Transcribed by Anam Khalid

Friday, November 14th, 2014

Radiation Pathologyby Dr. Joan PhelanGeneral Pathology

[Slide #1] [Radiation Induced Pathology]
[Dr. Phelan] Okay, lets go for our last hurrah here and actually I havent done I
enjoy this subject, so maybe thats why I made it from 4 to 5 because I thought I
could still stay awake and still keep talking between 4 to 5 because I happen to
like this subject. But anyway when we talk about radiation, its important to
distinguish between ionizing radiation and non-ionizing radiation. And usually I will
give you a question that asks you to do that so focus on that difference in the
information that Im going to give you. Okay?
[Slide #2] [Radiation Types]
[Dr. Phelan] Ionizing radiation is divided into four basic types. X-rays, which we
work with. Gamma rays, cosmic rays, radon but for us, the radiation that is most
specific to us, at least in our diagnostic radiology is x-rays.
[Slide #3] [Types of ionizing radiation]
[Dr. Phelan]--You know from your radiology course, quite a bit I think, about
ionizing radiation. It is a process where you knock an electron from an atom or you
gain an atom and you get either a positive or a negative atom that makes this kind of
unstable situation.
The primary mechanism that radiation uses to induce biologic damage is to damage
macromolecules and that is an interaction and you remember how much water is
involved in cells and we end up getting a radiolysis of water. And this gives us
hydroxyl radicals.
And thats the mechanism by which we get damage. The kind of damage we get is
something we will talk a little bit about in detail.
[Slide #5] [Sources of Radiation Exposure]
[Dr. Phelan] Sources for radiation exposurehere, particularly, ionizing radiation
from radon, which is in rocks and in I know in NY state Im not sure if its true in
every other state--you have to have your house tested for radon before you can sell
it. You have to figure out a way to get the radon out.
There are some natural sources that exclude radon that also account for radiation
exposure. Medical x-rays, nuclear medicine, consumer products and then some odds
and ends and others.
And to just give you an illustration of natural sources, when I worked in a pretty
large medical facility everybody wore x-ray radiation badges and suddenly couple of
our dental assistants started showing positive, higher radiation exposure on their
badges. And so we went through all kinds of examinations of our x-ray facilities to
try to figure out what in the world was happeningwhy these two dental assistants
were getting exposed when nobody else was. And then we finally figured out that
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they were taking their walks at lunchtime with their coats on. And with their badges
on and the radiation exposure that they were registering was the radiation from
their outside exposure. It was not dangerous exposure but it was what would
register on our badges as higher than normal inside radiation. Just give you a sense
that there really are natural sources for radiation.
[Slide #6] [Effects of ionizing radiation]
[Dr. Phelan] So what does ionizing radiation do? It produces free radicals. It breaks
chemical bonds. It produces new chemical bonds and cross-linkages between
macromolecules and it damages molecules that regulate vital cell processes such as
DNA, and RNA and proteins. And at low doses, most cells are able to repair damage.
At high doses, the result is cell death. But in the middle, we can end up having tissue
loss of function and we can have permanent changes to the cells that can be
transmitted to future generations of cells, which can end up in situations like cancer.
[Slide #7] [Free Radical Generation diagram]
[Dr. Phelan] If we look at this diagram and we look at the effect on this cell of a
number of different irritantsradiation is one of them. Okay? And here we have
radiation we have some others that, okay? That Dr. Kinnally talked to you about at
the beginning of the year. Inflammation should sound familiar. Reperfusion injury
should sound familiar. Again, because you're getting here an excess amount of
oxygen that is attacking or is the environment for the cell.
And then there is a production of ROS and one possibility is cell injury and the other
possibility is that the cell can neutralize the free radicals and actually have no cell
injury. And so you have a number of possibilities that might occur with free radicals.
[Slide #8] [Acute vs. Delayed Effects]
[Dr. Phelan] And so every damage from radiation or every attack, if you will, or
every exposurethats a better wordevery exposure to radiation is not going to
cause cell death and it may not cause a permanent death of the cell. The problem
youll see as we talk through this lecture, it does not appear that we can identify
where the lowest safety dose is and I think youve heard that over again. And so we
use a term in diagnostic radiation thats called ALARA which means ? As low as
reasonably okay.
So there are some acute effects from radiation exposure and these are the effects
that are seen immediately after large doses of radiation that are delivered over
short periods of time. And then there are delayed effects that appear months later
after a radiation exposure and it depends again, youll see in a little bit, whether or
not the entire body is exposed or only part of the body is exposed. Because we use
radiation in cancer therapy, radiation therapy for cancer, and you will get changes in
the skin over the area being radiated. You get tissue damage around the area in
addition to whatever cancer is being treated. Theres enormous amounts of damage
immediate and then theres also a lot of damage that continues later on after the
radiation treatment is over.
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[Slide #9] [Ionizing Radiation Injury Range]

