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today AEEDC Dubai 2015

science & practice16 AEEDC Dubai 2015 Since its commercial introduc- tion into dentistry in 2001, cone beam computed tomography (CBCT) has been rapidly evolving into a new standard of care in max- illofacial imaging. In just over a decade, CBCT has exploded onto the dental landscape and permit- teddentalprofessionalsadegreeof three-dimensional (3-D) anatomic truth in maxillofacial imaging pre- viously unavailable and un- attainable. Like many other new technologies, which have pro- gressed from the extraordinary to the ordinary and thus gained ac- ceptance by professionals and pa- tients,CBCThasadvancedfromex- ceptional use to almost common- place use in dentistry as cost de- creases, access to the technology increases, and potential adverse patient interaction (i.e. radiation exposure) is attenuated. Today, CBCT is seen by many in dentistry as the standard operating proce- dure for many dental implant, orthognathic, orthodontic, or en- dodontic cases. The advancement of CBCT in dentistry has caught the attention of manufacturers of radiological equipment. In 2001, only one com- pany sold a CBCT system. In 2014 thereareatleast20companiessell- ing CBCT machines and technol- ogy. Henry Schein, a leading dis- tributor of dental equipment, has seenCBCTsalesexpandfrom5%of their digital imaging sales to al- most50%ofdigitalimagingsalesin the last five years. CBCT has also been recognised by general dentists and specialists as a means by which they can sep- arate, identify, and distinguish their practices as being on the van- guard of technology in patient care. Today’s patients expect their dentist and physicians to be con- temporary with technology and services.CBCTprovidesthedoctor with a technology, which not only hassignificantadvantagesintreat- ingpatientsbutalsohasanotewor- thy “wow” factor as the 3-D images are seen on a large screen in “real time” for the doctor and patient to view. CBCT, like plain film radi- ographic studies, may be consid- eredarevenuegeneratorforaprac- tice. The more a CBCT machine is utilised, the more revenue it will generate. Additionally, the owner may allow others in the profession to utilise the machine for a fee, therebyreducinghisoverallcostof operation. Standard of care is a legal not a medical or dental concept. Stan- dards of care are constantly evolv- ing as methods and techniques in patient care improve. An appropri- ate definition for standard of care may include such language as: the dentistisunderdutytousethatde- gree of skill and care which is expected of a reasonably compe- tent and prudent dentist under the same or similar circumstances. Standards of care may be local, re- gional or national. Standard of care influences The influence of an emerging technology, like CBCT, into a new standard of care involves many criteria. These criteria include but are not limited to: court verdicts, expert testimony, literature sup- port, professional guidelines, cost and availability of the technology, reimbursementbythirdpartypay- ers, and multi-specialty use and recognition. Taken individually, these crite- ria do not constitute a mandate for any technology as a standard of care.Norarethesetheonlycriteria one may use in determining stan- dard of care. Taken together, these criteria provide strong evidence that CBCT technology has suffi- ciently evolved to be considered the standard of care in maxillofa- cial imaging in selected cases to as- sist the dentist in treatment for pa- tients in need of dental implants, orthognathic surgery, manipula- tion of difficult impacted teeth, or- thodontics,endodontics,andmany other facets of dentistry. The legal perspective The legal system in the United States is complex and fragmented. No database exists to search ver- dictsindentalmalpracticecasesin which CBCT has played an impor- tant 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 whichisa1923inacasediscussing the admissibility of a polygraph testasevidence.TheFreystandard maintains that scientific evidence presented to the court must be in- terpreted by the court as “gener- ally accepted” and expert testi- mony must be based on scientific methods that are sufficiently es- tablished and accepted In Frey, the court opined: “Just when a scientific principle or dis- covery crosses the line between the experimental and demonstra- ble stages is difficult to define. Somewhere in this twilight zone theevidentialforceoftheprinciple must be recognised, and while the courts will go a long way in admit- ting experimental testimony de- duced from a well-recognised sci- entific principle or discovery, the thing from which the deduction is made must be sufficiently estab- lished to have gained general ac- ceptance in the particular field in which it belongs.” In many jurisdictions and