RADIOLOGY

TOPIC 5 - PROTEKSI RADIASI

TOPIC 6 - ASPEK LEGAL

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 TOPIC 5 – PROTEKSI RADIASI

1. MAMPU MENJELASKAN DEFINISI DARI PROTEKSI RADIASI

Definition of Radiation
Radiation is the propagation and emission of energy in the form of electromagnetic waves. The
types of radiation include, light, heat and sound. The process of emitting those waves is also
referred to as radiation.
Radiation can best be described as energy which flows from a source that is able to create such
energy. Radiation can flow through air, vacuum or any other medium. Examples of radiation
include light and heat. There are two kinds of radiation, namely electromagnetic (like light rays,
for example), and particulate (e.g. alpha radiation).

What is radiation protection

Radiation protection, sometimes known as radiological protection, is the protection of people and
the environment from the harmful effects of ionizing radiation, which includes both particle
radiation and high energy electromagnetic radiation.

Three basic concepts apply to all types of ionizing radiation. When we develop regulations or
standards that limit how much radiation a person can receive in a particular situation, we
consider how these concepts might affect a person's exposure.

Basic Concepts of Radiation Protection

Time

The amount of radiation exposure increases and decreases with the time people spend near the
source of radiation.

In general, we think of the exposure time as how long a person is near radioactive material. It's
easy to understand how to minimize the time for external (direct) exposure. Gamma and x-rays
are the primary concern for external exposure.

However, if radioactive material gets inside your body, you can't move away from it. You have to
wait until it decays or until your body can eliminate it. When this happens, the biological half-
life of the radionuclide controls the time of exposure. Biological half-life is the amount of time it
takes the body to eliminate one half of the radionuclide initially present. Alpha and beta particles
are the main concern for internal exposure.

Distance

The farther away people are from a radiation source, the less their exposure.

How close to a source of radiation can you be without getting a high exposure? It depends on the
energy of the radiation and the size (or activity) of the source. Distance is a prime concern when
dealing with gamma rays, because they can travel long distances. Alpha and beta particles don't
have enough energy to travel very far.

As a rule, if you double the distance, you reduce the exposure by a factor of four. Halving the
distance, increases the exposure by a factor of four.

Why does exposure change more rapidly than the distance?

The area of the circle depends on the distance from the center to the edge of the circle (radius). It
is proportional to the square of the radius. As a result, if the radius doubles, the area increases
four times.
Think of the radiation source as a bare light bulb. The bulb gives off light equally in every
direction, in a circle. The energy from the light is distributed evenly over the whole area of the
circle. When the radius doubles, the radiation is spread out over four times as much area, so the
dose is only one fourth as much. (In addition, as the distance from the source increases so does
the likelihood that some gamma rays will lose their energy.

Exposure at 2 feet

Exposure at 4 feet

The exposure of an individual sitting 4 feet from a radiation source will be 1/4 the exposure of an
individual sitting 2 feet from the same source

Shielding

The greater the shielding around a radiation source, the smaller the exposure.

Shielding simply means having something that will absorb radiation between you and the source of the
radiation (but using another person to absorb the radiation doesn't count as shielding). The amount of
shielding required to protect against different kinds of radiation depends on how much energy they
have.
 A thin piece of light material, such as paper, or even the dead cells in the outer layer
of human skin provides adequate shielding because alpha particles can't penetrate it.
(Alpha) However, living tissue inside body, offers no protection against inhaled or ingested
alpha emitters.

Additional covering, for example heavy clothing, is necessary to protect against beta-

(Beta) emitters. Some beta particles can penetrate and burn the skin.

Thick, dense shielding, such as lead, is necessary to protect against gamma rays. The
higher the energy of the gamma ray, the thicker the lead must be. X-rays pose a
(Gamma) similar challenge, so x-ray technicians often give patients receiving medical or dental
X-rays a lead apron to cover other parts of their body.

Practical radiation protection tends to be a job of juggling the three factors to identify the most
cost effective solution.

2. MAMPU MENJELASKAN BAGAIMANA CARA MENDAPATKAN

PROTEKSI RADIASI PADA OPERATOR

The procedures outlined in this section are intended to decrease or eliminate radiation exposures
to staff and others. To achieve optimum safety, operators of dental X-ray equipment must make
every reasonable effort to keep radiation exposure to themselves and to others.

General Recommendations

1. A room must not be used at the same time for more than one radiological investigation.
2. All persons, other than the patient and those whose presence is essential, must leave the
room when a radiographic examination is carried out.
3. Personnel must always keep as far away from the primary radiation beam as practical.
Direct radiation exposure to personnel must not occur. Deliberate irradiation of an
individual for training purposes must never be allowed. Anatomical phantoms of the
 human head and jaw regions should be provided for student to practice radiography
during training courses.
4. All personnel must use the protective devices available.
5. The operation of an X-ray tube should be controlled from the control panel located
outside the radiography room or behind a protective barrier. In special circumstances,
where the operator is required to control the loading while at the side of the patient,
protective clothing must be worn.
6. The dental film should be fixed in position with a holding device, whenever possible,
otherwise it should be held by the patient. The dental practitioner or other personnel must
not hold the film in place for the patient during the procedure.
7. When there is a need to support children or weak patients, holding devices should be
used. If parents, escorts or other personnel and be positioned to avoid the primary
radiation beam. No one must regularly perform these duties.
8. An X-ray tube housing must not be held by hand during operation.
9. All operators of X-ray equipment, together with personnel who routinely participate in
radiological procedures must wear personnel dosimeters.
10. The personnel dosimeter must be worn under the protective clothing.
11. Energized dental X-ray equipment must not be left unattended.
12. Where a radiation dose in excess of 5% of the recommended dose limits for radiation
workers is specified and being received by any one person, an investigation about the
causes and appropriate remedial steps must be taken to improve techniques and protective
measures.
13. Dental X-ray equipment must only be operated by individuals who have been trained in
the safe use of the equipment and the procedures being performed.

