Radiation protection in dental imaging: challenges and strategies for fragile and non-cooperative patients

BACKGROUND: To analyze radiation protection strategies in dental imaging with specific emphasis on fragile and non-cooperative patients, including pediatric subjects, individuals with neurological or cognitive impairments, bedridden patients, wheelchair users, and patients with autism spectrum disorders.

METHODS: This narrative review synthesizes international guidelines, consensus documents, and published scientific evidence concerning radiation protection in dentistry, with particular focus on dose optimization, justification, equipment accessibility, and clinical challenges related to patient disability and limited cooperation.

RESULTS: Fragile and non-cooperative patients present specific difficulties in dental radiology, including impaired immobilization, positioning challenges, increased risk of repeated exposures, and incompatibility with standard acquisition protocols. Optimization of imaging protocols, appropriate selection of radiological techniques, limitation of field of view, and strict adherence to the ALARA (As Low As Reasonably Achievable) principle are essential to minimize unnecessary exposure.

CONCLUSIONS: Radiation protection in fragile dental patients requires a tailored, clinically driven approach that prioritizes justification and optimization over routine imaging. Enhanced operator training, appropriate equipment selection, and awareness of patient-specific limitations are fundamental to ensuring diagnostic efficacy while minimizing radiation risks.

CLINICAL SIGNIFICANCE: 1) Tailored Approach for Vulnerable Populations: radiation protection in fragile and non-cooperative patients, such as pediatric subjects or individuals with cognitive and physical disabilities, cannot rely on standard protocols but requires a clinically driven, individualized approach.
2) Justification and Optimization Priority: clinical decision-making must strictly prioritize the justification of each exposure and the ALARA (As Low As Reasonably Achievable) principle over routine imaging to minimize the significant collective radiation dose generated by high-volume dental procedures.
3) Technical Dose Reduction Strategies: the implementation of high-efficiency digital sensors, rectangular collimation in intraoral radiography, and the limitation of the Field of View (FOV) in CBCT examinations are essential technical measures to ensure diagnostic efficacy while reducing stochastic risks, especially in radiosensitive pediatric patients.
4) Overcoming Barriers to Care: enhanced operator training and the judicious use of portable X-ray devices in specific settings (e.g., bedridden or wheelchair-bound patients) are fundamental to overcoming physical and behavioral barriers, ensuring equitable and safe access to dental imaging.
5) Ethical Responsibility: oral healthcare providers bear the ethical responsibility of balancing diagnostic benefits with radiation risks, where choosing not to perform an examination may occasionally represent the most appropriate clinical decision for a fragile patient.

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