25 Legal Considerations










275
25
Legal Considerations
EDUCATIONAL OBJECTIVES
Upon completing this chapter, the student will be able to:
1. Dene the key terms listed at the beginning of the chapter.
2. Describe and be able to dierentiate between state and
federal regulations as they pertain to dental radiology and
licensure.
3. Discuss risk management, including:
• Understandtheconceptsofriskmanagementas
they apply to patient relations, ownership and
retention of radiographs, and the medical and radiation
history.
• Understandtheconceptofinformedconsent.
4. Understandthelegalstatusofinsuranceformsandthe
dental records.
KEY TERMS
condentiality
direct supervision
federal regulations
full disclosure
general supervision
Health Insurance Portability and
Accountability Act (HIPAA)
informed consent
liability
licensure
negligent
radiation inspection
records
res gestae
respondeat superior
risk management
standard of care
statute of limitations
specications for minimum ltration and accuracy and
reproducibility of the milliamperage time and kilovoltage
settings. ese standards are discussed in Chapters 1 and 3.
Actually, all x-ray equipment, regardless of the date of
manufacture, is subject to state, county, or city radiation
health codes. It is not unusual for the registration of x-ray
machines to be required and a fee charged for such a
permit. Many states or other jurisdictions require regular
radiation inspections of the x-ray machines in the dental
oce. Violations of the radiation code can lead to nes
or suspension of a dentist’s radiation permit. e positive
aspect of these inspections is that they serve as a quality
assurance (QA) procedure. e inspectors, as they measure
for violations, perform recommended QA procedures that
dental professionals could not do themselves because of
the need for sophisticated radiation-monitoring equipment.
Licensure
Regarding licensure, each state has its own policy for the
user of dental radiation. e dentist and dental hygienist,
who in all states is a licensed professional, usually do not
have to take an additional examination to be certied to
perform dental radiography. Generally, the dentist is also
Introduction
It may be a sign of the times, but a discussion of a subject
in the health sciences cannot be considered complete today
without mentioning the legal aspects that aect the profes-
sion. Radiology is no exception; it is probably the most
regulated discipline within dentistry, with its registration
and certication of x-ray machines, laws, and special testing
for operators of the equipment. erefore, the dental pro-
fessional must understand the laws and regulations, both
local and federal, that govern the use of radiation in this
profession.
e legal considerations with which the dental profes-
sional should be familiar regarding the use of ionizing
radiation in dentistry fall into three major categories: (1)
federal and state regulations regarding x-ray equipment and
its use, (2) licensure for users of x-ray equipment, and (3)
risk management.
Federal and State Regulations
All dental x-ray machines either manufactured or sold in the
United States must adhere to federal regulations (federal
governments performance standards), which include safety

276 CHAPTER 25 Legal Considerations
advance to patients about how the oce policy deals with
nancial arrangements, payments, recall procedures, and
the ling of insurance claims.
Dental professionals should never say anything negative
to a patient about equipment, procedures, sta, or anything
else in the oce. Remarks such as, “is timer is always o,
or “ese lms werent processed properly,” are unnecessary.
ese comments are considered “admissions against inter-
est,” also known as the theory of res gestae. Statements
made by anyone spontaneously at the time of an alleged
negligent act are admissible as evidence.
Informed Consent
e dental professional may participate in the process of
obtaining informed consent, which entails explaining to
the patient the nature and purpose of the procedure. is
is called full disclosure. In the case of taking radiographs,
full disclosure entails explaining to the patient, in lay terms,
the risks and benets to be derived. Recent legal decisions
have noted that it is equally important to inform the patient
of the risks of not having a specic procedure. In this case,
the patient must be told about the diseases that might go
undetected without radiography and the possible conse-
quences. If the patient is a minor, the parent or guardian
must consent.
If a patient refuses a recommended radiographic exami-
nation, this should be entered into the patients record to
justify why treatment will not be rendered. ere are few if
any dental procedures that should be done without current
and diagnostic radiographs, because their use is now the
accepted standard of care. Patient refusal is not a valid
reason for treating without radiographs.
Health Questionnaire
e dental professional always should review the patients
health history and questionnaire and update as necessary.
e dental professional should call to the dentists attention
any information that might contraindicate or change the
number and type of radiographs that are to be taken.
Records
It has been said that the three most important parts of a
defense in a malpractice suit are “records, records, records.
Dental radiographs are considered part of the patient’s dental
record and are considered legal documents. e number
and quality of the radiographs may be an important issue in
any litigation. If the quality is poor and nondiagnostic and
the procedures in question are based on the radiographs,
this substantially weakens the defense. If the radiographs
cannot be found or retrieved (if they are digital images),
again, the case for the defense is seriously compromised.
e most common error is the failure to make an entry
in the patient’s record when radiographs are taken; the
date, number, and type of radiograph should always be
responsible for prescribing the appropriate radiographs for
the patient and for formulating a diagnosis and treatment
plan as a result of a clinical and radiographic examination.
However, the dental hygienist may interpret or “read” the
radiographs without formulating an actual diagnosis based
on their interpretation.
e dental assistant may be required to take a radiology
examination other than the national certifying examina-
tion to be authorized to perform dental radiography. Some
states have exceptions in their radiation rules that allow an
uncertied dental assistant to take radiographs under the
direct supervision of a dentist. Direct supervision means
that the dentist is physically present in the oce when
the radiographs are taken. Hygienists may take radiographs
under the general supervision of a dentist, which means
that the hygienist is performing these tasks in a licensed
dentist’s oce or clinic, and the dentist can be reached
if necessary. In most states, dental assistants cannot take
extraoral projections other than a panoramic image.