Continuing education for operators involved in radiographing patients:

These operators are also recommended to attend a continuing education course every 5 years that
covers:

* principles of radiation physics

* risks of ionizing radiation

* radiation doses in dental radiography

* factors affecting doses in dental radiography

* principles of radiation protection

* statutory requirements
3. MAMPU MENJELASKAN BAGAIMANA CARA MENDAPATKAN
PROTEKSI RADIASI PADA PASIEN

"The guiding principle for use of diagnostic radiology in dentistry is to enhance the diagnostic
benefits of dental radiographs and minimize the associated radiation risks to patients and staff."

1.patient selection
2.conduct the examination
3.choice of intraoral technique
4.Processing the film

Patient selection
According to the ADA:
dentists (should) exercise professional judgment when prescribing diagnostic radiographs for
dental patients. Diagnostic radiography should be used only after clinical examination,
consideration of the patient's history and consideration of both the dental and the general health
needs of the patient.

Radiographic selection criteria, also known as high yield or referral criteria, are clinical or
historical findings that identify patients for whom a high probability exists that a radiographic
examination will provide information affecting their treatment or prognosis. When used in
ordering radiographs for caries detection, these guidelines have been found to result in 43%
fewer radiographs being made while missing what was felt to be an insignificant number of
lesions (3.3%).

Conduct of examination is divided to:

1. choice of equipment
2. choice of technique
3. operation of equipment
4. processing and interpetation of radiographic image
Choice of equipment includes:
1. Selection of image receptor
2. Focal spot to film distance
3. X-ray beam collimation
4. Filtration
5. Type of leaded apron collar

1. Receptor selection

According to the ADA,

The basis for selecting film types, film-intensifying screen combinations and other image
receptors is to obtain the maximum sensitivity (speed) consistent with the image quality required
for the diagnostic task.

Intraoral dental x rays film

intraoral dental x-ray film is available in three

speed groups-D, E, and F.

Faster films mean less exposure radiation. However, image quality decreases with increased
speed
The D-speed film is also called Ultraspeed; the E-speed is Ektaspeed; the F-speed is called
InSight

Ektaspeed required 40% less exposure time than Ultraspeed film; InSight film requires 60% less
exposure time than D-speed film and 20% less exposure than E-speed. Insight film has the
highest speed dental film for least radiation exposure for the patient.
With the original invention of regular speed film, A which requires 9s of exposure, it improved to
0.2s with E speed film, and 0.15s in F speed film.
To choose the best film, reduction in patient dose must be balanced against decreased image
resolution.
Studies of diagnostic value suggest that F speed film can still be used in routine radiographic
examinations, and is even capable of producing equal quality images as D and E when processed
in roller transport type automatic processor. But D speed films continue to prevail in popularity

Intensifying screens
Contemporary intensifying screens used in extraoral radiography use the rare earth elements
gadolinium and lanthanum. These rare earth phosphors emit green light on interaction with x
rays. Compared with the older calcium tungstate screens, rare earth screens qecrease patient
exposure by as much as 55% in panoramic and cephalometric radiography.
A further reduction in patient exposure during extraoral radiography can be achieved through T
grain films because of their flat structure enabled a larger cross section area for light gathering:

T-grain film used with rare earth screens is twice as fast as calcium tungstate screen-film
combinations and 11/3 times as fast as conventional rare earth screen-film combinations with no
loss in image quality. This same T-grain technology was incorporated into intraoral film by
Kodak to achieve the faster speeds of E and F films.
 2. Focal spot-to-film distance

The ADA states the following:

The combination of proper collimation and extended source-patient distance (focal spot-to-film
distance) will reduce the amount of radiation to the patient.
There are two standard focal spot-to-film distances (FSFDs) in intraoral radiography,
 20cm (8 inches)
 41 cm (16 inches)

When the x-ray tube is operated above 50 kVp, each of these distances satisfies the federal
regulation that the x-ray source-skin distance must not be less than 18 cm(7 inches) (assuming a
2.5cm [I-inch] distance from the skin surface to the film).
Even so, the FSFD is a subjective decision because it could result in results in less patient
exposure and a better diagnostic image:
Use of an FSFD longer distance results in a 32% reduction in exposed tissue volume.due to less
divergence of the x-ray beam
Also, it would theoretically increase radiograph resolution because of a smaller apparent focal
spot size. (clinical significance has been questioned)

3. Collimation
The ADA recommends the following:
The tissue area (and volume) exposed to the primary x-ray beam should not exceed the minimum
coverage consistent with meeting diagnostic requirements and clinical feasibility.
The federal government requires that the x-ray beam used in intraoral radiography be collimated
so that the field of radiation at the patient's skin surface is "contained in a circle having a
diameter of no more than 7 cm (23/4 inches)" when the x-ray tube is operated above 50kVp. In
view of the dimensions of no. 2 intraoral film (3.2 x 4.1 cm), a field size of this magnitude is
almost three times that necessary to expose the film. Consequently, limiting the size of the x-ray
beam even more than required by law may significantly reduce patient exposure.
Thus, collimation is important that:
  It reduces unecessary patient exposure
 A reduction is scatter radiation gives less film fog and a better image quality

Collimation is achieved using a position indicating device (PID)

But, PIDs must be used with a film holding instrument to center the now narrowed beam size of
the film for better radiographs
There are rectangular and circular PIDs
 4. Filtration

The ADA recommends the following:

Beam filtration should comply with federal and state regulations. The most judicious use of
filtration involves selective filtration of excessively high-energy as well as Excessively low-
energy radiation.