[Dr. Phelan] So, just, again, very similar information--high doses, membrane
damage, cellular necrosis.
Low dosesI may not be able to see under the microscope but there may be in low
doses some subcellular response. It may be some DNA damage. It may repair. You
might get genetic mutations and you might get chromosomal abnormalities. Or you
might get death through apoptosis. So theres a number of different possibilities
and its not easily identified what youre going to get. The higher the dose the more
likely to get damage.
[Slide #10] [Membrane Injury by Hydroxyl Radicals]
[Dr. Phelan] An effect of membrane injury by hydroxyl radicals is liquid
peroxidation. Here you're removing a radical, a hydroxyl radical, from a hydrogen
atom and you end up getting a number of different products but one of the products
is a free lipid radical and that becomes the first step in a chain reaction.
You can get hydroxyl radicals that cause cross-linking of membrane proteins. You
can get aggregation of membrane proteins and you can disrupt the function of the
membrane and the cell.
[Slide #11] [Acute Effects of Ionizing Radiation]
[Dr. Phelan] You can get DNA damage and we can active transcription factors and
so ionizing radiation can cause some very as multiple different ways of causing
damage to cells.
[Slide #12] [Delayed complication of ionizing radiation]
[Dr. Phelan] In the delayed damage from ionizing radiation we can have a scarring.
So the tissue is damaged and is not replaced by the same tissue. The tissue that
replaces is scar tissue and we end up having a different kind of fibroblast in the
tissue and some very dense collagen deposition in the area that was destroyed.
[Slide #13] [Carcinogenesis]
[Dr. Phelan] Carcinogenesis related to radiation exposure seems to need a latent
period from at least ten to twenty years and even longer.
[Slide #14] [Ionizing Radiation Effects]
[Dr. Phelan] And there is some information about the dose. A single dose of
radiation or ionizing radiation creates a greater injury than if you divide the doses.
And this is used in radiation treatment where the doses are divided to create the
greatest effect on the cancer tissue but the lowest possible injury to the surrounding
tissue. Rapidly dividing cells are most radiosensitive and well look at that in a just a
minute as we divide into different sensitivities of tissue.
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A single dose, a single whole-body dose, is more lethal than regional doses. And this
is the kind of exposure that people have had nuclear accidents. And Chernobyl, some
of the people that went into clean up were exposed to whole-body radiation. There
is also whole-body radiation that is used in bone marrow transplantation and, again,
usually you would like not for it to be lethal but for it to destroy bone marrow so
that you can replace it with something else.
So those cells that are dividing and are in their G2 phase are the most sensitive to
radiation. And different cell types differ in their response to radiationwhether or
not they can adapt or whether or not they get destroyed.
[Slide #15] [Ionizing Radiation Effects]
[Dr. Phelan] Stem cells are very radiosensitive. So bone marrow stem cells are very
radiosensitive and it is why bone marrow radiation can be used to destroy an
individuals bone marrow and replace it with stem cells. Very interesting that stem
cells both from the individual and from a donor are collected very much like
platelets are collected. Those cells have markers on their surface. This machine
takes an individuals blood and runs it through the machine and picks up all the
stem cells and puts them in a bag. Then those stem cells are given to the individual.
The radiation has been used to eliminate that patients original bone marrow. And
you give the stem cells through peripheral blood and they home to the space in bone
marrow and take up residence again and begin working. But radiation treatment,
whole-body radiation is used to be able to destroy the marrow throughout the body.
That doesnt come with some adverse effects as you can imagine because it affects
multiple other tissues as thats happening. And well see that with some categories
in a bit.
Low metabolic rate decreases radiosensitivity and that kind of makes sense. If the
cells that are turnover are the most sensitive those that arent turning over are the
least sensitive. So those cells that the fast they are turning over, the more
radiosensitive.
[Slide #16] [Ionizing Radiation Effects]
[Dr. Phelan] If we look at this diagram we can see some features of radiation and
radiation exposure. Here, we are forming our hydroxyl radical. And in proliferating
cells, were going to get DNA damage, potentially. They're not able to replicate and
they're dying by apoptosis in this route. Another possibility in those nonproliferating cells, these cells dont have the possibility of repairing and if the
damage or if the radiation exposure is enough, those cellular targets will die by
necrosis, not apoptosis because youre just damaging the cell membrane in the cell
and not triggering apoptosis but just destroying the cell from the outside.
[Slide #17] [Sensitivity of Tissues to Ionizing Radiation: Very Sensitive]

