Common Mistakes and Negligence in Pediatric Dental Radiography - Are We Really Aware?: A Cross-Sectional Study

Introduction

In various disciplines of Medicine and Dentistry, radiographs constitute an indispensable aid for diagnosing and monitoring the oral health care and dentofacial development in infants, children, adolescents, and persons with special health care needs.¹

Although radiation doses have been reduced due to the development of digital techniques, dental diagnostic X-ray imaging is the most frequently conducted diagnostic procedure for oral examinations.² Dental radiographic imaging constitutes a wide variety of views like the panoramic views, bitewings, occlusal and full mouth series that are commonly undertaken to diagnose oral diseases and assess the progress of treatment. In dental setups, intraoral periapical views are most often used in almost every dental procedure, commencing from basic restorations to complicated procedures like implant placement.³

However, variations in the quality of radiographs may lead to misinterpretation, resulting in incorrect diagnosis and treatment planning. Hence it is of paramount importance that dentists should be well informed and educated about positioning errors, processing errors and radiation exposures.³

Dental X-rays expose patients to relatively low radiation doses. However, several health hazards may arise especially in the head and neck region due to multiple exposures to radiation. This becomes very relevant among pediatric population, as children are most sensitive to radiation, are prone to absorb increased radiation doses, posing an indirect threat to their overall health. The risk of cancer, chiefly in the head and neck region due to radiation exposure has been mentioned in the past. Even though various studies have mentioned the possibility of increased risk for meningiomas due to prolonged radiation exposures, this has been controversial as a meta-analysis stated that there is no distinct and clear association between the both.⁴ Several other studies have reported the increased risk for various cancers associated with dental radiation exposure involving the head and neck region such as brain,^5,6 parotid gland,⁷ thyroid gland,⁸ and even cancer involving breasts.⁹ The situations resulting in radiographs without sufficient diagnostic quality where the radiographs have to be repeated, leads to unnecessary radiation exposure of the patients.¹⁰

It is mandatory for the dental staff to know the potential risks involved in dental radiography and also the significance of precautionary and preventive measures. It is of paramount importance to practice radiation protection by producing radiographs of high diagnostic quality while exposing the patient to the lowest practicable dose, providing the best treatment to the

patient.^11,12

In the present day scenario, it is highly likely that the knowledge and perception on radiographic protection among dental students and graduates is high, but their attitude towards taking appropriate precautions for radiation protection and safety might be low. Especially when there are numerous hazards posed to pediatric patients due to radiation exposure, it is necessary that undergraduates, postgraduates and practicing pediatric dentists must be made aware of the radiation doses, precautions and protocols to be followed for infants, children and adolescents when dealing with dental radiography.

The purpose of the present survey was to evaluate the knowledge and relative prevalence of common errors and negligence towards following proper radiographic techniques and radiation protection measures in pediatric dentistry.

This survey was thus conducted with the agenda of paving a pathway for advocacy research in order to reform policies and reduce errors occurring during practice by directing focus toward improving:

-Knowledge on radiology (technique, exposure, etc)

- Precautionary measures

- Practice attitudes especially in pediatric dentistry

Materials and Methods

A cross sectional study was conducted during the period of February 2022 to March 2022 using the social platforms as a mode of communication to conduct the survey. The present study involved a sample of 150 dental undergraduates, postgraduates and clinical practitioners around the state of Karnataka who deal with radiography on a daily basis in their clinical practice. The ethical clearance was sought from the ethical review board of the Krishnadevaraya College of Dental Sciences and Hospital Ethics Committee [Ethical Approval: KCDS/ Ethical Comm/33/2022-23]

An electronically based structured questionnaire was distributed online as Google form via social media platforms. The questionnaire included demographic data and information regarding knowledge, practice, attitude and common errors in relation to pediatric dental radiography and preventive measures for ionizing radiation, as well. The questionnaire comprised of multiple choice questions and was distributed among dental undergraduates, postgraduates, dental practitioners and pediatric dentists in dental institutions, government hospitals and private clinics in India. The questionnaire was stratified into three sections:

1. Knowledge regarding conventional and digital radiography

2. Knowledge regarding radiation techniques and safety

3. Radiographic practices

Completed questionnaires were collected by the end of March 2022 and the data collected were analyzed using the Statistical Package for Social Sciences [SPSS] for Windows, Version 22.0. (Released in 2013. Armonk, NY: IBM Corp).

