CBCT Dosimetry: Orthodontic Considerations

Sharon L. Brooks
This article reviews the general principles of radiation biology and dose
measurement. Effective doses for typical imaging examinations used in
orthodontics include: panoramic, 5.5 to 22 microsieverts (Sv); cephalometric, 2.4 to 6.2 Sv; large field-of-view cone beam CT, 58.9 to 1025.4 Sv. This
can be compared with average annual natural background radiation of 3000
Sv/yr. Issues of radiation risk, particularly for children, as well as mechanisms
for dose reduction are discussed. (Semin Orthod 2009;15:14-18.) 2009 Elsevier
Inc. All rights reserved.

he discovery of x-rays more than 100 years

ago brought about an era of increased
diagnostic capability in the healing arts. As
technology improved, clinicians moved from
simple bitewing and periapical intraoral radiographs to larger, more complex extraoral
views. It is hard to imagine an orthodontic
office today that does not use panoramic and
cephalometric radiographs to help make a
thorough assessment of the orthodontic patient before beginning treatment. Today many
orthodontic offices are substituting cone beam
computed tomography (CBCT) images for the
traditional orthodontic views for all patients,
while others are adding this type of imaging
only in specific types of cases, such as those
with impacted canines or requiring orthognathic surgery. It is expected that the use of
CBCT in orthodontics, as well as in other dental specialties, will continue to grow at a rapid
rate, bringing up the question about the radiation dose required for this type of imaging
and whether it is justified.
It did not take long after the discovery of
x-rays for the first reports of radiation injury to

From the University of Michigan School of Dentistry, Ann

Arbor, MI.
Address correspondence to Sharon L. Brooks, DDS, MS, University of Michigan School of Dentistry, Department of Periodontics and
Oral Medicine, 1011 N. University Avenue, Ann Arbor, MI 481091078. Phone: 734-764-1595; Fax: 734-764-2469; E-mail: slbrooks@
umich.edu
2009 Elsevier Inc. All rights reserved.
1073-8746/09/1501-0$30.00/0
doi:10.1053/j.sodo.2008.09.002

14

appear. Of course, the dose levels in the early

days were very high and the equipment not very
good, but there were numerous reports of radiation burns and the induction of cancer. One of
the pioneers of dental radiology, Dr. C. Edmund
Kells, developed cancer on his hands and arms,
due to prolonged exposure to the x-ray beam,
which led to more and more surgery and his
eventual suicide.1
Because we no longer use the very high doses
of the past, it is unlikely that we will ever see the
types of radiation injuries also seen in the past.
However, does that mean that there is no risk of
biological damage from the doses currently in
use? If the answer to that question is no, can we
measure the magnitude of the risk and then
make a judgment about whether this level of risk
is acceptable or not?
It has been observed for many years that
groups of individuals who received radiation exposure for a variety of conditions showed an
elevated risk of developing cancer.2 In the past
radiation was used to treat ankylosing spondylitis, a type of arthritis, postchildbirth mastitis, and
tonsillitis, among other conditions, which increased incidence of leukemia, breast cancer,
and thyroid cancer, respectively, leading to the
discontinuation of this practice. These groups of
patients, along with the large number of people
living in the Japanese cities of Hiroshima and
Nagasaki at the time of the dropping of the
atomic bomb at the end of World War II, make
up the population that has been studied to determine the relationship between radiation and
cancer.