Transcribed by Anam Khalid

Friday, November 14th, 2014

[Dr. Phelan] There are some tissues that are very sensitive to ionizing radiation and
these follow the same rules that I just gave you.
Hematopoietic cells--rapidly dividing cells. Lymphoid cellsrapidly dividing cells.
Spermatogonia are dividing cells. And ovarian cells have the potential to be dividing
cells. So these are very sensitive to ionizing radiation. They will very often be
destroyed for a high dose but might be injured in a lower dose.
[Slide #18] [Sensitivity of Tissues to Ionizing Radiation: Sensitive]
[Dr. Phelan] And then there are cells that are sort of in the middle and these are
considered tissues that are sensitive. Gastrointestinal mucosa. In a patient that has
radiation treatment even to the oral region, the mucosa sloughs and becomes
damaged. In whole body radiation the entire GI system might be damaged during
radiation. It will renew but its damaged as a result of the exposure to radiation.
Endothelial cellsso blood vessels can be affected by radiation. Hair follicles, breat
tissue, pancreas, bladder, heart, and lungs are sensitive but not as sensitive as these.
I think we could also fit probably salivary gland tissue in the sensitive tissues as a
tissue in our area that would fall in the sensitive area. The question on salivary
glandswe know that if a person has radiation treatment that affects the salivary
glands, that the salivary glands stop producing saliva immediately. One hypothesis
is that the first area or the first tissue that gets affected by radiation is actually the
endothelial cells, even faster than the parotid acinar cells. And by messing up or
destroying the endothelial cells you cause necrosis in the salivary glands because
you get an ischemic necrosis if you destroy the endothelial cells and the
microcirculation. So it's not really clear what comes first in salivary glands but we
know that as soon as you hit them with radiation exposure and radiation treatment
that person loses within a very short amount of time the functioning of those
salivary glands. So people that have radiation treatment to the head and neck very
often are left with very, very dry mouth.
[Slide #19] [Sensitivity of Tissues to Ionizing Radiation: Least Sensitive]
[Dr. Phelan] And then there are some tissues that are pretty insensitive. Bone and
cartilage that dont change much with radiation exposure. Skeletal muscle doesnt.
heart is a little bit more sensitive than skeletal muscle. Nervous tissue, again, is not
turning over very rapidly and so these tissues are much less sensitive. So you can
kind of think of these categories in relationship to how tissue reacts when it is
exposed to radiation treatment.
[Slide #20] [Developing embryo/fetus]
[Dr. Phelan] Okay, a developing embryo or fetus is most, it would make sense, its
most sensitive during the earliest stages of differentiation because thats the time,
when even later the embryo or fetus, or the fetus rather has still rapidly dividing
cells but not nearly as much as early in development. And again, first semester, first
trimester is the most sensitive when compared to second and third.
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[Slide #21] [Whole body radiation exposure vs. localized radiation exposure]
[Dr. Phelan] Another concept that Id like you to think about is whole body
radiation exposure versus localized. In treatment, we usually use localized. Not
always, but usually. Bone marrow transplant you would use whole body but in most
other treatments of cancers, the use of radiation is localized.
[Slide #22] [Whole Body Radiation]
[Dr. Phelan] And so a whole body radiation is going to come through in bone
marrow transplantation, as I just mentioned, in industrial accidents, and in
explosion of nuclear weapons and thats when the whole body gets radiated.
[Slide #23] [Acute Radiation Syndrome (Radiation Sickness)]
[Dr. Phelan] And in partial exposure, its usually in radiation treatment. There is
something called radiation sickness that occurs when a person has been exposed to
whole-body radiation and there are different syndromes that fall under radiation
sickness.
[Slide #14] [Acute Radiation Sickness]
[Dr. Phelan] And if you look at this well spend a couple of minutes with this so I
can try to explain to you whats going on here. Were looking at different responses
to whole-body radiation. Hematopoietic, which is usually bone marrow, or mostly
bone marrow. Intestinal which is GI and brain, okay? And if you're looking at the
dose here, it goes along this section. And so at a lower dose, because that tissue is
more sensitive, the hematopoietic or bone marrow is going to be affected. As you get
higher dose we will also see bone marrow affected but then you begin to see GI
effects.
And then we can get very high dose and you can have brain effects but youre still
going to get hematopoietic and intestinal responses as well as brain. So if you look at
the way the amount of radiation increases, we get increasing effects onhere we
have very sensitive here we have moderately sensitive and here we have pretty
insensitive but we still can affect the central nervous system if the exposure is high
enough. And that's what happens in accidental exposures or what happened in the
explosion of nuclear bombs.
[Slide #25] [Fetal Effects of Whole Body Radiation]
[Dr. Phelan] The fetal effects of whole body radiation have been identified and they
are developmental abnormalities that youve seen before. Reduced head size,
diminished overall growth, mental retardation, hydrocephaly, microopthalmia and I
can read the rest of them but so can you. Do you think that these are monotopic or
polytopic?
[Student]Both?

