RADIATION RISKS FROM DENTO-MAXILLOFACIAL RADIOGRAPHY
Sanjay M. Mallya, Assistant Professor Sotirios Tetradis, Professor and Chair Section of Oral & Maxillofacial Radiology School of Dentistry University of California, Los Angeles
ver the last few years there has been an increased attention in the media to issues of radiation exposure from diagnostic imaging. Recently, the New York Times published an article titled “Radiation worries rise with 3-D dental images” (1). This article appeared on the front-page of the print version and addressed the increasing use on Cone Beam CT scans in dentistry. Specifically, the authors expressed concern about its routine use in orthodontic patients, and in particular, children. The authors raised concerns that these imaging procedures may put children and teens at risk for extra radiation exposure. Every year millions of dental radiographs are taken in the United States. As dental care providers, we certainly recognize that these procedures are important for diagnosis and treatment planning. However, it is also our responsibility to ensure that this technology is applied judiciously. Indeed, it has been the long-standing position of the dental profession that we minimize the radiation exposure to our patients. This is a time when public sensitivity to radiation exposure is high, with concerns about radiation doses from medical CT exams and airport scanners. It is very likely that your patients will express concerns related to radiation risks. This article provides a brief overview of radiation risks and safety. We also provide information to assist in better discussing these issues with our patients. What are the risks from diagnostic radiation? The principal risk from diagnostic dental radiography is the risk of radiation-induced cancer. Radiation causes several different types of damage to DNA, which when misrepaired can cause mutations in genes essential to the regulation of cell growth. Radiation-induced cancer is a stochastic effect, which means that there is no threshold dose below which this effect does not occur. As the radiation dose increases, the risk of cancer induction increases. In diagnostic radiology, we can reduce the risk of radiation-induced cancer by minimizing the radiation dose to the patient. Certain tissues and organs are known to be more sensitive to radiation-induced cancer. Of relevance to dental imaging, these include the thyroid gland (especially in children and adolescents), the salivary glands and the red bone marrow in the jaws. It should be emphasized that the likelihood of cancer is rare but this possibility cannot be excluded. Why do I need dental x-rays/cone beam CT scans? Radiographs are important for diagnosis and treatment planning. However, we should always ensure that diagnostic radiation procedures occur only when necessary. All radiographic examinations should be ordered after a thorough clinical examination and should be based on selection criteria. It is important to emphasize to our patients that these radiographic procedures provide us with important information that we use for diagnosis and treatment NSIDE HIS SSUE planning, and thus, there is a benefit to the patient. For example, in our UCLA clinic, we have experience with CBCT scanning for almost a decade and we believe that judicious use of the technology is extremely valuable President’s Message ................. 2 in providing high-quality care for our patients. 2011 Fall CE Line-Up ................ 3 Which type of dental radiographic examination —intraoral, panoramic, or cone-beam CT scan — will provide the necessary Gadfly.................................... 4 information with the least amount of radiation exposure? Classified .............................. 4 Selection of the appropriate radiographic examination depends on the diagnostic task and varies from patient to patient, depending on the Radiation Risks continued ........... 5 clinical scenario. The type of examination and the frequency of Mobile Dental Clinic .................. 6 examination should be tailored to the individual needs of each patient. Selection criteria and guidelines for imaging have been developed by the Calendar ................................ 8 ADA and by professional societies (2, 3).
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P RESIDENT ’ S M ESSAGE
he sun has finally made an appearance to let us know that summer is officially here. But, before we know it, fall will be sneaking up on us. Although I fully intend to enjoy the sunshine and fun that summer will bring, I (like any other type A personality out there) will also be preparing for what is coming this fall. Every fall, as many of you are aware, the CDA holds its House of Delegates. It is through the House that many important issues related to organized dentistry and dentistry as a profession are addressed. It is an opportunity for CDA leaders to represent their membership by voting on issues brought forth by both the CDA and its members. I would like to take this opportunity to remind our membership that our component is represented by members within our dental society. Preparation is already beginning, so any concerns or issues that you, our membership, would like to have brought forth may be communicated through the dental society. As I have said before, it is the power of WE, our collective voice, that makes us a part of one of the strongest and most dedicated professional organizations.
