H

Lecture#4

-Done by: ‫شهد الفقيه & محمد رمضان‬

-Edited by: ‫حال الحامد‬

-Coordinated by : ‫خزامى أبوشتّال‬

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 Radiation biology
 At first, what do we mean when we say Radiation Biology?

Radiation Biology It’s the study of the effects of ionizing radiation on living tissue

 We have to know that our body can heal by itself, but sometimes, it simply can’t! Therefore,
in this case, we may need to use x-ray to heal.

 Radiotherapy is a very useful branch of therapy to fight cancer, so, sometimes we use x-ray
in high-doses in order to fight cancers, but it may cause ionization, which is harmful and
can produce biologic changes in living tissues.
Radiation Injury:
 In diagnostic imaging, not all x-ray pass through the patient and reach the dental x-ray film
(receptor), the patient’s tissues absorb some.

Remember: Absorption it refers to the total transfer of energy from the x-ray photon to
patient’s tissue.

 When x-ray energy is absorbed, chemical changes occur that result in biologic damage.

 Two specific mechanisms of radiation injury are possible:

1-Ionization 2-Free radical formation

1. Ionization:
 X-rays are a form of ionizing radiation; when x-rays strike patient’s tissue, ionization
results.

 As described, ionization is produced through the photoelectric effect or Compton scatter

and results in the formation of a positive atom and dislodged negative electron.

 The ejected high-speed electron will interact with other atoms within the absorbing tissues
causing chemical changes in the cell, which results in biologic damage.

 Ionization may have little effects on cells if the chemical changes don’t alter sensitive
molecules, or such changes may have a profound(deep) effect on structures of great
importance to cell function (e.g DNA)

2. Free radical formation:

 A free radical: An uncharged (neutral) atom or molecule exists with a single, unpaired
electron in its outermost shell. It’ also highly reactive and unstable.

 X-radiation causes cell damage primarily through the formation of free radicals.
 Free radicals formation occurs when an x-ray photon ionizes water, the primary component
of living cells.

 Ionization of water results in the production of hydrogen and hydroxyl free radicals

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Theories of radiation injury:
 Damage of living tissues caused by exposure to ionizing radiation may result from… a direct
hit and absorption of an x-ray photon within a cell… or from the absorption of an x-ray
Photon by the water within a cell accompanied by free radical formation.

 There are two theories to describe how radiation damages biologic tissues:

1. The direct theory:

 The direct theory of radiation injury suggests that cell damage results when ionizing
radiation directly hits critical areas, or targets, within the cell.
For example.. If x-ray photons directly strike the DNA of a cell, critical damage occurs, causing
injury to the irradiated organism.

 Direct injuries from exposure to ionizing radiation occur in frequently.

NOTE: Most x-ray photons pass through the cell and cause little or no damage.

 The most radiosensitive cells are those that have a high mitotic rate, undergo many future
mitoses, and are the most primitive in differentiation.

2. The indirect theory:

 The indirect theory of radiation injury suggest that

x-ray photons are absorbed within the cell and cause
the formation of toxins, which in turn damage the cell.
For example. when x-ray photons are absorbed by
the water within a cell, free radicals are formed:
the free radicals combine to form toxins (e.g H2O2),
which cause cellular dysfunction and biologic damage.

 Indirect injuries from exposure to ionizing radiation occur frequently because of the high
water content of cells.

 The chances of free radical formation and indirect injury are great because cell are 70% to
80% water.

 It’s the most common theory in radiation damage. Now, how to correlate the damage of tissue
with a dose?

 We have something called Dose-Response Curve…

Dose-Response Curve:
 If all ionizing radiation are harmful and produce biologic damage, what level of exposure is
considered acceptable?
 To establish acceptable levels of radiation exposure, it’s useful to plot the dose administered
and the damage produced.

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 With radiation exposure, a dose-response curve can be used to correlate the ‘response’ or
damage of tissue with the ‘dose’ or amount for radiation received.

 When dose and damage are plotted on a graph, a linear, no threshold relationship is seen.

 A linear relationship indicates that the response of the tissue is directly proportional to the
dose.

 A no threshold relationship indicates that a threshold dose level for damage doesn’t exist.

 Also, a no threshold dose-response curve suggests that no matter how small the amount

of radiation received, some biologic damage does occur.

Note that there is no safe amount of radiation exposure, in dental imaging, although the doses
received by patient are low, damage does occur.

 In threshold dose-response curve no damage will occur.

