Dental Tribune Asia Pacific Edition No. 1+2 Vol. 13

Trends & Applications DENTALTRIBUNE Asia Pacific Edition No. 1+2/201518 an adjunct to 2-D images and “CBCT may provide dose savings over multiple traditional images in complex cases”. Literature pertaining to the use of CBCT in endodontics first appeared in the Journal of Endodontics in 2003. The Ameri- can Association of Endodontists sponsor continuing education in endodontic related CBCT on their website and the organisa- tion devotes valuable time at its annual meeting to CBCT as it relates to modern endodontics. Most residencies (44 of 47) in endodontics provide CBCT for patient care. Literature pertaining to CBCT in dentistry dates back to 1998. The AAMOR devotes con- siderable effort to continuing education relating to CBCT both on its website, through CE events,andatitsannualmeeting. All seven ADA approved residen- cies in Radiology incorporate CBCT education and training into the resident curriculum. The tremendous value of anatomictruthincomplexortho- dontic cases involving patients with cleft lip and palate, im- pacted teeth, and maxillofacial deformities is widely recognised and discussed in the literature. Review of the AAO annual meet- ing lecture syllabus shows CBCT is a prominent topic for today’s orthodontist.Inarecentarticlein the Journal of Dental Education by Smith et al use of CBCT in orthodontic programmes in the US and Canada was evaluated. Thisarticleshowedthefollowing: • 83 per cent of orthodontic pro- grammes have access to CBCT, • 73 per cent of programmes report “regular” use of CBCT in patient diagnosis, • Areas of CBCT use focuses on diagnosis and treatment planning for: impacted teeth, craniofacial anomalies, TAD placement, TMJ assessment, upper airway analysis, and maxillofacial development. Literature discussing CBCT in periodontics first appeared in the AAP journal over a decade ago. The American Association of Periodontist annual meeting agenda and the Journal of Perio- dontology demonstrate a heavy influence of CBCT in the field of periodontics.All51post-doctoral US periodontal programmes use CBCT in patient care. The International Congress of Oral Implantologists (ICOI), the world’s largest dental implant organisation and provider of den- tal implant continuing education with an excess of 25,000 active members, published a consensus report on CBCT in its journal Implant Dentistry in April of 2012. In the article, authored by many leadersinthedentalimplantfield, the ICOI states: “The literature supportstheuseofCBCTindental implant treatment planning par- ticularly in regards to linear measurements, 3-D evaluation of alveolar ridge topography, prox- imity to vital anatomic structures, and fabrication of surgical guides.” The ICOI reminds the dentist that use of CBCT must be justified in each case and should be considered as an imaging alternative where conventional radiographs may not provide sufficient anatomic truth. Liter- ature discussing the application of CBCT in implant dentistry is ubiquitous and comprises the lion’s share of research in apply- ing CBCT technology to dentistry. Thevastmajorityofpost-doctoral residencies involved in dental implant patient care and all pri- vate dental implant training courses in the US incorporate CBCT in their dental implant education curriculum. Many professional organisa- tions in dentistry for general dentists and specialists have weighed in on CBCT by provid- ing recommendations, guide- lines, and a position paper. While these guidelines are beneficial in establishing a society or spe- cialty’s position on CBCT, they are not mandates. Recommen- dations, guidelines, CE pro- grammes, and position papers are used by professionals to in- fluence the practice of their dis- cipline. As the practice of the disciplinechangesinresponseto many factors including, but not limited to court verdicts, expert testimony, literature support, professional guidelines, cost of the technology, and reimburse- ment by third party payers; the recommendations, guidelines, and position papers may facili- tate the evolution of CBCT into a standard of care. Thus, in 2014 the professional organisations that comprise dentistry may not formally declare CBCT is the standardofcareforeverypatient, but these organisations do re- cognise the influence CBCT is having on the profession. Educational Institutional Participation Foratechnologytobeconsid- ered a standard of care, those in the profession must be educated in its application in patient care. In US, 56 of the 57 