Seminars in Orthodontics, Vol 15, No 1 (March), 2009: pp 14-18

CBCT Dosimetry

Much of the information we have on radiation

risks is based on a careful epidemiologic analysis of
these populations, looking at radiation doses received and radiation effects observed. Mathematical models were then developed to try to explain
the observations. Because the information is incomplete for all dose levels, there is some uncertainty in the exact shape of the dose-response
curve. However, even though the exact risk is
not known, there is little doubt that radiation
has an effect on the human body even at low
doses.
It is well known that radiation is a carcinogen,
along with various chemicals, viruses, and probably other entities. X-rays striking the nucleus of
a cell can disrupt cell mitosis and damage DNA,
leading to mutations that can be passed on to
future generations of the same cells (somatic
mutation) or to future offspring (genetic mutation). Some of the mutations may be lethal,
leading to cell death, some may modify the function of the cell to a lesser or greater degree,
perhaps by affecting the production of enzymes,
and some may change the cell enough to induce
cancer, when coupled with other initiator or
promoter entities.
The body has some DNA repair mechanisms
available, but these may not be sufficient to repair all DNA breaks, particularly if they occur in
both strands or if large pieces of the DNA are
removed or rearranged. Thus, the nonrepaired
damage can accumulate in the body.
There are many varieties of radiation-associated effects that can occur in the body. In one
type, described as deterministic, there appears
to be no damage until a certain threshold of
radiation is received. Once beyond the threshold, the severity of the damage is proportional to
the radiation dose. Examples of this type of effect include skin reddening, hair loss, and salivary gland dysfunction.
Other types of radiation effects, most notably
carcinogenesis and genetic mutations, are examples of stochastic effects, in which there is no
threshold for radiation damage but where the
probability of an effect is proportional to the
radiation dose. In this situation, it is possible that
a single hit of radiation can produce a nonrepaired mutation of the DNA that can lead to
cancer several years in the future. There is no
guarantee that the subject will ever develop cancer as a result of the radiation, but the more

15

radiation that is received, the more chances that

something will occur.
Not all cells in the body have the same degree
of sensitivity to radiation. In general, cells that
are dividing rapidly over several generations, are
primitive or immature, and are nonspecialized
are at higher risk for radiation effects due to the
impact of radiation on DNA and cell division.
Children are considered to be more sensitive to
radiation than adults, an issue in orthodontic
imaging due to the high proportion of children
in an orthodontic practice.

General Principles of Radiation

Dosimetry
To evaluate radiation risks from various imaging
techniques, radiation doses must be measured.
It is relatively easy for a health physicist to place
an ionization chamber in the x-ray beam used
for intraoral and cephalometric radiography
and determine the amount of radiation that
strikes the patient, but unfortunately, this procedure does not make it easy or even possibleto compare radiation doses for the various
imaging examinations. For example, in panoramic radiographs and CBCT imaging, the xray beam moves around the patients head, partially or totally, depending on technique, and
different parts of the anatomy receive different
amounts of radiation, depending on their location with respect to the center of rotation. The
surface exposure, while easy to measure, also
does not take into account the size of the radiation beam or the radiosensitivity of the tissues
exposed.
To allow a meaningful comparison of radiation dose, and thus risk, radiation exposures are
frequently converted to effective doses, measured in Sieverts (Sv or milli- [mSv] or micro[Sv]). In the calculation, the radiation dose to
specific tissues is measured, adjusted for amount
of that tissue in the field of view, and weighted
based on radiation sensitivity of the tissue. The
weighted tissue/organ doses are then summed
to produce the effective dose. This could be
thought simplistically as a weighted average of the
dose over the entire body. When this is done, the
dose for various imaging techniques can be compared. Comparisons can also be done with other
whole body doses, such as background radiation.

16

S.L. Brooks

The tissues/organs used to calculate the effective dose are specified by the International
Commission on Radiological Protection (ICRP).
While ICRP is an international advisory group,
which does not have force of law, its recommendations are accepted worldwide and form the
basis for much of radiation protection.
The organs used to calculate effective dose
for imaging of the head include the bone marrow, thyroid, esophagus, skin, bone surface, salivary glands, brain, and remainder tissues.3,4
The dose to the thyroid contributes the most to
the effective dose from dental imaging, but salivary glands, even though they have a lower
weighting factor, are also a significant component of the effective dose due to their location in
the field of view.

