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Applying the Principles Applying the Principles of Interpretation:of Interpretation:The Radiology ReportThe Radiology Report

Applying the Principles Applying the Principles of Interpretation:of Interpretation:The Radiology ReportThe Radiology ReportThe Radiology ReportThe Radiology ReportThe Radiology ReportThe Radiology Report

Steven R. Singer, DDSSteven R. Singer, DDSsrs2@columbia.edusrs2@columbia.edu

Why?• It is the obligation of the doctor who

prescribes the radiographic examination to:– Evaluate the images for adequacy– Interpret the image– Record the findings in the patient

record in a timely manner

Why?• Further, the patient must be

informed of the findings in a timely fashion and provided with treatment options

Why?• What if you are unable to obtain the

prescribed images, such as panoramic, cephalometric, or advance imaging?– You may refer you patient to an

Oral & Maxillofacial RadiologistOral & Maxillofacial Radiologist.

Why?• What if you are unable to interpret

the images?– You may consult with an Oral &

ll f l d l Maxillofacial Radiologist. To maintain the integrity of the patient’s record, patient consent should be obtained first.

Why?• What if you are unable to provide the

appropriate treatment– You may refer the patient to a specialist

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How?• A standardized form may be used to

report your radiographic findings. Not surprisingly, it is call a Radiology RReport.

How?•• A radiology report must contain the A radiology report must contain the

following information:following information:– Patient name and or/unique identifier– Date of radiographic examination– Radiographs included in the examination

How?•• A radiology report must contain the A radiology report must contain the

following information:following information:– Radiographic observations of anomalies,

lesions and the result of disease processes lesions, and the result of disease processes. Also, restorations that may not be clinically obvious should be described in the report. Poorly restored teeth should be objectively described. These may include open margins, open contacts, long or short RCT fills, etc.

How?•• A radiology report must contain the A radiology report must contain the

following information:following information:– Descriptions of missing, tipped, rotated,

d d d h h ld b l d d and extruded teeth should be included. Unerupted teeth should be noted.

– Charting may be used, as appropriate

How?•• A radiology report must contain the A radiology report must contain the

following information:following information:– Radiographic Interpretation of your

f d h l f d findings. This is a list of diseases or conditions that caused the changes from normal anatomy that you have observed.

How?• Please remember that we do not see

disease, per se, on a radiograph. Only the lesions are seen. It is our

b h d f h job to use the descriptions of these lesions to formulate a differential diagnosis.

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How?• For example, one may see generalized

mild horizontal bone loss around the teeth. The disease that caused h l l d ld these lesions is generalized mild

marginal periodontitis.

How?• One must be extremely cautious in

limiting the interpretation to what is directly observable on the radiograph Therefore descriptions radiograph. Therefore, descriptions such as chronicchronic are generally not included, unless a second set of radiographs, exposed at a different time, is available.

How?• A systematic approach to reporting is

desirable. This will make the information more easily retrievable at a later time.

• You must interpret the entire exam not • You must interpret the entire exam, not just the Region of InterestRegion of Interest (ROIROI)

• All of your findings must be recorded.

FMS 1

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FMS 2

42 42

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FMS 3

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43

FMS 4

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