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DENTAL RADIATION SAFETY IN RADIOGRAPHY POLICIES:

SCOPING REVIEW AND FINDINGS IN INDONESIA

Himma Illiyana, Masyitoh Basabih

Faculty of Public Health, Universitas Indonesia, Indonesia

Email: [email protected]

Abstract

Radiation safety is important to prevent deterministic and stochastic effects on patients. The

aims of this review are to summarize and provide an overview of radiography policies on dental

radiation safety and to identify the gaps between Indonesia’s radiography policies with

worldwide best practices. The review is based on the PRISMA-ScR. Articles are searched

through Embase, Pubmed and Scopus. Articles focused on dental radiation safety are included

with addition of policy documents found by manual searching. Results are summarized in a

table and in-text and analyzed by comparing with policies in Indonesia.Ten articles are

collected and identified as policy statement (n = 2), guideline (n = 2), and recommendation (n

= 6). Three themes are used to summarize the findings: (1) target, (2) qualified expert, and (3)

best practice. The result shows that all policies have incorporated safety radiation principles.

Radiography policies regulates: dental practitioners and trained operators as personnel

qualified to conduct radiography examination; appropriate technique and practical measures;

x-ray maintenance and radiological testing. The scope of radiography policies in Indonesia is

extensive, with health facilities and service providers as the primary policy targets.

Ke ywords

: radiation safety; dental practices; policy

INTRODUCTION

Dental and oral health practices are related to invasive procedures on patients and have a

different scope from general health practices. They are generally carried out through the stages of

establishing a diagnosis which forms the basis for determining a treatment plan. Radiology as a

supporting examination is often needed to assist dental practitioners ─ as in the case of impaction

by evaluating the position and type of impacted teeth, the depth of impaction, bone density, and

the relationship of impacted teeth to the surrounding anatomical structures.(Mardiyantoro et al.,

2019; Toppo, 2012)

The importance of radiology cannot be separated from the negative effects of radiation

produced from radiographic equipment. If it is not addressed properly, radiation exposure will

cause deterministic and stochastic effects on patients. The deterministic effect is an effect that is

seen if the radiation exposure to organs or tissues exceeds a certain threshold with a severity

proportional to the dose. The stochastic effect is caused by DNA damage due to sublethal radiation

and the severity does not depend on the dose (all-or-none responses).(White & Pharoah, 2014)

The radiation protection must have been incorporated into radiography policy. Three

principles of protection radiation by ICRP are justification, optimization and limitation.

Justification means that the decision to give radiation exposure must consider the benefits of

radiographic examination that is greater than the possible risks (Sonafist, 2023). Optimization

Injuruty: Interdiciplinary Journal and Humanity

Volume 2, Number 7, July 2023

e-ISSN: 2963-4113 and p-ISSN: 2963-3397

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emphasizes that the possibility of exposure, the number of people exposed, and the size of the dose

received must be kept to a minimum. Limitation provides exposure dose limits that do not exceed

a predetermined threshold.(ICRP, 2007) Therefore, it is necessary to have a policy to regulate the

use of equipment with radiation modalities in accordance with the rules to protect patients from

the dangers of radiation exposure. The aims of this review are: (1) to to summarize and provide an

overview of radiography policies on dental radiation safety, and (2) to identify the gaps of policy

between Indonesia’s radiography policies with worldwide best practices.

METHOD RESEARCH

The scoping review will be conducted in accordance with the Joanna Briggs Institute

methodology by using PRISMA flow diagram for the scoping review process.(Peter M, Godfrey

M Christina, Mcinerney P, 2015) Scoping reviews are evidence synthesis methodology that

organise available evidences, identify characteristics of particular issues or topics, and find gaps.

Unlike systematic reviews, they address broad questions and can be used as preliminary

methodology (Munn et al., 2022) Therefore, scoping review is used to find out more about what

are the important factors in radiation safety particularly in dentistry area.

