Vol. 89 No.

3 March 2000

ORAL SURGERY
ORAL MEDICINE
ORAL PATHOLOGY

ORAL AND MAXILLOFACIAL RADIOLOGY Editor: Sharon L. Brooks

Updated quality assurance self-assessment exercise in intraoral

and panoramic radiography
American Academy of Oral and Maxillofacial Radiology, Radiology Practice Committee
Arthur D. Goren, DMD,a R. Curtis Lundeen, DDS, MS,b S. Thomas Deahl II, DMD,c
Koji Hashimoto, DDS,d Stanley F. Kapa, DMD, MS,e Jerald O. Katz, DMD, MS,f
John B. Ludlow, DDS, MS,g Enrique Platin, MS, ED DRT(R)(QM),h Paul F. Van Der Stelt,
DDS, PhD,i and Lawrence Wolfgang, DDS,j Stony Brook, NY
SUNY STONY BROOK

This updated self-assessment exercise for the dental team by the Radiology Practice Committee of the American
Academy of Oral and Maxillofacial Radiology is intended to produce the highest quality diagnostic radiographs while keeping
patient exposure as low as is reasonably achievable. To continue to provide the best radiographic services to patients, those
involved in dental radiography need to be aware of the latest changes and advances in dental radiography and need to use
them in their practice. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:369-74)

In 1993, the Quality Assurance Committee of the for the dental team.1 The exercise was introduced as
American Academy of Oral and Maxillofacial Radio- part of a campaign to encourage the use of E-speed
logy (AAOMR) published a self-assessment exercise film, rectangular collimation, and quality assurance in
dental radiography. Although articles in various publi-
aAssistant clinical professor, General Dentistry, School of Dental cations by the AAOMR,2 the National Council on
Medicine, State University of New York at Stony Brook.
bAssociate professor, Division of Oral Radiology, School of Radiation Protection and Measurements,3 and the
Dentistry, Oregon Health Sciences University, Portland. American Dental Association4 have given specific
cAssociate professor, Department of Dental Diagnostic Sciences, recommendations for dental radiographic procedures,
University of Texas Health Science Center at San Antonio, and the dental profession has been rather lax in universally
chairman Radiology Practices Committee, American Academy of accepting these recommendations. The suggestions
Oral and Maxillofacial Radiology.
dAssociate professor, Department of Radiology, Nihon University that follow are intended to produce the highest quality
School of Dentistry, Tokyo. diagnostic radiographs while keeping patient exposure
eDiplomate of the American Board of Oral and Maxillofacial as low as reasonably achievable (ALARA). This exer-
Radiology. cise will assist all personnel involved in exposing
fAssociate professor, Department of Diagnostic Sciences, School of
dental radiographs, including dentists and allied dental
Dentistry, University of Missouri at Kansas City.
gAssociate professor, Department of Diagnostic Sciences and health professionals.
General Dentistry, University of North Carolina School of Dentistry,
Chapel Hill. DOSE REDUCTION AND TECHNIQUE
hClinical associate professor, Department of Diagnostic Sciences and
A. Is E-speed film used to minimize radiation?
General Dentistry, University of North Carolina School of Dentistry, Yes: Proper technique
Chapel Hill.
iProfessor, Oral and Maxillofacial Radiology, Academic Center for No: Needs improvement
Dentistry, Amsterdam. Previously, there had been complaints of decreased
jClinical associate professor, Department of Oral Diagnostic Services, contrast and increased fog, film graininess, and
School of Dental Medicine, State University of New York at Buffalo. processing sensitivity with the original E-speed film,
Received for publication Sept 21, 1999; returned for revision Oct 5, called Ektaspeed (Eastman Kodak, Rochester, NY),
1999; accepted for publication Nov 7, 1999.
Copyright © 2000 by Mosby, Inc.
which prompted its removal from the market and
1079-2104/2000/$12.00 + 0 7/16/104542 replacement with Ektaspeed Plus film. Ektaspeed Plus
doi:10.1067/moe.2000.104542 film reduces patient exposure by a factor of 2 when

