- Email: [email protected]
RADIOGRAPHIC GUIDELINES
LETTERS the assumption that current usual, customary and reasonable fees charged by dentists reflect effective cost containment. In fact, there is no evidence that the fees charged by dentists - are derived by a pricing method contingent on the actual cost of providing services; - represent a "reasonable" profit margin for the dentists themselves; - [have been] expertly analyzed by each provider towards "cost containment" within his or her own practice. While the percentage of dental expenditures as a segment of America's total health care market may have decreased slightly in recent years, one cannot ignore that the total dollars spent for health care have increased significantly. Dentistry may be getting a slightly smaller piece of the health care pie, but the pie itself is growing. It is for this reason that purchasers of health care benefits are scrutinizing their expenditures more carefully than ever. Finally, no conclusive studies exist that show that an appropriate level and quality of dental care is being delivered at current fee levels. The fee-for-service environment is inherently inflationary, and contains incentives to perform unnecessary dental procedures in an age of increasing competitiveness and decreasing dental pathology. Until an appropriate "baseline" is scientifically measured and the actual cost of appropriate dental services established, the authors' conclusion that DHMO premium dollars would not cover basic preventive services is unfounded. Bryan Quattlebaum, D.D.S. Gold River, Calif. 426 JADA, Vol. 127, April 1996
Authors' response: The article did not attempt to explain, or even mention, UCR fees. It used surveyed fees by reporting dentists for these costs to a typical amount available under a capitated plan. For that typical example, the amount of capitation payments to a practitioner would not cover those services at surveyed fee levels. Suffice it to say, fees are individually set at a level to cover actual costs and return a "reasonable" profit to the entrepreneur who takes the risk, makes the investment and has certain expertise. "Reasonable" profit should be adequate to compensate someone for years of schooling, large educational debt and business start-up costs and risks. We have no reason to assume that surveyed fees are "unreasonable." There is certainly evidence that a high correlation exists between dentists' fees and actual cost changes. In a June 1994 JADA' article, for example, dentists indicated they raised fees by $8.42 to cover the estimated $9.31 of direct costs associated with OSHA regulations, while absorbing the rest. Further, if the costs of all dental care are growing slower than costs for other sectors, it indicates that dentistry is embracing cost control more effectively than its counterparts. We do appreciate your applause for cost control for both parties. Readers may be interested to note that Dr. Quattlebaum is dental consultant, Dental Contract Section, Payments Systems Division of the California Department of Health Services. Marye C. Feldman, BA James B. Bramson, D.D.S. American Dental Association Chicago, Ill.
1. Feldman M, Bramson J. What is the cost of compliance? JADA 1994;125:682-6.
RADIOGRAPHIC GUIDELINES
It was a pleasure to read Dr. Marc Goldman's superb letter on dental radiographs in response to the article by Dr. Atchison and colleagues ("Assessing the FDA Guidelines for Ordering Dental Radiographs," October 1995 JADA). His comments reflect the real world of fine clinical diagnostic dentistry. No distant bureaucratic body should interfere with the dentist's judgment on when to take any or all radiographs. Every patient is an individual whose dental condition can vary from 100 percent free of all caries and oral pathology to severe dental disease of a devastating nature. Only the dentist can make the decision when and at what frequency to take not only periapical films, but also panoramic films, head plates, MRIs and even CAT scans. When is the ADA going to stand up and be a genuine representative for the practicing, hard-working dental practitioner and tell the FDA and all the insurance companies that we doctors make the professional decisions as to what, when, how and why to treat our patients? I would also like to comment on Dr. Goldman's interesting statement on benefits vs. risks for dental radiographs. I suggest that the FDA and all the third-party insurance companies make an extensive literature search starting with the National Library of Medicine in Washington, D.C., and every other library computer-based data bank and see if there has been any cancer, nausea, hereditary defect (immediate or
LETTERS latent), dizziness, burns or detrimental effects from modern dental diagnostic radiography. (I am not referring to historical references when Roentgen and Keels took the first radiographs in medicine and dentistry.) They will find that there have never been any documented, proven cases of medical problems because of dental diagnostic radiography! We should be treating our patients with dental problems and not treating third-party insurance companies. Again, I want to thank Dr. Goldman for a very refreshing essay on the best of dental care for our patients. Manuel I. Weisman, D.D.S. Augusta, Ga.
Authors' response: We thank Dr. Goldman for his interest and comments pointing out several complex issues regarding film selection in dental radiography. First, it is important to recognize that organized dentistry does indeed have a policy on the indications for obtaining radiographs. In 1989, the Council on Dental Materials, Instruments and Equipment recommended obtaining periapical radiographs on the basis of patient need, as suggested in the FDA Guide-
lines.,2
Our report showed that the use of these guidelines results in a low rate of missed radiographic findings, some of which were disease. Dr. Goldman, in his comments on this finding, opines that practicing private practitioners do not have "the leeway of 'missing' anything, not one carious lesion, one periapical lesion or subgingival calculus."
