Vol. 132 No.

5 November 2021

Estimation of x-ray radiation related cancers in US dental

offices: Is it worth the risk?
Douglas K. Benn, BDS, M Phil, DDS, PhD, Dipl Dental Radiology (Royal College of Radiologists,
England),a,b,1 and Peter S. Vig, DDS, PhD, JD, DOrth, FDSc,1

Objectives. The objective of this study was to estimate the possible number of cancer cases produced during 2019 in US dental
offices from radiography, estimate the possible reduction in those rates resulting from use of intraoral rectangular collimation and
selection criteria, and determine the frequency and quality of website radiation risk information and informed consent forms.
Study Design. An analysis of dental radiation examinations in 2014 to 2015 US national survey data, Nationwide Evaluation of
X-ray Trends, and National Council on Radiation Protection and Measurements surveys was performed, in addition to an analysis of
2008 to 2020 Journal of Clinical Orthodontics national orthodontic surveys for radiographic examination frequencies. Lifetime
attributable cancer risk estimates from US and European studies were used to generate the total dental and orthodontic office cancer
totals. In total, 150 offices were examined online for the quality and frequency of risk information in websites and consent forms.
Results. The 2019 estimate for all office cancers is 967. Collimation and selection criteria could reduce this to 237 cancer cases.
Most cancers arise from intraoral and cone beam computed tomography examinations, with 135 orthodontic cancers over 21
months (average treatment time). Collimation and selection criteria could reduce this to 68. Only 1% of offices use collimators or
informed consent for radiography. The website and consent information were of poor quality.
Conclusions. Dentists are not following selection criteria or using collimators according to guidelines. Up to 75% of cancer cases
could be avoided. (Oral Surg Oral Med Oral Pathol Oral Radiol 2021;132:597
608)

It is just over 125 years since Wilhelm Conrad from stochastic, random effects of ionizing radiation
R€ontgen discovered x-rays, with clinical applications exposure, causing sufficient damage to cells to lead to
commencing within months.1 Although the diagnostic cancer, DNA damage, or death of single cells. The risk
benefits were easily appreciated, the carcinogenic of cancer development from very low x-ray doses,
potential of low dose x-ray examinations was not using the linear no-threshold hypothesis,5,6 has been
known for a long time.2 X-ray exposures can be estimated from higher doses caused by atomic bombs
divided into high-dose, such as radiotherapy and fluo- and nuclear accidents. Because low-dose stochastic
roscopy, and low-dose diagnostic radiology. Once a cancers have no unique cellular characteristics to dif-
patient receives more than approximately 2 Gy of ferentiate them from cancers caused by chemicals,
absorbed dose to the skin, erythema can be seen.3 At viruses, and natural background radiation, predictions
these x-ray dose levels and above, the dose is classified of cancer generation are statistical.5 Any individual
as deterministic, meaning that it is high enough to guar- cancer in the head and neck region may be associated
antee observable side effects. Dental x-ray diagnostic with diagnostic radiation exposure, but cause and effect
examinations are nondeterministic because the effec- cannot be proven. Nevertheless, the linear no-threshold
tive doses (EDs) are in the range of 3 to 1000 mSv.4 At hypothesis for cancer is widely accepted and forms the
these levels there are almost always no clinically basis for teaching ALARA, exposing patients to doses
observable signs of radiation damage and the risk is as low as reasonably achievable.
“Dental x-rays are the most frequently used radio-
logic procedure in the US for healthy individuals.”
(page 108)6 For many years, researchers have been
a
Retired Professor, Division of Oral and Maxillofacial Radiology,
Department of Diagnostic Sciences, Creighton University, Omaha, measuring and estimating the doses and risks from den-
NE, USA.
b
Professor Emeritus, Division of Oral and Maxillofacial Radiology,
tal radiography; intraoral (IO), panoramic (Pan), cepha-
Department of Oral Sugery, University of Florida, Gainesville, FL, lometric (Ceph), and, more recently, cone beam
USA.
c
Former Professor and Chair, Section of Health Services Research,
The Ohio State University College of Dentistry, Columbus, OH, USA.
1
Statement of Clinical Relevance
Drs. Benn and Vig are members of the Clinical Advisory Board,
Smiles Direct Club PLC. US dentists may cause 967 cases of cancer per year
Received for publication Nov 6, 2020; returned for revision Dec 17,
2020; accepted for publication Jan 25, 2021.
from dental radiography. Use of rectangular collima-
Ó 2021 The Author(s). Published by Elsevier Inc. This is an open tion and selection criteria could reduce this to 237.
access article under the CC BY-NC-ND license (http:// The trend in orthodontic treatment is to replace lower
creativecommons.org/licenses/by-nc-nd/4.0/) dose panoramic and cephalometric radiography with
2212-4403/$-see front matter higher dose cone beam computed tomography.
https://doi.org/10.1016/j.oooo.2021.01.027