Search strategy and selection process

Articles are retrieved thorugh database searching of Embase, Pubmed and Scopus. The

search query (“dental radiation safety” AND “radiography OR radiology OR imaging” AND

“policy”) is used to identify articles on the topic. Articles screening is initially performed by

removing duplicates and identifying irrelevant articles through titles and abstracts. Full text

screening are conducted with the inclusion criteria for articles include: (1) published after 2010;

(2) published in English; (3) focused on dental radiation safety; (4) included but not be limited to

regulation, guideline, and recommendation; and (5) full text accessible. Additional articles are

included through manual searching which fulfilled the inclusion criteria of articles

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Figure 1. Flow diagram of literature selection process

Data extraction and analysis

All data relevant to the topic are extracted and presented by using table. Extracted data are

identifed as: characteristics (title, author, year, type of document); context (country/region); basic

regulation and year issued; and key finding. The data are compared to findings in Indonesia in

terms of: type and target of policy; radiation safety; institutional coordination; and harmonization

with other regulations.

RESULT AND DISCUSSION

A total of ten articles are obtained and reviewed (Table 1). An analysis is conducetd by using

descriptive summary which organized by aspects of: target of policy; role of qualified expert; and

implementation of best practice.

Table 1. Dental radiation safety articles, published after 2010

Title

Author, year

Countr

y/regio

Type

Basic

regulation

Year

issued

Key finding

Best clinical

practice

guidance for

prescribing

dental

radiograph in

children and

adolescents: an

EAPD policy

documment

Kühnisch et al.,

2020

Europe

Recomm

endation

The

European

Council

Directive

2013/59/Eur

atom

2013

Target

Pediatric patient.

Best practice

The workflow of radiograph examination

by taking into consideration of principles of

radiation protection (justification,

optimization, and limitation) and

cooperation of the child, as follows:

determine the benefit of radiographic

examination based on the clinical

examination, select the appropiate type and

technique, giving informed consent,

implementing protective measures,

positioning the patient and aligning the

image receptor correctly.

FDI policy

statement on

radiation safety

in dentistry

FDI, 2014

World

wide

Policy

statemen

FDI World

Dental

Federation

Radiation

Safety in

dentistry

2014

Target

All age patient.

Qualified expert

Appropriate training, education and

certification of operator are needed.

Best practice

The use of radiograph examination based on

the diagnosis with measures to reduce

radiation exposure, such as:

- technique: use fastest film

and receptor holder, collimate the

beam, use CBCT only when lower

dose technique are not sufficient.

- exposure time and dose: use

automatic exposure control or

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Title

Author, year

Countr

y/regio

Type

Basic

regulation

Year

issued

Key finding

appropriate technique to prevent

overexposure and underexposure.

- patient and operator

protection

- ensure the quality of

radiograph examination by

developing quality assurance

protocol.

Prescribing

dental

radiograph for

infants, children,

adolescents, and

persons with

special health

care needs

American

Academy of

Pediatric

Dentistry, 2018

USA

Guidelin

ADA/FDA

Dental

Radiographi

Examinatio

ns:

Recommen

dations for

Patient

Selection

and

Limiting

Radiation

2012

Target

Pediatric patient.

Best practice

Prescribing dental radiograph for children is

based on age and dental development age

and accompanied by good practice to

minimize radiation include: use fastest film,

collimate the beam, proper technique, use

protective measures, and limit the

radiograph examination.

National

guidelines for

dental diagnostic

imaging in the

developmental

age

Firetto et al.,

2019

Italia,

Europe

Recomm

endation

Italian

Legislative

Decree

187/00

The

European

Council

Directive

2013/59/Eur

atom

2000

2013

Target

Pediatric patient.

Best practice

Proposing the best practice to do radiograph

examination in pediatric patient by using

evaluation of scientific data, such as:

reducing area and intensity of the beam and

using lead thyroid collar in

orthopantomography, cephalometric, and

CBCT examination.

Radiation

protection in

Dental

Radiology – the

safe use of

radiographs in

dental practice

Nisha, et al.,

2014

India,

Asia

Recomm

endation

Target

All age patient.

Best practice

The machine has undergone testing.

