Should you use a Medical Radiologist to overread your CBCTs?
Most dentists I know take pride in the fact that we are separate from our colleagues in medicine – while our medical colleagues receive at best one full day of oral health training during their extensive education, dental schools around the country have set standards of education that incorporates medicine and the whole body. The mouth is often described as the gateway for several disease processes, from diabetes to hypertension. Early signs of critical medical conditions can be recognized within the oral cavity. It has been a long-standing standard of the Commision on Dental Accreditation (CODA) to include a “[…] biomedical knowledge base [that] must emphasize the oro-facial complex as an important anatomical area existing in a complex biological interrelationship with the entire body.” 1
Our profession has expanded its areas of specialty to further bridge the gap between dentistry and medicine – from orofacial pain and oral medicine to oral and maxillofacial radiology (OMFR). But is the reverse true – are our medical colleagues making efforts to better understand the dental profession and how it relates to medicine? Should you have a Medical Radiologist review your dental CBCT? Let’s explore this together as well as the training an OMFR receives, the real and unintended costs associated with choosing a medical radiologist report versus an OMFR report including liability coverage provided by an overread, and most importantly if we are failing our patients with subpar standards of care by choosing an OMFR instead of a Medical Radiologist as some in the medical radiology space might have you believe.
Medical Education and Oral Health
While dental schools have endeavored to incorporate medicine into its training, a quick search of the internet would suggest that our medical colleagues still have a long way to go. Harvard Medical School Primary Care Review published an article in January of 2022 regarding the school’s efforts to expand oral health education given to medical students. Regarding the current depth of clinical dental education in medical schools, the author states, “As it stands today, physical exam education focused on oral health for the current first-year medical students at HMS is almost exclusively limited to a total of 2 hours on a single Wednesday.” 2 In 2016, the AMA Journal of Ethics published an article citing findings that “69.3 percent of surveyed medical schools provide fewer than five hours of oral health curricula to their graduates.” 3
Knowing the limited understanding of our medical colleagues regarding oral health, let’s now specifically look at a concerning trend in recent years of medical radiologists advertising radiology overreads of dental CBCTs. For those who aren’t familiar, a radiology overread is simply a review of an image to rule out any incidental findings outside the initial reason for acquiring the image. This is typically done to provide legal coverage and quite simply to make sure nothing is missed. On the surface this appears to be a good thing as dental CBCTs often capture more than the dentition such as the cervical vertebrae, base of the skull, and other soft tissue areas that could have calcifications such as within the carotid artery. To make it even more enticing, as one dentist states, the service provided by one company “is less expensive than every dental radiologist [he] has previously worked with.” 4 This particular company goes one step further to preemptively answer the question of using an OMR (Oral & Maxillofacial Radiologist) over a [medical] Radiologist, stating, “Today’s CBCT imaging provides a view beyond the dentition, and it’s possible to discover issues within the head and neck area. Our medical radiologists properly identify incidental findings to ultimately help improve patient care.” 5 Their Chief Technology Officer would have you believe that dentistry is failing its patients: “Millions of medical images go unreviewed by radiologists every year in the dental space alone. These images have incidences of cancer, blocked arteries, and other pathologies that when identified can lead to life-saving early treatment. […] our goal is to bridge that gap and save lives through early detection.” 6 this begs the question – is an OMFR qualified to do an overread of a dental CBCT? Let’s explore what education they receive.
Oral and Maxillofacial Radiology Education
After four years of dental school, opportunities exist for the dentist to specialize in more specific areas of dentistry, such as Oral and Maxillofacial Radiology. While the specialty itself is not new, its venture into the private practice space was advanced with the addition of Cone Beam CT in private practice offices in the early 2010s. The accrediting body of the American Dental Association, the Commission on Dental Accreditation, has set carefully researched standards for the advanced dental education program in Oral and Maxillofacial Radiology. This includes a minimum of 24 months of education, with many programs extending this training time to 30-36 months with combined coursework leading to a Master’s degree. As part of every program is a required minimum time of 3 months rotating through medical radiology. Whether that rotation is in general radiology, head and neck radiology, or neuroradiology varies from program to program. It also involves coursework in medical radiology, radiation and imaging physics, radiation biology, radiation protection, oral and maxillofacial diagnostic imaging techniques, clinical oral and maxillofacial radiology, and evaluation and radiologic management of patients. As was the case in my residency and many others, radiobiology and the physics of Magnetic Resonance, Multi-detector Computed Tomography, Nuclear Medicine, Ultrasonography, and of course, Cone Beam Computed Tomography are often taken with the medical radiology residents. Residents also attend tumor boards and participate in case conferences with case presentations and lectures provided to fellow residents and dental students. The culmination of this comprehensive training is a rigorous two-part board examination administered by the American Board of Oral and Maxillofacial Radiology (ABOMR). 7
The Unintended Costs of Using a Medical Radiologist for CBCT Reports
A quick survey online of Oral and Maxillofacial Radiology companies reveals the current price of a standalone dental radiology CBCT report is in the range of $100 to $120 with some practices offering discounted pricing based on volume per month. In contrast, medical radiology reports are being advertised as low as $70 for those who upload dental CBCTs more frequently. This difference in price is meaningful if a practice is uploading 20 CBCTs monthly and significant if uploading 100+ CBCTs a month. Of course, like most things in dentistry, cost is not the only factor to consider when utilizing a service for your patient. Ask any dentist who has had the misfortune of using the least expensive dental lab only for it to cost the practice and dentist far more in headaches and heartaches.
