medicolegal issues related to cone beam ct

8/10/2019 Medicolegal Issues Related to Cone Beam CT

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Medicolegal Issues Related to Cone Beam CTBernard Friedland

The introduction of cone beam computed tomography into dentistry, and

particularly into private offices, has raised a number of medicolegal issues.Among the issues raised are who may own and operate the machines, forwhat purposes should the machines be used, how broadly or narrowlyshould the field be collimated, does the full volume need to be interpreted

and, if so, by whom? For images interpreted over the Internet (teleradiol-ogy), where must the interpreting radiologist be licensed? For images inter-preted by a nonradiologist, may patients legally sign a waiver of liability fora dentists interpretation of the films? This article explores these and otherissues related to the use of cone beam computed tomography in dentistry.(Semin Orthod 2009;15:77-84.) 2009 Elsevier Inc. All rights reserved.

The world of oral and maxillofacial radiol-ogy is undergoing not only rapid, but also

remarkable change. After decades of being lim-ited largely to two-dimensional intraoral, pan-oramic, and cephalometric (skull) radiographs,the discipline took a giant leap forward with theintroduction of cone beam computed tomogra-phy (CBCT) with its three-dimensional (3D)capabilities. While traditional or medical com-puted tomography has been available since the1970s,1 with the exception of oral surgeons, it

has not been widely used by dentists. Initially thiswas probably due to lack of access to the ma-chines, as well as the dollar cost of an examina-tion. Even as more machines became availableand the problem of access was no longer anissue, and the cost of examinations droppeddramatically, concerns about the cost-benefit ra-tio when the x-ray dose was considered in rela-tion to the information to be gained still pre-

vented the routine use of CT scans for mostdental applications.

The advent of maxillofacial cone beam CT inthe early 2000s2 radically altered the oraland maxillofacial radiology landscape. Primaryamong the reasons for the change is the enor-mous decrease in dose compared with acompa-rable examination on a medical CT,3,4 and thelower capital cost of a CBCT machine, making itaffordable for the dental market. Additional ad-vantages of all of the CBCT machineswith one

exceptionwhen compared with traditional CTis the open format of the CBCT machines,making claustrophobia a virtual nonissue, andthe fact that the patient is seated rather thanlying down, the latter position probably beingundesirable for most orthodontic examinations.These attributes of CBCT machines can be seenat the Web sites of the various CBCT manufac-turers (or athttp://www.cone beam.com/?q cbct-clinician/manufacturers). A further advan-tage of CBCT is that manufacturers have devel-oped the scanners with a view primarily toward

the dental market. This in turn has led to thedevelopment of dental-specific software appli-cations by a variety of vendors, especially inthe areas of implantology (NobelGuide, NobelBiocare, Yorba Linda, CA; SimPlant, Materi-alise, Ann Arbor, MI; EasyGuide, KeystoneDental, Burliungton, MA) and orthodontics(Dolphin 3D, Dolphin Imaging, Chatsworth,CA) and Quick Ceph (Quick Ceph Systems,San Diego, CA).

From the Division of Oral and Maxillofacial Radiology, Depart-ment of Oral Medicine, Infection & Immunity, Harvard School ofDental Medicine, Harvard University, Boston, MA.

Address correspondence to Bernard Friedland, BChD, MSc, JD,Assistant Professor & Head, Division of Oral and MaxillofacialRadiology, Department of Oral Medicine, Infection & Immunity,Harvard School of Dental Medicine, 188 Longwood Avenue,Boston, MA 02115. Phone: 617-432-4295; Fax: 617-432-2463;E-mail:[email protected]

2009 Elsevier Inc. All rights reserved.1073-8746/09/1501-0$30.00/0doi:10.1053/j.sodo.2008.09.010

77Seminars in Orthodontics, Vol 15, No 1 (March), 2009: pp 77-84
http://www.conebeam.com/?q=cbct-clinician/manufacturershttp://www.conebeam.com/?q=cbct-clinician/manufacturershttp://www.conebeam.com/?q=cbct-clinician/manufacturersmailto:[email protected]:[email protected]://www.conebeam.com/?q=cbct-clinician/manufacturershttp://www.conebeam.com/?q=cbct-clinician/manufacturers


