Contemporary medico-legal dental radiology

Australian Dental Journal 2012; 57:(1 Suppl): 9–15

doi: 10.1111/j.1834-7819.2011.01653.x

Contemporary medico-legal dental radiology

B Wright*

*Barrister-at-Law, Brisbane, Queensland.

ABSTRACT

The advent of extraoral radiology in general dental practice has become more widespread since 2000, particularly withdigital systems. With this comes a range of medico-legal risks for dentists not adverted to previously.These risks include a higher than expected radiation dose for some surveys, and the risk of a ‘loss of a chance’ for apatient whereby the images may disclose pathology not diagnosed by general dental practitioners using OPG and CBVTradiology.Practitioners need to apply relevant legal principles in deciding which surveys to order and record, and also need toexplain to patients the dosages of the radiation that they will likely receive. Practitioners also need to assess whether theresultant survey ought to be interpreted by a radiologist to diagnose any wider pathology with which a generalpractitioner may not be familiar. Extra caution needs to be used in ordering high dose radiology in paediatric patients.Dentists should not assume patients fully understand the nature of CBVT and MCT, and its risks and benefits.Consideration ought to be given to the volume of CBVT ordered dependent on factors such as patient age, symptoms,history and procedural intent.

Keywords: Legal, radiography.

Abbreviations and acronyms: CBVT = cone beam volume tomography; MCT = medically computed tomography; OPG =orthopantomograms; TMJ = temporomandibular joint.

INTRODUCTION

Prior to 2000, general dental practice radiology waslargely limited to interpreting intraoral film-basedimages. It was normal practice for orthopantomograms(OPGs), lateral cephalography and temporomandibularjoint imaging using plane films or tomography to bereferred to specialist medical radiology practices, orteaching institutions. Some orthodontic practicesrecorded their own analogue images.

The introduction of affordable digital equipmentallowing sophisticated radiology, with advances insoftware for dental imaging in recent years has seenthe creation and growth in Australia of the dentalspecialty of dentomaxillofacial radiology. These ser-vices include acquiring and interpretation of intraoraldigital imaging, orthopantomography, medically-basedhelical scan computerized tomography (MCT) and conebeam volume tomography (CBVT).

Australian dental practitioners are licensed to bothcreate images as an oral radiographer and interpret asoral radiologists. This paper will address some legal

ramifications of ordering and interpreting images fordental practice and consent in relation to radiology.There are significant risks for patients from theradiation dose as well as benefits from relevantinformation to be gained from radiology, and boththese issues are particularly heightened with referenceto extraoral imaging, especially with CBVT.

The legal risk that attaches to the interpreter of largevolume tomography (typically for a general dentistusing CBVT) will be assessed and the minimization ofsuch risk for dental practitioners who own and operateCBVT equipment, interpret their own CBVT data setsand order extraoral radiography examinations will bediscussed.

Licences to take dental radiographs and possess oralradiography machinery vary in each state or territory ofAustralia. It is worth noting that the national healthpractitioner registration system did not (and perhapscould not) make arrangements for more consistentregulations in relation to possession and use ofradiology machines. The need to register with statebodies with very different regulations is a significant

ª 2012 Australian Dental Association 9

Australian Dental JournalThe official journal of the Australian Dental Association

impediment to the free flow of oral health practitionersfrom one jurisdiction to another. It is hoped that thisinconsistency will be diminished.

LEGAL NATURE OF RADIOLOGY

It is well accepted that when one decides to record aradiograph, despite the fact that there is no physicaltouching, exposing a patient to ionizing radiation canbe deemed to be an assault or battery.1 Because ionizingradiation is invisible, there is arguably a higher dutythat the practitioner must observe in relation toinforming patients about radiology compared to otherdiagnostic services.

Factors that increase this duty compared to otherdental treatment include: the extended period betweenexposure and any presenting pathology; patients’general lack of understanding about ionizing radiationand in particular dosages of different radiographs; therapid changes in technology with both decreases forsome dosages in dental radiology and increases in otherforms; and changes in the resultant recommendationsfor diagnostic protocols.

