32 - 灰度层次：X射线安全与有效剂量 – 第32集

欢迎收听《牙髓之声》，本节目由美国牙髓病学协会为您呈现。

Welcome to Endo Voices brought to you by the American Association of Endodontists.

在这里，我们推动牙髓病学艺术与科学的发展，并与当今顶尖专家一起，致力于提升患者护理的最高标准。

The show where we are advancing the art and science of endodontics and promoting the highest standards of patient care with today's top experts in the field.

现在，有请我们的主持人，医生。

Now here's your host, Doctor.

马库斯·D.

Marcus D.

约翰逊。

Johnson.

非常感谢您加入我们，收听新一期的《牙髓之声》。

Thank you so much for joining us for another episode of Endo Voices.

今天我们有一位非常特别的嘉宾，医生。

We have a very special guest with us today, Doctor.

丽贝卡·米尔曼，她是副教授、医学物理学家，也是放射科学部门的负责人。

Rebecca Milman, who is the associate professor and a medical physicist and section chief of radiological sciences.

是的，我们今天要聊的就是放射学，涵盖牙科影像、辐射暴露、安全这些内容，希望能解答你或者你患者可能有的任何问题和顾虑。

Yes, radiology is what we're going to be discussing, talking everything about dental imaging, exposures, safety, and hopefully really addressing any questions or concerns you may have or that your patients have.

所以，米尔曼医生，真的非常感谢你。

So, Milman, can't thank you enough.

希望你假期过得愉快。

I hope that you've enjoyed a wonderful holiday season.

非常感谢你能来做客我们的播客。

Thank you so much for being a guest on the podcast.

非常感谢。

Thank you very much.

很感谢你邀请我来聊聊。

I appreciate the invitation to come and speak with you.

我还想提一下，她是科罗拉多大学医学院的教授，我对这所学校非常熟悉。

And I also want to mention that she is a professor at University of Colorado School of Medicine, I'm and very familiar with this institution.

我之前可能跟你说过，我出生在科罗拉多州的丹佛，那里现在还是我的家。

As I may have told you earlier, you know, I was born in Denver, Colorado, and it's still home.

你知道，纽约是我过去二十五年左右的家，但尽管如此，我在那里还是有点关系的。

You know, New York has been my home for the last twenty five years or so, but nonetheless, I have a little relation there.

所以和科罗拉多本地人聊天总是很愉快。

So it's always nice to talk with a Colorado Colorado native.

你是本地人吗？

Are you a native?

还是你从哪里来的？

Or where are you from?

我

I

不是科罗拉多本地人，但我在这里已经快十年了。

am not a Colorado native, but I've been here for almost ten years now.

所以这里和其他地方一样，都是家。

So it's as much home as anywhere else.

好，好。

Good, good.

而且，你知道，我确实想，我不想疏忽，也想感谢贾斯汀·斯图尔特，他是美国医学物理学家协会的项目经理，显然你就是代表这个组织发言的。

And, you know, I did want to I didn't want to be remiss and also want to thank Justin Stewart, who is the programs manager for the American Association of Physicists and Medicine, which is obviously the organization that you are speaking on behalf of.

他在促成这件事上帮了很大的忙，让我们能真的请你来做客。

And he was very instrumental in just kind of facilitating this so we could actually get you on as a guest.

所以非常感谢你。

So thank you so much.

也感谢医学物理学家协会。

And thank you to the the Association of Physicists and Medicine as well.

谢谢。

Thank you.

贾斯汀很棒。

Justin is fantastic.

哦，是的。

Oh, yeah.

喜欢他的活力，也绝对喜欢你的活力。

Love his energy and definitely love your energy.

所以，你知道，在牙科领域，特别是在牙髓病学中，X光片是每天的常规操作。

So, you know, within dentistry, specifically within endodontics, you know, X rays are a daily routine.

它们是我们日常工作中不可或缺的一部分，基本上用于治疗计划、诊断、预后判断等等。

They're part of our daily, just pretty much treatment planning, diagnosing, relative prognosis, you name it.

而且总会有一些争议，或者我们只是想通过这次对话来真正弄清楚如何定义牙科X光的安全性，并且讨论一些我们可以向患者传达的信息对比，让他们了解相对剂量、有效剂量等概念。

And there's always some sort of discrepancy or it's just we just kind of want to have this talk to really see how we can define what is the safety of, you know, dental x rays, and really just kind of talk about what are some of the comparisons that we can actually relay information to patients so that they can have an understanding of relative dose, effective dose and things of that nature.

然后还要讨论一下在牙科诊所工作的人可能面临的潜在风险，如果有的话，以及我们作为牙医和牙科辅助团队在日常工作中应该注意的年度测量值或剂量。

And then also just talk about the potential risk, if there are any, for those who work in the dental office and kind of what are the annual measurements or doses that we should really be aware of as we go about our day to day businesses, dentists and dental auxiliary team.

那么我们就从这里开始吧，医生。

So let's just start there, doc.

牙科X光安全吗？

Are dental X rays safe?

从一般角度来看，您怎么看？

Just from a general perspective, what would you say?

总的来说，X光是非常安全的。

So overall, X rays are very safe.