369
370 Goren et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
March 2000

compared with the Ultra-speed (D-speed) film, yet mation in Appendix 2.) Current selection criteria for
retains characteristics similar to the Ultra-speed film.5 prescribing radiographs suggest that routine semiannual
B. Is rectangular collimation used to restrict the or annual radiographs may expose patients to unneces-
beam to the size of periapical and bitewing films so sary radiation. The frequency of x-ray examinations
that the radiation dose to the patient is minimized? should be based on history, clinical examination, and
Yes: Proper technique other factors, such as risk of caries development.
No: Needs improvement F. For intraoral radiography, is the long cone
The use of rectangular collimation results in a reduc- paralleling technique used with a shielded, open-
tion to only 1⁄4 to 1⁄3 of the absorbed dose when ended, position-indicating device (PID, cone), and
compared with use of a round cylinder alone.4 An an appropriate film-holding device?
added benefit of rectangular collimators is the contrast Yes: Proper technique
improvement resulting from reduction of fogging from No: Needs improvement
secondary and scattered radiation. The long FFD (focus film distance) provides a source
C. Are radiographs that were taken at other to cone-end distance of at least 12 inches and produces
offices requested before taking new radiographs, a sharper image than what is obtained with the short (8-
and can a second copy of the radiographs be inch) FFD. The paralleling technique generally distorts
provided to requesting parties? radiographic images less and results in fewer retakes
Yes: Proper technique than does the bisecting angle technique.7 To minimize
No: Needs improvement scatter radiation, the PID should have a lead lining or
The availability, age, and quality of previous radio- be made of lead-containing plastic and should be open
graphs from other offices should be considered in at the patient end. The old pointed plastic cones should
determining the need for additional radiographs. never be used. Film-holding devices should be used
Double film packets are the best method for ensuring routinely to stabilize film placement, minimize distor-
that a second copy of a radiograph is available, but a tion, and prevent unnecessary exposure of the x-rays to
film-duplicating machine and duplicating film can also the patient’s hands. A device that provides rectangular
be used to produce additional copies. To avoid loss of collimation or allows the use of a rectangularly shaped
sharpness, the originals should be taken out of the PID should be selected.
mounts and placed in direct contact with the dupli- G. Is a leaded apron and thyroid collar used for
cating film. Care must be taken to ensure that the densi- patients during intraoral radiographic procedures?
ties are the same as the original. The duplicates must be Yes: Proper technique
identified with the patient’s name, date the originals No: Needs improvement
were taken, and “right” and “left” sides. A leaded apron and thyroid collar help to protect
D. Are rare-earth screens used for panoramic or radiosensitive tissues, and their use indicates concern
other extraoral radiographs? for the patient’s well-being. For panoramic radiog-
Yes: Proper technique raphy, use of a poncho apron that covers the front and
No: Needs improvement back of the patient is best. A leaded apron should not
All old calcium tungstate screens should be replaced be used if it might interfere with the production of the
with rare-earth screens, and the proper film must be panoramic image.8 Although leaded aprons are no
ordered to match the new screens. A screen/film longer used in Europe because they do not reduce the
system rated 200 speed or higher is recommended for already low gonadal dose, they continue to be used in
most extraoral radiography. A panoramic filter kit is the United States for legal reasons.9-12
available from Eastman Kodak to lower output for H. Is a kilovolt (peak) (kV[p]) setting of between
older equipment that cannot be adjusted easily. (See 60 and 70 used on my x-ray machine?
ordering information in Appendix 2.) Yes: Proper technique
E. Is the chart entitled “Guidelines for Prescrib- No: Needs improvement
ing Dental Radiographs” used as a patient selection A setting below 60 kV(p) results in a higher absorbed
criterion for prescribing radiographs? dose than desired. Direct current machines are now
Yes: Proper technique available that are safe to operate at a lower setting (60)
No: Needs improvement because of the more monochromatic x-ray spectrum.
The guidelines, developed by the Food and Drug There should be no need to exceed a setting of 90 kV(p).
Administration6 and endorsed by the American Dental A setting above 90 kV(p) will increase the patient dose.
Association,4 can be obtained without cost from Optimal settings are between 60 and 70 kV(p).
Eastman Kodak in the “Publication Guidelines for I. Is a technique chart posted near each x-ray
Prescribing Dental Radiographs.” (See ordering infor- machine that shows varying exposure times, mA, or
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Goren et al 371
Volume 89, Number 3