428 JADA, Vol. 127, April 1996
Recent research performed and reviewed by Bader and Shugars3 points out there are wide variations in dentists' diagnoses and treatment plans. They conclude that "even when differences in patients are controlled, variation in dentists' clinical decisions is ubiquitous. While its consequences remain undetermined, the variation in basic clinical decisions such as caries diagnosis signals the need to consider the extent to which the appropriateness of care is affected." The extent of loss of information resulting from the use of selected radiographs that we report is far less than the variation among dentists when diagnosing disease on radiographs. For example, a study by Noar and Smith4 examined variability in caries diagnosis. Their study found that "opinions as to whether caries was present and whether it required treatment showed a wide distribution. However, had the decisions been acted upon, between 1-6 percent of the sound surfaces would have been filled, but 2068 percent of teeth with clearly cavitated surfaces or histological evidence of dentin involvement would not have been filled." We must conclude that it is not uncommon for dentists to inadvertently "miss" lesions. In his assessment of the risks of exposure to ionizing radiation, Dr. Goldman points out that he is unaware of reports of radiation burns, dizziness, nausea or blurred vision after taking a complete set of X-rays. This is to be expected as the risk to patients from exposure to low levels of ionizing radiation is the possibility of radia-
tion carcinogenesis.5 While the extent of this risk is unknown, and may even be zero, the greatest risk from dental radiography is believed to be the chance of inducing leukemia and thyroid cancer.6 These conditions may appear many years following exposure and would be indistinguishable from nonradiation-induced cancers. While the benefits of radiographic examinations are many, we believe it is important to reduce unnecessary exposure whenever possible. Simple means include the use of Espeed film instead of D-speed film (approximately a 50 percent dose reduction), rectangular collimation instead of round collimation (a further 50 percent dose reduction), time-temperature processing instead of sight processing and selection criteria to identify the radiographs most likely to benefit our patients. Stuart C. White University of California, Los Angeles Kathryn A. Atchison University of California, Los Angeles 1. Council on Dental Materials, Instruments and Equipment. Recommendations in radiographic practices: an update, 1988. JADA 1989;118:115-7. 2. U.S. Department of Health and Human Services, Food and Drug Administration, Bureau of Radiological Health. The selection of patients for X-ray examinations: dental radiographic examinations. 1987;HHS FDA publication No.88-8273. 3. Bader JD, Shugars DA. Variation in dentists' clinical decisions. J Public Health Dent 1995;55:181-8. 4. Noar SJ, Smith BG. Diagnosis of caries and treatment decisions in approximal surfaces of posterior teeth in vitro. J Oral Rehabil 1990;17:209-18. 5. National Research Council. Health effects of exposure to low levels of ionizing radiation. BEIR V. Washington, D.C.: National Academy Press, 1990. 6. White SC. 1992 assessment of radiation risk from dental radiography. Dentomaxillofac Radiol 1992;21:118-26.
Authors' response: The article did not attempt to explain, or even mention, UCR fees. It used surveyed fees by reporting dentists for these costs to a typical amount available under a capitated plan. For that typical example, the amount of capitation payments to a practitioner would not cover those services at surveyed fee levels. Suffice it to say, fees are individually set at a level to cover actual costs and return a "reasonable" profit to the entrepreneur who takes the risk, makes the investment and has certain expertise. "Reasonable" profit should be adequate to compensate someone for years of schooling, large educational debt and business start-up costs and risks. We have no reason to assume that surveyed fees are "unreasonable." There is certainly evidence that a high correlation exists between dentists' fees and actual cost changes. In a June 1994 JADA' article, for example, dentists indicated they raised fees by $8.42 to cover the estimated $9.31 of direct costs associated with OSHA regulations, while absorbing the rest. Further, if the costs of all dental care are growing slower than costs for other sectors, it indicates that dentistry is embracing cost control more effectively than its counterparts. We do appreciate your applause for cost control for both parties. Readers may be interested to note that Dr. Quattlebaum is dental consultant, Dental Contract Section, Payments Systems Division of the California Department of Health Services. Marye C. Feldman, BA James B. Bramson, D.D.S. American Dental Association Chicago, Ill.
