Operational Topic

A study simulating clinical use of portable hand-held dental x-ray equipment

indicates that operator exposures can be considered As Low As Reasonably
Achievable (ALARA) when this equipment is used as directed by the manufacturer.

Maintaining Radiation Exposures

As Low As Reasonably Achievable
(ALARA) for Dental Personnel
Operating Portable Hand-Held
X-Ray Equipment
Thomas J. McGiff,*† Robert A. Danforth,‡ and Edward E. Herschaft§
AbstractVClinical experience indicates that unit’s protective backscatter shield. Dose to ography. Clinical experience in-
newly available portable hand-held x-ray the simulated operator was determined using dicates hand-held units produce
units provide advantages compared to tradi- an array of personal dosimeters and a pair
tional fixed properly installed and operated of pressurized ion chambers. The results in- good quality dental imagery while
x-ray units in dental radiography. However, dicate that the dose to an operator of this offering advantages compared to
concern that hand-held x-ray units produce equipment will be less than 0.6 mSv yj1 if fixed units in terms of equipment
higher operator doses than fixed x-ray units the device is used according to the manu- cost, operational efficiency, and
has caused regulatory agencies to mandate facturer’s recommendations. This suggests patient convenience. However,
requirements for use of hand-held units that that doses to properly trained operators of
go beyond those recommended by the manu- well-designed, hand-held dental x-ray units concern for the safety of operators
facturer and can discourage the use of this will be below 1.0 mSv yj1 (2% of the annual has caused numerous state regu-
technology. To assess the need for additional occupational dose limit) even if additional latory agencies to prohibit the use
requirements, a hand-held x-ray unit and no additional operational requirements are of hand-held equipment or to im-
a pair of manikins were used to measure the established by regulatory agencies. This level
pose operating requirements (e.g.,
dose to a simulated operator under two con- of annual dose is similar to those reported as
ditions: exposures made according to the man- typical dental personnel using fixed x-ray units requiring the operator to wear a
ufacturer’s recommendations and exposures and appears to satisfy the ALARA principal for lead apron) that are more strin-
made according to manufacturer’s recom- this class of occupational exposures. Health gent than those recommended
mendation except for the removal of the x-ray Phys. 103(Supplement 2):S179YS185; 2012 by the manufacturer. These ac-
Key words: operational topics; as low as tions create strong disincentives
* University of NevadaYLas Vegas, Risk Management
and Safety, Radiological Safety, 4505 Maryland reasonably achievable (ALARA); safety stan- for employing this new technol-
Parkway, Box 1042, Las Vegas, NV 89154-1042; dards; x-ray machines ogy. This study was conducted to
† Current address: National Institute of Standards and
Technology, Office of Safety, Health and Environ- determine if the use of hand-held
ment, 100 Bureau Drive Stop 1731, Gaithersburg, MD INTRODUCTION
20899-1731; ‡ UNLV School of Dental Medicine, x-ray units in dental radiography
Clinical Sciences Department (Oral and Maxillofacial
Radiology), 1001 Shadow Lane, MS7416, Las Vegas, Portable hand-held x-ray units produces an increase in the level
NV 89106; § UNLV School of Dental Medicine, are now available as an alternative of occupational dose to dental
Biomedical Sciences Department (Oral and Max-
illofacial Pathology), 1001 Shadow Lane, MS7412, to traditional, remotely operated personnel that warrants these ad-
Las Vegas, NV 89106.
The authors declare no conflicts of interest. fixed x-ray units for dental radi- ditional regulatory requirements.
It is well established that the
use of properly installed and op-
erated fixed x-ray units (Fig. 1)
Tom McGiff is a Senior Health Physicist at the National Institute of Standards and is an effective method of dental
Technology (NIST). Before coming to NIST he served as radiation safety officer for
Syracuse University, Cornell University, and UNLV. During this time he was also radiography that produces very
Director of EHS for Syracuse and Associate Director of EHS for Laboratory Safety
at Cornell. He received his M.S. in radiation biology from Colorado State University little occupational dose. The op-
and is certified by the American Board of Health Physics. Tom enjoys hiking, biking, erator exits the exposure room to
kayaking, and sailing and looks forward to each March 17th. His email is
mcgiff@nist.gov. stand behind a protective barrier,
Operational Radiation Safety www.health-physics.com S179