597
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598 Benn and P.S. Vig November 2021

computed tomography (CBCT).6 However, simple rec- (ADA) recommended “full-mouth series every 3 to
ommendations, such as using selection criteria7 to 5 years and bitewings every 1 to 2 years.” (Page A9)19
reduce the number of unnecessary radiographs and the In a limited hospital study, parents have reported not
implementation of rectangular collimation for intraoral receiving sufficient or understandable information
equipment8 to reduce the dose of IO, have not been regarding radiation dose and available imaging alterna-
widely adopted.8 Dose reductions of 80% have been tives to x-ray
based examinations.20 It is important to
reported when using rectangular collimators (RCs) and know what information patients are provided with, rel-
RCs with thyroid shields in children.4 The Nationwide evant to dental radiography, for informed consent. A
Evaluation of X-ray Trends (NEXT) dental survey review of the literature did not provide this for general
found that only 0.6% of offices used rectangular colli- dentistry, pediatric dentistry, or orthodontics offices.
mation in 2014 and 2015.8 A recent survey of pediatric The aim of this article was to estimate (1) the possi-
dentists reported that only 22% used rectangular ble total rates for cancer incidence in the United States
collimation.9 associated with dental and maxillofacial radiology, (2)
Previous work on dental radiography risk estimates the potential decrease in radiation dose if IO rectangu-
has described risk in terms of fatal cancer cases per lar collimation is used and if selection criteria are used
1 million radiographic examinations,10 per 100,000 for prescribing radiographs, and (3) the quality and
examinations,11 and even 3 per 18,200 examinations.12 number of informed consent forms.
However, no recent paper has presented a projection
for the total number of possible cancer cases resulting METHODS
from all dental offices or by specialty in the United Estimates for the number of examinations for the US
States. Children are especially sensitive to x-rays, with population from dental radiography (IO, Pan, CBCT)
girls more than twice as sensitive as boys.11,12 Children were derived from 2 reports: the 2014 to 2015 NEXT8
aged 11 to 15 years have more than twice the risk of and Medical Radiation Exposure of Patients in the
22-year-olds.11,12 Ludlow et al. estimated the risks for United States.21
IO, Pan, and Ceph examinations in 2008, but there was Estimates for the number of examinations for people
no assessment of the effects of age and sex.10 Recently, undergoing a course of orthodontic treatment in 2020
Johnson and Ludlow published estimates of ED using to 2021 were derived from the 2020 Journal of Clinical
phantoms to represent adults and 10-year-old chil- Orthodontics (JCO) study of orthodontic diagnosis and
dren.13 In 2008, CBCT was a relatively new radio- treatment procedures.14
graphic technology and was not included in the Estimates for the rate of cancer incidence per 1 mil-
estimations.10 Since then, CBCT has seen large market lion IO, Pan, and Ceph radiographic examinations
growth in US dental offices, especially in orthodontic were derived using data from Ludlow et al.10 and John-
practice, with an increase from 2% of all children in son and Ludlow.13 Corresponding estimates for CBCT
2008 to 16% in 2020 routinely undergoing CBCT examinations were derived from Hedesiu et al.11
examinations.14 In addition, a 2010 survey reported
that 18% of orthodontic residency programs routinely US population
used CBCT examinations on every patient.15 There- Intraoral risk estimation. The NEXT survey was per-
fore, it is important to study the radiation risks for formed from 2014 to 2015 and surveyed 199 dental
child orthodontic patients, because they have been offices.8 Since the survey, the number of dentists in the
reported as receiving multiple radiographic examina- United States has increased by 1.04% to 201,515 as of
tions from IO, Pan, Ceph, and CBCT in one course of 2019.22 The NEXT estimates for the number of radio-
treatment.14 graphic examinations were projected to 2019 using that
Dental patients are required to read and sign figure. The National Council on Radiation Protection
informed consent forms before any dental treatment and Measurements (NCRP) report21 stated that 72% of
can be performed.16 For a consent to be valid, the fol- patients receiving IOs were adults and 28% were chil-
lowing conditions apply: “(1) patient competence dren. These numbers were used to divide the total num-
(legal ability and capacity to understand and decide), ber of examinations into those for adults and those for
(2) disclosure of material information (in this case by children. The NEXT IO estimates were for the num-
the dentist), (3) understanding (by the patient), (4) vol- ber of complete radiographic examinations, not indi-
untariness (with respect to the patient), and (5) consent vidual intraoral radiographs. To use the Ludlow risk
(patient authorization to proceed).” (page 78)16 A num- estimates,10,13 it was first necessary to convert the
ber of studies have reported that dental informed con- NEXT IO examinations into full mouth x-ray
sent forms fail to comply with those aims.17,18 Geist (FMX) for adults or 4 bitewing (BW) equivalents
reported that some dental x-ray informed consent forms for children. NEXT provided the average number of
incorrectly stated that the American Dental Association IOs per examination for young children, children/
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Volume 132, Number 5 Benn and P.S. Vig 599

Table I. Estimation of US LAR for cancers generated in 2019 by dental radiography from NEXT8 and NCRP21 2014
to 2015 surveys
Type of radiographic No. of Equivalent Equivalent LAR for cancer Total no. of cancer cases for all radiographs
exam exams FMX 4 BWs per 106 exams* from each type of exam
Selection criteria

43% exams
Intraoral
Adult 216,103,680 95,085,619 7.5 713{ 193z 110
Child 84,040,320 18,675,627 6.1 114{ 83z 47
Total IO examsx 300,144,000 827{ 276z 157
Pan
Adult 16,370,554 2.2 36 21
Child 6,366,326 3.0 19 11
Total Pan examsx 22,736,880 55 32
Ceph
Adult 688,919 0.5 0.3 0
Child 1,771,507 1.1 1.9 0
Total Ceph examsk 2,460,427 1 0
CBCT
Adult 3,708,000 6.3 23 13
Child 1,468,000 41.5 61 35
Total CBCTx 5,176,000 84 48
Total x-ray exams 330,517,307
Total cancer cases 967 416 237
LAR, lifetime attributable risk; NEXT, Nationwide Evaluation of X-ray Trends; NCRP, National Council on Radiation Protection and Measure-
ments; FMX, full mouth x-ray; BW, bitewing; IO, intraoral; Pan, panoramic; Ceph, cephalometric; CBCT, cone beam computed tomography.
*LAR of cancer is calculated for children aged 10 to 12 years and adults aged 30 years.ySelection criteria estimate a 43% reduction in examina-
tions except Ceph, because risk equates to only 1 cancer case.
{Round collimation.
zRectangular collimator reduces ED by 73% (from 80% - 7% re-exposures).
xAll radiographic totals increased by 1.04% to match 2019 increase in dentists.
kTotal Cephs = 0.75% of all IO, Pan, and CBCT examinations.