NSDS New Trustee
Dr. Godfrey served as President of the Dental Society in 2008, and currently Valerie Godfrey, DDS serves as Co-Editor of the Oracle Newsletter. Trustee 2011-2013
Our sincerest thanks and appreciation to Dr. Dennis Nutter who served as Trustee from 2009 to 2011exercising diligence and care representing NSDS members' interests at the state association level.
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Dennis Nutter, DDS Trustee 2009-2011
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2011 Fall Program Line-Up Dental Compounding
SEPTEMBER 15 Thursday
DENTAL COMPOUNDING Registration..........................6:00 pm Dinner.....................................6:45 pm Program ..............................7 to 9 pm Rancho Solano Golf Club, Fairfield Member Dentist.........................$ 60 Auxiliary/Staff............................$ 60 Non-Member Dentist..............$ 90 Active Military...........................$ 40
High Tech Power Dental Office Dental Law, OSHA, Infection Control
PROGRAM: Despite the huge advances in the science of dentistry, the therapeutic options available to dental practitioners still have limitations. That is, no two patients are alike with respect to their dental needs. There is a subset of dental patients who have not responded to standard medicines or who are unable to use a commercially prepared medication. Compounding is customizing medications to the required potency, delivery system and if necessary, to the required flavor according to the patient's specific need. Its purpose is to increase patient medication compliance and help improve therapeutic outcomes for those patients failing to respond well to conventional drug therapy. In short, pharmacy compounding can enhance options when treating difficult-to-dose patients. You will learn what is new and available to the dental team, from gag reflux suppression medication to hard to find medications, and some commonly used dental dosage forms, from mouthwashes to popsicles and chapstick, and how to best work with the pharmacist to reach the desired goal. SPEAKER: CHUCK SNIPES, R.PH In 2002 with over 17 years experience in hospital (large and small) and retail (chain and independent) pharmacy practice, Chuck opened Davis Compounding Solutions (DCS) in Davis, California. A 'compounding only' practice, DCS allows him the opportunity to focus on improving therapy for patients under-served by conventional industrial pharmacy. He relishes the challenge of the 'difficult to treat' patient and his motto is "Compounding Solutions, not Problems".
Registration..........................7:30 am Program................ 8 am to 3:00 pm Breakfast & Lunch Included LOCATION TO BE ANNOUNCED
PROGRAM: Going Paperless: Is it really possible to go paperless? The fact is that it is possible to create a completely paperless dental record. And going paperless can save you tens of thousands of dollars. You will learn the step-by-step help in setting up a paperless office, including the eight essentials that need to be in place before you get started, four ways to digitize stuff, and front deskless workflow. There is even a budget and financial analysis that shows how your current paper system is costing you over $40,000. Using the Internet: The internet will have a more profound effect on the world we live in than any technological advance of the last century. More than cars, planes, electronics, telecommunications and all the rest. It will affect our lives in ways we cannot yet even imagine. You will learn the six reasons to have an office webpage and the four ways to drive traffic to your web page, technology-driven data based marketing, digital communications, for business (B2B) and for patients. Understanding the digital nervous system. The presentation includes active live program demonstrations and online action.
Member Dentist........................$ 285 Auxiliary/Staff...........................$ 130 Non-Member Dentist..............$ 340 Active Military...........................$ 130
SPEAKER: LAWRENCE F. EMMOTT, DDS is one of the most entertaining speakers in dentistry. He will have you laughing while you are learning. He is considered the leading dental high tech authority in the country and has over thirty years of experience as practicing general dentist in Phoenix, AZ. He is the founder and director and provides high tech dental consulting for dentists and industry. In 2008 Dr. Emmott compiled his columns and lectures into three high tech guides for dentists: Going Paperless, Computers In The Back, and Digital Radiography. He graduated from the University of Southern California School of Dentistry in 1977.