Typical Orthodontic Radiation Doses

Effective radiation doses for various imaging examinations used in orthodontic practice have
been calculated and published in the literature.
In general, there is little difference in the dose
for digital panoramic and cephalometric images
compared with their film-based counterparts, in
large measure due to the use of intensifying
screens with the film imaging that reduces the
required dose. The situation is not the same for
intraoral imaging, in which the digital images
are compared with direct exposure film that
requires a higher exposure.
Effective doses in the literature are expressed
using one of two ICRP criteria: the 1990 report3
or the 2007 report4 (available earlier in draft
form), with the major difference being in the

handling of dose to the salivary glands. In the

earlier report the salivary glands were considered as part of the remainder organs and as
such received a low weighting. In the 2007 report the salivary glands have been removed from
the remainder and have their own weighting.
Because the salivary glands receive a relatively
large dose in dental imaging, due to their location, considering them separately leads to a
higher calculated effective dose. In reading the
literature on effective dose, it is important to
determine which ICRP report was used to calculate the dose since this will affect any comparisons made.
Published effective doses for digital panoramic radiographs range from 5.5 to 22.0 Sv,
when the salivary glands are considered 2.4-6.2
Sv without,5,6 while digital cephalometric radiographs have effective doses of 2.2 to 3.4 Sv
with salivary glands, 1.6 to 1.7 Sv without.7,8
Therefore, a typical panoramic cephalometric
orthodontic examination will expose the patient
to 7.5 to 25.4 Sv effective dose (with salivary
glands). This compares with an average annual
natural (not including medical imaging or consumer products) background radiation dose in
the United States of 3.0 mSv (3000 Sv).9 See
Table 1.

CBCT Doses
In the last few years, the number of CBCT systems available has increased dramatically. Unfortunately, published dosimetry data are not available for most of these machines, although work
is under way to test them. Data have been pub-

Table 1. Effective Doses of Imaging Examinations Used in Orthodontics

Examination

E Sv (without sal gl)

E Sv (with sal gl)

Reference

Panoramic (digital)
Cephalometric (digital)
CBCT (full FOV)
NewTom 9000
NewTom 3G
MercuRay
i-CAT (9)
i-CAT (12)
Conventional CT
Background radiation

2.4-6.2
1.6-1.7

5.5-22.0
2.2-3.4

5
7

36.3
44.5
846.9
68.7
134.8
42 to 657
3 mSv/yr, 8 Sv/d

77.9
58.9
1025.4
104.5
193.4

6
10

Reported in 11
Reported in 9

All doses are from the literature and are expressed as effective dose (E) in Sv. They may be reported as without/with salivary
glands (sal gl), which refers to how the dose to the salivary gland is treated in the calculation of the effective dose. The dose
with salivary glands is probably a better representation of the real risk since the salivary glands are directly exposed during
maxillofacial imaging. FOV field of view.

CBCT Dosimetry

lished on four of the large field-of-view systems:

the NewTom 9000 (QR, Verona, Italy), NewTom
3G, CB MercuRay (Hitachi Medical Systems, Tokyo, Japan), and the i-CAT (Imaging Sciences
International, Hatfield, PA).10,11 See Table 1.
There are a number of factors that will affect
the radiation dose produced by a CBCT system:
the imaging parameters used (kVp, mAs);
pulsed beam versus continuous beam; amount,
type, and shape of beam filter; full 360 rotation
versus lesser rotation; and limited versus full
field of view. Some of these factors, such as type
of beam and filtration, are unique to a specific
machine, while other factors, such as field of
view, are under the control of the operator.
In general, the smaller the field of view, the
lower the radiation dose.10 Since the effective
dose is computed from a weighted summation of
doses to various organs, removing some organs
from the path of the x-ray beam will reduce the
effective dose. For example, since the radiation
received by the thyroid gland contributes a large
amount to the effective dose, limiting the beam
to the maxilla instead of the whole head produces a lower effective dose.
In orthodontics, if CBCT is being used to
replace the standard panoramic and cephalometric radiographs, it may not be possible to
reduce the height of the beam and still obtain
the desired information. On the other hand, if
the CBCT is being used to supplement other
imaging in specific cases, such as for the assessment of impacted canines, beam height can be
reduced to cover only the area of interest without exposing the entire head.
Operators of some CBCT machines have the
opportunity to affect radiation dose by the imaging parameters they select. Some machines
allow the operator to select tube potential and
current (kVp, mA), others use a fixed setting,
and still others use a smart beam that bases the
parameters on patient size. Using higher settings
increases the signal-to-noise ratio (SNR) but also
increases the dose. A higher SNR may look prettier, but it has not been shown to increase the
diagnostic quality of the image.12 It does not
affect the density and contrast of the image:
these are controlled by image processing of the
data and can be adjusted on the monitor by the
operator.