Protection from radiation exposure is

obtained from: lead barrier surrounding the

radiation area, the use of aprons for patients,

the use of screens or room settings that

place operator outside of the beam and

monitoring of operator doses, particularly

for pregnant women.

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Title

Author, year

Countr

y/regio

Type

Basic

regulation

Year

issued

Key finding

Lowering the

radiation dose in

dental offices

Radan, 2017

USA

Recomm

endation

ADA/FDA

Dental

Radiographi

Examinatio

ns:

Recommen

dations for

Patient

Selection

and

Limiting

Radiation

2012

Target

All age patient.

Qualified expert

Dental practitioners or specialists have

technological knowledge.

Best practice

For 2D radiographs, the exposure can be

minimized by adopting patient selection,

and using proper technique, the fastest film

or digital, rectangular collimation and

thyroid collar.

For 3D CBCT, optimizing radiographs by

using the smallest FOV, adjusting the

exposure setting to patient size and age, and

using thyroid collar.

Guidelines for

the safe use of

dental and

maxillofacial

cbct: a review

with

recommendation

s for south africa

Noffke, et al.,

2011

South

Africa

Recomm

endation

Target

All age patient.

Qualified expert

The operators have received training in

imaging software and radiation safety. The

referrer should have received sufficient

training in software usage and

interpretation.

Best practice

Professional judgment should be the basis

for prescribing CBCT. CBCT should be

used when conventional radiographs are

unable to provide sufficient information.

Radiation

shielding in

dentistry an

update

Crane and

Abbott, 2016

Australi

Recomm

endation

ARPANSA/

Code of

Practice and

Safety

Guide in

Dentistry

National

Radiation

Protection

Board/Guid

ance Notes

for Dental

Practitioner

2005

2001

2004

Target

All age patient.

Best practice

For intraoral radiograph, it is mandatory to

use thyroid shield whereas apron is used

when the beam is pointed at pregnant

patient’s trunk.

For extraoral radiograph, i.e. panoramic and

cephalometric, thyroid shield is optional

since it can obscure anatomical structure.

It is recommended to use rectangular

collimation and F-speed film.

Dental Radiation Safety In Radiography Policies: Scoping Review And Findings In Indonesia

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Title

Author, year

Countr

y/regio

Type

Basic

regulation

Year

issued

Key finding

s on the Safe

Use of-X-

ray

Equipment

European

Guidelines

on radiation

Protection

in Dental

Radiology

Dental

radiographic

examinations:

recommendation

s for patient

selection and

limiting

radiation

exposure

American

Dental

Association,

2012

USA

Guidelin

ADA/FDA

Dental

radiographi

examination

recommend

ations for

patient

selection

and limiting

radiation

exposure

2012

Target

All age patient.

Qualified expert

Dentists conduct a clicnical examination.

Appropiate education of the operator and

training to improve the quality of

examination are needed.

Best practice

The clinical assessment of the patient is

used in determining the need and the type of

radiographic images. To minimize the

radiation exposure by: selecting receptor,

using appropriate collimation and

techniques, using protectors for patients and

operators, developing quality assurance

protocols, communication of radiation risk

to patients, training and education of

practitioners.

Policy statement

6.14 radiation

safety

Australian

Dental

Association,

2019

Australi

Policy

Statemen

ADA

Federal

Council

Policy

Statement

6.14

2019

Target

All age patient.

Qualified expert

Dental radiograph should only be

administered by a trained and qualified

dental practitioner.

Best practice

Dentists and staff should make efforts to

minimize radiation risk. Optimization of

radiograph quality and quality control must

be carried out.