Unfortunately, as much of legal radiology processand direction comes from the USA, some Americanlegal terms have crept into the Australian health carelexicon. ‘Informed consent’ and ‘standard of care’ aretwo notable examples.

Informed consent is a term specifically disavowed byAustralian courts: ‘‘… the phrase ‘informed consent’ isapt to mislead as it suggests a test of the validity of apatient’s consent … Moreover, consent is relevant toactions framed in trespass, not in negligence. Anglo-Australian law has rightly taken the view that anallegation that the risks inherent in a medical procedurehave not been disclosed to the patient can only found anaction in negligence and not in trespass; the consentnecessary to negative the offence of battery is satisfiedby the patient being advised in broad terms of thenature of the procedure to be performed.’’2

By using the term standard of care, there is anerroneous suggestion that there is some omnipresent‘standard’ (perhaps more widely accepted because ofrecently introduced Practitioner Standards and Codesof Practice across various jurisdictions); but the truth issomething far less concrete.

The Bolam3 test as modified in Australia by commonlaw and legislation – basically the reference to widelyaccepted professional practice as a means of definingthe particularly appropriate level of care, with somestatutory and judicial limitations for extremes ofopinion – is what is used to establish a particularstandard in a particular individual clinical case wherenegligence is asserted in the delivery of treatment.

To remove any doubt, the standard of proceduralcare (as opposed to warning of material risks – such

as radiation dose) can only be decided with anexamination of the particular circumstances of eachclinical event. It is therefore meaningless to saythat, for example, an OPG survey is the ‘standardof care’.

In a situation where the proximity of a third molarapex to the inferior dental canal can be bettervisualized with CBVT prior to extraction, the decisionas to whether a CBVT ought to be ordered wouldsurely always be an example of practitioner applica-tion of knowledge and skill to the particularcircumstance. In such a circumstance, common sensewould dictate that a discussion ought to take placewith the patient as to the benefits of the extrainformation gained from the CBVT, compared withthe risk of the higher dose of radiation. Of course ifthe decision is made not to image with CBVT andthere is a paraesthesia that ensues after the removal ofthe tooth, the burden of proof in relation to causationwill still sit with the patient. But these questions areoften not legal questions. They are better answered byconsideration of what ought to be done for thepatient. Also, it is clear that merely recording a CBVTwill not stop the occurrence of a paraesthesia, it willpotentially merely give better information about howto avoid the outcome and give information that isuseful in deciding how to execute the extraction, orwhether to refer to a more experienced or specialistpractitioner. As radiation levels decrease with thisimaging compared to an OPG radiograph, the need toaddress the radiation issue decreases and there is morelikelihood that CBVT will be ordered. However, a fullvolume CBVT might not be appropriate if a smallvolume CBVT were available.

As CBVT becomes more widely available, there willbe instances where a patient may well ask why theywere not given an opportunity to have a three-dimensional CBVT radiograph.

Material risk

With similar particularity, valid consent to a radiolog-ical procedure can only be determined with theparticular procedure and particular patient in mind.To paraphrase Rogers v. Whitaker:2 ‘‘… a dentalpractitioner has a duty to warn a patient of a materialrisk inherent in the proposed treatment … a risk ismaterial if, in the circumstances of the particular case, areasonable person in the patient’s position, if warned ofthe risk, would be likely to attach significance to it(objective limb) … or … if the dental practitioner isaware or should reasonably be aware that the particularpatient, if warned of the risk, would be likely to attachsignificance to it (subjective limb) …This duty is subjectto the therapeutic privilege (meaning in instances wherethere is an emergency or other special situation).’’

10 ª 2012 Australian Dental Association

B Wright

Records

Radiological records belong to the practitioner providerwho recorded them or was responsible for recordingthem.4 In most cases this is the dentist or oralradiologist, or interestingly perhaps ultimately theowner of the practice, now that owners are notnecessarily practitioners – so that there may be amodern dichotomy of ownership and access.