dental schools (98 per cent) have CBCT avail- able for patient care for pre- doctoral students. Forty-seven (84 per cent) incorporate CBCT education in their pre-doctoral curriculum. In a survey per- formed by the author and others 202 general practice residency (GPR) and advanced education in general dentistry (AEGD) programmes were surveyed re- garding use of CBCT by their residents. Eighty-two programme directorsrespondedtothesurvey. Of the 82 respondents, 56 (68 per cent) of program directors (PDs) responded affirmatively when askedifCBCTwasusedinpatient care by their residents. The au- thoralsosurveyed102PDsinoral and maxillofacial programs in theUS.Fifty-fourPDsresponded. Of the 54 PDs responding 47 (87 per cent) affirmatively when asked if CBCT is used in patient care by their residents. In a phone survey of endodontic res - idencies, 44 of 47 PDs indicated their residents use CBCT in patient care. All seven ADA- approved oral and maxillofacial radiology programmes use CBCT in patient care. Additionally, all 51 periodontal residency PDs indicated that their residents employ CBCT technology in patient care. In orthodontics, 83 per cent of US-based ortho- dontic programmes use CBCT in patient care. Cost and Availability The cost of CBCT machines today range from US$150,000 to US$250,000 with yearly mainte- nance fees in the US$8,000 to US$20,000 range. As with any emerging technology, advances create a secondary market for slightlyusedmachines.Eachnew step forward in technology ren- ders the CBCT machine of only a fewyearsagoslightlyout-of-date, despite its obvious value and its superiority to two dimensional films. As time progresses and advancement in the quality and capabilities of the newest ma- chines demonstrate themselves, the slightly non-contemporary machine will represent a signifi- cant advancement for the dentist versus2-Dradiography,whilenot burdening the dentist with signif- icant cost. This will undoubtedly lead to an increase in the number of dental professionals utilising CBCT in their practices. The bottom line for most practices in regards to CBCT machines is: can I afford this for my practice? Todetermineaffordability,the price of the machine (purchase and maintenance) must be con- sidered against potential rev- enue generated by the machine. Revenue can be directly from patients,insurancecompanies,or fromotherdentistswhoutilisethe CBCT machine. A cost-effective alternative to owning and oper - ating a CBCT device can be the outsourcing of the study to a third party (dentist or facility) and in- sourcing the software necessary toemploytheimagesintreatment planning and diagnosis. CBCT machines are becom- ing ubiquitous as more dentist purchase the machines and more third party non-dentist owned imaging centres enter the market. Since more dentist and more patients are becoming ex- posed to the technology, patient acceptance will increase, facili- tating the incorporation of CBCT into the mainstream culture of dentistry. The increasing om- nipresence of CBCT technology will not singularly make it stan- dard of care, but it will serve to increase patient awareness of the technology, which in turn will influence what the public perceives as a standard of care. The insurance industry Reimbursement from major insurance companies and gov- ernment-sponsoredhealthcareis traditionally the last to embrace (i.e.payfor)anewservicesuchas CBCT. Although codes for med- ical CBCTs have been around for decades, specific codes for in of- ficeCBCTsbegantomaterialisein 2009. Current reimbursement rates for in-office CBCTs average around US$300, provided the study is covered. By providing dentists with a CPTcode,theinsuranceindustry has validated the technology of CBCT and thus acknowledged its value in treatment planning anddiagnosis.Astimeprogresses, insurance companies may, as they have in the past, require CBCT owner/operators to obtain a certification via the IAC or some other regulating entity for an owner/operator to qualify for financial reimbursement from any third party payer. Two of the major malpractice carriers of the insurance indus- try (OMNSIC and MedPro) have influenced the evolution of CBCT as a new standard of care by offering coverage for CBCT owner/operators commensurate with the level of risk to which the owner/operators are exposed. Were CBCT studies believed to be of little value or represent minimal risk these leaders in the dental malpractice industry would not offer such coverage. Additionally OMNSIC requires the owner/operator to have