17

Radiation in ChildrenAs Low as

Reasonably Achievable (ALARA)
Concerns have been raised in medical imaging
about the increased use of CT scans in children
because of the higher susceptibility of children
to the effects of radiation, with increased numbers of cancers predicted for the future of these
exposed children.13 In general, radiation doses
from medical CT scanners are higher than from
CBCT, but if CBCT becomes widespread in orthodontics, the collective dose to children could
be quite high. Even with the lowest dose CBCT
scanner on the market, the radiation dose is
higher with a full head scan than it is with panoramic and cephalometric radiographs.
The risk of cancer development as a result of
CBCT is not specifically known, particularly for
children. The effective dose calculations have
been used to try to estimate risk, usually expressed in terms of X number of excess cancers
per Y persons. Almost all of the risk estimates
have been based on adults because most of the
epidemiologic information available is on
adults. Using the ICRP probability coefficient of
6.0 102 Sv1 and the effective doses including
salivary glands,3,5-7,10 the risk estimates of cancer
induction or other stochastic effect are 0.3 to 1.3
10 6 for a dental panoramic radiograph, 0.1
to 0.2 10 6 for a cephalometric, and 3.5 to
61.5 10 6 for a full field-of-view CBCT.
At this point it is unknown whether the
information provided by a CBCT is sufficiently
greater than for traditional orthodontic imaging to justify its routine use in children. On
the other hand, it is also not clear whether the
estimated risk is significant enough to worry
about at all.
However, since stochastic effects of radiation
increase with exposure and the effects are not
seen for many years after exposure, the prudent
course is to apply the ALARA (As Low As Reasonably Achievable) principle to orthodontic imaging, as it is to other areas of radiation protection.14,15 That means that research should be
done to determine the true value of the extra
information in the diagnosis and management
of orthodontic cases, including the elucidation
of selection criteria that will identify those situations where the 3D information makes a substantial contribution to case management. Efforts should also be made by the manufacturers

18

S.L. Brooks

of CBCT equipment to reduce the radiation

dose produced by their machines and by the
operators to use the equipment in ways that will
keep the dose as low as possible while still obtaining the needed information. This may include reducing the height of the beam when a
full head view is not required and reducing the
imaging parameters to the lowest that would still
provide the desired information. In this way the
benefits of CBCT imaging can by realized while
the risks are minimized.

References
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Oral Radiol Endod 80:496-511, 1995
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2. Washington, DC, National Academies Press, 2006
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1990 Recommendations. ICRP Publication 60. Ann
ICRP 21:1-201, 1991
4. International Commission on Radiological Protection:
2007 Recommendations. ICRP Publication 103. Ann
ICRP 37:1-332, 2008
5. Gijbels F, Jacobs R, Debaveye D, et al: Dosimetry of
digital panoramic imaging. Part I: Patient exposure.
Dentomaxillofac Radiol 34:145-149, 2005

6. Ludlow JB, Davies-Ludlow LE, Brooks SL: Dosimetry of

two extraoral direct digital imaging devices: NewTom
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beam computed tomography for orthodontics. Masters
thesis, University of Michigan, 2007
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www.pediatricnews.com (Accessed 26 June 2008)
14. Brand JW, Gibbs SJ, Edwards M, et al: Radiation protection in dentistry. NCRP Report No. 145, 2003
15. Farman AG: ALARA still applies [editorial]. Oral Surg
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