Patient exposure may be reduced even further by removing both low- and high-energy x-ray
photons from the beam, leaving the mid-range energy photons to expose the film. This
suggestion resulted from the finding that the x-ray energies most effective in producing the
image are between 35 and 55keV. Selective filtration of both low- and high-energy photons has
been demonstrated with the rare earth elements samarium, erbium, yttrium, niobium, gadolinium,
terbium activated gadolinium oxysulfide (Lanex, Eastman Kodak), and thulium-activated
lanthanum oxybromide (Quanta III, DuPont). The use of these materials in combination with
aluminum filtration may reduce patient exposure by 20% to 80% compared with conventional
aluminum filtration alone, which attenuates few high-energy photons. However, exposure
reduction achieved with rare earth filtration has costs. Use of these filters requires a significant
increase in exposure time (as much as 50%), increasing both x-ray tube loading and the
possibility of patient movement during exposure. Additionally, image quality may suffer because
of a decrease in contrast, sharpness, and resolution.
 5. Lead aprons and collars

The ADA reccomends the following:

Leaded thyroid collars are strongly recommended. Although scatter radiation to the patient's
abdomen is extremely low, leaded aprons should be used to minimize patient's exposure to
radiation.*

What is ALARA ?
ALARA is an acronym for As Low As Reasonably Achievable. This is a radiation safety
principle for minimizing radiation doses and releases of radioactive materials by employing all
reasonable methods. ALARA is not only a sound safety principle, but is a regulatory requirement
for all radiation safety programs.
This philosophy recognizes the possibility that, no matter how small the dose, some adverse
effect may result. Consequently, any dose that can be reduced without difficulty, great expense,
or inconvenience should be reduced.

Choice of intraoral technique

 Receptor holders or film holders that position the receptor to coincide with the collimated
x-ray beam should be used. Radiographic film or any image receptor should not be held in the
oral cavity by the patient or the dental professional as it could be dangerous. There is a reduction
in number of unacceptable periapical films when film holders were used instead of patient
manual support.
Decision to which technique is used should be based on the diagnostic quality of the
resultant radiographs, the efficiency of using radiation, and the convenience of the technique.
The more efficient the technique, the fewer radiograph retakes will be required along with less
patient exposure.
 Undiagnostic radiographs was reduced when intraoral complete mouth examinations
were made with the paralleling technique instead of the bisection technique which leads to a
significant increase in patient exposure. The Precision instrument with rectangular field
collimation is used instead of the Rinn XCP instrument for parallel film placement as it reduces
patient exposure more.
Operating the equipment

Exposure settings should be established for optimal image quality.

Kilovoltage

A kilovoltage best suited to the diagnostic purpose should be used. The range of 70 to 100
kilovolt peak is suitable for most purposes. Kilovoltage is an important exposure factor that
controls energy of the x-ray beam.
Decrease in kilovoltage will cause a decrease in effective energy of the x-ray beam and
an increase in radiographic image contrast. Image of high contrast enable us to visualize large
differences in density within an object such as caries or soft tissue calcifications. However, the
effect of kilovoltage on the accuracy of caries diagnosis is negligible.
Similarly when the kilovoltage is increased, the effective energy of the x-ray beam is
increased and the radiographic image contrast decreases. Image of low contrast allows for the
visualization of smaller differences in density within an object and this is useful for periodontal
diagnosis, where minute changes in bone can be detected. High-kilovoltage techniques which
produce images of low contrast will reduce the effective dose delivered per intraoral
examination.

Milliampere-second
 Exposure time is the most crucial factor in influencing diagnostic quality among the three
technical conditions (tube voltage, filtration & exposure time). Both overexposed (too dark) and
underexposed (too light) radiographs result in repeat exposures,thereby leading to additional
patient exposure.
Image density is controlled by the quantity of x rays produced which is best controlled by
the combination of milliamperage and exposure time, termed milliampere-second (mAs).
Typically a radiograph of correct density will demonstrate very faint soft tissue outlines. Enamel
and dentin have an optical density of about 1.0. Optimal image density can be obtained by using
values listed, after considering the age and physical stature of the patient. If the kilovoltage is
increased to reduce image contrast, the mAs must be decreased or the radiograph will be
overexposed (too dark).
Phototimer is used to measure the quantity of radiation reaching the film and
automatically terminates the exposure when enough radiation has reached the film to provide the
required density. It is currently available with some panoramic machine.

Processing the film

Film processing should be performed under the manufacturer-recommended conditions

with proper processing equipment and a darkroom with safelights. Alternatively, an automatic
processor with an appropriate safelight hood may be used.
A major cause of unnecessary patient exposure is the overexposure of films compensated
by underdevelopment of the film. This also results in films that are of inferior diagnostic quality
because of incomplete development.
A properly exposed radiograph have no value if all its diagnostic information is lost as a
result of poor processing procedures. Improper processing can cause dental radiographs received
not readable. Time-temperature processing and maintained darkroom is the best way to ensure
optimal film quality. To help ensure optimal image quality, the technician should follow the film
manufacturer's recommendation for processing solutions.
Film processors can increase patient exposure if not correctly maintained. All films
retaken because of incorrect film density were directly related to processor variability.
Interpretation of the image

Radiographic images should be viewed under proper conditions with an illuminated

viewer to obtain maximum available information.
Radiographs are best viewed in a semi-darkened room with light transmitted through the
films without any extraneous light. Radiographs should be studied with the aid of a magnifying
glass to detect even the smallest change in image density. A variable-intensity light source should
also be available. Optimizing the radiologic process is the best way to ensure maximal patient
benefit with minimal patient and operator exposure.

