in com pliance with state regulations. Suggested state regulations for control of radiation have been pub lished and revised since 1962. Ap proximately 40 states have adopted the 1970 or 1974 revisions or were intending to adopt the 1978 revi sions of Part F, “X Rays in the Heal ing Arts,” according to a recent sur
394 ■ JADA, Vol. 103, September 1981
vey conducted by the Federal Drug Administration. The Bureau of R ad io lo gical Health also has worked with the states to develop a program called Dental Exposure Normalization Technique (DENT). The DENT pro gram provides a means of identify ing dental X-ray facilities where pa tient exposure exceeds the normal range, and for correcting the situa tion through consultation and edu cation. Under DENT, a panel of dentists established a range of exposures that would produce acceptable ra diographs at various settings. Pilot studies in cooperation with the state radiation agencies in Rhode Is land and New Hampshire showed that, of all the known dental X-ray machines in the two states, 46% ex ceeded the upper lim its of the DENT exposure ranges. After state personnel visited the dental offices to demonstrate X-ray procedures, the average exposure was a fifth of the former value with diagnostic quality of films main tained or improved. The DENT program can be adopted by radiation control agen cies that actively and routinely conduct compliance surveys, ac cording to the NCHCT report. The DENT program also can be used by radiation control agencies with minimal or nonexistent dental radiological health programs, the report added. Copies of An Overview of Dental Radiology, prepared by the Na tional Center for Health Care Tech nology and the Bureau of Ra diological Health, are available from NCHCT, 5600 Fishers Lane, Rockville, Md 20857.
vices in the healing arts to the public is $6 billion. It is estimated by the Bureau of Radiological Health that approxi mately 30% of the exposure to radia tion is unnecessary,” he said. The recent passage of Senator Ran dolph’s bill will not necessarily curtail debate on the subject of unnecessary exposure to radiation. And the concept that the bill is a “paper tiger” because it does not impose sanctions for com pliance and exempts dental schools and practitioners is misleading. If the Congress is unimpressed with the vol untary efforts of the states and the pro fessional community to regulate the use of low-level ion radiation, the law could be strengthened.
PROFESSION’S REACTION Many of the studies cited by Senator Randolph are based only on “informed opinion,” according to Dr. Mario V. Santangelo, assistant secretary of the ADA Council on Dental Education and the Commission on Dental Accredita tion. He notes, however, that “in view of the nationwide perceptions, there is little reason to wonder why the United States Congress and several state legis latures began to ask very pointed ques tions about the alleged overuse, mis use, and abuse of ionizing radiation by health professions.” During the past two years, the ADA, the A ADS, and the American Dental Hygienists’ Association (ADHA) have testified against proposed radiation legislation before several US Congres sional committees. In joint testimony in 1980, the three associations said they agreed with the intent of the legislation but opposed the mechanisms suggested for correct ing the perceived problems. Specif ically. they objected to the federal gov ernment becoming involved in matters of education, including the accredit ing, licensing, and credentialing pro cesses. The associations contended that, as one of the major health professions, the dental profession is not only en trusted with the responsibility but also
the obligation of safeguarding and pro tecting the well-being of the public it serves. “ Federal regulation or legislation should not be the necessary motivat ing force for the educational commu nity or the profession to protect the safety and health of the public,” Dr. Santangelo said. Dr. Brown told a House subcommit tee that “all segments of the dental pro fession are cognizant of and share the Congress’ and public’s concern about the use of any unnecessary ionizing radiation by the health professions, in cluding dentists and dental auxiliary personnel.” “ (We) likewise recognize that the (dental profession) has not only the re sponsibility, but also the obligation, for preparing all graduates—whether they be dentists, dental hygienists, or dental assistants— competently in all
aspects of radiology, including the po tential hazards to patient and user. Faculty at educational associations are not only committed to educating and training students in the judicious use of ionizing radiation, but also are equally committed to ensuring against its abuse,” he said. Dr. Brown emphasized the impor tance of radiographic examinations for diagnostic and treatment planning purposes in dentistry. He added that the ADA, ADHA, and AADS believe that “formal and continuing education are key factors in assuring that an indi vidual is and remains competent in the use of X radiation.” “Our associations believe further that through such education in d i viduals can be made to recognize the need to reduce or to eliminate unnec essary radiation in light of the poten tial harmful effects on low-level ioniz
ing radiation to both patient and operator,” he said. EDUCATIONAL ACTIVITIES In the past two years, the Council on Dental Education, Commission on Dental Accreditation, and AADS have strengthened efforts encouraging den tal educators to review their cur riculum in the area of dental radiology. The three groups have devoted con siderable time to addressing radiation issues in view of recent Congressional activities to establish criteria and guidelines for accrediting programs for the users of X-ray equipment and for developing credentialing or licen sure mechanisms for all personnel ex posing patients to ionizing radiation. Since 1979, the Commission, during accreditation site visits, has placed added emphasis on the teaching of ra-
A D A updates guidelines on dental radiography The American Dental Association, through its Council on Dental Mate rials, Instruments, and Equipment, h as is s u e d u p d a te d r e c o m mendations intended to promote the safety and effectiveness of diag nostic radiography. A complete text of the recom mendations appeared in the July issue of The Journal of the Ameri can Dental Association. The rec ommendations are in agreement with those of other groups in the area of radiation hygiene and prac tice. The recommendations are not new. They simply restate the Asso ciation’s position on use of dental radiology, a position that has been c o n s is te n t w it h th e r e c o m mendations for almost 20 years. The Council recommends that dentists “ use professional judg ment to determine the type, fre quency, and extent of each ra
