Dental radiography is one of the most frequent types of radiological procedures performed. One of the projections that have been done in the dental radiography is the intraoral radiography, which means the film is put inside the patient’s mouth. The intraoral can be divided into four, which are bitewing view, periapical view, occlusal view and full mouth series. There are conventional intraoral radiography and another one, with the advances in technology, the digital intraoral radiography is been developed. In this new imaging modality, the radiographic film is replaced by a sensor for the X-rays. The signal temporarily stored within the sensors is transferred to the computer, which displays an image that may be filed, interpreted, manipulated and quantified. The digital intraoral radiography is divided into two, which are two fundamentally different concepts for direct digital image acquisition, the CCD-based (charge-coupled device) and the Storage Phosphor systems.

The intraoral radiography is said to have a low exposure dose received by the patients. According to the several sources that can be trusted, the exposure dose received by the dental patient equivalent to a few days’ worth of background radiation environmental radiation exposure or similar to the dose received during a cross-country airplane flight. Digital dental radiography is more preferable because although film has been an inexpensive and reliable image receptor in dental radiography for a long time, the advantages of digital dental radiography over film include providing a lower radiation dose, a swift availability of radiographs, the possibility of image enhancement and no need for film processing chemicals.

DOSES IN INTRAORAL RADIOGRAPHY

In digital intraoral radiography, the mean exposure time and radiation surface dose for the PSP is greater than that for the CCD system by a factor of 2.45. However, there was also a significantly higher repeat rate using the CCD system compared to the PSP system. Therefore, despite the CCD system requiring more repeat exposures, the radiation received by the patient is less. CCD systems showed a larger dose reduction in comparison to PSP imaging plates. Another study reported that the dose reduction as a result of shorter exposure times exceeded the increase in doses as a result of the greater number of radiographs with both digital systems. However, with the CCD sensors the dose reduction per exposure was almost cancelled out by the increase in the number of radiographs taken.

Although the patient exposure associated with dental radiography is relatively low, intraoral radiography should be optimised in order to keep the radiation risk “as low as reasonably achievable”, something that is widely known as the ALARA principle but at the same time, produce a best quality of image. Any radiological procedure should be justified and modified in order to keep the radiation risk as low as reasonably achievable, especially to the children.

Compared to adults, children are more sensitive to the radiation exposure. Dose assessment is recommended to be performed on a regular basis to ensure that patient exposure is always kept within the recommended levels and at the same time, the malfunction of the equipment also can be detected. All radiological procedures carried out on children must adapt to special radiation protection measures, which aims at recognising and implementing possible dose reduction strategies in order to eliminate unnecessary and therefore unjustified radiation exposure. Over the past 20 years both the X-ray units and the X-ray receptors used in dental radiology have been evolved. Modern dental X-ray units incorporate high frequency generators, operate at higher tube potentials and produce X-ray spectra that have higher mean energy and therefore are more penetrating compared to those produced by older dental X-ray units. These improvements have contributed in the reduction of the radiation dose to the entrance skin surface of the patient and the enhancement of image quality.

According to Hart (2009), the new adult reference dose for intra-oral radiographs (2.3 mGy) is 40% lower than the 1999 value (4 mGy), probably owing to the use of faster film-screen and digital systems. This is the first time that a national reference dose for intra-oral radiographs on children has been recommended (1.5 mGy), and it is, 35% lower than the corresponding adult value.

Some studies show that there is a large dose variation between different X-ray units used for the same radiographic projection and it is relatively low. However, although radiation exposure from intaoral radiography is considered to be low, the patient may have a chance to undergo repeated dental radiological procedures. Therefore, the accumulated effect of the radiation exposure should be taken into consideration. Salivary gland and the thyroid gland are among the organs at risk in dental radiology. Salivary gland, which often lies within the primary beam in intraoral radiographic projections has been shown to receive dose from 0.02 mGy up to 0.1 mGy per examination.

As stated by Looe et al. (2006), dose received by the thyroid gland, mainly due to scattered radiation, is comparably less than those received by the salivary glands. On the other hand, the thyroid gland is one of the most radiosensitive organs for children and dose imparted on the thyroid gland should be minimised whenever possible.