in Federal court, the Frey standard is superseded by the Daubet stan- dard. The Daubet standard is used by a trial judge to make a prelimi- nary assessment of whether an ex- pert’s scientific testimony is based on reasoning or methodology that is scientifically valid and can prop- erly be applied to the facts at issue. Under this standard, the factors that may be considered in deter- mining whether the methodology is valid are: –theory or technique in question can be and has been tested, –it has been subjected to peer re- view and publication, –thereisaknownorpotentialerror rate, –the existence of maintenance standards controlling its opera- tion, –widespread acceptance within a relevant scientific community. The theory or technique behind medical grade computed tomogra- phy and CBCT has been tested and proven sound over many years of applicationinthemedicalandden- tal arena. The Hounsfield unit is the widely recognised standard quantitative scale for describing radiodensity and provides doctors with a known standard and error rate in computed tomography. The widespreadacceptanceofCBCTby themedicalanddentalcommunity is demonstrated by the ever in- creasing presence in dental and medical practices of the technol- ogy.Additionally,TheIntersocietal Accreditation Commission, an ac- creditation organisation for med- ical and dental imaging, has devel- oped guidelines and accreditation criteriafor3-DCBCTimaging.Thus CBCT appears to have satisfied both the Frey and Daubet criteria foracceptanceasastandardofcare technology. Not to discount the value of CBCT imaging or its ability to suc- cessfullysatisfytheFreyorDaubet criteria, the absence of CBCT is not de facto evidence of lack of a stan- dard of care imaging. Many pa- tients present to their dentist with uncomplicated cases where tra- ditional two-dimensional radi- ographic studies are appropriate and provide the dentist with stan- dardofcareimagingofthepatient. 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-di- mensional imaging with CBCT can also be used in uncomplicated cases,butitmaynotnecessarilybe considered as the standard of care for every case in 2014. Expert Testimony An expert is a person with suffi- cientminimalqualificationstoren- der an opinion on the subject athand.Notallexpertsarecreated equal, and in fact in three states (Iowa, South Dakota, and New Hampshire)anexpertneedonlybe qualified in a related field to offer an opinion. Experts are used by the courts to educate the judge andjuryastowhatconstitutesnor- mal minimal acceptable care ofapatientinagivenenvironment. Expert testimony is by defini- tiontheopinionofonepractitioner. It is an opinion based on fact, evidence, experience, and knowl- edge which the expert believes to be relevant, valid, and upheld in the scientific community. When reviewing a case for sus- pected malpractice the expert ex- aminesmanythings,including,but not limited to: chart notes, radi- ographic studies, depositions, and professional correspondences. In the last five years, the author has noticed a remarkable increase in thenumberofcasesinwhichplain- tiffs and defence attorneys, as well as experts, rely on pre and/or post- procedureCBCTimagingstudiesto assistinprovingmalpracticeorde- fending good practice. Post-treat- ment radiographic imaging to prove malpractice or support good practice is not new to medicine. In fact in the years preceding WWI, some of the highest malpractice claims were awarded in cases where post-treatment radiographs played a pivotal role. Logicwoulddictatethatifplain- tiffs and defence counsels and ex- pertsaremakingCBCTpartoftheir strategy, then CBCT must be not onlyprevalentandpertinentbutof significant value in the formation of an opinion by an expert (and the jury) when reviewing a case. CBCT canbeseenasanadditionalandim- portant piece of information to help explain why the doctor did what he did or why an unfortunate outcome occurred. Additionally, CBCTprovidespowerfulandeasily understandable images for layper- son jury. Recognising the value that CBCTaddstoacasedoesnotneces- sarily indicate that CBCT is the standard of care in each and every case.ThedecisiontoobtainaCBCT study before the procedure is determinedbythedentistbasedon his experience and knowledge of the case. Literature Support For any technology to be consid- ered as a standard of care, a plethoraofliteratureinsupportfor the technology should exist. The literature must discuss the risk and benefits of the technology, its application to patient care, and guidelines and protocols for ac- ceptable use. To assess the influence of CBCT in the dental literature, the author performed a PubMed literature search in October for the words Cone Beam ComputedTomography: Is dentistry ready for a new standard of care? Dr Lee M.Whitesides,USA

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