CH 40

Chapter 40
Legal I ssues, Quality Assurance,

and I nfection Control in Dental
Radiography

Copyright 2003, Elsevier Science (USA).
All rights reserved. No part of this product may be reproduced or transmitted in any
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Produced in the United States of America

ISBN 0-7216-9770-4
Copyright 2003, Elsevier Science (USA). All rights reserved.
I ntroduction
The dental assistant must be aware of the legal
responsibilities involved in taking dental radiographs.
There are both federal and state regulations that control
the use of dental x-ray equipment.
To ensure the highest quality and minimal risk to
patients in radiation exposure, a quality assurance
program is necessary.
Dental radiography procedures are not usually
considered high risk for the transmission of diseases.
However, infectious diseases present a significant
hazard in the dental office and dental professionals are
at an increased risk for acquiring such diseases.
Legal I ssues
There are three major categories of legal
considerations with which the dental assistant
should be familiar regarding the use of x-rays in
dentistry:
Federal and state regulations regarding x-ray
equipment and its use.
Licensure for individuals exposing radiographs.
Risk management for avoiding potential
lawsuits.
Federal and State Regulations
The use of dental x-ray equipment is regulated by both
federal and state regulations.
All dental x-ray machines manufactured or sold in the
United States after 1974 must meet federal regulations
which include safety specifications for minimum filtration
and accuracy of the milliamperage time and kilovoltage
settings.
Many states require x-ray machines to be registered and
charge a fee for this registration.
Most states have laws that require inspections of dental x-
ray equipment on a regular basis, for instance, every 5
years.
Licensure Requirements
The Consumer-Patient Radiation Health and Safety Act
is a federal law that requires persons who take dental
radiographs to be properly trained and certified.
It is up to the individual state to determine its own
policy regarding qualification of individuals exposing
radiographs.
X-ray certification requirements for the dental assistant
will vary from state to state.
Some states require DANB certification; other states
may require an additional examination.
Each state deals with dental radiography differently.
Risk Management
Risk management policies are designed to reduce the
likelihood of a malpractice lawsuit against the dentist.
The dental assistant has an important role in risk
management.
The dental assistant must be careful never to say
anything negative about the x-ray equipment or how it
is working.
Statements made without thinking, such as the timer
must be off, this thing never works right, or the
solutions are weak, are unnecessary and can make
the patient feel uncomfortable.
Statements made by anyone at the time of an alleged
negligent act are admissible as evidence in court.
I nformed Consent
It is the dentists responsibility to discuss the need
for radiographs and treatment procedures with the
patient.
The dental assistant may participate in the process
of obtaining informed consent.
Patients must give their informed consent for
dental radiographs, as well as for other
procedures.
For Valid I nformed Consent
The patient must be provided with the following
information in lay terms:
The risks and benefits of the radiographs.
The person who will be exposing the
radiographs.
The number and type of radiographs.
The consequences of not having the
radiographs.
Any alternative diagnostic aids that may
provide the same information as the
radiographs.
Liability
Under state laws, the supervising dentist is legally
responsible, or liable, for the actions of the dental
auxiliary.
This is called respondeat superior doctrine. It
means that the employer is responsible for the
actions of the employee.
However, even though dental assistants work
under the supervision of a licensed dentist, they
can also be held legally liable for their own actions.
Patient Records
It is very important to document the exposure of
dental radiographs.
The number of films exposed, as well as the quality
of the radiographs, may be an important issue in a
malpractice suit.
Radiographs that are of poor quality and are
nondiagnostic reflect against the dentist.