当我们谈到辐射和牙科X光，或者任何类型的影像检查产生的X光时，很快就会进入一些模糊地带。

And when we talk about radiation and dental x rays or any type of x rays from any sort of imaging, quickly get into gray areas.

所以我要先说，总体而言，牙科X光是非常安全的。

So I will start off by saying overall dental x rays are very safe.

很高兴听你这么说。

Nice to hear you say that.

我也这么认为。

So I believe so as well.

我读过一些文献，显然没有你那么深入的知识，但我同意这个说法。

Studying some literature, obviously, I don't have the in-depth knowledge that you've possessed, but I agree with that statement.

不过我想提一点，这是讨论辐射风险时一个非常常见的核心主题，就是像任何其他医疗程序或检查一样，目标是对患者的益处远大于任何相关风险。

So one thing I want to mention, though, this is really a very common underlying theme anytime we're talking about radiation risk, is just like any other medical procedure or exam, the goal is that the benefit of the to the patient, the benefit to the patient is much greater than any associated risk.

所以我们一直在评估的是，对患者的医疗益处与他们可能接受的任何检查所带来的辐射暴露风险之间的平衡。

And so that's constantly the evaluation that we are trying to keep in mind in terms of the medical benefit to the patient and the risk from the radiation exposure from whatever exam they may be having.

我很喜欢听你这么说。

Love to hear you say that.

而且，你知道，我相信这是大多数诊所，应该说所有诊所的首要任务，患者的安全是最重要的。

And, you know, and that's I believe that is a that's at the forefront of most practices of all practices, I should say, the patient's safety is the utmost priority.

而且无论如何，对于任何我们使用的影像技术或方法，我们总是在考虑它们，并且我们希望使用尽可能少的辐射暴露，但又要足够完成我们的工作。

And by all means, any sort of imaging that we would use techniques or methods, We're always considering them and we want to use the, I guess, least amount of radiation exposure as possible, but just enough so we can do our job.

但患者的安全始终是第一位的。

But also patient safety is always the number one priority.

所以谢谢你澄清这一点。

So thank you for clarifying that.

当我们谈到牙科X光时，让我们从有效剂量和患者剂量的角度来看，这样能给听众一些参考，让我们真正把问题放在背景中。

When we kind of speak on dental x rays, let's just have a perspective based on effective dose and kind of patient dose, just to give us some perspective to the listeners so we can really put things in context.

这里就开始有点复杂了，因为当我们谈论辐射剂量时，有很多不同的剂量指标可以使用。

So this is where things start to get a little bit tricky because when we talk about dose from radiation, there are a lot of different dose metrics that can be used.

我们可以谈论器官剂量，特别是当我们谈论对甲状腺等更放射敏感组织的剂量时，我们可以谈论甲状腺的器官剂量。

So we can talk about organ dose, and particularly if we're talking about dose to more radio sensitive tissues like the thyroid, we can talk about organ dose to the thyroid.

但正如你提到的，很多时候我们谈论的是有效剂量。

But as you mentioned, a lot of the time what we talk about is effective dose.

有效剂量的单位是西弗或毫西弗，它确实是一个很好的方式，用来比较不同类型辐射的生物效应。

So effective dose has units of Sieverts or millisieverts, and really is used, is a good way of comparing the biological effects from different types of radiation.

而且它考虑到了不同组织对辐射的敏感度不同。

And it accounts for the fact that different tissues have different sensitivities to radiation.

所以我想先说明一下，一般来说，我在这里提到的剂量，除非特别说明，都是指有效剂量。

So I do want to just kind of mention that upfront that in general, when I'm talking about dose here, I will be talking about effective dose unless I mentioned otherwise.

好的，我觉得这个区分很重要。

Okay, I think that's a great distinction to make.

那么有效剂量，如果我没理解错的话，简单来说，它可能是一个平均值，而且会根据暴露的身体组织不同而有所变化。

So the effective dose, if I'm kind of understanding just to paraphrase is maybe like an average kind of value, and I guess it differs based on body tissue that's being exposed.

我理解得对吗？还是说不同器官和组织会有区别？

Did I kind of get that right or different organs and tissue?

好的。

Okay.

是的。

Yes.

所以它在更广泛的层面上考虑了辐射的类型。

So it takes into account on a more general scale, it takes into account the type of radiation.

当然，如果是核电站事故之类的辐射，那和诊断X光产生的辐射类型是不同的。

So of course, if you have radiation from a nuclear power plant disaster or something, that's a different type of radiation than what we have from diagnostic X rays.

所以它把这一点也考虑进去了。

So it takes that into account.

同时，它也像你提到的，考虑了身体哪些部位实际受到了照射。

It also does take into account, like you mentioned, what parts of the body are actually being exposed.

明白了。

Gotcha.

为了再强调一下，我们讨论的是牙科放射学或X光，这些在大多数情况下被认为是安全的。

And just so I can reiterate again, so we understand that we're really speaking on dental radiography or X rays, which are classified as safe for the most part.

你刚才提到核暴露，我想确认一下。

Now you did mention if there was a nuclear exposure, just to clarify.

那种辐射显然是不安全的。

So that type of radiation is obviously not safe.

对吧？

Correct?