Copyright © 2012 Health Physics Society. Unauthorized reproduction of this article is prohibited.
T.J. McGiff et al.
FIG. 1. The typical arrangement for use of a fixed positioned, wall mounted, or otherwise self-supported, radiographic device to make intraoral
radiographs.
or simply remains at a prescribed
distance from the x-ray source
(usually at least 1.8 m), while
the exposure is being made. This
approach is often considered a
best-practice by the various state
regulatory agencies that govern
use of radiation producing devi-
ces in medicine. The mean annual
whole body dose to dental person-
nel in the US in 1980 is reported
to be in the range of to be 0.2
mSv yj1 to 0.7 mSv yj1 (Kumazawa
et al. 1984). The NCRP has indi-
cated that dental workers are not
expected to receive exposures
above 1 mSv yj1 (NCRP 2010).
These reports indicate that dental
personnel oper ating traditional
fixed x-ray units receive a mean
annual occupational dose that is
approximately 1% of the annual
occupational dose limit specified
by the radiation protection stan-
dards of most states.
New technology now offers an
alternative to fixed dental x-ray
equipment. One example is the
NOMAD (Aribex, 744 South, 400
East, Orem, UT 84097) portable
hand-held x-ray unit that was
approved by the United States
Food and Drug Administration
(U.S. FDA) as a medical device
in 2005. Until recently, this in-
strument has been used almost
exclusively by forensic dentists
to facilitate post-mortem iden-
tifi cation of victims in multi-
ple fatality incidents. Principal
among the catastrophes in which
the NOMAD device has been em-
S180
Copyright © 2012 Health Physics Society. Unauthorized reproduction of this article is prohibited.
ployed include the Indian Ocean
tsunami of 2004 and Hurricane
Katrina in 2005. Despite the suc-
cessful use of the NOMAD unit
in these and similar situations,
employing this type of device in
private dental practices has been
curtailed in the United States by
numerous individual state agen-
cies responsible for the safety of
those who operate radiation emit-
ing devices (Herschaft etal. 2010).
The primary concern motivat-
ing these regulatory actions is the
belief that hand-held x-ray devi-
ces do not keep radiation expo-
sure to dental personnel as low as
reasonably achievable (ALARA).
Fixed dental x-ray equipment pro-
duces very low operator exposures
due to three primary factors: 1) the
physical separation of the operator
from the patient and x-ray equip-
ment, 2) the frequent existence of
walls and other barriers that shield
the operator, and 3) the low risk
that a fixed unit may experience
damage that could compromise
the effectiveness of its internal
shielding. In contrast, operators
of hand-held x-ray equipment
(Fig. 2) stand adjacent to the
patient and the device. The only
protective physical barrier for the
operator is a small backscatter
shield attached to the open end
of the tube head of the unit.
Additionally, hand-held units
are more likely to experience da-
mage that may compromise their
internal shielding. Given these
differences, it is not surprising that
www.health-physics.com
Maintaining ALARA for dental personnel
regulatory agencies are concerned
that a transition from fixed to
hand-held equipment for routine
dental radiography could produce
an undesirable increase in the an-
nual dose to a large population of
workers.
Unfortunately, few sources of
information are currently avail-
able concerning the annual dose
actually received by operators of
hand-held dental equipment. In
2009, a manikin study was con-
ducted at the UNLV School of
Dental Medicine to evaluate oper-
ator dose from leakage and back-
scatter radiation using the NOMAD
unit for simulated diagnostic ex-
aminations (Danforth et al. 2009).
The results of this study indicated
that the annual whole body dose
to an operator making exposures
using recommended and atypical
procedures was 0.45 mSv yj1, or
0.9% of the maximum permis-
sible annual dose. However, this
study did not evaluate operator
dose in terms of maintaining expo-
sures to dental personnel ALARA,
which is essential to determin-
ing the level of regulatory inter-