1. Feldman M, Bramson J. What is the cost of compliance? JADA 1994;125:682-6.
RADIOGRAPHIC GUIDELINES
It was a pleasure to read Dr. Marc Goldman's superb letter on dental radiographs in response to the article by Dr. Atchison and colleagues ("Assessing the FDA Guidelines for Ordering Dental Radiographs," October 1995 JADA). His comments reflect the real world of fine clinical diagnostic dentistry. No distant bureaucratic body should interfere with the dentist's judgment on when to take any or all radiographs. Every patient is an individual whose dental condition can vary from 100 percent free of all caries and oral pathology to severe dental disease of a devastating nature. Only the dentist can make the decision when and at what frequency to take not only periapical films, but also panoramic films, head plates, MRIs and even CAT scans. When is the ADA going to stand up and be a genuine representative for the practicing, hard-working dental practitioner and tell the FDA and all the insurance companies that we doctors make the professional decisions as to what, when, how and why to treat our patients? I would also like to comment on Dr. Goldman's interesting statement on benefits vs. risks for dental radiographs. I suggest that the FDA and all the third-party insurance companies make an extensive literature search starting with the National Library of Medicine in Washington, D.C., and every other library computer-based data bank and see if there has been any cancer, nausea, hereditary defect (immediate or
LETTERS latent), dizziness, burns or detrimental effects from modern dental diagnostic radiography. (I am not referring to historical references when Roentgen and Keels took the first radiographs in medicine and dentistry.) They will find that there have never been any documented, proven cases of medical problems because of dental diagnostic radiography! We should be treating our patients with dental problems and not treating third-party insurance companies. Again, I want to thank Dr. Goldman for a very refreshing essay on the best of dental care for our patients. Manuel I. Weisman, D.D.S. Augusta, Ga.
Authors' response: We thank Dr. Goldman for his interest and comments pointing out several complex issues regarding film selection in dental radiography. First, it is important to recognize that organized dentistry does indeed have a policy on the indications for obtaining radiographs. In 1989, the Council on Dental Materials, Instruments and Equipment recommended obtaining periapical radiographs on the basis of patient need, as suggested in the FDA Guide-
lines.,2
Our report showed that the use of these guidelines results in a low rate of missed radiographic findings, some of which were disease. Dr. Goldman, in his comments on this finding, opines that practicing private practitioners do not have "the leeway of 'missing' anything, not one carious lesion, one periapical lesion or subgingival calculus."
428 JADA, Vol. 127, April 1996
Recent research performed and reviewed by Bader and Shugars3 points out there are wide variations in dentists' diagnoses and treatment plans. They conclude that "even when differences in patients are controlled, variation in dentists' clinical decisions is ubiquitous. While its consequences remain undetermined, the variation in basic clinical decisions such as caries diagnosis signals the need to consider the extent to which the appropriateness of care is affected." The extent of loss of information resulting from the use of selected radiographs that we report is far less than the variation among dentists when diagnosing disease on radiographs. For example, a study by Noar and Smith4 examined variability in caries diagnosis. Their study found that "opinions as to whether caries was present and whether it required treatment showed a wide distribution. However, had the decisions been acted upon, between 1-6 percent of the sound surfaces would have been filled, but 2068 percent of teeth with clearly cavitated surfaces or histological evidence of dentin involvement would not have been filled." We must conclude that it is not uncommon for dentists to inadvertently "miss" lesions. In his assessment of the risks of exposure to ionizing radiation, Dr. Goldman points out that he is unaware of reports of radiation burns, dizziness, nausea or blurred vision after taking a complete set of X-rays. This is to be expected as the risk to patients from exposure to low levels of ionizing radiation is the possibility of radia-
tion carcinogenesis.5 While the extent of this risk is unknown, and may even be zero, the greatest risk from dental radiography is believed to be the chance of inducing leukemia and thyroid cancer.6 These conditions may appear many years following exposure and would be indistinguishable from nonradiation-induced cancers. While the benefits of radiographic examinations are many, we believe it is important to reduce unnecessary exposure whenever possible. Simple means include the use of Espeed film instead of D-speed film (approximately a 50 percent dose reduction), rectangular collimation instead of round collimation (a further 50 percent dose reduction), time-temperature processing instead of sight processing and selection criteria to identify the radiographs most likely to benefit our patients. Stuart C. White University of California, Los Angeles Kathryn A. Atchison University of California, Los Angeles 1. Council on Dental Materials, Instruments and Equipment. Recommendations in radiographic practices: an update, 1988. JADA 1989;118:115-7. 2. U.S. Department of Health and Human Services, Food and Drug Administration, Bureau of Radiological Health. The selection of patients for X-ray examinations: dental radiographic examinations. 1987;HHS FDA publication No.88-8273. 3. Bader JD, Shugars DA. Variation in dentists' clinical decisions. J Public Health Dent 1995;55:181-8. 4. Noar SJ, Smith BG. Diagnosis of caries and treatment decisions in approximal surfaces of posterior teeth in vitro. J Oral Rehabil 1990;17:209-18. 5. National Research Council. Health effects of exposure to low levels of ionizing radiation. BEIR V. Washington, D.C.: National Academy Press, 1990. 6. White SC. 1992 assessment of radiation risk from dental radiography. Dentomaxillofac Radiol 1992;21:118-26.