Of course, now that much radiology is digital manypeople can apparently own, retain and control imagessimultaneously. No matter that multiple copies exist,ownership resides with the practitioner and provisionof copies need always be done with the provisions ofthe relevant privacy legislation firmly in mind. Requestsfor images ought to be provided only with a validsigned request or release form.

Radiographs – like all dental records – ought to bestored for at least 7–10 years past the age of 21, but thecommunity might well expect that permanent life-longretention of records is the norm. Although there is nolegal requirement to archive, rather than dispose ofrecords, in this digital age it is advisable to keep allrecords to assist with future treatment, to defend anynegligence claim, or to assist with a request for post-mortem identification.

Radiology versus radiography

Dentistry remains one of the health professions thatgenerally has the responsibility for requesting radiolog-ical studies, exposing the radiographs, and interpretingthe results, and finally making decisions based on theresults and interpretation. The specialty of dentomax-illofacial radiology has grown over the last 10 yearsthrough postgraduate training in dental schools inuniversities where specialist oral radiologists are trainedand who provide consultant services, usually in con-junction with specialist medical radiology practices.

Intraoral versus extraoral radiography

Dentists in general practice have always been respon-sible for the exposure and interpretation of intraoralradiographs, simply because referring these patients toradiological services would make the cost of dentistrymuch higher. Medical radiology services and theefficiency of their delivery is a significant constraint ingeneral dentistry. In fact, many dental procedures arecompletely dependent on intraoral radiology andimpossible to adequately perform without it; theseinclude endodontics, emergency pain relief and implanttherapies.

Extraoral radiology – at first principally OPGs –came to medical radiology imaging practices because ofthe Medicare rebate that attaches in certain circum-

stances on referral from dental practitioners to theprovision of OPG radiology reports.

OPG radiography and radiology and risk

In terms of dosage for dental imaging, the risks for filmand digital radiology are low compared to medicalradiography. It may be that after a discussion ofeffective dose for a digital OPG, no further discussionneeds to be held if the patient is satisfied with theexplanation in terms they can understand. A discussionof comparative doses to background radiation can beuseful. The benefit of the information that can begained by the low dose needs to be explained. Showingpatients a de-identified OPG image can also be veryhelpful in conducting an inclusive risk–benefit analysis.For the general dentist, the main medico-legal risk islack of diagnosis of pathology that may have been clearto an oral radiologist.

Whilst it is clear that examining intraoral radio-graphs for detection of decay or periodontal disease in aclinical practice requires a degree of experience andknowledge, often the radiographs are examined whilsttreating patients and not with the requisite time andappropriate viewing conditions allocated to the task.Radiographs ought to be reviewed with appropriatelighting and without interruption in the way thatradiologists examine radiographs. If intraoral radio-graphs are negligently read and give rise to an action innegligence (over-treatment of carious lesions, or failingto diagnose a lesion), the overall risk to the patient’sgeneral health is quite low and legal consequencescorrespondingly small. In addition, the ability to provea diagnosis as correct or otherwise from an intraoralradiograph – digital or film – is based on training thatall Australian trained dentists receive in radiographyand radiology for their undergraduate education.

When OPG radiographs are exposed and examined,the structures that are included for examination extendfar wider than the alveolar processes compared tointraoral radiological surveys. Specifically, the widertissues can involve malignancies and other pathologies.It seems obvious that unless dentists or radiologistsexamine the surveys and do so with appropriate timeand focus, there will be pathologies that will not bedetected and as such legal risks may arise. Obviously,some training in detecting these non-dental pathologiesought to be mandatory.

There is extraoral radiography and radiology trainingavailable in relatively few locations and the differentjurisdictions across Australia have widely differingrequirements for regulating equipment, licenses andinstallations. This seems driven by the fact thatalthough no Medicare rebate generally attaches to theOPG taken in private dental practice, the ability to seean image and interpret it instantly is a great benefit for



general practitioners. Many radiological imagingpractices do not provide digital images as they printfilms for interpretation, although this is changinggradually. Inevitably, the provision of the images froma radiologist on referral is such that there is a significantdelay from the time of referral to viewing of the image,and this will always remain at issue for general dentalpractitioners.

