- Email: [email protected]
Dental radiology
constitute waste because the situation would add cost without contributing value. Reduced waste promotes quality and results in reduced cost. Application to Oral Health Care.—Health care is a limited resource, so with lower costs more people could share in better oral health. Raising costs unnecessarily or not taking steps to reduce costs are unethical actions. Eight categories of waste have been identified. Defects are waste because someone must pay to fix the problem. Overproduction is waste; in dental offices this would be overtreating a patient or performing work before it is needed. Moving things around without purpose and waiting are wasteful as well. Inefficient patient scheduling could qualify as waste that can also affect the proper use of staff members. Although reducing unproductive motion is an area dentistry embraces to eliminate waste, overprocessing or doing work to standards higher than what is required tends to be a wasteful pursuit that dentistry values. Treating a single patient to the highest possible degree may not be better than treating two to a professionally acceptable level. Squandering talent is another wasteful activity.
Discussion.—Ethics is a pattern of behavior rather than discrete events. The overall impact of one’s actions is more important than specific acts. Because oral health care resources are a limited quantity, it is unethical to waste them through any of the activities mentioned as well as others. Developing systems to minimize waste are a more useful pursuit than using systems that focus on fixing symptoms.
Clinical Significance.—We should be judged on the basis of our overall impact and not just on the basis of actions here or there. Adopting a system that minimizes waste would benefit everyone by lowering costs and allowing more people to have access to the resources that are available.
Chambers DW: Muda ethics. J Calif Dent Assoc 40:107, 109, 2012 Reprints not available
Dental radiology Background.—Until 2000, general dental practice radiology usually consisted of interpreting intraoral film-based images. Orthopantomograms (OPGs), lateral cephalographs, and temporomandibular joint images were referred to specialist medical radiology practices or teaching institutions. With the availability of affordable digital equipment that could handle sophisticated radiology and included software for dental imaging, the specialty of dentomaxillofacial radiology has developed in Australia. These specialists concentrate on acquiring and interpreting intraoral digital images, OPGs, medically based helical scan computed tomograms (MCTs), and cone beam volume tomograms (CBVTs). The legal ramifications of ordering and interpreting images for dental practices and consent relative to radiologic issues were evaluated. Legal Issues.—Exposing the patient to ionizing radiation can be seen as assault or battery, so the patient must be properly informed about radiologic exposures. Factors that increase the importance of this duty to inform include the long period between exposure and possible pathologic conditions, patients’ common ignorance of the facts about ionizing radiation, rapid changes in technology that alter the dosages used, and changes in recommendations for diagnostic protocols. The US concepts of informed consent
and standard of care do not apply in Australia. The Australian approach is based on the common sense notion that a discussion should take place with the patient about the benefits of the information to be gained by imaging, the added information that might be gained using a higher dose of radiation, and the relationship of the benefits to the associated risks. What ought to be done for the patient is considered, including whether he or she should be referred to a more experienced or specialist practitioner. As radiation levels diminish with CBVT compared to OPG imaging, the need to address the radiation issue will decline and it becomes more likely that CBVTwill be done. Should a small-volume CBVT be available, a full-volume CBVT may become inappropriate. With wider availability of CBVT, patients may someday ask why they did not have the opportunity to have a three-dimensional CBVT radiograph. Several principles have been described to guide the use of imaging for dental patients. Valid consent to undergo a radiologic procedure must be based on the specific procedure and the specific patient. The radiologic records then belong to the practitioner who obtained them or was responsible for recording them or even the owner of the practice. With digital records, although many people may own, retain, and control images simultaneously, ownership still resides
Volume 58
Issue 5
2013
235
with the practitioner. Copies are made only with the provision of relevant privacy information and with a valid signed request or release form. Digital radiographs are essentially stored forever in archives, although there is no legal requirement to store most records beyond 7 to 10 years. Compared to medical radiography, the risks for film and digital radiology are low. To help patients better understand the risks, any discussion of comparative doses can include references to background radiation levels. Patients can also be shown an OPG image minus patient information during a risk-to-benefit analysis. The greatest legal risk general dentists face is not identifying a pathologic condition that an oral radiologist would have been able to detect. Proper lighting, privacy, and sufficient time are important parts of image interpretation. In general, the ability to make a diagnosis from an intraoral radiograph is based on training that all dentists educated in Australia receive during their undergraduate experience. Often OPG radiographs depict structures farther outside the area of interest than are captured on intraoral radiologic surveys. Unless dentists or radiologists examine the surveys carefully and unless they take sufficient time to focus, pathologic conditions may be missed, leading to legal ramifications. Training to detect these nondental pathologic conditions should be mandatory to ensure they are not missed. General practitioners have the advantage of being able to see a digital image and interpret it instantly. When images must come from a radiologist on referral, there is a significant delay between the referral and the ability to view an image. As tomography, radiography, and diagnostic services have expanded, and with relatively low-cost CBVT, competition has heightened. Dentists now often own and operate CBVT scanners. The medicolegal risks for practitioners who operate these machines are related to not fully explaining the radiation doses being used or when the significance of data sets and wider areas of exposure are not conveyed to the patient. Usually dentists refer patients to radiology providers or use their own machines to obtain data sets, then review what is dentally relevant. If machines with large volume capacity are used, the patient may receive large doses of radiation but only a small part of the data set may be clinically relevant. A less comprehensive data set and lower radiation dose can also pose problems, but these tend to be less serious. Negligence Issues.