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today AEEDC Dubai 2015

science & practice18 AEEDC Dubai 2015 articlethenlistsnineofthese“com- plex conditions”. In summation, the position paper recognises the value of CBCT as an adjunct to 2-D images and “CBCT may provide dose savings over multiple tradi- tional images in complex cases”. Literature pertaining to the use of CBCT in endodontics first ap- peared in the Journal of Endodon- tics in 2003. The American Associ- ation of Endodontists sponsor con- tinuingeducationinendodonticre- lated CBCT on their website and the organisation devotes valuable time at its annual meeting to CBCT as it relates to modern endodon- tics. Most residencies (44 of 47) in endodontics provide CBCT for pa- tient care. LiteraturepertainingtoCBCTin dentistry dates back to 1998. The AAMOR devotes considerable ef- fort to continuing education relat- ing to CBCT both on its website, through CE events, and at its an- nual meeting. All seven ADA ap- provedresidenciesinRadiologyin- corporate CBCT education and training into the resident curricu- lum. The tremendous value of anatomic truth in complex ortho- dontic cases involving patients with cleft lip and palate, impacted teeth, and maxillofacial deformi- ties is widely recognised and dis- cussed in the literature. Review of the AAO annual meeting lecture syllabus shows CBCT is a promi- nent topic for today’s orthodontist. In a recent article in the Journal of DentalEducationbySmithetaluse of CBCT in orthodontic pro- grammes in the US and Canada wasevaluated.Thisarticleshowed the following: –83 % of orthodontic programmes have access to CBCT, –73 % of programmes report “regu- lar”useofCBCTinpatientdiagno- sis, –Areas of CBCT use focuses on di- agnosis and treatment planning for: impacted teeth, craniofacial anomalies, TAD placement, TMJ assessment, upper airway analy- sis, and maxillofacial develop- ment. Literature discussing CBCT in periodontics first appeared in the AAP journal over a decade ago. The American Association of Peri- odontist annual meeting agenda and the Journal of Periodontology demonstrate a heavy influence of CBCT in the field of periodontics. All51post-doctoralUSperiodontal 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 Im- plant Dentistry in April of 2012. In thearticle,authoredbymanylead- ers in the dental implant field, the ICOI states: “The literature sup- ports the use of CBCT in dental im- plant treatment planning particu- larly in regards to linear measure- ments, 3-D evaluation of alveolar ridge topography, proximity to vi- tal anatomic structures, and fabri- cationofsurgicalguides.”TheICOI reminds the dentist that use of CBCTmustbejustifiedineachcase and should be considered as an im- aging alternative where conven- tional radiographs may not pro- vide sufficient anatomic truth. Lit- erature discussing the application of CBCT in implant dentistry is ubiquitous and comprises the lion’sshareofresearchinapplying CBCT technology to dentistry. The vast majority of post-doctoral resi- dencies involved in dental implant patient care and all private dental implant training courses in the US incorporate CBCT in their dental implant education curriculum. Many professional organisa- tions in dentistry for general den- tists and specialists have weighed in on CBCT by providing recom- mendations,guidelines,andaposi- tion paper. While these guidelines are beneficial in establishing a so- ciety or specialty’s position on CBCT, they are not mandates. Rec- ommendations, guidelines, CE pro- grammes, and position papers are used by professionals to influence the practice of their discipline. As the practice of the discipline changes in response to many fac- tors including, but not limited to court verdicts, expert testimony, literature support, professional guidelines, cost of the technology, and reimbursement by third party payers; the recommendations, guidelines, and position papers may facilitate the evolution of CBCT into a standard of care. Thus, in 2014 the professional organisa- tions that comprise dentistry may not formally declare CBCT is the standard of care for every patient, but these organisations do recog- nise the influence CBCT is having on the profession. Educational Institutional Participation For a technology to be consid- eredastandardofcare,thoseinthe profession must be educated in its application in patient care. In US, 56 of the 57 dental schools (98 %) have CBCT available for patient care for pre-doctoral students. Forty-seven (84 %) incorporate CBCT education in their pre-doc- toral curriculum. In a survey per- formed by the author and others 202 general practice residency (GPR) and advanced education in general dentistry (AEGD) pro- grammes were surveyed regard- ing use of CBCT by their residents. Eighty-two programme directors responded to the survey. Of the 82 respondents, 56 (68 %) of program directors (PDs) responded affirma- tively when asked if CBCT was used in patient care by their resi- dents. The author also surveyed 102 PDs in oral and maxillofacial programs in the US. Fifty-four PDs responded. Of the 54 PDs respond- ing 47 (87 %) affirmatively when asked if CBCT is used in patient care by their residents. In a phone survey of endodontic residencies, 44 of 47 PDs indicated their resi- dents use CBCT in patient care. All seven ADA-approved oral and maxillofacial radiology pro- grammesuseCBCTinpatientcare. Additionally,all51periodontalres- idencyPDsindicatedthattheirres- idents employ CBCT technology in patient care. In orthodontics, 83 % of US-based orthodontic pro- grammesuseCBCTinpatientcare. Cost and Availability The cost of CBCT machines to- day 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 slightly used machines. Each new step forward in technology ren- ders the CBCT machine of only a few years ago slightly out-of-date, despiteitsobviousvalueanditssu- periority to two dimensional films. As time progresses and advance- ment in the quality and capabili- ties of the newest machines demonstrate themselves, the slightly non-contemporary ma- chine will represent a significant advancement for the dentist ver- sus 2-D radiography, while not bur- dening the dentist with significant cost. This will undoubtedly lead to anincreaseinthenumberofdental professionals utilising CBCT in their practices. The bottom line for