vention that will produce the
optimum result.
The optimization of control
measures under the ALARA prin-
ciple is intended to include con-
sideration of economic costs and
overall benefits as well as the
consideration of risk to individ-
uals. The National Council on
Radiation Protection and Measure-
ments (NCRP) Report on Radiation
August 2012
The Radiation Safety Journal
FIG. 2. Positioning of operator and patient manikins and placement of LUXEL and TLD dosimeters. Measurements of operator dose were
obtained during simulated routine dental radiography employing a hand-held x-ray unit. Backscatter shield in place (right). Backscatter shield
removed (left).
Protection in Dentistry (2010)
states that, ‘‘For operators and
the public, the ALARA principle
applies to further reduction of
doses that are already below reg-
ulatory limits. The concept may
be extended to patients for whom
no regulatory limits exist. It states
that all reasonable efforts should
be made to reduce or eliminate
avoidable radiation exposure, so
long as scarce resources are not
unduly diverted from other soci-
etal needs that may be more criti-
cal.’’ Articulating the benefits of
hand-held dental x-ray units is
therefore a critical component of
the ALARA process.
The benefits associated with
hand-held dental units stem from
three key factors: equipment cost,
operational efficiency, and pa-
tient convenience. Use of a hand-
held dental x-ray unit can reduce
the investment required to equip
multiple operatories with moun-
ted units in a standard dental pra-
ctice. Reducing the inefficiency of
moving patients to a fixed x-ray
unit when one is not available at
the treatment location is an addi-
tional benefit, because relocation
can be uncomfortable or imprac-
tical for the patient (e.g., during
the administration of general anes-
thesia) and can prolong a proce-
Operational Radiation Safety
Copyright © 2012 Health Physics Society. Unauthorized reproduction of this article is prohibited.
dure. Therefore, regulatory agencies
need to consider the impact of the
restrictive requirements they place
on the use of hand-held dental x-
ray units in regard to these benefi-
cial issues.
This study was conducted to
assess the occupational risk to
dental personnel who operate
hand-held x-ray equipment in
accordance with manufacturer’s
instructions and to evaluate if ad-
ditional regulatory requirements
are necessary to maintain operator
exposures ALARA.
MATERIALS AND
METHODS
Operator exposure to radia-
tion from hand-held dental x-
ray equipment was evaluated
using the NOMAD hand-held x-
ray unit which operates at 60 kV
and 2.3 mA with an exposure
range of 0.01 j0.99 s. The focal
spot is 0.4 mm, inherent filtration
is 1.5 mm Al equivalent, x-ray
beam collimation is 60 mm
(round), and the source to skin
distance is 20 cm (Aribex NOMAD
User Manual 2005). A radiology
training manikin (DXTTR X-ray
Trainer, Dentsply/Rinn Corp.,
1212 Abbott Drive, Elgin, IL
60123) routinely employed in
clinical simulation teaching pro-
www.health-physics.com
Vol. 103, suppl 2 August 2012
grams at the UNLV School of
Dental Medicine was used as the
simulated imaging subject.
Human mandible, maxilla, and
dentition imbedded within the
head of the foam and rubber head
of this manikin provide dental
students the opportunity to
practice a variety of radiographic
techniques. In this study, they
served to produce what are be-
lieved to be realistic levels of
scattered radiation. A cardiopul-
monary resuscitation (CPR)
manikin wearing a lead apron
and thyroid collar to facilitate
placement of the dosimeters, was
used to simulate the operator of
the NOMAD unit.
The patient manikin was seated
in a dental chair and the Nomad
unit was positioned next to the
subject manikin in the orienta-
tion recommended by the manu-
facturer for making typical dental
exposures. The operator manikin
was then positioned consistent
with manufacturer’s instructions
for minimizing operator exposure
during use (Fig. 2).
LUXEL dosimeters were affixed
at nine locations on the outer sur-
face of the operator manikin’s lead
apron and thyroid collar, respec-
tively. These included the bridge
of the nose, left and right lateral