—Dosage and failure to diagnose are the two types of negligence claims that are filed. In dosage cases, any injury must be proved to be related to the dose of radiation used. The likelihood of injury and causation is lower with CBVT diagnostic imaging, but
236
Dental Abstracts
increases for pediatric patients and repeat exposures. Currently it is difficult to determine reasonable foreseeability, making lawsuits more unlikely. Material risk and warnings must be considered in the context of occupation and environmental considerations, diagnostic and therapeutic radiation history, and patient age and gender. Risks are greater with general CT radiology, so the duty to inform the patient is clearer. In addition, if a dentist refers a patient for radiology to investigate a pathologic condition, the more serious the suspected condition, the higher the duty to follow-up and check that the patient pursued the recommended investigation. The ‘‘loss of chance’’ is related to a determination of probability. For loss of chance to be the basis for a successful negligence claim, an increase in the risk of death from a condition undiagnosed from the image is not of itself enough to prove that the missed opportunity was the cause of the patient’s death. It must be more likely than not that the failure to diagnose a condition substantially caused the death. However, taking films based on clinical indications cannot be done as a ‘‘fishing expedition.’’ This protects the patient and the public from unnecessary radiation. In addition, issues may be related to the size of the collimation, which can be too wide or too narrow. Discussion.—Dentists who refer patients for CBVT and OPGs must explain radiation doses and risks to patients. Those who use their own machines to obtain these images must also explain about dosages and risks, but have a higher duty than those who merely refer patients to others. All nondental diagnoses from these images are the responsibility of the dentist if he or she does the interpretation. Costs for an interpretation from a referred source are included in estimates given to the patient. If small-volume CBVTs are used diagnostically, dentists should assess whether all the data set and possible information has been viewed and appropriately interpreted as well as whether an oral radiologist’s opinion would be appropriate. If large-volume CBVTs are used by dentists on their own machines, all data sets should be referred to a radiologist for review. The cost for this is also passed along to the patient. These dentists are at highest risk for medicolegal complications. No CBVTs should be ordered without appropriate discussion with the parent about dosage-related risks when the patient is a child. Ordinarily, dentists with their own CBVT machines should not order or expose CBVT for pediatric patients.
Clinical Significance.—Dentists need to consider the legal principles that apply to their use of imaging methods in house or referred out. Among the issues that arise are those related to dosages of radiation, interpretation, and
properly informing patients of the risks and benefits of the images to be obtained. The patient’s age, symptoms, and history and the intent of the procedure are all important factors to be weighed when making decisions about imaging.
Wright B: Contemporary medico-legal dental radiology. Austral Dent J 57:9–15, 2012 Reprints available from B Wright, Bennett Chambers, Level 6, 107 N. Quay, Brisbane QLD 4000, Australia; e-mail: [email protected]
EXTRACTS NIGHT LIGHTS Nighttime lights can disrupt sleep, increase the risk of cancer, cause poorer vision, and possibly lead to weight gain. The American Medical Association (AMA) has a new policy that recognizes exposure to excessive light at night from computer screens and other electronic media can disrupt sleep, especially for children and teens. The wrong type of light can make for unsafe driving conditions, with pupil constriction causing poorer vision. Outdoor lighting should shield against direct light in the eyes by directing it toward the ground. Melatonin production is disrupted by too much light at night, particularly blue light. Melatonin is believed to suppress cancer development, so a lack of melatonin may accelerate tumor growth. Animal studies show that exposure to light for 24 h a day dramatically increases the risk of some cancers. Human studies find exposure to light at night or frequent nighttime waking is linked to an increased risk of breast cancer. More research is needed to confirm a link between exposure to light at night and weight gain. Dr Mario Motta, a cardiologist at North Shore Medical Center, Salem, Massachusetts, and member of the AMA Council on Science and Public Health, notes that the effect of nighttime light on the human body is an emerging field of study. He recommends that parents keep their children on regular sleep schedules with no lights in the room. If the child is afraid of the dark, a dim red light is the best choice. [Rettner R: Light at Night Can Harm Your Health, Docs Say. MyHealthNewsDaily, June 6, 2012]
Volume 58
Issue 5
2013
237
Discussion.—Ethics is a pattern of behavior rather than discrete events. The overall impact of one’s actions is more important than specific acts. Because oral health care resources are a limited quantity, it is unethical to waste them through any of the activities mentioned as well as others. Developing systems to minimize waste are a more useful pursuit than using systems that focus on fixing symptoms.