4. MAMPU MENJELASKAN BAGAIMANA CARA MENDAPATKAN

PROTEKSI RADIASI PADA LINGKUNGAN
Shielding and X Ray room design
Purpose of Shielding
To protect:
 the patients (when not being examined)
 the X Ray department staff
 visitors and the public
 persons working adjacent to or near the X Ray facility

Data required include consideration of the design concept of radiation shielding:

 Type of X Ray equipment
 Usage (workload)
 Positioning
 Whether multiple tubes/receptors are being used
 Primary beam access
 Operator location
 Occupancy of Surrounding areas

Equipment design and acceptable safety standards

What equipment is to be used?
 General radiography
  Fluoroscopy (with or without radiography)
 Dental (oral, cephalometric)
 Mammography
 CT

The type of equipment is very important for the following reasons:

 where the X Ray beam will be directed
 the number and type of procedures performed
 the location of the radiographer (operator)
 the energy (kVp) of the X Rays

i) Positioning
The location and orientation of the X Ray unit is very important:
 distances are measured from the equipment
 the directions the direct (primary) X Ray beam will be used depend on the position and
orientation

ii) Surrounding areas

 The X Ray room must be designed with knowledge of the location and use of all rooms
which adjoin the X Ray room
 Obtain a plan of the X Ray room and surroundings (including level above and below)

iii) Usage
 Different X Ray equipment have very different usage.
 For example, a dental unit uses low mAs and low (~70) kVp, and takes relatively few X
Rays each week
 A CT scanner uses high (~130) kVp, high mAs, and takes very many scans each week.

 The total mAs used each week is an indication of the total X Ray dose administered

 The kVp used is also related to dose, but also indicates the penetrating ability of the X
Rays

 High kVp and mAs means that more shielding is required.

Shielding - Construction Problems
Some problems with shielding materials:
 Brick walls - mortar joints
 Lead inadequately bonded to backing
 Joints between sheets with no overlap
 Use of plate glass where lead glass specified

i) Brick walls - mortar joints

 Bricks should be solid and not hollow
 Bricks have very variable X Ray attenuation
 Mortar is less attenuating than brick
 Mortar is often not applied across the full thickness of the brick

ii) Lead inadequately bonded to backing

 Lead must be fully glued (bonded) to a backing such as wood or wallboard
 If the lead is not properly bonded, it may peel off after a few years
 Not all glues are suitable for lead (oxidization of the lead surface)

iii) Joints between sheets with no overlap

 There must be 10 - 15 mm overlap between adjoining sheets of lead
 Without an overlap, there may be relatively large gaps for the radiation to pass through

iv) Use of plate glass

 Leaded glass or acrylic should be used for windows
 Laminated layers of plate glass can be used where radiation levels are low, e.g., for the
wall at the foot of a CT scanner

Conclusion :
The design of shielding for an X Ray room is a relatively complex task, but can be simplified
by the use of some standard assumptions. Record keeping is essential to ensure traceability
and constant improvement of shielding according to both practice and equipment
modification
5. MAMPU MENJELASKAN MACAM – MACAM RADIASI

Main methods of monitoring and measuring radiation dose

There are three main devices (shown in Fig. 6.5), for monitoring and measuring radiation dose:
• Film badges
• Thermoluminescent dosemeters (TLD)
— Badge
— Extremity monitor
• lonization chambers.

Film badges

The main features of film badges are:

• They consist of a blue plastic frame containing a variety of different metal filters and a small
radiographic film which reacts to radiation
• They are worn on the outside of the clothes, usually at the level of the reproductive organs, for
1-3 months before being processed
• They are the most common form of personal monitoring device currently in use.

Advantages
• Provides a permanent record of dose received.
• May be checked and reassessed at a later date.
• Can measure the type and energy of radiation encountered.
• Simple, robust and relatively inexpensive.

Disadvantages
• No immediate indication of exposure — all information is retrospective.
• Processing is required which may lead to errors.
• The badges are prone to filter loss.
Thermoluminescent dosimeters

The main features of TLDs are:

• They are used for personal monitoring of the whole body and/or the extremities, as well as
measuring the skin dose from particular investigations
• They contain materials such as lithium fluoride (LiF) which absorb radiation and then release
the energy in the form of light when heated
• The intensity of the emitted light is proportional to the radiation energy absorbed originally
• Personal monitors consist of a yellow or orange plastic holder, worn like the film badge for 1-3
months.

Advantages
• The lithium fluoride is re-usable.
• Read-out measurements are easily automated and rapidly produced.
• Suitable for a wide variety of dose measurements.

Disadvantages
• Read-out is destructive, giving no permanent record, results cannot be checked or reassessed.
• Only limited information provided on the type and energy of the radiation.
• Dose gradients are not detectable.
• Relatively expensive.

Other ommon types of wearable dosimeters for ionizing radiation include:

 Quartz fiber dosimeter

 Film badge dosimeter
 Solid state (MOSFET or silicon diode) dosimeter

Ionization chambers

The main features of ionization chambers are:

• They are used for personal monitoring (thimble chamber) and by physicists (free-air chamber)
to measure radiation exposure
• Radiation produces ionization of the air molecules inside the closed chamber, which results in a
measurable discharge and hence a direct read-out
• They are available in many different sizes and forms.

Advantages
• The most accurate method of measuring radiation dose.
• Direct read-out gives immediate information.

Disadvantages
• They give no permanent record of exposure.
• No indication of the type or energy of the radiation.
• Personal ionization monitors are not very sensitive to low-energy radiation.
• They are fragile and easily damaged.

Practical radiation measurement is essential in evaluating the effectiveness of protection

measures, and in assessing the radiation dose likely to be received by individuals. The measuring
instruments for radiation protection are both "installed" (in a fixed position) and portable (hand-
held or transportable).

Installed instruments - fixed in positions which are known to be important in assessing the
general radiation hazard in an area. Examples are:

 installed "area" radiation monitors

 Gamma interlock monitors

 personnel exit monitors

 airborne particulate monitors.

The area radiation monitor will measure the ambient radiation, usually X-Ray, Gamma or
neutrons; these are radiations which can have significant radiation levels over a range in excess
of tens of metres from their source, and thereby cover a wide area.

Gamma radiation "interlock monitors" are used in applications to prevent inadvertant exposure
of workers to an excess dose by preventing personnel access to an area when a high radiation
level is present. These interlock the process access directly.

