THE EDITOR'S CORNER
The Food and Drug Administration estimates that 30% of diagnostic medical and dental x-rays are unnecessary, at a cost of $2 billion a year. The materials alone are estimated to cost $150 million, or an additional 7½% exclusive of labor costs to take and process these films. At the same time, publicity has been given to the still unresolved controversy over whether low level ionizing radiation is harmless or hazardous, especially with reference to genetic damage. It is difficult to prove that something is harmless and it is difficult to prove genetic damage in humans; but, in these contexts, it is timely for each orthodontist to reexamine his x-ray procedures and reassure himself that useless radiation in his office could be described as minimal.
There are opportunities for useless radiation which are procedural. Certain diagnostic x-rays at various levels of orthodontic practice have become customary. Depending on one's adherence, it might be customary to take a full-mouth series, a panoramic film, a cephalometric frontal and lateral film before treatment, after treatment, after retention, and some years later. In addition to these, progress cephalometric films might be taken at various intervals; as well as periapical films to check on root resorption, and panoramic films for tooth eruption, impaction, root parallelism, status of third molars. There is no question that all of these x-rays are justifiable and, indeed, may be the hallmark of a practice operating at the highest level. However, in order to be justifiable, all x-rays that are taken should not only be useful, but used. The fact that they may be useful to one orthodontist does not necessarily mean they would be useful to another.
Some useless radiation can be eliminated. Remakes and unreadable films, for example. Each office ought to keep track of the occurrence of both of these and take steps to correct this problem, if there is more than a minimal amount. Some duplication of exposures by the GP and the orthodontist could be reduced by the use of film duplication and duplicate film, although it must be recognized that not all films are equally useful to GPs and orthodontists, and that timeliness is also important to both.
A certain amount of useless radiation could be involved in what could be called "Just in Case" x-rays. "Just in case I want to analyze my cases some day" or "Just in case I want to take my Boards" or "Just in case I have to defend a malpractice suit". Each of these has a potentially defensible rationale, but each one--if it is the only reason for taking certain films--serves the doctor's needs more than the patient's. If x-rays are taken and not used in the diagnosis of a case, the monitoring of treatment, and posttreatment analysis, they become very difficult to justify. The value of posttreatment analysis is in evaluating the achievement of treatment objectives, both to terminate treatment with goals achieved and to add to the orthodontist's store of knowledge in the treatment of future patients. If posttreatment films are taken and not used at that time, their chief value is lost and their value as material for future analysis becomes suspect.
I like to think that any orthodontist who would be thinking about taking the Boards would be the kind of dedicated practitioner who would be using every means at his disposal to analyze and treat his patients well; and that the individual who may be taking films and not using them, but saving them for possible submission for his Boards, ought to give up on the idea that he will ever take his Boards and eliminate what is for him and the patients in his practice a useless procedure. Or, better still, he ought to investigate what other practitioners are finding useful about them.
The question of whether certain films ought to be taken merely for record purposes in light of increasing numbers of malpractice suits does not have a simple answer in medicine or dentistry. However, if one takes films and does not read them or trace them at the time, he might face a nasty awakening some years down the road to find that his own films supported the plaintiff's contention.
While orthodontists ought to be sure that all of the films they take are useful, they ought also to evaluate that the ones that they do not take are useless. We ought not to have a knee-jerk reaction to being grouped with all the other sources of radiation and all of us immediately look for additional ways to cut down only. It is also a time to evaluate whether we are shortchanging our patient or ourselves with too few films, especially in posttreatment evaluation.
Orthodontists get good marks on safety of equipment, minimizing of exposure time, use of collimators and lead aprons, use of long cones and film positioning devices; and orthodontists contribute a very small amount to the total radiation exposure of their patients. We must nevertheless not disregard the public concern over the potential hazard of radiation and the contribution of useless radiation to both the hazard and the cost. Either the patient is paying for the useless films or the doctor is, and that is an expense that can be justified for neither one.