diographic examination. The Asso ciation has consistently stated that X radiation for diagnostic purposes should be used only after clinical examination and careful considera tion of both the dental and the gen eral health needs of the patient. The deciding factor is the total welfare of the patient.” “The nature and extent of diag nosis for required patient care, rather than the concept of routine use of X rays as a part of periodic examinations of all patients, consti tute the only rational basis for determing the need, the type, and the frequency of radiographic examina tion. No preferred numerical fre quency can be expressed. It is im portant to recognize that as each pa tient is different from the next, so should radiographic examination be individualized for each patient,” according to the recommendations. The Council “does not agree with
a routine requirement of postopera tive radiographs to show proof of service rendered. Diagnostic ra diography should be lim ited to those instances in which the dentist anticipates the information is likely to contribute materially to proper diagnosis, treatment, and preven tion of disease, or all of these.” The Council recommendations also include guidelines for receptor selection, collimation, beam qual ity. leaded aprons and collars, re ceptor holders, operator protection, exposure and processing, quality assurance, image viewing. and con tinuing education. More comprehensive informa tion on dental radiology is con tained in the Dentist’s Desk Re ference: Materials, Instruments, and Equipment. Copies of this pub lication can be obtained from the American Dental Association, 211 E Chicago Ave, Chicago 60611.
DENTAL RADIOLOGY : SELF-REGULATION VS GOVERNMENT INTERVENTION « 3 9 5
diology. The Commission believes that formal education and training in dental radiology are the key factors in assuring that dental and dental auxil iary graduates are competent in the judicious use of ionizing radiation. A ll programs falling w ithin the Commission’s accreditation purview have been advised that site visit teams will be directing particular attention to radiology instruction and to the clini cal practices, policies and procedures used to control use of ionizing radia tion in providing patient care, said Dr. Santangelo. “The Commission fully expects that the educational process will prepare dentists to eliminate unnecessary use of X rays,” he said. One major cause of needless expo sure to ionizing radiation is the “over prescribing of radiographic proce dures for administrative purposes,” according to Dr. Santangelo. “Administrative dental X-ray exam inations are those that are authorized or required for reasons other than diagnosis and are generally unrelated to specific oral and dental treatment and preventive needs of patients,” he said. The ADA has “consistently opposed the unjustified use of administrative radiographs,” Dr. Santangelo added. “It must be recognized, however, that during the course of treating spe cific dental diseases and conditions, adjunctive radiographs may be essen tial during the process of treatment and are needed for good and accepted c lin ic a l practice. . . . (These) ra diographic examinations must be kept to a minimum, and their use must be based on selection criteria and rea soned professional judgment rather than on an arbitrary time frame,” he said. The American Association of Dental Schools also has developed a policy statement and curriculum guidelines
396 ■ JADA, Vol. 103, September 1981
on radiology (see related story). The guidelines, issued in 1979, include r e c o m m e n d a t io n s on p h y s ic a l facilities, instructional I teaching sup port for clinical activities, institutional obligations to the patient, and institu tional obligations to the student. In June of this year, more than 300 people attended a national conference to discuss the safety, efficacy, and cost-effectiveness of dental radiographic examinations. Sponsored by the National Center for Health Care Technology (NCHCT), the conference reflected the growing concern of the public, the profession, and government over the possible ad verse effects of exposure to low-level ionizing radiation. The US Congress in 1978 estab lished NCHCT to conduct and sponsor assessments of health care tech nologies. The assessments include evaluation not only for safety and effi cacy, but also for the social, ethical, and economic implications. The NCHCT conference considered the publication An Overview of Den tal Radiology, prepared by NCHCT in conjunction with the Bureau of Ra diological Health (BRH), the federal agency responsible for the manage ment of radiological activities. The goal of the conference was to “serve as a basis for planning and conducting future programs to improve the prac tice of dental radiology,” according to John C. Villforth, BRH director. The conference covered a number of topics, including X-ray equipment, quality assurance, selection criteria, bioeffects of ionizing radiation, re search needs, a d m in istra tiv e ra diographs, and instruction in dental radiology provided to dental and den tal auxiliary students. NCHCT con cluded that “with the advent of new technologies and continuing concern over radiation risk and health care costs, it is imperative that unproduc
t iv e r a d i a t i o n e x p o s u r e be minimized.” (See summary of confer ence on page 423.) The role of the personnel who ex pose and process dental radiographs is emphasized in the NCHCT overview, which noted that a “fundamental in fluence is the collective attitude of the dental profession regarding selection of patients for X-ray examinations.” The final recommendations from the June NCHCT conference ultimately w ill “enhance the practitioner’s ability to take care of his patient,” said Dr. Robert A. Goepp, NCHCT conference chairman. “ The conference initial findings place the responsibility of ordering dental radiographs where it can only be— on the practicing dentist. The con ference acknowledged that each pa tient has unique needs and that there is a unique relationship between doctor and patient,” he said, adding that the preliminary recommendations are in great part in agreement with prior ADA policy that a dentist use profes sional judgment based on the indi vidual needs of each patient in order ing dental radiographs. The conference findings are “ re freshing, as they are contrary to the re cent trends of increased regulation in the health care fie ld ,” Dr. Goepp added. “Instead, in this case, the conference supports the reality that only the den tist can determine the indicated need for an X-ray examination. Thus, the dentist can make the procedure fit the patient instead of making the patient fit the procedure, a frequent conse quence of regulation.”
