A Question From a Concerned Citizen.
Diagnosis April 3rd, 2007
I’m posting an email conversation I had recently. If any of you have other opinions (doesn’t matter if you agree or disagree with mine) please comment. It’ll benefit us all, especially since general dentistry hasn’t been my field for a few years:
Paraphrased question:
I mainly just had a question about appropriate screening at dental check-ups. What is the standard of care? Is a panorex a legitimate screening modality?Also, my wife just visited a new dentist who found an area that needed repair. Without asking he snapped some digital pics to show her. He could see the area clearly without the need for the pictures, and she surely would not have asked for them, especially if he had told her that they would cost almost a hundred dollars and not be covered by insurance. Do you think this warrants any action on our part other than refusing to pay. Any thoughts in general?
My response:
Did the new dentist take the Pan on your wife? Were the digital pictures xrays or intraoral photographs?
Their response:
The Panorex was done by a tech before my wife saw the dentist. He told her it was just routine screening. The digital pics were intraoral photographs. She had a cracked tooth in the back.
My answer:
Pans are an appropriate film for new patients and patients who haven’t had a comprehensive radiographic survey for a number of years. You get less radiated from a Pan than from a full mouth series (16-18 films) and you get more peripheral information from a Pan than the FMX (TMJ, sinuses, jaw anatomy). Unfortunately, the resolution of a pan is generally not good enough to definitively diagnose some types of caries and some other tooth-related issues so we’ll target individual areas with more specific films if we see something suspicious on the Pan. In their defense, Pans, especially the newer digital ones are becoming sharp enough to see incipient caries as precisely as we are able to on bitewing films.Intraoral cameras are a great tool in helping patients trust that what their dentist is saying is wrong with their teeth actually is. Many times teeth that need work are asymptomatic and patients don’t actually know if the recommended work is really needed. I take pictures of some of my cases so that when I send the note back to the referring dentist they don’t think I’m bullshitting them. Same idea.
Intraoral shots are sometimes a good idea for records, but are generally more important for patient education and information. As with anything in medicine and dentistry, the equipment is expensive though and some dentists feel the need to recoup their costs. IO cameras help to recoup their own costs, because by being able to show pt’s problems in their mouth more directly, pt’s are usually more interested in getting something done rather than waiting for pain to develop (at which point you might not be able to do anything). I haven’t heard of any offices that charge for IO pictures for this reason. But that obviously doesn’t mean it doesn’t happen.
Your financial responsibility with an office is part of any informed consent. Prior to a procedure being performed, if you were not aware that you would have to pay for the procedure, I can’t see how the office can make you pay. Along this same vein, and just as unethical, is when a therapeutic procedure is started and proceeds to the point of being irreversible (eg. a root canal procedure is started) and the office then tells you how much you’re going to have to pay.
Unfortunately, most patients don’t want to rock the boat and don’t complain and pay they bill. They become wiser for next time.
In your wife’s case, I can’t see how you’d take the case any further than refusing to pay for the pics because the only neligence was not informing your wife of costs. No damage or physical error was done by the dentist. If reported to a state dental board, they might warn the dentist about the way he practices, but that would probably be the end. And I don’t know if he’d change…
April 4th, 2007 at 5:23 am
When we were students (back me up on this Kissaki) standard baseline radiographic examination was described as at least an OPG AND bitewings (assuming the patient had posteriors which weren’t lone standing or which had interproximal areas that couldn’t be directly visually inspected). Further radiographic examination was dependent on clinical decisions.
These days I order a new OPG and bitewings if a patient hasn’t had them for more than 12 months – many dentists would find this to be wildly extravangant however I think it is justified since a) I work exclusively in public health so the patient isn’t footing the bill and b) our ability to recall patients in the public system is functionally nonexistent so I think every chance should be taken to screen for new pathology. Note these are economic reasons – I believe there is adequate justification for taking radiographs this often for clinical and diagnostic reasons, too.
The question about being charged for unrequested photos I’d leave for wiser minds than mine (minds belonging to people with more private experience as well). BUT, I will say that if they were unrequested and the fact that they would cost had not been discussed before hand, I personally wouldn’t feel under obligation to pay for them. Alot of digital systems these days can be displayed to the patient on in-house computer or tv screens and are excellent patient education tools – excellent and free. If a patient asks for a hardcopy or CD, however, I think attaching a cost-price is absolutely acceptable.
April 4th, 2007 at 7:45 am
Thanks for the info.