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The precise role that CBCT will play in allfields of dentistry is still in a state of flux. It isclear, however, that it will be used across alldisciplines, more for some than for others, andcertainly in orthodontics. In addition to the ap-

propriate use of CBCT in diagnosis and treat-ment, a purely medical issue, the advent ofCBCT has raised a number of medicolegal ques-tions, among them issues of ownership, the im-age volume to be covered, interpretation, andlicensure. Although this journal is directed pri-marily at orthodontists, as far as the medicolegalaspects of CBCT are concerned the same issuesapply to all dentists. Hence, I will use the worddentist instead of the more specific word, orth-odontist.

Purchasing and Ownership of a CBCTMachine

One of the legal issues concerns ownership of aCBCT machine, specifically who may own andoperate one. As far as the taking of images,especially extraoral films, is concerned, the prac-tice of oral and maxillofacial radiology variesacross the country. In general, it is fair to statethat in most of the country exposures are donein individual dental offices. On the West Coast,however, so-called dental x-ray laboratories take

a significant number of films. It is quite commonpractice for orthodontists in states such as Cali-fornia, Washington, and Nevada, for example, torefer patients to such facilities. In states wherex-ray laboratories exist, they do not have to beowned or run by a dentist. California, for in-stance, issues limited x-ray permits, one of whichpertains to dentistry and which allows an indi-vidual who has taken an approved course andpassed an examination to hold a limited dentalx-ray permit.5 It follows that under Californialaw an individual who is not a dentist or physi-

cian or a full-fledged medical x-ray technicianmay own and operate certain x-ray equipment,including CBCT machines. This permit holdermay expose patients only on a prescription froma licensed dentist. The x-ray laboratories provideonly a technical service and images made in suchfacilities images are not reported on by the fa-cility, although some of them may make arrange-ments with radiologists to read and report thecases.

Other states consider CBCT machines to bemedical devices, which means that all state lawspertaining to medical radiologic devices apply toCBCT systems. Some states limit the acquisitionof medical x-ray equipment, primarily CT, mag-

netic resonance imaging (MRI), and positronemission tomography (PET) scanners, basedon the perceived need for the machines. Topurchase a CT scanner, including a CBCT ma-chine, in these states one must show that thereis a need for such a machine. Among the statesthat have the so-called certificates of need(CON), the specifics of the laws vary, but therequirements may be quite onerous. Michiganis one state that has a CON requirement thatwas established in Public Act 256 of 1972.6 Instates that classify CBCT machines as a medical

device, the law may also require that suchmachines be operated only by a registeredmedical radiology technician, radiologist, orother health care professional with specifiedtraining.

In summary, therefore, some states allow evennondentists to own and operate CBCT ma-chines, while in others the laws make it difficultand sometimes practically impossible, due to theCON, for many fully licensed dentists or even ra-diologists to acquire a CBCT machine. Whetheronly radiologists, medical or oral and maxillofa-

cial, should be allowed to own and operateCBCT machines is an issue that has been raised.In Ontario, Canada, precisely this matter is un-der discussion. The Ontario Ministry of Healthset up an advisory committee (Diagnostic Imag-ing Safety Committee) to give advice on CTissues, including CBCT. The committees recom-mendation to the Ministry of Health is that TheHealing Arts Radiation Protection Act (HARPAct)7 be amended to restrict the purchase ofCBCT machines to oral and maxillofacial radi-ologists only. The ministry has yet to make anydecision, but currently there is an effective mor-atorium on the approval of dental CBCT scan-ners by anyone (Dr. Michael Pharoah, Head,Oral Radiology Department, Faculty of DentistryUniversity of Toronto, personal communication,January 2008). At the present time it seems un-likely that any American state will explicitly limitthe ownership of CBCT machines to radiolo-gists, although other requirements, such as a