Each state deals with dental radiography dierently. It is
not the purpose of this text to compile lists of these require-
ments, because they change rapidly. Dental professionals
should be knowledgeable about the rules and regulations
of the state or jurisdiction in which they are working and
should not assume that all state regulations are the same.
Risk Management
By far the most important legal aspect of dental radiology is
risk management. Risk management concerns the policies
and procedures designed to reduce the likelihood of suits for
malpractice against dentists and dental radiographers. All
members of the dental sta must be aware of and participate
in the risk management eorts of the oce if they are to
be eective.
First, it must be pointed out that liability, both profes-
sionally and legally, rests with the dentist and not the dental
hygienist or dental assistant. is is called the doctrine of
respondeat superior, or the “captain of the ship” principle;
more simply put, the captain of the ship is responsible for
the actions of the sailors. e dental professional may be
named in a lawsuit, but the liability is ultimately with the
employing dentist.
A dental hygienist falls under the doctrine of respondeat
superior if the hygienist is an employee. If the hygienist is the
one found to be negligent, the dentist’s insurance company
may decide to subrogate (sue the hygienists company for
a share of the award) the payment of the claim against the
hygienist or the hygienist’s insurance company. erefore,
the hygienist is well advised to carry professional liability
insurance. Hygienists who are independent contractors may
be sued alone.
Patient Relations
Avoiding misunderstandings is a critical component of
risk management. Dental oce sta must communicate in

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27525 Legal ConsiderationsEDUCATIONAL OBJECTIVESUpon completing this chapter, the student will be able to:1. Dene the key terms listed at the beginning of the chapter.2. Describe and be able to dierentiate between state and federal regulations as they pertain to dental radiology and licensure.3. Discuss risk management, including:• Understandtheconceptsofriskmanagementas they apply to patient relations, ownership and retention of radiographs, and the medical and radiation history.• Understandtheconceptofinformedconsent.4. Understandthelegalstatusofinsuranceformsandthedental records.KEY TERMScondentialitydirect supervisionfederal regulationsfull disclosuregeneral supervisionHealth Insurance Portability and Accountability Act (HIPAA)informed consentliabilitylicensurenegligentradiation inspectionrecordsres gestaerespondeat superiorrisk managementstandard of carestatute of limitationsspecications for minimum ltration and accuracy and reproducibility of the milliamperage time and kilovoltage settings. ese standards are discussed in Chapters 1 and 3.Actually, all x-ray equipment, regardless of the date of manufacture, is subject to state, county, or city radiation health codes. It is not unusual for the registration of x-ray machines to be required and a fee charged for such a permit. Many states or other jurisdictions require regular radiation inspections of the x-ray machines in the dental oce. Violations of the radiation code can lead to nes or suspension of a dentist’s radiation permit. e positive aspect of these inspections is that they serve as a quality assurance (QA) procedure. e inspectors, as they measure for violations, perform recommended QA procedures that dental professionals could not do themselves because of the need for sophisticated radiation-monitoring equipment.LicensureRegarding licensure, each state has its own policy for the user of dental radiation. e dentist and dental hygienist, who in all states is a licensed professional, usually do not have to take an additional examination to be certied to perform dental radiography. Generally, the dentist is also IntroductionIt may be a sign of the times, but a discussion of a subject in the health sciences cannot be considered complete today without mentioning the legal aspects that aect the profes-sion. Radiology is no exception; it is probably the most regulated discipline within dentistry, with its registration and certication of x-ray machines, laws, and special testing for operators of the equipment. erefore, the dental pro-fessional must understand the laws and regulations, both local and federal, that govern the use of radiation in this profession.e legal considerations with which the dental profes-sional should be familiar regarding the use of ionizing radiation in dentistry fall into three major categories: (1) federal and state regulations regarding x-ray equipment and its use, (2) licensure for users of x-ray equipment, and (3) risk management.Federal and State RegulationsAll dental x-ray machines either manufactured or sold in the United States must adhere to federal regulations (federal government’s performance standards), which include safety 276 CHAPTER 25 Legal Considerationsadvance to patients about how the oce policy deals with nancial arrangements, payments, recall procedures, and the ling of insurance claims.Dental professionals should never say anything negative to a patient about equipment, procedures, sta, or anything else in the oce. Remarks such as, “is timer is always o,” or “ese lms weren’t processed properly,” are unnecessary. ese comments are considered “admissions against inter-est,” also known as the theory of res gestae. Statements made by anyone spontaneously at the time of an alleged negligent act are admissible as evidence.Informed Consente dental professional may participate in the process of obtaining informed consent, which entails explaining to the patient the nature and purpose of the procedure. is is called full disclosure. In the case of taking radiographs, full disclosure entails explaining to the patient, in lay terms, the risks and benets to be derived. Recent legal decisions have noted that it is equally important to inform the patient of the risks of not having a specic procedure. In this case, the patient must be told about the diseases that might go undetected without radiography and the possible conse-quences. If the patient is a minor, the parent or guardian must consent.If a patient refuses a recommended radiographic exami-nation, this should be entered into the patient’s record to justify why treatment will not be rendered. ere are few if any dental procedures that should be done without current and diagnostic radiographs, because their use is now the accepted standard of care. Patient refusal is not a valid reason for treating without radiographs.Health Questionnairee dental professional always should review the patient’s health history and questionnaire and update as