The conversation brings up one more point of interest (which I’m guilty of doing). And that is ordering xrays without first doing an IO exam (or even seeing the patient)…
April 4th, 2007 at 9:35 am
just a quick note – i never allow anyone, be it an assistant, tech, or hygienist, to take readiographs without being seen by me first. at the new patient exam i will introduce myself, go over health history, and quicky peek in the mouth to see how many crowns, bridges, missing teeth, etc there are and then make my assesment from there. if a person has a seemingly virgin dentition, i ususally prescribe 4 bitewings, two anterior periapicals, and sometimes a panoramic if third molar exo or TMJ problems warrant it. i explain all this to the patient, then i let the assistant or hygienist do her thing. if any resto or caries looks particularly deep or if there’s a ton of crown and bridge, i get a periapical of that tooth.
radiographs shold be prescribed by a physician or dentist and like any drug or agent that is dispensed, should be tailored to the individual patient. the likelihood of “missing something” like a tumor or problem by NOT routinely radiographing the entire mouth is very slim and failure to take a “screening” FMS or a PAN on a completely virgin dentition that develops, say, a traumatic bone cyst would not hold up in court because routine “screening” panoramics are NOT the standard of care. neither is an FMS. a panoramic for pain in the jaw or clicking and popping of the TMJ, or evaluating eruption patterns on a mixed dentition is. i save the full mouth series for extreme perio and implant cases or if there’s multiple extractions or extensive pathology. unfortunately, when we were in dental school every patient got an FMS, mostly because us low-lifes needed to learn how to take rads, but as you all know dental schools are pretty much exempt from these things.
i think what was missing in this case was a lack of communication between this dentist and the patient. he or she should have told this woman what he was going to do and explained its purpose before executing it. and no patient should receive radiographs without first being examined by the treating dentist.
and btw, i would never charge for intraoral camera films. it’s like me charging extra for using rotary endo.
April 4th, 2007 at 11:35 am
Dr. Mommy D.D.S, you are…absolutely correct. A OPG is NOT the standard of care prescribed by most dental guidelines. A quick search of journal articles will show that the majority of papers consider regular OPG examinations to be unnecessary and expensive in a cost-benefit analysis sense.
So basically I can provide no concrete evidence to back up my statement. Now that is bad evidence based dentistry.
So how can I justify my support for regular “screening” OPG’s? The answer is, from a frank cost-benefit analysis, I can’t. Actually, even from a clinical usefulness perspective the evience supporting OPG’s is not particularly strong.
This however reminds me alot of an argument I’ve had with a pathology Professor in the local faculty. This professor has the firm belief that the soft tissue of ALL periapical radiolucencies should be submitted for histopathological examination if an extraction is carried out. Read that carefully. All. Periapical. Radiolucencies. Even the ones we are convinced are just periapical granulomas. I’ve always argued with him that this is an absolutely unworkable idea. The cost in terms of funding and manpower is just prohibitive. However his argument is to dispense with a cost-benefit analysis. In the span of a single year when he *was* able to institute this rule, histopath screening revealed four malignant neoplasms that had been mistaken for periapical infections. Now, the expense of all those screening to the institution? Probably huge. But the benefit to those four single patients of catching pathology earlier? Priceless.
But hey, even I can see that that is weak, anecdotal evidence and let’s face it, practices have to be run economically and efficiently.
So I’ll just say that currently, I am in a position to provide regular screening for patients at very little cost to them, so I see no reason why it shouldn’t be done. I would not necessarily expect the procedures to be adopted in all cases.
Actually, I will just say one last thing which I probably should have said earlier. Dentists have a tendency to concentrate too much on the teeth. The days where that was our sole responsibility are numbered. It is our responsibility to provide care, or at least screening, for the enitre oral milieu, and this includes the mandibular and maxillary bones as well as the sinuses and the orophayrnx. As an adjunct to clinical exam, I can’t think of a faster, easier way to image these areas than an OPG.
April 4th, 2007 at 11:38 am
Uhhh…just before anyone points out the glaring holes in my logic, let me say that I’m highly stressed out at the moment and I wrote this reply at 3 am. So i fully reserve the right to claim incompetence due to insanity…
April 4th, 2007 at 11:45 am
If a patient arrives for consultation with a poor quality or outdated xray, or one of the wrong area, I’ll ask for a new one without actually seeing the patient. I’ll also request different views if necessary.
If there’s some question about which tooth is bothering them, etc, I’ll see them prior to ordering films.
Scenario 1 above takes into account the fact that I can’t do my job without a film of the tooth in question and that I already know that I’ll need another film after seeing the one that was sent from the other office.
That’s my rationale anyway.
Charging for IO pics is like charging for local anesthetic for a filling.