Airborne contamination monitors measure the concentration of radioactive particles in the

ambient air to guard against radioactive particles being ingested, or deposited in the lungs of
personnel. These instruments will normally give a local alarm, but are often connected to an
integrated safety system so that areas of plant can be evacuated and personnel are prevented from
entering an air of high airborne contamination.

Personnel exit monitors (PEM) are used to monitor workers who are exiting a "contamination
controlled" or potentially contaminated area. These can be in the form of hand monitors, clothing
frisk probes, or whole body monitors. These monitor the surface of the workers body and
clothing to check if any radioactive contamination has been deposited. These generally measure
alpha or beta or gamma, or combinations of these.

Portable instruments - Portable instruments are hand-held or transportable. The hand-held

instrument is generally used as a survey meter to check an object or person in detail, or assess an
area where no installed instrumentation exists. They can also be used for personnel exit
monitoring or personnel contamination checks in the field. These generally measure alpha, beta
or gamma, or combinations of these.

Transportable instruments are generally instruments that would have been permanently installed,
but are temporarily placed in an area to provide continuous monitoring where it is likely there
will be a hazard. Such instruments are often installed on trolleys to allow easy deployment, and
are associated with temporary operational situations.
 Hand-held ion chamber survey meter in use
A number of commonly used detection instruments are listed below.
 ionization chambers

 proportional counters

 Geiger counters

 Semiconductor detectors

 Scintillation detectors

 Airborne particulate radioactivity monitoring

TOPIC 6 – ASPEK LEGAL

1. MAMPU MENYEBUT PERUNDANGAN – PERUNDANGAN YANG

MENGATUR TENTANG RADIASI
Ionizing radiation is the subject of considerable safety legislation designed to minimize the risks
to radiation workers and to patients. The International Commission on Radiological Protection
(ICRP) regularly publishes data and general recommendations based on the following general
principles:

Current UK legislation and guidelines

Legislation
There are two sets of regulations in the UK governing the use of ionizing radiation. They both
form part of The Health and Safety at Work Act1974 and comply with the provisions of the
European Council Directives 96/29/Euratom and 97/43/Euratom:

• The Ionising Radiations Regulations 1999 (SI 1999 No. 3232) (IRR 99) which replace the
Ionising Radiations Regulations 1985 (SI 1985 No. 1333).

• The Ionising Radiation (Medical Exposure) Regulations 2000 (SI 2000 No.1059)
(IR(ME)R2000) which replace the Ionising Radiation (Protection of Persons Undergoing
Medical Examination or Treatment) Regulations 1988 (SI 1988 No. 778).

Guidelines
There are three sets of guidelines, namely:

• Guidelines on Radiological Standards in Primary Dental Care published in 1994 by the

National Radiological Protection Board (NRPB) and the Royal College of Radiologists. These
guidelines and their recommendations cover all aspects of dental radiology and set out the
principles of good practice.

• Selection Criteria for Dental Radiography published in 1998 by the Faculty of General Dental
Practitioners of the Royal College of Surgeons of England. This booklet reviews the evidence
for, and provides guidance on, which radiographs are appropriate for different clinical conditions
and how frequently they should be taken.

• Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment published by the
Department of Health in 2001 which brings together the requirements of IRR99 and
IR(ME)R2000 as they relate to dentists, and includes the principles of good practice established
in the 1994 Guidelines.
Summary of the legislation and extracts from the 2001 Guidance Notes for Dental
Practitioners on the Safe Use of X-ray Equipment
Ionising Radiations Regulations 1999 (IRR99)

General points
• These regulations are concerned principally with the safety of workers and the general public
but also address the equipment aspects of patient protection.
• They came into force on 1st January 2000.
• They replace the Ionising Radiations Regulations 1985.

Essential legal requirements

• Authorization. Use of dental X-ray equipment for research purposes should be in accordance
with a generic authorization granted by the Health and Safety Executive (HSE).
• Notification. The HSE must be notified of the routine use of dental X-ray equipment and of any
material changes to a notification including a change in ownership of the practice or a move to
new premises.
• Prior risk assessment. This must be undertaken before work commences and be subject to
regular review. All employers are recommended to record the findings of their risk assessment,
but it is a requirement for employers with five or more employees. A five step approach is
recommended by the HSE:

1. Identify the hazards (i.e. routine and accidental exposure to X-rays)

2. Decide who might be harmed and how they might be affected
3. Evaluate the risks and decide whether existing precautions are adequate or whether more
precautions need to be taken. Implement additional precautions, if needed
4. Record the findings of the risk assessment
5. Review the risk assessment and revise it, if necessary.
• Restriction of exposure.
• Maintenance and examination of engineering controls.
• Contingency plans.
• Radiation Protection Adviser (RPA). A suitably trained RPA must be appointed in writing and
consulted to give advice on IRR99.The RPA should be an expert in radiation protection and will
be able to advise on compliance with the Regulations and all aspects of radiation protection,
including advice on:
— controlled and designated areas for all radiation equipment
— installation of new or modified X-ray equipment
— periodic examination and testing of engineering controls, safety features and warning signals
— systems of work
— risk assessment
— contingency plans
— staff training
— assessment and recording of doses received by patients
— quality assurance (QA) programmes.

• Designated areas. During an exposure, a controlled area will normally be designated around
the X-ray set as an aid to the effective control of exposures. The controlled area may be defined
as within the primary X-ray beam until it has been sufficiently attenuated by distance or
shielding and within 1.5 m of the X-ray tube and the patient. Normally, only the patient is
allowed in this area. This can be facilitated by the use of appropriate signs, as shown. An RPS—
usually a dentist or senior member of staff in the practice—should be appointed to ensure
compliance with IRR99 and the Local Rules. The RPS must be adequately trained and should be
closely involved with the radiography and have the authority to adequately implement their
responsibilities.
Classified persons. Division of staff into classified and non-classified workers and the dose
limits that apply to each group are discussed later. In dental practice, most staff are non-classified
unless their radiography workload is very high.