嗯，还是得看情况，因为这取决于你接触到的具体剂量。

Well, again, it depends because it depends on the exact dose that that you're exposed to.

明白了。

Gotcha.

好的。

Okay.

但另一方面，实际上在福岛核事故之后——我不想扯太远——但福岛事故之后，很多人被迫撤离，据估计，因撤离这些人而导致的疾病和死亡人数，远比他们留在原地因辐射暴露造成的要多得多。

The flip side is that actually after the Fukushima disaster, I don't want to get too off topic here, but after the Fukushima disaster, there were a lot of people who were displaced, and it's estimated that there were a lot more there's a lot more illness and mortality caused by displacing all of those individuals than would have been caused by radiation exposure if they had stayed where they were.

所以，这又变成了一个更复杂的问题。

And so, again, it becomes a it becomes a more complicated issue.

确实如此。

It really does.

我很高兴，你知道，那个……

And I'm so glad, you know, that.

我是说，我真的很佩服你。

I mean, I just commend you.

我是说，物理学家，那真的是远超我们牙医的工作范围。

I mean, physicists, that's like I mean, it's so beyond what we do as dentists.

但你能从那个角度来讲，真的很好。

But it's really nice to have you speak from that point of view.

所以我觉得，当我们说有效剂量的时候，其实就是看一个跟风险相关的量，就是某种平均值，用来衡量暴露以及某些组织或器官的暴露，以及这对身体到底有没有影响。

So I guess it's just easy to say that when we talk about effective dose, we're just really looking at a sort of a risk related quantity, just some way to have a an average, I guess, to base exposure and the exposure of certain tissues or organs and how that actually affects the body, if at all.

完全正确。

Absolutely.

我觉得你总结得非常好。

And I think that's an excellent way of putting it.

我还想提一点，我觉得很多医学工作其实是非常协作的，是跨学科的，我们经常把“跨学科”这个词挂在嘴边。

One thing that I'll also mention is I think it's really important that a lot of medicine, of course, is very collaborative, it's interdisciplinary, and we kind of throw that word in the interdisciplinary around a lot.

我觉得不同专业的人，无论是医学物理师、医生、牙医，还是做牙髓治疗的人，所有这些人都应该聚在一起讨论这些问题，因为我的视角也仅限于我个人的经验和直接接触的东西。

And I think it's really important that people from different specialties, whether it's medical physics, MDs, dentists, people who work with endodontics, all of these people, I think it's important that we come together and discuss some of these things because my perspective is also very limited to what my personal experience is and what I have direct contact with.

而且我觉得，像这样的讨论，真的能把各个领域的知识汇集起来，让我们真正弄清楚什么对病人护理最好，什么对病人有帮助，好让他们能做出明智的决定。

And I think that by having discussions such as this, it really takes the collective knowledge from all of these areas and allows us to really figure out what is best for patient care, is helpful for patients to know so that they can make informed decisions?

我觉得这部分真的非常重要。

And I think that part of it is really, really important.

医生。

Doctor.

米尔曼，从英雄主义的角度来说。

Milman speaking from a platform of heroics.

是的，我喜欢这个。

Yes, I love it.

一切都关乎病人的安全。

It's all about patient safety.

但我同意你的看法，如果我们能有一些跨学科的普遍讨论，就这些问题和价值观达成共识，那会让我们更容易理解，也更容易有效地治疗病人。

But I agree with you, if we can have some sort of universal discussion, interdisciplinary to have sound agreement on just these matters and the values and things of that nature just makes it all so much easier for us to understand and also much easier for us to treat patients effectively.

所以这让我想到我的下一个问题。

So that kind of leads me into maybe my next question.

就我们这次讨论的，特别是牙科X光来说，衡量辐射暴露的最佳指标是什么？

What is just for this conversation and dental x rays specifically, what's the best metric to kind of, you know, measure exposure?

然后这个指标是不是真的会在一生中累积？

And then is that really something that's cumulative over a lifetime?

你知道，它是那种一次性的事件，还是说……你能稍微给我们解释一下吗？

You know, is it something that's just, you know, one time instance or, you know, if you can just break that down for us a little bit?

那我分两部分来回答，可以吗？

So I'm going to answer that in two different parts, if that's okay.

没问题，没问题。

No, no.

你慢慢说。

Take your time.

我其实在努力跟上，所以你说的时候我在记笔记。

I'm really just trying to keep up, so I'm taking notes as you speak.

不不不。

No, no, no.

所以牙科X光的剂量，当然要看具体做的是哪种影像检查。

So dental X-ray doses, of course, it depends on exactly what type of imaging you're doing.

我们一直在讨论有效剂量，那我就给一些具体数字吧，因为我知道这才是大家真正关心的核心。

So, we've been talking about effective dose, so I'll put out some numbers because I know that that's really kind of getting down to the heart of this.

如果是全口牙列系列，就是口内咬翼片那种……

For full mouth series of intraoral bite ring...

咬翼片X光的有效剂量大约是35微西弗，也就是0.035毫西弗。

Bite wing X rays, the effective dose is gonna be about thirty five microsieverts, so point zero three five millisieverts.

明白了。

Gotcha.