kV(p) settings for patients of differing size and Film should be protected in the original boxes until
different areas of the mouth? used. Film should not be stored in a refrigerator
Yes: Proper technique because of the presence of small quantities of radioac-
No: Needs improvement tive material that are present in insulating materials,14
One setting does not produce adequate images of all which can lead to high fog levels. The operatory is not
patients or all areas of the mouth. A chart of rational, a good location for storage because of the possibility of
predetermined exposure values should be posted for all scattered radiation. Do not stock up on film; instead,
operators to use. Although machines and individual calculate film use and order accordingly. Check the
preferences vary, the proper exposure settings can be expiration date on the box before use.
determined by consulting the machine instruction N. Are the intensifying screens cleaned regularly
manual and by using a step-wedge or other exposure and cassettes and screens checked regularly for
phantom to determine appropriate exposure ranges for damage or discoloration (yellowing)?
optimum film density. Yes: Proper technique
J. Does the office design provide adequate No: Needs improvement
barrier protection? Screens should be checked frequently for damage
Yes: Proper technique and cleaned monthly with a screen cleaner, followed by
No: Needs improvement an antistatic solution. Do not use a regular detergent or
Patients and office staff in areas adjacent to the site a polishing detergent. Cassettes with light leaks or
of an x-ray machine should be protected from radia- other signs of wear and screens with cracking or yellow
tion. “Dental X-ray Protection” (NCRP Report No. discolorations should be replaced.
35), published by the National Council on Radiation
Protection and Measurements, contains specifications PROCESSING
on appropriate barrier materials and thicknesses.13 The O. Are a thermometer and timer always used
state radiation control agency should be helpful in when developing films manually, and are the manu-
determining whether current barriers meet minimum facturer’s instructions followed?
standards. Yes: Proper technique
No: Needs improvement
MACHINES AND EQUIPMENT Films that are not processed adequately lack diag-
K. Are x-ray machines inspected once a year or nostic information, and patients may require retakes,
as required by the state radiation control agency? resulting in overexposure to the patients. In addition,
Yes: Proper technique patients may be receiving too much radiation to
No: Needs improvement produce an adequate image if the proper developing
Qualified state inspectors indicate whether machines time and temperature are not used.
and practices meet minimum standards of state codes P. Are the manufacturer’s instructions followed
and may uncover potentially dangerous conditions or for the replenishment of solutions in manual tanks
malfunctions. and in automatic processors?
L. Does the x-ray machine have the proper Yes: Proper technique
amount of filtration? No: Needs improvement
Yes: Proper technique Solutions wear out through use, as well as through
No: Needs improvement disuse, and need daily replenishing to maintain the
Federal and state regulations dictate a proper amount proper concentration. Replenishment helps maintain
of filtration. By federal regulation, all machines manu- the optimum chemistry level to produce quality
factured after July 1974 that are capable of operating images. Follow guidelines according to the manufac-
from 50 to 70 kV(p) must have the equivalent of 1.5 turer’s specifications.
mm of aluminum; above 70 kV(p), 2.5-mm aluminum Q. Is a system in place to check the solutions for
equivalent. All machines (especially older machines) adequate strength?
should be checked for proper filtration. Inadequate Yes: Proper technique
filtration results in unnecessarily high doses of radia- No: Needs improvement
tion to patients. A sophisticated system (sensitometer-densitometer)
M. Are films stored properly, in a cool place away or a simple system (aluminum step-wedge or Dental
from radiation and chemical fumes, and used before Radiographic Quality Control Device; see ordering
the expiration date? information in Appendix 2) will indicate when solu-
Yes: Proper technique tions need to be changed. The dates of solution changes
No: Needs improvement should be posted in the darkroom.
372 Goren et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
March 2000