Non-OPG extraoral radiology

With the development of tomography, radiographic anddiagnostic services have expanded. Initially, CT scan-ners and other tomography were so expensive that theywere usually owned and operated by medical radiologyimaging businesses. The advent of relatively low-costCBVT, an increase in competition and an increase insales and marketing by dental companies, has led to thecurrent situation where dentists own and operate CBVTscanners. The principle medico-legal risks for practitio-ners operating these machines arise when radiationdoses are not fully explained to patients and when thepractitioner does not report on or consider the wholedata sets and wider areas of exposure, and limit theirinterest to the area in question. By way of example, if adentist wishes to place a single implant but capturesmuch more area, they should examine the wider areaand not simply the small space where the implant will beplaced. Often it is the case that the dentist does notknow the dosages the patient receives, and has notraining in diagnosing and reporting on the ‘non-dental’areas.

Dentists generally either refer patients to radiologyproviders or use their own machines (usually CBVT) torecord data sets and then review the dentally relevantsections of the data set. In machines with large volumecapacity, large doses of radiation can be delivered toprovide a whole of head exposure, but only a very smallamount of the data set might ever be examined andreported upon. In machines with lower volume oroperator-adjustable volume, the issues are less seriousbecause the data set is not as comprehensive, and alsothe dosage is much lower.

This raises the following issues to be resolved:(1) Whether the exposure of patients to large doses ofradiation is appropriate for the diagnostic purpose.(2) Whether dentists are responsible for the review of thewhole data set and are therefore additionally responsiblefor identifying and diagnosing all of the possible findingsthat are available as a result of that survey.(3) Whether dentists and patients know the receivedeffective dose from these machines and who is respon-sible for managing this in the minds of patients,regulators or tribunals.(4) Types of consent to be gained for OPG and CBVTsurveys.

(5) If responsibility is found to reside with dentists withextraoral machines, what minimization of the legal riskand improved patient outcomes can be effected.

Negligence

The two types of likely negligence claims that will arisefrom oral radiology relate to dosage and failure todiagnose.

Dosage

The tort of negligence is well understood by mostdental practitioners and patients. The aspects of the tortthat are perhaps most applicable in the current situationof dosage are causation, reasonable foreseeability andwarning of material risk.

The causation of an injury needs to be proven.Alternatively, the injury might well speak for itself inthat a dosage of radiation that is high initially, and ifrepeated, could give rise to a claim for damages. Whilstit would not be easy for a claimant to prove injury andcausation from CBVT diagnostic imaging, the likeli-hood would increase with paediatric patients andrepeat exposure patients. Australian courts have beenreluctant to give damages where causation is compli-cated in relation to a loss of a chance.5

The irrefutable fact is that the operation of CBVTwithout appropriate regulation and guidance will see ahigher dosage of radiation delivered to a patient base asa whole but more particularly to certain individuals.

The issue of reasonable foreseeability (and to someextent remoteness of damage) will be one of fact, andwill be determined by retrospective studies in thefuture. Currently, this is hard to determine and makesa successful suit more difficult.

In 1996 Webb et al. found that 50% of patientradiation exposure came from full body CT.6 O’Haresurmised that the availability of multislice CT has almostcertainly increased the potential for litigation, particu-larly in paediatric patients who have a two to three timesgreater likelihood of radiation induced cancer thanadults.7 Moss and Maclean surveyed 53 scanners andfound the effective dose varied by up to 36 fold.8 O’Harecites the lifetime mortality risk from a single CT to a one-year-old child has been held to be as high as 1:550.9

As to material risk and warnings, the wider questionof ionizing radiation dosages across a person’s circum-stances would be critical in discussing risk and thiswould include, but not be limited to, occupation andenvironmental considerations (long haul airline crew orradiographers would have a different risk profile to thatof a city office worker), diagnostic and therapeuticradiation history, and patient age and gender.