Diagnostic reference levels (DRLs) have been introduced by the European Union in the Medical Exposure Directive (MED) (97/43/Euratom). The directive requires the member states to promote the establishment and the use of DRLs and to ensure that implementation guidance is available (Poppe et al., 2006). A good practice is established when the required levels are not exceeded. The DRL is very important because inadequate techniques or machine malfunctions in the case where they are consistently exceeded can be detected during the examination, so that appropriate corrective action could be undertaken. Patients increased their chance to be subjected to unnecessarily high-radiation doses due to unsatisfactory equipment or inadequate techniques.

To establish the DRLs, entrance surface dose (ESD), dose area product (DAP) or other dose-related quantities may be used. In the intraoral radiography, DAP has been chosen as the measurement quantity as it could be measured without the patient in place and the field size of the beam is directly reflected on the measured value. Rectangular collimator is preferable compare to the cylindrical collimator because the rectangular one can fit the size and shape of the film better, eventhough most X-ray units in intraoral radiography is equipped with cylindrical collimators. Furthermore, the introduction of DRLs has lead to DAP meters being installed as an integral part in radiology equipment used for the automatic registration of patient dose. The DAP meters could also be a possibility for panoramic units. It is completed with the advent of digital radiography and the use of automatic exposure control for these examinations, so, such equipments would allow easy monitoring and follow-up of individual patient doses. It has been suggested that this dose area products are closely correlated with effective doses under specific circumstances because DAP are directly measurable or indirectly accessible from exposure.

In instance, Poppe et al. (2006) stated that the measured DAP values for maxillary molar examinations range from 3.8 to 134.8 mGy cm2. The minimum dose measured for non-digital systems was 17.4 mGy cm2 and the maximum value measured was 134.8 mGy cm2. The highest third quartile value was calculated for occlusal examinations, whereas the lowest value was calculated for mandibular incisor examination.

Moreover, there is a large difference between patient exposures among different dental facilities. Sometimes, the differences are up to a factor of 35 for the same examination. This s due to the inconsistencies of radiological practices performed in clinical routine such as different X-ray units, exposure techniques, film speed or even inadequate exposure setting and film developing procedures, and further. It can be seen that many dentists do not preferable using the dose-optimized programmes for the faster films. In addition, the correlation between DAP and tube loading may also be used as a rule of thumb in determining the imparted dose on patients. That’s why it is necessary to have the DRLs laid out as guidelines.

In intraoral radiography, periapical is the most commonly performed and usually two to four teeth are shown on the image providing full tooth structure, including pulp, root and gum anatomy. On the other side, bitewings are taken to show the upper and lower teeth together on a single image while occlusal radiography demonstrate the dental arches at right angles to the occlusal plane.

Although DRLs are useful in optimising radiological procedures by identifying inadequate exposure techniques, they still got the disadvantage. The problem is, they are lacking information in the risk associated with the radiological procedure. So, the other alternative is by using the conversion coefficient. It is used to estimate effective doses from DAP values have been published for common radiological procedures, including in intraoral radiography.

In intraoral radiography, basically, thyroid gland and brain tissue receive only a small fraction of dose caused by scattered radiation within the phantom except for occlusal examination of the maxilla where high dose was measured at the brain tissue. So, we can say that overall skin dose is also relatively low as only a small fraction of skin was exposed directly to the x-ray beam. Moreover, salivary gland which often lies within the primary beam is exposed to high dose during intraoral examinations. This gland received highest dose followed by the red bone marrow. Then, the mandibular angle also was exposed to a high exposure during most of the dental examinations. Doses measured at the thyroid gland and brain tissue were only attributed to scattered radiation and therefore considerably low. However, only low dose was recorded at the third cervical vertebra mainly due to scattered radiation.

The other factor that determines the exposure dose in the intraoral radiography is the type of film. It is remarkable that several facilities using an E or F speed film have higher doses than other facilities using the less sensitive D-speed films. For example, in the category of dentists using X-ray units operating at 65 kV, the lowest dose measured using D-speed film is 3.5 times lower than the highest dose measured using E or F speed film. However, the exposure time for the digital radiographic systems was set to 10-50% of that of E-speed film in most cases of intraoral radiography.