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Friday, November 14th, 2014

[Dr. Phelan]Okay, thats a good answer because you might be right, okay?
Primarily, they are polytopic because the fetus is going to be hit at one point,
usually. Trying to find a way to expose that fetus to radiation over a long period of
time would be difficult. So its usually the fetus is exposed at one time. It is possible
I can make you explain this. Who said monotopic? Somebody want to who was it
that said monotopic? Huh? Somebody did. Okay. If we were thinking about
monotopic somebody wont admit it because youre afraid of what Im going to
ask you. But youre going to actually come up with a way of explaining a monotpic
effect. That somehow the radiation mostly damaged one developing part and
because of that one developing part that didnt develop correctly that there was a
sequence anomaly so you had multiple other effects. I dont know that I could give
you a good example of that in radiation but I can see where if you came up with a
good example that you might be right on the potential for a monotopic effect. But for
the most part, its a polytopic effect but its everything thats being developed at that
time is whats being affected by the radiation.
[Slide #26] [Fetal Effects of Whole Body Radiation]
[Dr. Phelan] The information that we have about whole body radiation in a
population mostly comes from the experience when the US dropped bombs in Japan.
And were getting some more information now out of accident in Chernobyl. There
was also an accident in Pennsylvania a while back from which there is some
information emerging.
And so from Japan, pregnant women who are exposed to doses of 25 rads or greater,
did give birth to infants with developmental effects. So again, you're looking at the
effects on the fetus and the effect on development and you there were effects.
From that experience, the time for growth retardation and microcephaly seemed to
be between the 3rd and the 20th week. Major congenital malformations were
unlikely if they occurred after day 14, so it was very early exposure of the
developing embryo or fetus. It's possible that some low doses may make some
subtle effects that werent so easily identified.
[Slide #27] [Genetic Effects of Whole Body Radiation]
[Dr. Phelan] Then theres some questions about whether or not you get permanent
genetic damage that is transmitted in inherited diseases. And it appears that that did
not happenthat there really has not been evidence of genetic damage over that
has been inherited and passed onto other subsequent generations from changes
from exposure to radiation.
[Slide #28] [Aging Effects of Whole Body Radiation]
[Dr. Phelan] It didnt also appear that they could identify premature aging but
there clearly is identified increased or excess mortalitymore people died. And
why people died is because of malignant neoplasms and malignancies clearly
increased as a result of that radiation exposure.