R. Is the darkroom checked monthly for light The American Academy of Oral and Maxillofacial
leaks and proper use of the darkroom safelight? Radiology has published infection control guidelines
Yes: Proper technique for dental radiology.15
No: Needs improvement
Checking for light leaks around doors and light fixtures INTERPRETATION
and performing the “penny test” once a month will detect W. Are the surfaces of the viewboxes cleaned
sources of fog in films. The penny test is performed by regularly and the fluorescent tubes changed when
placing a penny on a pre-exposed film (use enough expo- needed?
sure to impart just a low density on the film), leaving the Yes: Proper technique
penny for 2 minutes and then processing the film. If an No: Needs improvement
image of the penny is observed after the film is High-quality radiographs must be viewed on a clean
processed, the source of the fogging must be determined surface. Fluorescent tubes should be replaced when the
and eliminated. A dark red filter (Kodak GBX-2 or equiv- ends blacken, not when they stop functioning, and all
alent) is needed. Even with the correct filter, the safelight tubes in a particular viewbox should be replaced at the
must be mounted at least 4 feet from open films and must same time.
never have a bulb greater than 15 W. X. Are radiographs viewed in a quiet, darkened
S. Has the daylight loader of my automatic room, with unused portions of the viewbox and
processor been checked for proper safelight unused spaces in the opaque film mount covered,
conditions? so that light reaches the eyes only through the
Yes: Proper technique radiographs?
No: Needs improvement Yes: Proper technique
A daylight loader in a normally lit room is a potential No: Needs improvement
source of fogging. An amber filter is inadequate for E- Subtle details in radiographs are best observed in a
speed and panoramic films and can fog film in as little as room that is free of distraction and extraneous light
5 seconds; a dark red (ruby) filter should be used. Check sources. Use of a variable intensity viewbox or
for light leaks, especially worn wrist cuffs, and try to “hotlight” (high-intensity lamp with rheostat) and a
place the processor away from direct overhead lighting magnifying glass also may be helpful.
(the darkroom remains the best place). To test the safe-
light filter, perform the penny test as described earlier. OPERATOR AND QUALITY ASSURANCE
T. Are chemicals always washed thoroughly Y. Do all dental team members have the proper
from the films before drying and mounting the films credentials to take radiographs of dental patients?
(ie, rinsed at least 10 minutes for manual processing Yes: Proper technique
and with use of running or frequently changed water No: Needs improvement
bath for automatic processing)? Check with the state dental board to make sure all
Yes: Proper technique dental team members have the proper training and
No: Needs improvement credentials.
If chemicals are left in the gelatin emulsion, films Z. Is a log kept of films that are retaken?
will eventually develop brown or yellow stains that Yes: Proper technique
obscure the image. No: Needs improvement
U. Is the darkroom kept spotless and the manual A record of date taken, operator, reason for retake, and
solution tanks cleaned at each solution change? For corrective action identifies repeated errors or downward
automatic processors, is a cleaning film run through trends in careful technique that may indicate a need for
the processor daily and the machine disassembled machine servicing or inservice refresher training.
and cleaned weekly? AA. Have all members of the dental team taken a
Yes: Proper technique continuing education course in the past 3 years in
No: Needs improvement radiation hygiene, radiographic technique, or inter-
Cleanliness and order in the darkroom and in auto- pretation?
matic processors should be the same as in the opera- Yes: Proper technique
tory. Without clean counter tops, tanks, and rollers, No: Needs improvement
radiographs invariably will have some artifacts that The ability to produce the best radiographs consis-
interfere with accurate diagnosis. tently with the least radiation (ALARA concept) and
V. Is infection control practiced during all phases to interpret all the details is a complicated task that
of radiography? takes learning and relearning through continuing
Yes: This is the only answer permitted education courses.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Goren et al 373
Volume 89, Number 3

BB. Does the office have a quality assurance volved in dental radiography should keep themselves
program that ensures high-quality diagnostic radio- informed. The Radiology Practice Committee of the
graphs with the least amount of radiation exposure AAOMR intends for this exercise to help them all
to patients and staff? achieve this goal.
Yes: Proper technique
No: Needs improvement REFERENCES
The ALARA concept should be implemented now. 1. Lundeen RC, Gratt BM, Katz JO, Tyndall DA, Brand JW,
By going through this exercise, dental team members Pettigrew JC, Jr, et al. Provision of radiographic services: a self-
will know what they need to do. In a radiation-aware assessment exercise for dental team members. Gen Dent
1993;41:144-7.
practice, all the answers to the questions should be 2. American Academy of Dental Radiology Quality Assurance
yes. If some of the answers were no, this exercise Committee. Recommendations for quality assurance in dental
should be kept as an outline for a quality-assurance radiography. Oral Surg Oral Med Oral Pathol 1983;55:421-6.
3. Quality assurance for diagnostic imaging equipment: recom-
program to which new guidelines can be added from mendations of the National Council on Radiation Protection and
time to time. Measurements. Report No. 99. Bethesda, Md: National Council
on Radiation Protection and Measurements; 1988.
4. Council on Dental Materials, Instruments, and Equipment.
SUMMARY Recommendations in radiographic practices: an update, 1988.
Radiography is a dynamic aspect of all dental prac- JADA 1989;118:115-7.
tices. Now that oral and maxillofacial radiology has 5. Ludlow JB, Platin E. Densitometric comparisons of Ultra-speed,
Ektaspeed, and Ektaspeed Plus intraoral films for two
become an approved ADA specialty, it is important that processing conditions. Oral Surg Oral Med Oral Pathol Oral
all the dental team members provide the best radio- Radiol Endod 1995;79:105-13.
graphic services possible to patients. There have been 6. The Dental Radiographic Patient Selection Criteria Panel and
Joseph LP. The selection of patients for x-ray examinations:
several changes in the past few years in dental radiog- dental radiographic examinations. Publication No. 88-8273.
raphy, such as new state regulations, improved film and Rockville, Maryland: Center for Devices and Radiological
screen combinations, and the use of digital image Health, Food and Drug Administration; 1987.
7. Hirschmann PN. Guidelines on radiology standards for primary
receptors and new equipment. To continue to provide dental care: a resume. Brit Dent J 1995;178:165-7.
the best radiographic services to patients, those in- 8. Whitcher BL, Gratt BM, Sickles EA. A leaded apron for use in