OCTOBER 21 Friday
HIGH TECH POWER DENTAL OFFICE
NOVEMBER 17 Thursday
DENTAL LAW, OSHA & INFECTION CONTROL
Registration..........................2:00 pm Program Starts....................2:30 pm Program Ends......................8:00 pm Rancho Solano Golf Club, Fairfield Member Dentist........................$ 130 Auxiliary/Staff...........................$ 95 Non-Member Dentist..............$ 195 Active Military...........................$ 95
PROGRAM: The Dental Board requires all licensed dental professionals (DDS, DMD, RDA, RDH, etc.) to take approved CE courses in Infection Control (Bloodborne Pathogen Standards) and California Dental Law every two years for license renewal. Cal-OSHA requires employers to train their workers annually in Bloodborne Pathogens, hazard Communication, General Safety, Emergency Response and other standards based on the nature and size of your facility. This course will fulfill the Dental Board’s mandatory educational requirements as noted above.
Please complete required information If you are registering more than one person, please print all names. 1. CHECK: Mail registration form with check to 1023 Empire Street, Fairfield, CA 94533 2. CHARGE: Mail or fax (707-428-6085) registration form AND phone 707-386-5676 to provide credit card information
SEP 15 $
Please provide 48 hour cancellation notice for a full refund or application to a future CE Program.
Contact Phone Confirmation Email
OCT 21 $
NOV 17 $
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ORACLE Newsletter of the Napa-Solano Dental Society 1023 Empire Street Fairfield, CA 94533 Phone: 707.428.3894 Mobile: 707.386.5676 (Exec Dir) Fax: 707.428.6085 E-Mail: email@example.com www.napasolanodentalsociety.org EDITORS Thomas Campbell, DDS 707.745.1994 Valerie Godfrey, DDS 707.429.5200 James Stich, DDS 707.427.8836 SERVING THESE COMMUNITIES Allendale Rio Vista American Canyon Rutherford Angwin Saint Helena Benicia Spanish Flat Calistoga Suisun City Deer Park Sunol Dixon Travis AFB Fairfield Vacaville Liberty Farm Vallejo Napa Yountville Nut Tree OFFICERS & BOARD MEMBERS President…………………Angie Ring, DDS Past President …. James Sanderson, DDS President-Elect………… Bryan Scott, DMD Treasurer…………………Jan Gerber, DDS Trustee……………… Valerie Godfrey, DDS At-Large……………… Marc Bowen, DDS At-Large……………… Anita Ford, DDS At-Large……………… Walter Kuzma, DDS At-Large………………… Art Louie, DDS At-Large………………Robert Sprott, DDS At-Large……………… Otto Tebrock, DDS Committee Chairs Membership……..James Sanderson, DDS Community Health……. Franklin Woo DDS CE Program……………..Mark Sutter, DDS By-Laws………… Thomas Campbell, DDS Ethics…………………….Bryan Scott, DDS Cal-D-PAC………………James Stich, DDS Peer Review……………..Vic Chaney, DDS Well Being……………...Jeffrey Webb, DDS THE MISSION OF THE NAPA-SOLANO DENTAL SOCIETY IS TO BE THE RECOGNIZED SOURCE FOR SERVING THE NEEDS AND ISSUES OF ITS MEMBERS, WHILE ASSISTING THEM IN THEIR SERVICE TO THE PUBLIC.
