Dentomaxillofacial Radiology (2005) 34, 304307 q 2005 The British Institute of Radiology http:/ /dmfr.birjournals.

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RESEARCH

Quality control and diagnostic reference levels in intraoral dental radiographic facilities
K Hatziioannou*,1, E Psarouli2, E Papanastassiou3, P Bousbouras4, H Kodona1, O Kimoundri1 and M Delichas3
Medical Physics Department, Papageorgiou Hospital, 56403 Thessaloniki, Greece; 2Medical Physics Department, Ippokratio University Hospital, 54250 Thessaloniki, Greece; 3Medical Physics Laboratory, Medical School, Aristotle University of Thessaloniki, 54006 Thessaloniki, Greece; 4Social Security Institution, 19 Aristotelous st., 54624 Thessaloniki, Greece
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Objectives: A quality control program in intraoral radiographic equipment was conducted aiming to verify compliance with the latest legal requirements and to measure radiation dose in order to contribute to the establishment of appropriate diagnostic reference levels. Methods: This study was performed in 191 intraoral radiographic facilities in Northern Greece. The quality control program included visual inspection of the unit, registration of its characteristics, measurement and calculation of several radiological parameters, including entrance surface dose, and overall compliance with legislation requirements. Results: Most units (61.8%) were found to perform within their corresponding specications. Exposure timer accuracy was the parameter that the dental units showed the poorest performance. Inadequate beam ltration was found in almost half of the older 50 kVp units. Entrance surface dose showed signicant discrepancies, varying from 0.30 mGy to 16.09 mGy with a third quartile value of 3.37 mGy. Conclusions: A diagnostic reference level of 3.5 mGy is considered to be a realistic value for all intraoral equipment currently operating in Greece. However, for newly installed units, a value of 2.8 mGy is considered to be more appropriate. Dentomaxillofacial Radiology (2005) 34, 304307. doi: 10.1259/dmfr/38802780 Keywords: quality control, entrance dose, DRLs Introduction Dental radiographic examinations represent one of the most frequently undertaken radiological examinations in the European Union. In UK alone, a national survey during the period 1997 to 1998 estimated that over 19 million intraoral radiographs were undertaken each year.1 Data concerning 1991 1996 show that in countries belonging in healthcare level I, 365 intraoral examinations were performed, on average, per 1000 population.2 Although the effective dose delivered to the patient per radiograph is relatively small, namely of the order of a few mSv,2 the collective dose to the population is signicant due to the large number of radiographs taken. Furthermore, the large discrepancy in radiation doses delivered due to different exposure conditions, equipment characteristics
*Correspondence to: Konstantinos Hatziioannou, Medical Physics Department, Papageorgiou Hospital, 56403 Thessaloniki, Greece; E-mail: hatzikim@panafonet.gr Received 22 December 2004; revised 16 May 2005; accepted 16 June 2005

and performance has led many countries to revise technical specications and quality criteria for dental radiological practice. Greece has incorporated such guidelines into the recently revised National Radiation Protection Legislation.3 Following new biological information on radiation harm and modied risk estimates, the basic recommendations of the International Commission on Radiological Protection (ICRP) were revised in Publication 604 and new quantities and concepts were introduced. In optimization there was the important new concept of constraint with the main implication in diagnostic radiology being that of dose constraints for the patient. The concept of diagnostic reference levels for patients was rst introduced in ICRP Publication 735 and was adopted by the European Commission.6 The diagnostic reference levels are derived from the observed distributions in large-scale dose surveys and are usually set at the level of the third quartile in the above distributions.

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There are over 7000 dental X-ray facilities operating in Greece. The aim of the present study was to perform a quality control program in intraoral radiographic facilities, to verify compliance with the latest legal requirements and to measure radiation dose in order to contribute to the establishment of appropriate diagnostic reference levels. Materials and methods This study was performed in 191 intraoral radiographic facilities in Northern Greece during 2002 2003. The facilities entered the study after applying for issue or renewal of their operation license to the competent Authorities. The quality control protocol consisted of: (a) visual inspection of the mechanical stability of the X-ray unit; (b) registration of unit characteristics, i.e. manufacturer, model, year of installation, collimator type, focus-to-skin distance (FSD), operating tube potential and tube current, typical irradiation times; (c) measurement and calculation of unit radiological parameters, i.e. radiation eld size, tube potential accuracy and reproducibility, exposure timer accuracy and reproducibility, beam half value layer (HVL), radiation output, typical entrance surface dose; (d) average weekly workload; and (e) overall compliance with radiation protection legislation requirements. According to the Greek Legislation requirements all units must be equipped with an open-ended collimator whose length should not allow FSDs less than 20 cm and eld sizes at FSD larger than 70 mm. It is recommended that the maximum eld size not exceed 60 mm at FSD. Furthermore, tube potential accuracy and reproducibility should be better than ^ 10%. Exposure timer accuracy and reproducibility should be better than ^ 10%. HVL should be more than 1.5 mm Al for units operating at 70 kVp or less. In cases where some of the requirements were not met, corrective measures were suggested and their application was veried on a second visit to the facility. Measurement of parameters Radiation eld size was measured on an appropriately exposed radiographic lm placed in contact with the collimator end. Tube potential was measured using an Unfors Instruments type 9002 kVp-meter (Sweden), which measures tube potential with an accuracy of less than ^ 1%. Five consecutive measurements were performed. Using the following equation, tube potential accuracy was calculated for each of these measurements and the highest value was recorded: kVp accuracy % 100 kVpmeas 2 kVpselect kVpselect

