We appreciated the “Litigation and legislation” column by Laurence Jerrold in the October 2014 issue (Jerrold L. Seeing before doing. Am J Orthod Dentofacial Orthod 2014;146:530-3).
Dr Jerrold’s primary concern was that it may be common practice to take a radiograph before the patient is examined, and this could include cone-beam computed tomography. Since the radiation dose from cone-beam computed tomography is 4 times or more greater than a panoramic image, this is a significant concern. Despite looking at the legal aspects, the American Dental Association’s Code of Ethics, and the statements of its Council of Scientific Affairs, he found no documentation to suggest that this should not be undertaken. His conclusion appears to be equivocal; as he says, “there’s just no easy answer.”
Fortunately, in the United Kingdom, we have a definitive answer. The “Ionising Radiation (Medical Exposure) Regulations” (2000) states that “No person shall carry out a medical exposure unless it has been justified by the practitioner as showing a sufficient net benefit.” Clearly, it is not possible for a practitioner to show that an exposure will have a net benefit to the patient without a clinical examination.
To clarify these regulations for practitioners, the British Orthodontic Society produced a booklet, “Orthodontic Radiographs—Guidelines,” now in its third edition (the fourth edition is in preparation). These guidelines state that “the use of ionising radiation in clinical practice is governed by law—criminal law—in the UK.” Practitioners have had their licence to practice withdrawn as a result of inappropriate use of x-rays, and at least 1 practitioner has received a custodial sentence.
The editor of the AJO-DO (in 2008) reviewed the British Orthodontic Society Guidelines and wrote, “I do believe the BOS points us in a direction that could result in more ideal care for many patients.” In his review of the book Guidelines for the Use of Radiographs in Clinical Orthodontics, radiologist D. L. Gander wrote, “Perhaps the AAO might be inspired to publish a more meaningful set of radiographic guidelines after the exceptional example set by their British colleagues.”
Whereas the British Orthodontic Society Guidelines have a number of recommendations, the unequivocal conclusion and interpretation of the law are that there are no indications for the exposure of a radiograph before a clinical examination. Every x-ray must be justified.
So, in the United Kingdom, we have the answer to the question posed by Dr Jerrold, with guidelines for practitioners to use, knowing that they are acting both within the law and in the best interests of their patients.