However, in some clinics and hospitals, working with faster film type or higher tube voltage is not always associated with lower exposure. Many precaution measures could be taken at no cost to reduce the patient exposure by choosing the appropriate exposure parameters. Operators of X-ray units shall pay special attention to ensure that the right radiological equipment and techniques are used when performing radiological procedures on the dental patient. When using the faster film types, the operator should reduce the exposure time, so that the level of radiation exposure received is not beyond with the acceptance level of radiation exposure in intraoral radiography. Still, it is very important for the technologists to be informed about the necessity and importance of reducing the exposure times when working with the faster film types

The quantitative aspects of radiation doses is needed to observe and determine the necessary radiation protective measures and at the same time, can help the general public to allay radiation fear in dental radiography. Because, it is afraid to develop certain disease and the highest risk in intraoral radiography is leukemia and thyroid cancer, even in doses as low as 500 mSv. On the other hand, even low doses of radiation can cause changes in the DNA of the cell that may not be lethal but that could cause the mutations that could lead to cancer. Most of these DNA changes are discovered and repaired before they cause problems, but the repair mechanism is not perfect and some of the changes may persist and accumulate. Non-repairable damage is more likely to occur with higher doses or dose rates but there is a chance that even a single small “hit” of radiation could produce a mutation that could cause cancer. The more radiation a person is exposed to, the more chances he has of receiving a non-repaired DNA injury. Similar surveys conducted in dental radiographic facilities over the last 10 years have demonstrated a trend for reduction of the ESD, with the use of faster films and digital receptors, as well as with modern x-ray units and rectangular collimation. The emphasis should be increased to the structures located in the oral region, particularly the salivary glands.

At the gonadal areas, the gonads are not in the line of exposure, especially during intra-oral or panoramic radiography. However, the dose to the genetic cells results from scattered radiation in dental radiography. Scatter radiation during dental radiography may result in exposure of the dental personnel in the area. A dentist or dental auxiliary may accumulate perceptible amounts of radiation doses from his repeated exposure to scatter radiation. The precaution also must be highlighted to the pregnant women because the excessive exposure dose received by the pregnant women may result in spontaneous abortion, congenital abnormalities, microcephaly and decreased mental efficiency.

From the study by Brooks (2008), shown that the doses actually used to obtain dental radiographs are frequently higher than what can be obtained in ideal situations. For example, a recent study done in Spain that measured entrance doses in several thousand dental offices reported that there was frequently no difference in radiation dose with different films and in different locations within the mouth. According to the revised recommendations for calculating effective dose, dental radiography involves 32% to 422% more risk than that previously thought. Therefore, efforts should be made to reduce dose as much as possible but not at expense of image quality and diagnostic accuracy.

In addition, different groups of teeth need different exposure times for obtaining quality diagnostic information. Moreover, the patient dose is determined not only by the amount of radiation per exposure, but also by the number of radiographs taken. A recent study shows that the total number of radiographs taken by dentists using digital radiography was significantly larger than the number of radiographs taken by film users. The number of radiographs taken by dentists using solid-state systems compared to film-users while phosphor plate users took 32% more radiographs. The main reason when taking more radiographs is to achieve better diagnostics and description about certain condition of the patient. Eventhough it provides better diagnosis, positioning errors occurred more often in digital radiography than in film-based radiography. This is due to the stiffness of the digital sensors that is significantly more difficult to position in the patient’s mouth, rather than the positioning film and more uncomfortable for the patient although.

CONCLUSION

In conclusion, digital intra-oral radiography is a well-accepted diagnostic tool in dental

practice. However, some of the claims made by manufacturers of digital systems, are not valid to their full extent. For instance, the dose reduction per exposure is real, but it is still to be determined what the actual dose reduction is because of the fact that dentists tend to make more radiographs when using a digital system.

Sometimes, the importance of the level of exposure dose received by the dental patient is underestimated. Due to this, it could lead to the poor characteristics of x-ray device, inadequate film processing conditions and outdated techniques used. Regular quality control of dental x-ray units can eliminate deficiencies related to equipment. Inadequate technique is a more significant problem, because dentists and radiology technicians are insufficiently educated in the field of radiation protection.