adolescents, and adults. NEXT also provided the For adults, the average number of IOs, including re-
number of re-exposures per examination. By com- exposures, was 8.8 Assuming that a FMX had 18 radio-
bining these numbers, it was found that the average graphs, 8 radiographs were equivalent to 0.44 FMX.
young child or child/adolescent had 4.5 intraoral The FMX equivalents were generated by multiplying
exposures per examination. Because most of these this number times the number of adult examinations.
were likely BWs, it was assumed that each child The adult FMX ED was 86 mSv (0.086 mSv).13 This
examination was equivalent to 4 BWs. The BW assumed photostimulable phosphor plates or F-speed
dose was estimated by taking the ED of 89 mSv for film and a round collimator.13 The average LAR for a
the 10-year-old FMX of 12 IOs13 and dividing this 30-year-old male or female is 875 (BEIR VII, table
by 3, producing a 4 BW ED of 30 mSv. The 4 BW 12D1).5 Using the same calculation described above to
lifetime attributable risk (LAR) for 10-year-olds estimate the child BW LAR, the 30-year-old adult
was calculated from the BEIR VII (Biological LAR was 7.5 cancer cases per 1,000,000 examinations.
Effects of Ionizing Radiation; table 12D1),5 which The total number of cancer cases from IO examina-
contains the number of predicted lifetime cancer tions was multiplied by 0.2 to estimate an 80% reduc-
cases per 100,000 persons exposed to a single dose tion in cancer cases due to using RCs in adults and RCs
of 0.1 Gy. The 30 mSv ED was converted into with thyroid shields in children.4 However, due to cone
0.030 mSv to match the 100 mGy units used in the cuts that may make the image nondiagnostic, about 7%
LAR table. Because the BEIR VII table is for of these exposures will need to be repeated, reducing
100,000 exposures, the LAR number was multi- the dose saved from 80% to 73%.23-26 Therefore, the
plied by 10 to adjust for 1,000,000 exposures. IO total risk was reduced by 73%. A further reduction
The BEIR VII LAR is 2611 for 10-year-old girls of 43% was applied by assuming that selection criteria
and 1445 for boys. The average for both sexes is 2028. would be used by all dentists.27-29
By multiplying 2028 by 0.030 mSv and dividing by 10,
the LAR for a 10-year-old child is 6.1 cancer cases per Panoramic risk estimation. The NEXT survey did not
1,000,000 exposures (Table I). contain an estimate of the annual examination
ORAL AND MAXILLOFACIAL RADIOLOGY OOOO
600 Benn and P.S. Vig November 2021

workload because of the lack of reliable estimates for estimated to be 41.5 per million examinations (children
the number of panoramic systems in the United States aged 11 to 12 years).5 The LAR of 41.5 is an average
at the time of the survey. However, the later NCRP of 53.4 cancer cases for females and 29.6 cancer cases
report21 did, so their numbers were used. The NCRP for males, which hides the large risk difference
report had a proportion of adult and child examinations between girls and boys. The 21- to 22-year-old Euro-
similar to that in the NEXT survey. Because a Pan pean group ED of 72.5 mSv was used to estimate LAR
examination is usually one radiograph, the Pan radio- at age 30. The rationale was that head size does not
graphs were set to equal the examination number. The change after age 21 to 22 and that one can estimate the
adult ED of 19 mSv10 was used to calculate the LAR of LAR at 30 years using BEIR VII data. This is a better
2.2 cancer cases per million examinations for a 30- estimate for adults, because LAR decreases with age.
year-old adult and LAR of 3.0 cancer cases for a 10- Similarly, a 30-year-old’s LAR of 6.3 cancer cases per
year-old child using BEIR VII risk estimates,5 similar million exposures was an average of 7.7 for females
to the child BW and adult FMX calculations above. and 4.9 for males.

Ceph risk estimation. The NEXT and NCRP surveys Orthodontic population
could not generate an accurate number of Ceph exami- The 2020 JCO study was completed by 153 respond-
nations but it was estimated that they were less than ents with an active caseload of at least 50 patients per
1% of all dental x-ray imaging examinations. All IO, year, which is approximately 1.4% of the 10,814 ortho-
Pan, and CBCT examinations were added and multi- dontists listed in the ADA 2019 estimate of practicing
plied by 0.0075 (or 0.75%) to give an estimate of less orthodontists.22
than 1% (2,460,427 Cephs; Table I). The ratio of adult Orthodontists reported the percentage of cases in
to child patients for orthodontic treatment was calcu- which they “routinely” or “occasionally” used FMX,
lated from the 2020 JCO survey as 28% adults to 72% Pan, Ceph, and CBCT for “pretreatment,” “progress,”
children. The ED of 5.6 mSv per lateral cephalometric and “posttreatment” records. For the dose and risk calcu-
examination10 was used to calculate the LAR5 for 10- lations, because “occasionally” had no definite interpre-
year-olds of 1.1 cancer cases per million examinations tation, these reports were excluded; only “routinely”
and 0.5 cancer cases for 30-year-olds, using the method was interpreted as radiographic examinations performed
discussed above. on all patients. Although BW and periapical (PA) radio-
graphs were recorded separately from FMX because
CBCT risk estimation. The NEXT and NCRP surveys their numbers and doses were low (
3% routinely
provided estimates of CBCT examinations, separated examined) and the number of radiographs was unknown
by child and adult examinations. The child and adult (1-4 BWs, 1-13 periapicals), BWs and PAs were
examination proportions compared very closely with excluded from the dose risk calculations. However, they
the IO and Pan surveys. The NEXT and NCRP child were included in a comparison to see how the percent-
EDs were similar to those from a European pediatric age of radiographic examinations changed between
study,11 although the European study provided EDs for 2016 and 2020 to help validate the data (Table II).
8 age groups from 0 to 20 years. Therefore, the ED of The LAR of cancer cases per million examinations
204.8 mSv for 11- to 12-year-olds from the European for FMX was calculated using the ED for adults of 86
study was used, because this age group had the highest mSv13 and the ED for children of 89 mSv.13 Adult and
ED and could match the age for initial orthodontic child FMX examinations comprised 18 and 12 IO
examinations. The BEIR VII LAR cancer risk was radiographs, respectively.13 The LARs for 12-year-

