Research

The Dental Specialist’s Cost-Benefit Analysis Of Referring A CBCT To An Oral And Maxillofacial Radiologist

Joshua J Orgill,DDS, Oral and Maxillofacial Radiology Resident, The University of Iowa College of Dentistry
joshua-orgill@uiowa.edu  
Contribution: Conception of the idea and design of the work, acquisition, analysis, and interpretation of the data. Drafting the manuscript and overseeing the completion..
Suvendra Vijayan,BDS, MS, MPH, Assistant Professor, University of Pittsburgh School of Dental Medicine
suvendrav@gmail.com   phone: 319-335-9656   fax: 319-335-7351
Contribution: Conception of the idea of the work, analysis, verification of data analysis, drafting, editing, and approval of final draft..
Sindhura Anamali,B.D.S, M.S, Assistant Professor, The University of Iowa College of Dentistry
sindhura-anamali@uiowa.edu   phone: Conception of the idea of the work, analysis, verification of data analysis, drafting, editing, and approval of final draft.   fax: 319-335-7351
Contribution: Analysis and interpretation of the data, revising and editing drafts, and approving final manuscript..
Veeratrishul Allareddy,BDS, MS, Professor, The University of Iowa College of Dentistry
veeratrishul-allareddy@uiowa.edu   phone: 319-335-9656   fax: 319-335-7351
Contribution: Conception of the idea and design of the work, acquisition, analysis, and interpretation of the data. Revising, editing, and approval of final draft..

Address for correspondence

Joshua J Orgill, DDS
Email : joshua-orgill@uiowa.edu
Address : The University of Iowa College of Dentistry 801 Newton Road Iowa City, IA 52242-1010

Published on : 24 Jan 2019

INTRODUCTION:

Cone beam computed tomography (CBCT) is well-established as a useful diagnostic and treatment planning tool in dentistry. Much attention has been given to selection principles for use of CBCT, incidental findings on CBCTs, and who should be interpreting the CBCT scans. This discussion on who should be interpreting the scans, which has taken place over the past 10 years, has focused on incidental findings and the difficulty of detecting and properly identifying them. The major concern of incidental findings is those which are found outside the jaws in areas less familiar to dentists. A systematic review by Edward et al. found that 85.3% of incidental findings were outside the dentition and associated alveolus region and concluded that “complete and proper review of the entire image, regardless of field of view or region of interest” is emphasized by their findings 1 . Studies have shown incidental findings rates as high as 93.4% with up to 3.2 incidental findings per CBCT scan 2 . Studies have also shown that 45.9% - 56.52% of incidental findings required monitoring, follow-up, treatment, or referral 3 4 . The necessity for complete and experienced review is further emphasized by Warhekar et al. which found in their review of 795 cases that 11 (1.4%) of the cases had an oral malignancy as an incidental finding 5 . The ADA council on Scientific Affairs issued an advisory statement in 2012 stating that “the complete image data set must be interpreted by an appropriately qualified health care provider” and that a “thorough radiological report” be provided to the prescribing provider if referred or that the findings be entered into the patient record if interpreted by prescribing provider 6 . Then there is a question of who is qualified to interpret the entire CBCT scan. A study done by Allareddy et al. demonstrates the need for a thorough knowledge of potential findings as they described 76 different conditions visualized in 1000 CBCT scans 7 . Even so, this is a controversial question that has not been resolved and seems that it will continue for some time more. Each dental specialist differs in their knowledge and experience with CBCT interpretation and thus differs in their comfort and ability. This study is not discussing the issue of who is qualified or who is not qualified to read CBCT scans but rather limits itself to the cost benefit advantages of referring to an Oral and Maxillofacial Radiologist. A common argument made by dental specialists is that they lose money each time they refer a CBCT scan out to an Oral and Maxillofacial Radiologist for interpretation. Upon our examination of the literature we found no research in the literature that explores this question. This and questions like it are especially valuable to explore as CBCT continues to become more used by dental specialists who already face an increasing workload and responsibility. Thus, the purpose of this paper is to determine the cost- benefit advantage if any of each dental specialty for referring to an Oral and Maxillofacial Radiologist versus interpreting CBCT scans on their own.