Results

Figure 1 represents the distribution of study participants. Out of 145 respondents, 62 (42.8%) were undergraduates and 83 (57.2%) had already attained a bachelor’s degree in dentistry. Almost 50% of the questions regarding knowledge on radiology were incorrectly answered by the undergraduates when compared to the qualified dentists. 

Table 1 presents the comparison of responses to the questions related to knowledge and practices regarding conventional radiography and it was noted that majority of the respondents chose bisecting angle (77.9%) as the most common radiographic technique and the frequently used angulations for maxillary and mandibular primary posteriors as +30^o and -10^o (51.7%). When surveyed for radiographic practices, results showed that majority of the respondents used gloves and barrier envelopes as a measure of asepsis while obtaining radiographs, exposed patients to radiation not more than three times at each appointment and reported cone cut as the most frequent radiological error occurring during radiographic procedures.

Table 2 represents the comparison of responses to questions related to knowledge regarding general radiography in dental practice and the findings demonstrate that majority of population, both undergraduates and graduates were aware that digital radiography produces less radiation during exposure compared to conventional radiography and were also aware of the Position Distance Rule to be 6ft at 90^o -135^o and the protocol of ALARA [As Low As Reasonably Achievable] (No significant difference among undergraduates v/s others). Respondents also reported intraoral periapical radiographs and extraoral orthopantomograms as the most commonly required radiographs, especially in pediatric dentistry. It was also observed that number of respondents unaware of double pack films and their use were significantly high (44.8%). Also, regarding the appropriate radiation dose for intraoral radiography, around 36.6% of the population provided the correct response while 35.2% of the participants were unaware of the radiation dose generally used. Another interesting finding was that an equal number of undergraduate students reported that rectangular or the circular collimator further reduces radiation exposure when compared to each other, which only demonstrates the lack of knowledge regarding the appropriate use of a collimator and prevention of radiation exposure when it comes to dental radiography (Figure 2).

Table 3 represents the comparison of responses to the questions related to radiographic practice in pediatric dentistry. It was observed that majority of the participants used thyroid collars and lead aprons for the patients (49.7%) and practiced standing behind the lead barriers during radiation exposure (61.4%). However, 49.7% of the population stated that intraoral positioning devices were seldom used while taking an Intraoral periapical radiograph (IOPAR) for pediatric patients and majority of the respondents (47.6%) practiced holding the intraoral film in the child’s mouth during radiation exposure.

Table 4 depicts the comparison of responses to the questions related to knowledge on general radiography in dental practice. Majority of the qualified dentists (75.9%) as well as undergraduates (46.8%) were aware of the use of Size 0 film for pediatric patients. The present study findings also indicate that majority of the respondents were aware of the most common intraoral and extraoral radiographs used as well the Position Distance Rule. However, when asked about the minimum age considered safe to expose a paediatric patient to radiation, significant difference (p <0.001) in the responses among the undergraduates and qualified dentists was observed with majority of the undergraduates (54.8%) responding incorrectly as three years and above (Figure 3).

Figure 4 represents the significant differences in responses to questions regarding general radiography. Majority of the qualified dentists (54.2%) agreed that E speed films were the most commonly used films in pediatric dentistry, while majority of the undergraduates (41.9%) were unaware as to which speed film was used.

Owing to the various hazards caused by improper radiation and prolonged radiation exposures, especially among pediatric patients who are more sensitive to radiation, this survey was conducted to evaluate the knowledge, practice and attitudes among dental students and practitioners in India indirectly paving a way to reform policies with education and to reduce future errors during dental radiographic procedures.