Duties of'manufacturers. The installer is responsible for the critical examination and report of all
new or significantly modified X-ray equipment, which should include:
— a clear and unambiguous description of the equipment and its location
— an evaluation of the acceptability of the location in relation to the operator's position and the
room's warning signs and signals, if applicable
— an evaluation of the acceptability of the equipment's warning signals
— an evaluation of the acceptability of the exposure control
— confirmation that the equipment's safety features are in place and operating correctly (e.g.
beam dimensions and alignment, beam filtration and timer operation)

• X-ray equipment. All equipment must be critically examined and acceptance tested before
being put into clinical use and then routinely tested as part of a QA programme.
All equipment (X-ray generating and image receptors) should comply with the general
requirements in the regulations namely:

*Intraoral radiography
— Tube voltage should not be lower than 50 kV. New equipment should operate within the range
60-70 kV.
— All equipment should operate within 10% of the stated or selected kV setting.
— Beam diameter should not exceed 60 mm at the patient end of the spacer cone or beam
indicating device.
— Rectangular collimation should be provided on new equipment and fitted to existing
equipment at the earliest opportunity and the beam size should not exceed 40 by 50 mm.
— Total beam filtration (inherent and added) should be 1.5 mm of aluminium for sets operating
below 70 kV and 2.5 mm of aluminium for sets operating above 70 kV and should be marked on
the tube housing.
— The focal spot position should be marked on the outer casing of the tubehead.
— Focal spot to skin distance (FSD) should be at least 100 mm for sets operating below 60 kV
and 200 mm for sets operating above 60 kV.
— Film speed controls and finely adjustable exposure time settings should be provided.
— The fastest film available (E or F speed) that will produce satisfactory diagnostic images
should be used.

*Panoramic radiography
— Equipment should have a range of tube potential settings, preferably from 60 to 90 kV.
— The beam height at the receiving slit of cassette holder should not be greater than the film in
use (normally 125 mm or 150 mm). The width of the beam should not be greater than 5 mm.
— Equipment should be provided with adequate patient-positioning aids incorporating light
beam markers.
— New equipment should provide facilities for field-limitation techniques.

*Cephalometric radiography
— Equipment must be able to ensure the precise alignment of X-ray beam, cassette and patient.
— The beam should be collimated to include only the diagnostically relevant area (see Ch. 13).
— To facilitate the imaging of the soft tissues, an aluminium wedge filter should be provided at
the X-ray tubehead, in preference to one at the cassette.

*All equipment:
— Should have a light on the control panel to show that the mains supply is switched on.
— Should be fitted with a light that gives a clear and visible indication to the operator that an
exposure is taking place and audible warnings should also provide the operator with the same
information
— Exposure switches (timers) should only function while continuous pressure is maintained on
the switch and terminate if pressure is released
— Exposure switches should be positioned so that the operator can remain outside the controlled
area and at least 2 m from the X-ray tube and patient
— Exposure times should be terminated automatically.
Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R 2000)

General points
• These regulations are concerned with the safety of patients.
• They came into force on 13th May 2000.
• They replace the Ionising Radiation (Protection of Persons Undergoing Medical Examination
or Treatment) Regulations 1988.

• New positions of responsibility are defined, namely:

— the employer
— the referrer
— the practitioner
— the operator.

Essential legal requirements

• Duties of employers. The employer (legal person) is the person or body corporate with natural
or legal responsibility for a radiologicalinstallation. He/she is responsible for providing the
overall safety of the practice and for ensuring that staff and procedures conform with the
regulations. In addition, the legal person must provide a framework of written procedures for
medical exposures which should include information on:
— procedures for correctly identifying patients before radiography
— authorization and justification of all clinical exposures to ensure that the justification process
has taken place
— justification of medicolegal exposures
— identification of pregnant patients
— compliance with and details of QA programmes
— assessment of patient dose

• Duties of the Practitioner, Operator and Referrer.

The referrer: a registered doctor or dentist or other health professional entitled to refer a patient
to a practitioner for a medical exposure. The referrer is responsible for supplying the
practitioner with sufficient information to justify an appropriate exposure.

The practitioner: a registered doctor or dentist or other health professional entitled to take
responsibility for a medical exposure. The practitioner must be adequately trained to take
decisions and the responsibility for the justification of every exposure.

The operator: the person conducting any practical aspect of a medical exposure.

Practical aspects include:

* patient identification
* positioning the film, patient or X-ray tubehead
* setting the exposure parameters
* pressing the exposure switch to initiate the exposure
* processing films
* clinical evaluation of radiographs
* exposing test objects as part of the QA programme.
The operator must be adequately trained for his/her role in the exposure (see later).

• Justification of individual medical exposures. Before an exposure can take place, it must be
justified (i.e. assessed to ensure that it will lead to a change in the patient's management and
prognosis) by an IRMER practitioner and authorized as the means of demonstrating that it has
been justified. Every exposure should be justified on the grounds of:
— the availability and/or findings of previous radiographs
— the specific objectives of the exposure in relation to the history and examination of the patient
— the total potential diagnostic benefit to the patient
— the radiation risk associated with the radiographic examination
— the efficacy, benefits and risks of alternative techniques having the same objective but
involving no or less exposure to ionizing radiation.
• Optimization. All doses must be kept as low as reasonably practicable (ALARP) consistent
with the intended purpose. This includes the need to apply QA procedures to the optimization of
patient dose (see Ch. 16).
• Clinical audit. Provisions must be made for clinical audit. Suitable topics could include the
various aspects of the QA programme (see Ch.16), the appropriateness of radiographic requests
and the clinical evaluation of radiographs.
• Expert advice. The regulations lay down the need for, and involvement of a Medical Physics
Expert (MPE) who would give advice on such matters as the measurement and optimization of
patient dose. However, the need for medical physics support in dental practice is fairly limited
and in most cases the RPA should be able to act as the MPE.
• Equipment. The keeping and maintenance of an up-to-date inventory of each item of equipment
is required and should include:
— name of manufacturer
— model number
— serial number or other unique identifier
— year of manufacture
— year of installation.