Exposure time and radiation output were measured using a RTI Electronics AP Solid Dose 200 multimeter (Sweden). The accuracy in time measurements was better than ^ 1%, whereas in dose measurements it was better than 2%. Exposure time accuracy and reproducibility were calculated for four frequently used exposure timer settings, using analogous methodology. Radiation output was measured in air at FSD for at least four exposure timer settings and the calculated mean value was expressed in mGy mAs21. HVL was calculated from radiation output measurements at focus-to-dosemeter distance of 50 cm using aluminium lters. The HVL was obtained by plotting the decreasing dose with increasing lter. Entrance surface dose was measured at the surface of a 5 cm thick polystyrene block using the most typical exposure setting. All equipment used for the measurements of radiological parameters was calibrated prior to the onset of the study at appropriate calibration laboratories.

Results Table 1 summarizes some basic unit characteristics such as year of installation, operating high voltage, eld diameter and the number of digital units. Table 2 presents the results of the quality control measurements, displaying the mean values, standard deviations and range for the measured parameters, as well as the number of units that were found not to perform according to the required criteria. The mean values for tube potential and timer accuracy (namely 1.0% and 7.4%) state that, on average, the measured values were found to be 1.0% and 7.4% higher than the corresponding set ones. Mean values for beam HVL and tube output are presented separately according to operating tube potential, since both parameters are strongly affected by the applied high voltage. In Figure 1, all entrance dose values measured for each unit are shown in ascending order. The dotted horizontal line shows the 3rd quartile value (3.37 mGy). Figure 2 presents the distribution of entrance surface doses according to operating high voltage.

Table 1

Summary of basic unit characteristics N (%) 67 (35.6) 121 (64.4) 26 5 10 36 114 (13.6) (2.6) (5.2) (18.8) (59.7)

Basic unit characteristics Year of installation before 2000 after 2000 Operating high voltage 50 kVp 50 60 kVp 60 kVp 65 kVp 70 kVp Field diameter # 60 mm 60 70 mm Number of digital units

Tube potential reproducibility was calculated from the coefcient of variation of the above ve measurements.

169 (90.9) 17 (9.1) 7 (3.7)

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Table 2

QC and DRLs in intraoral radiology K Hatziioannou et al

Results of the quality control measurements Standard Mean deviation Min. Max. 17.4 6.5 77.9 11.8 N out of limit (%) 13 (6.8) 55 (28.8) 1 (0.5)

kVp accuracy (%) kVp reproducibility (%) Timer accuracy (%) Timer reproducibility (%) HVL (mmAl) 50 kVp 50 60 kVp 60 kVp 65 kVp 70 kVp Tube output at FSD (mGy mAs21) 50 kVp 50 60 kVp 60 kVp 65 kVp 70 kVp

1.0 1.0 7.4 1.2 1.6 2.1 1.8 2.2 2.4 0.62 0.46 0.67 0.51 0.65 0.65

5.8 1.1 21.4 2.1 0.2 0.5 0.3 0.3 0.3 0.24 0.32 0.16 0.20 0.23 0.21

2 20.8 0.0 2 51.6 0.0 0.9 1.2 1.2 1.6 1.7 0.10 0.10 0.47 0.16 0.11 0.25

2.1 11 (42.3) 2.5 1 (20.0) 2.1 1 (10.0) 3.0 3.3 1.50 1.30 0.90 0.73 1.30 1.50

HVL, half value layer; FSD, focus to surface distance

Discussion The intraoral units examined cover a wide range of manufacturers and models. The vast majority of the measurements presented in this work concerned dental units installed in newly established clinics, therefore the sample can not be considered to be completely representative of all dental units operating in Northern Greece. On the other hand, the issue of the amended national radiation protection legislation has obliged older installations to replace or modify their equipment in order to comply with the latest requirements. The overall condition of the vast majority of units was satisfactory. No mechanical or electrical instabilities were identied. Seven out of 191 units (3.7%) were digital. The beam limiting devices in 15 units (7.9%) were originally found not to comply with legal requirements: they were

