Are you reporting on your dental radiographs?

Article written by Dr Ann Monteith B.D.Sc(Melb) FICD Community Relations Officer/Professional Consultant ADAVB

Intra-Oral and Extra-Oral Radiographs

If we take the time to carefully read the definition of item numbers in the 13th Edition of ADA – The Australian Schedule of Services and Glossary, most of the radiographic item numbers we routinely use; 022,031,033 035,036,037 and 038, refer to the “taking and interpreting” of a particular radiograph.

Whilst findings from these radiographs are utilised in the treatment planning for a patient, we know from the clinical records we see, and anecdotally, that few practitioners write detailed reports on the images they take.

The ADA in their Guidelines for Content of Dental Records states that clear documentation is required of the “diagnostic information for each radiograph taken”. Ahpra, in its self-reflective tool on dental records, states the following:

After reviewing a random sample of your records are you reassured that you routinely record, identify and manage the following clinical information?

  • Radiographs, scans, images models, charts (including a record of your interpretation radiographic/scan/images/models/charts)

The failure to report appropriately on these images may lead to important pathological findings being overlooked, especially in the case of OPGs which also include an image of other parts of the head and neck anatomy.

Cone Beam Computed Tomography

When we consider the other radiographic item, 026, this refers to the acquisition of the CBCT ONLY and that interpretation of these radiographs are covered under the item numbers 087,088,089,090 and 091.  

The ADA has stated under Policy 6.22 – Dento-Maxillofacial Cone Beam Computed Tomography that:

“Dentists must be responsible for ensuring that the entire data in any CBCT that they prescribe is reviewed and interpreted by a practitioner with suitable training and experience with appropriate records maintained”.

From a Professional Indemnity point of view there are two main areas where this reporting may become an issue if it is not undertaken and recorded accordingly

  • Health Fund Audit – where the item numbers that include “taking and interpretation” are used and it is not evident that interpretation has been applied. This may result in Health funds declining to pay these benefits when this reporting has not been documented.
  • Misdiagnosis – the more serious event where a radiograph has been taken or requested and a life-threatening finding is not identified and acted upon, resulting in significant health concerns to the patient that could have been avoided by early diagnosis. Failing to diagnose pathological radiographic findings would be considered professional negligence and may be reported to Ahpra or if serious enough become a medical compensation claim.

It is important that every radiographic image we take is reviewed carefully and our findings are well documented.

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