Clinical Significance.—We should be judged on the basis of our overall impact and not just on the basis of actions here or there. Adopting a system that minimizes waste would benefit everyone by lowering costs and allowing more people to have access to the resources that are available.
Chambers DW: Muda ethics. J Calif Dent Assoc 40:107, 109, 2012 Reprints not available
Dental radiology Background.—Until 2000, general dental practice radiology usually consisted of interpreting intraoral film-based images. Orthopantomograms (OPGs), lateral cephalographs, and temporomandibular joint images were referred to specialist medical radiology practices or teaching institutions. With the availability of affordable digital equipment that could handle sophisticated radiology and included software for dental imaging, the specialty of dentomaxillofacial radiology has developed in Australia. These specialists concentrate on acquiring and interpreting intraoral digital images, OPGs, medically based helical scan computed tomograms (MCTs), and cone beam volume tomograms (CBVTs). The legal ramifications of ordering and interpreting images for dental practices and consent relative to radiologic issues were evaluated. Legal Issues.—Exposing the patient to ionizing radiation can be seen as assault or battery, so the patient must be properly informed about radiologic exposures. Factors that increase the importance of this duty to inform include the long period between exposure and possible pathologic conditions, patients’ common ignorance of the facts about ionizing radiation, rapid changes in technology that alter the dosages used, and changes in recommendations for diagnostic protocols. The US concepts of informed consent
and standard of care do not apply in Australia. The Australian approach is based on the common sense notion that a discussion should take place with the patient about the benefits of the information to be gained by imaging, the added information that might be gained using a higher dose of radiation, and the relationship of the benefits to the associated risks. What ought to be done for the patient is considered, including whether he or she should be referred to a more experienced or specialist practitioner. As radiation levels diminish with CBVT compared to OPG imaging, the need to address the radiation issue will decline and it becomes more likely that CBVTwill be done. Should a small-volume CBVT be available, a full-volume CBVT may become inappropriate. With wider availability of CBVT, patients may someday ask why they did not have the opportunity to have a three-dimensional CBVT radiograph. Several principles have been described to guide the use of imaging for dental patients. Valid consent to undergo a radiologic procedure must be based on the specific procedure and the specific patient. The radiologic records then belong to the practitioner who obtained them or was responsible for recording them or even the owner of the practice. With digital records, although many people may own, retain, and control images simultaneously, ownership still resides
Volume 58
Issue 5
2013
235
with the practitioner. Copies are made only with the provision of relevant privacy information and with a valid signed request or release form. Digital radiographs are essentially stored forever in archives, although there is no legal requirement to store most records beyond 7 to 10 years. Compared to medical radiography, the risks for film and digital radiology are low. To help patients better understand the risks, any discussion of comparative doses can include references to background radiation levels. Patients can also be shown an OPG image minus patient information during a risk-to-benefit analysis. The greatest legal risk general dentists face is not identifying a pathologic condition that an oral radiologist would have been able to detect. Proper lighting, privacy, and sufficient time are important parts of image interpretation. In general, the ability to make a diagnosis from an intraoral radiograph is based on training that all dentists educated in Australia receive during their undergraduate experience. Often OPG radiographs depict structures farther outside the area of interest than are captured on intraoral radiologic surveys. Unless dentists or radiologists examine the surveys carefully and unless they take sufficient time to focus, pathologic conditions may be missed, leading to legal ramifications. Training to detect these nondental pathologic conditions should be mandatory to ensure they are not missed. General practitioners have the advantage of being able to see a digital image and interpret it instantly. When images must come from a radiologist on referral, there is a significant delay between the referral and the ability to view an image. As tomography, radiography, and diagnostic services have expanded, and with relatively low-cost CBVT, competition has heightened. Dentists now often own and operate CBVT scanners. The medicolegal risks for practitioners who operate these machines are related to not fully explaining the radiation doses being used or when the significance of data sets and wider areas of exposure are not conveyed to the patient. Usually dentists refer patients to radiology providers or use their own machines to obtain data sets, then review what is dentally relevant. If machines with large volume capacity are used, the patient may receive large doses of radiation but only a small part of the data set may be clinically relevant. A less comprehensive data set and lower radiation dose can also pose problems, but these tend to be less serious. Negligence Issues.—Dosage and failure to diagnose are the two types of negligence claims that are filed. In dosage cases, any injury must be proved to be related to the dose of radiation used. The likelihood of injury and causation is lower with CBVT diagnostic imaging, but
