DR Rushton PDF

Workshop on dental Cone Beam CT SEDENTEXCT
Justification of CBCT
and Guidelines for
Clinical Use
Dr. Vivian E. Rushton
Clinical Guidelines
Systematically developed
statements to assist practitioner
and patient decisions about
appropriate healthcare for
specific clinical circumstances
(Field and Lohr 1990)
Systematic Review Process
Structured process involving several
steps:
1. Well formulated question
2. Comprehensive data search
3. Unbiased selection and abstraction
process
4. Validity assessment of papers
5. Synthesis of data
Evidence Based Practice
4
Implement findings
Formulate
answerable
question
Find evidence
Evaluate
performance
Appraise
for validity
and
usefulness
Clinical
decision
Information
need
Further research
required
systematic reviews
Why are guidelines needed?
A useful investigation is
one in which the result
positive or negative will
inform clinical
management and/or add
confidence to the
clinicians diagnosis
Justification
Relates to Council Directive
97/43/Euratom
Scope and definition of
justification greatly expanded
in the Directive 97/43/ Euratom
of 3rd June 1997
Justification forms the basis of
all EU documents relating to
the use of ionising radiation
It is probable that there are significant justification
problems in radiological practice in the developing
world. In the West , recent studies indicate that > 20% of
examinations may not be appropriate; this can be as high
as 45% in special cases , and up to 75% for specific
techniques
JUSTIFICATION
All exposures must be justified and
recorded
Justification requires that the patient
receives a net benefit from the x-ray
examination
Radiography of patients prior to clinical
examination can NEVER be justified

All CBCT examinations must be justified on
an individual basis by demonstrating that
the benefits to the patients outweigh the
potential risks. CBCT examinations should
potentially add new information to aid the
patients managements
ED BP

CBCT should not be selected unless a
history and clinical examination have been
performed. Routine imaging is
unacceptable practice
ED BP
Why Referral Criteria?
CBCT equipment was being used in
clinical practice without the benefit of
referral criteria initially
Local referral criteria were adopted in
some hospitals
Concerns expressed regarding the use of
CBCT especially in children
Priority given to derive referral criteria