S181
T.J. McGiff et al.
aspects of the neck, and left and
right sides of the upper, mid, and
lower chest. Dose to the extremi-
ties of the operator manikin was
monitored with two thermolumi-
nescent (TLD) ring dosimeters.
One TLD was positioned in the
area of the fingers on each hand of
the simulated operator. The limit
of photon sensitivity for the
LUXEL and TLD dosimeters are
0.01 mSv and 0.3 mSv, respective-
ly. LUXEL and TLD dosimeters
were supplied and read by
Landauer Inc., 2 Science Road,
Glenwood, IL 60425. One set of
dosimeters, in the configuration
described above, was employed
to monitor operator exposure to
scatter radiation in each of two
exposure protocols: 1) a protocol
with the Nomad protective back-
scatter shield in place at the open
end of the tube head as specified
by the manufacturer and 2) a
protocol with the Nomad protec-
tive backscatter shield removed
from the tube head.
Radiation levels were also mea-
sured using two pressurized ion
chambers (Victoreen Model 451P,
Fluke Biomedical, 6920 Seaway
Blvd., Everett, WA 98203). One
instrument was positioned along-
side the operator manikin at mid
chest height and 75 cm from the
head of the patient manikin. The
second instrument was positioned
75 cm from the head of the patient
manikin at 90 degrees to the di-
FIG. 3. Positioning of ion chamber instruments relative to location of operator and patient manikins.
S182
Copyright © 2012 Health Physics Society. Unauthorized reproduction of this article is prohibited.
rection of the x-ray beam (Fig. 3).
The location of the second in-
strument was selected based on
professional judgment to simulate
the exposure to a bystander who
was not protected by the NOMAD
backscatter shield. Manufacturer’s
specifications indicate the accura-
cy of the 451P pressurized ion
chamber is T10% of reading be-
tween 10% and 100% of full-scale
for photon radiation above 25 keV.
Using the NOMAD’s 6-foot-long
remote exposure control cable, a
total of 400 x-ray exposures were
made; 200 exposures for each ex-
perimental protocol as previously
described. NOMAD exposure times
were 0.20 s at 60 kVp and 2.3 mA.
These are the exposure parameters
established for commonly used
dental radiographic image storage
devices, including digital Scan X
(Air Techniques Inc., 1295 Walt
Whitman Road, Melville, NY
11747) phosphor storage plate
sensors and for Insight (Eastman
Kodak Co., 343 State Street,
Rochester, NY 14650) F speed film.
These settings are also compatible
with the guidelines for patient
exposure published by Aribex in
the NOMAD User Manual (2010).
The decision to use 200 x-ray ex-
posures per protocol was based on
the expectation that this would be
sufficient to test the hypothesis
that use of the NOMAD in place
of a fixed x-ray unit would result
in operator doses in excess of
www.health-physics.com
Maintaining ALARA for dental personnel
1 mSv yj1. Readings on the ion
chambers were recorded after every
5 exposures.
RESULTS
Table 1 shows the dose to the
head, torso, and hands of the
simulated operator. With two ex-
ceptions, all measured doses are
less than the limit of sensitivity of
the dosimeters reported by the
manufacturer. The exceptions are
doses to the mid chest right side
and upper chest left side of the
operator manikin for exposures
made without the backscatter
shield in place. These readings
are only three fold greater than
the dosimeter’s limit of sensitivity.
Ion chamber measurements for
locations adjacent to the operator
manikin and at 90 degrees to the
x-ray beam are shown in Table 2.
All are well above the limit of de-
tection for the instruments. Radi-
ation levels adjacent to the
operator increased approximately
10 fold when the backscatter
shield was removed. Radiation
levels at 90 degrees from the beam
are approximately 16 fold greater
than the radiation levels adjacent
to the simulated operator when
the backscatter shield is in-place
and approximately the same as
the radiation levels adjacent to
the simulated operator when the
backscatter shield is removed.
The dosimeter and ion cham-
ber measurements were used to
August 2012
The Radiation Safety Journal Vol. 103, suppl 2 August 2012