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CON or a minimum number of annual exami-nations that must be done, may exclude manydentists. The purpose of requiring a minimumnumber of annual examinations is to assure thatoperators maintain a certain level of compe-

tency.While in-office ownership of a CBCT machine

by a dentist or group of dentists in a grouppractice may be subject to some of the restric-tions above, the legal requirements for owner-ship and use are probably generally not tooproblematic. The situation is far more complex,however, if a dentist enters into a joint purchaseof a machine with a physician. Due to the cost ofa CBCT machine some dentists have consideredthis option. If a dentist is considering the latteroption, he should be aware that he might run

afoul of the Stark law.8

The Stark law prohibitsphysicians from making referrals for a desig-nated health service, payable by Medicare orMedicaid, to any entity with which the physicianshave a financial relationship. Designated healthservices include the taking and interpretation ofa CT scan in a physicians office or freestandingfacility. If a dentist were to enter into a businessrelationship with a physician, almost all of whomaccept Medicare and/or Medicaid payments,the dentist, even though he does not himselfaccept such payments, might find himself under

investigation together with the physician(s) forpotential violations of the law. Even in the un-likely event that a physician is not subject to theprovisions of the Stark law, he is still subject tothe federal antikickback statute.9 The antikick-back statute provides for criminal penalties forcertain acts impacting Medicare and Medicaidreimbursable services. The Stark and antikick-back laws are extremely complicated and arewell beyond both the scope of this article andthe expertise of the author. The best advice thatcan be given to a dentist is to consult an attorney

who specializes in the Stark and antikickbacklaws before embarking on any joint purchasewith a physician or a dental care provider whoaccepts Medicare or Medicaid. Even in the caseof physicians who are not subject to the Starklaw, state medical boards may have regulationsthat have similar effects and prohibit self-referralby physicians to facilities in which they own aninterest, in keeping with the Code of Ethics ofthe American Medical Association.10

The Field of View

One of the issues raised by CBCT is just whichanatomical area of the jaws and head or neckshould be included in a study. For example,assume one takes a CBCT scan of the fully eden-tulous maxilla for purposes of evaluating thefeasibility of placing implants. Does the imageprovide sufficient coverage if the beam is colli-mated (in the vertical) to include just the alve-olar bone and only 2 to 3 mm superior to thesinus floor? Or is it necessary to include more ofor perhaps even the entire sinus? The generalprinciples of radiology dictate that the taking offilms be based on clinical indications and thatexaminations not be done as part of a fishingexpedition.11,12 The rationale for this is to pro-tect both the individual patients and the public

health from unnecessary radiation. Thus, in theexample above, if the patient has no sinus symp-toms and no sinus pathology is suspected onclinical examination, there is not a strong argu-ment for including the whole sinus. The answerto how large an area to cover also includes,however, the desires of the treating clinician,although this should not generally override well-accepted principles of radiation hygiene. In theabove example, some clinicians may insist onseeing all the way to the orbital floor. Further,some software programs require that certain an-

atomic landmarks be included since the pro-gram uses them as (anatomical) fiduciary mark-ers.

It is also possible to collimate too narrowly,either accidentally or by design, and thus toexclude structures that reasonably ought to beincluded. The issue of purposely collimating toonarrowly is closely related to the reading or in-terpretation of the films, an issue discussed indepth below. CBCT machines are increasinglybeing marketed to private practitioners who arenot oral and maxillofacial radiologists. Compa-

nies target market is especially orthodontistsand practitioners who place dental implants.These practitioners typically do not have suffi-cient training to interpret the films beyond theconfines of their specialty or daily area of prac-tice. Some practitioners believe that one way toovercome the issue of interpretation is to colli-mate down to the smallest area possible. Forexample, if an orthodontist does a CT to evalu-ate an impacted maxillary canine, the idea

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would be to collimate the beam to include justthe tooth and nothing superior or inferior to it.The danger with this approach, however, is thatone may miss pathology that is contributing tothe noneruption or impaction of the tooth. Sim-

ilarly, when radiographing the temporomandib-ular joint (TMJ), if one were to collimate toonarrowly, one could potentially miss pathologythat is not located directly on or in the condyleor glenoid fossa, but that is contributing to theTMJ problem. In principle, the anatomical areacovered by a CT scan should be no differentthan would have been covered by a plain-filmexamination. The extent of the examinationshould be based on the patients symptoms andthe findings on clinical examination.