This article was written by Linda Punch, senior editor, ADA News, with legislative material pre pared by Nanci Langley, contributing editor, A D A News.
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self-regulation vs government intervention The efforts of the dental profession and the federal government to ensure the safe use of low-level ionizing radiation in dentistry are discussed.
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ince the use of X rays in dentistry was first introduced in the late 1920s, the dental profession has endeavored to ensure the safe and effective use of dental radiography. Continued pressure from the public, however, has brought government to question the need to regulate the use of X rays in dentistry. In the past 15 years, Congress and the Executive Branch have studied a number of proposals designed to alleviate national con cerns about radiation and its potential hazards. On July 31, 1981, the US Congress approved legislation calling for fed eral standards for accrediting of train ing programs and licensing or credentialing of individuals who operate ra diographic equipment, excluding den tists, physicians, and chiropractors. PROFESSIONAL SELF-REGULATION The concerns expressed by the public and the legislators attempting to regu late dental radiography are shared by the American Dental Association and other professional groups. The ADA,
however, has long supported the con cept that regulation of use of ionizing radiation in dentistry is the responsi bility of the profession, not govern ment. The ADA also has consistently op posed federal government interven tion in accrediting and credentialing activities, saying there is no justifica tion for duplicating activities already being carried out by well-established private and state efforts. The Association cites many exam ples to support its contention that the dental profession is making every ef fort to control the use of ionizing radia tion in dentistry. ■ The ADA has policies regarding radiation equipment and radiation safety for practice. Specific policies also stipulate the need to use profes sional judgment in determining the number and frequency of radiographic examinations to secure necessary diagnostic information. In 1968, the ADA House of Delegates adopted a resolution stating that “Radiographic examination is a diagnostic procedure. The dentist’s professional judgment should determine the frequency and
“It’s the profession’s public responsibility to assure adequate protection of pu b lic health from unnecessary radiation exposure and to assure efficacious patient radiologic services.” Dr. W illia m E. B row n
DENTAL RADIOLOGY : SELF-REGULATION VS GOVERNMENT INTERVENTION ■ 389
extent of each radiographic examina tion.” ■ Ionizing radiation is used exclu sively for diagnostic and research purposes in d e n tis try and, u n lik e medicine, is not used for therapeutic reasons. ■ Significant improvements have been made to reduce ionizing radia tion delivered to patients through use of X-ray equipm ent manufactured under federal guidelines and stan
dards as well as the standards of the Association. Ionizing radiation also has been reduced through the use of filitratio n , co llim ation, open-end cones, electronic timers, lead aprons and thyroid protective collars, filmholding and cone-positioning devices, and rare earth screens. ■ The whole-body marrow dose from dental X-ray sources is very small. Dental radiography procedures contribute only approximately 3% of
the average total adult active bone marrow dose for a year. ■ D ental aux iliarie s u sin g ra diographic equipment function at the direction and under the supervision of dentists. ■ The American Association of Dental Schools (AADS) has adopted strong policies concerning the teach ing of radiology and use of ionizing radiation in dental, dental auxiliary, and dental specialty education.
Schools urged to review use of ionizing radiation In 1979, the American Association of Dental Schools (AADS) officially urged dental educators to review their schools’ procedures to control the use of ionizing radiation and to modify any practices that do not conform to acceptable standards. AAD S recom m endations in clude: ■ Physical facilities. All existing r a d io g r a p h ic e q u ip m e n t and facilities should be upgraded to meet all regulations specified and/or recommended by The Radia tion Control for Health and Safety Act of 1968, NCRP handbook 35 on dental X-ray protection, and the ADA recommendations on accept able radiographic practices. Radiographic facilities should be designed or modified to maximize student I operator / patient protec tion from unnecessary exposure to ionizing radiation. F ilm processing, in c lu d in g time-temperature relationships, should be monitored regularly (pre ferably daily) to assure film quality. ■ Instructional / teaching sup port for clinical activities. Faculty and supporting technical staff should be knowledgeable and skill ful in all radiographic procedures and preferably licensed in the field of dental radiology. S tu d e nts s h o u ld be clearly supervised by faculty or staff dur
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ing all clinical radiographic proce dures conducted on patients. Tech niques to minimize patient expo sure should be emphasized. ■ Institutional obligations to the patient. Patients should not be sub jected to a large number of retakes to satisfy technical perfection rather than clinical acceptability. (A m i n i m a l l y a c c e p t a b le complete-mouth radiographic sur vey should demonstrate, at least one time, each root apex and each interproximal space, without over lapping and with clarity and accu racy.) Students should not serve as live technique mannequins unless some benefit is to be received by taking and interpreting the radiographs. Patients should not be subjected to mass radiographic screening ex aminations before clinical exami nation to determine the need and desirability of specific radiographs to aid in evaluating their accepta bility as clinic patients. Radiographs should be made available to private practitioners or other appropriate professionals when so requested by patients who indicate they no longer desire treatment or care at the institution. Radiographs should be limited to the minim um number needed for a complete diagnostic workup of the patient’s dental needs.