Table II. Change in number of orthodontic radiographic examinations 2008 to 2014, 2014 to 2020,* JCO 2008 to
2020 survey data14,32
Change in no. of x-ray exams 2014 to 2020 Change in no. of x-ray exams 2008 to 2014
Type of x-ray exam Pre-treatment % Progress % Post-treatment % Pre-treatment % Progress % Post-treatment %
Full mouth series +7 +2 +6 +1 0
1
BW series
2 0
2
1 0
1
Periapicals
5
1
1
1 +1
1
Panoramic
6
8 +2
5 +1
4
Cephalometric +6 +4 +8
10 +3
9
CBCT +6 +1 +8 +8 +5 +5
JCO, Journal of Clinical Orthodontics; BW, bitewing; CBCT, cone beam computed tomography.
*Orthodontists who said they routinely use pre-treatment, progress and post-treatment radiographic examinations during a course of treatment.
OOOO ORIGINAL ARTICLE
Volume 132, Number 5 Benn and P.S. Vig 601

olds and 30-year-olds were 16.24 and 7.5 cancer cases year age bands), sex, and type of radiographic exami-
per million examinations, respectively.5 The proportion nation (Figure 1). The EDs for IO, Pan, and Ceph were
of adults and children in the orthodontic population taken from Ludlow et al.10 and Johnson and Ludlow.13
(28% and 72%, respectively) was used to ensure that EDs for CBCT were taken from Hedesiu et al.11 and
the LARs for different age groups were applied to the used to estimate the LAR, as described above. How-
correct proportions of the population. ever, the male and female risk estimates were not aver-
In a similar manner, Pan and Ceph LARs were calcu- aged in order to show the difference between the sexes.
lated using EDs of 19 mSv and 5.6 mSv, respectively.10
Because the number of routine pretreatment CBCT RESULTS
examinations increased by 8% from 2008 to 2014 and NEXT survey
another 6% (10% to 16%) from 2014 to 2020 For 300,144,000 IO examinations the risk estimate was
(Table II),14 we calculated what the risk would be if 827 possible cancer cases, of which 114 were in chil-
the number of CBCT examinations increased from dren (14%). From 22,736,880 Pan examinations, there
16% to 50% for routine pretreatment. At the same were 55 possible cancer cases, with 35% in children.
time, the number of Pans and Cephs that could be gen- Of 2,460,427 Ceph examinations, there was 1 possible
erated from the CBCT machines was proportionately cancer. For 5,176,000 CBCT examinations there were
reduced; that is, 86% Pans was reduced by 50% to 36% 84 possible cancer cases, with 73% in children. If rect-
and 70% Cephs was reduced to 20% (Table III). Rou- angular collimators were used for the IO examinations,
tine pretreatment CBCT examinations were increased reducing the dose by up to 73%, the number of cancer
to 86% to replace all Pans and Cephs so their numbers cases could be reduced from 827 to 276. By applying
became 0% (Table III). selection criteria to all radiographic examinations, a
further 43% reduction26-29 was estimated, reducing all
Survey of informed consent cancer cases from 967 to 237 (Table I).
Using an Internet web browser, a randomly identified
population was created for 1 general dental office JCO survey
(GDO), 1 pediatric office (PO), and 1 orthodontic The estimates were for radiographic examinations of
office (OO) for each US state, for a total of 50 for each all US orthodontic patients (21,573,930) who com-
category (total of 150 offices). The search criteria for menced a course of treatment starting in 2020. The
the population were as follows: estimated total number of possible cancer cases was
Because CBCT devices generate the highest doses, the 135: FMX 18, Pan 40, Ceph 6, and CBCT 71
search criteria were “family dentistry,” “CBCT,” and the (Table III). Using rectangular collimation for FMX
name of a US state. For GDOs, potential candidate offices examinations, the numbers could decrease from 18
were searched for information on a CBCT machine, any to 5 (see Methods). A further 43% reduction, using
descriptive text about ionizing radiation/risk, and the selection criteria applied to all radiographic exami-
presence of an online-accessible patient consent form for nations, could lower the total number of cancer
treatment. If any text was present describing radiation cases from 135 to 68.
risk, such as “More radiation than a conventional dental If the future number of routinely prescribed pre-
radiograph,” “More risk for children than adults,” or treatment CBCT examinations were to increase
“100 to 200 times less radiation than a medical CT of the from 16% to 50%, there would be no change in the
head,” this was noted as a specific attempt to indicate number of cancer cases attributable to FMX. How-
risk, although of poor quality. Lastly, consent forms were ever, the extra CBCT could be used to generate
examined for the presence of information relating to risks fewer Pan radiographs, reducing the number of can-
and benefits of radiographic examinations. cer cases attributable to Pan from 40 to 12. Simi-
A similar search was made for POs and OOs but larly, the number of cancer cases attributable to
CBCT was excluded from the POs because its inclu- Ceph would reduce to only 1. The increase in
sion yielded very few search results. An additional CBCT would result in a net increase of 119 cancer
inclusion criterion was that offices must have board- cases to a total of 254. If the CBCT examinations
certified pediatric dentists and orthodontists. Some were increased to 86%, replacing all current Pan
offices did have CBCT machines and this was examinations, there would still be 18 cancer cases
recorded; otherwise, they were recorded as having IO attributable to FMX, 0 to Pan, 0 to Ceph, and 343
and/or Pan and/or Ceph machines. to CBCT, for a total of 361 (Table III).
Between 2008 and 2014 there was very little change
Sample dental x-ray informed consent in the frequency of routinely prescribing FMX, BW, or
A sample informed consent form was constructed that PA (Table II). From 2014 to 2020 there was an increase
included risk estimations for children, adults (5- or 10- in FMX with a corresponding fall in BW and PA. From
 602 Benn and P.S. Vig
ORAL AND MAXILLOFACIAL RADIOLOGY
Table III. Estimate of all US orthodontic cancers generated over a single 21-month course of treatment 2020 to 2021
Exam type Pretreatment No. of x-ray LAR of cancer, Progress exams, No. of LAR of Posttreatment No. of x-ray LAR of Total x-ray Total LAR of cancer
exams, % all exams all patientsy % all x-ray cancer, exams % all exams cancer, exams
orthodontists* orthodontists* exams all orthodontists* all
patientsy patientsy
All Rectangular Selection
exams collimator criteria
43%