Responsibility for Interpreting CTImages

While there are many reasons that a dentist orpractice may not acquire a CBCT machineincluding issues of space, recovering the cost ofthe machine, having to learn and maintain ad-ditional software and hardwareprobably themajor reason that is emerging as a barrier toacquiring a machine relates to the interpreta-tion of the images. This is a quite commonconcern expressed by dentists. Indeed, I amaware of practitioners who have actually ordered

CBCT machines, only to put the order on holdbased solely on their concerns about liabilityrelated to interpreting the images.

Facilities such as dental x-ray laboratories andmedical radiology facilities, including hospitalsthat do so-called dental CT scans (eg, for im-plant planning, to locate an impacted tooth orfor orthodontic purposes), do not read andwrite a report of the case. In fact, medical facil-ities typically include a specific disclaimer suchas the one from the Massachusetts General Hos-pital, which states: These images were NOT

reviewed by a Mass General radiologist for diag-nostic purposes, and NO radiological review, re-port, or professional bill was generated. Theseimages are intended for review by dental careprofessionals to aid in dental implant or extrac-tion surgical planning. Mass General Imagingmakes no diagnostic claims regarding these im-ages. If there are concerns regarding pathologyand a radiological consult is desired, please con-tact . . .. Whether dentists have the CT scans

performed by such facilities or whether they takethem in their own offices, they are concernedthat they will assume liability for reading thescan. This concern is well placed. Not only willthey be responsible for reading the scan as it

pertains to their area of practice or the particu-lar reason for which the image was taken, butthey will also be responsible for reading theentire image volume.

While there are no legal cases specifically con-cerning the matter of the scope of interpreting aCBCT scan, the issue can fairly be regarded assettled. A CT is no different than any otherimagea dentist cannot read only part of apanoramic film, or only part of a lateral cepha-logram. For example, should an orthodontistmiss an enlarged sella turcica resulting from atumor on a lateral cephalogram,13 the dentistreading the cephalogram cannot offer as an ex-cuse in any legal proceeding that I read onlypart of the film or I read the film only as itrelates to the orthodontic diagnosis and treat-ment. The dentist is obligated to read all of thefilm. That this is accepted to be the standardwithin the profession is borne out by a recenteditorial in the orthodontic literature.14 More-over, in determining the standard of care, courtslook to what the practice in the profession is,15,16

and as is evident from the editorial referencedabove, the practice is to read all of the film.

Courts are not likely to allow a lower standard ofcare than the profession demands of itself. Mal-practice carriers have expressed similar senti-ments.17

Dentists have given consideration to limitingtheir liability for reading CT scans by havingpatients sign a waiver of liability for their inter-pretation of the films. Such a waiver of liabilitycarries no legal weight and will be null and voidin any legal proceeding.18-20 This is simply anaffirmation of the fact that the profession as awhole, and not an individual practitioner, sets

the standard of care. Further, malpractice carri-ers will not permit a dentist to write such adisclaimer nor will they honor it.17 Another vari-ation of the theme that dentists have consideredis to give patients the choice of whether to havethe films read by a radiologist. According to thisline of reasoning, since the decision is entirelyup to the patient there should be no liability onthe part of the practitioner for any non- or mis-diagnosis. This approach too will not work.

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While patients may make treatment decisions,their choices are limited by the bounds of ac-cepted standards of care. No dentist would per-mit a patient to agree to fill only two canals on amolar tooth undergoing endodontic treatment

and then to place a crown because the dentist isunable to navigate the third canal or because thepatient can only afford to have two canals filled.Such a scenario would call for a referral to anendodontist or foregoing the crown. The sameprinciples apply to the interpretation of films.