■ Institutional obligations to the student. Students should be taught to assess critically the need for diagnostic radiographic informa tion and to evaluate the risk to the patient before ordering the ra diographs needed to determine the patients oral health needs. Students should be well prepared to assume the challenges of clinical dental radiography and should re ceive appropriate guidance from faculty and staff. T echn ical perfection in ra diographic procedures should be achieved on mannequins. Students should be taught to recognize clini cal situations in which it may be necessary to compromise technical perfection. Students should be allowed to take no more than three retakes on a complete-mouth radiographic sur vey without the direct supervision of faculty or staff. More than three retakes indicate a lack of minimally acceptable skills, and close super vision is justified. Students should be prepared to establish private practices in which adequate concern is given to select ing equipment and following pro cedures that will minimize radia tion to the patient and assure high quality film s for diagnostic in terpretation.
■ The AADS Section of Oral Ra diology, in cooperation w ith the Am erican Academy of Dental Ra diology, recently revised model cur ricular guidelines in radiology for use by educational institutions. ■ Dental radiology is an integral component of all dental and dental auxiliary curriculums. ■ The activities of the ADA Com mission on Dental Accreditation have been intensified in evaluating qualifi cations of faculty, instruction in ra diology, the clinical practices regard ing the control and monitoring of uses of sources emitting ionizing radiation, X-ray equipment and radiography and support facilities, and patient records. The self-regulatory activities of the dental profession were cited by Dr. W illiam E. Brown in testimony before a Congressional subcommittee study ing regulation of dental radiography. Dr. Brown is a member and former
“Federal regulation or leg islation should not be the necessary motivating force for the educational com munity or the profession to protect the safety and health of the public.” Dr. M a rio V. Santangelo
chairman of the ADA Council on Den tal Education and the Commission on Dental Accreditation. Organized dentistry’s efforts in these areas “demonstrate rather con clusively that the dental profession is not only interested in, but has taken positive steps to ensure that the na tion ’s public health and safety are safeguarded. . . . It’s the profession’s p u b lic r e s p o n s ib ility to assure adequate protection of public health from unnecessary radiation exposure and to assure efficacious patient ra diologic services,” Dr. Brown said.
FEDERAL REGULATION Despite the efforts of the dental profes sion, concerns about the alleged lack of regulation of dental radiology still flourish. In recent years, some mem bers of Congress have stepped up ef forts to regulate dental and medical radiology based on several studies and reports suggesting that health profes sionals unnecessarily subject patients to low levels of ionizing radiation. Other legislative initiatives have at tempted to reorganize the manage ment of the nation’s radiation protec tion activities by removing such ac tivities from the Food and Drug Ad ministration Bureau of Radiological Health to the Environmental Protec tion Agency. After the 1979 Three Mile Island in cident, President Jimmy Carter re sponded to public concern about radi ation and issued a presidential order announcing a series of initiatives on low-level ionizing radiation, includ ing establishment of a national advi sory Radiation Policy Council. The presidential council— which is devel oping a series of papers on radiation— is expected to be discontinued this fall. Although Congress has considered a number of radiation bills over the past ten years, the majority of the proposals sought to impose federal standards for the accrediting of training programs and licensing or credentialing of indi viduals who operate radiographic equipment, excluding dentists, physi
cians, and chiropractors. They in clude: ■ 97th Congress (1981-1982). HS 646, sponsored by Sen. Jennings Randolph (D-WVa), and added as an amendment to HR 3982 approved by Congress. HR 2457, identical to S 646, was re ferred to the House commerce health subcommittee. The ADA has opposed HR 2457 in a letter to subcommittee chairman Henry Waxman (D-Calif). ■ 96th Congress (1979-1980). S 8500, sponsored by Senator Ran dolph, was added as an amendment to the health manpower legislation and approved by Congress. However, House-Senate conferees were unable to resolve differences between their re spective health manpower bills and the measure died. HR 6023, HR 6057, and S 2539 were
“The conference supports the reality that only the den tist can determine the indi cated need for an X-ray ex amination. Thus, the dentist can m ake the procedure fit the patien t instead of m ak ing the patien t fit the proce dure.” Dr. Robert A . G oepp
DENTAL RADIOLOGY : SELF-REGULATION VS GOVERNMENT INTERVENTION ■ 391
similar to Senator Randolph’s bill but died in committee. HR 6745 sought to reorganize all governmental agencies responsible for ad m in istering io n iz in g radiation under the Environmental Protection Agency. As of Sept 15, 1980, the ADA had testified three times during the past 14 months in opposition to proposals im posing federal standards and reor g a n iz in g ad m in istra tiv e re sp on sibilities. ■ 95th Congress (1977-1978). S 1695, introduced by Senator Ran dolph, and HR 431, HR 4573, HR 6948, and HR 8691. All bills would have set federal guidelines as under the ap proved 1981 Randolph amendment. ■ 94th Congress (1975-1976). S 1261, sponsored by Senator Ran dolph, HR 559, and HR 12548 again
“In spite of the risk to indi viduals from radiation ex posure and the known ad verse health effects that m ay result, in 39 of our states any individual m ay operate X-ray equipment, regardless of training or qualifications. ” Sen. Jennings R a n d o lp h
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seeking federal standards. ■ 93rd Congress (1973-1974). S 667, sponsored by Senator Ran dolph, and HR 673, HR 1113, and HR 9126 to establish m inim um federal guidelines. S 2724, to establish a federal radia tion prospection agency. HR 672, HR 1526, and H R 9125 to di rect the Secretary of Health, Educa tion, and Welfare to set radiation stan dards for and to conduct regular in-
