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ePaper created 2015-02-16, 09:59:52 | version 1.33.01
science & practice18 Show Preview IDS Cologne 2015 Since its commercial introduction intodentistryin2001,conebeamcom- puted tomography (CBCT) has been rapidly evolving into a new standard of care in maxillofacial imaging. In justoveradecade,CBCThasexploded onto the dental landscape and permit- ted dental professionals a degree of three-dimensional (3-D) anatomic truth in maxillofacial imaging previ- ously unavailable and unattainable. Like many other new technologies, which have progressed from the ex- traordinary to the ordinary and thus gained acceptance by professionals andpatients,CBCThasadvancedfrom exceptional use to almost common- place use in dentistry as cost de- creases, access to the technology in- creases, and potential adverse patient interaction (i.e. radiation exposure) is attenuated. Today, CBCT is seen by many in dentistry as the standard op- erating procedure for many dental im- plant, orthognathic, orthodontic, or endodontic cases. The advancement of CBCT in den- tistry has caught the attention of man- ufacturers of radiological equipment. In2001,onlyonecompanysoldaCBCT system. In 2014 there are at least 20 companiessellingCBCTmachinesand technology. Henry Schein, a leading distributor of dental equipment, has seen CBCT sales expand from 5% of their digital imaging sales to almost 50% of digital imaging sales in the last five years. CBCT has also been recognised by general dentists and specialists as a means by which they can separate, identify, and distinguish their prac- tices as being on the vanguard of tech- nology in patient care. Today’s pa- tients expect their dentist and physi- cians to be contemporary with tech- nology and services. CBCT provides the doctor with a technology, which not only has significant advantages in treating patients but also has a note- worthy“wow”factorasthe3-Dimages areseenonalargescreenin“realtime” for the doctor and patient to view. CBCT, like plain film radiographic studies, may be considered a revenue generator for a practice. The more a CBCT machine is utilised, the more revenue it will generate. Additionally, theownermayallowothersinthepro- fession to utilise the machine for a fee, therebyreducinghisoverallcostofop- eration. Standard of care is a legal not a medical or dental concept. Standards of care are constantly evolving as methods and techniques in patient care improve. An appropriate defini- tion for standard of care may include such language as: the dentist is under dutytousethatdegreeofskillandcare whichisexpectedofareasonablycom- petent and prudent dentist under the same or similar circumstances. Stan- dards of care may be local, regional or national. Standard of care influences Theinfluenceofanemergingtech- nology, like CBCT, into a new standard of care involves many criteria. These criteria include but are not limited to: court verdicts, expert testimony, liter- ature support, professional guide- lines, cost and availability of the tech- nology, reimbursement by third party payers, and multi-specialty use and recognition. Taken individually, these criteria do not constitute a mandate for any technology as a standard of care. Nor arethesetheonlycriteriaonemayuse indeterminingstandardofcare.Taken together, these criteria provide strong evidence that CBCT technology has sufficiently evolved to be considered the standard of care in maxillofacial imaging in selected cases to assist the dentist in treatment for patients in need of dental implants, orthognathic surgery, manipulation of difficult im- pacted teeth, orthodontics, endodon- tics, and many other facets of den- tistry. The legal perspective The legal system in the United States is complex and fragmented. No database exists to search verdicts in dental malpractice cases in which CBCT has played an important or piv- otal role. For a new technology to be- come admissible as a standard of care incourt,itmustpasstheFryetest.This standard comes from Frye v. United States which is a 1923 in a case dis- cussing the admissibility of a poly- graph test as evidence. The Frye stan- dard maintains that scientific evi- dence presented to the court must be interpreted by the court as “generally accepted” and expert testimony must be based on scientific methods that are sufficiently established and ac- cepted. In Frye, the court opined: “Just when a scientific principle or discov- erycrossesthelinebetweentheexper- imental and demonstrable stages is difficult to define. Somewhere in this twilight zone the evidential force of the principle must be recognised, and while the courts will go a long way in admitting experimental testimony de- duced from a well-recognised scien- tific principle or discovery, the thing from which the deduction is made must be sufficiently established to havegainedgeneralacceptanceinthe particular field in which it belongs.” In many jurisdictions and in Fed- eral court, the Frye standard is super- seded by the Daubert standard. The Daubert standard is used by a trial judge to make a preliminary assess- ment of whether an expert’s scientific testimony is based on reasoning or methodology that is scientifically valid and can properly be applied to thefactsatissue.Underthisstandard, the factors that may be considered in determining whether the methodol- ogy is valid are: –theory or technique in question can be and has been tested, –it has been subjected to peer review and publication, –there is a known or potential error rate, –the existence of maintenance stan- dards controlling its operation, –widespread acceptance within a rel- evant scientific community. The theory or technique behind medical grade computed tomography and CBCT has been tested and proven sound over many years of application in the medical and dental arena. The Hounsfield unit is the widely recog- nised standard quantitative scale for describing radiodensity and provides doctorswithaknownstandardander- ror rate in computed tomography. The widespread acceptance of CBCT by the medical and dental community is demonstrated by the ever increasing presence in dental and medical prac- tices of the technology. Additionally, The Intersocietal Accreditation Com- mission,anaccreditationorganisation for medical and dental imaging, has developed guidelines and accredita- tion criteria for 3-D CBCT imaging. Thus CBCT appears to have satisfied both the Frye and Daubert criteria for acceptance as a standard of care tech- nology. Not to discount the value of CBCT imaging or its ability to successfully satisfy the Frye or Daubert criteria, the absence of CBCT is not de facto ev- idence of lack of a standard of care im- aging. Many patients present to their dentist with uncomplicated cases where traditional two-dimensional ra- diographic 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 den- tist with superior anatomic evidence Cone Beam ComputedTomography: Is dentistry ready for a new standard of care? Dr Lee M.Whitesides,USA LEADERSHIP VISIT US AT HALL 10.1 STAND C-061 www.lascod.comMADEINITALY AD