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[Slide #29] [Localized Radiation Injury]

[Dr. Phelan] Now we look at localized radiation injury and here we have primarily
radiation associated with radiation therapy. That's how you get localized radiation
injuryits hard to think about a way of getting it any other way unless you have an
occupational exposure where somebody was only exposed in one part of the body
but thats pretty far fetched. And the clinically important tissue: skin, lungs, salivary
glands, heart, kidney, bladder, intestine and these are tissues that are difficult to
shield during radiation therapy. Now as radiation therapy is given, there is a system
thats used with a mask, trying to direct the radiation to only the tumor area. There
are systems used in oral care in treating oral cancer where there are shields trying
to shield the salivary glands out of the beam of the treatment radiation.
[Slide #30] [Effects of Radiation Therapy ]
[Dr. Phelan] Shielding is helpful and also how much the effect is depends upon
which tissue is getting affected. And in the oral cavity, the oral mucosa will get
affected, but it will regenerate. Salivary glands will get affected but they wontthey
get destroyed and the patient has a profound xerostomia for a very long time. The
blood supply to bone is affected and it is never regenerated. And so when a person is
being evaluated prior to radiation treatment, one of the questions we ask to
ourselves is which teeth have to be extracted because we probably never again will
be able to safely extract teeth in that patient. And so that patient is going to suffer
from very dry mouth, very high risk of caries, and its going to be very difficult to do
any extractions in that patient. So sometimes conservative in a pre-radiation
workup is extracting a lot more teeth than we think of as conservative.
[Slide #31] [Vascular Injury due to Ionizing Radiation]
[Dr. Phelan] The vascular injury is primarily the microcirculation and the
endothelial cells swell and the vascular walls get thicker and the tissue that is
supplied by that microcirculation is much less well-supplied. Its probably part of
the reason for radionecrosis because that bone just is never supplied again with the
same microvasculature.
[Slide #32] [Pathogenesis of Delayed Radiation Injury]
[Dr. Phelan] The compromise of the vascular supply leads to a very delayed and
forever radiation injury. And theres a strange fibrotic repair that follows radiation.
[Slide #34] [Pathogenesis of Delayed Radiation Injury]
[Dr. Phelan] And here are some pictures of This is normal fibrous connective
tissue. This is a higher magnification but these are the strange cells that are present
in a post-radiation fibrous connective tissue.
[Student]--Can you back up like two slides where you said chronicdo you mean
the injury is ongoing or just the time after like
[Dr. Phelan]Okay, what happens is the injury the effect now is the delayed effect
and
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[Slide #34] [Pathogenesis of Delayed Radiation Injury]

