Dental Radiographs

[Panscan]

This is a nonsensical argument. No the standard is not that you call every single possible cavity on a head ct. no the standard is not that a normal head ct excludes dental disease. We don’t even image the teeth a lot of times, we may just catch a few maxillary teeth. It’s not like we’re completely scanning through the mandible and needlessly radiating the patient.

I think you have more liability than you think when you independently interpret cross sectional studies that can show pathology you aren’t looking for. Continue to roll the dice, it’s your call. To equate that to “missing” a cavity which isn’t able to be visualized on the imaging modality in question is hilarious. The scales of magnitude here are drastically different.

You’re specifically saying things you didn’t appreciate initially on your cbct then you look in their mouth and go back and look at your cbct . That’s confirmation bias. You already know the answer. That doesn’t mean it was visible initially and you’re certainly biased in your second look.

I don’t think you fundamentally understand how radiology works and that’s ok. It’s probably best we stop talking about this as well clearly disagree. Have a good day.

[molar roller]

I also don't think you understand what dentists do all day, because you keep on bringing up cavities in every post. But that's OK. We don't have to agree. You have a good day as well.

[Aligner]

I think the disconnect here, in regards to the original concern about imaging liability is the asymmetric liability present in a dentist missing "something" versus a radiologist missing "tooth something". As well as the asymmetric scale at which dentists & radiologists view dental findings.

To Panscan 's point, it seems reasonable that it would behoove any dentist taking images of areas outside the scope of their expertise to consult with a radiologist to cover their a**. This seems understandable coming from someone who I assume is used to diagnosing life threatening pathology on a daily basis, when compared to a dentist who more routinely deals with long term chronic maintenance of a persons dentition. If a dentist were to miss something "in the orbit" (to use the example used in this thread), the probability that this missed pathology is something that can/will result in a severe negative outcome to the patient (blindness, death, etc) I would presume is much higher RELATIVE to the negative patient outcome that could/would occur as a result of a radiologist missing something tooth related (tooth extraction). Not to say a dental abscess couldn't result in a severe outcome for a patient, but the likelihood of a severe negative outcome RELATIVE to some head/neck mass is probably small in comparison. For this reason, from a liability perspective my assumption is that a radiologist has little to no liability over missed dental disease when compared to a dentist having moderate liability over missed "something". Whether or not these situations have been litigated and if there is any real concern about judgements going above policy limits is a great question for any lawyers in the forum.

To molar roller 's point, most things in dentistry can often be found/diagnosed clinically by an experienced dentist much sooner than they appear on any imagine, and good dental diagnosis & treatment often means catching things when they are small before they become large & problematic so that they can be treated in the most conservative manner. If a radiologist were to find "something" tooth-related on a CT (cracked tooth), this crack would likely be massive from the perspective of a dentist. So massive, that the treatment options for this tooth become very limited & conservative tx likely out the window. For this reason, can a radiologist identify tooth disease, yes... but the idea that a radiologist would speak like he/she has any confidence/authority in diagnosing dental disease is quite frankly very naïve on the part of the radiologist, and to use @Panscan's own words why phsyicians "get a bad look" when they try to argue about topics in dentistry when it is obvious that they have only a cursory knowledge of dental disease. To put in perspective, a radiologist diagnosing tooth disease is like identifying a hole in a dam, while the river is already flooded. A dentist would identify the crack in the dam and repair it before it becomes a hole and floods the river. Not to say radiologists are not highly detailed or don't work in high resolution, they just don't have the training in dentistry to see the forest beyond the trees when it comes to tooth-related disease.

[Panscan]

I’m not saying I’m catching subtle dental disease or things that a dentist wouldn’t see looking in someone’s mouth . I don’t have the opportunity to look in someone’s mouth. The only opportunity I have is the pictures in front of me. Yes I 100% believe the stuff I call will likely be later stage and likely visible earlier by a dentist on a clinical exam but that’s not the relevant comparison. If the person had a clinical exam earlier they wouldn’t have presented with the findings that show up for me. The goal is to prevent it from getting even worse. I can’t go back in time and tell them to go to a dentist earlier, I have one encounter and I can either a) say nothing or b) tell them there is stuff that needs evaluated by someone that can take care of it. I think most people would say b is preferable. I really don’t see what is not extremely clear about this.

If you make the grand statement that you can’t see a tooth fracture, a cavity, periodontal disease( there’s actually a differential, they aren’t all abscesses) then you 100% lose me and I think you’re crazy, full stop. These things can objectively be seen with imaging. This is not debatable. If you want to say subtle ones can’t be seen, sure 100% could agree, but that is not what was said.

[Panscan]

I think the disconnect here, in regards to the original concern about imaging liability is the asymmetric liability present in a dentist missing "something" versus a radiologist missing "tooth something". As well as the asymmetric scale at which dentists & radiologists view dental findings.

To Panscan 's point, it seems reasonable that it would behoove any dentist taking images of areas outside the scope of their expertise to consult with a radiologist to cover their a**. This seems understandable coming from someone who I assume is used to diagnosing life threatening pathology on a daily basis, when compared to a dentist who more routinely deals with long term chronic maintenance of a persons dentition. If a dentist were to miss something "in the orbit" (to use the example used in this thread), the probability that this missed pathology is something that can/will result in a severe negative outcome to the patient (blindness, death, etc) I would presume is much higher RELATIVE to the negative patient outcome that could/would occur as a result of a radiologist missing something tooth related (tooth extraction). Not to say a dental abscess couldn't result in a severe outcome for a patient, but the likelihood of a severe negative outcome RELATIVE to some head/neck mass is probably small in comparison. For this reason, from a liability perspective my assumption is that a radiologist has little to no liability over missed dental disease when compared to a dentist having moderate liability over missed "something". Whether or not these situations have been litigated and if there is any real concern about judgements going above policy limits is a great question for any lawyers in the forum.