most practices in regards to CBCT machinesis:canIaffordthisformy practice? To determine affordability, the priceofthemachine(purchaseand maintenance) must be considered against potential revenue gener- ated by the machine. Revenue can be directly from patients, insur- ancecompanies,orfromotherden- tistswhoutilisetheCBCTmachine. A cost-effective alternative to own- ing and operating a CBCT device canbetheoutsourcingofthestudy to a third party (dentist or facility) and in-sourcing the software nec- essary to employ the images in treatment planning and diagnosis. CBCT machines are becoming ubiquitous as more dentist pur- chasethemachinesandmorethird party non-dentist owned imaging centres enter the market. Since moredentistandmorepatientsare becoming exposed to the technol- ogy, patient acceptance will in- crease, facilitating the incorpo- rationofCBCTintothemainstream cultureofdentistry.Theincreasing omnipresence of CBCT technology will not singularly make it stan- dard of care, but it will serve to in- crease patient awareness of the technology, which in turn will in- fluence what the public perceives as a standard of care. The insurance industry Reimbursement from major in- surance companies and govern- ment-sponsored health care is tra- ditionally the last to embrace (i.e. pay for) a new service such as CBCT. Although codes for medical CBCTs have been around for decades,specificcodesforinoffice CBCTs began to materialise in 2009. Current reimbursement rates for in-office CBCTs average around US$300, provided the study is covered. By providing dentists with a CPT code, the insurance industry has validated the technology of CBCT and thus acknowledged its valueintreatmentplanninganddi- agnosis. As time progresses, in- surance companies may, as they have in the past, require CBCT owner/operatorstoobtainacertifi- cation via the IAC or some other regulating entity for an owner/op- erator to qualify for financial re- imbursement from any third party payer. Two of the major malpractice carriers of the insurance industry (OMNSIC and MedPro) have influ- enced the evolution of CBCT as a new standard of care by offering coverage for CBCT owner/opera- tors commensurate with the level of risk to which the owner/opera- tors are exposed. Were CBCT stud- ies believed to be of little value or represent minimal risk these lead- ersinthedentalmalpracticeindus- try would not offer such coverage. Additionally OMNSIC requires the owner/operator to have CBCT im- ages interpreted by a dental or medical radiologist to minimise risk. Multispecialty use and recognition Dentistry has nine recognised specialties; four (oral and maxillo- facial surgery, endodontics, 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 re- maining five specialties, periodon- tics and prosthodontics could logi- cally be appropriate groups to pro- duce a position paper on CBCT given their members participation in dental implant treatment of pa- tients. Paediatric dentistry may soonprovideapositionpaperonce the long-term studies have been done to assess the risk versus ben- efitsanalysiswithrespecttotheto- taloverallradiationdoseanditsef- fect on the paediatric population. The specialty of dental public health is unlikely to weigh on the matter. ThevalueCBCThasindiagnosis and treatment of patients is wide- spread and recognised by medical disciplines such as plastic and re- constructive surgery, ENT, Cranio- facial/CLP surgeons, and OMFS trauma surgeons. These medical disciplines recognise the high quality three dimensional detail CBCT provides and assists doctors inthetreatmentplanninganddiag- nosis of their patients. Such widespread and multidisciplinary application 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 im- aging to patients and doctors. There is little dispute that CBCT provides superior representation of the anatomy verses 2-D plain films. Quality of product acknowl- edged,atleastfouraspectsofCBCT must work their way through the dental culture before CBCT be- comes A standard of care: cost, availability, legal, and patient expectations. Two of these aspects (cost and availability) will more likely than not be determined by the invisible hand of the market as the Keynesians laws of supply and demand move the dental industry toprovidethebestpossibleservice at a price patients and insurance companies are willing to pay. The third (legal) will be slowly deter- minedinthecourtsystemsasattor- neys and experts begin to rely more on CBCT in support of their clients’ cases. Patient expectations are diffi- cult to accurately ascertain. We knowpatientsexpectourpractices tobecontemporary.Buyingthelat- est and greatest machine for your practice may not be wise if cost exceeds benefits both clinically and financially. As CBCT becomes widely accepted and expected by ourpatientsduetoaggressivemar- keting or clinical relevance, incor- porating the technology into one’s practice may not be entirely neces- sary but prudent as others in the profession who possess the tech- nology appear to be more contem- porary and advanced in their pa- tient care. Therearemanyquestionsyetto be answered definitively regard- ing CBCT: 1. Who is responsible (and liable) for interpreting the images? 2. Isanentirefieldofviewinterpre- tation necessary or simply the pertinent structures? 3. Must all images be interpreted by a board certified oral and maxillofacial radiologist or can theorderingdoctorinterpretthe images? 4. What level of training is suffi- cient to own and operate the ma- chine, as well as, and interpret CBCT images? 5. What cases deserve a CBCT? 6. IfthepatientrefusesaCBCTand the dentist believes a CBCT is necessary for successful case completion, must the dentist complete the case without the CBCT study or can he refuse the case without fear of legal reper- cussions? Lastly, as mentioned earlier, standardofcareisanevolvingcon- cept. Darwin stated clearly any organism (or concept in this case) which is subject to the laws of evo- lution must adapt in response to outside forces in order to survive. The standard of care in dentistry is adaptingtoCBCTasforces(legal,fi- nancial,clinical,andconsumer)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. Dr Lee M. Whitesides is an oral sur- geon from Dunwoody near Atlanta in the US. Dr Lee M. Whitesides

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