When referring a patient for a CBCT
examination, the referring dentist must supply
sufficient clinical information (results of a
history and examination) to allow the CBCT
Practitioner to perform the Justification
process
ED BP
Consensus Guidelines of the European Academy of
Dental and Maxillofacial Radiology
Section 3.3: The Basic Principles
AIMS and OBJECTIVES
To collect and analyse relevant published
material and any published guidelines relating
to cone beam computed tomography
To develop evidence based guidelines on the
use of CBCT in dentistry including referral
criteria, quality assurance guidelines and
optimisation strategies
Methodology
Methodology was previously detailed in
the Interim Guidelines
Published guidelines on CBCT obtained
for France , Denmark, Germany and
Norway and reviewed by the Panel
Grading Systems used for levels of
evidence
Grade
A
At least one meta analysis, systematic review, or RCT rated as 1++,
and directly applicable to the target population; or a systematic
review of RCTs or a body of evidence consisting principally of studies
rated as 1+, directly applicable to the target population and
demonstrating overall consistency of results
B
A body of evidence including studies rated as 2++, directly applicable
to the target population, and demonstrating overall consistency of
results; or extrapolated evidence from studies rated as 1++ or 1+
C
A body of evidence including studies rated as 2++, directly applicable
to the target population, and demonstrating overall consistency of
results; or extrapolated evidence from studies rated as 2++
D
Evidence level 3 or 4; or extrapolated evidence from studies rated as
2+
GP Good practice ( based on clinical expertise of the guideline group)
Safety and Efficacy of a New and
Emerging Dental X-ray Modality
www.sedentexct.eu
2008-2011
.... is the acquisition of
the key information
necessary for sound and
scientifically based
clinical use of dental
Cone Beam Computed
Tomography (CBCT)
.....to use the information
to develop evidence-
based guidelines dealing
with justification,
optimisation and referral
criteria ....... for users of
CBCT
Diagnostic Accuracy
Hierarchical model proposed by Fryback and
Thornbury, 1991
Technical efficacy
Diagnostic accuracy efficacy
Diagnostic thinking efficacy
Therapeutic efficacy
Patient outcome efficacy
Societal efficacy
Clinical applications
Restoring the dentition
Caries detection
Periodontology
Periapical pathosis and endodontics
Surgical applications
Exodontia
Implant Dentistry
Bony Pathoses
Trauma
Orthognathic Surgery
The developing jaws and
dentition
Impacted teeth
Cleft palate
Routine orthodontics
Recommendations of the
Systematic Literature Review
Restoring the dentition
Caries detection
Periodontology
Periapical pathosis
and endodontics
Implantology
Images from Tsuchida et al (2007) Oral
Surg 2007; 104:412-416
Caries detection: Approximal
Studies included used a valid reference
(index) standard
Seven studies of proximal caries: Tsuchida
et al.,2007; Haiter-Neto et al.,2007; Young et al.,2009;
Qu et al., 2010; Kayipmaz et al., 2010; Senel et al.,
2010; Zhang et al., 2011).
In five in vitro studies with ROC
analysis, no differences between CBCT
and intraoral radiography
Two other studies (Haiter-Neto et al.,2008;
Young et al.,2009) found higher sensitivity
for detection of proximal dentine caries with
small volume CBCT
Caries detection:
Occlusal
Three studies: Haiter-Neto et al.,2008; Young et
al., 2009;Kayipmaz et al., 2010.
Each showed increased sensitivity for
occlusal caries compared with
conventional radiography
Some loss of specificity (Young et al.,
2009)
For occlusal caries, depth correlates better
than intraoral radiography in vitro.
In vivo, metallic restorations will degrade
image and reduce diagnostic accuracy

CBCT is not indicated as a method of
caries detection and diagnosis
B
Caries detection
Periodontal diagnosis
Limited literature relating to
periodontal assessment.
Two accuracy studies
identified (Mol &Balasundaram, 2008
and Noujeim et al., 2009)
CBCT was superior to intraoral
radiography for crater and furcation
defect imaging
(Vandenberghe et al 2008; Ito et al
2001; Kasaj & Willershausen 2007;
Naitoh, 2006)

CBCT may be indicated in selected
cases of intra-bony defects and
furcation lesions, where clinical and
conventional radiographic
examinations do not provide the
information needed for management
C

CBCT is not indicated as a standard
method of imaging periodontal bone
support
C
Periodontal diagnosis

Where CBCT images include the teeth, care
should be taken to check for periodontal bone
levels when performing a clinical evaluation
(report)
GP
Periapical diagnosis
Properly validated in vivo studies
impossible due to lack of a true
reference standard
More recent studies have shown
that CBCT identifies more
periapical defects following
apiceptomy than conventional
imaging
Four studies eligible for the
systematic review: Stavropoulos and
Wenzel, 2007; de PaulaSilva et al., 2009; Patel
et al., 2009; Sour et al. 2009).
Periapical diagnosis
CBCT is not indicated as a standard method for
identification of periapical inflammatory pathosis
GP

CBCT may be indicated for periapical
assessment, in selected cases, when
conventional radiographs give a negative
finding when there are contradictory
positive clinical signs and symptoms
C

Where CBCT images include the teeth , care should
be taken to check for periapical disease when
performing a clinical evaluation ( report)
GP
Endodontics
Endodontics
No study satisfied inclusion
criteria for systematic review
One study (Blattner et al., 2010)
provided data to allow it to be
formally reviewed finding that
sensitivity for MB2 canals was 77%
Due to a paucity of information
regarding diagnostic accuracy ,
the Panel could not support its
general use for this purpose

CBCT may be considered for selected cases
where intraoral radiographs provide
information on root canal anatomy that is
equivocal or inadequate for planning
treatment, most probably in multi rooted teeth
C