[Dr. Phelan] what happened here is the radiation treatment usually
compromises the vascular supply so much that you get ischemic necrosis. And what
you have in necrosis is you lose the tissue. The tissue is damaged and then the tissue
has to be replaced. And the tissue that is necrotic is replaced with scar.
[Student]Im sorry, I meant the one forward, where it says chronic. Did you meant
that the radiation injury is no, no, that that there you go.
[Dr. Phelan]Actually, yeah. Actually, what happens is that chronic means that it
doesn't resolveit stays there.
[Student]--So not prolonged radiation exposure ...
[Dr. Phelan]Its not chronic radiation, its chronic damage. Thank you.
[Slide #35] [Non-neoplastic complications of radiation--Delayed Radiation Injury]
[Dr. Phelan] There are a number of neoplastic effects that have been associated
with exposure to radiation. One of the problems that we have in the diagnostic
radiology that we use which is a incredibly small percentage of medical radiation
exposure incredibly small compared to the exposure or the amount of radiation
thats used in medicine. But there is radiation complications and for us one of the
areas that is for most concernand it isnt on here because it isnt made for us in
dentistryis the potential for damage and neoplastic transformation in the thyroid.
And as you know, whats happened in the development of panoramic radiographs,
over time the panoramic radiographs or the radiographic equipment has been
altered. When it first came out, all of the radiation would end up being beamed at
the thyroid. And now the equipment moves the beam around so that it isn't directed
at the thyroid for the entire pan.
Another issue is our cone beam CTs. And again, there is exposure to the entire head
and neck area, including the thyroid. We need to very careful that we dont use that
equipment unless we need it for diagnostic procedures.
[Slide #36] [Ionizing Radiation and Cancer]
[Dr. Phelan] And I think you all recognize that we are working really hard and
youll see it more when you get into the clinic to pick what images we need in order
to be able to support the diagnosis or to be able to make the diagnosis. If the patient
has a lot of periodontal disease, were going to need a full mouth series of
radiographs and thats going to be much better for our diagnosis than if we use a
panoramic radiograph for which you cannot see the details. There are other
situations where youre looking at extracting third molars and you need a pan or a
cone beam. There are pathologic processes where you need a cone beam. There are
implant treatment planning where cone beam is the best imaging technique.
However, we need to be careful to match the imaging that we need to the diagnostic
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procedures that we want to do. There are animal experiments. There are
occupational exposures. There is radiation treatment for non-neoplastic conditions
and a number of ways that we have actually learned that ionizing radiation is
associated with the potential development for cancer.
An example Ill give you here, we have seen a case of a patient with a disease called
fibrous dysplasia that we talked a little bit about in developmental abnormalities
completely benign, okay? But it is disfiguring. It is a cosmetic issue, particularly in
the jaws when particularly a young person has an expanding jaw, either maxilla or
mandible. And initially, there were attempts to treat that with radiation treatment.
The problem was, years later, that bone then transformed into an osteosarcoma. So
there were a number of cases that made it clear that there was association between
radiation treatment for fibrous dysplasia and the development of bone cancer in
those lesions. We actually saw a case in one of our oral pathology meetings where
there had been a patient that had acne and had undiagnosed fibrous dysplasia. The
acne was treated with very low dose radiation treatment and as a 40-year-old
individual twenty years later, she developed a osteosarcoma in the maxilla in the
environment of the fibrous dysplasia. So we know there are certain kinds of nonneoplastic conditions that should no be treated with radiation because they have the
potential for transforming.
[Slide #37] [Ionizing Radiation and Cancer]
[Dr. Phelan] Early days of taking dental x-rays--the way they were taken is the
dentist or the dental assistant held the x-ray film in the patients mouth. Or before
there was really an understanding of the dangers of radiation. In order to test the
beam, the radiologist would test their equipment by placing their hand in the path of
the beam. There was also a time when you went to shoe stores and you can find this
if you hunt around on your if you good it, there was a time when shoe stores in
the United States in order to see if your shoes fit, there was a piece of equipment
that looks something like a podium and it was actually a fluoroscope. You put your
feet in the bottom part of it and looked in the eyepieces and you pushed the button
and you radiated your feet to see if your feet fit in the shoes. There was a time when
we really didnt understand the potential for radiation damage to human tissue.
And so there are a number of dentists and dental assistants who developed either
squamous cell carcinoma or basal cell carcinoma on their hands because they held
the x-ray film in the patients mouth. Its a lot easier to take x-rays that way,
however, its not a good idea.
[Slide #38] [Ionizing radiation and Cancer]
[Dr. Phelan] There is an episode of osteoscarcoma and other carcinomas in the
paranasal sinuses from people who used radium to paint on watch dials at a time,
again, when it wasnt clear how dangerous this was. And what they would do is, in
order to paint the watch dials, they had to have a very thin brush in one or two
bristles, and they would take a brush and put it in their mouths and make the point
on the brush as pointy as they could and then they would paint the dials. There was
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a recent program on PBS looking at different occupational hazards that emerged

