BIOLOGICAL RISK, RISKS

ASSOCIATED WITH X-RAYS AND

RADIATION PROTECTION

Dr. Iesha Lapun

Lecturer in Dentistry
SMHS- UPNG
MDS Candidate (Oral Medicine)
(BDS, DipClinDent- UPNG)
Aims and Objectives
By the end of this session, students should be able to;
• To understand and explain what Radiation Injury is.
• To list and explain the classification of the Biological Effects of
radiation.
• To outline and summarize the radiation effect on tissues and cells.
 Introduction
• All ionizing radiations are harmful and produce biologic changes in
living tissues.
• Although the amount of x-radiation used in dental imaging is small,
biologic damage does occur.
• The dental radiographer must have a working knowledge of radiation
biology, the study of the effects of ionizing radiation on living tissue,
to understand the harmful effects of x-radiation.
 RADIATION INJURY
MECHANISMS OF INJURY
• In diagnostic imaging, not all x-rays pass through the patient and reach the
dental x-ray receptor; some are absorbed by the patient’s tissues.
• Absorption refers to the total transfer of energy from the x-ray photon to
patient tissues. When an x-ray energy is absorbed by a patient’s tissues a
chemical change occurs that results in biologic damage.
• Two specific mechanisms of radiation injury are possible:
1. Ionization
2. Free radical formation
 Ionization
• Ionization is produced through the
photoelectric effect or Compton scatter and
results in the formation of a positive atom and
a dislodged negative electron.
• Ionization may have little effect on cells if the
chemical changes do not alter sensitive
molecules, or such changes may have a
profound effect on structures of great
importance to cell function (e.g., DNA).
 Ionization
X-ray photon
interacts with Excitation Chemical
tissue Changes
Break Bonds

Biological
Change

The x-ray photon interacts with tissues and results in ionization, excitation, or breaking of molecular bonds, all of
which cause chemical changes that result in biologic damage.
 Free Radical Formation
• X-radiation causes cell damage primarily through the formation of
free radicals. Free radical formation occurs when an x-ray photon
ionizes water, the primary component of living cells.
• Ionization of water results in the production of hydrogen and
hydroxyl free radicals.
• To achieve stability, free radicals may;
a. Recombine without causing changes in the molecule
b. Combine with other free radicals and cause changes
c. Combine with ordinary molecules to form a toxin (e.g., hydrogen
peroxide) capable of producing widespread cellular changes.
THEORIES OF RADIATION INJURY
• Damage to living tissues caused by exposure to ionizing radiation may
result from a direct hit and absorption of an x-ray photon within a cell
or from the absorption of an x-ray photon by the water within a cell
accompanied by free radical formation.
• Two theories are used to describe how radiation damages biologic
tissues:
I. Direct theory
II. Indirect theory
 Direct Theory
• The direct theory of radiation injury suggests that cell damage results
when ionizing radiation directly hits critical areas, or targets, within
the cell. For example, if x-ray photons directly strike the DNA of a cell,
critical damage occurs, causing injury to the irradiated organism.

• Direct injuries from exposure to ionizing radiation occur infrequently;