—Adequate training for other operators:

Dental nurses and other such operators should preferably possess the Certificate in Dental
Nursing or they must have received adequate and documented training specific to the tasks that
they undertake. Dental nurses (or other staff), who simply 'press the exposure button' after the
patient has been prepared by another adequately trained operator, may only do so in the
continued presence and under the direct supervision of that operator.

— Continuing education and training for practitioners:

Continuing education and training in all aspects of dental radiology should be part of
practitioners and operators life-long learning covering all aspects of radiation protection
including:
* principles of radiation physics
* risks of ionizing radiation
* radiation doses in dental radiography
* factors affecting doses in dental radiography
* principles of radiation protection
* statutory requirements
* selection criteria
* quality assurance.

• Lead protection. The confusion and controversy which surrounded the use of lead protection
was the main instigating factor in the 1994 NRPB/RCR guidelines. They concluded that patient
protection was best achieved by implementation of practical dose reduction measures in relation
to clinical judgement, equipment and radiographic technique and not by lead protection. This
view has been endorsed in the 2001 Guidance Notes which state:
— There is no justification for the routine use of lead aprons for patients in dental radiography.
— Thyroid collars, should be used in those few cases where the thyroid may be in primary beam.
— Lead aprons do not protect against radiation scattered internally within the body, and only
provide a practicable degree of protection in the case of the infrequently used vertex occlusal
projection. Even in this case, the use of the lead apron could only be regarded as prudent for a
female patient who is, or may be, pregnant.
— Protective aprons, having a lead equivalence of not less than 0.25 mm, should be provided for
any adult who provides assistance by supporting a patient during radiography.
— When a lead apron is provided, it must be correctly stored (e.g. over a suitable hanger) and
not folded. Its condition must be routinely checked including a visual inspection at annual
intervals.

Specific requirements for women of childbearing age. The developing fetus is most susceptible to
the dangers of ionizing radiation during the period of organogenesis (2-9 weeks) — often before
the woman knows that she is pregnant. IR(ME)R2000 prohibits the carrying out of a medical
exposure of a female of childbearing age without an enquiry as to whether she is pregnant if the
primary beam is likely to irradiate the pelvic area. This is highly unlikely in dental radiography.
Even so, it is recommended, essentially for psychological reasons, that the operator should
enquire of all women of childbearing age whether they are pregnant or likely to be pregnant. If
the answer is yes, then, in addition to the routine protective measures appropriate for all patients,
the following specific points should be considered:
— The justification should be reviewed to ensure that only radiographs that are absolutely
necessary are taken, e.g. delay routine periodic checks.
— The patient should be reassured that a minimal dose is being employed and the patient given
the option to delay the radiography.
— As mentioned earlier, it may be prudent to use a protective lead apron when taking the
infrequently used vertex occlusal projection.

Dose limitation and annual dose limits

For the purposes of dose limitation, the ICRP has divided the population into three groups:
• Patients
• Radiation workers (classified and nonclassified)
• General public.

Patients

Examinations directly associated with illness

• There are no set dose limits.
• The decision to carry out such an investigation should be based on:
— A correct assessment of the indications
— The expected yield
— The way in which the results are likely to influence the diagnosis and subsequent treatment
— The clinician having an adequate knowledge of the physical properties and biological effects.

Systematic examinations (periodic health checks)

• There are no set dose limits.
• The information obtained should be important to the patient's health.

Examinations for occupational, medicolegal or insurance purposes

• There are no set dose limits.
• The benefit is primarily to a third party.
• The patient should at least benefit indirectly.

Radiation workers
Radiation workers are those people who are exposed to radiation during the course of their work.
This exposure carries no benefit only risk. The ICRP further divides these workers into two
subgroups depending on the level of occupational exposure:
• Classified workers
• Non-classified workers.

Classified workers
• Receive high levels of exposure to radiation at work (if Local Rules are observed this is highly
unlikely in dental practice).
• Require compulsory personal monitoring.
• Require compulsory annual health checks.

Non-classified workers (most dental staff)

• Receive low levels of exposure to radiation at work (as in the dental surgery).
• The annual dose limits are 3/10 of the classified workers' limits. Provided the Local Rules are
observed, all dental staff should receive an annual effective dose of considerably less than the
limit of 6 mSv
Hence, the regulations suggest the setting of 'Dose Constraints'. These represent the upper level
of individual dose that should not be exceeded in a well-managed practice and for dental
radiography the following recommendations are made:

1 mSv - for employees directly involved with the radiography (operators)

0.3 mSv - for employees not directly involved with the radiography and for members of the
general public.

In addition to the above dose limits, the legal person must ensure that the dose to the fetus of any
pregnant member of staff is unlikely to exceed 1 mSv during the declared term of the pregnancy.
• Personal monitoring (see later) is not compulsory, although it is recommended if the risk
assessment indicates that individual doses could exceed 1 mSv per year. The 2001 Guidance
Notes state that in practice this should be considered for those staff whose weekly workload
exceeds 100 intraoral or 50 panoramic films, or a pro-rata combination of each type of
examination.

