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science & practice 21Show Preview IDS Cologne 2015 in treatment planning and diagnosis. Three-dimensional imaging with CBCT can also be used in uncompli- cated 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 suffi- cient 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 ex- pertneedonlybequalifiedinarelated field to offer an opinion. Experts are usedbythecourtstoeducatethejudge andjuryastowhatconstitutesnormal minimalacceptablecareofapatientin a given environment. Expert testimony is by definition the opinion of one practitioner. It is an opinionbasedonfact,evidence,experi- ence, and knowledge which the expert believes to be relevant, valid, and up- held in the scientific community. When reviewing a case for sus- pected malpractice the expert exam- ines many things, including, but not limited to: chart notes, radiographic studies, depositions, and professional correspondences. In the last five years, the author has noticed a re- markable increase in the number of cases in which plaintiffs and defence attorneys, as well as experts, rely on preand/orpost-procedureCBCTimag- ing studies to assist in proving mal- practice or defending good practice. Post-treatment radiographic imaging to prove malpractice or support good practiceisnotnewtomedicine.Infact in the years preceding WWI, some of the highest malpractice claims were awarded in cases where post-treat- ment radiographs played a pivotal role. Logic would dictate that if plain- tiffsanddefencecounselsandexperts are making CBCT part of their strat- egy,thenCBCTmustbenotonlypreva- lent and pertinent but of significant valueintheformationofanopinionby an expert (and the jury) when review- ing a case. CBCT can be seen as an ad- ditional and important piece of infor- mation to help explain why the doctor didwhathedidorwhyanunfortunate outcomeoccurred.Additionally,CBCT provides powerful and easily under- standable images for layperson jury. Recognising the value that CBCT adds to a case does not necessarily in- dicate that CBCT is the standard of care in each and every case. The deci- sion to obtain a CBCT study before the procedure is determined by the den- tist based on his experience and knowledge of the case. Literature Support For any technology to be consid- ered as a standard of care, a plethora ofliteratureinsupportforthetechnol- ogy should exist. The literature must discuss the risk and benefits of the technology, its application to patient care, and guidelines and protocols for acceptable use. To assess the influence of CBCT in the dental literature, the author per- formed a PubMed literature search in October for the words cone beam CT, conebeamCT+dental,conebeamCT+ dentalimplants,conebeamCT+ortho- dontics, cone beam CT + oral surgery, cone beam CT + endodontics in the search line. The results are in Table 1. Evaluation of Table 1 data clearly shows a significant presence in the lit- erature of articles pertaining to the use of CBCT in the various disciplines in dentistry. The vast majority of liter- ature discovered pertains to address- ing the use of CBCT in treatment plan- ning and diagnosis of patients in den- tal implant therapy, oral and maxillo- facial surgery, orthodontics, and endodontics. Articles on new applica- tions of CBCT technology to patient care were also prevalent in the sam- ple. Some articles addressed the risk and benefits of CBCT but none de- nounced CBCT as harmful to the pa- tient or insignificant in treatment planning and diagnosis. Two similar PubMed reviews of the literature on CBCT were performed by authors Alamri et al (Applications of CBCT in dental practice: A review of the litera- ture. Gen Dent 2012; 60(5): 390–400) andDeVosetal(Cone-beamcomputer- ized tomography (CBCT) imaging of the oral and maxillofacial region: A systematicreviewoftheliterature.Int J Oral Maxillofax Surg 2009; 38: 609–625).Bothoftheseexhaustivear- ticles demonstrate the plethora of lit- eratureaddressingCBCTanditsappli- cation in the many disciplines in den- tistry. Professional Guidelines For a technology such as CBCT to becomeastandardofcareindentistry, guidelines for its use and application in patient care must be established by the organisational bodies of those dis- ciplines in dentistry who employ the technology to treat patients. In den- tistry,thedentalpractitionersmostin- volved in the use and application of CBCT in patient care include general dentists, oral and maxillofacial sur- geons, endodontists, oral and maxillo- facial radiologists, orthodontists, and periodontists. The American Dental Association hasover180,000licenseddentistsrep- resenting approximately 75 % of den- tists in the USA. The American Dental Association published an advisory statement article in its principal jour- nal,TheJournaloftheAmericanDental Association, in August 2012. The arti- cle discusses the many positive as- pects of CBCT, but stops short of call- ing CBCT a new standard of care. Rather, the ADA encourages the den- tist to use CBCT “selectively, as an ad- junct to conventional radiography.” The ADA further recognises the value and presence of CBCT by including CBCT-related courses at its annual meetings and continuing education courses during the year. The American Association of Oral and Maxillofacial Surgery (AAOMS) has over 9,000 members representing approximately 95 % of oral and max- illofacial surgeons practising in the US. Literature addressing the applica- tion of CBCT in oral and maxillofacial surgery has been around since 2007. The AAOMS has offered continuing educationintheuseandapplicationof CBCT for patient care as far back as 2011.TheAAOMShasworkedwiththe IAC to develop guidelines and accred- itation criteria for 3-D CBCT imaging. In a recent survey of OMFS residency programmes, 87 % of programme di- rectorsacknowledgedtheuseofCBCT in patient care by their residents. The American Association of En- dodontists (AAE) and the American Association of Oral and Maxillofacial Radiologists(AAOMR)havereleaseda formal position paper on CBCT. This paper makes many important points, such as limiting the field of vision to minimise radiation exposure and in- crease resolution, careful patient se- lectioninCBCT,andtheresponsibility of the clinician to interpret the entire image. The position paper goes on to declare “the use of CBCT in endodon- tics should be limited to the assess- ment and treatment of complex condi- tions.” The article then lists nine of these “complex conditions”. In sum- mation, the position paper recognises the value of CBCT as an adjunct to 2-D images and “CBCT may provide dose savings over multiple traditional im- ages in complex cases”. Literature pertaining to the use of CBCT in endodontics first appeared in theJournalofEndodonticsin2003.The AmericanAssociationofEndodontists sponsor continuing education in en- dodontic related CBCT on their web- siteandtheorganisationdevotesvalu- able time at its annual meeting to CBCT as it relates to modern endodon- tics. Most residencies (44 of 47) in en- dodontics provide CBCT for patient care. Literature pertaining to CBCT in dentistry dates back to 1998. The AAMORdevotesconsiderableeffortto continuingeducationrelatingtoCBCT bothonitswebsite,throughCEevents, and at its annual meeting. All seven ADA approved residencies in Radiology incorporate CBCT educa- tion and training into the resident cur- riculum. The tremendous value of anatomic truth in complex orthodon- tic cases involving patients with cleft lip and palate, impacted teeth, and maxillofacial deformities is widely recognisedanddiscussedinthelitera- ture. Review of the AAO annual meet- ing lecture syllabus shows CBCT is a prominent topic for today’s orthodon- tist. In a recent article in the Journal of Dental Education by Smith et al use of CBCT in orthodontic programmes in the US and Canada was evaluated. This article showed the following: –83 % of orthodontic programmes have access to CBCT, –73 % of programmes report “regular” use of CBCT in patient diagnosis, –AreasofCBCTusefocusesondiagno- sis and treatment planning for: im- pacted teeth, craniofacial anomalies, TAD placement, TMJ assessment, up- per airway analysis, and maxillofa- cial development. 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 demon- strateaheavyinfluenceofCBCTinthe field of periodontics. All 51 post-doc- toral 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 dental THE LOW RADIATION SENSOR DURABLE DDESIGN, EFFICIENT IMAGING ray2 www.suni.com international@suni.com WORLD’S THINNEST SENSOR SUPERIOR PATIENT COMFORT plusdr. 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