Stochastic and nonstochastic radiation effect:

 The deleterious effects of ionizing radiation on human tissue can be divided into two types:
Stochastic and nonstochastic.
 Stochastic effect:
 Occur as a direct function of dose.
 The probability of occurrence increases with increasing absorbed dose.
 However, the severity of effects doesn’t depend on the magnitude of the absorbed dose.
 As in the case of nonthreshold radiation effects, stochastic effects don’t have a dose
threshold.
 Examples: Cancers and genetic mutations.
 Nonstochastic effect:
 Somatic effects that have threshold, and increase in severity with increased absorbed dose.
 Nonstochastic effects only occur after a threshold of exposure has been exceeded.
 Examples: Skin erythema, Loss of hair, Cataract formation, Decreased fertility, Radiation
sickness, Teratogenesis, and Fetal death.

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(Compared with stochastic effects, nonstochastic effects require larger
radiation doses to cause serious impairment of health)

Sequence of radiation injury:

 Chemical reactions (ionization or free radical formation) that follow the absorption of
radiation occur rabidly at the molecular level. However, varying amounts of time are required for
these changes to alter cells and cellular functions.

 As a result, the observable effects of radiation are not visible immediately after exposure,
instead, following exposure, a latent period occurs.

 A latent period: The time that elapses between exposure to ionizing radiation and the
appearance of observable clinical signs.

 The latent period may be short or long, depending on the total dose of radiation received
in addition, the amount of time, or rate, it took to receive the dose

(The more radiation received and the faster the dose rate, the shorter the latent period) Note, as a
dentist, we use a small amount of radiation in a long time, so, the latent period is
Long.

 After the latent period, a period of injury occurs.

 A variety of cellular injuries may result, including: Cell death, Changes in cell function,
breaking or clumping of chromosomes …. etc.

 The last event in the sequence of radiation injury is the recovery period.

 Not all cellular radiation injuries are permanent. With each radiation exposure, cellular
damage is followed by repair.

 The recovery period depends on a number of factors, cells can repair the damage caused by
radiation.

 The effects of radiation exposure are additive, and unrepaired damage accumulates in the
tissues.
 The accumulation effects of repeated radiation exposure can lead to health problems as
Cancer, Cataract, Birth defects.
Determining factors for radiation injury:
In addition to understanding the mechanisms, theories
and sequence of radiation injury, it’s important to recognize
the factors that influence radiation injury, and they include->

 Total dose: Quantity of radiation received or absorbed.

 Dose rate: Rate at which exposure to radiation occurs and

absorption takes place.

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  (dose rate =dose/time)

 Amount of tissue irradiated: Areas of the body exposed to radiation.(extensive radiation

injury occurs when large areas of the body are exposed because of the damage to the blood
forming tissue)

 Cell sensitivity: More damage occurs in cells that are sensitive to radiation.

 Age: Children are more susceptible to radiation damage than adults are.

 Radiation effects: They can be classified into:

• Short-term and long-term effects
• Somatic and genetic effects
• Radiation effects on cells
• Radiation effects on tissues and organs

Short and long term effects…

 Following the latent period, effects that are seen within minutes, days, or weeks are termed
short-term effect.
 Short-term effects are associated with large amounts of radiation absorbed in a short time.
 Acute radiation syndrome (ARS) is a short-term effect and includes…. Nausea, Vomiting,
Diarrhea, Hair loss, and Hemorrhage.
 Short-term effects are not applicable to dentistry.
 Effects that appear after years, decades, or generations are termed long-term effects.
 Long-term effects are associated with small amounts of radiation absorbed repeatedly over
a long period.
 Repeated low levels of radiation exposure are linked to the induction of….. Cancer, Birth
abnormalities, and Genetic defects.

Somatic and genetic effects…

 Somatic cells: the cells in the body except the reproductive cells (e.g sperm)

 Genetic cells:the reproductive cells.

 Depending on the type of cell injured by radiation, the biologic effects of radiation can be
classified as somatic or genetic.

 Somatic effects are seen in a person who has been irradiated.

Radiation injuries that produce changes in somatic cells produce poor health in the irradiated
individual.
 Major somatic effects of radiation exposure are not transmitted to future generation.
 Genetic effects are not seen in the irradiated person but are passed on to future
generations.
 Radiation injuries that produce changes in genetic cells don’t affect the health of the
exposed individual, instead, the radiation-induced mutations affect the health of the
offspring.
 Genetic damage can’t be repaired.

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 Radiation effects on cells…

 Ionizing radiation may affect the nucleus of the cell, the cytoplasm, or the entire cell.

 The cell nucleus is more sensitive to radiation than the cytoplasm.

 The damage in the nucleus will affect the chromosomes containing DNA and result in
disruption of cell division, which in turn may lead to disruption of cell function or to cell death,
A cell that is sensitive to radiation is termed radiosensitive.