METHODS:

Data for annual gross billing and annual hours worked for each dental specialist were obtained from the American Dental Association’s (ADA) Health Policy Institute 2016 Survey of Dental Practice which was published in January 2017 8,9 . The average fee for private practice Oral and Maxillofacial Radiologists and the time spent on an average interpretation was obtained through a survey of 15 different Oral and Maxillofacial Radiologist service providers or companies which offer such service. Average hourly production for each dental specialty was calculated from the annual gross billing and annual hours worked data. The hourly fee for an Oral and Maxillofacial Radiologist was calculated based on the average fee and time spent per CBCT scan. A comparison of production verses fees paid for Oral and Maxillofacial Radiologist interpretation based on an hourly rate were calculated and results of adjusted gross earnings was reported. From these results, the difference in earnings between referring and not referring to an Oral and Maxillofacial Radiologist were then calculated and reported as savings with referral. (Figure 1)

RESULTS:

Data from the ADA’s Health Policy institute 2016 Survey of Dental Practice was used and the total hourly production for each of the dental specialists was calculated based on the “Gross Billing Per Dentist for Owner Specialists in Private Practice” data and the “Average Hours per Year in the Dental office for the Primary Private Practice of Dentists, by Employment Situation” under “All owners” heading for hours worked per year data 8,9 . The average “gross billings per dentist for owner specialists in private practice, 2015” for each specialty is as follows: Oral and Maxillofacial Surgeons is $1,408,990; Endodontists is $834,340; Orthodontists is $910,540; Periodontists is $962,530; and Prosthodontists is $908,710. The “Average Hours per Year in the Dental office for the Primary Private Practice of Dentists, by Employment Situation” under “All owners” is 1,703.9. This information was combined and the average hourly gross billing for each specialty was calculated. The ADA’s survey defined gross billings as “gross billings per dentist.” The average hourly gross billing for each specialty is as follows: Oral and Maxillofacial Surgeons is $826.92; Endodontists is $489.72; Orthodontists is $534.39; Periodontists is $564.90; Prosthodontists is $533.31. The average time spent per CBCT scan by an Oral and Maxillofacial Radiologist is 20 minutes which results in an average of 3 CBCT scans interpreted per hour, as reported by phone survey. The average fee per CBCT scan by an Oral and Maxillofacial Radiologist is $85, obtained by an internet search. Combined, the total fee for 1 hour, or 3 scans, referred to an Oral and Maxillofacial Radiologist is $255. The average hourly gross billings were then used with the average hourly fee for an Oral and Maxillofacial Radiologist and the adjusted gross hourly earnings were calculated. The hourly adjusted gross earnings for each specialty is as follows: Oral and Maxillofacial Surgeons is $571.92; Endodontists is $234.72; Orthodontists is $279.39; Periodontists is $309.90; Prosthodontists is $278.31. The adjusted gross hourly earnings describes the dollar value that a dental specialist is able to produce during an average hour less the hourly fee for an Oral and Maxillofacial Radiologist. The adjusted gross hourly earnings for all dental specialists that do not refer out CBCT scans is $0. This is determined by $0 production from specialist specific patient care and an Oral and Maxillofacial Radiologist fee of $0, since no referral was made. Thus, the adjusted gross hourly earnings for referral to an Oral and Maxillofacial Radiologist is the same amount as the difference of earnings between referring and not referring CBCT scans to an Oral and Maxillofacial Radiologist and is referred to, in this paper, as savings with referral (see Figure 1). The Oral Surgeon that refers 3 CBCT scans to an Oral and Maxillofacial Radiologist will have an average earning of $571.92 more than the Oral Surgeon that self-interprets 3 CBCT scans and thus has a $571.92 savings with referral. The following is a presentation of scenarios based on a dental specialist that makes around 1 CBCT scan per day (24 per month) over the space of one month and one year and the associated adjusted gross earnings described as savings (see Figure 2). For the Oral and Maxillofacial Surgeon that makes 24 CBCT scans per month saves $4,575.36 per month while saving $54,904.32 each year (see Figure 3). For the Endodontist that makes 24 CBCT scans per month saves $1,877.76 each month while saving $22,533.12 each year. For the Orthodontist that makes 24 CBCT scans per month saves $2,235.12 each month while saving $26,821.44 each year. For the Periodontist that makes 24 CBCT scans per month saves $2,479.20 each month while saving $29,750.40 each year. For the Prosthodontist that makes 24 CBCT scans per month saves $2,226.48 each month while saving $26,717.76 each year (see Table 1).

