BDA ADVICE NOTE

Advice on guidance: Safe Use of X-ray Equipment 2nd Edition

Here we outline the most significant updates made to the Guidance Notes for Dental
Practitioners on the Safe Use of X-ray Equipment 2nd Edition (2020). This is designed to
provide you with an overview of the most important changes, and abridged extracts are
included. However, members are advised to refer to the original document for complete
information.

Contents:

1. Registering with the Health and Safety Executive

2. Controlled areas - warning signs and/or warning lights
3. Dose monitoring of persons who enter controlled areas
4. Contingency plans - investigate when activated and rehearse
5. Monitor radiation levels at the boundaries of controlled areas
6. Employers to co-operate when employees work on another’s premises
7. CBCT - training required for referrers, practitioners and operators
8. Optimisation of patient dose
9. Acceptance and routine testing
10. QA of digital imaging systems and viewing screens
11. QA of image quality rating and analysis
12. Service engineers, testing of dental X-ray equipment
13. Disposal or selling-on of X-ray equipment
14. Record retention times for IRR17 and IRMER17
15. Appendices to note

1
 1. Registering with the Health and Safety Executive

All dental practices must register their ‘work with a radiation generator’ with the Health and
Safety Executive (HSE), or the HSENI in Northern Ireland and this registration must be
updated if subsequent ‘material changes’ occur (Section 2.2 and Appendix A refers).

Notable points include:

• The ‘certificate of registration’ and ‘summary details of registration’ should be

downloaded and retained by the practice.
• subsequent change in the details submitted to HSE when the registration was first
made will require the employer to amend the relevant details
• only a “material change” will involve payment of another fee – for example, if a
practice starts using mobile X-ray equipment at care homes, this would be a
material change, but simply buying a new type of dental X-ray would not
• If the name or address of the practice changes, this will require the original
registration to be cancelled and a new registration application to be made.

2. Controlled areas - warning signs and/or warning lights

There is updated guidance provided on the extent, duration and demarcation (ie. using
warning signs and/or warning lights) of controlled areas during dental radiography or dental
CBCT imaging (Section 2.11 refers).

Notable points include:

• When a controlled area extends to any entrance to the X-ray room, access through
that entrance must be effectively restricted
• Unless the radiation risk assessment identifies that it is not reasonably practicable
to do so, warning signs should be provided in visible positions at each accessible
entrance to the controlled area, including any entrance at which the operator may
stand to initiate exposures.

3. Dose monitoring of persons who enter controlled areas

New guidance is provided on the legal requirement to assess doses to persons who need to
enter controlled areas (Section 2.14 refers).

Notable points include:

• All staff who enter controlled areas should be issued with an approved dosimetry
service (ADS) personal dosemeter which reports the assessed doses to the
employer
• Issue staff with direct-reading electronic personal dosemeters that are suitable for
use with X-rays
• Keep a log of the doses locally

2
• As part of the arrangements for area monitoring, estimate the annual doses based
on measurements made at the operator’s position.

4. Contingency plans - investigate when activated and rehearse

There are new requirements to formally investigate the circumstances when contingency
plans are activated and they also need to be rehearsed (Section 2.17 refers)

Notable points include:

• Should any contingency plan be enacted, the employer must investigate the
circumstances (in consultation with the RPA) to identify the underlying causes and
to determine if any action is required to prevent a reoccurrence of the incident.
• A record of this investigation should be made and kept for at least two years.
• If any person receives a radiation exposure as a result of the incident, this should
be noted on any relevant dose record.
• If it is suspected that the exposure exceeds a statutory dose limit, then the HSE
must be informed forthwith.
• In addition, contingency plans must be rehearsed at suitable intervals to test their
effectiveness and to ensure all relevant staff are aware of the plans and the actions
that should be taken
• An annual interval would be appropriate, or following any significant changes to the
contingency plans.

5. Monitor radiation levels at the boundaries of controlled areas

The legal requirement to monitor radiation levels at the boundaries of controlled areas
continues and the most appropriate method must be devised in consultation with the RPA
and documented in the risk assessment (Section 2.19 refers).

6. Employers to co-operate when employees work on another’s premises

New guidance outlines the requirement for employers to co-operate when employees work
with dental X-ray equipment on another employer’s premises and this includes
arrangements for the formal handover of responsibility (Section 2.22 refers).

Notable points include:

• Employers whose employees are likely to operate dental X-ray equipment on other
employers’ premises must consult their RPA to ensure their risk assessment, local
rules and contingency plans adequately cover this work
• There must also be suitable arrangements for the handover process put in place
and Appendix C provides a template form for this.