Worldwide review of dental radiation safety

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All articles have incorporated three principles of radiation protection (i.e. justification,

optimisation, and limitation) by ICRP.(ICRP, 2007) Justification is used to determine the benefits

of radiograph examination outweighing the possible risks. The decision to proceed with the

radiograph examination is proposed by dental practitioners only after conducting clinical

examination.(American Dental Association, 2012; Policy Statement 6 . 14 – Radiation Safety,

2019; Kühnisch et al., 2020; Noffke et al., 2011) The risks of radiograph examination are

communicated to patients through informed consents. All risks associated with the procedures

must be disclosed to the patient by the practitioners to protect against any claim of negligence,

legal and medico-legal litigation.(Bhadauria et al., 2018; Gambhir et al., 2014)

Several important aspects to optimize the quality of radiograph with minimum to zero

radiation exposure are identified. Collimation of the beam with fixed or handheld equipment is

required to reduce the exposure dose.(American Academy of Pediatric Dentistry, 2018; American

Dental Association, 2012; Crane & Abbott, 2016; FDI World Dental Federation, 2014; Radan,

2017) Using collimators have benefit of reducing scatter radiation which enhances image

quality.(White & Pharoah, 2014) This has been proven in a study that a rectangular collimator can

reduce effective dose by 51% in adults and 66% in children.(Johnson & Ludlow, 2020) Image

receptor selection based on the type of image acquisition technique (i.e. analog, computed and

digital radiography). For analog and computed radiography, it is recommended to use the fastest

film receptor. CCD (charged coupled device) and PSP (photostimulable phosphor plates) are

commonly used in digital radiography.(American Academy of Pediatric Dentistry, 2018;

American Dental Association, 2012; Crane & Abbott, 2016; FDI World Dental Federation, 2014;

Radan, 2017) When comparing the time for the acquisition of image, CCD is the best option

because it requires little time.(Sudarsini et al., 2020)

Protective equipments are used to shield the sensitive and compromised patients from

unnecessary radiation exposure.(American Academy of Pediatric Dentistry, 2018; American

Dental Association, 2012; Crane & Abbott, 2016; FDI World Dental Federation, 2014; Firetto et

al., 2019; Kühnisch et al., 2020; Nisha et al., 2014; Radan, 2017). A study found that children are

more likely than adults to get cancer following radiation exposure because their tissues and organs

are still in the development stage.(Kutanzi et al., 2016) Protective measures, such as standing

behind protective barrier and increasing the distance between operators and the x-ray machine, are

also required to protect operators from unnecessary radiation exposure.(American Dental

Association, 2012; FDI World Dental Federation, 2014; Nisha et al., 2014) In a research study, the

positioning of handhelds x-ray devices has an impact on radiation received by operators, therefore

it is important to use anti-scatter grid to provide a safe zone.(Makdissi et al., 2016) According to

other studies, there is correlation between dental x-ray exposure to cancers and tumors in the head

and neck regions of dental practitioners and radiographers.(Hwang et al., 2018)

It is imperative for radiology installation to develop quality control and quality assurance

protocols which includes maintenance procedures. The protocols are required to ensure that the x-

ray machine is functioning and safety precautions are implemented.(American Dental Association,

2012; Policy Statement 6 . 14 – Radiation Safety, 2019; FDI World Dental Federation, 2014; Nisha

et al., 2014; Noffke et al., 2011) Lack of x-ray equipment maintenance may cause late detection

of equipment failure, results in increased repair costs and delayed services.(Ngoye et al., 2022) All

information and test results are recorded and reviewed on annual basis.

Radiography policies in Indonesia

Policies related to radiology have been issued by the government of Indonesia as a policy

maker and Bapeten (nuclear energy regulatory agency of Indonesia) as an institution that supervise

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the use of equipment with radiation (Table 2). These policies are issued by different institutions,

some of them are without any interrelationship between policies. In this situation, it creates

disharmony which prevented regulations from being implemented effectively and efficiently, and

are unable to provide guidance for the community. Coordination between institutions is not carried

out, therefore the objectives of the policies will not be reached. It is known that good regulations

have the ability to integrate implementing agencies.(Sabatier & Mazmanian, 1980)

. Table 2. Radiography policies issued based on years

Type of policy

2000 - 2010

2011 - 2022

Government

regulation

Regulation number 63/2000

consists of radiation dose and

safety management.

Regulation number 33/2007

consists of management,

radiation protection, technique,

and safety verification.

Regulation of

Minister of

Health

Regulation number 780/2008

includes diagnostic,

radiotherapy, and nuclear

radiology services.

Regulation number 24/2022

regulates radiology services

based on the capabilities of

health facilities according to

human resources and

equipment.