GADFLY - DR. OTTO TEBROCK SOCIAL SECURITY SURPRISES WIKILEAKS EXPOSES STATE SECRETS AND INSISTS ON TRANSPARENCY IN GOVERNMENT. SOCIAL SECURITY HAS AN OPACITY WHICH NEEDS TO BE FURTHER ILLUMINATED. The Government Pension Offset (GPO) and Windfall Elimination Provision (WEP) is a convolution which needs straightening to be understood. This is of particular impact on self employed with a working spouse in government or school jobs, or anyone with non-social security covered employment income. The Windfall Elimination Provision is officially described "to ensure all American workers are treated equally". In fact, it ensures workers are treated unequally, and in reality, penalizes a spouse who actually works! What it does is save cash for social security and encourages spouses not to work. Let's suppose.... Dr. X has paid the maximum social security tax of 12.4% for 35 years paying about $330,000. into the fund as of 2010. The maximum social security benefit is based on the highest 35 years of earnings. If the maximum tax has been paid for 35 years ( the 36th year is a gift to the government and they thank you). Additional years of earnings will not raise the payout, Dr X' benefit at age 66 is $28,800. per year. At age 66, Dr X' spouse is eligible for half of X's $ 28,800 or $14,400. But Dr.X' spouse was a teacher and receives a pension from the school district of $21,000 per year. The amount of the social security pension paid for through payroll tax of Dr.X for the spouse is decreased by 2/3 of the school pension (21,000 X .66) or $14,000 due to the Windfall Elimination Provision, leaving $400. annual. The $14,000 loss per year continues until death. A more troubling scenario.... A military pilot serves 20 years, survives two wars and multiple deployments. and retires landing a job at UC Davis in the B school as a professor in systems management. After 25 years at UC Davis, the professor is pensioned at $30,000 per year. The 20 years of payroll tax to ss yields a payout of $20,000 per year. The WEP/GPO provisions require 2/3 of the university pension to offset the ss pension. Two thirds of $30,000 is $20,000 and completely zeros out any social security payout. The $20,000 forfeit annually continues until death making the 20 years of social security payroll tax a total loss. Last year more than 1,300,000 pensioners had reductions in benefits due to the Windfall Elimination and/or Government Pension Offset provisions. This is your government working for you!
CLASSIFIED ADS POSITIONS WANTED PEDIATRIC DENTIST Dr. Reena Grover is a GP dentist with 1.5 years of pediatric experience seeking a pediatric-focused job in the Bay Area. She is a UOP 2009 graduate. Please contact her at firstname.lastname@example.org or 510-378-3782.
RDH: RDH looking for dental hygiene position in the Napa / Solano area after recently relocating from Texas. I have a decade of experience and a current California Dental Hygiene license. Available immediately for temporary or permanent employment. Please contact Catherine Smith, RDH, BA, at (972) 765-5579 or by email at email@example.com.
RDH: RDH looking for dental hygiene position, prefer Napa area. I have almost 20 years experience working in the dental field as both a certified dental assistant and as a dental hygienist. I am diode laser certified. Interested in any type of dental hygiene opportunities, temporary or permanent. For a full resume or questions, contact April Skennion at firstname.lastname@example.org DA: Recent graduate of Modesto Junior College Dental Assisting Program. Experience interning in dental offices and will be completing RDA exams in August 2011; available June 7, 2011. Contact Hannah Pointon 209.262.8884
DA: Experienced Dental assistant looking to resume dental career. Interested in chair side or front office,full or part time. Contact Jean at 707-252-6021. Resume and references upon request.
