Standards › Standard 31 › Policies
Policy · DEN-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 31.8
At a glance
- Every radiograph is justified before the exposure and the justification is recorded (DEN-FRM-003).
- Dose is optimised with the right receptor, collimation and protocol.
- Repeat exposures are reviewed and recorded.
- Full-mouth radiography is not taken without a clinical reason.
- Stop and get help straight away if: a radiograph is taken with no justification recorded.
1. Purpose
To make sure each dental radiograph is justified and that the dose to the patient is as low as reasonably achievable (31.8).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Dental X-rays give a dose of radiation. A radiograph that is not needed adds risk without benefit, and a dose that is too high can be avoided by setting the machine correctly.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Radiation protection lead | Owns the justification criteria and the dose protocol | Clinical director |
| Clinician | Justifies each radiograph before the exposure | Radiation protection lead |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Justify.
- Decide and record the clinical reason for the radiograph on DEN-FRM-003.
Key point: Justified.
Step 2. Optimise.
- Select the receptor, collimation and protocol for the patient.
Key point: Optimised.
Step 3. Review.
- Review repeat exposures and record the reason.
Key point: Reviewed.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Radiographs with a recorded justification | 100% | Monthly | Radiation protection lead | Escalate to the clinical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| DEN-FRM-003 | Radiograph justification record | Record |
| DEN-PLN-001 | Radiation protection programme for dental imaging | Plan |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the CDC guidelines for infection control in dental health-care settings (Kohn et al., 2003), ISO 17665 for moist-heat sterilisation, the Minamata Convention on Mercury (2013), IAEA Specific Safety Guide SSG-46 (2018), Council Directive 2013/59/Euratom, and the ADA guidelines on sedation (2016). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)