CBCT images interpreted by a dental or medical radiologist to minimise risk. Multispecialty use and recognition Dentistry has nine recog- nised specialties; four (oral and maxillofacial surgery, endo- dontics, oral and maxillofacial radiology, and orthodontics) and the American Dental Association have produced literature to address the impact of CBCT on patient care. Of the remaining five specialties, periodontics and prosthodontics could logically beappropriategroupstoproduce a position paper on CBCT given their members participation in dental implant treatment of pa- tients. Paediatric dentistry may soon provide a position paper once the long-term studies have been done to assess the risk ver- susbenefitsanalysiswithrespect to the total overall radiation dose and its effect on the paediatric population. The specialty of den- tal public health is unlikely to weigh on the matter. The value CBCT has in diag- nosis and treatment of patients is widespread and recognised by medical disciplines such as plasticandreconstructivesurgery, ENT, Craniofacial/CLP surgeons, and OMFS trauma surgeons. Thesemedicaldisciplinesrecog- nise the high quality three di- mensional detail CBCT provides and assists doctors in the treat- ment planning and diagnosis of their patients. Such widespread and multidisciplinary applica- tion of CBCT imaging con- tributes to CBCT is becoming a new standard of care. CBCT in the dental culture Many in the dental profession acknowledge the benefit of 3-D imaging to patients and doctors. There is little dispute that CBCT provides superior representa- tion of the anatomy verses 2-D plain films. Quality of product acknowledged, at least four as- pects of CBCT must work their way through the dental culture before CBCT becomes A stan- dard of care: cost, availability, legal, and patient expectations. Two of these aspects (cost and availability)willmorelikelythan not be determined by the in- visible hand of the market as the Keynesians laws of supply and demand move the dental indus- try to provide the best possible service at a price patients and insurance companies are willing to pay. The third (legal) will be slowly determined in the court systems as attorneys and experts begin to rely more on CBCT in support of their clients’ cases. Patient expectations are dif- ficult to accurately ascertain. We know patients expect our practices to be contemporary. Buying the latest and greatest machine for your practice may not be wise if cost exceeds bene- fits both clinically and finan- cially. As CBCT becomes widely accepted and expected by our patients due to aggressive mar- keting or clinical relevance, in- corporating the technology into one’spracticemaynotbeentirely necessary but prudent as others in the profession who possess thetechnologyappeartobemore contemporary and advanced in their patient care. There are many questions yet to be answered definitively regarding CBCT: 1. Whoisresponsible(andliable) for interpreting the images? 2. Is an entire field of view inter- pretation necessary or simply the pertinent structures? 3. Must all images be interpreted by a board certified oral and maxillofacial radiologist or can the ordering doctor inter- pret the images? 4. What level of training is suf - ficient to own and operate the machine, as well as, and inter- pret CBCT images? 5. What cases deserve a CBCT? 6. If the patient refuses a CBCT and the dentist believes a CBCTisnecessaryforsuccess- ful case completion, must the dentistcompletethecasewith- out the CBCT study or can he refuse the case without fear of legal repercussions? Lastly, as mentioned earlier, standard of care is an evolving concept. Darwin stated clearly any organism (or concept in this case) which is subject to the laws of evolution must adapt in re- sponse to outside forces in order to survive. The standard of care in dentistry is adapting to CBCT as forces (legal, financial, clini- cal, and consumer) act upon the industry to account for the powerful influence CBCT has on treatment planning and diagno- sis of patients. While recognising that all that glitters is not gold, CBCT may soon represent a new gold standard by which many cases will be judged. DT DrLeeM.Whitesides is an oral surgeon from Dunwoody near Atlanta in the US. He can be contacted at Drmac5678@gmail.com. Contact Info ﬂ page 16DT DTAP0115_14-18_Whitesides 09.02.15 11:00 Seite 3 DTAP0115_14-18_Whitesides 09.02.1511:00 Seite 3

Dental Tribune Asia Pacific Edition No. 1+2 Vol. 13

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