To molar roller 's point, most things in dentistry can often be found/diagnosed clinically by an experienced dentist much sooner than they appear on any imagine, and good dental diagnosis & treatment often means catching things when they are small before they become large & problematic so that they can be treated in the most conservative manner. If a radiologist were to find "something" tooth-related on a CT (cracked tooth), this crack would likely be massive from the perspective of a dentist. So massive, that the treatment options for this tooth become very limited & conservative tx likely out the window. For this reason, can a radiologist identify tooth disease, yes... but the idea that a radiologist would speak like he/she has any confidence/authority in diagnosing dental disease is quite frankly very naïve on the part of the radiologist, and to use @Panscan's own words why phsyicians "get a bad look" when they try to argue about topics in dentistry when it is obvious that they have only a cursory knowledge of dental disease. To put in perspective, a radiologist diagnosing tooth disease is like identifying a hole in a dam, while the river is already flooded. A dentist would identify the crack in the dam and repair it before it becomes a hole and floods the river. Not to say radiologists are not highly detailed or don't work in high resolution, they just don't have the training in dentistry to see the forest beyond the trees when it comes to tooth-related disease.

That's not my problem. Again I'm not sure what you want, should we just ignore it? I am confident I can identify dental disease that is apparent on imaging, yes, because that is literally my job. Am I confident I could identify dental disease looking in your mouth or that I could fix it? No, that is not my job. Again, I'm not sure how this dichotomy cannot be differentiated. I can tell a neurosurgeon there is a low-grade astrocytoma in the brain and "diagnose it", that doesn't mean I'm cutting their head open and pulling it out. The job is literally to identify things on imaging. I'm not sure why it's hard to understand someone who looks at images for a living would be similar in ability at looking at images of the teeth, as someone whose job is taking care of the teeth and adjacent structures. Again, I'm not saying I can fill a cavity.

This hole in a dam thing makes no sense. Again it's not a contest, I'm not saying "everyone should get a head CT because we can see cavities your dentist misses," the point is that we do a sh*tload of imaging of the head and neck in the ED, and guess what is often included in the field of view? The teeth! Obviously lots of people have dental disease. Again I'm not sure what the alternative is, to just ignore it? Ya I'm gonna have to pass on that one.

[jacoavlu]

I'm a radiologist. Most radiologists suck at all dental stuff. That's the truth. I can name and number the teeth, most of the time.

I'm sure there are some that are really good. Most are assuredly not.

Could a dentist be sued for a missed incidental finding on a CBCT? Sure. Very unlikely, but bad luck can happen to us all. Wrong place wrong time.

Does that mean all CBCTs should be overread by a radiologist? No, my opinion. That's not free. At least, I wouldn't do it for free. So you're going to increase the cost of care and then the question becomes, with what benefit?

We could do some research and collect the data, crunch some numbers and then argue about how much morbidity and mortality would be avoided and at what cost. My opinion, it ain't likely to be worth it.

Panscan the truth is, in the real world a whole lot of imaging goes on that radiologists don't lay eyes on. And it's ok, we stay pretty busy.

[molar roller]

Thank you for the real world perspective, jacoavlu . Well put, and I'm not sure why it needed to get so contentious.

[Panscan]

I don't feel strongly about the overreading CBCT, like Jacoavlu said I doubt there is a significant difference but it's certainly up for debate and certainly the concept of " I don't know what I'm looking at in the orbit," is probably not a good mentality to have if you are routinely imaging the orbit. That's not really going to be a valid defense if you miss something.

I got more pissed about the claims regarding what you can and cannot do with imaging which it appears we fundamentally disagree on .

[Molar Mechanic]

I'll admit I just quickly read through the last two pages. Once or twice a year a patient will show me a medical radiologist report, and my general opinion is similar to that of jacoavlu. That is really not intended as a slight upon anyone. A lot of dental pathology reported may or may not be real, and I often wonder why they mentioned one abscess but not the other one. I always appreciate the effort, just like my ENT friend appreciates the sinus cases I send him, even if some of them I'm misguided.

Medical CT scans don't suffer from the scatter radiation and artifacting because the dose is significantly greater, and the machine (correct me if I'm wrong) only scans one axial plane at a time, whereas the cbct is attempting to scan the entire subject in one rotation. The teeth are actually easier to read on a medical scan. The resolution is radically less than what I need for my very detailed procedure.

My understanding is that we dentists do have some liability for all findings on our images. The panorex can capture the sinuses, floors of the orbit, and sometimes the pituitary. I always do an eye scan of these areas, but have no illusions of competence. That said, a panorex is questionably diagnostic of those areas... At least that is my story. 🤷♂️

The big disconnect here is in the differences between dental and medical billing. From my perspective, medical decisions seem to be made with little or no regard to cost. Once the deductible is met, the patient nor provider need to be cognizant of cost. Anything legitimately justifiable can be billed. In the dental model, the patient is writing a check that day, and benefits are capped. The cost : benefit is front and center on both the provider's and patient's thoughts. The increased cost of an over-read would dramatically reduce the number of images, and an overall decrease in quality of care given.