DISCUSSION:

With nearly 800 CBCT machines sold in the U.S. each year 10 , there are a lot of questions dental specialists are asking about how to deal with the interpretation of the CBCT scans. In the literature there are several studies that show the importance of reviewing the entire CBCT scan due to the high number of incidental findings reported in scans of normal patients without any known pathosis in the regions of interest. Just a few of these studies have already been presented in the introduction of this paper. These previously described studies and many other studies have all come to the same conclusion that “it is essential that a person trained in advanced interpretation techniques in radiology interprets cone beam computed tomography scans” and that there is an undeniable “need for complete reporting of the data set.” 1,2,4,6,7,11-16 Thus, there is no longer a need for discussion about the necessity and obligation to review the entire CBCT scan. The ADA council on Scientific Affairs 2012 advisory statement stating the necessity of such a complete examination and reporting of such examinations was preceded by the 2008 executive opinion statement given by the American Academy of Oral and Maxillofacial Radiology which states “The practitioner who operates a CBCT unit, or requests a CBCT study, must examine the entire image dataset.” 16 The question that is most hotly debated is who should be interpreting the CBCT scans. The advisory statement issued by the ADA council on Scientific Affairs noted that “formal standards for CBCT training and education” was beyond the scope of that statement and stated this question would be shared with “the Commission on Dental Accreditation and other educational groups for consideration.” 6 The executive opinion statement given by the American Academy of Oral and Maxillofacial Radiology states that the “dentist using CBCT should be held to the same standards as board-certified oral and maxillofacial radiologists, just as dentists excising oral and maxillofacial lesions are held to the same standards as OMF surgeons.” 16 Considering the high rate of incidental findings there is evidence to support the need for experienced and knowledgeable interpretation of CBCT scans. In support of this, the Academy of Osseointegration reported in their clinical practice guidelines which were published in 2016 found that 88.37% of respondents felt that “Referral to a person who is trained in advanced interpretation techniques in radiology may be necessary.” 17 There is no doubt that Oral and Maxillofacial Radiologists are experts in the field of dental diagnostic image interpretation. The standards and training requirements set by CODA for Oral and Maxillofacial Radiology residencies in the United States and Canada attest to that, as do the standards set by CODA for each of the other 8 recognized dental specialties attest to their expertise in their respective areas. The question that has yet to be discussed with any formal investigation is the financial aspect of referring CBCT scans for interpretation to an Oral and Maxillofacial Radiologist. The findings of this study show that there is a significant cost savings for all dental specialists, especially for the Oral and Maxillofacial Surgeons. Therefore, the discussion of what to do for interpretation of CBCT scans should also consider the financial aspect. All dentists would agree that money should not dictate treatment. But when it comes to referring CBCT scans to an Oral and Maxillofacial Radiologist this study now provides evidence that saving money actually comes with high quality of care. Thus, this scenario of referral provides a double benefit of significant savings while maintaining the highest quality of care. The savings seen is independent of the referring dental specialists’ ability and knowledge of CBCT interpretation. This independence in a specialist’s ability to interpret CBCT scans was maintained in this study by using the same time for interpretation of CBCT scans for both the specialist and the Oral and Maxillofacial Radiologist in calculating production loss. This establishes the interpretation time for each dental specialist at the same level as the Oral and Maxillofacial Radiologist. Thus, the argument against referring CBCT scans to an Oral and Maxillofacial Radiologist based on perceived financial losses due to the associated interpretation fee appear to be unfounded.

CONCLUSIONS:

The findings of this study can now be combined with those of other studies to provide a more complete and informed assessment of how to handle the interpretation of CBCT scans. With the findings of the significant cost-benefit savings for each dental specialist, combined with the advanced training and knowledge that Oral and Maxillofacial Radiologists have of CBCT scans, the referral of CBCT scans to an Oral and Maxillofacial Radiologist for interpretation has clear advantages. Thus, independent of a dental specialist’s ability to interpret CBCT scans, each dental specialist stands to lose a significant amount of production each hour spent on proper interpretation of CBCT scans when other specialist specific tasks could be performed. Combining this with the reduction in liability, the referral of CBCT scans to an Oral and Maxillofacial Radiologist is an efficient and cost-effective means of interpretation of CBCT scans for all dental specialist. Any chance of bias was minimized by using the ADA’s survey for the data on the income and hours worked for each of the dental specialists reported. The data collected for Oral and Maxillofacial Radiologist fees and interpretation time was collected from survey of 15 Oral and Maxillofacial Radiologists rather than relying on the information and opinion from one or two Oral and Maxillofacial Radiologists. Future studies looking at this same information might include a survey of all Oral and Maxillofacial Radiologists for a more representative and more accurate data on fees and interpretation time.