necessary. e dental professional should call to the dentist’s attention any information that might contraindicate or change the number and type of radiographs that are to be taken.RecordsIt has been said that the three most important parts of a defense in a malpractice suit are “records, records, records.” Dental radiographs are considered part of the patient’s dental record and are considered legal documents. e number and quality of the radiographs may be an important issue in any litigation. If the quality is poor and nondiagnostic and the procedures in question are based on the radiographs, this substantially weakens the defense. If the radiographs cannot be found or retrieved (if they are digital images), again, the case for the defense is seriously compromised.e most common error is the failure to make an entry in the patient’s record when radiographs are taken; the date, number, and type of radiograph should always be responsible for prescribing the appropriate radiographs for the patient and for formulating a diagnosis and treatment plan as a result of a clinical and radiographic examination. However, the dental hygienist may interpret or “read” the radiographs without formulating an actual diagnosis based on their interpretation.e dental assistant may be required to take a radiology examination other than the national certifying examina-tion to be authorized to perform dental radiography. Some states have exceptions in their radiation rules that allow an uncertied dental assistant to take radiographs under the direct supervision of a dentist. Direct supervision means that the dentist is physically present in the oce when the radiographs are taken. Hygienists may take radiographs under the general supervision of a dentist, which means that the hygienist is performing these tasks in a licensed dentist’s oce or clinic, and the dentist can be reached if necessary. In most states, dental assistants cannot take extraoral projections other than a panoramic image.Each state deals with dental radiography dierently. It is not the purpose of this text to compile lists of these require-ments, because they change rapidly. Dental professionals should be knowledgeable about the rules and regulations of the state or jurisdiction in which they are working and should not assume that all state regulations are the same.Risk ManagementBy far the most important legal aspect of dental radiology is risk management. Risk management concerns the policies and procedures designed to reduce the likelihood of suits for malpractice against dentists and dental radiographers. All members of the dental sta must be aware of and participate in the risk management eorts of the oce if they are to be eective.First, it must be pointed out that liability, both profes-sionally and legally, rests with the dentist and not the dental hygienist or dental assistant. is is called the doctrine of respondeat superior, or the “captain of the ship” principle; more simply put, the captain of the ship is responsible for the actions of the sailors. e dental professional may be named in a lawsuit, but the liability is ultimately with the employing dentist.A dental hygienist falls under the doctrine of respondeat superior if the hygienist is an employee. If the hygienist is the one found to be negligent, the dentist’s insurance company may decide to subrogate (sue the hygienist’s company for a share of the award) the payment of the claim against the hygienist or the hygienist’s insurance company. erefore, the hygienist is well advised to carry professional liability insurance. Hygienists who are independent contractors may be sued alone.Patient RelationsAvoiding misunderstandings is a critical component of risk management. Dental oce sta must communicate in 277CHAPTER 25 Legal Considerations• BOX 25.1 Health Insurance Portability and Accountability Act of 1996The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was signed into law by President Bill Clinton on August 21, 1996. Conclusive regulations were issued on August 17, 2000, to be instated by October 16, 2002. HIPAA requires that the transactions of all patient health care information be formatted in a standardized electronic style. In addition to protecting the privacy and security of patient information, HIPAA includes legislation on the formation of medical savings accounts, the authorization of a fraud and abuse control program, the easy transport of health insurance coverage, and the simplication of administrative terms and conditions.HIPAA encompasses three primary areas, and its privacy requirements can be broken down into three types: privacy standards, patients’ rights, and administrative requirements.1. Privacy Standards. A central concern of HIPAA is the careful use and disclosure of protected health information (PHI), which generally is electronically controlled health information that can be distinguished individually. PHI also refers to verbal communication, although the HIPAA Privacy Rule is not intended to hinder necessary verbal communication. The U.S. Department of Health and Human Services (USDHHS) does not require restructuring, such as soundproong, architectural changes, and so forth, but some caution is necessary when exchanging health information by conversation.An Acknowledgment of Receipt Notice of Privacy Practices, which allows patient information to be used or divulged for treatment, payment, or health care operations (TPOs), should be procured from each patient. A detailed and time-sensitive authorization can also be issued, which allows the dentist to release information in special circumstances other than TPOs. A written consent is also an option. Dentists can disclose PHI without acknowledgment, consent, or authorization in very special situations, such as perceived child abuse, public health supervision, fraud investigation, or law enforcement with valid permission (i.e., a warrant). When divulging PHI, a dentist must try to disclose only the minimum necessary information to help safeguard the patient’s information as much as possible.It is important that dental professionals adhere to HIPAA standards because health care providers (as well as health care clearinghouses and health care plans) who convey electronically formatted health information via an outside billing service or merchant are considered covered entities. Covered entities may be dealt serious civil and criminal penalties for violation of HIPAA legislation. Failure to comply with HIPAA privacy requirements may result in civil penalties of up to $100 per offense with an annual maximum of $25,000 for repeated failure to comply with the same requirement. Criminal penalties resulting from the illegal mishandling of private health information can range from $50,000 and/or 1 year in prison to $250,000 and/or 10 years in prison.2. Patients’ Rights. HIPAA allows patients, authorized representatives, and parents of minors, as well as minors, to become more aware of the health information privacy to which they are entitled. These rights include, but are not limited to, the right to view and copy their health information, the right to dispute alleged breaches of policies and regulations, and the right to request alternative forms of communicating with their dentist. If any health information is released for any reason other than TPO, the patient is entitled to an account of the transaction. Therefore, it is important for dentists to keep accurate records of such information and to provide them when necessary.The HIPAA Privacy Rule determines that the parents of a minor have access to their child’s health information. This privilege may be overruled, such as in cases in which there is suspected child abuse or the parent consents to a term of condentiality between the dentist and the minor. The parents’ rights to access their child’s PHI also may be restricted in situations in which a legal entity, such as a court, intervenes and when a law does not require a parent’s consent. For a full list of patient rights provided by HIPAA, be sure to acquire a copy of the law and understand it well.3. Administrative Requirements. Complying with HIPAA legislation may seem like a chore, but it does not have to be so. It is recommended that dental professionals become appropriately familiar with the law, organize the requirements into simpler tasks, begin compliance early, and document their ofce’s progress in compliance. An important rst step is to evaluate the current information and practices of the ofce.Dentists need to write a privacy policy for their ofce, a document for their patients detailing the ofce’s practices recorded. ere are no exceptions to this rule. Postoperative, working endodontic, or retakes must be recorded or the records will be deemed incomplete. Individual radiographs, a series of radiographs, and panoramic radiographs should be appropriately labeled and dated. e issue of the legal status of digital radiographs and possible alterations of the images is discussed in Chapter 15.Condentialitye patient’s records are condential. e contents or nd-ings in these records should never be discussed or shown to anyone outside the oce. Condentiality also per-tains to any radiographs or photographs that are part of the record. Since April 2000, it has also been necessary that all records comply with the Health Insurance Portability and Accountability Act (HIPAA; Box 25.1).Ownershipe dentist is the guardian and keeper of dental records; these records are the property of the dentist. Patients may request a copy of their radiographs; this request should be written and signed by the patient. A fee may be charged for this duplication. Laws dier from state to state on whether a dental oce must give the radiographs to the patient if the fee for this service has not been paid. In some states, the radiographs or copies must be given to the patient even if the fee has not been paid. e dentist may pursue collection but only after giving the radiographs to the patient. is is not true in all states, which underscores that members of the dental team must be familiar with the laws regulating practice in the state in which they work.e dentist should be informed of this request and an entry made in the record of when and to whom the Continued 278 CHAPTER 25 Legal ConsiderationsChapter Summary• edentalprofessionalshouldbefamiliarwiththelegalconsiderations concerning the use of ionizing radiation in dentistry. ese concerns include the state and federal regulations regarding x-ray equipment, licensure require-ments for dental radiographers, and risk management procedures and policies.• Dentists and dental hygienists have certain specicresponsibilities that they are permitted to perform in regard to dental radiography by virtue of their licensing regulations. e rules concerning dental assistants’ use of radiation in a dental practice vary from state to state.(Reproduced with permission from Mosby’s Dental Dictionary, St Louis, MO, 2004, Mosby.)Data from: HIPAA Privacy Kit and http://www.ada.org/prof/prac/issues/topics/hipaa/index.html.concerning PHI. The American Dental Association’s HIPAA Privacy Kit includes forms that the dentist can use to customize a privacy policy. It is useful to try to understand the role of health care information for patients and the ways in which they deal with the information while they are visiting the dental ofce. The dentist should train the staff, making sure they are familiar with the terms of HIPAA and the ofce’s privacy policy and related forms. HIPAA requires that the dentist designate a privacy ofcer, a person in the ofce who will be responsible for applying the new policies, elding complaints, and making choices involving the minimum necessary requirements. Another person with the role of contact person will process complaints. A Notice of Privacy Practices—a document detailing the patient’s rights and the dental ofce’s obligations concerning PHI—also must be drawn up. Furthermore, any role of a third party with access to PHI must be clearly documented. This third party is known as a business associate (BA) and is dened as any entity who, on behalf of the dentist, takes part in any activity that involves exposure of PHI. The HIPAA Privacy Kit provides a copy of the USDHHS “Business Associate Contract Terms,” which provides a concrete format for detailing BA interactions.The main HIPAA privacy compliance date, including all staff training, was April 14, 2003, although many covered entities who submitted a request and a compliance plan by October 15, 2002, were granted 1-year extensions. The dentist can contact the local branch of the ADA for details. It is recommended that dentists prepare their ofces ahead of time for all deadlines, which include preparing privacy policies and forms, business associate contracts, and employee training sessions.For a comprehensive discussion of all of these terms and requirements, a complete list of HIPAA policies and procedures, and a full collection of HIPAA privacy forms, contact the ADA for a HIPAA Privacy Kit. The relevant ADA website is www.ada.org/goto/hipaa. Other websites that may contain useful information about HIPAA are:• USDHHSOfceofCivilRights(www.hhs.gov/ocr/hipaa)• WorkGrouponElectronicDataInterchange(www.wedi.org/SNIP)• PhoenixHealth(www.hipaadvisory.com)• USDHHSOfceoftheAssistantSecretaryforPlanningandEvaluation(http://aspe.os.dhhs.gov/admnsimp/)• BOX 25.1 Health Insurance Portability and Accountability Act of 1996—cont’dduplicate radiographs were sent. In the case that the patient is going to another dental oce, it is