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RADIATION RISKS FROM DENTO-MAXILLOFACIAL RADIOGRAPHY CONTINUED FROM PAGE
What procedures can I use to ensure that patient radiation exposure is as low as possible? The basic philosophy is to use the minimum amount of radiation possible, without compromising diagnostic quality. This is the basis for the ALARA (As Low As Reasonably Achievable) principle. There are several approaches that dentists can use to minimize patient exposure. For intraoral radiography, dentists should use fast films (F-speed instead of D-speed)—this will reduce dose by 50% without compromising diagnostic accuracy. Digital technologies such as photostimulable storage phosphor (PSP) plates and solid-state detectors (CCD/CMOS sensors) also offer additional dose reductions. However, in digital radiography the appearance of an overexposed image can be adjusted after the exposure. To gain the benefits of decreased exposure that digital imaging offers, operators should optimize exposure factors to use the minimal exposure time required to produce diagnostic quality images. This will require operators to optimize these exposure times for their particular receptors. Use of rectangular collimators can further reduce patient dose from intraoral radiography by 50%. Such collimators are available as modifications to the x-ray tube head or incorporated into film/sensor positioning devices. Protective aprons must be used to reduce radiation exposure to other regions of the body. California Code of Regulations requires that “Each patient undergoing dental radiography shall be draped with a protective apron of not less than 0.25 millimeter lead-equivalent to cover the gonadal area.” Whenever possible, use thyroid collars to shield the thyroid gland from radiation, especially in children. When a cone-beam CT scan is necessary, how are the settings adjusted to minimize radiation dose? Radiographic examinations should be tailored to individual diagnostic tasks. For example, in our UCLA Clinic, we always use the smallest possible field of view to evaluate the region of interest. Thus, we use limited cone beam scans for short edentulous areas, TMJ evaluations, fracture tooth surveys, endodontic evaluations etc. For larger edentulous areas or to evaluate larger regions of the jaw, we make larger field of view cone-beam scans, again, using the smallest possible field. The most important point is that by customizing the examination, we can ensure that all patients receive the minimum dose required for their individual imaging needs. What are the units of measurement for radiation exposure? The traditional unit of radiation exposure is Roentgen (R), which measures the amount of ionization in air produced by x- or gamma-radiation. Roentgen is a useful unit to denote exposure at the skin surface during a radiographic examination. From a radiobiological viewpoint, we are interested in how much of this energy is imparted to the biological tissues. This is termed absorbed dose and is measured in rads or Grays (Gy, 1Gy=100 rads). The total detriment produced by x-rays is dependent not only on the amount of x-radiation absorbed, but also on the types of tissues exposed. Different tissues have different sensitivities to radiation. Thus, radiation dose is often conveyed as effective dose, which considers the relative contribution of each tissue/organ to the total detriment produced by radiation. The unit of effective dose is the Sievert (Sv, 1 Sv=100 rems). What is background radiation? How do I convey radiation doses to patients? Background or natural radiation is radiation from naturally occurring radionuclides in the earth’s surface, internal radiation from radionuclides such as potassium-40 and carbon-14 within our body, and cosmic rays. In the US, the average effective dose from background radiation is approximately 3 milliSieverts (mSv) per year. When describing the radiation doses delivered by dental radiography, a simple approach is to compare the diagnostic dose with dose from background or natural radiation. Table I lists the radiation doses from common dental examinations and equates the dose to the number of days of background radiation. Table I: Radiation Doses and Risks from Common Dental Radiographic Examinations In summary, we should utilize radiation judiciously to obtain maximum diagnostic benefits with minimal risk Probability of Number of days Effective dose fatal cancer to our patients. Although we should always apply of background Examination (microSieverts) (per million radiation examinations) ALARA principles for every patient, we should Intraoral recognize the increased radiation susceptibility of FMX, D-speed film, round collimation 388 47 21 FMX, F-speed film or PSP, round collimation 171 21 9 children, adolescents and pregnant women. Recent FMX, F-speed film, rectangular collimation 35 4 2 media attention has increased public awareness of Posterior bitewings, Rectangular collimation 5 0.6 0.3 Extraoral radiation use in the dental office. We should be Panoramic 9-26 1-3 0.8-1.3 sensitive to our patients’ concerns regarding radiation Cephalometric 3-6 0.5-1 0.3 Cone Beam CT exposure and discuss with them the risks and benefits 3D Accuitomo (Morita), 4cm x 4cm 20 3 1.3 of various imaging modalities. Ultimately, under our NewTom 3G, full field of view 68 8 3.7 i-CAT (next generation, landscape scan) 74 9 3.9 guidance the patient should make an informed decision i-CAT extended scan 235 29 14 for the necessary imaging. Hitachi CB Mercuray 569 69 34 Data from Oral Radiology, 6 edition, eds: White and Pharoah and Ludlow JB et al. J Am Dent Assoc 2008; Links and resources 139(9):1237-43. 