spections of diagnostic and other X-ray systems. ■ 92nd Congress (1971-1972). S 426, sponsored by Senator Ran dolph. S 3588, to establish an independent agency. Earlier legislation in cluded HR 16920 in the 89th, 1965-1966 Congress that sought to authorize grants to states that agreed to m a in ta in record keeping systems for employees who
A D A ’s history in promoting The American Dental Association has consistently and emphatically sought to ensure the safety of dental X-ray examinations. Since 1966, the ADA has had formal policy on radiation hygiene. Following is a chronological listing of all policies and activities of the Association re lated to radiation hygiene in dental practice: ■ October 1965. The ADA House of Delegates calls for the Council on Dental Research to expand efforts to emphasize the principles of protec tion from unnecessary exposure to ionizing radiation through educa tion of the profession. The House also directs the ADA, through its program for evaluating devices, to encourage and stimulate the search for new materials and techniques which would further reduce expo sure to radiation by reasonable means. ■ February 1968. The ADA Councils on Dental Materials and Devices and Dental Research issue their first set of recommendations on radiation hygiene and practice to the profession. The lead-off rec o m m e n d a tio n states that ra diographic examination is “a diag nostic procedure. The dentist’s pro fessional judgment should deter mine the frequency and extent of each radiographic examination.” ■ October 1968. The ADA House
of Delegate amends Association policy on radiation hygiene to read “ Radiographic examination is a diagnostic procedure. The dentist’s professional judgment should determine the frequency and extent of each radiographic examination.” ■ May 1972. The Council on Dental Materials and Devices re peats in The Journal of the Ameri can Dental Association its recom mendations on radiographic prac tices first published in 1968. a November 1972. The ADA H o u s e of D e le g a te s a d o p ts “Guidelines on Use of Radiographs in Dental Care Programs” which stipulate that the use of radiographs should only be for determining the extent of liability of the program and in no case should infringe on the professional judgment of the dentist or the dentist-patient rela tionship. ■ November 1974. The ADA House of Delegates adopts policy on a d m in is tr a tiv e use of radiographs indicating that a diag nosis and treatment plan cannot be made from radiographs alone. The policy also stipulates that benefits shall not be determined solely on the basis of radiographic evidence. ■ November 1974. The ADA House of Delegates amends the “Guidelines on Use of Radiographs in Dental Care Programs” to indi-
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are or may be exposed to ionizing radi ation, and HR 1267 in the 87th, 19611962 Congress to establish a work m e n ’s com pensation program for people handling radiology equipment. Such legislation has failed to be enacted until the recent passage of HR982, the 1981 Omnibus Reconcilia tion Act, w hich included such an amendment sponsored by Senator Randolph. However, an important difference in
this proposal, now public law, is that there are no provisions to impose any penalties or conditions on the states which do not comply with its require ments. The law requires the Secretary of Health and Human Services, “in con sultation with specified federal and state agencies an d pro fessio n al societies,” such as the ADA, to estab lish m inim um federal standards for 1J the accreditation of educational pro
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cate that the “Association is op posed to any third party’s policy or attempts to require a mandatory submission of radiographs in every case or on a blanket, automatic basis.” New guidelines adopted in 1976 reiterate the ADA position on m an d a to ry s u b m is s io n of ra diographs. ■ January 1975. The Council on Dental Materials and Devices pub lishes an updated version of its 1968 recom m endations on radiographic practices. The update reiterates diagnostic need for ra diographic examination of the pa tient and that the frequency and ex tent of each X ray depend on the dentist’s professional judgment. ■ March 1978. The Council on Dental Materials and Devices issues an upd ated version of recom mendations on radiographic prac tices reiterating that both the dental and general health needs of a pa tient must be considered before taking diagnostic X rays. ■ May 1980. The ADA Commis sion on D ental A c c re d ita tio n adopts standards for training dental assistants and dental hygienists in radiographic procedures. The standards became effective Jan 1, 1981. m October 1980. The ADA House of Delegates adopts a resolution supporting the principle that den tists who choose to delegate the task
of exposing radiographic films should delegate the function to per sonnel who have had sufficient training in quality and safety of such procedures. The resolution states that the Association “sup ports the principle that dentists delegate the responsibility of ex posing radiographic film only to dental assistants who have had adequate formal education in such procedures. . . . Qualifications for the exposure of radiographic films by dental assistants should be de termined and evaluated on a state level.” In forwarding the resolution to the House, the ADA Council on Dental Education notes that it be lieves the profession is responsive to the need for adequate training of all dental assistants who use ioniz ing radiation. The Council also said it believes there is a need to estab lish m inim um qualifications for dental assistants who expose ra diographic film and that the re sponsibility for determining and evaluating these qualifications should rest with the states. ■ July 1981. The Council on Den tal Materials, Instruments, and Equipment issues an updated ver sion of recommendations on ra diographic practices. The update appears inThe Journal of theAmerican Dental Association.