Appendix 1 Dental Radiography Self-assessment Checklist

Checkpoint Proper technique Needs improvement
A. Use E-speed film Yes No
B. Use rectangular collimation Yes No
C. Obtain earlier radiographs when possible Yes No
D. Use rare-earth screens for panoramic Yes No
E. Use selection criteria for prescribing radiographs Yes No
F. Use long-cone technique and film holder Yes No
G. Use leaded apron and thyroid collar Yes No
H. Use kV(p) of 60 to 70 Yes No
I. Have technique chart posted Yes No
J. Use adequate barrier protection Yes No
K. Inspect x-ray machine regularly Yes No
L. Use proper filtration Yes No
M. Store film properly Yes No
N. Maintain screens and cassettes properly Yes No
O. Use time-temperature technique for manual film processing Yes No
P. Replenish processing solutions properly Yes No
Q. Use system to check strength of processing solutions Yes No
R. Check darkroom for light-tightness Yes No
S. Check daylight loader for safelight conditions Yes No
T. Wash films thoroughly after processing Yes No
U. Keep darkroom, processing equipment clean Yes No
V. Practice infection control for radiography Yes No
W. Clean viewboxes, change lamps as needed Yes No
X. Provide optimal film-viewing conditions Yes No
Y. Maintain staff’s proper credentials Yes No
Z Keep retake log Yes No
AA. Update radiography knowledge regularly Yes No
BB. Maintain quality assurance program for office Yes No
374 Goren et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
March 2000

panoramic dental radiography. Oral Surg Oral Med Oral Pathol APPENDIX 2
1980;49:467-70.
9. NRPB. Guidelines on Radiology Standards for Primary
To order the Dental X-ray Beam Filter Kit, to reduce
Dental Care: report by the Royal College of Radiologists and output on panoramic machines, “The Guidelines for
the National Radiological Protection Board. Vol 5 No 3. Prescribing Dental Radiographs,” publication No. N-
London:National Radiological Protection Board;1994.
10. Wood RE, Harris AM, van der Merwe EJ, Nortje CJ. The
80A (brochure), or to receive technical advice, call
leaded apron revisited: Does it reduce gonadal radiation dose Eastman Kodak at 1-800-933-8031.
in dental radiology? Oral Surg Oral Med Oral Pathol 1991;71: To order the Dental Radiographic Quality Control
642-6.
11. Stenstrom B, Rehnmark-Larsson S, Julin P, Richter S.
Device, write to Dental Radiographic Devices, PO Box
Radiation shielding in dental radiography. Swed Dent J 9294, Silver Spring MD; or call 1-301-598-6543.
1983;7:85-91. To order the following Eastman Kodak publications:
12. Schmidt K, Velders XL, van Ginkel FC, van der Stelt PF.
Strahlenschutz durch Rontgenkragen. Quintessenz 1999;50:1,
1. “Successful Panoramic Radiology,” publication
55-61. No. N-406, 1996
13. Dental x-ray protection: recommendations of the National 2. “Exposure and Processing for Dental Radiog-
Council on Radiation Protection and Measurements. Report No.
35. Washington, DC: National Council on Radiation Protection
raphy,” publication No. N-413, 1998
and Measurements; 1970. 3. “Radiation Safety in Dental Radiography,” publi-
14. Platin E, Nesbit SP, Ludlow JB. The influence of storage condi- cation No. N-414, 1998
tions on film characteristics of Ektaspeed Plus and Ultra-speed
films. JADA 1999;130:211-8.
4. “Quality Assurance in Dental Radiography,”
15. American Academy of Oral and Maxillofacial Radiology. publication No. N-416, 1998
Radiation infection control guidelines for dental radiographic 5. “Successful Intraoral Radiography,” publication
procedures. Oral Surg Oral Med Oral Pathol 1992;73:248-9.
No. N-418, 1997:
Reprint requests: Call Eastman Kodak at 1-800-233-1650 or write
Arthur D. Goren, DMD Eastman Kodak Company Advertising Distribution
School of Dental Medicine Order Entry, Department 454
127 Westchester Hall
SUNY Stony Brook 343 State St
Stony Brook, NY 11794-8702 Rochester, NY 14650-3009