over the years and this was one of them that was described in detail.
Uranium workers inhaled radioactive dust and got lung cancer.
[Slide #39] [Ionizing Radiation and Cancer]
[Dr. Phelan] Thymic radiation of children and you remember where the thymus
ishas led to an association with thyroid cancer. There's an increase in thyroid
cancer related to the nuclear accident in Chernobyl.
Young women who are children who have been treated with radiation at least in the
chest area for lymphoma developed breast cancer later on. And there are a number
of episodes of leukemia and other malignancies that have emerged from treating
certain diseases, particularly ankylosing spondylitis, which we saw in our
autoimmune diseases with radiation. Atom bomb survivors, again, are an increased
was an increased incidence of cancers.
[Slide #40] [Ionizing Radiation and Cancer]
[Dr. Phelan] There was a time, again, before it was clear as to how dangerous
radiation was that radiation treatment was used for ring worm. Ring worm could be
tough to get rid of and those children developed brain tumors.
Angiosarcoma of the liverrelated to radioisotopes. And again, atom bomb
survivors, multiple myeloma and lymphoma. So there is clearly an association with
radiation and cancer.
[Slide #42] [Claus EB ]
[Dr. Phelan] There was a paper in 2012. Its now 2014 so I think this was right
before you guys came to dental school. And it was in a very well-known cancer
journal, Journal of Cancer, and it made a flurry and a half. Okay? Because these
people did this study and what they came up with is exposure Ill read it
exposure from dental x-rays performed in the past, when radiation exposure was
greater than in the current era, appears to be associated with an increased risk of
intracranial meningioma. As with all sources of artificial ionizing radiation,
considered used of this modifying risk factor may be of benefit to patients. Well,
youve been working with Dr. Saks a little bit well, first of all they did this study on
dental radiology as a prospective study by calling people up as adults to find out
what kind of x-rays they had as children. Do you know what kind of x-rays you had
as a child? So how do you figure that out? The other problem is they didn't have any
dentists in their whole team trying to figure out how they would ask these
questions. So they came out with a whole series of results that suggested that our
dental radiographs were the cause of some intracranial meningiomas. Well, they
might but this study was not one that was going to give us the kind of information
that we needed to because it was a very, very badly done study but it got in a very,
very well-known journal.

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[Slide #43] [Is there a threshold dose of ionizing radiation?]