Table 1. Dose to simulated operator from 200 radiographs measured with and without the backscatter shield in place.

Backscatter shield in-place (mSv) Backscatter shield removed (mSv)

Dosimeter location Deep Eye Shallow Deep Eye Shallow
Nose Ma M M M M M
Neck right side M M M M M M
Neck left side M M M M M M
Upper chest right side M M M M M M
Upper chest left side M M M 0.03 0.03 0.03
Mid chest right side M M M 0.02 0.02 0.02
Mid chest left side M M M M M M
Lower chest right side M M M M M M
Lower chest left side M M M M M M
Finger right side NAb NA M NA NA M
Finger left side NA NA M NA NA M
a
M = Less than the limit of photon sensitivity for the Luxel and TLD dosimeters of 0.01 mSv and 0.3 mSv, respectively.
b
NA = Not measurable with the type of dosimeter used.

project the annual dose to an
operator using the Nomad for
routine dental examinations in a
typical dental practice. It was as-
sumed that an operator in a busy
dental practice makes 12,500
exposures per year with the
Nomad (50 exposures per day, 5
days per week, 50 weeks per year).
The authors believe it is unlikely
that this usage rate will be reached
or exceeded by a Nomad operator
in a typical dental practice. The
projected annual doses shown in
Table 3 were calculated by ex-
trapolating the results obtained
from the 200 exposures made
during this study to the 12,500
exposures estimated for the an-
nual work load of an actual dental
practice.
Based on dosimeter results, the
projected annual dose to the op-
erator head/torso and extremities
from using the Nomad unit with
the backscatter shield in place
would be less than 0.6 mSv yj1
and less than 20 mSv yj1, respec-
tively. With the backscatter shield
removed, the annual dose to the
head/torso increased to 2 mSv yj1
and the dose to the extremities
Table 2. Radiation levels from 200 radiographs under each of two exposure
scenarios.
Meter location
Adjacent to operator manikin
90 degrees from the beam
a
Extrapolated from a measurement of 0.026 uC kgj1 for 50 radiographs.
Operational Radiation Safety
remained less than 20 mSv yj1.
These are conservative estimates
because they are based on either
the highest recorded dose received
by any one of the dosimeters or,
when no measurable dose was
received, on the limit of sensitiv-
ity of each type of the dosimeter.
Table 3 also includes an alter-
nate estimate of the annual dose
to the head and torso of an oper-
ator. This was determined from
measurements made with the ion
chamber located adjacent to the
operator manikin. Using this meth-
od, the estimated annual dose to
an operator is 0.03 mSv yj1 if
the backscatter shield is in place
and 0.25 mSv yj1 if the back-
scatter shield is not used. These
values are approximately an order
of magnitude below the estimate of
the maximum annual dose derived
from the dosimeter measurements.
The annual dose to a bystander
located near a patient was estimat-
ed from the ion chamber measure-
ments made at a location 90 degrees
from the path of the beam. Re-
gardless of whether the backscat-
ter shield is in place or not, the
level of radiation exposure to an
Backscatter shield Backscatter shield
in-place (uC kgj1) removed (uC kgj1)
0.01a 0.10
0.16 0.12
www.health-physics.com
individual at this location is ap-
proximately equal to that of an
operator making exposures with-
out the protection of the backscat-
ter shield. Although the projected
annual dose to a bystander in this
location during 12,500 exposures
is still low (less than 1 mSv yj1),
it is highly unlikely that an indi-
vidual would be present at this lo-
cation on a routine basis.
DISCUSSION
The development of reliable
hand-held x-ray units for dental
and medical radiography has raised
concern that the use of this type of
equipment as an alternative to fixed
x-ray units for routine examina-
tions would produce unacceptably
high occupational exposures to op-
erators. This study indicates that this
concern is not warranted with re-
spect to dental examinations made
with the particular unit tested and
possibly for similar types of exam-
inations made with comparable
hand-held x-ray units.
No guideline for occupational
radiation exposure levels exists
that is specific for dental radiog-
raphy. A report summarizing oc-
cupational exposures in the U.S.
during 1980 (Kumazawa et al.
1984) indicated that dental equip-
ment operators were among the
least exposed category of radiation
workers. This study indicated that
the mean annual dose equivalent
was 0.2 mSv yj1 among all dental
S183