全景影像的话，大概是20微西弗。

For panoramic imaging, it's around twenty microsieverts.

头颅测量影像会稍微低一点，大概5到10微西弗。

For cephalometric imaging, it's slightly lower, maybe five to ten microsieverts.

而真正剂量会高一些的，我想大多数人都知道，就是锥形束CT。

And really where it gets to be higher is, and I think that most people are aware of this, is with the use of cone beam CT.

这个先别展开讲，好吧。

Please don't touch on that, yeah.

对，锥形束CT检查的有效剂量确实更高，接近两百微西弗，也就是零点二毫西弗。

Yeah, so a cone beam CT exam does have a higher effective dose, and it's closer to two hundred microsieverts, so zero point two millisieverts.

不过我想强调一下，这仍然比其他诊断影像检查的剂量低得多，比如传统的CT扫描。

So I do want to emphasize this is still much lower than what we see in other forms of diagnostic imaging, you know, for a traditional CT scan, for example.

但随着锥形束CT的普及，我们确实需要留意这一点。

But with the proliferation, sorry, proliferation of complete CT, it is something that we that we want to be aware of.

而且这又回到了利弊权衡的问题上。

And again, it comes back to this benefit risk evaluation.

我这里讲的是风险这一部分。

The risk part is what I'm speaking about here.

至于好处，我其实不太能评价。

The benefit is something that I really can't speak to.

我觉得你和你的听众显然更有资格来谈这个问题，也就是患者从这些检查中获得了哪些益处。

And that's something that I think you and your audience, obviously is much better, much better qualified to comment on is what is the benefit that patients are deriving from these exams?

医生。

Dr.

您提到这一点我非常高兴，因为这确实关系到，比如说，作为牙髓病医生，我们会遇到各种各样的病例。

I'm so glad you mentioned that because it's really just about, for instance, as an endodontist, we see so many different variations of cases.

有时候是未治疗过的牙齿，也就是说没有进行过牙髓治疗。

Sometimes it's a virgin tooth, meaning there's been no treatment in terms of endodontic treatment.

有时候是再治疗。

Sometimes it's a retreatment.

之前已经有人做过治疗。

Someone has already conducted treatment before.

而且还有很多解剖学上的考虑。

And this and then there's also a lot of anatomical considerations.

所以我们有一个立场声明，在指出不同的临床情况时，会推荐使用CBCT，但这显然不是强制性的或类似的规定。

And so we have a position statement when we're kind of indicating different clinical scenarios where a CBCT would be recommended, but it's not obviously like a mandate or anything of that nature.

然而，为了让我们能够查看病例并做出正确的诊断，然后说，你知道吗，根据我们的发现，我们认为如果继续下去，任何牙髓治疗对患者来说风险大于益处。

However, for us to be able to look at a case and make a correct diagnosis and say, you know what, based on what we find, we feel that to move forward, any sort of endodontic treatment would be more of a risk than a benefit to the patient.

通过进行这种影像检查，我们就能帮患者省下不少钱和时间，不用老往牙科诊所跑。

Just by taking that doing conducting that imaging, we're able to prevent the patient from obviously a lot of expense and time in the dental chair.

所以在牙髓病学中，CBCT的价值确实一直都能体现出来。

So it's the value is definitely illustrated consistently throughout endodontics when we talk about the CBCT.

我喜欢你提到的普及趋势。

And I like how you're hinting about the proliferation.

我们看到越来越多的诊所正因为这个原因开始采用并引入这项技术。

And we see that there are a lot more practices adopting and bringing this technology into their practices just for that reason.

现在，如果我理解得没错，你说CBCT的平均辐射剂量是0.2。

Now, if I'm clear, you said it was on average, CBCT is, think it was 0.2.

对。

Yes.

零点二零。

Point two zero.

是的，毫西弗。

Yeah, millisieverts.

那为了澄清一下，一毫西弗等于一千微西弗，对吧？

And just so clarification, one millisievert is equal to 1,000, correct?

对。

Yes.

好的。

Okay.

这是给听众们说明的。

Just for the audience.

好的，很好。

Okay, good.

那如果我们讨论这种剂量和相关的风险，你整体上看到的情况是怎样的？

So if we're talking about that sort of dose, and any relative risk, what are you kind of seeing throughout?

比如，我们开始说“好，在这个水平，这种暴露下，我们现在开始看到证据可能支持某种癌症风险或发病率、死亡率的增加”的阈值是多少？

Like, what is a threshold upon which we start to say, okay, at this level, with this exposure, we now start to see that maybe the evidence is supporting some sort of increased cancer risk or incidence mortality.

你能给我们这些数字吗？

Can you just give us those numbers maybe?

所以这就是事情变得比较复杂的地方。

And so this is where things become more muddled.

物理学家很容易去测量产生的剂量以及患者接受的剂量。

And it's very easy for physicists to go in or it's very easy to go in and measure how much dose is being produced and how much dose patients are receiving.

比较难的是把这些数据放到具体情境中，然后说这对患者的健康意味着什么。

What's more difficult is to then try to put that into context and say, what does this mean for the health of patients?

所以即使是锥形束CT的0.2毫西弗有效剂量，也远低于我们已知会增加风险的阈值。

So even this zero point two millisieverts effective dose from cone beam CT is still well below where we know that there's an increased risk.