In cases of general CT radiology, the risks are greaterand the duty to inform is clearer. Cardinal et al.


B Wright

explored the issue of informing patients of risks andbenefits of radiological examinations: ‘‘In addition tothe need to educate patients, studies have underscoredthe need to better educate referring physicians, demon-strating that referring physicians often have limitedknowledge of the radiation dose and associated risksfor common radiologic examinations. This is unfortu-nate, for two reasons. First, this knowledge is relevantfor appropriate medical decision making in orderingradiologic examinations. Second, referring physiciansare well positioned to initiate patient education on therisks associated with these examinations. Referringphysicians often have good pre-existing relationshipsand well-developed lines of communication. They alsoshould understand the benefits of the radiology exam-ination they are ordering for particular patients andhave the opportunity to involve the patients in thedecision-making process further upstream. By the timepatient education can occur in the radiology depart-ment, a patient may have taken time off work and madea long trip to the radiology department, and completingthe examination may be a foregone conclusion.’’10

This is a practical application of the principle thatresponsibility for the damages that flow from such areferral do not necessarily sit singularly with theradiologist or the dentist. If a dentist refers a patientfor radiology for the investigation of pathology, themore serious the suspected pathology, the higher theduty there is to follow up and check that the patient didhave the referred investigation performed. There isAustralian authority that the duty of care to a patientextends much wider to the referral and even follow upof patients.11

Failure to diagnose

The issue of failure to diagnose in radiology can becharacterized as a loss of chance. However, that loss ofchance must be a matter of a determination ofprobability. In a case about failure to diagnose a breastcancer, it was held that: ‘‘A mere material increase inthe risk of injury followed by the eventuation of the riskin question is insufficient to establish causation. Theplaintiff must establish that it was probable that the riskcreated by the tortfeasor came home.’’12

In other words, for a loss of a chance, an increase inthe risk of a death from, for example, pathology whichwas undiagnosed from a CBVT, will not of itself beenough to prove that the failure to diagnose caused thepatient death. It must be more likely than not that thefailure to diagnose substantially caused the death.

However, does a dental practitioner have a respon-sibility to diagnose other pathology from a CT scan?Does the dentist take on that responsibility by orderinga CT scan that has a volume that is larger than the areaof interest?

Friedland’s paper contemplates most of these issues –albeit from a US perspective.13 It is of guidance and thesection on field of view, reproduced below, is appositeto questions of appropriate ordering and selection offield of view.

‘‘One of the issues raised by CBCT is just whichanatomical area of the jaws and head or neck should beincluded in a study. For example, assume one takes aCBCT scan of the fully edentulous maxilla for purposesof evaluating the feasibility of placing implants. Doesthe image provide sufficient coverage if the beam iscollimated (in the vertical) to include just the alveolarbone and only 2 to 3 mm superior to the sinus floor? Oris it necessary to include more of or perhaps even theentire sinus? The general principles of radiology dictatethat the taking of films be based on clinical indicationsand that examinations not be done as part of ‘a fishingexpedition’.’’

‘‘The rationale for this is to protect both theindividual patient’s and the public health from unnec-essary radiation. Thus, in the example above, if thepatient has no sinus symptoms and no sinus pathologyis suspected on clinical examination, there is not astrong argument for including the whole sinus. Theanswer to how large an area to cover also includes,however, the desires of the treating clinician, althoughthis should not generally override well-accepted prin-ciples of radiation hygiene. In the above example, someclinicians may insist on seeing all the way to the orbitalfloor. Further, some software programs require thatcertain anatomic landmarks be included since theprogram uses them as (anatomical) fiduciary markers.’’

