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ePaper created 2014-12-05, 15:38:45 | version 1.33.01
I 07 opinion _ CBCT in dental office I cone beam4_2014 _Standard of care influences The influence of an emerging technology, like CBCT, into a new standard of care involves many criteria.Thesecriteriaincludebutarenotlimitedto: court verdicts, expert testimony, literature support, professional guidelines, cost and availability of the technology, reimbursement by third party payers, and multi-specialty use and recognition. Taken individually, these criteria do not consti- tute a mandate for any technology as a standard of care. Nor are these the only criteria one may use in determining standard of care. Taken together, these criteria provide strong evidence that CBCT technology has sufficiently evolved to be consid- eredthestandardofcareinmaxillofacialimagingin selected cases to assist the dentist in treatment for patients in need of dental implants, orthognathic surgery, manipulation of difficult impacted teeth, orthodontics, endodontics, and many other facets of dentistry. _The legal perspective The legal system in the United States is complex and fragmented. No database exists to search ver- dicts in dental malpractice cases in which CBCT has played an important or pivotal role. For a new tech- nology to become admissible as a standard of care in court, it must pass the Frey test. This standard comes from Frey v. United States which is a 1923 in a case discussing the admissibility of a polygraph test as evidence. The Frey standard maintains that scientific evidence presented to the court must be interpretedbythecourtas“generallyaccepted”and expert testimony must be based on scientific meth- ods that are sufficiently established and accepted In Frey, the court opined: “Just when a scientific principle or discovery crosses the line between the experimental and demonstrable stages is difficult to define. Somewhere in this twilight zone the evidentialforceoftheprinciplemustberecognised, andwhilethecourtswillgoalongwayinadmitting experimentaltestimonydeducedfromawell-recog- nisedscientificprincipleordiscovery,thethingfrom which the deduction is made must be sufficiently established to have gained general acceptance in the particular field in which it belongs.” In many jurisdictions and in Federal court, the FreystandardissupersededbytheDaubetstandard. The Daubet standard is used by a trial judge to make a preliminary assessment of whether an ex- pert’s scientific testimony is based on reasoning or methodology that is scientifically valid and can properly be applied to the facts at issue. Under this standard, the factors that may be considered in determining whether the methodology is valid are: _theory or technique in question can be and has been tested, _it has been subjected to peer review and publi- cation, _there is a known or potential error rate, _the existence of maintenance standards control- ling its operation, _widespreadacceptancewithinarelevantscientific community. The theory or technique behind medical grade computed tomography and CBCT has been tested andprovensoundovermanyyearsofapplicationin themedicalanddentalarena.TheHounsfieldunitis the widely recognised standard quantitative scale for describing radiodensity and provides doctors with a known standard and error rate in computed tomography.ThewidespreadacceptanceofCBCTby themedicalanddentalcommunityisdemonstrated by the ever increasing presence in dental and med- ical practices of the technology. Additionally, The IntersocietalAccreditationCommission,anaccred- itationorganisationformedicalanddentalimaging, has developed guidelines and accreditation criteria for 3-D CBCT imaging. Thus CBCT appears to have satisfied both the Frey and Daubet criteria for ac- ceptance as a standard of care technology. Not to discount the value of CBCT imaging or its ability to successfully satisfy the Frey or Daubet criteria,theabsenceofCBCTisnotdefactoevidence oflackofastandardofcareimaging.Manypatients present to their dentist with uncomplicated cases where traditional two-dimensional radiographic studies are appropriate and provide the dentist with standard of care imaging of the patient. For the more complicated cases, 3-D imaging may be employed to provide the dentist with superior anatomic evidence in treatment planning and diagnosis. Three-dimensional imaging with CBCT can also be used in uncomplicated cases, but it may not necessarily be considered as the standard of care for every case in 2014. _Expert Testimony An expert is a person with sufficient minimal qualifications to render an opinion on the subject at hand. Not all experts are created equal, and in fact in three states (Iowa, South Dakota, and New Hampshire) an expert need only be qualified in a related field to offer an opinion. Experts are used by the courts to educate the judge and jury as to what constitutes normal minimal acceptable care of a patient in a given environment. CBE0414_06-11_Whitesides 28.11.14 11:55 Seite 2 CBE0414_06-11_Whitesides 28.11.1411:55 Seite 2