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To irradiate or not to irradiate?
In another unfortunate and sad case for all concerned, a dentist has been struck off by the General Dental Council (GDC) following a public hearing into allegations of misconduct. Amongst other charges were these simple but so important failings – Failure to conduct necessary assessments, including:
- Failure to conduct full extraoral and intraoral examinations;
- Failure to take routine bitewing radiographs;
Taking x-rays has always been a minefield for us. Some dentists feel it is not worth doing and some are pedantic about getting everything right, and take loads of them. Some dentists read the guidance and feel they need to take more, some read the guidance and interpret them as needing to take less. Some dentists – on a busy and stressful day – just simply forget.
What do we have to do?
Well, we all need to read and know the details enshrined in “Ionising Radiations Regulations 1999 (IRR99) and the Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER)”. This, in itself, is frightening and enough to put you off practice for life. The advice is that we justify each individual exposure, record the results and keep a record of quality. X-ray exposure should only be considered within the risk context of ALARP (As Low as Reasonably Practicable) and an individual exposure considered only if it is going to have an effect on the direction of treatment.
So what does the above mean in clinical terms? Simple and specific guidelines are published by Faculty of General Dental Practice (UK), The Royal College of Surgeons of England in ‘Selection Criteria for Dental Radiography’, and the basic rule is:
Frequency of images is driven by individual risk assessment of likelihood of decay
Risk assessment can be measured by how cariogenic the patient’s diet is, or how good their oral hygiene is. The best and most obvious risk factor is whether or not they actually have active caries in their mouth – right now!
Active caries = ‘High Risk’
Caries at last check-up = ‘Moderate Risk’
No caries recently = ‘Low Risk’
It’s as simple as that!
The guidance says that having made a risk assessment, we then behave as follows:
- Patients at a High risk should have six-monthly Bitewing x-rays until no new or active lesions are apparent and the individual has entered another risk category.
- Patients at a Moderate risk should have annual Bitewing x-rays until no new or active lesions are apparent and the individual has entered another risk category
- Patients at a Low risk should have bi-annual Bitewing x-rays
- Extended periods can then be employed if there is continued explicit evidence of Low risk
The GDC take this aspect of practice very seriously and, if you are ever under investigation, it is one thing they will look for. Additionally, if a patient ever brings a formal complaint you will be very vulnerable to legal action if appropriate rays had not been taken.
Dr John Shapter – QCS Expert Dental Contributor