grams to train individuals performing X-ray procedures, excluding dental and medical schools, and 2) the certifi cation of persons, other than dentists, physicians, and chiropractors, who administer radiographic procedures. The Secretary also is required to provide a m odel state law for ra diographic procedure safety, and to write guidelines for the safe and effec tive use of radiation— to minimize un necessary exposure. Because there are no penalties for noncompliance with the regulations, the legislation is based on the assump tion that the states will comply within the specified three-year period. In introducing the measure earlier this year, Senator Randolph acknowl edged the benefits of radiologic ser vices in the diagnosis and treatment of injuries and illness. He said, however, that “there is evidence that current procedures result in a greater risk to consumer patients than is necessary.” “In spite of the risk to individuals from rad iation exposure and the known adverse health effects that may result, in 39 of our states any in d i vidual may operate X-ray equipment, regardless of training or qualifications. Of the estimated 130,000 to 170,000 persons who operate the n a tio n ’s 250,000 pieces of medical (and dental) X-ray equipment, only 85,000 have demonstrated their competence in voluntary certification or state licens ing examinations. Seventy-five per cent of all nonhospital radiological procedures in the United States are performed by noncredentialed ra diologists,” he said. “Medical and dental sources of radi ation currently account for over 90% of all hum an exposures to manmade ionizing radiation. By contrast, the normal operation of nuclear power plants accounts for less than 1% of the consumer’s exposure to ionizing radi ation,” he said. Health care costs also would be cut through better regulation of low-level ionizing radiation, Senator Randolph added. “The annual cost of radiation ser-
DENTAL RADIOLOGY : SELF-REGULATION VS GOVERNMENT INTERVENTION ■ 393
State regulation of radiology Most states now have active regula tory programs for the registration and inspection of X-ray equipment, according to the National Center for Health Care Technology (NCHCT). In conjunction with federal per formance standards, “ these pro grams have been instrumental in correcting equipment-related radi ation exposure problems. In the past, significant exposure reduc tions were achieved through atten tion to such factors as beam filtra tion. collimation, and timer accu racy," according to the NCHCT re port, An Overview of Dental Ra diology. A 1977 US Department of Health, E ducation, and Welfare report found that 38 states had regulatory programs for dental I medical X-ray activities, five states had voluntary activities, and eight states com bined regulatory and voluntary programs. A lthough the number of m a chines increased between 1975 and 1977, the number of inspections decreased slightly, NCHCT said. Of the estimated 145,000 dental X-ray machines in the United States in 1977, 92.6% were registered with state agencies. The 24,833 inspections con ducted represented 17.2% of the total estimated number of machines reported. Of the estimated 82,123 facilities, 5% were not in com pliance with state regulations. Suggested state regulations for control of radiation have been pub lished and revised since 1962. Ap proximately 40 states have adopted the 1970 or 1974 revisions or were intending to adopt the 1978 revi sions of Part F, “X Rays in the Heal ing Arts,” according to a recent sur
394 ■ JADA, Vol. 103, September 1981
vey conducted by the Federal Drug Administration. The Bureau of R ad io lo gical Health also has worked with the states to develop a program called Dental Exposure Normalization Technique (DENT). The DENT pro gram provides a means of identify ing dental X-ray facilities where pa tient exposure exceeds the normal range, and for correcting the situa tion through consultation and edu cation. Under DENT, a panel of dentists established a range of exposures that would produce acceptable ra diographs at various settings. Pilot studies in cooperation with the state radiation agencies in Rhode Is land and New Hampshire showed that, of all the known dental X-ray machines in the two states, 46% ex ceeded the upper lim its of the DENT exposure ranges. After state personnel visited the dental offices to demonstrate X-ray procedures, the average exposure was a fifth of the former value with diagnostic quality of films main tained or improved. The DENT program can be adopted by radiation control agen cies that actively and routinely conduct compliance surveys, ac cording to the NCHCT report. The DENT program also can be used by radiation control agencies with minimal or nonexistent dental radiological health programs, the report added. Copies of An Overview of Dental Radiology, prepared by the Na tional Center for Health Care Tech nology and the Bureau of Ra diological Health, are available from NCHCT, 5600 Fishers Lane, Rockville, Md 20857.