You might be thinking that this situation is certainly different than choosing a good lab. Medical radiologists have had 4 years of medical radiology training in addition to their 4 years of medical school, and even some have an additional year or two of fellowship training in areas such as head and neck radiology or neuroradiology. So wouldn’t they know more than an OMFR when it comes to things outside the dentition?
Before we can answer that question, I believe it is important to consider what medical radiologists know about the maxillofacial region as incidental findings don’t just occur outside the maxillofacial region but also within. Having sat alongside my colleagues in Neuroradiology and fellows in training for the same, it was often my role to explain odontogenic findings to my medical colleagues, specifically as it relates to the teeth. Reviewing report after report during my 3 months of training, the most common phrase I saw regarding the oral maxillofacial region was simply “metal artifact caused by dental amalgam.” There was a complete apathy to odontogenic findings as it specifically related to teeth, such as recurrent apical periodontitis of previously endodontically treated teeth. In one such example, I was told there was simply nothing to report as the tooth already had a root canal as I witnessed a likely periodontal cyst elevating the floor of the maxillary sinus. At another time, I presented a case of Cherubism to the Neuroradiology faculty and fellows after being told they had never heard of this condition before. While an admittedly uncommon disease, it is covered in every dental education and is a common board question. The oral and maxillofacial surgeon who was working on the case remarked to me in a tumor board how detailed the report was, even going as far as describing the position of the developing teeth buds – and when he found out I had written it, he remarked that it suddenly made sense because a medical radiologist would not have concerned themselves with such details. All this to say that while our medical colleagues are excellent at finding these incidental findings in the spine, base of the skull, and arteries, as discussed earlier we as OMFRs have been given excellent training in the same but also we know and understand odontogenic findings and how that will impact the dentists treatment planning. As dentists ourselves we are concerned with the minutiae: try explaining to a medical radiologist a subtle finding such as PDL space widening or why it holds significance.
Alright, so you figure, I’ll just send my dental CBCTs for an overread by a medical radiologist because it is cheaper, and I’ll send anything that looks like it might be more dental related to an OMFR. Sounds fair, right? Outside of our medical colleagues potentially missing dental incidental findings that could impact the health and wellbeing of the patient there is an unintended consequence that is likely not being considered by my dental colleagues. Let’s take a step back and evaluate where things stand currently with medical radiology inching their way into the dental space. At least one medical radiology accrediting company is getting involved in accrediting dental CBCTs while also advocating for radiology reports for every dental CBCT that is taken. They are of course conveniently partnered with a medical radiology company advertising medical overreads for the patient’s safety while providing legal coverage for the dentist. On the surface this might seem noble and I certainly would never dissuade someone from going above and beyond to provide the best care for their patients. The real question is do we want our medical colleagues setting a standard of care of having a medical radiology report for all dental CBCTs taken under the guise of safety for the patient? Or do we want to maintain control of our profession and utilize a specialty that understands both dental and medical findings. The choice currently rests with us as dentists, but it may not always unless we are willing to not take the easy way out.
Liability
No discussion of radiology, whether in the medical or dental space, is complete without a discussion on liability. Unlike our medical colleagues, evaluating dental radiographs is often a daily task for most dentists and dental specialists, so it should come as no surprise that when we are discussing being knowledgeable to reliably interpret intraoral (periapicals, bitewings, etc.) and panoramic radiographs, there is no conversation needed regarding the capabilities of the dentist as we received formal education encompassing these radiographic modalities. CBCT, however, is still in its infancy at many institutions and therefore many dentists have not received formal training while in dental school. This is not to say that one cannot become competent in this particular area of dentistry. The American Academy of Oral and Maxillofacial Radiology (AAOMR) in its own executive statement says as such: “It is desirable for practitioners to undergo specific training to perform CBCT examinations successfully.” 8 As is the case with any other radiograph acquired in dentistry it is ”the responsibility of the practitioner obtaining the CBCT images to interpret the findings of the examination. Just as a pathology report accompanies a biopsy, an imaging report must accompany a CBCT scan.” 8 In a CBCT acquired to create a reconstructed panoramic image, this will undoubtedly involve capturing the base of the skull, paranasal sinuses, cervical spine, and the airway spaces. As per the official statement by the AAOMR, if this is outside your comfort level, it is imperative to the overall health of the patient this evaluation be elevated to an OMFR specialist: “Qualified specialist OMFRs may be able to assist diagnostically when practitioners are unwilling to accept the responsibility to review the whole exposed tissue volume.” 8 How this could play out in the legal space if a medical radiologist provides a radiology report instead of an OMR is currently unknown, however, you better believe if a dental incidental finding is missed that results in legal action, an OMFR would certainly be the expert witness for the case. An OMFR has the education to appropriately evaluate and thus provide legal coverage for incidental findings both within and outside of the maxillofacial region of dental CBCTs. While tempting to use a less expensive service, the unintended consequences of leaving the door open for medical radiologists to set standards of care should be carefully weighed. Ultimately as Oral & Maxillofacial Radiologists, we are here to assist when regions are captured outside your comfort and ability.
Ryan Holmes, DDS
Oral & Maxillofacial Radiologist / Co-Founder
True View Dental Radiology
References
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Image credits: Credit goes to Raquelsfranca from megapixel.com for image 1, Adobe stock photos for image 2.
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