7. CBCT - training required for referrers, practitioners and operators

3
Updated recommendations are provided on the training required for referrers, practitioners
and operators with respect to dental CBCT (Section 3.10 refers)

Notable points include:

• As dental CBCT is not sufficiently taught in undergraduate dental programmes nor

in the professional qualifications of other dental care professionals, further training
is required for all dental practice staff, including those intending to refer patients
• Although IRMER17 does not require any specific training for referrers, it is
recommended that it be undertaken to ensure that referrals are appropriate and in
accordance with current referral guidelines
• Appendix H sets out the “adequate training for work with dental cone-beam CT
equipment”.

8. Optimisation of patient dose

IRMER17 places the responsibility on the practitioner for ensuring patient doses are ALARP
(‘as low as reasonably practicable’) through the appropriate selection of equipment and
methods.

Notable points include:

• The practitioners are the one who justifies the exposure and the operator who
undertakes the exposure.
• Employers should ensure that all staff involved with the selection of X-ray
equipment are aware of patient dose “ALARP”
• Employers should ensure that equipment is designed, constructed and installed in
compliance with recognised British, European or international standards
• The MPE (medical physics expert) must also be consulted on the technical
specifications for equipment, especially with dental CBCT or hand-held equipment.

9. Acceptance and routine testing

Updated guidance is provided on the content of acceptance and routine testing, together
with the recommended intervals between such tests (Section 5.2 refers).

Notable points include:

• IRMER17 requires the employer to undertake adequate testing (‘acceptance

testing’) before X-ray equipment is put to clinical use and installers often provide
this at the same time as the critical examination (also required under IRR17)
• Employers should confirm with the installer that both the critical examination and
acceptance test will be carried out, and a report of the results provided, before
clinical use commences
• Routine tests should normally be carried out at intervals not exceeding three years,
except in the special circumstances (See Section 5.2.3) where annual testing is
recommended

4
• Annual testing should be maintained until the MPE advises that acceptable
performance has been restored or achieved.

10. QA of digital imaging systems and viewing screens

Advice on quality assurance of digital imaging systems and viewing screens has also been
updated (Section 5.3.).

Notable points include:

• Intra oral image/panoramic and cephalometric image receptors – issues include

undertaking a visual inspection and checking for image uniformity and quality
• Display screens will deteriorate over time and should be check and adjusted
regularly
• Where film-based imaging systems are used, strict attention should be paid to
correct and consistent film processing to produce good quality radiographs and
avoid the repeat examinations.

11. QA of image quality rating and analysis

The main reason for the QA programme is to ensure consistent production of adequate
quality radiographs diagnostic purposes, while minimising patient doses. As such, image
quality should be monitored on a regular basis (Section 5.4.).

Notable points include:

• The change from a three-point scale for quality rating to a two-point scale for all
forms of dental radiography and dental CBCT imaging
• Images are now rated either ‘diagnostically acceptable’ (‘A’) or ‘not acceptable’
(‘N’) (see Table 5.2. – Page 92)
• Common faults in conventional dental radiographs and dental CBCT images are
summarised in Appendix J.

12. Service engineers, testing of dental X-ray equipment

Work undertaken by dental X-ray equipment engineers is subject to IRR17 and advice is
under Section 6.1.

Notable points include:

• Advising on issue like adequate room plans and technical details of X-ray
equipment to all allow the practice to consult its RPA over planned
installation/relocation of X-ray equipment
• Installing the equipment and ensuring that the critical examination is completed
satisfactorily
• Passing on adequate information regarding the safe use, testing and maintenance
of the equipment.

5
 13. Disposal or selling-on of X-ray equipment

When X-ray equipment has reached the end of its useful working life, the practice must
make sure it is disposed of with due regard to radiation safety (Section 6.2.).

Notable points include:

• If disposing of, cut the plug off and remove/obscure any trefoil symbols of ionising
radiation hazard that might cause unnecessary alarm
• Ask disposing contractor to provide documentary evidence of its eventual safe and
appropriate disposal.
• If selling/transferring, adequate information must be passed to the new user
regarding the safe use, testing and maintenance of the equipment as would the
original supplier (Section 2.9.1).

14. Record retention times for IRR17 and IRMER17

There is new guidance on retention times for various records required to be kept under
both IRR17 and IRMER17 (Section 6.3.).

Notable points include:

• Because some records are required to be kept, recommended times are suggestion
in Table 6.1 (page 97)
• In addition, NHS GDS record retention timescales are referred to.

15. Appendices to note

A number of helpful appendices are supplied:

Appendix A Registration with HSE (guidance)

Appendix B Proforma risk assessment (IRR17)
Appendix C Template handover form (IRR17)
Appendix D Examples of template employer’s procedures (IRMER17)
Appendix E Template service-level agreement (between referrers and the receiving
practice)
Appendix F Template imaging referral form
Appendix G Guideline exposure protocols
Appendix H Adequate training for work with dental CBCT equipment
Appendix I Adequate testing requirements for X-ray equipment and ancillary equipment
Appendix J Common image quality faults in dental radiographs and dental CBCT imaging
Appendix K Glossary.