Decision number 1014/2008

standardises radiology services

according to the type and class

of health facilities.

Bapeten

regulation

Bapeten chairman’s regulation

number 8/2011 regulates permit

requirements, radiation safety

requirements, interventions,

and records and reports in the

use of x-ray equipment.

Bapeten chairman’s regulation

number 4/2020 provides

requirements of radiation safety

in diagnostic and

interventiontal radiology

include: management, radiation

protection, technique and

verification.

Technical guideline provides

practical guidance and

recommendations for

practitioners and operators to

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Type of policy

2000 - 2010

2011 - 2022

ensure the radiation protection

in dental radiology facilities.

Radiography policies in Indonesia regulates the requirements of personnel, equipment,

technique, quality control and quality assurance. In this sense, these policies share much in

common with radiography policies in other countries or regions. However, the policies target

groups are health facilities and person involved in services while foreign policies recognise and

emphasise on patients as policy beneficiaries ─ especially those who are at greater risk.

The scope of radiology stated in regulations is mostly broad and general in nature, therefore

the regulations can be implemented in various health services and facilities regardless of the type.

However, it raises the weaknesses of regulations in areas that have not been specifically regulated.

It is found that there is no state regulation in Indonesia that regulates the radiology services in

dentistry despite radiology is often needed to determine diagnosis and treatment plan. Technical

guideline is provided by Bapeten but it does not have the force of regulations or laws, and as a

means to comply with regulatory standards.

Table 3. Comparison of national and international policies

Aspect of policy

National

International

Type

Only technical guide for

dental radiography

Regulation (American Dental

Association, 2012; Policy

Statement 6 . 14 – Radiation

Safety, 2019)

Guideline/recommendation

(American Academy of

Pediatric Dentistry, 2018;

American Dental Association,

2012; Firetto et al., 2019;

Kühnisch et al., 2020; Nisha et

al., 2014; Noffke et al., 2011;

Radan, 2017)

Target

Health facilities, service

provider

Service provider

Patient/specific age and

groups are mentioned

(American Academy of

Pediatric Dentistry, 2018;

Firetto et al., 2019; Kühnisch

et al., 2020)

Radiation

safety

Qualified

expert

Doctors, specialist, operator,

protection officer

Specifically mention dental

practitioner, operator

X-ray

equipment

CBCT is regulated only in

Bapeten regulation.

Mention all type of dental x-

rays, including CBCT

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Aspect of policy

National

International

Justification

In general, radiograph

examination must be

recommended by doctors or

specialists with a clinical

examination

Dental radiograph

examination must be

recommended by dentist with

a clinical examination

(American Dental

Association, 2012; Policy

Statement 6 . 14 – Radiation

Safety, 2019; Kühnisch et al.,

2020; Radan, 2017)

Optimization

and limitation

Not specifically mentioned

but elaborated in Bapeten

regulations

Stated

QC and QA

Annual x-ray maintenance

test, dosimetry

Protocols are needed

Coordination

Across institutions and

professionals. Bapeten

conducts utilization

supervision.

There are institutions

providing guideline and

recommendation (Policy

Statement 6 . 14 – Radiation

Safety, 2019)

Harmonization of

regulations

Not all of the policies

mentioned it, such as

Bapeten is missing in

Regulation of Minister of

Heath No.24/2020.

Regional regulations as the

basic for formulation of state

regulations/guidelines

CONCLUSION

Dental radiography policies provide dental practitioners and operators with detailed

practices to ensure the quality of diagnostic imaging while maintaining the protection of both

patients and operators, leads to the following conclusion: dental radiography should be prescribed

by dental practitioners and conducted by trained operators; appropriate technique and practical

measures must be taken to minimize the risks of radiation; x-ray maintenance and radiological

testing are required regularly. In Indonesia, the scope of radiography policies is broad with health

facilities and service providers as the main target of policy. Radiation safety in dental practices is

provided in Bapeten’s technical guideline as written guidance on minimum standards for facility

design, specifications for dental x-ray equipment quality assurance program.

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