[Dr. Phelan] Okay, so you know about ALARA. You also know from your radiation
course that theres no low dose of radiation thats low enough for us to ignore.
[Slide #44] [Human epidemiologic studies ]
[Dr. Phelan] So our answer is we use what we need to use because we need it for
diagnostic purposes. But we dont need it just because we need it. We really think
carefully about what we need. Years ago, we took full mouth series on every patient
that walked in the door and we did it even before we looked in their mouths. Weve
come a long way in trying to pick what we need to get a diagnosis but if we need it,
we need it. We just have to think about what it is that were doing.
[Slide #45] [Does background radiation present a risk?]
[Dr. Phelan] Questions about background radiationat this point, there doesnt
seem to be good evidence of background radiation of causing risks related to
radiation exposure.
[Slide #46] [Radon]
[Dr. Phelan] However, there is relationship between radon and lung cancer. And so
there really is an attempt to try to remove radon exposure from homes.
[Slide #47] [Nonionizing Radiation]
[Dr. Phelan] We have a few minutes to talk about nonionizing radiation and the one
I am most concerned that you recognize as nonionizing is ultraviolet light and thats
the exposure to sunlight. That is different from ionizing radiation. And microwaves,
electric power, radio waves, infraredthose are all nonionizing radiation.
[Slide #48] [Solar radiation]
[Dr. Phelan] But the one we know most about is the ultraviolet light thats related
to solar radiation.
[Slide #48] [Ultraviolet Radiation]
[Dr. Phelan] There are three typesA, B, C. Ozone in the atmosphere should absorb
UVB and almost all UVC. Window glass blocks UVB. Sunblock blocks UVA and UVB.
[Slide #49] [Acute Effects of Ultraviolet Radiation UVA and UVB]
[Dr. Phelan] However, the acute effects of UVA and UVB are something that you all
know of as sunburn. Okay? And you get acute inflammation and remember what you
get with sunburn-redness, pain, swelling, blistering, edema, all of those signs of
inflammation that you know. You also know that with effects of ultraviolet radiation,
A and B, that theres a change in melanin and we get an increase in melanocytes. We
get a change in the dendritic processes and melanin gets transferred to
keratinocytes or epithelial cells and we get tan. There is a depletion of Langerhans
cells that occurs in response to sun exposure and theres injury to epithelial cells.
And sometimes that results in destruction or apoptosis.

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Friday, November 14th, 2014

[Slide #51] [Chronic Effects of UV Radiation]

[Dr. Phelan] We get premature aging of skin. You see people that have been out in
the sun as young people and middle-aged, either working in the sun or on sailboats
or however they're getting exposed. And they have a decrease in the elastin and they
also have a change in the type I collagen and they get wrinkles. And so they get very,
very dramatic wrinkles. And the connective tissue changes accumulate over time
and we can actually see them under the microscope.
[Slide #52] [Ultraviolet Light Exposure and Cancer]
[Dr. Phelan] There are three cancers that are associated with ultraviolet light
exposure. Actinic keratosis is a pre-cancer. Its like a cancer carcinoma in situ. But
these are the three potentially infiltrating carcinomas. Basal cell carcinoma and
melanoma are a bit different in their exposures. Non-melanomas are related to total
exposure.
[Slide #53] [Ultraviolet Rays (Non-ionizing Radiation)]
[Dr. Phelan] So for squamous cell and basal cell, the more exposure you have the
more time you spend on your boat, the more time you spend in the sun if youre a
worker out in the sun, the more time you spend out in the sun, the more at risk you
are the paler skin you are the less melanin you have the more youre susceptible
to those. For melanoma, that appears to be related to intense exposure and episodes
of sunburn. And the earlier in life you have those episodes of sunburn, the more at
risk you are as you get to be an older young person, that doesnt wait so long. None
of these are related to oral melanoma because oral melanoma is not a sun
exposurenot an exposure problem and well talk about it next year. And so there
are steps that are described that are related to the possible changes that might
cause us skin damage.
[Slide #54] [Microwave Radiation]
[Dr. Phelan] A microwave, at this point, its not really clear. Theyve done a couple
of studies to try to figure out if they could identify any cancer risk from microwave
and they really havent confirmed it. Theres concerns and keep watching.
[Slide #55] [Non-ionizing Electromagnetic Fields]
[Dr. Phelan] Nonionizing electromagnetic fieldsthis relates to high voltage lines
and the concern about cell phones and whether or not cell phones can be related to
brain cancer. But at this point, the epidemiologic evidence doesnt support this. But
there really is some conflicting data and so I would watch this and see what we've
got. But there is no clear evidence at the present time.
[Slide #56] [More information to come]
[Dr. Phelan] So Im going to ask you to follow media reports with caution because
media reports tell you what they want to sell their papers on. So be real careful. You
know how to use PubMed. You know how to use the library for information on some
of these nonionizing radiations and cancer. Watch PubMed and watch the scientific

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Friday, November 14th, 2014

studies that come up to see what you get. And we finished one minute over. So have
a nice weekend.

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