CBCT is not indicated as a standard
method for demonstration of root canal
anatomy
GP
Surgical Endodontic Treatment
Limited literature
Use of CBCT as part of planning
and performing surgical procedures
seems capable of justification on
empirical grounds

CBCT may be indicated for selected cases
when planning surgical endodontic
procedures. The decision should be based
upon potential complicating factors, such
as the proximity of important anatomical
structures
GP
Internal and External Root
Resorption
Four research studies included in
systematic review
(Liedke et al., 2009; Patel et al., 2009; Kamboroglu
& Kurson 2010; Durack et al., 2009)
Majority of studies laboratory based
Difficulties with unpredictability of the
condition and the limitation of existing
literature being laboratory based

CBCT may be indicated for selected cases,
where endodontic treatment is complicated
by concurrent factors, such as resorption
lesions, combined periodontal/endodontic
lesions, perforations and atypical pulp
anatomy
C

CBCT may be indicated in selected cases of
suspected, or established, inflammatory
external root resorption or internal resorption,
where three-dimensional information is likely
to alter the management or prognosis of the
tooth
D
Endodontic applications of CBCT
Reference
Differentiation of pathosis from normal anatomy
Relationships with important anatomical structures
Aiding management of dens invaginatus and
aberrant pulpal anatomy
External resorption
Internal resorption
Lateral root perforation by a post
Accessory canal identification
Surgical management of fractured instrument
Aiding surgical endodontic planning
Cotton et al, 2007
Cotton et al, 2007
John, 2008
Siraci et al, 2006
Maini et al, 2008
Cohenca et al, 2007
Walter et al, 2008
Patel et al, 2007
Patel & Dawood, 2007
Cotton et al, 2007
Young 2007
Cotton et al, 2007
Nair et al, 2007
Tsurumachi et al, 2007
Patel et al, 2007
Dental Trauma
Seven publications included in
systemic review (Hassan et al. 2009; Iikubo
et al. 2009; Wenzel et al., 2009; Hassan et al.
2010; Kamboroglu et al., 2010; Ozer 2010;
Varshozas et al., 2010)
Low resolution scans (0.3mm or larger
voxel size) may not offer diagnostic
advantage (Wenzel et al., 2009; Hassan et al.
2010; Kamboroglu et al., 2010; Melo et al.,2010)

High resolution CBCT is indicated in the
assessment of dental trauma (suspected root
fracture) in selected cases , where
conventional radiographs provide inadequate
information for treatment planning
B
Application of CBCT for
dento-alveolar trauma
Reference
Root fractures
Luxation injuries
Avulsion
Root resorption as a post-trauma
complication
Terakado et al 2000
Cohenca et al 2007a
Cotton et al 2007
Nair et al, 2007
Patel & Dawood 2007
Melo et al. 2010
Cohenca et al 2007a
Patel et al 2007
Walter & Krastl 2008
Cohenca et al 2007b
Walter et al, 2008
Exodontia
Large number of studies
Conclusions are that CBCT
offers advantages for the
surgeon in showing the
anatomical position of
mandibular third molars were
there is a close relationship to
the ID canal.

Where conventional radiographs suggest a
close between a mandibular third molar
and the inferior dental canal, and when a
decision to perform surgical removal has
been made, CBCT is indicated
B

CBCT may be indicated for pre-surgical
assessment of an unerupted tooth in
selected cases where conventional
radiographs fail to provide the information
required
GP
Implantology
Main driver for
development of CBCT
Conventional (medical) CT
has been the main method
Radiation dose
advantage of CBCT
Image quality
advantages
Cone beam Conventional CT
Implants: Special indications for cross-
sectional imaging

Single
tooth

a. incisive canal
b. descent of maxillary sinus
c. clinical doubt about shape of alveolar ridge
Partially
dentate
a. descent of maxillary sinus
b. clinical doubt about shape of alveolar ridge
Maxilla
Edentulous

a. descent of maxillary sinus
Single
tooth

a. clinical doubt about position of mandibular canal
Partially
dentate

a. clinical doubt about position of mandibular canal or
mental foramen
Mandible
Edentulous

a. severe resorption
c. clinical doubt about position of mandibular canal if
posterior implants are to be placed