usually not advised to send dental records, including radiographs, directly to the patient but rather to the new dental practice instead. It is also not recommended to send or give the original radiographs to a patient. ere is no defense if there are no radiographs in the possession of the dental oce. However, on occasion, the court may request or subpoena the original radiographs. If this happens, the dental profes-sional must comply with the court’s request.RetentionDental radiographs should be kept for 7 years after the patient ceases to be a patient in the oce, depending on the specic state’s laws. Ideally, they should be kept for as long as possible. Actions that can be brought against a dentist depend on the statute of limitations. e usual time limitation for an adult is 3 years after the discovery of the injury or when the injury should have been discovered. For children, it is 3 years after they reach their maturity, which in some states is 21 years. Suits therefore can be brought many years past the mandated 7 years of retention of radiographs.Insurance ClaimsIt is the legitimate right of the insurance company to request copies of pretreatment radiographs to evaluate a treatment plan. e original conventional or digital radiographs should never be sent to the insurance company because they may be lost. In either case, the dentist is left without an important part of the patient’s record and, in case of litigation, the fact that the originals were lost is not an appropriate defense.As mentioned in Chapter 6, radiographs should never be taken to prove to the insurance company that the services have been performed. e result of this action would be an administrative radiograph, which is considered unsuitable. 279CHAPTER 25 Legal ConsiderationsChapter Review QuestionsShort Answer Questions1. Is the insurance company permitted to request pretreat-ment and posttreatment radiographs? Explain your answer.2. Who has ownership of the radiographs? What are the patients’ rights in requesting their radiographs? Explain your answer.3. How long is a dental practice required to keep a patient’s records, including radiographs, after the patient has left the practice? Explain your answer.4. What are the licensing and certication requirements for each dental professional regarding the use of radiation in dentistry? Explain your answer.5. What is the purpose of the HIPAA Act? Explain your answer.6. What is meant by the terms: a. Risk management b. Respondeat superior c. Res gestae d. Informed consent e. Full disclosureBibliographyIannucci JM, Howerton LJ: Dental radiography: Principles and tech-niques, ed 5, St Louis, MO, 2016, Elsevier Saunders.Weissman BJ, Serman NJ: e law and who can expose dental radiographs, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 90:663–665, 2000.• If and when a patient refuses radiographs, the dentalprofessional is advised not to render treatment to that individual as it is not acceptable to treat a patient without the appropriate diagnostically acceptable radiographs available to the respective operator as a result of the patient’s refusal.• Dentalprofessionalsareresponsibleforknowingthelegalregulations of the state that they are employed in regard-ing condentiality, the ownership of the radiographs, informed consent, and the retention of a patient’s dental records, including their dental radiographic images. 280Common Error SummariesAppendix A 281APPENDIX A Common Error SummariesCommon Processing Error Appearance Cause RemedyFogged lm Overall gray appearance due to diminished contrast.Darkroom errors: Light leaks, smartphone light exposure, improper safelight, improper lm storage, and outdated lm.Check for light leaks.Turn off smartphone before entering a darkroom.Check safelight with “coin test.”Store lm in cool area and away from sources of scatter radiation.Check expiration date on lm box, and use old lm rst.Underdeveloped lm (thin image)Light (thin) in appearance.Insufcient developing time.Cold developing solution.Weak developing solution.Change solution every 2–3 wks (or more frequently if necessary).Use time–temperature method of developing.Utilize “reference lm,” step wedge, or dental radiographic normalizing and monitoring device to check solution strength.Overdeveloped lm (dense image)Dark (dense) in appearance.Prolonged developing time.Hot developing solution.Use time–temperature method of developing.Perform daily quality assurance (QA) checks on solution strength.Developer cutoff A straight radiopaque border on the upper edge of the top lm on the processing rack or was not exposed to developing solution in the automatic processor.This represents an undeveloped area of the lm. Keep processing tanks full.When the solutions are allowed to deplete in the processing tanks, the lms on the top positions of the racks may not be covered by solution when the racks are placed in the tanks.This error should be differentiated from collimator cutoff, which will give a curved radiopaque border if circular collimation is used and a straight border if rectangular collimation is used.In collimator cutoff, the lm portion is unexposed. In developer cutoff, the lm portion is undeveloped.If the level of solution has dropped, do not add water. Add replenisher solution to maintain the desired levels.This error can also occur in automatic processing.Clear lms No image is seen.Emulsion is removed completely.Films remain in the water bath from 24 to 48 hours.Films are in the xer for prolonged periods of time.Film is unexposed.Films are placed in the xer before the developer.Films should be removed from the water bath before the end of the day.Films should not be left in the xer overnight or for prolonged periods.Keep unexposed and exposed lms separated. Remember to plug the machine in and turn it on before exposures are performed. Do not process unexposed lms.If processing manually, place the lms in the developer solution before the xer. Make sure the xer solution is positioned after the developer (from left to right) in the automatic processors.Stained lms Splotches on the lm (dark spots = developer; light spots = xer.)Wet or dirty working surface. Keep all surfaces in the darkroom clean and dry.Discolored lms Yellowish-brown lms. Inadequate xation. Fix lm optimally for at least 10 minutes or double the developing time.Return all “wet readings” (which are xed for 3 minutes) to the xer tank after the patient has been treated (for at least 7 more minutes to equal an optimal xing time of 10 minutes).Common Processing ErrorsContinuedTABLE A1 282 APPENDIX A Common Error SummariesCommon Processing Error Appearance Cause RemedyTorn emulsion Film emulsion is torn off. If lms overlap or touch while drying, they will stick together.In separating the lms, the emulsion is usually torn off