Figure 2 Distribution of entrance surface doses (measured at the most frequently used exposure factors for each unit) for each operating high voltage subgroup

Figure 1 All entrance surface dose values (measured at the most frequently used exposure factors for each unit) shown in ascending order. The dotted horizontal line represents the 3rd quartile value (3.37 mGy)
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either short open-ended or closed-tip cones, allowing for an FSD of less than 20 cm. All these units had their beam limiting devices properly modied in order to full the requirements. The average workload, as stated by the dentists, was found to be 11 radiographs per week, ranging from 5 to 75. It is believed that this number underestimates the true

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workload by about 50%, since many dentists seemed reluctant to state the actual number of radiographs taken. Furthermore, many dentists were just commencing clinical practice, therefore the numbers they stated were based merely on estimates. The quality control measurements revealed that the majority of units conformed to the established requirements, since in 118 units (61.8%) all parameters were found within the corresponding acceptable range. High voltage accuracy was found to be within acceptable limits in 93.2% of all units. High voltage reproducibility was less than 7% in all units. 71.2% of all units showed acceptable timer accuracy, whereas only one unit presented poor timer reproducibility. Inadequate beam ltration was found in 13 units (6.8%), 11 of which were operating at 50 kVp, indicating that almost half of 50 kVp units lacked adequate ltration. Tube output showed a wide range of values (0.1 1.5 mGy mAs21, mean 0.62 mGy mAs21). It should be noted that no actual measurement of the mAs was performed, therefore tube output was calculated based on selected mAs. Entrance doses varied from 0.30 mGy to 16.09 mGy (mean 2.94 ^ 2.17 mGy). The calculated third quartile value was 3.37 mGy. In 11 units (5.8%) the entrance dose exceeded 7 mGy, in 3 of which (1.6%) it exceeded 10 mGy. Entrance doses, as shown in Figure 2, are dependent on the operating high voltage. The mean entrance dose was 4.51 mGy for the 50 kVp units, 3.50 mGy for the
References
1. Tanner RJ, Wall BF, Shrimpton PC, Hart D, Bungay DR. Frequency of medical and dental X-ray examinations in the UK 1997/98. Chilton, UK: NRPB-R320, 2000. 2. United Nations. Sources and effects of ionizing radiation, volume I: sources. United Nations Scientic Committee on the Effects of Atomic Radiation. 2000 Report to the General Assembly, with scientic annexes. United Nation Sales Publication, Sales No E.00.IX.3, New York: 2000. 3. Hellenic Radiation Protection Legislation, FEK 216, 6-3-2001, Athens: 2001. 4. International Commission on Radiological Protection. 1990 recommendations of the International Commission on Radiological Protection. Publication 60. Ann ICRP 21 (1 3), Oxford: Pergamon Press, 1991.

50 65 kVp units and 2.36 mGy for the 70 kVp units. Exposure time is another parameter that signicantly inuences entrance dose. Units producing entrance doses above 3.37 mGy were found to operate at signicantly higher exposure times than those producing doses below this reference value (P , 0.01). For the subgroup of 121 units installed after 2000, the calculated third quartile value was 2.8 mGy. It is suggested that this lower value could be adopted as a diagnostic reference level for newly installed equipment. In the UK, the reference dose for bitewing exposure is 2.5 mGy at 70 kVp and 5.0 mGy at 50 kVp, using Espeed lms.7 Napier8 proposed a UK reference dose of 4 mGy, based on the rounded quartile value of dose values measured in 6344 intraoral units. For units operating at 60 70 kVp using E-speed lm the corresponding third quartile value was 2.1 mGy. Gonzalez et al proposed a Spanish reference dose of 3.5 mGy, derived from quality control tests in 307 units.9 In conclusion, this study should be considered as a preliminary effort to establish diagnostic reference levels in dental radiology in Greece. Considering that there are many old 50 kVp units currently operating in Greece, which are not adequately represented in our sample, it is proposed that a preliminary diagnostic reference level of 3.5 mGy should be adopted as being more realistic. However, for newly installed equipment, a reference value of 2.8 mGy is considered to be more appropriate.

5. International Commission on Radiological Protection. Radiological protection and safety in medicine. Publication 73. Ann ICRP 26 (2), Oxford: Pergamon Press, 1996. 6. European Commission. European guidelines on quality criteria for diagnostic radiographic images. Report EUR 16260. Luxembourg: 1996. 7. The Institute of Physics and Engineering in Medicine. Recommended standards for the routine performance checking of diagnostic X-ray imaging systems, IPEM Report 77. York: IPEM, 1997. 8. Napier I. Reference doses for dental radiography. Br Dental J 1999; 186: 392 396. 9. Gonzalez L, Vano E, Fernandez R. Reference doses in dental radiodiagnostic facilities. Br J Radiol 2001; 74: 153 156.

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