‘‘It is also possible to collimate too narrowly, eitheraccidentally or by design, and thus to exclude structuresthat reasonably ought to be included. The issue ofpurposely collimating too narrowly is closely related tothe reading or interpretation of the films, an issuediscussed in depth below. CBCT machines are increas-ingly being marketed to private practitioners who arenot oral and maxillofacial radiologists. Companies’target market is especially orthodontists and practitio-ners who place dental implants. These practitionerstypically do not have sufficient training to interpret thefilms beyond the confines of their specialty or daily areaof practice. Some practitioners believe that one way toovercome the issue of interpretation is to collimatedown to the smallest area possible. For example, if anorthodontist does a CT to evaluate an impactedmaxillary canine, the idea would be to collimate thebeam to include just the tooth and nothing superior orinferior to it. The danger with this approach, however,is that one may miss pathology that is contributing tothe noneruption or impaction of the tooth. Similarly,when radiographing the temporomandibular joint(TMJ), if one were to collimate too narrowly, onecould potentially miss pathology that is not located



directly on or in the condyle or glenoid fossa, but that iscontributing to the TMJ problem. In principle, theanatomical area covered by a CT scan should be nodifferent than would have been covered by a plain-filmexamination. The extent of the examination should bebased on the patient’s symptoms and the findings onclinical examination.’’

Friedland also addressed the issue of responsibilityfor interpretation: ‘‘While there are no legal casesspecifically concerning the matter of the scope ofinterpreting a CBCT scan, the issue can fairly beregarded as settled. A CT is no different than any otherimage—a dentist cannot read only part of a panoramicfilm, or only part of a lateral cephalogram. Forexample, should an orthodontist miss an enlarged sellaturcica resulting from a tumor on a lateral cephalo-gram, the dentist reading the cephalogram cannot offeras an excuse in any legal proceeding that ‘I read onlypart of the film’ or ‘I read the film only as it relates tothe orthodontic diagnosis and treatment’. The dentist isobligated to read all of the film … Moreover, indetermining the standard of care, courts look to whatthe practice in the profession is, and as is evident fromthe editorial referenced above, the practice is to read allof the film. Courts are not likely to allow a lowerstandard of care than the profession demands of itself.’’

Whilst this is no doubt a fair assessment of the law inthe USA, it is by no means certain to be applied inAustralia. However, it would be likely to be ofsignificant influence and guidance. The issue of whetherpatient choice can be involved was also addressed.13

‘‘While patients may make treatment decisions, theirchoices are limited by the bounds of accepted standardsof care. No dentist would permit a patient to agree tofill only two canals on a molar tooth undergoingendodontic treatment and then to place a crownbecause the dentist is unable to navigate the third canalor because the patient can only afford to have twocanals filled. Such a scenario would call for a referral toan endodontist or foregoing the crown. The sameprinciples apply to the interpretation of films.’’

If it is accepted that dentists must ensure that after awide-area survey the patient has a complete diagnosis,and the dentist lacks the skills and experience toprovide this, it is logical that it be referred to an oral ormedical radiologist. In the USA, no national dentalregulations mean that radiology telemedicine is quitedifficult. No such barriers exist in Australia.

It has been established in the High Court case ofChappel v. Hart,14 that when making treatmentdecisions, there is a responsibility on the treatingpractitioner to advert as to whether the procedure (inthe present case, reading of a radiology image) in theparticular circumstances could not be better performedby a more experienced practitioner. As oral radiologistsbecome more prevalent, the onus to refer becomes

somewhat stronger. It may be the case that whether oneorders a CBVT survey for dental treatment or not, thepatient might well have a reasonable expectation tohave interpretation (of all the data available) performedas a matter of right – to reinforce the view of Friedland.

It would seem that if one refers a patient (and ⁄ or theirimage) to an oral radiologist, the responsibility for theexpertise in reading and interpreting that radiographresides with the radiologist. Of course, the wording of thereferral will be determinative of where the responsibilitylies for which structures and the interpretation of theimage in relation to those structures.