the base in the overlapped areas.Check that drying lms do not touch. If they are stuck together, separate them by applying water.Scratched lms Radiopaque line on lm. Not carefully placing a second lm rack into a tank already containing one rack.Not discarding racks with broken clips.Fingernails too long.Be careful not to touch one lm rack with another lm rack when placing them into the tank.Discard any lm racks that have sharp edges or broken clips.Keep ngernails trimmed and avoid scratching lms with ngernails. Don gloves when applicable.Lost lms in tankMissing lms/lms on the bottom of the tank.Films not rmly clipped onto rack. Check that lms are rmly clipped onto the rack before placing them into the developer.Fluoride artifact Black mark on radiograph.Some uorides, especially stannous uoride, will produce black marks on radiographs.Operator should wash hands thoroughly before handling lms or change gloves when applicable.Reticulation Image has a wrinkled or stained-glass appearance.Film developed at an elevated temperature and then placed in a cold water bath (or vice versa); the sudden change in temperature causes the swollen emulsion to shrink rapidly and gives the image a wrinkled (or stained-glass) appearance.Avoid a sharp contrast in temperature between processing solutions and the water bath.Air bubbles White (unprocessed) spots on radiograph.If air bubbles are trapped on the lm, the chemicals cannot affect the emulsion in that area.Film hanger should be gently agitated when placed into the solutions.Static marks Multiple black linear streaks or spots seen most often on cold, dry days.Intraoral lm packets forcefully opened in the darkroom.Extraoral lm not carefully slid out of the box.Carefully remove lm from packet or extraoral lm box.Extraoral lm not carefully loaded and unloaded into and out of the cassette.Carefully load and unload extraoral lm in cassette.Dragging feet over carpeting and not grounding yourself before unwrapping the lm.Operators should ground themselves and should avoid friction that will produce static electricity.Automatic ProcessingDaylight loaders:Light leakFilm fog, a ruined lm, or unusual artifacts.Removing one’s hands from the bafes before the lm has entered the processor.Operator must keep hands inside the daylight loader until the lm has been completely taken up by the automatic processor.Hand bafes that have lost their elasticity should be repaired or replaced.Dirty rollers Radiolucent bands or white chalky smudges appear on nished lm.Rollers are not cleaned properly. Rollers should be cleaned periodically by soaking them according to the manufacturer’s recommendations.A piece of extraoral lm should be run through the processor every workday to clean the rollers.Overlapped lmsImage of overlapped lm on nished lm.Films are fed into the processor too quickly. The operator should not feed the lm into the processor immediately after placing the previous lm.The operator should wait at least 10 seconds before putting another lm into the processor.New York University College of Dentistry Radiology Department.TABLE A1Common Processing Errors—cont’d 283APPENDIX A Common Error SummariesCommon Exposure Error Appearance Cause Remedy***Collimator cutoff (cone cutting)A curved or straight radiopaque border representing an unexposed area on the image.The x-ray beam is not centered on the receptor.The central ray of the x-ray beam should be aligned with the center of the receptor.Utilization of a localizing ring with a receptor-holding device can decrease or eliminate the incidence of collimator cutoff.Make sure the patient does not move after the PID is placed for an exposure.*Film reversal (formerly known as the “herringbone effect”)A light lm with the geometric pattern from the lead foil backing embossed on it.The receptor is placed backward in the mouth.Always note the front and the back of the lm packet.Place the white side (front) of the lm toward the lingual (palatal) aspect of the tooth.***Improper receptor placement The entire desired area (tooth or teeth) does not appear on the image.***The patient does not bite down completely on the bite piece of the receptor-holder (inadequate closure).***Make sure that the patient bites completely on the bite piece with both opposing maxillary and mandibular teeth.***The center of the receptor is not aligned with the center of the appropriate tooth (depending on the specic projection being exposed).***Align the center of the receptor with the center of the area (tooth or teeth) being radiographed.**Incorrect placement of the sensor on the adhesive bite piece or *failure to place the lm to the base of the slot in the lm holder (the incisal edge or occlusal surface is cut off).**Make sure that the placement of the sensor is on the adhesive bite piece or *the lm packet is entirely in the bite piece slot correctly.***Horizontal overlapping The interproximal areas of the teeth appear to be overlapped when they are not actually overlapped in the patient’s mouth.The central ray is not directed perpendicular to the receptor in the horizontal plane.Direct the central ray through the contact areas in the horizontal plane.The receptor is not placed parallel to the tooth or teeth in the horizontal plane.Place the receptor parallel to the tooth or teeth in the horizontal plane.*Black straight or crescent marksBlack marks (artifacts) appear on the lm.Excessive bending of the lm packet that results in a cracked emulsion.Do not bend or over-manipulate the lm while placing it in the lm holder or in the patient’s mouth.***Underexposed image (light image)[Conventional and digital radiographic error. However, light images can be adjusted with contrast/density modications when utilizing a digital radiographic system.]Light (thin) in appearance. Inadequate exposure due to improper settings, including size of the patient setting, conventional vs. digital setting, and exposure time setting.Check that all settings on the control panel are correct for each patient and exposure.Failure to press and hold the exposure button until the indicator light goes off and the sound signal ends.Maintain pressure on the exposure button until the indicator light goes off and the sound signal ends.Failure to place the PID as close to the localizing ring and to the patient as possible.Make sure that the PID is as close to the localizing ring and to the patient as possible.Common Exposure ErrorsContinuedTABLE A2 284 APPENDIX A Common Error SummariesCommon Exposure Error Appearance Cause Remedy***Overexposed image (dense image)[Conventional and digital radiographic errors. However, dark images can be adjusted with contrast/density modications when utilizing a digital radiographic system.]Dark (dense) in appearance. Excessive exposure due to improper settings, including the size of the patient setting, conventional vs. digital setting, and exposure time setting.Check that all settings on the control panel are correct for each patient and exposure.