Patterns of radiograph use in a population of commerically insured children

were calculated to identify high-risk, high-need patients: number of extractions, problem-focused evaluations, restorations, endodontic therapies, periodontic therapies, prosthodontic therapies, oral surgery codes, and orthodontic treatment codes.

^,

To balance the risks and benefits and to minimize radiation exposure the guidelines also suggest that decisions should be individualized (for example, by age, type of dentition, or whether it is a new patient or recall appointment) and always preceded by a clinical examination and review of patient history and caries risk.

^,

In agreement with the literature, we found that child age was associated with the number of radiographs obtained over time. The 0- through 5-year age group had the lowest number of radiographs regardless of the type of oral health care provider. This is expected, as younger pediatric patients only have primary dentition and, in many cases, because of spacing between primary teeth, the clinical examination allows for visualization of proximal contacts.

Thus, radiographs do not provide a clear benefit over visual examination for detection of carious lesions in most children younger than 6 years.

Many providers may also decide to postpone radiographs until a later age for patient comfort and owing to behavioral issues.

also using private dental insurance claims, found that GDs prescribed more panoramic radiographs in patients younger than 5 years, whereas PDs prescribed more for 7- through 8-year-olds, with no differences by provider in 9- through 18-year-olds. In our study, patients aged 6 through 12 years were also less likely to undergo panoramic radiography if seen by a GD than a PD, with provider type not being a factor for 13- through 18-year-olds. Obtaining panoramic radiographs more frequently in older children aligns with current guidelines, which state that these radiographs should not be recommended for routine care before eruption of the permanent mandibular first molars.

^,

The fact that GDs obtain them more frequently in younger children may be associated with issues concerning behavior management or the need to anticipate potential problems that could require early referral. On the other hand, it is unclear why 6- to 12-year-olds were more likely to undergo lateral cephalometric radiography if seen by a GD.

The 6- through 12-year age group had more radiographs prescribed by PDs, which is expected as contacts close and radiographs can facilitate interproximal caries diagnosis. The 13- through 18-year age group had more radiographs as prescribed by GDs, with no significant difference in number of radiographs ordered per visit by GDs and PDs. As pediatric patients gets older, GDs would tend to refer these patients less often to a PD and would feel more comfortable treating them in their office; this would increase the number of radiographs in this age group. Also, these patients are going to have a mostly permanent dentition, and the need for radiographs to assess proximal surfaces that are no longer visualized clinically increases in this age group.

These trends are similar to claims data from the Netherlands, in which PDs obtained more radiographs in children until 8 years of age, with no significant difference among providers for children aged 12 through 17 years.

A survey of GDs in England found that whereas 71% of respondents accepted the influence of high-risk factors (that is, multiple restorations, irregular attendance, and poor oral hygiene) in prescribing bite-wing radiographs, the influence of low-risk factors was less clear, with only good oral hygiene and few restorations perceived as relevant.

Also, fissure sealants were an influence in favor of radiography by almost one-third of dentists, even when radiographs are not indicated before placing a sealant.

Dentists were also influenced by patients’ opinions and by fear of legal consequences.

^,

As expected, endodontic therapies had the greatest increase in the rate of radiographs, as most of these procedures would require multiple radiographs.

However, the number of restorations did not reflect the need for radiographs. In fact, additional numbers of restorations slightly decreased the rate of radiographs per visit. This may be explained, in part, by the fact that restored teeth are unlikely to require radiographic follow-up evaluation in pediatric patients.

Factors more strongly associated with overprescription were

seeing patients after images were obtained, owning a panoramic and a cone-beam computed tomographic imaging system, and the belief that images should be obtained to screen for occult pathoses.

• ▪

  Data collected were based on claims of a single commercial insurance company (and how they reimburse for radiographs may also affect behaviors) and may not represent other segments of dental practice, for example, out-of-pocket payments and public insurance (Medicaid).

• ▪

  The number of radiographs obtained per age group is likely underestimated, as it is expected that poor-quality radiographs that are reobtained would not be submitted for insurance coverage.

• ▪

  Limitations in the available claims data affected factors that were assessed to determine clinical needs.

• ▪
  As we did not have access to sociodemographic data, it is not known how these factors may have affected the study outcomes. Similar limitations have been identified in other radiographic prescription studies.

  ¹⁰

  • Yepes J.F.
  • Powers E.
  • Downey T.
  • et al.

  Prescription of panoramic radiographs in children: a health services assessment of current guidelines.