References:

  1. Edwards R, Altalibi M, Flores-Mir C. The frequency and nature of incidental findings in cone- beam computed tomographic scans of the head and neck region: a systematic review. The Journal of the American Dental Association. 2013;144(2):161-170.
  2. Price JB, Thaw KL, Tyndall DA, Ludlow JB, Padilla RJ. Incidental findings from cone beam computed tomography of the maxillofacial region: a descriptive retrospective study. Clinical oral implants research. 2012;23(11):1261-1268.
  3. Drage N, Rogers S, Greenall C, Playle R. Incidental findings on cone beam computed tomography in orthodontic patients. Journal of orthodontics. 2013;40(1):29-37.
  4. Barghan S, Tahmasbi Arashlow M, Nair MK. Incidental Findings on Cone Beam Computed Tomography Studies outside of the Maxillofacial Skeleton. International journal of dentistry. 2016;2016.
  5. Warhekar S, Nagarajappa S, Dasar PL, et al. Incidental findings on cone beam computed tomography and reasons for referral by dental practitioners in indore city (mp). Journal of clinical and diagnostic research: JCDR. 2015;9(2):ZC21.
  6. Affairs ADACoS. The use of cone-beam computed tomography in dentistry: an advisory statement from the American Dental Association Council on Scientific Affairs. The Journal of the American Dental Association. 2012;143(8):899-902.
  7. Allareddy V, Vincent SD, Hellstein JW, Qian F, Smoker WR, Ruprecht A. Incidental findings on cone beam computed tomography images. International journal of dentistry. 2012;2012.
  8. Association AD. Income, gross billings, and expenses: selected 2015 results from the survey of dental practice (tables in excel). Chicago, IL: Health Policy Institute. 2017.
  9. Association AD. Characteristics of private dental practices: Selected 2015 results from the survey of dental practice (tables in excel). Chicago, IL: American Dental Association. 2017.
  10. Akash A. Global CBCT Dental Imaging Market is Expected to Reach USD 817.5 Million by 2023 with a CAGR of 9.8%. 2017; http://www.prnewswire.com/news-releases/global-cbct-dental- imaging-market-is-expected-to-reach-usd-8175-million-by-2023-with-a-cagr-of-98- 300444090.html.
  11. Çaglayan F, Tozoglu Ü. Incidental findings in the maxillofacial region detected by cone beam CT. Diagnostic and Interventional Radiology. 2012;18(2):159.
  12. Edwards R, Alsufyani N, Heo G, Flores-Mir C. The frequency and nature of incidental findings in large-field cone beam computed tomography scans of an orthodontic sample. Progress in orthodontics. 2014;15(1):37.
  13. Lopes IA, Tucunduva RM, Handem RH, Capelozza ALA. Study of the frequency and location of incidental findings of the maxillofacial region in different fields of view in CBCT scans. Dentomaxillofacial Radiology. 2016;46(1):20160215.
  14. Pette GA, Norkin FJ, Ganeles J, et al. Incidental findings from a retrospective study of 318 cone beam computed tomography consultation reports. International Journal of Oral & Maxillofacial Implants. 2012;27(3).
  15. Rogers SA, Drage N, Durning P. Incidental findings arising with cone beam computed tomography imaging of the orthodontic patient. The Angle orthodontist. 2011;81(2):350-355.
  16. Carter L, Farman AG, Geist J, et al. American Academy of Oral and Maxillofacial Radiology executive opinion statement on performing and interpreting diagnostic cone beam computed tomography. In: Mosby; 2008.
  17. Stanford CM. Academy of Osseointegration's Summit on Clinical Practice Guidelines for the Edentulous Maxilla: Overview, Process, and Outcomes--Changing the Face of Implant Dentistry. International Journal of Oral & Maxillofacial Implants. 2016;31.

Figure 1

Graph shows the savings of CBCT referral which is determined by the difference of the hourly gross billing when referring to an Oral and Maxillofacial Radiologists vs self-interpreting CBCT scans.

Figure 2

Formula demonstrating how calculations were done for hourly, monthly, and annual savings with referral vs self-interpretation using average hourly production and average Oral and Maxillofacial Radiologist fees for CBCT interpretation.

Figure 3

Example calculations for hourly, monthly, and annual savings with referral vs. self- interpretation for Oral and Maxillofacial Surgeons.

Table 1

data for each specialist includes annual gross billing, hourly gross billing, hourly savings with referral, monthly savings, and annual savings with referral. The savings with referral is the difference of gross billing when referring to an Oral and Maxillofacial Radiologists vs self-interpreting CBCT scans. Monthly and annual savings with referral is based on 24 CBCT scans per month.

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