*Double exposure Two images appear on one lm.Using the same lm packet for more than one exposure.Separate the exposed lms from the unexposed lms.When using a lm packet with a barrier envelope, remove the barrier envelope immediately after exposure so that it is easy to distinguish between the exposed and unexposed lms.***Blurred images Wavy or fuzzy image. Patient, receptor, or tubehead (PID) movement during exposure.Adjust the tubehead/arm to prevent vibration and drifting.Always keep an eye on the patient, especially when exiting the operatory.Ask the patient “not to move” before exiting the operatory.**When using a digital sensor with an attached wire, watch the wire for any movement that might indicate that the sensor moved inside the patient’s mouth.***Failure to remove dental appliances and facial jewelryRadiopaque (metal) images are superimposed on the image.Failure to ask the patient to remove any metallic objects from the mouth or facial area that may be in the way of the primary beam.For intraoral radiographs, remove any obstructive intraoral appliances, eyeglasses, and facial jewelry before exposure.For panoramic/extraoral radiographs, remove any obstructive intraoral appliances; facial, intra/extraoral and neck jewelry; hair accessories; and hearing aids before exposure.**Sensor cable artifact on a digital imageThe sensor cable wire is superimposed over the oral structures being imaged.Failure to move the wire (and its metallic components) out of the way of the primary beam.Be sure to move the sensor wire out of the way of the primary beam before leaving the x-ray cubicle (or room) to press the exposure button.If the sensor is placed upside-down on the bite piece, the wire will be more difcult to keep out of the way of the primary beam. This could be a warning sign that the sensor is not in the holder correctly.***Elongation Lengthening of the image. Inadequate vertical angulation.Improper occlusal plane orientation because of patient positioning.Poor receptor placement.Increase the vertical angulation.The occlusal plane should be parallel to the oor.The receptor should be placed parallel to the tooth in the paralleling technique and as close to the tooth as possible (forming an angle with the tooth) when utilizing the bisecting angle technique.***Foreshortening Shortening of the image. Excessive vertical angulation. Improper occlusal plane orientation because of patient positioning.Poor receptor placement.Decrease the vertical angulation.The occlusal plane should be parallel to the oor.The receptor should be placed parallel to the tooth in the paralleling technique and as close to the tooth as possible (forming an angle with the tooth) when utilizing the bisecting angle technique.Bitewing Radiographs***Horizontal overlapping The interproximal areas of the teeth appear to be overlapping when they are not actually overlapped in the patient’s mouth.The central ray is not directed perpendicular to the receptor in the horizontal plane.The receptor is not placed parallel to the tooth or teeth in the horizontal plane.The beam should be aligned in the horizontal plane so that it is at right angles to the tooth and receptor.The receptor should be placed parallel to the tooth or teeth in the horizontal plane.***Collimator cutoff (cone cutting)A curved or straight radiopaque border representing an unexposed area on the image.The x-ray beam is not directed at the center of the receptor.Make sure to aim the central ray at the center of the receptor.If a bitewing tab is being used, the bite tab could be kept visible by asking the patient to smile and revealing the tab for better aim.The operator can keep a nger on the tab while positioning the PID and directing the central ray at the tab.A localizing ring can be used to help center the x-ray beam.***Improper receptor placement The entire desired area (tooth or teeth) does not appear on the image.Failure to center the receptor so that all desired structures are seen.Place the receptor so that its center is lined up with the recommended central area for that specic bitewing projection (e.g., 2nd premolar for the premolar bitewing).The patient fails to close completely on both sides (maxillary and mandibular) of the bite piece (Inadequate Closure).Make sure that the patient closes down on both sides of the bite piece when taking bitewings so that the maxillary and mandibular teeth are represented equally on the image.*Errors involving conventional (lm-based) radiography only**Errors involving digital radiography only***Errors involving conventional (lm-based) and digital radiographyNew York University College of Dentistry Radiology Department.TABLE A2Common Exposure Errors—cont’d 285APPENDIX A Common Error SummariesCommon Exposure Error Appearance Cause Remedy***Overexposed image (dense image)[Conventional and digital radiographic errors. However, dark images can be adjusted with contrast/density modications when utilizing a digital radiographic system.]Dark (dense) in appearance. Excessive exposure due to improper settings, including the size of the patient setting, conventional vs. digital setting, and exposure time setting.Check that all settings on the control panel are correct for each patient and exposure.*Double exposure Two images appear on one lm.Using the same lm packet for more than one exposure.Separate the exposed lms from the unexposed lms.When using a lm packet with a barrier envelope, remove the barrier envelope immediately after exposure so that it is easy to distinguish between the exposed and unexposed lms.***Blurred images Wavy or fuzzy image. Patient, receptor, or tubehead (PID) movement during exposure.Adjust the tubehead/arm to prevent vibration and drifting.Always keep an eye on the patient, especially when exiting the operatory.Ask the patient “not to move” before exiting the operatory.**When using a digital sensor with an attached wire, watch the wire for any movement that might indicate that the sensor moved inside the patient’s mouth.***Failure to remove dental appliances and facial jewelryRadiopaque (metal) images are superimposed on the image.Failure to ask the patient to remove any metallic objects from the mouth or facial area that may be in the way of the primary beam.For intraoral radiographs, remove any obstructive intraoral appliances, eyeglasses, and facial jewelry before exposure.For panoramic/extraoral radiographs, remove any obstructive intraoral appliances; facial, intra/extraoral and neck jewelry; hair accessories; and hearing aids before exposure.