73%z dose
FMX 12 648,840 10 3 162,210 2 7 378,490 6 1,189,540 18 5 3
Pan 86 4,650,020 15 6 3,244,200 11 78 4,217,460 14 12,111,680 40 40 23
Ceph 70 3,784,900 4 18 973,260 1 28 1,513,960 1 6,272,120 6 6 2
CBCT 16 865,120 30 7 378,490 14 14 756,980 27 2,000,590 71 71 40
Total 9,948,880 4,758,160 6,866,890 21,573,930 135 122 68
Increase CBCTs to 50% to partially replace Pan and Ceph
FMX 12 648,840 10 3 162,210 2 7 378,490 6 1,189,540 18 5 3
Pan 36 2,270,940 7 0 0 0 28 1,513,960 5 3,784,900 12 12 7
Ceph 20 1,081,400 1 0 0 0 0 0 0 1,081,400 1 1 1
CBCT 50 2,703,500 94 18 973,260 34 50 2,703,500 94 6,380,260 223 223 127
Total 12,436,100 254 241 138
Increase CBCTs to 86% to replace all Pan and Ceph
FMX 12 648,840 10 3 162,210 2 7 374,080 6 1,175,680 18 5 3
Pan 0 0 0 0 0 0 0 0 0 0 0 0 0
Ceph 0 0 0 0 0 0 0 0 0 0 0 0 0
CBCT 86 4,650,020 162 18 973,260 34 78 4,217,460 147 9,840,740 343 343 196
Total 11,016,420 361 348 199

LAR, lifetime attributable risk; FMX, full mouth x-ray; Pan, panoramic; CBCT, cone beam computed tomography; Ceph, cephalometric.
*Percentage of all orthodontists who reported routinely making examinations on all patients.
yLAR cancer estimates are for all US orthodontic examinations. LAR estimates are for 10- to 11-year-old children and 30-year-old adults during one 21-month treatment period 2020 to 2021.
zRectangular collimation is only applicable to intraoral radiographs.

November 2021
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Volume 132, Number 5 Benn and P.S. Vig 603

Fig. 1. Sample dental x-ray informed consent. Reproduced with permission from Dental and Maxillofacial Radiology Omaha
LLC.

2008 to 2014, CBCT increased 8% with a similar Informed consent

reduction in Pan and Ceph. From 2014 to 2020, CBCTs The informed consent survey revealed 50 GDOs with
continued a similar rise, with a reduction in Pans but a CBCT machines (100%), 1 of 50 POs with a CBCT unit
rise in Cephs. (2%) and 49 with IO/Pan/Ceph units (98%), and 11 OOs
ORAL AND MAXILLOFACIAL RADIOLOGY OOOO
604 Benn and P.S. Vig November 2021

Table IV. Internet survey of dental offices for patient radiation risk information and informed consent forms
X-ray machines
Office IO, Pan, Ceph CBCT Risk example provided Radiographic consent
General dentists (n = 50) 0 50 (100%) 7 (14%) 2 (4%)
Pedodontists (n = 50) 49 (98%) 1 (2%) 2 (4%) 0
Orthodontists (n = 50) 39 (78%) 11 (22%) 7 (14%) 0
IO, intraoral; Pan, panoramic; Ceph, cephalometric; CBCT, cone beam computed tomography.