 A cell that is resistant is termed radioresistant.

 The response of a cell to radiation exposure is determined by:

 Mitotic activity: Cells that divide frequently or undergo many divisions over time are
more sensitive.

 Cell differentiation: Cells that are immature or not highly specialized are more sensitive.

 Cell metabolism: Cells that have a higher metabolism are more sensitive.

Radiation effects on tissues and organs…

 Tissues and organs vary in their sensitivity to radiation.

 Radiosensitive organs are composed of radiosensitive cells and include: Lymphoid tissue,
Bone marrow, Testes, and Intestines.

 Examples of radiosensitive tissues: Salivary glands, Kidney, and Liver.

 In dentistry, some tissues and organs are designated as ‘critical’ because they are exposed to
more radiation than others are during imaging procedures.

 A critical organ is an organ that, if damaged, diminishes the quality of a person’s life.

 Critical organs exposed during dental imaging procedures in the head and neck region
include the following:
 Thyroid gland.
 Bone marrow
 Skin
 Lens of the eye
(Critical organs are those oat affected by radiation)

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Radiation Measurements:
 Units of measurements:
 Radiation can be measured in the same manner as other physical concepts such as, time,
distance, and weight.
 The units of radiation are used to define three quantities of radiation:
1) Exposure. 2) Dose. 3) dose equivalent.
 At present, two systems are used to define radiation measurements:

1) The older system or traditional system or standard system, it includes the following units:
 Roentgen (R)
 Radiation absorbed dose (rad)
 Roentgen equivalent (in) man (rem)

2) The SI (newer) units of radiation measurement, it includes the following units:

 Coulombs/kilogram (C/kg)
 Gray (Gy)
 Sievert (Sv)

 Exposure measurement:

 The term exposure refers to the measurement of ionization in air produced by x-rays.

 The traditional unit if exposure for x-rays is the roentgen (R).

 The roentgen is a way of measuring radiation exposure by determining the amount of

ionization that occurs in air.

 The roentgen has limitations as a unit of measurement. It measures the amount of energy
that reaches the surface of an organism, but it doesn’t describe the amount of radiation
absorbed.

 No SI unit for exposure that is equivalent to the roentgen exists. Instead, exposure is simply
stated in coulombs per kilograms (C/Kg)

 Note, the coulombs is a unit of electrical charge.

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Dose Measurement
 The amount of energy absorbed by tissue
 Traditional unit is the rad (radiation absorbed dose)
 SI equivalent is the gray
 1 Gy = 100 rads

Dose Equivalent Measurement

 Used to compare biologic effects of different kinds of radiation

 How I can compared the damage depending on the type of radiation? the absorbed dose of
any form of radiation that produces the same biologic effect in humans as 1rad of x-
radiation
 Traditional unit is the rem (roentgen equivalent man)

Rem = RAD * weighting factor

 Calculate by multiplying dose in RAD by appropriate weighting factor

 X-rays, gamma rays and beta particles WR = 1
 Fast neutrons (10 keV-100 keV) and protons WR =10
 SI equivalent is the sievert
 1 Sv = 100 rems

Effective Dose
 Allows doses from different investigations of different parts of the body to be compared, by
converting all doses to an equivalent whole body dose.

 How I can compared the damage of tissues? Does the damage of intestine like the damage
of nerve & muscle? The answer is NO. SO, We can compare it by multiplying the equivalent

 dose of rem by tissue weighting factor:

Effective dose (E) = equivalent dose (H) X tissue weighting factor (WT)

 SI unit : Sievert (Sv)

 The greater the risk of damage, the higher the tissue weighting factor.

Sources of Radiation Exposure

1. Natural background radiation
The most common in natural radiation is the radon gas. Radon
gas is present in under soils, so when have construction new
building then we expect radon to go out from the ground and to
inhale by our lungs.

2. A form of ionizing radiation that is ubiquitous in the

environment
3. Cosmic radiation
4. Stars and sun
5. Terrestrial radiation
6. Radioactive materials in the earth and air

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 
In the diagram ,almost 50% of radiation is man-made and 50 % from nature

The most common source of artificial is medical that we used in medical diagnosis and
treatment
Sources of Radiation Exposure ‫هون الدكتور ما ركز عليه وفشق عنه‬

 Artificial or human made radiation

 Resulting from modern technology
 Includes consumer products, fallout from atomic weapons, weapons production, and the
nuclear fuel cycle
 Medical radiation including medical radiographic procedures, dental radiography,
fluoroscopy, nuclear medicine, and radiation therapy