vices in the healing arts to the public is $6 billion. It is estimated by the Bureau of Radiological Health that approxi mately 30% of the exposure to radia tion is unnecessary,” he said. The recent passage of Senator Ran dolph’s bill will not necessarily curtail debate on the subject of unnecessary exposure to radiation. And the concept that the bill is a “paper tiger” because it does not impose sanctions for com pliance and exempts dental schools and practitioners is misleading. If the Congress is unimpressed with the vol untary efforts of the states and the pro fessional community to regulate the use of low-level ion radiation, the law could be strengthened.
PROFESSION’S REACTION Many of the studies cited by Senator Randolph are based only on “informed opinion,” according to Dr. Mario V. Santangelo, assistant secretary of the ADA Council on Dental Education and the Commission on Dental Accredita tion. He notes, however, that “in view of the nationwide perceptions, there is little reason to wonder why the United States Congress and several state legis latures began to ask very pointed ques tions about the alleged overuse, mis use, and abuse of ionizing radiation by health professions.” During the past two years, the ADA, the A ADS, and the American Dental Hygienists’ Association (ADHA) have testified against proposed radiation legislation before several US Congres sional committees. In joint testimony in 1980, the three associations said they agreed with the intent of the legislation but opposed the mechanisms suggested for correct ing the perceived problems. Specif ically. they objected to the federal gov ernment becoming involved in matters of education, including the accredit ing, licensing, and credentialing pro cesses. The associations contended that, as one of the major health professions, the dental profession is not only en trusted with the responsibility but also
the obligation of safeguarding and pro tecting the well-being of the public it serves. “ Federal regulation or legislation should not be the necessary motivat ing force for the educational commu nity or the profession to protect the safety and health of the public,” Dr. Santangelo said. Dr. Brown told a House subcommit tee that “all segments of the dental pro fession are cognizant of and share the Congress’ and public’s concern about the use of any unnecessary ionizing radiation by the health professions, in cluding dentists and dental auxiliary personnel.” “ (We) likewise recognize that the (dental profession) has not only the re sponsibility, but also the obligation, for preparing all graduates—whether they be dentists, dental hygienists, or dental assistants— competently in all
aspects of radiology, including the po tential hazards to patient and user. Faculty at educational associations are not only committed to educating and training students in the judicious use of ionizing radiation, but also are equally committed to ensuring against its abuse,” he said. Dr. Brown emphasized the impor tance of radiographic examinations for diagnostic and treatment planning purposes in dentistry. He added that the ADA, ADHA, and AADS believe that “formal and continuing education are key factors in assuring that an indi vidual is and remains competent in the use of X radiation.” “Our associations believe further that through such education in d i viduals can be made to recognize the need to reduce or to eliminate unnec essary radiation in light of the poten tial harmful effects on low-level ioniz
ing radiation to both patient and operator,” he said. EDUCATIONAL ACTIVITIES In the past two years, the Council on Dental Education, Commission on Dental Accreditation, and AADS have strengthened efforts encouraging den tal educators to review their cur riculum in the area of dental radiology. The three groups have devoted con siderable time to addressing radiation issues in view of recent Congressional activities to establish criteria and guidelines for accrediting programs for the users of X-ray equipment and for developing credentialing or licen sure mechanisms for all personnel ex posing patients to ionizing radiation. Since 1979, the Commission, during accreditation site visits, has placed added emphasis on the teaching of ra-
A D A updates guidelines on dental radiography The American Dental Association, through its Council on Dental Mate rials, Instruments, and Equipment, h as is s u e d u p d a te d r e c o m mendations intended to promote the safety and effectiveness of diag nostic radiography. A complete text of the recom mendations appeared in the July issue of The Journal of the Ameri can Dental Association. The rec ommendations are in agreement with those of other groups in the area of radiation hygiene and prac tice. The recommendations are not new. They simply restate the Asso ciation’s position on use of dental radiology, a position that has been c o n s is te n t w it h th e r e c o m mendations for almost 20 years. The Council recommends that dentists “ use professional judg ment to determine the type, fre quency, and extent of each ra
diographic examination. The Asso ciation has consistently stated that X radiation for diagnostic purposes should be used only after clinical examination and careful considera tion of both the dental and the gen eral health needs of the patient. The deciding factor is the total welfare of the patient.” “The nature and extent of diag nosis for required patient care, rather than the concept of routine use of X rays as a part of periodic examinations of all patients, consti tute the only rational basis for determing the need, the type, and the frequency of radiographic examina tion. No preferred numerical fre quency can be expressed. It is im portant to recognize that as each pa tient is different from the next, so should radiographic examination be individualized for each patient,” according to the recommendations. The Council “does not agree with
a routine requirement of postopera tive radiographs to show proof of service rendered. Diagnostic ra diography should be lim ited to those instances in which the dentist anticipates the information is likely to contribute materially to proper diagnosis, treatment, and preven tion of disease, or all of these.” The Council recommendations also include guidelines for receptor selection, collimation, beam qual ity. leaded aprons and collars, re ceptor holders, operator protection, exposure and processing, quality assurance, image viewing. and con tinuing education. More comprehensive informa tion on dental radiology is con tained in the Dentist’s Desk Re ference: Materials, Instruments, and Equipment. Copies of this pub lication can be obtained from the American Dental Association, 211 E Chicago Ave, Chicago 60611.