with CBCT units (22%) and 39 with IO/Pan/Ceph units treatment.11 The authors did not specify risk in terms of
(78%; Table IV). fatal cases for IO, Pan, and Ceph, as in the papers by
GDO websites revealed that 43 provided no useful Ludlow et al.10 and Johnson and Ludlow,13 but rather
information about dose risk, such as “Digital x-rays cancers for all examinations, because combining fatal
have 80% less risk than conventional dental film” cancers and nonfatal cancers might be confusing for
(86%). Seven provided a little more useful general readers. All cancer estimates in this article are expressed
information, such as “CBCT has more radiation than as the incidence per million x-ray examinations.
conventional dental x-rays and children have a higher NEXT is a periodic national survey of clinical medi-
risk than adults” (14%). Only 2 GDOs specifically pro- cal facilities performing selected diagnostic x-ray pro-
vided a “CBCT Consent Form” (4%). One office stated cedures, performed jointly by the Conference of
that all patients must agree to have a CBCT at the ini- Radiation Control Directors and the US Food and Drug
tial examination. Administration. It is also supported by the American
Of POs, 48 provided no useful information about College of Radiology. The unit for the survey in this
risk (96%). A total of 17 stated that they followed the study was the clinical site (office) rather than individ-
American Academy of Pediatric Dentistry recommen- ual dentists. One hundred and ninety sites were ran-
dations of BW at 6- to 12-month intervals, depending domly selected for survey in 25 states. The NEXT
on caries risk, and Pan every 3 years (34%). Only 1 of survey was unable to estimate the number of Pan
the POs provided a detailed useful description of risk machines in use because of a lack of data. However, a
(2%). No offices provided a CBCT consent form. subsequent survey,21 which included Pan, combined all
Of OOs, risk examples were provided in 7 offices data with the NEXT data to estimate the number of Pan
(14%) and only 1 office had a useful description of examinations.
risk (2%). None had CBCT consent forms. The 2020 JCO survey was part of a regular 6-year
series that records types and frequency of radiographic
DISCUSSION investigations per orthodontist, not per clinical site as
Cancers of the oral cavity and pharynx comprise 3% of in the NEXT survey. The small sample size of 153
cancers diagnosed in the United States each year.30 respondents has an error of §11% at the 99th percen-
From 2007 to 2016 these rates increased.31 In 2017, a tile. The surveys started in 1986, followed by 1996,
total of 46,157 new cancers in the oral cavity and phar- 2008, 2014, and 2020. Because the 2 earliest surveys
ynx were diagnosed and 10,126 people died.30 In addi- did not include digital IO or CBCT, only the 2008,
tion, 22,827 new cancers in the brain and nervous 2014, and 2020 surveys were compared (Table II).14,32
system were diagnosed and 16,804 people died.30 The NEXT survey shows that the greatest number of
Based on our risk estimates of 967 cancers generated radiographic examinations are IOs. The authors’ esti-
from dental radiography in 2019, this could represent mate is 330,517,307 total radiographic examinations in
2% of new cancers in the oral cavity/pharynx, 4% of 2019, with the equivalent of about 95 million FMX for
brain tumors, or 1.5% of combined oral cavity/pharynx adults and 19 million 4 BW exposures for children.
and brain cancers. The estimate for cancers generated from the 2019 IO
In this article, we derived estimates for the possible examinations is 827, of which 14% were in children;
number of cancer cases associated with IO, Pan, and for Pan, 55, with 35% on children; and for CBCT, 84,
Ceph examinations based on published values for risk with 73% in children; the risk associated with Ceph is
from the Ludlow et al.10 and Johnson and Ludlow13 esti- very low, with about 1 cancer, most likely in a child.
mates of fatal cancers per 1 million examinations. The The vast majority of dental radiography occurs in
CBCT risk was derived from the LAR for cancer (nonfa- GDOs, so what can be done to reduce the doses? Two
tal cancer) per 1 million examinations.11 The LAR esti- things: Collimation of the x-ray beam to reduce the
mates were used because they provided specific volume of tissue irradiated and use of selection criteria
estimates of EDs for single and multiple CBCT exami- to reduce the number of exposures. If all BW and PA
nations, such as those found in courses of orthodontic intraoral exposures used rectangular, rather than round,
OOOO ORIGINAL ARTICLE
Volume 132, Number 5 Benn and P.S. Vig 605