Risk and Risk Estimates

 “The potential risk of dental radiography inducing a fatal cancer in an individual has been
estimated to be 3 in 1 million”

 “The risk of a person developing a cancer spontaneously is much higher, or 3300 in 1

million”

Amounts of Radiation Used in Dentistry

 Factors

1- Receptor sensitivity

 F speed film requires 50% to 60% less radiation than D speed film
 Digital receptors require even less radiation

2- Technique used

 Extraoral techniques use intensifying screens and require less exposure than direct
exposure intraoral film. (Extraoral technique it means reuse more radiation than
intraoral technique)
 Cone Beam Computed Tomography (CBCT) requires higher levels of radiation compared
to intraoral or extraoral imaging.

3- Kilovoltage used

 We know the kilovolt will affect quality and quantity ,however by using 15% rule we can get
benefit from decreasing the dose into half

4- Collimation

 Rectangular collimation reduces the amount of tissue exposed 60% to 70% compared to
round collimation because we use rectangular films in dentistry.

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 Risk V.S Benefit of Dental Radiographs
 Dental radiographs should be prescribed for a patient only when the benefit of disease
detection outweighs the risk of biologic damage.

 When dental radiographs are properly prescribed and exposed, the benefit of disease
detection far outweighs the risk of damage something we call it ALARA.

ALARA:
- A: As
- L: Low
- A: As
- R: Reasonably
- A: Achievable but NOW is
changed into Practical
because no dose limit for
patient

REVISION: - ( ‫) الدكتور هون عمل مراجعة سريعة للمحاضرات السابقة‬

: ‫ رابط الفيديو‬, 9:30 ‫المحاضرة بتبلش من الدقيقة‬
https://youtu.be/pfNM4nOCaPc

 Dental radiograph can be used assist growth, implant, root canal treatment, impaction and
caries.

 Extraoral imaging modalities: panorama (2D), submentovertx, 3d (CT, CBCT, MRI),

ultrasound for pregnancy.

 Can the CBCT generating panorama from them? ANS: yes

 We don’t use ionizing radiation in MRI and ultrasound

‫ا‬  Doblar ultrasound : is ultrasound in the neck that showed us the carotid artery and blood
flow .

 In digital, imagine we can’t modified the resolution that related to focal spot size, but we can
modified the contrast brightness and density.

 Contrast is differences in density and is important to see the details of resolution.

 Digital imagine is depend on the specification you can buy ( ‫)مهم واحتمال الدكتور يجيبه باالمتحان‬

 There are internal converter/analog internal converter in Intensifying screen that convert
the radiation(x-ray) into light ,therefore the radiation will be decreased into half.

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 1- The latent period in radiation biology is the time between:
a. Initial injury and repair.
b. Subsequent doses of radiation.
c. Cell rest and cell mitosis.
d. Exposure to x-radiation and clinical symptoms.

Answer: d

2- A free radical:
a. An uncharged molecule.
b. Has an unpaired electron in the outer shell.
c. Highly reactive and unstable.
d. Combines with molecules to form toxins.
e. All of the above.

Answer: e

3- Which factor(s) contribute(s) to radiation injury?

a. Total dose.
b. Dose rate.
c. Cell sensitivity.
d. Age.
e. All of the above.

Answer: e

4-Which statement is correct?

a. Short-term effects are seen with small amounts of radiation absorbed in a

short period.
b. Short-term effects are seen with small amounts of radiation absorbed in a
long period.
c. Long-term effects are seen with small amounts of radiation absorbed in a
short period.
d. Long-term effects are seen with small amounts of radiation absorbed in a long
period.

Answer: d

5- Radiation injuries that are not seen in the person irradiated but occur in future
generations are termed:

a. Somatic effects.
b. Genetic effects.
c. Cumulative effects.
d. Short-term effects.
e. Long-term effects.

Answer: b

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 1- the amount of energy that is absorbed by tissue is:

a. dose measurement
b. effective dose
c. exposure measurement

Answer : a

2- The most common artificial radiation is:

a. medical diagnosis & treatment

b. consumer products
c. radon

Answer : a

3- Which of the following is correct about receptor sensitivity Factor:

a. F Speed film requires 60% to 50% less than D speed film

b. F Speed film requires 50% to 60% less than D speed film

c. F Speed film requires 50% to 60% more than D speed film

Answer: b

4- The unit for measuring the abosrption of x-ray is termed:

a. roentgen
b. rem
c. rad
d. siveret

Answer: c

5- Dental radiographs should be prescribed for a patient only when the benefits of disease
detection outweighs the risk of biologic damage.

a. True
b. False

Answer :a

THE END

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