DENTAL RADIOLOGY : SELF-REGULATION VS GOVERNMENT INTERVENTION « 3 9 5
diology. The Commission believes that formal education and training in dental radiology are the key factors in assuring that dental and dental auxil iary graduates are competent in the judicious use of ionizing radiation. A ll programs falling w ithin the Commission’s accreditation purview have been advised that site visit teams will be directing particular attention to radiology instruction and to the clini cal practices, policies and procedures used to control use of ionizing radia tion in providing patient care, said Dr. Santangelo. “The Commission fully expects that the educational process will prepare dentists to eliminate unnecessary use of X rays,” he said. One major cause of needless expo sure to ionizing radiation is the “over prescribing of radiographic proce dures for administrative purposes,” according to Dr. Santangelo. “Administrative dental X-ray exam inations are those that are authorized or required for reasons other than diagnosis and are generally unrelated to specific oral and dental treatment and preventive needs of patients,” he said. The ADA has “consistently opposed the unjustified use of administrative radiographs,” Dr. Santangelo added. “It must be recognized, however, that during the course of treating spe cific dental diseases and conditions, adjunctive radiographs may be essen tial during the process of treatment and are needed for good and accepted c lin ic a l practice. . . . (These) ra diographic examinations must be kept to a minimum, and their use must be based on selection criteria and rea soned professional judgment rather than on an arbitrary time frame,” he said. The American Association of Dental Schools also has developed a policy statement and curriculum guidelines
396 ■ JADA, Vol. 103, September 1981
on radiology (see related story). The guidelines, issued in 1979, include r e c o m m e n d a t io n s on p h y s ic a l facilities, instructional I teaching sup port for clinical activities, institutional obligations to the patient, and institu tional obligations to the student. In June of this year, more than 300 people attended a national conference to discuss the safety, efficacy, and cost-effectiveness of dental radiographic examinations. Sponsored by the National Center for Health Care Technology (NCHCT), the conference reflected the growing concern of the public, the profession, and government over the possible ad verse effects of exposure to low-level ionizing radiation. The US Congress in 1978 estab lished NCHCT to conduct and sponsor assessments of health care tech nologies. The assessments include evaluation not only for safety and effi cacy, but also for the social, ethical, and economic implications. The NCHCT conference considered the publication An Overview of Den tal Radiology, prepared by NCHCT in conjunction with the Bureau of Ra diological Health (BRH), the federal agency responsible for the manage ment of radiological activities. The goal of the conference was to “serve as a basis for planning and conducting future programs to improve the prac tice of dental radiology,” according to John C. Villforth, BRH director. The conference covered a number of topics, including X-ray equipment, quality assurance, selection criteria, bioeffects of ionizing radiation, re search needs, a d m in istra tiv e ra diographs, and instruction in dental radiology provided to dental and den tal auxiliary students. NCHCT con cluded that “with the advent of new technologies and continuing concern over radiation risk and health care costs, it is imperative that unproduc
t iv e r a d i a t i o n e x p o s u r e be minimized.” (See summary of confer ence on page 423.) The role of the personnel who ex pose and process dental radiographs is emphasized in the NCHCT overview, which noted that a “fundamental in fluence is the collective attitude of the dental profession regarding selection of patients for X-ray examinations.” The final recommendations from the June NCHCT conference ultimately w ill “enhance the practitioner’s ability to take care of his patient,” said Dr. Robert A. Goepp, NCHCT conference chairman. “ The conference initial findings place the responsibility of ordering dental radiographs where it can only be— on the practicing dentist. The con ference acknowledged that each pa tient has unique needs and that there is a unique relationship between doctor and patient,” he said, adding that the preliminary recommendations are in great part in agreement with prior ADA policy that a dentist use profes sional judgment based on the indi vidual needs of each patient in order ing dental radiographs. The conference findings are “ re freshing, as they are contrary to the re cent trends of increased regulation in the health care fie ld ,” Dr. Goepp added. “Instead, in this case, the conference supports the reality that only the den tist can determine the indicated need for an X-ray examination. Thus, the dentist can make the procedure fit the patient instead of making the patient fit the procedure, a frequent conse quence of regulation.”
This article was written by Linda Punch, senior editor, ADA News, with legislative material pre pared by Nanci Langley, contributing editor, A D A News.