collimators, approximately 80% dose reduction could The above estimates relate to all dental radiography
occur.4 The authors would like to state that a cone cut provided in dental offices. It is of interest to examine
that does not obscure a diagnostically important region the risks and trends in orthodontics, however. This is a
does not need to be repeated. Allowing for cone cuts large specialty in which the majority of patients are
and 7% repeats,23-25 the overall dose reduction would children, who are at elevated risk of developing cancer.
decrease from 80% to about 73%. From our estimates,
the number of GDO-related cancers from IO examina- The JCO 2008 to 2020 surveys
tions could decrease from 827 to 276. This is a signifi- The authors were surprised at the number of orthodont-
cant reduction without reducing needed examinations. ists who reported “routinely” making pretreatment, dur-
Currently fewer than 1% of GDOs use rectangular col- ing-treatment (“progress”), and posttreatment
limation,8 but an NCRP report states that rectangular radiographic examinations (Table III). Between 2008
collimation shall be used.33 Similarly, when making and 201432 there was almost no change in the number of
Pan, Ceph, or CBCT exposures, it is important to select FMX, BW, or PA examinations (Table II). The number
the minimum exposure from the correct settings for of orthodontists routinely prescribing CBCT increased
age and the smallest field or volume possible. Adult 8% and Pan and Ceph declined by a similar amount. Pre-
size, full head CBCT volumes for all patients produce sumably this represented the early introduction of CBCT
the highest doses. Similarly, high resolution usually technology, which can be used to generate replacement
increases the dose. Pan and Ceph. Between 2014 and 2020,14 routine FMX
Another way to decrease dose is to reduce the num- increased 7% with a smaller drop in BW and PA. It
ber of unnecessary exposures by adhering to estab- would appear that FMX partially replaced BW and
lished selection criteria.7,28,29 There should never be selected PA. CBCT increased a further 6% and Pan
prescription of radiographs before a clinical examina- declined by a similar amount. However, Ceph increased
tion, per the NCRP report.33 The purpose of the clinical 6%. Once again, it could be that increased use of CBCT
examination is to decide what question(s) a specific was matched by the decreased use of Pan, explaining
radiographic examination can answer. The answers their reduction. The trends overall are worrying because
should also affect treatment.7 Clinical examinations FMX and CBCT produce much higher doses than
can provide risk estimates for caries and periodontal selected BW, PA, Pan, and Ceph. Unlike the NEXT/
diseases. These estimates should be incorporated into NCRP studies,8,21 which related to a 12-month period
the decision-making process so that individuals with a during 2014 to 2015 and estimated radiographic exami-
low risk of dental disease have longer intervals nations for all offices, the JCO studies are based on
between radiographic examinations than individuals examinations related to a course of treatment. The aver-
with a higher risk.7 Unfortunately, it is well docu- age course of treatment was estimated to be over a 21-
mented that most dentists will image patients on a rou- month period.14 In the time period 2020 to 2021 the
tine (annual or semi-annual) basis, including patients at authors estimate that 135 LAR cancer cases could be
low risk for dental caries.26,27 In addition, in a nation- generated, mostly in children. The highest risk is from
wide survey, 82% of hygienists reported that there CBCT (71 cancer cases), followed by Pan (40 cancer
were times when dentists did not perform clinical cases; Table III). In contrast to GDOs, the lower number
examinations before prescribing radiographs.27 One- of FMX could generate fewer cancer cases (about 18).
third of hygienists reported that radiography intervals However, whereas rectangular collimators could reduce
were based on the patient’s insurance reimbursement.27 the number of cancer cases from 827 to 276 attributed to
The authors suggest that until office surveys report that GDOs, the number attributed to OOs would only
variable radiographic intervals of 6 to 36 months are decrease from 18 to 5. Using appropriate selection crite-
being used, linked to the risk of caries and periodontal ria would seem to be the only option in orthodontic prac-
disease, the dental profession is overprescribing radio- tice to significantly reduce the risk of cancer. If the
graphs. At this time it is difficult to know the precise current trend of replacing Pans (effective dose 19 mSv)
amount of overprescription, but from our calculations with CBCT (effective dose 132-205 mSv for individuals
we believe that at least a 43% reduction in IOs could aged 9-16 years) continues, the cancer rate could
be achieved with no impact on the quality of patient increase significantly. If the number of CBCTs used rou-
care/outcomes.7,28,29 If this reduction is combined with tinely in pretreatment diagnosis increases to 50% so that
the use of rectangular collimation, the total number of Pans decrease from 86% to 36%, the cancer rate will
cancer cases could be reduced from 967 (Table I) to almost double, from 135 to 254. If the 86% of orthodont-
237 for all types of dental radiography. Mupparapu ists routinely exposing Pan images replace them with
et al. recently reported that size 1 and size 0 rectangular CBCT images, the increase in cases will be from the cur-
collimators are needed for pediatric radiography.34 rent 40 for Pan plus 71 for CBCT (a total of 111) to 343
ORAL AND MAXILLOFACIAL RADIOLOGY OOOO
606 Benn and P.S. Vig November 2021

for CBCT, for a net increase of 232 cancer cases with no Osteosarcomas are rare in the jaws, occurring in about
diagnostic advantage, unless CBCT can be used to 1 in 2,000,000 people aged 0 to 19 years.40 Two mil-
answer a specific question requiring 3D information. lion Pans on asymptomatic patients with no signs of
However, this needs to be justified by selection criteria. cancer are likely to cause 2 to 8 cancers depending on
It should be stressed that our calculations of cancer the age and sex of the patient. More than 40 years ago,
risk were only made based on the group of orthodontists Zeichner et al. reported that dental radiographic screen-
who reported routinely making specific radiographic ing was not an effective way to detect unknown cancers
examinations. The ED and LAR cancer risk were not of bone.41 The more common early squamous cell car-
estimated for orthodontists making occasional expo- cinomas are found in the mucosa by clinical examina-
sures. This means that our cancer risk estimates are an tion, not by radiographs.
underestimate. It is also important to state that probably What may be the response of an orthodontist, who is
3% of patients are routinely undergoing pretreatment, currently exposing a girl of 10 to 14 years to 3 CBCTs
progress, and posttreatment CBCT imaging, for a total over a 2-year period, to reading that the risk of this
of 3 CBCT examinations in a 21-month period child developing cancer is about 1 in 6000? We expect
(Figure 1).14 For 10- to 14-year-old girls (the highest it is a shock, because we do not believe that they are
risk group), this would create an LAR of 1 in 6000 intentionally producing this high risk of developing
(Figure 1).5 cancer, nor are they likely aware of the risks associated
What is the justification for routinely exposing FMX with this radiologic imaging procedure. Our Internet
for 12% of pretreatment, 3% of progress, and 7% of sample of 150 dental offices in 50 states shows that
posttreatment patients?14 FMX are usually indicated dentists believe that the risks of cancer from dental
“. . . when the patient has clinical evidence of general- radiography are trivial. The examples of risk that the
ized oral disease or a history of extensive dental vast majority of dentists provided to their prospective
treatment.” (Table 1, Page 5)7 Because 76% of patients patients were devoid of good examples conveying
are children and 71% of these are at least 251% above accurate risk estimates. In addition, the fact that only
the federal poverty level,35 it would not be expected 1% of dentists provided an informed radiography con-
that these children have high levels of disease. In fact, sent form demonstrates their belief in a lack of legal
if they are at high risk for dental disease, should they risk to themselves. Perhaps it is that, unlike general
be having orthodontic treatment? Why did orthodont- anesthesia in a dental office, where a death from treat-
ists adopt a change of practice from 2014 to 2020 when ment is a known tragedy for the patient, their family,
they moved away from BW and selected PA to FMX and possibly professionally for the dentist, a diagnosis
from 2008 to 2014? Perhaps part of the answer may be of cancer in a dental patient cannot be attributed to a
that more general dentists are performing aligner ther- particular x-ray imaging event—it is an unknown anon-
apy and using FMX. However, it still does not explain ymous event. However, the risk of death from a general
why so many children in the age group 11 to 16 years anesthetic in a dental office is 1 in 300,000.42 The risk
are receiving FMX for orthodontic treatment. of cancer for a girl of 5 to 15 years from 4 BW is about
Another question is why do so many orthodontists 1 in 130,000 and that from a Pan is about 1 in 200,000
acquire Ceph images? Traditionally, orthodontists (Figure 1).
included Cephs as part of full records. Originally these A possible solution to the lack of awareness of dental
radiographs were considered necessary to make com- radiology risks is to require an informed consent form
parisons over time in the size and shape of the jaws and that includes the following specific information: (1) a
bones of the face and the orofacial soft tissues. Super- statement by the dentist listing the type of radiographic
imposition of successive serial Cephs over time was examinations proposed, (2) the clinical need for the
used to assess changes attributed to treatment, growth, examination, (3) the likely treatment that will result if
and development. Today it is no longer believed that the condition is detected, or (4) appropriate referral to
facial growth can be reliably predicted in either amount a specialist, in addition to a list of cancer risk by exami-
or direction. A number of studies dispute the clinical nation type, age, and sex, as well as a statement for
utility of cephalometric analysis. There is no justifica- comparison of the 1:500,000 risk of cancer from cos-
tion for retaining cephalometric radiographs as part of mic rays in a 4- to 5-hour flight.43 A sample form is
orthodontic diagnosis or treatment planning.36-39 By shown in Figure 1.
avoiding unnecessary Cephs, which are low dose, the Finally, we would like to state that there are definite
transition to high-dose CBCTs can be prevented. Simi- benefits to having appropriate radiographic examina-
larly, the use of high-dose CBCTs to replace low-dose tions. However, the literature does not provide quanti-
Pans should be avoided. tative measures of benefit, making it difficult to
Why are dentists taking so many radiographs? Is it perform a careful comparison of risk vs benefit. It
that they fear missing an unknown cancer? would be beneficial for others to model benefit to make
OOOO ORIGINAL ARTICLE
Volume 132, Number 5 Benn and P.S. Vig 607