Copyright © 2012 Health Physics Society. Unauthorized reproduction of this article is prohibited.
T.J. McGiff et al. Maintaining ALARA for dental personnel

Table 3. Projected annual dose to an operator and by-stander with and without the backscatter shield in place.

Operator dose based on Operator based on ion Bystander dose based on ion
dosimeter data (mSv/y) chamber data (mSv/y) chamber data (mSv/y)
Head/torso Extremities Head/torso Extremities Head/torso Extremities
Backscatter shield in-place G 0.6 G 20 0.03 na 0.4 na
Backscatter shield removed 2 G 20 0.25 na 0.3 na

workers and 0.7 mSv yj1 among
those dental workers who received
at least one measurable dosim-
eter reading. In reviewing this
and other data, the NCRP stated
that dental workers are not ex-
pected to receive exposures greater
than the recommended threshold
dose for individual monitoring of
1 mSv yj1 (NCRP 2010). Accepting
1 mSv yj1 (2% of the annual oc-
cupational dose limit) as a guide-
line for satisfying ALARA exposure
for occupational dose to dental
personnel appears quite reasonable.
On the other hand, prohibiting
the use, or establishing addition-
al regulatory requirements for the
use, of a new technology in situa-
tions where occupational doses are
unlikely to exceed 1 mSv yj1 seems
unnecessary. This is especially true
if these requirements impose fi-
nancial burdens and otherwise re-
strict diagnostic and logistical
benefits for patient care.
The simulation described in this
study indicates that the annual
dose to dental personnel who use
the unit according to the manu-
facturer’s instructions will be less
than 0.6 mSv yj1, and perhaps
as low as 0.03 mSv yj1, to the
head and torso. The value of 0.6
mSv yj1 is likely to be an over es-
timate since there was no mea-
surable dose on any dosimeter
following 200 simulated expo-
sures and the detection limit of
the dosimeter was used to calcu-
late the dose. An exposure of 0.03
mSv yj1 may be closer to actual
annual dose received by an oper-
ator because this estimate is based
on readings that were well above
the detection level of the alternate
measurement technique.
Several factors may affect how
well the results of this study pre-
dict the actual exposure to back-
scatter radiation by operators of
hand-held dental x-ray equip-
ment. Foremost is the fact that,
unlike true clinical use, the ori-
entation and locations of the ra-
diation source, scattering material
and detectors used in this study
were static. In addition, the ion
chamber instrument was not posi-
tioned directly behind the Nomad
unit where an operator would be
located and thus the measure-
ments may be biased by the non-
uniformity that is known to exist
in the radiation field surrounding a
dental patient. However, the radi-
ation intensity at a given distance
around the patient is known to
vary by only a factor of approxi-
mately three fold (NCRP 2010).
Even if the extrapolated annual
dose is increased by a factor of
three to allow for the worst case
conditions, the ion chamber mea-
surements suggest an operator’s dose
will still be less than 0.1 mSv yj1.
Adding to the conservative na-
ture of the operator dose estimates
in this study is the fact that they are
calculated on the assumption that
the operator annually performs a
very large number of imaging ex-
posures (12,500 radiographs in a
single year). Additionally, the dose
estimates derived from dosimeter
readings will overestimate the effec-
tive dose equivalent to the operator
due to the non-uniform exposure of
the operator’s body.
This study confirms that use of
the shield is important to limiting
operator exposure. However, it
should be noted that even if the
backscatter shield is never used
(arguably among the worst-case
exposure scenarios) the projected
annual dose to an operator dose
would be 2 mSv yj1 based on the
dosimeter results and only 0.25
mSv yj1 based on ion chamber
measurements. Avoiding this rel-
atively small but unnecessary in-
crease in operator dose could be
accomplished by appropriate train-
ing of operators prior to their use
of this equipment. Formal train-
ing for operators of any type of
dental x-ray equipment is already
a recommendation of the NCRP
(2010) and should be provided
to all individuals who operate
hand-held units.
Results of ion chamber mea-
surements made at 90 degrees
to the direction of the beam in-
dicate that in the event that a
bystander was present in this lo-
cation, the resulting dose would
be approximately 0.4 mSv yj1,
even if that individual was present
during all 12,500 dental exposures.
In actual practice there is no
need for anyone other than the
patient and operator to be in the
immediate area and bystanders
should not be allowed within
2 m of the x-ray unit as recom-
mended by NCRP (2010).
Results of this simulation study
are corroborated by other recent
research involved with monitor-
ing scatter radiation to dental staff
when using hand-held dental x-ray
units in a clinical environment
with actual patients (Gray et al.
2012)**. Bailey et al. stated that
switching from conventional wall
mounted x-ray units to hand-held
units increased the percentage of
dosimeters with no measurable
reading from 78% to 94% and
** Bailey E, Gray J, Ludlow J. Image quality
and radiation does comparison for intraoral
radiography: Hand-held, battery powered ver-
sus conventional x-ray systems. Presented at
the 41st Annual Conference on Radiation Con-
trol Conference of Radiation Control Program
Directors; 2009.