在有效剂量低于100毫西弗的情况下，我们确实没有持续且强有力的证据表明癌症风险会增加。

We really don't have consistently strong evidence that there's an increased risk of cancer at effective doses below one hundred millisieverts.

很好。

Love that.

100毫西弗。

One hundred millisieverts.

所以相当于，不管那是多少，500次锥形束CT检查。

So the equivalent of whatever that is, five hundred cone beam CT exams.

我还要强调一下，那是急性剂量一百毫西弗。

And I will also emphasize that that's acute doses of one hundred millisieverts.

好的。

Okay.

澄清一下，急性剂量，就是

Just to clarify, acute doses, just

就是一次性全部接受的剂量。

So those delivered all at once.

所以我们知道，如果有五百次……

So we know that having 500...

如果一个人一生中做了五百次锥形束CT检查，那和……

If somebody were to have five hundred beam CT, five hundred cone beam CT exams spread over the lifetime of a patient does not have the same...

和一次性接受一百毫西弗的剂量所造成的生物损伤是不一样的。

Deliver the same biological damage as if you had a single dose of one hundred millisieverts.

明白了。

Understood.

我觉得这个区分很棒，说得非常好。

I think that's a great distinction and a lovely point to make.

我……

I...

但它仍然是累积的……

But it still is a cumulative...

暴露量确实是累积的，但你说的是急性还是长期，接受的量是不同的。

Exposure is still cumulative, but just you're saying acute versus over a long term, it's a different amount that's received.

所以，它并不完全是累积的。

So, it's not exactly cumulative.

但在回答这个问题之前，我想先提一点。

But before I address that, though, I do want to make one comment.

就像我说的，一百毫西弗是我们有确凿证据表明癌症风险增加的那个点。

So, the one hundred millisieverts is what's, like I said, that is the point where we have strong definitive evidence that there's an increased cancer risk.

不过，有很多研究探讨了不同牙科影像检查中甲状腺受到的剂量与癌症风险增加或甲状腺问题之间的关系。

However, there have been a lot of studies that have looked at the relationship between dose to the thyroid from different dental imaging exams and increased cancer risk or issues with the thyroid.

这些研究的结果好坏参半。

And those results have been mixed.

有些研究显示甲状腺癌风险增加，有些则没有。

Some studies have shown an increased thyroid cancer risk, some have not.

实际上，我们对此并没有确切的答案。

And the reality is we don't really have a definitive answer on that.

而且我们可能永远也不会知道，因为风险要么非常小，要么可能根本不存在。

And we may never know because the risk is either very small, it may not exist.

但已经进行的研究确实结果不一。

But the studies that have been done really have had mixed results.

有些研究显示风险增加，但仅限于1970年之前接受牙科X光检查的人，那时候的辐射剂量更高。

Some have shown an increased risk, but only for individuals who had dental x rays prior to 1970 when the doses were higher.

有些研究发现，年龄暴露与癌症发病率之间没有关联。

Some found no association between the aged exposure and cancer incidence.

有些研究发现癌症风险增加，但仅限于患者年龄在15岁以下时暴露的情况。

Some found an increased cancer risk, only for only when the exposure was when the patients were under the age of 15.

所以这些研究，嗯，很多都有局限性，我不能说全部，但很多确实有。

And so all of these studies have well, a lot of them, I shouldn't say all, but a lot of them have limitations.

它们依赖于人们回忆自己什么时候做过牙科X光，做了多少次。

They're relying on people remembering when and how many dental x rays they had.

这些研究确实引发了很多疑问，比如风险到底有多大？

There are a lot of these things really do raise questions of what is the risk?

现实是，我们真的不知道。

The reality is we really just don't know.

我们知道风险要么很小，要么不存在，但我们确实无法量化这个风险。

We know that it's either small or nonexistent, but we really haven't been able to quantify what that risk is.

明白了。

Gotcha.

我很高兴你把这些点讲得很透彻，而且我喜欢你给了我们一些数值，让我们有个大概的范围。

And I'm so glad that you really hit home on those points, but I love the fact that you gave us some values just to kind of ballpark and have a range.

我们就用那个数字来讨论吧，就是100毫西弗。

And I'm going stick with that number just for our conversation of the 100 millisieverts.

我觉得你讲得挺好的，很清楚地说明了证据确实支持在那个阈值以下，没有强有力的证据或研究证明癌症发病率或死亡率会增加，对吧？

I think that was pretty good, pretty clear that the evidence really supports that below that threshold, there's not strong evidence or research to support that there's an increased cancer incidence or incidence of mortality, correct?

没错。

That is correct.

好的，很好。

Okay, good.

行。

All right.

非常感谢。

Thank you so much.

你回答得真的很棒。

I mean, you really answered that very well.

我知道这里面有很多不一致的地方。

I mean, I know it's just so much discrepancy in there.

就像你说的，研究中有很多差异，但这是一个基于证据的播客。

Like you said, there's a lot of variation in the research, but this is an evidence based podcast.

所以你能至少给我们提供这个视角，真的很好。

So it's really nice that you're able to at least just give us that perspective.

非常感谢你。

So thank you so much.