Issues Related to Referring Out theInterpretation of CT Scans

It is not uncommon nowadays to hear practitio-ners who are considering getting a CBCT ma-chine complain that it is not fair that they shouldbe required to read all of a CT scan. The shortanswer is that they are not required to read itthemselves, just as they are not required to per-form any other procedure that they are not com-petent to perform. Neither the law nor ethicsrequires that a dentist be able to do everythingonly that if he is unable to undertake the workthat he should refer the patient to an appropri-ately qualified individual. It is probably fair tostate that, with the exception of individuals whohave completed a formal program in oral andmaxillofacial radiology, most orthodontists, and

dentists in general, do not have the expertise tointerpret CT scans, nor do they feel comfortabledoing so. Thus, they are obligated to refer thereading of the images.

While modern technology has made the re-ferral of the reading of images a simple matter,the law has not caught up with these changes.On the technical side, it is a simple matter for adentist to have the images, which are all digital,read remotely by a radiologist. Cases can beburned to a CD that is mailed to the radiologist,who interprets the case and sends back a written

report, whether by fax, e-mail, or traditionalmail. Faster, more efficient, and more likely tobe done nowadays is for dentists to upload casesfrom their computer to a file transfer protocol(FTP) server. FTP is a method of transferringdata over a network or the Internet. An FTPserver is a Web server to whichone can log ontoand upload or download files.21 Typically, theradiologist will have set up an FTP site to whichthe dentist simply connects over the Internet

using his browser. From the referring dentists per-spective, no special software is required. If thedentist uploads the raw data in Digital Imagingand Communications in Medicine (DICOM) for-mat, the radiologist can view the case using any

number of commercially available software pack-ages. DICOM is a standard developed by AmericanCollege of RadiologyNational Electrical Manufac-turers Association (ACR-NEMA) for communica-tions between medical imaging devices.22 Once hehas read the case, the radiologist writes a reportand sends it in one of the aforementioned ways oruploads it to the FTP server from which the dentistdownloads it.

Unfortunately, while technology has devel-oped apace, dental licensing laws remain firmlyentrenched in centuries past andplace barriersto the use of this technology.23 Little or noprogress has ensued at the federal level on thetelemedicine front and legislation introduced24

to address has not passed. There is no nationaldental (or medical) license, nor does one stateautomatically recognize a license granted by an-other state. This means that to practice in a state,a dentist must have a valid license in that state.New York law exemplifies the general rule inthat: It is the location of the patient that defineswhere the care has been deliveredand the juris-diction of applicable regulations.25 It furtherstates: Whether the out-of-state practitioner is

reimbursed is irrelevant.25The licensing laws present a problem for a

dentist in, for example, North Dakota, whowishes to have his radiographs read by an oraland maxillofacial radiologist in Iowa. Under cur-rent law, a dentist needs to be licensed in thestate in which he is practicing. Traditionally, adentist sees patients in the state in which hispractice is located. This means that a dentist whois seeing patients in North Dakota must be li-censed in that state. The purpose of licensinglaws is to protect the health and welfare of the

citizens of a state.26

With teleradiology the radi-ologist can be located anywhere where he canobtain access to the images, usually over theWeb. Based on the underlying reason for licen-sure, and assuming it to be the true purpose oflicensingas opposed to using licensure for eco-nomic protectionist purposes,27,28it is reason-able for a state to require that radiologists read-ing the images of its citizens be licensed in thatstate, even though the radiologists may be living



