An Illuminating Legal Perspective on Dental Radiology

This blog about dental radiology was written by Al Anthony Mercado, Esq., of Fager Amsler Keller & Schoppmann, LLP.

The use of radiology modalities in dentistry can be viewed from both a clinical and legal perspective. In this article, we will explore the use of radiology in dentistry from a legal perspective and discuss radiology modalities, guidelines, standard of care and malpractice.  

The two radiographic modalities we will focus on in this article are x-rays (full-mouth series, panoramic, bitewing, etc.) and cone-beam computed tomography (CBCT).  X-rays can take the form of conventional film or digital imaging. While either may be suitable, digital imaging may offer reduced radiation exposure and the advantage of image analysis that may enhance sensitivity and reduce error introduced by subjective analysis.

CBCT is a radiographic technique introduced to the United States dental market in 2001. CBCT technology uses a cone-shaped source of ionizing radiation and a two-dimensional detector and can provide multidimensional and dimensionally accurate images for diagnosis and treatment planning.  Although the radiation doses from dental CBCT exams are generally lower than other CT exams, dental CBCT exams typically deliver more radiation than conventional dental X-ray exams. 

The American Dental Association (ADA) has published a guideline concerning the use of x-rays. The ADA Council on Scientific Affairs has published a separate statement on the use of CBCT. In addition, there has been literature published on the appropriate use of x-rays and CBCT by various authors and specialty societies. While there may be differences in opinion on the use of each modality, all concur that the determination of the appropriate modality should be made on an individualized basis based upon a patient’s clinical examination and history. 

According to the ADA guidelines, x-rays are part of the diagnostic process in the treatment of patients.  The determination of whether to utilize x-rays in patient care depends on several factors that include, but are not limited to:

  • Patient age with dental developmental stage
  • Whether this is a new patient or recall patient
  • Positive clinical findings
  • Positive historical findings

Some of the clinical findings supporting the use of x-rays include clinical caries or increased risk for caries; no clinical caries or no increased risk for caries; periodontal disease or a history of periodontal treatment; and growth and development assessment. Some historical findings supporting the use of x-rays include existing implants, other dental and craniofacial pathology, previous endodontic/restorative work and history of dental caries.

The ADA guidelines with recommendations for dental radiographs can be found here.

The ADA guidelines conclude that dental radiographs should be taken only when there is an expectation that the diagnostic yield will help patient care.

The Standard of Care and Dental Malpractice: In order to sustain a viable claim for dental malpractice the plaintiff must prove the following through clear and convincing evidence:

  1. The existence of a dentist-patient relationship
  2. A departure from the standard of care, and
  3. The departure from the standard of care proximately caused an injury/damages.

For our purpose here, we will focus on the “standard of care.” As a preliminary matter the reader should understand that attorneys in dental malpractice cases use a device only available to them called the “retrospecto scope.” This allows them to review, assess and criticize dental treatment using the standard of care, retrospectively.

Sarcasm aside, the standard of care in dentistry represents how a similarly qualified dentist in a community would practice under the same or similar circumstances. It is established through federal and state standards, ADA guidelines, Academy/Society recommendations, policy and procedures, peer-reviewed literature, journals as well as advances in techniques and technology. It is incumbent upon each dentist to engage in continuing education and reassessment of competency.

In a dental malpractice case, a dentist may face questioning about the decision to use (or not use) dental radiographs. Similarly, even where dental radiographs are used, a dentist may be questioned about the type of x-ray done (full-mouth, panoramic or bitewing based upon patient complaints or other clinical findings), the interpretation of the x-rays, comparison of previous x-rays, follow-up with the patient, treatment based upon the x-rays and shielding of the patient.  

In cases involving CBCT, a dentist may be questioned about their competency in the use of CBCT (i.e., training and experience). Similarly, a dentist may be questioned about whether CBCT is the “better modality” or “standard” for use in a particular case (i.e., an orthodontic case).  

A dentist can minimize the risk of liability related to dental radiographs by:

  • Keeping current on federal and state standards, ADA guidelines, Academy/Society recommendations, policy and procedures, peer-reviewed literature and journals concerning the use of dental radiographs.
  • Documentation of the clinical and historical findings that serve as the rationale for dental radiographs as well as the type, area and number of radiographs.  
  • Communication with patients about the benefits and risks of dental radiographs as well as the risks of refusing them.  This would include providing educational information as necessary. More specifically:
    • Review the benefits and risks of the procedure before it is performed.
    • Discuss if the imaging exam is necessary and if there are equally useful alternative exams that use no or less ionizing radiation.
    • Ask if the facility uses radiation reduction techniques such as size-based protocols for children.
  • ALARA Principle (As Low as Reasonably Achievable) to minimize the patient’s exposure to radiation.
  • Developing, and adhering to, a practice for the interpretation of dental radiographs, documenting the results and follow-up.
  • Comparison of previous dental radiographs and documentation of the comparison.
  • In the absence of symptoms, developing a best practice for obtaining dental radiographs.
  • Documentation of communications with patients, consultants and physicians about the results of dental radiographs. This would also include phone, email and, if used, text communications. 
  • Document compliance with all patient shielding protocols as well as maintenance on equipment.

From a legal perspective, to minimize the risk of a departure from standard of care in the use of dental radiographs resulting in a dental malpractice claim, a dentist should keep current with use information and use dental radiographs as part of an individualized treatment plan based upon clinical and historical findings. 

If you would like to read other information for dentists, visit our resources page. Policyholders also have access to MLMIC’s toll free 24/7 Legal Hotline: (855) FAKS-LAW (1-855-325-7529). Our experts are available to help you address any challenges that may arise.