Discussion

Radiographs are valuable diagnostic tools in pediatric dentistry and it is of paramount importance that the dentist and the associated dental staff are equipped with knowledge regarding potential errors in techniques and processing of dental radiographs. Errors in radiography in turn lead to repeated radiation exposures resulting in exposure of patients to unnecessary amounts of radiation. The wastage of radiographic films due to these errors adds to needless financial burden.³ 

Apart from patients being exposed to unavoidable radiation during dental diagnosis, dental practitioners also face potential occupational hazards due to repeated radiation exposures. A systematic review conducted in 2018 by Su-Yeon Hwang et al.,² demonstrated statistically significant association between dental X-ray exposure and tumours in the head and neck region such as tumours involving brain, thyroid gland and meningiomas. The review article also found a strong association between the use of full mouth x-rays and risk of developing salivary gland cancer. Outcomes of leukemia, cataracts, low birth weight and thumb carcinomas were also reported in association to being exposed to radiation.

Another literature review by Vissink A et al., (2003) examined 21 papers regarding dental diagnostic radiation exposure and its association to the health hazards and stated that 18 articles proved a statistically significant positive correlation between dental x-ray exposure and risk of cancer in the head and neck regions, especially the brain and thyroid.^13-15 

Halboub et al., in 2015 presented a case report of a dental radiologist who was exposed to dental radiation for 15 long years and developed finger cancer eventually. This report provides evidence that long term exposure to dental radiation can pose a potential risk to overall health.¹⁶

In the following year, another paper by Kim YJ et al., reported that the collective dose for dental professionals who worked for longer time periods was high.¹⁷ Apart from these factors, children in particular are highly sensitive to radiation exposure compared to adults due to their active cell division, putting them at a higher risk for cancer in the head and neck region. Thus, the importance of basic awareness of the minimal doses of radiation exposure, optimum radiographic techniques, radiation protection and latest ICRP [International Commission of Radiological Protection] recommendations should be highlighted, taught and practiced among dental clinicians.^18,2

Almohaimede et al. (2020) in Saudi Arabia stated that in order to decrease the occupational dose, the ICRP recommends to follow three main factors such as shielding walls, positioning x-ray beam in a direction towards the shielded area and the distance of operator from the radiation exposure should be at least six feet away from the patient at an angle of 90°–135° (position distance rule).¹⁹

Lower doses of radiation exposure for longer time periods results in absorption of high levels of radiation dose by the human body and is more likely to cause a stochastic effect. In 2014, the term ALADA (As Low As Diagnostically Acceptable) was introduced by Bushberg as an alternative to the previously termed acronym ALARA (As Low As Reasonably Achievable) to emphasize the seriousness of optimization in medical and dental imaging. Nonetheless, various studies all around the world prove that this is not being followed as required.¹⁹ A literature review in 2020 was done to assess the knowledge of dental practitioners regarding radiation safety and protocol. A large number of published articles during the period 1994-2020 from all over the world, have acknowledged the lack of knowledge regarding radiation protection and techniques followed among dental professionals. The review showed significant results that dental students do not have the basic required knowledge to perform dental radiographic procedures while following radiation safety.^20,21  

Conclusion

Knowledge regarding the appropriate radiation techniques, practice and use of the preventive measures in radiation protection is inadequate, especially among the undergraduate dental students.

The importance of adopting preventive measures for radiation protection needs to be stressed among general practitioners, pediatric postgraduate students, and pediatric dentists belonging to government sectors and private setups. Means to increase awareness and implementation of regulations should be addressed to limit the errors.

The present survey findings not only explored the errors and lacunae in the radiographic procedures but can also assist in paving ways to direct the focus onto curriculum reforms needed to alleviate knowledge and awareness among undergraduates regarding appropriate radiographic procedures and practices, especially in pediatric dentistry.

Conflict of interest

None