236
Dental Abstracts
increases for pediatric patients and repeat exposures. Currently it is difficult to determine reasonable foreseeability, making lawsuits more unlikely. Material risk and warnings must be considered in the context of occupation and environmental considerations, diagnostic and therapeutic radiation history, and patient age and gender. Risks are greater with general CT radiology, so the duty to inform the patient is clearer. In addition, if a dentist refers a patient for radiology to investigate a pathologic condition, the more serious the suspected condition, the higher the duty to follow-up and check that the patient pursued the recommended investigation. The ‘‘loss of chance’’ is related to a determination of probability. For loss of chance to be the basis for a successful negligence claim, an increase in the risk of death from a condition undiagnosed from the image is not of itself enough to prove that the missed opportunity was the cause of the patient’s death. It must be more likely than not that the failure to diagnose a condition substantially caused the death. However, taking films based on clinical indications cannot be done as a ‘‘fishing expedition.’’ This protects the patient and the public from unnecessary radiation. In addition, issues may be related to the size of the collimation, which can be too wide or too narrow. Discussion.—Dentists who refer patients for CBVT and OPGs must explain radiation doses and risks to patients. Those who use their own machines to obtain these images must also explain about dosages and risks, but have a higher duty than those who merely refer patients to others. All nondental diagnoses from these images are the responsibility of the dentist if he or she does the interpretation. Costs for an interpretation from a referred source are included in estimates given to the patient. If small-volume CBVTs are used diagnostically, dentists should assess whether all the data set and possible information has been viewed and appropriately interpreted as well as whether an oral radiologist’s opinion would be appropriate. If large-volume CBVTs are used by dentists on their own machines, all data sets should be referred to a radiologist for review. The cost for this is also passed along to the patient. These dentists are at highest risk for medicolegal complications. No CBVTs should be ordered without appropriate discussion with the parent about dosage-related risks when the patient is a child. Ordinarily, dentists with their own CBVT machines should not order or expose CBVT for pediatric patients.
Clinical Significance.—Dentists need to consider the legal principles that apply to their use of imaging methods in house or referred out. Among the issues that arise are those related to dosages of radiation, interpretation, and
properly informing patients of the risks and benefits of the images to be obtained. The patient’s age, symptoms, and history and the intent of the procedure are all important factors to be weighed when making decisions about imaging.
Wright B: Contemporary medico-legal dental radiology. Austral Dent J 57:9–15, 2012 Reprints available from B Wright, Bennett Chambers, Level 6, 107 N. Quay, Brisbane QLD 4000, Australia; e-mail: [email protected]
EXTRACTS NIGHT LIGHTS Nighttime lights can disrupt sleep, increase the risk of cancer, cause poorer vision, and possibly lead to weight gain. The American Medical Association (AMA) has a new policy that recognizes exposure to excessive light at night from computer screens and other electronic media can disrupt sleep, especially for children and teens. The wrong type of light can make for unsafe driving conditions, with pupil constriction causing poorer vision. Outdoor lighting should shield against direct light in the eyes by directing it toward the ground. Melatonin production is disrupted by too much light at night, particularly blue light. Melatonin is believed to suppress cancer development, so a lack of melatonin may accelerate tumor growth. Animal studies show that exposure to light for 24 h a day dramatically increases the risk of some cancers. Human studies find exposure to light at night or frequent nighttime waking is linked to an increased risk of breast cancer. More research is needed to confirm a link between exposure to light at night and weight gain. Dr Mario Motta, a cardiologist at North Shore Medical Center, Salem, Massachusetts, and member of the AMA Council on Science and Public Health, notes that the effect of nighttime light on the human body is an emerging field of study. He recommends that parents keep their children on regular sleep schedules with no lights in the room. If the child is afraid of the dark, a dim red light is the best choice. [Rettner R: Light at Night Can Harm Your Health, Docs Say. MyHealthNewsDaily, June 6, 2012]
Volume 58
Issue 5
2013
237