a risk vs benefit comparison possible. Until then, our 9. Campbell RE, Wilson S, Zhang Y, Scarfe WC. A survey on radi-
responsibility is First Do No Harm. ation exposure reduction methods including rectangular collima-
tion for intraoral radiography by pediatric dentists in the United
States. J Am Dent Assoc. 2020;151:287-296.
CONCLUSIONS 10. Ludlow JB, Davies-Ludlow LE, White SC. Patient risk related to
Dentists are possibly causing about 967 new cancer common dental radiographic examinations: the impact of 2007
cases per year in the head and neck regions. Most of International Commission on Radiological Protection recom-
mendations regarding dose calculation. J Am Dent Assoc.
the cancer risk is from intraoral and CBCT radio-
2008;139:1237-1243.
graphs. The use of intraoral rectangular collimation 11. Hedesiu M, Marcu M, Salmon B, et al. Irradiation provided by
with selection criteria, as stipulated in ADA guide- dental radiological procedures in a pediatric population. Eur J
lines7 and the NCRP report,33 may reduce the number Radiol. 2018;103:112-117.
of cancer cases from 967 to 237. 12. De Felice F, Di Carlo G, Saccucci M, Tombolini V, Polimeni A.
Dental cone beam computed tomography in children: clinical
Orthodontists are adopting CBCT technology with a
effectiveness and cancer risk due to radiation exposure. Oncol-
reduction in the number of Pan examinations. In 2020 ogy. 2019;96:173-178.
to 2021 all orthodontic courses of treatment may gener- 13. Johnson KB, Ludlow JB. Intraoral radiographs. A comparison of
ate 135 cancer cases. This is probably an underesti- dose and risk reduction with collimation and thyroid shielding. J
mate. Future replacement of low-dose Ceph and Pan Am Dent Assoc. 2020;151:726-734.
14. Keim RG, Vogels DS, Vogels PB. 2020 JCO study of orthodon-
radiographs by higher dose CBCT images could gener-
tic diagnosis and treatment procedures, part 1: results and trends.
ate 361 cancer cases, mostly in children. J Clin Orthod. 2020;54:581-610.
Use of an informed consent form containing suffi- 15. Smith BR, Park JH, Cederberg RA. An evaluation of cone-beam
cient information to help the patient and dentist under- computed tomography use in postgraduate orthodontic programs
stand the risk of cancer formation may help to reduce in the United States and Canada. J Dent Educ. 2011;75:98-106.
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ACKNOWLEDGEMENT Coll Dent. 2005;72:27-31.
We acknowledge the expertise and encouragement of 18. Moreira NCF, Pach^eco-Pereira C, Keenan L, Cummings G,
Flores-Mir C. Informed consent comprehension and recollection
Dr. Ruben Pauwels, associate professor at Aarhus Insti- in adult dental patients: a systematic review. J Am Dent Assoc.
tute of Advanced Studies, Aarhus University, Den- 2016;147. 605-619.e7.
mark, who assisted us with the lifetime attributable risk 19. Geist JR. Informed refusal in oral and maxillofacial radiology:
of cancer calculations. Thanks also to Dr. David C. does it exist? Oral Surg Oral Med Oral Pathol Oral Radiol.
Spelic, medical physicist, who provided invaluable 2018;125:A8-A10.
20. Oikarinen HT, Perttu AM, Mahajan HM, et al. Parents’ received and
information about the NEXT study and also reviewed a expected information about their child’s radiation exposure during
draft of our article. radiographic examinations. Pediatr Radiol. 2019;49:155-161.
21. National Council on Radiation Protection and Measurements.
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