Sharpening your x-ray vision.
Radiographs are an essential part of the practice of dentistry – for diagnosis of dental disease, as well as treatment planning and monitoring.
The Radiation Safety Act 2016 and supporting regulations came into force in early 2017 and established a new framework for safe and beneficial use of ionising radiation while protecting public health and the environment from its harmful effects. This legislation replaced the previous Act and regulations.
A patient recently complained to the Dental Council about their dentist who refused to remove a tooth without taking a pre-operative radiograph. The patient was adamant that they had the right to refuse an x-ray and the dentist was not entitled to refuse to treat just because of this. From the patient’s point of view, it was a simple decayed tooth which had fractured, and extraction was the only option.
Under the Code of Health and Disability Services Consumers’ Rights consumers have the right to make an informed choice and give informed consent (Right 7). Specifically, every consumer has the right to refuse services and to withdraw consent to services.
Does the dentist have the right to refuse to treat a patient?
It is unwise to undertake any extraction without an appropriate pre-operative radiograph. Once the reasons for requiring a radiograph have been fully explained and the reason behind the refusal understood (for example it may relate to additional costs or concern about radiation) then one option is to terminate the relationship with the patient.
Care is required in situations where you refuse to proceed with treatment and taking advice from your association or indemnifier can be helpful to minimise complaints or the likelihood of the patient taking action.
Remember that in an emergency there is an obligation to help the patient – relief of pain, treating infection or stabilising after trauma – or ensuring a referral for appropriate care.
An examination for a dentate patient almost always will include radiographs. One option is to include radiography in the cost estimate rather than charging for each radiograph separately. Patients may have legitimate concerns regarding radiation – especially those receiving radiation treatment. Involving specialist colleagues can be helpful in managing these situations.
Getting it right
Council regularly undertakes practice audits – at random and in responses to notification of concerns. This will usually include a review of patient records which usually includes radiography. Radiography comes at a cost – both financial and biological cost. It is important radiographs are fit for purpose and this includes appropriate field of view and acceptable quality of the image.
Routine bitewing radiographs are a fundamental diagnostic tool and the expected field of view includes interproximal contact areas and bone levels from first premolar back.
In some patients a second view may be required, or a larger film or sensor used – especially in the presence of third molars.
Quite often during practice audits it is apparent that the hard, bulky nature of some digital sensors can present real challenges in positioning to ensure the appropriate field of view (example below). The key is to evaluate the images and ensure they are fit for purpose.
Periapical radiographs must show a clear view of the apex of appropriate teeth.
Having taken a radiograph for a specific purpose – in the example above a review of root canal treatment – there is an obligation to record incidental findings. Caries on the first molar and the presence of the third molar visible in these pictures should be noted.
With extra oral radiographs the evaluation for incidental findings can be challenging. OPG, cephalometric radiographs and CBCT scans all require expertise to evaluate the whole image. If appropriate, images can be referred to our specialist colleagues for assessment.
Keeping radiographs as part of the dental records
Patients are entitled to a copy of their dental records. Radiographs are an essential component and digital radiographs are easy to copy. Radiographic film is less so. Taking a digital photo of the image on a lightbox is an option to ensure radiographs remain with the practitioner’s records.
Placing the equipment carefully
When extra-oral radiographic equipment is installed into an existing practice, there are health and safety concerns to consider. In one practice audit, we found new equipment had been installed on the other side of the wall from the receptionist’s desk. When asked, it was apparent that the practice has not considered taking radiation measurements or installing insulation for protection.
In another practice extraoral equipment had been installed adjacent to a passageway from waiting room to the bathroom. The solution found by the practice was to use road cones to prevent access to the area when the equipment was in use.
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