你知道吗，有趣的是，每当我有一个病人，我真的想给他们解释的时候，有时候病人会对做CBCT有顾虑。

You know, what's funny is whenever I have a patient and I'm really trying to give them sometimes patients will have a concern about taking the CBCT.

而且我应该提一下，我们说的是小视野，大概是五乘八。

And I should also mention that we're talking limited field of view, maybe five by eight.

对大多数牙髓病医生来说，我们不是做整个上颌骨或下颌骨的全面扫描。

We're not talking a full scan of the full maxilla or mandible for most endodontists.

我们实际上看的是小视野。

We're really looking at a limited field of view.

但总会有，我不一定总是遇到，但确实有一些病人因为辐射暴露而有点犹豫。

But there's always, I don't necessarily always, but there are a few patients that have a little bit of hesitation because of the exposure.

所以我试着给他们打个比方，比如如果你要从纽约飞到洛杉矶。

So I try to give them an analogy saying maybe if you were to fly from New York to L.

对，这种背景辐射差不多，或者，我该怎么用通俗的话来说呢？

A, this background radiation is similar or, you know, how should I really word that in a layman's term?

因为我们刚才讨论的内容很专业，什么毫西弗、微西弗之类的，要让病人真正明白这个剂量对应的风险有多大。

Because what we just discussed is very advanced, the millisieverts and, you know, microsieverts and this and that, so that a patient can really understand what is the really the relative risk associated with that dose.

其实有几个不同的东西可以用来做比较。

So there are a couple of different things that you can you can use for comparison.

一个是你刚才提到的，比如你坐飞机横跨美国，从东海岸飞到西海岸，额外受到的辐射大约是35微西弗。

One, as you mentioned, is if you have a cross country flight, if you fly from the East Coast to the West Coast, the additional radiation you get is about 35 micro sieverts.

这比锥形束CT检查的辐射量还是要少一些，但也不是零。

So still less than what you get from a cone beam CT exam, but it's not zero.

另一个有用的参考就是看美国的背景辐射。

Other thing that can be useful is just looking at background radiation in The United States.

美国平均每天的背景辐射大约是8微西弗多一点。

So background radiation on average in The US is a little over eight microsieverts per day.

每年大约是3毫西弗多一点。

It's a little over three millisieverts per year.

如果你住在丹佛，那辐射量会稍微超过两倍。

If you live in Denver, it's a little more than twice

一英里高，宝贝。

Mile high, baby.

没错。

Exactly.

所以，仅仅因为住在丹佛，而不是住在海平面附近的地方，比如佛罗里达海岸，人们每年就会多受到大约六毫西弗的辐射。

And so just by living in Denver, instead of living somewhere at sea level, you know, on the on the Florida Coast, people are exposed to to a little over six millisieverts of radiation every year.

我的一位同事，辛西娅·麦卡洛，她是梅奥诊所的医学物理学家，她有一个非常好的方式来描述这个，我觉得。

And one thing that a coworker of mine, Cynthia McCullough, who's a medical physicist at Mayo Clinic, she had a very, very good way of describing this, I think.

所以我要把功劳归给她。

So I'm giving her credit for this.

但正如她指出的，我们周围到处都有背景辐射，人类已经进化到可以在这种辐射环境中健康生活……

But as she pointed out, there is background radiation all around us, humans have evolved to live healthfully within...

在这种背景辐射下。

With that background radiation.

而这次锥形束CT检查的风险其实……

And the risk from this cone beam CT exam is really...

确实会有额外的辐射暴露，但跟咱们平时一直接触的背景辐射相比，其实高不了多少。

There is an additional exposure, but it's really not that much higher than background radiation that we're all exposed to all the time.

医生。

Doctor.

我很喜欢这个。

I love that.

你刚说的是梅奥诊所的……

And that's you said Doctor.

麦卡洛医生吗？

McCullough out of Mayo Clinic?

医生。

Doctor.

是的。

Yes.

医生。

Doctor.

对，我记得梅奥诊所不是在克利夫兰附近吗，离那儿不远。

Yeah, I think Mayo from wasn't that right outside of Cleveland, not too far.

如果我没记错的话，我是在凯斯西储大学读的专科，但我们经常接触到梅奥诊所。

I'm not mistaken, but I studied in a case Western for specialty, but we come across the Mayo Clinic quite often.

很棒的内容。

Great stuff.

非常感谢你把这个话题带进讨论。

Really appreciate you bringing that into the conversation.

我喜欢那些关于飞行的相对数据。

I love those relative figures on the flights.

所以实际上，即使我从纽约飞到丹佛，或者从纽约飞到洛杉矶，我受到的辐射暴露也比我去做年度牙科检查时拍全套口腔X光片，甚至做锥形束CT（CBCT）要多得多，对吧？

So realistically speaking, even if I go from New York to Denver, New York to LA, I'm getting substantially more radiation exposure than if I go for my yearly dental exam and they want to do the full mouth series of X rays or even a cone beam CBCT, correct?

嗯，实际上，跨州飞行受到的35微西弗辐射，和拍一套口腔内全套X光片差不多。

Well, so it's actually so the 35 microsieverts for the cross country flight is about the same as you're getting from an intraoral full mouth series.