S184 www.health-physics.com August 2012

Copyright © 2012 Health Physics Society. Unauthorized reproduction of this article is prohibited.
The Radiation Safety Journal
decreased the mean monthly dose
to individuals who received a
measurable reading by 33% from
0.027 mSv to 0.009 mSv. These
authors concluded that the annual
dose to the 6% of operators who
received the maximum levels of
exposure to be 0.1 mSv yj1. Their
report further stated that dose to
the patient (both entrance dose
and dose-area product) was essen-
tially equal while the resolution
and contrast produced by the
hand-held unit was superior. Gray
et al. reported that the average
monthly dose for the handheld
systems was 0.28 mSv vs. 7.86 mSv
(deep dose equivalent) for the
wall-mounted systems, a differ-
ence that is statistically signifi-
cant at the p = 0.01 level.
CONCLUSION
This investigation suggests that
the NOMAD hand-held x-ray unit
employed in this study is suitable
for use in routine dental radiogra-
phy provided it is operated accord-
ing to the recommendations of the
manufacturer by properly trained
personnel. This conclusion is sup-
ported by measurements of the
dose received by a simulated op-
erator. These measurements were
made using both personal dosi-
meters and ion chamber instru-
ments during a simulation of 200
x-ray exposures to a dental patient
manikin that is believed to pro-
duce a realistic level of scattered
radiation. An annualized extrap-
olation of these results indicates
that radiation exposure to opera-
tors who use the device according
to the manufacturer’s instructions
would be less than 0.6 mSv yj1.
The factors used to extrapolate
from experimental data to equip-
ment operator annual doses are
believed to be realistic and con-
servative. However, because this
study was limited to static mea-
Operational Radiation Safety
Copyright © 2012 Health Physics Society. Unauthorized reproduction of this article is prohibited.
surements of simulated exposures
made according to the alignment
and positioning recommendations
of the manufacture, variations in
alignment and positioning that are
likely to occur in actual clinical use
are not included in the study. As a
result, the study’s findings are only
an estimate of the dose an oper-
ator would receive in clinical use.
Although no guideline for occu-
pational radiation exposure levels
exists that is specific for dental ra-
diography, it is reasonable to assume
that a technology that maintains
annual radiation exposure to den-
tal personnel below 1 mSv yj1 (2%
of the annual occupational dose
limit), and possibly below 0.1
mSv yj1, while providing benefits
in terms of operating costs, effi-
ciency, and patient comfort and
convenience, is capable of main-
taining radiation exposure to levels
that can be considered ALARA.
Measurements made with the
backscatter shield removed from
the unit indicate that the dose
to an operator would not exceed
2 mSv yj1. This simulation of
improper operator technique veri-