most x-ray photons pass through the cell and cause little or no
damage.
 Indirect Theory
• The Indirect theory of radiation injury suggests that x-ray photons are
absorbed within the cell and cause the formation of toxins, which in
turn damage the cell.
• For example, when x-ray photons are absorbed by the water within a
cell, free radicals are formed
• The free radicals combine to form toxins (e.g.,H2O2), which cause
cellular dysfunction and biologic damage.
• Indirect injuries from exposure to ionizing radiation occur frequently
because of the high water content of cells (cells are 70% to 80%
water).
Example s of free radicals created when water irradiated.
Free radicals can combine with e ach other to form toxins such as hydrogen peroxide
 SEQUENCE OF INJURY
1. Exposure to radiation – causing ionization and free radical formation
at the molecular level of cells in the human body.
2. Latent period – the time that elapses between exposure to ionizing
radiation and the appearance of observable clinical signs. It may be
short or long depending On the total dose of radiation received and
the time (rate) it took to receive the dose. The more radiation
received and the faster the dose rate, the shorter the latent period
• Period of Injury – a variety of cellular injuries may result,
including cell death, changes in cell function, breaking or
clumping of chromosomes, formation of giant cells, cessation
of mitotic activity, and abnormal mitotic activity.
• Recovery period – some radiation injuries are temporary,
where cellular damage from radiation is followed by repair.
Most of the damage caused by low-level radiation is repaired
within the cells of the body
• The cumulative effects of repeated radiation exposure can lead
to health problems(e.g. cancer, cataract formation, or birth
defects).
 Determining factors for Radiation Injury
• Total dose – quantity of radiation received, or the total amount of
radiation energy absorbed. More damage occurs when tissues absorb
large quantities of radiation
• Dose rate – rate at which exposure to radiation occurs and absorption
takes place (dose rate=dose/time). More radiation damage takes place
with high dose rates because a rapid delivery of radiation does not allow
time for the cellular damage to be repaired.
• Amount of tissue irradiated – areas of the body exposed to radiation.
Total-body irradiation produces more adverse systemic effects than if
small, localized areas of the body are exposed. Extensive radiation injury
occurs when large areas of the body are exposed because of the damage
to the blood-forming tissues.
• Cell sensitivity – more damage occurs in cells that are most sensitive to
radiation, such as rapidly dividing cells and young cells.
• Age– children are more susceptible to radiation damage than adults.
 Dose Response Curve
• To establish acceptable levels of radiation exposure, it is useful to plot
the dose administered and the damage produced.
• When dose and damage are plotted on a graph, a linear, non
threshold relationship is seen.
BIOLOGICAL EFFECTS
• CLASSIFICATION OF THE BIOLOGICAL EFFECTS
• The biologically damaging effects of ionizing radiation are classified
into two(2) main categories:
1. DETERMINISTIC effects – Somatic
2. STOCHASTIC effects – Somatic & Genetic
- Somatic cells – refers to non reproductive cells
- Genetic cells – refers to reproductive cells
• The Somatic effects are further subdivided into:
• Acute or immediate effects – appearing shortly after exposure, e.g. as
a result of large whole body doses.
• Chronic or long-term effects– becoming evident after a long period of
time, the so called latent period (20years or more), e.g. leukaemia
SOMATIC DETERMINISTIC EFFECTS
• Damaging effects to the body of the person exposed that will
definitely result from a specific high dose of radiation
• Severity of the effect is proportional to the dose received
• Eg. 0.1 Gy- in utero birth defects
0.5 Gy- Cataracts
3.0 Gy- Radiation Burns
Dental X-rays- micro grays
• Appropriate radiation protection mechanisms and occupational
exposure dose limits can be put in place to reduce the likelihood of
these effects occurring
 SOMATIC STOCHASTIC EFFECTS
• These damaging effects may be induced when the body is exposed to
any dose of radiation.
• Their development is random and depends on the laws of chance and
probability. Examples of somatic stochastic effects include leukaemia
and certain tumours.
• Experimentally- it has not been possible to establish a safe dose
• Lower the radiation dose, the lower the probability of cell damage.
 GENETIC STOCHASTIC EFFECTS
• These effects also do not have a dose threshold and are not seen in
the irradiated person but in future generations.
• Mutations result from any sudden change to a gene or chromosome
by ionizing radiation
• Radiation to the reproductive organs may damage the DNA of the
sperm or egg cells. This may result in a congenital abnormality in the
offspring of the person irradiated.
 RADIATION EFFECTS ON CELLS

• The cell, or basic structural unit of all living organisms, is composed

of a central nucleus and surrounding cytoplasm. Ionizing radiation
may affect the nucleus, the cytoplasm, or the entire cell.
• The cell nucleus is more sensitive to radiation than is the cytoplasm.
• Damage to the nucleus affects the chromosomes containing DNA
and results in disruption of cell division, which, in turn, may lead to
disruption of cell function or cell death
• A cell that is sensitive to radiation is termed radiosensitive
• One that is resistant is termed radio-resistant.
• The response of a cell to radiation exposure is determined by the
following:
• Mitotic activity: Cells that divide frequently or undergo many
divisions over time are more sensitive to radiation
• Cell differentiation: Cells that are immature or are not highly
specialized are more sensitive to radiation.
• Cell metabolism: Cells that have a higher metabolism are more
sensitive to radiation.
• Cells that are radiosensitive include blood cells, immature
reproductive cells, and young bone cells. The cell that is most
sensitive to radiation is the small lymphocyte.
• Radio-resistant cells include cells of bone, muscle, and nerve.
 RADIATION EFFECTS ON THE ORGANS
• Cells are organized into the larger
functioning units of tissues and
organs. As with cells, tissues and
organs vary in their sensitivity to
radiation
• Radiosensitive organs are composed
of radiosensitive cells and include the
lymphoid tissues, bone marrow,
testes, and intestines. Examples of
radio-resistant tissues include the
salivary glands, kidney, and liver.
• Cumulative effects of repeated
radiation exposure on tissues and
organs are shown on the right.
 SOURCES OF RADIATION
Source of radiation

Natural/ Background Manmade/Artificial

Cosmic radiation Fallout from nuclear explosions

Gamma radiation Radioactive waste discharged from nuclear
Radiation from ingested isotopes, establishments
e.g in certain foods  Medical and dental diagnostic radiation
Radon and its decay products,  Radiation from occupational exposure
As a gas, radon diffuses readily from rocks through soil and
can be trapped in poorly ventilated houses and then
breathed into the lungs.

