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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 21-24

Audit of the quality of intraoral periapical radiograph: An institutional study


Department of Oral Medicine and Radiology, Nair Hospital Dental College, Mumbai, Maharashtra, India

Date of Web Publication1-Oct-2019

Correspondence Address:
Sunita Shankarrao Patankar
Department of Oral Medicine and Radiology, Nair Hospital Dental College, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomr.jomr_12_19

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  Abstract 


Objectives: To reduce the radiation exposure to patients, to improve the diagnostic proficiency of radiographs, and to collect data which will help decide the action of improvement in performance. Materials and Methods: The audit consisted of two cycles: Audit Cycle 1 analyzed randomly selected 400 recently taken intraoral periapical (IOPA) radiograph and the quality of each film was recorded according to subjective quality rating of radiograph given by the national board of radiation protection (NPRB) guidance and put them into Grades 1, 2, or 3. Audit Cycle 2 radiographs from Grades 2 and 3 were further randomly reevaluated to determine the causes of error and these are classified into faults due to positioning, exposure, and chemical processing. Frequency (n) and percentage (%) of outcome of various grades overall and with respect to independent variables will be compared using Chi-square test. Results: Of the 400 IOPA radiographs, 180 (45%) score Grade 1, 165 (41.3%) score Grade 2, and 55 (13.8%) score Grade 3. In Grade 2, IOPA radiographs of 163 (40.7%) were found to be positioning error, 45 (11.2%) exposure error, and 9 (5.5%) chemical processing. In Grade 3 (out of 57 IOPA), radiographs were rejected due to positioning faults in 45 (28.8%), exposure error in 7 (4.3%), and chemical processing in 3 (1.8%). Conclusion: The overall quality of radiographs was not found to be satisfactory when compared with standard recommendations of the National Board of Radiation Protection of UK. When the audit of the quality was done at regular intervals, it can be used as a guide to effective dose reduction and reduction of unnecessary irradiation of the patients and staff.

Keywords: Audit, intraoral periapical radiograph, quality assurance


How to cite this article:
Patankar SS, Karjodkar FR, Sansare KP, Vora S. Audit of the quality of intraoral periapical radiograph: An institutional study. J Oral Maxillofac Radiol 2019;7:21-4

How to cite this URL:
Patankar SS, Karjodkar FR, Sansare KP, Vora S. Audit of the quality of intraoral periapical radiograph: An institutional study. J Oral Maxillofac Radiol [serial online] 2019 [cited 2019 Nov 21];7:21-4. Available from: http://www.joomr.org/text.asp?2019/7/2/21/268234




  Introduction Top


Clinical audit is a quality improvement process that seeks to improve patient care and outcome through systematic review of care and comparison with unambiguous criteria followed by the execution of change.

It has been defined as “the systematic appraisal of the implementation and outcome of any process in the context of prescribed targets and standards.”[1] The audit is a multidisciplinary activity and an integral part of the quality management system.[2]

According to the Atomic Energy Regulatory Board guideline, audit should be conducted at regular intervals.[3] The audit is also a major part of dental radiology, with the regulations stating the necessity for sites with radiographic equipment to have in place quality assurance program.[4],[5]

If radiographs are of good quality first time, then diagnosis can proceed, patients are not exposed to unnecessary radiation, and practice time and resources are conserved. Repeat radiographs because of poor quality are not to be confused with the second radiograph taken because additional information is often prompted by the first radiograph. Careful thought is needed during audit so that performance can be accurately measured and improvements to practice executed.[6],[7]

Methods of dose reduction include factors related to X-ray equipment such as filtration, collimation, image receptor, voltage, and method of X-ray generation. There are patient factors such as patient preparation and careful positioning and beam aligning devices. Quality assurance programs and use of selection criteria for different radiographs further ensure that the radiation dose is kept to the minimum.[8],[9]

Here, we analyzed the image quality of intraoral periapical (IOPA) radiographs and it is important to regularly audit and ensure that radiographs are not repeated and radiation dose to the patient is kept as low as possible.

Aim

  • To collect data which will help decide the action of improvement in performance.


Objectives

  • To emphasize any potential problems involving quality issues within the service
  • To decrease radiation exposure to patients
  • To improve the diagnostic proficiency of radiographs.



  Materials and Methods Top


The audit consisted of two cycles: Audit Cycle I examined randomly selected 400 recently taken IOPA radiograph in the department of oral and maxillofacial radiology based on the subjective quality rating of radiograph given by the National Board of Radiation Protection (NPRB) guidance of UK and put them into Grades 1, 2, or 3.[8] The intraoral radiograph were scrutinized by the 2nd year postgraduate resident.