**Sensor cable artifact on a digital imageThe sensor cable wire is superimposed over the oral structures being imaged.Failure to move the wire (and its metallic components) out of the way of the primary beam.Be sure to move the sensor wire out of the way of the primary beam before leaving the x-ray cubicle (or room) to press the exposure button.If the sensor is placed upside-down on the bite piece, the wire will be more difcult to keep out of the way of the primary beam. This could be a warning sign that the sensor is not in the holder correctly.***Elongation Lengthening of the image. Inadequate vertical angulation.Improper occlusal plane orientation because of patient positioning.Poor receptor placement.Increase the vertical angulation.The occlusal plane should be parallel to the oor.The receptor should be placed parallel to the tooth in the paralleling technique and as close to the tooth as possible (forming an angle with the tooth) when utilizing the bisecting angle technique.***Foreshortening Shortening of the image. Excessive vertical angulation. Improper occlusal plane orientation because of patient positioning.Poor receptor placement.Decrease the vertical angulation.The occlusal plane should be parallel to the oor.The receptor should be placed parallel to the tooth in the paralleling technique and as close to the tooth as possible (forming an angle with the tooth) when utilizing the bisecting angle technique.Bitewing Radiographs***Horizontal overlapping The interproximal areas of the teeth appear to be overlapping when they are not actually overlapped in the patient’s mouth.The central ray is not directed perpendicular to the receptor in the horizontal plane.The receptor is not placed parallel to the tooth or teeth in the horizontal plane.The beam should be aligned in the horizontal plane so that it is at right angles to the tooth and receptor.The receptor should be placed parallel to the tooth or teeth in the horizontal plane.***Collimator cutoff (cone cutting)A curved or straight radiopaque border representing an unexposed area on the image.The x-ray beam is not directed at the center of the receptor.Make sure to aim the central ray at the center of the receptor.If a bitewing tab is being used, the bite tab could be kept visible by asking the patient to smile and revealing the tab for better aim.The operator can keep a nger on the tab while positioning the PID and directing the central ray at the tab.A localizing ring can be used to help center the x-ray beam.***Improper receptor placement The entire desired area (tooth or teeth) does not appear on the image.Failure to center the receptor so that all desired structures are seen.Place the receptor so that its center is lined up with the recommended central area for that specic bitewing projection (e.g., 2nd premolar for the premolar bitewing).The patient fails to close completely on both sides (maxillary and mandibular) of the bite piece (Inadequate Closure).Make sure that the patient closes down on both sides of the bite piece when taking bitewings so that the maxillary and mandibular teeth are represented equally on the image.*Errors involving conventional (lm-based) radiography only**Errors involving digital radiography only***Errors involving conventional (lm-based) and digital radiographyNew York University College of Dentistry Radiology Department. 286 APPENDIX A Common Error SummariesCommon Error/Cause Resultant Image Panoramic RemedyPatient positioned too far forward Upper and lower teeth are blurred and narrow; spinal column is superimposed on the ramus; premolars are overlapped.Patient’s teeth or edentulous ridges must be in proper anterior-posterior position on the bite block.Patient positioned too far back Upper and lower teeth are blurred and widened; increased ghosting of the mandible also appears.Patient’s teeth or edentulous ridges must be in proper anterior-posterior position on the bite block.Patient’s head tilted up; forehead too far back; chin is too far forwardUpper incisors out of focus; the radiopaque hard palate is superimposed over the apices of the upper teeth; condyles are off the image.The reference lines on the patient’s face, the Frankfort plane or the ala-tragus line, should be aligned parallel to the oor.Patient’s head tilted down; chin is back; forehead is forwardLower incisors are blurred; the radiopaque image of the hyoid bone is superimposed on the anterior part of the mandible; the superior portions of the condyles may be cut off the image; premolars are overlapped.The reference lines on the patient’s face, the Frankfort horizontal plane or the ala-tragus line, should be aligned parallel to the oor.Patient moved during exposure The part of the receptor being exposed at the time of movement appears blurred.Talk to patients prior to and, if possible, during exposure to remind them not to move.Patient failed to place the tongue on the roof of the mouthAn airspace is created that produces a radiolucent band below the palate and superimposed over the apices of the maxillary teeth.Remind patients to keep their tongue against the roof of their mouth during exposure.Patient does not sit or stand erect (patient is slouching)The spinal column causes a triangular radiopacity to be superimposed on the anterior teeth.Keep patient’s spine erect during positioning.Failure to remove metallic objects, such as dentures, jewelry (including facial jewelry), hair accessories, hearing aids, and eyeglasses from the face, head, neck, and mouthRadiopaque ghosting will appear on the opposite side and higher than the actual image with less detail and denition than the actual image and may obscure desired structures.Remove all metallic objects from the face, head, neck, and mouth regions before exposure.Lead apron placed above the level of the claviclesA large radiopacity will appear on the image. Keep the lead apron low on the patient (below the level of the clavicles); never use a thyroid collar.Film cassette slowing down because of patient contactBlack vertical band will appear on the image due to localized overexposure.Exposing the patient to unnecessary radiation.Position the patient carefully; make sure that the receptor will not contact the patient before actually exposing the projection (especially patients with large frames).Static electricity (conventional panoramic radiography only)Electrostatic artifact; black linear streaks resembling bare tree branches without leaves.Be careful not to pull lm quickly and forcefully out of box and not to rub lm on lm screens during lm loading, especially on cold/dry days.The operators should ground themselves and avoid friction that will produce static electricity.New York University College of Dentistry Radiology Department.Common Errors in Conventional/or Digital Panoramic RadiographyTABLE A3

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