Sir, a 24-year-old female attended my surgery for a routine examination. Aside from stained fissures her dentition was unrestored and symmetrical. Twelve months earlier a pair of digital bitewing radiographs had been taken but not labelled. Both radiographs were displayed as if they were from the same side. As a foundation dentist being observed by the training programme director, I was simply asked to identify and orientate them correctly...

Photostimulable phosphor storage plates are commonly used as image receptors in digital radiography. The plates can be seen as having two sides; an 'imaging' side containing a layer of barium fluorohalide phosphor and a 'reverse' side being a flexible plastic backed support. For cross infection control purposes intraoral plates are inserted into protective barrier envelopes. These also have two distinct sides with contrasting materials or patterns used.1

Use of phosphor plates can lead to a dilemma. When taking a right-sided bitewing radiograph, if the 'imaging' side of the plate is placed towards the tube head, the resulting image will correctly orientate teeth on the right side. However if the 'imaging' side were to face away from the tube head, an image is still recorded but orientated as if it was taken on the left side (opposite). In both instances though, once the plates are scanned the 'mark' or 'dot' will remain in the same position. When looking at a scanned image, no definitive method exists to determine when a plate has been exposed with the 'imaging' side away from the X-ray tube head.

Following on from an awkward discussion with my training programme director, I undertook an audit which identified further similar cases within our practice. On addressing the issue at a peer review meeting, the following leaning points were identified and an action plan agreed:

  • All phosphor plates within the practice should be labelled

  • Training to ensure all phosphor plates are correctly orientated within the barrier envelopes

  • Training to ensure all operators are orientating the phosphor plates correctly within the patient's mouth; ie the text printed on the back of the phosphor plate ('reverse' side) is closest to the tongue

  • All processed radiographs should be correctly orientated and only rotated on the software if required

  • No 'flipping' of processed radiographs should be required

  • To state the side of the mouth and teeth present on the radiograph

  • A complete report for all radiographs.

A significant concern raised by our training programme director was that three other dental foundation training practices had the same problem. This was 'without looking that hard'. Potentially, this is a national issue and not one limited to a couple of practices. Ultimately, non-labelled and non-orientated digital radiographs contradict IR(ME)R 2000 regulations; are of potential limited value as a baseline index; and pose a risk for wrong side surgery.