明白了。

Gotcha.

好的。

Okay.

它比锥形束CT的辐射还要低一些。

It is lower still than a cone beam CT.

但你也可以这样想：如果你住在佛罗里达，然后你坐飞机去……

But you can also think about it in terms of, okay, well, if you live in Florida and you take a...

你知道，你去科罗拉多度假几周，你的背景辐射就会增加。

You know, you take you go on vacation for a couple of weeks to Colorado, you're increasing your background radiation right there.

而且这增加的背景辐射量，跟做一次锥形束CT所受到的辐射差不多。

And that becomes more comparable to that cone beam CT that the radiation that you're getting from that cone beam CT is the same as the additional background you're gonna get from going on vacation in Colorado for a couple weeks.

非常感谢你解释得这么清楚。

Thank you so much for clarifying that.

还有一件事……

And one thing that...

抱歉。

Sorry.

我只想确保我们讨论一件事，因为我不想之前把它忽略掉，因为这是一个非常非常重要的点，就是累积剂量的概念。

Just one thing that I do wanna make sure that we discuss because I I didn't didn't want to blow it off before because it's a really, really important point is this idea of cumulative dose.

所以我不知道你是否

So I don't know if you

想让我现在讨论还是稍后讨论。

want me to discuss that now or later.

不，请尽情讲，我们知道你在认真听。

No, please speak at length and know you're we're attentively listening.

所以，我确实想谈谈这个，因为我觉得关于这个有很多误解。

So, so I do want to address it because I think that there's a there's a lot of misconception about this.

而且，把很多不同检查的有效剂量加起来是非常诱人的，无论是牙科X光成像还是其他类型的成像。

And the it's very it's very tempting to add up the effective doses from a bunch of different exams, whether it's from dental X-ray imaging or other types of imaging.

然后说，好吧，我们提到了这个100点，需要多少次锥形束CT检查才能达到那个100毫西弗？

And to say, Okay, well, we mentioned this 100 point, how many cone beam CT exams does it take to get to that one hundred millisieverts?

但实际上，我们没有任何证据表明这种剂量是累积的。

But in reality, we don't have any evidence that this dose is cumulative.

所以目前，最被接受的辐射风险模型是所谓的线性无阈值模型，也就是LNT模型。

And so right now, the most accepted model of radiation risk is what's known as the linear no threshold model or the LNT model.

这个模型认为，任何辐射暴露都带有一定风险，而且风险随着剂量的增加而线性上升。

And this states that any radiation exposure carries some risk and that the risk increases linearly as dose increases.

但它并没有说，一次暴露会让人对后续暴露的伤害更敏感。

However, it does not state that an exposure makes a person more susceptible to damage from subsequent exposures.

换句话说，它并不认为风险是累积的。

Other words, doesn't say that the risk is cumulative.

举个例子，我经常用这个例子来说明，因为我一直在想各种方式来解释这一点。

And one example that I like to give because I tried to think of different ways to sort of illustrate this.

比如，如果我买彩票，第一次买的时候，中奖概率可能是百万分之一。

But one example is if I play the lottery and the lottery, the first time I play the lottery, my chances of winning may be one in a million.

而每次买彩票，那次中奖的概率仍然是百万分之一。

And each time I play the lottery, the chances of me winning that time is still one in a million.

所以我第一百次买彩票，中奖的几率还是一百万分之一。

So for the hundredth time I play the lottery, my chances of winning is still one in a million.

还是一百万分之一。

Still one in million.

但是，我已经买了100次彩票，所以我总体上中奖的几率稍微增加了一点，但这对我第一百零一次买彩票时中奖的可能性完全没有影响。

However, I've played the lottery a 100 times, so my overall chances of ever winning has increased slightly, but it has no effect whatsoever on whether...

对第一百零一次买彩票时中奖的可能性没有影响。

On how likely I am to win that hundred and first time I play.

这其实就是LNT模型所说的，第一百次牙科X光或第一百次锥形束CT检查的风险，和第一次的风险是一样的。

And this is really what the L and T model says, that the risk from the hundredth dental X-ray or hundredth cone beam CT exam is the same as the risk from the first one.

这真的是……

That is really just...

太神奇了。

That's phenomenal.

我喜欢你这样的解释方式。

I love the way that you frame that.

但我们不能真的这么说。

But we would we couldn't really say that.

我想，是不是有很多预测只是假设性的危害，你知道，这种恐惧、这种害怕是从哪来的，就是觉得这些辐射是累积的，随着时间推移暴露会增加，提高某些癌症等疾病的风险？

I guess, is there this maybe a lot of predictions just like hypothetical harm, you know, like, where is this kind of this fear, this phobia coming from, you know, that these are cumulative and that the exposure over time adds up and increases your risk for certain incidents of cancer and things of this nature?

我觉得很多是源于恐惧，也源于想为患者做到最好，把风险降到最低。

I think that a lot of it is rooted in fear and a lot of it is rooted in wanting to do what is best for patients and to minimize that risk.

而且我觉得这真的是过度谨慎了。

And I think that it really is an overabundance of caution.

我真的完全不怪任何人。

And I really I don't fault anybody for that at all.