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and practicing out of state. The counter-argu-ment is that if the radiologist residing in Iowa islicensed there, then North Dakota should notrequire him to be licensed in North Dakota.Sending the images to Iowa, the argument goes,

is akin to the patient traveling to Iowa to see adentist. If a North Dakotan traveled to Iowa tosee a dentist, North Dakota does not require thatthe Iowa dentist be licensed in North Dakota,and would lack any constitutional basis for re-quiring it. The problem with comparing thereading of images over the Internet with thepatient traveling to an out-of-state dentist is thatwhen the patient travels out of state, he is doingso knowingly and of his own free will, whereaswhen the images are sent out of state, the dentistand not the patient makes that choice. Onemight argue that by informing the patient thatthe images will be read by a nonlicensed andout-of-state radiologist and getting the patientsconsent, the patient is agreeing to go out ofstate, much as the patient above who travelsfrom North Dakota to Iowa. While argumentscan be made pro and con in support of this lineof reasoning, the simple fact of the matter isthat, to date, no state has explicitly adopted a lawor policy that would permit the out-of-state andnonlicensed dentist to read films of its citizens.There is no reliable study, and certainly nonepublished, that has surveyed state dental boards

as to their licensing requirements for out-of-statedentists who read films of the citizens of theirstate. The issue is obviously one that concernsnot only the referring dentist, but the radiologistas well. That the matter is one that should betaken seriously by the radiologist is borne out by acase where California is pursuing a criminal caseagainst a physician who prescribed medication fora California resident over the Internet wherethephysician did not have a California license.29

A further wrinkle in the licensing scenarioused above is that the radiologist may be re-

quired to be licensed in both North Dakota andIowa, even if the radiologist is reporting only onNorth Dakota cases. This is because the consti-tutional standard that a state has to meet tojustify requiring licensure is extremely low30 andboth states could credibly argue that the radiol-ogist is practicing in its state. To further compli-cate matters, assume that the Iowa radiologistrents server space in Arizona, it may even bepossible for Arizona to require him to be li-

censed there on the basis that the virtual patientis located in that state, although this would likelybe a close constitutional call. There are, as yet,no decided cases on this issue. Even if it were tobe held by a court that a state where the server is

located may constitutionally require licensure,one would hope that no state would exercisesuch authority.

Some medical boards have considered theissue of telemedicine. However, even among theboards that have fully considered the matter,lack of uniformity of the laws across states is stilla marked feature. Some medical boards requirea full license in that state for an out-of-stateradiologist to read images taken of its citizensin-state, but some have enacted forms of limitedlicenses that apply in cases of telemedicine. TheFederation of State Medical Boards maintains anupdated list of state telemedicine licensing laws.31

Another idea that dentists have floated in anattempt to overcome the licensing dilemma is tocouch the radiologists interpretation as merelybeing a second opinion and that, therefore,even an out-of-state radiologist does not need alicense to read the films. A true second opinionis the process of seeking an evaluation by an-other doctor or surgeon to confirm the diagno-sis and treatment plan of a primary physician, orto offer an alternative diagnosis and/or treat-ment approach.32A second opinion only applies

when the primary dentist has in fact made adiagnosis and then seeks another dentists opin-ion. Massachusetts has a licensing exception foran out-of-state physician who is providing a sec-ond opinion. The exception applies to a physi-cian or surgeon resident in another state who isa legal practitioner therein, when in actual con-sultation with a legal practitioner of the com-monwealth (emphasis added).33 Even then, asinterpreted by the Massachusetts Board of Reg-istration in Medicine, the licensing exceptionapplies only when such consultation is made on

a one-time or occasional basis. If a physicianregularly consults a non-Massachusetts licensedphysician, the licensing exception does not ap-ply (Debra Stoller, Senior Board Counsel, Mas-sachusetts Board of Registration in Medicine,personal communication, January, 2008). Instates that do not explicitly allow for secondopinions by unlicensed physicians, it is likely thatin practice they probably follow very much thesame principles. Given the definition and pur-

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pose of a second opinion, a dentist who is seek-ing the services of a radiologist to read CT scansthat he is unable to read himself cannot crediblyclaim that he is seeking a second opinion, themore so when such consultation is sought on an

ongoing or routine basis.