The radiation dose to dentists and their staff can come from:
• The primary beam, if they stand in its path
• Scattered radiation from the patient
• Radiation leakage from the tubehead. The main protective measures to limit the dose that
workers might receive are therefore based mainly on a combination of common sense and the
knowledge that ionizing radiation is attenuated by distance and obeys the inverse square law.
The main dose limitation measures relate to:
• Distance from the source of radiation—staff should stand outside the controlled area (see Fig.
6.1) and not in the line of the primary beam. If these positions cannot be obtained, appropriate
lead screens/barriers should be used
• Safe use of equipment—as summarized in the 2001 Guidance Notes
• Radiographic technique—staff should be adequately trained and follow the recommendations
summarized in the 2001 Guidance Notes
• Monitoring

General public
This group includes everyone who is not receiving a radiation dose either as a patient or as a
radiation worker, but who may be exposed inadvertently, for example, someone in a dental
surgery waiting room, in other rooms in the building or passers-by. The annual dose limits for
this group have been lowered to 1 mSv, as shown in Table 6.2 although the suggested 'Dose
Constraint' is 0.3 mSv (see earlier). The general public are at risk from the primary beam, so
specific consideration should be given to:
• The siting of X-ray equipment to ensure that the primary beam is not aimed directly into
occupied rooms or corridors
• The thickness/material of partitioning walls
• Advice from the RPA (see 1999 Regulations) on the siting of all X-ray equipment, surgery
design and the placement of radiation warning signs.
2. MAMPU MENYEBUT PERUNDANGAN – PERUNDANGAN YANG
MENGATUR TENTANG PERMANFAATAN RADIASI

REGULATIONS GOVERNING THE USE OF RADIATION

Because of their potentially hazardous properties, the use of certain radioactive materials must be
closely regulated to protect the health and safety of the public environment.
Federal agencies have issued regulations designed to protect the environment and the human
population from radiation, including radiation from low-level radioactive waste. Regulations
established by federal agencies can be found in the Code of Federal Regulations (CFR). The
Code is divided into "Titles". Each agency publishes its regulations under an assigned Title.
Titles are further subdivided into "Parts" for specific topics.
Agencies that maintain regulations applicable to low-level radioactive waste are the
 Department of Transportation (Title 49)
 Nuclear Regulatory Commission (Title 10)
  Environmental Protection Agency (Title 40)

Federal Regulations

Department of Transportation (Title 49)

The Department of Transportation's regulations are primarily concerned with the transportation
requirements for "hazardous materials", which include low-level radioactive waste. These regulations
govern, for example, the types of containers that must be used for various materials, labeling on
containers and vehicles, and papers that must accompany each shipment. The Department of
Transportation regulations that affect the shipment of low-level waste are listed in the table below

Table 1. Department of Transportation Regulations

49 CFR General information, regulations, and definitions
171
49 CFR Hazardous materials table, special provisions, hazardous materials communications
172 requirements, and emergency response information requirements
49 CFR General requirements for shipment and packaging
173

Nuclear Regulatory Commission (Title 10)

The Nuclear Regulatory Commission's regulations establish licensing requirements for low-level
radioactive waste disposal facilities and standards for packaging and shipping low-level
radioactive waste. A commercial low-level radioactive waste disposal facility must obtain a
license from the Nuclear Regulatory Commission before it can begin operations. Part 61 of Title
10 of the Code of Federal Regulations (usually denoted 10 CFR 61) establishes the standards for
issuing a license to a low-level waste disposal facility. The regulation includes limits on the
annual radiation exposure allowed at the boundary of the disposal facility site.

Nuclear Regulatory Commission Regulations

10 Requirements for training of radiation workers and inspections of licensed facilities
CFR
19
10 Limits on radiation doses and concentrations of radioactive materials
CFR
20
10 Environmental protection regulations applicable to facilities licensed by the Nuclear
CFR Regulatory Commission
51
10 Requirements for low-level radioactive waste disposal facilities
CFR
61
10 Requirements for packaging and transportation of radioactive materials; standards for
CFR Nuclear Regulatory Commission approval of packaging and shipping procedures
71

A transporter of low-level radioactive waste must comply with both the Nuclear Regulatory
Commission's regulations and those of the Department of Transportation.

Part 20 of Title 10 of the Code of Federal Regulations (10CFR20), is entitled "Standards for
Protection Against Radiation". This regulation was written by the Nuclear Regulatory
Commission to "establish standards for protection against radiation hazards arising out of
activities under licenses issued by the Nuclear Regulatory Commission". It sets limits on
radiation doses for workers in the nuclear industry and for the public. In addition, the regulation
contains tables of the allowable concentrations of various radionuclides in the air and water. It
also states that licensees should attempt to keep all radiation doses and releases of radioactive
material "as low as reasonably achievable".

Environmental Protection Agency (Title 40)

An existing Environmental Protection Agency regulation (40CFR190) sets limits on radiation

doses received by members of the public and on the amount of radioactive materials nuclear
facilities may introduce into the general environment.
Environmental Protection Agency Regulations

40 CFR 190 Limits on radiation doses to the public

40 CFR 193 Radiation protection standards for low-level radioactive waste disposal
(not yet released)

The training as referred, shall at least include material:

a. nuclear legislation;

b. Sources of Radiation in the use of nuclear energy;

c. biological effects of radiation;

d. Radiation units and scale;

e. principles of radiation protection and safety;

f. Radiation measuring instruments, andg. action in a state of emergency.

Article 25

Justification for use of X-rays aircraft referred to in Article 24 paragraph (1a) shall be based on
the consideration that the benefits far outweigh the risk of radiation hazard posed.

Article 26

Doctor or Dentist in the form of a referral or consultation should give providing justification to
Radiation Exposure to the patient for diagnostic purposes or Interventional.

Article 27
Each of Radiology examinations are conducted for purposes of employment, legal, or medical
insurance without clinical indications are not allowed, unless it is necessary to:

a. Provide important information about the health of a person being examined, or

b. The process of proving the occurrence of an offense.

Radiological examination referred to in paragraph

Shall be based on the request Physician or Dentist organization consulted with health-
related professions.

Article 28

Selective examination of the mass of population groups using X-ray plane is only allowed if the
individual benefits are examined or for the population as a whole, is greater than the risk
determined by Radiology Specialists or Doctors Competent.

Article 29

Plane X-ray Mammography may not be used for breast screening when there is no clinical
indication, except for:

a. Women over the age of 40 (forty) years, with consideration that the benefits outweigh
the risks, and

b. Women under the age of 40 (forty) years old and has a history undue risk factors, such
as having a family history of breast carcinoma in the nearby.