不，不。

No, no.

而且对于所有这些事情，还有一个情感因素。

And there is also for all of these things, there's also an emotional component.

你提到过有些患者因为辐射而对做锥形束CT检查非常犹豫。

You had mentioned patients who are very hesitant to have a cone beam CT exam because of the radiation.

你也许可以坐在那里给他们做比较，给他们看数据，这可能会改变一些人的想法，也可能不会。

And you may be able to sit there and give them comparisons and give them data, and that may change some people's minds and it and it may not.

我觉得我的总体目标不是说服人们接受别人推荐的每一次锥形束CT检查，而是帮助提供者和患者获得有用的信息，让他们能够做出真正知情的决定。

I guess that my overall goal is not to convince people that they should agree to every cone beam CT exam that somebody recommends, but to help give both providers and patients useful information that they can then use to make truly informed decisions.

是的。

Yes.

嗯，对你问题的简短回答是，我不知道。

Well, the short answer to your question is, I don't know.

不。

No.

我的意思是，就是这样，你知道，这只是对此的猜测。

I mean, and that's just it, you know, and this was just really speculation on that.

我觉得你提出了一些非常中肯的观点，而且从更广泛的角度来看，电视名人、社交媒体、口口相传等等，有太多因素可以说有影响，但我真的觉得你用中彩票的概率来比喻，说得太精彩了。

And I think that, you know, you're bringing up some really valid points and just kind of even from a more broad stance that the influence of TV personality, social media, things like this, and also just word-of-mouth, you know, there's so many factors that we could say contribute, but I really think that was brilliant how you phrase that about the probability of winning the lottery.

我希望你能给我带来一些好运，因为今晚在纽约，奖金差不多有六亿美元了。

And I hope that you're sending me some good luck because tonight in New York, it's almost I think it's 600,000,000.

我妈妈正好来城里看我，她让我帮她买几张彩票。

So my mom who's visiting in town, she asked me to get her a couple of lotto tickets.

所以我希望这次能中一次。

So I hope this is one time.

只要，只要

As long as long as

她明白，只要她明白这次买不买彩票，跟她下次中奖的概率没关系。

she realizes as long as she realizes that whether or not she buys lotto tickets this time has no effect on how likely she is to win next time.

你知道吗，特别好笑，她说她买彩票买了好多年了。

You know, it's so funny because she's like, I've been playing the lotto for years.

我……

I'm...

这次该轮到我中了。

This this my turn to hit.

所以我觉得她相信那种累积效应。

So I think she's open on that cumulative effect.

但上帝是好的。

But God is good.

所以我们看看会发生什么。

So we'll see what happens.

但非常感谢你。

But thank you so much for that.

那么，医生，我们接下来要做的。

So what we're going do, Doctor.

米尔曼，我们稍作休息，听一下赞助商的广告。

Milman, we're going to just take a break and listen in for our sponsors.

回来后，我们会讨论安全以及这对牙科行业意味着什么。

And when we get back, we're going to talk about safety and what that means for the dental profession.

好的。

All right.

非常感谢。

Thank you so much.

感谢您收听Endo Voices，我们正在与一位非常有趣的医生进行对话。

Thank you for tuning into Endo Voices, and we are having a fascinating discussion with Doctor.

丽贝卡·米尔曼，她是科罗拉多大学医学院的副教授和医学物理学家。

Rebecca Milman, is the associate professor and a medical physicist at the University of Colorado School of Medicine.

我还想特别提一下您简历上的另一项成就，如果我没记错的话，您还担任过委员会主席，负责教育和实施工作，推动停止使用患者性腺和胎儿屏蔽。

And I did want to highlight just another piece of your resume is that you were also the chair on the committee, if I'm getting this right, on education and implementation efforts for discontinuing the use of patient gonadal gonadal and fetal shielding.

这名字可真够长的。

That's a mouthful.

是的，确实。

Yes, it is.

是的，我是。

I am.

而且我……

And I'm...

所以那个委员会做的第一件事，其实就是想了个新名字。

So the first thing that that committee did actually was come up with a new name.

谢谢。

Thank you.

谢谢。

Thank you.

我觉得这真的会……

I mean, I think that's gonna really...

这对我们大家都有帮助。

That's gonna help us all.

是的。

Yes.

所以这个委员会实际上叫CARES委员会，就是“辐射教育中屏蔽进展的沟通”委员会。

So the so the committee actually is it's the CARES committee, Communicating Advances in Radiation Education for Shielding.

太棒了。

Love it.

医生。

Doctor.

唐·弗罗什，杜克大学的儿科放射科医生，想出了这个名字，我们很快就采用了，因为我根本记不住你刚才说的那个缩写。

Don Frosh, who's a pediatric radiologist at Duke, came up with that and we quickly jumped on that because there was no way I was going to be able to remember the acronym that you just spouted off.

我都没法跟你重复一遍，因为我记不住。

Would not be able to repeat that to you because I can't

记不住是什么。

remember what it is.

是的，过去几年我有幸担任那个委员会的主席。

Yes, I've had the privilege I've had the privilege of of chairing that committee for the last couple of years.

对。

Yes.

好。

Good.

好。

Good.

好的。

Okay.