Harris et al. European Association of Osseointegration guidelines for the use of diagnostic
imaging in implant dentistry. Clin Oral Implants Res 2002; 13: 566-570.
*modified from Harris et al.2002
Implant Dentistry
No studies included for systematic review
on diagnostic accuracy
Studies on geometric accuracy supported
the use of CBCT for linear measurements
Better subjective image quality for
important structures compared with MSCT
Several studies reviewed the accuracy of implant
placement using surgical guides reporting that, within
specified limits of error, CBCT is an effective method of
providing the data for the manufacture of surgical
guides

CBCT is indicated for cross-sectional imaging
prior to implant placement as an alternative to
existing cross- sectional techniques where
the radiation dose is shown to be lower
D

For cross-sectional imaging prior to implant
placement, the advantage of CBCT with
adjustable fields of view, compared with
conventional CT, becomes greater where the
region of interest is a localised part of the
jaws, as a similar sized field of view can be
used
GP
Bony Pathosis
Four studies were reviewed by the Panel
(Hendrikx et al., 2010; Momin et al., 2009; Rosenberg
et al., 2010; Simon et al., 2006)
Panel concluded that in cases of oral
malignancy, other cross-sectional
imaging (MSCT, MR) would be
performed first as part of a diagnostic
work-up.

Where it is likely that evaluation of soft tissues
will be required as part of the patients
radiological assessment, the appropriate initial
imaging should be conventional multislice CT
or MR rather than CBCT
BP

CBCT may be indicated for evaluation of
bony invasion of the jaws by oral
carcinoma when the initial imaging
modality used for diagnosis and staging
(MR or multislice CT) does not provide
satisfactory information
D
Maxillofacial Trauma
Confined to hospital practice
Currently imaged by plain
radiography and/or conventional
CT
One study identified for systematic
review (Sirin et al 2010) reporting
no differences between CT and
CBCT
Several case studies/case series
confirmed these findings for trauma
in the facial region

For maxillofacial fracture assessment ,
where cross-sectional imaging is judged to
be necessary, CBCT may be indicated as
an alternative imaging modality to
conventional CT where radiation dose is
shown to be lower and soft tissue detail is
not required
D
Impacted
teeth: canines

For the localised assessment of an impacted
tooth (including consideration of resorption
of an adjacent tooth) where the current
imaging method of choice is MSCT, CBCT
may be preferred because of reduced
radiation dose
GP
External resorption in relation to
unerupted teeth
CBCT may be indicated for the localised
assessment of an impacted tooth (including
consideration of resorption of an adjacent tooth)
where the current imaging method of choice is
conventional dental radiography and when the
information cannot be obtained adequately by
lower dose conventional (traditional) radiography
C
External resorption in relation to
unerupted teeth
For the localised assessment of an impacted tooth
(including consideration of resorption of an
adjacent tooth), the smallest volume size
compatible with the situation should be selected
because of the reduced radiation dose. The use of
CBCT units offering only large volumes
(craniofacial CBCT) requires very careful
justification and is generally discouraged
GP BP
Application of CBCT for orthodontics
Reference
Cleft palate assessment
Tooth position and localisation
Resorption related to impacted teeth
Measuring bone dimensions for mini-implant
placement
Mssig et al 2005
Hamada et al 2005
Wrtche et al 2006
Chaushu et al, 2004
Kau et al 2005
Nakajima et al 2005
Walker et al 2005
Liu et al 2007
Liu et al 2008
Mussig et al 2005
Kau et al 2005
Liu et al 2008
Gracco et al 2006
King et al 2006
Gracco et al 2007
Gracco et al 2008
Kim et al 2007
Application of CBCT for orthodontics
Reference
For rapid maxillary expansion
3-dimensional cephalometry
Surface imaging integration
Airway assessment
Age assessment
Investigation of orthodontic-associated
paraesthesia
King et al 2007
Rungcharassaeng et al 2007
Garrett et al 2008
Baumrind et al 2003
Swennen & Scutyser 2006
Lane & Harrell 2008
Maal et al 2008
Aboudara et al, 2003
Kau et al 2005
Ogawa et al 2007
Shi et al 2007
Erickson et al 2003
Cleft palate
Use of CBCT in this condition
has been the subject of
several non-systematic
reviews
3 dimensional imaging used
to determine volume of bone
needed for grafting and
adequacy of bone fill after
surgery