Documentation of Dental Radiographs
The dental record must include the following
information:
Informed consent.
The number and type of radiographs exposed.
The rationale for exposing the radiographs.
The diagnostic interpretation.
Ownership of Dental Radiographs
Radiographs are the property of the dentist, even
though the patient, or the patients insurance
company, paid for them.
This is because dental radiographs are a part of
the patients records.
Patients have a right to reasonable access of their
records.
Make an entry in the chart stating when and to
whom the duplicate radiographs were sent.
NEVER give or send the original radiographs to a
patient.
When Patients Refuse Dental Radiographs
When this occurs, the dentist must decide whether an
accurate diagnosis can be made without radiographs
and whether treatment can be provided.
The use of dental radiographs is now the accepted
standard of care.
No document can be signed to release the dentist from
liability. Even if the patient suggests signing a release
or waiver that will release the dentist from liability, it
would be considered invalid if an injury did result.
It should be recorded in the patients record if a
patient refuses recommended radiographs.
Patient Education
As a dental assistant, you should understand and be
sensitive to the patients concern and fears about
exposure to radiation during dental radiographs.
The dental assistant is often the person that the
patient feels most comfortable with in confiding these
fears.
The dental assistant can explain to the patient just
how important radiographs are in detecting diseases
and planning treatment.
Patients can be informed of the federal and state laws
enacted for their protection.

Quality Assurance in the Dental Office
Quality assurance is a way of assuring that
everything possible is being done to produce high-
quality diagnostic radiographs.
It includes both quality control tests that
monitor dental x-ray equipment, supplies, and film
processing.
It also includes quality administration
procedures that include records of maintenance
and record-keeping logs.
I nfection Control in Dental Radiography
Dental radiography presents unique infection
control problems because of the potential for
operator contamination and cross contamination to
other patients and to other members of the dental
team.
Constant movement by the operator from the oral
cavity to the exposure controls outside the
operatory to the darkroom and finally to film
mounting increases the risk of exposing others to
infectious diseases.
Radiography Operatory Preparation
The first step in preparation of the operatory is to
determine the surfaces to be covered or
disinfected with a high-level surface disinfectant.
In general, surfaces that cannot be easily cleaned
and disinfected should be protected by a barrier-
most commonly plastic or foil barriers.
Surface barriers are preferred to be on electrical
switches because of the possibility of the cleaner
and disinfectant causing an electrical short.
Fig. 40-4 Radiography operatory with barriers in place.
Fig. 40-4
X-Ray Machine
The tubehead, position-indicating device (PID),
control panel, and exposure button must all be
covered or carefully disinfected.
Fig. 40-5 X-ray equipment with barriers in place.
Fig. 40-5
Lead Apron
The lead apron should be considered
contaminated and wiped with a disinfectant
after each use.
The Dental Chair
The back and arms of the chair, the headrest, and
the headrest adjustment controls must all be
covered or disinfected.
Once the radiography operatory is set up, the film
and film-holding devices should be prepared.
The Work Area
The work area where the x-ray film and film-
holding devices are placed during exposure should
be disinfected and then a barrier should be placed.
This can be a paper sheet, paper towels, or plastic
cover.
Once the procedure is completed, the barriers
should be discarded. Surfaces not protected by
barriers should be cleaned and disinfected.

Fig 40-6 A, A plastic surface barrier is placed. B, After each exposure, the dental
assistant wipes the film dry using a paper towel and then places the exposed film into
a plastic bag that has been taped to the wall.
Fig. 40-6
Preparation of Supplies and Equipment
Before beginning the procedure, gather all the
supplies that you might need to decrease the
chance of cross-contamination.
For example, think about the type of film-holding
devices, cotton rolls, and bitewing tabs that may
be needed if the patient has an edentulous area.
If you need some additional supplies during the
procedure, either use overgloves (food handlers
gloves) or ask someone for assistance.
Film
Dental film should be dispensed from a central area in a
disposable container, such as a paper cup or an envelope.
To minimize contamination by saliva, a clear plastic barrier
envelope may be placed over the film packet.
Films that are enclosed in a clear plastic barrier packet are
available commercially.
The barrier-protected film packets are exposed and brought
to the processing area.
The barriers are contaminated and must be removed very
carefully without touching the inner packet so the packet
can be handled with bare hands.
Fig. 40-7 Protective barrier on x-ray film.
Fig. 40-7
Contaminated Film Packets
The contaminated film packet is the major source
of cross-contamination during radiographic
procedures.
When the packet is removed from the patients
mouth, it is coated with saliva (or, on occasion,
contaminated with blood).
For this reason, the operator must always wear
gloves while handling contaminated film packets.
Decontamination of Film Packets
Wipe saliva from the film packet using a dry 2 x 2
inch gauze sponge or a paper towel.
Do not attempt to sterilize the film packet. Heat
sterilization will destroy the image.
Some film manufacturers permit light spraying of
the film packets with a disinfectant spray;
however, immersion of the packet in a disinfecting
solution can result in the solution seeping into the
emulsion and damaging the image.

