Issues Related to Standard of Care: ALARA & ALADA

With the increased use of diagnostic radiation within healthcare, it is imperative that dental radiography is used with regard to the overall dose patients may be receiving. The concept of ALARA, As Low As Reasonably Achievable, helps ensure that the radiation dose is kept as low as possible to achieve the desired outcome.7 In fact, there is a call for imaging specialists to educate colleagues regarding the difference between a "beautiful" image and a "diagnostically acceptable" image, which is the premise of the new concept ALADA, or "as low as diagnostically acceptable."12

It is up to the dental radiographer to determine the type of examination and number of images to take according to the individual needs of each patient. The American Dental Association (ADA) has created a guide for determining when to perform various dental radiographic examinations.6 Table 7 outlines the effective radiation doses for various dental radiographic examinations.13 This provides perspective on the amount of radiation required for a full-mouth intraoral series compared to a panoramic image.

Table 7. Effective Radiation Doses for Dental Radiographic Examination.13
Radiographic Exam Average Effective Dose (Adults) in Millisieverts (mSv)
Digital panoramic radiography 0.01
Intraoral X-Ray 0.005
Full mouth series (18 images) with PSP or F-speed film and rectangular collimation 0.035
Bitewing (4 images) with PSP plates or F-speed film and rectangular collimator 0.005

According to White et al., the public is more knowledgeable of the importance of radiation protection, especially at high doses, because of the correlation between radiation and other childhood cancers, like leukemia.14 This is a concern because children are more susceptible to cancers due to radiation exposure as to the high turnover rate of cells during replication.14 The Image Gently in Dentistry campaign has been designed to improve education and awareness of radiation safety in pediatric maxillofacial radiology. One of the educational tools used in the campaign is a "Six-Step Plan" to help minimize radiation to children (Table 8).14

Table 8. Six-step plan to minimize radiation exposure to children.14
1 Select x-rays for patient’s individual needs, not as a routine
2 Use the fastest image receptor possible
3 Collimate the x-ray beam to expose the area of interest only (rectangular collimation is best)8
4 Use thyroid collars
5 Reduce exposure time according to child’s size
6 Use CBCT only when necessary