Because of that, it is best to select the imaging technique that will provide that information with the lowest radiation dose. To obtain that, dental equipment must stay in good condition, including film processing apparatus and solutions, and use good technique to avoid retakes. In addition, using fast film or digital imaging and small collimation, whenever feasible, will also keep the radiation dose as low as reasonably achievable, or ALARA which is a goal worth pursuing. in general, both entrance and effective doses are reduced when higher film speed (E-speed or F-speed instead of D-speed) or digital imaging is used. In addition, rectangular collimation of the beam also reduces the effective dose because less tissue is exposed in total. There are no such things as necessary “routine” radiographs the way there are required. Instead, dentists must make radiographs only when they think they are necessary to make an accurate dental assessment or diagnosis to reduce the number of X-rays taken to the minimal needed for dental health. Efficient implementation of the basic principles of radiation protection, particularly which the practice optimization through the quality assurance program, is the only adequate way of reducing the patient dose and at the same time, preserving the quality of diagnostic information.

Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members

Research is the key contributor of professional development in many professions, particularly healthcare. It allows practitioners to inform, adjust and monitor particular ways of practice or issues. The ability to evaluate research evidence appropriately is essential to avoid the assumption that all published research is of equal merit and validity. In order to critically appraise the article, ‘Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members’ (Evans, Murray, Patrick, Fitzgerald, Smith & Cameron, 2010), the ten point CASP (Critical Appraisal Skills Programme, 2006) framework is used. Current literature will be utilised to guide the discussion and reflection in order to conclude the overall strength of this article.

The study’s aims are concisely stated and numbered clearly. This is of importance in research keeping the main focus well established and succinct, allowing readers to easily understand the objectives (Collins, 2010; Gerrish & Lacey, 2010; Stommel & Wills, 2004). and reduce the chance of inter-researcher confusion. The authors discussed their reasons for focussing on clinical handovers, highlighting that communication difficulties can lead to serious, even fatal mistakes. A previous study is used to confirm the severity of this problem. Khan (2008) illustrates the benefits of using previous studies in one’s background enforce the discussion of why the research is relevant. The researchers discuss the MIST (Mechanism-Injuries-Signs-Treatment) template used in the military, pointing out that little is known about its effectiveness in more general settings. Other ways of improving

communication

are discussed, such as radio pre-alerts and the use of electronic tablets, noting that as yet effectiveness is unproven, supporting the value of this new research.

The researchers have not disclosed reasons for choosing qualitative methodology; however, it is appropriate to their aims. They intended to obtain and illuminate personal views and subjective experiences of using the MIST template during handover, in turn modifying the template in response to recurring findings. The stated aim of understanding issues affecting handover efficiency can be best researched via the qualitative method in order to gain participants’ interpretations of the other professionals involved and to enlighten the interactions between these groups (Block, 2006). The gathering of opinions on data transmission methods and data display within the emergency department (ED) provides a more in-depth understanding of how errors occur and furthermore, how this problem could be improved (Bowling & Ebrahim, 2005).

The research design used in this study is grounded theory. This specifically enables a new theory to arise from data in order to explain social phenomenon and human behaviour (Chears, 2009; Williams, 2012). It could be argued that the researchers are not developing a new theory in relation to the improvement of the ‘minimum dataset’ as they merely adapt the MIST template (an already established theory), whereas typically, grounded theory forms a theory from original data collected during a study, not by testing a theory from previous literature in the field (Giles, 2002). In contrast, Henandez (2011) recommends using datasets from previous research in order to collate secondary and primary research, allowing the combination of ideas to form a theory. Furthermore, the findings seem to show that grounded theory has been used within ‘attributes of an affective and ineffective handover’: A set of ideas designed to explain what constitutes handover quality has been developed. An example: 11 out of the 17 participants expressed that a poor handover includes extraneous information and interruptions. The researchers developed this as a theory to explain why poor handovers may occur. They have described their use of grounded theory but not clarified why they have used this method or with what aims they wished to develop new theories.

