Every CBCT Scan Needs To Be Reviewed

The liability of CBCT Scans.

Year after year we are seeing the adoption of CBCT machines in dental offices continue to rise. It's clear that the incredibly detailed 3D images CBCT scans provide are game changers for the dental industry. Not only in fields such as endodontics, temporomandibular joint (TMJ) analysis, airway evaluation, and dental implant planning; but also for general practitioners as well. CBCT scans allow you to see a much clearer picture of any treatment or procedure you may be performing.

But what about the visible areas outside of the dentition? What about areas unrelated to your expertise or procedures? If a critical finding is missed because it was out of the scope of your expertise, not only could this have a life-altering effect on your patient, but you and your practice can also be held liable for missing the pathology.

Here is the simple truth regarding CBCT scans:

“All scans should be read by someone competent to interpret them” and “Whoever reads the scan is responsible for reading all of it, not only the anatomic region for which the scan was taken.6

Data from our first 1252 scans interpreted by our radiologists.

Taking your own CBCT scans.

The interpretation of CBCT images remains one of the most vexing problems for practitioners who take their own scans and is potentially among their greatest sources of liability.

Dentists who take their own scans are responsible for reading them. This does not mean that either ethically or legally the dentist has to personally read them, only that he or she bears responsibility for making sure that they are read by a competent individual. This is no different from a dentist who refers out any other procedure that he or she is not competent to perform.

Truth is, Dentists have two options: Interpret the images themselves or refer to a radiologist to read them.

Whoever reads the scan is responsible for reading all of it, not only the anatomic region for which the scan was taken.

This standard is no different from that for any other image taken. A dentist cannot read only part of a cephalogram or panoramic image. For example, in orthodontics, a dentist is responsible not only for that part of the image pertinent to an orthodontic analysis, but for anything that appears anywhere on the image. An editorial in the orthodontic literature bears testimony to the fact that this is the accepted standard within the profession.

Failure to diagnose.

The single largest source of medical malpractice lawsuits is failure to diagnose.3 It is better to avoid practicing defensive medicine. Moreover, it amounts to medical malpractice.1

Estimates suggest one-third of misdiagnosis errors involve cancer. Some common examples of medical negligence in cancer misdiagnosis cases include failure to identify tumors on radiology images and failure to order appropriate testing.4 Specifically with regards to cancer, a simple Google search will yield numerous lawyers who specialize in malpractice cases related to failures to diagnose cancer.

One element commonly cited in legal articles relating to medical malpractice claims is that you must show the practitioner failed in their duties, it is especially unhelpful to fail relative to other reasonable doctors. This article from the Mayo Clinic, however, notes that “Most dentists perform an examination of your mouth during a routine dental visit to screen for oral cancer. Some dentists may use additional tests to aid in identifying areas of abnormal cells in your mouth.

Dentists and dental hygienists have a duty to screen for oral cancers, and dentists have a duty to timely refer their patients to other medical professionals for diagnosis, follow-up and treatment of oral cancers, the lawsuit states.2

“Another obstacle the dentist must overcome is to educate themselves to look beyond the dental bases to anatomic regions with which they are less familiar. These include the cranial vault, the paranasal sinuses, the nasal cavity, the airway, and the cervical spine. And, those dentists thinking that a smaller field of view will relieve them of all of this responsibility are wrong.7

What if I use a smaller Field of View?

“In the American system of Jurisprudence, a practitioner is far more likely to be sued for not using technology as opposed to being sued for using it. Thus the inclination to use new technologies, including CBCT, is driven in part by the fear of malpractice.6

“Improper technical parameters also may lead to liability. These include… selecting an inappropriate field of view… A too small FOV may preclude the ability to interpret the image correctly.6

From an example shown in the published research paper “Liabilities and Risks of Using Cone Beam Computed Tomography”,6 regarding a scan taken for maxillary implant planning, Bernard Friedland and Dale Allan Miles say, “Too small a FOV carries its own risk. If a dentist takes a small FOV scan and sees pathology in the maxillary sinus, but is unable to visualize the superior border of the pathology, then the dentist is obligated to obtain a second scan that includes the entire sinus. This is necessary for two reasons. First, the clinician will not be able to ascertain from the small FOV scan whether the pathology is impinging on the ostium or may do so after surgery such as a sinus augmentation. Second, the clinician will not be able to identify the nature of the pathology.

What if I have my patients sign a waiver form?

Attempts to limit malpractice liability are not restricted to CBCT, nor are they new, but they have gained new traction since the introduction of CBCT, and especially as dentists purchased machines and started taking their own scans rather than referring patients to radiology facilities. Dentists untrained in the interpretation of CBCT scans became concerned about liability in the event they misinterpreted a scan. One course of action that has been suggested is to ask a patient to sign a waiver of liability; that is, in effect to require a patient to give up the right to sue for negligence. Waivers of liability have no legal effect and courts will ignore them. Most jurisdictions that have considered the matter have held that physicians and hospitals cannot require patients to waive their rights to recover damages for negligence.

Because requiring a patient to waive his or her right to sue will not pass muster, practitioners have considered another tack. This one involves letting the patient choose whether to have the scan read. The thinking here is that by leaving the decision up to the patient, there should be no liability on the part of the dentist for any misdiagnosis. This tactic also will not work.6

Not having medical images, specifically CBCT images, read by a competent radiologist is not compliant with basic standards of care. The choices offered to patients to allow them to make informed decisions are limited by the bounds of the accepted standard of care. For example, no dentist would permit a patient to agree to a restoration on a tooth that clearly requires endodontic therapy first, because such treatment would be below the standard of care. Similarly, not having a CT scan read is below the standard of care.

External case studies.

Conclusion

Heres the reality. If your practice owns and operates a CBCT machine, you’re scans need to be reviewed by a radiologist. Not only for the benefit of your patients, but for the benefit of your practice as well.

After all, a missed malignancy is much more likely to result in liability with a big payout than almost anything else a dentist does. Although malignancies are rare compared with typical dental pathology, so that the risk of encountering one and not diagnosing it is small, if the risk does materialize, the consequences are great, most especially for the patient. The damage to the dentist’s reputation and especially his or her conscience, and not the financial penalty, maybe the greatest casualty.6

DentalRay is the only place that connects Dentistry and Medical Radiologists to review the entire anatomy visible in a CBCT scan. Our radiologists are fully credentialed, and licensed in the state where the scan is taken. With our automation options, all you have to do is take the scan, and we’ll do the rest.

Sources:

1. Preventing medico-legal issues in clinical practice
2. Redmond, Bend dental offices sued for $27M in tongue cancer case
3. The top 5 reasons for malpractice lawsuits against doctors
4. Cancer Misdiagnosis Lawsuits and Settlements
5. Oral Cancer Screening
6. Liabilities and Risks of Using Cone beam Computed Tomography
7. Reporting Findings in the Cone Beam Computed Tomography Volume