Film-Holding Devices
Film-holding instruments and bite-blocks that are
placed in the patients mouth are semicritical items
and must be sterilized or high-level disinfected
before reuse.
The alternative is to use disposable film holders
and discard them after a single use.
Sterilized film-holding devices should remain
packaged until the patient is seated and the
patient can view the opening of the package.
Patients appreciate knowing that proper infection
control procedures are in place throughout the
office.
Miscellaneous I tems
Other miscellaneous items include cotton rolls that
can be used to stabilize film placement and paper
towels that can be used to wipe saliva from
exposed films.
A disposable container, such as a paper cup
labeled with the patients name, is also necessary
to collect the exposed films.
All miscellaneous items should be dispensed from a
central supply area.

Gloves and protective clothing must be worn while
exposing radiographs and handling the
contaminated films.
Because radiographic procedures do not involve
the aerosol produced by the dental handpiece, a
mask and glasses are optional while radiographic
films are being made.
Preparation of the Operator
Fig. 40-8 While wearing the appropriate personal protection, the operator
places the lead apron on the patient.
Fig. 40-8
I nfection Control During Exposure
After gloving, the operator should be careful not to
touch any surfaces that are not covered.
The best way to do this is to develop a sequence in
which the operator touches as few surfaces as
possible.
After each exposed film is removed from the
patients mouth, it must be wiped with a paper
towel to remove excess saliva.
Collection of Contaminated Films
Once dried, each film must be placed in a disposable
container (plastic bag or paper cup) that is labeled with
the patients name.
This container will be used to transport the films to the
darkroom.
The outside surface of this container must not be
touched by gloved hands.
To prevent film fog caused by radiation, the container
should never be placed in a room where additional
films are being exposed.
Exposed films should never be placed in the operators
laboratory or uniform pocket.
Film-Holding Devices
During exposure, film-holding devices should be
transferred from the covered work area to the
patients mouth and then back to the same area.
Contaminated instruments should never be placed
on an uncovered surface.

Management of Contaminated I tems
After Exposure
After completion of film exposure, all contaminated
items must be discarded, and any uncovered surfaces
must be disinfected.
Contaminated radiography items must be handled in
the same manner as recommended for other
contaminated dental instruments.
Contaminated items must be discarded while wearing
gloves; this includes the disposable surface coverings.
The operator should carefully unwrap all covered
surfaces; the actual surfaces that are wrapped should
not be touched by gloved hands.

Film-holding devices
While the operator is wearing gloves, the contaminated
film-holder must be removed from the treatment area
and placed in the area designated for contaminated
instruments.
Handwashing
After the removal and disposal of all contaminated
items, the gloves must be removed and the hands
washed.
Surface disinfection
Any uncovered areas that were contaminated during
exposure must be cleaned and disinfected using an EPA-
registered hospital-grade disinfectant and utility gloves.
Management of Contaminated I tems
After Exposure- contd
Film Transport
The disposable container should never be touched
by gloved hands.
Only after the gloves have been removed, the
hands have been washed and dried, the patient
has been dismissed, and the area has been
cleaned and disinfected should the operator carry
the disposable container holding the contaminated
films to the darkroom.

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Chapter 40

Legal I ssues, Quality Assurance,

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