Digital and film radiography

In a case discussed by O’Hare, a misidentificationoccurred subsequent to a death as a result of mislabel-ling of film radiographs.15 A body was released whenidentification was not correct. The importance of thesecases is that manual labelling of film after the recordingof a radiograph is clearly more prone to error than theconventional digital system whereby a patient’s detailsare entered or selected prior to the exposure of theimage.

In addition, the dosages of a properly calibrated andoperated digital system are widely accepted to besignificantly lower than a comparable film system,16

despite some reported inconsistencies with systems(PSP v. Sensor) and the accommodation of changesby clinicians to digital systems.17

Increases in resolution in both sensors and monitorsmean that there is less reason to persist with film fordental intraoral procedures.

SUMMARY AND RECOMMENDATIONS

(1) Dentists who refer patients for CBVT and OPGsneed to explain the risks of radiation dosages.(2) Dentists who record OPGs and CBVT in their ownpremises with their own machines also need to explaindosages and risks, but with a higher duty than thosemerely referring.(3) Dentists who record OPG radiographs must takeresponsibility for all non-dental diagnosis from suchimages or alternatively have them assessed on referralby an oral radiologist or medical radiologist andinclude this cost in their estimate of fees to the patient.(4) Dentists who record small volume CBVT fordiagnostic purposes need to make assessments as towhether all of the data set and possible information hasbeen viewed and appropriately interpreted and whetherreferral to an oral radiologist is appropriate for viewingthe data set.(5) Dentists who record large volume CBVT (with novariable volume options) in their own premises withtheir own machines need to refer all data sets to an


B Wright

appropriate radiologist for review and include this costin their estimate of fees to the patient. These dentists areat most medico-legal risk.(6) Dentists should not order CBVT without appro-priate individual discussion of dosage related risks forall paediatric patients.(7) Dentists with their own CBVT machines ought notordinarily order or expose CBVT for paediatric patients.

REFERENCES

1. O’Hare WSJ. Medico Legal Radiology. Elsevier Australia,2007:17.

2. Rogers v. Whitaker (1992) 175 CLR 479.

3. Bolam v. Friern Hospital Management Committee [1957] 1 WLR582.

4. Breen v. Williams (1996) 186 CLR 71.

5. Tabet v. Gett [2010] HCA 12.

6. Webb DV, Solomaon SB, Thomson JEM. Background radiationlevels and medical exposure levels in Australia. Radiat ProtectionAust 2000;16:25–32.

7. O’Hare WSJ. Medico Legal Radiology. Elsevier Australia,2007:16.

8. Moss M, MacLean D. Paediatric and adult computed tomogra-phy practice and patient dose in Australia. Australas Radiol2006;50:33–40.

9. Brenner DJ, Elliston CD, Hall EJ, Berdon WE. Estimated risks ofradiation-induced fatal cancer from pediatric CT. AJR Am JRoentgenol 2001;176:289–296.

10. Cardinal JS, Gunderman RB, Tarver RD. Informing patientsabout risks and benefits of radiology examinations; a reviewarticle. J Am Coll Radiol 2011;8:402–408.

11. Tai v. Hatzistavrou [1999] NSWCA 306.

12. Sydney South West Area Health Service v. Stamoulis [2009]NSWCA 153.

13. Friedland B. Medicolegal issues related to cone beam CT. SeminOrthod 2009;15:77–84.

14. Chappel v Hart [1998] HCA 55.

15. O’Hare WSJ. Medico Legal Radiology. Elsevier Australia,2007:185–186.

16. Hayakawa Y, Shibuya H, Ota Y, Kuroyanagi K. Radiation dos-age reduction in general dental practice using digital intraoralradiographic systems. Bull Tokyo Dent Coll 1997;38:21–25.

17. Wenzel A, Møystad A. Work flow with digital intraoral radiog-raphy: a systematic review. Acta Odontol Scand 2010;68:106–114.

Brad WrightBarrister-at-Law

Bennett ChambersLevel 6

107 North QuayBrisbane QLD 4000

Email: [email protected]



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Contemporary medico-legal dental radiology