Audit Cycle II radiographs from Grades 2 and 3 were further randomly reevaluated to determine the causes of error and these are classified into faults due to:

  1. Positioning errors such as cone cutting, film bending, elongation, and shortening
  2. Exposure errors such as dark or light radiograph
  3. Chemical processing such as yellow or brown stain.


In this audit, IOPA radiographs of recently taken had been taken and old radiographs (>1 day) were excluded. Institutional ethical clearance was obtained prior.


  Results Top


Four hundred IOPA radiographs were assessed subjectively according to the criteria mentioned [Table 1] and scored into the Grade 1, 2, or 3. Data obtained were compiled on MS Office Excel Sheet (version 2010) and subjected to statistical analysis using Statistical package for social sciences (SPSS v 21.0, IBM [United State]). Descriptive data such as frequencies and percentage have been depicted. In this audit, study reading was taken by one observer and the same observer reexamined 25% of IOPA radiograph after 15 days, and the average of the two readings was taken for the study.
Table 1: Subjective quality rating scale given by the national board of radiation protection

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In Audit Cycle I – 180 (45%) IOPA radiographs score Grade 1, 165 (41.3%) IOPA radiographs score Grade 2, and 55 (13.8%) IOPA radiographs score Grade 3 [Table 2]. Audit Cycle II after the results of the Audit Cycle I analyzes the IOPA radiographs of Grade 2 and Grade 3 randomly to determine the cause of error. In Grade 2, IOPA radiographs of 165 (40.7%) were found to be positioning error, 45 (11.2%) exposure error, and 9 (5.5%) chemical processing. In Grade 3, radiographs were rejected due to positioning faults in 45 (28.8%), exposure error in 7 (4.3%), and chemical processing in 3 (1.8%) [Table 3].
Table 2: Audit Cycle 1

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Table 3: Audit Cycle II

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In this audit study, out of 220 IOPA [Grade 1 and 2] shows, number of unacceptable IOPA 55 (42.6 %), apex missing 15 (11.6%), apex obscured 2 (1.6%), incorrect vertical elongation 33 (25.6%), incorrect horizontal angulation 32 (24.8%), film bending 19 (14.7%) cone cutting 129 (100 %), positioning errors 70 (54.3%), inadequate density and contrast 9 (7%), weak 136 developer 2 (1.6%), weak fixer 11 (8.5 %) [Table 4].
Table 4: Frequency of faults in Grade 2 and Grade 3

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  Discussion Top


The discovery of X-rays has proved to be beneficial to human. These benefits have been greatly utilized for medical diagnostic and therapeutic purposes. X-ray has its own adverse effects because it causes ionization of molecules in body tissues, and this, among other hazards, is known to cause cancer and other malignancies. Radiographic exposure is often repeated when there is any significant fault along the processes that are involved in producing an image.

In the present study, 400 random IOPA radiographs were taken and assessed according to subjective quality rating scale of the NRPB guidance [Table 1]. In Audit Cycle I – 180 (45%) IOPA radiographs were excellent (Grade 1 – percentage of target of radiograph taken are <70); 165 (41.6%) were diagnostically acceptable (Grade 2 – percentage of target of radiograph taken are more than 20); 57 (13.8%) are unacceptable (Grade 3 – percentage of target taken are more than 10).

The IOPA radiographs of Grade 2 and Grade 3 (Audit Cycle II) were randomly assessed to determine the cause of error. In Grade 2, 165 (40.7%) IOPA radiographs showed positioning error, 45 (11.2%) showed exposure error, and 9 (5.5%) showed chemical processing error. In Grade 3 (out of 55 IOPA), 45 (28.8%) IOPA radiographs were rejected due to positioning errors. Seven (4.3%) radiographs showed exposure error and 3 (1.8%) were due to chemical processing. In this audit study, majority of errors are due to positioning error than chemical and exposure. Many of the audits done in the literature showed that errors are due to positioning errors of either the film or the X-ray tube, which was similar in our audit. Emanuel[6] found in their results that of the 112 radiographs taken, 71% had no processing or developing errors and the majority of errors were due to positioning problems rather than developing, which were similar to our results.

In this audit study, out of 220 IOPA [Grade 1 and 2] shows, number of unacceptable IOPA 55 (42.6 %), apex missing 15 (11.6%), apex obscured 2 (1.6%), incorrect vertical elongation 33 (25.6%), incorrect horizontal angulation 32 (24.8%), film bending 19 (14.7%) cone cutting 129 (100 %), positioning errors 70 (54.3%), inadequate density and contrast 9 (7%), weak developer 2 (1.6%), weak fixer 11(8.5 %). Here, we found that majority of error is due to positioning followed by chemical processing and exposure. Salami et al.[10] in their audit result found that, of the 50 IOPA radiographs, 18 (36%) scored Grade 1, 25 (50%) scored Grade 2, and 7 (14%) scored Grade 3. Of the seven IOPA views that scored Grade 3, rejection rate analysis showed that 80% had proximal overlap, 74% had no visible 3 mm of bone around the apex, and 70% showed the whole tooth was not visible on the film, which was similar to our results.