1. New York times article: Published in the New York Times on November 22, 2010, available online at http://www.nytimes.com/2010/11/23/us/23scan.html?emc=eta1 2. The use of dental radiographs: update and recommendations. J Am Dent Assoc 2006; 137(9):1304-12. Available online at http://jada.ada.org/cgi/content/full/137/9/1304 3. Joint Position Statement of the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology: USE OF CONE-BEAM COMPUTED TOMOGRAPHY IN ENDODONTICS. Available online at http://www.aaomr.org/?page=AAOMRAAE Permission to reprint from the Western Los Angeles Dental Society as published in West Views Newsletter, Vol 42, No. 1 and No. 2 th
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QUEENâ€™S MOBILE DENTAL CLINIC IS LAUNCHED AND EXPANDS SERVICES FOR LOW-INCOME YOUTH Queen of the Valley Medical Centerâ€™s new Mobile Dental Clinic is sporting a new look and a new sloganâ€? â€œWe go Miles for Healthy Smiles,â€? thanks to the ingenuity of some of the Queenâ€™s staff. Thanks to a generous grant from the Sisters of St. Joseph, the Queen was able to update its original, aging dental clinic, and early this year a brand new state of the art mobile clinic was launched. However, the unit arrived unwrapped â€“ or as clinic director Dr. Maryam Mohsenzadeh describes it, â€œa big, generic white bus. Of course we wanted a design that reflects both the spirit and the message of the clinic and we couldnâ€™t be happier with the results!â€? With the purchase and licensing of its new unit in October 2010, and the new design, the QVMC Mobile Dental Clinic has already exceeded its target patient numbers and proven the value of early and regular dental care. The increase in capacity from two dental chairs to three has allowed for an increase in the number of sites served. The clinic now reaches 8 low income schools. In fact, Dr. Mohsenzadeh notes, â€œWe have just added yet another regular site at the Napa County Office of Education which serves 472 pre-school, disadvantaged and special needs children and teensâ€?. The clinic now sees an average of 309 patients per month, or 25-30 each day â€“ an increase of 40% since the new unit arrived. Doctors report that more than 90% of patients are free of dental decay at their 6-month recall visits, with virtually all repeat patients showing improved knowledge and practice of oral hygiene and regular preventive care. Dr. Mohsenzadeh observes: â€œThe QVMC Mobile Dental Clinic is clearly filling a critical gap in the care in Napa County. With our new unit, the clinic is able to deliver affordable dental care for many more low income families that, otherwise, would not receive dental servicesâ€?. The dental clinic accepts all the government-based dental insurance, and also sees uninsured patients on a sliding-fee scale. This is critical, as uninsured and underinsured families often cannot afford regular dental care. â€œOur commitment to education and preventive care is now paying off in improved oral hygiene among our patients, with a sharply reduced need for immediate interventions, and fewer fillings and other procedures among repeat patients. Itâ€™s rewarding to know that the new unit has helped put smiles on thousands of young faces.â€?
Dr. Maryam Mohsenzadeh
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This article and photos were excerpted and printed with permission from the Valley Friday Bulletin, a Queen of the Valley Publication, February 18, 2011 and April 15, 2011.
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2011 CALENDAR OF EVENTS - SAVE THE DATE GM MEETINGS & CE PROGRAMS BOARD MEETINGS Board meetings are on the 2nd Tuesday of the month at 6:15 p.m. at the Dental Society Office as follows: February 8 May 10 September 13 November 8 3RD ANNUAL SHRED-A-THON & FLU SHOT CLINIC Sat, October 29 9 am to Noon Dental Society Office
September 15 (Thursday) GM & CE Program 5:30 pm, Rancho Solano Golf Club, Fairfield Chuck Snipes - Dental Compounding September 30 (Friday) New Dentist Program & Mixer 4:00 pm (tentative) Topic/Speaker/Format: to be announced October 21 (Friday) All Day CE Program 8:00 am – 4:00 pm, Location TBD Lawrence Emmott, DDS – High Tech Power Dental Office November 17 (Thursday) GM & CE Program 2:00 pm – 8:00 pm, Rancho Solano Golf Club, Fairfield Dental Law, Infection Control, OSHA
1023 Empire Street Fairfield, California 94533 PRSRT STD U.S. Postage PAID SUISUN, CA PERMIT NO. 20