Insurance Considerations

If a dentist refers the reading of a CT scan to anout-of-state radiologist and the patient sues theradiologist for negligence, it is possible that thedentist may find himself on the financial hook. Ifthe radiologists malpractice carrier covers theradiologist only for the state in which he tookout the malpractice coverage, the carrier mayrefuse to provide coverage for what it considersout-of-state practice, leading the patient to suethe dentist instead. This is even more likely if thestate in which the patient resides requires theradiologist to be licensed there and he is not.While it is possible for the radiologist or thereferring dentist to, in turn, sue the radiologistsmalpractice carrier to provide coverage, it soonbecomes evident just how complicated the legalprocess can become. As the expression goes,one does not want to buy a lawsuit, even if theodds of winning are great. It is preferable by farto avoid any kind of suit. Referral to an unli-censed radiologist probably may also put the

referring dentist at a slightly higher risk of a suitfor negligent referral, although such suits arerare to begin with.34

Conclusion

What advice then can currently be given to adentist or orthodontist who is considering ac-quiring a CBCT machine? He should be certainthat state law imposes no impediments to theacquisition and operation of a CTCT unit byhim. It is incumbent on him to read the entire

image volume or to have it read by someone whois competent to do so. To do this, he may have tobecome competent to read the images or, as ismore likely, he may refer the reading of theimages to a radiologist. If he chooses the latterpath, at a minimum he should be sure that theradiologist is licensed in the state in which thereferring dentist practices. Referral to a radiolo-gist who is not licensed in the state might makethe dentist vulnerable to disciplinary action by

the dental board and may also make him guiltyof the crime of aiding and abetting the unli-censed practice of dentistry (California Businessand Professions Code 2264). Some states wherethe radiologist is physically located may require

that he also be licensed there as well and if theradiologist is not licensed there the dentistshould ascertain if a license is needed. This canbe done by directing an inquiry to the dentalboard. The dentist should ensure that the radi-ologist carries malpractice coverage and that hiscarrier will cover him for out-of-state practice.

Cone beam CT holds great promise for bothpatients and dentists, but it comes with potentialpitfalls. With careful planning and the use ofappropriately qualified individuals to aid in in-terpretation, dentists can enhance their practiceand best serve the interests of their patients.

References

1. White S, Pharoah M: Oral Radiology Principles andInterpretation. 5th ed. St Louis, Mosby-Year Book Med-ical Publishers, 2004

2. Sukovic P: Cone beam computed tomography in craniofa-cial imaging. Orthod Craniofac Res 6(Suppl 1):31-36, 2003

3. Clark DE, Danforth RA, Barnes RW, Burtch ML: Radia-tion absorbed from dental implant radiography: a com-parison of linear tomography, CT scan, and panoramicand intra-oral techniques. J Oral Implantol 16:156-164,1990

4. Tsiklakis K: Dose reduction in maxillofacial imaging us-ing low dose cone beam CT. Eur J Radiol 56:413-417,2005

5. California Health and Safety Code 106955-107111.The appropriate sections are available athttp://law.justia.com/california/codes/hsc/106955-107111.html

6. http://audgen.michigan.gov/digests/01_02/3964401L.htm

7. R.,S.O. 1990, Ch. H. 2 23. The HARP Act is available athttp://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90h02_e.htm#BK23

8. 42 C.F.R. 411.350 through 411.3899. 42 U.S.C. 1320a-7b

10. Code of Ethics of the American Medical Association,2006: 8.032, pp 188-189

11. U.S. Department of Healthand Human Services, Food andDrug Administration: The selection of patients for x-rayexaminations. 1987: HHS publication FDA 88-8273. Theguidelines are available at http://www.ada.org/prof/resources/topics/topics_radiography_examinations.pdf

12. Council on Dental Materials, Instruments and Equip-ment: Recommendations in radiographic practices: anupdate, 1988. J Am Dent Assoc 118:115-117, 1989

13. Friedland B, Meazzini MC: Incidental finding of an en-larged sella turcica on a lateral cephalogram. Am JOrthod Dentofacial Orthop 110:508-512, 1996

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14. Turpin DL: Befriend your oral and maxillofacial radiol-ogist. Am J Orthod Dentofacial Orthop 131:697, 2007

15. Brune v. Belinkoff, 354 Mass. 102, 235 N.E. 2d 793(1968)

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