Dr. Iesha Lapun, 2021

 RADIATION MEASUREMENTS
• Two systems are used to define
radiation measurements:
• 1. The older system is referred to as
the traditional system, or standard
system; and
• 2. The newer system is the metric
equivalent known as the SI system, or
Système International d’Unités
(International System of Units).
Dr. Iesha Lapun, 2021
• The traditional units of radiation
measurement include the following:
Roentgen (R)
Radiation absorbed dose (rad)
Roentgen equivalent (in) man (rem)
Curie (Ci)
• The SI units of radiation measurement
include the following:
Coulombs/kilogram (C/kg)
Gray (Gy)
Sievert (Sv)
Becquerel (Bq)
Iannucci M Joen and Howerton Laura Jansen, 2017.

Dr. Iesha Lapun, 2021

 DOSIMETRY
Unit of Measurement What it is

Exposure Roentgen (Traditional unit of Energy produced by the x-ray tube

measurement)
SI unit: C/kg= 3.88 X 10 R
Absorbed Dose Gray 3 Energy absorbed in tissues
1 Gy= 100 Rads
Equivalent Dosage Sievert Energy absorbed in tissue multiplied
1 Sievert= 100 rems by radiation weighting factor (usually
1 for x-ray)
Effective Dosage Sievert Energy absorbed in the tissue
1 Sievert= 100 rems multiplied by the tissue factor
 RISK AND RISK ESTIMATES
• A risk can be defined as the likelihood of adverse effects or death
resulting from exposure to a hazard
• In dental imaging, risk is the likelihood of an adverse effect,
specifically cancer induction, occurring from exposure to ionizing
radiation.
• The potential risk of dental imaging inducing a fatal cancer in an
individual has been estimated to be approximately 3 in 1 million
DENTAL RADIATION AND EXPOSURE RISKS
• To calculate the risk from dental imaging procedures, doses to critical
organs must be measured. As previously defined, damage to a critical
organ diminishes the quality of an individual’s life.
• With dental imaging procedures, the critical organs (Risk Elements) at
risk include:
• Thyroid gland – Although the primary beam does not irradiate the
thyroid gland in dental imaging procedures, thyroid radiation
exposure does occur. An estimated dose of 6000 mrad (0.06 Gy) is
necessary to produce cancer in the thyroid gland; such a large dose
does not occur in dental imaging.
• Bone marrow – The areas of the maxilla and mandible exposed during
dental imaging account for a very small percentage of active bone marrow.
The risk of cancer induction (leukemia) is directly associated with the
amount of blood producing tissues irradiated and the dose. Leukemia is
induced most likely at doses of 5000 mrad (0.05 Gy) or more; a dose of
such magnitude does not occur in dental imaging.
• Skin – A total of 250 rad (2.5 Gy) in a 14-dayperiod causes erythema, or
reddening, of the skin. To produce such changes, more than 500 dental
films (F-speed film, exposure rate 0.7 R/second) in a 14-day period would
have to be exposed. This scenario does not occur in dental imaging.
• Eyes – More than 200,000 mrad (2 Gy) are necessary to induce cataract
formation (cloudiness of lens) in the eyes. Again, such high doses are not a
consideration in dental imaging.
 Patient Exposure and Dose
• Dental patients must be protected from excess exposure to radiation.
• The amount of radiation exposure that results from dental imaging varies,
depending on the following;
• Receptor choice: Radiation exposure can be reduced by using digital sensors. The
use of sensors can reduce exposure time by 50% to 90% when compared to
conventional radiography. Radiation exposure can be limited by using the fastest
film available. The use of F speed film instead of D-speed reduces the absorbed
dose by 60%.
• Collimation: Radiation exposure can be limited by using rectangular collimation.
The use of rectangular collimation instead of round collimation reduces the
absorbed dose by 60% to 70%.
• Technique: Radiation exposure can be limited by increasing the target-receptor
distance. The use of the paralleling technique and increased target-receptor
distance reduces the skin dose.
 RISK VERSUS BENEFIT OF DENTAL IMAGES
• X-radiation is harmful to living tissues. Because biologic damage
results from x-ray exposure, dental images should be prescribed for a
patient only when the benefit of disease detection outweighs the risk
of biologic damage.
• When dental images are properly prescribed and exposed, the benefit
of disease detection far outweighs the risk of damage from x-
radiation.
REFERENCES
• Ghom Anil Govindrao, 2008. Textbook of Oral Radiology. Elsevier, New
Delhi, India.
• Iannucci M Joen and Howerton Laura Jansen, 2017. Dental
Radiography Principles and Techniques. 5th ed. Elsevier, Canada.
• Whaites Eric, 2009. Radiography and Radiology for Dental Care
Professionals. Churchhill Livingstone-Elsevier, China.
• White C Stuart and Pharoah J Michael, 2014. Oral Radiology Principles
and Interpretation. 7th ed. Elsevier, Canada.