In this study, we observed that processing errors were less because all radiographs were processed with manual method. Felippe et al.[11] found that processing errors were the commonest, which was not similar to our result.

In our audit study found that overexposure to lesser extent underexposure as well as patient motion to be the main reason for the rejection (diagnostically unacceptable). These could be due to the suboptimal x-ray machine performance and poor technical skill element of inattentiveness. These findings were similar to audit conducted by Zewdeneh D, Teferi S, Admassie D[12] In our audit we found that exposure errors like light or dark radiographs were negligible as exposure parameters were checked regularly before taking radiographs and developing solution was checked and changed time to time.

All radiographs taken should be properly numbered and processed. Repeat radiographs should be taken under guidance of senior staff to avoid radiographer workload, crowding of waiting room. The cost of processing chemical and equipment maintenance will be less. The disadvantage of audit is to follow-up in specific period.

Recommendation

  • Use appropriate radiograph for treatment planning
  • Receptor-positioning devices using the long cone technique facilitating rectangular collimation should be used for intraoral radiography wherever possible
  • Those involved in radiography should receive adequate training for the resolution of radiological practices and relevant competence in radiation protection
  • Continuing education and training after qualification is required, particularly when new equipment or techniques are adopted
  • All staff should be trained on how to manage the patients with gagging problems and uncooperative young children
  • The darkroom technician is to ensure that the films are adequately labeled and processed
  • Radiographic parameter (kV, mA, and ms) should be set, before taking radiographs.



  Conclusion Top


The overall quality of radiographs was not found to be satisfactory when compared with standard recommendations of the NRPB of UK. When the audit of the quality of radiograph would be done at regular interval, it can be used as a guide to reduced effective dose and unnecessary irradiation to patients, students and staff. Its results will help to raise awareness of quality issues within the services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
European Communities (Medical Ionising Radiation Protection) (Amendment) Regulations 2010.  Back to cited text no. 1
    
2.
Dance DR, Christofides S, Maidment ADA, McLean ID, Ng KH (Eds.), “Diagnostic Radiology Physics: A Handbook for Teachers and Students,” International Atomic Energy Agency 2014.  Back to cited text no. 2
    
3.
Singh TD, Jayaraman T, Arunkumar Sharma B. Assessment of radiological protection systems among diagnostic radiology facilities in North East India. J Radiol Prot 2017;37:68-83.  Back to cited text no. 3
    
4.
Department of Health. The Ionising Radiation (Medical Exposure) Regulations 2000. London: The Stationery Office; 2000. Available from: http//www.hmso.gov.uk/si/si2000/20001059 htm. [Last accessed on 2005 Jul 26].  Back to cited text no. 4
    
5.
Ionising Radiation (Medical Exposure) Regulations 2017 and guidance www.gov.uk/government/publications/the-ionising-radiation-medicalexposure-regulations-2017. [Last accessed on 2018 Jun 27].  Back to cited text no. 5
    
6.
Emanuel R. A retrospective audit on the quality of periapical and bitewing radiographs taken in a primary care setting. Qual Prim Care 2003;11:305-8.  Back to cited text no. 6
    
7.
Emanuel RJ, Hussain N, Sullivan MO. A retrospective audit of radiograph quality: Completing the audit cycle. Qual Prim Care 2005;13:1495-2.  Back to cited text no. 7
    
8.
Rout J, Brown J. Lonizing radiation regulations and the dental practitioner: 3. Quality assurance in dental radiography. Dent Update 2012;39:334-6, 338-9.  Back to cited text no. 8
    
9.
Janssens A. Radiation Protection-European Guidelines on Radiation Protection in Dental Radiology. Vol. 136. European Commission; 2004. p. 53-83.  Back to cited text no. 9
    
10.
Salami A, Al Halabi M, Hussei I, Kowash M. An Audit on the Quality of Intra-Oral Digital Radiographs Taken in a Postgraduate Paediatric Dentistry Setting. OHDM 2017;16.  Back to cited text no. 10
    
11.
Felippe MC, Nassri MR, Burgos PG, De Freitas SF, Lagemarques JL. Quality of periapical radiographs taken by undergraduate students during endodontic treatment. Rev Sul Bras Odontolo 2009;6:63-9.  Back to cited text no. 11
    
12.
Zewdeneh D, Teferi S, Admassie D. X-ray reject analysis in Tikur Anbessa and Bethzatha Hospitals. Ethiop J Health Dev 2008;22:63-7.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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