Articles and Position Statements
AADC Position Statement: Cone Beam Computer Tomography

Cone Beam Computer Tomography

Position Statement

Introduction

Recently there has been an increased interest in the field of CBCT as evidenced by articles in contemporary journals, adoption of new CDT Codes to reflect the data gathering and interpretation of images, general discussion in the industry about when and where the procedures are most appropriate, as well as the risk versus benefits of the procedures. AADC Position Committee decided to do a search of the literature to answer some questions. Specifically:

1. Does there exist at the present time sufficient data to establish a cost/benefits analysis as to radiation risk?

2. Is there a need for the technology in dentistry and if so is it a generalized or specialized need?

3. Does CBCT have a role in routine diagnostics?

4. Are there unintended consequences, such as establishing an unnecessary high bar as Standard of Care?

5. Is there sufficient understanding surrounding the risk of liability for any failure to identify possible pathology in the interpretation of CBCT images?

Methods

Sixty-one articles were reviewed using Medline as a resource. Many of these referenced articles gathered by the Cochrane Institute and so were judged to meet the criteria of the Committee; i.e. large population studies with double blind conditions when appropriate and longitudinal consequence long enough to provide meaningful data. One interesting article from November 2012 provided data from a survey of dental schools in the US, Great Britain, and Australia about dental students and graduate dental students who received training in CBCT. Several articles dealt with various applications of the technology and a few centered on the subjects of cost and radiation in an effort to provide standardization.

This paper will attempt to organize those papers to establish a position of standards, suggested usage, and next steps toward implementing the technology into the dental delivery system.

Background

Cone Beam Computed Tomography (CBCT) is a medical imaging technique consisting of x-ray computed tomography where the x-rays are divergent, forming a cone. During the CBCT scan, the scanning machine rotates around the patient’s head, obtaining hundreds of distinct images. The specialized scanning software collects the data and reconstructs it producing 3-dimensional anatomical data that can be manipulated and visualized with specialized software58.

Articles concerning dental application for CBCT began in 2005 with a significant article from Canada describing the technique published in 200657. Initial interest was in use of CBCT as an adjunct to placement of implants. From the beginning there were economic concerns over the advantage of CBCT versus conventional 2-dimensional images. In medicine the comparable discussion centered on the advantages over conventional CT scans. In both cases there arose serious concerns over whether the newer technology offered significant advantages.

A 2011 study showed that 89% of dental schools in the United States offered training in the use of CBCT. Fewer (62.5%) of schools in the UK and only one (14%) school in Australia offered training8. In all three countries, much of the training was directed to graduate studies. It is clear that more training in the use and interpretation of CBCT imaging should be included in dental schools both at the undergraduate dental school and graduate dental school curricula. This should be accomplished before more expanded use of this technology can be properly accomplished.

Regardless, the technology was there, and soon dentistry began to search for applications. First was whether there was more precise information for implant placement by using a 3D image18, 22, 30, 31, 33, 38, 40, followed shortly by Periodontists searching for more precise results from sinus lifts11, 14. Soon Endodontists were looking for applications in repairing root fractures, finding hidden canals, and facilitating apical surgery2, 13, 32, 49, 50. Orthodontists followed, looking for bone density, precise screw placement, facilitation of impacted canine eruption and other related issues4, 24, 25, 28, 41, 56.

Although the Oral and Maxillo-Facial Surgeons were familiar with the medical applications of the technology and the potential value in implant placement, they began to find more specific dental applications, such as: variance in stab wound damage to cortical or cancellous bone, placement of zygoma implants, and treatment of cleft lip and palate3, 12, 15.

The search for applications of CBCT are far-ranging across many disciplines and in many countries39, 16, 31, 35, 19. Clearly we need to see what data is available from this growing list of CBCT use. It would seem prudent to have more science before we rush to find more applications for the technology.

Evaluation

A review of the literature on this topic was less a study in the efficacy of the procedure than an opportunity to determine what effect the technology will have on how common procedures are being performed. Four basic questions arose:

1. Is there sufficient data to determine a cost/benefit analysis25?

2. Has the liability for possible diagnostic errors been evaluated?

3. Is there evidence that the technology demonstrates a new “gold standard” for use in common procedures7, 17, 27, 42, 51, 55?

4. Has enough data been collected to establish radiation dosage standards or implementation standards20, 23, 34, 44, 53?

From our review we would have to say the answer at this point in time to all four questions would be “No.” Several authors led us to this conclusion: Christianson in more than one paper argues that a dentist’s desire to embrace new technology should be tempered by a comfort level or discomfort level with how he or she is performing the procedure with current technology42, 51, while other authors take an opposing, but cautiously so, view7. Many of the articles confined themselves to descriptions of the applications rather than conclusions as to their value.

The Committee also felt that it might be premature to support applications since that might imply their acceptance and have an unintended consequence of setting a Standard of Care, which would negatively affect Access to Care by requiring special training or special procedures in placing implants, providing orthodontic care, or even providing dentures, all procedures which are commonly provided at the present time without CBCT.

Conclusions and Recommendations

1. A Cost/Benefit analysis remains elusive. Questions arise even as to what actually defines the Current Dental Terminology codes and who would provide them.

2. What procedures and diagnostic imaging are currently available and adequate for routine use? Is CBCT necessary for most procedures?

3. As with most dental procedures what is likely to evolve will be a variation in the tools and technology individual dentists will use in the delivery of dental care: Choices will be made using the criteria of what is in the interest of the patient concluded from Evidenced-based Dentistry and Best Practices, what is most cost-effective to achieve the desired result, and what meets the needs and desires of the patient.

4. Radiation is a continuing concern to both the profession and the public as we have seen in the now expanded use of digital radiography. Caution should be the watchword and unnecessary risk should be a major factor before embracing this technology.

Position

Given the preponderance of evidence, it is the position of the AADC that CBCT imaging is not indicated for routine diagnostic imaging for dental procedures, as an improvement over current procedures. At the present time, CBCT imaging should be considered and reserved for situations where other existing imaging techniques are not adequate and only CBCT can clearly demonstrate the anatomy, when diagnostically difficult situations may directly affect treatment options. However, dental schools should strive to educate undergraduate dental and graduate students in the use and applications of the technology, so that they may take an intelligent position as to how to incorporate the technology in their practice.

Reference

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AADC Positions Committee

Michael DL Weisenfeld, DDS, Chair

Dee FitzGerald, DDS, Principal author

Andrew Mogelof, DDS

Cary Sun, DDS

Marc Zweig, DDS

Stephanie Lepsky, DDS

Robert Sherman, DDS