fies the importance of using the
backscatter shield and properly
positioning the unit. However, it
also indicates that this serious de-
viation from proper use technique
would not result in extraordinarily
high exposures to dental personnel.
Recent assessments of the im-
pact of using hand-held x-ray
units in place of traditional fixed
x-ray units for dental radiography
have been conducted (Gray et al.
2012)**. Results and conclusions
of this study can also be corrob-
orated with those stated in these
recent reports. Thus, the infor-
mation available at this time does
not support a prohibition on the
use of hand-held x-ray units in
dental radiography or the need
to mandate precautions or restric-
tions beyond those identified by
www.health-physics.com
Vol. 103, suppl 2 August 2012
the manufacturer. As such, signif-
icant benefit or reduction in staff
radiation dose through mandated
precautions requiring additional
shielding efforts, (e.g., wearing a
lead apron) is not indicated. How-
ever, any operator concerned about
additional exposure when using
this hand-held x-ray unit can
choose to take appropriate shield-
ing precautions and/or use radi-
ation monitoring devices.
AcknowledgmentsVThe study investigators
were not financially remunerated and
have no financial investments in Aribex,
Inc. (744 South 400 East, Orem, UT 84097),
Landauer, Inc. (2 Science Road Glenwood,
IL 60425), or Fluke Biomedical (6920 Sea-
way Blvd, Everett, WA 98203). The NOMAD
x-ray unit, the VICTOREEN Model 451P
(Fluke Biomedical) pressurized ion chamber
instruments, the dosimeters, and the DXTR
X-ray Trainer (Dentsply/Rinn Corporation)
were obtained from the University of
Nevada Las Vegas (UNLV).
REFERENCES
Aribex NOMADi Dental Portable X-ray
System for Intraoral Radiographic Im-
aging. User manual. Orem, UT: Aribex,
Inc; 2005, 2010.
Danforth RA, Herschaft EE, Leonowich JA.
Operator exposure to scatter radiation
from a portable hand-held dental radia-
tion emitting device (Aribexi NOMADi)
while making 915 intraoral dental radio-
graphs. J Foren Sci 54:415Y421; 2009.
Gray JE, Bailey ED, Ludlow JB. Dental staff
doses with handheld dental intraoral x-
ray units. Health Phys 102:137Y142; 2012.
Herschaft EE, Hermsen KP, Danforth RA,
McGiff TJ. Current radiation safety reg-
ulatory policies and the utilization sta-
tus in the United States of the Nomadi
portable hand held dental radiation
emitting device. Presented at the 62nd
Annual Meeting of the American Academy
of Forensic Sciences; Colorado Springs,
CO: The American Academy of Forensic
Sciences; F50, Vol 16: pp 265Y66, 2010.
Kumazawa S, Nelson DR, Richardson ACB.
Occupational exposure to ionizing radi-
ation in the United States: A compre-
hensive review for the year 1980 and a
summary of trends for the years 1960-
1985. Springfield, VA: National Techni-
cal Information Service; EPA 520/1Y84/
005; 1984.
National Council on Radiation Protection
and Measurements. Report on radiation
protection in dentistry. Bethesda, MD:
NCRP; 2010.
S185