In relation to the recruitment strategy, Daymon & Holloway (2011) illuminate the importance of disclosing the setting, timeframe and people involved in research in order to clarify the boundaries of the study. Here, details of inclusion of participants are thorough and well recorded, including geographical locations, timeframes and demographics. ‘Table 1’ shows all participants had a mean of 5 years post-graduate experience, indicating that those with considerable experience were selected. The researchers used purposive sampling method to find a representative group (participants with experience of transporting trauma patients to a trauma service) and used convenience sampling within this representative group to ensure all participants could contribute to the data (Monsen & Horn, 2008). Purposive sampling is highly targeted and forms a specific group, resulting in this method being subject to bias, however, if the researchers are aiming to investigate a phenomenon relating to specific groups of people (e.g. paramedics and trauma team members), then purposive sampling is appropriate to warrant the correct target group is selected (Newell & Burnard, 2011). In addition, the researchers have explained how they have selected a representative trauma team sample; by involving individuals from different specialty groups involved in management of trauma patients (e.g. burns, anaesthetics). There is no record of anyone who chose not to take part.

Data collected via semi-structured interviews was an appropriate way to address the research aims, but there are flaws. Researchers needed to record the subjective experiences of this group of professionals in order to determine the key factors causing communication errors. However, information such as the location of interviews is not stated. Japec (2008) points out how the social context of interviews can affect responses. We do not know whether interviews were carried out in a controlled environment (i.e. in the same room, similar time of day and without disturbances). Moreover, the researchers have not disclosed the reasons why the interview method was chosen. Moniff and Whitehead (2010) and Blaikie (2010) illustrate the importance of including this information, to allow the reader to see the relevance of chosen data collection techniques. Furthermore, there is no description of how the data was recorded; a vital element in research to increase confirmability and replicability (Gerrish & Lacey 2010). The form of data cannot be distinguished through the software used (NVIVO 8.0) as it can upload text, videos and tape recordings (Edhlund, 2007).

The use of a minimum topic guide for interviews ensures that similar data is collected from participants and eliminates the sequence of questions being different (Holloway & Wheeler, 2010). However, the researchers were ambiguous when discussing their use of the topic guide in the study design. They state it was used when interviewing the trauma team speciality groups about the minimum dataset for handover, yet, do not clearly state whether it was used for questions on effective and ineffective handovers, data transmission or data display (even though these prompts appear in the topic guide). There is also no reference to use of the topic guide during interviewing paramedics (although paramedic specific questions are present on the guide leading to assumption that the guide was used).

The interview method enhances data as it shows body language and non-verbal interactions (Gerrish & Lacey, 2010). However, it can skew results: social desirability can lead to the participant answering a question so as to please the researcher or sound like a ‘good practitioner’ (Rubin & Babbie, 2010). In addition, the ‘interviewer effect’ may occur (where interviewers subtly influence participants responses through wording of the questions or body language), especially as some researchers belonged to the professions being studied.

In this research, the relationship between researchers and participants has not been sufficiently reflected upon. There has been no consideration of how reflexivity and experimenter bias may have influenced the choice of questions (e.g. the topic guide), the sample selection and location. With no comment on who developed the topic guide, we do not know if it was one researcher or a collaboration. This information is essential: if experimenter triangulation was utilised, this would decrease the chance of experimenter bias and reflexivity skewing the questions, increasing credibility of the research (Merrian, 2009). Researchers have not examined their role within sample recruitment either. One researcher is employed by Ambulance Victoria, and another by the Alfred Hospital – Presumably personal backgrounds influenced the choice of these two institutions for sample collection, however, there is no personal reflexivity expressed to determine that they have considered their potential bias in this area. Reflexivity is critical in order to increase the rigor of the research; recognising how personal experiences, disposition and emotions can influence research choices allows researchers to compensate for this where possible, and understand the importance of documenting subjective issues (Kirby, Greaves & Reid, 2006).

In consideration of ethical issues, the researchers have not discussed how, or even if they briefed and debriefed the participants. Adequate briefing is essential do participants know exactly what to expect and are aware of their rights (Fowler, O’Neill & Helvert, 2011). Briefing also allows participants to give informed consent and avoids passive deception, whereby the researchers deceive participants by omission (Cottrell & McKenzie, 2011). Debriefing is equally important, allowing participants to raise any issues experienced during the research (Jackson, 2011; Morrow, Boaz, Brearley & Ross, 2012). An ethics committee has approved this research, meaning the emotional impacts on researchers and participants have been assessed and the safeguards and well-being of the participants have been evaluated (Holloway & Wheeler, 2010). This implies that ethical considerations have adequately been taken into account, although more detail should have been provided.