Where the current imaging method of
choice for the assessment of cleft palate
is MSCT, CBCT may be preferred where
radiation dose is lower. The smallest
volume size compatible with the situation
should be selected because of reduced
radiation dose
C
Temporary Orthodontic Anchorage Using
mini-implants
Several studies conducted to measure available bone
thickness for placing temporary anchorage devices
(TADs)
CBCT has been shown to be used by some as a clinical
tool prior to placement in order to identify optimal position
Research found that 3-dimentional imaging was only
needed in rare cases (Jung et al., 2010)

CBCT is not normally indicated for
planning the placement of temporary
anchorage devices in orthodontics
GP
Generalised application of CBCT for the
developing dentition
Simple algorithms are available (Isaacson et al; 2008 )
Algorithms for selecting radiographs for orthodontic
patients are also available (European Commission
2004)
No evidence to support the routine use of large volume
CBCT at any stage of orthodontic treatment

Large volume CBCT should not be used
routinely for orthodontic diagnosis
GP

Research is needed to define robust
guidance on clinical selection for large
volume CBCT in orthodontics, based upon
quantification of benefit to patient outcome
GP
For complex cases of skeletal abnormality,
particularly those requiring combined
orthodontic/surgical management, large volume
CBCT may be justified in planning the definitive
procedure, particularly where MSCT is the current
imaging method of choice
GP
Cleft palate

Where the current imaging method of
choice for the assessment of cleft palate
is MSCT, CBCT may be preferred where
radiation dose is lower. The smallest
volume size compatible with the situation
should be selected because of reduced
radiation dose
C
Orthognathic Surgery
The patients likely to be candidates for orthognathic
surgery (with significant facial deformity) are more likely
to benefit from crosssectional imaging
Papers included reviews: (Caloss et al., 2007; Edwards
2010; Popat et al., 2010; Swennen et al., 2009)
CBCT is indicated, in selected cases,
where only bone information is required,
for obtaining threedimensional datasets
of the craniofacial skeleton
C
Temporomandibular Joint
The majority of patients with signs and symptoms are
suffering from myofascial pain/dysfunction or internal
disc derangements. Appropriate imaging is magnetic
resonance imaging.
For bony pathology, consider whether the identification
of bony pathology will alter management of the patient
Four diagnostic accuracy papers with valid reference
standards (Honda et al., 2006; Hintze et al., 2007; Honey
et al. 2007; Marques et al.,2010).
Temporomandibular Joint
CBCT images provided similar diagnostic
accuracy to conventional CBCT and greater
accuracy than panoramic radiography and
linear tomography in the detection of condylar
cortical erosion
No differences noted in diagnostic accuracy
between CBCT and conventional tomograms
The Research Diagnostic Criteria highlight that
imaging of the TMJ is not required for a
diagnosis (Petersson 2010)
No clear evidence as to when TMD patients
should be imaged

Where the existing imaging modality for
examination of the TMJ is conventional
CT, CBCT is indicated as an alternative
where radiation dose is shown to be
lower
B
Acknowledgement: The research leading to these
results has received funding from the European
Atomic Energy Communitys Seventh Framework
programme FP7/ 2007-2011 under grant agreement
no. 212246 (SEDENTEXCT: Safety and Efficacy of a
New and Emerging Dental X-ray Modality).

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