With respect to the data analysis, grounded theory is defined and clearly explained. In the abstract, thematic analysis was said to be used, but there is no reference to it in the data analysis section. There is, however a clear demonstration of its stages in the description of how the 3 nodes were developed through collecting reoccurring responses and developing them into codes and themes. Open coding has been used, which primarily allows codes and subsequently themes to emerge from the text alone; by using axial coding in addition, the researchers’ concepts and categories are implemented whilst re-reading the text in order to check that categories truthfully represent responses and to examine how concepts are related, increasing credibility and validity (Babbie, 2012).

However, researchers have not explained how they collaborated to determine what data to present, nor do they disclose any outliers or contradicting results. Reflexivity can affect this process as their subjective thoughts may influence their choices. The researchers have not considered this issue, resulting in reduced credibility (Brink, 2006). They refer to a ‘general consensus’ when talking about the usability of MIST – rather vague and ignoring differing responses. Nevertheless, sufficient data is presented to support the findings. Quotes are implemented to support the data and MIST is rewritten and displayed, including responses. The attribute box allows readers to distinguish differing views between professionals; adding credibility to the data transmission results. Finally, by assigning a third researcher, experimenter bias is reduced and to some degree helps the issue of reflexivity, as researchers’ past experiences will all differ, affecting how they may perceive participants’ answers, and subsequently code the text. Triangulation of researchers adds rigor to the research (Inoue, 2012).

There is a relatively clear statement of findings in the research; data is affirmed under primary nodes developed by thematic analysis clearly and concisely and they are also logically discussed in the order of aims. Hinshaw (2011) emphasises the importance of clearly presented results to allow the reader easy access to the main outcomes and suggested action points. Specific quotes arising from the interviews to corroborate and increase dependability of the results (Streubert & Carpenter, 2011). Discussions are made for and against the researchers’ suggestions. Supporting discussions include the concept of ‘time out’ in theatres where team members pause and complete a checklist to ensure safety (this current practice boasts reduction in surgical error), reinforcing the results where paramedics state an effective handover is one where the receiving body stop and exercise listening skills. An example where researchers challenge their findings is the reference to a study, concluding information recall of just 36% even when paramedics were provided with handover training. Using evidence to challenge their research demonstrates that the researchers are not prejudiced in favour of their own results and that they recognise the need to consider additional barriers (Brink, 2006).

However, the researchers have not discussed the credibility of their findings; they have employed researcher triangulation to reduce intrinsic biases, but have not mentioned how this improves credibility and rigor in the discussion. There is no comment about respondent validation, raising the question whether this was carried out. It is a of checking the truthfulness of research, by giving participants the findings to comment on if there is any misinterpretation: an effective way of reducing researcher bias (Pope & Mays, 2006).

The value of this research is limited: the researchers acknowledge their results form a basis for development and recognise that trails and further research must be carried out. Findings are discussed in light of current practice, recognising that the MIST tool needs to be trialled further. Researchers also acknowledge that training will have to be developed for paramedics (as with any new proposed method in ambulance services). It is stated that noise barriers need to be evaluated, however, no new areas of research are proposed. Researchers have not discussed whether their research can be transferred to other populations. They have briefly discussed generalizability, stating the research should be generalised to other hospitals with caution as the data was collected in a busy referral hospital. They also recognise that selecting paramedics with experience in trauma settings can lead to decreased generalizability, as paramedics with less trauma experience may have differing views.

In conclusion, this research boasts excellent presentation and structure comprising strong background and aims. Utilising qualitative methodology enabled researchers to gain subjective experiences and views from healthcare professionals to provide a deeper understanding of how communication errors occur during handover and propose a multifactorial strategy for improvement. It could be argued that the researchers are not developing a new theory, therefore not utilising grounded theory correctly, however, there is ample literature disputing this, stating that it is acceptable to build on existing theory in order to develop a new one. The research has been carried out in the light of the original aims throughout and the results are clearly presented, with additional quotes to enforce points. However, there is minimal consideration of potential biases and the effect of reflexivity, reducing credibility. Furthermore, many methods have not been justified (research method, use of grounded theory, data collection and data presentation) leading to overall low rigor and credibility. Finally, it is recognised that this research will not change future practice without further research and trailing. Nevertheless, the original data collected here and strategies for improvement presented make this research a valuable contribution to the field. (182)

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